Preoperative Sodium Research Articles

7169 Association of preoperative sodium concentration with prognosis in renal cell carcinoma

Retroperitoneal lymph node dissection (RPLND) and adjuvant chemotherapy are two adjuvant treatment options for patients with clinical Stage I nonseminomatous germ cell tumors of the testis (NSGCT). Aim of this trial was to prove the advantage of one cycle of bleomycin, etoposide, and cisplatin (BEP) chemotherapy compared with RPLND in terms of recurrence.Between 1996 and 2005, 382 patients were randomly assigned to receive either RPLND (n = 191) or one course of BEP (n = 191) after orchidectomy. The primary study end point was the rate of recurrence. The trial was powered to detect a 7% reduction (from 10% to 3%) of recurrence with chemotherapy compared with surgery.After a median follow-up of 4.7 years, 2 and 15 recurrences were observed in the intention-to-treat population with chemotherapy and surgery, respectively (P = 0.0011). The difference in the 2-year recurrence-free survival rate between chemotherapy (99.46%; 95% CI, 96.20%–99.92%) and surgery (91.87%; 95% CI, 86.87%–95.02%) was 7.59% (95% CI, 3.13%–12.05%). The hazard ratio to experience a tumor recurrence with surgery as opposed to chemotherapy was 7.937 (95% CI, 1.808–34.48).To our knowledge, this is the largest randomized trial investigating adjuvant treatment strategies in clinical Stage I NSGCT, which showed the superiority of 1 course BEP over RPLND performed according to community standards to prevent recurrence. Although not standard treatment, 1 course of BEP is active in an unselected group of patients with clinical Stage I disease and merits further investigation.

Prognostic Factors in Renal Cell Carcinoma: Association of Preoperative Sodium Concentration with Survival

Conventional renal cell carcinoma (RCC) has a variable natural history, and determining individual prognosis is important to guide management. We have examined the prognostic significance of a large number of hematologic and biochemical variables, as well as traditional tumor-related factors in patients with RCC. Patients undergoing nephrectomy for newly diagnosed RCC between September 1998 and March 2005 were invited to participate. Clinical, pathologic, and laboratory data were recorded in each case, and immunophenotyping was carried out on a subset of patients. A planned subset analysis of patients presenting with N0M0 disease was done. Two hundred twelve patients with RCC formed the study population. In addition to tumor-related factors, multivariate analyses revealed preoperative serum sodium concentration to be independently and significantly associated with overall survival and disease-free survival when considered as both a continuous variable and when dichotomized to above and below the median value [139 mmol/L; reference range 135-145 mmol/L, hazard ratio 0.44, 95% confidence interval (95% CI) 0.22-0.88, P = 0.014]. Five-year overall survival estimates for patients above and below the median serum sodium were 67.6% (95% CI 54.2-80.9) and 44.3% (95% CI 32.8-55.8), respectively. These findings persisted in the N0M0 subgroup analysis. We have confirmed the prognostic value of traditional tumor-related factors but, to our knowledge, these are the first data to show that low preoperative sodium concentration may be an important factor associated with reduced survival in patients with RCC, suggesting that serum sodium should be considered with established prognostic variables in modeling survival in RCC.

Preoperative sodium concentration as a possible predictor of survival in patients with renal cell carcinoma

10601 Background: Conventional renal cell carcinoma (RCC) has a variable natural history, and determining individual prognosis is important to guide management. In this cross-sectional study of RCC, a large number of parameters including hematological and biochemical as well as traditional tumor-related factors have been assessed for their prognostic significance. Methods: Consecutive, unselected patients undergoing nephrectomy for newly diagnosed RCC were invited to participate. Primary end-points were overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS). A subset analysis of patients presenting with localized N0 disease was planned. Univariate and multivariate Cox's proportional hazards models were used. Results: 212 patients with RCC formed the study population. Tumor-related factors including grade, stage, presence of necrosis and vascular invasion were prognostic for survival on multivariate testing, in agreement with previous reports. In multivariate analyses pre-operative serum sodium (sNa) was found to be independently and significantly associated with OS and DFS when considered as a continuous variable (see table ). In a further exploratory analysis for all patients when sNa was dichotomized into above/below the median value (139 mmol/l; normal range: 135–145 mmol/l), 3-year OS estimates above and below the median were 74%, 95% CI [64%, 85%] and 54%, 95% CI [44%, 64%]; corresponding figures for 5 years were 68%, 95% CI [54%, 81%] and 44%, 95% CI [33%, 56%]. Conclusions: We have confirmed the prognostic value of traditional tumor-related factors but, to our knowledge, these are the first data to demonstrate that pre-operative sodium concentration may be an important factor associated with survival in patients with RCC. This result suggests that sNa should be considered with established prognostic parameters in modeling survival in RCC. [Table: see text] No significant financial relationships to disclose.

