Comparison of short-axis out-of-plane versus long-axis in-plane ultrasound-guided radial arterial cannulation in adult patients: a randomized controlled trial

Abstract

Background

The current available literature is not unanimous in reporting the utility of short-axis and long-axis techniques for radial artery cannulation in both adults and children. This study was designed to compare short-axis out-of-plane (SA-OOP) and long-axis in-plane (LA-IP) techniques in ultrasound-guided radial artery cannulation in adults.

Methods

In this prospective randomized controlled trial, 150 adult patients of American Society of Anesthesiologists physical status I–III aged between 18 and 70 years were included. All patients were randomized into two groups (group SA-OOP) and (group LA-IP) of 75 each undergoing ultrasound-guided radial artery cannulation. The primary outcome was successful cannulation in the first attempt. Secondary outcomes included antero-posterior arterial diameter, skin-to-artery distance, ultrasonic localization time, cannulation time, no of attempts to cannulate artery, cannula insertion failure, and vascular complications.

Results

First-attempt arterial cannulation was successful in 80 % of patients in the SA-OOP group as opposed to 82.6 % patients in the LA-IP group (p = 0.67). The time to cannulate the artery was similar between the two groups, but the time to localize artery was significantly higher in the long-axis technique (p < 0.001).

Conclusions

The first-attempt cannulation success rate and cannulation time in adult patients are similar in ultrasound-guided radial artery cannulation with both short-axis as well as long-axis techniques.

Trial registration Clinical Trial Registry of India (CTRI/2015/02/005552).

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Everolimus-associated stomatitis in a patient who had renal transplant

Everolimus is used as an immunosuppressant in renal allograft transplant rejection and in metastatic breast cancer treatment. One side effect of everolimus is stomatitis, referred to as mammalian target of rapamycin inhibitor-associated stomatitis. This side effect can affect treatment course and contribute to discontinuation of therapy or dose reduction, previously reported in the treatment of metastatic breast cancer. Here, we present a case of everolimus-associated stomatitis with a novel management method with intralesional triamcinolone that allows for continuous course of everolimus.

http://ift.tt/2eRMxu8

Bronchial schwannoma: a singular lesion as a cause of obstructive pneumonia

Bronchial schwannomas are very rare pulmonary lesions, but its awareness is important to reach correct diagnosis and decide proper intervention. Clinical and radiological characteristics are mainly unspecific and pathological examination usually provides the definite diagnosis. In small lesions, endoscopic approach may be sufficient, but in large lesions associated with organising pneumonia surgical intervention may be required. Prognosis is typically favourable. We describe a case of a woman, aged 66 years, with productive cough and sporadic haemoptysis, dyspnoea, anorexia, excessive sweating and weight loss with 2 months evolution. CT scan showed a soft tissue dense lesion on the left hilum with 3.75 cm with 18-Fludeoxyglucose uptake. Left upper lobectomy was performed. Gross examination revealed a polypoid mass without necrosis, histologically showing cellular dense (Antoni A) and less dense (Antoni B) areas with Verocay bodies, slightly pleomorphic spindle cells, without mitotic activity and positive for S100 protein on immunohistochemistry.

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Leukaemic infiltration of the optic nerve head: a rare site of initial relapse

A 24-year-old male patient with acute lymphoblastic leukaemia (ALL), in complete remission, presented with the symptoms of gradual onset painless diminution of vision in the right eye (OD) of 2-month duration. On examination, best-corrected visual acuity in OD was finger-counting at 1 m and near vision was less than N₃₆. Anterior segment examination was normal, except for the presence of relative afferent pupillary defect in OD. Fundus examination showed optic disc oedema, peripapillary and vitreous haemorrhage, dilated and tortuous veins over the disc and presence of subretinal infiltrates and subretinal fluid around the optic disc. Clinical picture was suggestive of leukaemic infiltration of the optic nerve head. Cytological analysis of the cerebrospinal fluid did not show any abnormal cells or blasts .Vitreous biopsy from OD was suggestive of leukaemic infiltration. After radiotherapy, the leukaemic infiltrates regressed and visual acuity improved to 6/6, N₆ in OD.

http://ift.tt/2eRHvOl

Mycobacterium fortuitum infection of the scalp after a skin graft

Mycobacterium fortuitum is a non-tuberculous mycobacterium found in the soil and water of most regions of the world, and it can cause disease in immunocompetent and immunocompromised hosts. We present a 52-year-old man who developed a scalp abscess under a free flap for cranium coverage after a motor vehicle accident. Culture of material drained from the abscess grew M. fortuitum.

