Reduced coronary flow reserve (CFR), an indicator of coronary microvascular dysfunction, is seen in type 2 diabetes mellitus (T2DM) and predicts cardiac mortality. Since aldosterone plays a key role in vascular injury, the aim of this study was to determine whether mineralocorticoid receptor (MR) blockade improves CFR in individuals with T2DM. Sixty-four men and women with well-controlled diabetes on chronic ACE inhibition (enalapril 20 mg/day) were randomized to add-on therapy of spironolactone 25 mg, hydrochlorothiazide (HCTZ) 12.5 mg, or placebo for 6 months. CFR was assessed by cardiac positron emission tomography at baseline and at the end of treatment. There were significant and similar decreases in systolic blood pressure with spironolactone and HCTZ but not with placebo. CFR improved with treatment in the spironolactone group as compared with the HCTZ group and with the combined HCTZ and placebo groups. The increase in CFR with spironolactone remained significant after controlling for baseline CFR, change in BMI, race, and statin use. Treatment with spironolactone improved coronary microvascular function, raising the possibility that MR blockade could have beneficial effects in preventing cardiovascular disease in patients with T2DM.

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Background Frailty is a customized marker of biological age that helps to gauge an individual's functional physiologic reserve and ability to react to stress and is associated with increased postoperative morbidity and mortality. In order to mitigate frailty preoperatively, the concept of prehabilitation has entered the forefront which encompasses multidisciplinary interventions to improve health and lessen the incidence of postoperative decline. The purpose of this study is to investigate the impact of prehabilitation on postoperative outcomes in frail, surgical patients. Methods A comprehensive literature search was performed by two independent researchers according to PRISMA guidelines. Inclusion criteria were (1) a randomized controlled trial, case-control or observational study; (2) prehabilitation intervention; (3) frailty assessment; and (4) surgical intervention. Results There were five articles included in the review. Evaluation of these articles demonstrated prehabilitation may improve operative outcomes in frail surgical patients. There were no assessments as to whether prehabilitation was cost-effective although it was feasible. Prehabilitation programs should include elements of exercise, nutrition, and psychosocial counseling. Frailty should be assessed with a validated index in surgical patients who may undergo prehabilitation. Conclusion Prehabilitation in frail surgical patients may be the appropriate process through which providers can lessen operative risk. Currently, however, there is little evidence supporting the use of prehabilitation in this population with only five studies identified in this systematic review. More randomized controlled trials are clearly needed.

BACKGROUND Optimal management following index laparotomy is poorly defined in secondary peritonitis patients. Although “open abdomen” (OA), or temporary abdominal closure with planned relaparotomy, is used to reassess bowel viability or severity of contamination, recent studies demonstrate comparable morbidity and mortality with primary abdominal closure (PC). This study evaluates differences between OA and PC following emergent laparotomy. METHODS Using the Premier database at a quaternary care center (2012–2016), nontrauma patients with secondary peritonitis requiring emergent laparotomy were identified (N = 534). Propensity matching for PC (n = 331; 62%) or OA (n = 203; 38%) was performed using variables: Mannheim Peritonitis Index, lactate, and vasopressor requirement. One hundred eleven closely matched pairs (PC:OA) were compared. RESULTS Five hundred thirty-four patients (55.0% female; mean age, 59.6 ± 15.5 years) underwent emergent laparotomy. Of the OA patients, 136 (67.0%) had one relaparotomy, while 67 (33.0%) underwent multiple reoperations. Compared to daytime cases, laparotomies performed overnight (6 pm–6 am) had more temporary closures with OA (42.8% OA vs. 57.2% PC, p = 0.04). When assessing by surgeon type, PC was performed in 78.7% of laparotomies by surgical subspecialties compared to 56.7% (p < 0.0001) of acute care surgeons. After propensity matching, OA patients had increased postoperative complications (71.2% vs. 41.4%, p < 0.0001), mortality (22.5% vs. 11.7%, p = 0.006), and longer median length of stay (13 vs. 9 days, p = 0.0001). CONCLUSION Open abdomen was performed in 38.0% of patients, with one-third of those requiring multiple reoperations. Complications, mortality rates, and costs associated with OA were significantly increased when compared to PC. Given these findings, future studies are needed to determine appropriate indications for OA. LEVEL OF EVIDENCE Therapeutic/care management, level IV.