A randomised single-blind study to improve health-related quality of life by treating anaemia of chronic kidney disease with Aranesp® (darbepoetin alfa) in older people: STIMULATE

Background

The prevalence of chronic kidney disease (CKD) increases with age, and the risk of significant anaemia increases as renal function declines. The objectives of this study were to assess the effect of darbepoetin alfa administration on health-related quality of life (HRQOL) through treatment for anaemia in older patients with CKD.

Methods

In this multicentre, randomised, placebo-controlled trial, older patients (aged ≥70 years) with CKD (Stages 3–5, predialysis) and haemoglobin (Hb) < 11.0 g/dL were randomised to darbepoetin alfa (n = 28) or placebo (n = 23). HRQOL was measured using a number of instruments including Short Form-36 (SF-36) and Functional Assessment of Cancer Therapy-Anaemia (FACT-An).

Results

The primary endpoint, mean SF-36 Vitality Score at Week 24, was comparable between the darbepoetin alfa (51.4 [95 % CI 48.0, 54.9]) and placebo (46.7 [40.9, 52.5]) groups. Darbepoetin alfa-treated patients experienced statistically significant improvements in some SF-36 and FACT-An Subscale Scores. Mean Hb was higher with darbepoetin alfa (12.5 [12.1, 12.9] g/dL) than with placebo (10.5 [10.1, 11.0] g/dL). The safety profiles were comparable between the treatment groups. The study was limited by only 20 % of the planned patient recruitment being achieved.

Conclusions

Darbepoetin alfa increased Hb and, within study limitations, suggested that improvements in some HRQOL domains in older CKD patients with anaemia may be achieved with more physiological haemoglobin.     

Bovine haemoglobin is more potent than autologous red blood cells in restoring muscular tissue oxygenation after profound isovolaemic haemodilution in dogs

Purpose

This study compares the effects of stored red cells, freshly donated blood and ultrapurified polymerized bovine haemoglobin (HBOC) on haemodynamic variables, oxygen transport capacity and muscular tissue oxygenation after acute and almost complete isovolaemic haemodilution in a canine model.

Methods

Following randomization to one of three groups, 24 anaesthetized Foxhounds underwent isovolaemic haemodilution with 6% hetastarch to haematocrit levels of 20%, 15% and 10% before they received isovolaemic stepwise augmentation of 1 g · dl^?1 haemoglobin. In Group 1, animals were given autologous stored red cells which they had donated three weeks before. In Group 2, animals received freshly donated blood harvested during haemodilution. In Group 3, animals were infused with HBOC. Skeletal muscle tissue oxygen tension was measured with a polarographic 12 μ needle probe.

Results

In all groups, heart rate and cardiac index were increased with decreasing vascular resistance during haemodilution (P < 0.05). Haemodynamic variables showed a reversed trend during transfusion when compared to haemodilution but remained below baseline (P < 0.05). Arterial and venous oxygen content were changed in parallel to changes of haematocrit and haemoglobin concentrations but were lower in Group 3 than in Groups 1 and 2 (P < 0.05) during transfusion. In contrast, the oxygen extraction ratio was higher in Group 3 (59 ± 8%, P < 0.01) at the end of transfusion than in Group 1 (37 ± 13%) and 2 (32 ± 5%). In Group 3, mean tissue oxygen tension increased from 16 ± 5 mmHg after haemodilution to 56 ± 11 mmHg after transfusion (P < 0.01) and was higher than in Group 1 (41 ± 9, P < 0.01) and Group 2 (29 ± 11, P < 0.01). While in Group 3 an augmentation of 0.7 g · dl^?1 haemoglobin resulted in restoring baseline tissue oxygenation, higher doses of 2.7 g · dl^?1 and 2.1 g · dl^?1 were needed in Groups 1 and 2 to reach this level (P < 0.01).

Conclusion

The results show a higher oxygenation potential of HBOC than with autologous stored red cells because of a more pronounced oxygen extraction.     

Impact of hemoglobin levels on renal and non-renal clinical outcomes differs by chronic kidney disease stages: the Gonryo study

Background

Anemia greatly affects the development of renal and cardiovascular outcomes in chronic kidney disease (CKD) patients. However, the impact based on CKD stage remains unclear.

