Clinical outcomes of percutaneous interventions in saphenous vein grafts using drug-eluting stents compared to bare-metal stents: a comprehensive meta-analysisof all randomized clinical trials

Background:

Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug‐eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta‐analysis of all existing randomized controlled trials (RCTS) comparing bare‐metal stents (BMS) and DES in SVGPCIs.

Hypothesis:

PCI in patients with SVG disease using DES may reduce need for repeat revascularization without an excess mortality when compared to BMS.

Methods:

An aggregate data meta‐analysis of clinical outcomes in RCTs comparing PCI with DES vs BMS for SVGs reporting at least 12 months of follow‐up was performed. A literature search between Janurary 1, 2003 and September 30, 2011 identified 4 RCTs (812 patients; DES = 416, BMS = 396). Summary odds ratio (OR) and 95% confidence interval (CI) were calculated using the random‐effects model. The primary endpoint was all‐cause mortality. Secondary outcomes included nonfatal myocardial infarction (MI), repeat revascularization, and major adverse cardiac events (MACE). These outcomes were assessed in a cumulative fashion at 30 days, 18 months, and 36 months.

Results:

There were no intergroup differences in baseline clinical and sociodemographic characteristics. At a median follow‐up of 25 months, patients in the DES and BMS group had similar rates of death (OR: 1.63, 95% CI: 0.45–5.92), MI (OR; 0.83, 95% CI: 0.27‐2.60), and MACE (OR: 0.58, 95% CI: 0.25–1.32). Patients treated with DES had lower rates of repeat revascularization (OR: 0.40, 95% CI: 0.22–0.75).

Conclusions:

In this comprehensive meta‐analysis of all RCTs comparing clinical outcomes of PCI using DES vs BMS in patients with SVG disease, use of DES was associated with a reduction in rate of repeat revascularization and no difference in rates of all‐cause death and MI. Clin. Cardiol. 2012 DOI: 10.1002/clc.21984 Dr. Virani is supported by a Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA‐09‐028), and has research support from Merck and National Football League Charities (all grants to the institution and not individual). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Outcomes of preoperative Angiotensin-converting enzyme inhibitor therapy in patients undergoing isolated coronary artery bypass grafting

The association between preoperative use of angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass grafting (CABG) remain controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACE inhibitors. A retrospective analysis of 8,889 patients who underwent isolated CABG from 2000 through 2011 was conducted. The primary outcome of interest was the incidence of major adverse events (MAEs) defined as a composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. The secondary outcome was the incidence of individual outcomes included in MAEs. Logistic regression analyses were performed. Of 8,889 patients, 3,983 (45%) were on preoperative ACE inhibitors and 4,906 (55%) were not. Overall incidence of MAEs was 38.1% (n = 1,518) in the ACE inhibitor group compared to 33.6% (n = 1,649) in the no-ACE inhibitor group. Preoperative use of ACE inhibitors was independently associated with MAEs (odds ratio 1.13, 95% confidence interval 1.03 to 1.24), most of which was driven by a statistically significant increase in postoperative renal dysfunction (odds ratio 1.18, 95% confidence interval 1.03 to 1.36) and atrial fibrillation (odds ratio 1.15, 95% confidence interval 1.05 to 1.27). In-hospital mortality, postoperative myocardial infarction, and stroke were not significantly associated with preoperative ACE inhibitor use. Analyses performed after excluding patients with low ejection fractions yielded similar results. In conclusion, preoperative ACE inhibitor use was associated with an increased risk of MAEs after CABG, in particular postoperative renal dysfunction and atrial fibrillation.     

Hypoxie als ein Schlüsselfaktor im Entzündungsgebiet bei rheumatischen Erkrankungen

Chronic inflammatory diseases are characterized by hypoxia and subsequent cellular adaptation via hypoxia-inducible factor (HIF). Modulation of these adaptation mechanisms provides the basis for ideas on how to improve the effects of known drugs and for the development of novel therapeutic approaches.     

