Πέμπτη 12 Απριλίου 2018
Asymmetrical intrapleural pressure distribution: a cause for scoliosis? A computational analysis
Abstract
Purpose
The mechanical link between the pleural physiology and the development of scoliosis is still unresolved. The intrapleural pressure (IPP) which is distributed across the inner chest wall has yet been widely neglected in etiology debates. With this study, we attempted to investigate the mechanical influence of the IPP distribution on the shape of the spinal curvature.
Methods
A finite element model of pleura, chest and spine was created based on CT data of a patient with no visual deformities. Different IPP distributions at a static end of expiration condition were investigated, such as the influence of an asymmetry in the IPP distribution between the left and right hemithorax. The results were then compared to clinical data.
Results
The application of the IPP resulted in a compressive force of 22.3 N and a flexion moment of 2.8 N m at S1. An asymmetrical pressure between the left and right hemithorax resulted in lateral deviation of the spine towards the side of the reduced negative pressure. In particular, the pressure within the dorsal section of the rib cage had a strong influence on the vertebral rotation, while the pressure in medial and ventral region affected the lateral displacement.
Conclusions
An asymmetrical IPP caused spinal deformation patterns which were comparable to deformation patterns seen in scoliotic spines. The calculated reaction forces suggest that the IPP contributes in counterbalancing the weight of the intrathoracic organs. The study confirms the potential relevance of the IPP for spinal biomechanics and pathologies, such as adolescent idiopathic scoliosis.
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Editorial Board
Publication date: May 2018
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms, Volume 1861, Issue 5
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Conserved association of Argonaute 1 and 2 proteins with miRNA and siRNA pathways throughout insect evolution, from cockroaches to flies
Publication date: Available online 12 April 2018
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Mercedes Rubio, Jose Luis Maestro, Maria-Dolors Piulachs, Xavier Belles
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Perioperative management of transcatheter, aortic and mitral, double valve-in-valve implantation during pregnancy through left ventricular apical approach
Annals of Cardiac Anaesthesia 2018 21(2):185-188
Pregnant women with stenotic degeneration of bioprosthetic cardiac valves may require another valve replacement procedure when their symptoms deteriorate with progression of pregnancy, but fetal mortality is higher with cardiac surgery done on cardiopulmonary bypass. Transcatheter valve-in-valve implantation may help to improve the fetal and maternal outcomes in these situations. Double valve-in-valve implantation is rare and has not been reported in a pregnant patient. We report, for the first time, the case of a pregnant woman with stenotic bioprosthetic valves in the mitral and aortic positions, who underwent a successful concomitant, transcatheter, double valve-in-valve implantation through the left ventricular apical route during the second trimester of her precious pregnancy.
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Dishonesty in medical research and publication and the remedial measures
Annals of Cardiac Anaesthesia 2018 21(2):111-113
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Absent right superior vena cava and persistent left superior vena cava in a patient with bicuspid aortic valve with aortic stenosis
Annals of Cardiac Anaesthesia 2018 21(2):212-214
Persistent left superior vena cava (LSVC) with absent right SVC (RSVC) is a rare congenital anomaly. If undetected, the condition may pose difficulties in central venous catheter insertion, pacemaker electrode insertion, and cannulation during cardiopulmonary bypass. We describe a case of persistent LSVC with absent RSVC, who was diagnosed to have bicuspid aortic valve with aortic stenosis.
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Immediate extubation after cardiac surgery should be part of routine anesthesia practice for selected patients
Annals of Cardiac Anaesthesia 2018 21(2):114-115
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Anesthetic challenges of a patient with the communicating bulla coming for nonthoracic surgery
Annals of Cardiac Anaesthesia 2018 21(2):200-202
Management of a patient with a giant bulla coming for a nonthoracic surgery is rare, and its anesthetic management is very challenging. It is imperative to isolate only the subsegmental bronchus, in which the bulla communicates to avoid respiratory morbidities such as pneumothorax, emphysema or atelectasis of the surrounding lung parenchyma, and postoperative respiratory failure. Herewith, we want to report the anesthetic challenges of a patient with giant bulla communicating into one of the subsegmental right upper lobe bronchus for splenectomy.
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Pulmonary hypertension and cardiac anesthesia: Anesthesiologist's perspective
Annals of Cardiac Anaesthesia 2018 21(2):116-122
Perioperative management of pulmonary hypertension remains one of the most challenging scenarios during cardiac surgery. It is associated with high morbidity and mortality due to right ventricular failure, arrhythmias, myocardial ischemia, and intractable hypoxia. Therefore, this review article is intended toward the anesthetic considerations in the perioperative period, with particular emphasis on the selection of technique and choice of anesthesia with maintenance, anesthetic drugs, and the recent intraoperative recommendations for prevention and treatment of pulmonary hypertensive crisis.
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Retraction: Annals of cardiac anesthesia: Beacon journey toward excellence: 2015–2017
Annals of Cardiac Anaesthesia 2018 21(2):221-221
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Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study
Annals of Cardiac Anaesthesia 2018 21(2):123-128
Background: Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients. Aim and Objective: To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery. Materials and Methods: After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index (CI), pulmonary capillary wedge pressure (PCWP), pulse oximetry, and arterial blood gases with serum lactates at as T0 (baseline), T1 (15 min after obtuse marginal and/or PDA anastomoses), T2 (at end of surgery), T3 (6 h after surgery in Intensive Care Unit [ICU]), T4 (12 h after surgery), and T5 (24 h after surgery in ICU). Vasopressor was added to maintain mean arterial pressure >60 mmHg. Chi-square/Fisher's exact/Mid P exact test and Student's t-tests were applied for categorical and continuous data. Results: CI was greater and PCWP reduced significantly in Group L during intraoperative and early postoperative period. Serum lactate concentration was lower in patients pretreated with levosimendan. Incidence of postoperative atrial fibrillation (POAF) (36.6 vs. 6.6%; P = 0.01), low cardiac output syndrome (LCOS) (30% vs. 6%; P = 0.02), and acute kidney injury (23.3% vs. 6.7%; P = 0.04) was less in Group L. Three patients (10%) in control group required conversion to cardiopulmonary bypass (CPB) as compared to none in the study group. There was no difference regarding ICU or hospital stay and mortality in both groups. Conclusion: Preoperative levosimendan helps in successful conduct of OPCAB and reduces the incidence of LCOS, POAF, conversion to CPB, and requirement of intra-aortic balloon pump.