Methods

We prospectively followed 2,602 Japanese CKD patients under the care of nephrologists. CKD was defined according to cause, estimated glomerular filtration rate <60 mL/min, and/or proteinuria. Patient outcomes [primary end-points: cardiovascular events (CVEs), all-cause mortality, and end-stage kidney disease (ESKD) requiring renal replacement therapy] were assessed in association with basal hemoglobin (Hb) levels (<10, 10–12 and ≥12 g/dL), stratified by CKD stages.

Results

During follow-up, 123 patients developed CVEs, 41 died, and 220 progressed to ESKD. For stages G3, G4 and G5, ESKD frequencies were 2.8, 64.4, and 544.8 person-years, while CVEs and death were 25.6, 45.6, and 76.3 person-years, respectively. The combined endpoint rate was significantly higher in patients with Hb <10 versus Hb 10–12 g/dL, but a higher risk for CVEs and death with Hb <10 g/dL was found only in G3 [hazard ratio (HR) 4.49, (95 % confidence interval (95 % CI) 2.06–9.80)]. In contrast, risk for ESKD with Hb <10 g/dL was found only in G4 [HR 3.08 (95 % CI 1.40–6.79)] and G5 [HR 1.43 (95 % CI 1.01–2.05)]. No increased risks with higher Hb levels were found.

Conclusion

The impact of renal anemia of Hb <10 g/dL on clinical outcomes differed by CKD stage, with a significantly high risk for CVEs and all-cause mortality in G3 and progression to ESKD in G4 and G5.

     

Extra-uterine renal growth in preterm infants: Oligonephropathy and prematurity

Background

Nephron number in humans is determined during fetal life. The objective of this study was to investigate the effects of preterm birth on nephron number using renal volume as a surrogate for nephron number.

Methods

This observational study was conducted over 12 months in a tertiary perinatal center. Preterm babies less than 32 weeks of gestation were recruited and followed until discharge. Term infants were recruited for comparison. The babies underwent renal sonography and renal function measurements at 32 and 38 weeks corrected age. The primary outcome measurement was total kidney volume at 38 weeks and the secondary outcome was estimated glomerular filtration rate (eGFR).

Results

Forty-four preterm infants and 24 term infants were recruited. At 38 weeks corrected age, premature infants had lower total kidney volume than term infants (21.6?±?5.7 vs. 25.2?±?5.7 ml; p?=?0.02) and a significantly lower eGFR (73.6 [IQR 68.1–77.6] vs. 79.3 [IQR 72.5–86.6] ml·min^?1·1.73 m^?2; p?=?0.03). There was a significant correlation between total kidney volume and eGFR in premature and term babies.

Conclusions

Premature infants have smaller kidney volume and likely decreased nephron number and lower estimated glomerulofiltration rate relative to infants born at term.     

Visualization of subcapsular hepatic malignancy by indocyanine-green fluorescence imaging during laparoscopic hepatectomy

Background

Although laparoscopic hepatectomy has increasingly been used to treat cancers in the liver, the accuracy of intraoperative diagnosis may be inferior to that of open surgery because the ability to visualize and palpate the liver surface during laparoscopy is relatively limited. Fluorescence imaging has the potential to provide a simple compensatory diagnostic tool for identification of cancers in the liver during laparoscopic hepatectomy.

Methods

In 17 patients who were to undergo laparoscopic hepatectomy, 0.5 mg/kg body weight of indocyanine green (ICG) was administered intravenously within the 2 weeks prior to surgery. Intraoperatively, a laparoscopic fluorescence imaging system obtained fluorescence images of its surfaces during mobilization of the liver.

Results

In all, 16 hepatocellular carcinomas (HCCs) and 16 liver metastases (LMs) were resected. Of these, laparoscopic ICG fluorescence imaging identified 12 HCCs (75 %) and 11 LMs (69 %) on the liver surfaces distributed over Couinaud’s segments 1–8, including the 17 tumors that had not been identified by visual inspections of normal color images. The 23 tumors that were identified by fluorescence imaging were located closer to the liver surfaces than another nine tumors that were not identified by fluorescence imaging (median [range] depth 1 [0–5] vs. 11 [8–30] mm; p < 0.001).

Conclusions

Like palpation during open hepatectomy, laparoscopic ICG fluorescence imaging enables real-time identification of subcapsular liver cancers, thus facilitating estimation of the required extent of hepatic mobilization and determination of the location of an appropriate hepatic transection line.     

