Predictors of severe postoperative hyperglycemia after cardiac surgery in infants: a single-center, retrospective, observational study

Abstract

Purpose

Hyperglycemia is a common issue in infants after cardiac surgery for congenital heart disease. Poor glycemic control is suspected to be associated with adverse postoperative outcomes. This study was performed to investigate clinical factors contributing to hyperglycemia in the perioperative period in infats.

Methods

A total of 69 infants (aged 1–12 months) who were admitted to Yokohama City University Hospital Intensive Care Unit (ICU) after surgical repair of congenital heart diseases with cardiopulmonary bypass (CPB) were retrospectively analysed. Hyperglycemia was defined as blood glucose ≥ 250 mg/dL on ICU admission. Clinical background, operative factors, and postoperative factors were compared between the hyperglycemic and non-hyperglycemic groups. Additionally, multivariate analysis was performed to identify factors contributing to hyperglycemia.

Results

Nineteen (27.5%) and 50 (72.5%) infants were classified into the hyperglycemic and non-hyperglycemic groups, respectively. Hyperglycemic infants were significantly younger, shorter, and weighed less, with a higher rate of chromosomal abnormalities. Intraoperatively, they also experienced longer CPB and surgery times and had higher peak lactate levels and higher inotropic requirements. Hyperglycemia was related to longer mechanical ventilation and longer ICU stays. Multivariate analysis detected intraoperative hyperglycemia, longer CPB time, younger age and chromosomal abnormality as significant factors.

Conclusion

Adding to hyperglycemia during the operation, longer CPB time younger age and chromosomal abnormality were identified as predictors of high blood glucose levels at ICU admission.

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Linear doggybone DNA vaccine induces similar immunological responses to conventional plasmid DNA independently of immune recognition by TLR9 in a pre-clinical model

Abstract

Vaccination with DNA that encodes cancer antigens is a simple and convenient way to raise immunity against cancer and has already shown promise in the clinical setting. Conventional plasmid DNA is commonly used which together with the encoded antigen also includes bacterial immunostimulatory CpG motifs to target the DNA sensor Toll-like receptor 9. Recently DNA vaccines using doggybone DNA (dbDNA™), have been developed without the use of bacteria. The cell-free process relies on the use of Phi29 DNA polymerase to amplify the template followed by protelomerase TelN to complete individual closed linear DNA. The resulting DNA contains the required antigenic sequence, a promoter and a poly A tail but lacks bacterial sequences such as an antibiotic resistance gene, prompting the question of immunogenicity. Here we compared the ability of doggybone DNA vaccine with plasmid DNA vaccine to induce adaptive immunity using clinically relevant oncotargets E6 and E7 from HPV. We demonstrate that despite the inability to trigger TLR9, doggybone DNA was able to induce similar levels of cellular and humoral immunity as plasmid DNA, with suppression of established TC-1 tumours.

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Satisfaction in rhinoplasty: the possible impact of anxiety and functional outcome

Abstract

Background

Rhinoplasty is a complex but commonly applied surgical procedure. Patient satisfaction is the least discussed but one of the most important determinants of surgical success.

Objectives

Evaluation of the patient satisfaction together with surgeon satisfaction were the main goals of this study. The roles of anxiety, gender, age and follow-up period were also studied.

Patients and methods

53 eligible patients operated by the first two authors within the previous 2 years were enrolled in the study. The medical records were reviewed for demographic data as well as the details of the surgical procedure. Functional and esthetic satisfactions of the patients were evaluated by VAS and ROE respectively. Surgeon satisfaction was evaluated by VAS in crosswise manner. Anxiety was measured by STAI_s and STAI_t scales.

Results

The analysis concerning esthetic results as well as functional results did not reveal any significant difference between the two surgeons (p = 0.132, p = 0.43 respectively). ROE scores were significantly different among patients with "good" and "very good" functional results. The difference between surgeon satisfaction and patient satisfaction was found to be insignificant (p = 0.273). Correlation analysis yielded a positive correlation between STAI_I and STAI_II (Pearson r = 0.335, p = 0.014) but not between STAI scores and ROE scores. Moreover, there was no relation between anxiety scores and the functional results. Likely, gender as well as age, follow-up, and surgical technique were not found to have any effect on patient satisfaction either.

Conclusion

Patient satisfaction is preferential in rhinoplasty. In our patient series, patient satisfaction was shown to be correlated with functional outcome but not with surgeon satisfaction. Anxiety was not found to have a significant impact on results of rhinoplasty. Our results should be interpreted cautiously keeping in mind that our patients' primary drive for rhinoplasty was functional.

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Inpatient treatment of patients with idiopathic sudden sensorineural hearing loss: a population-based healthcare research study

Abstract

Purpose

The aim was to determine inpatient treatment rates of idiopathic sudden sensorineural hearing loss (ISSNHL) with focus on diagnostics, treatment, and outcome.

Methods

A retrospective population-based study in the federal state Thuringia in 2011 and 2012 was performed on all 490 inpatients (51% females, median age: 60 years) treated for ISSNHL (Median duration: 7 days). The association between analyzed parameters and the probability of recovery was tested using univariable and multivariable statistics.

Results

The inpatient treatment rate for ISSNHL was 11.23 per 100,000. 172 patients (35%) had an outpatient treatment prior to inpatient treatment. For pure-tone audiometry of the three most affected frequencies (3PTAmax), the initial median hearing loss was 66.67 dB, the median absolute hearing gain ΔPTA_abs was 10.0 dB, and the median relative hearing gain in relation with the contralateral side ΔPTA_{rel contral} was 30.86%. 51% of the patients reached a ΔPTA_abs of ≥ 10 dB. About 2 of 5 patients recovered to a ΔPTA_{rel contral} ≥ 50% or reached ≤ 10 dB of contralateral ear. The multivariate analysis revealed that an ISSNHL on the left side [Hazard ratio (HR) = 1.6.88; confidence interval (CI) = 1.161–2.454], no down-sloping audiogram type (HR = 2.016; CI = 1.391–2.921), and no prior outpatient prednisolone treatment (HR = 2.374; CI = 1.505–3.745) were independent factors associated with better recovery (ΔPTA_abs ≥ 10 dB).

Conclusion

Inpatient treatment of ISSNHL is variable in daily practice. The population-based recovery rate was worse than reported in clinical trials. More standardization and clearer criteria for outpatient, inpatient, and salvage therapy are needed.

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O-GlcNAcylation in Oral Squamous Cell Carcinoma

Abstract

Background

Two post-translational mechanisms commonly demonstrated in various cancers are protein phosphorylation and glycosylation by O-linked β-N-acetylglucosamine (O-GlcNAc). However, only phosphorylation of the epidermal growth factor receptor (EGFR)/Akt pathway has been reported in oral squamous cell carcinoma (OSCC). Therefore, we aimed to determine both post-translational modifications in OSCC tissues and in oral cancer cells compared to normal tissues and oral keratinocytes and to find correlations of these modifications with histological grading.

Methods

Thirty-two OSCC and ten normal formalin-fixed and paraffin-embedded sections were probed with the anti-O-GlcNAc, anti-O-GlcNAc transferase (OGT), anti-phosphorylated-EGFR^tyr1173 and anti-phosphorylated-Akt^ser473 antibodies following standard immunohistochemistry. The immunohistochemical (IHC) score was determined using the Fromowitz standard. Whole cell lysates of oral cancer cells and normal oral keratinocytes were immunoblotted with the anti-O-GlcNAc antibody.

Results

The median IHC scores of O-GlcNAc or OGT between OSCC and normal tissues were not different, whereas those of phosphorylated-EGFR^tyr1173 and phosphorylated-Akt^ser473 were significantly higher in OSCC than normal tissues (p < 0.001 and p < 0.01, respectively). Similarly, expression of O-GlcNAcylated proteins in oral cancer cells and normal oral keratinocytes did not differ. In the OSCC group, the median IHC scores of O-GlcNAc and OGT were significantly lower than those of phosphorylated-EGFR^tyr1173 and phosphorylated-Akt^ser473 (p < 0.01 and p < 0.001, respectively). The IHC scores of O-GlcNAc or OGT were not determined to correlate with histological grading.

Conclusion

Unlike other types of cancers, our findings demonstrate that the levels of O-GlcNAcylation are not significantly increased in OSCC tissues or in oral cancer cells and are not associated with the histological grading of OSCC.

This article is protected by copyright. All rights reserved.

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Vaccines for the Paramyxoviruses and Pneumoviruses: Successes, Candidates, and Hurdles

Viral Immunology , Vol. 0, No. 0.


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A prospective cohort-study of 122 adult patients presenting to an otolaryngologist's office with globus pharyngeus

Abstract

Objectives

To investigate the epidemiology of globus pharyngeus in adult patients presenting to the otolaryngologist's office. Also the predictors of persisting symptoms, prevalence of anxiety and the effect of clinical assessment were analyzed.

Design

This was a prospective cohort study. Follow-up was done using a postal questionnaire.

Setting

One otolaryngologists' office comprising three medical doctors.

Participants

122 consecutive globus patients presenting to one otolaryngology office in a one-year period.

Main outcome measures

Globus incidence, gender- and age-distribution, predictors of persisting symptoms and the patient's health related concerns.

Results

3.8% of first-time visits were regarding globus. The mean age was 48 years [range 20-88 y] and a female predominance was found (ratio 1.49). 84% experienced anxiety, mainly due to fear of cancer. The most common pathological findings were reflux (15.6%) and post-infectious inflammation (10.6%). 21.4% of questionnaire-responders reported full remission of their symptoms. Three predictors regarding symptom persistence were identified: Male gender (OR 1.52), smoking (OR 3.4) and difficulties in breathing (OR 8.7). Patients with concomitant foreign body sensation were less likely to have persisting symptoms (OR 0.42). No cases of malignant disease were encountered. 94.7% was reassured by the office visit.

