Anesthesia for carotid endarterectomy: where do we stand at present?

Carotid endarterectomy (CEA) is a surgical procedure performed to reduce the incidence of embolic and thrombotic stroke. Although only a preventive procedure, CEA carries the risk of perioperative complications. There is constant searching for an optimal anesthetic technique. There are pros and cons for both anesthetic techniques used: regional (RA) and general anesthesia (GA). A large number of studies have compared RA and GA techniques in CEA surgery patients. The primary outcome was the proportion of patients with stroke, myocardial infarction, or death. However, neither the GALA trial nor the pooled analysis was adequately powered to reliably detect an effect of type of anesthesia on mortality. It may therefore be appropriate to consider other additional parameters (stress response, incidence of postoperative delirium and cognitive impairment, functional recovery, total surgery time, intensive care unit requirement, hospital stay, hospital costs and patients satisfaction) when comparing the outcomes of the two techniques. Although, the debate continues as to whether regional anesthesia or general anesthesia is safer, the choice of anesthetic technique is a complex decision and surgical teams should be able to offer both RA and GA. The individual approach is the ideal choice and should be determined at the discretion of the surgeon, anesthetist and patient depending on the clinical situation and own preferences

EFEKTIVITAS METODE RAPID TEST HBsAg DALAM MENDETEKSI PENYAKIT HEPATITIS B

Indonesia telah menjadi negara terbesar kedua mengidap Hepatitis B. Diagnosis Hepatitis B ditegakkan berdasarkan gejala dan deteksi virus antigen hepatitis B menggunakan metode rapid test dan ELISA. Tujuan utama penelitian ini adalah menganalisis efektifitas metode rapid test dibanding ELISA dalam mendeteksi penyakit hepatitis B. Penelitian ini menggunakan desain penelitian observasional cross sectional analitik dengan jumlah sampel sebanyak 30 orang. Hasil uji Rapid Test HBsAg One Step ”Answer” dibanding ELISA menggunakan IBM SPSS Statistic for window No. 20 dengan tabel 2x2, dapat diketahui nilai sensitivitas, spesifisitas, nilai prediksi positif (PPV), nilai prediksi negatif (NPV) dan nilai akurasi. Selain itu menganalisis kurva ROC untuk menentukan nilai AUC (Area Under the Curve). Hasil Tabel 2x2, didapatkan nilai sensitivitas sebesar 84%, nilai spesifisitas sebesar 100%, Nilai PPV sebesar 100%, Nilai NPV sebesar 89% dan Akurasi sebesar 93% dan dengan kurva ROC memiliki nilai Area Under the Curve 92,3%. Hasil tersebut menunjukkan bahwa Rapid Test HBsAg One Step”Answer” memiliki nilai AUC sangat baik. Nilai sensitivitas, spesifisitas, PPV, NPV dan nilai Akurasi juga telah melampaui standar rekomendasi dari World Health Organization

Endothelins - clinical perspectives

Endothelins (ET) are a group of endogenous peptides, which have a strong and long-lasting vasocon-strictive effect. Three isoforms of endothelins coded by three different genes have been identified to date. Endothelin-1 (ET-1) is the most potent vasoconstrictive agent currently identified, and it was originally isolated and characterized from the culture media of aortic endothelial cells. Two other iso-forms, named endothelin-2 (ET-2) and endothelin-3 (ET-3), were subsequently identified, along with structural homologues isolated from the venom of Actractapis engaddensis known as the sarafotoxins. The biological effects of endothelin production are determined via activation of one or two G-protein coupled receptors, endothelin receptors A (ETRA) and B (ETRB1 and ETRB2). Recently endothelin receptor C (ETRC) was discovered, however, its functions and distribution still remain unclear. The effects mediated by ET-1 via ETRA are vasoconstriction, bronchoconstriction and secretion of aldosterone. Agonists related to the ETRB1 activation cause vasodilatation by stimu-lating NO, PGI2 and endothelium-derived hyperpolarizing factor (EDHF). In contrast, coupling to ETRB2 causes vasoconstriction. Involvement of ET has been demonstrated in the pathophysiology of certain disorders. In this review, we discuss the physiological and pathophysiological role of endothe-lium-derived ET-1, the pharmacology of its two receptors, focusing on the role of ET-1 in the develo-pment of some pathophysiological conditions

