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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Hussain A, Crispi V, Ajab S, Isaac E, Elshafie G, Loubani M. Is the use of dual antiplatelet therapy following urgent and emergency coronary artery bypass surgery associated with increased risk of cardiac tamponade? J Clin Transl Res 2021; 7:229-233. [PMID: 34104825 PMCID: PMC8177840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND AND AIM Cardiac tamponade is a recognized post-cardiac surgery complication, resulting in increased morbidity and mortality. The 2016 American College of Cardiology and American Heart Association Guidelines recommended the use of Dual Antiplatelet Therapy (DAPT) in the management of patients undergoing urgent or emergency coronary artery bypass grafting (CABG). The effect of DAPT on cardiac tamponade rates was investigated in comparison to aspirin monotherapy (AMT). MATERIALS AND METHODS Prospectively collected data from a tertiary cardiac surgery center was analyzed to identify the patients who underwent urgent and emergency CABG between January 2015 and January 2018. The patients were categorized as aspirin monotherapy (AMT) and Dual Antiplatelet Therapy (DAPT) groups. The primary outcome was total cardiac tamponade rate and secondary outcomes were length of hospitalization and 30-days and 1-year mortality. RESULTS A total of 246 eligible patients were included across both arms and compared for confounding variables. Cardiac tamponade was observed in 9 (7.3%) and 8 (6.5%) of AMT and DAPT groups, respectively (P=0.802). The average hospital stay in days was similar in both groups (AMT=8.4 vs. DAPT=8.1, P=0.82), whereas tamponade patients experienced a significantly longer hospitalization when compared to non-tamponade patients (9.8 vs. 8.1 days, P=0.047). The 30-days and 1-year mortality were similar in both groups and were 0.8% and 1.6%, respectively. CONCLUSION Overall, this study demonstrated that DAPT in urgent or emergency CABG patients is not associated with an increased risk of cardiac tamponade, length of hospital stay or mortality. RELEVANCE FOR PATIENTS This study demonstrated that the use of DAPT in patients undergoing CABG as an urgent or emergency procedure following myocardial infarction is not associated with an increased risk of bleeding and has many associated benefits.
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Affiliation(s)
- Azar Hussain
- 1Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK,
Corresponding author: Azar Hussain Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Castle Road, Cottingham, HU16 5JQ, UK E-mail:
| | - Vassili Crispi
- 2Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Shereen Ajab
- 1Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Emmanuel Isaac
- 1Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ghazi Elshafie
- 1Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Mahmoud Loubani
- 1Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Elshafie G, Kumar P, Djearaman M, Aliverti A, Naidu B. The Effect of Benign and Malignant Pleural Disease on Chest Wall Mechanics. Am J Respir Crit Care Med 2017; 196:241-242. [DOI: 10.1164/rccm.201611-2241le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ghazi Elshafie
- Heart of England National Health Service Foundation TrustBirmingham, United Kingdom
- Queen Elizabeth Hospital BirminghamBirmingham, United Kingdomand
| | - Prem Kumar
- Queen Elizabeth Hospital BirminghamBirmingham, United Kingdomand
| | - Madava Djearaman
- Heart of England National Health Service Foundation TrustBirmingham, United Kingdom
| | | | - Babu Naidu
- Heart of England National Health Service Foundation TrustBirmingham, United Kingdom
- Queen Elizabeth Hospital BirminghamBirmingham, United Kingdomand
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Elshafie G, Kumar P, Motamedi-Fakhr S, Iles R, Wilson RC, Naidu B. Measuring changes in chest wall motion after lung resection using structured light plethysmography: a feasibility study. Interact Cardiovasc Thorac Surg 2016; 23:544-7. [PMID: 27316661 DOI: 10.1093/icvts/ivw185] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/29/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We describe the use of structured light plethysmography (SLP)-a novel, non-contact, light-based technique for measuring tidal breathing-among a cohort of patients undergoing lung resection. In this feasibility study, we examined whether changes in chest wall motion or in asynchrony between regions of the thoraco-abdominal wall could be identified after surgery. METHODS Fifteen patients underwent wedge resection (n = 8) or lobectomy (n = 7). All patients underwent two SLP assessments (before surgery and on Day 1 post-surgery). Each assessment captured data during 5 min of quiet (tidal) breathing. RESULTS When data were averaged across all patients, motion on the operated side of the thorax was significantly reduced after surgery (mean change from presurgery ± standard deviation: -14.7 ± 16.5%, P = 0.01), while motion on the non-operated side increased (15.9 ± 18.5%, P = 0.01). Thoraco-abdominal asynchrony also increased (mean change ± standard deviation: 43.4 ± 55.1%, P = 0.01), but no significant difference was observed in right-left hemi-thoracic asynchrony (163.7 ± 230.3%, P = 0.08). When analysed by resection type, lobectomy was associated with reduced and increased motion on the operated and non-operated side, respectively, and with an increase in both right-left hemi-thoracic and thoraco-abdominal asynchrony. No significant changes in motion or asynchrony were identified in patients who underwent wedge resection. CONCLUSIONS SLP was able to detect changes in chest wall motion and asynchrony after thoracic surgery. Changes in this small group of patients were consistent with the side of the incision and were most apparent in patients undergoing lobectomy.
