Prevention of hypotension after induction of anesthesia after preoperative tune-up. A preliminary report of the Groningen tune-up study

Objective: To investigate whether the frequently occurring hypotension after induction of anesthesia can be prevented by preoperative treatment at the ICU guided by hemodynamic data obtained from a pulmonary artery (PA) catheter.Design: Prospective controlled open randomized single center studySetting: University tertiary referral hospital.Patients: Thirty-one patients undergoing major vascular- or abdominal surgery.Interventions: Patients were randomized to either the control group or the ICU group. Patients allocated for the ICU group were admitted to the ICU the day before the operation and treatment was started aimed at a CI≥4.0 l/min/m2. No special treatment was given to the control group the day before the operation. Anesthesia was induced with etomidate, rocuronium and sufentanil.Measurements and main results: Seventeen patients were allocated for the control group and 14 for the ICU-group. Mean ages were 65±2.5 and 66±2.5 years, respectively. Both groups were comparable regarding age, sex, blood pressure and type of operation. Filling pressures at admission on the ICU were: central venous pressure 3±2 mm Hg and pulmonary capillary wedge pressure 8±3 mm Hg while CI was 3.2±0.8 l/min/m2. The hemodynamic goal was achieved in all 14 patients of the ICU-group preoperatively with a background infusion of three l/24 h crystalloids, after a mean infusion of 1623±552 ml colloids, and in seven patients a median dose of 3 μg/kg/min (range 2-6) dopamine. Blood pressure before induction was comparable in both groups. The fall in systolic BP 10 min after induction of anesthesia was 22±18 in the ICU-group versus 41±17 mm Hg in the control group (p=0.004). The fall in diastolic BP was 11±6 mm Hg in the ICU group versus 25±11 mm Hg in the control group (p=0.0003). No differences between the groups in changes of heart rate were observed: a decrease of 13±7 bpm (95% confidence intervals 8.5 to 17.0) in the ICU group versus 15±14 (95% confidence intervals 7.6 to 21.9) bpm in the control group (p=0.6).Conclusions: Hypotension after induction of anesthesia is significantly attenuated by preoperative treatment aiming at a CI≥4.0 l/min/m2 in high risk patients planned for major vascular- or abdominal surgery. (See Editorial p. 213) Copyright (C) 1999 Elsevier Science B.V

Non-surgical treatment of purulent pericarditis, due to non-encapsulated Haemophilus influenzae, in an immunocompromised patient

A 59-year-old woman suffering from rheumatoid arthritis was admitted with pleural empyema and pericarditis due to non-encapsulated H. influenzae, and developed signs of cardiac tamponade. Purulent pericarditis resolved after ultrasound guided percutaneous aspiration and systemic antimicrobial therapy. Serial echocardiographic examinations showed a slowly vanishing effusion. Long term follow-up revealed no evidence of pericardial constriction. This case illustrates that life-threatening purulent pericarditis in an immunocompromised patient may respond well to non-surgical treatment. (C) 1999 Elsevier Science B.V. All rights reserved

The Power of Flash Mob Research Conducting a Nationwide Observational Clinical Study on Capillary Refill Time in a Single Day

BACKGROUND: Capillary refill time (CRT) is a clinical test used to evaluate the circulatory status of patients; various methods are available to assess CRT. Conventional clinical research often demands large numbers of patients, making it costly, labor-intensive, and time-consuming. We studied the interobserver agreement on CRT in a nationwide study by using a novel method of research called flash mob research (FMR). METHODS: Physicians in the Netherlands were recruited by using word-of-mouth referrals, conventional media, and social media to participate in a nationwide, single-day, "nineto-five," multicenter, cross-sectional, observational study to evaluate CRT. Patients aged >= 18 years presenting to the ED or who were hospitalized were eligible for inclusion. CRT was measured independently (by two investigators) at the patient's sternum and distal phalanx after application of pressure for 5 s (5s) and 15 s (15s). RESULTS: On October 29, 2014, a total of 458 investigators in 38 Dutch hospitals enrolled 1,734 patients. The mean CRT measured at the distal phalanx were 2.3 s (5s, SD1.1) and 2.4 s (15s, SD1.3). The mean CRT measured at the sternum was 2.6 s (5s, SD1.1) and 2.7 s (15s, SD1.1). Interobserver agreement was higher for the distal phalanx (k value, 0.40) than for the sternum (k value, 0.30). CONCLUSIONS: Interobserver agreement on CRT is, at best, moderate. CRT measured at the distal phalanx yielded higher interobserver agreement compared with sternal CRT measurements. FMR proved a valuable instrument to investigate a relatively simple clinical question in an inexpensive, quick, and reliable manner

Common alleles at 6q25.1 and 1p11.2 are associated with breast cancer risk for BRCA1 and BRCA2 mutation carriers

Two single nucleotide polymorphisms (SNPs) at 6q25.1, near the ESR1 gene, have been implicated in the susceptibility to breast cancer for Asian (rs2046210) and European women (rs9397435). A genome-wide association study in Europeans identified two further breast cancer susceptibility variants: rs11249433 at 1p11.2 and rs999737 in RAD51L1 at 14q24.1. Although previously identified breast cancer susceptibility variants have been shown to be associated with breast cancer risk for BRCA1 and BRCA2 mutation carriers, the involvement of these SNPs to breast cancer susceptibility in mutation carriers is currently unknown. To address this, we genotyped these SNPs in BRCA1 and BRCA2 mutation carriers from 42 studies from the Consortium of Investigators of Modifiers of BRCA1/2. In the analysis of 14 123 BRCA1 and 8053 BRCA2 mutation carriers of European ancestry, the 6q25.1 SNPs (r2= 0.14) were independently associated with the risk of breast cancer for BRCA1 mutation carriers [hazard ratio (HR) = 1.17, 95% confidence interval (CI): 1.11-1.23, P-trend = 4.5 × 10-9for rs2046210; HR = 1.28, 95% CI: 1.18-1.40, P-trend = 1.3 × 10-8for rs9397435], but only rs9397435 was associated with the risk for BRCA2 carriers (HR = 1.14, 95% CI: 1.01-1.28, P-trend = 0.031). SNP rs11249433 (1p11.2) was associated with the risk of breast cancer for BRCA2 mutation carriers (HR = 1.09, 95% CI: 1.02-1.17, P-trend = 0.015), but was not associated with breast cancer risk for BRCA1 mutation carriers (HR = 0.97, 95% CI: 0.92-1.02, P-trend = 0.20). SNP rs999737 (RAD51L1) was not associated with breast cancer risk for either BRCA1 or BRCA2 mutation carriers (P-trend = 0.27 and 0.30, respectively). The identification of SNPs at 6q25.1 associated with breast cancer risk for BRCA1 mutation carriers will lead to a better understanding of the biology of tumour development in these women