Conclusion

The incidence of globus is 3.8% in the otolaryngologist's office. Female gender and concomitant foreign body sensation were predictive for presenting to the clinic even if symptom remission had occurred. Male gender, smoking and self-perceived breathing difficulties were predictive for persisting symptoms. Globus is an anxiety causing symptom, but reassurance is provided by clinical examination by the otolaryngologist.

This article is protected by copyright. All rights reserved.

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A Differential Diagnosis of a Head and Neck Bony Lesion: Review of a Case Series with 18 Patients with Extra-Intestinal Features of Familial Adenomatous Polyposis

Abstract

We would like to draw to the attention of head and neck surgeons the following disease that can present first to head and neck specialists with either a head and neck lump or following an incidental finding on radiological imaging. Familial Adenomatous Polyposis (FAP) is a hereditary disease caused by a mutation in the APC gene on chromosome 5, which is inherited in an autosomal dominant fashion with complete penetrance but variable expression(1). However in approximately 25% of cases it arises from a de novo mutation of the APC gene(1).

This article is protected by copyright. All rights reserved.

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Five-year outcome of endoscopic laser cricopharyngeal myotomy: our experience in 10 patients

Abstract

Cricopharyngeal spasm is a failure of the cricopharyngeus muscle to relax and can be a cause of dysphagia.

Endoscopic laser cricopharyngeal myotomy with mucosal repair is associated with reduced operative times, inpatient stay and lower morbidity with favourable subjective short-term outcomes, although long-term outcomes are less well known.

In our cohort of patients, the majority had a subjectively improved swallow in the long-term although some did have regression of symptoms but remained better than pre-operatively.

Subjectively our cohort of patients appeared to favour less well in the long-term with regards to reflux symptoms, the majority fairing worse than pre-operatively at least 5 years previously.

This paper would suggest that as clinicians we can advise patients that in the long-term, laser cricopharyngeal myotomy will improve and maintain swallowing symptoms but that their reflux symptoms may be exacerbated over time.

This article is protected by copyright. All rights reserved.

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Editorial Board

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Table of Contents

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Title Page

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Validation of the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) Questionnaire: A Prospective Analysis of Facial Plastic and Reconstructive Surgery Procedures

Facial plast Surg
DOI: 10.1055/s-0037-1615282

Although periorbital edema and ecchymosis are commonly encountered after facial plastic and reconstructive surgery procedures, there is currently no validated grading scale to qualify these findings. In this study, the modified "Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE)" questionnaire is used as a grading scale for patients undergoing facial plastic surgery procedures. This article aims to validate a uniform grading scale for periorbital edema and ecchymosis using the modified SPREE questionnaire in the postoperative period. This is a prospective study including 82 patients at two different routine postoperative visits (second and seventh postoperative days), wherein the staff and resident physicians, physician assistants (PAs), patients, and any accompanying adults were asked to use the modified SPREE questionnaire to score edema and ecchymosis of each eye of the patient who had undergone a plastic surgery procedure. Interrater and intrarater agreements were then examined. Cohen's kappa coefficient was calculated to measure intrarater and interrater agreement between health care professionals (staff physicians and resident physicians); staff physicians and PAs; and staff physicians, patients, and accompanying adults. Good to excellent agreement was identified between staff physicians and resident physicians as well as between staff physicians and PAs. There was, however, poor agreement between staff physicians, patients, and accompanying adults. In addition, excellent agreement was found for intraobserver reliability during same-day visits. The modified SPREE questionnaire is a validated grading system for use by health care professionals to reliably rate periorbital edema and ecchymosis in the postoperative period. Validation of the modified SPREE questionnaire may improve ubiquity in medical literature reporting and related outcomes reporting in future.
[...]

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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In response to: Unsolved enigma of atrial myxoma with biventricular dysfunction

Aanchal Dixit, Prabhat Tewari, Rashmi Soori, Surendra Kumar Agarwal

Annals of Cardiac Anaesthesia 2018 21(1):107-107

Thanks to Raut et al.[1] for appreciating our efforts in managing the case of biatrial myxomas. A brief discussion is warranted here on the types, size of cardiac myxomas, interleukin 6 (IL-6) levels, left ventricle (LV) dysfunction, and their relation. IL-6 is a pleiotropic cytokine with a variety of biologic activities, including differentiation of B cell, thymocytes, and T cells; activation of macrophages; and stimulation of hepatocyte to produce acute-phase proteins such as C-reactive protein.[2],[3] It is also said to have paracrine, endocrine, and autocrine growth functions.[3]

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Role of transesophageal echocardiography during left atrial appendage occlusion device closure in a patient with non-valvular atrial fibrillation and angiodysplasia of the colon

Dinesh Kumar, Sunil Kumar, Nagraj Desai

Annals of Cardiac Anaesthesia 2018 21(1):88-91

Atrial fibrillation is the most common arrhythmia associated with significant mortality and morbidity secondary to thrombo-embolism. To prevent this thrombo-embolism oral anticoagulation therapy is the recommended treatment. In patients with contraindications to oral anticoagulation therapy, percutaneous left atrial appendage occlusion device is indicated. TEE is essential to guide in all the stages of LAA device deployment. Right from pre-procedure screening, to guiding during deployment, to rule out any complications and post-procedure surveillance and monitoring long term outcomes.

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Perioperative renal protection during cardiac surgery: A choice between dopamine and dexmedetomidine

Rajinder Singh Rawat, Said Musallam Al Maashani

Annals of Cardiac Anaesthesia 2018 21(1):4-5



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Successful resolution with apixaban of a massive left atrial appendage thrombus due to nonrheumatic atrial fibrillation: A case report and review

Bader Abu Ghalyoun, Matthew Lempel, Hamid Shaaban, Fayez Shamoon

Annals of Cardiac Anaesthesia 2018 21(1):76-77

A 32-year-old woman with a past medical history of paroxysmal atrial fibrillation, long QT syndrome, and implantation of an automatic iimplantable cardioverter-defibrillator (AICD) following cardiac arrest presented with disabling symptoms of paroxysmal atrial fibrillation due to recurrent AICD shocks. Before curative ablation, transesophageal echocardiography was performed to assess for existing thrombi. This is a rare case of successful resolution with apixaban of a massive left atrial appendage thrombus due to non-rheumatic atrial fibrillation that was successfully treated with apixaban.

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Noninvasive ventilation using bipap: Expanding indications to post cardiac surgery care

William T McGee

Annals of Cardiac Anaesthesia 2018 21(1):6-7



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Pneumopericardium after minimally invasive atrial septal defect closure

Aditya Lamba, Rahul Dutta, Rajesh K Chand

Annals of Cardiac Anaesthesia 2018 21(1):99-100

Minimally invasive atrial septal defect (ASD) closure is a commonly performed cardiac surgical procedure and has good outcome. We report an interesting chest X-ray showing pneumopericardium in a patient who underwent ASD closure using a minimally invasive approach.

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Prophylaxis of postoperative nausea and vomiting after cardiac surgery in high-risk patients: A randomized controlled study

Sébastien Champion, Laëtitia Zieger, Caroline Hemery

Annals of Cardiac Anaesthesia 2018 21(1):8-14

Context: The role of prophylaxis for postoperative nausea and vomiting (PONV) in cardiac surgery is under debate. Aims: To study the risk factors for PONV after cardiac surgery and the role of betamethasone with or without droperidol for its prevention. Setting and Design: Randomized open-label controlled study comparing standard care with PONV prophylaxis from February to November 2016. Methods: Five hundred and two patients with planned nonemergent cardiac surgery were included. Interventions: In the intervention arm, PONV prophylaxis (4 mg betamethasone with/without 0.625 mg droperidol) was administered in high-risk patients (two or more risk factors). Patients in the control arm were treated as per routine hospital practices. Results: Female sex, past history of PONV, and migraines were associated with a significantly increased risk of PONV, while motion sickness, smoking status, and volatile anesthetics were not. Pain and treatment with nefopam or ketoprofen were associated with an increased risk of PONV. PONV was less frequent in the active arm compared to controls (45.5% vs. 54.0%, P = 0.063; visual analogic scale 10.9 vs. 15.3 mm, P = 0.043). Among the 180 patients (35.6%) with ≥2 risk factors, prophylaxis was associated with reduced PONV (intention-to-treat: 46.8% vs. 67.8%, P = 0.0061; per-protocol: 39.2% vs. 69%, P = 0.0002). In multivariate analysis, prophylaxis was independently associated with PONV (odds ratio [OR]: 0.324, 95% confidence interval: 0.167–0.629, P = 0.0009), as were female sex, past history of PONV, and migraines (OR: 3.027, 3.031, and 2.160 respectively). No drug-related side effects were reported. Conclusion: Betamethasone with/without droperidol was effective in decreasing PONV in high risk cardiac surgical patients without any side effect.

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Concomitant neurogenic and vascular thoracic outlet syndrome due to multiple exostoses

Hosseinali Abdolrazaghi, Azade Riyahi, Morteza Taghavi, Pezhman Farshidmehr, Abolfazl Mohammadbeigi

Annals of Cardiac Anaesthesia 2018 21(1):71-73

We report a rare case of multiple hereditary exostosis where patient presented with bilateral base of neck exostoses with concurrent compression of brachial plexus and subclavian artery and vein. The patient was a young 26-year-old woman with chief complaints of pain in the left upper extremity, paresthesia in the left ring and little finger, and weakness in hand movement and grip. On referral, history, physical examination, radiological imaging, and electrodiagnostic tests evaluated the patient. Due to severe pain and disability in performing routine activities, surgical intervention was necessary. In the current case, the patient had thoracic outlet syndrome with concomitant venous, arterial, and neurogenic sub types. Radial pulse returned and pain associated with brachial plexus compression was resolved after the surgery.

