Comparison of on pump and off pump coronary surgery: risk factors for neurological outcome

Objective: Cerebrovascular accidents (CVA) are devastating complications after coronary artery bypass grafting (CABG). The reported incidence of neurological complications after conventional CABG (CCABG) is 3–6%. Off-pump coronary bypass grafting (OPCAB) has been associated in recent studies to a decreased morbidity and risk of perioperative stroke. Nevertheless, uncertainty still surrounds the relative benefits of OPCAB. We investigated whether, in our experience, OPCAB was associated with lower neurological morbidity than conventional CABG approach. Methods: Eight thousand and two patients underwent isolated CABG at our institution between January 1998 and January 2005. OPCAB operation was performed on 1415 patients. Data were prospectively collected. A multiple logistic regression analysis was used to evaluate the influence of the two different surgical techniques on the neurological outcomes. Results: Patients in the OPCAB group were significantly older (66.2 vs 63.5%, p < 0.0001), had a higher incidence of renal injury (5.4 vs 2.4%, p < 0.0001), and were more redo interventions (6.95 vs 1.53%, p < 0.0001). The CCABG patients were more urgent at operation (5.46 vs 3.26, p = 0.0007), were less hypertensive (57.6 vs 63% of the patients, p = 0.0003) more diabetics (22 vs 20.6%, NS), and had an ejection fraction less than 0.40 (10.4 vs 9.6%, NS). CVA incidence was similar in both groups (Type I outcome: OPCAB = 0.70% vs CCABG = 0.68%, p = 0.91; Type II outcome OPCAB = 0.70% vs CCABG = 0.83%, p = 0.63). Conclusions: In our experience patients undergoing CCABG were not exposed to a grater risk of neurological adverse events when compared to OPCAB patients.     

Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Characteristics of burn patients at a major burn center in Shanghai

In China, burns are becoming a major cause of morbidity and mortality with large societal and economic implications. To date, there is little epidemiological data on burns in China to direct prevention efforts. This study describes the characteristics of burn patients admitted to a major burn center in Shanghai using a burn registry developed in Toronto, Canada. A retrospective review of burn patients discharged from the Shanghai's Rui Jin Hospital Burn Unit, between March 1st 2002 and April 30th 2003, was conducted. Of 527 patients discharged, 307 were acute burn patients and 302 (98.4%) had complete data to be included in the study. There were 214 (71%) males and 88 (29%) females with a male to female ratio of 2.4:1. The median age was 30 years, and the median total body surface area burned was 10%. The majority of burns occurred at work (58%), and the most frequent etiology was flames (39%) followed by scalds (31%) and contact with hot objects (15%). Sixteen (5%) patients had inhalation injury and six (2%) patients died. There were 70 (23%) children (0–14 years), 221 (73%) adults (15–59 years) and 11 (4%) seniors (60 years and above). Children had more scald burns (83%) and the majority (83%) occurred at home. Adults had more flame burns (46%) and the majority (79%) were work-related injuries. Seniors had more flame burns (73%) and the majority (55%) occurred in domestic incidents. Seniors had deeper burns (13%, p = 0.005), required more escharotomies (55%, p = 0.002), required more operations (2, p = 0.051) and had higher mortality (36%, p < 0.001) than other age groups. These results provide compelling evidence for performing population-based studies to identify risk factors that are susceptible to modification in each age group.     

Does the Aristotle Score predict outcome in congenital heart surgery?

Objective: The Aristotle Score has been proposed as a measure of ‘complexity’ in congenital heart surgery, and a tool for comparing performance amongst different centres. To date, however, it remains unvalidated. We examined whether the Basic Aristotle Score was a useful predictor of mortality following open-heart surgery, and compared it to the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system. We also examined the ability of the Aristotle Score to measure performance. Methods: The Basic Aristotle Score and RACHS-1 risk categories were assigned retrospectively to 1085 operations involving cardiopulmonary bypass in children less than 18 years of age. Multiple logistic regression analysis was used to determine the significance of the Aristotle Score and RACHS-1 category as independent predictors of in-hospital mortality. Operative performance was calculated using the Aristotle equation: performance = complexity × survival. Results: Multiple logistic regression identified RACHS-1 category to be a powerful predictor of mortality (Wald 17.7, p < 0.0001), whereas Aristotle Score was only weakly associated with mortality (Wald 4.8, p = 0.03). Age at operation and bypass time were also highly significant predictors of postoperative death (Wald 13.7 and 33.8, respectively, p < 0.0001 for both). Operative performance was measured at 7.52 units. Conclusions: The Basic Aristotle Score was only weakly associated with postoperative mortality in this series. Operative performance appeared to be inflated by the fact that the overall complexity of cases was relatively high in this series. An alternative equation (performance = complexity/mortality) is proposed as a fairer and more logical method of risk-adjustment.     