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Inverted left atrial appendage during minimally invasive mitral valve repair
Annals of Cardiac Anaesthesia 2018 21(2):192-194
Inverted left atrial appendage (LAA) is a rare complication in cardiac surgery. The echocardiographic appearance often leads to misdiagnosis of thrombus or some other cardiac mass. Patients misdiagnosed in this way often undergo unnecessary anticoagulation or surgical treatment. Recently, minimally invasive mitral valve surgery (MIMVS) has become more widespread. However, as the incision for MIMVS through the right thoracotomy is very small, the inverted LAA is not within the surgical field of the cardiac surgeon. We present a case of inverted LAA during MIMVS and provide images from transesophageal echocardiography.
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Comparison of immediate extubation versus ultrafast tracking strategy in the management of off-pump coronary artery bypass surgery
Annals of Cardiac Anaesthesia 2018 21(2):129-133
Introduction: Ultrafast tracking of anesthesia (UFTA) is practiced routinely, whereas immediate on-table extubation after off-pump coronary artery bypass (OPCAB) grafting surgery has many concerns. The purpose of our study was to evaluate the safety and feasibility of immediate extubation (IE) versus UFTA. Methods: Sixty patients were enrolled who underwent OPCAB surgery. The two groups IE and UFTA had thirty patients each. Inclusion criteria were patients for OPCAB surgery including left main stenosis. Exclusion criteria were patients with Ejection Fraction(EF) <30%, with unstable hemodynamics, on intra-aortic balloon pump (IABP), with renal dysfunction, with associated valvular heart diseases, on inotropes, on temporary pacemaker, with intraoperative conversion to on-pump coronary artery bypass grafting (CABG), who are chronic smokers, and with chronic obstructive pulmonary disease. Statistical analysis was done with Minitab 15 software. Descriptive statistics were summarized as mean, standard deviation, and percentage. Student's t-test was used to determine the significance of normally distributed parametric values. Z-test was used for proportion. Statistical significance was accepted at P < 0.05. Results: OT extubation was found to be safe as no patient had reintubation or respiratory insufficiency. None of the patients in either group had postoperative myocardial infarction, stroke, low cardiac output, mediastinitis, and renal failure. Hypothermia, blood transfusion, atrial fibrillation, and re-exploration did not occur. Intensive Care Unit length of stay was similar in the two groups. Discharge day is statistically significant (P = 0.001), with 5.66 days in the IE group and 6.36 days in the UFTA group. Time spent in the operating room at the end of surgery is statistically significant, with 14.03 min in UFTA group and 33.9 min in IE group. Conclusion: IE appears to be safe and effective in OPCAB patients without any major complications. It can be achieved after fulfilling traditional extubation criteria but is confined to highly selective group of patients.
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Absent superior vena cava in tetralogy of fallot
Annals of Cardiac Anaesthesia 2018 21(2):205-207
Absent superior vena cava (SVC) is an asymptomatic congenital systemic venous anomaly which is rarely detected and compatible with normal life. Undiagnosed absent SVC may cause problems during cardiac catheterization or cardiac surgery. We present our surgical experience in a patient with tetralogy of Fallot who had undiagnosed absent SVC.
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Assessment of the effect of two regimens of milrinone infusion in pediatric patients undergoing fontan procedure: A randomized study
Annals of Cardiac Anaesthesia 2018 21(2):134-140
Objective: The aim of the study was to compare the effect of two different regimens of milrinone on hemodynamics and oxygen saturation in pediatric patients undergoing Fontan procedure. Design: This was a randomized study. Setting: Cardiac centers. Patients: This study included 116 patients undergoing Fontan procedure. Material and Methods: Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose at the beginning of cardiopulmonary bypass (CPB) followed by infusion 0.5–0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from CPB followed by infusion 0.5–0.75 μg/kg/min in the PSICU. Measurements: Heart rate, mean arterial blood pressure, central venous pressure, transpulmonary pressure, cardiac index, pharmacological support, lactate level, urine output, oxygen saturation, ICU, and hospital length of stay. Main Results: There were no changes in the heart rate and mean arterial blood pressure (P > 0.05). The increase in the postoperative central venous pressure, transpulmonary pressure and lactate level was lower in Group E than Group L (P < 0.05). The increase in the postoperative cardiac index, oxygen saturation, and urine output was higher in Group E than Group L (P < 0.05). The requirement for pharmacological support was lower in the Group E (P < 0.05). The ICU and hospital length of stay were shorter in the Group E than Group L (P < 0.05). Conclusion: Early use of milrinone during Fontan procedure facilitated the weaning from CPB, decreased the elevation in the central venous pressure, transpulmonary gradient pressure, and the requirement for pharmacological support. Furthermore, it increased the cardiac index and arterial oxygen saturation.
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Radio-opaque tricuspid aortic valve seen in X-Ray chest as mercedes-benz sign
Annals of Cardiac Anaesthesia 2018 21(2):218-219
We are presenting a very interesting X-ray image of the calcific aortic valve in a septuagenarian male patient who underwent successful aortic valve replacement.
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Milrinone: is bolus bad?
Annals of Cardiac Anaesthesia 2018 21(2):141-142
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View point: Retraction is a pain but scientific misconduct is a crime!
Annals of Cardiac Anaesthesia 2018 21(2):109-110
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Dexmedetomidine versus ketofol sedation for outpatient diagnostic transesophageal echocardiography: A randomized controlled study
Annals of Cardiac Anaesthesia 2018 21(2):143-150
Background: Moderate sedation is required for out-patient transesophageal echocardiography (TEE). Our objective was to compare the effect of Ketofol and dexmedetomidine for outpatient procedural sedation in diagnostic TEE with a hypothesis that Ketofol would be as effective as dexmedetomidine. Patients and Methods: Fifty adult patients of age group 18-60 years with atrial septal defect, rheumatic valvular heart disease undergoing diagnostic TEE in the outpatient echocardiography laboratory were randomized into two groups, group D and group KF. GROUP D: Dexmedetomidine infusion -200 μg in 20 ml normal saline. GROUP KF: Ketofol infusion: (ketamine: propofol, 1mg: 3 mg in 20 ml syringe). Loading dose of drug at 1ml/kg/hour IV till Ramsay sedation score (RSS) ≥ 3 achieved followed by maintenance infusion at 0.05 ml/kg/hour till end of procedure. Results: The primary outcome - time to achieve Ramsay sedation score ≥ 3 was significantly lesser with Ketofol as compared to Dexmedetomidine 260[69] seconds vs 460 [137], (p value<0.05).Conclusion: In out-patient setting, ketofol is favourable over dexmedetomidine for sedation regimen for diagnostic TEE as lesser time is taken to achieve optimal sedation with lesser hemodynamic perturbations, post procedure complications and better cardiologist satisfaction.