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Weston-Hurst syndrome: a rare fulminant form of acute disseminated encephalomyelitis (ADEM)

A 25-year-old Pakistani woman presented to the emergency department with a 2-day history of rapidly progressive tetraplegia followed by sudden loss of consciousness. This was preceded by an upper respiratory tract infection. On examination, she was deeply comatose with a GCS of 3/15 and intact brainstem reflexes. She was in respiratory distress, and an endotracheal tube had been passed. She had flaccid quadriplegia with depressed deep tendon reflexes and upgoing plantar response. Her MRI brain with contrast showed extensive brainstem involvement with haemorrhagic foci along with signal changes in the corpus callosum. The patient was put on a respirator. She was given IV methyl prednisolone, and later on 5 sessions of plasmapheresis were performed. After 3 months, the patient gradually recovered and started communicating. Her motor power had improved to 2/5 in her arms and 1/5 in the lower extremities. She was then discharged for further rehabilitation at home.

http://ift.tt/2eRKd67

Cemento-ossifying fibroma of mandible mimicking complex composite odontome

Cemento-ossifying fibroma (COF) is a fibro-osseous lesion or non-odontogenic tumour that affects craniofacial bones. These lesions are included in the spectrum of fibro-osseous lesions arising from periodontal ligament cells, which can deposit combination of cementum and bone surrounded by fibrous tissue. It clinically, macroscopically and radiologically resembles complex composite odontome and can be differentiated only on the basis of histopathology. They usually occur solitarily as a painless and expansile spherical or ovoid jawbone mass that may displace the roots of adjacent teeth. They predominantly occur in females in third and fourth decades of life. We present a case report of a 20-year-old man, with a mildly painful swelling in the mandible which was successfully treated with enucleation and diagnosed as COF. Its resemblance to complex composite odontome and unique surgical approach are highlighted in this paper.

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Leiomyosarcoma of great saphenous vein localised to the calf

We present the case of a 76-year-old man with a 2-month history of mildly tender swelling in the right calf for which he had an initial excision and then a wide local excision followed by a split skin graft because the initial histopathology confirmed that there was a Grade I leiomyosarcoma of great saphenous vein. A simple lump in the lower limb could be a malignant vascular tumour and should always be considered in the list of differential diagnosis of a lump in the lower limb.

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Sudden-onset monocular blindness following orbito-zygomatic craniotomy for a ruptured intracranial aneurysm

We report the first case of sudden-onset ipsilateral blindness following orbito-zygomatic craniotomy and clipping of a ruptured anterior communicating artery aneurysm. CT showed no new intracranial or intraorbital pathology. Visual evoked potentials testing, electroretinography and diffuse flash stimulation all indicated loss of right optic nerve function. Although the patient made an excellent neurological recovery, complete right-sided monocular blindness persisted at 6-month follow-up. We postulate that external pressure on the eyeball, resulting in posterior ischaemic optic neuropathy, was the primary cause of our patient's blindness. This has been hypothesised in the 3 previously published cases of blindness following pterional or frontal craniotomy for aneurysm repair. Intraoperatively, the surgeon must avoid unnecessary pressure on the eyeballs and handle the optic nerves with the utmost care. Incomplete understanding of the mechanisms of sudden visual loss postcraniotomy may result in under-reporting of this adverse event. Nevertheless, its seriousness warrants discussion during consent.

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Histopathologic features in actinic cheilitis by the comparison of grading dysplasia systems

Abstract

Objective

This study aimed to determine the histopathological findings in actinic cheilitis (AC) and lip squamous cell carcinomas (LSCC) diagnosed at Federal University of Santa Catarina in order to attempt to predict the evolution from AC to LSCC based on the comparison of two dysplasia classification systems.

Methods

Histopathological features were evaluated according to the World Health Organization classification of dysplasia and binary system of classification. Also, in LSCC, pattern, stage of invasion and degree of keratinization were evaluated. A total of 58 cases of AC and 70 cases of LSCC were studied and data correlation was performed using statistical analysis.

