Cardiac surgery in Indigenous Australians--how wide is 'the gap'?

BACKGROUND

Cardiovascular disease remains the leading cause of mortality in the Indigenous Australian population. Limited research exists in regards to cardiac surgery in the Aboriginal and Torres Strait Islander (ATSI) population. We aimed to investigate risk profiles, surgical pathologies, surgical management and short term outcomes in a contemporary group of patients.

METHODS

Variables were assessed for 557 consecutive patients who underwent surgery at our institution between August 2008 and March 2010.

RESULTS

19.2% (107/557) of patients were of Indigenous origin. ATSI patients were significantly younger at time of surgery (mean age 54.1±13.23 vs. 63.1±12.46; p=<0.001) with higher rates of preventable risk factors. Rheumatic heart disease (RHD) was the dominant valvular pathology observed in the Indigenous population. Significantly higher rates of left ventricular impairment and more diffuse coronary artery disease were observed in ATSI patients. A non-significant trend towards higher 30-day mortality was observed in the Indigenous population (5.6% vs. 3.1%; p=0.244).

CONCLUSIONS

Cardiac surgery is generally required at a younger age in the Indigenous population with patients often presenting with more advanced disease. Despite often more advanced disease, surgical outcomes do not differ significantly from non-Indigenous patients. Continued focus on preventative strategies for coronary artery disease and RHD in the Indigenous population is required.

Recurrent left ventricular thrombus in Crohn's disease: a rare presentation

A 40-year-old man with Crohn's disease was found to have recurrence of a large left ventricular mass on echocardiography during workup for stricturoplasty. He presented with left limb emboli. He had been diagnosed with a left ventricular thrombus 2 years earlier, with multiple cerebral and peripheral emboli, and underwent surgery. We carried out redo surgery, and histology revealed organized thrombus. We discuss the management of this complex case.

Identification of isothiazole-4-carboxamidines derivatives as a novel class of allosteric MEK1 inhibitors

The development of potent, orally bioavailable, and selective series of 5-amino-3-hydroxy-N(1-hydroxypropane-2-yl)isothiazole-4-carboxamidine inhibitors of MEK1 and MEK-2 kinase is described. Optimization of the carboxamidine and the phenoxyaniline group led to the identification of 55 which gave good potency as in vitro MEK1 inhibitors, and good oral exposure in rat.

Discovery of 3-hydroxy-4-carboxyalkylamidino-5-arylamino-isothiazoles as potent MEK1 inhibitors

3-Hydroxy-4-carboxyalkylamidino-5-arylamino-isothiazoles were discovered as potent in vitro MEK1 inhibitors.

Late manifestation of a large congenital tracheoesophageal fistula in an adult

Congenital tracheoesophageal fistula in an adult is a rare condition. We describe the clinical presentation in a young woman after video-assisted thoracoscopic pleurodesis for spontaneous pneumothorax. She was found to have a very wide and short fistula in her neck. The tracheoesophageal defect was closed by a trap-door flap, using the posterior wall of the trachea. The patient made an uncomplicated recovery.

Bioglue: a review of the use of this new surgical adhesive in thoracic surgery

BACKGROUND

Alveolar air leaks and broncho-pleural fistulae after thoracic surgical procedures contribute significantly to hospital morbidity and mortality. BioGlue has offered the thoracic surgeon an alternative to the products presently used to reduce the incidence of these complications. This retrospective study reviews our experience with this new adhesive.

METHODS

Forty patients upon whom BioGlue was used were identified through operation records. Pre-, intra- and postoperative data were collected to establish use, indications and outcome.

RESULTS

The predominant underlying pathology was malignancy. In 32 patients BioGlue was used during the primary procedure while in the remaining eight, persistent air- or lymph-leak led to a further procedure requiring the use of glue. The indications for BioGlue use were alveolar air leak (36), broncho-pleural fistula (2) and lymph leak (2). There was one death. In 35 out of 36 patients with alveolar air leak, BioGlue controlled the leak at the site of application.

CONCLUSIONS

Our results in this particular patient group indicate that BioGlue is a reliable adjunct in the reduction of alveolar air leaks. Although further studies are necessary to establish the role of BioGlue in thoracic surgery in comparison to other sealants, these initial results are promising.

Hydrodissection Technique of Harvesting Left Internal Thoracic Artery

Use of internal thoracic arteries in coronary artery bypass surgery has become universal. Skeletonized internal thoracic artery is useful in coronary artery surgery for sequential anastomosis as it also provides a long length of graft. Skeletonizing the conduit is technically more difficult than harvesting it as a pedicle graft. We describe a technique of harvesting the internal thoracic artery in which 10 to 20 mL of normal saline is injected into the fascial plane of the left side of chest wall along the course of artery to develop a plane of dissection.

Economic evaluation of pioglitazone hydrochloride in the management of type 2 diabetes mellitus in Canada

INTRODUCTION

Recently published clinical trial results have demonstrated that, in patients with type 2 diabetes mellitus, treatment with pioglitazone hydrochloride as a first-line therapy can lead to significant improvements in glycosylated haemoglobin, total cholesterol, high density lipoprotein cholesterol and triglycerides. Given the results of these trials, we assessed the cost effectiveness of the use of pioglitazone as a first-line therapy in Canada.

METHODS

A Markov model was used to determine the health outcomes and economic impact for patients with type 2 diabetes, from the perspective of a provincial ministry of health. The model incorporated six complications of diabetes: hypoglycaemia, acute myocardial infarction, stroke, lower extremity amputation, nephropathy, and retinopathy. Transition probabilities and costs were taken from published literature. Analysis compared treatment strategies with different first-line therapies: pioglitazone, glibenclamide (glyburide), metformin, and diet and exercise.

RESULTS

Compared with other strategies, a pioglitazone-based strategy was estimated to reduce the cumulative incidence of severe clinical events and long-term complications by between 23 and 36% and to increase discounted life expectancy by between 0.13 and 0.35 life-years. The discounted incremental cost per life-year gained of a first-line pioglitazone-based strategy was 54,000 Canadian dollars ($Can) compared with metformin, $Can42,000 compared with glibenclamide and $Can27,000 compared with diet and exercise.

CONCLUSIONS

When compared with other currently funded chronic therapy, these results demonstrate that a treatment strategy employing pioglitazone as a first-line therapy may be cost effective for certain patient strata.

Fabrication of strong long-period gratings in hydrogen-free fibers with 157-nm F2-laser radiation

Long-period gratings were fabricated in standard telecommunication fiber (Corning SMF-28) by use of what is believed to be record short-wavelength light from a 157-nm F(2) laser. Strong loss peaks were formed without the need for enhancement techniques such as hydrogen loading. The magnitude of the attenuation peak was sensitive to the single-pulse laser fluence, decreasing with increasing pulse fluence as a result of nonuniform 157-nm laser interaction with both the fiber cladding and core. The long-period fiber gratings have good wavelength stability (Dlambda~7 nm) under thermal annealing at 150 degrees C.