[Evaluation of a protocol for selective ordering of preoperative tests in healthy subjects]

Small molecule therapeutics to treat the β-globinopathies

PURPOSE OF REVIEW

The current review focuses on recent insights into the development of small molecule therapeutics to treat the β-globinopathies.

RECENT FINDINGS

Recent studies of fetal γ-globin gene regulation reveal multiple insights into how γ-globin gene reactivation may lead to novel treatment for β-globinopathies.

SUMMARY

We summarize current information regarding the binding of transcription factors that appear to be impeded or augmented by different hereditary persistence of fetal hemoglobin (HPFH) mutations. As transcription factors have historically proven to be difficult to target for therapeutic purposes, we next address the contributions of protein complexes associated with these HPFH mutation-affected transcription factors with the aim of defining proteins that might provide additional targets for chemical molecules to inactivate the corepressors. Among the enzymes associated with the transcription factor complexes, a group of corepressors with currently available inhibitors were initially thought to be good candidates for potential therapeutic purposes. We discuss possibilities for pharmacological inhibition of these corepressor enzymes that might significantly reactivate fetal γ-globin gene expression. Finally, we summarize the current clinical trial data regarding the inhibition of select corepressor proteins for the treatment of sickle cell disease and β-thalassemia.

[Quality indicator survey of anaesthesia records in hospitals of Aquitaine]

OBJECTIVES

Assessing the quality of anaesthesia records according to the criteria of the reference frame of professional practices evaluation proposed by the French Anaesthetists College (Cfar) in 2005.

STUDY DESIGN

Retrospective, multicentric study.

MATERIALS AND METHODS

Fifty anaesthesia records were randomly selected from each of the 64 health care settings in Aquitaine with an inpatient surgery activity. Survey sampling was based on hospital stays longer than 24h occurring during the second half of 2005 and including a surgical procedure under anaesthesia, excepting local anaesthesia or regional analgesia for labour and delivery. Information regarding the 10 evaluation criteria defined by the Cfar and the French National Authority for Health were gathered. For each setting, the mean completion of the 50 records was rated by a global indicator defined by the number of criteria in conformity divided by the number of relevant criteria.

RESULTS

Three thousand one hundred and ninety-three anaesthetic files were screened. The completion of criteria varied between 1 and 92% with a wide dispersion for some criteria according to settings. Completions of airway assessment, preanaesthetic visit and perianaesthetic incidents/accidents were lower than 50%. The median conformity rate of the global indicator was 57%.

CONCLUSION

This study brings information concerning the clinical relevance of anaesthesia records and preoperative evaluation practices.

[Preoperative assessment of hemostasis in private clinics in Nord-Pas-de-Calais]

OBJECTIVES

This study aimed at: i) stating what the routines are regarding ordering of preoperative coagulation test; ii) evaluating the impact on the use of pre-operative orders from the data obtained during the first and the second parts of the study.

STUDY DESIGN

Descriptive and comparative epidemiologic study.

PATIENTS AND METHODS

This study was performed twice, and lasted for one day each during two consecutive years (1998 and 1999). It concerned 22 private clinics in the French region 'Nord-Pas-de-Calais'. The anaesthesiologists who took part in the project had to fill out an easy and brief questionnaire concerning each patient who had been admitted to the operating area. It dealt mainly with the presence or the absence, of a preoperative laboratory screening, and with who ordered the test and which tests. The results of the first part of the study (1998) have been evaluated several times with the involved anaesthesiologists. Before repeating the study in 1999, the results were first discussed and compared to the recommendations of the experts.

RESULTS

In 1998, preoperative coagulation tests were ordered for 81% of the patients (n = 662), which in more than half the cases were ordered by an anaesthesiologists. In less than 5% of the cases, one or more abnormalities were detected out of which half were predictable because of the patients previous medical history. Only one of the patients in the study suffered from an haemorrhagical problem although he had a normal coagulation screening. A year after, the ordering of a preoperative coagulation check included 75% of the patients (n = 400), which represents a small but nonetheless significant decrease of the number of orders compared to 1998 (p < 0.05). The proportion of preoperative laboratory screening prescribed by an anaesthesiologist remained the same. There were one or more abnormalities in 1% of the screening tests that were obtained. A patient had a haemorrhagical problem while she had a normal coagulation screening.

CONCLUSIONS

In this study, repeated feed-back to the writers of the preoperative orders in the time interval between the two parts of the study did not induce a noticeable decrease in the number of preoperative coagulation tests ordered. The results show the necessity of a different approach to present scientific knowledge in order to modify medical behaviour.

Preoperative clinical assessment of hemostatic function in patients scheduled for a cardiac operation

BACKGROUND

Bleeding during and after cardiac operations is usually attributed to inadequate surgical hemostasis or cardiopulmonary bypass-induced disorders of hemostasis. Patient-related factors often are neglected.

METHODS

Articles published between 1976 and 1996 on the preoperative assessment of surgical patients were reviewed to determine the clinical elements most likely to predict increased perioperative blood requirements.

RESULTS

Preoperative assessment is based on a carefully conducted interview (history of bruising, petechiae, recent or excessive bleeding after operation, chronic drug therapy) and physical examination. A standardized questionnaire to enhance the reliability of the assessment is presented. Thus, patients at high risk of being transfused can be identified early on and may be enrolled in various programs designed to decrease bleeding and the need for allogeneic blood transfusions.

CONCLUSIONS

Clinical assessment of hemostatic function before cardiac operations is both effective and efficient. It obviates the need for routine laboratory testing and favors the introduction of blood conservation strategies early on during the process of care.

[Current practice and attitude of anesthesiologists for prescribing preoperative investigative tests]

A telephone enquiry was undertaken to assess current practice among French anaesthetists, and to obtain their opinion, concerning preoperative laboratory screening tests. It included 204 anaesthetists, randomly selected from the membership directory of the French Society of Anaesthetics and Intensive Care. The sample was concordant with the distribution (sex and age) given by the specialists' list of the National Medical Council. It comprised 64.2% male anaesthetists, and the overall mean age was 44.2 years. On average, each anaesthetist carried out 26 elective and 4 emergency anaesthetist a week. An organized preanaesthetic consultation was available in only 73% of public hospitals. However, even when existing, it does not automatically concern all surgical stations of the hospital and only 59% of patients benefit from that consultation. In 55% of patients the screening tests had still been made before the preanaesthetic consultation for scheduled surgery. About 15% of patients were seen for the first time by an anaesthetist on the very day of surgery. A routine prescription of preoperative tests was not systematic. Non prescription ranged from 7 to 34% of patients, depending on the tests. The responders recognized that for the same tests the rate could be comprised between 21 and 66% of patients. Moreover, 38% of anaesthetists admitted that sometimes they did not see results of the prescribed tests before carrying out the anaesthetic. Overprescription of preoperative tests has been recognized. However, legal, organisational, relational or economical reasons are given which may explain difficulties met with to rationalize prescription of these tests.