Immunohistochemistry-detected microscopic tumor spread affects outcome in en-bloc resection for T3-chest wall lung cancer

Objective: This study is aimed at analyzing the effect of immunohistochemistry-detected microscopic tumor spread on long-term survival after en-bloc lung and chest wall resection for T3-chest wall non-small cell lung cancer (NSCLC). Methods: We retrospectively reviewed 47 patients (mean age 64.4 ± 7.1 years, range 48–77) who underwent radical en-bloc lung and chest wall resection for NSCLC between 1987 and 2000. Resection margins, invasion depth, and lymph nodes were re-assessed by immunohistochemistry with AE1/AE3 anti-cytokeratin and anti-CEA monoclonal antibodies. Results: Operative mortality and morbidity were 2.1% and 34%, respectively. At immunohistochemistry analysis, five patients (10.6%) revealed microinfiltration of the resection margins that was significantly correlated with the development of local recurrence (p < 0.005). Nodal micrometastases were found in 4 out of 33 N0 patients (12.1%), and correlated with distant relapse (p < 0.001). Overall and disease-free survivals were significantly influenced by N-status (p < 0.001), especially after re-evaluation of micrometastases (p < 0.0001), and resection margins microinfiltration (p < 0.0001) being these last two the only significant prognostic factors at Cox regression analysis. Five-year overall survival in radically resected patients was 73%. Conclusions: In this study immunohistochemical analysis allowed to identify patients at higher risk of recurrence following en-bloc resection for T3-chest wall NSCLC.     

Pretreatment with recombined human erythropoietin attenuates ischemia–reperfusion-induced lung injury in rats

Objective: Based on the findings that erythropoietin (EPO) has been proved to be a multiple functional cytokine to attenuate ischemia–reperfusion (I/R) injury in various organs such as brain, heart, and kidney in animals, this experiment was designed to evaluate the effect of pretreatment with recombined human erythropoietin (rhEPO) on I/R-induced lung injury. Methods: Left lungs of rats underwent 90 min of ischemia and then were reperfused for up to 2 h. Animals were randomly divided into three experimental groups as sham group, I/R group, and rhEPO + I/R group (a single dose of rhEPO was injected intraperitoneally 3000 U/kg 24 h prior to operation). Lung injury was evaluated according to semi-quantitive analysis of microscopic changes, tissue polymorphonuclear neutrophils (PMNs) accumulation (myeloperoxidase (MPO) activity), and pulmonary microvascular permeability (Evan's blue dying method). Peripheral arterial and venous blood samples were obtained for blood–gas analysis after 5 min occlusion of right lung hilus at the end of reperfusion. The serum concentration of tumor necrosis factor (TNF)- was also measured by the method of enzyme-linked immunosorbent assay. Results: Histological injury scoring revealed significantly lessened lung alveolus edema and neutrophils infiltration in the rhEPO pretreated group compared with I/R group (p < 0.05). The rhEPO pretreated animals exhibited markedly decreased lung microvascular permeability (p < 0.05) and myeloperoxidase activity (p < 0.05). Blood–gas analysis demonstrated that the pretreated animals had significantly ameliorated pulmonary oxygenation function (p < 0.05). The serum concentration of tumor necrosis factor- in rhEPO pretreated group was markedly decreased compared with that of I/R group (p < 0.05). Conclusions: Pretreatment with rhEPO appears to attenuate I/R-induced lung injury. This function is partly related with the capacity that rhEPO inhibits the accumulation of polymorphonuclear neutrophils in lung tissue and decreases the systematic expression of tumor necrosis factor-.     

