Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients

Purpose

The study assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) preoperative cardiac assessment guidelines impact patient management and predict major cardiac events in patients undergoing orthopedic surgery.

Subjects and methods

We conducted a retrospective review of 338 consecutive orthopedic preoperative evaluations performed by internal medicine consultants. Major cardiac events were defined as myocardial infarction, congestive heart failure, and sudden cardiac death.

Results

Major cardiac events occurred in 5.7% of patients. Patients with minor or absent ACC/AHA clinical risk predictors were less likely to have major cardiac events (P = .007). More than half (51%) of patients meeting ACC/AHA indications for noninvasive cardiac tests did not receive them. However, most (69%) major cardiac events occurred in patients not meeting criteria for cardiac testing. Abnormal noninvasive cardiac testing results did not alter medication recommendations and only resulted in coronary revascularization in 0.6% of patients. Only 3% of patients with abnormal noninvasive cardiac testing results had major cardiac events. Patients with abnormal cardiac test results were more likely to have recommendations for perioperative beta-blockade (P <.01). Patients aged more than 70 years (odds ratio 5.0; 95% confidence interval, 1.32-19.28) and patients undergoing hip surgery (odds ratio 7.5, 95% confidence interval, 1.02-54.55) were more likely to have major cardiac events. Major cardiac events occurred in 12% of urgent and 4% of elective procedures (P = .009).

Conclusions

The ACC/AHA guidelines accurately predict cardiac risk in orthopedic surgery. Abnormal noninvasive cardiac test results rarely affected preoperative recommendations, but improved compliance with beta-blocker therapy. Advanced age, urgent procedures, and hip surgery were associated with increased risk of major cardiac events.     

Follow-up of intracranial aneurysms treated with matrix detachable coils: a single-center experience

BACKGROUND AND PURPOSE: Matrix coils are polymer-coated bioactive coils used in treatment of intracranial aneurysms. The current study is aimed at evaluating the efficacy and safety of these coils in treatment of ruptured and unruptured aneurysms. METHODS: Seventy-seven consecutive patients with 84 aneurysms were included in the study. Forty-six aneurysms were treated with Matrix coils alone, and 38 were treated with Matrix coils in combination with other coils/devices. Angiographic follow-up was available in 64 patients with 70 aneurysms. Length of follow-up ranged from 6 to 28 months with mean of 10 months. Both postembolization and follow-up angiograms were graded on a 3-point Raymond scale. Aneurysms were classified as stable, improved, or recanalized based on the follow-up angiograms. Recanalization was considered major if it was saccular and its size would theoretically permit retreatment with coils. RESULTS: At the end of the initial procedure, 47 (56.0%) aneurysms showed complete occlusion (Raymond 1), 20 (23.8%) showed contrast filling the neck of the aneurysm (Raymond 2), and 16 (19.0%) showed contrast filling the sac of the aneurysm (Raymond 3). Of the 70 aneurysms in which follow-up angiograms were available, 55.7% remained stable in appearance, 20.0% showed improved occlusion, and 24.3% demonstrated recanalization; 8.6% demonstrated major recanalization. There were 2 aneurysm rebleeds (both incompletely packed); one resulted in death. CONCLUSION: Matrix coils are safe to use and the recanalization rate of aneurysms treated with these coils appears to be at least comparable with historical studies with Guglielmi detachable coils.     

Eating disorders across two cultures: does the expression of psychological control vary?

OBJECTIVE: Because both the expression of eating disorder (ED) symptoms and preferred psychological control styles may be affected by culture, the purpose of the present study was to examine whether the expression of psychological control in women with EDs varies across two cultures. METHOD: North European Australian and Chinese Singaporean women (n = 117) with anorexia nervosa (n = 36), bulimia nervosa (n = 13) and eating disorders not otherwise specified (n = 3), and without an ED (n = 65) recruited in Australia and Singapore completed a multidimensional inventory assessing sense of control, domains of control, preferred means by which to gain control, and motivation for control. RESULTS: Although the normative control profile for each culture differed slightly, control profiles among those with an ED were very similar across both cultures. However, the directionality and extent of specific aspects of control pathology associated with the presence of an ED differed across cultures. North European Australians with an ED were much more deviant from the cultural norm than their Chinese Singaporean ED counterparts in relation to overall sense of control, methods of gaining control, and control in the domain of body. Chinese Singaporean woman with an ED were much more deviant from the cultural norm than their North European Australian ED counterparts in the domain of control over impulses. CONCLUSIONS: Having an ED powerfully distorts psychological control irrespective of culture. However the degree, directionality, and form of the displacement from normal control styles is also culture dependent. This has implications for treatments that attempt to redress or correct control issues in people with an ED in other cultures.     