Results

The presence of dyskeratosis and keratin pearls was found to be strongly associated with severe dysplasia and could represent higher proximity between the severe dysplasia in AC and LSCC. Also, changes related to the nuclei, such as hyperchromasia, nuclear pleomorphism, anisonucleosis, increase in the number and size of nucleoli, increased number of mitoses, and atypical mitoses indicate progression in dysplasia spectrum.

Conclusion

Knowledge of clinical and histological features of AC and LSCC lead to better understanding of factors possibly associated with malignant transformation of epithelial dysplasia.

This article is protected by copyright. All rights reserved.

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Quantitative and functional analysis of CD69+ T regulatory lymphocytes in patients with periodontal disease

Abstract

Background

Periodontal disease is chronic inflammatory process that affects the attachment structures of the teeth and constitutes a significant cause of tooth loss in adults. Although different bacteria play an important role in the triggering of this condition, the progression and severity of the disease are strongly affected by the host immune response, which is under the control of different immune-regulatory mechanisms, including T regulatory (Treg) cells. The aim of this study was to assess the frequency and function of CD69⁺ Treg lymphocytes in patients with chronic periodontal disease.

Methods

Peripheral blood samples (n=33) and gingival tissue (n=9) were obtained from patients with chronic periodontal disease. Blood samples from 25 healthy individuals were also studied. Levels of CD69⁺ Treg lymphocytes in peripheral blood and gingival tissue were determined by six-color multi-parametric flow cytometry, immunofluorescence and immunohistochemistry. The immune-regulatory function of CD69⁺ Treg cells was tested by an in vitro assay of inhibition of lymphocyte activation.

Results

Percentages of CD69⁺ Treg cells were significantly higher in the peripheral blood from patients with active periodontal disease compared to healthy controls, and these percentages inversely correlated with the periodontal attachment loss. Increased numbers of these Treg cells were detected in the gingival tissue from active PD patients compared to their peripheral blood. However, the suppressive function of CD69⁺ Treg cells was significantly diminished in patients with periodontal disease compared to healthy controls.

Conclusions

Our data suggest that CD69⁺ Treg cells seem to be another important piece in the complex immunopathogenesis of periodontal disease.

This article is protected by copyright. All rights reserved.

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A commentary on the paper: Facial trauma in the Trojan War

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The utility of live video capture to enhance debriefing following transcatheter aortic valve replacement

David P Seamans, Boshra F Louka, F David Fortuin, Bhavesh M Patel, John P Sweeney, Louis A Lanza, Patrick A DeValeria, Kim M Ezrre, Harish Ramakrishna

Annals of Cardiac Anaesthesia 2016 19(5):6-11

Background: The surgical and procedural specialties are continually evolving their methods to include more complex and technically difficult cases. These cases can be longer and incorporate multiple teams in a different model of operating room synergy. Patients are frequently older, with comorbidities adding to the complexity of these cases. Recording of this environment has become more feasible recently with advancement in video and audio capture systems often used in the simulation realm. Aims: We began using live capture to record a new procedure shortly after starting these cases in our institution. This has provided continued assessment and evaluation of live procedures. The goal of this was to improve human factors and situational challenges by review and debriefing. Setting and Design: B-Line Medical's LiveCapture video system was used to record successive transcatheter aortic valve replacement (TAVR) procedures in our cardiac catheterization/laboratory. An illustrative case is used to discuss analysis and debriefing of the case using this system. Results and Conclusions: An illustrative case is presented that resulted in long-term changes to our approach of these cases. The video capture documented rare events during one of our TAVR procedures. Analysis and debriefing led to definitive changes in our practice. While there are hurdles to the use of this technology in every institution, the role for the ongoing use of video capture, analysis, and debriefing may play an important role in the future of patient safety and human factors analysis in the operating environment.

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"TEE or not to TEE?"

