Orthostatic responses to dietary sodium restriction during heat acclimation

Several studies have shown that individuals consuming low-salt diets and working in the heat have an increased risk or incidence of heat injury, suggestive of inadequate cardiovascular adjustment. Furthermore, others have shown that prolonged work in hot climates can precipitate orthostatic hypotension and syncope. This study was designed to evaluate the effects of moderate-salt (MS) and low-salt (LS) diets on the circulatory responses and incidence of presyncopal symptoms to an orthostatic test (OT) during successive days of heat acclimation (HA). Seventeen unacclimatized male soldiers (mean +/- SE: age 20+/-1 yrs) participated in this two-phase study. The first phase consisted of a seven day dietary stabilization period during which all subjects consumed similar diets of about 4000 kcal/day containing 8g NaCl and lived in a dormitory setting (21 C, 30% RH). The second phase commenced on day eight and consisted of dietary NaCl restriction and 10 days HA (days 8-17). Volunteers were randomly assigned to either the MS diet (n=9) providing 8g NaCl/day or the LS diet (n=8) furnishing just 4g NaCl/day. The acquisition of HA was manifested in both groups by reductions in exercising rectal temperature and heart rate (HR); these characteristics were similar in the MS and LS diets. The OT was performed at 21 C on day seven of the stabilization phase and on days 9, 11, 13, 15, and 17 of the HA phase, before and after 8.5 hr of intermittent treadmill walking in a hot environment. Blood pressure (BP) and HR responses at 1,2, and 4 min and any presyncopal symptoms were recorded after assuming an upright position from recumbency. All subjects completed the OT before and after prolonged exercise in the heat without incidence of either hypotension or presyncopal symptoms irrespective of dietary-salt intake and day of HA. The results indicate that the prolonged work in the heat can be performed without orthostatic hypotension or syncope while consuming 4g NaCl/day with adequate fluid replacement. Furthermore, the circulatory responses to OT showed no improvement with successive days of HA irrespective of dietary-salt intake

Mortality after surgery in Europe: a 7 day cohort study

Background: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.Methods: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher’s exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.Findings: We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9–3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19 1·05; p=0·06] for Finland to 6·92 [2·37–20·27; p=0·0004] for Poland).Interpretation: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.Funding: European Society of Intensive Care Medicine, European Society of Anaesthesiology