TSH Signaling Overcomes B-RafV600E–Induced Senescence in Papillary Thyroid Carcinogenesis through Regulation of DUSP6

B-RafV600E oncogene mutation occurs most commonly in papillary thyroid carcinoma (PTC) and is associated with tumor initiation. However, a genetic modification by B-RafV600E in thyrocytes results in oncogene-induced senescence (OIS). In the present study, we explored the factors involved in the senescence overcome program in PTC. First of all, we observed down-regulation of p-extracellular signal-regulated kinases 1/2 and up-regulation of dual specific phosphatase 6 (DUSP6) in the PTC with B-RafV600E mutation. DUSP6 overexpression in vitro induced extracellular signal-regulated kinases 1/2 dephosphorylation and inhibited B-RafV600E–induced senescence in thyrocytes. Although DUSP6 protein was degraded by B-RafV600E–induced reactive oxygen species (ROS), thyroid-stimulating hormone (TSH) stabilized DUSP6 protein by increasing Mn superoxide dismutase expression and inhibited B-RafV600E–induced senescence. Although serum TSH was not increased, its receptor was markedly upregulated in PTC with B-RafV600E. Furthermore, TSH together with DUSP6 reactivated Ras signaling, resulted in activation of Ras/AKT/glycogen synthase kinase 3β, and stabilized c-Myc protein by inhibiting its degradation. These observations led us to conclude that increased TSH signaling overcomes OIS and is essential for B-RafV600E–induced papillary thyroid carcinogenesis.Abbreviations: PTC, papillary thyroid carcinoma; OIS, oncogene-induced senescence; TSH, thyroid-stimulating hormone; TSHR, TSH receptor; DUSP, dual specific phosphatase; IP, immunoprecipitation; ROS, reactive oxygen species; SOD, superoxide dismutase; GPx1, glutathione peroxidase-1     

Activation-induced cytidine deaminase acts as a mutator in BCR-ABL1-transformed acute lymphoblastic leukemia cells

The Philadelphia chromosome (Ph) encoding the oncogenic BCR-ABL1 kinase defines a subset of acute lymphoblastic leukemia (ALL) with a particularly unfavorable prognosis. ALL cells are derived from B cell precursors in most cases and typically carry rearranged immunoglobulin heavy chain (IGH) variable (V) region genes devoid of somatic mutations. Somatic hypermutation is restricted to mature germinal center B cells and depends on activation-induced cytidine deaminase (AID). Studying AID expression in 108 cases of ALL, we detected AID mRNA in 24 of 28 Ph(+) ALLs as compared with 6 of 80 Ph(-) ALLs. Forced expression of BCR-ABL1 in Ph(-) ALL cells and inhibition of the BCR-ABL1 kinase showed that aberrant expression of AID depends on BCR-ABL1 kinase activity. Consistent with aberrant AID expression in Ph(+) ALL, IGH V region genes and BCL6 were mutated in many Ph(+) but unmutated in most Ph(-) cases. In addition, AID introduced DNA single-strand breaks within the tumor suppressor gene CDKN2B in Ph(+) ALL cells, which was sensitive to BCR-ABL1 kinase inhibition and silencing of AID expression by RNA interference. These findings identify AID as a BCR-ABL1-induced mutator in Ph(+) ALL cells, which may be relevant with respect to the particularly unfavorable prognosis of this leukemia subset.     