Intestinal ischaemia following cardiac surgery: a multivariate risk model

Objective: Intestinal ischaemia following cardiac surgery is a serious complication, which carries a high mortality rate. Several studies have examined pre-operative and intra-operative risk factors. We aimed to develop a multivariate risk model to identify those patients at highest risk of intestinal ischaemia. Methods: Data was prospectively collected for 10,976 consecutive cardiac surgery patients from our institution between April 1997 and March 2004. Fifty (0.5%) patients developed post-operative intestinal ischaemia. A forward stepwise multivariate logistic regression analysis was undertaken to identify predictors of developing intestinal ischaemia. Intra-operative and post-operative variables were censored at the time of onset of intestinal ischaemia. Results: The predictors of post-operative intestinal ischaemia were: post-op inotrope and dialysis support (OR 6.7; p < 0.001), post-op ventilation >48 h (OR 5.1; p < 0.001), age at operation (OR 1.06 [for each additional year]; p < 0.001), post-op atrial fibrillation (OR 2.3; p = 0.014) and blood loss in intensive care unit (ICU) >700 ml (OR 2.0; p = 0.037). The predictive ability of this model was very good with an area under the receiver operating characteristic curve of 0.93. In-hospital mortality for the patients who developed intestinal ischaemia was 94% (47/50) compared to 3.6% (390/10,926) for the other patients (p < 0.001). Conclusions: Although the incidence of intestinal ischaemia following cardiac surgery is low, the prognosis for these patients is very poor. We have identified several risk factors, and developed a multivariate prediction tool, which may be useful in identifying patients at high-risk of developing intestinal ischaemia.     

Relationship of Circulating Total Homocysteine and C-Reactive Protein to Trabecular Bone in Postmenopausal Women

Homocysteine (Hcy) and C-reactive protein (CRP) are novel risk factors for osteoporosis. The purpose of this analysis was to determine the relationship of Hcy and CRP to volumetric trabecular bone, but also to assess their relationship to areal composite bone in healthy postmenopausal women (N = 184). We used peripheral quantitative computed tomography to assess volumetric bone at the distal tibia and dual-energy X-ray absorptiometry to assess areal composite bone at the proximal femur and lumbar spine. Multiple regression revealed that 22% of the variability in trabecular bone mineral content (F = 9.59, p ≤ 0.0001) was accounted for by weight (12.4%; p ≤ 0.0001), hemoglobin (5.5%; p = 0.0006), uric acid (4.2%; p = 0.003), and blood glucose (1.5%; p = 0.07). Multiple regression revealed that 5.4% of the variability in trabecular bone mineral density (F = 3.36; p = 0.020) was accounted for by hemoglobin (4.2%; p = 0.006) and Hcy (1.5%; not significant, p = 0.10). Total Hcy and CRP were not significantly related to trabecular bone, perhaps because these were nonosteoporotic women. However, our results suggested a weak but negative relationship between Hcy and trabecular bone. Further investigation is needed to examine the relationship of Hcy as an endogenous bioactive molecule to trabecular bone loss in early postmenopausal women and the response of trabecular bone to dietary intervention.     

Genetic background influences fluoride's effects on osteoclastogenesis

Excessive fluoride (F) can lead to abnormal bone biology. Numerous studies have focused on the anabolic action of F yet little is known regarding any action on osteoclastogenesis. Little is known regarding the influence of an individual's genetic background on the responses of bone cells to F. Four-week old C57BL/6J (B6) and C3H/HeJ (C3H) female mice were treated with NaF in the drinking water (0 ppm, 50 ppm and 100 ppm F ion) for 3 weeks. Bone marrow cells were harvested for osteoclastogenesis and hematopoietic colony-forming cell assays. Sera were analyzed for biochemical and bone markers. Femurs, tibiae, and lumbar vertebrae were subjected to microCT analysis. Tibiae and femurs were subjected to histology and biomechanical testing, respectively. The results demonstrated new actions of F on osteoclastogenesis and hematopoietic cell differentiation. Strain-specific responses were observed. The anabolic action of F was favored in B6 mice exhibiting dose-dependent increases in serum ALP activity (p < 0.001); in proximal tibia trabecular and vertebral BMD (tibia at 50&100 ppm, p = 0.001; vertebrae at 50 and 100 ppm, p = 0.023&0.019, respectively); and decrease in intact PTH and sRANKL (p = 0.045 and p < 0.001, respectively). F treatment in B6 mice also resulted in increased numbers of CFU-GEMM colonies (p = 0.025). Strain-specific accumulations in bone [F] were observed. For C3H mice, dose-dependent increases were observed in osteoclast potential (p < 0.001), in situ trabecular osteoclast number (p = 0.007), hematopoietic colony forming units (CFU-GEMM: p < 0.001, CFU-GM: p = 0.006, CFU-M: p < 0.001), and serum markers for osteoclastogenesis (intact PTH: p = 0.004, RANKL: p = 0.022, TRAP5b: p < 0.001). A concordant decrease in serum OPG (p = 0.005) was also observed. Fluoride treatment had no significant effects on bone morphology, BMD, and serum PYD cross-links in C3H suggesting a lack of significant bone resorption. Mechanical properties were also unaltered in C3H. In conclusion, short term F treatment at physiological levels has strain-specific effects in mice. The expected anabolic effects were observed in B6 and novel actions hallmarked by enhanced osteoclastogenesis shifts in hematopoietic cell differentiation in the C3H strain.     