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Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges

Aniruddha Ramesh Janai, Wilfried Bellinghausen, Edwin Turton, Carmine Bevilacqua, Waseem Zakhary, Martin Kostelka, Farhad Bakhtiary, Joerg Hambsch, Ingo Daehnert, Florian Loeffelbein, Joerg Ender

Annals of Cardiac Anaesthesia 2018 21(1):15-21

Objective: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. Design: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. Setting: A single-center study at a university affiliated heart center. Participants: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. Methods: Primary and staged biventricular repair of complete AV canal defects. Measurements and main results: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. Conclusion: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.

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Mechanical discordance between left atrium and left atrial appendage

Arash Khamooshian, Jelliffe Jeganthan, Yannis Amador, Roger J Laham, Feroze Mahmood, Robina Matyal

Annals of Cardiac Anaesthesia 2018 21(1):82-84

During standard transesophageal echocardiographic examinations in sinus rhythm (SR) patients, the left atrial appendage (LAA) is not routinely assessed with Doppler. Despite having a SR, it is still possible to have irregular activity in the LAA. This situation is even more important for SR patients where assessment of the left atrium is often foregone. We describe a case where we encountered this situation and briefly review how to assess the left atrium and its appendage in such a case scenario.

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Dexmedetomidine for prevention of skeletal muscle ischaemia-reperfusion injury in patients with chronic limb ischaemia undergoing aortobifemoral bypass surgery: A prospective double-blind randomized controlled study

Tanveer Singh Kundra, Ashwini Thimmarayappa, Manasa Dhananjaya, N Manjunatha

Annals of Cardiac Anaesthesia 2018 21(1):22-25

Background: Dexmedetomidine is a selective α-2 agonist used for sedation. It has also been shown to have myocardial protective effect and prevent ischemia-reperfusion injury in off-pump coronary artery bypass patients. The aim of our study was to assess the effect of dexmedetomidine for prevention of skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery. Methodology: Sixty adult patients (Group dexmedetomidine n = 30, Group normal saline n = 30) undergoing aortobifemoral bypass surgery were recruited over 3 months. Randomization was done using a computer-generated random table. The attending anesthesiologist would be blinded to whether the drug/normal saline was being administered. He would consider each unlabeled syringe as containing dexmedetomidine and calculate the volume to be infused via a syringe pump accordingly. Dexmedetomidine infusion (1 mcg/kg) over 15 minutes was given as a loading dose, followed by maintenance infusion of 0.5 mcg/kg/h till 2 h postprocedure in Group dexmedetomidine (D) while the same volume of normal saline was given in the control Group C till 2 h postprocedure. Creatine phosphokinase (CPK) values were noted at baseline (T0), 6 h (T1), 12 h (T2), and 24 h (T3) after the procedure. Hemodynamic variables (heart rate [HR] and mean blood pressure [MAP]) were recorded at T0, T1, T2, and T3. Results were analyzed using unpaired Student's t-test, P < 0.05 was considered statistically significant. Results: MAP and HR significantly decreased in Group D as compared to control group (P < 0.05). However, the decrease was never <20% of the baseline. The CPK values at 6, 12, and 24 h were statistically significant between the two groups. Conclusion: Dexmedetomidine prevents skeletal muscle ischemia-reperfusion injury in patients undergoing aortobifemoral bypass surgery.

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Quadricuspid aortic valve: A rare intraoperative diagnosis by transesophageal echocardiography

Anupam Das, Ummed Singh, Palleti Rajashekar

Annals of Cardiac Anaesthesia 2018 21(1):95-96

Quadricuspid aortic valve (QAV) is a rare congenital anomaly frequently associated with other anomalies particularly coronary anomalies. It may be detected on transthoracic or transesophageal echocardiography. We present here a case report of a 27-year-old male patient with a QAV, the valve being regurgitant and requiring aortic valve replacement. It has been reported as isolated case reports in the literature and various theories exist to the development of QAV. The diagnosis requires a high degree of suspicion and a detailed assessment, and if asymptomatic, then patients need to be carefully followed up for the development of aortic regurgitation.

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Assessment the effect of dexmedetomidine on incidence of paradoxical hypertension after surgical repair of aortic coarctation in pediatric patients

Rabie Soliman, Dalia Saad

Annals of Cardiac Anaesthesia 2018 21(1):26-33

Objective: The aim of the study was to assess the effect of dexmedetomidine on the incidence of paradoxical hypertension in patients undergoing aortic coarctation repair. Design: Randomized observational study. Setting: University hospital and cardiac center. Patients: The study included 108 pediatric patients with isolated aortic coarctation. Methods: The patients were classified into two groups (each = 54): Group D: the patients received dexmedetomidine as a loading dose of 0.5 μg/kg over 10 min followed by infusion 0.3 μg/kg/h during surgery and continued for the first 48 postoperative hours. Group C: The patients received an equal amount of normal saline. The medication was prepared by the nursing staff and given to anesthetist blindly. The collected data included the heart rate, systolic and diastolic arterial blood pressure, incidence, onset, severity and treatment of paradoxical hypertension, fentanyl dose and end-tidal sevoflurane concentration, amount of blood loss and urine output. Main Results: The heart rate, systolic and diastolic blood pressure decreased significantly with dexmedetomidine than Group C (P < 0.05). The incidence and severity of the paradoxical hypertension was lower with dexmedetomidine than Group C (P = 0.011, P = 0.017, respectively). The onset the paradoxical hypertension was earlier in Group C than dexmedetomidine (P = 0.026). The dose of fentanyl and sevoflurane concentration decreased significantly with dexmedetomidine (P = 0.034, P = 0.026, respectively). The blood loss decreased with dexmedetomidine (P = 0.020) and the urine output increased with dexmedetomidine (P = 0.024). The incidence of hypotension and bradycardia was more with dexmedetomidine (P < 0.05). Conclusion: Dexmedetomidine is safe in pediatric patients undergoing aortic coarctation repair. It minimized the incidence and severity of paradoxical hypertension. It decreased the required antihypertensive medications.

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Spontaneous coronary artery dissection in anabolic steroid misuse

Aghighe Heidari, Feridoun Sabzi, Reza Faraji

Annals of Cardiac Anaesthesia 2018 21(1):103-104



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A randomized controlled trial comparing the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass, assessed by changes in N-terminal brain natriuretic peptide

Balaji Kuppuswamy, Kirubakaran Davis, Raj Sahajanandan, Manickam Ponniah

Annals of Cardiac Anaesthesia 2018 21(1):34-40

Objective: The objective of the study is to compare the myocardial protective effects of isoflurane with propofol in patients undergoing elective coronary artery bypass surgery on cardiopulmonary bypass (CPB), the cardio protection been assessed by changes in N-terminal brain natriuretic peptide (NT proBNP). Methodology and Design: This study is designed as a participant blinded, prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India. Participants: Patients undergoing elective coronary artery bypass surgery on CPB. Intervention: Anesthesia was maintained with 0.8–1.2 end tidal concentrations of isoflurane in the isoflurane group and in the propofol group, anesthesia was maintained with propofol infusion as described by Roberts et al. Measurements: Hemodynamic data were recorded at frequent intervals during the surgery and up to 24 h in the Intensive Care Unit (ICU). The other variables that were measured include duration of mechanical ventilation, dose and duration of inotropes in ICU, (inotrope score), duration of ICU stay, NT proBNP levels before induction and 24 h postoperatively, creatine kinase-MB levels in the immediate postoperative, first and second day. Results: Mean heart rate was significantly higher in propofol group during sternotomy, (P = 0.021). Propofol group had a significantly more number of patients requiring nitroglycerine in the prebypass period (P = 0.01). The increase in NT proBNP from preoperative to postoperative value was lesser in the isoflurane group compared to propofol even though the difference was not statistically significant. The requirement of phenylephrine to maintain mean arterial pressure within 20% of baseline, mechanical ventilation duration, inotrope use, duration of ICU stay and hospital stay were found to be similar in both groups. Conclusion: Propofol exhibit comparable myocardial protective effect like that of isoflurane in patients undergoing coronary artery bypass graft surgery. Considering the unproven mortality benefit of isoflurane and the improved awareness of green OT concept, propofol may be the ideal alternative to volatile anesthetics, at least in patients with good left ventricular function.

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Atrioventricular septal defects

Sandeep Chauhan

Annals of Cardiac Anaesthesia 2018 21(1):1-3



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Long-term quality of life postacute kidney injury in cardiac surgery patients

Pankaj Kumar Mishra, Heyman Luckraz, Jayanta Nandi, Alan Nevill, Ramesh Giri, Andrew Panayiotou, Johann Nicholas

Annals of Cardiac Anaesthesia 2018 21(1):41-45

Background: Acute renal failure after cardiac surgery is known to be associated with significant short-term morbidity and mortality. There have as yet been no major reports on long-term quality of life (QOL). This study assessed the impact of acute kidney injury (AKI) and renal replacement therapy (RRT) on long-term survival and QOL after cardiac surgery. The need for long-term RRT is also assessed. Materials and Methods: Patients who underwent cardiac surgery between 2005 and 2011 (n = 6087) and developed AKI (RIFLE criteria, n = 570) were included. They were propensity-matched 1:1 to patients without renal impairment (control). Data were prospectively collected, and health-related QOL questionnaire was sent to patients who were alive at least 1-year postoperatively at the time of the study. Results: There was no significant difference in the preoperative characteristics between the two groups (age, gender, left ventricular ejection fraction, procedure, urgency, logistic Euroscore), respectively. Median follow-up was 52 months. Survival data were available in all patients. Questionnaires were returned in 64% of eligible patients. Long-term survival was significantly lower, and QOL, in particular the physical aspect, was significantly worse for the AKI group as compared to non-AKI group (38.8 vs. 44.2, P = 0.002), especially so in patients who required RRT. In alive respondents, despite an 18% (66/359) incidence of ongoing renal follow-up, the need for late RRT was only in 1.1% (4/359). Conclusion: AKI and especially the need for RRT following cardiac surgery are associated with increased long-term mortality as well as worse quality of life in a propensity-matched control group.