Do Cardiac Neuropeptides Play a Role in the Occurrence of Atrial Fibrillation After Coronary Bypass Surgery?

One of the potential mechanisms to explain the occurrence of postoperative atrial fibrillation (AF) is imbalance of autonomic nervous system tone. The myocardium is innervated not only by cholinergic and adrenergic nerves but also by peptidergic nerves that synthesize and secrete neuropeptides. To investigate the possible role of cardiac neuropeptides in the development of AF after coronary artery bypass grafting (CABG), we analyzed the plasma levels of substance P (SubP), neuropeptide Y (NPY), and angiotensin II (Ang II) in patients who underwent elective on-pump CABG. This prospective study group included 83 consecutive patients scheduled for elective, on-pump CABG. Depressed left ventricular (LV) function (ejection fraction [EF] less than 0.30), concomitant cardiac procedures, history of atrial fibrillation, second or third degree atrioventricular block, implanted pacemaker, postoperative myocardial infarction, use of class I or III antiarrhythmic drug, and hemodynamic deterioration were exclusion criteria. Preoperative and postoperative serum levels of SubP, NPY, and AngII were measured by radioimmunoassay technique. Postoperative AF occurred in 27 patients (32.5%). Using multivariate logistic regression analyses, only a decrease in SubP level (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 0.767 to 0.99, p = 0.031) and an increase in AngII level (OR = 2.61, 95% CI = 1.002 to 1.021, p = 0.023) after CABG were found to be independently associated with AF. Increased age (p = 0.02), diabetes mellitus (p = 0.023), preoperative use of beta blocker (p = 0.024), proximal right coronary artery involvement (p = 0.024), low preoperative sodium levels (p = 0.023), low LVEF (p = 0.013), and increased mitral E wave deceleration time (p = 0.044) were also associated with AF. These results indicate that the increase in AngII and the decrease in SubP after CABG may play a role in the occurrence of postoperative AF. Further studies are needed to define the physiologic and pathologic relevance of these substances at the occurrence of AF in patients who undergo CABG.

Comparison between Monopolar and Bipolar TURP in Treating Benign Prostatic Hyperplasia: 1-Year Report

Purpose. The major complication of traditional monopolar TURP is water intoxication due to absorption of distilled water during extended resection. A newly developed bipolar electrocautery device which uses saline irrigation decreases the risk of TUR syndrome. The aim of this study was to evaluate the efficacy and safety of this bipolar system. Methods. From April to October 2003, a total of 40 patients aged 58 to 86 years (mean: 69.3 yr) were randomized into two comparable groups; one underwent bipolar TURP and the other received monopolar TURP. Pre-operative and post-operative serum sodium concentration, hemoglobin level, resection time, blood loss and weight of specimen were evaluated. Qmax, I-PSS and bladder neck contracture were reassessed at 6-month and 1-year follow-ups. Results. There were no significant differences in hemoglobin level, blood loss, resection time or weight of specimen between the two groups. However, the difference in serum sodium level after operation was significantly greater in the monopolar group (p＜0.001). Conclusions. The bipolar electrocautery device is safer than the traditional monopolar device for the TURP procedure; the bipolar device decreases the risk of TUR syndrome and produces results similar to those obtained with the monopolar device at 6-month and 1 year follow-ups.

