The predictive value of the preoperative hemoglobin value after coronary artery bypass grafting (CABG) has not been well established. We studied how the preoperative hemoglobin level affects the ...survival of patients after CABG. Late mortality was compared with that of a general population.
Early and late mortality of all consecutive patients undergoing isolated CABG between January 1998 and December 2007 were determined. Patients were classified into 4 groups stratified by preoperative hemoglobin level. The cutoff point for anemia was 13 g/dL for men and 12 g/dL for women. Expected survival of a matched general Dutch population cohort was obtained from the database of the Dutch Central Bureau for Statistics. After the exclusion of 122 patients who were lost to follow-up and 481 patients with missing preoperative hemoglobin levels, complete data were obtained in 10,025 patients. Multivariate logistic regression analyses revealed anemia to be an independent risk factor for higher early mortality. Cox regression analyses revealed low hemoglobin level, both as a continuous variable and as a dichotomous variable (anemia), to be a predictor of higher late mortality. Compared with expected survival, patients with the lowest preoperative hemoglobin levels had a worse outcome, whereas patients with the highest hemoglobin levels had a better outcome.
A lower preoperative hemoglobin level is an independent predictor of late mortality in patients undergoing CABG, whereas anemia is a risk factor for early and late mortality. Compared with the general population, anemic patients had worse survival than expected, whereas nonanemic patients had better survival than expected.
In many societies, the majority of adults regularly consume alcohol. However, only a small proportion develops alcohol addiction. Individuals at risk often show a high sensation-seeking/low-anxiety ...behavioural phenotype. Here we asked which role EF hand domain containing 2 (EFhd2; Swiprosin-1) plays in the control of alcohol addiction-associated behaviours. EFhd2 knockout (KO) mice drink more alcohol than controls and spontaneously escalate their consumption. This coincided with a sensation-seeking and low-anxiety phenotype. A reversal of the behavioural phenotype with β-carboline, an anxiogenic inverse benzodiazepine receptor agonist, normalized alcohol preference in EFhd2 KO mice, demonstrating an EFhd2-driven relationship between personality traits and alcohol preference. These findings were confirmed in a human sample where we observed a positive association of the EFhd2 single-nucleotide polymorphism rs112146896 with lifetime drinking and a negative association with anxiety in healthy adolescents. The lack of EFhd2 reduced extracellular dopamine levels in the brain, but enhanced responses to alcohol. In confirmation, gene expression analysis revealed reduced tyrosine hydroxylase expression and the regulation of genes involved in cortex development, Eomes and Pax6, in EFhd2 KO cortices. These findings were corroborated in Xenopus tadpoles by EFhd2 knockdown. Magnetic resonance imaging (MRI) in mice showed that a lack of EFhd2 reduces cortical volume in adults. Moreover, human MRI confirmed the negative association between lifetime alcohol drinking and superior frontal gyrus volume. We propose that EFhd2 is a conserved resilience factor against alcohol consumption and its escalation, working through Pax6/Eomes. Reduced EFhd2 function induces high-risk personality traits of sensation-seeking/low anxiety associated with enhanced alcohol consumption, which may be related to cortex function.
Summary
Cardiac surgery with cardiopulmonary bypass provokes a systemic inflammatory response syndrome caused by the surgical trauma itself, blood contact with the non-physiological surfaces of the ...extracorporeal circuit, endotoxemia, and ischemia. The role of endotoxin in the inflammatory response syndrome has been well investigated. In this report, we reviewed recent advances in the understanding of the pathophysiology of the endotoxin release during cardiopulmonary bypass and the possible therapeutic strategies aimed to reduce the endotoxin release or to counteract the inflammatory effects of endotoxin. Although many different strategies to detoxify endotoxins were evaluated, none of them were able to show statistically significant differences in clinical outcome.
summary Three commercial systems for whole blood separation were compared to obtain the buffy coat composed of platelet‐rich plasma (BC‐PRP) and leucocytes . These samples of the buffy coat were used ...to make a platelet gel (PG), which was used to measure platelet growth factor (PGF) release, to perform a white blood cell (WBC) count and to measure myeloperoxidase (MPO) release from WBCs. Aliquots of whole blood obtained from ten volunteers were distributed either to a blood cell separator (The Electa Cell‐Separator™, E‐CS) or to a tabletop centrifuge (Gravitational Platelet Sequestration System™, GPS) to prepare the BC‐PRP. The third system combines the BC‐PRP production by E‐CS with a micro porous filter (Autologous Growth Factor filter™, AGF) to enrich for the BC‐PRP. Autologous thrombin was used to activate the BC‐PRP and to prepare the PG and subsequently to degranulate the platelet concentrate. Platelet‐derived growth factor‐AB and transforming growth factor‐β1 were present in high levels after thrombin activation of the E‐CS or GPS prepared samples. However, the AGF prepared samples released their growth factors before thrombin activation. The WBCs were significantly increased with each of the three systems. Contrary to the AGF, no leucocyte degranulation occurred with the E‐CS or GPS prepared samples, based upon the low MPO concentrations in the BC‐PRP. The three types of apparatus had different harvesting capacities for collecting the enriched platelets and the release of high concentrations of PGF. When the E‐CS and GPS, but not the AGF, were used, low levels of MPO were maintained in the PG, which potentially contributes to antimicrobial properties of platelet gel at the site of application.