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Affiliation(s)
- Ghazi Elshafie
- Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK School of Clinical and Experimental Medicine, The Medical School, University of Birmingham, Birmingham, UK
| | - Prem Kumar
- School of Clinical and Experimental Medicine, The Medical School, University of Birmingham, Birmingham, UK
| | | | - Richard Iles
- PneumaCare Ltd, Prospect House, Ely, Cambridgeshire, UK Evelina London Children's Hospital, London, UK
| | | | - Babu Naidu
- Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK School of Clinical and Experimental Medicine, The Medical School, University of Birmingham, Birmingham, UK
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Elshafie G, Acosta J, Aliverti A, Bradley A, Kumar P, Rajesh P, Naidu B. Chest wall mechanics before and after diaphragm plication. J Cardiothorac Surg 2016; 11:25. [PMID: 26832454 PMCID: PMC4736549 DOI: 10.1186/s13019-016-0419-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 01/21/2016] [Indexed: 11/29/2022] Open
Abstract
Background Following diaphragmatic plication for unilateral paralysis, the effect on global chest wall function are unknown. Our hypothesis was that chest wall function would improve in both sides of the chest after plication of the paralysed side. Case Presentation Using Optoelectronic Plethysmography, total and regional chest wall volumes were measured in one patient before and after left diaphragmatic plication. Volumes were recorded at quiet breathing. Respiratory capacity improved during quiet breathing when measured before and 6 months after surgery. These improvements occur at the abdominal-rib cage level in both operated and contralateral. Prior to surgery the abdominal rib cage motion was out of phase to the upper rib cage and abdominal compartment in both sides of the chest. Synchrony of all three compartments was restored after plication. Conclusion This physiological study is the first published data in humans to show improvement in chest wall motion both in operated and contralateral side following diaphragmatic plication for unilateral paralysis.
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Affiliation(s)
- Ghazi Elshafie
- Heart of England Foundation Trust, Birmingham, B9 5SS, UK.,Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Johanna Acosta
- International Digital Laboratory, University of Warwick, Coventry, CV4 7AL, UK
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Amy Bradley
- Heart of England Foundation Trust, Birmingham, B9 5SS, UK
| | - Prem Kumar
- Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Pala Rajesh
- Heart of England Foundation Trust, Birmingham, B9 5SS, UK
| | - Babu Naidu
- Heart of England Foundation Trust, Birmingham, B9 5SS, UK. .,Birmingham Medical School, University of Birmingham, Birmingham, UK.
