The role of surgeon's intuition for acute type A aortic dissection in an era of evidence-based medicine: a prospective cohort study.

Background: Intuition may play a role in clinical practice. This prospective cohort study aimed to explore whether surgeons' intuition is valid in predicting the operative mortality of acute type A aortic dissection (ATAAD). Methods: After admission (before surgery), attending surgeons were asked to rate the mortality on a scale of 1 to 10, with 1 to 3 representing unlikely, 4-6 possible, and 7-10 very likely. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis was performed to assess the accuracy of prediction models. Results: A significantly higher Surgeon's Score [5.0 (2.0, 8.0) vs. 8.0 (7.0, 10.0)] was observed in the mortality group, compared to the survival group. The odds ratio (OR) for Surgeon's Score was 1.32 [95% confidence interval (CI): 1.09-1.66, P=0.009]. Least absolute shrinkage and selection operator (LASSO) regression picked the following variables as significant predictors for early mortality of ATAAD: Surgeon's Score, Penn classification, age, aortic regurgitation, coronary artery disease, chronic obstructive pulmonary disease, platelet count, and ejection fraction. The AUC for the German Registry for Acute Aortic Dissection Type A (GERAADA) score and Surgeon's Score were 0.740 (95% CI: 0.625-0.854), and 0.710 (95% CI: 0.586-0.833), respectively. The combined model of GERAADA score and Surgeon's Score yielded an AUC of up to 0.761 (95% CI: 0.638-0.884). Conclusions: Intuition certainly has a place alongside evidence-based medicine. The duet of intuition and statistics-based scoring systems allows us to make more accurate predictions, potentially resulting in more rational clinical decisions.

Eutectic Crystallization Activates Solid-State Zinc-Ion Conduction.

Solid-state zinc (Zn) batteries offer a new candidate for emerging applications sensitive to volume, safety and cost. However, current solid polymeric or ceramic electrolyte structures remain poorly conductive for the divalent Zn2+ , especially at room temperature. Constructing a heterogeneous interface which allows Zn2+ percolation is a viable option, but this is rarely involved in multivalent systems. Herein, we construct a solid Zn2+ -ion conductor by inducing crystallization of tailored eutectic liquids formed by organic Zn salts and bipolar ligands. High-entropy eutectic-networks weaken the ion-association and form interfacial Zn2+ -percolated channels on the nucleator surfaces, resulting in a solid crystal with exceptional selectivity for Zn2+ transport (t Zn 2 + =0.64) and appreciable Zn2+ conductivity (σ Zn 2 + =3.78×10-5  S cm-1 at 30 °C, over 2 orders of magnitude higher than conventional polymers), and finally enabling practical ambient-temperature Zn/V2 O5 metal solid cells. This design principle leveraged by the eutectic solidification affords new insights on the multivalent solid electrochemistry suffering from slow ion migration.

Unraveling H+/Zn2+ Sequential Conversion Reactions in Tellurium Cathodes for Rechargeable Aqueous Zinc Batteries.

Progress toward practical rechargeable aqueous zinc (Zn) batteries is impeded by the low energy density. The use of tellurium (Te) cathodes featuring multielectron redox reactions offers one possible approach to mitigating this dilemma. However, the corresponding energy-storage mechanisms in aqueous electrolytes are not established yet. Here, we uncover a H+/Zn2+-involved sequential conversion reaction with 6e- transfer for Te-based cathodes, which accounts for the outstanding capacity (over 460 mAh g-1 at 50 mA g-1). Two distinct redox processes, corresponding to TeO2 ↔ Te and Te ↔ ZnTe, are explicitly revealed within the electrochemical window of routine aqueous Zn electrolytes. The mechanism elucidated here complements the understanding of energy-dense Te centers and propels the exploration of high-capacity electrodes for multivalent battery chemistries.

Effect of a smartphone-based intervention on secondary prevention medication prescriptions after coronary artery bypass graft surgery: The MISSION-1 randomized controlled trial.

