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Sepehripour AH, Saso S, Harling L, Punjabi P, Ashrafian H, Athanasiou T. Does off-pump coronary revascularization reduce mortality in re-operative coronary artery surgery? A meta-analysis of observational studies. Perfusion 2013; 28:340-9. [PMID: 23520171 DOI: 10.1177/0267659113482173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Re-operative coronary artery bypass grafting (CABG) is a challenging operation that is often performed in a high-risk patient group. Avoiding cardiopulmonary bypass (CPB) in these patients is hypothesised to be advantageous due to the reduced invasiveness and physiological stress of off-pump coronary artery bypass grafting (OPCAB). The aims of this study were to assess whether OPCAB may improve outcomes in patients undergoing re-operative CABG. METHODS Twelve studies, incorporating 3471 patients, were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were 30-day and mid-term mortality. Secondary endpoints were completeness of revascularization, mean number of grafts per patient and the effect of intra-operative conversion on mortality. RESULTS A significantly lower rate of 30-day mortality was observed with OPCAB (OR 0.51, 95% CI [0.35, 0.74]), however, no difference was demonstrated in mid-term mortality. Significantly less complete revascularization and mean number of grafts per patient were observed in the OPCAB group. Meta-regression revealed no change in 30-day mortality when the effect of conversion from one technique to the other was assessed. CONCLUSIONS Off-pump techniques may reduce early mortality in selected patients undergoing re-operative CABG; however, this does not persist into mid-term follow-up. OPCAB may also lead to intra-operative conversion and, although this did not affect outcomes in this study, these results are constrained by the limited data available. Furthermore, OPCAB may increase target vessel revascularization and, consequently, incomplete revascularization which, whilst not reflected in the short-term outcomes, requires longer-term follow-up in order to be fully assessed.
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Ahmed K, Ashrafian H, Harling L, Patel VM, Rao C, Darzi A, Hanna GB, Punjabi P, Athanasiou T. Safety of training and assessment in operating theatres--a systematic review and meta-analysis. Perfusion 2012; 28:76-87. [PMID: 23015638 DOI: 10.1177/0267659112460882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Procedural outcomes can be used to assess the performance of specialists and trainees. This article establishes a systematic evidence base for the safety of training in the operating theatre. It also explores the possibility of using early, intermediate and late procedural outcomes of cardiac surgical operations to evaluate the performance of the clinicians and the healthcare system. METHODS Medline, EMBASE and PsycINFO databases were searched. Comparative studies evaluating quality indicators of cardiac surgical procedures (coronary artery bypass grafting (CABG) and valve surgery) were included. guidelines from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used. RESULTS Fourteen studies met the inclusion criteria. For CABG, meta-analysis of outcomes did not show any significant differences between the technical and non-technical skills of trainees versus specialists apart from bypass time (less for specialists) and intensive care unit (ICU) length of stay (less for trainees). Studies reporting outcomes on valve surgery also did not report any statistically significant differences amongst the outcomes. CONCLUSION This systematic review did not discern any significant differences between the procedural outcomes of trainees and specialists, which indicates that trainees are safe to operate under senior supervision. In addition, this article recommends that various procedural outcomes can be used to evaluate the performance of clinicians and healthcare systems. Prospective studies need to be performed, taking into account the specific contribution of trainees and specialists during the procedure. This will give a clearer indication of safety and performance of trainees and specialists in the operating theatre.
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Mukherjee D, Ashrafian H, Kourliouros A, Ahmed K, Darzi A, Athanasiou T. Intra-operative conversion is a cause of masked mortality in off-pump coronary artery bypass: a meta-analysis. Eur J Cardiothorac Surg 2012; 41:291-9. [DOI: 10.1016/j.ejcts.2011.05.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 05/07/2011] [Accepted: 05/09/2011] [Indexed: 01/11/2023] Open
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Ibrahim M, Rao C, Ashrafian H, Chaudhry U, Darzi A, Athanasiou T. Modern management of systolic anterior motion of the mitral valve. Eur J Cardiothorac Surg 2012; 41:1260-70. [DOI: 10.1093/ejcts/ezr232] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ashrafian H. Leonardo da Vinci’s Vitruvian Man: a renaissance for inguinal hernias. Hernia 2011; 15:593-4. [DOI: 10.1007/s10029-011-0845-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 06/18/2011] [Indexed: 10/18/2022]
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Ashrafian H, Athanasiou T, Li JV, Bueter M, Ahmed K, Nagpal K, Holmes E, Darzi A, Bloom SR. Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. Obes Rev 2011; 12:e257-72. [PMID: 20880129 DOI: 10.1111/j.1467-789x.2010.00802.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.