Evaluation of lymph node metastasis in patients with gastric cancer: a comparison of the directionality of lymph node metastasis and the total number of metastatic lymph nodes

Purpose

The clinical impact of the directionality of lymph node (LN) metastasis was assessed in comparison with the staging by the Japanese Classification of Gastric Carcinoma (JCGC), a numerical LN staging system.

Methods

Two hundred forty-one gastric cancer patients who were diagnosed pathologically to have LN metastasis, and 54 patients who underwent preoperative multidetector-row computed tomography (MDCT) with an image thickness of 1 mm were classified into three groups (unidirectional [Uni-], bidirectional [Bi-], and tridirectional [Tri-] groups) depending on the directionality of their LN metastasis.

Results

The prognosis of the Uni-group was better than that of the Bi- or the Tri-group when assessed on the basis of the pathological findings of metastatic LN and also the preoperative MDCT findings. The exact preoperative evaluation was 70.2 % for the directionality system and 61.7 % for the JCGC system, respectively. The stages were less frequently underestimated by the directionality system than the JCGC system (P < 0.02, 19.1 vs. 34.0 %), and the staging could be more precisely performed by both systems in combination.

Conclusions

More precise preoperative evaluation of disease stage could be obtained by the directionality system and the JCGC system in combination.     

Low 1,25-dihydroxyvitamin D level is associated with erythropoietin deficiency and endogenous erythropoietin resistance in patients with chronic kidney disease

Purpose

Erythropoietin (EPO) deficiency and resistance to endogenous EPO is an important pathophysiological feature in anemia of chronic kidney disease (CKD). Low 1,25 dihydroxyvitamin D [1,25(OH)₂D] level is known to contribute to anemia of CKD. We aimed to investigate the associations between serum 1,25(OH)₂D and anemia, EPO deficiency, and endogenous EPO resistance in patients with CKD.

Methods

This study included 409 patients with CKD [glomerular filtration rate (GFR)?<?60 ml/min/1.73 m²] who were not on dialysis therapy. Patients on exogenous EPO therapy and patients with iron deficiencies were excluded. Endogenous EPO resistance was assessed by calculating the ratio of endogenous EPO to hemoglobin (Hb) (endogenous EPO/Hb ratio). The associations of Hb level, endogenous EPO level, and the endogenous EPO/Hb ratio with clinical and laboratory variables were investigated by univariate and multivariate analyses.

Results

In univariate analysis, serum 1,25(OH)₂D level was correlated with the Hb level, endogenous EPO level, and the endogenous EPO/Hb ratio. Multiple regression analysis revealed that the serum 1,25(OH)₂D level remained significantly associated with the Hb level (β?=?0.532, P?<?0.001), endogenous EPO level (β?=?0.149, P?=?0.010), and the endogenous EPO/Hb ratio (β?=???0.187, P?=?0.002), even after adjusting for other confounding factors, including the levels of parathyroid hormone and the inflammatory marker C-reactive protein.

Conclusion

The serum 1,25(OH)₂D level exhibited significant associations with anemia, EPO deficiency, and endogenous EPO resistance in CKD patients. These associations were independent of secondary hyperparathyroidism and inflammation status.

     

Plasma methemoglobin as a potential biomarker of anemic stress in humans

Purpose

Transfusion of allogeneic red blood cells (RBCs) is one of the main treatments of acute anemia secondary to blood loss and fluid resuscitation within the operating room. Decisions to transfuse blood are based largely on intermediate biological markers (hemoglobin, arterial oxygen saturation, blood pressure, heart rate) which may not accurately reflect inadequacy of tissue oxygen delivery. Based on experimental studies, we hypothesized that anemia-induced tissue hypoxia activates adaptive mechanisms which promote local vascular nitric oxide (NO) production to improve tissue perfusion and survival during acute anemia. Hemoglobin (Hb) oxidation to methemoglobin (MetHb) may be a byproduct of such local NO production. Therefore, we tested the hypothesis that MetHb is a biomarker of hypoxic-anemic stress during acute hemodilution associated with cardiopulmonary bypass.

