Similar survival 15 years after coronary artery surgery irrespective of left main stem stenosis.

OBJECTIVES: To evaluate 15-year survival after coronary artery bypass grafting (CABG) in relation to grade left main stenosis (LMS) and right coronary artery (RCA) obstruction. DESIGN: Coronary angiographic findings were prospectively collected in 977 patients who had CABG for stable angina during 1994-1995 and were included in the Swedish Coronary Revascularization - Swedish Council of Technology Assessment study. RESULTS: Significant LMS was present in one fifth of the patients and significant RCA obstruction was found in 61% of those with LMS and in 68% of patients without LMS. The patients were categorized as no LMS (Group I), LMS without RCA obstruction (Group II) or significant LMS with significant right coronary artery (RCA) obstruction (Group III). Early mortality did not differ in the three groups and was 1.2, 1.2% and 0.8% in group I, II and III, respectively. Corresponding survival at 15 years was similar 51%, 47% and 47%, respectively. In multivariable analysis older age, smoking, severe angina, positive stress test, hypertension, diabetes mellitus and ejection fraction < 50% were risk factors for death at 15 years. CONCLUSIONS: Death 15 years after CABG correlated to clinical variables but was not predicted from presence of LMS with or without significant associated RCA obstruction.

Fetal monitoring with computerized ST analysis during labor: a systematic review and meta-analysis.

BACKGROUND: Computerized ST analysis of fetal electrocardiography (ECG) combined with cardiotochography (CTG) has been introduced for intrapartum monitoring and is the prevailing method when ST analysis (STAN®) is used. OBJECTIVE: To assess the evidence that computerized ST analysis during labor reduces the incidence of fetal metabolic acidosis, hypoxic ischemic encephalopathy, cesarean section, instrumental vaginal delivery or the number of instances where fetal scalp blood sampling is used as compared with CTG only. METHODS: Search of PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL and CRD databases. SELECTION CRITERIA: CTG only compared with CTG + computerized ST analysis. DATA COLLECTION AND ANALYSIS: Studies were assessed using pre-designed templates. Meta-analyses of included randomized controlled trials were performed using a random effects model. RESULTS: Risk ratio for cord metabolic acidosis with STAN® was 0.96 [95% confidence interval (CI) 0.49-1.88]. Risk ratio for cesarean sections or instrumental vaginal deliveries for fetal distress was 0.93 (95%CI 0.80-1.08) and for fetal scalp blood sampling 0.55 (95%CI 0.40-0.76). Encephalopathy cases were not assessed due to their low incidence. CONCLUSIONS: There is not enough scientific evidence to conclude that computerized ST analysis reduces the incidence of metabolic acidosis. Cesarean sections and instrumental vaginal deliveries due to fetal distress or other indications are the same, regardless of method, but STAN® reduces the number of instances which require scalp blood sampling.

Induction of labor versus expectant management for post-date pregnancy: is there sufficient evidence for a change in clinical practice?

OBJECTIVES: To compare perinatal and maternal outcomes between elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond. DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE) and PsycINFO (1980 to November, 2007). Inclusion criteria were systematic reviews and randomized controlled trials comparing elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond. Three or more reviewers independently read and evaluated all selected studies. Data were extracted and analyzed using Review Manager Software. MAIN OUTCOME MEASURES: Perinatal mortality. RESULTS: Thirteen trials fulfilled the inclusion criteria for the meta-analysis. Elective induction of labor was not associated with lower risk of perinatal mortality compared to expectant management (relative risks (RR): 0.33; 95% confidence intervals (CI): 0.10-1.09). Elective induction was associated with a significantly lower rate of meconium aspiration syndrome (RR: 0.43; 95% CI: 0.23-0.79). More women randomized to expectant management were delivered by cesarean section (RR: 0.87; 95% CI: 0.80-0.96). CONCLUSIONS: The meta-analysis illustrated a problem with rare outcomes such as perinatal mortality. No individual study with adequate sample size has been published, nor would a meta-analysis based on the current literature be sufficient. The optimal management of pregnancies at 41 weeks and beyond is thus unknown.

The Swedish Council on Technology Assessment in Health Care (SBU) systematic overview of radiotherapy for cancer including a prospective survey of radiotherapy practice in Sweden 2001--summary and conclusions.