Effect of risk-adjusted, non-dialysis-dependent renal dysfunction on mortality and morbidity following coronary artery bypass surgery: a multi-centre study

Objective: As little is known about the impact of non-dialysis-dependent renal dysfunction on short- and mid-term outcomes following coronary surgery we have conducted a large multi-centre study comparing patients with no history of renal dysfunction to those with preoperative renal dysfunction. Methods: Data was prospectively collected on 19,625 consecutive patients undergoing isolated coronary surgery between 1997 and 2003 from four institutions. Sixty-seven patients had a history of dialysis support prior to coronary surgery, and were excluded from the main analysis of the study. The remaining 19,558 patients were divided into two groups based on preoperative serum creatinine level, patients with preoperative renal dysfunction with serum creatinine levels >200 μmol/L without dialysis support and control patients with preoperative serum creatinine levels <200 μmol/L. Case-mix was accounted for by developing a propensity score, which was the probability of belonging to the non-dialysis-dependent renal dysfunction group, and included in the multivariable analyses. Results: There were 19,172 patients with preoperative serum creatinine levels <200 μmol/L and 386 patients with serum creatinine levels >200 μmol/L without dialysis support. The propensity score included sex, body mass index, co-morbidity factors (respiratory disease, diabetes, cerebrovascular disease, hypertension, and hypercholesterolemia), ejection fraction, left main stem stenosis, emergency status, prior cardiac surgery, off-pump surgery, and the logistic EuroSCORE. After adjusting for the propensity score, patients with preoperative non-dialysis-dependent renal dysfunction had significantly higher in-hospital mortality (adjusted odds ratio 3.0, p < 0.001), stroke (adjusted odds ratio 2.0, p = 0.033), atrial arrhythmia (adjusted odds ratio 1.5, p = 0.003), prolonged ventilation (adjusted odds ratio 2.1, p < 0.001), and post-op stay > 6 days (adjusted odds ratio 2.6, p < 0.001). One thousand one hundred and eighty-three (6.1%) deaths occurred during 58,062 patient-years follow-up. After adjusting for the propensity score, the adjusted hazard ratio of mid-term mortality for non-dialysis-dependent renal dysfunction was 2.7 (p < 0.001). Conclusions: Patients undergoing coronary surgery with non-dialysis-dependent renal dysfunction have significantly increased perioperative morbidity and mortality. Mid-term survival is also significantly reduced at 5-years.     

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BackgroundSevere burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.MethodsWe obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.ResultsAge, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.DiscussionThis analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.     

A Pilot Study of Body Composition and Bone Mineral Density in Healthy Men From Argentina

A precise assessment of bone mineral density (BMD) and body composition can be performed using dual-energy X-ray absorptiometry (DXA). Values of body composition for males would be useful to evaluate the occurrence of alterations in body composition in a number of diseases. The objectives of this study were to establish BMD and body composition values in healthy men and to analyze age-related changes. BMD and body composition of total body and subareas were determined in 116 healthy men (aged 20–79 yr) using DXA. Comparison between 20–29- and 70–79-yr-old men showed that older subjects were shorter (p < 0.03), and had a higher body mass index (p < 0.01). Fat mass increased (+46.7%; p < 0.001) especially in the trunk. Lean mass (LM) decreased (−9.4%; p < 0.05) mainly in the arms and legs. Bone mineral content (BMC) and BMD decreased (−15.3% [p < 0.001], −6.3% [p < 0.05], respectively). Correlation was observed between BMC and LM (r = 0.7, p < 0.01). Values of BMD and body composition in healthy men were obtained. A relation was observed between bone mass and body composition, suggesting that the age-related decrease in LM may be associated to bone mass loss. Further studies should be conducted to elucidate the role of body composition in the occurrence of osteoporosis in men.     

