What is new in fasting guidelines of surgical patients? Review of the literature

The concept of perioperative starvation requires an update on a more balanced physiological bias. The old British dictum "nil by mouth from midnight" is a thing of the past. We need to administer food and fluids as early as possible both before both before and after surgery and to avoid or reduce hospital infections. Resumption of bowel movements is very rapid, and the patients are fed and experience no thirst and thus have better compliance during their hospital stay. Moreover, the social cost is reduced. A short review of the rules of various Associations of Anaesthetists both in Europe and the US shows that today the starvation time is reduced, and re-feeding after surgery is implemented early. For clear fluids a 2-h period before surgery without ingestion of clear fluids is enough, whilst in most countries a 6-h period of starvation for solid foods is the rule, but if proper distinctions are made between the various nutrients given to the patients, this time could be reduced to 2-3 hours.     

Pneumonia in acute leukemia patients during induction therapy: experience in a single institution

Pneumonia is still a complication leading to high morbidity and mortality rates in acute leukemia (AL) patients. To evaluate the incidence, risk factors and outcome of pneumonia in a single institution we retrospectively studied 288 patients observed between 1994 and 2000, affected by AL (218 acute myeloblastic leukemia and 70 acute lymphoblastic leukemia [ALL]) treated with an anthracycline-containing induction regimen. Of 288 patients, 80 (27.7%) developed pneumonia: 67/80 had acute myelogenous leukemia (AML) and 13/80 had ALL. At univariate analysis only advanced age correlated with the risk of pneumonia (P < 0.001). Of the 80 pneumonia cases, 25 (31.2%) were microbiologically documented and 65 (68.8%) were clinically demonstrated; pneumonia responded to treatment in 44/80 (55%) patients; among the patients with positive outcome of their pneumonia 33/44 (75%) achieved complete remission whereas only 2/36 (5%) patients with a negative outcome achieved complete remission. At multivariate analysis the determinants of positive outcome of pneumonia were younger age (P < 0.05), the achievement of complete remission (P < 0.005) and the recovery of neutrophils (P < 0.005).     

Oxidative stress in renal anemia of hemodialysis patients is mitigated by epoetin treatment

BACKGROUND/AIMS: Oxidative stress often occurs in chronic hemodialysis (HD) patients. The objective of our study was to investigate the interrelationship between oxidative stress and the degree of renal anemia. METHODS: In 107 consecutive HD patients, serum concentrations of two major aldehydic lipid peroxidation (LPO) products, 4-hydroxynonenal (HNE) and malondialdehyde (MDA), and of protein carbonyls were analyzed as parameters of oxidative stress and related to the degree of renal anemia. Additionally, in 76 patients treated with epoetin long-term changes in the serum levels of aldehydic LPO products were observed. RESULTS: In HD patients, serum levels of HNE, MDA, and protein carbonyls are increased in comparison to controls. The lower the hemoglobin, i.e. the stronger the degree of renal anemia, the higher the serum concentrations of HNE, MDA, and protein carbonyls. The HNE and MDA levels decreased during HD. Long-term studies on the correction of renal anemia by epoetin demonstrated a mitigation of oxidative stress during this therapy. During periods of 1 and 2 years, it was observed that the serum levels of HNE and MDA could be reduced. CONCLUSION: Chronic renal failure is connected with oxidative stress which correlates with the degree of renal anemia, and the serum levels of aldehydic LPO products could be reduced during correction of renal anemia by epoetin.     