Functional Reorganization and Recovery After Constraint-Induced Movement Therapy in Subacute Stroke: Case Reports

Preliminary assessments of the feasibility, safety, and effects on neuronal reorganization measured with transcranial magnetic stimulation (TMS) from Constraint-Induced Movement Therapy (CIMT) of the upper extremity were made in eight cases of subacute stroke. Within fourteen days of their stroke, patients were randomly assigned to two weeks of CIMT or traditional therapy. Baseline motor performance and cortical/subcortical representation for movement with TMS were assessed before treatment. Post-treatment assessments were made at the end of treatment and at three months after the stroke. The TMS mapping showed a larger motor representation in the lesioned hemisphere of the CIMT patients as compared to the controls at the three-month follow-up assessment. The enlarged motor representation in the lesioned hemisphere for hand movement correlated with improved motor function of the affected hand, suggesting a link between movement representation size as measured with TMS and functionality. These results suggest that TMS can be safely and effectively used to assess brain function in subacute stroke and further suggest that CIMT may enhance cortical/subcortical motor reorganization and accelerate motor recovery when started within the first two weeks after stroke.     

Relations among Glycemic Control, Circulating Endothelial Cells, Nitric Oxide, and Flow Mediated Dilation in Patients with Type 2 Diabetes Mellitus

Circulating endothelial cells (CEC) have been identified as a surrogate marker of endothelial dysfunction. The aim of this study was to determine the association of glycemic control with CEC and endothelial function in patients with type 2 diabetes mellitus (DM).We studied 30 patients with type 2 DM and 20 age and sex matched healthy controls (HC). Number of circulating endothelial cells was measured by flow cytometry. Endothelial function was studied by measuring flow mediated vasodilation (FMD%) in the brachial artery and serum level of nitric oxide (NO).CEC count was significantly elevated in patients with DM, than HC (35.3±15.1 vs. 7.3±2.4, p<0.001) and in patients with HbA1c>7 than patients with HbA1c≤7 (47.4±5.5 vs. 19.5±5.7, p<0.001). FMD% and NO were lower in DM patients than HC (3.5±0.85 vs. 9.5±3.1, p<0.001 and 37.8±6.1 vs. 64.1±5.7, p<0.001 respectively). FMD% and NO were lower in patients with HbA1c>7 as compared to patients with HA1c≤7 (2.8±0.4 vs. 4.3±0.4, p<0.001 and 33.1±2.9 vs. 43.9±2.8, respectively, p<0.001). HbA1c correlated negatively with FMD% and NO levels and positively with CEC. CEC count correlated negatively with FMD% and NO. There was a significant positive correlation between CEC count and HBA1c (p<0.001 for all correlations).CEC is associated with markers of endothelial dysfunction and disease control in patients with type 2 DM. These findings suggest a potential role of CEC in the pathophysiology of cardiovascular disease in type 2 diabetic and raise the importance of tight glycemic control.     

Serum adipokines and low density lipoprotein subfraction profile in hypopituitary patients with growth hormone deficiency

The aim was to evaluate the concentrations of lipid subfractions in relation to adipokines and metabolic parameters in adult growth hormone (GH)-deficient hypopituitary patients on conventional replacement therapy. The study included 21 GH deficient-hypopituitary patients (age: 36.0 ± 15.1 years, male/female: 7/14) on conventional replacement therapy other than GH and 20 comparable controls (age: 37.3 ± 14.0 years, male/female: 6/14). Lipid subfractions (Lipoprint system), serum adipokine (leptin, adiponectin, resistin) concentrations, body composition, a surrogate marker for insulin resistance (HOMA) and conventional lipid profile were evaluated. No statistically significant difference was found with respect to HOMA, adipokine concentrations and anthropometric parameters between patients and controls except for significantly increased waist-to-hip ratio in hypopituitary group. Total and LDL cholesterol concentrations were significantly higher in the patients. LDL particle size (268.88 ± 3.16 vs. 271.31 ± 3.11 ?, P = 0.151) and small-dense LDL subfraction did not differ significantly. According to logistic regression analysis, triglyceride concentrations ≥1.69 mmol/L was the sole parameter significantly and independently predicted small (<268 ?) LDL particle size (P = 0.019) in the whole group. Increased triglyceride concentrations affect LDL particle size in GH-deficient hypopituitary patients. Small dense LDL seems not directly contribute to atherogenic potential in hypopituitarism.     

Nocturnal Medications Dosing: Does It Really Make a Difference in Blood Pressure Control Among Patients with Chronic Kidney Disease?