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Ashrafian H, Athanasiou T, le Roux CW. Heart remodelling and obesity: the complexities and variation of cardiac geometry. Heart 2010; 97:171-2. [DOI: 10.1136/hrt.2010.207092] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ashrafian H, Bueter M, Ahmed K, Suliman A, Bloom SR, Darzi A, Athanasiou T. Metabolic surgery: an evolution through bariatric animal models. Obes Rev 2010; 11:907-20. [PMID: 20051020 DOI: 10.1111/j.1467-789x.2009.00701.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Metabolic surgery was developed through the application and experience gained from bariatric or weight loss procedures. Much of our knowledge from the procedures comes from the study of animal models, where they have revealed anatomic feasibility, systemic physiological elements and cellular metabolic effects. The first generation of operation included the jejunoileal bypass and partial ileal bypass that led to the development of the current procedures including Roux-en-Y gastric bypass, biliopancreatic diversion, adjustable gastric banding and sleeve gastrectomy. These operations carry significant metabolic benefits and can reduce the risk of diabetes, heart disease and cancer. Further insights from these animal models can reveal genetic, molecular and systemic effects that can enhance and develop the next generation of metabolic operations.
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Ashrafian H, Darzi A. Surgical instruments: objects of beauty and dread. West J Med 2010. [DOI: 10.1136/bmj.c5620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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35
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Ashrafian H. Clinical diagnosis in the ancient British Epic Poem Beowulf. Clin Otolaryngol 2010; 35:448-9. [DOI: 10.1111/j.1749-4486.2010.02202.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ashrafian H, Athanasiou T, Li JV, Bueter M, Ahmed K, Nagpal K, Holmes E, Darzi A, Bloom SR. Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. OBESITY REVIEWS : AN OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION FOR THE STUDY OF OBESITY 2010. [PMID: 20880129 DOI: 10.1111/j.1467–789x.2010.00802.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.
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Abozguia K, Elliott P, McKenna W, Phan TT, Nallur-Shivu G, Ahmed I, Maher AR, Ashrafian H, Watkins H, Frenneaux MP. 061 Metabolic alteration in hypertrophic cardiomyopathy (METAL-HCM Study): randomised double blinded placebo controlled trial of perhexiline therapy in patient with hypertrophic cardiomyopathy. BRITISH HEART JOURNAL 2010. [DOI: 10.1136/hrt.2010.195966.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Patel V, Ahmed K, Ashrafian H. Letter 3: Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients (Br J Surg 2009; 96: 473–481). Br J Surg 2009; 96:953; author reply 955. [DOI: 10.1002/bjs.6761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ashrafian H, Salih C, Darzi A, Athanasiou T. Pulsatile anorectal varices and pulsatile hepatosplenomegaly secondary to traumatic tricuspid regurgitation. J Postgrad Med 2009; 55:75-6. [PMID: 19242089 DOI: 10.4103/0022-3859.48450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ashrafian H, Watkins H. Exercise-induced ventricular dysfunction in hypertrophic cardiomyopathy: stunning by any other name? Heart 2007; 94:1251-3. [DOI: 10.1136/hrt.2007.123166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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42
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Ashrafian H. Jacques-Louis David and his post-traumatic facial pathology. J R Soc Med 2007. [DOI: 10.1258/jrsm.100.7.341-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ashrafian H, Griselli M, Rubens MB, Mullen MJ, Sethia B. Pulmonary homograft endocarditis 19 years after a Ross procedure. Thorac Cardiovasc Surg 2007; 55:55-6. [PMID: 17285476 DOI: 10.1055/s-2006-924099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the case of a patient with acute pulmonary homograft endocarditis secondary to Streptococcus agalactiae from a cat-bite. He had undergone a Ross procedure nineteen years earlier. In view of unremitting infection with large pulmonary trunk and right pulmonary artery vegetations, the patient underwent successful pulmonary vegetectomy and homograft replacement.
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Abstract
Yet another guideline on the prevention of infective endocarditis has been published, this time limiting prophylaxis to high-risk patients.
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Ashrafian H. William Penny Brookes (1809-1895): forgotten Olympic Lord of the Rings. Br J Sports Med 2005; 39:969. [PMID: 16306509 PMCID: PMC1725082 DOI: 10.1136/bjsm.2005.019331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The contribution of Dr William Penny Brookes (1809-1895) to the Olympic Games is scarcely reported in the medical literature. Presented here is a brief report of his life and work. Furthermore, the need to promote public health and fitness through the Olympics is re-emphasised.
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Ashrafian H. The medical riddle of the Great Sphinx of Giza. J Endocrinol Invest 2005; 28:866. [PMID: 16370572 DOI: 10.1007/bf03347583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Lithium is still the treatment of choice in bipolar affective disorder. The patient presented here represents an example of the possible severity of metabolic defects resulting from lithium use. In this case, it caused severe intractable nephrogenic diabetes insipidus (NDI). Our case report draws attention to 2 important messages. The first is the complexity in treating psychiatric patients that is often not borne out in the medical literature. The second is the role and power of pharmacological augmentation. While the role of these agents has been appreciated for some time, the use of carbamazepine and of drug combinations is not as well recognized. We emphasize the clinical features of NDI, lithium's metabolic sequelae and furthermore collate the most up-to-date account of the signalling effects conferred by these agents in a summary diagram.
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Ashrafian H, Swan L. The mechanism of formation of pulmonary arteriovenous malformations associated with the classic Glenn shunt (superior cavopulmonary anastomosis). Heart 2002; 88:639. [PMID: 12433901 PMCID: PMC1767473 DOI: 10.1136/heart.88.6.639] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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50
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Ashrafian H, Watkins H. Myocardial dysfunction in hypertrophic cardiomyopathy. Circulation 2001; 104:E165. [PMID: 11748129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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