The aim of the current study was to identify surgical factors associated with long-term patency of grafts used in coronary artery bypass grafting (CABG). The present study analyzed data from 127 patients who underwent CABG at our institute between 2000 and 2006 and presented for ambulatory examination and coronary computed tomography angiography evaluation of graft patency in 2016 (139.78±36.64 months post-CABG). The 127 patients received 340 grafts (2.68 grafts/patient) and 399 distal anastomoses (3.14 anastomoses/patient), 220 (55.14%) with arterial grafts and 179 (44.86%) with saphenous vein grafts. Graft patency varied according to coronary territory, proximal anastomosis type (in situ graft, composite graft, graft anastomosed to the ascending aorta), Y anastomosis angle (47.21° for patent arterial grafts vs. 56° for occluded), and distal anastomosis angle (in sequential anastomoses irrespective to graft type, 48.60° for patent side-to-side anastomosis vs. 53.97° for occluded, 65.12° for patent end-to-side anastomosis vs. 90.80° for occluded; in single end-to-side anastomosis of arterial grafts, 39.46° for patent and 44.94° for occluded). A single end-to-side anastomosis angle 60° or greater was associated with a 5.149 occlusion odds ratio (OR) (P<0.001) for arterial grafts. Venous grafts were not sensitive to single end-to-side anastomosis angle. In conclusion, a small anastomosis angle for proximal Y and distal anastomoses is associated with a higher long-term patency of the free graft. Radial artery grafts registered higher patency rates when anastomosed to the ascending aorta compared with composite grafting with the left internal thoracic artery, whereas in situ right internal thoracic artery (RITA) anastomosed to the right coronary territory is associated with a lower patency rate compared with free RITA used to revascularise the anterolateral or circumflex territory in composite grafting.

The phenomenon of defensive medicine existed for decades in the United States but in Romania emerged lately following malpractice litigation and mass media aggression. Defensive medicine develops when doctors prescribe tests or procedures and avoid to treat high-risk patients or to perform certain high-risk procedures in order to reduce the risk of medical liability. This essay discusses the basis and principles of defensive medicine, analyses its causes and effects and debates the major problems affectingRomanian healthcare system, notably cross-border medical assistance. Finally, the authors examine alternatives to prevent defensive medicine practices with emphasis on cardiovascular surgery. Among physicians, some degree of defensive medicine will always exist, as long as malpractice risks shadow the doctors' every footstep.

Background: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. Results: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p < 0.001). Door-to-balloon time did not differ significantly between the two periods (p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54–3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54–5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). Conclusion: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality.

Ricin, a toxic glycoprotein found in the seeds of castor oil plant, is capable of irreversible cellular adhesion and inhibition of protein synthesis. The authors performed an up to date review concerning the chemical structure, mechanism of action, poisoning symptoms and treatment, and potential uses of ricin as a biochemical weapon. Castor oil plant is easy to cultivate and harvest worldwide and, except the United States of America, cultures and processing plants are not supervised. Ricin extraction does not require laborious and costly technique and it is undetectable once in the body (except for urine in case of ricin ingestion). Poisoning generates nonspecific symptoms and is potentially fatal with no antidote or specific treatment available. Forensic specialists must be aware of symptoms and post-mortem findings in order to make a correct diagnosis of ricin poisoning.

Methanol intoxication is a potentially fatal medical condition associated with basal ganglia and subcortical white matter necrosis. The authors present the case of a 34 years-old female with putaminal necrosis and haemorrhagic stroke secondary to methanol intoxication. The patient was hospitalized in the intensive care unit with severe metabolic acidosis and bilateral blindness after ingesting an unspecified amount of methanol. Computed tomography (CT) examination performed at hospital admission revealed a hypodense, inhomogeneous aspect of lenticular nuclei with ischemia in observation. In the 18th day post-ingestion the patient went into deep coma and a new CT examination was performed revealing an intracerebral hematoma involving the right lenticular nucleus, right external and extreme capsule, and right insula with uncal herniation. Neurosurgical decompression was attempted with unfavourable outcome and exitus. Necropsy examination revealed bilateral lenticular necrosis and a hematoma between the base of the right lenticular nucleus and insular cortex with destruction of the claustrum, external and extreme capsules. Methanol poisoning (mostly accidental) is not uncommon in our country and its metabolite, the formic acid, is a potent central nervous system toxin. Bilateral lenticular necrosis is a typical finding in methanol intoxication due to formic acid accumulation with decrease in mitochondrial adenosine triphosphate (ATP) synthesis responsible for cellular toxicity.