The groups were compared with a log-rank test. Cox proportional hazards regression was used to discriminate risk factors associated with time of death. To discriminate independent risk factors, multivariable modeling was performed with methods of stepwise selection, with RVEF groups and candidate variables all competing for entry into a final model predicting perioperative and day complications, long-term cardiac re-hospitalization, and worsening CHF, and late mortality.
Univariate and multivariate analyses were performed in the same manner to identify predictors of late mortality. There were no statistically signficant differences in type of surgery performed and in cardioplegia used among RVEF groups. In patients undergoing isolated CABG procedures, median perfusion and cross clamp times were 70 minutes range 30— and 40 minutes range 18— , respectively, with one case of off-pump surgery data not shown.
One hospital death occurred in a patient who had valve surgery.
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No day repeat cardiac hospitalization was observed. These findings were similar in valve surgical patients Table 2. Of those patients undergoing valve procedures vs. However, of those 23 patients with long-term cardiac re-hospitalizations, risk factors associated with RV dysfunction were low in abnormal group i.
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There were no statistically signficant differences in the incidence of long-term worsening CHF and cardiac re-hospitalization among CABG and valve surgeries Table 3. LVEF did not influence cardiac re-hospitalization. Risk factors associated with RV dysfunction included incidence of CHF, obesity, COPD and pulmonary hypertension did not affect early and long-term outcomes data not shown. However, higher incidence of significant TR and advanced age were predictive of worse survival Table 4.
However, the results of the multivariate analysis should be interpreted with caution, given the relatively small number of events in this patient group as reflected by large confidence intervals. The type of surgery did not affect long-term survival Tables 3 and 4. The number below each year indicates the number of patients at risk. In addition, patients who underwent valve surgery with an abnormal RVEF had an increased incidence of late repeat cardiac hospitalizations. In recent years, attention has been focused on the RV function and its association with morbidity and mortality.
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The RV is affected by changes in afterload, preload, and contractility [ 12 , 13 ]. In surgical patients, some consideration of RV function is warranted as many surgically relevant disease states may potentially alter such determinants of RV function [ 14 , 15 ]. In the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock SHOCK trial, patients presenting with right ventricular shock, despite younger age and with single vessel disease, had higher mortality than those patients with left ventricular shock [ 16 ].
RV dysfunction was predictive of worse survival in patients with pulmonary hypertension [ 17 ] and in symptomatic heart failure [ 18 ]. In a study of patients, Adhyapak and colleagues reported that rapid progression occurred more in patients with abnormal RVEF than those with preserved RVEF, irrespective of the co-existing pulmonary hypertension in both groups [ 18 ].
Our data showed that abnormal RVEF led to long-term cardiac re-hospitalizations. This may be partly attributable to the failure of the of right ventricle to maintain flow required to have adequate LV preload, thus leading to progressive decompensation [ 18 ]. Transient decline in right ventricular systolic function after cardiopulmonary bypass has been previously described [ 14 ], however, the magnitude of the long-term impact of post-RV dysfunction, if any, is unknown [ 20 ].
We cannot reliably predict which patients will have transient RV dysfunction and which patients will have persistent RV dysfunction [ 21 ]. Additional studies have shown that clinically silent severe RV enlargement may occur in asymptomatic patiens with normal right ventricular pressure and no pulmonary hypertension and mitral disease [ 22 , 23 ]. It is possible that the presence of signficant TR may mask the decreased contractility of the RV, leading to an underestimation of patients who actually have impaired RV function.
Earlier work showed that TR severity correlates with poor surival in patients with apparently well-adapted RV function but early reduced contractile reserve [ 22 ]. Evaluation of RVEF in the postoperative setting and by echocardiogram is technically challenging [ 24 , 25 ].
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Although our patient population is small, it is one of the larger studies, which has demonstrated the prognostic value of RVEF using CMR following cardiac surgery. Our data demonstrated that LVEF does not appear to increase risk of early complications and long-term mortality in this patient cohort. This finding is consistent with contemporary studies of isolated CABG [ 29 — 32 ].
In a recent study of over patients, Yoo and colleagues found that severe LV dysfunction was not associated with reduced long-term survival 2—8 years [ 32 ]. However, other contemporary studies do not support these findings [ 33 , 34 ]. It is important to acknowledge that LVEF is certainly an important prognostic factor in less selected populations. This is a single-institution, nonrandomized study. As in many observational studies, we acknowledge that indication bias is a particular problem in our study.