Ambulatory blood pressure (BP) monitoring is superior to clinic BP monitoring in predicting long-term consequences of hypertension. This has raised interest in diurnal variation in BP and elevation in nighttime BP as a prognostic and therapeutic target. Several studies have identified prevalence of nocturnal hypertension in patients with accelerated progression of chronic kidney disease and target organ damage. Some studies suggest that nocturnal BP can be lowered by changing administration of antihypertensive medication to bed time; whether that results in retarding kidney disease progression is not very clear. Further research is needed to determine if certain classes of medications or interventions are superior in controlling nocturnal hypertension, and protocols need to be developed to screen patients for monitoring nocturnal BP. Further studies are needed to evaluate long-term renal outcomes of evening dosing in patients with nocturnal hypertension and chronic kidney disease.     

Single-Stage Operative Management of Laparoscopic Sleeve Gastrectomy Leaks Without Endoscopic Stent Placement

Background

Leaks occur in 1.4–20 % (Bohdjalian et al., Obes. Surg. 20:535–540, 2010; Nocca et al., Obes Surg. 18:560–565, 2008; Stroh et al., 19:632–640, 2009; Aurora et al., Surg. Endosc. 26:1509–1515, 2012) of patients following laparoscopic sleeve gastrectomy (LSG). Leaks may lead to major morbidity and prolonged hospitalization. Endoscopic stent placement is a potential management strategy that needs expertise and also has recognized complications (stent migration, significant dysphagia, and failure) (Rosenthal et al., Surg. Obes Relat. Dis. 8:8–19, 2012). A standard method of managing leaks following LSG has not been established. This study aims to evaluate the outcomes of consecutive patients with leaks following LSG managed at BMI Abu Dhabi Tertiary Multidisciplinary Bariatric Surgery, Abu Dhabi, UAE.

Methods

We examined all patients presenting to BMI Abu Dhabi between February 2010 and May 2012 with leaks following LSG. Data were obtained from the hospital medical record, and IRB approval was obtained. All patients were managed by utilizing a standardized operative management strategy without the use of endoscopic stenting.

Results

A total of five patients were referred to us for higher level of care; during the same time period, we performed 71 LSGs without a leak. Patients were optimized and resuscitated adequately before surgery. Intraoperatively, all patients had endoscopy, and a T tube was placed inside the leak if clearly identifiable. Otherwise, the leak site was drained adequately without attempting to place sutures, and a jejunostomy tube was inserted. All leaks healed following an initial period of hospital stay, followed by an outpatient period on jejunostomy tube feeding and nil per os.

Conclusion

Single-stage operative management of leaks after LSG utilizing a standardized operative strategy without the use of endoscopic stenting is both safe and effective.     

Anesthesia for children with mitochondrial disorders: a national survey and review

Purpose

Mitochondrial diseases are a heterogeneous group of disorders. Patients with such diseases often need general anesthesia for diagnostic procedures and surgery; guidelines are lacking for the anesthetic care of these patients.

Methods

We conducted a survey to investigate the current practices of pediatric anesthesiologists in the US in order to determine and document current practice. The survey consisted of twenty questions, including two demographic questions. A link to the survey was sent via email to members of the Society for Pediatric Anesthesia (2440), and was available online for 14 weeks.

Results

Only 503 completed the survey: a response rate of 20.61 %. Among the responders, 93.2 % had children with mitochondrial disorders among their patients, but only 11 % had institutional guidelines for such cases in place. Among the responders, 80.3 % used the standard nil per os (NPO) status guidelines, while the rest give intravenous dextrose solution once NPO was in effect. Only 18.3 % took precautions for malignant hyperthermia during treatment. The majority of the practitioners chose sevoflurane as the safest inhaled agent for induction and maintenance (89.7 and 78.5 %, respectively). Regional anesthesia was deemed safe by 97.3 % of the responders. Lactated Ringer’s solution was considered safe for these children by 49 %; only 47.8 % used dextrose-containing fluids for fluid replacement. The blood glucose was monitored by 72.7 %, and the majority (85 %) of this monitoring was done in a postanesthesia care unit.

Conclusion

Although the response rate was low, the majority of the responders provide care to these children routinely, so it can be inferred that the results of this survey are the closest published results to the true trend.