Methods

With institutional ethics approval, routine laboratory arterial blood gas and co-oximetry values were obtained from 295 patients undergoing heart surgery during February 1 to September 30, 2010, and the values were assessed retrospectively. All samples with an arterial oxygen saturation value ??90% were included (n?=?1,421). The maximal change in Hb associated with hemodilution on cardiopulmonary bypass was determined within 48 hr of surgery (n?=?180). A chart review was performed to determine the incidence of RBC transfusion and exogenous nitrate administration. All anonymous data were analyzed by linear regression to determine the relationship between Hb and MetHb. A Wilcoxon Signed Rank Test and Student??s t test were used to determine changes in Hb, MetHb, and carboxyhemoglobin (CarboxHb) levels. All data are presented as mean and significance was assigned at P?<?0.05.

Results

A significant decrease in Hb [118 (20) g·L^?1 vs 94 (18) g·L^?1] was associated with an increase in MetHb [0.88 (0.22)% vs 0.95 (0.24)%] (P?<?0.001 for both), but not CarboxHb [1.08 (0.47)% vs 1.08 (0.49)%]. Regression analysis revealed a significant relationship between the change in Hb and MetHb (F?=?40.3; P?<?0.001) but not between the change in Hb and CarboxyHb (F?=?0.2; P?=?0.694). This correlation was not influenced by RBC transfusion or exogenous nitrate use.

Conclusions

A negative correlation was observed between the change in Hb and MetHb in patients undergoing cardiac surgery and cardiopulmonary bypass. These data support the previously unreported hypothesis that MetHb may be a marker of anemic stress associated with reduced tissue perfusion during acute hemodilution in humans. Further prospective studies are needed to determine if these changes in MetHb are linked to adverse outcomes in patients undergoing cardiac surgery.     

Lower Glycemic Fluctuations Early After Bariatric Surgery Partially Explained by Caloric Restriction

Background

We assessed the acute impact of laparoscopic Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) compared to caloric-matched control group without surgery on glucose excursion in obese patients with type 2 diabetes, and examined if this was mediated by changes in insulin resistance, early insulin response or glucagon-like peptide (GLP)-1 levels.

Methods

Six-day subcutaneous continuous glucose monitoring (CGM) recordings were obtained from patients beginning 3 days before GBP (n?=?11), SG (n?=?10) or fasting in control group (n?=?10). GLP-1, insulin and glucose were measured during 75 g oral glucose tolerance testing at the start and end of each CGM.

Results

Post-operative hyperglycaemia occurred after both surgeries in the first 6 h, with a more rapid decline in glycaemia after GBP (p?<?0.001). Beyond 24 h post-operatively, continuous overlapping of net glycaemia action reduced from baseline after GBP (median [interquartile range]) 1.6 [1.2–2.4] to 1.0 [0.7–1.3] and after SG 1.4 [0.9–1.8] to 0.7 [0.7–1.0]; p?<?0.05), similar to controls (2.2 [1.7–2.5] to 1.3 [0.8–2.8] p?<?0.05). Higher log GLP-1 increment post-oral glucose occurred after GBP (mean ± SE, 0.80?±?0.12 vs. 0.37?±?0.09, p?<?0.05), but not after SG or control intervention. Among subgroup with baseline hyperglycaemia, a reduction in HOMA-IR followed GBP. Reduction in time and level of peak glucose and 2-h glucose occurred after both surgeries but not in controls.

Conclusions

GBP and SG have a similar acute impact on reducing glycaemia to caloric restriction; however, with a superior impact on glucose tolerance.     

Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis

Introduction

To identify the preoperative predictors of requirement for postoperative allogenic blood transfusion following hip and knee joint arthroplasty.

Materials and methods

We analysed the retrospective data on patients with rheumatoid arthritis who had undergone either total hip or knee arthroplasty at a single university teaching hospital. Factors of age, sex, procedure type, preoperative haemoglobin, blood transfusion data, comorbidities and body mass index were investigated for association with postoperative allogenic blood after hip or knee arthroplasty.

Results

Three hundred and forty nine cases of patients with rheumatoid arthritis were reviewed. 21 % (n = 72) required allogenic blood transfusion. The only significant predictive preoperative factors associated with postoperative blood transfusion were a low preoperative haemoglobin (Hb) level (p < 0.001), procedure of total hip arthroplasty (p = 0.008), a previous history of myocardial infarction (p = 0.038) and previous allogenic blood transfusion (p = 0.03). A preoperative haemoglobin <120 g/l was associated with a tenfold increase in transfusion requirement. All patients with a preoperative Hb level <90 g/l were transfused.

