Endogenous endotoxemia of intestinal origin during cardiopulmonary bypass. Role of type of flow and protective effect of selective digestive decontamination

OBJECTIVE

To evaluate the possible related factors to endotoxemia and cytokine activation during the ischemic phase of extracorporeal surgery, and the effect of selective digestive decontamination (SDD) as a preventive measure.

DESIGN

Prospective, open, randomized trial.

SETTING

Two multidisciplinary ICUs (tertiary care hospitals).

PATIENTS

One hundred consecutive patients undergoing cardiopulmonary bypass (CPB), randomly allocated to two groups; gut decontamination (group I = 50 cases) and controls (group II = 50 cases).

INTERVENTIONS

Preoperative administration of oral non-absorbable antibiotics (polymyxin E, tobramycin and amphotericin B) versus no administration.

MEASUREMENTS AND RESULTS

The assessment of decontamination by means of the bacteriologic control of rectal swabs. Determinations of gastric intramucosal pH (gastric pHi) and plasma endotoxin, tumor necrosis factor (TNF) aNd interleukin-6 (IL-6) before surgery and during the ischemic and reperfusion phases of bypass. Rectal aerobic Gram-negative bacilli (AGNB) were significantly reduced in the treated patients and in 56% total eradication was achieved. Endotoxin, TNF and IL-6 plasma levels were significantly lower in this group. By contrast, both endotoxin and TNF/IL-6 levels and gastric pHi correlated with the type of surgical flow (pulsatile versus non-pulsatile).

CONCLUSIONS

SDD reduces the gut content of enterobacteria. This may explain the lower endotoxin and cytokine levels detected in decontaminated patients. In addition to SDD, the type of flow employed during bypass seems to influence endotoxemia and cytokine levels.

Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

CLINICAL QUESTION

Do adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery.

CURRENT PRACTICE

SAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations.

RECOMMENDATION

The guideline panel makes a strong recommendation against surgery.

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation.

THE EVIDENCE

Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery.

UNDERSTANDING THE RECOMMENDATION

The panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.

Seasonal and specific diet variations in sympatric red and fallow deer of southern Spain: a preliminary approach to feeding behaviour

We studied the diet composition and diet overlap in sympatric red deer (Cervus elaphus hispanicus) and fallow deer (Dama dama) throughout a whole year in order to determine variation due to season, species, sex and age class by analysing rumen contents samples of 81 red and 69 fallow deer shot monthly during 2008–09 in Sierra de Andújar Natural Park, southern Spain. We assessed diet similarity and possible inter- and intra-specific foraging competition. We found different foraging strategies for both species and sexes during constraint periods, and several theoretical considerations of specific interactions and behaviour are discussed with respect to the Mediterranean environment. In both species an annual diet dominated by grasses was recorded, peaking in spring. Browses were an important food resource at the end of winter and at the end of summer, and fruit more in autumn and winter. Red deer ingested a higher proportion of browse than fallow deer, which consumed more acorns and for a longer time showed a better ability to compensate for nutritional constraint periods. An overall decline in diet similarity in summer and at the end of winter led us to assume that exploitative competition between red and fallow deer and even between sexes was probable. Red deer females showed low diet similarity to other deer, while there was a great diet overlap between red deer males and fallow deer females at the end of summer. Differences detected between both two species and sexes do not always support predictions deriving from specific body size and morpho-physiological characteristics, but can probably be explained as a consequence of different metabolic demands. The relationship between plant nutritional attributes and food selection according to reproductive or physiological status and seasonal demands for both sexes and species should be researched in order to perform a better assessment of deer feeding behaviour.

A Double-Blinded Placebo Randomized Controlled Trial Evaluating Short-term Efficacy of Platelet-Rich Plasma in Reducing Postoperative Pain After Arthroscopic Rotator Cuff Repair: A Pilot Study

Background:

We aimed to determine whether patients with arthroscopically repaired rotator cuff (RC) tears would have reduced pain and improved function after ultrasound-guided platelet-rich plasma (PRP) injections compared with placebo injection.

Hypothesis:

PRP compared with placebo (saline) was more effective in reducing pain at the site of an RC injury that has undergone arthroscopic repair.

Study Design:

Randomized controlled trial.

Level of Evidence:

Level 2.