Antithrombin deficiency and its relationship to severe burns

Antithrombin (AT) is an important endogenous anticoagulant and exhibits marked anti-inflammatory properties. To evaluate the incidence of AT deficiency in severe burn and its correlation to the variables of the abbreviated burn severity index (ABSI), length of hospital stay (LOS) and mortality we collected data on the substitution of human plasma-derived AT concentrate in 201 consecutive patients suffering from severe burn. One hundred and eight patients (54%) developed AT deficiency during their hospitalisation and, according to our institutional practice, received substitution therapy by continuous infusion to maintain physiological plasma activity (70-120%). The mean administered dose served as a measure of AT deficiency. The percentage of patients in an AT deficient state was highest within the first 5 days after injury. It was 26% on day 1 and between 38% and 41% on days 2-5 and thereafter decreased constantly over time. A multiple regression analysis between the dependent variable mean administered dose of AT concentrate and the independent variables age, total body surface area burned (TBSA), gender, inhalation injury (INHAL), full thickness burn (FTB), LOS and mortality was performed. Age, gender and FTB showed no significant influence on the development of AT deficiency. Increasing TBSA and INHAL clearly increase the risk of developing AT deficiency (p-values 0.0001 and 0.037). The analysis also identified AT deficiency as an independent predictor of LOS and mortality (p-values 0.036 and 0.003). Development of AT deficiency is a frequent event after burn with significant correlation to TBSA and INHAL, increased mortality rates and longer hospital stays.     

Mortality and risk factors for surgical lung biopsy in patients with idiopathic interstitial pneumonia

Background: The overall safety of surgical lung biopsy in patients with idiopathic interstitial pneumonia (IIP) remains controversial. This study was performed to investigate the mortality and complication rate and identify the risk factors for surgical lung biopsy in patients with IIP. Methods: A total of 200 patients with IIP who underwent surgical lung biopsy at the Asan Medical Center, Korea, from April 1990 to August 2003, were enrolled. Complications and mortality were analyzed retrospectively. Results: (1) The mortality rate 30 days after the surgical lung biopsy was 4.3%, which was significantly higher than the control group. Biopsy performed at the time of acute exacerbation (AE) resulted in higher 30-day mortality (28.6%) compared to non-AE (3.0%; p < 0.05). AE was followed by biopsy itself in three cases. (2) Univariate analysis indicated that lower FVC, lower DL_CO, and presence of AE were significant risk factors for 30-day mortality (p < 0.05). However, multivariate analysis revealed that only AE (OR: 11.334, 95% CI: 1.727–74.365, p = 0.011) was an independent risk factor. (3) The patients with low DL_CO (<50% predicted) had higher mortality and complication rate than high DL_CO group. Conclusion: Our data suggested that the presence of acute exacerbation at the time of biopsy and lower DL_CO were predictors of higher mortality after the surgical lung biopsy.     

Impact of HIV Infection on Total Body Composition in Treatment—Naive Men Evaluated by Dual-Energy X-ray Absorptiometry Comparison of 90 Untreated HIV-Infected Men to 241 Controls

The aim of this study was to establish the contribution of human immunodeficiency virus (HIV) itself on body composition changes evaluated by dual-energy X-ray absorptiometry (DXA). Body composition evaluated by DXA in 90 HIV never treated men, without comorbidity, or current or past opportunistic infections were compared with 241 healthy volunteers. The mean duration of seropositivity from HIV diagnosis was 41 ± 62 mo, mean CD4 and viral load at the time of DXA were 402/mm³ ± 263 (control values 500–1200/mm³) and 4.2 log copies/mL ± 1.3. Mean age (41 vs 39 yr, respectively, for HIV never treated patients and controls) and mean height (174.5 vs 176 cm) were not different, but mean weight was lower among HIV never treated patients (69.8 vs 78.7 kg). Mean total body bone mineral density (BMD) of naive HIV-infected patients was lower than that of controls (1.20 vs 1.23 g/cm², p = 0.01) but not after adjustment on age, height, lean mass (LM), and fat mass ratio (FMR = % trunk fat mass/% lower limb fat mass). Fat mass (13.2 vs 16.5 kg, p < 0.0001) and LM (53.5 vs 59 kg, p < 0.0001) of naive HIV-infected patients were lower whatever the adjustment variables. The FMR was lower in naive HIV-infected men (1.0 vs 1.3, p < 0.0001) because of a decreased trunk fat mass. After adjustment on age, height, LM, and fat mass, the lower limbs fat mass percentage was higher in HIV-infected men. The profile of naïve HIV-infected patients displayed low lean and fat masses, and a fat mass repartition characterized by a predominant loss in the trunk. Those alterations may result from the catabolic effect of the chronic HIV infection.     

