Marilou Hervas-Malo

Forced Euvolemic Diuresis With Mannitol and Furosemide for Prevention of Contrast-Induced Nephropathy in Patients With CKD Undergoing Coronary Angiography: A Randomized Controlled Trial

BACKGROUND Contrast-induced nephropathy is common in patients with coronary angiography. Mechanistically, forced euvolemic diuresis with mannitol and furosemide ought to prevent contrast-induced nephropathy. Our objectives are to: (1) undertake a randomized trial testing this hypothesis, and (2) conduct a meta-analysis of our findings with 2 earlier studies. STUDY DESIGN (1) Randomized allocation-concealed controlled trial with blinded ascertainment of outcomes, and (2) random-effects meta-analysis of 3 trials. SETTING & PARTICIPANTS Single-center study of consenting adults with serum creatinine level greater than 1.7 mg/dL undergoing coronary angiography; patients unable to tolerate fluid challenge or receiving dialysis were excluded. Two previous trials had randomly assigned 159 patients. INTERVENTION Forced euvolemic diuresis with saline, mannitol, and furosemide compared with saline hydration controls. All patients were pretreated with at least 500 mL of half-normal saline before angiography; during and 8 hours after, urine output was replaced milliliter per milliliter with half-normal saline. OUTCOMES & MEASUREMENTS The primary outcome was contrast-induced nephropathy within 48 hours of the procedure, defined as a 0.5-mg/dL absolute or 25% relative increase in creatinine level. RESULTS Overall, 92 patients were allocated to intervention (n = 46) or control (n = 46). Mean age was 64 +/- 14 (SD) years, 23% were women, 37% had diabetes, 47% used oral furosemide, mean creatinine level was 2.8 +/- 1.6 mg/dL, and most patients (72%) underwent diagnostic catheterization. Patients had a net positive fluid balance (389 +/- 958 mL for intervention versus 655 +/- 982 mL for controls; P = 0.2). Contrast-induced nephropathy occurred in 23 (50%) intervention patients versus 13 (28%) controls (relative risk, 1.77; 95% confidence interval, 1.03 to 3.05; P = 0.03; adjusted odds ratio, 3.73; P = 0.03). Within 48 hours, creatinine level had increased by 0.8 +/- 1.1 mg/dL with intervention versus 0.2 +/- 0.6 mg/dL for controls (P = 0.002). Overall, 11 (12%) patients died or required dialysis, with no difference according to allocation status (P = 0.5). Random-effects meta-analysis of published data (3 trials; 251 patients) suggests furosemide-based interventions lead to significant harm compared with hydration: pooled relative risk, 2.15; 95% confidence interval, 1.37 to 3.37; I(2) = 0%. LIMITATIONS Small single-center study that cannot determine whether harms were related to furosemide, mannitol, or a combination. CONCLUSIONS Forced euvolemic diuresis led to a significantly increased risk of contrast-induced nephropathy. This strategy should be abandoned, and our results suggest that oral furosemide therapy perhaps should be held before angiography.

Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury

BackgroundCardiac surgery-associated acute kidney injury (CSA-AKI) contributes to increased morbidity and mortality. However, its pathophysiology remains incompletely understood. We hypothesized that intra-operative mean arterial pressure (MAP) relative to pre-operative MAP would be an important predisposing factor for CSA-AKI.MethodsWe performed a prospective observational study of 157 consecutive high-risk patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The primary exposure was delta MAP, defined as the pre-operative MAP minus average MAP during CPB. Secondary exposure was CPB flow. The primary outcome was early CSA-AKI, defined by a minimum RIFLE class - RISK. Univariate and multivariate logistic regression were performed to explore for association between delta MAP and CSA-AKI.ResultsMean (± SD) age was 65.9 ± 14.7 years, 70.1% were male, 47.8% had isolated coronary bypass graft (CABG) surgery, 24.2% had isolated valve surgery and 16.6% had combined procedures. Mean (± SD) pre-operative, intra-operative and delta MAP were 86.6 ± 13.2, 57.4 ± 5.0 and 29.4 ± 13.5 mmHg, respectively. Sixty-five patients (41%) developed CSA-AKI within in the first 24 hours post surgery. By multivariate logistic regression, a delta MAP≥26 mmHg (odds ratio [OR], 2.8; 95%CI, 1.3-6.1, p = 0.009) and CPB flow rate ≥54 mL/kg/min (OR, 0.2, 0.1-0.5, p < 0.001) were independently associated with CSA-AKI. Additional variables associated with CSA-AKI included use of a side-biting aortic clamp (OR, 3.0; 1.3-7.1, p = 0.012), and body mass index ≥25 (OR, 4.2; 1.6-11.2, p = 0.004).ConclusionA large delta MAP and lower CPB flow during cardiac surgery are independently associated with early post-operative CSA-AKI in high-risk patients. Delta MAP represents a potentially modifiable intra-operative factor for development of CSA-AKI that necessitates further inquiry.