Background The effect of obesity on the long-term outcome after coronary artery bypass graft surgery (CABG) remains controversial. We analyzed data of patients undergoing CABG in a single center, to ...determine the predictive value of body mass index in combination with comorbidities on early and late mortality. Methods Early and late mortality of consecutive patients undergoing isolated CABG from January 1998 until December 2007 were determined. Patients were classified into five groups according to preoperative body mass index: underweight, normal weight, overweight, obese, and morbidly obese. Results After excluding 122 patients who were lost to follow-up and 236 patients with missing preoperative body mass index, 10,268 patients were studied. Multivariate logistic regression analyses showed that underweight was associated with higher early mortality (hazard ratio 2.63; 95% confidence interval: 1.13 to 6.11, p = 0.025). Multivariate Cox regression analyses did reveal morbid obesity as an independent predictor of late mortality (hazard ratio 1.67, 95% confidence interval: 1.15 to 2.43, p = 0.007). Conclusions Among patients undergoing isolated CABG, underweight is an independent predictor for early mortality, and morbid obesity is an independent predictor for late mortality.
The therapeutic use of autologously prepared, platelet-leukocyte-enriched gel (PLG) is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. The ...effectiveness of this procedure lies in the delivery of a wide range of platelet growth factors mimicking the physiologic wound healing and reparative tissue processes. Despite an increase in PLG applications, the structures and kinetics of this autogenously derived biologic material have not been observed.
A review of the most recent literature was performed to evaluate the use of PLG in various surgical disciplines.
The review showed that the application of PLG has been extended to various surgical disciplines including orthopedics, cardiac surgery, plastic and maxillofacial surgery, and recently also endoscopic surgery.
This review demonstrates the usefulness of PLG in a wide range of clinical applications for improvement of healing after surgical procedures.
Objective: The optimal timing for discontinuation of clopidogrel before surgery remains under debate. The purpose of this study is to determine the effect of preoperative clopidogrel administration ...on postoperative blood loss and the total requirements of homologous blood products after coronary artery bypass grafting (CABG). We also evaluated the perioperative complications. Methods: Consecutive patients (n = 130) undergoing elective CABG were recruited and randomised between 2006 and 2007. In 38 patients (group 1), treatment with clopidogrel was discontinued 5 days prior to surgery, in 40 patients (group 2) 3 days before surgery and in 40 other patients (group 3) clopidogrel was stopped on the day of surgery. Results: Significantly more postoperative blood loss was observed in group 3 compared to group 1 (929 ± 472 ml vs 664 ± 312 ml; p = 0.009). Other group comparisons were not significant. Blood loss after 12 h and at drain removal was also significantly higher in group 3. Patients in group 3 also had higher total requirements of homologous blood products (p = 0.046) and a significantly higher need for fresh frozen plasma (FFP) transfusion (p = 0.034). Univariable regression analyses revealed that continuing clopidogrel till the day of surgery (group 3) was predictive for postoperative blood loss (β = 0.289; p = 0.007) and the total requirements of homologous blood products after surgery (β = 0.280; p = 0.008). These effects remained the same in multivariable analyses. Conclusions: Continuation of clopidogrel until the day of surgery induces significantly more postoperative blood loss and increases significantly the total requirements of homologous blood products and FFP transfusion after surgery. The blood loss and the use of blood products in the group that stopped at 3 days preoperatively were similar to that of the group that stopped at 5 days preoperatively.
The long-term (five-year) comparative results of treatment of multivessel coronary artery disease with stenting or coronary artery bypass grafting (CABG) is at present unknown.
The Arterial ...Revascularization Therapies Study (ARTS) was designed to compare CABG and stenting in patients with multivessel disease.
A total of 1,205 patients with the potential for equivalent revascularization were randomly assigned to CABG (n = 605) or stent implantation (n = 600). The primary clinical end point was freedom from major adverse cardiac and cerebrovascular events (MACCE) at one year; MACCE at five-year follow-up constituted the final secondary end point.
