Restrictive vs liberal blood transfusion strategy in patients with symptomatic coronary artery disease: meta-analysis from randomized controlled trials

Background Anemia is common in patients with symptomatic coronary artery disease. Observational studies investigated blood transfusion threshold in symptomatic coronary artery disease but results were conflicting. Meta-analyses evaluating transfusion threshold utilized data mainly from observational trials but no meta-analysis, to our knowledge, used data solely from randomized clinical trials. Objective The goal of our study is to evaluate efficacy and safety outcomes in anemic patients presenting with symptomatic coronary artery disease using pooled data from randomized clinical trials. Methods We queried Medline, Embase and Cochrane data bases for randomized clinical trials comparing restrictive blood transfusion (defined as transfusion when hemoglobin is less than 8 gm/dl) vs liberal blood transfusion (transfusion when hemoglobin is less than 10 gm/dl) in patients presenting with symptomatic artery disease or acute coronary syndrome. We identified 3 randomized controlled trials; MINT, CRIT and REALITY trials. Data were pooled from 3 trials. Efficacy outcomes evaluated were all-cause mortality and New or recurrent myocardial infarction. Safety outcomes were congestive heart failure at 30-day follow up. Results A total of 820 patients were included in our meta-analysis; 420 patients in restrictive blood transfusion protocol and 400 in liberal blood transfusion protocol There was no difference between two groups at 30-day follow up in all identified outcomes (all-cause mortality, new or recurrent myocardial infarction, and Congestive heart failure). 55 patients died (22/420 in restrictive group and 33/400 in liberal group). Risk ratio of all-cause mortality in restrictive group was 0.63 [95% CI (0.38–1.07), P=0.09, I2=30%]. 15/420 in restrictive group and 16/400 in liberal group had new or recurrent myocardial infarction. Risk ratio of myocardial infarction in restrictive group was 0.91 [95% CI (0.46–1.80), P=0.78, I2=0%]. 20/420 patients in restrictive group and 24/400 in liberal group had congestive heart failure with risk ratio of 0.80 [95% CI (0.19–3.37), P=0.30, I2=76%] in restrictive group. Conclusion Our meta-analysis showed similar outcomes between restrictive and liberal transfusion policies in patients presenting with symptomatic coronary artery disease of acute myocardial infarction. Our findings are consistent with available data about restricting transfusion in general population. Restricting blood transfusion might be cost-effective. Further studies are warranted to evaluate long term safety and efficacy of such approach. FUNDunding Acknowledgement Type of funding sources: None.

Effects of Intraoperative Fluid Management on Postoperative Outcomes After Pericardiectomy

Background: The effects of intraoperative fluid management on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the relationship between intraoperative fluid management and postoperative outcomes in these patients.Methods: We retrospectively studied 92 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to the restrictive group and the liberal group according to the intraoperative total fluid infusion rate. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the relationship between the intraoperative total fluid infusion rate and postoperative outcomes.Results: There were 46 (50.0%) cases in the restrictive group and 46 (50.0%) cases in the liberal group. Compared with the liberal group, the restrictive group had significantly lower incidences of postoperative complications and cardiac complications (P = 0.005 and P = 0.006, respectively). Binary logistics regression analysis also showed the increased risks of postoperative complications (OR, 3.551; 95% CI, 1.192–10.580; P = 0.023) and cardiac complications (OR, 6.037; 95% CI, 1.472–25.052; P = 0.013) at the liberal group. In addition, the restrictive group had shorter postoperative hospital stay (P = 0.026) in comparison to the liberal group.Conclusion: In patients with constrictive pericarditis undergoing pericardiectomy the intraoperative total fluid infusion rate was significantly associated with postoperative outcomes. Restrictive fluid management strategy was related to the positive effects on enhanced recovery after surgery and could be advised as the preferred intraoperative fluid management policy.

Prevalence and characteristics of childfree adults in Michigan (USA)

Childfree individuals choose not to have children, which makes them a distinctive group from parents who have had children, not-yet-parents who plan to have children, and childless indivduals who would have liked to have children. Most research on parental status and psychosocial characteristics has not effectively distinguished childfree individuals from other non-parents or has relied on non-representative samples. In this study, we use a representative sample of 981 Michigan adults to estimate the prevalence of childfree individuals, to examine how childfree individuals differ from parents and other types of non-parents in life satisfaction, political ideology, and personality, and to examine whether childfree individuals are viewed as an outgroup. We find that over a quarter of Michigan adults identified as childfree. After controlling for demographic characteristics, we find no differences in life satisfaction and limited differences in personality traits between childfree individuals and parents, not-yet-parents, or childless individuals. However, childfree individuals were more liberal than parents, and those who have or want(ed) children felt substantially less warm toward childfree individuals than childfree individuals felt toward each other. Given the prevalence of childfree individuals, the risks of their outgroup status, and their potential role in politics as a uniquely liberal group, it is important for demographic research to distinguish the childfree from others and to better understand these individuals.