Simple cognitive testing (Mini-Cog) predicts in-hospital delirium in the elderly

control group (2.2 0.3 pg/mL before and after treatment). Serum IL-6 remained unchanged in both groups. In the Hochuekkito-treated group, serum prealbumin level, a marker of nutritional status, increased from 23.6 1.1 mg/dL to 26.6 1.2 mg/dL, whereas it was unchanged in the control group. These data suggest that Hochuekkito improves systemic inflammation and nutritional status in older patients with moderate to severe COPD, although the mechanisms of Hochuekkito have not been defined. Systemic inflammation, in addition to nutritional status, is a determinant of quality of life and prognosis in COPD patients. Further larger studies on its effects and mechanisms of action will be needed, although Hochuekkito has a long history of use in patients with COPD and weakness, and its safety has been clinically established.

Cardiovascular assessment of diabetic end-stage renal disease patients before renal transplantation.

Background. Although consensus guidelines for preoperative cardiovascular (CV) assessment exist, diabetic patients with renal insufficiency (DM/RI) undergoing assessment for renal transplantation are a unique high-risk group that remains poorly investigated. Methods. A consecutive cohort of DM/RI patients being assessed for renal transplantation was studied. We analyzed the ability of clinical characteristics and noninvasive investigation to predict significant coronary artery disease (CAD) and incidence of major adverse CV events. Results. Baseline characteristics (n=280) are as follows: mean age 48.6 years (±11.5 standard deviation), 66% men, diabetes duration 22.6 years (mean±8.9 standard deviation), 92% hypertension, 46% hypercholesterolemia, 24% family history CAD, and 21% known CAD. Abnormal myocardial perfusion imaging was found in 27.8%, and 56.5% had CAD more than or equal to 50%. Although positive myocardial perfusion imaging was the only independent predictor of CAD (odds ratio 7.18, 95% confidence interval 2.98–17.3), a poor negative predicted value was observed with normal imaging in 50.3% of patients having CAD more than or equal to 50%, 35.4% CAD more than 70%, and 41.8% Duke angiographic score more than or equal to 4. At mean follow up of 4 years (median 3.9), 76 of 280 patients suffered major adverse cardiovascular events including 17% mortality. Angiographic evidence of CAD (≥70% odds ratio 1.81, 95% confidence interval 1.02–3.23) was the only independent predictor of major adverse cardiac events. Conclusion. DM/RI patients being assessed for renal transplantation have frequent CV risk factors, high likelihood of CAD, and a 28% incidence of major adverse cardiac events after 4 years. Myocardial perfusion imagining is of little clinical utility as a screening tool for CAD in this population. Only angiographic CAD was predictive of subsequent major adverse cardiac events. Further studies of risk stratification and revascularization in this high-risk population are warranted.