A systematic assessment of radiotherapy for cancer was conducted by The Swedish Council on Technology Assessment in Health Care (SBU) and published in 1996. The assessment reviewed the scientific literature up to 1993 on the use of radiotherapy in the treatment of solid tumours, and estimated the costs associated with radiotherapy. It also described the current practise of radiotherapy in Sweden 1992 and compared practise with scientific knowledge. The SBU has now conducted a follow-up study on radiotherapy for cancer, including a review of the scientific literature from 1994 and a prospective survey of radiotherapy practise in Sweden 2001. The following conclusions were drawn: The role of radiotherapy as an important form of treatment for cancer with both curative and palliative intent has been further confirmed. The use of radiotherapy in Sweden has increased and is now at the internationally recommended level. Radiotherapy in Sweden is mostly given in accordance with the scientific evidence but may still be underutilized in certain situations. The resources for radiotherapy are being utilized more efficiently. The costs of radiotherapy are still 5% of the total cost of cancer care, while the cost of an individual treatment (fraction) has decreased. The need for radiotherapy capacity will increase. In addition, half of the treatment equipment will have to be replaced in the next few years.

A prospective survey of radiotherapy practice 2001 in Sweden.

A prospective survey of radiotherapy practice in Sweden was conducted during 12 weeks in the autumn of 2001. All hospitals that provided radiotherapy participated, and all patients who started radiotherapy during the study period were included. The final patient sample comprised 5,105 treatments given to 4,171 patients. The results were compared with those of a similar survey conducted in 1992, and the following conclusions were drawn: A substantial increase in the use of radiotherapy was noted; The estimated proportion of cancer cases receiving radiotherapy (compared to the incident number of cases) had increased from 32% in 1992 to 47%; The proportion of cancer patients receiving radiotherapy was estimated at between 37 and 46%; 54% of treatments were given with curative intent, a small increase since 1992; The difference between regional and county departments for proportion of treatments with curative intent had diminished; Treatments with curative intent used a higher proportion of resources measured in terms of fractions; The proportion of palliative treatment was slightly lower than in 1992, but the absolute number of treatments had increased by more than 20%; No improvement in participation in clinical trials was noted; Treatments given with curative intent were more complex with more fields; Hyperfractionation was used, mainly in treatments of cancers of the head and neck, lung, and bladder; The use of brachytherapy for non-gynaecological malignancies had increased dramatically; Treatment of bone metastases with a single or few fractions was used much more frequently; Dose planning and patient set-up showed a high standard but quality control of dosimetry of given treatment did not fully comply with Swedish and European recommendations; The treatment devices seem to be used more efficiently.

Medium-term survival and quality of life of Swedish octogenarians after open-heart surgery.

OBJECTIVE: Operative mortality after open-heart interventions in the octogenarian population is relatively well known. Less has been reported on the medium term survival and quality of life of this growing subgroup of patients. METHODS: One hundred and eighty-three consecutive patients aged between 80 and 84 years when they underwent open-heart surgery between January 1995 and June 2000 were retrospectively analysed. The patients were followed up for 36 months as regards survival and compared, after matching for age and gender, to survival in the general Swedish population. The health-related quality of life (HRQOL) of surviving patients was assessed in February 2001 using the SWED-QUAL questionnaire. After matching for differences by age and gender, survival results were compared to Swedish national survival data, and functioning and well-being to the corresponding national norm data. Pre-, intra- and post-operative variables were evaluated as predictors for mortality, survival and quality of life. RESULTS: The 30-day mortality rate was 4.6% (n = 8). The 36-month survival rate, that was 85.6%, did not differ significantly (P = 0.078) from that of a cohort of the Swedish population matched for age and gender. There was no significant difference in survival between male and female patients (P = 0.545). Systemic hypertension was the only variable found to be a statistically significant predictor of 36-month mortality (P = 0.009). As concerns HRQOL, patients had significantly better physical functioning, satisfaction with physical functioning, relief of pain and emotional well-being (P < 0.01) and similar quality of sleep (P = 0.106) as the normal population. Male patients and male normal population responders had similar HRQOL (P > 0.05) while female patients reported significantly better HRQOL than their population counterparts on all five dimensions (P < 0.01). CONCLUSIONS: Patients 80-84 years of age may be operated on with acceptable operative mortality and benefit from improved functioning and well-being. Survival and quality of life after open-heart surgery among patients aged 80-84 years of age are comparable to, or even better than in the general Swedish population.

