Patient selection for routine troponin monitoring after noncardiac surgery

BACKGROUND: Myocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk. METHODS AND RESULTS: This observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed. CONCLUSIONS: To improve selection of high-risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2

Dynamics of the bacterial gut microbiota in preterm and term infants after intravenous amoxicillin/ceftazidime treatment

BACKGROUND: It is important to understand the consequences of pre-emptive antibiotic treatment in neonates, as disturbances in microbiota development during this key developmental time window might affect early and later life health outcomes. Despite increasing knowledge regarding the detrimental effect of antibiotics on the gut microbiota, limited research focussed on antibiotic treatment duration. We determined the effect of short and long amoxicillin/ceftazidime administration on gut microbiota development during the immediate postnatal life of preterm and term infants. METHODS: Faeces was collected from 63 (pre) term infants at postnatal weeks one, two, three, four and six. Infants received either no (control), short-term (ST) or long-term (LT) postpartum amoxicillin/ceftazidime treatment. RESULTS: Compared to control infants, ST and LT infants' microbiota contained significantly higher abundance of Enterococcus during the first two postnatal weeks at the expense of Bifidobacterium and Streptococcus. Short and long antibiotic treatment both allowed for microbiota restoration within the first six postnatal weeks. However, Enterococcus and Bifidobacterium abundances were affected in fewer ST than LT infants. CONCLUSIONS: Intravenous amoxicillin/ceftazidime administration affects intestinal microbiota composition by decreasing the relative abundance of Escherichia-Shigella and Streptococcus, while increasing the relative abundance of Enterococcus and Lactobacillus species during the first two postnatal weeks. Thriving of enterococci at the expense of bifidobacteria and streptococci should be considered as aspect of the cost-benefit determination for antibiotic prescription.</p

Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury

Background: Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. Design: An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. Methods: Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. Results: A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5–2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9–4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4–2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0–1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3–3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1–1.8; P = 0.003), but had no added value on top of other predictors. Conclusions: Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors

Accounting for Breakout in Britain: The Industrial Revolution Through a Malthusian Lens

Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation – or postoperative myocardial injury – can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation

Modulation of purinergic signaling by NPP-type ectophosphodiesterases

Extracellular nucleotides can elicit a wide array of cellular responses by binding to specific purinergic receptors. The level of ectonucleotides is dynamically controlled by their release from cells, synthesis by ectonucleoside diphosphokinases and ectoadenylate kinases, and hydrolysis by ectonucleotidases. One of the four structurally unrelated families of ectonucleotidases is represented by the NPP-type ectophosphodiesterases. Three of the seven members of the NPP family, namely NPP1–3, are known to hydrolyze nucleotides. The enzymatic action of NPP1–3 (in)directly results in the termination of nucleotide signaling, the salvage of nucleotides and/or the generation of new messengers like ADP, adenosine or pyrophosphate. NPP2 is unique in that it hydrolyzes both nucleotides and lysophospholipids and, thereby, generates products that could synergistically promote cell motility. We review here the enzymatic properties of NPPs and analyze current evidence that links their nucleotide-hydrolyzing capability to epithelial and neural functions, the immune response and cell motility

Multiple P2Y receptors couple to calcium-dependent, chloride channels in smooth muscle cells of the rat pulmonary artery

BACKGROUND: Uridine 5'-triphosphate (UTP) and uridine 5'-diphosphate (UDP) act via P2Y receptors to evoke contraction of rat pulmonary arteries, whilst adenosine 5'-triphosphate (ATP) acts via P2X and P2Y receptors. Pharmacological characterisation of these receptors in intact arteries is complicated by release and extracellular metabolism of nucleotides, so the aim of this study was to characterise the P2Y receptors under conditions that minimise these problems. METHODS: The perforated-patch clamp technique was used to record the Ca(2+)-dependent, Cl(- )current (I(Cl,Ca)) activated by P2Y receptor agonists in acutely dissociated smooth muscle cells of rat small (SPA) and large (LPA) intrapulmonary arteries, held at -50 mV. Contractions to ATP were measured in isolated muscle rings. Data were compared by Student's t test or one way ANOVA. RESULTS: ATP, UTP and UDP (10(-4)M) evoked oscillating, inward currents (peak = 13–727 pA) in 71–93% of cells. The first current was usually the largest and in the SPA the response to ATP was significantly greater than those to UTP or UDP (P < 0.05). Subsequent currents tended to decrease in amplitude, with a variable time-course, to a level that was significantly smaller for ATP (P < 0.05), UTP (P < 0.001) and UDP (P < 0.05) in the SPA. The frequency of oscillations was similar for each agonist (mean≈6–11.min(-1)) and changed little during agonist application. The non-selective P2 receptor antagonist suramin (10(-4)M) abolished currents evoked by ATP in SPA (n = 4) and LPA (n = 4), but pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid (PPADS) (10(-4)M), also a non-selective P2 antagonist, had no effect (n = 4, 5 respectively). Currents elicited by UTP (n = 37) or UDP (n = 14) were unaffected by either antagonist. Contractions of SPA evoked by ATP were partially inhibited by PPADS (n = 4) and abolished by suramin (n = 5). Both antagonists abolished the contractions in LPA. CONCLUSION: At least two P2Y subtypes couple to I(Cl,Ca )in smooth muscle cells of rat SPA and LPA, with no apparent regional variation in their distribution. The suramin-sensitive, PPADS-resistant site activated by ATP most resembles the P2Y(11 )receptor. However, the suramin- and PPADS-insensitive receptor activated by UTP and UDP does not correspond to any of the known P2Y subtypes. These receptors likely play a significant role in nucleotide-induced vasoconstriction