Methods:

We conducted a 2-centered, blinded, randomized controlled trial comparing the level of pain in patients undergoing arthroscopic repair. Patients were randomized to either PRP or saline (placebo). They received 2 ultrasound-guided injections of the randomized product: 1 intraoperatively and 1 at 4 weeks postoperatively. The primary outcome measure was shoulder pain demonstrated using a visual analog scale (VAS) at 6 weeks postoperatively. Secondary outcomes included the EuroQol-5 Dimensions (EQ-5D); the Western Ontario Rotator Cuff Index (WORC); and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as adverse events and revision surgeries. Patients were assessed clinically preoperatively and at 2, 4, and 6 weeks postsurgery. A prespecified interim analysis was conducted after 50% of patients were recruited and followed.

Results:

We recruited 25 patients when interim power analysis led to an early trial termination. Follow-up was 96%. The mean difference between groups was not statistically significant (–1.81; 95% CI, –4.3 to 1.2; P = 0.16). The EQ-5D, WORC, and DASH scores also did not show significant differences between groups at week 6 (P = 0.5, 0.99, and 0.9, respectively). There were no revision surgeries, and 4 adverse events (3 PRP, 1 saline).

Conclusion:

There was no statistical difference in outcome measures when augmenting arthroscopically repaired RC tears with PRP.

Clinical Relevance:

Identifying therapies that improve outcomes in patients with RC tears remains a challenge and deserves ongoing investigation.

Determinants of urinary thioethers, D-glucaric acid and mutagenicity after exposure to polycyclic aromatic hydrocarbons assessed by air monitoring and measurement of 1-hydroxypyrene in urine: a cross-sectional study in workers of coke and graphite-electrode-producing plants

A cross-sectional epidemiological study was performed on 286 workers from two coke oven and one graphite electrode plants. The aim was to evaluate the usefulness of monitoring 1-hydroxypyrene (1-HOP) in urine for assessing exposure to polycyclic aromatic hydrocarbons (PAHs), and that of the urinary excretion of thioethers and D-glucaric acid, and the mutagenic activity of urine as indicators or biological effects of PAHs. The results confirm that 1-HOP determination in urine probably reflects exposure to PAHs by all routes and is not significantly influenced by the smoking habit. In comparison with the total PAHs in the air and 1-hydroxypyrene in urine, taken as reference exposure parameters, the results indicate that urinary D-glucaric acid excretion is not positively influenced by PAHs exposure; thioethers determination in urine is of poor value, since the smoking habit is a strong confounding factor. The determination of urinary mutagenicity might contribute to the detection of groups of workers exposed to potentially genotoxic PAHs.

Policies and management of overabundant deer (native or exotic) in protected areas

A workshop was convened in Chile in August 2010 as part of the 7th International Deer Biology Congress (IDBC). Its aim was to explore global differences in the policies and management of overabundant deer in protected areas. The main goal of the workshop was to provide South American researchers and managers with a snapshot of some of the approaches to management of deer overabundance used in a diverse array of case studies from North America, Europe, Australia and New Zealand. Various case studies were presented to illustrate the different methodological approaches in implementing deer control measures. Some general recommendations were formulated.

Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions

BACKGROUND

Shoulder pain and disability pose a diagnostic challenge for clinicians owing to the numerous causes that exist. Unfortunately, the evidence in support of most clinical tests is weak or absent.

PURPOSE

To determine the diagnostic validity of physical examination maneuvers for rotator cuff lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

Consecutive shoulder patients recruited for this study were referred to 2 tertiary orthopaedic clinics. A surgeon took a thorough history and indicated his or her certainty about each possible diagnosis. A clinician performed the physical examination for diagnoses where uncertainty remained. Arthroscopy was considered the reference standard for patients who underwent surgery, and MRI with arthrogram was considered the reference for patients who did not. The sensitivity, specificity, and likelihood ratios were calculated to investigate whether combinations of the top tests provided stronger predictions of the presence or absence of disease.

RESULTS

There were 139 participants. None of the tests were highly sensitive for diagnosing rotator cuff tears or tendinosis. Tests for subscapularis tears were all highly specific. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears. Closer analysis revealed the internal rotation and lateral rotation lag sign did not improve the ability to diagnose subscapularis or supraspinatus tears, respectively, although the lateral rotation lag sign demonstrated a discriminatory ability for tear size.

