Association between albumin administration and survival in cardiac surgery: a retrospective cohort study

Purpose

Albumin is widely used during and after on-pump cardiac surgery, although it is unclear whether this therapy improves clinical outcomes.

Methods

This observational study utilized the Cerner Health Facts® database (a large HIPAA-compliant clinical-administrative database maintained by Cerner Inc., USA) to identify a cohort of 6,188 adults that underwent on-pump cardiac surgery for valve and/or coronary artery procedures between January 2001 and March 2013. Of these, 1,095 patients who received 5% albumin with crystalloid solutions and 1,095 patients who received crystalloids alone on the day of or the day following cardiac surgery were selected by propensity-score matching. The primary outcome was all-cause in-hospital mortality. Three secondary outcomes analyzed include acute kidney injury severity, major morbidity composite, and all-cause 30-day readmissions.

Results

In the propensity-score matched cohort, receipt of perioperative 5% albumin was associated with decreased risk of in-hospital mortality (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3 to 0.9; P = 0.02) and lower all-cause 30-day readmission rates (OR, 0.7; 98.3% CI, 0.5 to 0.9; P < 0.01). Albumin therapy was not associated with differences in overall major morbidity (OR, 0.9; 98.3% CI, 0.7 to 1.2; P = 0.39; composite) or acute kidney injury severity (OR, 0.9; 98.3% CI, 0.6 to 1.4; P = 0.53) compared with therapy with crystalloid solutions.

Conclusions

In this large retrospective study, use of 5% albumin solution was associated with significantly decreased odds of in-hospital mortality and all-cause 30-day readmission rate compared with administration of crystalloids alone in adult patients undergoing on-pump cardiac surgery. These results warrant further studies to examine fluid receipt, including 5% albumin, in surgical populations via randomized-controlled trials.

     

The lesser evil? Initiating a benzodiazepine prescription in general practice: A qualitative study on GPs’ perspectives

OBJECTIVE: Chronic benzodiazepine (BZD) use is widespread and linked with adverse effects. There is consensus concerning the importance of initiating BZD as a crucial moment. Nevertheless specific research in this field is lacking. This paper addresses the views of GPs on why they start prescribing BZDs to first-time users. DESIGN: Qualitative study with five focus groups analysed using a systematic content analysis. SETTING: Regions of Ghent and Brussels in Belgium. SUBJECTS: A total of 35 general practitioners. MAIN OUTCOME MEASURE: The GPs' perspective on their initiating of BZD prescribing. RESULTS: GPs reported that they are cautious in initiating BZD usage. At the same time, GPs feel overwhelmed by the psychosocial problems of their patients. They show empathy by prescribing. They feel in certain situations there are no other solutions and they experience BZDs as the lesser evil. They admit to resorting to BZDs because of time restraint and lack of alternatives. GPs do not perceive the addictive nature of BZD consumption as a problem with first-time users. GPs do not specifically mention patients' demand as an element for starting. CONCLUSION: The main concern of GPs is to help the patient. GPs should be aware of the addictive nature of BZD even in low doses and a non-pharmacological approach should be seen as the best first approach. If GPs decide to prescribe a BZD they should make plain to the patient that the medication is only a "temporary" solution with clear agreements with regard to medication withdrawal.     

Restriction of dietary energy intake has a greater impact on bone integrity than does restriction of calcium in exercising female rats

We sought to elucidate the effects of restricting calcium, energy, or food on the skeletal integrity of exercising female rats. Female Sprague-Dawley rats (4 mo old) were randomly assigned to 5 groups (n = 10/group): ad libitum intake of an AIN-93M diet (Research Diets D10012M, Research Diets, Inc.) with no exercise (AL-S) or with exercise (AL-EX) or to 1 of 3 exercising restriction groups [40% restriction of calcium only (CAR-EX), energy only (ER-EX), or food (FR-EX)]. All EX rats were treadmill trained 3 d/wk, 45 min/d for 12 wk at ~60% maximal oxygen consumption. After 12 wk, total body bone mineral content (by DXA) and body mass, but not lean mass, were lower in ER-EX (-17%) and FR-EX rats (-13%) compared with the AL-EX group. CAR-EX had few negative effects on bone geometry (by peripheral quantitative computed tomography) or histomorphometry. However, declines in total volumetric bone mineral density at the proximal tibia metaphysic (PTM) were observed in ER-EX (-6%) and FR-EX (-8%) groups; only FR-EX rats exhibited increased osteoclast surface and decreased mineral apposition rate in PTM cancellous bone. Decrements in serum estradiol, uterine weights, or both in these 2 groups implicate altered estrogen status as contributory. Urine pH declined significantly by 12 wk in all restricted groups, but net acid excretion increased only in CAR-EX rats. These findings, when compared with published data on sedentary rats, suggest that treadmill running exercise may mitigate some, but not all, deleterious effects on bone after chronic energy or food restriction but is more protective during calcium restriction.     