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Mitral valve repair in infective endocarditis during pregnancy
Annals of Cardiac Anaesthesia 2018 21(2):189-191
Infective endocarditis (IE) during pregnancy and subsequent cardiac surgery are rare and associated with a high risk of mortality for the mother and fetus. It is difficult to determine the right time for cardiac intervention when IE is diagnosed early in pregnancy. A 33-year-old previously healthy woman in the 11th week of pregnancy was diagnosed with IE and underwent surgical intervention. The cardiopulmonary bypass settings and the anesthetic drugs were carefully chosen. Although she was in good health, while being discharged, the fetus did not survive. Anesthesiologists prioritizing the mother's survival should aim to improve fetal outcomes in such cases.
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Utility of thromboelastography versus routine coagulation tests for assessment of hypocoagulable state in patients undergoing cardiac bypass surgery
Annals of Cardiac Anaesthesia 2018 21(2):151-157
Introduction: Peri-operative monitoring of coagulation is important to diagnose potential cause of hemorrhage, to manage coagulopathy and guide treatment with blood products in patients undergoing cardiac surgery with cardiopulmonary bypass. This study was done to evaluate usefulness of Thromboelastography (TEG) and routine coagulation tests (RCT) in assessing hemostatic changes and predicting postoperative bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: Fifty adult patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled in this prospective study. Preoperative and post-operative samples were collected for routine coagulation tests and TEG. Regression analysis and test of significance using Pearson's correlation coefficient was performed to assess correlation between routine coagulation tests and corresponding TEG parameters .Regression analysis was done to study relation between blood loss at 24 hours and various coagulation parameters. Results: The Routine coagulation test i.e. PT, INR, APTT showed no significant correlation with corresponding TEG parameters in pre-operative samples. However platelet count significantly correlated (p = 0.004) with MA values in postoperative samples. A significant correlation (p = 0.001) was seen between fibrinogen levels and alpha angles as well as with MA in both baseline preoperative and postoperative samples. TEG parameters R time and MA in postoperative samples were the only parameters that predicted bleeders with fair accuracy. Conclusion: Though the techniques of RCT and TEG are different, a few RCT e.g. platelet count and fibrinogen correlated with corresponding TEG parameters i.e. MA and Alpha angle. TEG parameters (R time and MA in postoperative samples) were able to predict blood loss better than RCT.
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Tricuspid stenosis: A rare and potential complication of ventricular septal occluder device
Annals of Cardiac Anaesthesia 2018 21(2):195-199
Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal defect an easy and effective management option. Although there are reports of aortic and tricuspid valvular regurgitation after deployment of ASOD, only few cases of tricuspid stenosis (TS) has been reported so far in the literature. We report a case of malaligned ASOD that occurred after successful device closure resulting in TS along with mild tricuspid and aortic regurgitation requiring surgical retrieval. Transesophageal echocardiography played crucial role in detecting the cause of tricuspid valve dysfunction besides providing continuous monitoring during the procedure. We intend to emphasize the need of echocardiographic evaluation of the tricuspid valvular apparatus and aortic valve during and after the device deployment even after the successful device closure to prevent this rare complication.
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Factors associated with delayed cardiac tamponade after cardiac surgery
Annals of Cardiac Anaesthesia 2018 21(2):158-166
Context: Cardiac tamponade (CT) following cardiac surgery is a potentially fatal complication and the cause of surgical reintervention in 0.1%–6% of cases. There are two types of CT: acute, occurring within the first 48 h postoperatively, and subacute or delayed, which occurs more than 48 h postoperatively. The latter does not show specific clinical signs, which makes it more difficult to diagnose. The factors associated with acute CT (aCT) are related to coagulopathy or surgical bleeding, while the variables associated with subacute tamponade have not been well defined. Aims: The primary objective of this study was to identify the factors associated with the development of subacute CT (sCT). Settings and Design: This report describes a case (n = 80) and control (n = 160) study nested in a historic cohort made up of adult patients who underwent any type of urgent or elective cardiac surgery in a tertiary cardiovascular hospital. Methods: The occurrence of sCT was defined as the presence of a compatible clinical picture, pericardial effusion and confirmation of cardiac tamponade during the required emergency intervention at any point between 48 hours and 30 days after surgery. All factors potentially related to the development of sCT were taken into account. Statistical Analysis Used: For the adjusted analysis, a logistical regression was constructed with 55 variables, including pre-, intra-, and post-operative data. Results: The mortality of patients with sCT was 11% versus 0% in the controls. Five variables were identified as independently and significantly associated with the outcome: pre- or post-operative anticoagulation, reintervention in the first 48 h, surgery other than coronary artery bypass graft, and red blood cell transfusion. Conclusions: Our study identified five variables associated with sCT and established that this complication has a high mortality rate. These findings may allow the implementation of standardized follow-up measures for patients identified as higher risk, leading to either early detection or prevention.