Restrictive versus liberal perioperative fluid strategies to prevent post-dural puncture headache after cesarean delivery

Background Post-dural puncture headache is a common complication after cesarean delivery. The role of fluid therapy in prevention of post-dural puncture headache is not clear. The aim of this work is to compare restrictive versus liberal perioperative fluid protocols in prevention of post-dural puncture headache. A randomized controlled trial was conducted including 100 full-term pregnant women undergoing cesarean delivery under spinal block. After receiving spinal block, all patients received 1.5 mcg/kg phenylephrine and crystalloid co-load at a rate of 10 mL/h. Patients were assigned into either restrictive group (did not receive fluid preload + received postoperative crystalloid therapy at a rate of 2 mL/kg/h till resuming oral fluids) or liberal group (received crystalloid preload 5 mL/kg before spinal block + received postoperative crystalloids at a rate of 6 mL/kg/h till resuming oral fluids. Both groups were compared according to the incidence of post-dural puncture headache, pain scores, systolic blood pressure, heart rate, incidence of post-spinal hypotension, nausea, and vomiting. Results The incidence of post-dural puncture headache was lower in the restrictive group compared to the liberal group {10(20%) vs 22(44%), P = 0.018}. All other secondary outcomes were comparable between both groups. Conclusion Restrictive fluid therapy was associated with lower incidence of PDPH after cesarean delivery without impacting patient hemodynamic profile.

Who are the childfree?

Objective: This study examines how childfree individuals differ from parents and other types of non-parents in subjective well-being, political ideology, and personality, and examines whether childfree individuals are a stigmatized outgroup.Background: Childfree individuals choose not to have children. Most research on parental status and psychosocial characteristics has not distinguished childfree individuals from other non-parents or has relied on non-representative samples.Method: This study uses a representative sample of 981 Michigan adults to estimate the prevalence of childfree individuals. The study also estimates a series of multiple regressions to examine differences between childfree individuals, parents, and other types of non-parents and to examine whether childfree individuals are perceived by others as an outgroup.Results: Over a quarter of Michigan adults identified as childfree. After controlling for demographic characteristics, we found no differences in subjective well-being and limited differences in personality traits between childfree individuals and parents, not-yet-parents, or childless individuals. However, childfree individuals were more liberal than parents. Additionally, individuals who have or want(ed) children felt substantially less warm toward childfree individuals than childfree individuals felt toward each other.Conclusions: Given the prevalence of childfree individuals, the risks of their outgroup status, and their potential role in politics as a uniquely liberal group, it is important for demographic research to distinguish the childfree from others and to better understand these individuals.

Effects of intraoperative fluid management on postoperative outcomes after pericardiectomy

Background The effects of intraoperative fluid management on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the relationship between intraoperative fluid management and postoperative outcomes in these patients.Methods We retrospectively studied 92 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to the restrictive group and the liberal group according to the intraoperative total fluid infusion rate. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the relationship between the intraoperative total fluid infusion rate and postoperative outcomes.Results There were 46 (50.0%) cases in the restrictive group (2.68 to 7.46 ml/kg/h) and 46 (50.0%) cases in the liberal group (7.47 to 20.55 ml/kg/h). Compared with the liberal group, the restrictive group had significantly lower incidences of postoperative complications and cardiac complications (P=0.005 and P=0.006, respectively). Binary logistics regression analysis also showed the increased risks of postoperative complications (OR, 3.551; 95%CI, 1.192-10.580; P=0.023) and cardiac complications (OR, 5.083; 95%CI, 1.206-21.426; P=0.027) at the liberal group. In addition, the restrictive group had shorter postoperative hospital stay (P=0.026) in comparison to the liberal group.Conclusion In patients with constrictive pericarditis undergoing pericardiectomy the intraoperative total fluid infusion rate was significantly associated with postoperative outcomes. Restrictive fluid management strategy could exert positive effects on enhanced recovery after surgery and might be the preferred intraoperative fluid management policy.

Dynamics of respect: Evidence from two different national and political contexts

In (post-)modern, plural societies, consisting of numerous subgroups, mutual respect between groups plays a central role for a constructive social and political life. In this article, we examine whether group members’ perception of being respected by outgroups fosters respect for these outgroups. In Study 1, we employed a panel sample of supporters of the Tea Party movement in the United States (N = 422). In Study 2, we employed a panel sample of members of the LGBTI community in Germany (N = 262). As disapproved target outgroups, we chose in Study 1 homosexuals in the United States, while in Study 2, we chose supporters of the German populist, right-wing political party „Alternative für Deutschland“. Our studies thus constituted a complementary, nearly symmetrical constellation of a liberal group and a conservative political group each. Among Tea Party movement supporters, respect from a disapproved outgroup consistently predicted respect for that outgroup. Among German LGBTI community members, this effect of respect from a disapproved outgroup was found in some of our analyses. For this latter sample, there was furthermore a tendency of societal respect to predict respect for a disapproved outgroup longitudinally. Additionally, we observed for both of our samples that respect from other ingroup members decreased respect for a disapproved outgroup. The dynamics of mutual respect in these two complementary intergroup contexts are discussed as well as the importance of direct intergroup reciprocity and superordinate group membership as routes to mutual respect.

