Adrenergic Receptor Genotype but Not Perioperative Bisoprolol Therapy May Determine Cardiovascular Outcome in At-risk Patients Undergoing Surgery with Spinal Block: The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study: A Double-blinded, Placebo-controlled, Multicenter Trial with 1-Year Follow-up

Background: Neuraxial blockade is used as primary anesthetic technique in one third of surgical procedures. The authors tested whether bisoprolol would protect patients at risk for cardiovascular complications undergoing surgery with spinal block.

Methods: The authors performed a double-blinded, placebo-controlled, multicenter trial to compare the effect of bisoprolol with that of placebo on 1-yr composite outcome including cardiovascular mortality, nonfatal myocardial infarction, unstable angina, congestive heart failure, and cerebrovascular insult. Bisoprolol was given orally before and after surgery for a maximum of 10 days. Adrenergic receptor polymorphisms and safety outcome measures of bisoprolol therapy were also determined.

Results: A total of 224 patients were enrolled. Spinal block could not be established in 5 patients. One hundred ten patients were assigned to the bisoprolol group, and 109 patients were assigned to the placebo group. The mean duration of treatment was 4.9 days in the bisoprolol group and 5.1 days in the placebo group. Bisoprolol therapy reduced mean heart rate by 10 beats/min. The primary outcome was identical between treatment groups and occurred in 25 patients (22.7%) in the bisoprolol group and 24 patients (22.0%) in the placebo group during the 1-yr follow-up (hazard ratio, 0.97; 95% confidence interval, 0.55-1.69; P = 0.90). However, carriers of at least one Gly allele of the [beta]1-adrenergic receptor polymorphism Arg389Gly showed a higher number of adverse events than Arg homozygous (32.4% vs. 18.7%; hazard ratio, 1.87; 95% confidence interval, 1.04-3.35; P = 0.04).     

Cost reduction of perioperative coagulation management in cardiac surgery: value of ‘bedside’ thrombelastography (ROTEM)

Objective: Demographic changes and aggressive platelet inhibition have resulted in a marked increase in blood- and coagulation product expenditure and costs in cardiac surgery. We analyzed ‘bedside’ coagulation test (ROTEM) in order to verify clot forming quality for the purpose of finding a cost-effective treatment path. Methods: Annual treatment costs of all cardiosurgical patients were analyzed before (729 patients) and after (693 patients) implementation of ‘bedside’ ROTEM. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and coagulation factors: pooled coagulation concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. Number of resternotomies and early mortality was assessed and compared in both periods. Results: After ROMTEM implementation cumulative RBC expenditure showed 25% decrease while PltC exhibited 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (−80%) while rFVIIa were entirely omitted. Fibrinogen, however, increased two-fold. Cumulative average monthly costs of all blood products decreased from 66,000€ to 45,000€ (−32%). Coagulation factor average monthly costs decreased from 60,000€ to 30,000€ (−50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1.580€. Total number of resternotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. Conclusion: Cumulative costs for treatment of perioperative coagulation disorders can be reduced by ‘bedside’ ROTEM analysis to achieve a selective substitution management. Saved costs for blood- and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.     

Severity of vertebral fracture reflects deterioration of bone microarchitecture

Introduction Bone microarchitecture, a component of bone strength, is generally measured on transiliac bone biopsy samples. The objective of this study was to determine whether assessment of four grades of vertebral fracture severity could serve as a noninvasive surrogate marker for trabecular bone volume and microarchitecture. Methods Baseline vertebral fracture severity was determined by semiquantitative assessment of spine radiographs from 190 postmenopausal women with osteoporosis. Bone-structure indices were obtained by 2D histomorphometry and 3D microcomputed tomography (CT) analyses. Significance of differences was determined after adjusting for age, height, and lumbar spine bone mineral density. Results There were significant (P < 0.05) trends in decreasing bone volume, trabecular number, and connectivity, and increasing trabecular separation with greater vertebral fracture severity. Histomorphometric bone volume was 25 and 36% lower (P < 0.05) in women with moderate and severe fractures than in women with no fractures, respectively. Compared with women without fractures, women with mild, moderate, and severe fractures had lower (P < 0.05) microCT bone volume (23, 30, and 51%, respectively). Conclusions Microarchitectural deterioration was progressively worse in women with increasing severity of vertebral fractures. We conclude that assessment of vertebral fracture severity is an important clinical tool to evaluate the severity of postmenopausal osteoporosis.     

The comparative effects of bariatric surgery on weight and type 2 diabetes

Background: Epidemiological evidence confirms that risk of developing type 2 diabetes is related to weight gain. Weight reduction is beneficial as relative risk is reduced to 0.13 for weight loss >20 kg. This raises the question of effectiveness of bariatric surgery on 1) weight loss and 2) diabetes-related outcomes in morbidly obese patients. Methods: We reviewed the literature using Medline. Only 2 meta-analyses reporting on both outcomes were included, as well as 50 systematic reviews or primary studies. Results: Meta-analyses mainly based on case series data as well as controlled studies confirm that bariatric surgery is highly effective in obtaining weight reduction in morbidly obese patients up to 60% of the excess weight, along with resolution of preoperative diabetes in more than 75% of cases. Among bariatric surgery techniques, malabsorptive procedures (biliopancreatic diversion and gastric bypass) appear to be more effective on both outcomes than restrictive procedures (gastroplasty and gastric banding). Conclusion: Even if more studies are needed to confirm current evidence, bariatric surgery is effective for controlling diabetes. It appears as an efficient strategy from economic modeling due to savings from reduction in diabetes-related costs.     