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Next-Generation Sequencing of the Complete Mitochondrial Genome of the Endangered Species Black Lion Tamarin Leontopithecus chrysopygus (Primates) and Mitogenomic Phylogeny Focusing on the Callitrichidae Family
We describe the complete mitochondrial genome sequence of the Black Lion Tamarin, an endangered primate species endemic to the Atlantic Rainforest of Brazil. We assembled the Leontopithecus chrysopygus mitogenome, through analysis of 523M base pairs (bp) of short reads produced by next-generation sequencing (NGS) on the Illumina Platform, and investigated the presence of nuclear mitochondrial pseudogenes and heteroplasmic sites. Additionally, we conducted phylogenetic analyses using all complete mitogenomes available for primates until June 2017. The single circular mitogenome of BLT showed organization and arrangement that are typical for other vertebrate species, with a total of 16618 bp, containing 13 protein-coding genes, 22 transfer RNA genes, 2 ribosomal RNA genes, and 1 non-coding region (D-loop region). Our full phylogenetic tree is based on the most comprehensive mitogenomic dataset for Callitrichidae species to date, adding new data for the Leontopithecus genus, and discussing previous studies performed on primates. Moreover, the mitochondrial genome reported here consists of a robust mitogenome with 3000X coverage, which certainly will be useful for further phylogenetic and evolutionary analyses of Callitrichidae and higher taxa.
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A retrospective investigation of HLA-B*5801 in hyperuricemia patients in a Han population of China
Background Hyperuricemia and gout have become increasingly prevalent in China. Allopurinol is an effective urate-lowering therapy, but it has severe side effects. HLA-B*5801 is highly associated with the allopurinol-induced toxic epidermal necrolysis and Stevens–Johnson syndrome. Patients and methods In this retrospective report, we had genotyped HLA-B*5801 in 253 cases of hyperuricemia and gout patients in a Han population in Shenzhen and analyzed the clinical management of medications. Results We found 30 carriers of the HLA-B*5801 allele in 253 cases of hyperuricemia or gout patients in the population (11.9%). Allopurinol was prescribed in both HLA-B*5801-positive and HLA-B*5801-negative groups. The evaluation of four models with or without genetic screening and management of allopurinol or febuxostat indicated that the HLA-B*5801 screening had significant cost benefit for clinical management. Conclusion For appropriate management and cost-effectiveness, the HLA-B*5801 allele should be screened in all patients with hyperuricemia and gout in the Chinese population. Correspondence to Youming Zhang, MB, MSc, DPhil, Functional Genomics Group, Genomic Medicine Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, Dovehouse Street, London SW3 6LY, UK E-mail: y.zhang@imperial.ac.uk *Dewen Yan and Youming Zhang contributed equally to the writing of this article. Received November 22, 2017 Accepted March 7, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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Quality of life after robot-assisted transmediastinal radical surgery for esophageal cancer
Abstract
Background
The aim of this retrospective study was to assess postoperative quality of life (QOL) after robot-assisted radical transmediastinal esophagectomy, defined as a nontransthoracic esophagectomy with radical mediastinal lymphadenectomy combining a robotic transhiatal approach and a video-assisted cervical approach. The results were compared to those of transthoracic esophagectomy.
Methods
In this study, all consecutive patients who underwent robot-assisted radical transmediastinal esophagectomy or transthoracic esophagectomy for esophageal cancer at University of Tokyo between January 2010 and December 2014 were included. The European Organization for Research and Treatment of Cancer (EORTC)'s quality of life questionnaires QLQ-C30 and QLQ-OES18 were sent to all patients that were still living, had no recurrence or other malignancy, and had not undergone a reoperation because of complications after esophagectomy.
Results
We were able to survey 63 (98.4%) of 64 eligible patients. We assessed and compared the QOL scores of both groups of patients. Compared to transthoracic esophagectomy, transmediastinal esophagectomy was associated with better QOL. Global health status and the physical, role, and cognitive function scale scores were significantly superior in the transmediastinal esophagectomy group (P = 0.004, < 0.0001, 0.007, 0.002, respectively). Fatigue, nausea and vomiting, pain, appetite loss, reflux, and taste scores were significant lower (superior) in the transmediastinal esophagectomy group (P = 0.003, 0.032, 0.025, 0.018, 0.001, 0.041, respectively).
Conclusions
This study indicates that robot-assisted radical transmediastinal esophagectomy is associated with better postoperative QOL compared to transthoracic esophagectomy. A larger study and prospective analyses are needed to confirm the current results.
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High preoperative modified frailty index has a negative impact on short- and long-term outcomes of octogenarians with gastric cancer after laparoscopic gastrectomy
Abstract
Background
The proportion of elderly patients who undergo surgery has rapidly increased. However, clinical indicators that predict outcomes are limited. Frailty is thought to estimate physiological reserves, although its use has not been evaluated in laparoscopic surgical patients. This study aimed to evaluate the significance of preoperative modified frailty index (PMFI) in octogenarians undergoing a laparoscopic gastrectomy.
Methods
We reviewed prospectively collected data from 119 patients with gastric cancer (GC) aged 80 years or older who underwent a radical laparoscopic gastrectomy (RLG) between January 2007 and December 2012. Three baseline frailty traits were measured using routine preoperative laboratory data: albumin < 3.4 g/dL, haematocrit < 35%, and creatinine > 2 mg/dL. Patients were categorized by the number of positive traits as follows: low preoperative modified frailty index (LPMFI): 0–2 traits and high preoperative modified frailty index (HPMFI): 3 traits. We compared patient characteristics, operative outcomes, pathological results, morbidity, and survival.
Results
A total of 43 (36.1%) patients were considered HPMFI, and 76 (63.9%) patients were considered LPMFI. HPMFI was associated with an increased risk of postoperative complications (HPMFI group: odds ratio 2.506; 95% CI, 1.113–5.643, P = 0.027). With a median follow-up of 39.0 months, the 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates for the entire cohort were 47.9, 34.3, and 51.7%, respectively. Significant differences were observed in OS (HPMFI group, 37.2%; LPMFI group, 53.9%; P = 0.038) and RFS (HPMFI group, 23.3%; LPMFI group, 40.5%; P = 0.012) between the groups, but no difference was found for CSS (HPMFI group, 43.5%; LPMFI group, 56.4%; P = 0.078).
Conclusions
HPMFI based on an easily calculable preoperative measure may be useful for predicting postoperative complications and have a negative impact on 3-year OS and RFS after an RLG in octogenarians. Therefore, HPMFI can serve as a low-cost, simple screen for high-risk individuals who might suffer more than expected during the postoperative period after an RLG.
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Clinical feasibility of a new full-thickness endoscopic plication device (GERDx™) for patients with GERD: results of a prospective trial
Abstract
Background
Previous studies suggest clinical effectiveness of endoscopic full-thickness plication in selected patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess the clinical safety and efficiency of the GERDx™ device by evaluating clinical parameters, reflux symptom scores, and quality of life (QoL).