Mukul Kapoor

Annals of Cardiac Anaesthesia 2016 19(5):1-1



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Utility of perioperative transesophageal echocardiography

K Muralidhar

Annals of Cardiac Anaesthesia 2016 19(5):2-5



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Echo for diastology

Candice Morrissey

Annals of Cardiac Anaesthesia 2016 19(5):12-18

Diastolic dysfunction ranging from impaired relaxation of the left ventricle to heart failure with preserved ejection fraction (HFpEF) is a common finding in the cardiac surgery population. It is important for the peri-operative echocardiographer to have a developed understanding of the pathophysiology of diastolic dysfunction and the echocardiographic features that determine where on the spectrum of diastolic function and dysfunction a patient lies

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Perioperative management of left ventricular assist devices

OP Sanjay

Annals of Cardiac Anaesthesia 2016 19(5):19-20

The use of mechanical circulatory support for patients with severe heart failure is on the rist. The poeoperative, intraoperative and postoperative challenges the anaesthesiologists skills. These are discussed in this review.

http://ift.tt/2dnoDGr

Transesophageal echocardiography evaluation of tricuspid and pulmonic valves

Aneeta Bhatia

Annals of Cardiac Anaesthesia 2016 19(5):21-25

The tricuspid is the lost valve and the pulmonary being the most anterior, is not visualized well on TEE; The Pulmonary valve is a semilunar valve that separates the right ventricle from the pulmonary artery. It is situated anterior and superior to the aortic valve, almost at right angle to the aortic valve and parallel to the beam of the ultrasound.

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Left ventricular global systolic function assessment by echocardiography

Suresh Chengode

Annals of Cardiac Anaesthesia 2016 19(5):26-34

The left ventricle, with its thickened myocardial walls, unlike the right ventricle has no measurable geometric shape. It has a conical apex and its function quantification, needs intensive, 2D, 3D and M mode transesophageal echocardiography, which is described in this review.

http://ift.tt/2dnrLlu

Three-dimensional transesophageal echocardiography: Principles and clinical applications

Annette Vegas

Annals of Cardiac Anaesthesia 2016 19(5):35-43

A basic understanding of evolving 3D technology enables the echocardiographer to master the new skills necessary to acquire, manipulate, and interpret 3D datasets. Single button activation of specific 3D imaging modes for both TEE and transthoracic echocardiography (TTE) matrix array probes include (a) live, (b) zoom, (c) full volume (FV), and (d) color Doppler FV. Evaluation of regional LV wall motion by RT 3D TEE is based on a change in LV chamber subvolume over time from altered segmental myocardial contractility. Unlike standard 2D TEE, there is no direct measurement of myocardial thickening or displacement of individual segments.

http://ift.tt/2e1fnFR

Transesophageal echocardiography evaluation of the thoracic aorta

TA Patil, Arno Nierich

Annals of Cardiac Anaesthesia 2016 19(5):44-55

Transesophageal echocardiography (TEE) can be used to identify risk factors such as aortic atherosclerosis [2] before any sort of surgical manipulations involving aorta and its related structures. TEE has become an important noninvasive tool to diagnose acute thoracic aortic pathologies. TEE evaluation of endoleaks helps early detection and immediate corrective interventions. TEE is an invaluable imaging modality in the management of aortic pathology. TEE has to a large extent improved the patient outcomes.

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An update on transesophageal echocardiography views 2016: 2D versus 3D tee views

Poonam Malhotra Kapoor, Kanchi Muralidhar, Navin C Nanda, Yatin Mehta, Naman Shastry, Kalpana Irpachi, Aditya Baloria

Annals of Cardiac Anaesthesia 2016 19(5):56-72

In 1980, Transesophageal Echocardiography (TEE) first technology has introduced the standard of practice for most cardiac operating rooms to facilitate surgical decision making. Transoesophageal echocardiography as a diagnostic tool is now an integral part of intraoperative monitoring practice of cardiac anaesthesiology. Practice guidelines for perioperative transesophageal echocardiography are systematically developed recommendations that assist in the management of surgical patients, were developed by Indian Association of Cardiac Anaesthesiologists (IACTA). This update relates to the former IACTA practice guidelines published in 2013 and the ASE/EACTA guidelines of 2015. The current authors believe that the basic echocardiographer should be familiar with the technical skills for acquiring 28 cross sectional imaging planes. These 28 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination and adds 5 more additional views, introduced for different clinical scenarios in recent times. A comparison of 2D TEE views versus 3D TEE views is attempted for the first time in literature, in this manuscript. Since, cardiac anaesthesia variability exists in the precise anatomic orientation between the heart and the oesophagus in individual patients, an attempt has been made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