Conclusions

The ability to identify those within this high-risk group who are likely to receive blood transfusion allows for an informed, appropriate and cost effective approach to blood management strategies.     

Determinants of hemoglobin variability in stable peritoneal dialysis patients

Purpose

Significant within-patient hemoglobin (Hb) level variability is well recognized in particularly hemodialysis patients. Several factors such as hospitalizations, intercurrent diseases and IV iron therapy are found to be related to Hb variability (Hb-var). In this observational study, we aimed to identify predictors and outcome of Hb-var in peritoneal dialysis (PD) patients without hospitalization, intercurrent disease and IV iron therapy during the study period.

Methods

All patients were in the maintenance phase of short-acting erythropoiesis-stimulating agents (ESAs) therapy. The target range of Hb was 11–12 g/dL according to KDOQI Guidelines in 2007. The desired range of Hb was 11–12.5 g/dL. Patients’ demographic and laboratory data were collected at baseline. Atherosclerotic disease was assessed using carotid intima-media thickness (CIMT). We assessed Hb variability with various methods using SD Hb_mean, SD Hb_range and the velocity of Hb change. Hb deflect_positive, Hb deflect_negative, Hb values and ESA dosing were recorded monthly for 6 months.

Results

This study included 50 prevalent PD patients (mean age 46.9 ± 13.7 years, 25 women). The mean velocity of Hb change was negatively correlated with age and positively correlated with frequent ESA dose changes. Higher albumin and residual renal function (RRF) were also positively correlated with Hb deflect_positive. Patients with CIMT ≥0.7 cm had lower SD Hb range compared to CIMT <0.7 cm. Cumulative survival was better in patients with Hb levels consistently ≥10 g/dL compared to patients who had Hb <10 g/dL for at least 1 month. However, Hb-var was not associated with mortality.

Conclusions

In PD patients without hospitalization, intercurrent disease(s) or IV iron therapy, young age, higher albumin or RRF and lower CIMT were associated with greater oscillations in response to ESA therapy. Careful and appropriate ESA dose changes considering these parameters could minimize Hb variability in these patients.     

Effect of erythropoiesis-stimulating agents on hemoglobin level,fatigue and hospitalization rate in renal palliative care patients

Objectives

To investigate the effect of erythropoiesis-stimulating agents (ESAs) on hemoglobin (Hb) level, fatigue and hospitalization rate in renal palliative care (PC) patients.

Method

A retrospective cohort study was done between April 2011 and January 2013 in renal palliative care clinic of clustered hospitals in Hong Kong. The study participants included end-stage renal patients (CrCl < 15 ml/h) decided not for dialysis (ESA 39 patients; control 31 patients). From healthcare databases, we retrieved the patient demographics, laboratory results, reasons and time of hospitalizations during the study period. Fatigue was measured by Edmonton Symptom Assessment Scale.

Results

Most were elderly patients and about half of patients had underlying diabetes mellitus. Baseline mean Hb levels were similar (7.57 ± 0.97 g/dL for ESA vs 7.77 ± 0.72 g/dL for control). Mean Hb was raised significantly after 3 and 6 months of ESA injections (9.42 and 9.40 g/dL respectively, P < 0.05). Fatigue was reduced significantly at 3 and 6 months after treatment (P = 0.006 and P = 0.017 respectively). All-cause hospitalization was reduced significantly and there was a trend toward reduction in red blood cell transfusion requirement in the ESA group (P = 0.084).

Conclusion

This study demonstrated that use of ESAs in renal PC was effective and might help in reducing fatigue and hospitalizations rate.     

The intracranial volume pressure response in increased intracranial pressure patients: Part 1. Calculation of the volume pressure indicator

Background

The intracranial pressure (ICP) is usually continuously monitored in the management of patients with increased ICP. The aim of this study was to discover a mathematic equation to express the intracranial pressure–volume (P–V) curve and a single indicator to reflect the status of the curve.

Methods

Patients with severe brain damage who had bilateral external ventricular drainage (EVD) from December 2008 to February 2010 were included in this study. The EVD was used as drainage of CSF and ICP monitor. The successive volume pressure response [6] values were obtained by successive drainage of CSF from ICP 20–25 to 10?mmHg. Parabolic, exponential, and linear regression models were designed to have a single parameter as the indicator to determine the P–V curves.