Methods
Prospective one-arm trial evaluating the outcome of forty patients with GERD subjected to endoscopic plication with the GERDx™ device. We included patients with at least one typical reflux symptom despite treatment with a PPI for > 6 months, pathologic esophageal acid exposure, hiatal hernia of size < 2 cm, and endoscopic Hill grade II–III. Evaluation of Gastrointestinal Quality of Life Index (GIQLI), symptom scores, esophageal manometry, and impedance-pH-monitoring were performed at baseline and at 3 months after surgery. (Trial Registration: ClinicalTrials.gov NCT 01798212.)
Results
There were no intraoperative complications. Four out of forty patients experienced postoperative complications requiring intervention. Seven of forty patients were subjected to laparoscopic fundoplication 3 months after endoscopic plication due to persistent symptoms and were lost to further follow-up. Thirty out of forty patients were available at 3-month follow-up. There was an improvement of the GIQLI score, from a mean of 92.45 ± 18.47 to 112.03 ± 13.11 (p < 0.001). The general reflux-specific score increased from a mean of 49.84 ± 24.83 to 23.93 ± 15.63 (p < 0.001), and the DeMeester score from a mean of 46.48 ± 30.83 to 20.03 ± 23.62 (p < 0.001). There was no significant change in manometric data after intervention. Three of thirty patients continued daily antireflux medication.
Conclusions
Endoscopic plication with the GERDx™ device reduced distal acid exposure of the esophagus, reflux-related symptoms, and improved GIQLI scores with minimal side effects in a selected cohort of patients and may be a safe alternative in the treatment of GERD.
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Ultrasonographic Findings in a latissimus dorsi injury in a beach volleyball player
No abstract available
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Clinical improvements are not explained by changes in tendon structure on UTC following an exercise program for patellar tendinopathy
Objectives The aim of this study was to investigate the effects of a 4-week in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by Ultrasound Tissue Characterization (UTC). Design Randomized clinical trial. Volleyball and basketball players (16-31 years, n=29) with clinically diagnosed patellar tendinopathy were randomized to a 4-week isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-week UTC scan was used to evaluate change in tendon structure. Results No significant change in tendon structure or dimensions on UTC was detected after the exercise program, despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area (mCSA) of aligned fibrillar structure (echo-types I+II) (Z=-0.414,p=0.679) as well as disorganized structure (echo-types III + IV) (Z=-0.370,p=0.711) did not change over the 4-week exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups. Conclusion Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-week isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement of symptoms. It seems that structural improvements are not required for a positive clinical outcome. Corresponding author: M. van Ark. m.van.ark@pl.hanze.nl; tel +31 (0)50 361 77 0, fax +31 (0)50 361 77 17 Author disclosures Mathijs van Ark has been supported by Foundation "De Drie Lichten", "Wetenschappelijk College Fysiotherapie" and "Anna Foundation | NOREF" in The Netherlands for this project. This study has also been supported by the Australian Institute of Sport (Clinical Research Fund). Jill Cook, Sean Docking and Ebonie Rio were supported by the Australian Collaboration for research into sports injury and its prevention (ACRISP), which is one of the International Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). Jill Cook is a NHMRC practitioner fellow (ID 105849). Sean Docking has been supported by the Monash Postgraduate Publication Award. Jill Cook is a director and shareholder in Trackside Technologies, the applicant of a patent directed to using ultrasound to monitor connective tissue and compositions for treating connective tissue. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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Quality Improvement Education in Residency Training: A Review
Hospitals and health care institutions have strong external and internal pressures to improve patient safety and health care quality. Quality improvement education has been mandated for resident physicians by the Accreditation Council for Graduate Medical Education. This review describes didactic and experiential curricula for residents in quality improvement interventions as well as factors that create challenges to implementing such a curriculum and those that foster it. Resident attitudes, faculty capacity, institutional resources, and dedicated time are critical elements influencing the success of quality improvement curricula. Faculty interest in quality improvement could be enhanced by academic recognition of their work. Recommendations to facilitate publication of quality improvement efforts are described. Correspondence: Teresa L. Massagli, MD, 4800 Sand Point Way NE, MS OB.8.410, Seattle WA 98105. P: 206.987.1500. F: 206.987.2651. Terry.massagli@seattlechildrens.org Disclosures: All authors have no disclosures No funding was received for this project Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
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Evidence-Based Physiatry (EBP)
No abstract available
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Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery
BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway. METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway. RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36–7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02–5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02–1.50; P = .04). CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted. Accepted for publication February 16, 2018. 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Jay W. Schoenherr, MD, Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599. Address e-mail to jschoenherr@aims.unc.edu. © 2018 International Anesthesia Research Society
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Textbook of Rapid Response Systems: Concept and Implementation, 2nd ed
No abstract available
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Pain and Its Long-term Interference of Daily Life After Critical Illness
BACKGROUND: Persistent pain likely interferes with quality of life in survivors of critical illness, but data are limited on its prevalence and risk factors. We sought to determine the prevalence of persistent pain after critical illness and its interference with daily life. Additionally, we sought to determine if intensive care unit (ICU) opioid exposure is a risk factor for its development. METHODS: In a cohort of adult medical and surgical ICU survivors, we used the brief pain inventory (BPI) to assess pain intensity and pain interference of daily life at 3 and 12 months after hospital discharge. We used proportional odds logistic regression with Bonferroni correction to evaluate the independent association of ICU opioid exposure with BPI scores, adjusting for potential confounders including age, preadmission opioid use, frailty, surgery, severity of illness, and durations of delirium and sepsis while in the ICU. RESULTS: We obtained BPI outcomes in 295 patients overall. At 3 and 12 months, 77% and 74% of patients reported persistent pain symptoms, respectively. The median (interquartile range) pain intensity score was 3 (1, 5) at both 3 and 12 months. Pain interference with daily life was reported in 59% and 62% of patients at 3 and 12 months, respectively. The median overall pain interference score was 2 (0, 5) at both 3 and 12 months. ICU opioid exposure was not associated with increased pain intensity at 3 months (odds ratio [OR; 95% confidence interval], 2.12 [0.92–4.93]; P = .18) or 12 months (OR, 2.58 [1.26–5.29]; P = .04). ICU opioid exposure was not associated with increased pain interference of daily life at 3 months (OR, 1.48 [0.65–3.38]; P = .64) or 12 months (OR, 1.46 [0.72–2.96]; P = .58). CONCLUSIONS: Persistent pain is prevalent after critical illness and frequently interferes with daily life. Increased ICU opioid exposure was not associated with worse pain symptoms. Further studies are needed to identify modifiable risk factors for persistent pain in the critically ill and the effects of ICU opioids on patients with and without chronic pain. Accepted for publication February 16, 2018. Funding: C.G.H. is supported by American Geriatrics Society Jahnigen Career Development Award and National Institutes of Health R01HL111111, R03AG045085 (Bethesda, MD). This project was supported by the National Institutes on Aging AG027472 (Bethesda, MD). 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 (https://ift.tt/KegmMq). Trial Registry Number: NCT00392795. Reprints will not be available from the authors. Address correspondence to Christina J. Hayhurst, MD, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Ave S, Medical Arts Bldg 526, Nashville, TN 37212. Address e-mail to christina.j.hayhurst@vanderbilt.edu. © 2018 International Anesthesia Research Society
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Does the Incidence of Postoperative Complications After Inguinal Hernia Repair Justify Hospital Admission in Prematurely and Term Born Infants?
