Objective To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this ...setting. Design and Setting Systematic literature review and international web-based survey. Participants More than 300 physicians from 62 countries. Interventions Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality. Measurements and Main Results Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions. Conclusion The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics.
Objectives The aim of this study was to assess whether small arteries from visceral fat of obese patients show a reduced nitric oxide (NO)-dependent relaxation, as compared with lean control ...subjects, focusing on the role of the pro-inflammatory cytokine tumor necrosis factor (TNF)-α. Background Visceral obesity is characterized by endothelial dysfunction. Methods Small arteries from 14 obese (body mass index 48.4 ± 11 kg/m2 ) and 14 control subjects (body mass index 24.9 ± 2 kg/m2 ), dissected after a visceral fat biopsy (laparoscopy), were evaluated on a pressurized micromyograph. Endothelium-dependent relaxation was assessed by acetylcholine. The NO availability, superoxide production, and inflammation were assessed by testing acetylcholine under the nitric oxide synthase (NOS) inhibitor Nω -nitro-L-arginine methylester, tempol (superoxide scavenger), and infliximab (monoclonal anti–TNF-α antibody), respectively. The roles of nicotinamide adenine dinucleotide phosphate oxidase and inducible nitric oxide synthase (iNOS) were assessed by their selective inhibitors apocynin and S-methylisothiourea (SMT), respectively. Vascular superoxide generation (dihydroethidium staining) protein expression of TNF-α and NOS isoforms (Western Blot) and TNF-α localization (immunohistochemistry) were assessed. Results Vessels from obese patients displayed a blunted relaxation to acetylcholine and a reduced inhibitory effect of Nω -nitro-L-arginine methylester. These alterations were normalized by tempol or infliximab while being partly ameliorated by apocynin and SMT. Vascular superoxide generation was increased (p < 0.01) in obese patients. This condition was abrogated by both tempol and infliximab and partly (p < 0.05 vs. control subjects) reduced by apocynin or SMT. Enhanced TNF-α and iNOS expression together with increased TNF-α localization in the vascular media were detected. Conclusions Small arteries from visceral fat of obese patients are characterized by an increased TNF-α production, which reduces NO availability by promoting superoxide generation via nicotinamide adenine dinucleotide phosphate oxidase and iNOS activation.
Background In peritoneal dialysis, the high glucose load absorbed from dialysis fluid contributes to several metabolic abnormalities, including insulin resistance. We evaluate the efficacy of a ...peritoneal dialysis solution containing l -carnitine as an additive to improve insulin sensitivity. Study Design Multicenter parallel randomized controlled trial. Setting & Participants Nondiabetic uremic patients on continuous ambulatory peritoneal dialysis enrolled in 8 peritoneal dialysis centers. Intervention Patients were randomly assigned to receive peritoneal dialysis diurnal exchanges with either a standard glucose-based solution (1.5% or 2.5% according to the patient's need) or a glucose-based solution (identical glucose amount) enriched with l -carnitine (0.1%, weight/volume; 2 g/bag) for 4 months, the nocturnal exchange with icodextrin being unmodified. Outcomes & Measurements The primary outcome was insulin sensitivity, measured by the magnitude of change from baseline in glucose infusion rate (in milligrams per kilogram of body weight per minute) during a euglycemic hyperinsulinemic clamp. Secondary outcomes were safety and tolerability, body fluid management, peritoneal dialysis efficiency parameters, and biochemistry tests. Results 35 patients were randomly assigned, whereas 27 patients (standard solution, n=12; experimental solution, n = 15) were analyzed. Adverse events were not attributable to treatment. Glucose infusion rates in the l -carnitine–treated group increased from 3.8 ± 2.0 (SD) mg/kg/min at baseline to 5.0 ± 2.2 mg/kg/min at day 120 ( P = 0.03) compared with 4.8 ± 2.4 mg/kg/min at baseline and 4.7 ± 2.4 mg/kg/min at day 120 observed in the control group ( P = 0.8). The difference in glucose infusion rates between groups was 1.3 (95% CI, 0.0-2.6) mg/kg/min. In patients treated with l -carnitine–containing solution, urine volume did not change significantly ( P = 0.1) compared to a significant diuresis reduction found in the other group ( P = 0.02). For peritoneal function, no differences were observed during the observation period. Limitations Small sample size. Conclusions The use of l -carnitine in dialysis solutions may represent a new approach to improving insulin sensitivity in nondiabetic peritoneal dialysis patients.
Objective With more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This ...international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence. Design and Setting A web-based international consensus conference. Participants More than 1,000 physicians from 77 countries participated in this web-based consensus conference. Interventions Systematic literature searches (MEDLINE/PubMed, June 8, 2011) were used to identify the papers with a statistically significant effect on mortality together with contacts with experts. Interventions were considered eligible for evaluation if they (1) were published in peer-reviewed journals, (2) dealt with a nonsurgical intervention (drug/technique/strategy) in adult patients undergoing surgery, and (3) provided a statistically significant mortality increase or reduction as suggested by a randomized trial or meta-analysis of randomized trials. Measurements and Main Results Fourteen interventions that might change perioperative mortality in adult surgery were identified. Interventions that might reduce mortality include chlorhexidine oral rinse, clonidine, insulin, intra-aortic balloon pump, leukodepletion, levosimendan, neuraxial anesthesia, noninvasive respiratory support, hemodynamic optimization, oxygen, selective decontamination of the digestive tract, and volatile anesthetics. In contrast, aprotinin and extended-release metoprolol might increase mortality. Conclusions Future research and health care funding should be directed toward studying and evaluating these interventions.