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Commentary: Comments on thoracic outlet syndrome

Gauranga Majumdar, Surendra Kumar Agarwal

Annals of Cardiac Anaesthesia 2018 21(1):74-75



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Design and standardization of tools for assessing the perceived heart risk and heart health literacy in Iran

Habibolah Khazaei, Saeid Komasi, Ali Zakiei, Mohsen Rezaei, Peyman Hatamian, Mohammad Jashnpoor, Mozhgan Saeidi

Annals of Cardiac Anaesthesia 2018 21(1):46-52

Objectives: The aim is to achieve the standard tools for heart health, the present study aimed to design, develop, and standardize the two questionnaires of perceived heart risk scale (PHRS) and heart health literacy scale (HHLS). Methods: The present study was a methodological research conducted on the residents of Kermanshah Province, Iran, using the multi-stage cluster sampling. Further, considering the scientific methods in the psychometric field, the design of the research questionnaires was conducted. In addition, the viewpoints of experts in different domains were qualitatively and quantitatively included to assess the validity of the questionnaires. To assess the reliability of the questionnaires, a sample including 31 subjects was first selected and studied within a fortnight's interval. Then, the reliability and validity of the scales were assessed using factor analysis and Cronbach's alpha in a sample of 771 subjects. Results: After reviewing the viewpoints of experts, the items were adjusted and implemented in the first sample at two stages. The results were indicative of the stability and acceptability of the Cronbach's alpha. In addition, the validity and reliability of the questionnaires were confirmed in the second sample too. Conclusion: According to the results of the present study, it can be concluded that the two questionnaires of PHRS and HHLS had acceptable reliability and validity.

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Bleeding in the lung complicates a routine intracardiac repair: What went wrong!!!

Neeti Makhija, Rohan Magoon, Minati Choudhury, Sivasubramanian Ramakrishnan

Annals of Cardiac Anaesthesia 2018 21(1):78-81

Cyanotic congenital heart disease presents an increased tendency to bleed in view of subtle coagulation defects. Airway bleeding can be particularly difficult to manage while maintaining an adequate ventilation. An isolated lung bleed with the exclusion of possible traumatic, medical and surgical causes of bleeding, should alert the attending anesthesiologist to the possibility of the collateral-related bleeding. Preoperative coil embolization remains an important initial management step in a case of tetralogy of Fallot (TOF) with major aortopulmonary collaterals. Nevertheless, the coiling of the collaterals in certain specific case scenarios is not feasible, rendering the management of a lung bleed, all the more challenging. We, hereby discuss a case of a 7-year-old girl with a massive endotracheal bleed at the time of weaning from cardiopulmonary bypass after corrective surgery for TOF. The subsequent approach and management are discussed. The optimal management of tetralogy with collaterals mandates an effective communication among the cardiologist, radiologist, anesthesiologist, and the surgeon.

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Expression of CD163 in hereditary gingival fibromatosis: a possible association with TGF-β1

Abstract

Background

Although several studies have discussed some of the molecular and cellular changes associated with hereditary gingival fibromatosis (HGF), its pathogenesis is still largely unclear. This study was directed to detect and outline the degree of relationship between the immunophenotyped macrophages (M2) expressing CD163 and TGF-β1 in patients with gingival overgrowth due to HGF.

Methods

Biopsies from 20 patients suffering from HGF and 20 normal control subjects were harvested, histologically and immunohistochemically stained then, analyzed and statistically compared and correlated for CD163 immunoexpression and TGF-β1.

Results

All HGF specimens expressed TGF-β1 by most of the connective tissue fibroblasts, with statistically high significant mean of area % (2.61±0.41) compared to normal controls (0.11±0.06) (p=0.001). All control specimens revealed negligible CD163 immunostaining of the few inflammatory cells found with a mean area of % (0.69±0.12), while the specimens of HGF cases showed statistically significant higher CD163 expression (3.39±0.75) at (p=0.007). A statistically significant higher mean % of M2-cells expressing CD163 in relation to the total number of the inflammatory cells was revealed in HGF (34.46±2.04) compared to the control group (16.36±2.39) (p-value ≤ 0.05). Moderate correlation between CD163 and TGF-β1 was detected in HGF (r =0.451), (p-value<0.05).

Conclusions

CD163 and TGF-β1 were clearly expressed in HGF cases compared to healthy control patients, with significant correlation. In HGF, the increase in CD 163-positive cells was specific and not dependent on the chronic gingival inflammation.

This article is protected by copyright. All rights reserved.

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Accuracy of FDG PET-CT response assessment following radiotherapy alone for head and neck squamous cell carcinoma: retrospective analysis of 45 patients

Abstract

FDG PET-CT is an established tool for response assessment following definitive concurrent chemoradiotherapy for head and neck squamous cell carcinoma with a high negative predictive value guiding treatment decisions.

Little data is available regarding the accuracy of FDG PET-CT for response assessment following definitive radiotherapy without chemotherapy.

We retrospectively analysed the accuracy of FDG PET-CT for response assessment following radiotherapy alone without planned neck dissection in 45 patients.

PET-CT had a high negative predictive value of 93% and positive predictive value of 88%.

Based upon the high negative predictive value, PET-CT can be used to avoid surgical intervention following radiotherapy alone

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Adverse Effect of Mobile Phone on Hearing in Healthy Individuals: A Clinical Study

Abstract

The mobile phone is a ubiquitous piece in this modern world. An estimated 85% of Americans, 80% of the British, and perhaps 75% of Indians use it, as of today. Mobile phones communicate by transmitting radio waves through a network of fixed antennas called base stations. Radio frequency waves are electromagnetic fields, and unlike ionizing radiation such as X-rays or gamma rays, can neither break chemical bonds nor cause ionization in the human body. 1000 participants from outpatient department of a tertiary care center over a period of one and a half years, were included in the study and were divided equally into case (> 1 year use) and control (< 1 year use) groups. Out of 500 cases, maximum 233(46.6%) subjects were using mobile since last 4–6 year and 134(26.8%) were using mobile since last 7–9 year and maximum 344(68.8%) subjects were using mobile 1–3 h/day and 145(29.0%) were using mobile 4–6 h/day.

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Orthognathic surgery in Melnick–Needles syndrome: a review of the literature and report of two siblings

Melnick–Needles syndrome (MNS) is a rare congenital X-linked dominant skeletal dysplasia, characterized by exophthalmos, a prominent forehead, and mandibular hypoplasia and retrognathism. Dental features may include anodontia, hypodontia, or oligodontia. Increased collagen content, unpredictable collagen synthesis, and abnormal bony architecture have raised concerns regarding bone splitting intraoperatively and bone healing postoperatively. This report describes the cases of two sisters with MNS, who successfully underwent orthognathic surgery consisting of bilateral mandibular ramus osteotomies combined with advancement genioplasty and iliac crest bone grafting, to correct the classical MNS facial deformity of mandibular retrognathia.

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Impact of crack cocaine use on the occurrence of oral lesions and micronuclei

The aim of this study was to investigate the occurrence of oral lesions and micronuclei in crack cocaine users. A cross-sectional study was conducted involving 106 crack users and 106 non-users matched for age, sex, and tobacco use. Socio-demographic characteristics, the consumption of psychoactive substances, and the occurrence of fundamental lesions were investigated. Cellular changes in the oral mucosa (karyolysis, karyorrhexis, 'broken egg' events, and micronuclei) were determined by exfoliative cytology for 54 participants in each group.

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Correction

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Adverse Effect of Mobile Phone on Hearing in Healthy Individuals: A Clinical Study

Abstract

The mobile phone is a ubiquitous piece in this modern world. An estimated 85% of Americans, 80% of the British, and perhaps 75% of Indians use it, as of today. Mobile phones communicate by transmitting radio waves through a network of fixed antennas called base stations. Radio frequency waves are electromagnetic fields, and unlike ionizing radiation such as X-rays or gamma rays, can neither break chemical bonds nor cause ionization in the human body. 1000 participants from outpatient department of a tertiary care center over a period of one and a half years, were included in the study and were divided equally into case (> 1 year use) and control (< 1 year use) groups. Out of 500 cases, maximum 233(46.6%) subjects were using mobile since last 4–6 year and 134(26.8%) were using mobile since last 7–9 year and maximum 344(68.8%) subjects were using mobile 1–3 h/day and 145(29.0%) were using mobile 4–6 h/day.

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Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report

Aortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present wi...

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Inside EMS Podcast: The development of airway, intubation skills

Download this podcast on iTunes, SoundCloud or via RSS feed In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson discuss the development of airway and intubation skills. With many systems removing intubation as a skill set for paramedics, how do we prepare for a better trained EMS provider" Learn more about the EMS1 Academy and schedule a free demo.

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Serial In-Office Intralesional Steroid Injections in Airway Stenosis

This case-series study examines the association of serial in-office intralesional steroid injection after endoscopic dilation with surgery-free interval in adults with subglottic and proximal tracheal stenosis.

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Histopathological and Inflammatory Features of Open Mastoid Cavities

This study of tissue samples from a cohort of patients with chronically discharging open radical mastoid cavities investigates the histopathological and inflammatory features of these cavities and association of different types with treatment outcome.

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Facial Pain and Diplopia in a Young Boy

A young boy presented with left facial and eye pain with intermittent diplopia on upward and lateral gaze; imaging showed a well-circumscribed posterior-medial extraconal mass extending into the orbital apex with dorsal extension into the left cavernous sinus. What is your diagnosis?

