Clopidogrel responsiveness in chronic kidney disease patients with acute coronary syndrome

Objective: Cardiovascular diseases are the leading cause of death in patients with chronic kidney disease (CKD). There is conflicting evidence about effect of CKD on clopidogrel responsiveness. We aimed to evaluate the clopidogrel responsiveness in CKD patients with acute coronary syndrome (ACS). Methods: A total of 101 patients; 55 with moderate to severe CKD and 46 with normal renal function or mild CKD, hospitalized with ACS were included in our study. Multiplate test was used to determine clopidogrel responsiveness. Platelet aggregation results were presented as aggregation unit (AU)*min and values over 470 AU*min were accepted as clopidogrel low responders. Results: The 101 patients (mean age 64.76±8.67 years; 61 [60.4%] male) were grouped into the two study groups as follows: group 1; 55 patients with eGFR<60 ml/min/1.73 m2 and group 2; 46 patients with eGFR>60 ml/min/1.73 m2. 35 patients (34.7%) of the study population were found to have low response to clopidogrel (16 [34.8%] patients in group 1 and 18 [33.3%] patients in group 2, p=0.879) . There was no significant difference between group 1 and 2 for Multiplate test results (414.67±281.21 vs 421.56±316.19 AU*min, p=0.909). Clopidogrel low responsiveness were independently related to Multiplate test results of aspirin responsiveness (OR=1.004, CI 1.002–1.007, p=0.001) and hemoglobin (OR=0.727, CI 0.571–0.925, p=0.010). Multiplate results were also independently related to Multiplate test results of aspirin responsiveness (β=0.402, p<0.0001) and hemoglobin (β=-0.251, p=0.007). Conclusion: Platelet response to clopidogrel does not differ between patients with eGFR < 60 ml/min/1.73 m2 and eGFR>60 ml/min/1.73 m2

Internal Jugular Vein Cannulation: An Ultrasound-Guided Technique Versus a Landmark-Guided Technique

OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications

Evaluation of the effect of mitral stenosis severity on the left ventricular systolic function using isovolumic myocardial acceleration

Background: Isovolumic acceleration (IVA) is a new tissue Doppler parameter in the as­sessment of systolic function of both left and right ventricles. It remains unaffected with the changes in pre- and after-load within the physiological range. The aim of our study was to assess the effect of mitral stenosis degree, which is determined by echocardiography, on the left ventricular (LV) function using IVA. Methods: A total number of 62 patients with mitral stenosis (MS) and 32 healthy controls were examined. The severity of MS (mild, moderate, and severe) was determined on the basis of mitral valve area (MVA) and the mean diastolic mitral gradient findings. The peak myocardial velocities during isovolumic contraction, systole, early diastole and late diastole were measured by using tissue Doppler imaging (TDI). Results: All TDI-derived global LV basal wall systolic (peak myocardial isovolumic contra­ction velocity, peak myocardial systolic velocity and IVA), and diastolic velocities (peak early and late diastolic velocities) were significantly decreased in the patients with MS, compared to the healthy patients (p &lt; 0.001, for all). However, IVA was not different when the degree of MS was evaluated (p = 0.114). In addition, IVA was not correlated with the MVA (r = 0.185, p = 0.150). Conclusions: Left ventricular function is impaired in patients with MS regardless of the severity of the disease.

Interventions for hyperhidrosis in secondary care : a systematic review and value-of-information analysis

Background: Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable. Objective: To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care. Methods: A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only. Results and conclusions: Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life. Limitations: The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla. Future work: Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Cognitive functions after tiva with dexmedetomidine