BACKGROUND: Postoperatively, young infants are admitted overnight in view of the risk for respiratory complications such as desaturation and apnea. This risk seems much lower than previously reported. Until what age this risk persists, and which infants might actually qualify for day-care treatment, is unknown. METHODS: We retrospectively reviewed medical charts from preterm infants 1 month of age are uncommon, which justifies day-care admission for this type of surgical procedure. Accepted for publication March 9, 2018. Funding: None. The authors declare no conflicts of interest. M. Massoud and A. Y. R. Kühlmann contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to A. Y. Rosalie Kühlmann, MD, Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Postbus 2060, Room SK 1268, 3000CB Rotterdam, the Netherlands. Address e-mail to a.kuhlmann@erasmusmc.nl. © 2018 International Anesthesia Research Society
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Dexmedetomidine Sedation for Paroxysmal Supraventricular Tachycardia Ablation Is Not Associated With Alteration of Arrhythmia Inducibility
BACKGROUND: Dexmedetomidine (Dex) is an attractive agent for procedural sedation due to its unique pharmacodynamic profile, specifically affording predictable sedation without concurrent respiratory depression. However, Dex has previously been reported to prevent or terminate arrhythmias. The purpose of this study was to investigate paroxysmal supraventricular tachycardia (PSVT) inducibility and homeostatic stability during electrophysiology studies (EPSs) and ablation when a standardized Dex protocol was used as the primary sedation agent. METHODS: We performed a retrospective review of 163 consecutive procedures for PSVT ablation that received Dex as the primary sedative with adjunct fentanyl and midazolam boluses (DEX-FENT-MIDAZ). This cohort was compared to 163 consecutive control procedures wherein strictly fentanyl and midazolam were used for sedation. The primary outcome reviewed was PSVT inducibility assessed before ablation. Reviewed secondary outcomes included level of sedation and intraprocedure hemodynamics and oxygenation. RESULTS: The arrhythmia profiles of the DEX-FENT-MIDAZ and control cohorts were very similar. The overall incidence of a "negative" EPSs in which arrhythmia was not induced was 24% in the DEX-FENT-MIDAZ group and 26% in the control group (P = .7). Unintended deep sedation was significantly less with DEX-FENT-MIDAZ (4.3% vs 27%; P ≤ .0001). However, DEX-FENT-MIDAZ use was associated with a higher incidence of intraprocedure hypotension. CONCLUSIONS: Dex sedation during EPSs is not associated with a reduction in PSVT inducibility. The therapeutic utility of Dex during EPS arises from the predictable sedation Dex affords but is associated with an increased incidence of intraprocedure hypotension. Accepted for publication February 5, 2018. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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 (https://ift.tt/KegmMq). This material is the result of the work supported with resources and the use of facilities at the Veterans Affairs Portland Health Care System. The contents do not represent the views of the US Department of Veterans Affairs or the US Government. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines for reporting observational studies were followed while conducting this study and for preparation of this manuscript. Reprints will not be available from the authors. Address correspondence to Peter M. Jessel, MD, Division of Cardiology, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239. Address e-mail to JesselP@ohsu.edu. © 2018 International Anesthesia Research Society
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Resistin Is a Novel Marker for Postoperative Pain Intensity
BACKGROUND: Pro- and anti-inflammatory cytokines (adipokines) associated with adipose tissue can modulate inflammatory processes and lead to systemic inflammatory conditions such as metabolic syndrome. In the present pilot study, we investigated 3 major adipokines (leptin, adiponectin, and resistin) and 2 nonspecific proinflammatory cytokines (tumor necrosis factor α and interleukin-6) with regard to their association with postoperative pain intensity. METHODS: We analyzed a total of 45 single-nucleotide polymorphisms of the adipokines in 57 patients with postlaparotomy pain. We adjusted for multiple testing to reduce the chance of false-positive results by controlling the false discovery rate. Serum levels of the adipokines and proinflammatory cytokines were measured in another 36 patients undergoing laparotomy. A stepwise multiple linear regression analysis using these measurements and opioid dosages as independent variables was performed to explore the factors associated with postoperative pain. RESULTS: Only 1 variant of the resistin gene (rs3745367) demonstrated a significant association with postoperative pain (P
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Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital
BACKGROUND: No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS: Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS: Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale 48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%–50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%–35.9%) a severe disability (GOS 3), 0.6% (0%–3.2%) a vegetative state (GOS 2), and 27.6% (21.5%–34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43–79 years). Life-prolonging therapies were limited in 95.6% (85.2%–99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%–99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%–100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%–27.3%) of the patients, and 34.9% (22.4%–49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS: At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged. Accepted for publication March 5, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Giovanna Brandi, MD, Surgical Intensive Care Unit, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland. Address e-mail to giovanna.brandi@usz.ch. © 2018 International Anesthesia Research Society
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Airway Management Practice in Adults With an Unstable Cervical Spine: The Harborview Medical Center Experience
