Rolf-Hasso Boedeker

Anemia Before Coronary Artery Bypass Surgery as Additional Risk Factor Increases the Perioperative Risk

BACKGROUND A negative relationship between anemia before coronary artery bypass graft (CABG) surgery and the perioperative mortality has been shown. We tried to clarify whether anemia only expresses an increased perioperative risk or is a risk factor per se in a two-institution database. METHODS In the years 2005 and 2006, 185 of 3,311 patients undergoing isolated first-time CABG surgery had anemia defined as hematocrit less than 33% or Hb≤11 g/dL. Preoperative and postoperative data of patients having anemia and patients having normal hematocrit were compared using χ2-tests or Fishers exact tests regarding structural group differences. To determine factors influencing perioperative mortality, methods of logistic regression were used. RESULTS The 30-day mortality of anemic patients (12.9%) was significantly higher (p<0.001) than the mortality of nonanemic patients (2.2%). Patients having anemia, though, had a worse risk profile before surgery: high European System for Cardiac Operative Risk Evaluation values (median, 7 in anemic patients versus 4 in nonanemic patients), acute myocardial infarction (9.7% in anemic versus 2% in nonanemic patients), diabetes mellitus (45.4% in anemic versus 33.3% in nonanemic patients), and cardiogenic shock (5.4% in anemic versus 0.8% in nonanemic patients) were significantly more frequent in the anemic group. However, taking these risks in account, the logistic regression revealed preoperative anemia still to be a mortality-increasing factor in patients undergoing CABG surgery (odds ratio 3.727, confidence interval: 2.196 to 6.324). Furthermore, anemia was a risk factor for perioperative morbidity (major adverse cardiovascular events) after CABG surgery (odds ratio 2.199, confidence interval: 1.423 to 3.397). CONCLUSIONS In our patient group undergoing CABG surgery, preoperative anemia increased the mortality risk by 3.4, even when taking the higher perioperative risk of anemic patients into consideration.

Sinus lift augmentation using autogenous bone grafts and platelet-rich plasma: radiographic results.

OBJECTIVES Autologous bone grafting and sinus floor elevation is a widely accepted method for reconstruction of the atrophic maxilla. The aim of this investigation was to examine the influence of platelet-rich plasma (PRP) on bone grafting in sinus floor augmentation. STUDY DESIGN A prospective, controlled, randomized study including 34 patients undergoing sinus augmentation before implant placement was designed. The intervention group had additional treatment with PRP. Radiographic imaging was performed by computerized tomography (CT) and panoramic radiography 4 months after augmentation and before implant placement. RESULTS Bone density showed no significant increase when PRP was used in combination with autologous bone grafting compared with autologous bone alone. CONCLUSIONS This study showed no positive effect of PRP on bone density in CT evaluation when used in sinus floor augmentation. Bone density in the CT showed no correlation to histomorphometric evaluation.

Topical use of platelet-rich plasma to influence bone volume in maxillary augmentation : a prospective randomized trial

Background and Objectives  The atrophic posterior maxilla often requires restoration of the alveolar ridge due to a lack of bone quantity and quality before dental implant placement. The aim of this study was to verify the hypothesis that platelet‐rich plasma (PRP) has an influence on bone density in the maxilla after sinus floor elevation in combination with autologous cancellous bone from the iliac crest. Therefore, a randomized, prospective, controlled trial was set up in two centres.

Accuracy of photographic assessment compared with standard anthropometric measurements in nonsynostotic cranial deformities.

Objective Anthropometric landmarks of the skull have traditionally been used to describe cranial deformities resulting from nonsynostotic plagiocephaly or brachycephaly. Recently, digital photography has become an important tool for characterizing facial and cranial pathologies. The purpose of this study was to compare standard anthropometric cranial measurements with measurements taken from cranial photographs. Patients Standardized digital images in the supracranial view and cranial anthropometric measurements were obtained from 122 children between the ages of 3 and 15 months. The photographs were assessed using Quick Ceph® software. The cephalic index and cranial vault asymmetry index were used to indicate the degree of cranial deformity. Children were classified into plagiocephaly, brachycephaly, and the combination of both. To determine interobserver variability, two clinicians separately measured the cephalic index and cranial vault asymmetry index from digital photographs in 70 infants of the plagiocephalic group. Results To compare interassay reliability for these methods of obtaining the cephalic index and cranial vault asymmetry index, the differences between photographically and anthropometrically derived values were plotted against anthropometrically derived values alone (Bland-Altman plots). The photographic method satisfied the limits of agreement (cephalic index, 7.51%; cranial vault asymmetry index, 6.57%) and showed slightly lower values represented by the respective bias (cephalic index, 1.79%; cranial vault asymmetry index, 3.03%). Comparison between observers revealed excellent agreement, detected by the intraclass correlation coefficient of .982 for the cephalic index and .946 for the cranial vault asymmetry index. Conclusion Our results demonstrate that digital photography is a reliable tool for quantifying cranial deformities. Furthermore, it is rapid, noninvasive, and reproducible. However, we continue to use both methods in clinical practice.