Short- and long-term outcome of patients aged 65 and over after cardiac surgery

To analyze the short and long-term outcome of patients aged 65 years and over, after cardiac surgery. Over a 12-year period we analyzed 1750 patients with a mean age of 70.09 3.94 years. They were classified into three age groups: between 65 and 69 (n = 709), between 70 and 74 (n = 695) and 75 years and above (n = 346). Follow-up information was obtained by telephone conversation after a 6-month and 3-year period of discharge from the hospital. Included in the follow-up were 1235 patients and an interview was conducted with 501 (40.6%) patients or their next of kin. Even though the in-hospital morbidity was highest in the oldest age group, there were no significant differences between groups (p = 0.051). There was no significant difference between groups in the length of hospital stay. The greatest in-hospital mortality was noted in the oldest age group (p = 0.046) compared to patients in the age groups between 65 and 69 and between 70 and 74 years old (p = 0.023 and p = 0.036). In the follow-up study, there was a significantly smaller telephone feedback response in the oldest age group compared to the youngest group (p = 0.003). There were no differences between the groups with respect to mortality and cardiac death after the 6-month and 3-year periods of discharge from hospital. Our data showed that despite a poor short – and long-term outcome in patients aged 75 and over, all patients had an acceptable operative risk

Coronary artery aneurysm: case report

<p>Abstract</p> <p>Introduction</p> <p>Aneurysms of the left main coronary artery are rare with an incidence of 0.1% in large angiographic series. The majority are atherosclerotic in origin. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic and idiopathic. The primary complication is myocardial ischemia or infarction, with rupture being rare. Treatment options include anticoagulation, custom made covered stents, reconstruction, resection, and exclusion with bypass.</p> <p>Case Presentation</p> <p>A 66 year-old man was referred for evaluation of a 2 × 2 centimeter saccular aneurysm originating from the distal left main coronary artery. There was associated calcification and mild stenosis of the LM. The workup was prompted by a non-ST elevation myocardial infarction suffered following a laparotomy for a ruptured appendix. The past medical history was pertinent for hypertension, hyperlipidemia, and a left carotid endarterectomy.</p> <p>Cardiopulmonary bypass with hyperkalemic cardioplegic arrest was utilized. The aneurysm was exposed in the atrioventricular groove. The aneurysm was resected and oversewn. Calcification precluded patch angioplasty. The patient then underwent coronary bypass grafting with the left internal thoracic artery placed to the left anterior descending artery and a reversed greater saphenous vein graft to an obtuse marginal branch of the circumflex artery. The postoperative course was uneventful and discharge to home occurred on the fourth postoperative day. Surgical pathology confirmed an atheromatous coronary artery aneurysm.</p> <p>Conclusion</p> <p>Left main coronary artery aneurysms in adult patients are predominantly atherosclerotic in origin. The clinical presentation is that of myocardial ischemia, likely from associated embolism. Rupture is rare. Operative treatment is exclusion and revascularization.</p

Long-term stability of clinically relevant chemistry analytes in pleural and peritoneal fluid

Introduction: Our aim was to investigate the stability of clinically relevant analytes in pleural and peritoneal fluids stored in variable time periods and variable storage temperatures prior to analysis. Materials and methods: Baseline total proteins (TP), albumin (ALB), lactate dehydrogenase (LD), cholesterol (CHOL), triglycerides (TRIG), creatinine (CREA), urea, glucose and amylase (AMY) were measured using standard methods in residual samples from 29 pleural and 12 peritoneal fluids referred to our laboratory. Aliquots were stored for 6 hours at room temperature (RT); 3, 7, 14 and 30 days at - 20°C. At the end of each storage period, all analytes were re-measured. Deviations were calculated and compared to stability limits (SL). Results: Pleural fluid TP and CHOL did not differ in the observed storage periods (P = 0.265 and P = 0.170, respectively). Statistically significant differences were found for ALB, LD, TRIG, CREA, urea, glucose and AMY. Peritoneal fluid TP, ALB, TRIG, urea and AMY were not statistically different after storage, contrary to LD, CHOL, CREA and glucose. Deviations for TP, ALB, CHOL, TRIG, CREA, urea and AMY in all storage periods tested for both serous fluids were within the SL. Deviations exceeding SL were observed for LD and glucose when stored for 3 and 7 days at - 20°C, respectively. Conclusions: TP, ALB, CHOL, TRIG, CREA, urea and AMY are stable in serous samples stored up to 6 hours at RT and/or 30 days at - 20°C. Glucose is stable up to 6 hours at RT and 3 days at - 20°C. The stability of LD in is limited to 6 hours at RT

Use of biochemical parameters for non-invasive screening of oesophageal varices in comparison to elastography-based approach in patients with compensated advanced chronic liver disease