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Elshafie G, Steyn R, Bishay E, Kalkat M, Rajesh P, Naidu B. 171 Early chest mechanics changes post lung cancer resection: the effect of post operative pulmonary complications on chest wall mechanics. Lung Cancer 2016. [DOI: 10.1016/s0169-5002(16)30188-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Elshafie G, Kalkat M, Steyn R, Bishay E, Rajesh P, Naidu B. 91 The effect of benign and malignant pleural disease on chest wall mechanics. Lung Cancer 2016. [DOI: 10.1016/s0169-5002(16)30108-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Elshafie G, Aliverti A, Pippa L, Kumar P, Kalkat M, Naidu B. Surgery corrects asynchrony of ribcage secondary to extra-thoracic tumor but leads to expiratory dysfunction during exercise. J Cardiothorac Surg 2015; 10:187. [PMID: 26684847 PMCID: PMC4684600 DOI: 10.1186/s13019-015-0355-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 10/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effect of chest wall tumours on chest wall mechanics is uncertain even less is known about the effects of resection and reconstruction. Our aim is to study how chest wall mechanics are altered in chest wall sarcoma and to determine the effect of chest wall reconstruction on chest wall kinetics. CASE PRESENTATION Using Optoelectronic Plethysmography (OEP), total and regional chest wall volumes were measured in a patient with unilateral extra-thoracic chest wall sarcoma, before and 5 months after resection and reconstruction, during quiet breathing and exercise using cycle ergometry. During quiet breathing the unilateral tumour was associated with reduced in motion of the lower rib cage and abdominal compartments on both sides of the chest as well as asynchronous motion of the contralateral lower rib cage. Surgery corrected these abnormalities in quiet breathing. But during exercise there was a reduction in the upper rib cage motion compared to pre-operative measures from 0.43+/-0.06 to 0.36 +/- 0.02 L postoperatively (p <0.05). This impairment was characterised by a significant increase in the end expiratory volume on the operated side of the chest 5 months after surgery by 6.5 +/- 0.6 and 5.7 +/- 0.7 % during 50 and 100 % exercise respectively (p <0.0001) a finding that was not replicated in the non-operated side. CONCLUSION This physiological study demonstrates the negative effect of chest wall tumours on global chest wall mechanics during quiet breathing and exercise and shows that surgery reverses this abnormality, but only at rest.
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Affiliation(s)
- Ghazi Elshafie
- Department of Thoracic Surgery, Heart of England NHS foundation trust, Bordesley Green East, Birmingham, West Midlands, B9 5SS, UK.,School of Clinical and Experimental Medicine, The Medical School, Vincent Drive University of Birmingham, Birmingham, B15 2TT, UK
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, P.zza L. da Vinci, 32, 20133, Milan, Italy
| | - Ludovica Pippa
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, P.zza L. da Vinci, 32, 20133, Milan, Italy
| | - Prem Kumar
- School of Clinical and Experimental Medicine, The Medical School, Vincent Drive University of Birmingham, Birmingham, B15 2TT, UK
| | - Maninder Kalkat
- Department of Thoracic Surgery, Heart of England NHS foundation trust, Bordesley Green East, Birmingham, West Midlands, B9 5SS, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Heart of England NHS foundation trust, Bordesley Green East, Birmingham, West Midlands, B9 5SS, UK. .,School of Clinical and Experimental Medicine, The Medical School, Vincent Drive University of Birmingham, Birmingham, B15 2TT, UK.
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Elshafie G, Naidu B. The use of structured light plethysmography in assessing the outcome of lung reduction. J Cardiothorac Surg 2015. [PMCID: PMC4695754 DOI: 10.1186/1749-8090-10-s1-a359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Elshafie G, Naidu B. Cardiopulmonary benefits of a cosmetic chest wall surgery. J Cardiothorac Surg 2015. [PMCID: PMC4695801 DOI: 10.1186/1749-8090-10-s1-a303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Elshafie G, Aliverti A, Rajesh P, Steyn R, Bishay E, Kalkat M, Naidu B. F-031THE IMPROVEMENT OF EXERCISE CAPACITY AFTER SURGICAL CORRECTION OF PECTUS CARINATUM IS ASSOCIATED WITH REVERSAL OF DYNAMIC HYPERINFLATION. Interact Cardiovasc Thorac Surg 2015. [DOI: 10.1093/icvts/ivv204.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Elshafie G, De Boer W, Steyn R, Bishay E, Kalkat M, Rajesh P, Wilson R, Naidu B. 170: Novel thoraco-abdominal analysis technology can measure early respiratory changes following lung cancer resection. Lung Cancer 2015. [DOI: 10.1016/s0169-5002(15)50164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Elshafie G, Canon JA, Aliverti A, Bradley A, Parker K, Rajesh PB, Naidu B. 153-I * THE EFFECT OF DIAPHRAGMATIC PLICATION ON CHEST WALL DYNAMICS. Interact Cardiovasc Thorac Surg 2014. [DOI: 10.1093/icvts/ivu276.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Elshafie G, Nawaytou O, Binesmael T, Lopez A, Mehta D. Coronary artery bypass grafting on dialysis-dependent chronic renal failure patients: short and long-term outcomes, a 12 year experience. Int J Surg 2012. [DOI: 10.1016/j.ijsu.2012.06.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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