Mechanisms behind operating room blood transfusions in coronary artery bypass graft surgery patients with insignificant bleeding.

OBJECTIVE: To investigate situations in cardiac surgery when transfusions are sometimes used for indications other than to compensate for surgical bleeding. DESIGN: Retrospective study. SETTING: Cardiac surgery unit at a university teaching hospital. PARTICIPANTS: Patients scheduled for coronary artery bypass graft surgery (n = 2,469). INTERVENTIONS: A subgroup of patients with surgical bleeding of < or = 400 mL (n = 982) was selected to identify mechanisms leading to perioperative erythrocyte transfusion. MEASUREMENTS AND MAIN RESULTS: Bleeding of >400 mL triggered transfusion. At less than this bleeding volume, other indications were noted: unstable angina, use of blood cardioplegia, and bad surgical outcome, such as inotropic support. After exclusion of these predictors and anemic patients, the strongest predictors were female gender (p < 0.001), weight < or = 70 kg (p < 0.001), cardiopulmonary bypass (CPB) time > or = 90 minutes (p = 0.002), CPB cooling < or = 32 degrees C (p = 0.038), and advanced age (p < 0.001). Results from a more detailed study of medical records showed that within its normal concentration range, the operating room-transfused patients had lower hemoglobin levels. When followed postoperatively in the intensive care unit and ward, these patients continued to receive more transfusions (p < 0.05) even though their bleeding in the intensive care unit did not differ from the control subjects. CONCLUSION: Some patients are transfused because of institutional bias of an anticipated need rather than for true surgical bleeding. A concern of hemodilution from standard CPB circuits suggests a possible advantage with low-priming volume for smaller adult female patients.

Five-year mortality for stable angina in a medical practice study and a randomized trial.

OBJECTIVE: Evolution of revascularization and medical therapy has increased the probability of improved survival in patients with stable angina. The present investigation tests the hypothesis that medical practice will generate lower mortality than randomly assigned bypass surgery in the European Coronary Surgery Study (ECSS) two decades earlier. METHOD: Using eligibility criteria of ECSS, a clinical decision strategy (CDS) cohort of 362 patients was selected from a nationwide study of medical practice in Sweden. Access to the individual data allowed common protocol design to compare 5-year mortality between CDS and surgical strategy of ECSS. RESULTS AND INTERPRETATION: CDS advised bypass surgery (BS) or percutaneous transluminal coronary angioplasty (PTCA) in 93% and medical treatment alone in 7%, while 94% of 394 patients randomized to surgery (Euro-S) in ECSS obtained BS. Operative mortality was 3.2% for Euro-S while no operative deaths occurred in CDS reflecting medical progress during two decades. However, the 5-year mortality for CDS decreased first when the risk ratio was adjusted for age, diabetes mellitus and hypertension (RR = 0.49 with 95% CI 0.26-0.93) p = 0.03 suggesting a need for improved comprehensive medical care.

A multicenter randomized controlled trial of injections of sterile water and saline for chronic myofascial pain syndromes.

A randomised controlled trial was used to test the hypothesis that cutaneous injections of sterile water (SWI) have no benefit over saline (PSI) as a method of pain reduction among patients with myofascial pain syndromes. Six general practitioners located at 6 different clinics of general practice treated 117 patients (91 female, 26 male, aged > or = 25 years) with myofascial pain syndrome for at least 3 months in one or both of the upper quadrants of the body. Patients were randomised to receive either SWI or PSI which was administered sub- and intracutaneously on 1 occasion. The patients received a mean number of 10 injections of 0.5 ml of either substance. The main outcome measure was pain intensity which was measured with visual analogue scales before intervention, 10 min after intervention and 14 days after intervention. We found no statistically or clinically significant difference in pain level reduction between the 2 groups. However, patients who received SWI reported a much more painful treatment experience than those who received PSI. Our study shows that injections of sterile water are substantially more painful but demonstrate no better clinical outcome than similar injections of saline as a method to treat patients with chronic myofascial pain syndrome.