Influence of enteral nutrition on cytokine response in resective liver surgery

Postoperative infectious complications are nowadays a major problem in liver surgery. Better surgical outcomes with a consequent reduction in treatment and hospitalisation costs are a primary objective. The aim of this prospective, randomised study was to evaluate the cytokine response during and after portal clamping in patients undergoing liver resection and continuously fed with enteral nutrition as compared to patients receiving parenteral nutritional support. Forty patients with liver tumours were divided into two groups of 20 on the basis of the presence or absence of chronic liver disease. Furthermore, the latter group of 20 were randomised to two subgroups A and B of 10 patients on the basis of the different perioperative nutrition modalities. Group A patients were fed by so-called uninterrupted enteral nutrition, which means without interruption from the day before surgery with a nutritional solution delivered via a nasojejunal tube. The patients in group B were submitted to hepatic resection with parenteral nutritional support. Liver resection had to consist in resection of at least 30% of the parenchyma in non-cirrhotic patients or in segmental resection in cirrhotic ones. Ten milliliter blood samples were harvested before operation, and 10, 30 and 60 min after declamping and at 24 h. Interleukin 6 and a-tumour necrosis factor values were detected in blood samples. The values of C reactive protein and of prealbumin were recorded at 72 h postoperatively. We also evaluated postoperative complications, resumption of bowel movements, oral intake of nourishment, and patient discharge. Values in blood samples in the two groups showed a statistically significant difference in interleukin 6 values only after 24 h (10 min: group A 121 +/- 25.3, group B 156 +/- 31.4; after 24 h: group A 31.5 +/- 12, group B 105.1 +/- 24.1), while the a-tumour necrosis factor assay showed no significant difference between the two groups. However, there was an appreciably longer hospital stay (group A 10.9 +/- 3.1 days (range: 7-21 days), group B 13.2 +/- 2.7 days (range: 8-19 days) (P < 0.02) and a quicker resumption of bowel movements in group A. The data available show that uninterrupted enteral nutrition produces a modulation of the cytokine response following portal clamping. A lower cytokine activation cascade reduces the impact of the action of cytokines on the hepatic parenchyma with consequent enhancement of the hepatic Kupffer cell component. These factors thus substantially reduce the length of the patient's hospital stay and consequently the cost of medical care.     

Usefulness of the high triglyceride-to-HDL cholesterol ratio to identify cardiometabolic risk factors and preclinical signs of organ damage in outpatient children

OBJECTIVE

To evaluate whether the high triglyceride-to-HDL cholesterol (TG-to-HDL-C) ratio is associated with cardiometabolic risk (CMR) factors and preclinical signs of organ damage in an outpatient population of white children and adolescents.

RESEARCH DESIGN AND METHODS

The study population included 884 subjects (aged 6–16 years), of whom 206 (23%) were normal weight, 135 (15%) were overweight, and 543 (61%) were obese. Biochemical variables were analyzed in the whole sample, whereas homocysteine and left ventricular (LV) geometry and function were evaluated in 536 and 258 children, respectively.

RESULTS

The percentage of pubertal children (P < 0.001), as well as measurements of BMI, waist circumference, homeostasis model assessment of insulin resistance, white blood cell count, alanine aminotransferase (ALT), systolic blood pressure (P < 0.0001, for all), creatinine (P < 0.001), and diastolic blood pressure (P < 0.02), increased from the lowest to the highest tertile of the TG-to-HDL-C ratio. Age, sex, homocysteine, and glomerular filtration rate did not change. Moreover, interventricular septum thickness, relative wall thickness, and LV mass index (P = 0.01 to P < 0.0001) increased across tertiles of the TG-to-HDL-C ratio. Children with a TG-to-HDL-C ratio ≥2.0 showed a two- to threefold higher risk of elevated ALT levels and concentric LV hypertrophy than those with a TG-to-HDL-C ratio <2.0, independent of confounding factors.

CONCLUSIONS

The high TG-to-HDL-C ratio is associated with several CMR factors and preclinical signs of liver and cardiac abnormalities in the outpatient, white pediatric population. Thus, a TG-to-HDL-C ratio ≥2.0 may be useful in clinical practice to detect children with a worsened CMR profile who need monitoring to prevent cardiovascular disease in adulthood.There is growing interest in the identification of cardiovascular risk factors at an early stage of life because increased BMI (1), altered glucose homeostasis (2), and high blood pressure (3) in childhood are associated with a high risk of developing obesity, diabetes, hypertension, and coronary artery disease in adulthood. Few prospective studies have analyzed the abnormalities of the lipid profile from childhood to adulthood. The Bogalusa Heart Study (4) and the Muscatine Study (5) have demonstrated that the best predictor of lipid or lipoprotein levels in adulthood is the level observed in childhood, underscoring the importance of assessing the lipid profile early in life, although the cutoff to define dyslipidemia in children still is debated (6).In adults, lipoprotein ratios are recognized as being more useful than isolated lipid values for cardiovascular disease risk assessment because they better reflect the interactions between lipid fractions (7). In particular, the triglyceride-to-HDL cholesterol (TG-to-HDL-C) ratio is closely related to both insulin resistance and cardiometabolic risk (CMR) in a white population (8).The clinical and prognostic significance of the TG-to-HDL-C ratio in the pediatric population is, at present, unclear. Weiss et al. (9) have recently demonstrated that the TG-to-HDL-C ratio measured in late adolescence predicts a proatherogenic lipid profile in adulthood independently of obesity and weight gain. Whether a high TG-to-HDL-C ratio is able to detect CMR factors and preclinical signs of organ damage in the pediatric population has not yet been investigated. To address this issue, we explored the relationship between the TG-to-HDL-C ratio and CMR factors as well as its association with subclinical signs of liver and cardiac abnormalities in an outpatient, white pediatric population.     