Comparison of Two Intravenous Fluid Management Strategies in COVID-19 Patients in Hubei, China: A Retrospective Multicenter Study

Background Optimal fluid management in patients with COVID-19 has not been reported. This retrospective, multicenter study investigated the impact of intravenous infusion volume in the early stage of COVID-19 on clinical outcomes. Methods 127 patients from two tertiary hospitals were separated into the “conservative” and “liberal” groups based on average daily intravenous infusion volume within the first seven days after admission. Basic information, demographic and epidemiological characteristics, laboratory findings, treatments, and outcome measures were retrieved from medical records. The disease progression and prognosis were analyzed and compared. Results The average daily intravenous infusion volume within 7 days was 500 (150–700) ml/day in the conservative-strategy group (n = 87), and 1100 (1000–1288) ml/day in the liberal-strategy group (n = 40) (p < 0.001). There were no statistical differences in median age, male-to-female ratio, epidemiology, laboratory findings on admission, comorbidities, and average daily urine output within the seven days (p > 0.05). The final K+ in the liberal group was slightly higher than that at admission, and the final hematocrit level in the conservative group had a significant difference than that at admission (p < 0.05). The mean (± SD) duration of hospitalization was 22.41 ± 11.99 days in the conservative group and 25.28 ± 12.08 days in the liberal group (p = 0.120). However, compared to the liberal group, conservative group had statistically lower rates of disease progression (9.3% vs 37.5%, p < 0.001), mechanical ventilation (2.3% vs 27.5%, p < 0.001) and in-hospital mortality (2.3% vs 15.0%, p = 0.012). Conclusions Although there appeared to be no significant difference in the duration of hospitalization between using conservative and liberal fluid management strategies, the former was associated with lower rates of disease progression, mechanical ventilation and in-hospital mortality without increased nonpulmonary-organ dysfunction. These results support the importance of implementing conservative intravenous fluid infusion in the early stage of COVID-19.

Correlation between Intraoperative Fluid Administration and Outcomes of Pancreatoduodenectomy

Background. Intraoperative fluid (IOF) administration plays an important role during major abdominal surgery although increased fluid intake can adversely influence postoperative outcomes. However, the effect of the IOF rate on the outcomes of pancreatoduodenectomy (PD) is unclear. Methods. 151 patients, who underwent PD at Binzhou Medical University Hospital between January 2010 and May 2017, were categorized into three groups according to IOF rates (ml/kg/hr): restricted (<10, n=47), standard (10–15, n=76), and liberal (>15, n=28). Results. The overall postoperative morbidity was 56.95%. The incidence of postoperative pancreatic fistula (POPF) was 11.26%. The in-hospital mortality rate was 7.28% with the most common cause being grade C POPF and secondary intra-abdominal infections. The patients in the liberal group had significantly higher incidences of POPF (25%) and respiratory complications (21.43%). The other outcome parameters such as recovery of bowel function, hospital stay, and postoperative daily drainage were similar among the groups. Multivariable analysis confirmed the IOF rate to be most strongly associated with POPF (odds ratio: 5.195, confidence interval: 1.142–23.823, P=0.023) and respiratory complications (odds ratio: 7.302, confidence interval: 0.676–58.231, P=0.025). Conclusions. The IOF rate significantly affects the incidence of POPF and respiratory complications after PD. Careful patient-oriented fluid therapy may help to prevent these complications.

Fluidoterapia perioperatoria y complicaciones post pancreatectomía distal videolaparoscópica

Despite mortality in pancreatic surgery has decreased over the last decade, morbidity remains high. One of the most important causes is pancreatic fistula. Recent studies have demonstrated the importance of fluid therapy management during the perioperative period in major abdominal surgeries. This finding was observed first in colonic surgery, demonstrating that overload of fluids increases postoperative complications. Objective. To evaluate the impact of fluid management on postoperative complications after laparoscopic distal pancreatectomy. Material and methods. Descriptive, retrospective study of a prospective database of patients whom underwent laparoscopic distal pancreatectomy from November 2011 to September 2018. Thirty patients were evaluated and divided in two groups depending on the fluid management (restrictive, or liberal). The data were collected from the anesthesia protocols and nursery reports (until 3rd postoperative day). Demographics, length of stay, kind of fluid management and complications were analyzed. For statistical analysis SPSS®v.21 was used (p < 0.05 was considered significant). Results. Out of 30 patients, 17% were male, mean age was 55 ± 18 years (r 19-82); 17 patients (57%) were included in the liberal group and 13 (43%) in the restrictive group. Twenty-three patients developed complications; 16 (53%) belonged to liberal group whereas 7 (23%) to restrictive group. (p = 0.01). Fourteen patients of liberal group vs. 6 patients of restrictive group had postoperative pancreatic fistula (p = 0.04). There were 7 patients (23%) in liberal group. and 4 (13%) patients in restrictive group with clinically relevant pancreatic fistula (13%, p = NS). Ninety day-mortality was 3.3, with no differences between groups. Conclusion. After laparoscopic distal pancreatectomy, liberal fluid administration at the perioperative period is associated with an increase in the incidence of complication, specially favoring the development of pancreatic fistula.