RESUMEN
OBJECTIVE: To compare the efficacy of ilioinguinal/iliohypogastric (IINB) nerve block to transversus abdominis plane (TAP) block in controlling incisional pain after open inguinal hernia repair. PATIENTS AND METHODS: This was a prospective randomized clinical trial of 90 patients who received either IINB (N=45) or TAP block (N=45) using 0.2% bupivacaine 15 mL under ultrasound (US) guidance based on a random assignment in the postanesthesia care unit after having an open repair of inguinal hernia. Numeric Rating Scale (NRS) scores were recorded immediately following, 4, 8, 12, and 24 hours after completion of the block. NRS scores at rest and during movement were recorded 24, 36, and 48 hours after surgery. Analgesic satisfaction level was also evaluated by a Likert-based patient questionnaire. RESULTS: NRS scores were lower in the IINB group compared to the TAP block group both at rest and during movement. The difference in dynamic pain scores was statistically significant (P=0.017). In addition, analgesic satisfaction was significantly greater in the IINB group than the TAP block group (mean score 2.43 vs 1.84, P=0.001). Postoperative opioid requirements did not differ between the two groups. CONCLUSION: This study demonstrated that compared to TAP block, local blockade of ilioinguinal and iliohypogastric nerves provides better pain control after open repair of inguinal hernia when both blocks were administered under US guidance. Greater satisfaction scores also reflected superior analgesia in patients receiving IINB.
RESUMEN
BACKGROUND: Diabetic nephropathy (DN) is characterized by albuminuria, hypertension, and a progressive decline in glomerular filtration rate. The 3-hydroxy-3-methylglutaryl coenzyme A is a well-known agent that is active in lowering total plasma and low-density lipoprotein cholesterol (LDL-C) levels in cases with hypercholesterolemia. Hence, in this study, proteinuria changes at the beginning and after the withdrawal of lovastatin in patients with type 2 DN (T2DN) were studied. MATERIALS AND METHODS: Lovastatin was administered for thirty male patients with T2DN and then was withdrawn. Twenty-four hours, urine creatinine and protein levels were determined. RESULTS: The mean levels of total cholesterol and LDL-C were reduced without any change in the triglyceride (TG) level while the high-density lipoprotein cholesterol (HDL-C) level was increased. There was a reverse linear correlation between the changes in the level of HDL-C and the changes in the level of 24 h urine protein after 90 days of lovastatin therapy (P = 0.007, r = -0.484). CONCLUSIONS: Short-term 3-month lovastatin therapy has no effect on proteinuria levels in patients with T2DN despite the antihyperlipidemic effects and reverse correlation of proteinuria with HDL-C.
RESUMEN
INTRODUCTION: Myocardial ischemia may coincide and interact with sepsis and inflammation. Our objective was to examine the effects of bacterial endotoxin on myocardial functions and cell injury during acute ischemia. METHODS: Rabbits were pretreated with incremental doses of E. Coli lipopolysaccharide (LPS) or normal saline. Myocardial ischemia was induced by 50-minute occlusion of left anterior descending artery. S-TNFaR was additionally used to block the effects LPS. RESULTS: Ventricular contractility as it was measured by dp/dt during systole decreased from 2445± 1298 to 1422 ± 944 mm Hg/s, P = .019. Isovolumetric relaxation time as an index of diastolic function was prolonged from 50±18 ms to 102± 64 ms following ischemia. Pretreatment with low concentrations of LPS (<1 µg) had no effect on dp/dt, while at higher concentrations it suppressed both contractility and prolonged IVRT. Cell injury as measured by cardiac troponin I level increased to 15.1± 3.2 ng/dL following ischemia and continued to rise with higher doses of LPS. While blocking TNFa did not improve the myocardial contractility after ischemia, it eliminated additional deleterious effects of LPS. CONCLUSION: Lower doses of LPS had no deleterious effect on myocardial function, whereas higher doses of this endotoxin cause cardiac dysfunction and increased extent of injury.