Post-operative hyponatraemia in orthopaedic injury

Post-operative hyponatraemia can be dangerous and can go unrecognised as the presenting signs and symptoms are often confused with post-operative or post-anaesthesia sequelae. Infusion of dextrose containing fluids in the peri-operative period is a well-documented cause of this electrolyte imbalance. We conducted a retrospective study to identify the incidence of hyponatraemia following surgery for orthopaedic injury. Medical notes and fluid charts of the patients were scrutinised. We detected 32 cases of post-operative hyponatraemia over a period of 1 year. Eleven hundred and thirty-one patients underwent orthopaedic surgery during this period. Calculated incidence of hyponatraemia was 2.8%. In the hyponatraemic group, the mean pre-operative sodium was 134 mmol/l and mean post-operative sodium was 126 mmol/l. There was a statistically significant difference between mean pre-operative and mean post-operative serum sodium concentration ( P<0.0001, two sample t-test). The mean volume of dextrose containing fluids received by each patient was 3.26 l. There is a significant risk of hyponatraemia following orthopaedic surgery, especially in the elderly. Orthopaedic units need to be aware of this easily avoidable condition. Fluid infusion regimes should be carefully formulated with exclusion of dextrose containing fluids to prevent the danger of hyponatraemia.

Skin test development in leprosy: progress with first-generation skin test antigens, and an approach to the second generation.

One of the most urgent needs from leprosy research is a test for infection. The lepromin test is not suitable as a diagnostic test for leprosy, and neither the Rees nor the Convit soluble antigens has appeared sufficiently specific. Because two new antigens, MLSA-LAM and MLCwA, may not fully meet the requirements for specificity, we have embarked upon the preparation of a second generation of skin test antigens. Size-fractionated cryptozoic proteins were prepared from M. leprae by electroelution from preoperative sodium dodecylsulphate-polyacrylamide gel electrophoresis, and individual fractions were probed with polyclonal and monoclonal antibody reagents to identify both known and novel proteins. In addition, immunological responses were assessed in M. leprae-sensitized guinea pigs against both crude subcellular fractions (cytosol, membrane, and soluble cell wall proteins) and the size-fractionated cytosolic proteins. A particularly promising subcellular fraction is the membrane fraction of M. leprae, which contains many proteins unique to the organism. Clinical trials of the M. leprae membrane proteins are now being planned.

Comparing Ultrafiltration and Centrifugation During and After Pediatric Cardiopulmonary Bypass

Blood processing techniques related to pediatric cases have previously been generalized from adult experiences. Twenty-two pediatric patients (&lt;25 kilograms) undergoing cardiopulmonary bypass (CPB) for various congenital defects were prospectively randomized into an ultrafiltration or centrifugation group. Sixty-one variables were compared. The blood infused from the ultrafiltration technique contained significantly more heparin (p=0.0001) and more plasma-free hemoglobin (PFH) (p=0.0001) levels than the centrifugation blood. Centrifugation patients had a significantly higher hematocrit (p=0.0066) than the ultrafiltration group twenty minutes postoperatively. The ultrafiltration patients (mean=431.82cc±116.8) received less total packed red blood cell volume before and during bypass than the centrifugation group (mean=534.091cc±113.07). In the centrifugation group, wash volumes showed positive correlation to postoperative blood sodium levels (r= +0.4006, p&lt; 0.05). No significant difference was found between postoperative and preoperative sodium levels (p&gt; 0.05). PFH levels for both groups showed a significant positive correlation to postoperative creatinine levels (r= +.4029, p&lt; 0.05) suggesting decreased postoperative renal function, but a significant negative correlation to post-bypass hematocrit (r= -.4548, p&lt; 0.05). Post-bypass heparin levels in the circuit showed a significant positive correlation to heparin levels in the reinfusion blood for the ultrafiltration group (r= +.8025, p&lt;0.05). Post-bypass PFH level in the circuit showed a significant positive correlation to PFH levels in the reinfusion blood for both groups (r= +.5339, p&lt;0.05). No significant difference existed between the ultrafiltration and centrifugation groups for postoperative prothrombin and partial thromboplastin times. For pediatric cases, the centrifugation technique was found to be superior for post-bypass blood processing based on a higher postoperative patient hematocrit and the presence of less heparin and less PFH in the reinfused blood. The ultrafiltration technique was found to be superior for intraoperative blood processing due to a lower total packed red cell volume addition before and during bypass.

