Objective To investigate evidence retrieval, appraisal, and reevaluation during evidence-based clinical decision making in China. Also, to analyze the related factors, so as to find the problems in the course of evidence-based clinical decision making and put forward corresponding solutions. Methods We searched Chinese Biomedical Literature Disc (CBM) and China Journal Full-text Database (Medical sciences) of the China National Knowledge Infrastructure (CNKI) to collect clinical evidence-based case reports. Relevant information was extracted from these reports by a selfdesigned investigation form.Then statistical analyses were performed. Results The search tools used in the course of evidence-based clinical decision making varied. The most frequently used were MEDLINE/PubMed (82.08%) and The Cochrane Library (60.38%). 30.63% of evidence-based case reports described the search strategy in detail, and 9.01% described how they modified their search strategy. All doctors evaluated the association between evidence and disease, but few of them integrated patient factors and relevant external factors when evaluating evidence. The scientific nature and validity of the evidence was evaluated in 74 evidence-based case reports (66.67%), and such evaluation was mainly based on the criteria of evidence grading (50.00%). Reevaluation was mentioned in 85.59% of evidence-based case reports. Conclusion In China, the application of evidence-based decision making varied in different clinical departments. Problems existed in the course of evidence retrieval, appraisal, and reevaluation. This revealed the low information diathesis level of doctors and their lack of evidence-based medicine knowledge. It is suggested that information education and evidence-based medicine education should be strengthened to improve doctors’ ability to use evidence-based clinical decision making. It is also recommended that the search tools, relevant search strategy, the modification of search strategy, and reevaluation on practice results of each case should be mentioned in evidence-based case reports.
We reported a 65-year-old female who was admitted to our institute with "recurrent subxiphoid pain accompanied by dyspnea for more than 10 days". Electrocardiogram examination suggested acute extensive anterior ST segment elevation myocardial infarction. Preoperative transthoracic echocardiography suggested ventricular septal rupture. The patient was planned for the repair of ventricular septal rupture with cardiopulmonary bypass. The formation of left ventricular aneurysm was diagnosed by intraoperative transesophageal echocardiography (TEE). The surgeon decided to abdopt the modified incision of left ventricular approach guided by TEE, which greatly improved the prognosis of the patient. The surgery duration was 197 min, aortic cross-clamping time was 56 min, cardiopulmonary bypass time was 69 min, and the patient was safely admitted to ICU after the surgery. Extubation was performed on the first day postoperatively, and the intra-aortic balloon pump support was retreated on the second day postoperatively. Postoperative echocardiography showed that no obvious residual shunt was observed after ventricular septal repairment and ventricular aneurysm resection. The patient was discharged on the 12th day after the surgery. Additionally, the mental condition was good and daily activities were not limited within 6 months postoperatively.
We reported a 59-year-old male with exertional angina pectoris, and the coronary angiography showed multiple vessel lesions. The initial strategy was coronary artery bypass grafting (CABG). The measurement of quantitative flow ration (QFR) before operation indicated that the posterior descending branch (PD) did not need to be treated. The left circumflex branch (LCX) was small, and the QFR of the left anterior descending branch (LAD) and the first diagonal branch (D1) was<0.8. Therefore, the LAD and D1 were re-vascularized. The operation strategy was changed to on-pump CABG through a small incision, and the final strategy was LIMA-D1-LAD (sequential), fractional flow reserve (FFR) of distal LAD and D1 after CABG were>0.8 by computed tomography FFR. SYNTAX scores after CABG were 20 and the functional SYNTAX scores after CABG were 3, indicating a good prognosis.
One of its primary surgical treatments of tricuspid regurgitation is tricuspid valve biological valve replacement. Catheter tricuspid valve-in-valve implantation is a novel interventional alternative for biological valve failure. The non-invasive lung fluid measuring device remote dielectric sensing (ReDSTM) has been increasingly incorporated into clinical practice as a means of monitoring chronic heart failure in recent years. This report describes the process and outcomes of the first instance of perioperative lung fluid volume evaluation following transcatheter tricuspid valve implantation utilizing ReDSTM technology. The patient has a short-term, substantial increase in postoperative lung fluid volume as compared to baseline.