At five years, there were 48 and 46 deaths in the stent and CABG groups, respectively (8.0% vs. 7.6%; p = 0.83; relative risk RR, 1.05; 95% confidence interval CI, 0.71 to 1.55). Among 208 diabetic patients, mortality was 13.4% in the stent group and 8.3% in the CABG group (p = 0.27; RR, 1.61; 95% CI, 0.71 to 3.63). Overall freedom from death, stroke, or myocardial infarction was not significantly different between groups (18.2% in the stent group vs. 14.9% in the surgical group; p = 0.14; RR, 1.22; 95% CI, 0.95 to 1.58). The incidence of repeat revascularization was significantly higher in the stent group (30.3%) than in the CABG group (8.8%; p < 0.001; RR, 3.46; 95% CI, 2.61 to 4.60). The composite event-free survival rate was 58.3% in the stent group and 78.2% in the CABG group (p < 0.0001; RR, 1.91; 95% CI, 1.60 to 2.28).
At five years there was no difference in mortality between stenting and surgery for multivessel disease. Furthermore, the incidence of stroke or myocardial infarction was not significantly different between the two groups. However, overall MACCE was higher in the stent group, driven by the increased need for repeat revascularization.
Aims To compare coronary stent implantation and bypass surgery for multivessel coronary disease in patients with renal insufficiency. Methods and results In the ARTS trial, 142 moderate renal ...insufficient patients (Ccr<60 mL/min) with multivessel coronary disease were randomly assigned to stent implantation (n=69) or CABG (n=73). At 5 years, there was no significant difference between the two groups in terms of mortality (14.5% in the stent group vs. 12.3% in the CABG group, P=0.81), or combined endpoint of death, cerebrovascular accident (CVA), or myocardial infarction (MI) (30.4% in the stent group vs. 23.3% in the CABG group, P=0.35). Among patients who survived without CVA or MI, 18.8% in the stent group underwent a second revascularization procedure when compared with 8.2% in the surgery group (P=0.08). The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (P=0.04). Conclusion At 5 years, the differences in mortality and combined incidence of death, CVA, and MI between coronary stenting and surgery did not reach statistically significant level. However, the occurrence of MACCE in the stent group was higher than in the CABG group, mainly driven by the higher incidence of repeat revascularization in the stent group.
Urban air quality and human health are among the key aspects of future urban planning. In order to address pollutants such as ozone and particulate matter, efforts need to be made to quantify and ...reduce their concentrations. One important aspect in understanding urban air quality is the influence of urban vegetation which may act as both emitter and sink for trace gases and aerosol particles. In this context, the "Berlin Air quality and Ecosystem Research: Local and long-range Impact of anthropogenic and Natural hydrocarbons 2014" (BAERLIN2014) campaign was conducted between 2 June and 29 August in the metropolitan area of Berlin and Brandenburg, Germany. The predominant goals of the campaign were (1) the characterization of urban gaseous and particulate pollution and its attribution to anthropogenic and natural sources in the region of interest, especially considering the connection between biogenic volatile organic compounds and particulates and ozone; (2) the quantification of the impact of urban vegetation on organic trace gas levels and the presence of oxidants such as ozone; and (3) to explain the local heterogeneity of pollutants by defining the distribution of sources and sinks relevant for the interpretation of model simulations. In order to do so, the campaign included stationary measurements at urban background station and mobile observations carried out from bicycle, van and airborne platforms. This paper provides an overview of the mobile measurements (Mobile BAERLIN2014) and general conclusions drawn from the analysis. Bicycle measurements showed micro-scale variations of temperature and particulate matter, displaying a substantial reduction of mean temperatures and particulate levels in the proximity of vegetated areas compared to typical urban residential area (background) measurements. Van measurements extended the area covered by bicycle observations and included continuous measurements of O3, NOx, CO, CO2 and point-wise measurement of volatile organic compounds (VOCs) at representative sites for traffic- and vegetation-affected sites. The quantification displayed notable horizontal heterogeneity of the short-lived gases and particle number concentrations. For example, baseline concentrations of the traffic-related chemical species CO and NO varied on average by up to ±22.2 and ±63.5 %, respectively, on the scale of 100 m around any measurement location. Airborne observations revealed the dominant source of elevated urban particulate number and mass concentrations being local, i.e., not being caused by long-range transport. Surface-based observations related these two parameters predominantly to traffic sources. Vegetated areas lowered the pollutant concentrations substantially with ozone being reduced most by coniferous forests, which is most likely caused by their reactive biogenic VOC emissions. With respect to the overall potential to reduce air pollutant levels, forests were found to result in the largest decrease, followed by parks and facilities for sports and leisure. Surface temperature was generally 0.6–2.1 °C lower in vegetated regions, which in turn will have an impact on tropospheric chemical processes. Based on our findings, effective future mitigation activities to provide a more sustainable and healthier urban environment should focus predominantly on reducing fossil-fuel emissions from traffic as well as on increasing vegetated areas.
PDF
