Beta-blockers do not provide survival benefit in a population with angiographic coronary artery disease without myocardial infarction or reduced ejection fraction: A meta-analysis.

BACKGROUND: While beta-blockers have been widely used for patients with stable coronary artery disease (CAD), some concerns have been raised that beta blockers do not have survival benefit in this population. We conducted a meta-analysis to determine the effects of beta blockers on all-cause and cardiac mortality in adults with CAD without previous myocardial infarction (MI) or reduced ejection fraction. METHODS: A systematic search of PubMed, Web of Science, Medline/Ovid and Google Scholar through March 2016 identified 4 studies that reported angiographic CAD without previous myocardial infarction or reduced ejection fraction. Fixed-effects pooled odds ratios and 95% confidence intervals of all-cause and cardiac mortality were estimated. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess overall quality of evidence. RESULTS: A total of 17,397 patients were analyzed. In both all-cause and cardiac mortality analysis, no serious limitation was identified. Beta-blockers were not associated with reductions in all-cause mortality (odds ratios=0.910, 95% confidence intervals 0.797-1.039, p=.163) or cardiac mortality (odds ratio=0.926, 95% confidence interval 0.773-1.110, p=.407). CONCLUSION: Beta-blockers do not provide any survival benefit in patients with angiographic CAD without history of MI or reduced ejection fraction.

Low-dose cyclophosphamide improves survival in a murine treatment model of sepsis.

Sepsis is a complex medical condition characterized by a systemic inflammatory response in the setting of infection. We hypothesized that combining antibiotics plus an immunosuppressant would protect against the morbidity and mortality of polymicrobial sepsis in mice better than would antibiotics alone. We used a murine cecal-ligation-and-puncture model in which mice were treated either with imipenem plus cyclophosphamide or imipenem alone. Titration to a low cyclophosphamide dose revealed that combination therapy increased survival by 20% compared with imipenem alone (56% vs. 36%, P < 0.001). To investigate the mechanism by which combination therapy did this, we reviewed quantitative and qualitative markers of the systemic immune response, end-organ damage, and the local immune response at the site of injury. Cyclophosphamide treatment was not associated with depletion of peripheral leukocytes or differences in pulmonary damage. However, mice that received combination therapy had higher plasma granulocyte colony-stimulating factor levels than did those treated with antibiotics alone. In addition, mice treated with cyclophosphamide had higher levels of bacterial colonization in intestinal Peyer's patch lymph nodes at 72 h after the septic insult. Intraperitoneal macrophage phenotypes and phagocytosis activity did not differ between groups. We conclude that the inflammatory response plays a significant role in the mortality of polymicrobial sepsis and that the regulation of this element is both feasible and beneficial in this disease model.

Predicting strangulated small bowel obstruction: an old problem revisited.

BACKGROUND: Diagnosing intestinal strangulation complicating a small bowel obstruction (SBO) remains a considerable challenge. Despite decades of experience and numerous studies, no clinical indicators have been identified that reliably predict this life-threatening condition. Our goal was to determine which clinical indicators in patients with SBO can be used to independently predict the presence of strangulated intestine. METHODS: Medical records were reviewed for 192 adult patients operated on for acute SBO over an 11-year period (1996-2006). Seventy-two preoperative clinical, laboratory, and radiologic findings at admission were examined. Data from patients with strangulated intestine were compared to data from patients without bowel compromise. Likelihood ratios were generated for each significant parameter in a multivariate logistic regression analysis. RESULTS: Forty-four patients had bowel strangulation requiring bowel resection, and 148 had no strangulation. The most significant independent predictor of bowel strangulation was the computed tomography (CT) finding of reduced wall enhancement, with a sensitivity and specificity of 56% and 94% [likelihood ratio (LR) 9.3]. Elevated white blood cell (WBC) count and guarding were moderately predictive (LR 1.7 and 2.8). CONCLUSION: Regression analysis of multiple preoperative criteria demonstrates that reduced wall enhancement on CT, peritoneal signs, and elevated WBC are the only variables independently predictive of bowel strangulation in patients with SBO.

Open incisional hernia repair at an academic tertiary care medical center.

OBJECTIVE: To describe the postoperative complication rates of a large consecutive series of patients who underwent open incisional ventral hernia repair. DESIGN: Retrospective medical record review of an accumulated database. SETTING: University tertiary care medical center. PATIENTS: All patients who underwent open incisional ventral hernia repair from March 1, 2003, through February 28, 2008. INTERVENTION: Open incisional ventral hernia repair. MAIN OUTCOME MEASURES: Postoperative complications, including hernia recurrences. RESULTS: A total of 507 cases (465 patients; female to male ratio, 1.1:1) met our criteria; median follow-up was 40 months. In 23.5% of the cases, repair had been attempted previously, and 16.4% had previously undergone organ transplant. The postoperative complication rate was 38.1%. Hernias recurred in 18.9% of cases. Perioperative mortality was 1.0%. Patients undergoing transplant were more likely than those not undergoing transplant to have a hernia recurrence (16.3% vs 32.5%; P < .001) and were equally likely to have a postoperative complication (36.9% vs 44.6%; P = .19). Patients who underwent repair of a recurrent incisional hernia were as likely to have a hernia recurrence as those who underwent initial repair (21.0% vs 18.3%; P = .52) but more likely to have an overall complication (47.9% vs 35.1%; P = .01). CONCLUSIONS: In this series of incisional hernia repairs at a tertiary care center, the overall recurrence rate of 18.9% is comparable to that of other published series. Ours is the largest published series of recurrent hernias that shows a recurrence rate comparable to that for initial repairs. This outcome may be the result of greater use of more complex repair techniques.