Newborn literacy program effective in increasing maternal engagement in literacy activities: an observational cohort study

BackgroundLiteracy is important for success in school and in adulthood. Book-gift programs at birth exist to help develop these foundations early on. The effectiveness of the Read to Me! Nova Scotia Family Literacy Program (a program where books and literacy materials are given to families in hospital when their baby is born) on the duration and frequency with which mothers engage in reading and other literacy based activities with their newborns was assessed.MethodsAn observational cohort study design was used. Mothers of babies who received the Read to Me! package in Nova Scotia born between January-August 2006 made up the intervention group (N = 1051). Mothers of babies born in Prince Edward Island between December 2006 and March 2008 made up the control group (N = 279) and did not receive any literacy package when their baby was born. A phone questionnaire was conducted consisting of questions regarding frequency and duration of maternal engagement in language and literacy-based activities with their infants. These activities included reading, singing, talking, listening to CDs and the radio and watching TV. Babies were aged 0–10 months at the time of the interview.ResultsMothers who received the Read to Me! literacy package spent significantly more time reading to their babies, 17.9 ± 17.6 min/day compared to controls 12.6 ± 10.7 min/day, (p < 0.0001).ConclusionsRead to Me! may be an inexpensive, easy to administer and effective intervention which results in increased shared reading of mothers and their newborns.

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: A longitudinal study

BACKGROUND Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women. OBJECTIVES We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively. DESIGN Longitudinal extension survey following participation in a clinical trial. SETTING Ten Canadian centres. PARTICIPANTS Women (222) who participated in the Womens Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview. METHODS Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants. RESULTS Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR)=2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR=4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR=2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p=0.017), visit another type of provider (i.e., naturopath or chiropractor, p=0.004), or use any health care service (p<0.0001). CONCLUSIONS Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.

Clinical risk scoring beyond initial troponin values: Results from a large, prospective, unselected acute chest pain population

BACKGROUND Risk stratifying the diverse group of patients who present to hospital with chest discomfort remains challenging. Current clinical risk models, typically derived from selected populations, are limited by their relative complexity and the absence of a well-defined role of troponin. OBJECTIVE To derive a simple clinical risk score from a large, unselected population of patients with chest discomfort and to delineate the prognostic value of an initial troponin measurement. METHODS Prospective, consecutive data were collected from patients who presented to a tertiary care hospital. Multivariate analysis was used to identify variables predictive of the primary end point: death, nonfatal myocardial infarction or revascularization at 30 days. Integer values were assigned, generating a risk score to quantify individual patient risk. RESULTS Among 1054 patients, predictor variables included ST-segment deviation (strongest predictor -- assigned two points), male sex, prior congestive heart failure, three or more cardiac risk factors and prior acetylsalicylic acid use (one point each). There was a progressive increase in events with increasing total score (P<0.0001), with a 15-fold gradient from scores of 0 to 4 and greater. Although a negative troponin measurement was associated with fewer events for all scores, patients with higher scores remained exposed to substantial risk. A negative initial troponin measurement conferred a negative predictive value of 97.3% (95% CI 93.7% to 99.1%) among patients with a risk score of 0. CONCLUSION Significant 30-day events occurred in patients with elevated risk scores, despite negative initial troponin measurements, emphasizing the importance of clinical risk stratification. This simple clinical risk score, in conjunction with a single troponin I measurement, facilitates triage of patients who present to hospital with chest discomfort.

51 Coronary Artery Bypass Graft Harvest Site and Post-Op Recovery in Women

Methods: Data were collected on CHD risk factors from 80 patient-partner pairs as part of a multi-factorial exploratory prospective study. This study was unusual in collecting data on both patients and partners early in the treatment trajectory just after it had been confirmed that the patient would go on the waiting list for CABG surgery. Results: The patients had significantly reduced their modifiable CHD risk factors by 4 months post-operatively, whilst the partners significantly increased their CHD risk factors. At 4 months follow-up the patients still had an average 1.78 modifiable CHD risk factors and the partners an average of 1.54 risk factors. There were significant differences between the patients and partners for the total number of modifiable CHD risk factors preand post-operatively. The pattern that emerged post-CABG indicated a move towards concordance in risk factors between the patients and partners. The patients’ greater post-operative total number of CHD risk factors was significantly predicted by their greater total number of pre-operative CHD risk factors and by being female. Similarly, the partners’ greater total number of pre-operative modifiable CHD risk factors significantly predicted their higher total number of post-operative CHD risk factors. Conclusions: This study highlights the potential that pre-operative rehabilitation and the use of interventions preand post-operatively that target the patient and their partner have for the primary and secondary prevention of CHD.