Malignant melanoma is a kind of highly malignant tumor, which mainly occurs in the skin, mucous membrane, and rarely in the breast. Here we reported a case of malignant melanoma in the chest wall skin with mammary metastasis. A sizable pigment spot on the skin of the thoracic region was found at the patient’s birth, existing for 50 years with quite atypical clinical manifestation. A nodule at 12 o’clock of the left breast was found by ultrasound four months ago, who was mistaken for a fibroadenoma. As a result, the patient received a minimally invasive excision of the breast lesion, after which the pathological report suggested malignant melanoma. By sharing this case, we aimed to discuss the diagnosis and treatment of this kind of atypical malignant melanoma in detail and provide some clinical experience.
Pregnancy complicated by aortic root aneurysm in patients with Marfan syndrome is one of the main causes of termination of pregnancy or even death in pregnant women. A very small number of pregnant women require cardiac surgery to preserve pregnancy under extracorporeal circulation, and all surgeries use aortic root replacement. We reported a 30-year-old patient with severe aortic regurgitation combined with giant aortic root aneurysm and Marfan syndrome in mid-pregnancy. Valve-sparing root replacement using reimplantation technology was performed via a multidisciplinary cooperation model. This not only achieved the patient’s desire to continue pregnancy but also avoided the anticoagulation and bleeding complications brought by mechanical valve replacement, reduced pregnancy risks and improved long-term quality of life. Postoperative echocardiography showed a small amount of aortic valve regurgitation, aortic valve coaptation height of 0.6 cm, effective height of 1.1 cm, maximum aortic flow velocity of 1.4 m/s, mean transvalvular pressure gradient of 4.4 mm Hg, and satisfactory clinical results.
Thymoma complicated with polymyositis and myasthenia gravis is a rare case, which can be clearly diagnosed and given symptomatic treatment according to its own diagnostic criteria, imaging and laboratory examinations. This paper reports the clinical data of a thymoma patient with polymyositis and myasthenia gravis admitted to the Seventh Affiliated Hospital of Sun Yat-Sen University, and discusses the possible pathogenesis and treatment methods.
A 71-year-old male presented with esophageal cancer and severe aortic valve regurgitation. Treatment strategies for such patients are controversial. Considering the risks of cardiopulmonary bypass and potential esophageal cancer metastasis, we successfully performed transcatheter aortic valve implantation and minimally invasive three-incision thoracolaparoscopy combined with radical resection of esophageal cancer (McKeown) simultaneously in the elderly patient who did not require neoadjuvant treatment. This dual minimally invasive procedure took 6 hours and the patient recovered smoothly without any surgical complications.
ObjectiveTo introduce the method and preliminary experience of robot-assisted bilateral internal mammary arteries (BIMA) harvesting for off-pump coronary artery bypass grafting (OPCAB) with 5 grafts via left anterolateral minithoracotomy.MethodsBIMA were harvested using the da Vinci robotic surgical system, and the right internal mammary artery (RIMA) was pulled out of the thoracic cavity through right second intercostal space. Intercepting the distal part of the RIMA for the BIMA composite Lima-Rima Y graft and anastomosing the great saphenous vein with remaining RIMA end to end. The Y graft anastomosed with left anterior descending (LAD) branch and diagonal branches (DIAG), artery-vein graft sequentially anastomosed with blunt round branch, left ventricular posterior branch and posterior descending branch.ResultsThe operation succeeded without hemodynamic instability and intra aortic balloon pump (IABP) implantation or cardiopulmonary bypass. The blood flow of Y graft was 24 mL/min, and the blood flow of artery-vein graft was 30 mL/min. Ventilator assistance time was 35 hours, ICU staying time was 62 hours, and postoperative myocardial enzymes increased temporarily. Postoperative coronary CTA showed that all the grafts were patency, and cardiac ultrasound indicated that the heart function was normal. The patient cured and discharged from hospital 7 days after operation.ConclusionRobot-assisted bilateral internal mammary artery harvesting for OPCAB with 5 grafts via left anterolateral minithoracotomy is feasible, which can achieve complete revascularization.
We reported three cases of stageⅢ/N2 non-small cell lung cancer (NSCLC) treated with neoadjuvant immunotherapy and stereotactic body radiation therapy (SBRT) in our hospital, including 2 males and 1 female with a mean age of 65.7 years. The patients received two doses of the programmed cell death protein-1 inhibitor toripalimab after 1 week of SBRT. Thereafter, surgery was planned 4-6 weeks after the second dose. One patient achieved pathologic complete response, one achieved major pathologic response (MPR), and one did not achieve MPR with 20% residual tumor. There were few side effects of toripalimab combined with SBRT as a neoadjuvant treatment, and the treatment did not cause a delay of surgery.