Uric acid and acute kidney injury in high-risk patients for developing acute kidney injury undergoing cardiac surgery: A prospective multicenter study

PURPOSE

It is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI.

DESIGN

Multicenter prospective international cohort study.

SETTING

Fourteen university hospitals in Spain and the United Kingdom.

PARTICIPANTS

We studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥ 4 points, from July to December 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

AKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (≥7 mg/dL) and AKI. Elevated preoperative AUS (≥7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81-3; P = .17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95%CI 0.93-1.19, P = .37).

CONCLUSIONS

Hyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

The EPICTER score: a bedside and easy tool to predict mortality at 6 months in acute heart failure

Aims

Estimating the prognosis in heart failure (HF) is important to decide when to refer to palliative care (PC). Our objective was to develop a tool to identify the probability of death within 6 months in patients admitted with acute HF.

Methods and results

A total of 2848 patients admitted with HF in 74 Spanish hospitals were prospectively included and followed for 6 months. Each factor independently associated with death in the derivation cohort (60% of the sample) was assigned a prognostic weight, and a risk score was calculated. The accuracy of the score was verified in the validation cohort. The characteristics of the population were as follows: advanced age (mean 78 years), equal representation of men and women, significant comorbidity, and predominance of HF with preserved ejection fraction. During follow‐up, 753 patients (26%) died. Seven independent predictors of mortality were identified: age, chronic obstructive pulmonary disease, cognitive impairment, New York Heart Association class III–IV, chronic kidney disease, estimated survival of the patient less than 6 months, and acceptance of a palliative approach by the family or the patient. The area under the ROC curve for 6 month death was 0.74 for the derivation and 0.68 for the validation cohort. The model showed good calibration (Hosmer and Lemeshow test, P value 0.11). The 6 month death rates in the score groups ranged from 6% (low risk) to 54% (very high risk).

Conclusions

The EPICTER score, developed from a prospective and unselected cohort, is a bedside and easy‐to‐use tool that could help to identify high‐risk patients requiring PC.

Importance of tissue sampling, laboratory methods, and patient characteristics for detection of Pneumocystis in autopsied lungs of non-immunosuppressed individuals

To understand the epidemiological significance of Pneumocystis detection in a lung tissue sample of non-immunosuppressed individuals, we examined sampling procedures, laboratory methodology, and patient characteristics of autopsy series reported in the literature. Number of tissue specimens, DNA-extraction procedures, age and underlying diagnosis highly influence yield and are critical to understand yield differences of Pneumocystis among reports of pulmonary colonization in immunocompetent individuals.

[Evolution of the intake and nutritional status of zinc, iron and copper in women undergoing bariatric surgery until the second year after surgery]

INTRODUCTION

Bariatric surgery allows a significant reduction in weight and improvement of comorbidities associated with obesity in the long term, but it can also adversely affect the nutritional status of some micronutrients.

OBJECTIVES

To evaluate changes in intake and parameters of nutritional status of zinc, iron and copper in patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG), until the second postoperative year.

METHODS

We prospectively studied 45 women undergoing GBP or SG (mean age 35.2 ± 8.4 years, mean BMI 39.8 ± 4.0 kg/m²), every 6 months We measured intake and status indications nutritional zinc, iron and copper, and annually evaluated body composition. The contribution of minerals through supplements represented twice the recommended intake for a healthy woman in patients undergoing GT and three times for GBP.

RESULTS

20 women underwent GBP and 25 SG. In both groups there was a significant reduction in weight and body fat percentage, which was maintained until the second postoperative year. Women who have had a greater commitment GBP nutritional status of zinc, iron and copper, that patients undergoing SG.

CONCLUSIONS

Gastric bypass Roux-Y produces a greater commitment of nutritional status of zinc, iron and copper sleeve gastrectomy. It should evaluate whether administration of supplementation fractional improve the absorption of these nutrients.