Oesophageal varices are routinely diagnosed by esophagogastroduodenoscopy (EGD), and their bleeding has high mortality. We aimed to evaluate diagnostic performance of biochemical tests in comparison to elastography-based approaches, as non-invasive alternatives to EGD, for ruling-out high risk oesophageal varices (HRV). Retrospective analysis of patients (N = 861) who underwent liver stiffness measurement (LSM) by transient elastography (TE) in a single centre over 5-year period, with available results of EGD (within 3 months from LSM). Only patients with suspicion of compensated advanced chronic liver disease (cACLD) defined by LSM ≥ 10 kPa were included comprising the final cohort of 73 subjects. Original and expanded Baveno VI criteria (B6C), controlled attenuation parameter (CAP), platelet count (PLT), aspartate aminotransferase to PLT ratio index (APRI), Fibrosis-4 index (FIB4), model for end stage liver disease (MELD) score were evaluated against the results of EGD that served as the reference method. Analysed patients had median age 62 years, 59/73 (0.81) were males, 54/73 (0.74) had alcoholic/non-alcoholic fatty liver disease, and 21/73 (0.29) had HRV. In multivariate logistic regression analysis only LSM and PLT were independently associated with HRV. The best performing tests for ruling-out HRV (% of spared EGD; % of missed HRV) were respectively: LSM 214x109/L (21.9%; 0%); FIB4 ≤ 1.8 (21.4%; 0%), APRI ≤ 0.34 (12.3%; 0%). CAP, MELD = 6 alone or combined with PLT > 150(x109/L) did not show acceptable performance. The best performing biochemical tests for ruling-out HRV in our cohort of patients were PLT and FIB-4, but they were still outperformed by elastography-based approaches

In sickness and in health: pivotal role of vitamin D

Within the last several years, frequency of vitamin D testing has multiplied substantially all over the world, since it has been shown to have an important role in many diseases and conditions. Even though liquid chromatography - tandem mass spectrometry (LC-MS/MS) has been identified as “gold standard” method for vitamin D measurement, most laboratories still use immunochemistry methods. Besides analytical problems (hydrophobicity, low circulating concentrations, ability to bind to lipids, albumins and vitamin D binding protein, presence of multiple vitamin D metabolites and variable ratios of 25(OH)D2 and 25(OH)D3 in the blood), vitamin D shows great preanalytical variability, since its concentration is drastically influenced by seasonal changes, exposure to sun, type of clothes or sun block creams. Vitamin D is mostly measured in serum or plasma, but new studies are showing importance of measuring vitamin D in pleural effusions, breast milk, urine, synovial fluid and saliva. Besides the main role in calcium homeostasis and bone metabolism, many studies linked vitamin D deficiency with cancer, cardiovascular diseases, diabetes, fertility and many other conditions. However, even though initial observational studies indicated that supplementation with vitamin D might be beneficial in disease development and progression; first results of well-designed randomized controlled prospective studies did not find differences in frequency of cardiovascular events or invasive cancer between patients taking vitamin D supplementation compared to placebo. In the light of these recent findings, validity of excessive vitamin D testing remains an open question

Analytical evaluation of the clinical chemistry analyzer Olympus AU2700 plus

Background: The objective of this study was to perform the analytical evaluation of the clinical chemistry analyzer Olympus AU2700 plus. The evaluation was performed according to the guidelines of the European Committee for Clinical Laboratory Standards (ECCLS). Materials and methods: The evaluation consisted of determination of within-run and between-run imprecision, inaccuracy and comparison with Olympus AU2700. The tested analytes were: glucose, creatinine, urate, total bilirubin, cholesterol, tryglicerides, calcium, phosphate, iron, unsatura-ted iron binding capacity, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase, alpha-amylase, alkaline phosphatase, potassium, sodium, chloride, C-reactive protein, antistreptolysin O and rheumatoid factor. Results: The results showed low within-run and between-run imprecision and acceptable inaccuracy for all analytes. High correlation with AU2700 analyzer was found. Intercept and slope (with 95% confidence interval) met the preferences of Passing-Bablok regression for all of the analytes except alanine aminotransferase, sodium, rheumatoid factor, creatine kinase, total bilirubin and tryglicerides. Conclusions: Olympus AU2700 plus analyzer shows acceptable precision and accuracy for majority of analytes, with the exception of sodium and chloride. Instrument is fully comparable with Olympus AU2700 analyzer for all but several analytes (ALT, RF, sodium, CK, total bilirubin and tryglicerides), where only some minor deviations (constant and proportional difference) were observed