Itraconazole inhibits HMEC-1 angiogenesis

Abnormal angiogenesis is implicated in a number of human diseases and endothelial growth inhibition represents a common approach in tumor therapy. Recently itraconazole, frequently used in humans as antifungal drug, which blocks the biosynthesis of cholesterol, has been found to be antiangiogenic in primary umbilical vein endothelial cells. However, the exact antiangiogenic mechanisms remain largely unknown. In this paper, we studied the effect of itraconazole in human dermal microvascular endothelial cells (HMEC-1), an immortalized cell line to study adult angiogenesis. A 50% reduction of microtubule formation was observed after itraconazole treatment which was partially rescued by cholesterol addition. We found that itraconazole inhibits angiogenesis markers such as VEGF, AAMP and e-NOS. mTOR and ERK1/2 phosphorylation as well as the expression of Gli1, one of the main controllers of the Shh pathway, were also inhibited by itraconazole. Cholesterol addition did not completely rescue inhibition of these pathways, suggesting that the itraconazole antiangiogenic activity could be due to multiple mechanisms. Our results may contribute to novel approaches to block angiogenesis with therapeutic application.     

The first Italian patient with oculopharyngodistal myopathy: case report and considerations on differential diagnosis

Oculopharyngodistal myopathy is a clinicopathologically distinct muscular disease. The underlying genetic defect has not been identified. We report here a 43-year old woman with asymmetric bilateral ptosis, dysphonia, swallowing difficulties, and weakness of the distal leg muscles. Serum creatine kinase was moderately increased. Electromyography revealed myopathic changes and myotonic discharges. Both cardiologic and pneumologic evaluation did not reveal abnormalities. Muscle computed tomography images showed adipose tissue replacement of abdominis rectus, lateral vastus, adductor magnus, and both the posterior and anterior compartment muscles below the knee, with prevalent involvement of medial gastrocnemius muscle. Muscle biopsy uncovered changes in fiber size and the presence of atrophic fibers with rimmed vacuoles of varying diameter, and core-like structures in type I fibers. Diagnosis was performed according to clinical and histopathologic findings, which were fully consistent with the other reported patients, and on the genetic exclusion of similar conditions such as oculopharyngeal muscular dystrophy, myotonic dystrophy type 1 and multi-minicore disease associated to RYR1 mutations. Differential diagnosis with mitochondrial myopathies, facioscapulohumeral muscular dystrophy and distal myopathies was also considered. This is the first Italian case of oculopharyngodistal myopathy, further suggesting the worldwide distribution of this rare neuromuscular disorder.     

Bond strength evaluation of three self-adhesive luting systems used for cementing composite and porcelain

Self-adhesive resin cements were recently introduced with the purpose of simplifying the cementation technique, as they combine the use of adhesive and cement in a single application, eliminating the need for pretreatment of the tooth. In the present study a microtensile bond strength test (μ-TBS) was used to compare three self-adhesives, an etch-and-rinse and a self-etch luting system, in the cementation of resin-based composite (RBC) and ceramic disks to dentin. Freshly extracted molars were transversally sectioned to expose flat, deep dentin surfaces. Cylindrical specimens (5 mm in diameter and 10 mm in height), consisting of RBC disks and leucite-based glass ceramic disks, were produced. The RBC disks were sandblasted with 50-μm Al2O3. The ceramic disks were conditioned with 9.5% hydrofluoric acid gel and silane application. All of the disks were then bonded to dentin surfaces employing five different luting agents: iCEM Self Adhesive (Heraeus Kulzer), MaxCem (Kerr Corporation), RelyX UniCem (3M ESPE), EnaCem HF (Micerium), and Panavia F2.0 (Kuraray-Dental). The products were applied according to the manufacturers' instructions. The specimens were sectioned perpendicular to the adhesive interface to produce multiple beams measuring approximately 1 mm2 in cross section. For each experimental group 12 beams were tested. The preterm failures were also taken into account. All of the specimen preparations were performed by the same operator. The beams were tested under tension at a crosshead speed of 0.5 mm/min until failure. Mean μ-TBS values were calculated for each group. Data were analyzed by a two-way analysis of variance, and multiple comparisons were performed using a Tukey test (α=0.05). The UniCem group showed the lowest number of preterm failures among the tested self-adhesive systems. When premature debondings were included in the mean value calculation, bond strength values for the UniCem group were statistically equal to or even higher than those achieved with the other self-adhesives, although these values were still statistically worse than those obtained using traditional multi-step luting agents.