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Comparative efficacy of Er,Cr:YSGG and Er:YAG lasers for etching of composite for orthodontic bracket bonding

Abstract

Several techniques have been proposed to obtain a durable bond, and the efficacy of these techniques is assessed by measuring parameters such as bond strength. Laser has provided a bond strength as high as that of acid etching in vitro and has simpler use with shorter clinical time compared to acid etching. This study aimed to compare the efficacy of Er:YAG and Er,Cr:YSGG lasers for etching and bonding of composite to orthodontic brackets. No previous study has evaluated the effect of these particular types of laser. A total of 70 composite blocks were randomly divided into five groups (n = 14): group 1, etching with phosphoric acid for 20 s; group 2, Er:YAG laser irradiation with 2 W power for 10 s; group 3, Er:YAG laser with 3 W power for 10 s; group 4, Er,Cr:YSGG laser with 2 W power for 10 s; group 5, Er,Cr:YSGG laser with 3 W power for 10 s. Metal brackets were then bonded to composites, and after 5000 thermal cycles, they were subjected to shear bond strength test in a universal testing machine after 24 h of water storage. One sample of each group was evaluated under a scanning electron microscope (SEM) to assess changes in composite surface after etching. The adhesive remnant index (ARI) was calculated under a stereomicroscope. Data were statistically analyzed. The mean and standard deviation of shear bond strength were 18.65 ± 3.36, 19.68 ± 5.34, 21.31 ± 4.03, 17.38 ± 6.94, and 16.45 ± 4.26 MPa in groups 1–5, respectively. The ARI scores showed that the bond failure mode in all groups was mainly mixed. The groups were not significantly different in terms of shear bond strength. Er:YAG and Er,Cr:YSGG lasers with the mentioned parameters yield optimal shear bond strength and can be used as an alternative to acid etching for bracket bond to composite.

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Balancing Infection Control and Environmental Protection as a Matter of Patient Safety: The Case of Laryngoscope Handles

No abstract available

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Validation of a Second-Generation Near-Infrared Spectroscopy Monitor in Children With Congenital Heart Disease

BACKGROUND: Cerebral oximetry using near-infrared spectroscopy is a noninvasive optical technology to detect cerebral hypoxia-ischemia and develop interventions to prevent and ameliorate hypoxic brain injury. Cerebral oximeters are calibrated and validated by comparison of the near-infrared spectroscopy–measured cerebral O2 saturation (SctO2) to a "field" or reference O2 saturation (REF CX) calculated as a weighted average from arterial and jugular bulb oxygen saturations. In this study, we calibrated and validated the second-generation, 5 wavelength, FORE-SIGHT Elite with the medium sensor (source-detector separation 12 and 40 mm) for measurement of SctO2 in children with congenital heart disease. METHODS: After institutional review board approval and written informed consent, 63 children older than 1 month and ≥2.5 kg scheduled for cardiac catheterization were enrolled. Self-adhesive FORE-SIGHT Elite medium sensors were placed on the right and left sides of the forehead. Blood samples for calculation of REF CX were drawn simultaneously from the aorta or femoral artery and the jugular bulb before (T1) and shortly after (T2) baseline hemodynamic measurements. FORE-SIGHT Elite SctO2 measurements were compared to the REF CX (REF CX = [0.3 SaO2] + [0.7 SjbO2]) using Deming regression, least squares linear regression, and Bland-Altman analysis. RESULTS: Sixty-one subjects (4.5 [standard deviation 4.4] years of age; 17 [standard deviation 13] kg, male 56%) completed the study protocol. Arterial oxygen saturation ranged from 64.7% to 99.1% (median 96.0%), jugular bulb venous oxygen saturation from 34.1% to 88.1% (median 68.2%), the REF CX from 43.8% to 91.4% (median 76.9%), and the SctO2 from 47.8% to 90.8% (median 76.3%). There was a high degree of correlation in SctO2 between the right and left sensors at a given time point (within subject between sensor correlation r = 0.91 and 95% confidence interval [CI], 0.85–0.94) or between T1 and T2 for the right and left sensors (replicates, within subject between time point correlation r = 0.95 and 95% CI, 0.92–0.96). By Deming regression, the estimated slope was 0.966 (95% CI, 0.786–1.147; P = .706 for testing against null hypothesis of slope = 1) with a y intercept of 2.776 (95% CI, −11.102 to 16.654; P = .689). The concordance correlation coefficient was 0.873 (95% CI, 0.798–0.922). Bland-Altman analysis for agreement between SctO2 and REF CX that accounted for repeated measures (both in times and sensors) found a bias of −0.30% (95% limits of agreement: −10.56% to 9.95%). CONCLUSIONS: This study calibrated and validated the FORE-SIGHT Elite tissue oximeter to accurately measure SctO2 in pediatric patients with the medium sensor. Accepted for publication November 28, 2017. Funding: This study was supported by corporate funding, participation in data analysis, and contribution to manuscript writing by CAS Medical Systems, Inc, Branford, CT. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Viviane G. Nasr, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to viviane.nasr@childrens.harvard.edu. © 2018 International Anesthesia Research Society

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Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes

BACKGROUND: Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health. METHODS: We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions. RESULTS: The SUD plastic handle generates an estimated 16–18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5–6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4–5 uses, and reusable blades 5–7 uses, before loss. CONCLUSIONS: LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options. Accepted for publication October 23, 2017. Funding: J.D.S. was supported by an Anesthesia Patient Safety Foundation award. L.A.R. was supported by a Provost's award for undergraduate research at Northeastern University. M.J.E. was supported by departmental start-up funds at Northeastern University. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Jodi D. Sherman, MD, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, TMP3, New Haven, CT 06520. Address e-mail to jodi.sherman@yale.edu. © 2018 International Anesthesia Research Society

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Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model

No abstract available

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Myocardial Protection by Glucose–Insulin–Potassium in Moderate- to High-Risk Patients Undergoing Elective On-Pump Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND: Low cardiac output syndrome is a main cause of death after cardiac surgery. We sought to assess the impact of glucose–insulin–potassium (GIK) to enhance myocardial protection in moderate- to high-risk patients undergoing on-pump heart surgery. METHODS: A randomized controlled trial was performed in adult patients (Bernstein–Parsonnet score >7) scheduled for elective aortic valve replacement and/or coronary artery bypass surgery. Patients were randomized to GIK (20 IU of insulin, 10 mEq of potassium chloride in 50 mL of glucose 40%) or saline infusion given over 60 minutes on anesthetic induction. The primary end point was postcardiotomy ventricular dysfunction (PCVD), defined as new/worsening left ventricular dysfunction requiring inotropic support (≥120 minutes). Secondary end points were the intraoperative changes in left ventricular function as assessed by transoesophageal echocardiography, postoperative troponin levels, cardiovascular and respiratory complications, and intensive care unit and hospital length of stay. RESULTS: From 224 randomized patients, 222 were analyzed (112 and 110 in the placebo and GIK groups, respectively). GIK pretreatment was associated with a reduced occurrence of PCVD (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.25–0.66). In GIK-treated patients, the left systolic ventricular function was better preserved after weaning from bypass, plasma troponin levels were lower on the first postoperative day (2.9 ng·mL−1 [interquartile range {IQR}, 1.5–6.6] vs 4.3 ng·mL−1 [IQR, 2.4–8.2]), and cardiovascular (RR, 0.69; 95% CI, 0.50–0.89) and respiratory complications (RR, 0.5; 95% CI, 0.38–0.74) were reduced, along with a shorter length of stay in intensive care unit (3 days [IQR, 2–4] vs 3.5 days [IQR, 2–7]) and in hospital (14 days [IQR, 11–18.5] vs 16 days [IQR, 12.5–23.5]), compared with placebo-treated patients. CONCLUSIONS: GIK pretreatment was shown to attenuate PCVD and to improve clinical outcome in moderate- to high-risk patients undergoing on-pump cardiac surgery. Accepted for publication November 20, 2017. Funding: This study was supported by Département d'Anesthesiologie, Pharmacologie and Soins Intensifs of the University Hospital of Geneva. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). All authors read and approved the final manuscript. Reprints will not be available from the authors. Address correspondence to Marc Licker, MD, Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva and Faculty of Medicine, CH-1206 Geneva, Switzerland. Address e-mail to marc-joseph.licker@hcuge.ch. © 2018 International Anesthesia Research Society

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Intravenously Administered Lidocaine and Magnesium During Thyroid Surgery in Female Patients for Better Quality of Recovery After Anesthesia

BACKGROUND: Although systemic lidocaine and magnesium have been widely studied as perioperative analgesic adjuvants, they have been rarely evaluated with respect to recovery quality under the same conditions. We compared the quality of recovery 40 (QoR-40) scores of female patients who received intravenous lidocaine, magnesium, and saline during thyroidectomy to investigate their effects on comprehensive recovery from anesthesia. METHODS: In this prospective, double-blind trial, 135 female patients scheduled for open thyroidectomy were randomly assigned to the lidocaine group (group L), magnesium group (group M), or control group (group C). Immediately after induction, lidocaine (2 mg/kg for 15 minutes followed by 2 mg/kg/h) was administered in group L and magnesium sulfate (20 mg/kg over 15 minutes followed by 20 mg/kg/h) was administered in group M. Group C received an equivalent volume of saline. The QoR-40 survey was conducted on postoperative days 1 and 2. RESULTS: The mean global QoR-40 scores on postoperative day 1 were 186.3 (standard deviation, 5.5) in group L, 184.3 (4.7) in group M, and 179.4 (17.8) in group C, and there was a significant difference only between group L and group C (mean difference, 6.9; adjusted P = .018). Among the 5 dimensions of QoR-40, emotional state, physical comfort, and pain were superior in group L compared to group C. CONCLUSIONS: Lidocaine administered intravenously during anesthesia led to better quality of postoperative recovery measured by QoR-40 compared with the group C. Magnesium was found to be insufficient to induce any significant improvement with the dose used in the present study. Accepted for publication November 28, 2017. Funding: This work was supported by the Yonsei University Research Fund (grant number: 4-2013-0719). The authors declare no conflicts of interest. Clinical Trial: NCT02018276 at clinicaltrials.gov. Institutional review board: The study protocol was approved by the Institute Research Committee at Severance Hospital, Yonsei University Health System (IRB number: 4-2013-0719). Human Research Protection Center, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 120–752, Republic of Korea. E-mail: hpc@yuhs.ac. Reprints will not be available from the authors. Address correspondence to Jeong-Rim Lee, MD, PhD, Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50–1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. Address e-mail to leejeongrim@gmail.com. © 2018 International Anesthesia Research Society

