22 Jan 10
Posted in Diabetes, Pre-operatie evaluation at 0:32 by Laci
By Y Hsin-Chieh, B Duncan, M Schmidt, N Wang F Brancati
Ann Int Med 2010;152:10-17
Cigarette smoking is an established predictor of incident type 2 diabetes mellitus, but the effects of smoking cessation on diabetes risk are unknown.
Objective
To test the hypothesis that smoking cessation increases diabetes risk in the short term, possibly owing to cessation-related weight gain.
Design
Prospective cohort study.
Setting
The ARIC (Atherosclerosis Risk in Communities) Study.
Patients
10 892 middle-aged adults who initially did not have diabetes in 1987 to 1989.
Measurements
Smoking was assessed by interview at baseline and at subsequent follow-up. Incident diabetes was ascertained by fasting glucose assays through 1998 and self-report of physician diagnosis or use of diabetes medications through 2004.
Results
During 9 years of follow-up, 1254 adults developed type 2 diabetes. Compared with adults who never smoked, the adjusted hazard ratio of incident diabetes in the highest tertile of pack-years was 1.42 (95% CI, 1.20 to 1.67). In the first 3 years of follow-up, 380 adults quit smoking. After adjustment for age, race, sex, education, adiposity, physical activity, lipid levels, blood pressure, and ARIC Study center, compared with adults who never smoked, the hazard ratios of diabetes among former smokers, new quitters, and continuing smokers were 1.22 (CI, 0.99 to 1.50), 1.73 (CI, 1.19 to 2.53), and 1.31 (CI, 1.04 to 1.65), respectively. Further adjustment for weight change and leukocyte count attenuated these risks substantially. In an analysis of long-term risk after quitting, the highest risk occurred in the first 3 years (hazard ratio, 1.91 [CI, 1.19 to 3.05]), then gradually decreased to 0 at 12 years.
Limitation
Residual confounding is possible even with meticulous adjustment for established diabetes risk factors.
Conclusion
Cigarette smoking predicts incident type 2 diabetes, but smoking cessation leads to higher short-term risk. For smokers at risk for diabetes, smoking cessation should be coupled with strategies for diabetes prevention and early detection.
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01 Jan 10
Posted in Anesthesia, Anticoagulation, Coronary artery disease, Pre-operatie evaluation at 16:19 by Laci
by P Chassot, A Delabays, D Spahn
Best Pract Res Clin Anaesthesiol 2007; 21:241–256
Performing a surgical procedure on a patient undergoing anti-platelet therapy raises a dilemma: is it safer to withdraw the drugs and reduce the haemorrhagic risk, or to maintain them and reduce the risk of myocardial ischaemic events? Based on recent clinical data, this review concludes that the risk of coronary thrombosis on anti-platelet drugs withdrawal is much higher than the risk of surgical bleeding when maintaining them. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is mandatory as long as the coronary stents are not fully endothelialized, which takes 6–24 weeks depending on the technique used, but might be required for a longer period
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29 Nov 09
Posted in Immunisation, Pre-operatie evaluation at 21:03 by Laci
By J Siebert, K Posfay-Barbe, W HAabre, C Siegrist
Pediatr Anesth 2007;17:410-410
Anesthesia and surgery exert immunomodulatory effects and some authors argue that they may exert additive or synergistic influences on vaccine efficacy and safety. Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course. There is a lack of consensus approach among anesthesiologists to the theoretical risk of anesthesia and vaccination. Few studies have assessed the influence of anesthesia and surgery on pediatric vaccine responses. We have undertaken an extensive review of articles published in English between 1970 and 2006 meeting the criteria: measurement of immune parameters following general anesthesia in children. By searching the major medical databases (OVID Medline, PubMed, ISI Web of Science) and references cited in the articles themselves, among 277 articles obtained none examined directly the influence of anesthesia/surgery on vaccine responses. Only 16 original reports assessed the influence of several anesthetic agents on various markers of immunity including lymphocyte numbers and functions. These results are reinterpreted here in view of our current understanding of the immune mechanisms underlying vaccine efficacy and adverse events. We conclude that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 h) and that the current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. However, respecting a minimal delay of 2 days (inactivated vaccines) or 14–21 days (live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications.
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Posted in Immunisation, Pre-operatie evaluation at 20:54 by Laci
By J Short, J Van Dr Walt and D Zoanetti
Pediatr Anesth 2006;16:514-522
There is no direct evidence of any major interaction between immunization and commonly used anesthetic agents and techniques in children, but it is possible that immunosuppression caused by anesthesia and surgery may lead to decreased vaccine effectiveness or an increased risk of complications. In addition, diagnostic difficulty may arise if a recently immunized child suffers from postoperative pyrexia or malaise.
Aim
The aim of this study was to ascertain anesthetists’ attitudes and practices regarding anesthesia and immunization.
Methods
We conducted an international survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) and the Society for Paediatric Anaesthesia of New Zealand and Australia (SPANZA).
Results
Two hundred and ninety-six (52.1%) APAGBI and 86 (49.4%) SPANZA responses were analyzed. There was no consensus of approach to this theoretical risk among respondents. In total, 60% of respondents would anesthetize a child for elective surgery within 1 week of receiving a live attenuated vaccine, but 40% would not. Few hospitals have formal policies on this issue and government guidance is based on a lack of evidence for adverse events rather than positive evidence of safety.
Conclusions
There is a theoretical risk associated with anesthesia and surgery in recently immunized children. An international postal survey failed to find a consensus to this risk among pediatric anesthetists. From a risk management perspective, a review of the available evidence suggests that it would be prudent to adopt a cautious approach where the timing of elective surgery is discretionary. We therefore recommend that elective surgery and anesthesia should be postponed for 1 week after inactive vaccination and 3 weeks after live attenuated vaccination in children.
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