The impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study.

PurposeAmbulatory surgery is a major area of surgical and anesthetic practice, and preoperative clinics are being increasingly used for low-risk surgical procedures. This study investigated the impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery.MethodsThis was a retrospective cohort study of 968 consecutive patients undergoing cataract surgery. Details of medical conditions, surgical, anesthetic, and postoperative information were collected from medical records. A logistic regression model was developed using propensity score adjustment for baseline characteristics.ResultsOut 968 patients included, 240 (24.7%) underwent outpatient preoperative evaluation. There were no perioperative major cardiovascular events. Hypertension occurred in 319 (33%) patients, accounting for 79.7% of all adverse events. Preoperative evaluation resulted in a lower hypertension rate after adjustment for propensity score (OR=0.6; 95% CI 0.41-0.93); no effects were observed on posterior capsule rupture and emergency visits/hospitalization within 7 days of surgery. Eighty-nine patients (9.3%) had an initial systolic pressure ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture (P=0.158) or postoperative adverse events (P=0.902). Median waiting time to surgery was 6 and 2 months for evaluated and non-evaluated patients, respectively (P<0.001).ConclusionsIn the context of low-risk surgery and no major perioperative and postoperative outcomes, it appears that outpatient preoperative evaluation has no role in reducing adverse events in cataract surgery candidates. Despite fewer hypertensive episodes observed in evaluated patients, these episodes were not associated with any medical or surgical outcomes.

Comparison of two bioelectrical impedance devices and dual-energy X-ray absorptiometry to evaluate body composition in heart failure.

BACKGROUND: The utilisation of bioelectrical impedance analysis (BIA) in heart failure can be affected by many factors and its applicability remains controversial. The present study aimed to verify the adequacy of single-frequency BIA (SF-BIA) and multifrequency BIA (MF-BIA) compared to dual-energy x-ray absorptiometry (DEXA) for evaluating body composition in outpatients with heart failure. METHODS: In this cross-sectional study, 55 patients with stable heart failure and left ventricle ejection fraction ≤45% were evaluated for fat mass percentage, fat mass and fat-free mass by DEXA and compared with the results obtained by SF-BIA (single frequency of 50 kHz) and MF-BIA (frequencies of 20 and 100 kHz). RESULTS: MF-BIA and DEXA gave similar mean values for fat mass percentage, fat mass and fat-free mass, whereas values from SF-BIA were significantly different from DEXA. Both SF-BIA and MF-BIA measures of body composition correlated strongly with DEXA (r > 0.8; P < 0.001), except for fat mass assessed by SF-BIA, which showed a moderate correlation (r = 0.760; P < 0.001). MF-BIA also showed a better agreement with DEXA by Bland-Altman analysis in all measurements. However, both types of equipment showed wide limits of agreement and a significant relationship between variance and bias (Pitmans's test P > 0.05), except MF-BIA for fat-free mass. CONCLUSIONS: Compared with DEXA, MF-BIA showed better accuracy than SF-BIA, although both types of equipment showed wide limits of agreement. The BIA technique should be used with caution, and regression equations might be useful for correcting the observed variations, mainly in extreme values of body composition.

Nutritional orientation, knowledge and quality of diet in heart failure: randomized clinical trial.

BACKGROUND: Non-pharmacological measures are recommended for heart failure patients. However, most studies evaluate low sodium diet, while little is known about the effects of interventions to improve adherence and knowledge of patients about diet content. OBJECTIVE: To evaluate if a global nutritional orientation could affect nutritional knowledge, adherence to food guidelines, anthropometrics and quality of life in heart failure patients. METHODS: Forty six patients were randomized to intervention or control group. Both groups received usual care with medical and nursing staff; the intervention group received additional nutritional guidance about diet and its relationship with disease, sources of nutrients, and reduction of dietary sodium and fats. Enforcement of the nutritional guidance was performed after 4 weeks. Both groups were evaluated at baseline, and after 6 weeks and 6 months. Evaluations included anthropometric parameters, sodium excretion in 24-hour urine, dietary recall, nutrition knowledge and quality of life questionnaires. RESULTS: Mean age of included patients was 58 ± 10 years and 70% were male. After 6 months of follow-up, the nutritional knowledge of intervention group increased compared to control (p < 0.05). Caloric, fat and sodium intake decreased in the intervention group compared to control (p < 0.05). No significant differences were seen in quality of life or anthropometric parameters. CONCLUSIONS: Nutritional orientation was effective to modify 1) knowledge about food and nutrition, and 2) quality of diet in outpatients with heart failure. Further studies are necessary to evaluate the benefits on quality of life and prognosis.