[Epidural anesthesia for coronary revascularization in the conscious patient]

Thoracic epidural anesthesia has been widely used to complement general anesthesia in coronary artery bypass grafting. The main advantages of the combination are excellent pain control and a less pronounced stress response to surgery. The invasiveness of surgery to treat ischemic heart disease has been attenuated thanks to the use of the mini-sternotomy and coronary anastomosis without extracorporeal circulation. In 4 patients, coronary artery revascularization was carried out via a mini-sternotomy, grafting the anterior descending artery to the left internal thoracic artery under high thoracic epidural anesthesia (block of segments T1-T8) with a perfusion of 0.75% ropivacaine and fentanyl in a conscious patient. There were no hemodynamic or respiratory complications during surgery. The mean duration of stay in the intensive care unit was less than 18 hours and the mean hospital stay was less than 5 days. Postoperative coronary arteriograms demonstrated the patency of all grafts and all patients were asymptomatic at 1 month. Our initial experience suggests that the use of only high thoracic epidural anesthesia is feasible in coronary revascularization in selected, cooperative patients who require a single coronary bypass graft.

[Comparison of 2 techniques for inhaled anesthetic induction with sevoflurane in coronary artery revascularization]

OBJECTIVE

Our objective was to evaluate efficacy, side effects, and hemodynamic alterations during anesthetic induction with sevoflurane in patients undergoing coronary artery bypass surgery, comparing the techniques of administration with tidal volume breathing and with vital capacity breaths.

MATERIAL AND METHODS

This was a randomized controlled trial enrolling 30 patients scheduled for myocardial revascularization. Anesthetic induction with inhaled sevoflurane was performed with 2 techniques: sevoflurane administered with tidal volume breathing (n=15) and with vital capacity breaths (n=15). We assessed time until a bispectral index (BIS) of 50 or less was reached. We also recorded adverse effects and alterations in hemodynamic variables during induction.

RESULTS

The time to induction was significantly shorter in the tidal volume group. The time until reaching a BIS of 50 or less was significantly shorter in the vital capacity group. Hemodynamics were similar in both groups (no significant differences). In both groups mean arterial pressure decreased significantly from baseline (P<0.05) and systolic and diastolic blood pressures both decreased slightly, with no significant heart rate or ST segment changes. Adverse effects were few and not serious.

CONCLUSIONS

Mean arterial pressure decreased in both groups, with no significant differences. The results indicate that hemodynamic stability seems to be similar with both techniques for providing inhaled anesthetic induction with sevoflurane.

Occurrence of bacterial indicators and bacteriophages infecting enteric bacteria in groundwater in different geographical areas

AIMS

The aim of this research was to determine the suitability of coliphages (bacteriophages) for assessing the microbial quality of groundwater.

METHODS AND RESULTS

The number of several bacterial indicators (faecal coliforms, Escherichia coli, enterococci and spores of sulfite-reducing clostridia) and bacteriophages (somatic coliphages, F-specific RNA bacteriophages and bacteriophages infecting Bacteroides fragilis) were determined in groundwater of aquifers in various geographical areas. Results show that the relative abundance, determined as percentages of positive detections, of the bacterial indicators and bacteriophages varies depending on the aquifer.

CONCLUSIONS

A single bacterial indicator may not be enough to assess microbiological quality in certain aquifers. One bacterial indicator and a bacteriophage parameter provide more information than two bacterial indicators.

SIGNIFICANCE AND IMPACT OF THE STUDY

Coliphages (CPH) provide different information from that provided by bacterial indicators on the microbial quality of groundwater in different geographical areas. Easy, fast and inexpensive methods for the detection of CPH are feasible in both industrialized and developing countries.

Reduction of bacterial indicators and bacteriophages infecting faecal bacteria in primary and secondary wastewater treatments

AIMS

To compare the suitability of various bacterial and viral indicators to assess the removal of faecal micro-organisms by primary and secondary wastewater treatment processes.