Sodium fluoride therapy in stapedial otosclerosis

Pre-operative sodium fluoride (NaF) has been used in 21 out of 192 consecutive cases of active footplate stapedial otosclerosis in moderate doses (20 mgms twice daily) for six months. These 21 cases had vascular type of otosclerotic lesion which was earlier confirmed on tympanotomy. Out of 16 of these cases in 11 cases (68.8%) significant decrease in vascularity of the otosclerotic lesion has been noted during stapedectomy performed after six months of sodium fluoride therapy.

Intraarterial 9-beta-methyl carbacyclin improves canine polytetrafluoroethylene graft patency.

This study examined the effect of 9-beta-methyl carbacyclin, a synthetic, stable prostacyclin analog, on canine polytetrafluoroethylene (PTFE) graft patency. Twenty-five dogs had 4 mm x 7 cm PTFE grafts implanted bilaterally into the femoral arteries. A subcutaneous infusion pump was used to deliver either saline solution (control) or 9-beta-methyl carbacyclin (Ciprostine) at 100 (CARB-100) or 200 ng/kg/min (CARB-200) through a femoral artery branch just proximal to one of the femoral grafts, with the contralateral graft serving as a noninfused control. Graft-platelet deposition (with 111In-labeled platelets) was measured between the fifth and seventh days, with patency determined on the seventh day. Dogs were classified as aggregators (AGG [+]) if the preoperative epinephrine-enhanced sodium arachidonate platelet aggregation was greater than 20%. CARB-200 infusion significantly improved ipsilateral graft patency (80%) compared with noninfused grafts (50%, p less than 0.05), or grafts in control and CARB-100 dogs (43%, p less than 0.05). Anastomotic platelet deposition was decreased bilaterally in CARB-200 dogs by 45% to 59% compared with CARB-100 and control dogs (p less than 0.05). With the exception of grafts infused with CARB-200, AGG (+) dogs had significantly lower graft patency (26%) than nonaggregator AGG (-) dogs (71%, p less than 0.01). CARB-200 infusion significantly improved graft patency in AGG (+) dogs (71%), compared with control and CARB-100-infused grafts (19%, p less than 0.025). Intra-arterial 9-beta-methyl carbacyclin improved early PTFE graft patency and inhibited platelet deposition in a severe canine model, independent of baseline platelet aggregation status, which also had an important effect on graft patency.

Unilateral Toxic Multicystic Goiter-Reply

In Reply. —Dr Daniels is correct to point out that a low dose of levothyroxine can produce thyrotoxicosis in the presence of autonomous thyroid tissue. As stated in the figure legend in our article, the patient had not been receiving levothyroxine therapy three weeks before the preoperative sodium iodide I 123 thyroid scan. Several weeks later, the patient became clinically mildly hyperthyroid, with a serum thyroxine uptake of 16.0 μg/dL. At that time, she had not received any levothyroxine therapy for six weeks. Nevertheless, the indication for surgery was not the mild hyperthyroidism, but the mass effect of the enlarged left thyroid gland, which was causing a pressure sensation in the patient's neck. Potassium iodide in pharmacologic doses has been used for many years to prepare thyrotoxic patients for surgery. In addition to producing a prompt block to thyroid hormone secretion, iodide decreases vascularity within 14 days, 1 making the

Preoperative sodium appetite experience and hypothalamic lesions in rats.

When a sodium deficit is induced in rats without lesions, they increase their saline intake regardless of prior experience. By contrast, this experiment found that rats with lateral hypothalamic lesions increased their saline intake only when they had had preoperative experience ingesting saline in response to a sodium deficit. Rats were given natriuretic and mineralocorticoid treatments to induce sodium appetite. The role of preoperative experience in neural function are discussed.