Inflammation,Apoptosis, and Necrosis Induced by Neoadjuvant Fas Ligand Gene Therapy Improves Survival of Dogs With Spontaneous Bone Cancer

Fas ligand (FasL) gene therapy for cancer has shown promise in rodents; however, its efficacy in higher mammals remains unknown. Here, we used intratumoral FasL gene therapy delivered in an adenovirus vector (Ad-FasL) as neoadjuvant to standard of care in 56 dogs with osteosarcoma. Tumors from treated dogs had greater inflammation, necrosis, apoptosis, and fibrosis at day 10 (amputation) compared to pretreatment biopsies or to tumors from dogs that did not receive Ad-FasL. Survival improvement was apparent in dogs with inflammation or lymphocyte-infiltration scores >1 (in a 3-point scale), as well as in dogs that had apoptosis scores in the top 50th percentile (determined by cleaved caspase-3). Survival was no different than that expected from standard of care alone in dogs with inflammation scores ≤1 or apoptosis scores in the bottom 50th percentile. Reduced Fas expression by tumor cells was associated with prognostically advantageous inflammation, and this was seen only in dogs that received Ad-FasL. Together, the data suggest that Ad-FasL gene therapy improves survival in a subset of large animals with naturally occurring tumors, and that at least in some tumor types like osteosarcoma, it is most effective when tumor cells fail to express Fas.     

Transcatheter placement of a low-profile biodegradable pulmonary valve made of small intestinal submucosa: a long-term study in a swine model

OBJECTIVE: We sought to investigate a placement of a percutaneous low-profile prosthetic valve constructed of small intestinal submucosa in the pulmonary position in a swine model. METHODS: Twelve female farm pigs were stented at the native pulmonary valve to induce pulmonary insufficiency. Once right ventricular dilation occurred, the small intestinal submucosa valve was implanted. The pigs were followed up with transthoracic echocardiographic Doppler scanning. One animal died of heart failure before valve replacement. Animals were euthanized at 1 day, 1 month, 3 months, 6 months, and 12 months after valve implantation. RESULTS: The small intestinal submucosa pulmonary valve showed effective reversal of pulmonary regurgitation. There were no misplacements during deployment. There were no embolizations. One-year echocardiographic follow-up showed minimal regurgitation and no stenosis for a valve/vessel ratio of 0.78 or greater. Histologic examination demonstrated intensive remodeling of the small intestinal submucosal valve. Within 1 month, the surface was covered by endothelium, and fibroblasts invaded the interior. Over the following months, the small intestinal submucosal valve remodeled without apparent graft rejection. CONCLUSION: The small intestinal submucosa valve has the potential for graft longevity without the need for anticoagulation or immunosuppression. Histologic remodeling of the valve tissue provides a replacement capable of resembling a native valve that can be placed percutaneously with low-profile delivery systems.     

Academic detailers’ and general practitioners’ views and experiences of their academic detailing visits to improve the quality of analgesic use: process evaluation alongside a pragmatic cluster randomized controlled trial

Background

Continuous medical education strategies, including academic detailing (AD), have mixed effects on the quality of prescribing in general practice. Alongside a cluster-randomized controlled trial (cRCT) to assess the effectiveness of AD visits (on appropriate prescribing of analgesics for chronic pain in osteoarthritis) by Farmaka, an independent drug information center, we performed a process evaluation to identify possible barriers and success factors to improve these AD visits, both from the perspective of the academic detailers delivering the visits and the general practitioners (GPs) receiving them.