BACKGROUND: Airway management in the presence of acute cervical spine injury (CSI) is challenging. Because it limits cervical spine motion during tracheal intubation and allows for neurological examination after the procedure, awake fiberoptic bronchoscopy (FOB) has traditionally been recommended. However, with the widespread availability of video laryngoscopy (VL), its use has declined dramatically. Our aim was to describe the frequency of airway management techniques used in patients with CSI at our level I trauma center and report the incidence of neurological injury attributable to airway management. METHODS: Adults presenting to the operating room with CSI without a tracheal tube in situ between September 2010 and June 2017 were included. All patients were intubated in the presence of manual-in-line stabilization, a hard cervical collar, or surgical traction. Worsening neurological status was defined as new motor or sensory deficits on postoperative examination. RESULTS: Two hundred fifty-two patients were included, of which 76 (30.2%) had preexisting neurological deficits. VL was the most frequent initial airway management technique used (49.6%). Asleep FOB was commonly performed alone (30.6%) or in conjunction with VL (13.5%). Awake FOB was rarely performed (2.3%), as was direct laryngoscopy (2.8%). All techniques were associated with high first-attempt success rates, and no cases of neurological injury attributable to airway management technique were identified. CONCLUSIONS: Among patients with acute CSI at a high-volume academic trauma center, VL was the most commonly used initial intubation technique. Awake FOB and direct laryngoscopy were performed infrequently. No cases of neurological deterioration secondary to airway management occurred with any method. Assuming care is taken to limit neck movement, providers should use the intubation technique with which they have the most comfort and skill. Accepted for publication February 26, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Michael G. Holmes, MD, Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St, BB-1469, Seattle, WA 98195. Address e-mail to mgholmes@uw.edu. © 2018 International Anesthesia Research Society
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The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine
No abstract available
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Obstructive Sleep Apnea in Pregnant Women: A Review of Pregnancy Outcomes and an Approach to Management
Among obese pregnant women, 15%–20% have obstructive sleep apnea (OSA) and this prevalence increases along with body mass index and in the presence of other comorbidities. Prepregnancy obesity and pregnancy-related weight gain are certainly risk factors for sleep-disordered breathing in pregnancy, but certain physiologic changes of pregnancy may also increase a woman's risk of developing or worsening OSA. While it has been shown that untreated OSA in postmenopausal women is associated with a range of cardiovascular, pulmonary, and metabolic comorbidities, a body of literature is emerging that suggests OSA may also have serious implications for the health of mothers and fetuses during and after pregnancy. In this review, we discuss the following: pregnancy as a vulnerable period for the development or worsening of OSA; the associations between OSA and maternal and fetal outcomes; the current screening modalities for OSA in pregnancy; and current recommendations regarding peripartum management of OSA. Accepted for publication February 14, 2018. Funding: This research was supported in part by NIH 5T32GM008600-20. Devices used in Dr Dominguez's and Dr Habib's research have been loaned by ResMed and Itamar Medical. Dr Habib is a Senior Editor for Anesthesia & Analgesia. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jennifer E. Dominguez, MD, MHS, Department of Anesthesiology, Duke University Medical Center, Box 3094, Mail Sort #9, Durham, NC 27710. Address e-mail to Jennifer.dominguez@dm.duke.edu. © 2018 International Anesthesia Research Society
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Pharmacological Characterization of Levorphanol, a G-Protein Biased Opioid Analgesic
BACKGROUND: Levorphanol is a potent analgesic that has been used for decades. Most commonly used for acute and cancer pain, it also is effective against neuropathic pain. The recent appreciation of the importance of functional bias and the uncovering of multiple µ opioid receptor splice variants may help explain the variability of patient responses to different opioid drugs. METHODS: Here, we evaluate levorphanol in a variety of traditional in vitro receptor binding and functional assays. In vivo analgesia studies using the radiant heat tail flick assay explored the receptor selectivity of the responses through the use of knockout (KO) mice, selective antagonists, and viral rescue approaches. RESULTS: Receptor binding studies revealed high levorphanol affinity for all the μ, δ, and κ opioid receptors. In 35S-GTPγS binding assays, it was a full agonist at most µ receptor subtypes, with the exception of MOR-1O, but displayed little activity in β-arrestin2 recruitment assays, indicating a preference for G-protein transduction mechanisms. A KO mouse and selective antagonists confirmed that levorphanol analgesia was mediated through classical µ receptors, but there was a contribution from 6 transmembrane targets, as illustrated by a lower response in an exon 11 KO mouse and its rescue with a virally transfected 6 transmembrane receptor splice variant. Compared to morphine, levorphanol had less respiratory depression at equianalgesic doses. CONCLUSIONS: While levorphanol shares many of the same properties as the classic opioid morphine, it displays subtle differences that may prove helpful in its clinical use. Its G-protein signaling bias is consistent with its diminished respiratory depression, while its incomplete cross tolerance with morphine suggests it may prove valuable clinically with opioid rotation. Accepted for publication February 9, 2018. Funding: This study was supported by grants from the National Institute on Drug Abuse (DA006241, DA007242), the Peter McManus Charitable Trust, Mayday Fund and Relmada Therapeutics, Inc (to G.W.P.), a core grant from the National Cancer Institute to MSKCC (CA008748), and the National Natural Science Foundation of China (81673412 to Z.L). 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Gavril W. Pasternak, MD, PhD, Department of Neurology and Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065. Address e-mail to pasterng@mskcc.org. © 2018 International Anesthesia Research Society
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Blood Pressure Coefficient of Variation and Its Association With Cardiac Surgical Outcomes
BACKGROUND: Multiple studies completed in the ambulatory nonsurgical setting show a significant association between short- and long-term blood pressure variability and poor outcomes. However, perioperative blood pressure variability outcomes have not been well studied, especially in the cardiac surgical setting. In this study, we sought to assess whether systolic and mean arterial blood pressure variability were associated with 30-day mortality and in-hospital renal failure in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Furthermore, blood pressure variability has not been evaluated specifically during each phase of surgery, namely in the pre-, intra- and postbypass phases; thus, we aimed also to assess whether outcomes were associated with phase-specific systolic and mean arterial blood pressure variability. METHODS: All patients undergoing cardiac surgery from January 2008 to June 2014 were enrolled in this retrospective, single-center study. Demographic, intraoperative, and postoperative outcome data were obtained from the institution's Society of Thoracic Surgery database and Anesthesia Information Management System. Systolic and mean