Effect of Prophylactic Dalteparin on Anti-factor Xa Levels in Morbidly Obese Patients After Bariatric Surgery

Background

There are limited data on appropriate dosing of low-molecular-weight heparins (LMWH) for venous thromboembolism (VTE) prophylaxis in bariatric surgery. The objective of this study was to describe the postoperative effects of LMWH dalteparin on anti-factor Xa (AFXa) level in morbidly obese patients undergoing bariatric surgery.

Methods

This was a retrospective study. Morbidly obese patients (BMI?≥?40 kg/m² or BMI?>?35 kg/m² with at least one significant co-morbidity) received subcutaneous dalteparin 7,500 IU daily during the postoperative period after biliopancreatic derivation with duodenal switch. AFXa level was measured 4 h after the fourth dalteparin administration.

Results

One hundred and thirty-five patients with a mean BMI of 53.7 kg/m² were included into this study. Only 60% of patients had targeted AFXa levels (0.2–0.5 UI/ml). There was a statistical difference in body weight between individuals with sub-target AFXa levels and those with values over target (159.4?±?35.8 vs. 134.6?±?24.2, p?=?0.0310). There were three haemorrhages documented. These events were not associated with elevated AFXa values.

Conclusion

These findings indicate that the 7,500 IU dalteparin dosage is appropriate for the majority of morbidly obese patients undergoing bariatric surgery. The present study, however, suggests that this dose might not be sufficient for patient with a very high body weight.     

Parenteral Nutrition Does Not Improve Postoperative Recovery from Radical Cystectomy: Results of a Prospective Randomised Trial

Background

After radical cystectomy, patients are in a catabolic state because of postoperative stress response, extensive wound healing, and ileus.

Objective

To evaluate whether recovery can be improved with total parenteral nutrition (TPN) in patients following extended pelvic lymph node dissection (ePLND), cystectomy, and urinary diversion (UD).

Design, setting, and participants

We conducted a prospective, randomised, single-centre study of 157 consecutive cystectomy patients.

Intervention

Seventy-four patients (group A) received TPN during the first 5 postoperative days, with additional oral intake ad libitum. Eighty-three patients (group B) received oral nutrition alone.

Outcome measurements and statistical analysis

The primary outcome was the occurrence of postoperative complications. Secondary outcomes were time to recovery of bowel function, biochemical nutritional (serum albumin, serum prealbumin, serum total protein) and inflammatory (C-reactive protein) parameters, length of hospital stay, and costs attributed to the TPN. The Pearson χ² test was used for dichotomous variables; the Wilcoxon rank sum test was used for continuous variables.

Results and limitations

Postoperative complications occurred in 51 patients (69%) in group A and in 41 patients (49%) in group B (p = 0.013), a difference resulting from group A having more infectious complications than group B (32% vs 11%; p = 0.001). Serum prealbumin and serum total protein were significantly lower in group B on postoperative day 7 but not on postoperative day 12. Time to gastrointestinal recovery and length of hospital stay did not differ between the two groups. The costs for TPN were €614 per patient. A potential limitation is the use of a glucose-based parenteral nutrition without lipids.

Conclusions

Postoperative TPN is associated with a higher incidence of complications, mainly infections, and higher costs following ePLND, cystectomy, and UD versus oral nutrition alone.     

Bicipital groove orientation: considerations for the retroversion of a prosthesis in fractures of the proximal humerus

The bicipital groove anatomy is well documented, and this groove is used as a landmark to guide retroversion during implantation of a shoulder prosthesis. Whereas the proximal part of the groove is used in osteoarthritis, the distal part is used in fractures. If used in 4-part fracture cases, we must assume that the bicipital groove orientation is constant from proximal to distal. We measured the groove orientation in 40 cadaveric humeri using 3 superimposed computed tomography sections. The reference axis was the transepicondylar axis at the elbow level. The measured angle of the bicipital groove was 55.8 degrees +/- 4.5 degrees at the anatomic neck and 65.1 degrees +/- 3.5 degrees at the surgical neck. This difference (mean of 9.3 degrees, with extremes of -3 degrees and 22.5 degrees) was statistically significant. We confirmed a wide range of variation from 22 degrees to 89 degrees in the orientation of the groove. Because the values listed in the literature for lateral fin placement of a prosthesis have not been measured at the surgical neck level and because of the great variation in groove orientation, we caution surgeons about the use of the bicipital groove as a reliable landmark in shoulder replacement for fractures. Considering the risk of over- or under-retroversion of the prosthesis, we recommend the use of a fracture jig with retroversion set to 20 degrees.     

Retention of dental sealants placed on sound teeth and incipient caries lesions as part of a service‐learning programme in rural areas in Mexico

International Journal of Paediatric Dentistry 2012; 22: 451–458 Background. Dental sealants are an effective treatment for the prevention and management of caries. Objective. To determine the retention of sealants placed in a rural setting in Mexico as part of an international service‐learning (ISL) programme and to determine associations between dental sealant’s retention and caries diagnosis at the time of sealant placement. Methods. Children aged 6–15 were examined for dental caries, received sealants by dental students as part of an ISL programme, and were re‐examined 4, 2, or 1 years after placement to assess sealant survival. Sealants were placed on permanent sound surfaces and enamel caries lesions [International Caries Assessment and Detection System (ICDAS) criteria]. Sealant survival was explored using Cochran–Mantel–Haenszel tests and multivariate prediction models. Results. 219 (46%) of 478 (mean age = 10.53 SD = 5.11) children who had received sealants returned for a recall examination (mean age = 10.89 SD = 3.11). After 1–4 years, 96.4% to 60.6% of the sealants placed on sound teeth had survived, and for sealants placed on surfaces with enamel caries lesions (ICDAS 1–3), 94.2% to 55.6% had survived. Differences were not statistically significant. Conclusions. Sealants had survival rates comparable to those previously reported in the literature. Sealants placed on sound and enamel caries lesions had similar survival rates.     

