Background Video-assisted thoracoscopic surgery (VATS) offers reduced morbidity compared with open thoracotomy (OT) for pulmonary surgery. The use of VATS over time has increased, but at a modest rate in civilian populations. This study examines temporal trends in VATS use and compares outcomes between VATS and OT in the Veterans Health Administration (VHA). Methods Patients who underwent pulmonary surgery (wedge or segmental resection, lobectomy, or pneumonectomy) at Veterans Affairs centers from 2008 to 2018 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Project database. The cohort was divided into OT and VATS and propensity score matched, taking into account the type of pulmonary resection, preoperative diagnosis, and comorbidities. Thirty-day postoperative outcomes were compared. The prevalence of VATS use and respective complications over time was also analyzed. Results A total of 16,895 patients were identified, with 5,748 per group after propensity matching. VATS had significantly lower rates of morbidity and a 2-day reduction in hospital stay. Whereas 76% of lung resections were performed open in 2008, nearly 70% of procedures were performed using VATS in 2018. While VATS was associated with an 8% lower rate of major complications compared with thoracotomy in 2008, patients undergoing VATS lung resection in 2018 had a 58% lower rate of complications (p < 0.001). Conclusions VATS utilization at VHA centers has become the predominant technique used for pulmonary surgeries over time. OT patients had more complications and longer hospital stays compared with VATS. Over the study period, VATS patients had increasingly lower complication rates compared with open surgery.
OBJECTIVES Factors such as more diffuse atherosclerosis, plaque instability and accelerated vascular calcification in patients with chronic and end-stage renal disease (ESRD) can potentially present intraoperative challenges in coronary artery bypass grafting (CABG) procedures. We evaluated whether patients with chronic and ESRD experienced more surgical strategy changes and/or graft revisions than patients with normal renal function when undergoing CABG procedures according to a protocol for intraoperative high-frequency ultrasound and transit-time flow measurement (TTFM). METHODS Outcomes of CABG for patients with chronic and ESRD and patients with normal renal function enrolled in the multicentre prospective REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study were compared retrospectively. The primary end point was frequency of intraoperative surgical strategy changes. The secondary end point was post-protamine TTFM parameters. RESULTS There were 95 patients with chronic and ESRD and 921 patients with normal renal function. Patients with chronic and ESRD undergoing CABG according to a protocol for intraoperative high-frequency ultrasound and TTFM had a higher rate of strategy changes overall [33.7% vs 24.3%; odds ratio (OR) = 1.58; 95% confidence interval (CI) = 1.01–2.48; P = 0.047] and greater revisions per graft (7.0% vs 3.4%; odds ratio = 2.14; 95% CI = 1.17–3.71; P = 0.008) compared to patients with normal renal function. Final post-protamine graft TTFM parameters were comparable between cohorts. CONCLUSIONS Patients with chronic and ESRD undergoing CABG procedures with high-frequency ultrasound and TTFM experience more surgical strategy changes than patients with normal renal function while achieving comparable graft flow. Clinical trial registration number: ClinicalTrials.gov NCT02385344
This fMRI study examined whether hemodynamic responses to affectively-salient stimuli were abnormally prolonged in remitted bipolar disorder, possibly representing a novel illness biomarker. A group of 18 DSM-IV bipolar I-diagnosed adults in remission and a demographically-matched control group performed an event-related fMRI gender-discrimination task in which face stimuli had task-irrelevant neutral, happy or angry expressions designed to elicit incidental emotional processing. Participants’ brain activation was modeled using a “fully informed” SPM5 basis set. Mixed-model ANOVA tested for diagnostic group differences in BOLD response amplitude and shape within brain regions-of-interest selected from ALE meta-analysis of previous comparable fMRI studies. Bipolar-diagnosed patients had a generally longer duration and/or later-peaking hemodynamic response in amygdala and numerous prefrontal cortex brain regions. Data are consistent with existing models of bipolar limbic hyperactivity, but the prolonged frontolimbic response more precisely details abnormalities recognized in previous studies. Prolonged hemodynamic responses were unrelated to stimulus type, task performance, or degree of residual mood symptoms, suggesting an important novel trait vulnerability brain dysfunction in bipolar disorder. Bipolar patients also failed to engage pregenual cingulate and left orbitofrontal cortex – regions important to models of automatic emotion regulation – while engaging a delayed dorsolateral prefrontal cortex response not seen in controls. These results raise questions about whether there are meaningful relationships between bipolar dysfunction of specific ventromedial prefrontal cortex regions believed to automatically regulate emotional reactions and the prolonged responses in more lateral aspects of prefrontal cortex.
OBJECTIVES Despite society guideline recommendations, intraoperative high-frequency ultrasound (HFUS) and transit-time flow measurement (TTFM) use in coronary artery bypass grafting (CABG) has not been widely adopted worldwide. This retrospective review of the REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study assesses the impact of protocolled high-frequency ultrasound/TTFM use in specific technical circumstances of CABG. METHODS Three REQUEST study sub-analyses were examined: (i) For off-pump (OPCAB) versus on-pump (ONCAB) procedures: strategy changes from preoperative plans for the aorta, conduits, coronary targets and graft revisions; and for all REQUEST patients, revision rates in: (ii) arterial versus venous grafts; and (iii) grafts to different cardiac territories. RESULTS Four hundred and two (39.6%) of 1016 patients undergoing elective isolated CABG for multivessel disease underwent OPCAB procedures. Compared to ONCAB, OPCAB patients experienced more strategy changes regarding the aorta [14.7% vs 3.4%; odds ratios (OR) = 4.03; confidence interval (CI) = 2.32–7.20], less regarding conduits (0.2% vs 2.8%; OR = 0.09; CI = 0.01–0.56), with no differences in coronary target changes or graft revisions (4.1% vs 3.5%; OR = 1.19; CI = 0.78–1.81). In all REQUEST patients, revisions were more common for arterial versus venous grafts (4.7% vs 2.4%; OR = 2.05; CI = 1.29–3.37), and inferior versus anterior (5.1% vs 2.9%; OR = 1.77; CI = 1.08–2.89) and lateral (5.1% vs 2.8%; OR = 1.83; CI = 1.04–3.27) territory grafts. CONCLUSIONS High-frequency ultrasound/TTFM use differentially impacts strategy changes and graft revision rates in different technical circumstances of CABG. Notably, patients undergoing OPCAB experienced 4 times more changes related to the ascending aorta than ONCAB patients. These findings may indicate where intraoperative assessment is most usefully applied. Clinical trial registration number ClinicalTrials.gov: NCT02385344
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