Preoperative fasting times: Prescribed and actual fasting times at Universitas Hospital Annex, Bloemfontein, South Africa.

BACKGROUND: Guidelines recommend a preoperative fasting period of 6 hours for solid food and 2 hours for clear fluids. Because of fixed meal times and imprecise operation starting times, patients often fast for an extended period of time. OBJECTIVE: To investigate the prescribed preoperative fasting times, and the actual duration of fasting, compared with the internationally accepted fasting times for solid food and clear fluids. METHODS: Patients (N=105) aged 14 - 60 years, who were scheduled for elective surgery in the morning session (list starting time 07h00), were included in this prospective study. On arrival in theatre, all patients were asked when they last ate and drank. Anaesthetic records were used to determine the prescribed fasting times and operation starting times. RESULTS: For solids, patients were most frequently prescribed to start fasting from 22h00 to 00h00 (53.3% and 39.1%, respectively). No patient fasted <8 hours. The median duration of fasting was 14 hours and 45 minutes (range 9 hours and 45 minutes - 19 hours and 5 minutes). For fluids, patients were most frequently prescribed to start fasting from 05h00 (46.7%), 00h00 (27.6%) and 22h00 (7.6%). In practice, no patient ingested fluids after 22h30 or <9 hours preoperatively. The median fasting time for oral fluids was 13 hours and 25 minutes (range 9 hours and 37 minutes - 19 hours and 5 minutes). CONCLUSION: Most patients started fasting too early preoperatively, consequently withholding food and oral fluids for longer than recommended. An increased awareness regarding complications of unnecessarily long fasting times, and interventions to correct this problem, is required.

Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure: background, aims and design of the RACE 3 study.

BACKGROUND: Rhythm control for atrial fibrillation (AF) is cumbersome because of its progressive nature caused by structural remodelling. Upstream therapy refers to therapeutic interventions aiming to modify the atrial substrate, leading to prevention of AF. OBJECTIVE: The Routine versus Aggressive upstream rhythm Control for prevention of Early AF in heart failure (RACE 3) study hypothesises that aggressive upstream rhythm control increases persistence of sinus rhythm compared with conventional rhythm control in patients with early AF and mild-to-moderate early systolic or diastolic heart failure undergoing electrical cardioversion. DESIGN: RACE 3 is a prospective, randomised, open, multinational, multicenter trial. Upstream rhythm control consists of angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, mineralocorticoid receptor antagonists, statins, cardiac rehabilitation therapy, and intensive counselling on dietary restrictions, exercise maintenance, and drug adherence. Conventional rhythm control consists of routine rhythm control therapy without cardiac rehabilitation therapy and intensive counselling. In both arms, every effort is made to keep patients in the rhythm control strategy, and ion channel antiarrhythmic drugs or pulmonary vein ablation may be instituted if AF relapses. Total inclusion will be 250 patients. If upstream therapy proves to be effective in improving maintenance of sinus rhythm, it could become a new approach to rhythm control supporting conventional pharmacological and non-pharmacological rhythm control.

Planning and monitoring of patients for electrical cardioversion for atrial fibrillation.

OBJECTIVES: This study evaluated the waiting list for elective electrical cardioversion (ECV) for persistent atrial fibrillation (AF), focusing on when and why procedures were postponed. We compared the effects of management of the waiting list conducted by physicians versus management by nurse practitioners (NPs) and we evaluated the safety of our anticoagulating policy by means of bleeding or thromboembolic complications during and after ECV. BACKGROUND: Not all patients selected for ECV receive their treatment at the first planned instance due to a variety of reasons. These reasons are still undocumented. METHODS: We evaluated 250 consecutive patients with persistent AF admitted to our clinic for elective ECV. RESULTS: Within 5 to 6 weeks, 186 of 242 patients (77%) received ECV. The main reason for postponing an ECV was an inadequate international normalised ratio (INR); other reasons included spontaneous sinus rhythm and switch to rate control. A total of 23 of the 147 patients (16%) managed by the research physician were postponed due to an inadequate INR at admission versus 4 out of 98 patients (4%) managed by NPs (p = 0.005) CONCLUSION: An inadequate INR is the main reason for postponing an ECV. Management of ECV by NPs is safe and leads to less postponing on admission.

Cardiac gene expression profiling - the quest for an atrium-specific biomarker.