BACKGROUND: Studies found that patients who underwent coronary artery bypass grafting (CABG) often fail to receive optimal evidence-based secondary prevention medications. We evaluated the effectiveness of a smartphone-based quality improvement effort on improving the prescription of medical therapies. METHODS: In this cluster-randomized controlled trial, 60 hospitals were randomized to a control arm (n = 30) or to an intervention arm using smartphone-based multifaceted quality improvement interventions (n = 30). The primary outcome was the prescription of statin. The secondary outcomes were prescription of beta-blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker (ACE inhibitor or ARB), and optimal medical therapy for eligible patients. RESULTS: Between June 1, 2015 and September 15, 2016, a total of 10,006 CABG patients were enrolled (5,653 in 26 intervention and 4,353 in 29 control hospitals, 5 hospitals withdrew). Statin prescribing rate was 87.8% in the intervention arm and 84.4% in the control arm. We saw no evidence of an effect of intervention on statin prescribing in the intention-to-treat analysis (odds ratio [OR], 1.31; 95% confidence interval (CI), 0.68-2.54; P = .43) or in key patient subsets. The prescription rates of ACE inhibitor or ARB and optimal medical therapy were comparable between study groups, while beta-blocker was more often prescribed in the intervention arm. Post hoc analysis demonstrated a greater increase in statin prescribing rate over time in the intervention arm. CONCLUSIONS: A smartphone-based quality improvement intervention compared with usual care did not increase statin prescribing for patients who received CABG. New studies focusing on the best practice of this technique may be warranted.

Smartphone-based application to improve medication adherence in patients after surgical coronary revascularization.

BACKGROUND: Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG. METHODS: The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle. RESULTS: A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months). CONCLUSIONS: A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.

An In-hospital Mortality Risk Model for Patients Undergoing Coronary Artery Bypass Grafting in China.

BACKGROUND: To meet the demand of increasing surgical volume and changing of patient's risk profiles of coronary artery bypass grafting in China, we developed a new risk model that predicts in-hospital mortality. METHODS: The analysis included patients who underwent coronary artery bypass grafting between January 2013 and December 2016 at 87 hospitals in the Chinese Cardiac Surgery Registry. Patients in years 2013 to 2015 were randomly divided into training (n = 31,297 [75%]) and test (n = 10,432 [25%]) samples; 2016 patients (n = 15047) comprised the validation sample. Demographic and clinical risk factors were identified. The Harrell C statistic was used to evaluate model discrimination, and the Hosmer-Lemeshow goodness-of-fit test was used to assess calibration. RESULTS: The 56,776 patients were a mean age of 61.8 (SD, 8.8) years, and 24.6% were women. Overall, in-hospital mortality was 2.1%. The final model included 21 risk factors represented by 16 unique variables. The model achieved good discrimination, with a C statistic of 0.79 (95% confidence interval [CI], 0.77-0.80) in the training sample, 0.79 (95% CI, 0.76-0.82) in the test sample, and 0.78 (95% CI, 0.76-0.81) in the validation sample. Model calibration was good according to the Hosmer-Lemeshow test (P > .05 in the 3 samples). Compared with the European System for Cardiac Operative Risk Evaluation 2011 revision (EuroSCORE II) and the Sino(Chinese) System for Coronary artery bypass grafting Operative Risk Evaluation (SinoSCORE), the model had better discrimination and calibration. CONCLUSIONS: We developed and evaluated a model with 16 risk factors that predicted in-hospital mortality risk after coronary artery bypass grafting in China. This updated model may help surgeons and hospitals better identify high-risk patient.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2).

BACKGROUND: Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG. METHODS: The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization. DISCUSSION: Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings. TRIAL REGISTRATION: https://clinicaltrials.gov (NCT02432469).

Increased Short-Term and Mid-Term Major Complications Were Observed in Elderly Patients with Renal Dysfunction after Surgical Ventricular Restoration.

BACKGROUND: This study was conducted to explore the impact of renal dysfunction on short-term and mid-term outcomes in elderly patients. METHODS: Patients over 65 years of age receiving surgical ventricular restoration (SVR) were included in the study. They were stratified through estimated glomerular filtration rate (eGFR), with a cutoff point of 60 mL/min/1.73m2. Risk-adjusted analysis, including propensity score matching, was carried out to compare short-term and mid-term outcomes between the two groups of patients. RESULTS: From January 1999 to December 2015, a total of 280 elderly patients underwent SVR. Of the patients, 79 had eGFR lower than 60 mL/min/1.73m2 and were considered to have renal dysfunction. Mortality was higher in the renal dysfunction group than the normal renal function group, with marginal significance (adjusted P value = .06). The need for mechanical supports (adjusted P value = .04) was higher in the renal dysfunction group. Hemofiltration (adjusted P value < .01) and requirements for transfusion (adjusted P value = .03) were significantly higher in the renal dysfunction group than in the group with normal renal function. The presence of renal dysfunction was associated with higher risk of major adverse cerebro-cardiovascular events (MACCE) than normal renal function (HR = 2.34, 95% CI = 1.34 - 4.08, P = .003). CONCLUSION: Compared to patients with normal renal function, elderly SVR patients with renal failure have a higher incidence of short-term mechanical support, mid-term mortality, and MACCE events.

