Objective improvement with coronary anastomosis simulation training: meta-analysis.

BACKGROUND: Coronary artery anastomosis training and assessment are vital for patient safety and for conferring a prognostic benefit. A systematic review and meta-analysis were performed to analyse the impact of simulation on coronary anastomosis proficiency in terms of time taken and skill score. METHODS: This review was conducted in accordance with PRISMA guidelines, searching PubMed, Embase and Cochrane databases on 10 October 2020, using the terms 'Coronary anastomosis simulation' or 'vascular anastomosis simulation' and 'anastomosis simulation'. Studies included had objective measurement of scores of before and after simulation. Meta-analysis was performed using RevMan, version 5.4 (Cochrane Library). RESULTS: From a pool of 1687 articles, 12 articles evaluating the use of simulation in teaching coronary anastomosis were identified, with objective scores at baseline and after simulation. The 12 papers included 274 subjects. Data on 223 subjects could be extracted for analysis in performing coronary anastomosis in a simulated environment. Eight trials evaluated improvement in time and 12 trials evaluated performance using an objective evaluation score. In comparison with no formal simulation training, simulation was associated with improved skill in a five-point scale (standardized mean difference 1.68 (95 per cent c.i. 1.23 to 2.13; P < 0.001)) and time (mean difference 205.9 s (95 per cent c.i. 133.62 to 278.18; P < 0.001)) in trials included in the meta-analysis. Furthermore, novice cardiothoracic surgeons benefited more from simulation as regards time improvement compared with senior cardiothoracic surgeons (293 versus 120 s improvement; P = 0.003). Fidelity of simulator did not have a significant effect on rates of improvement. CONCLUSION: Simulation-based training in coronary anastomosis is associated with improved time efficiency and overall performance in comparison with no intervention. Further studies are necessary to determine the optimum timing of trainees progressing from simulation training to live operating.

Mitral valve replacement due to Libman-Sacks endocarditis: lower limb cellulitis as a red herring.

A 56-year-old woman was admitted due to new ulceration and acute digital ischaemia on a background of chronic leg ulcers bilaterally. Vasculitis screening returned strongly positive lupus anticoagulant levels and elevated anticardiolipin antibodies; these remained elevated at repeat testing. A diagnosis of antiphospholipid syndrome was made. Transthoracic echocardiogram identified a mitral valve lesion suggestive of vegetation and mild mitral valve regurgitation. Blood cultures taken throughout her inpatient admission were negative. Mechanical mitral valve replacement was performed 3 months later, and subsequent culture of the excised tissue returned as sterile. Histological examination showed no morphological signs of infective endocarditis.

Solitary fibrous tumour of mediastinum: an often asymptomatic neoplasm.

Solitary fibrous tumours (SFTs) are rare neoplasms derived from mesenchymal cell lines. They are often asymptomatic, follow an indolent growth pattern and are more often benign than malignant. Here, we present a case of a very large, asymptomatic mediastinal SFT in an otherwise healthy man. A 67-year-old Irish man was referred for workup of an asymptomatic murmur. Auscultation of the lung fields revealed diminished breath sounds on the right side. Chest X-ray identified a 20 cm mass localised within the thorax. CT of the thorax confirmed a pleural based, solid lesion with no local invasion. CT-guided core biopsies were reported as consistent with SFT. Primary excision of the lesion was undertaken via median sternotomy. Histological examination confirmed a diagnosis of SFT. The patient remains well at this time. Primary excisive surgery is a safe and effective treatment modality for SFTs.

Inhaler screw-up: A real world cystic fibrosis (CF) case.

A 40-year-old male with Cystic Fibrosis developed a sudden onset choking, cough, dyspnea and hemoptysis after using his inhaler. He presented to A&E. CT scan located a foreign body in his right bronchus intermedius (RBI). Rigid bronchoscopy was performed and removed a plastic rawl plug with screw from his RBI. He made a rapid recovery. On questioning he mentioned he had stored his inhaler uncapped in the same pocket he had this screw which he found at work. Small objects can lodge in inhalers due to their design/mouthpiece uncapping. This can result in endobronchial foreign body aspiration. This case highlights the importance of replacing inhaler cap when not in use.

Coexistent sarcoidosis and lymphangioleiomyomatosis in a patient with cystic lung disease.