Procalcitonin-a sepsis parameter in severe burn injuries

Procalcitonin (PCT) levels increase in patients with systemic infections; the highest levels have been found in sepsis. This study tested whether plasma procalcitonin level was related to sepsis, CRP, burn size, inhalation injury or mortality in severely burned patients over the entire clinical course.

In 27 patients with 51 (20–91)% TBSA, PCT was measured three times weekly from admission over the entire course of stay in a single ICU. Daily scoring by the “Baltimore Sepsis Scale” was performed. The patients were assigned to three groups depending on the clinical course and outcome: A=no septic complications, B=septic complications–survivors, C=septic complications–non-survivors.

PCT levels were elevated slightly at admission (mean 2.1 ng/ml) except in three patients who suffered electrical burns (mean 15.7 ng/ml). PCT peak levels correlated well with the Scoring values (r=0.84) while CRP did not (r=0.64). Peak PCT levels were significantly higher (p<0.005) in septic patients (B and C) who averaged 49.8±76.9 ng/ml, than in non-septic patients (A) who averaged peak levels of 2.3±3.7 ng/ml. The highest PCT levels were found immediately before death (86.8±97 ng/ml).

Seven patients had an inhalation injury III°. In these patients at 24 h postburn, there was no relationship between PCT levels and inhalation injury but during the later days postburn there were significant differences in PCT levels in patients with versus without inhalation injury. All patients with inhalation injury III° developed septic complications.

There was no positive correlation between the PCT-admission-levels and the TBSA, but there was a positive correlation between the TBSA and the mean peak PCT levels during the later days postburn (r=0.73; p<0.05). The cut-off value of 3 ng/ml we found reliable to indicate severe bacterial or fungal infection. PCT values over 10 ng/ml increasing over the following days were found only in life-threatening situations due to systemic infections. The individual course of PCT in one patient is more important than absolute values. PCT presented in this study as a useful diagnostic parameter in severely burned patients.     

Peak Bone Density in Croatian Women: Variations at Different Skeletal Sites

It is known that different skeletal sites have different peak bone mass at different times and lose bone at different rates. The purpose of the study was to assess bone mineral density (BMD) in healthy female student population (N = 220), aged 18–25 yr and to analyze whether young women of that age have already started to lose the bone mass at the trabecular and cortical parts of skeleton. The influence of dietary intake and physical activity on their bone mass was also assessed. BMD was measured, using dual-energy X-ray absorptiometry technique, in spine, proximal femur, and distal third of the radius and in total body. Significant negative correlation between age and bone mass was found in all skeletal regions (p < 0.05 spine; p < 0.0001 total femur; and p < 0.01 total body) except in cortical part of the radius. Peak bone mass in young Croatian women was achieved before the age of 20, but later in the long-bone cortical skeleton, where BMD continued to increase after mid-20s. The BMD values are comparable with those from National Health and Nutrition Examination Survey study, except for the cortical part of the radius, where it is significantly lower. Body weight and physical activity were the most significant positive predictors of bone density in all measured sites.     

Long-term experiences on cardiac retransplantation in adults

Background: It remains disputed whether cardiac retransplantation should be performed. This study aimed to evaluate our long-term experiences on cardiac retransplantation in adults. Patients and methods: Between March 1989 and December 2004, 2% (28/1290) of cardiac retransplantations were performed. Results: The reasons for cardiac retransplantation were cardiac allograft vasculopathy (n = 13; 47%), primary graft failure (n = 11; 39%), and refractory acute rejection (n = 4; 14%). The 30-day mortality risk was 29% (acute rejection: 50%; primary graft failure: 36%; cardiac allograft vasculopathy: 15%, p = 0.324), compared to 8.5% for primary cardiac transplantation (p < 0.001). The causes of early death were acute rejection (n = 3; 37%), multiorgan failure (n = 3; 37%), primary graft failure (n = 1; 13%), and right ventricular failure (n = 1; 13%). The late mortality rate was 96/1000 patient-years. The causes of late death were acute rejection (n = 4; 50%), cardiac allograft vasculopathy (n = 2; 25%), multiorgan failure (n = 1; 13%), and infection (n = 1; 13%). The 1-, 5-, 10-, and 15-year survival was respectively 78, 68, 54, and 38% (primary cardiac transplantation), and 46, 41, 32, and 32% (cardiac retransplantation) (p = 0.003). The short-term survival for cardiac retransplantation due to cardiac allograft vasculopathy was likely better than primary graft failure and refractory acute rejection (p = 0.09). Conclusion: The overall outcomes of cardiac retransplantation are significantly inferior to primary cardiac transplantation. Cardiac retransplantation should be only performed for selected patients.     

