Richard P. Anderson

The Rationale for Incorporation of HIPAA Compliant Unique Patient, Surgeon, and Hospital Identifier Fields in The STS Database

he Congenital Heart Institute of Florida (CHIF), All Children’s Hospital and Saint Josephs Children’s Hospital of Tampa, niversity of South Florida College of Medicine, Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida; University of lorida, Gainesville and Jacksonville, Florida; Virginia Mason Medical Center, Seattle, Washington; University of Colorado enver, School of Medicine, Aurora, Colorado; Children’s Hospital Boston, Harvard University, Boston, Massachusetts; and Brody chool of Medicine, East Carolina University, Greenville, North Carolina

Understanding logistic regression analysis in clinical reports: an introduction.

M of our understanding of biological effects and their determinants is gained through statistical regression analysis. Linear and nonlinear regression methods are often applied in the basic sciences. Clinical studies that evaluate the relative contribution of various factors to a single binary outcome, such as the presence or absence of death or disease, most often employ the method of logistic regression. The purpose of this article is to provide an introduction sufficient to permit clinicians who are unfamiliar with regression methodology to understand and interpret its results. We will begin by describing linear regression techniques in order to present basic concepts. We will then consider logistic regression at greater length because of its importance and increasing use by cardiothoracic surgeons. The calculations involved in logistic regression are complex, but currently available personal computers and ubiquitous statistical software have brought the capability for performing the analysis to the desktop of virtually all clinicians. Consequently, one can hardly find a recent medical journal that does not include at least one report that employs this technique. Figure 1 illustrates the increasing use of logistic regression in studies appearing in three thoracic surgical journals during the last decade. After a description of logistic regression, we will present a clinical example illustrating the technique.

Beta blockade to prevent atrial dysrhythmias following coronary bypass surgery

BACKGROUND Atrial fibrillation and atrial flutter (AF) frequently complicate coronary artery bypass surgery (CABG) and increase hospital stay as well as morbidity. Studies of drug prophylaxis to prevent AF with beta-adrenergic blocking agents administered in fixed doses have had conflicting results. METHODS One hundred patients were randomized to receive metoprolol or placebo following CABG. A dosing algorithm was used to achieve clinically significant beta-adrenergic blockade. RESULTS There was no significant difference between the incidence of AF in the metoprolol (24%) and placebo (26%) groups. However, the incidence of AF in all patients having CABG at this institution declined over the period of the study from 31% to 23% (P < .025), in association with the adoption of a continuous technique of cardioplegia delivery. CONCLUSIONS Metoprolol is not efficacious for the prevention of post-CABG AF even when dosage is titrated to achieve clinical evidence of beta blockade. It is likely that the adoption of a continuous cardioplegia technique caused a reduction in our incidence of post-CABG AF.

Role of surgery in the treatment of inflammatory breast carcinoma

Twenty-eight patients with inflammatory carcinoma of the breast have been retrospectively reviewed. Overall 5 year survival was 25 percent. There was a trend toward improved survival in patients who received chemotherapy which did not achieve statistical significance. Sixteen patients underwent mastectomy as part of their treatment. These patients had a 48 percent 5 year survival which was significantly better than the survival in patients who did not undergo mastectomy. Furthermore, mastectomy resulted in better control of the local disease. Of 12 patients who did not undergo mastectomy, local control was initially obtained in only 2, and both of these patients suffered local recurrence within 1 year. Our data support the conclusion that mastectomy be combined with preoperative and postoperative multiagent cytotoxic chemotherapy in the treatment of inflammatory carcinoma of the breast. More precise staging may permit better prognostic stratification of patients with this highly malignant cancer.

Anterior transpericardial closure of a main bronchus fistula after pneumonectomy

A young woman sustained a penetrating wound to the right anterior chest during a vehicular accident. Septic complications led to emergency pneumonectomy followed by infection of the pleural space and disruption of the right bronchus closure. Her condition improved after creation of a pleural window for dependent drainage and gauze packing of the pleural space. Subsequently, the open bronchial stump was closed utilizing a transpericardial approach through a median sternotomy incision which permitted eventual closure of the pneumonectomy space without thoracoplasty. When the length of the bronchial stump permits its application, the transpericardial approach to postpneumonectomy bronchial fistula closure offers important advantages over conventional transpleural techniques.

Introducer insertion of mini-thoracostomy tubes

Introducer insertion of a small caliber chest tube is easily mastered, fast, and nearly painless. Outpatient management of spontaneous pneumothorax with a 12 F. polyvinylchloride catheter and a Heimlich valve appears both safe and economical in a selected group of patients. Introducer chest tube insertion is well tolerated, in contrast to the discomfort experienced during insertion of chest tubes by means of blunt dissection or trocar. In addition, the high risk of injury to the lung or other viscera by trocars is avoided.

Perioperative ischemic injury after coronary bypass graft surgery

Two hundred twelve patients who underwent isolated coronary bypass graft surgery were prospectively evaluated for perioperative ischemic injury. All patients underwent preoperative and postoperative testing with technetium 99m pyrophosphate first-pass ventriculography combined with myocardial uptake scans, 12-lead electrocardiography, and serial creatinine phosphokinase MB determination. Fifteen percent of the patients had ischemic injury with at least two test results positive, but only 4 percent had positive results of all three tests. No single test proved adequate. Enzyme levels were highly sensitive and had value as a screening test. The electrocardiogram was specific but only moderately sensitive. The single best test was the radionuclide scan with good sensitivity and no false-positive results. All three tests are required to rigorously diagnose ischemic injury.

Uses of the balloon-tipped catheter in biliary tract surgery☆☆☆

Abstract Diagnostic and therapeutic uses of the Fogarty balloon-tipped catheter in biliary tract surgery are reported. Case reports demonstrating these technics are presented. The advantages, limitations, and potential complications of these maneuvers are described.

Surgical management of coexisting coronary artery and valvular heart disease.

Abstract Coexisting coronary artery disease poses risks to the patient with valvular heart disease and complicates management. In ninety-one patients, preoperative coronary arteriography demonstrated obstructing coronary lesions that were treated by bypass grafts at valve surgery. These combined operations were found safe and effective for most patients.

Early experience with the automatic implantable cardioverter defibrillator in sudden death survivors

Medical management of life-threatening ventricular arrhythmias is difficult because of the toxicity and limited efficacy of antiarrhythmic drugs. The automatic implantable cardioverter defibrillator (AICD) offers protection against malignant ventricular arrhythmias and allows some patients to be managed without antiarrhythmic drugs. We reviewed our experience with the AICD to determine its safety and efficacy. Since June 1987, 24 patients (mean age 63 years) who survived out-of-hospital ventricular fibrillation or hemodynamically unstable ventricular tachycardia not associated with acute myocardial infarction had implantation of an AICD. None had inducible monomorphic ventricular tachycardia associated with ventricular aneurysm. Twenty-three had abnormal left ventricular function (mean ejection fraction 0.32). There were no operative deaths and three complications. At last follow-up (mean 8.9 months) 23 patients were alive. Eight patients had one or more AICD discharges associated with symptomatic or monitored cardiac arrest. AICD implantation can be performed with low risk and appears to be an effective alternative to antiarrhythmic therapy with toxic drugs.