Results

The mean of parameter “a” in the exponential equation is 1.473?±?0.054; in the parabolic equation, it is 0.332?±?0.061; and in the linear equation, it is 1.717?±?0.209. All regression equations of P–V curves had statistical significance (p?<?0.005). Parabolic and exponential equations are closer to the original ICP curve than linear equation (p?<?0.005). There is no statistically significant difference between parabolic and exponential regressions.

Conclusions

The P–V curve can be expressed with linear, parabolic, and exponential regression models in increased ICP patients. The parabolic and exponential equations are more accurate methods to represent the P–V curve. The single parameter in the three regression equations can be compared in different conditions of one patient in clinical practice.     

Surgeon Volume Versus Morbidity and Cost in Patients Undergoing Pancreaticoduodenectomy in an Academic Community Medical Center

Background

Despite trends toward regionalization of care, the majority of pancreaticoduodenectomies (PD) are performed in community hospitals by surgeons with varying degrees of experience. We analyzed the impact of several variables, including surgeon volume, on outcomes following PD within a high-volume community-based teaching hospital system.

Methods

Patients who underwent PD from 2005 to 2008 were reviewed retrospectively. Perioperative data, complications, and hospital financial data was queried. A high-volume (HV) surgeon was defined as an average of 10 or more PD per year.

Results

Ninety-four patients underwent PD with an overall operative mortality rate of 9.6% (HV 2.2%, LV 16.0%), major complication rate of 32% (HV 18%, LV 44%), and median cost of $30,860 (HV $27,185, LV $33,007). Factors predictive of death were age (p?<?0.02), body mass index (p?<?0.01), and surgeon volume (p?<?0.05). Factors predictive of major complication were surgeon volume (p?<?0.01) and body mass index (p?<?0.01). Factors predictive for increased length of stay for patients discharged from the hospital were surgeon volume (p?<?0.02) and preoperative ASA classification (p?<?0.05).

Conclusions

Surgeon volume and patient body mass index have a significant impact on perioperative morbidity following PD in a community teaching hospital.     

Maintaining high hemoglobin levels improved the left ventricular mass index and quality of life scores in pre-dialysis Japanese chronic kidney disease patients

Background

Anemia is common among patients with chronic kidney disease (CKD). The introduction of erythropoietin treatment has changed anemia management, but the therapeutic hemoglobin (Hb) target is still under debate, and clinical evidence for its effect on cardiac functions and QOL is sparse.

Methods

A 16-week dose–response study and a 32-week follow-Up study were combined. After correcting anemia of less than 10 g/dl in pre-dialysis Japanese CKD patients, a higher Hb target (12–13 g/dl) by darbepoetin alfa (DPO) was compared with the conventional Hb target by epoetin alfa (EPO). Outcomes were anemia correction, management of the left ventricular mass index (LVMI) and QOL scores.

Results

No significant difference was seen in Hb at baseline and week 16, but a significant difference was recorded at week 34 (12.34 ± 0.93 g/dl for DPO and 10.43 ± 0.90 g/dl for EPO). In both groups, LVMI decreased similarly until week 16, but the decrease of EPO was retarded, and a significant difference between LVMI was seen only in DPO at week 34 (100.7 ± 16.6 g/m² for DPO and 110.9 ± 25.2 g/m² for EPO). Relationships between Hb and LVMI change at week 34 were examined by stratifying Hb into four groups (Hb <10 g/dl, 10 g/dl ≤ Hb <11 g/dl, 11 g/dl ≤ Hb <12 g/dl and 12 g/dl ≤ Hb), and a decrease of LVMI was prominent in the 12 g/dl ≤ Hb group. Correction of anemia to 11 g/dl or more led to improved QOL scores. No safety difference was observed among the treatments.

Conclusions

Targeting a higher Hb around 12 g/dl was more beneficial than targeting conventional Hb in terms of reduction of LVMI and QOL. Further studies to determine the appropriate Hb target are necessary.     

Calcium homeostasis influences radiological fracture healing in postmenopausal women

Introduction

Recent studies suggest that calcium and 25-[OH]-cholecalciferol represent substantial co-factors in fracture healing. However, there still seems to be no sustainable consensus regarding the influence on fracture healing patterns. In this study, the influence of calcium and vitamin D levels on fracture callus formation was prospectively analysed using pQCT scan.