The present case-control study aimed to identify the main factors associated with colonization with carbapenemase-producing Klebsiella pneumoniae (CPKP) in acute care facilities. Administration of ...carbapenems (odds ratio OR, 3.67; 95% confidence interval CI, 1.37-9.83) and other antibiotics (OR, 2.83; 95% CI, 1.10-7.31) during the hospital stay was significantly associated with outcome. The design of this study, with concurrent selection of controls and matching by hospital ward and date of screening, provides a more accurate estimation of relative risks for CPKP colonization than previous investigations.
Is Le Fort I Osteotomy Associated With Maxillary Sinusitis? Nocini, Pier Francesco, MD, DDS; D'Agostino, Antonio, MD; Trevisiol, Lorenzo, MD ...
Journal of oral and maxillofacial surgery,
02/2016, Letnik:
74, Številka:
2
Journal Article
Recenzirano
Purpose The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus. Materials ...and Methods Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values. Results The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant ( P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater ( P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury. Conclusions The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.
Purpose The purpose of the present study was to analyze the relation between zygomatic implants and symptomatic and radiologic modifications of the maxillary sinuses. Materials and Methods A ...retrospective cohort study of patients who underwent zygomatic implant rehabilitation at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2005 through May 2014 was designed. The primary predictor variable was time (pre- vs postoperative). Concerning outcome variables, radiologic findings of thickened mucosa or opacification of the maxillary sinuses were evaluated on computed tomograms using the Lund-Mackay Staging System. Clinical symptoms were evaluated using the Sino-Nasal Outcome Test-20 (SNOT-20). The parameters assessed underwent descriptive statistical analysis. Results The sample was composed of 41 patients (mean age, 54 yr; 61% women). Preoperatively, 12% had sinus findings. Postoperatively, 46% had sinus findings ( P = .0001 by McNemar paired test). Preoperatively, 12% had a SNOT-20 score higher than 11. Postoperatively, 15% had a SNOT-20 score higher than 11 ( P = 1 by McNemar paired test). Conclusions In accordance with data in the literature data, placement of zygomatic implants does not seem to be associated with severe rhinosinusitis complications. However, in a considerable number of patients, asymptomatic radiologic alterations of the paranasal sinuses were observed. Therefore, it is important to plan assessments of the prosthetic and peri-implant components of the procedure and the postoperative homeostasis of the maxillary sinuses.
Purpose To evaluate the long-term results of cheekbone augmentation using porous hydroxyapatite granules mixed with microfibrillar collagen in a large group of patients. Materials and Methods Four ...hundred thirty patients who underwent zygomatic augmentation and intermaxillary osteotomy were evaluated clinically, radiologically, and histologically. Results Complications were found in 13 patients (1.56%). There were no relevant radiologic differences in prosthesis volume after 1 month (T1) or after 24 months (T2) in any patient; there were no clinically relevant differences in 110 patients after 36 months. At T1, the prosthesis had a granular structure and the granules had not migrated; at T2, the prosthesis was staunchly adhering to the underlying bone. Over time, the radiopacity of the material increased. Histologic results of 19 biopsy specimens obtained from 8 patients 2 years after the procedure showed prominent ossification with low inflammation, confirming new bone formation over time. According to the visual analog scale, the patients were generally satisfied with the aspects that were considered. Conclusion Hydroxyapatite and collagen composite used during malarplasty produced a successful outcome. Its main drawback is a learning curve that is longer than for more frequently used implantable biomaterials.
Contrast-enhanced abdominal CT is the gold standard for the diagnosis of acute mesenteric ischemia (AMI). CT findings include several anomalies like bowel wall thickening, thinning, attenuation, ...decreased enhancement, dilated fluid-filled loops, pneumatosis, and portal venous gas. A rare case of gas found only in the superior mesenteric artery (SMA) is presented. A contrast-enhanced CT scan was performed in emergency on an 80-year-old man with vague and diffuse abdominal pain, which showed findings of occlusive AMI. Gas was found in the context of the SMA and its branches, but not in the mesenteric and portal veins. The patient underwent emergency surgery but he died the next day in the intensive care unit for complications. The rare CT finding of gas in SMA during an AMI should be considered a radiological sign of irreversible intestinal damage: surgical prompt intervention is needed, even if the mortality rate is high.
Background We investigated whether the use of left ventricular-assisted (LVA) technique in beating heart myocardial revascularization would exert less impact on patients adhesion molecules and ...oxygenation index as compared with conventional cardiopulmonary bypass (CPB). Methods Sixty-six consecutive patients undergoing myocardial revascularization were randomly assigned either to LVA (group A, 34 patients) or CPB (group B, 32 patients). Adhesion molecules and oxygenation indexes were measured at baseline and at various time points postoperatively. Results Pre-operative clinical and demographic data did not differ between the 2 groups. The 2 groups were also similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, postoperatively patients treated with LVA had a reduced levels of adhesion molecules compared with patients treated with CPB, as indicated by a significant difference in endothelial leukocyte adhesion molecule-1 ( P = .002), intercellullar adhesion molecule-1 ( P = .0001), and vascular cell adhesion molecule-1 ( P = .004). The oxygenation index at 1 ( P = .04) and 3 hours ( P = .03) postoperatively was better in the LVA group than in the CPB group. Conclusion Patients undergoing beating heart myocardial revascularization with LVA show reduced levels of adhesion molecules and better oxygenation index than patients treated with CPB.
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