Development and Evaluation of Heartbeat: A Machine Perfusion Heart Preservation System.

Static cold storage is accompanied with a partial safe ischemic interval for donor hearts. In this current study, a machine perfusion system was built to provide a better preservation for the donor heart and assessment for myocardial function. Chinese mini-swine (weight 30-35 kg, n = 16) were randomly divided into HTK, Celsior, and Heartbeat groups. All donor hearts were respectively preserved for 8 hours under static cold storage or machine perfusion. The perfusion solution is aimed to maintain its homeostasis based on monitoring the Heartbeat group. The ultrastructure of myocardium suggests better myocardial protection in the Heartbeat group compared with HTK or Celsior-preserved hearts. The myocardial and coronary artery structural and functional integrity was evaluated by immunofluorescence and Western blots in the Heartbeat. In the Heartbeat group, donor hearts maintained a high adenosine triphosphate level. Bcl-2 and Beclin-1 protein demonstrates high expression in the Celsior group. The Heartbeat system can be used to preserve donor hearts, and it could guarantee the myocardial and endothelial function of hearts during machine perfusion. Translating Heartbeat into clinical practice, it is such as to impact on donor heart preservation for cardiac transplantation.

Coronary endarterectomy with coronary artery bypass graft decreases graft patency compared with isolated coronary artery bypass graft: a meta-analysis.

OBJECTIVES: This meta-analysis aims to assess the graft patency quantitatively and statistically. METHODS: Eleven observational studies were identified by systematic literature search, incorporating 3311 patients undergoing coronary endarterectomy (CE) + coronary artery bypass graft (CABG) and 3990 undergoing isolated CABG, which were analysed using random-effects modelling. Heterogeneity, quality of scoring and risk of bias were assessed and reangiographic outcomes were documented. RESULTS: Adjunctive CE decreased graft patency [odds ratios = 0.43, 95% confidence interval [0.29-0.63], z = 4.33, P < 0.0001] with moderate heterogeneity, while the baseline demographics differed considerably. CONCLUSIONS: Whether CE remains a viable option to CABG requires novel studies collecting corresponding data from bench to bedside. To achieve satisfactory efficacy, surgeons should carefully weigh possible benefits and adverse effects of CE and prepare the surgical strategy adequately.

Rationale and design of a randomized cluster trial to improve guideline-adherence of secondary preventive drugs prescription after coronary artery bypass grafting in China: Measurement and Improvement Studies of Surgical Coronary Revascularization: Secondary Prevention (MISSION-1) Study.

OBJECTIVES: The benefits of secondary preventive drugs after coronary artery bypass grafting have been thoroughly established. However, the prescription rates of these drugs are low at discharge in China. We sought to evaluate the effectiveness of continuous quality improvement with mobile-based interventions for clinicians on improving the guideline-adherence of secondary preventive drugs prescription. METHODS AND RESULTS: The quality MISSION-1 study is a cluster-randomized controlled trial. We enrolled 60 hospitals with a bypass surgery volume of more than 30 a year and randomly assigned them into the intervention group or the control group in a 1:1 ratio using minimized random grouping. The intervention group undertakes a series of mobile-based interventions, while the control group maintains a routine practice pattern. All sites consecutively register patients who underwent isolated coronary artery bypass grafting and submit in-hospital data. We require supporting documents regarding prescription information at discharge to adjudicate the outcome measures. The estimated sample size of enrolled patients is 9,600. The primary outcome measure is the prescription rate of statins for eligible patients at discharge. The secondary outcome measures are ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimal medical therapy. MISSION-1 study is now recruiting patients. CONCLUSIONS: The MISSION-1 study has the potential to identify the effectiveness of interventions on improving secondary prevention adherence at discharge after bypass surgery in China and further disseminate findings to other settings to improve the quality of care.