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Two RCTs evaluating the effect of statin pre-treatment suggested effectiveness in preventing post-operative AF, possibly through anti-inflammatory effects (OR 0.57, 95% CI 0.42–0.77) [ 187 , 188 ].

Table 31 summarizes the recommendations concerning the prevention and treatment of atrial fibrillation in CABG patients.

Table 31
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Prevention and treatment of atrial fibrillation with coronary artery bypass grafting

Table 31
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Prevention and treatment of atrial fibrillation with coronary artery bypass grafting

In patients with paroxysmal AF it is worthwhile to rule out ischaemia as a potential cause. A high prevalence of obstructive CAD was observed among patients with AF undergoing systematic multislice CT, confirming the hypothesis that AF could be a marker of advanced coronary atherosclerosis. Issues related to antiplatelet therapy in patients under anticoagulants are discussed in Section 12.4.

The relationship between supraventricular arrhythmia other than AF and/or atrial flutter and CAD is unclear. During supraventricular tachycardia episodes, ECG changes and clinical symptoms suggestive of cardiac ischaemia may be present. Screening for CAD should be restricted to patients with typical symptoms outside arrhythmia episodes, who have a high-risk profile or increasing frequency of arrhythmia episodes [ 191 ].

Because of the effectiveness of percutaneous catheter ablation techniques for the treatment of accessory pathways, such as in Wolff-Parkinson-White syndrome, surgery should be restricted to patients after failed catheter ablation, with complex congenital heart disease or scheduled for valve surgery. Anti-arrhythmic surgical procedures should be performed in experienced centres.

In the setting of transient cardiac ischaemia, within 24–48 h of ACS, during primary PCI for STEMI or late after MI, ventricular arrhythmias are a major cause of death. Large RCTs have shown a beneficial effect of ICD therapy in survivors of life-threatening arrhythmias and in patients at risk of sudden death (primary prevention).

Patients with LVEF ≤ 35% are at risk of sudden cardiac death and may benefit from ICD therapy. However, screening for and treating cardiac ischaemia is required prior to ICD implantation because LV function may recover after revascularization of viable myocardium [ 16 ]. ICD therapy should be postponed for at least 3 months after PCI or CABG to allow time for LV recovery. In patients with large scar areas, recovery of LVEF is less likely and ICD implantation may be considered appropriate shortly after revascularization.

Patients surviving out-of-hospital cardiac arrest are at high risk of recurrence. Prevention of potentially lethal recurrence starts with a systematic evaluation of the underlying pathology and the subsequent risk for recurrence, to allow the implementation of an individualized treatment plan.

Considered the top of the food chain in the ocean, the great white shark is the ultimate predatory organism. The shark’s keen sense of smell allows it to track the scent of blood for miles underwater, leading it to wounded animals and corpses it can devour. The great white is one of only a few sharks ever documented leaping from the water in a strike on prey. Great whites often feed on seals, which are very agile and can outturn the shark. However, the sharks usually strike from below, honing in on the seal and hitting it at great speeds. Cells around the shark’s mouth are sensitive to small electrical impulses given off by prey, and the shark can literally feel its prey before it touches it. This makes the great white one an ultimate predatory organism.

Organelle Eukaryotic Prokaryotic

1. A single blue whale weighs almost 40,000 pounds. A colony of aspen trees that share a root system and were derived from the same seed weighs almost 13,000,000 pounds. The combined weight of all bacteria on Earth is somewhere around 1.1 x 1014, or 110,000,000,000,000 pounds. What is the largest organism on Earth? A. Blue Whale B. Aspen Tree C. Bacteria

1. A single blue whale weighs almost 40,000 pounds. A colony of aspen trees that share a root system and were derived from the same seed weighs almost 13,000,000 pounds. The combined weight of all bacteria on Earth is somewhere around 1.1 x 1014, or 110,000,000,000,000 pounds. What is the largest organism on Earth?
Answer to Question #1
B is correct. While the blue whale is massive, it is no match for a clonal grove of aspen trees. Although the trees look like individuals to us, they are all connected to a massive underground root system. The oldest tree known, “Pando”, is thought to be 80,000 years old. The bacteria, while massive together, represent trillions of individual organisms, each independent of each other. Take out one bacteria, the rest will be fine. Ruin Pando’s roots and millions of trees could be lost. That is what makes the Aspen tree the largest living organism.