Overexpression of FKBP51 in idiopathic myelofibrosis regulates the growth factor independence of megakaryocyte progenitors

Idiopathic myelofibrosis (IMF) is a chronic myeloproliferative disorder characterized by megakaryocyte hyperplasia and bone marrow fibrosis. Biologically, an autonomous megakaryocyte growth and differentiation is noticed, which contributes to the megakaryocyte accumulation. To better understand the molecular mechanisms involved in this spontaneous growth, we searched for genes differentially expressed between normal megakaryocytes requiring cytokines to grow and IMF spontaneously proliferating megakaryocytes. Using a differential display technique, we found that the immunophilin FKBP51 was 2 to 8 times overexpressed in megakaryocytes derived from patients' CD34(+) cells in comparison to normal megakaryocytes. Overexpression was moderate and confirmed in 8 of 10 patients, both at the mRNA and protein levels. Overexpression of FKBP51 in a UT-7/Mpl cell line and in normal CD34(+) cells induced a resistance to apoptosis mediated by cytokine deprivation with no effect on proliferation. FKBP51 interacts with both calcineurin and heat shock protein (HSP)70/HSP90. However, a mutant FKBP51 deleted in the HSP70/HSP90 binding site kept the antiapoptotic effect, suggesting that the calcineurin pathway was responsible for the FKBP51 effect. Overexpression of FKBP51 in UT-7/Mpl cells induced a marked inhibition of calcineurin activity. Pharmacologic inhibition of calcineurin by cyclosporin A mimicked the effect of FKBP51. The data support the conclusion that FKBP51 inhibits apoptosis through a calcineurin-dependent pathway. In conclusion, FKBP51 is overexpressed in IMF megakaryocytes and this overexpression could be, in part, responsible for the megakaryocytic accumulation observed in this disorder by regulating their apoptotic program.     

Continuous facial nerve monitoring during pleomorphic adenoma recurrence surgery

OBJECTIVES: Surgery of recurrent pleomorphic adenoma (RPA) is known to lead to a high facial nerve complication rate. The efficacy of the continuous facial nerve monitoring (CFNM) technique remains to be proven in RPA surgery. The goal was thus to evaluate facial nerve palsy rates and the recovery period after parotidectomy for RPA using CFNM by way of continuous electromyography and to compare these rates and the operation time with those of patients who had undergone surgery without facial nerve monitoring. DESIGN: Cohort study. PATIENTS: Forty-seven patients were referred for RPA (1981-2003). Among them, 32 (18 unmonitored and 14 monitored) patients displayed no preoperative facial palsy, and histologic analyses revealed evidence of recurrence. The operation time and the extent and duration of postoperative facial nerve palsy were examined in both groups (monitored vs. unmonitored). Both groups had a similar clinical appearance distribution. RESULTS: Facial nerve paralysis was estimated using the House-Brackmann grading scale. CFNM reduced the intensity of facial nerve paralysis independently of the kind of surgery performed. The complete deficit rates were 0% for the monitored group and 5.6% for the unmonitored group. Postoperative facial nerve paralysis was significantly lower (P = .01) in the monitored group than in the unmonitored group. CFNM improved the duration of facial paralysis (P = .001) in the monitored group. The operation time was significantly lower in the monitored group than in the unmonitored group (P = .001). CONCLUSIONS: Routine use of CFNM during RPA surgery improves the surgical outcome. The facial nerve deficit can be reduced, and the recovery of facial nerve function is faster.     

An effective strategy for diagnosing occupational asthma: use of induced sputum

Monitoring airway inflammation by means of induced sputum cell counts seems to improve the management of asthma. We sought to assess whether such monitoring at the end of periods at and away from work combined with the monitoring of PEF could improve the diagnosis of occupational asthma. We enrolled subjects suspected of having occupational asthma. Serial monitoring of PEF was performed during 2 weeks at and away from work. At the end of each period, induced sputum was collected. Specific inhalation challenge was subsequently performed. PEF graphs were interpreted visually by five independent observers. Forty-nine subjects, including 23 with positive specific inhalation challenge, completed the study. The addition of sputum cell counts to the monitoring of PEF increased the specificity of this test, respectively, by 18 (range [r] 13.7-25.5) or 26.8% (r 24.8-30.4) depending if an increase of sputum eosinophils greater than 1 or 2% when at work was considered as significant. The sensitivity increased by 8.2% (r 4.1-13.4) or decreased by 12.3% (r 3.1-24.1) depending on the cutoff value in sputum eosinophils chosen (greater than 1 or 2%, respectively). The addition of sputum cell counts to PEF monitoring is useful to improve the diagnosis of occupational asthma.