Minimal immunoreactive plasma β-endorphin and decrease of cortisol at standard analgesia or different acupuncture techniques

Background and objective: Acupuncture has been claimed to be associated with activation of the endogenous antinociceptive system. The analgesic effects of acupuncture have been ascribed to &bgr;‐endorphin interacting with opioid receptors. However, firstly, the release of &bgr;‐endorphin into the blood has been proven to be induced by stress, i.e. under dysphoric conditions, and, secondly, if released under stress, &bgr;‐endorphin has been shown not to be analgesic. Our aim was to test whether &bgr;‐endorphin immunoreactive material is released into the cardiovascular compartment during acupuncture comparing the most frequently used types of acupuncture with standard pain treatment under apparently low stress conditions. Methods: This prospective study included 15 male patients suffering from chronic low back pain. &bgr;‐Endorphin immunoreactive material and cortisol were measured in the plasma of patients who underwent, in randomorder, therapy according to a standard pain treatment, traditional Chinese acupuncture, sham acupuncture, electro acupuncture and electro acupuncture at non‐acupuncture points before, at and after the treatment. Statistical analysis was performed using two‐way ANOVA with repeated measures. Results: A decrease in plasma cortisol concentration measured over the five treatment protocols was highly significant (P < 0.001). The &bgr;‐endorphin immunoreactive material concentrations in plasma were minimal at all times and in all treatment conditions. The influence of treatments by various acupuncture procedures on cortisol and &bgr;‐endorphin immunoreactive material plasma concentrations over the three time points was not significantly different. Conclusions: &bgr;‐endorphin immunoreactive material in blood is not released by any type of acupuncture as tested under low stress conditions.

Dimethylarginine metabolism during acute and chronic rejection of rat renal allografts

Background. Dimethylarginines are inhibitors of NO synthesis and are involved in the pathogenesis of vascular diseases. In this study, we ask the question if asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) levels change during fatal and reversible acute rejection, and contribute to the pathogenesis of chronic vasculopathy. Methods. The Dark Agouti to Lewis rat strain combination was used to investigate fatal acute rejection. Fischer 344 kidneys were transplanted to Lewis rats to study reversible acute rejection episode and the process of chronic rejection. Isograft recipients and untreated Lewis rats were used as controls. l-arginine derivatives were determined by HPLC, and ADMA-metabolizing enzymes were studied by quantitative RT–PCR and western blotting. Results. Renal transplantation transiently increased dimethylarginine levels independent of acute rejection. ADMA plasma levels did not importantly differ between recipients undergoing fatal or reversible acute rejection, whereas SDMA was even lower in recipients of Fisher 344 grafts. In comparison to isograft recipients, ADMA and SDMA levels were slightly elevated during reversible, but not during the process of chronic rejection. Increased dimethylarginine levels, however, did not block NO synthesis. Interestingly, protein methylation, but not ADMA degradation, was increased in allografts. Conclusions. Our data do not support the concept that renal allografts are protected from fatal rejection by dimethylarginines. Dimethylarginines may play a role in triggering chronic rejection, but a contribution to vascular remodelling itself is improbable. In contrast, differential arginine methylation of yet unknown proteins by PRMT1 may be involved in the pathogenesis of acute and chronic rejection.

Eating problems in very low birthweight children are highest during the first year and independent risk factors include duration of invasive ventilation.

This study aimed to investigate the incidence and time course of eating problems in children born with a very low birthweight (VLBW) and to identify the perinatal risk factors.

Response of proopiomelanocortin and gonado- or lactotroph systems to in-vitro fertilisation procedures stress

OBJECTIVE To analyse for the first time the response of the corticotroph-type and the melanotroph-type pituitary proopiomelanocortin (POMC) system with regard to in-vitro fertilisation (IVF) treatment using self-developed highly specific non-cross-reacting radioimmunoassay. STUDY DESIGN SETTING University hospital. patients: A total of 28 patients undergoing IVF oocyte retrieval. Cross sectional exploratory study, one factorial design with repeated measurements on one factor, non-parametric tests. Blood was collected before anaesthesia (t(A)) (n=28) and immediately after oocyte retrieval (t(B)) (n=28). MAIN OUTCOME MEASURE(S) beta-endorphin immunoreactive material (IRM), acetyl-N-beta-endorphin IRM, beta-lipotropin IRM, ACTH, cortisol, estradiol, progesterone, prolactin, luteinizing hormone, and follicle-stimulating hormone. For determination of authentic beta-endorphin [beta-endorphin (1-31)] a highly specific two-site fluid phase immunoprecipitation radioimmunoassay was developed, which did not cross-react with any beta-endorphin derivative or any other opioid peptide tested. RESULTS No response of acetyl-N-beta-endorphin IRM and of authentic beta-endorphin (1-31) was observed to oocyte retrieval in contrast to a significant increase of corticotroph-type proopiomelanocortin derivatives. A significant rise in prolactin plasma concentration indicates a pronounced lactotroph response to oocyte retrieval stress. No significant correlation between POMC derivates and prolactin and between POMC derivatives and gonadotropins or sexual steroids except for ACTH and progesterone and for beta-endorphin IRM and estradiol was observed. CONCLUSION IVF treatment stress led to significant corticotroph-type POMC and lactotroph responses, but not to responses of authentic beta-endorphin or melanotroph-type POMC in women undergoing oocyte retrieval.

International survey on the perioperative management of pulmonary endarterectomy: the perfusion perspective

Introduction: Pulmonary endarterectomy (PEA) is the most effective treatment available for chronic thromboembolic pulmonary hypertension (CTEPH). Patient selection, surgical technique and perioperative management have improved patient outcomes, which are traditionally linked to surgical and center experience. However, optimal perfusion care has not been well defined. The goal of the international survey was to better characterize the contemporary perfusion management of PEA and highlight similarities and controversies. Method: The combined caseload of 15 participating centers was 5,066 cases. Topics queried included materials and types of cardiopulmonary bypass (CPB) equipment, choice of prime, fluid management, deep hypothermia strategy, temperature management, treatment of acid-base abnormalities and intraoperative hematocrit as well as anticoagulation management for heparin-induced thrombocytopenia. Conclusion: Our assessment could provide a base for further advancement and may help design future studies to elucidate the impact of perfusion in this challenging field.