Kidney Injury after Cardiac Surgery: Prevention-Associated Cost Reduction

INTRODUCTION

Cardiac surgery may induce acute kidney injury and the need for renal replacement therapy. It is also associated with higher hospital costs, morbidity and mortality. The aims of this study were to investigate predictors of cardiac surgery associated acute kidney injury in our population and to determine the burden of acute kidney injury in elective cardiac surgery, evaluating the potential cost effectiveness of preventing it through the application of the Kidney Disease: Improving Global Outcomes bundle of care to high-risk patient groups identified by the [TIMP-2]x[IGFBP7] used as a screening test.

MATERIAL AND METHODS

In a University Hospital single-center retrospective cohort study we analyzed a consecutive sample of adults who underwent elective cardiac surgery between January and March 2015. A total of 276 patients were admitted during the study period. Data from all patients was analyzed until hospital discharge or the patient's death. The economic analysis was performed from the hospital costs' perspective.

RESULTS

Cardiac surgery associated acute kidney injury occurred in 86 patients (31%). After adjustment, higher preoperative serum creatinine (mg/L, ORadj = 1.09; 95% CI: 1.01 - 1.17), lower preoperative hemoglobin (g/dL, ORadj = 0.79; 95% CI: 0.67 - 0.94), chronic systemic hypertension (ORadj = 5.00; 95% CI: 1.67 - 15.02), an increase in cardiopulmonary bypass time (min, ORadj = 1.01; 95% CI: 1.00 - 1.01) and perioperative use of sodium nitroprusside (ORadj = 6.33; 95% CI: 1.80 - 22.28) remained significantly associated with cardiac surgery related acute kidney injury. The expected cumulative surplus cost for the hospital linked with cardiac surgery associated acute kidney injury (86 patients) was €120 695.84. Based on a median absolute risk reduction of 16.6%, by dosing kidney damage biomarkers in every patient and using preventive measures in high-risk patients, we would expect a break-even point upon screening 78 patients, which would translate, in our patient cohort, into an overall cost benefit of €7145.

CONCLUSION

Preoperative hemoglobin, serum creatinine, systemic hypertension, cardiopulmonary bypass time and perioperative use of sodium nitroprusside were independent predictors of cardiac surgery associated acute kidney injury. Our cost-effectiveness modelling suggests that the use of kidney structural damage biomarkers combined with an early prevention strategy could be associated with potential cost savings.

ASP-2/Trans-sialidase chimeric protein induces robust protective immunity in experimental models of Chagas' disease

Immunization with the Amastigote Surface Protein-2 (ASP-2) and Trans-sialidase (TS) antigens either in the form of recombinant protein, encoded in plasmids or human adenovirus 5 (hAd5) confers robust protection against various lineages of Trypanosoma cruzi. Herein we generated a chimeric protein containing the most immunogenic regions for T and B cells from TS and ASP-2 (TRASP) and evaluated its immunogenicity in comparison with our standard protocol of heterologous prime-boost using plasmids and hAd5. Mice immunized with TRASP protein associated to Poly-ICLC (Hiltonol) were highly resistant to challenge with T. cruzi, showing a large decrease in tissue parasitism, parasitemia and no lethality. This protection lasted for at least 3 months after the last boost of immunization, being equivalent to the protection induced by DNA/hAd5 protocol. TRASP induced high levels of T. cruzi-specific antibodies and IFNγ-producing T cells and protection was primarily mediated by CD8⁺ T cells and IFN-γ. We also evaluated the toxicity, immunogenicity, and efficacy of TRASP and DNA/hAd5 formulations in dogs. Mild collateral effects were detected at the site of vaccine inoculation. While the chimeric protein associated with Poly-ICLC induced high levels of antibodies and CD4⁺ T cell responses, the DNA/hAd5 induced no antibodies, but a strong CD8⁺ T cell response. Immunization with either vaccine protected dogs against challenge with T. cruzi. Despite the similar efficacy, we conclude that moving ahead with TRASP together with Hiltonol is advantageous over the DNA/hAd5 vaccine due to pre-existing immunity to the adenovirus vector, as well as the cost-benefit for development and large-scale production.

Cone Beam Computed Tomographic imaging in orthodontics

Over the last 15 years, cone beam computed tomographic (CBCT) imaging has emerged as an important supplemental radiographic technique for orthodontic diagnosis and treatment planning, especially in situations which require an understanding of the complex anatomic relationships and surrounding structures of the maxillofacial skeleton. CBCT imaging provides unique features and advantages to enhance orthodontic practice over conventional extraoral radiographic imaging. While it is the responsibility of each practitioner to make a decision, in tandem with the patient/family, consensus-derived, evidence-based clinical guidelines are available to assist the clinician in the decision-making process. Specific recommendations provide selection guidance based on variables such as phase of treatment, clinically-assessed treatment difficulty, the presence of dental and/or skeletal modifying conditions, and pathology. CBCT imaging in orthodontics should always be considered wisely as children have conservatively, on average, a three to five times greater radiation risk compared with adults for the same exposure. The purpose of this paper is to provide an understanding of the operation of CBCT equipment as it relates to image quality and dose, highlight the benefits of the technique in orthodontic practice, and provide guidance on appropriate clinical use with respect to radiation dose and relative risk, particularly for the paediatric patient.

Efecto de tres dietas en el crecimiento de crías de cocodrilo americano Crocodylus acutus

Se estudió el efecto de tres dietas con sustitución de pescado marino (20 y 40%) por hígado de res en el crecimiento y supervivencia, así como el efecto de la temperatura en el consumo de alimento de crías de Crocodylus acutus. Los cocodrilos alimentados con la dieta de 40% de hígado tuvieron el mayor crecimiento y un 100% de supervivencia, con potencial de mayor tolerancia a condiciones invernales.