CONCLUSION

No test in isolation is sufficient to diagnose a patient with rotator cuff damage. A combination of tests improves the ability to diagnose damage to the rotator cuff. It is recommended that the internal rotation and lateral rotation lag signs be removed from the gamut of physical examination tests for supraspinatus and subscapularis tears.

Predictive Factors for Development of Diabetes Mellitus Post-Heart Transplant

INTRODUCTION

It is known that there is a high incidence of diabetes mellitus (DM) among heart transplant (HT) patients, which may be up to 30% at 5 years. The presence of DM has been associated with increased morbidity (infections, renal dysfunction, or graft vascular disease), and its development has been related primarily to immunosuppressive therapy. The objective of this study was to determine, in our experience, the presence of predictive variables for the development of DM following HT.

METHODS

We studied 315 consecutive non-DM patients (88.6% men, mean age 51.5 years) who underwent HT in our hospital from November 1987 to May 2003, analyzing all variables that could be related to the development of DM during follow-up. Student t-test and chi(2) test were used for univariate statistical analysis and logistic regression for multivariate analysis.

RESULTS

Of the 315 patients, 64 developed DM (20.3%) during a mean follow-up of 3.3 years. The univariate analysis showed that patients developing DM are older (54.9 +/- 8.7 versus 50.7 +/- 11.8 years, P = .008), have a higher body mass index (BMI) (27.3 +/- 3.8 versus 25.7 +/- 3.7, P = .003), a higher prevalence of HT (37.5% versus 23.5%, P = .023), a lower frequency of urgent HT (9.4% versus 26.2%, P = .004), are more often treated with steroids (85.9% versus 70.1%, P = .011) and tacrolimus (12.5% versus 4.4%, P = .015), and have a higher frequency of rejection episodes (71.2% versus 44.6%, P = .001). Multivariate analysis identified the following as predictive factors for the development of DM: age (OR = 1.04, P = .013), urgent HT (OR = 0.36, P = .031), treatment with tacrolimus (OR = 3.89, P = .012), and number of rejections (OR = 2.34, P = .002).

CONCLUSION

In our population, age, urgent HT (which had a protective effect), treatment with tacrolimus, and number of rejections were independent predictive variables for the development of DM during follow-up.

Imaging findings in posterior instability of the shoulder

Posterior shoulder instability refers to the symptoms and signs resulting from excessive posterior translation of the humerus. Magnetic resonance (MR) imaging is the radiological modality of choice in the diagnostic assessment of posterior instability. Computed tomography (CT) is useful in the evaluation of osseous abnormalities associated with posterior instability. A detailed description of the posterior osseous and labroligamentous abnormalities has evolved recently, and many variant lesions of the posteroinferior labrum and/or capsular structures have been described. As the recommended surgical management of lesions associated with posterior instability is a lesion-specific approach, awareness of the specific lesions that have been described in association with posterior instability helps in pre-surgical planning. The purpose of this article is to review the classification of, and injury mechanisms leading to, posterior shoulder instability and to describe imaging findings associated with posterior instability, with emphasis on MR imaging.

mTOR Inhibitors: Do They Help Preserve Renal Function?

BACKGROUND

Renal function deterioration is one of the main problems facing heart transplant recipients. The mammalian target of rapamycin (mTOR) inhibitors, in combination with or replacing calcineurin inhibitors, may help preserve renal function. The aim of this study was to evaluate the progression of renal function after switching the immunosuppressive regimen.

PATIENTS AND METHODS

We studied 23 heart transplant recipients (5.5 +/- 4.5 years since transplantation). An mTOR inhibitor was introduced to replace cyclosporine (everolimus, 65%; sirolimus, 35%). Patient clinical characteristics and renal function were studied after switching. The statistical analysis used Student t test for paired data.

