Primary coronary artery bypass surgery in the presence of decreasing preoperative renal function: effect on short-term outcomes.

BACKGROUND: This study evaluated the impact of decreasing renal function on short-term outcomes in patients undergoing primary coronary artery bypass grafting (CABG). METHODS: The study period was from February 1999 to February 2009. Data on 4050 patients undergoing primary CABG were prospectively collected and analyzed retrospectively. The study population was divided into 3 groups: the CABG:N group, patients with preoperative serum creatinine levels <2 mg/dL (n = 3947); the CABG:RF group, patients with preoperative creatinine levels >2 mg/dL (n = 87); and the CABG:D group, patients on dialysis (n = 16). RESULTS: The significant differences between the groups (CABG:D > CABG:RF > CABG:N) in short-term outcomes were with respect to blood product use (P < .001), postoperative acute myocardial infarction (P < .001), pulmonary complications (P .001), infection (P < .001), and death (P < .001). The risk of short-term death (30 days) in the CABG:D group (4/16, 25%) was 25 times greater than that in the CABG:N group (38/3947, 0.96%). CONCLUSION: CABG in the presence of renal failure is associated with significant morbidity and mortality.

Association between body mass index and outcome of coronary artery bypass.

Studies have shown disparate findings regarding body mass index and outcomes after coronary artery bypass. We analyzed body mass index and other clinical variables that might predict morbidity and mortality after primary isolated coronary artery bypass. Data on 4,425 patients (79% men) were reviewed retrospectively. They were classified as underweight (1.6%), normal weight (65%), obese (32%), and morbidly obese (1.4%) according to body mass index <20, 20-29, 30-39, and >40 kg·m(-2), respectively. Multiple logistic regression was used for correlates of 30-day outcome. Cox regression was used for predictors of late outcome in underweight and morbidly obese patients. There were 45 (1%) deaths and 234 (5%) cases of morbidity within 30 days. Independent correlates of 30-day morbidity were smoking, logistic EuroSCORE, blood and blood product transfusions. Correlates of 30-day mortality were logistic EuroSCORE and blood transfusion. The only independent predictor of late death in underweight and morbidly obese patients was preoperative arrhythmia. Body mass index was not a predictor of 30-day morbidity or mortality. The 1-, 3-, and 7-year survival rates were not significantly different between underweight and morbidly obese patients. Body mass index did not affect short-term outcomes after primary coronary artery bypass grafting.

Cardiac surgery in the presence of dialysis: effect on mid-term outcomes and quality of life.

BACKGROUND: this study evaluates the impact on short and mid-term outcomes and quality of life of dialysis dependent patients undergoing cardiac surgery. The benefit to patients from a bio-psycho-social perspective is put into context via an inter-personal patient interview. METHODS: the study period was from February 1999 to February 2009. Data on 45 dialysis dependent patients undergoing cardiac surgery was prospectively collected and analysed retrospectively. The mean age was 59.9 years and sex ratio (M:F) of 32:13. All patients were New York Heart Association (NYHA) class >2 preoperatively. Fifty-five percent (25/45) of these patients had coronary artery bypass graft surgery (CABG) and 28% (12/45) aortic valve replacement surgery alone. Forty-two variables were studied to define predictors of outcome. Follow-up was 100% (18/18) with a mean follow-up time of 48.1 months (0-124 months). They were followed up with quality of life and functional coping score surveys (SF-36). RESULTS: the main postoperative morbidities were pulmonary complications 20% (9/45), multi-organ failure 11% (5/45) and blood transfusion rates 40% (18/45). The 30 day mortality of the dialysis patients was 13.3% (6/45) and late death was 54% (21/39). Increasing age, pulmonary complications and blood product usage were the significant predictors of both 30 day mortality (age: p=0.02, pulmonary: p=0.003, blood product usage: p=0.03) and late death (age: p=0.008, pulmonary: p=0.02, blood product usage: p=0.02). New York Heart Association class was I-II in 83% (15/18) on long term follow up. All five patients awaiting renal transplants received their transplant in the first six months post-operatively. The overall survival at one year was 78% and five years was 40%. On SF-36 health questionnaire all patients scored less on physical functioning than the Australian norms (24.89 ± 4.10). CONCLUSIONS: cardiac surgery in the presence of renal failure is associated with significant morbidity and mortality. The overall survival and quality of life of dialysis patients undergoing cardiac surgery is poor.