Nutritional orientation, knowledge and quality of diet in heart failure; randomized clinical trial / Orientación nutricional, conocimiento y calidad de la dieta en la insuficiencia cardíaca; ensayo aleatorizado

Background: Non-pharmacological measures are recommended for heart failure patients. However, most studies evaluate low sodium diet, while little is known about the effects of interventions to improve adherence and knowledge of patients about diet content. Objective: To evaluate if a global nutritional orientation could affect nutritional knowledge, adherence to food guidelines, anthropometrics and quality of life in heart failure patients. Methods: Forty six patients were randomized to intervention or control group. Both groups received usual care with medical and nursing staff; the intervention group received additional nutritional guidance about diet and its relationship with disease, sources of nutrients, and reduction of dietary sodium and fats. Enforcement of the nutritional guidance was performed after 4 weeks. Both groups were evaluated at baseline, and after 6 weeks and 6 months. Evaluations included anthropometric parameters, sodium excretion in 24-hour urine, dietary recall, nutrition knowledge and quality of life questionnaires. Results: Mean age of included patients was 58 ± 10 years and 70% were male. After 6 months of follow-up, the nutritional knowledge of intervention group increased compared to control (p < 0.05). Caloric, fat and sodium intake decreased in the intervention group compared to control (p < 0.05). No significant differences were seen in quality of life or anthropometric parameters. Conclusions: Nutritional orientation was effective to modify 1) knowledge about food and nutrition, and 2) quality of diet in outpatients with heart failure. Further studies are necessary to evaluate the benefits on quality of life and prognosis (AU)

Introducción: Medidas no farmacológicas se recomiendan en la insuficiencia cardíaca. Sin embargo, la mayoría de los estudios evalúa dietas restrictas en sodio, mientras que poco se sabe sobre el efecto de intervenciones para mejorar la adherencia y el conocimiento sobre dieta. Objetivo: Evaluar si una orientación nutricional puede modificar la adherencia a la dieta, conocimiento nutricional, antropometría y calidad de la vida en pacientes con insuficiencia cardíaca. Métodos: 46 pacientes fueron aleatorizados al grupo control o intervención. Ambos recibieron el tratamiento habitual del equipo; el grupo intervención recibió además orientación sobre la dieta y su relación con la enfermedad, fuentes de alimentos y reducción de las grasas y sodio. Ambos los grupos fueron evaluados al principio del estudio, 6 semanas y 6 meses. Evaluaciones incluían antropometría, sodio en la orina de 24 h, el recordatorio alimenticio, y los cuestionarios de conocimiento nutricional y de la calidad de la vida. Resultados: La media de edad fue de 58 ± 10 años y 70% eran hombres. Después de 6 meses, el conocimiento nutricional del grupo intervención aumentó en comparación al grupo control (p < 0,05). La ingestión calórica, de grasa y del sodio reducirán en grupo intervención, comparado con el grupo control (p < 0,05). No hubo diferencias significativas en la calidad de vida y antropometría. Conclusiones: La orientación nutricional fue efectiva en la modificación de 1) conocimiento nutricional, y 2) calidad de la dieta en pacientes con insuficiencia cardiaca. Más estudios que evalúan los beneficios en la calidad de la vida y pronóstico son necesarios (AU)

Impact of beta-2 Thr164Ile and combined beta-adrenergic receptor polymorphisms on prognosis in a cohort of heart failure outpatients.