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Efficacy of Ultrasound-Guided Serratus Plane Block on Postoperative Quality of Recovery and Analgesia After Video-Assisted Thoracic Surgery: A Randomized, Triple-Blind, Placebo-Controlled Study

BACKGROUND: The optimal regional technique for analgesia and improved quality of recovery after video-assisted thoracic surgery (a procedure associated with considerable postoperative pain) has not been established. The main objective in this study was to compare quality of recovery in patients undergoing serratus plane block (SPB) with either ropivacaine or normal saline on the first postoperative day. Secondary outcomes were analgesic outcomes, including postoperative pain intensity and opioid consumption. METHODS: Ninety patients undergoing video-assisted thoracic surgery were randomized to receive ultrasound-guided SPB with 0.4 mL/kg of either 0.375% ropivacaine (SPB group) or normal saline (control group) after anesthetic induction. The primary outcome was the 40-item Quality of Recovery (QoR-40) score at 24 hours after surgery. The QoR-40 questionnaire was completed by patients the day before surgery and on postoperative days 1 and 2. Pain scores, opioid consumption, and adverse events were assessed for 2 days postoperatively. RESULTS: Eighty-five patients completed the study: 42 in the SPB group and 43 in the control group. The global QoR-40 scores on both postoperative days 1 and 2 were significantly higher in the SPB group than in the control group (estimated mean difference 8.5, 97.5% confidence interval [CI], 2.1–15.0, and P = .003; 8.5, 97.5% CI, 2.0–15.1, and P = .004, respectively). The overall mean difference between the SPB and control groups was 8.5 (95% CI, 3.3–13.8; P = .002). Pain scores at rest and opioid consumption were significantly lower up to 6 hours after surgery in the SPB group than in the control group. Cumulative opioid consumption was significantly lower up to 24 hours postoperatively in the SPB group. CONCLUSIONS: Single-injection SPB with ropivacaine enhanced the quality of recovery for 2 days postoperatively and improved postoperative analgesia during the early postoperative period in patients undergoing video-assisted thoracic surgery. Accepted for publication November 28, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Hyun Jeong Kwak, MD, PhD, Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, 1198 Guwol-dong, Namdong-gu, Incheon 405–760, Republic of Korea. Address e-mail to hyun615@gilhospital.com. © 2018 International Anesthesia Research Society

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Complications Associated With Mortality in the National Surgical Quality Improvement Program Database

BACKGROUND: Attributing causes of postoperative mortality is challenging, as death may be multifactorial. A better understanding of complications that occur in patients who die is important, as it allows clinicians to focus on the most impactful complications. We sought to determine the postoperative complications with the strongest independent association with 30-day mortality. METHODS: Data were obtained from the 2012–2013 National Surgical Quality Improvement Program Participant Use Data Files. All inpatient or admit day of surgery cases were eligible for inclusion in this study. A multivariable least absolute shrinkage and selection operator regression analysis was used to adjust for patient pre- and intraoperative risk factors for mortality. Attributable mortality was calculated using the population attributable fraction method: the ratio between the odds ratio for mortality and a given complication in the population. Patients were separated into 10 age groups to facilitate analysis of age-related differences in mortality. RESULTS: A total of 1,195,825 patients were analyzed, and 9255 deceased within 30 days (0.77%). A complication independently associated with attributable mortality was found in 1887 cases (20%). The most common causes of attributable mortality (attributable deaths per million patients) were bleeding (n = 368), respiratory failure (n = 358), septic shock (n = 170), and renal failure (n = 88). Some complications, such as urinary tract infection and pneumonia, were associated with attributable mortality only in older patients. DISCUSSION: Additional resources should be focused on complications associated with the largest attributable mortality, such as respiratory failure and infections. This is particularly important for complications disproportionately impacting younger patients, given their longer life expectancy. Accepted for publication December 5, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Robert E. Freundlich, MD, MS, 1211 21st Ave S, Suite MAB 526, Nashville, TN 37212. Address e-mail to Robert.e.freundlich@vanderbilt.edu. © 2018 International Anesthesia Research Society

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Five Steps to Successfully Implement and Evaluate Propensity Score Matching in Clinical Research Studies

In clinical research, the gold standard level of evidence is the randomized controlled trial (RCT). The availability of nonrandomized retrospective data is growing; however, a primary concern of analyzing such data is comparability of the treatment groups with respect to confounding variables. Propensity score matching (PSM) aims to equate treatment groups with respect to measured baseline covariates to achieve a comparison with reduced selection bias. It is a valuable statistical methodology that mimics the RCT, and it may create an "apples to apples" comparison while reducing bias due to confounding. PSM can improve the quality of anesthesia research and broaden the range of research opportunities. PSM is not necessarily a magic bullet for poor-quality data, but rather may allow the researcher to achieve balanced treatment groups similar to a RCT when high-quality observational data are available. PSM may be more appealing than the common approach of including confounders in a regression model because it allows for a more intuitive analysis of a treatment effect between 2 comparable groups. We present 5 steps that anesthesiologists can use to successfully implement PSM in their research with an example from the 2015 Pediatric National Surgical Quality Improvement Program: a validated, annually updated surgery and anesthesia pediatric database. The first step of PSM is to identify its feasibility with regard to the data at hand and ensure availability of data on any potential confounders. The second step is to obtain the set of propensity scores from a logistic regression model with treatment group as the outcome and the balancing factors as predictors. The third step is to match patients in the 2 treatment groups with similar propensity scores, balancing all factors. The fourth step is to assess the success of the matching with balance diagnostics, graphically or analytically. The fifth step is to apply appropriate statistical methodology using the propensity-matched data to compare outcomes among treatment groups. PSM is becoming an increasingly more popular statistical methodology in medical research. It often allows for improved evaluation of a treatment effect that may otherwise be invalid due to a lack of balance between the 2 treatment groups with regard to confounding variables. PSM may increase the level of evidence of a study and in turn increases the strength and generalizability of its results. Our step-by-step approach provides a useful strategy for anesthesiologists to implement PSM in their future research. Accepted for publication November 21, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Reprints will not be available from the authors. Address correspondence to Steven J. Staffa, MS, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to Steven.Staffa@childrens.harvard.edu. © 2018 International Anesthesia Research Society

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Adding to Our Competitive Advantage: Making the Case for Teaching Communication and Professionalism

No abstract available

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Hydroxyethyl Starch 130/0.4 and Its Impact on Perioperative Outcome: A Propensity Score Matched Controlled Observation Study

BACKGROUND: Adverse effects of hydroxyethyl starches (HESs) have been verified in patients suffering from sepsis or kidney disease, but not in surgical patients at large. The investigation aimed to determine whether the use of HES 130/0.4 was associated with the incidence of acute postinterventional adverse events compared to Ringer's acetate alone in a perioperative setting. METHODS: This propensity score matched, controlled observational study was performed in a single-centre university hospital. The perioperative data of 9085 patients were analyzed. Group matching was based on 13 categories including demographic data, type of procedure, and 5 preexisting comorbidities. Duration of procedure and intraoperative transfusion requirements were integrated in the matching process to reduce selection and indication bias. The primary outcome was incidence of postoperative kidney failure. Secondary outcomes were in-hospital mortality, fluid requirements, blood loss, hemodynamic stability, and the need for postoperative intensive care unit (ICU) treatment. RESULTS: The administration of HES 130/0.4 was not associated with an increased frequency of postoperative kidney failure. In-hospital mortality (Ringer's acetate: 2.58%; HES 130/0.4: 2.68%) and the need for ICU care (Ringer's acetate: 30.5%; HES 130/0.4: 34.3%) did not differ significantly between groups. Significant intergroup differences were observed for mean blood loss (Ringer's acetate: 406 ± 821 mL; HES 130/0.4: 867 ± 1275 mL; P

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Nonpharmacologic Management of Acute Singultus (Hiccups)

No abstract available

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In Response

No abstract available

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α-Asarone Alleviated Chronic Constriction Injury–Induced Neuropathic Pain Through Inhibition of Spinal Endoplasmic Reticulum Stress in an Liver X Receptor–Dependent Manner