Methods

94 postmenopausal females with distal radius fractures and consecutive surgery were included. Calcium, 25-[OH]-cholecalciferol, parathyroid hormone and bone-specific alkaline phosphatase levels were obtained prior surgical treatment and after 6 weeks. A pQCT scan was performed on both sites. Bone mineral density and fracture callus area were determined after detecting the outer border contour at a threshold of 280 mg/ccm. Patients received daily supplements of 1000 mg calcium and 880 IU 25-[OH]-cholecalciferol.

Results

Mean 25-[OH]-cholecalciferol level was 19.61 ± 21.87 ng/ml, mean parathyroid hormone level was 52.6 ± 58.9 ng/l and mean Ca level was 2.23 ± 0.35 mmol/l. After 6 weeks of supplementation a significant increase of calcium (p < 0.001) and 25-[OH]-cholecalciferol (p < 0.001), and a significant decrease of parathyroid hormone (p < 0.001) levels were observed. Sixth week follow-up fracture callus area correlated significantly with postoperative normal range calcium levels on the fractured site (p = 0.006). Bone mineral density correlated with age (p < 0.001), but not with calcium and 25-[OH]-cholecalciferol levels after 6 weeks. All fractures presented timely adequate callus formation.

Conclusion

Calcium and parathyroid hormone serum levels influence fracture callus area interpreted as fracture callus formation patterns. Calcium levels within physiological range accounted for highest fracture callus area. Therefore, a balanced calcium homeostasis is required for appropriate callus formation.     

Pulmonary resections in a tertiary care center—a prospective observational study of outcome

Introduction

In order to assess short term outcomes of pulmonary resections in one year, a prospective observational study was made. To assess the predictive factors for postoperative complications.

Subject and methods

Twenty eight patients who underwent pulmonary resections were included in the study prospectively from January 2011 to December 2011 in a single unit in a tertiary care cancer hospital and short term outcomes were analysed.

Results

Twenty patients underwent pulmonary resection for malignant conditions and 8 for benign conditions. Surgeries performed were lobectomy in 9, bilobectomy in 5, pneumonectomy in 3, lobectomy with chest wall excision in 3 and wedge resection in 8 patients. Of 8 patients who underwent wedge resection; 7 were for benign conditions and one for metastatic gestational trophoblastic neoplasia. Six patients developed postoperative complications. Two had air leak, one patient had prolonged ICU stay (>1 week), one had pneumonia and 2 had surgical site infection. Pulmonary complications occurred in 2 patients, both had Diffusing Capacity of the Lung for Carbon Monoxide (DLCO) <80 %; one had pneumonia and the other was on mechanical ventilation for 48 hours and ICU for 9 days. Four of the patients who developed complication had Eastern Cooperative Oncology Group (ECOG) performance status of 3 and two of them who developed complication had ECOG performance status of two.

Conclusion

DLCO is an important predictor for postoperative complication apart from performance status, pulmonary function tests, smoking and diabetes mellitus.     

The impact of body mass index on treatment outcomes among traumatic brain injury patients in intensive care units

Purpose

Obesity is a risk factor in treatment outcomes of critically ill patients. This study was conducted to determine the impact of obesity on the likelihood of recovery from traumatic brain injury (TBI) in intensive care unit (ICU) patients.

Methods

We carried out a prospective study on 115 head injury patients who were admitted to the ICU of Poursina Hospital, Rasht, in the one-year period between July 2006 and June 2007. Obese patients (body mass index [BMI] ≥ 30 kg/m²) were compared with non-obese patients (BMI < 30 kg/m²). Demographic information, acute physiology and chronic health evaluation scores, Injury Severity Scores (ISS), Glasgow Coma Scale scores, and ICU mortality incidences were recorded.

Results

Obese patients had significantly higher ICU mortality rates compared to non-obese patients (p = 0.02). Furthermore, we observed a trend towards a higher ICU mortality rate in obese patients with ISS > 25 (p = 0.04). Moreover, obesity was associated with prolonged mechanical ventilation, ICU length of stay (ILOS), and hospital length of stay (HLOS) (p < 0.001).

Conclusions

Obesity was associated with increased ICU mortality and prolonged dependency on mechanical ventilation, ILOS, and HLOS in patients with TBI. However, further prospective studies with larger sample sizes are needed to substantiate these findings.