Mortality prediction after cardiac surgery: blood lactate is indispensible.

BACKGROUND: Blood lactate is accepted as a mortality risk marker in intensive care units (ICUs), especially after cardiac surgery. Unfortunately, most of the commonly used ICU risk stratification scoring systems did not include blood lactate as a variable. We hypothesized that blood lactate alone can predict the risk of mortality after cardiac surgery with an accuracy that is comparable to those of other complex models. We therefore evaluated its accuracy at mortality prediction and compared it with that of other widely used complex scoring models statistically. METHODS: We prospectively collected data of all consecutive adult patients who underwent cardiac surgery between January 1, 2007, and December 31, 2009. By using χ2 statistics, a blood lactate-based scale (LacScale) with only four cutoff points was constructed in a developmental set of patients (January 1, 2007, and May 31, 2008). LacScale included five categories: 0 (≤ 1.7 mmol/L); 1 (1.8-5.9 mmol/L), 2 (6.0-9.3 mmol/L), 3 (9.4-13.3 mmol/L), and 4 (≥ 13.4 mmol/L). Its accuracy at predicting ICU mortality was evaluated in another independent subset of patients (validation set, June 1, 2008, and December 31, 2009) on both study-population level (calibration analysis, overall correct classification) and individual-patient-risk level (discrimination analysis, ROC statistics). The results were then compared with those obtained from other widely used postoperative models in cardiac surgical ICUs (Sequential Organ Failure Assessment [SOFA] score, Simplified Acute Physiology Score II [SAPS II], and Acute Physiology and Chronic Health Evaluation II [APACHE II] score). RESULTS: ICU mortality was 5.8% in 4,054 patients. LacScale had a reliable calibration in the validation set (2,087 patients). It was highly accurate in predicting ICU mortality with an area under the ROC curve (area under curve [AUC]; discrimination) of 0.88. This AUC was significantly larger than that of all the other models (SOFA 0.83, SAPS II: 0.79 and APACHE II: 0.76) according to DeLong's comparison. Integrating the LacScale in those scores further improved their accuracy by increasing their AUCs (0.88, 0.81, and 0.80, respectively). This improvement was also highly significant. CONCLUSION: Blood lactate accurately predicts mortality at both individual patient risk and patient cohort levels. Its precision is higher than that of other commonly used "complex" scoring models. The proposed LacScale is a simple and highly reliable model. It can be used (at bedside without electronic calculation) as such or integrated in other models to increase their accuracy.

Daily-Mean-SOFA, a new derivative to increase accuracy of mortality prediction in cardiac surgical intensive care units.

BACKGROUND: Sequential organ failure assessment (SOFA) score is widely used in many cardiac surgical intensive care units (ICUs). Its derivatives (mean and maximum values) are known to be more accurate than the original daily values of SOFA itself. However, they were designed for research purposes and could be calculated only after ICU discharge. We aimed to develop a reliable derivative that can be easily calculated daily (Daily-Mean-SOFA) for aiding daily-decision-making and resource allocation. METHODS: All consecutive adult cardiac surgical patients from our ICU between January 1, 2007 and December 31, 2008 were included. We obtained Initial-SOFA (on day 1), the Original-Daily-SOFA value from the 1st to the 6th postoperative day, Max-SOFA (highest SOFA value during the whole ICU-stay), Mean-SOFA (sum of all daily SOFA values/the length of ICU-stay), and the new "Daily-Mean-SOFA" from day 2 to 6 (sum of SOFA from day 1 until day-n/n). We compared their accuracies at predicting ICU mortality using calibration and discrimination statistics. RESULTS: Total 2801 patients were included. The newly developed "Daily-Mean-SOFA" was significantly more accurate than the corresponding SOFA value of the same day in correctly predicting survival and mortality in the whole study population (OCC: 94.1 to 95.0%) and in accurately identifying the individual patient's risk of mortality (AUC: 0.859 to 0.904). It was better than all other derivatives except the Mean-SOFA which was superior to it (OCC: 96.3%; AUC: 0.913). CONCLUSIONS: The Daily-Mean-SOFA is a reliable derivative for daily risk stratification in cardiac ICUs. Due to its accuracy and daily availability, it may be used for risk-directed therapy in cardiac ICUs.

A clinical and economic evaluation of fast-track recovery after cardiac surgery.

