Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique.

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study.

INTRODUCTION: Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery. METHODS: We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo. RESULTS: The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score). CONCLUSIONS: This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

Dietary iron, animal fats, and risk of Parkinson's disease.

BACKGROUND: Recent studies have proposed a role for diet in Parkinson's disease (PD). PD is characterized by a high deposition of iron and a low concentration of ferritin in the substantia nigra. Few data in the literature are available on the possible role of dietary iron in the development of PD. METHODS: In a population-based, case-control study, we addressed the hypothesis that high dietary iron intake was associated with PD. We assessed dietary iron intake with a semiquantitative food-frequency questionnaire in 104 PD patients and 352 control subjects, frequency matched for age and gender. We also studied the association of PD and dietary iron and animal fat intake in the presence of different iron stores measured by transferrin saturation. RESULTS: No significant differences were observed between patients' and control subjects' dietary intake of iron from food or supplements (odds ratio [OR] for the highest quartile of intake, 0.9; 95% confidence interval [95% CI], 0.6, 1.3; p for trend = 0.60). Among those with low transferrin saturation levels (lower 50%), the odds ratio for PD associated with animal fat intake was ninefold higher than the risk of those with low intake (OR, 9.0; 95% CI, 2.7-29.9). Among those with high transferrin saturation, risk of PD was two times higher (relative risk, 1.9; 95% CI, 0.5-7.2) for those who reported high intake of animal fat compared with those who reported low intake. CONCLUSION: Dietary iron intake after caloric adjustment was not associated with an increased risk of PD. However, the previously described association between animal fat intake and PD was modified by iron level stores as measured by transferrin saturation. These observations suggest that dietary fat and a systemic defect in iron metabolism may act synergistically in the process of lipid peroxidation in PD.