Serial selection for invasiveness increases expression of miR-143/miR-145 in glioblastoma cell lines

<p>Abstract</p> <p>Background</p> <p>Glioblastoma multiforme (GBM) is the most common primary central nervous system malignancy and its unique invasiveness renders it difficult to treat. This invasive phenotype, like other cellular processes, may be controlled in part by microRNAs - a class of small non-coding RNAs that act by altering the expression of targeted messenger RNAs. In this report, we demonstrate a straightforward method for creating invasive subpopulations of glioblastoma cells (IM3 cells). To understand the correlation between the expression of miRNAs and the invasion, we fully profiled 1263 miRNAs on six different cell lines and two miRNAs, miR-143 and miR-145, were selected for validation of their biological properties contributing to invasion. Further, we investigated an ensemble effect of both miR-143 and miR-145 in promoting invasion.</p> <p>Methods</p> <p>By repeated serial invasion through Matrigel^®-coated membranes, we isolated highly invasive subpopulations of glioma cell lines. Phenotypic characterization of these cells included <it>in vitro </it>assays for proliferation, attachment, and invasion. Micro-RNA expression was compared using miRCURY arrays (Exiqon). In situ hybridization allowed visualization of the regional expression of miR-143 and miR-145 in tumor samples, and antisense probes were used investigate <it>in vitro </it>phenotypic changes seen with knockdown in their expression.</p> <p>Results</p> <p>The phenotype we created in these selected cells proved stable over multiple passages, and their microRNA expression profiles were measurably different. We found that two specific microRNAs expressed from the same genetic locus, miR-143 and miR-145, were over-expressed in our invasive subpopulations. Further, we also found that combinatorial treatment of these cells with both antisense-miRNAs (antimiR-143 and -145) will abrogated their invasion without decreasing cell attachment or proliferation.</p> <p>Conclusions</p> <p>To best of our knowledge, these data demonstrate for the first time that miR-143 and miR-145 regulate the invasion of glioblastoma and that miR-143 and -145 could be potential therapeutic target for anti-invasion therapies of glioblastoma patients.</p

Postoperative myocardial injury phenotypes and self-reported disability in patients undergoing noncardiac surgery: a multicentre observational study

Background: Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. Methods: This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. Results: We included 888 patients of mean age 69 (range 53–91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5–6.2), but scores remained stable after surgery (β: 1.2, 95% CI: –3.2–5.6). Before surgery, patients with MI (n=36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3–10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3–20.2; β: 8.1, 95% CI: 3.0–13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: –4.50–7.29, P=0.642). Conclusions: Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery

P2Y1 and P2Y12 receptor cross-talk in calcium signalling: Evidence from nonstarved and long-term serum-deprived glioma C6 cells

The current work presents results of experiments on the calcium response evoked by the stimulation by extracellular nucleotides occurring in control, nonstarved glioma C6 cells and in cells after long-term (96 h) serum starvation. Three nucleotide receptors were studied: P2Y1, P2Y2 and P2Y12. Two of them, P2Y1 and P2Y2, directly stimulate calcium response. The protein level of the P2Y2 receptor did not change during the serum starvation, while P2Y1 protein level fell dramatically. Observed changes in the calcium response generated by P2Y1 are directly correlated with the receptor protein level as well as with the amount of calcium present in the intracellular calcium stores, partially depleted during starvation process. The third receptor, P2Y12, did not directly evoke calcium response, however it is activated by the same ligand as P2Y1. The experiments with AR-C69941MX, the P2Y12-specific antagonist, indicated that in control and serum-starved cells, calcium response evoked by P2Y1 receptor is potentiated by the activity of P2Y12-dependent signaling pathways. This potentiation may be mediated by P2Y12 inhibitory effect on the plasma membrane calcium pump. The calcium influx enhanced by the cooperation of P2Y1 and P2Y12 receptor activity directly depends on the capacitative calcium entrance mechanism