Rhabdomyolysis and acute kidney injury: creatine kinase as a prognostic marker and validation of the McMahon Score in a 10-year cohort: A retrospective observational evaluation

BACKGROUND: High-volume fluid resuscitation and the administration of sodium bicarbonate and diuretics have a theoretical renoprotective role in patients at high risk of acute kidney injury (AKI) following rhabdomyolysis. Abnormally elevated creatine kinase has previously been used as a biological marker for the identification of patients at high risk of AKI following rhabdomyolysis. OBJECTIVE: To assess the sensitivity and specificity of plasma creatine kinase (admission and peak values) for the prediction of AKI requiring renal replacement therapy (RRT) or of death in patients with confirmed rhabdomyolysis. To compare the diagnostic performance of creatine kinase with the McMahon score. DESIGN: Retrospective observational study. Data collection included McMahon and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores; daily creatine kinase; daily creatinine and electrolytes; ICU length of stay and mortality. SETTING: Neurosciences and Trauma Critical Care Unit (Cambridge, UK). PATIENTS: In total, 232 adults with confirmed rhabdomyolysis (creatine kinase > 1000 Ul−1) admitted to Neurosciences and Trauma Critical Care Unit between 2002 and 2012. MAIN OUTCOME MEASURES: AKI, RRT and mortality. RESULTS: Forty-five (19%) patients developed AKI and 29 (12.5%) patients required RRT. Mortality was significantly higher in patients who developed AKI (62 vs. 18%, P 

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C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: A randomised clinical trial

BACKGROUND: Airway management in the emergency room can be challenging when patients suffer from life-threatening conditions. Mental stress, ignorance of the patient's medical history, potential cervical injury or immobilisation and the presence of vomit and/or blood may also contribute to a difficult airway. Videolaryngoscopes have been introduced into clinical practice to visualise the airway and ultimately increase the success rate of airway management. OBJECTIVE: The aim of this study was to test the hypothesis that the C-MAC videolaryngoscope improves first-attempt intubation success rate compared with direct laryngoscopy in patients undergoing emergency rapid sequence intubation in the emergency room setting. DESIGN: A randomised clinical trial. SETTING: Emergency Department of the University Hospital, Zurich, Switzerland. PATIENTS: With approval of the local ethics committee, we prospectively enrolled 150 patients between 18 and 99 years of age requiring emergency rapid sequence intubation in the emergency room of the University Hospital Zurich. Patients were randomised (1 : 1) to undergo tracheal intubation using the C-MAC videolaryngoscope or by direct laryngoscopy. INTERVENTIONS: Owing to ethical considerations, patients who had sustained maxillo-facial trauma, immobilised cervical spine, known difficult airway or ongoing cardiopulmonary resuscitation were excluded from our study. All intubations were performed by one of three very experienced anaesthesia consultants. MAIN OUTCOME MEASURES: First-attempt success rate served as our primary outcome parameter. Secondary outcome parameters were time to intubation; total number of intubation attempts; Cormack and Lehane score; inadvertent oesophageal intubation; ease of intubation; complications including violations of the teeth, injury/bleeding of the larynx/pharynx and aspiration/regurgitation of gastric contents; necessity of using further alternative airway devices for successful intubation; maximum decrease of oxygen saturation and technical problems with the device. RESULTS: A total of 150 patients were enrolled, but three patients had to be excluded from the analysis, resulting in 74 patients in the C-MAC videolaryngoscopy group and 73 patients in the direct laryngoscopy group. Tracheal intubation was achieved successfully at the first attempt in 73 of 74 patients in the C-MAC group and all patients in the direct laryngoscopy group (P = 1.0). Time to intubation was similar (32 ± 11 vs. 31 ± 9 s, P = 0.51) in both groups. Visualisation of the vocal cords, represented as the Cormack and Lehane score, was significantly better using the C-MAC videolaryngoscope (P 

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Implementation of patient blood management remains extremely variable in Europe and Canada: the NATA benchmark project: An observational study

BACKGROUND: Preoperative anaemia is associated with increased postoperative morbidity and mortality. Patient blood management (PBM) is advocated to improve patient outcomes. OBJECTIVES: NATA, the 'Network for the advancement of patient blood management, haemostasis and thrombosis', initiated a benchmark project with the aim of providing the basis for educational strategies to implement optimal PBM in participating centres. DESIGN: Prospective, observational study with online data collection in 11 secondary and tertiary care institutions interested in developing PBM. SETTING: Ten European centres (Austria, Spain, England, Denmark, Belgium, Netherlands, Romania, Greece, France, and Germany) and one Canadian centre participated between January 2010 and June 2011. PATIENTS: A total of 2470 patients undergoing total hip (THR) or knee replacement, or coronary artery bypass grafting (CABG), were registered in the study. Data from 2431 records were included in the final analysis. MAIN OUTCOME MEASURES: Primary outcome measures were the incidence and volume of red blood cells (RBC) transfused. Logistic regression analysis identified variables independently associated with RBC transfusions. RESULTS: The incidence of transfusion was significantly different between centres for THR (range 7 to 95%), total knee replacement (range 3 to 100%) and CABG (range 20 to 95%). The volume of RBC transfused was significantly different between centres for THR and CABG. The incidence of preoperative anaemia ranged between 3 and 40% and its treatment between 0 and 40%, the latter not being related to the former. Patient characteristics, evolution of haemoglobin concentrations and blood losses were also different between centres. Variables independently associated with RBC transfusion were preoperative haemoglobin concentration, lost volume of RBC and female sex. CONCLUSION: Implementation of PBM remains extremely variable across centres. The relative importance of factors explaining RBC transfusion differs across institutions, some being patient related whereas others are related to the healthcare process. The results reported confidentially to each centre will allow them to implement tailored measures to improve their PBM strategies.