Preoperative C-reactive protein is predictive of long-term outcome after coronary artery bypass surgery

Background: Increased levels of C-reactive protein (CRP) are associated with the presence and severity of atherosclerosis, and with increased risk of coronary events as well as of cardiac events after coronary percutaneous intervention. Methods: We have investigated whether preoperative CRP had an impact on the long-term outcome of 843 patients who underwent on-pump coronary artery bypass surgery (CABG). Results: Among operative survivors, patients with preoperative CRP <1.0 mg/dL had significantly better 12-year overall survival rate (74.1% vs 63.0%, p = 0.004) and survival freedom from fatal cardiac event (86.7% vs 78.1%). Multivariate analysis including patients’ age, extracardiac arteriopathy, urgent/emergent operation, recent myocardial infarction, congestive heart failure, left ventricular ejection fraction, atrial fibrillation, transient ischemic attack/stroke, number of distal anastomoses, diabetes, and preoperative CRP ≥1.0 mg/dL or <1.0 mg/dL, showed that the latter was an independent predictor of late all-cause mortality (p = 0.017, RR 1.60, 95% CI 1.09–2.35). Its impact on overall survival was particularly evident in patients with left ventricular ejection fraction <50% (CRP < 1.0 mg/dL: 58.7% vs CRP ≥ 1.0 mg/dL: 43.7%, p < 0.00001). Conclusions: Increased preoperative levels of CRP are associated with significantly decreased overall survival after primary on-pump CABG.     

The "lively" cytokines network in beta-Thalassemia Major-related osteoporosis

Osteoporosis affects approximately 40–50% of adult patients with β-Thalassemia Major (βTM). Recent data have implicated an altered modulation of the osteoprotegerin (OPG)/receptor activator of NFkB ligand (RANKL) system in the pathogenesis of βTM-osteoporosis. OPG/RANKL system acts downstream from IL-1, IL-6 and TNF- and it may be the final actor mediating the effects of these cytokines on the regulation of both postmenopausal and metabolic bone resorption. However, to date, there are no data on circulating levels of these pro-resorptive cytokines in βTM patients. We investigated the potential relationships among these cytokines, several markers of bone turnover and bone mineral density (BMD) in βTM patients.

IL-1, IL-6 and TNF-, OPG and RANKL serum levels, hemato-urinary bone remodeling markers and bone mineral density (BMD) at L2L4 and femoral neck as well as erythropoietin (EPO), 17β-estradiol, and free-testosterone levels were measured in 30 well treated βTM patients and in 20 healthy subjects, matched for age, sex and BMI with the patients.

βTM patients showed an altered bone turnover, with increased deoxypyridinoline (D-PYR) levels (P < 0.0001), decreased osteocalcin (BGP) concentrations (< 0.0001) and significantly lower lumbar (P = 0.001) and femoral (P < 0.05) BMD values as compared to controls. Circulating levels of IL-1 (P < 0.0001), TNF- (P < 0.0001) and IL-6 (P < 0.05) were all increased in βTM patients as compared with controls. In βTM patients, IL-1 was significantly related with D-PYR (r = 0.5; P < 0.05), RANKL (r = 0.7; P = 0.03) and IL-6 (r = 0.3; P = 0.006); IL-6 was also significantly correlated with D-PYR (r = 0.5; P < 0.05) and EPO levels (r = 0.3; P = 0.03); TNF- showed a negative correlation with L2L4 BMD (r = − 0.4; P < 0.05).

Our data demonstrate, for the first time, an association between increased circulating levels of pro-resorptive cytokines and an altered bone turnover in βTM-patients, suggesting their involvement in the pathogenesis of βTM-osteoporosis.