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Guidelines of the Indian Association of Cardiovascular and Thoracic Anaesthesiologists and Indian College of Cardiac Anaesthesia for perioperative transesophageal echocardiography fellowship examination

Kanchi Muralidhar, Deepak Tempe, Yatin Mehta, Poonam Malhotra Kapoor, Chirojit Mukherjee, Thomas Koshy, Prabhat Tewari, Naman Shastri, Satyajeet Misra, Kumar Belani

Annals of Cardiac Anaesthesia 2016 19(5):73-78

During current medical care, perioperative transesophageal echocardiography (TEE) has become a vital component of patient management, especially in cardiac operating rooms and in critical care medicine. Information derived from echocardiography has an important bearing on the patient's outcome. The Indian Association of Cardiovascular and Thoracic Anaesthesiologists (IACTA) has promoted the use of TEE during routine clinical care of patients undergoing cardiac surgery. An important mission of IACTA is to oversee training and certify anesthesiologists in the perioperative and intensive care use of TEE. The provision of "Fellowship" is by way of conducting IACTA - TEE fellowship (F-TEE) examination. This has been done annually for the past 7 years using well-established curriculums by accredited national and international societies. Now, with the transformation and reconstitution of IACTA education and research cell into the newly formed Indian College of Cardiac Anaesthesia, F-TEE is bound to meet international standards. To ensure that the examinations are conducted in a transparent and foolproof manner, the guideline committee (formulated in 2010) of IACTA has taken the onus of formulating the guidelines for the same. These guidelines have been formally reviewed and updated since 2010 and are detailed here to serve as a guide to both the examinee and examiner ensuring standardization, efficiency, and competency of the IACTA F-TEE certification process.

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Associate Editorial Board

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Editorial Board

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In the October BJA...

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General Information

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Contents Page

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Chronic postsurgical pain in children: prevalence and risk factors. A prospective observational study

Background

Chronic postsurgical pain (CPSP) is well known in adults, with prevalence rates ranging from 10 to 50%. Little is known about the epidemiology of CPSP in children. The aim of this prospective observational study was to evaluate the prevalence of CPSP after surgery in children.

Methods

After informed consent, children aged six to18 yr were included. Characteristics and risk factors for CPSP were recorded. Exclusion criteria included ambulatory surgery, refusal, inability to understand and change of address. All eligible children completed a preoperative questionnaire the day before surgery about pain, anxiety and their medical history. All data concerning anaesthetic and surgical procedures, such as acute pain scores (VAS) during the first 24 h were recorded. Three months after surgery all included children were sent a postoperative questionnaire about pain at the surgical site.

Results

Altogether, 291 children were enrolled; the mean age was 12 yr, most subjects were male (60%). The most common type of surgery was orthopaedic (63%). In the 258 patients who completed the study, the prevalence of CPSP was 10.9%, most often with a neuropathic origin (64.3%). The two main risk factors were the existence of recent pain before surgery (<1 month) and the severity of acute postoperative pain (VAS >30 mm) in the first 24 h after orthopaedic and thoracic surgeries. Six months after surgery, only five children needed a visit with a chronic pain practitioner.

Conclusions

These results highlight the necessity of evaluating and treating perioperative pain in order to prevent CPSP in children.

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Leukemia inhibitory factor (LIF) potentiates antinociception activity and inhibits tolerance induction of opioids

Background

The efficacy of opioids typically decreases after long-term use owing to the development of tolerance. Glial activation and the upregulation of proinflammatory cytokines are related to the induction of tolerance. We investigated the effect of leukemia inhibitory factor (LIF) on morphine analgesia and tolerance.

Methods

LIF concentrations in rat spinal cords were measured by polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) after morphine administration. LIF distribution was examined using confocal microscopy. To evaluate the effects of LIF on morphine analgesia and tolerance, LIF was intrathecally administered 30 min before morphine injection. The analgesic effect of morphine was evaluated by measuring tail-flick latency. Human LIF concentrations from the cerebrospinal fluid (CSF) of opioid tolerant patients were also determined by specific ELISA.