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Enhanced Recovery for Major Abdominopelvic Surgery

No abstract available

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Increased expression of interleukin-23 associated with progression of colorectal cancer

Background and Objectives

The prognostic significance of interleukin-23 in colorectal cancer remains unclear. We designed this study to investigate the association between colorectal cancer and interleukin-23 (IL-23) or interleukin-23 receptor (IL-23R) expression and the resulting clinical features and survival.

Methods

Immunohistochemical staining was performed for IL-23 and IL-23R in colorectal cancer samples. H-score was calculated to compare the expression of IL-23 and IL-23R. The median of H-score was used as the cut-off value to separate patients into high or low expression groups. The differences in clinicopathological features were evaluated. Cox regression hazard ratios were used for survival analysis.

Results

A total of 129 colorectal cancer patients were enrolled. H-score for the late TNM stage patients was higher than that for the early TNM stage patients (P = 0.002). Patients with high IL-23 expression were associated with advanced pathological T category (P < 0.001) and late TNM stage (P = 0.003). High IL-23 expression was associated with poor 5-year disease-free survival and overall survival in patients (P = 0.048 and P = 0.028, respectively). Multivariate adjustment demonstrated a significant association between high IL-23 expression and overall survival (hazard ratio = 1.865, P = 0.041).

Conclusions

Elevated IL-23 expression was associated with poor outcome and can be used as a prognostic biomarker for colorectal cancer. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

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Borderline operability in hepatectomy patients is associated with higher rates of failure to rescue after severe complications

Background/Objective

To understand the influence of age and comorbidities, this study analyzed the incidence and risk factors for post-hepatectomy morbidity/mortality in patients with "borderline" (BL) operability, defined by the preoperative factors: age ≥75 years, dependent function, lung disease, ascites/varices, myocardial infarction, stroke, steroids, weight loss >10%, and/or sepsis.

Methods

All elective hepatectomies were identified in the 2005–2013 ACS-NSQIP database. Predictors of 30-day morbidity/mortality in BL patients were analyzed.

Results

A 3,574/15,920 (22.4%) patients met BL criteria. Despite non-BL and BL patients undergoing similar magnitude hepatectomies (P > 0.4), BL patients had higher severe complication (SC, 23.3% vs. 15.3%) and mortality rates (3.7% vs. 1.2%, P < 0.001). BL patients with any SC experienced a 14.1% mortality rate (vs. 7.3%, non-BL, P < 0.001). Independent risk factors for SC in BL patients included American Society of Anesthesiologists (ASA) score >3 (odds ratio, OR – 1.29), smoking (OR – 1.41), albumin <3.5 g/dl (OR – 1.36), bilirubin >1 (OR – 2.21), operative time >240 min (OR – 1.58), additional colorectal procedure (OR – 1.78), and concurrent procedure (OR – 1.73, all P < 0.05). Independent predictors of mortality included disseminated cancer (OR – 0.44), albumin <3.5 g/dl (OR – 1.94), thrombocytopenia (OR – 1.95), and extended/right hepatectomy (OR – 2.81, all P < 0.01).

Conclusions

Hepatectomy patients meeting BL criteria have an overall post-hepatectomy mortality rate that is triple that of non-BL patients. With less clinical reserve, BL patients who suffer SC are at greater risk of post-hepatectomy death. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

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Pharmacokinetic dose adjustment of 5-FU in modified FOLFOX7 plus bevacizumab for metastatic colorectal cancer in Japanese patients: a-JUST phase II clinical trial

Abstract

Purpose

Dose adjustment of 5-fluorouracil (FU) based on pharmacokinetic monitoring has been shown to reduce toxicities and increase efficacy compared with dosing based on body surface area in patients with metastatic colorectal cancer (mCRC). We evaluated the efficacy and safety of pharmacokinetic dose adjustment of FU in a modified FOLFOX7 (mFOLFOX7) plus bevacizumab regimen in Japanese patients with previously untreated mCRC.

Methods

This single-arm, multicenter phase II trial enrolled 48 patients with mCRC. Treatment consisted of 5 mg/kg intravenous bevacizumab followed by mFOLFOX7 (oxaliplatin 85 mg/m² on day 1, infused leucovorin 200 mg/m², followed by a 2400 mg/m² infusion of FU for 46 h starting on day 1), repeated every 2 weeks. FU concentrations were measured by immunoassay between 18 and 36 h after the start of continuous FU infusion, and the FU dose was then adjusted if required in subsequent cycles. The primary endpoint was response rate.

Results

The median initial area under the concentration–time curve for FU was 23 mg h/L. Twenty-nine patients (60%) achieved the target concentration at the first cycle, and all 48 achieved it within the fourth cycle. The overall frequency of grade 3/4 adverse effects was 38%, with no significant difference between patients who did and not require dose adjustments. The overall response rate was 48% (95% confidence intervals = 34–62%). The median progression-free and overall survival rates were 11.3 and 24.1 months, respectively.

Conclusions

Pharmacokinetic dose adjustment of FU in mFOLFOX7 plus bevacizumab can optimize FU concentrations promptly and is safe in Japanese patients with mCRC.

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