Learning a novel technique to identify possible melanomas: are Australian general practitioners better than their U.K. colleagues?

BACKGROUND: Spectrophotometric intracutaneous analysis (SIAscopy) is a multispectral imaging technique that is used to identify 'suspicious' (i.e. potentially malignant) pigmented skin lesions for further investigation. The MoleMate system is a hand-held scanner that captures SIAscopy images that are then classified by the clinician using a computerized diagnostic algorithm designed for the primary health care setting. The objectives of this study were to test the effectiveness of a computer program designed to train health care workers to identify the diagnostic features of SIAscopy images and compare the results of a group of Australian and a group of English general practitioners (GPs). METHODS: Thirty GPs recruited from the Perth (Western Australia) metropolitan area completed the training program at a workshop held in March 2008. The accuracy and speed of their pre- and post-test scores were then compared with those of a group of 18 GPs (including 10 GP registrars) who completed a similar program at two workshops held in Cambridge (U.K.) in March and April, 2007. RESULTS: The median test score of the Australian GPs improved from 79.5% to 86.5% (median increase 5.5%; p < 0.001) while the median test score of the English GPs improved from 74.5% to 86.5% (median increase 9.5%; p < 0.001). The Australian GPs had significantly higher pre-test scores but there were no significant differences in post-test scores between the Australian and English GPs or between the GPs and GP registrars. There was no significant difference in scores between GPs with previous dermoscopy experience or dermatology training. CONCLUSION: Most of the SIAscopy features can be learnt to a reasonable degree of accuracy with this brief computer training program. Although the Australian GPs scored higher in the pre-test, both groups had similar levels of accuracy and speed in interpreting the SIAscopy features after completing the program. Scores were not affected by previous dermoscopy experience or dermatology training, which suggests that the MoleMate system is relatively easy to learn.

Evaluation of the MoleMate training program for assessment of suspicious pigmented lesions in primary care.

BACKGROUND: Pigmented skin lesions or 'moles' are a common presenting problem in general practice consultations: while the majority are benign, a minority are malignant melanomas. The MoleMate system is a novel diagnostic tool which incorporates spectrophotometric intracutaneous analysis (SIAscopy) within a non-invasive scanning technique and utilises a diagnostic algorithm specifically developed for use in primary care. The MoleMate training program is a short, computer-based course developed to train primary care practitioners to operate the MoleMate diagnostic tool. OBJECTIVES: This pre-trial study used mixed methods to assess the effectiveness and acceptability of a computer-based training program CD-ROM, developed to teach primary care practitioners to identify the seven features of suspicious pigmented lesions (SPLs) seen with the MoleMate system. METHOD: Twenty-five practitioners worked through the MoleMate training program: data on feature recognition and time taken to conduct the assessment of each lesion were collected. Acceptability of the training program and the MoleMate system in general was assessed by questionnaire. RESULTS: The MoleMate training program improved users' feature recognition by 10% (pre-test median 73.8%, p<0.001), and reduced the time taken to complete assessment of 30 SPLs (pre-test median 21 minutes 53 seconds, median improvement 3 minutes 17 seconds, p<0.001). All practitioners' feature recognition improved (21/21), with most also improving their time (18/21). Practitioners rated the training program as effective and easy to use. CONCLUSION: The MoleMate training program is a potentially effective and acceptable informatics tool to teach practitioners to recognise the features of SPLs identified by the MoleMate system. It will be used as part of the intervention in a randomised controlled trial to compare the diagnostic accuracy and appropriate referral rates of practitioners using the MoleMate system with best practice in primary care.