RESUMEN
BACKGROUND: Severe vasodilatation is commonly seen upon weaning from cardiopulmonary bypass (CPB). We examined the effects of vasopressin (arginine vasopressin [AVP]) on acute kidney injury (AKI) in postoperative period. METHODS: The records of 483 patients undergoing coronary bypass surgery on CPB from 2004 to 2008 were retrospectively reviewed. Demographic, anthropometric, comorbid condition, and perioperative clinical/laboratory data were collected along with postoperative complications. Patients were grouped based on the perioperative use of AVP, and AKI was used as the primary end point. Univariate and multivariate logistic regression analyses were used, followed by propensity score matching for AKI. Null hypothesis was rejected at P < .05. RESULTS: Postoperative AKI occurred in 14.5% of patients. Arginine vasopressin was administered to 280 patients during the perioperative period. The prevalence of AKI in AVP was 20%, whereas it was 6.1% in controls (P < .0001). Arginine vasopressin was an independent factor that predicted the occurrence of AKI (odds ratio, 3.60; 95% confidence interval, 1.22-10.62; P = .02). However, after propensity score matching, the association between AKI and AVP was lost (P = .073). CONCLUSION: Acute kidney injury is a common complication after cardiac surgery, and vasopressin use increases its incidence; however, this effect may rely on several clinical factors, and its true effect should be examined by large randomized trials.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Arginina Vasopresina/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Vasoconstrictores/efectos adversos , Puente Cardiopulmonar/efectos adversos , Estudios de Casos y Controles , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Milrinona/uso terapéutico , Oportunidad Relativa , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The functional capacity to perform the activities of daily living is identified as an independent predictor of perioperative mortality but is not formally incorporated in the American Society of Anesthesiologists (ASA) classification. Our primary objective was to assess whether functional capacity is an independent predictor of 30-day and long-term mortality in a general population and, if so, to define how it may formally be incorporated into the routine preoperative ASA classification assessment. METHODS: This retrospective, observational cohort study was conducted using 1998 to 2009 data extracted from the Veterans Affairs Surgical Quality Improvement Program of Western New York, a perioperative prospectively maintained database. Mortality follow-up was performed for all records in 2013. This population-based sample included all patients undergoing any noncardiac surgery (n = 12,324). Each patient's ASA class (assigned preoperatively) was appended with subclasses A or B, with A representing patients who were functionally independent and B representing partially or fully dependent patients. The primary outcome was all-cause mortality during the follow-up period. Secondary outcomes included 30-day postoperative complications and mortality. Multivariate logistic regression was used to identify independent risk factors for mortality. RESULTS: The likelihood for mortality was significantly lower for A patients than B patients within each ASA class. The odds ratios for mortality for group A patients significantly favored survival over group B within each ASA class (0.14, 0.29, and 0.50, for ASA class II, III, and IV, respectively, each P < 0.0001). The odds ratio for mortality of IIB over IIIA patients was 1.92 (95% confidence interval [CI], 1.19-3.11; P = 0.01); 1.29 (95% CI, 1.04-1.60; P = 0.03) for IIIB over IVA patients; and 2.03 (95% CI, 0.99-4.12, P=0.11) for IVB over ASA V patients, despite each higher class carrying a greater disease burden, by definition. The area under the curve the receiver operator characteristic curve was 0.811 ± 0.010 for traditional ASA classification in predicting death within 30 days, which improved 4.7% to 0.848 ± 0.008 using the modified ASA classification, P < 0.00001. CONCLUSIONS: Functional capacity was an independent predictor of mortality within each ASA class, indicating that it should be considered for incorporation into the routine preoperative evaluation. Functional dependence may be an indication for increasing a patient's ASA class by 1 class-point to better reflect his or her perioperative risk, but prospective validation of these findings is recommended, as this is a preliminary study.
Asunto(s)
Actividades Cotidianas , Indicadores de Salud , Estado de Salud , Complicaciones Posoperatorias/mortalidad , Procedimientos Quirúrgicos Operativos/mortalidad , Anciano , Área Bajo la Curva , Causas de Muerte , Bases de Datos Factuales , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Valor Predictivo de las Pruebas , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Factores de Tiempo , Estados Unidos , United States Department of Veterans AffairsRESUMEN
OBJECTIVE: This study examined the effect of perioperative acute kidney injury (AKI) on long-term kidney dysfunction and death after lower extremity revascularization. Perioperative AKI is commonly seen in the form of mild rises of serum creatinine after major cardiovascular surgeries. Its effect on long-term survival and development of chronic kidney disease (CKD) is well established in cardiac surgery patients. However, there are no data on the effect of AKI on long-term outcomes after revascularization for lower limb ischemia. METHODS: We retrospectively reviewed the patients with peripheral arterial occlusive diseases who underwent endovascular or surgical revascularization of the lower extremities from 2001 through 2010. All demographic and clinical information have been maintained prospectively by the surgeon and followed up by the research team. Perioperative AKI was defined as rises of ≥0.3 mg/dL in serum creatinine from the values measured preoperatively. The primary end points were development of CKD (estimated glomerular filtration rate <60 mL/min) and all-cause mortality. Univariate and multivariate analyses were performed to examine relevant associations. RESULTS: Within the study period, 717 patients underwent 875 procedures. Mean follow-up was 42 ± 14 months. AKI developed in 86 patients after the index procedure. Overall prevalence of CKD diagnosed postoperatively was 14.9%. Overall mortality reported within the follow-up period was 55.9%. Perioperative AKI was a significant predictor of CKD (area under the curve, 0.84 ± 0.13) and all cause mortality (area under the curve, 0.82 ± 0.12). CONCLUSIONS: Perioperative AKI is associated with an increased occurrence of CKD and a higher mortality rate after revascularization procedures of the lower extremities.