Results

Chronic morphine administration upregulated LIF concentrations in rat spinal cords. Intrathecal injection of LIF potentiated the analgesic action of morphine. Patch clamp recording of spinal cord slices showed that LIF enhanced DAMGO ([D-Ala², N-MePhe⁴, Gly-ol]-enkephalin)-induced outward potassium current. The development of tolerance was markedly suppressed by exogenous LIF, whereas neutralizing the endogenously released LIF with anti-LIF antibodies accelerated the tolerance induction. Moreover, LIF concentrations in the CSF of opioid-tolerant patients were higher than those in the opioid-naive controls.

Conclusions

Intrathecal administration of LIF potentiated morphine antinociceptive activity and attenuated the development of morphine tolerance. Upregulation of endogenously released LIF by long-term use of opioids might counterbalance the tolerance induction effects of other proinflammatory cytokines. LIF might be a novel drug candidate for inhibiting opioid tolerance induction.

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Preoperative butorphanol and flurbiprofen axetil therapy attenuates remifentanil-induced hyperalgesia after laparoscopic gynaecological surgery: a randomized double-blind controlled trial

Background

Several studies indicate that remifentanil exposure may engender opioid-induced hyperalgesia. Butorphanol and flurbiprofen axetil are proposed as adjunctive analgesics for postoperative pain control. This randomized double-blind controlled study was designed to investigate the antihyperalgesic effects of butorphanol combined with flurbiprofen axetil on opioid-induced hyperalgesia.

Methods

One hundred and twenty patients undergoing elective laparoscopic gynaecological surgery with sevoflurane anaesthesia were randomized to one of four groups, as follows: intraoperative sufentanil 0.30 µg kg^–1 (Group S); remifentanil 0.30 µg kg^–1 min^–1 (Group R); intraoperative remifentanil and pre-anaesthesia butorphanol 20 µg kg^–1 (Group B); or intraoperative remifentanil and pre-anaesthesia butorphanol 10 µg kg^–1 combined with flurbiprofen axetil 0.5 mg kg^–1 (Group BF). Sufentanil was used to control postoperative pain. The threshold and area of postoperative mechanical hyperalgesia were measured with Von Frey filaments. Pain intensity, sufentanil consumption, and side-effects were recorded for 24 h after surgery.

Results

Compared with Group S, remifentanil anaesthesia increased the pain score, postoperative sufentanil consumption, and area of hyperalgesia [mean 49.9 (sd 8.6) vs 60.5 (10.0) cm², P<0.001] and reduced the hyperalgesia threshold on the dominant inner forearm [mean 89.5 (sd 23.4) vs 60.6 (22.6) g, P=0.004]. Compared with Group R, the pain score, sufentanil consumption, and area of hyperalgesia were reduced and hyperalgesia threshold was elevated likewise in Groups B and BF. However, the efficacy in Group BF was higher than in Group B (P=0.021).

Conclusions

The preoperative combination of butorphanol and flurbiprofen axetil effectively ameliorated opioid-induced hyperalgesia in patients undergoing laparoscopic gynaecological surgery under sevoflurane–remifentanil anaesthesia.

Clinical trial registration

NCT02043366.

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Selective primary outcome reporting in high-impact journals of anaesthesia and pain

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'Bougie-assisted' cricothyroidotomy technique

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Plan D: cannula first, or scalpel only?

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Surgical intervention during a Can't intubate Can't Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)?

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DAS guidelines: the end for pre-paralysis mask ventilation check?

http://ift.tt/2e2WxiL

What makes a good systematic review and meta-analysis?

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Evidence no longer supports use of cricoid pressure

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Poor agreement in significant findings between meta-analyses and subsequent large randomized trials in perioperative medicine

Background

The reliability of meta-analysis (MA) in predicting the findings of subsequent large randomized controlled trials (RCTs) has not been assessed in perioperative medicine and anaesthesia.

Methods

Using Medline and PubMed, large RCTs (n≥1000) published since 2000 in the anaesthesia and perioperative medicine/critical care literature were identified. All previous MAs of RCTs investigating the same intervention and population were sourced. For all reported major morbid endpoints common to each, results (significant/non-significant P<0.05) were compared.

Results

18 large RCTs and 44 prior MAs investigating the effects of 16 interventions were identified. Where endpoint results in the large RCTs were each compared with the single largest recent preceding MA, 35 of a total of 57 outcomes were predicted correctly by the MAs (61.4%). The odds ratio for a significant result from MA compared with the subsequent large RCT was 3.6, P=0.033 Bonferroni corrected. The positive predictive value of MAs was 22.7%; the negative predictive value was 85.7%, Kappa was 0.094 indicating slight agreement. The estimated power for each endpoint for large RCTs and MAs were similar, but the median study size for large RCTs was larger than that of the MAs, n=4,482 vs 1,389, P<0.0001.