However, we attempted to minimize this by use of restriction and high-quality data.
Enrollment in our study was restricted to patients referred for CMR study by the cardiologists and cardiac surgeons. Evaluation of RVEF was performed as a pre-operative risk assessment in those patients. Thus, both groups were similar with respect to most characteristics, comorbid conditions and type of procedures. Congress suggests with some whimsical license a variant of informal diplomacy. Another twist on informal diplomacy is explicit. In addition to situating the story of the National Council on United States-China Trade within sophisticated discussions of informal diplomacy, U.
Additionally, some might seek to integrate the story of the Council with recent studies of the ideological and institutional transfer of economic theories from the United States to China. I can offer only two criticisms, one a factual correction and the other an interpretive dissent. In the course of arguing against reductionist economic explanations for events in diplomatic history—an argument with which I agree—Talley posits William A.
Williams as a foil. I would argue that Williams—along with his colleagues in the so-called Wisconsin School of history—saw American imperialism as the outcome of several dynamics that are more long-range and universal than corporate special pleading.
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As indicated by the following passage in Tragedy , Williams saw imperialism as a policy that was far-sighted, oriented toward the general interest, and broadly popular:. This broad support for expansion, and particularly overseas economic expansion, rested upon an agreement among conservatives and liberals even many radicals joined in for a few years , and Democrats and Republicans, from all sections and groups of the country.
A strong majority agreed that foreign policy could and should play an important—if not crucial—part in recovering from the depression of the s and in forestalling future difficulties. While Williams acknowledged the role of export-oriented corporate capitalists, he included smaller businessmen and, especially, farmers among the central actors promoting an imperialist policy. He also discussed the role of intellectual and political grand strategists. This is not to make normative judgements about either the Americans who developed and supported imperialist policies or about the historians who have studied them.
It is simply to understand what the historians have written. I note, in closing, that Talley segues to Williams after critiquing an article by Bruce Mazlish, which I have not yet read W hen the Editors of H-Diplo generously organized a Roundtable Review of Forgotten Vanguard , I anticipated responses from scholars who, given their familiarity with the topic, might offer the most intelligent and even trenchant critiques.
In a broader academic world in which many published works are never read, much less cited, such an incisive dialogue is a welcomed opportunity. I have but a few remarks in response, which I will address to each of the individual reviewers. He identifies the interrelation of business and diplomacy during the rapprochement and the mediating role the Council played in this peculiar period. He is receptive to the continuing difficulties Taiwan posed for trade relations, the American experience with the Soviets as an analogue for the experience with the Chinese, and the broader historiography of non-governmental organizations NGOs.
If there is a preponderance of the evidence in either direction, it is toward autonomy rather than dependency. This is not to say, of course, that it divorced itself from the state. Furthermore, it used its chimerical status to its own advantage when negotiating with the Chinese. The Council lay between these contrasting extremes. Though Washington and Beijing continued to determine the rules of the game with various controls and regulations, the Council pursued initiatives under its own steam— and with governmental cooperation—to expand the scope of bilateral trade.
As with Millwood, Wheeler is similarly receptive to the main arguments in Forgotten Vanguard. I agree with his suggestion that the Council, in its efforts to persuade Congress to adopt trade agreements with China, was conducting a kind of informal diplomacy. Senators and Representatives, some of whom went so far as to liken Chinese leader Deng Xiaoping to Adolf Hitler and China to a concentration camp.
Its Washington office closed in due to budgetary pressures, though the organization persists in a somewhat diminished capacity. Footnote 31 of the Introduction will be corrected in subsequent editions. A case in point is the presidential election, in which U. While each statement was made in the heat of debate, each also undoubtedly resonated with a large swath of the American electorate, which has grown increasingly suspicious of U.
The second and more profound level on which this thesis lives or lived is in the neoliberal conception that American business and soft power, directed through international institutions, could mold China to American interests. As I point out in the introduction, China was—and remains—too powerful for the United States to effect the sort of internal reconfiguration imagined by Secretary of State John Hay and critiqued by historian William Appleman Williams. Nevertheless, the belief that the transformative power of American capital could reform Chinese society informed American policymakers at key turning points in U.
Take, for instance, President George H. Presidents Bill Clinton and George W. Bush also cloaked their accommodating and even forgiving U. Integrating China more deeply into the international trade system, for example through its admission to the World Trade Organization ultimately doubling U.
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Lin writes that because the Council was set up to serve diplomatic interests, it must not have been set up to serve private interests. The language here is key.
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