A Validated Questionnaire to Assess the Knowledge of Psychiatric Aspects of Alcohol Use Disorder

ABSTRACT. Background: To the best of our knowledge, there is no validated instrument for measuring knowledge of psychiatric aspects of alcohol use disorder (AUD) amongst medical students. Our aim was to develop an instrument for this purpose and to describe the instrument's psychometric properties. We also investigated whether the instrument could demonstrate a significant change in scores following an educational intervention consisting of a 60-minute PowerPoint lecture on AUD, associated handouts, and role-plays. Methods: The Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) was developed from the Kaplan and Saddock textbook synopsis chapter on alcohol related disorders. The questionnaire included 6 categories of clinically relevant material: metabolism of alcohol, short-term effects of alcohol, long-term effects of alcohol, AUD, alcohol withdrawal, and alcohol use in pregnancy. The KPAAQ was administered to 75 medical students in Years 4 and 5 from the Hebrew University in Jerusalem, Israel, during a relevant clinical rotation. Following the initial administration of the KPAAQ, the students attended a 60-minute lecture (in Hebrew) based on material from the University of Sydney's learning module on alcohol. The KPAAQ was readministered to the students immediately following the lecture. Results: The KPAAQ demonstrated good reliability (Cronbach α =.92 for all questions) and validity r(209) =.674, P <.001. Knowledge of alcohol and alcoholism significantly increased after the educational intervention (F(2, 154) = 151.60, P <.001). Post hoc comparisons using the Scheffe test revealed a significant positive change in knowledge after students received the intervention (mean difference = 33, P <.001). Conclusions: These initial findings suggest that the KPAAQ is a reliable and valid instrument for assessing medical student knowledge of psychiatric aspects of AUD over 6 clinical categories.     

Intraplantar injection of bergamot essential oil induces peripheral antinociception mediated by opioid mechanism

This study investigated the effect of bergamot essential oil (BEO) containing linalool and linalyl acetate as major volatile components in the capsaicin test. The intraplantar injection of capsaicin (1.6 μg) produced a short-lived licking/biting response toward the injected paw. The nociceptive behavioral response evoked by capsaicin was inhibited dose-dependently by intraplantar injection of BEO. Both linalool and linalyl acetate, injected into the hindpaw, showed a significant reduction of nociceptive response, which was much more potent than BEO. Intraperitoneal (i.p.) and intraplantar pretreatment with naloxone hydrochloride, an opioid receptor antagonist, significantly reversed BEO- and linalool-induced antinociception. Pretreatment with naloxone methiodide, a peripherally acting μ-opioid receptor preferring antagonist, resulted in a significant antagonizing effect on antinociception induced by BEO and linalool. Antinociception induced by i.p. or intrathecal morphine was enhanced by the combined injection of BEO or linalool. The enhanced effect of combination of BEO or linalool with morphine was antagonized by pretreatment with naloxone hydrochloride. Our results provide evidence for the involvement of peripheral opioids, in the antinociception induced by BEO and linalool. Combined administration of BEO or linalool acting at the peripheral site, and morphine may be a promising approach in the treatment of clinical pain.     

Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample

Purpose

Necrotising soft tissue infection (NSTI) is a deadly disease associated with a significant risk of mortality and long-term disability from limb and tissue loss. The aim of this study was to determine the effect of hyperbaric oxygen (HBO₂) therapy on mortality, complication rate, discharge status/location, hospital length of stay and inflation-adjusted hospitalisation cost in patients with NSTI.

Methods

This was a retrospective study of 45,913 patients in the Nationwide Inpatient Sample (NIS) from 1988 to 2009.

Results

A total of 405 patients received HBO₂ therapy. The patients with NSTI who received HBO₂ therapy had a lower mortality (4.5 vs. 9.4 %, p?=?0.001). After adjusting for predictors and confounders, patients who received HBO₂ therapy had a statistically significantly lower risk of dying (odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.29–0.83), higher hospitalisation cost (US$52,205 vs. US$45,464, p?=?0.02) and longer length of stay (LOS) (14.3?days vs. 10.7?days, p?Conclusions This retrospective analysis of HBO₂ therapy in NSTI showed that despite the higher hospitalisation cost and longer length of stay, the statistically significant reduction in mortality supports the use of HBO₂ therapy in NSTI.