METHODS AND RESULTS

The numbers of several bacterial indicators [faecal coliforms (FC), enterococci (ENT) and sulphite-reducing clostridia (SRC)] and bacteriophages (somatic coliphages, F-specific RNA phages and bacteriophages infecting Bacteroides fragilis strain RYC2056) were determined in incoming raw sewage and effluents from various primary and secondary wastewater treatment processes in several geographical areas. Reductions in the numbers of indicators were calculated as log10 reductions. Processes based on removal and mild disinfection, showed no significant differences in the elimination of any of the indicators tested or between geographical areas. In contrast, treatment processes that include strong microbial inactivation, such as lime-aided flocculation and lagooning, showed significant differences between the log10 reductions of the various micro-organisms studied, FC showing the highest reduction and spores of SRC and phages infecting B. fragilis the lowest.

CONCLUSIONS

The microbial elimination performance of treatment processes based principally on removal and mild disinfection can be evaluated with a single indicator. In contrast, processes with additional disinfecting capabilities require more than one indicator for accurate evaluation of the treatment; bacteriophages are good candidates for use as second indicators.

SIGNIFICANCE AND IMPACT OF THE STUDY

Bacteriophages provide additional information for the evaluation of microbial elimination in some treatment plants. The easy, fast and cheap methods available for phage determination are feasible both in industrialized and developing countries.

[The specific cox-2 inhibitor valdecoxib provides effective analgesia after inguinal hernia surgery]

OBJECTIVE

To compare 3 oral analgesic doses--valdecoxib 20 mg, valdecoxib 40 mg and controlled-release diclofenac 75 mg--to placebo in the treatment of pain after inguinal herniorrhaphy.

METHOD

An international multicenter double-blind placebo-controlled trial comparing parallel groups receiving oral valdecoxib 20 or 40 mg, controlled-release diclofenac 75 mg, or placebo every 12 hours over a period of 36 hours. The study enrolled 269 patients undergoing inguinal herniorrhaphy with spinal anesthesia. Pain intensity difference, the sum pain intensity difference, need for rescue medication, and overall patient satisfaction were compared.

RESULTS

Valdecoxib 40 mg and controlled-release diclofenac 75 mg take every 12 hours provided similar analgesia that was significantly more efficacious than placebo as shown by the sum pain intensity difference at 12 hours. Both treatments decreased pain intensity in comparison with baseline throughout the study. Differences were significant in comparison with placebo at 8-10 hours through 24 hours of administration of the first dose. No significant differences between valdecoxib 20 mg and placebo were observed. The percentage of patients needing rescue medication was significantly lower in the valdecoxib 40 mg group (30% in that group vs. 52% for placebo), and that difference was not seen for any of the other groups. All treatments were well tolerated.

CONCLUSIONS

Valdecoxib 40 mg and diclofenac 75 mg provided similar quality of analgesia for treating pain after inguinal herniorrhaphy.

Pneumocystis jiroveci isolates with dihydropteroate synthase mutations in patients with chronic bronchitis

Since mutations in the dihydropteroate synthase (DHPS) gene possibly associated with sulfonamide resistance have been reported in patients with Pneumocystis jiroveci (previously carinii) pneumonia, and since P. jiroveci colonization has been recently demonstrated in patients with chronic pulmonary diseases, the present study aimed to investigate the possible occurrence of P. jiroveci DHPS mutations in patients with chronic bronchitis. P. jiroveci colonization was detected in 15 of 37 non-selected patients with chronic bronchitis by amplifying the large subunit of the mitochondrial gene of the ribosomal RNA using nested PCR. DHPS mutations were demonstrated using touchdown PCR and restriction enzyme analysis in two of eight patients with chronic bronchitis and in two of six patients from the same region who had AIDS-associated Pneumocystis pneumonia. In all cases, mutations were observed in subjects with no prior exposure to sulfonamides. These data could have important implications for public health, since (i) P. jiroveci colonization could speed the progression of chronic bronchitis, and (ii) these patients, who are customary sputum producers, could represent a reservoir for sulfonamide-resistant strains with the potential ability to transmit them to immunocompromised hosts susceptible to Pneumocystis pneumonia.

Occurrence and densities of bacteriophages proposed as indicators and bacterial indicators in river waters from Europe and South America

AIMS

To evaluate the feasibility of bacteriophages as a complementary tool for water quality assessment in surface waters from different parts of the globe.