2. Many plants produce offspring in the form of seeds. To create seeds, the male gamete has to meet the female gamete and fertilization must occur. This can occur to many eggs at once and many plant prepare a huge number of seeds at the same time. You see a dandelion plant in your yard. The yellow petals of the three different flowers have been replaced by a white puffball connected to hundreds of seeds. How many organisms are present? A. 1 B. <300 C. >300

2. Many plants produce offspring in the form of seeds. To create seeds, the male gamete has to meet the female gamete and fertilization must occur. This can occur to many eggs at once and many plant prepare a huge number of seeds at the same time. You see a dandelion plant in your yard. The yellow petals of the three different flowers have been replaced by a white puffball connected to hundreds of seeds. How many organisms are present?

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Abstract

Randomized controlled trials (RCTs) are performed with the primary goal of understanding the safety and efficacy of a new therapy in a selected group of patients. Even when evidence from these studies strongly favours a new therapy, its role in routine clinical practice may be unclear because of the considerable differences between its efficacy (in clinical trials) and its effectiveness (in the real-life setting). Real-life studies are observational studies that are essential to document benefits and harms of therapy in a wider population and to determine whether patients in routine practice are achieving expected outcomes. In the first article of this supplement, we discuss the relative strengths and limitations of RCTs and real-life studies and explore the current and potential uses of real-life studies in the field of thrombosis, including identifying new safety signals, assessing outcomes in special populations and raising questions about factors affecting medication adherence and persistence. Real-life studies provide a bridge from the results of RCTs to daily clinical practice.

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It is widely accepted that randomized controlled trials (RCTs) are the gold standard for demonstrating the efficacy of a given therapy (i.e. effect under ideal circumstances). 1 Real-life studies, on the other hand, can complement this by demonstrating effectiveness (i.e. true benefit to patients in routine practice). 1 Real-life data have been defined as data used for decision-making that are not collected in conventional RCTs, 2 and such data cover a wide range of research methodologies and very different data sources, including databases, patient and population surveys, patient chart reviews, and observational data from cohort studies and registries.

Randomized controlled trials are often are designed with numerous controls, and may especially involve inclusion and exclusion criteria that may limit the ability to answer questions related to the real-life delivery of healthcare. The baseline characteristics, risk profiles, and treatment patterns of the patients recruited in RCTs may differ largely to those receiving treatment in routine clinical practice. Real-life data gathered using broader inclusion criteria and fewer exclusion criteria would therefore help to bridge the gap between RCTs and daily clinical practice. Real-life studies are essential to document benefits and harms of therapy in a wider population (including special populations who are not routinely enrolled in RCTs, such as the very young and very old, and those with multiple comorbidities) and to determine whether patients in routine practice are achieving expected outcomes. The key differences between efficacy and effectiveness studies are outlined in Table 1 .

Figure 2
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Time interval between hospital admission and onset of infection for the most frequently isolated pathogens in a series of 24,179 cases of nosocomial bloodstream infection (BSI). CoNS, coagulase-negative staphylococci;

Figure 2
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Time interval between hospital admission and onset of infection for the most frequently isolated pathogens in a series of 24,179 cases of nosocomial bloodstream infection (BSI). CoNS, coagulase-negative staphylococci;

Primary BSI, in which no source could be determined, was seen in 12,893 patients (53%). Secondary BSI originated from intravenous catheters in 5749 patients (24%), from the urinary tract in 1580 patients (6.5%), and from the lower respiratory tract in 1539 patients (6%). However, culture samples from distant sites were infrequently collected; therefore, some points of origin might not have been detected.

Of the 1890 Candida isolates causing nosocomial BSI, C. albicans was the most common, accounting for 54% of cases of Candida BSI, followed in rank order by C. glabrata (19%), C. parapsilosis (11%), and C. tropicalis (11%) ( figure 3 ). Crude mortality was lowest for C. albicans infection (37%) and highest for C. krusei infection (59%) ( figure 3 ). There was an increase in the proportion of Candida species isolated from blood cultures from 8% in 1995 to 12% in 2002 ( P < .001, trend analysis). Also, the proportions of C. albicans and C. parapsilosis among these isolates increased between 1995 and 2002, but the proportions of C. tropicalis and C. glabrata decreased.

Figure 3
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Distribution of species in 1890 cases of bloodstream infection and associated crude mortality

Figure 3
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Distribution of species in 1890 cases of bloodstream infection and associated crude mortality

Antimicrobial susceptibility . Methicillin resistance was detected in 1699 S. aureus isolates (41% of tested isolates) and in 4946 CoNS isolates (75%). The proportion of S. aureus isolates with methicillin resistance was significantly higher among ICU patients than among ward patients (44% vs. 40%; P = .004), and there was also a trend toward a higher proportion of S. aureus isolates resistant to methicillin among patients without neutropenia than among patients with neutropenia (42% vs. 32%; P = .054, figure 4 ). The proportion of S. aureus isolates resistant to methicillin increased from 22% in 1995 to 57% in 2001 ( P < .001, trend analysis; figure 5 ).

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