Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026: 01/11/18

Πέμπτη 11 Ιανουαρίου 2018

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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Cytologic Diagnosis of Biliary Strictures: FISH or Cut the Sensitivity Rate?

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Ultra-Deep Genomic Sequencing of HCV NS5A Resistance-Associated Substitutions in HCV/HIV Coinfected Patients

Abstract

Background and Aims

The prevalence of naturally occurring HCV-NS5A resistance-associated substitutions (RAS) to DAA drugs might affect the response to treatment in HCV/HIV coinfected subjects. There are limited data on the frequency of HCV-NS5A naturally occurring drug-RAS at baseline in HCV/HIV coinfected patients when ultra-deep sequencing methodologies are applied.

Methods

HCV-NS5A-RAS were evaluated among 25 subjects in each group. Patients were matched by age, gender, and hepatic fibrosis stage category to control for selection bias.

Results

Within subtype 1a, RAS were observed in 28% of HCV monoinfected and 48% of HCV/HIV coinfected subjects. More patients in the HCV/HIV coinfected group had clinically relevant mutations to DAA directed at NS5A.

Conclusion

While the clinical significance of this observation may be limited in highly drug adherent populations, some HCV/HIV coinfected persons may be at greater risk of viral resistance if suboptimal dosing occurs.

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Base-Resolution Analysis of DNA Methylation Patterns Downstream of Dnmt3a in Mouse Naive B Cells

The DNA methyltransferase, Dnmt3a, is dynamically regulated throughout mammalian B cell development and upon activation by antigenic stimulation. Dnmt3a inactivation in hematopoietic stem cells has been shown to drive B cell-related malignancies, including chronic lymphocytic leukemia (CLL), and associates with specific DNA methylation patterns in transformed cells. However, while it is clear that inactivation of Dnmt3a in hematopoietic stem cells has profound functional impacts, the consequences of Dnmt3a inactivation in cells of the B lineage are unclear. To assess whether loss of Dnmt3a at the earliest stages of B cell development lead to DNA methylation defects that might impair function, we selectively inactivated Dnmt3a early in mouse B cell development and then utilized Whole Genome Bisulfite Sequencing to generate base-resolution profiles of Dnmt3a^+/+ and Dnmt3a^-^/^- naïve splenic B cells. Overall, we find that global methylation patterns are largely consistent between Dnmt3a^+/+ and Dnmt3a^-^/^-naïve B cells, indicating a minimal functional impact of DNMT3A in mature B cells. However, loss of Dnmt3a induced 449 focal DNA methylation changes, dominated by loss-of-methylation events. Regions found to be hypomethylated in Dnmt3a^-^/^- naïve splenic B cells were enriched in gene bodies of transcripts expressed in B cells, a fraction of which are implicated in B cell-related disease. Overall, the results from this study suggest that factors other than Dnmt3a are the major drivers for methylome maintenance in B cell development.

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Genomic Understanding of an Infectious Brain Disease from the Desert

Rhinocladiella mackenziei accounts for the majority of fungal brain infections in the Middle East and is restricted to the arid climate zone between Saudi Arabia and Pakistan. Neurotropic dissemination caused by this fungus has been reported in immunocompromised, but also immunocompetent individuals. If untreated, the infection is fatal. Outside of humans, the environmental niche of R. mackenziei is unknown, and the fungus has been only cultured from brain biopsies. In this paper we describe the whole genome re-sequencing of two Rhinocladiella mackenziei strains from patients in Saudi Arabia and Qatar. We assessed intra-species variation and genetic signatures to uncover the genomic basis of the pathogenesis and potential niche adaptations. We found that the duplicated genes (paralogs) are more susceptible to accumulate significant mutations. Comparative genomics with other filamentous ascomycetes revealed a diverse arsenal of genes likely engaged in pathogenicity, such as the degradation of aromatic compounds and iron acquisition. In addition, intracellular accumulation of trehalose and choline suggest possible adaptations to the conditions of arid climate region. Specifically protein family contractions were found, including short-chain dehydrogenase/reductase SDR, the cytochrome P450 (E-class) and the G-protein beta WD-40 repeat. Gene composition and metabolic potential indicate extremotolerance and hydrocarbon assimilation, suggesting a possible environmental habitat of oil-polluted desert soil.