METHODS AND RESULTS

Faecal coliform bacteria, enterococci, spores of sulphite-reducing clostridia, somatic coliphages, F-specific RNA bacteriophages and bacteriophages infecting Bacteroides fragilis were determined by standardized methods in raw sewage and in 392 samples of river water from 22 sampling sites in 10 rivers in Argentina, Colombia, France and Spain, which represent very different climatic and socio-economic conditions. The results showed that the indicators studied maintained the same relative densities in the raw sewage from the different areas. Classifying the river water samples according to the content of faecal coliform bacteria, it can be observed that the relative densities of the different bacterial indicators and bacteriophages changed according to the concentration of faecal coliform bacteria. There was a relative increase in the densities of all groups of bacteriophages and sulphite-reducing clostridia with respect to faecal coliforms and enterococci in the samples with low counts of faecal coliform bacteria.

CONCLUSIONS

The numbers of bacterial indicators and bacteriophages were similar in the different geographical areas studied. Once released in rivers, the persistence of the different micro-organisms differed significantly. Bacteriophages and spores of sulphite-reducing clostridia persisted longer than faecal coliforms and enterococci.

SIGNIFICANCE AND IMPACT OF THE STUDY

Bacteriophages in river water samples provide additional information to that provided by bacteria about the fate of faecal micro-organisms in river water. The easy, fast and cheap methods for phage determination are feasible both in industrialized and developing countries.

[Analgesia and sedation in the subarachnoid anesthesia technique: comparative study between remifentanil and fentanyl/midazolam]

OBJECTIVE

To assess the efficacy and safety of remifentanil in comparison with fentanyl-midazolam for analgesia and sedation during subarachnoid anesthesia.

MATERIAL AND METHODS

Sixty ASA I-III patients between 25 and 75 years old and scheduled for inguinal hernia repair were enrolled. Before the subarachnoid block, the patients were randomly assigned to receive an intravenous infusion of 0.1 microgram.Kg-1.min.-1 of remifentanil (group R) or 1 microgram.Kg-1 of fentanyl and 0.02 mg.Kg-1 of midazolam (group F). Ten minutes later a subarachnoid block to L3-L4 was performed with 10 mg of hyperbaric bupivacaine. We recorded intensity of pain during performance of the block on a simple verbal scale, the observer's assessment of alertness/sedation (OAA/S), hemodynamic variables, respiratory frequency and SpO2, level of comfort and side effects.

RESULTS

Over 70% of patients had no pain or slight pain during the subarachnoid puncture and absence of pain was significantly greater in group R than in group F (37% vs. 16%, p < 0.05). Sedation was adequate during surgery in both groups (OAA/S 2-3). There were no differences in level of comfort between the two groups. The incidences of hypoxemia, hypoventilation and excessive sedation were significantly higher in group R (40%, 20% and 16%, respectively; p < 0.05).

CONCLUSIONS

Remifentanil is more effective for treating pain associated with a subarachnoid block and provides cardiovascular stability with a limited level of sedation per dose, but its use is associated with a high incidence of respiratory depression.

[Acute selective tolerance to remifentanil after prolonged infusion]

We describe the cases of 3 patients who received anesthesia with remifentanil continuously infused at rates of 0.8 to 1.25 micrograms.kg-1.min-1 for at least 3 hours. Upon emergence from anesthesia, after withdrawal of the anesthetic gas, satisfactory levels of consciousness, spontaneous breathing and absence of pain were achieved under maintenance doses of remifentanil greater than 0.8 microgram.kg-1.min-1; such doses are related to the development of ventilatory depression, apnea and significant sedation. Acute tolerance to remifentanil is under debate at present. Such tolerance involves decreased efficacy of an opiate or the need for higher doses to maintain an effect after exposure. The development of tolerance is related mainly to the pharmacokinetics of an opiate, a short half-life and infusion periods exceeding 3 hours, and in the case of remifentanil, to the use of high doses. The most likely explanation for de phenomena described would be the development of selective acute tolerance to ventilatory depression and to sedation, with no effect on the antinociceptive effects of remifentanil. Clinical trials should be carried out to assess the development of acute tolerance to remifentanil and its possible perioperative repercussions.