A 45-year-old lady presented acutely with pleuritic chest pain, haemoptysis, and dyspnoea. Her background was significant for a 1.4 cm renal angiomyolipoma, and she was an ex-smoker without any relevant family history. A computed tomography (CT) pulmonary angiogram was negative for a pulmonary embolism but demonstrated diffuse cystic change throughout both lungs. A bronchoscopy confirmed a normal endobronchial tree, and pulmonary function tests demonstrated moderate airways obstruction, with reversibility and a normal diffusion capacity for carbon monoxide (DLCO). A video-assisted thoracoscopic surgery (VATS) lung biopsy showed non-caseating granulomas, and serum angiotensin converting enzyme (ACE) was elevated consistent with a diagnosis of pulmonary sarcoidosis. Further sectioning indicated focal areas that stained positive for Human Melanoma Black 45 (HMB-45), confirming lymphangioleiomyomatosis (LAM). A diagnosis of cystic lung disease secondary to coexistent sarcoidosis and LAM was made.

Glycolysis inhibition as a cancer treatment and its role in an anti-tumour immune response.

Increased glycolysis is the main source of energy supply in cancer cells that use this metabolic pathway for ATP generation. Altered energy metabolism is a biochemical fingerprint of cancer cells that represents one of the "hallmarks of cancer". The immune system can prevent tumour growth by eliminating cancer cells but this editing process ultimately results in poorly immunogenic cells remaining allowing for unchallenged tumour growth. In this review we look at the glycolysis pathway as a target for cancer treatments. We also examine the interplay between the glycolysis modulation and the immune response as an anti-cancer therapy.

Surgical repair of an asymptomatic giant right coronary artery aneurysm.

Background Coronary artery aneurysm (CAA) is a rare finding, being mostly diagnosed on angiography or at autopsies. It is defined as being a dilation of the coronary artery that exceeds the diameter of the patient's largest coronary vessel by 1.5 to 2 times. Case Report We describe the operative correction of a giant right CAA measuring in excess of 10 cm. Conclusion Management of giant CAAs is not standardized and surgical strategy remains controversial. In our case, the patient has a successful surgical repair with no postoperative shunts on follow-up investigations.

The antiendotoxin agent taurolidine potentially reduces ischemia/reperfusion injury through its metabolite taurine.

BACKGROUND: Cardiopulmonary bypass results in ischemia/reperfusion (I/R)-induced endotoxemia. We conducted a prospective randomized trial to investigate the effect of taurolidine, an antiendotoxin agent with antioxidant and membrane-stabilizing properties, on patients undergoing coronary artery bypass grafting (CABG). METHODS: A total of 60 patients undergoing CABG were randomized into 4 groups. St Thomas' Hospital cold crystalloid cardioplegia was used in groups A and B, and cold blood cardioplegia in groups C and D. Groups A and C received a placebo infusion of normal saline, whereas groups B and D were administered intravenous taurolidine. Arrhythmias induced by pro- and anti-inflammatory cytokines (interleukin [IL]-6 and IL-10), and I/R were assessed perioperatively. RESULTS: Administration of taurolidine in crystalloid cardioplegia patients resulted in a significant decrease in serum IL-6 and an increase in serum IL-10 at 24 hours postaortic unclamping compared to placebo (P < .0001). Although not statistically significant, this trend in serum IL-6 decrease was mirrored in the blood cardioplegia patients (P = .068). Taurolidine treatment also significantly decreased I/R-induced arrhythmias compared to placebo in the crystalloid cardioplegia patients (P < .003). There were fewer I/R-induced arrhythmias compared to placebo in the blood cardioplegia patients; the difference, however, was marginal and not statistically significant (P = .583). CONCLUSION: This study demonstrates that administration of taurolidine in CABG patients induces a potent anti-inflammatory response that is associated with a significant decrease in arrhythmias.

Clinical implication and prognostic significance of standardised uptake value of primary non-small cell lung cancer on positron emission tomography: analysis of 176 cases.