BACKGROUND: Neuropathic pain is an intractable and complex disease. Recent studies have shown a close relationship between endoplasmic reticulum (ER) stress and neuropathic pain. Here, we investigated the effect of α-asarone, an ER stress inhibitor, on chronic constriction injury (CCI)–induced neuropathic pain. METHODS: Two parts were included in this study. In part 1, rats were assigned to 7 groups: the sham group, the sham + α-asarone 20 mg/kg group, the CCI group, the CCI + vehicle group, the CCI + α-asarone 5 mg/kg group, the CCI + α-asarone 10 mg/kg group, and the CCI + α-asarone 20 mg/kg group. After surgery, the rats were treated with α-asarone or normal saline daily. Pain thresholds were measured, and samples of the L3–6 spinal cord were taken for western blotting and immunofluorescence on day 7. In part 2, rats were intrathecally implanted with PE-10 tubes and divided into 4 groups: the CCI + α-asarone 20 mg/kg group, the CCI + α-asarone 20 mg/kg + vehicle group, the CCI + α-asarone 20 mg/kg + SR9243 group, and the CCI group. Five rats in each group were separated for behavioral tests 1 hour after intrathecal injection. The rest of them were killed for western blotting on day 7. RESULTS: In this study, CCI surgery significantly induced mechanical allodynia and thermal hyperalgesia. CCI surgery significantly induced activation of ER stress (PERK-eIF2α, IRE1α, CHOP, and XBP-1s) in rats. However, treatment with 20 mg/kg of α-asarone significantly alleviated CCI-induced activation of ER stress. Behavioral results showed that daily treatment with 20 mg/kg of α-asarone significantly alleviated CCI-induced nociceptive behaviors, on day 7 (mechanical allodynia, P = .016, 95% confidence interval, 0.645–5.811; thermal hyperalgesia, P = .012, 95% confidence interval, 0.860–6.507). Furthermore, α-asarone induced upregulated expression of liver X receptor β (LXRβ) and downstream proteins in the spinal cord. The LXR antagonist SR9243 completely inhibited the anti-ER stress and antinociceptive effects of α-asarone in rats. CONCLUSIONS: α-Asarone relieved CCI-induced neuropathic pain in an LXR-dependent manner. α-Asarone may be a potential agent for treatment of neuropathic pain. Accepted for publication November 30, 2017. Funding: This study was supported by grants from the National Natural Science Foundation of China (81471135, 81771206, and 81271244 to Dr Zou) and the Natural Science Funds for Distinguished Young Scholar of Hunan Province (2017JJ1036 to Dr Zou). The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Wangyuan Zou, MD, PhD, Department of Anesthesiology, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, Hunan 410008, China. Address e-mail to wangyuanzou@csu.edu.cn. © 2018 International Anesthesia Research Society

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Human papillomavirus and nasopharyngeal cancer

Abstract

Background

There are no existing high-volume studies characterizing human papillomavirus (HPV)-associated nasopharyngeal cancer (NPC).

Methods

The National Cancer Data Base (NCDB) was queried for NPC with known HPV (2004-2013). Logistic regression ascertained factors associated with HPV-positivity. Kaplan-Meier overall survival (OS) was evaluated between HPV-positive and HPV-negative cohorts; Cox proportional hazards modeling assessed factors associated with OS. Patients with nonmetastatic disease receiving definitive chemoradiotherapy underwent propensity-matched OS analysis.

Results

Altogether, 956 patients were analyzed (32% HPV-positive and 68% HPV-negative). Median follow-up was 23 months (range 0-67 months). The patients with HPV-positive disease were younger, less likely to be uninsured, lived in more educated areas, and presented with more advanced T (but not N/overall) classification. Median OS for HPV-positive and HPV-negative groups were 50 and 43 months, respectively (P = .171). The HPV status did not independently predict for OS (P = .183). No OS differences were observed after propensity matching (P = .734).

Conclusion

In what we believe as the only large study of HPV-associated NPC, HPV neither correlates with nor predicts survival in NPC. Owing to the difficulty of addressing causality in database studies, further work must corroborate the findings herein.

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Human papillomavirus in the nasopharynx: A true entity?

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Monitoring of patient’s molecular markers in liver and thyroid during the study. Alanine aminotransferase (ALT); Aspartate aminotransferase (AST); Alkaline phosphatase (AP); Gamma-glutamyl transferase (GGT); Indirect (unconjugated) bilirubin (IB); Free thyroxine (Free T4); Free triiodothyronine (Free T3); Liver function test (LFT); Thyroid hormones (TH).

Figure 1: Monitoring of patient's molecular markers in liver and thyroid during the study. Alanine aminotransferase (ALT); Aspartate aminotransferase (AST); Alkaline phosphatase (AP); Gamma-glutamyl transferase (GGT); Indirect (unconjugated) bilirubin (IB); Free thyroxine (Free T4); Free triiodothyronine (Free T3); Liver function test (LFT); Thyroid hormones (TH).

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Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive end-expiratory pressure

BACKGROUND Harmful effects of spontaneous breathing have been shown in experimental severe acute respiratory distress syndrome (ARDS). However, in the clinical setting, spontaneous respiration has been indicated only in mild ARDS. To date, no study has compared the effects of spontaneous assisted breathing with those of fully controlled mechanical ventilation at different levels of positive end-expiratory pressure (PEEP) on lung injury in ARDS. OBJECTIVE To compare the effects of assisted pressure support ventilation (PSV) with pressure-controlled ventilation (PCV) on lung function, histology and biological markers at two different PEEP levels in mild ARDS in rats. DESIGN Prospective, randomised, controlled experimental study. SETTING Basic science laboratory. PARTICIPANTS Thirty-five Wistar rats (weight ± SD, 310 ± 19) g received Escherichia coli lipopolysaccharide (LPS) intratracheally. After 24 h, the animals were anaesthetised and randomly allocated to either PCV (n=14) or PSV (n=14) groups. Each group was further assigned to PEEP = 2 cmH2O or PEEP = 5 cmH2O. Tidal volume was kept constant (≈6 ml kg−1). Additional nonventilated animals (n=7) were used as a control for postmortem analysis. MAIN OUTCOME MEASURES Ventilatory and mechanical parameters, arterial blood gases, diffuse alveolar damage score, epithelial integrity measured by E-cadherin tissue expression, and biological markers associated with inflammation (IL-6 and cytokine-induced neutrophil chemoattractant, CINC-1) and type II epithelial cell damage (surfactant protein-B) were evaluated. RESULTS In both PCV and PSV, peak transpulmonary pressure was lower, whereas E-cadherin tissue expression, which is related to epithelial integrity, was higher at PEEP = 5 cmH2O than at PEEP = 2 cmH2O. In PSV, PEEP = 5 cmH2O compared with PEEP = 2 cmH2O was associated with significantly reduced diffuse alveolar damage score [median (interquartile range), 11 (8.5 to 13.5) vs. 23 (19 to 26), P = 0.005] and expressions of IL-6 and CINC-1 (P = 0.02 for both), whereas surfactant protein-B mRNA expression increased (P = 0.03). These changes suggested less type II epithelial cell damage at a PEEP of 5 cmH2O. Peak transpulmonary pressure correlated positively with IL-6 [Spearman's rho (ρ) = 0.62, P = 0.0007] and CINC-1 expressions (ρ = 0.50, P = 0.01) and negatively with E-cadherin expression (ρ = −0.67, P = 0.0002). CONCLUSION During PSV, PEEP of 5 cmH2O, but not a PEEP of 2 cmH2O, reduced lung damage and inflammatory markers while maintaining epithelial cell integrity. Correspondence to Pedro L. Silva, PhD, Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, 21941-902 Rio de Janeiro, RJ, Brazil Tel: +55 21 3938 6530; fax: +55 21 2280 8193; e-mail: pedro.leme@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Fibrinolysis and antifibrinolytic treatment in the trauma patient

Purpose of review The role of antifibrinolytics in trauma haemorrhage and early coagulopathy remains controversial with respect to patient selection, dosage, timing of treatment, and risk of thrombotic complications. This review presents our current understanding of the mechanisms of fibrinolysis in trauma, diagnostic evaluation, and the evidence base for treatment. Recent findings Excessive fibrinolysis following severe injury is a major component of acute traumatic coagulopathy and contributes to the high mortality from trauma haemorrhage. The protein C pathway, endothelial dysfunction, platelet activity, shock, and tissue injury are key to the development of hyper fibrinolysis in trauma. D-dimer and viscoelastic haemostatic assays (rotational thromboelastometry, TEG) remain the best available diagnostic modalities but have a number of limitations compared with plasma biomarkers of fibrinolytic activation, for example, plasmin-α2-antiplasmin complex. Current evidence supports the continued empiric use of tranexamic acid in major trauma haemorrhage. Summary Improving the outcomes for bleeding trauma patients requires a deeper understanding of the mechanisms driving hyperfibrinolysis and the subsequent switch toward a prothrombotic state. Discovering the interplay between platelet activity, fibrinogen utilization, the immune response, and the fibrinolytic system may lead to development of novel therapeutics. Correspondence to Ross A. Davenport, Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, UK. Tel: +44 020 737 40723; E-mail: ross.davenport@qmul.ac.uk Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Renal replacement therapy in critically ill patients: who, when, why, and how

Purpose of review The increasing incidence of acute kidney injury has the immediate effect of a growing need for renal replacement therapy (RRT). Shedding light on the questions of who, when, why, and how RRT should be performed is difficult to accomplish because of ambiguous study results, poor quality evidence, and low standardization. Recent findings Critically ill patients are exposed to multiple factors known to deteriorate kidney function. Especially severe fluid overload is strongly associated with worse outcome and may be considered as a trigger for initiating RRT. In the absence of life-threatening complications, a strategy of early initiation of RRT might be most advantageous keeping in mind the potential adverse effects of RRT. By providing better hemodynamic stability and superior control of fluid balance continuous RRT is the first choice therapeutic tool as compared with intermittent techniques. The femoral and jugular veins are the preferred insertion sites for temporary catheters. Although data are still weak, there is some preliminary evidence that regional citrate anticoagulation is superior to systemic heparinization. Summary The best management of RRT is still a subject of controversy. Continuous RRT with regional citrate anticoagulation via a temporary catheter in a jugular vein is the recommended first choice treatment option in critically ill patients with acute kidney injury. Correspondence to Alexander Zarbock, MD, University of Münster, Department of Anesthesiology, Intensive Care and Pain Medicine, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany. Tel: +49 (251) 8347282; fax: +49 (251) 8844057; e-mail: zarbock@uni-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Storage injury and blood transfusions in trauma patients