RESULTS

The reason for the transplantation was ischemic cardiopathy (52%), dilated myocardiopathy (39%), or other causes (9%). Mean age at time of transplantation was 52 +/- 9 years. Comorbidities were as follows hypertension (43%), insulin-dependent diabetes (22%), hypercholesterolemia (39%), and ex-smokers (70%). The reason for the switch was increased creatinine (65%), appearance of tumors (26%), or others (8%). Previous creatinine level was 1.89 +/- 0.6 mg/dL with clearance of 61.7 +/- 23 mL/min and at the end of follow-up (mean follow-up, 11 +/- 6 months) creatinine level was 2.0 +/- 1.45 mg/dL with clearance of 68.3 +/- 35 mL/min, namely, no significant difference (P = .49 and P = .57, respectively). In the subgroup of patients who switched treatment due to renal dysfunction, initial creatinine level was 2.38 +/- 0.4 mg/dL with clearance of 42.3 +/- 10 mL/min and at the end of follow-up it was 2.28 +/- 0.2 mg/dL and 43.6 +/- 11 mL/min, respectively (P = .68 for creatinine and clearance).

CONCLUSIONS

The introduction of mTOR inhibitors to the immunosuppressant regimen may be useful to delay renal functional deterioration caused by calcineurin inhibitors.

What is the best biomarker for diagnosis of rejection in heart transplantation?

INTRODUCTION

Acute cellular rejection is a major cause of graft loss in heart transplantation (HT). Endomyocardial biopsy remains the gold standard for its diagnosis, but it is an invasive procedure not without risk. A proinflammatory state exists in rejection that could be assessed by determining plasma levels of inflammatory biomarkers.

OBJECTIVE

To analyze the utility of various inflammatory markers, which is most important and what values best classify patients to diagnose rejection.

MATERIALS AND METHODS

A prospective study in 123 consecutive cardiac transplant recipients was conducted from January 2002 to December 2006. Fibrinogen protein (Fgp) and function (Fgf), C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and sialic acid (SA) determinations were performed at one, two, four, six, nine, and 12 months post-HT at the same time as biopsies. Coronary arteriography and intravascular ultrasound were performed on the first and last follow-up visits. Heart-lung transplants, retransplants, pediatric transplants, patients who died in the first month, and patients who refused consent were excluded. Also excluded were determinations that coincided with renal dysfunction, active infection, hemodynamic instability, or a non-evaluable biopsy. The final analysis included 79 patients and 294 determinations. The correlation between the levels of these biomarkers and the presence of rejection in the biopsy (> or = ISHLT grade 3) was studied.

RESULTS

We did not find significant differences in the values of any of the markers analyzed on the six follow-up visits. Only CRP showed significant and sustained differences between the two groups (with and without rejection) from the second follow-up visit (month 2). The area under the curve showed significant differences in Fgp (0.614, p = 0.013), Fgf (0.585, p = 0.05), TNF-alpha (0.605, p = 0.02), SA (0.637, p = 0.002) and mainly CRP (0.765, p = 0.0001). CRP levels below 0.87 mg/dL ruled out rejection with a specificity of 90%.

CONCLUSIONS

Among the inflammatory markers analyzed, CRP was the most useful parameter for non-invasive screening of acute cellular rejection in the first year post-HT.

Impact of Smoking on Survival After Heart Transplantation

INTRODUCTION

Smoking is an important risk factor in any population group. According to previous studies, having been a smoker before heart transplantation (HT) confers a greater likelihood of developing any type of tumor or other complication after HT. Our objective was to determine the impact of having been a smoker before HT on survival, respiratory complications during the postoperative period, and long-term tumor development.

MATERIALS AND METHODS

After excluding combined transplantations, pediatric transplantations, and retransplantations, we retrospectively reviewed 288 HT performed between November 1987 and September 2006. We divided patients into nonsmokers (including those who quit smoking more than 1 year before HT (n = 163), exsmokers for less than 1 year (n = 76), and those who smoked until HT (n = 49). The statistical tests were chi-square, Student t, analysis of variance (ANOVA), and Kaplan-Meier curves.

RESULTS

There were more male patients among smokers and exsmokers than nonsmokers (93.9% vs 96.1% vs 82%, respectively; P = .003). There were no differences in baseline characteristics between the groups. Exsmokers remained intubated for a longer time than smokers or nonsmokers (33.4 +/- 44.6 vs 14.2 +/- 7.3 vs 17.9 +/- 19.2, respectively; P = .05). We observed the same trend in recovery unit stay (7.9 +/- 10.5 days vs 4.4 +/- 1.88 days vs 4.84 +/- 3.49 days, respectively; P = .021). The development of any type of tumor was also more frequent among smokers and exsmokers, although not significantly. The survival rate was similar in nonsmokers and exsmokers, although higher than in smokers (89.57 vs 92.11% vs 81.63%, respectively; P = .031). We did not observe differences in the causes of death.

