Plasma renin activity and risk of cardiovascular and mortality outcomes among individuals with elevated and nonelevated blood pressure

BACKGROUND: We sought to evaluate plasma renin activity (PRA) levels and risk of mortality and cardiovascular events among individuals with elevated blood pressure [systolic blood pressure (SBP) ≥ 140 mmHg] and those with controlled blood pressure (SBP < 140 mmHg) in a large diverse population. METHODS: A retrospective cohort study between January 1, 2007, and December 31, 2013, among adults (≥ 18 years) within an integrated health system was conducted. Subjects were categorized by SBP into 2 groups: SBP < 140 mmHg and SBP ≥ 140 mmHg and then further categorized into population-based PRA tertiles within each SBP group. Cox proportional hazard modeling was used to estimate hazard ratios for cardiovascular and mortality outcomes among tertiles of PRA levels. RESULTS: Among 6,331 subjects, 32.6% had SBP ≥ 140 mmHg. Multivariable hazard ratios and 95% confidence interval for PRA tertiles T2 and T3 compared to T1 in subjects with SBP ≥ 140 mmHg were 1.42 (0.99–2.03) and 1.61 (1.12–2.33) for ischemic heart events; 1.40 (0.93–2.10) and 2.23 (1.53–3.27) for congestive heart failure; 1.10 (0.73–1.68) and 1.06 (0.68–1.66) for cerebrovascular accident; 1.23 (0.94–1.59) and 1.43 (1.10–1.86) for combined cardiovascular events; and 1.39 (0.97–1.99) and 1.35 (0.92–1.97) for all-cause mortality, respectively. Among the SBP < 140 mmHg group, there was no relationship between PRA levels and outcomes. CONCLUSION: Higher PRA levels demonstrated increased risk for ischemic heart events and congestive heart failure and a trend toward higher mortality among individuals with SBP ≥ 140 mmHg but not among those with SBP < 140 mmHg.

Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy

Since its introduction, there have been many refinements in the technique and implementation of robotic-assisted radical prostatectomy [RARP]. However, it is unclear whether operative outcomes are influenced by surgical case order. We evaluated the effect of case order on perioperative outcomes for RARP within a large health maintenance organization. We conducted a retrospective review of RARP cases performed at our institution from September 2008 to December 2010 using a single robotic platform. Case order was determined from surgical schedules each day and surgeries were grouped into 1[st], 2[nd] and 3[rd] round cases. Fourth round cases [n = 1] were excluded from analysis. We compared clinicopathological variables including operative time, estimated blood loss [EBL], surgical margin rates and complication rates between groups. Of the 1018 RARP cases in this cohort, 476 [47%] were performed as 1[st] round cases, 398 [39%] 2[nd] round cases and 144 [14%] 3[rd] round cases by a total of 18 surgeons. Mean operative time was shorter as cases were performed later in the day [213 min vs. 209 min vs. 180 min, P < 0.0001] and similarly, EBL also decreased with surgical order [136 mL vs. 134 mL vs. 103 mL, P = 0.01]. Transfusion rates, surgical margin rates and complication rates did not significantly differ between groups. Patients undergoing RARP later in the day were much more likely to have a hospital stay of 2 or more days than earlier cases [10% vs. 11% vs. 32%, P = 0.01]. Surgical case order may influence perioperative outcomes for RARP with decreased operative times and increased length of hospital stay associated with later cases. These findings indicate that select perioperative factors may improve with ascending case order as the surgical team "warms up" during the day. In addition, 3[rd] round cases can increase hospital costs associated with increased lengths of hospital stay. Knowledge of these differences may assist in surgical planning to improve outcomes and limit costs