Conclusions

There was a strong tendency towards positive findings in MA not substantiated by subsequent large RCTs, which was not attributable to differences in study power. This finding suggests caution in clinical decision-making in anaesthesia and perioperative medicine based on findings of meta-analysis.

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Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults: Need to be revisited?

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Impact of balanced tetrastarch raw material on perioperative blood loss: a randomized double blind controlled trial

Background

As 6% hydroxyethyl starch (HES) 130/0.40 or 130/0.42 can originate from different vegetable sources, they might have different clinical effects. The purpose of this prospective, randomized, double-blind controlled trial was to compare two balanced tetrastarch solutions, one maize-derived and one potato-derived, on perioperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

We randomly assigned 118 patients undergoing elective cardiac surgery into two groups, to receive either a maize- or a potato-derived HES solution. Study fluids were administered perioperatively (including priming of CPB) until the second postoperative day (POD#2) using a goal directed algorithm. The primary outcome was calculated postoperative blood loss up to POD#2. Secondary outcomes included short-term incidence of acute kidney injury (AKI), and long-term effect (up to one yr) on renal function.

Results

Preoperative and intraoperative characteristics of the subjects were similar between groups. Similar volumes of HES were administered (1950 ml [1250–2325] for maize-HES and 2000 ml [1500–2700] for potato-HES; P=0.204). Calculated blood loss (504 ml [413–672] for maize-HES vs 530 ml [468–705] for potato-HES; P=0.107) and the need for blood components were not different between groups. The incidence of AKI was similar in both groups (P=0.111). Plasma creatinine concentration and glomerular filtration rates did vary over time, although changes were minimal.

Conclusions

Under our study conditions, HES 130/0.4 or 130/0.42 raw material did not have a significant influence on perioperative blood loss. Moreover, we did not find any effect of tetrastarch raw material composition on short and long-term renal function.

Clinical trial registration

EudraCT number: 2011-005920-16.

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Atracurium -- check, ventilation -- check

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Sodium bicarbonate does not prevent postoperative acute kidney injury after off-pump coronary revascularization: a double-blinded randomized controlled trial

Background

Acute kidney injury (AKI) is a common morbidity after off-pump coronary revascularization. We investigated whether perioperative administration of sodium bicarbonate, which might reduce renal injury by alleviating oxidative stress in renal tubules, prevents postoperative AKI in off-pump coronary revascularization patients having renal risk factors.

Methods

Patients (n=162) having at least one of the following AKI risk factors were enrolled: (i) age >70 yr; (ii) diabetes mellitus; (iii) chronic renal disease; (iv) congestive heart failure or left ventricular ejection fraction <35%; and (v) reoperation or emergency. Patients were evenly randomized to receive either sodium bicarbonate (0.5 mmol kg^–1 for 1 h upon induction of anaesthesia followed by 0.15 mmol kg^–1 h^–1 for 23 h) or 0.9% saline. Acute kidney injury within 48 h after surgery was assessed using the Acute Kidney Injury Network criteria.

Results

The incidences of AKI were 21 and 26% in the bicarbonate and control groups, respectively (P=0.458). Serially measured serum creatinine concentrations and perioperative fluid balance were also comparable between the groups. The length of postoperative hospitalization and incidence of morbidity end points were similar between the groups, whereas significantly more patients in the bicarbonate group required prolonged mechanical ventilation (>24 h) relative to the control group (20 vs 6, P=0.003).

Conclusions

Perioperative sodium bicarbonate administration did not decrease the incidence of AKI after off-pump coronary revascularization in high-risk patients and might even be associated with a need for prolonged ventilatory care.

Clinical trial registration

NCT01840241.