CONCLUSIONS

Patients who smoke or have smoked until shortly before HT showed a poorer prognosis and a longer recovery unit stay. There was also a trend to increased tumor development.

Analysis of the Impact of Donor Gender on Early Mortality

INTRODUCTION

Many studies have shown a detrimental effect of female donor gender on heart transplantation (HT) outcome.

OBJECTIVE

We retrospectively evaluated our experience in HT to determine the effect of donor gender on early survival.

MATERIALS AND METHODS

We divided the sample of 464 primary HT from November 1997 to September 2006 into 4 groups: G1, female donor to a male recipient; G2, male donor to a male recipient; G3, male donor to female recipient; and G4, female donor to a female recipient. We performed a descriptive study of the baseline characteristics. The chi(2) test was used to determine differences in early mortality (30 days) between groups and a multivariate analysis to identify confounding factors to increase mortality.

RESULTS

Although the univariate study showed that G1 showed a significantly lower early survival rate (84%) than G2 (91%), the multivariate study adjusted for donor and recipient weight and size, urgency level, previous surgery, and age only showed urgency level (odds ratio [OR] 2.6; 95% confidence interval [CI] 1.2-5.57; P = .016) and previous surgery (OR 5.8; 95% CI 2.7-12.4; P < .01) to be predictors of early mortality. When baseline characteristics were analyzed, we found that 31% of HT in G1 were urgent versus 18% in G2, and 32% of patients in G1 had previous surgery versus 17% in G2.

CONCLUSIONS

Donor gender did not appear to negatively affect early survival. In our series, urgent HT in male recipients with a female was more frequent than with a male donor heart. The higher early mortality in male recipients of an urgent HT from a female than from a male donor was attributable to a higher baseline risk profile.

Mortality After Heart Transplantation in Adults With Congenital Heart Disease: A Single-Center Experience

The number of congenital heart disease (CHD) patients transplanted to date is small. The results are comparable to those undergoing heart transplantation (HT) for other etiologies. However, advances in pediatric surgery over recent years (eg, the Fontan procedure) has increased the demand for HT by a growing number of children who reach adulthood and who also have a different profile. We analyzed the clinical profile and survival of our CHD patients compared with other etiologies.

MATERIALS AND METHODS

From July 17, 1991 to December 31, 2006, eight HT were performed in our center for CHD. A descriptive study determined the baseline characteristics and survival of these patients, compared with those of the overall transplant group and other subgroups (dilated cardiomyopathy, ischemic heart disease).

RESULTS

Mean age was 26 years. Four (50%) CHD patients were diagnosed with single-ventricle anatomy, associated or not with other lesions; none had been operated with the Fontan procedure. Two patients died prematurely. Early, 1-, and 10-year survival was 75% at each time point. Early, 1-, and 10-year survival in the group with other diagnoses was 90%, 78%, and 60%, respectively, and in the dilated cardiomyopathy group it was 94%, 86%, and 72%, respectively.

CONCLUSION

The current number of CHD transplant patients was small and young. The most common etiology was single-ventricle anatomy without a prior Fontan operation. Overall survival was comparable to HT for dilated cardiomyopathy.

Interventions for displaced radial head fractures: network meta-analysis of randomized trials

BACKGROUND

The purpose of this study was to conduct a systematic review of studies comparing treatments for displaced radial head fractures (RHFs) and perform a network meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched electronic databases and reviewed the reference lists of included studies and prior systematic reviews. We included RCTs and cohort studies that (1) compared treatments for displaced RHFs in adults and (2) reported a functional outcome or postoperative complications. Data from RCTs were synthesized using a Bayesian network meta-analysis. We compared the proportion of patients categorized as "excellent" or "good" according to the Broberg and Morrey scale and the rate of postoperative complications using odds ratios (OR) with 95% credible intervals (CrI).