Methods

We performed semi-structured interviews with 20 GPs who participated in the cRCT and 13 academic detailers. The interviews were transcribed verbatim and analysed using thematic analysis.

Results

GPs viewed AD visits as a practical and useful CME strategy, that is less time consuming than other CME activities, and the visitors as providers of objective and independent information relevant to their daily practice with whom they can have meaningful discussion. Academic detailers saw themselves as content experts, mainly informing GPs about the topic and not emphasizing on behavior change. Both GPs and academic detailers believed that the AD visits could have better interaction and discussion if performed in small groups. According to the GPs, the visits on analgesic use provided some new and relevant information as well as clarifying some misconceptions. They increased awareness of the disadvantages of particular non-steroidal anti-inflammatory drugs and of the lower doses of paracetamol that should be prescribed for chronic use, which may have changed their beliefs and/or attitudes towards more appropriate prescribing for osteoarthritis. However, the transfer of knowledge into practice was seen as not so straightforward.

Conclusions

GPs view AD visits as a credible and interesting way of CME that enhances their knowledge and increases reflection on their prescribing behavior.

     

Neurocognitive function profile in HIV-infected school-age children

OBJECTIVES: Evaluation of neurocognitive function of school-age children with HIV. DESIGN: Cross-sectional observational study. METHODS: Twenty-two children (median age 9.46 years) with perinatally acquired HIV infection were administered a global intelligence test and tests from the Amsterdam Neuropsychological Tasks (ANT) program. The relationship between various patient-, disease- and treatment factors and neurocognitive outcome variables was examined. RESULTS: Compared with age-appropriate norms, mean IQ of the HIV-infected children was in the average range. However, the HIV-infected children performed poorer on several neuropsychological tests compared with age-appropriate norms. Executive function (attentional flexibility, visuospatial working memory) and processing speed emerged as the most sensitive cognitive measures in relation to HIV disease. The correlational analyses resulted in only two significant outcomes, showing that higher CD4% at initiation of highly active antiretroviral therapy (HAART) and longer treatment duration were associated with better working memory function and attentional control, respectively. CONCLUSIONS: These exploratory data suggest that subtle neurocognitive impairments may exist in HIV-infected school-age children, in particular characterized by compromised executive function and slowed information processing. Further research with larger sample sizes is needed to confirm these findings.     

Tissue microarray immunohistochemical expression of estrogen, progesterone, and androgen receptors in uterine leiomyomata and leiomyosarcoma

BACKGROUND: Benign uterine leiomyomata (LMA) are hormonally responsive neoplasms. To the authors' knowledge, little is known regarding the hormonal expression patterns of leiomyosarcomas (LMSs) of the uterus. The objective of the current study was to assess the immunohistochemical (IHC) patterns of estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (AR) expression in LMA and LMS of the uterus using a tissue microarray. The authors also sought to assess the prognostic value of ER, PR, and AR expression in LMS. METHODS: Between January 1991 and March 2001, 25 patients were identified with primary uterine LMS for whom tissue was available. A tissue microarray was created with 3 representative cores from each of the LMS cases, as well as from 19 cases with benign uterine LMA. IHC staining was scored as follows: negative (0-1) and positive (2-3). Outcome analyses were performed for LMS only. First recurrence was determined from the time of the initial diagnosis. Survival was determined from the time of the initial diagnosis to last follow-up. RESULTS: ER, PR, and AR positivity in LMA compared with LMS was as follows: ER, 78% versus 40% (P = 0.03); PR, 88% versus 38% (P = 0.001); and AR, 32% versus 40% (P = 0.75). There was no difference noted with regard to IHC expression based on stage of LMS. The median overall survival for patients with LMS was 23.5 months (95% confidence interval, 19.5, NR). When adjusted for stage, PR and AR were found to be predictive of a lower risk of recurrence (P = 0.01 and P = 0.035, respectively). ER, PR, and AR were not found to be associated with overall survival after adjustment for stage. Tumor stage was found to be associated with survival (P = 0.005). CONCLUSIONS: The rate of ER and PR expression was found to be significantly less in uterine LMS compared with LMA. ER, PR, and AR expression was observed in approximately 30-40% of uterine LMS cases. In the current series, PR and AR expression appeared to be associated with disease-free survival but were not found to correlate with overall survival.