BACKGROUND: In the last 5 decades, the care of cardiac surgical patients has improved with the aid of strategies aimed at facilitating patient recovery. One of the innovations in this context is "fast-tracking" or "rapid recovery." This process refers to all interventions that aim to shorten a patient's stay in the intensive care unit (ICU) through accelerating the patient's transfer to a step-down or telemetry unit and to the general ward. METHODS: Patients were allocated to 2 groups. The fast-track group (n = 84) went through an independent theatre recovery unit (TRU). The patients were then transferred on the same day to an intermediate care unit and transferred on the following day to the ward. The intensive care group (52 patients) went to the ICU for at least 1 day, after which they were transferred to the ward. RESULTS AND DISCUSSION: The fast-track pathway significantly reduced the length of stay (LOS) in an intensive care facility (P < .001). The duration of intubation was reduced from a median of 4.08 hours (range, 1.17-13.17 hours) in the intensive care group to 2.75 hours (range, 0.25-18.57 hours) in the fast-track group (P < .001). However, the median values for total hospital LOS, incidences of complications, reintubation, and readmission were similar for the 2 groups. The incidence of failure in the fast-track group was 10%. The mean (SD) cost of the perioperative care was £4182 ± £2284 ($6683 ± 3650) for the fast-track patients, compared with £4553 ± £1355 ($7277 ± $2165) for the intensive care group. CONCLUSION: Fast-track recovery after cardiac surgery decreases the intensive care LOS and the total duration of intubation. It is a cost-effective strategy compared with conventional recovery protocols; however, it does not reduce the total hospital LOS or the incidence of complications.

Bone Infarction Mimicking a Bone Metastasis on 18F-Prostate-Specific Membrane Antigen PET/CT.

ABSTRACT: 18F-prostate-specific membrane antigen (PSMA) PET/CT imaging is increasingly used in staging, assessment of biochemical recurrence, and treatment response in men with prostate cancer. We present a case report of a 70-year-old man who underwent 18F-PSMA PET/CT imaging to investigate biochemical recurrence following radical prostatectomy for prostate adenocarcinoma. New focal moderate PSMA uptake was identified in the left femur. A previous PSMA study, performed 5 months earlier, was normal. A subsequent MRI scan demonstrated that the PSMA avidity corresponded to a new femoral bone infarct. An English literature search revealed no previous cases of PSMA tracer uptake in bone infarction.

FDG PET/CT in Sacroiliac IgG4 Disease.

ABSTRACT: A 68-year-old woman with abdominal pain and a raised C-reactive protein was investigated with a CT of the abdomen. CT showed an irregular soft tissue mass anterior to the aorta, which was thought to be neoplastic. The patient underwent 18F-FDG PET/CT, which demonstrated hypermetabolic activity in this mass, as well as further foci of hypermetabolic activity in head and neck, sacroiliac joints, and pelvic floor muscles. A CT-guided biopsy of the sacroiliac joint was performed and revealed IgG4-related disease.

Prostate Artery Embolization for Benign Prostate Hyperplasia Review: Patient Selection, Outcomes, and Technique.

Prostate artery embolization (PAE) is a minimally invasive technique in managing men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). BPH is one of the commonest causes of LUTS in men, associated with high morbidity and economic burden. Patients suffering from LUTS secondary to BPH, severe enough to warrant intervention traditionally underwent transurethral resection of the prostate or open prostatectomy. PAE is an emerging alterative technique with promising data. In this paper we review important elements to running a safe PAE practice including careful patient selection, exclusion criteria, complications, and efficacy of PAE compared to other techniques. This paper also reviews the basic anatomy and techniques relevant to PAE, including common anatomical variants.

Grossly delayed massive subcutaneous emphysema following laparoscopic left hemicolectomy: A case report.

INTRODUCTION: Surgical emphysema is a known early complication of laparoscopic surgery, common during upper gastrointestinal and gynaecological surgery; the authors present the first case of delayed subcutaneous emphysema following a laparoscopic left hemicolectomy. PRESENTATION OF CASE: A 52-year-old woman underwent a laparoscopic left hemicolectomy for a sigmoid malignancy; on the third post-operative day after an uneventful procedure, she developed a massive surgical emphysema involving her face, neck and chest with associated pneumoperitoneum but without any evidence of pneumothorax. A gastrograffin enema ruled out an anastomotic leak. Apart from a borderline tachycardia, mildly low saturations and an area of erythema in her right flank, she was totally asymptomatic. The emphysema resolved spontaneously around the 6th post-operative day. DISCUSSION: Massive subcutaneous surgical emphysema after laparoscopic colorectal surgery is a rare complication and can me managed conservatively with a good outcome. CONCLUSION: To our knowledge, this represents the first case of delayed massive surgical emphysema following colorectal surgery, the aetiology of which has still not been clearly explained, after exclusion of the most common causes.

Review of application of mass spectrometry for analyses of anterior eye proteome.

Proteins have important functional roles in the body, which can be altered in disease states. The eye is a complex organ rich in proteins; in particular, the anterior eye is very sophisticated in function and is most commonly involved in ophthalmic diseases. Proteomics, the large scale study of proteins, has greatly impacted our knowledge and understanding of gene function in the post-genomic period. The most significant breakthrough in proteomics has been mass spectrometric identification of proteins, which extends analysis far beyond the mere display of proteins that classical techniques provide. Mass spectrometry functions as a "mass analyzer" which simplifies the identification and quantification of proteins extracted from biological tissue. Mass spectrometric analysis of the anterior eye proteome provides a differential display for protein comparison of normal and diseased tissue. In this article we present the key proteomic findings in the recent literature related to the cornea, aqueous humor, trabecular meshwork, iris, ciliary body and lens. Through this we identified unique proteins specific to diseases related to the anterior eye.