Genetic polymorphisms of adrenergic receptors (ARs) have been associated with the development, progression, and prognosis of patients with heart failure (HF), with few data for the Brazilian population. We evaluated the role of the beta2-AR Thr164Ile polymorphism at codon 164 on prognosis in a prospective study on 315 adult Brazilian HF patients, predominantly middle-aged Caucasian men in functional class I-II, with severe left ventricular systolic dysfunction. Genomic DNA was extracted from peripheral blood and beta2-AR164 genotypes were detected by PCR followed by restriction fragment length analysis. During a median follow-up of 3 years, 95 deaths occurred and 57 (60%) were HF-related. Unexpectedly, Ile164 carriers (N = 12) had no HF-related events (log-rank P value = 0.13). Analysis using genotype combination with beta1-AR polymorphisms at codons 49 and 389 identified patients with favorable genotypes (Thr164Ile of beta2-AR, Gly49Gly of beta1-AR and/or Gly389Gly of beta1-AR), who had lower HF-related mortality (P = 0.01). In a Cox proportional hazard model adjusted for other clinical characteristics, having any of the favorable genotypes remained as independent predictor of all-cause (hazard ratio (HR): 0.41, 95%CI: 0.17-0.95) and HF-related mortality (HR: 0.12, 95%CI: 0.02-0.90). These data show that the beta2-AR Thr164Ile polymorphism had an impact on prognosis in a Brazilian cohort of HF patients. When combined with common beta1-AR polymorphisms, a group of patients with a combination of favorable genotypes could be identified.

Impact of β-2 Thr164Ile and combined β-adrenergic receptor polymorphisms on prognosis in a cohort of heart failure outpatients

Genetic polymorphisms of adrenergic receptors (ARs) have been associated with the development, progression, and prognosis of patients with heart failure (HF), with few data for the Brazilian population. We evaluated the role of the β2-AR Thr164Ile polymorphism at codon 164 on prognosis in a prospective study on 315 adult Brazilian HF patients, predominantly middle-aged Caucasian men in functional class I-II, with severe left ventricular systolic dysfunction. Genomic DNA was extracted from peripheral blood and β2-AR164 genotypes were detected by PCR followed by restriction fragment length analysis. During a median follow-up of 3 years, 95 deaths occurred and 57 (60 percent) were HF-related. Unexpectedly, Ile164 carriers (N = 12) had no HF-related events (log-rank P value = 0.13). Analysis using genotype combination with β1-AR polymorphisms at codons 49 and 389 identified patients with favorable genotypes (Thr164Ile of β2-AR, Gly49Gly of β1-AR and/or Gly389Gly of β1-AR), who had lower HF-related mortality (P = 0.01). In a Cox proportional hazard model adjusted for other clinical characteristics, having any of the favorable genotypes remained as independent predictor of all-cause (hazard ratio (HR): 0.41, 95 percentCI: 0.17-0.95) and HF-related mortality (HR: 0.12, 95 percentCI: 0.02-0.90). These data show that the β2-AR Thr164Ile polymorphism had an impact on prognosis in a Brazilian cohort of HF patients. When combined with common β1-AR polymorphisms, a group of patients with a combination of favorable genotypes could be identified.

The role of adrenergic receptor polymorphisms in heart failure.

The main function of the cardiac adrenergic system is to regulate cardiac work both in physiologic and pathologic states. A better understanding of this system has permitted the elucidation of its role in the development and progression of heart failure. Regardless of the initial insult, depressed cardiac output results in sympathetic activation. Adrenergic receptors provide a limiting step to this activation and their sustained recruitment in chronic heart failure has proven to be deleterious to the failing heart. This concept has been confirmed by examining the effect of beta-blockers on the progression of heart failure. Studies of adrenergic receptor polymorphisms have recently focused on their impact on the adrenergic system regarding its adaptive mechanisms, susceptibilities and pharmacological responses. In this article, we review the function of the adrenergic system and its maladaptive responses in heart failure. Next, we discuss major adrenergic receptor polymorphisms and their consequences for heart failure risk, progression and prognosis. Finally, we discuss possible therapeutic implications resulting from the understanding of polymorphisms and the identification of individual genetic characteristics.