Asunto(s)
Lesión Renal Aguda/etiología , Procedimientos Endovasculares/efectos adversos , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Insuficiencia Renal Crónica/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Distribución de Chi-Cuadrado , Enfermedad Crónica , Creatinina/sangre , Procedimientos Endovasculares/mortalidad , Femenino , Tasa de Filtración Glomerular , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Modelos de Riesgos Proporcionales , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
The aim of the study was to determine statin drug association with patency, limb salvage rates and survival after revascularization in patients with chronic limb ischemia. We retrospectively reviewed all patients who underwent revascularization for intermittent claudication or critical limb ischemia between 05/2001 and 12/2009. Patients were grouped based on statin therapy at the time of revascularization. Early postoperative outcomes as well as patency, limb salvage, and survival rates were compared between groups. Of 717 patients, 397 (55.4%) were on statins. The incidence of major adverse cardiac events (MACE) was significantly lower in the statin group. Patency and limb salvage rates were similar; however, survival was significantly better in the statin group. Non-statin use, coronary artery disease, chronic pulmonary obstructive disease, renal insufficiency, critical limb ischemia, and age >70 years were found to be independently associated with decreased survival. Statin use was associated with improved survival, but not with long-term patency and limb salvage.
RESUMEN
OBJECTIVE: To investigate the impact of early versus late renal replacement therapy (RRT) on mortality in patients with acute kidney injury (AKI) after cardiac surgery. DESIGN: Meta-analysis of 9 retrospective cohort studies and 2 randomized clinical trials extracted from the Medline engine from 1950 to 2013. SETTING: University medical school. PARTICIPANTS: 841 Patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 841 patients were studied. Pooled estimates of the odds ratio with 95% confidence interval using a random-effect model were conducted as well as the heterogeneity, publication bias, and sensitivity analysis. Primary outcome was 28-day mortality, and secondary outcome was the intensive care unit (ICU) length of stay. The 28-days mortality rate was lower in the early RRT group (OR = 0.29, 95% CI, 0.16-0.52, p<0.0001, NNT = 5). Heterogeneity was high (I2 = 56%), and publication bias was low. Secondary outcome suggested 3.9 (1.5-6.3) days shorter ICU stay in the early RRT group, p<0.0001, with extremely high heterogeneity (I(2) = 99%), and low publication bias. Specifically, studies before 2000 and studies with mortality less than 50% in the late RRT group reported significantly higher odds ratio and mean difference than overall value favoring early RRT. CONCLUSION: Early initiation of RRT for patients with AKI after cardiac surgery revealed lower 28-days mortality and shorter ICU length of stay. However, this was based on 11 studies of various qualities with very high heterogeneity of results. Defining treatment guidelines needs further research with a larger and better database.
Asunto(s)
Lesión Renal Aguda/terapia , Enfermedad Crítica/terapia , Complicaciones Posoperatorias/terapia , Terapia de Reemplazo Renal/métodos , Lesión Renal Aguda/etiología , Lesión Renal Aguda/mortalidad , Anciano , Anciano de 80 o más Años , Enfermedad Crítica/epidemiología , Enfermedad Crítica/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Terapia de Reemplazo Renal/mortalidadRESUMEN
OBJECTIVES: Perioperative acute kidney injury (AKI) is not uncommon, following revascularization. HDL has been shown to reduce organ injury in animal models. The aim of the study is to examine the association of HDL on AKI in patients undergoing revascularization for chronic limb ischemia. METHODS: All patients who underwent revascularization between June 2001 and December 2009 were analyzed. Patients on dialysis and with incomplete data were excluded. Patients were grouped for HDL < or ≥40 mg/dL. Univariate and multivariate analysis were used to identify factors associated with AKI. RESULTS: A total of 684 patients were included. Eighty-two (12.0%) patients developed postoperative AKI (15.7% in low HDL group vs. 6.3% in high HDL group, p < 0.001). The AKI group were more likely to be older (71.5 ± 10.1 vs. 68.0 ± 10.8, p = 0.01), ASA 4 class (26% vs. 14%, p < 0.001), to have albumin <3 g/dL (59% vs. 32%, p < 0.001), low HDL levels (79% vs. 58%, p < 0.001), DM (61% vs. 44%, p = 0.005), CAD (67% vs. 55%, p = 0.003), preoperative chronic kidney disease (CKD) stage III-IV (55% vs.39%, p < 0.001), to present with critical limb ischemia (82% vs. 63%, p = 0.001), and to be on ACEI (67% vs. 51%, p = 0.006). Multivariate logistic regression analysis showed low HDL (Odds Ratio (OR) 1.66 [1.23-2.24]) and serum albumin levels <3 g/dL (OR 1.66 [1.29-2.13], p < 0.001) were independently associated with increased odds for developing AKI. Propensity score analyses showed low HDL was independently associated with increased odds of AKI (OR 2.4 (1.4-4.2)). CONCLUSIONS: AKI following revascularization is not uncommon (12.0%), and lower concentrations of HDL and serum albumin are associated with increased odds of postoperative AKI. There was also a trend of higher prevalence of AKI among those with pre-existing CKD.
