Prophylactic steroids for pediatric open heart surgery.

BACKGROUND: The immune response to cardiopulmonary bypass in infants and children can lead to a series of postoperative morbidities and mortality i.e. hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the pediatric patient remains unclear. OBJECTIVES: To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in pediatric open heart surgery. SEARCH STRATEGY: The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional handsearch of the EMRO database for Arabic literature was performed. Grey literature was searched and experts in the field were contacted for any unpublished material. No language restrictions were applied. SELECTION CRITERIA: All randomized and quasi-randomized controlled trials of open heart surgery in the pediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. DATA COLLECTION AND ANALYSIS: Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. MAIN RESULTS: All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favor of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation [WMD (95% CI) -0.50 hours (-1.41 to 0.41); -0.20 degrees C (-1.16 to 0.77) and -0.63 hours (-4.02 to 2.75), respectively]. AUTHORS' CONCLUSIONS: The use of prophylactic steroids in pediatric patients to reduce postoperative complications commonly experienced following cardiopulmonary bypass surgery is not supported by the existing evidence. Further well designed and adequately powered randomized controlled trials are needed to more accurately estimate the benefit and harm of this intervention.

Relevance of apolipoprotein E polymorphism for coronary artery disease in the Saudi population.

BACKGROUND: The apolipoprotein E alleles epsilon2 and epsilon4 have been reported as independent risk factors for coronary artery disease (CAD) and as predictors for the development of atherosclerosis. METHODS AND RESULTS: We determined by polymerase chain reaction the distribution of apolipoprotein E polymorphism in 320 Saudi blood donors (BD), 96 CAD patients, and 40 control subjects who had undergone angiography. Compared to controls, only epsilon4 was elevated in CAD patients. More than 61% (P <.0001) of the patients had angina, and 52.1% (P <.05) were diabetic; both of these factors were strongly associated with the presence of allele epsilon2. The epsilon2 allele was also associated with hypertension, elevated serum triglycerides, and total cholesterol. On the other hand, the allele epsilon4 appeared to be associated with increased risk of CAD and was also associated with hypertension, 3-vessel disease, and restenosis. CONCLUSIONS: Accordingly, epsilon4 may be associated with increased risk of CAD, whereas epsilon2 appears to be a predictor of several risk factors for atherosclerosis.

Differential regulation of atrial and brain natriuretic peptides and its implications for the management of left ventricular volume overload.

BACKGROUND: In this study, we investigated the possibility that the atrial and brain natriuretic peptide expression in left ventricular volume overload (VOL) is transcriptionally regulated. We further evaluated the diagnostic and/or prognostic potential of this expression for the management of patients with this disorder. DESIGN: We compared the myocardial mRNA expression and plasma levels of the two peptides in VOL patients using donor hearts and in healthy blood donors as controls. RESULTS: The atrial natriuretic peptide (ANP) mRNA was elevated by 38% (P < 0.03) in the right atrium and by 53% (P < 0.003) in the left atrium, but was unchanged in the ventricular chambers of the patient group (n = 19) compared with controls (n = 8). Plasma ANP concentration was elevated by 62% (P < 0.001) compared with blood donor controls (n = 79). It increased slightly (by 36%) 2 h following surgery, and remained at 64% higher (P < 0.03 vs. presurgery) for the 5 days following surgery. The brain natriuretic peptide (BNP) mRNA was elevated by approximately one-fold in both the left ventricle (P < 0.02) and right atrium (P < 0.05), by 94% (P < 0.02) in the right ventricle and by 89% (P < 0.05) in the left atrium. Its plasma level in the patients was 3.4-fold (P < 0.00003) higher than in control subjects. It increased significantly by 1.2-fold (P < 0.01) 2 h following surgery, but dropped significantly (P < 0.05 vs. 2 h post surgery) to presurgical levels 5 days following surgery. CONCLUSION: The results show chamber-specific elevation in both atrial and brain natriuretic peptide expression and differences in their circulating levels in VOL, suggesting that BNP is a potential prognostic indicator in the postsurgical management of these patients.