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The effect of acceptance and commitment therapy on the mental health of women patients with type II diabetes

Marziyeh Kaboudi, Fateme Dehghan, Arash Ziapour

Annals of Tropical Medicine and Public Health 2017 10(6):1709-1713

Background: Diagnosis of diabetes will have a significant impact on patients' psychosocial functioning and patients should devote sufficient time and energy to self-manage the disease. This study aimed to evaluate the effectiveness of treatment based on acceptance and commitment model on the mental health of women with diabetes type II. Methods: The present study is an experimental study with pretest-posttest control group design. The sample consisted of 26 women with diabetes from Kermanshah who were recruited using convenience (availability) sampling and were randomly divided into experimental and control groups. All patients completed the 28-item general health questionnaire before and after the intervention. Data were analyzed using univariate analysis of covariance and applying SPSS version 23. Results: The results clearly showed that the posttest scores of mental health in the experimental group were significant compared to the control group (P

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Advocating for the implementation of recommended measures to improve infant and young child feeding

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1835-1836

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World Health Organization calls for the adoption of updated guidelines for the management of chlamydial, gonococcal, and syphilitic infections

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1403-1404

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Prevalence and pattern of parasitic infestations among nomadic Fulani children in a grazing reserve in Northwestern Nigeria

Halima Bello-Manga, Aisha Indo Mamman, H Idris Suleiman, Adebola Olayinka, Abubakar Umar Musa, Kana Abubakar Musa

Annals of Tropical Medicine and Public Health 2017 10(6):1799-1804

Background: Nomadic pastoralists lack access to basic sanitary and health-care facilities mainly because their mode of life makes them a hard to reach group. In the Nigerian context, there is dearth of knowledge about the interplay between their lifestyle and health indices.Therefore, this study is aimed at determining the association between the prevalence of parasitic infestation among nomadic Fulani children in Ladduga grazing reserve, Kaduna, Northwestern Nigeria. Aim: The aim of this study was to assess the prevalence and pattern of parasitic infestation among nomadic Fulani children in Ladduga grazing reserve, Kaduna, Northwestern Nigeria. Materials and Methods: A cross-sectional descriptive study was conducted using questionnaires, physical examination, automated hemocytometry, enzyme-linked immunosorbent assay-based serum ferritin assay, and formol-ether concentration-based stool tests on 337 children (5–15 years) at Ladduga grazing reserve, Northwestern Nigeria. Data were analyzed using SPSS version 20.0. Results: The prevalence of parasitic infestation was 14.4% (49/337). The predominant parasites found were hookworm species, i.e., Necator americanus and Ancylostoma duodenale (46.9%) and Schistosoma mansoni (26.6%) while Ascaris lumbricoides, Hymenolepis nana, and Enterobius vermicularis accounted for 26.6%. Anemia was found in 40.4% (137/340) of the children with a statistically significant difference between younger (5–9 years) and older children (10–15 years; P

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Saving lives of mothers and newborns from infections around the time of childbirth by strengthening health sector response to the public health concern of antibiotic resistance

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1405-1406

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Identifying and investigating exercise activity on the factors of physical fitness and well-being of the staff at the Isfahan University of Technology

Jahangir Hamidi Tehrani, Mojtaba Babaei Khorzoghi

Annals of Tropical Medicine and Public Health 2017 10(6):1661-1667

Objective: The results of the conducted studies investigating the prevalence of machinery life and increase of cardiovascular diseases imply that motor poverty and especially low aerobic power and increase in blood fat are among primary risk factors in cardiovascular diseases. To prevent these discomforts, doing regular physical and exercise activities are recommended; hence, people's participation in physical activities and their awareness of physical status and well-being factors, especially blood fat and cardiovascular profile are of utmost importance. The general purpose of this study, besides awareness of the participants' physical well-being, is to investigate the effect of exercise activities on physical fitness and blood fat profile in the staff of Isfahan University of Technology. Methods: A semi-experimental method with clinical experiments was used in this research, and the effect of 8 weeks of 45–50-min sessions of exercise, twice a week, and on the staff's physical performance was investigated. An experimental and a control group were randomly selected from volunteer male staff. The research variables were measured from the participants, and the results were addressed through SPSS software and statistical formulas and considering research hypotheses regarding the degree of variable changes. Results: The results of this study showed that comparing the degree of changes of the variables of body weight, body mass index, 1600-meter race, sit-ups 94-meter race, Swedish swimming, and blood cholesterol was significantly changed at P < 0.05 level after training period compared to before-training, and there was no significant change at P < 0.05 level in other research variables. Moreover, it was observed that the degree of changes of the variables of 1600-meter race, sit-up, stretch board, Swedish swimming, low-density lipoprotein (LDL), high-density lipoprotein, and the experimental group was significantly different at P < 0.05 level compared to the control group, and there was no significant difference at P < 0.05 level. Conclusion: It was observed from the results of this study that aerobic exercise trainings cause the increase of power, cardiovascular endurance, muscular endurance, and suitable changes in blood fat and the degree of the staff's flexibility. Therefore, attending program to increase the staff's physical activity level and physical fitness seems necessary. Furthermore, to control body fat, it is advised that men regularly measure their blood cholesterol after the age of 35, and LDL should be lower than 130 mg/dl but better to be lower than 100 mg/dl in the patients suffering from cardiovascular disease.