RESULTS

We included 20 studies (4 RCTs). The evidence from RCTs examined radial head arthroplasty (RHA), open reduction and internal fixation (ORIF) with metal implants (ORIF-M), and ORIF with biodegradable implants (ORIF-B). The network meta-analysis demonstrated that patients treated with an RHA had greater odds of achieving an "excellent" or "good" score compared with ORIF-M (OR, 22.5; 95% CrI, 2.73-299.58) and ORIF-B (OR, 11.83; 95% CrI, 0.58-324.57). For postoperative complications, RHA patients had a lower odds of experiencing a complication than ORIF-M (OR, 0.15; 95% CrI, 0.01-1.81) and ORIF-B (OR, 0.16; 95% CrI, 0.01-3.06) patients.

CONCLUSION

The network meta-analysis of RCTs indicated that RHA results in better function and reduced postoperative complications than ORIF-M and ORIF-B over 2 years in the treatment of displaced RHFs.

mTOR Inhibitors and Their Secondary Effects in Cardiac Trasplant Recipients: A Descriptive Study

BACKGROUND

Mammalian target of rapamycin (mTOR) inhibitors are relatively new drugs in the field of cardiac transplantation (HT), hence the need for further study of their secondary effects. We described the nature and incidence of secondary effects of these drugs in a group of HT recipients.

PATIENTS AND METHODS

We studied 23 HT recipients aged 52 +/- 9 years (Male: 91%, body mass index: 27 +/- 3.7, ischemic cardiopathy: 52%, dilated cardiomyopathy: 39%) who were started on an mTOR inhibitor (everolimus: 65%, sirolimus: 35%) as part of their treatment. We have described the secondary effects detected during a follow-up period of 10.7 +/- 6 months.

RESULTS

The reasons for starting the drug were renal impairment (65%), tumors (26%), and others (8%). During follow-up, 17% of patients required a dose reduction and 12% required drug withdrawal: edemas: 4%, recurrent infection: 4%, and hemolytic-uremic syndrome: 4%. Drug-attributable edemas presented in 26% of patients. Thirty nine percent suffered an infection that required hospital admission, 89% of which were lung and all bacterial two patients died due to the infection). The mean time to first infection was 5 +/- 6 months. In patients who had a treatment change due to tumors, 50% experienced improvement. We did not detect alterations in cholesterol, triglycerides, creatinine, or leukocytes. There was a nonsignificant trend toward decreased hemoglobin and platelet levels (P = .07 and P = .056, respectively).

CONCLUSIONS

Lung infection was the principal complication among our patients treated with mTOR inhibitors. A large percentage required dose reduction (17%) and even drug withdrawal (12%) due to secondary effects.

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

Course of Patients With Chronic Hepatitis C Virus Infection Undergoing Heart Transplantation

OBJECTIVE

The objective of this study was to describe the clinical course of patients with chronic hepatitis C virus (HCV) infection undergoing heart transplantation (HT).

MATERIALS AND METHODS

Among 499 patients transplanted in our hospital between January 1989 and September 2006, 11 subjects (2.2%) had chronic HCV infection. We analyzed liver function laboratory parameters pretransplantation as well as at 3, 6, 12 months, and last available, pre- and postsurgical hepatobiliary ultrasounds, and mortality. The mean time since HT was 32 +/- 23 months.

RESULTS

No abnormalities in the liver parenchyma were observed on the ultrasound examinations performed before or after transplantation. There were 3 deaths (27%), none of which was related to HCV infection. Liver function laboratory parameters remained stable during the follow-up.

CONCLUSIONS

The clinical course of patients with chronic HCV infection undergoing HT whose presurgical assessment did not show significant liver damage was favorable. No morphological or laboratory abnormalities were observed that would suggest reactivation of the infection during the follow-up.

Induction Therapy With Daclizumab in Heart Transplantation—How Many Doses?

Since their introduction onto the market, interleukin-2 antagonists have been increasingly used by a growing number of transplant units. Their benefits versus OKT3 appear evident, although the optimal dose remains to be established. Our objective was to establish possible differences related to the use of two versus five doses of daclizumab.

MATERIALS AND METHODS

This study evaluated 81 consecutive patients treated with two bolus doses of daclizumab (1 mg/kg) on days 1 and 14 posttransplantation. We excluded retransplantations, pediatric transplantations, and combined transplantations. We compared our series to a previous trial involving the administration of a single bolus dose every 14 days (five boluses in total). Study variables included the number of graft rejections, the number of infections, and the mortality. Statistical analysis was performed using the chi square and Student's t tests. Significance was set at P < .05.