Asunto(s)
Lesión Renal Aguda/etiología , Extremidades/irrigación sanguínea , Isquemia/cirugía , Lipoproteínas HDL/sangre , Procedimientos Quirúrgicos Vasculares/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/epidemiología , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , New York/epidemiología , Periodo Perioperatorio , Prevalencia , Estudios RetrospectivosRESUMEN
BACKGROUND: Human breast milk, the sole source of nutrition during the early neonatal period, is rich in nutrients, hormones, growth factors, and immunoactive molecules, which influence the growth, development, and immune status of the newborn infant. It had long been thought that breast milk is an adequate source of anthracitic activity for the newborns and growing child. OBJECTIVE: Human milk is a complex biologic fluid which contains nutritional and protective factors such as Osteoprotegerin (OPG), at levels 1000-fold higher than normal human serum. Since OPG and Receptor activator of nuclear factor-kappa B ligand (RANKL) system are tightly involved in bone remodeling and immune activity, the study was designated to evaluate the effect of breastfeeding on serum soluble receptor activator of nuclear factor-kappa B ligand (sRANKL) /OPG ratio in full term neonates in comparison with those of formula feeding full term neonates. MATERIALS AND METHODS: In this cross-sectional study serum levels of OPG and sRANKL in 45 breastfed infants were compared to those of 44 formula-fed full term infants. The levels of serum OPG, sRANKL, and Tumor necrosis factor alpha (TNFα) were determined by standard techniques using enzyme-linked immunosorbent assay kits. RESULTS: The serum levels of OPG were significantly higher (P < 0.001), and the concentrations of TNFα was markedly lower (P = 0.024) in breastfed infants than those of formula-fed infants. No marked differences were observed between the serum levels of sRANKL in the two study groups (P = 0.8). CONCLUSIONS: High OPG and low TNFα levels in serum of breastfed infants are important factors involved in remodeling of bone, and immune activity may prove superiority of breastfeeding over formula feeding during infancy.
RESUMEN
BACKGROUND/AIM: A high uric acid (UA) level is demonstrated as a major risk factor of nephropathy and cardiovascular events in people with type 2 diabetes (T2D). This study aimed to evaluate the lovastatin effect on serum UA levels in people with type 2 diabetic nephropathy (T2DN). METHODS: Thirty patients completed the study course, out of 38 adult male patients with T2DN who were initially enrolled. Lovastatin, 20 mg/d, was administered for 90 days. Afterwards, lovastatin was withdrawn for the next 30 days. Blood samples were obtained at baseline, after 45 and 90 days of intervention, and 30 days after the withdrawal of lovastatin. The serum level of UA was assessed by the uricase/PAP method. The lipid profile and high-sensitivity C-reactive protein (hs-CRP) were determined using commercial reagents and the ELISA method. RESULTS: After 90 days of lovastatin intervention, cholesterol (Chol) and low-density lipoprotein cholesterol (LDL-C) levels significantly decreased and the high-density lipoprotein cholesterol (HDL-C) level increased significantly, despite the unchanged level of triglyceride (TG). After withdrawal, Chol, TG, and LDL-C levels were significantly increased, without any change in the HDL-C level. The baseline serum UA level was 5.94 ± 2.02 mg/dL and not changed after the intervention (5.95 ± 2.21 mg/dL; p = 0.969) and withdrawal period (5.80 ± 1.51 mg/dL; p = 0.647). The changes of serum UA levels were not correlated with the changes of serum hs-CRP levels, both after intervention and withdrawal (p = 0.963 & p = 0.835). CONCLUSIONS: Lovastatin does not have any effect on the serum UA level in people with T2DN. There is no correlation between the anti-lipidemic and anti-inflammatory effects of lovastatin and its effect on serum UA.