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Phase II Study of Neo-adjuvant Chemoradiotherapy for Squamous Cell Esophageal Cancer

Conditions:   Esophageal Cancer;   Chemoradiation;   Surgery
Interventions:   Radiation: radiotherapy;   Procedure: Surgery
Sponsor:   Shanghai Chest Hospital
Recruiting - verified October 2016

http://ift.tt/2dnc129

Bioimmunoradiotherapy (Cetuximab/RT/Avelumab)

Condition:   Carcinoma, Squamous Cell of Head and Neck
Interventions:   Drug: avelumab;   Radiation: radiotherapy;   Drug: cetuximab
Sponsors:   The Netherlands Cancer Institute;   Merck Sharp & Dohme Corp.
Not yet recruiting - verified October 2016

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Active Surveillance on Papillary Thyroid Microcarcinoma

Conditions:   Thyroid Cancer;   Papillary Thyroid Microcarcinoma
Intervention:  
Sponsor:   Seoul National University Hospital
Recruiting - verified October 2016

http://ift.tt/2dncOjH

Objektive Hördiagnostik mit DPOAE

Zusammenfassung

Hintergrund

Distorsionsprodukte otoakustischer Emissionen (DPOAE) und transient evozierte otoakustische Emissionen (TEOAE) sind im Gehörgang messbare Schallwellen, die als Nebenerscheinung der cochleären Verstärkung entstehen und ein objektives Verfahren zur Diagnostik von Innenohrfunktionsstörungen darstellen. Konventionelle DPOAE- und TEOAE-Verfahren ermöglichen die Detektion eines Hörverlusts jedoch nur mit unbefriedigender Genauigkeit.

Fragestellung

Durch Berücksichtigung des Entstehungsmechanismus der DPOAE soll deren Genauigkeit in der Innenohrdiagnostik gesteigert werden.

Material und Methode

DPOAE bestehen aus zwei an unterschiedlichen Orten der Cochlea entstehenden Komponenten, welche Artefakte aufgrund von Interferenz erzeugen können und mithilfe von Kurzpulsstimulation im Zeitbereich getrennt werden. Optimale Anregungspegel werden zur Akquise von DPOAE mit möglichst maximaler Amplitude verwendet. DPOAE-Daten und Békésy-Audiogramme wurden von 41 Probanden in einem klinisch relevanten Frequenzbereich von 1,5 bis 6 kHz erfasst.

Ergebnisse

Kurzpuls-Primärtöne ermöglichen eine artefaktfreie Erfassung von DPOAE. Die mittels semilogarithmischen Wachstumsfunktionen geschätzten Distorsionsproduktschwellen korrelieren signifikant mit den subjektiv erfassten Hörschwellen und ermöglichen die Detektion eines Hörverlusts von ≥20 dB HL mit 95 % Sensitivität bei nur 5 % falsch-positiven Diagnosen. Diese Genauigkeit wurde mit einer Messzeit von etwa 1–2 min pro Frequenz erreicht.

Schlussfolgerungen

Durch die Komponententrennung der Kurzpuls-DPOAE und Anwendung von optimalen Anregungsparametern kann die Genauigkeit in der Diagnostik von Schädigungen des cochleären Verstärkers über die von konventionellen DPOAE- und TEOAE-Verfahren hinaus gesteigert werden.

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A commentary on the paper: Facial trauma in the Trojan War

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Another face of demodicosis

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Chemotherapeutic effect of Zerumbone on melanoma cells through mitochondria-mediated pathways

Summary

Background

Zerumbone (ZER) is a phytochemical that appears to regulate cell proliferation and apoptosis. It has been reported to have an anti-tumour effect in various malignant cells; however, the effect and the mechanism of ZER on melanoma cells needs to be clarified.

Aim

To explore whether ZER has an effect on human melanoma cells and to identify the mechanisms involved.

Methods

We determined the chemotherapeutic action of ZER on the human malignant melanoma (MM) A375 cell line by CCK-8 immunohistochemistry, Hoechst 33342 staining and flow cytometry analysis. We also investigated the signalling pathways by which ZER induces apoptosis in A375 cells, using western blotting, reverse transcription PCR and caspase-3 activity analysis.

Results

ZER induced significant cytotoxic action in A375 cells. Hoechst 33342 staining and flow cytometry apoptosis analysis further demonstrated that ZER induced apoptosis in A375 cells. Treatment with ZER downregulated Bcl-2 gene and protein levels, upregulated Bax and Cytochrome c gene and protein levels, and activated Caspase-3.

Conclusions

ZER might have a chemotherapeutic effect on human melanoma cells through mitochondria-mediated pathways.

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