The role of adrenergic receptor polymorphisms in heart failure

The main function of the cardiac adrenergic system is to regulate cardiac work both in physiologic and pathologic states. A better understanding of this system has permitted the elucidation of its role in the development and progression of heart failure. Regardless of the initial insult, depressed cardiac output results in sympathetic activation. Adrenergic receptors provide a limiting step to this activation and their sustained recruitment in chronic heart failure has proven to be deleterious to the failing heart. This concept has been confirmed by examining the effect of ß-blockers on the progression of heart failure. Studies of adrenergic receptor polymorphisms have recently focused on their impact on the adrenergic system regarding its adaptive mechanisms, susceptibilities and pharmacological responses. In this article, we review the function of the adrenergic system and its maladaptive responses in heart failure. Next, we discuss major adrenergic receptor polymorphisms and their consequences for heart failure risk, progression and prognosis. Finally, we discuss possible therapeutic implications resulting from the understanding of polymorphisms and the identification of individual genetic characteristics.

Increased plasma levels of endothelin 1 and von Willebrand factor in patients with type 2 diabetes and dyslipidemia.

OBJECTIVE: Endothelial markers endothelin 1 (ET-1) and von Willebrand factor (vWF) were assessed in patients with type 2 diabetes and dyslipidemia and in patients with hypercholesterolemia. RESEARCH DESIGN AND METHODS: In this case-control study, plasma ET-and vWF levels were measured by enzyme-linked immunosorbent assay in 35 normoalbuminuric type 2 diabetic patients with dyslipidemia (56+/-5 years), in 21 nondiabetic patients with hypercholesterolemia (52+/-7 years), and in 19 healthy control subjects (45+/-4 years). All of the individuals were normotensive and nonsmokers. Urinary albumin was measured by immunoturbidimetry. RESULTS: ET-1 levels were higher (P<0.0001) in type 2 diabetic dyslipidemic patients (1.62+/-0.73 pg/ml) than in both nondiabetic hypercholesterolemic patients (0.91+/-0.73 pg/ml) and control subjects (0.69+/-0.25 pg/ml). vWF levels were significantly increased (P = 0.02) in type 2 diabetic (185.49+/-72.1%) and hypercholesterolemic (163.29+/-50.7%) patients compared with control subjects (129.70+/-35.2%). In the multiple linear regression analysis. ET-1 was significantly associated (adjusted r2 = 0.42) with serum triglyceride levels (P<0.001), age (P<0.01), insulin sensitivity index (P<0.02), and albuminuria levels (P<0.04). vWF levels were associated (adjusted r2 = 0.22) with albuminuria (P<0.001), fibrinogen levels (P<0.02), and BMI (P<0.03). CONCLUSIONS: Compared with hypercholesterolemic patients, type 2 diabetic patients with dyslipidemia have increased levels of ET-1 and vWF which may indicate more pronounced endothelial injury. These findings appear to be related to components of the insulin resistance syndrome.

Increased expression of tumor necrosis factor-alpha in diabetic macrovasculopathy.

Large vessel disease, a common feature of diabetes mellitus, appears to run an aggressive course, but its cellular and molecular aspects remain partially elucidated. Although in common atherosclerosis and especially in other forms of accelerated vasculopathy, immunoinflammatory mechanisms participate in the disease process, it is unclear whether this is present in diabetic vasculopathy. We hypothesized that diabetic macrovasculopathy, compared with classical atherosclerosis, is associated with increased immunoinflammatory features and matrix accumulation. In this study, vessel segments obtained after lower-limb amputation for advanced atherosclerotic disease, from type 2 diabetic patients (n = 20; 68.9+/-10.9 years) and nondiabetic patients (n = 16; 67.1+/-14.6 years) were analyzed. Histological characteristics (extent of intimal proliferation, cellularity, and fibrosis) were semiquantitatively graded in the two lesion types. Using immunohistochemistry, the presence of T cells and macrophages, accumulation of fibronectin, and expression of tumor necrosis factor-alpha was also assessed. Histological features of these advanced atherosclerotic lesions were similar in the two lesions examined. By immunohistochemistry, a similar pattern of T-cell and macrophage infiltration and fibronectin accumulation was observed. Nevertheless, increased expression of tumor necrosis factor-alpha was observed in diabetic lesions (13/19 patients had positive staining), whereas only 2 of 16 lesions from nondiabetic patients had positive staining (p < 0.003), with an odds ratio of 15.17 (confidence interval 2.12-139.5). These data suggest that increased expression of tumor necrosis factor-alpha observed in the diabetic lesions may reflect an enhanced inflammatory activity associated with the development of vascular lesions in type 2 diabetic patients.