Continuation of Angiotensin-Converting Enzyme Inhibitors on the Day of Surgery Is Not Associated With Increased Risk of Hypotension Upon Induction of General Anesthesia in Elective Noncardiac Surgeries.

OBJECTIVE: The aim of this study was to find out whether the preoperative continuation of angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) treatment is associated with intraoperative hypotension immediately after induction of general anesthesia in elective noncardiac surgeries. DESIGN: Retrospective cohort study. SETTING: Single institutional university hospital. PARTICIPANTS: Four hundred patients who underwent elective noncardiac surgery under general anesthesia, with ACE-I or ARB on their list of preoperative home medications, were included. INTERVENTION: Preoperative ACE-I and ARB use was evaluated, and patients were divided into an ACE-I/ARB group versus non-ACE-I/ARB group. MEASUREMENTS: The primary outcome measure was intraoperative hypotension after induction of general anesthesia. The secondary outcome measure was preoperative medication use, medications taken the morning of surgery, induction medication and dosage, and vasopressor medication use during induction. RESULTS: Three hundred forty-nine patients were included for final analysis. The mean admission American Society of Anesthesiologists status was 2.7 ± 0.5, age 65 ± 11 years, and body mass index 31 ± 6.9 kg/m2. There were no statistically significant changes between the no ACE-I/ARB group and the ACE-I/ARB group in systolic blood pressure (p = 0.853), diastolic blood pressure (p = 0.357), and heart rate (p = 0.220) change over the 15 minutes. There was no statistical difference in induction medication dose (propofol, fentanyl, and rocuronium) and pressor use (p = 0.137) for hypotension between the 2 groups. Statistically significant hypotension (p < 0.001) occurred in both groups equally over 15 minutes. CONCLUSION: Continuation of ACE-I/ARB on the day of surgery was not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries.

Identification of a ubiquitously active promoter of the murine activation-induced cytidine deaminase (AICDA) gene.

Somatic hypermutation and class switch recombination of immunoglobulin genes are dependent on the presence of the activation-induced cytidine deaminase (AICDA) enzyme. AICDA expression is restricted to activated B-lymphocytes in the germinal centers. It has been suggested that inappropriate expression of AICDA may lead to genome instability and aberrant affinity maturation of putative autoreactive antibodies. To better understand the molecular control of its tightly regulated expression we have identified the transcription initiation site and an upstream, conserved promoter region of the murine AICDA gene. The promoter lacks a consensus TATA box but contains an initiator (Inr) element and is active in several murine and human cell lines irrespective of endogenous AICDA expression. Mutagenesis analysis identified a functionally important Sp-binding site which binds both Sp1 and Sp3 in vitro in all cell types. Contrary to a recent report, no evidence was found for direct Pax5-binding at this DNA site. We discuss the role of ubiquitous and lymphoid-specific factors in the control of AICDA gene transcription.

A 61-year-old woman develops polyuria after hip revision.

A 61-year-old previously healthy woman developed progressive hearing and visual loss over a period of 2-3 months prior to admission. Her medical/surgical history was remarkable for a left hip arthroplasty 11 years ago requiring revision approximately 6 months prior to admission. After dislocating the revised hip, she re-presented to her surgeon and underwent a closed reduction. Several weeks following the reduction, the patient began having polyuria and symptoms of hearing and vision loss along with numbness in her extremities and abdominal region.