Purpose of review The aim of the present review was to concisely summarize recent studies and current knowledge about effects of red blood cell storage injury in trauma patients. Recent findings Despite a pathophysiological rationale for older packed red blood cells (PRBCs) being associated with adverse events in the host organism, recent large clinical trials failed to show negative effects of transfusion with older PRBCs on clinically relevant outcomes in mixed patient population. However, there is a lack of well-designed randomized controlled trials focusing on the effects of storage lesion of PRBCs in trauma patients. Summary In the absence of specific evidence for trauma patients, we recommend to continue with a conservative transfusion regime and standard of care blood banking practice of using older PRBCs first. Correspondence to Haibo Zhang, MD, PhD, Interdepartmental Division of Critical Care Medicine, Departments of Anesthesia and Physiology, University of Toronto, Room 619, LKSKI, 30 Bond Street, Toronto, ON M5B 1W8, Canada. E-mail: zhangh@smh.ca Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Presentation of Lesions of Nose and Paranasal Sinuses at a Tertiary Care Center in Central India

Abstract

A variety of non-neoplastic and neoplastic conditions involve the nasal cavity, paranasal sinus and are fairly common presentation encountered in clinical practice. Sinonasal lesions are a common finding in all age groups. The lesion of nose and paranasal sinuses are very deceptive so, the presenting features, clinical examination, nasal endoscopy, radiodiagnosis and histopathology are employed conjointly to reach a diagnosis. This cross sectional study was conducted between November 2014 and September 2016. 150 patients with nasal or paranasal sinus lesions attending ENT OPD were included. Among 150 patients there was a male predominance in all lesion except malignant lesions and most of the patients 72 (48%) were in the age group 11– 30 years. Mean age of presentation for benign lesions was 33.64 years and of malignant lesions was 49.14 years. The study showed that 96 (64%) of the nose and PNS lesions were of inflammatory nature followed by 22 (15%) benign, 18 (12%) granulomatous and 14 (9%) malignant, Inflammatory polyp being the most common diagnosis. Haemangioma was the most common benign neoplastic lesion whereas in granulomatous lesions most common diagnosis was tuberculosis. The maximum lesions 74 (49%) were in maxillary antrum. The most common clinical presentation was nasal obstruction, with unilateral nasal obstruction seen in 84 (56%) cases and bilateral nasal obstruction in 50 (33.3%) cases. Angiofibroma 6 (4%) was exclusively seen in adolescent males. Olfactory neuroblastoma 4 (2.6%) was diagnosed in females with mean age of presentation of 30 years. Sinonasal lesions display a complex and interesting spectrum of clinical, radiological and histopathologic features. The non-neoplastic lesions are numerous, the morphologic variants of neoplasms are many and most of them present as polypoid masses which are impossible to distinguish clinically. Hence a proper workup including histopathological and radiological categorization is essential in the management of these lesions.

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Strengthening the case for gender-neutral and the nonavalent HPV vaccine

Abstract

Purpose

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020.

Methods

PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)].

Results

There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a "herd effect" for females by preventing the propagation of the virus.

Conclusion

Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

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In This Issue

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Cover

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Subscriptions

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Table of Contents

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Rbm10 regulates inflammation development via alternative splicing of Dnmt3b

Abstract

RNA-binding motif 10 (Rbm10) is an RNA-binding protein that regulates alternative splicing, but its role in inflammation is not well defined. Here, we show that Rbm10 controls appropriate splicing of DNA (cytosine-5)-methyltransferase 3b (Dnmt3b), a DNA methyltransferase, to regulate the activity of NF-κB-responsive promoters and consequently inflammation development. Rbm10 deficiency suppressed NF-κB-mediated responses in vivo and in vitro. Mechanistic analysis showed that Rbm10 deficiency decreased promoter recruitment of NF-κB, with increased DNA methylation of the promoter regions in NF-κB-responsive genes. Consistently, Rbm10 deficiency increased the expression level of Dnmt3b2, which has enzyme activity, while it decreased the splicing isoform Dnmt3b3, which does not. These two isoforms associated with NF-κB efficiently, and overexpression of enzymatically active Dnmt3b2 suppressed the expression of NF-κB targets, indicating that Rbm10-mediated Dnmt3b2 regulation is important for the induction of NF-κB-mediated transcription. Therefore, Rbm10-dependent Dnmt3b regulation is a possible therapeutic target for various inflammatory diseases.

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Extensively re-organized systemic lymph nodes provide a feasible environment for self-reactivity in lupus-prone NZB × NZW F1 mice

Abstract

Lymphadenopathy is a frequently observed symptom in systemic lupus erythematosus, although the immunological role of lymph nodes (LNs) in systemic autoimmunity remains largely unknown. Here, we performed comprehensive and systematic analyses of LNs in lupus-prone NZB × NZW F1 (BWF1) mice, demonstrating extensive tissue re-organization of the systemic LNs with follicular expansion, hyper germinal center (GC) formation, atrophy of the paracortical T-cell area and expansion of the medulla in aged BWF1 mice bearing glomerulonephritis. The proportion of B cells was significantly increased in these reactive LNs but not in the spleen, and lymphocyte subsets involved in antibody production, i.e. GC B cells, follicular helper T cells and plasma cells, were elevated. Draining LNs of the affected organs, such as the renal and cervical nodes, showed enhanced tissue re-organization and accumulation of effector lymphocytes, suggesting the presence of a positive feedback loop of regional responses. LN cells isolated from disease-bearing animals produced anti-DNA antibody, indicating activation of autoreactive lymphocytes in situ. The substantial development of disease and LN alterations in mice that received a splenectomy at a young age points to the importance of other secondary lymphoid organs, most likely LNs, for the progression of autoimmune responses independent of the spleen. Taken together, our findings highlight the value of taking LN alterations and activities into consideration for understanding the pathogenesis of systemic autoimmunity.

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Lysosome biogenesis regulated by the amino-acid transporter SLC15A4 is critical for functional integrity of mast cells

Abstract

Mast cells possess specialized lysosomes, so-called secretory granules, which play a key role not only in allergic responses but also in various immune disorders. The molecular mechanisms that control secretory-granule formation are not fully understood. Solute carrier family member 15A4 (SLC15A4) is a lysosome-resident amino-acid/oligopeptide transporter that is preferentially expressed in hematopoietic lineage cells. Here, we demonstrated that SLC15A4 is required for mast-cell secretory-granule homeostasis, and limits mast-cell functions and inflammatory responses by controlling the mTORC1–TFEB signaling axis. In mouse Slc15a4^−/− mast cells, diminished mTORC1 activity increased the expression and nuclear translocation of TFEB, a transcription factor, which caused secretory granules to degranulate more potently. This alteration of TFEB function in mast cells strongly affected the FcεRI-mediated responses and IL-33-triggered inflammatory responses both in vitro and in vivo. Our results reveal a close relationship between SLC15A4 and secretory-granule biogenesis that is critical for the functional integrity of mast cells.

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Impact of donor and recipient human cytomegalovirus status on kidney transplantation

Abstract

Human cytomegalovirus (HCMV) is considered to be a major pathogen that affects the outcome of solid organ transplantation (TX). Both recipient and donor may be HCMV positive, therefore HCMV re-infection is possible after TX. However, little is known how cytomegalovirus (CMV) transmitted from an infected donor to an infected recipient modulates the recipient's already suppressed immunity, and what the clinical consequences are. To investigate these issues, 52 kidney recipients were followed up for 2 years after TX. T, B and natural killer (NK) lymphocytes, naive and memory T subsets, CD28 expression, relative telomere length, CMV-specific lymphocytes and serum cytokines were measured several times post-TX. Patients were monitored for signs of CMV viremia and other infections. The most important observation was that CMV-specific lymphocytes expand vastly in HCMV-infected recipients who received kidneys from infected donors, in comparison with uninfected donors. Despite this, a higher rate of HCMV viremia was found. Immune deterioration was confirmed by an increased number of CD28-negative T lymphocytes, inverted CD4/CD8 index and shortened telomeres. This was superior in HCMV-infected recipients transplanted from infected donors, when compared with uninfected. In conclusion, CMV alters the immune system in kidney transplant recipients and promotes immune exhaustion.

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Presentation of Lesions of Nose and Paranasal Sinuses at a Tertiary Care Center in Central India

Abstract

A variety of non-neoplastic and neoplastic conditions involve the nasal cavity, paranasal sinus and are fairly common presentation encountered in clinical practice. Sinonasal lesions are a common finding in all age groups. The lesion of nose and paranasal sinuses are very deceptive so, the presenting features, clinical examination, nasal endoscopy, radiodiagnosis and histopathology are employed conjointly to reach a diagnosis. This cross sectional study was conducted between November 2014 and September 2016. 150 patients with nasal or paranasal sinus lesions attending ENT OPD were included. Among 150 patients there was a male predominance in all lesion except malignant lesions and most of the patients 72 (48%) were in the age group 11– 30 years. Mean age of presentation for benign lesions was 33.64 years and of malignant lesions was 49.14 years. The study showed that 96 (64%) of the nose and PNS lesions were of inflammatory nature followed by 22 (15%) benign, 18 (12%) granulomatous and 14 (9%) malignant, Inflammatory polyp being the most common diagnosis. Haemangioma was the most common benign neoplastic lesion whereas in granulomatous lesions most common diagnosis was tuberculosis. The maximum lesions 74 (49%) were in maxillary antrum. The most common clinical presentation was nasal obstruction, with unilateral nasal obstruction seen in 84 (56%) cases and bilateral nasal obstruction in 50 (33.3%) cases. Angiofibroma 6 (4%) was exclusively seen in adolescent males. Olfactory neuroblastoma 4 (2.6%) was diagnosed in females with mean age of presentation of 30 years. Sinonasal lesions display a complex and interesting spectrum of clinical, radiological and histopathologic features. The non-neoplastic lesions are numerous, the morphologic variants of neoplasms are many and most of them present as polypoid masses which are impossible to distinguish clinically. Hence a proper workup including histopathological and radiological categorization is essential in the management of these lesions.

http://ift.tt/2FpQrEm