RESULTS

There were no differences between groups in the baseline characteristics of the patients. The number of rejection episodes during the first year was significantly lower among the patients in our series treated with two bolus doses of daclizumab than in the series of patients treated with five bolus doses: 24 (30%) vs 17 (61%) episodes (P = .003). No significant differences were observed for mortality: the group receiving two boluses registered 10 deaths (12%) versus two (7%) in the group receiving five boluses (P = .4), or infection rate: 11 patients (40%) in the group receiving five bolus versus 31 patients (38%) in the group given two bolus doses (P = .9).

CONCLUSIONS

Our results suggested that induction therapy with two doses of daclizumab was at least as effective in preventing rejection as five doses, with no negative effects on patient survival.

Radial head arthroplasty: fixed-stem implants are not all equal-a systematic review and meta-analysis

Background

Numerous fixed-stem implants exist for radial head arthroplasty; therefore, we conducted a systematic review to compare the safety and efficacy of different types of fixed-stem implants.

Methods

We conducted a literature search, updated from a previous systematic review, to identify studies evaluating a fixed-stem radial head arthroplasty implant for any indication. We extracted data on revision rates, specific complications, and functional scores. We pooled results across studies using a random-effects method, using proportions for dichotomous data and mean values for functional scores. We analyzed outcomes by indication and specific implant.

Results

We included 31 studies. Studies included patients with radial head fractures only, terrible-triad injuries, or Essex-Lopresti injuries or included a heterogeneous population. We identified 15 different fixed-stem implants. The results of our analysis revealed that patients with terrible-triad injuries may be at an increased risk of revision and instability and patients with Essex-Lopresti injuries may be at an increased risk of arthritis, capitellar erosion, and osteolysis. After removing these outliers and pooling the results by specific device, we observed variability across devices in the rates of revision, arthritis, capitellar erosion, instability, and osteolysis, as well as in functional scores.

Conclusion

Differences were seen across different implants in revision rates, certain complications, and functional scores. This study highlighted that these devices should be evaluated within the context of the patient population under examination, as patients with Essex-Lopresti or terrible-triad injuries may demonstrate worse outcomes relative to those with a fracture only.

Does Amiodarone Influence Early Mortality in Heart Transplantation?

The use of amiodarone before transplantation has been linked to an increased number of complications, acute graft failures, and early mortality after a heart graft. We undertook a retrospective, descriptive, case-controlled study involving early mortality and acute graft failure. The 396 consecutive patients included 25 subjects who had been prescribed amiodarone for at least 30 days before transplantation. We excluded retransplantations, pediatric transplantations, and combined transplantations. The endpoints were early mortality and acute graft failure. No significant differences were observed in early mortality and acute graft failures. The multivariate analysis did not reveal any variable that correlated with early mortality. Our study did not support the idea that amiodarone constituted a negative predictor of early survival or acute graft failure.

Correlation between beta-adrenoceptors and G-protein-coupled receptor kinases in pretransplantation heart failure

INTRODUCTION

Prolonged catecholamine overstimulation of the myocardium in chronic heart failure causes a reduction in the number and functionality of beta1-adrenoceptors (beta1-AR) of the heart. Desensitization of beta1-AR is mediated by their phosphorylation by a group of cytosolic kinases (G-protein-coupled receptor kinases GRK). In advanced heart failure, an increase in GRK levels associated with the severity of the disease has been observed.

OBJECTIVE

The objective of this study was to analyze messenger RNA (mRNA) levels of beta1-AR in the myocardium of patients who underwent transplantation for advanced heart failure and their correlation with expression of the major cardiac isoenzymes of GRK.

MATERIALS AND METHODS

Myocardial tissue samples were obtained from the left ventricles of 14 explanted hearts of patients who underwent transplantation for dilated (n = 7) and ischemic (n = 7) cardiomyopathy. RT-PCR techniques were used to analyze mRNA levels of beta1-AR and the isoenzymes GRK2, GRK3, and GRK5.

RESULTS

We observed a significant correlation between beta1-AR and the 3 subtypes of GRK (R(2) = 0.668, 0.71, and 0.318, respectively).

CONCLUSIONS

In patients with advanced heart failure pretransplantation, we observed a significant correlation between beta1-AR and GRK2 and GRK3 levels. GRK5, the subtype predominantly expressed in the myocardium, showed a lesser correlation with beta1-AR levels.