Amaç: Lumbar disk hernisi nedeniyle opere olacak hastalarda total intravenöz anesteziye (TİVA) deksmedetomidin HCl eklenmesinin postoperatif kognitif fonksiyonlara etkisinin Mini Mental Durum Testi (MMSE) kullanılarak incelenmesidir.Gereç ve Yöntem: Etik kurul onayı alındıktan sonra Beyin Cerrahisi Kliniğince Lumbar disk hernisi nedeniyle operasyona alınan ASA I-II , 40 hasta çalışmaya dahil edildi. Hastalar rasgele iki gruba ayrıldılar. Grup I (n= 20) hastalara propofol- remifentanil verildi, Grup II (n= 20) hastalara propofol- remifentanil infüzyonunun yanına deksmedetomidin eklendi ve her iki gruba da operasyondan önce Mini Mental Durum Testi (MMSE) ve eğitimsizler için Standardize Mini Mental Test ( SMMT-E) adı verilen ve hatırlama, dikkat ve hesaplama yapımını değerlendirmek amacıyla soru- cevaptan oluşan bir test uygulandı. Bu testler daha sonra postoperatif 2. saat, 24. saat, 1. hafta ve 1. ayda tekrarlandı.Hastalara operasyon odasında kalp atım hızı, non invaziv arter basıncı, periferik oksijen satürasyonu ve Bispektral İndeks (BİS) monitörizasyonu uygulandı. Ayrıca entübasyondan sonra ekspiryum sonu karbondioksit konsantrasyonu önceden belirlenen tüm dönemlerde kaydedildi.Her iki gruba indüksiyonda propofol infüzyonu ilk 30 dakika 12 mg. kg-1 , ikinci 30 dakika 9 mg. kg-1 olarak başlandı ve operasyon sonuna kadar BİS değerleri 40-60 arasında tutulacak şekilde ayarlandı. Aynı zamanda opioid olarak remifentanil infüzyonu 0.5 ? g.kg-1 uygulandı ve kalp hızı, tansiyon arteriyele göre doz ayarlaması yapıldı. Deksmedetomidin infüzyonu ise yükleme dozu yapılmadan 0.5 ? g.kg-1 başlandı ve doz değişimi yapılmadı. Endotrakeal entübasyon için roküronyum 0.5 mg. kg-1 iv. uygulandı.Hastaların infüzyon kesilme, spontan solunum, el sıkma ve göz açma zamanları, toplam kullanılan propofol, remifentanil ve deksmedetomidin değerleri kayıt edildi.Ayılma odasındaki değerlendirmede modifiye Aldrete skorlaması kullanıldı. İstatistiksel değerlendirmede eşleştirilmiş t testi ve Mann- Whitney testi kullanıldı.Sonuçlar: Her iki grubun demografik verileri arasında istatistiksel farklılık saptanmadı. Mini Mental Durum Testi açısından iki grup arasında belirgin farklılık saptanmazken, deksmedetomidin eklenen grupta intraoperatif remifentanil kullanımı daha az olarak saptandı. Aynı zamanda deksmedetomidin grubunda intraoperatif hemodinamik parametreler de daha iyi olarak bulundu. Erken derlenme bulguları (spontan solunum, el sıkma ve göz açma zamanları) her iki grupta aynı saptanırken postoperatif ağrı skorları ayılma odasında, deksmedetomidin grubunda daha düşüktü.Tartışma: Total intravenöz anestezi grubunda ve Total intravenöz anesteziye deksmedetomidin eklenen grupta erken derlenme zamanı ve kognitif fonksiyonlar arasında fark saptanmazken intraoperatif hemodinamik parametreler deksmedetomidin eklenen grupta daha iyi olarak saptandı.Background: The purpose of this study was to compare immediate recovery restoration of cognitive function after remifentanil- propofol(total intravenous anesthesia-TİVA) or remifentanil- propofol- dexmedetomidine anesthesia in patients undergoing lumbar discectomy.Methods: After approval by the local ethical committee and after obtaining written informed consents, patients were enrolled in this randomized, double- blind, prospective controlled study.Fourthy patients with ASA I and II were allocated to either the TIVA (n= 20) or TIVA + dexmedetomidine (TIVA+D) (n= 20) group. Anesthesia induction was obtained with infusion for first thirty minutes 12mg . kg-1, second thirty minutes 9 mg. kg-1 and then maintenance was achieved with a propofol infusion according to Bispectral İndex (BİS) ratio. The TIVA group recieved remifentanil 0.5 ? g. kg-1 per minute as an infusion throughout the procedure. The TIVA + D group received remifentanil and propofol as TIVA group , plus dexmedetomidine infusion 0.5 g. kg-1 per minute. Muscle relaxation was achieved with rocuronium 0.5 mg. kg-1 for the intubation.The Mini-Mental State (MMSE) test or Standardized Mini-Mental test (SMMT-E) was used to assess cognitive function preoperatively and postoperative 2and 24 hours, one week and one month respectively. Recovery characteristics were also evaluated with Alderette scores. İntraoperative hemodynamics were also analyzed. Incidence of hypotensive and hypertansive episodes, postoperative vomiting, and heart rates were recorded.Results: Mini mental state scores did not differ significantly between the two groups. Patients receiving TIVA+ D had significantly (p < 0.05) less use of remifentanil intraoperative. Also intraoperative hemodynamics were better preserved with TIVA + D group. Aldrette scores were not differ in two group. İmmediate recovery was not differ ( eye opening, spontan ventilation, obeying commands) between groups, but postoperative pain was less in dexmedetomidine group.Discussion and Conclusion: İntraoperative hemodynamics were better preserved with dexmedetomidine. Postoperative recovery and restoration of cognitive functions seem to be similar in two groups