Repeat Transarterial Chemoembolization (TACE) for Progressive Hepatic Carcinoid Metastases Provides Results Similar to First TACE

Background Transarterial chemoemobolization (TACE) is commonly used to treat metastatic carcinoid tumors; however, the management of progressive disease is less clear. We sought to determine if patients with disease progression after TACE would benefit from repeat TACE. Methods The records of 27 patients undergoing repeat TACE for radiologic or symptomatic progression after TACE for metastatic carcinoid were reviewed and compared to 122 undergoing first TACE. Overall and progression-free survivals were estimated by the Kaplan–Meier method. Results Mean disease-free interval after first TACE was 11.8 months. Radiologic response was observed in 61% compared to 82% after first TACE (p = 0.058); hormone response in 64% compared to 80% (p = 0.159); and symptomatic response in 77% compared to 92% (p = 0.053). The complication rate after repeat TACE was lower than after first TACE (p = 0.03). Median overall survival was similar after repeat (28.1 months) and first TACE (33.3 months) (p = 0.53). Progression-free survival was shorter after repeat TACE but not significantly so. No factor examined could predict survival after repeat TACE. Conclusion Repeat TACE for patients with hepatic carcinoid metastases failing first TACE or having evidence of disease progression is safe and offers a viable treatment option. Presented at the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, DC, May, 2007.     

Urinary tract infection caused by <Emphasis Type="Italic">Haemophilus influenzae</Emphasis> and <Emphasis Type="Italic">Haemophilus parainfluenzae</Emphasis> in children

There are few reports on urinary tract infections caused by Haemophilus influenzae or Haemophilus parainfluenzae in children. The true incidence is not known, since bacteria of Haemophilus species do not grow in standard urine culture media. With the objective of investigating the occurrence and character of urinary tract infections (UTIs) caused by Haemophilus bacteria in children, we searched the files of our UTI clinic. Over a 24-year period 36 children with Haemophilus spp. bacteriuria were identified out of a total of more than 5,000 UTI episodes. There was a significant gender difference in that Haemophilus influenzae dominated in girls and Haemophilus parainfluenzae in boys. With one exception, all children had important urinary tract abnormalities, such as malformation, gross reflux or bladder dysfunction. Permanent renal damage was seen in 25. We conclude that growth of Haemophilus bacteria in urine is associated with serious urinary tract abnormalities. The inability of bacteria of the Haemophilus species to grow in standard media commonly used for culture of uropathogens suggests that the true frequency of these strains as a cause of urinary tract infections is underestimated.     

BCL-XL expression levels influence differential regional astrocytic susceptibility to 1,3-dinitrobenzene

The selective vulnerability of brainstem astrocytes to 1,3-dinitrobenzene is mediated by a 10-fold lower threshold for opening of the cyclosporin A-inhibitable mitochondrial permeability transition pore (mtPTP). BCL-XL, BAX and BCL-2 are members of the BCL-2 protein family known to regulate both apoptotic and necrotic cell death signaling at the mtPTP. The levels at which these proteins are expressed relative to one another, where in the cell they are located and whether they are post-translational modified contributes greatly to the balance in active agonistic to active antagonistic BCL-2 proteins, and this critical balance has been hypothesized to dictate regional astrocytic susceptibility to DNB. The effects of DNB on the balance in expression of the BCL-2 family proteins have been evaluated in F344 rat DNB-sensitive (brainstem) and non-sensitive (cortical) tissue homogenates and primary astrocytes. No significant treatment-related alterations in BCL-XL, BAX or BCL-2 protein expression are observed in rat tissue homogenates or primary astrocytes. However, moderate increases in BCL-XL are observed only in DNB-treated rat cortical astrocytes, and these increases may be sufficient to shift the constitutive balance in expression of antagonistic to agonistic BCL-2 proteins from a ratio which favors BAX to one in which BAX and BCL-XL are comparably expressed. Rat primary brainstem and cortical astrocytes are also transiently transfected with bcl-xl to evaluate whether or not moderate enhancement of BCL-XL protein expression levels are sufficient to alter regional sensitivity to DNB in vitro. BCL-XL overexpression minimizes DNB-induced inhibition of succinate dehydrogenase (complex II) activity and increases significantly the concentration of DNB required to induce MPT onset in primary brainstem and cortical astrocytes. Results from the current investigation suggest that modest region-specific alterations in the balance in expression of antagonistic to agonistic BCL-2 proteins may adequately explain differential regional sensitivity to DNB-induced mitochondrial dysfunction.