Biomarkers are gaining increasing interest to predict risk but also to aid in diagnostics. Tissue-specific biomarkers are of utmost importance to detect diseases of respective organs. As of yet there are no atrium-specific biomarkers for risk stratification of atrial disease, such as atrial fibrillation. Bioinformatics such as mRNA microarrays can help to detect tissue-enriched and possibly tissue-specific expressed genes that can be targets for biomarkers. We describe an approach to identify genes preferably expressed in atrial cardiomyocytes compared with ventricular cardiomyocytes by RNA microarray and confirmed by quantitative real-time polymerase chain reaction. By this approach we identified several atrium-enriched genes but also ventricle-enriched genes. As expected atrial natriuretic peptide (ANP) mRNA showed higher expression in atrial cardiomyocytes while with adrenergic stimulation expression was almost as high in ventricular as in atrial cells. Brain-type natriuretic peptide (BNP), however, was not different between atrial and ventricular cells giving a possible explanation for increased levels of NT-proBNP in atrial fibrillation patients. Interesting identified candidates are serpine1 and ltbp2 as atrium-enriched genes whereas alpha-adrenergic receptor subtype 1b and S100A1 expression was significantly higher in ventricular cells. The identified genes need to be confirmed in human tissue and might ultimately be tested as potential biomarkers for atrial stress. (Neth Heart J 2010;18:610-4.).

[Non-pharmacological treatment of heart failure: implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy]. / Niet-farmacologische behandeling van hartfalen: implanteerbare cardioverter-defibrillator (ICD) en cardiale-resynchronisatietherapie.

The non-pharmacological therapy of heart failure, in particular an implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy or biventricular stimulation, improves symptoms and survival in patients with heart failure. An ICD is indicated in many patients with heart failure following cardiac arrest unless reversible causes are demonstrable. Selected patients with a left ventricular ejection fraction < or = 35% due to either ischaemic (>40 days after a myocardial infarction) or nonischaemic cardiomyopathy are candidates for ICD implantation as the primary prevention of sudden cardiac death. Patients who continue to have severe symptoms despite maximal pharmacotherapy, with a left ventricular ejection fraction < or = 35% and a wide QRS complex, are candidates for cardiac resynchronisation therapy to improve both symptoms and survival.

Congener-specific model for polychlorinated biphenyl effects on otter (Lutra lutra) and associated sediment quality criteria.

A model for risk assessment was built for simultaneous, congener-specific PCB bioaccumulation from sediment to fish to otters (Lutra lutra). Toxic equivalence factors (TEFs) were used to sum individual congeners in otters to a toxic equivalent concentration (TEQ) relative to 2,3,7,8-tetrachlorodibenzo-p-dioxin. Microbial dechlorination and burial in sediments and bioaccumulation are modeled to predict time trends of PCB concentrations in otters. Effects of accumulated PCBs on otters were assessed for vitamin A metabolism and reproduction, taking model uncertainty into account. Three locations in The Netherlands were modeled with PCB levels in sediment of 1 to 171 pg TEQ/g organic carbon (OC). Almost 100% reduction in litter size was predicted for the most polluted area in 1996. Due to large associated uncertainty, a period of 25 to 80 years may be needed for recovery of otter vitamin A levels and litter size at this site. Calculated median sediment quality criteria (SQC) range between 1 and 12 pg TEQ/g OC, depending on the chosen effect criterion. Uncertainty in calculated effects and SQCs is substantial and is mainly caused by uncertainty in PCB congener 126 accumulation.

Polychlorinated biphenyls in the Eurasian otter (Lutra lutra).

Several authors have suggested that contamination by polychlorinated biphenyls (PCBs) constitutes one of the major causes of the decline of the Eurasian otter (Lutra lutra) in large parts of Europe. This chapter provides an overview of available information regarding PCBs in European otters. Data on PCB concentrations in European otter tissues differ qualitatively among authors. Variations may be found in the organs used for analysis, the analytical method, and format of reported data (lipid weight vs. fresh weight, total PCB vs. congener-specific), which complicates a comparison of all data. Further, concentrations may be highly variable within an otter population, or even among individuals inhabiting the same area. Generally, average PCB levels in otters appear to be highest in areas where the species is in decline (mean levels ranging from 50 to 180 mg/kg fat) and thriving otter populations are correlated with low mean PCB tissue concentrations (mean levels less than 30 mg/kg fat). However, high levels have recently been found in thriving otter populations in Scotland, especially Shetland, leading some researchers to the conclusion that the alleged role of PCBs in the decline of the otter is likely to have been exaggerated. However, it is neither possible to dismiss the role of PCBs in the otter's decline as exaggerated nor to assume their important role as proven. The data presented in this review include information in support of both views. Most studies on PCBs in otters report total PCBs only, congener-specific data being quite rare. Information on levels of non-ortho congeners, the most toxic PCBs, is even more limited. Because congener patterns may vary between different otters, the total PCB concentration may not always be an accurate estimator of toxicity. To make a proper assessment of the impact of environmental PCB levels on the performance of otter populations and to establish "safe PCB levels" in sediment and fish, a number of toxicokinetic processes have to be elucidated. In general, the following chain of effects should be studied: concentrations in sediment-->concentrations in prey organisms-->concentrations in otter-->physiological effects-->population effects. Recommendations are made regarding possible areas of research.