OBJECTIVE: We sought to assess the clinical implication and prognostic significance of maximum standardised uptake value (SUV(max)) of primary non-small cell lung cancer (NSCLC) staged by integrated PET-CT. METHODS: A retrospective review was carried out on 176 consecutive patients with histologically proven NSCLC who underwent staging with integrated PET-CT prior to curative intent surgical resection. SUV(max) of primary NSCLC were measured and correlated with tumour characteristics, lymph node involvement, surgical stage, type of surgical resection and survival following resection. RESULTS: SUV(max) was significantly higher in centrally located tumours, tumours > or =4.0 cm, squamous cell subtype, poorly differentiated tumours, advanced T stage, advanced nodal stage, pleural invasion, and patients requiring complex surgical resection. SUV(max) value of 15 was the best discriminative cut-off value for survival generated by log-rank test. When patients were stratified based on this value, those with SUV(max) >15 were more likely to have centrally located tumours, squamous cell subtype, advanced T stage, advanced nodal stage, advanced American Joint Committee on Cancer (AJCC) stage, larger tumour size and required more advanced surgical resections than a simple lobectomy. Overall survival was significantly longer for patients with SUV(max) < or =15 than those with SUV(max) >15. Furthermore, nodal stage specific survival following resection (i.e. non-N2 and N2) were significantly better in patients with SUV(max) < or =15 than SUV(max) >15. CONCLUSION: SUV(max) correlates with tumour characteristics, surgical stage and prognosis following resection. SUV(max) may be a useful preoperative tool, in addition to other known prognostic markers, in allocating patients with potentially poor prognosis preoperatively to neoadjuvant chemotherapy prior to resection in order to improve their overall survival. Prospective and randomised trials are warranted.

Positron emission tomography staging of pleural deposits following Monaldi's procedure: an accurate reflection or a false staging?

Positron emission tomography (PET) has become widely available in staging non-small cell lung cancer (NSCLC) and despite its high accuracy, false positive staging remains a problem. We report a rare case where such false positive staging caused a dilemma in optimal management.

Predictors of acute renal failure requiring renal replacement therapy post cardiac surgery in patients with preoperatively normal renal function.

Acute renal failure requiring continuous renal replacement therapy post cardiac surgery carries a high mortality. Most studies have focused on patients with impaired renal function preoperatively but little is known about predictors of such a complication in patients with preoperatively normal renal function. This is a retrospective review of a prospective collected database. A total of 1609 patients underwent cardiac surgery over a 4-year period. Dialysis was required in 47 patients (2.9%). Univariate analysis identified the following as significant risk factors: age, female gender, chronic obstructive pulmonary disease, congestive cardiac failure, creatinine clearance, Euro, Parsonnet and Cleveland clinic scores, body mass index, non-isolated CABG, cardiopulmonary bypass time, extubation time and pulmonary complications (P<0.05). Multivariate analysis identified EuroSCORE, congestive cardiac failure, insulin-dependent diabetes, emergency surgery, postoperative extubation time and pulmonary complications as independent risk factors (P<0.05). In-hospital mortality and length of stay (P<0.0001) were higher in dialysis group. Acute renal failure requiring dialysis post cardiac surgery is associated with a higher mortality and prolonged hospital stay. By identifying higher risk patients, early planned preventative measures should be readily available to both reduce the incidence of such a complication and improve utilisation of hospital resources.

Factors causing inaccurate staging of mediastinal nodal involvement in non-small cell lung cancer patients staged by positron emission tomography.

Despite documented superiority of positron emission tomography over other investigative modalities in the preoperative staging of non-small cell lung cancer, a proportion of patients will have an inaccurate staging of their mediastinal nodes. The aim of this retrospective review is to analyse the clinicopathological factors responsible for inaccurate nodal staging by integrated PET-CT. A total of 100 consecutive patients with histologically proven non-small cell lung cancer underwent staging with PET-CT prior to lung resection. Thirty-three patients, inaccurately staged by PET-CT, were analysed. Univariate analysis identified the following as significant in causing inaccurate nodal staging: history of tuberculosis (P=0.039) and non-insulin dependant diabetes (P=0.014). In multivariate analysis, we have identified the following as independent factors in causing inaccurate staging of mediastinal lymph nodes: rheumatoid arthritis, non-insulin dependent diabetes, history of tuberculosis, presence of atypical adenomatous hyperplasia and pneumonia (P<0.05). The highest rate of inaccuracy in mediastinal nodal staging was in nodal station 4 (11%, P=0.01) followed by station 7 (10%, P=0.02) and station 9 (3.5%, P=0.01). Interpretation of PET-CT staging of the mediastinum in patients with a history of the above should be with caution, as the incidence of false upstaging and down staging in these subgroups is high. Vigilance of such factors may improve the accuracy of PET-CT in staging mediastinal lymph nodes. Histological confirmation should always be sought.

Idiopathic chronic constrictive pericarditis secondary to calcified pericardial haematoma.

Pericardial haematoma is a rare entity that is thought to arise acutely as a consequence of blunt chest wall injury. We report our experience with a chronic form of presentation in which calcified pericardial haematoma presented as a mass causing chronic constrictive pericarditis symptoms in a patient with no prior history of chest wall injury. The ability to recognize such a rare occurrence is vital as surgery will often be curative.