arterial blood pressure variability were assessed using the coefficient of variation (CV). The primary outcomes were 30-day mortality and in-hospital renal failure in relation to the entire duration of a case, while the secondary outcomes assessed phase-specific surgical periods. In an effort to control the family-wise error rate, P values <.0125 were considered significant for the primary outcomes. results: of patients analyzed died within days surgery and experienced in-hospital renal failure. after adjusting covariates we found a statistically association between increasing cv systolic blood pressure mortality every increase in cvsbp there was odds death ratio confidence interval p .0001 experiencing failure with driven primarily by prebypass period because during phase .01 not postbypass .08 no mean arterial either or any including bypass phase. conclusions: variability associated development phase-specific relationships observed. further research is required to determine how prospectively detect elucidate opportunities intervention. accepted publication february funding: v. prasad supported us department defense national science engineering graduate fellowship. b. subramaniam institutes health project grant gm statistical writing support provided center anesthesia excellence at beth israel deaconess medical center. authors declare conflicts interest. reprints will be available from authors. address correspondence balachundhar md mph harvard school one rd c-650 boston ma e-mail bsubrama international society>
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The effect of a single textured insole in gait rehabilitation of individuals with stroke
Rehabilitation interventions designed to restore gait symmetry in individuals with stroke are not always effective. The goal was to evaluate the long-term effect of using a single textured insole in gait rehabilitation. Ten individuals with stroke who showed asymmetrical stance were randomly divided into two groups and participated in physical therapy. Individuals in the experimental group received a 6-week physical therapy while being provided with a textured insole in the shoe on the unaffected side. Individuals in the control group received a 6-week physical therapy only. Both groups underwent a battery of identical tests before the start of the rehabilitation intervention, following its completion, and 4 months after the end of therapy. After the intervention, weight bearing (WB) on the affected side and gait velocity increased in the experimental group (P
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Aquatic Training in Upright Position as an Alternative to Improve Blood Pressure in Adults and Elderly: A Systematic Review and Meta-Analysis
Abstract
Background
Meta-analyses have shown that land training (LT) reduces blood pressure; however, it is not known whether aquatic training (AT) promotes this same effect.
Objective
The aim was to conduct a meta-analysis on the effects of AT on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in adults and elderly and compare them to those of LT and no training [control group (CG)].
Data Sources
Embase, PubMed, Cochrane and Scopus were searched up to May 2017.
Study Eligibility Criteria
Studies that evaluated the effect of upright AT (i.e., AT performed in upright position) on the blood pressure of adult individuals and the elderly who did not present with cardiovascular disease (other than hypertension) were included.
Data Analysis
Two independent reviewers screened search results, performed data extraction and assessed risk of bias. Random effect was used, and the effect size (ES) was calculated by using the standardized mean difference with a 95% confidence interval.
Results
AT promoted a reduction in SBP (ES − 1.47; 95% CI − 2.23 to − 0.70; p < 0.01) compared to CG. This effect is maintained with training progression (ES − 1.52; 95% CI − 2.70 to − 0.33; p = 0.01) and no progression (ES − 1.43; 95% CI − 2.64 to − 0.23; p = 0.02). These effects were significant only in hypertensive (ES − 2.20; 95% CI − 2.72 to − 1.68; p < 0.01), and not in pre-hypertensive individuals. AT promoted a decrease in DBP (− 0.92; 95% CI − 1.27 to − 0.57; p < 0.01) after training with progression (− 0.81; 95% CI − 1.62 to − 0.001; p = 0.04) and no progression (− 1.01; 95% CI − 1.40 to − 0.62; p < 0.01) in pre-hypertensive (− 1.12; 95% CI − 1.53 to − 0.70; p < 0.01) and hypertensive patients (− 0.69; 95% CI − 1.31 to − 0.06; p = 0.03). AT promoted similar reductions in SBP compared to LT; however, reduction of DBP in hypertensive patients was lower (1.82; 95% CI 0.84 to 2.79; p < 0.01).
Conclusion
AT promotes blood pressure reduction in adults and elderly. The reduction in SBP in those performing AT is similar to those performing LT, but reduction of DBP is lower in the AT group compared to that in the LT group.
Systematic Review Registration Number
CRD42016049716.
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Pre-migration Trauma, Repatriation Experiences, and PTSD Among North Korean Refugees
Abstract
Many studies on refugees suggested that refugees' traumatic events associated with post-traumatic stress disorder (PTSD). However, it is unknown whether refugees' PTSD was caused by their negative experience before or after the entry of their destination country. Thus, a separation of refugees' pre-migration from their post-migration experience is particularly important in understanding the causal impact of trauma. Using a sample from North Korean refugees, this study investigates the prevalence of PTSD symptoms, the impact of tortured trauma, repatriation experiences, on PTSD among North Korean refugees (n = 698). We found that North Korean refugees in our sample (a) demonstrated a high rate of current probable PTSD; (b) were demonstrated a higher frequency of repatriation experiences with a greater risk for PTSD symptoms. The findings suggest that particular types of trauma for populations with particular socio-demographic characteristics may be at a greater risk of PTSD.
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Smoking Among Chinese Livery Drivers
Abstract
We aimed to assess a key risk factor for lung cancer, smoking, in a vulnerable group, Chinese livery drivers in New York City (NYC). This is a nested cohort study conducted in the summer/fall of 2014 within a larger NIMHD-funded R24 program, the Taxi Network. The Taxi Network Needs Assessment (TNNA) survey was administered to a broad demographic of drivers. This study reports on the TNNA survey smoking-related results among NYC Chinese livery drivers. 97 drivers participated. Mean age was 44.7 years, 2.1% were English proficient, and 23.4% were living below the poverty line. Most were insured (82.5%), had a PCP (82.5%), and had had a routine check-up within the past year (79%). 73% were current or former smokers. Culturally and linguistically tailored smoking cessation interventions, strategies to mitigate exposure to air pollution, and programs to facilitate lung cancer screening should be developed and implemented for high-risk Chinese livery drivers.
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