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World Health Organization raises concern over the urgent need to respond to the multiple outbreaks of infectious diseases reported in South Sudan amidst the ongoing conflict

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1407-1408

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An investigation of the impact of Kelussia odoratissima extract on mice with secondary hyperlipidemia

Kaveh Berenjian, Amir Kiani

Annals of Tropical Medicine and Public Health 2017 10(6):1752-1755

Introduction: For many years, human beings have applied plants as medicine and their healing impact has been proved for many years. Kelussia odoratissima is a biennial, edible, and fragrant plant with medicinal and food applications. This plant is dedicated to some pastures of Iran and this plant is not reported in other regions around the world. Flavonoids are the most important ingredient of this plant. Materials and Methods: In this study, to evaluate the effect of feeding mice with secondary hyperlipidemia with K. odoratissima, we used thirty mice with secondary hyperlipidemia of similar weight and divided them into three equal groups. For 3 weeks, the first and second groups were fed with the extract of K. odoratissima with doses of 600 mg/kg weight of mice and 1200 mg/kg weight of mice, respectively, and triglyceride, low-density lipoprotein (LDL), total cholesterol, and weight of mice were evaluated. Results: The results showed that, at the end of the 1st week, there was no significant change in any of the groups, but at the end of the 2nd week, in the first group, there was a reduction of LDL; in the second group total cholesterol and triglyceride without any weight change were reduced and LDL factors, total cholesterol, and triglyceride had low weight change; and in the third group, there was an increase of LDL factors, total cholesterol, and triglyceride and an increase of weight. At the end of the 3rd week, in the first group, there was a reduction of LDL factors, total cholesterol, and triglyceride and a little weight reduction; in the second group there was a reduction of LDL factors, total cholesterol, and triglyceride and a considerable reduction of the weight; and in the third group, LDL factors and total cholesterol, triglycerides, and weight of mice were increased. Conclusion and Discussion: Hydroalcoholic extract of the plant reduced total cholesterol, triglyceride, LDL, and weight of mice using K. odoratissima. Except two groups that were administered K. odoratissima, the weight of the other animals was increased. The increase in the activity of lipoprotein lipase as the mediator of hydrolysis of triglyceride in chylomicron causes free fatty acids to generate energy or be stored as fat.

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Zika virus disease outbreak in Brazil: Existing challenges and role of young people in containing the infection

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1409-1410

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Drinking juice and tongue bee sting: A case

Won Sriwijitalai, Viroj Wiwanitkit

Annals of Tropical Medicine and Public Health 2017 10(6):1829-1830

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World Health Organization appeals for investment in the strengthening of the global health workforce to accomplish financial growth

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1411-1412

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Meeting the health care needs of the millions of the refugee population through the mobile clinics approach

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1401-1402

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Strengthening childbirth services in conflict-affected regions of South Sudan

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1413-1414

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Comparing turmeric extract plus animal butter synthetic poultice effect in two home-based and aseptic-based preparation methods in terms of microbial load

Zahra Tazakori, Mansoureh Karimollahi, Zahra Haghighi, Mansoureh Karimollahi

Annals of Tropical Medicine and Public Health 2017 10(6):1686-1690

Background and Objective: Based on increase in individuals' inclinations toward the use of natural and traditional products in curing some diseases in a systemic and localized manner, the survey of the pathogenic factors which are transferred through such products is of a great importance from the health perspectives. Furthermore, because the emergence of infections due to nonstandard method of preparing some of these natural drugs has not been accurately determined, a poultice mixture consisting of turmeric extract and animal butter was compared in two home-based and aseptic-based preparation methods in terms of microbial load and their effects on the process of pressure ulcer healing is investigated in this study. Materials and Methods: In this study, two poultice mixtures were initially prepared in a home-based method and the other under aseptic conditions, transferred to the laboratory where the specimens were cultured under sterile conditions, in microbe-culturing plates under microbiological hood with a dilution rate of 1–10. After the specified time duration elapsed, the plates containing the culture media were evaluated in terms of bacterial and fungal growth. To prepare a poultice based on standardized methods, turmeric was sufficiently bought from the medicinal herbs market and then put in ethanol 95% v/v. Animal butter underwent separation during a 24 h period in rotary evaporation device under reduced condensation pressure, and after its water was oozed out in 70°C, the concentrate was placed in the incubator. Turmeric extract and animal butter were mixed under bacteriology hood with sterilized wheat flour in autoclave. Finally, the poultice prepared aseptically was tested on seven human specimens and the results were evaluated using pressure ulcer scale for healing (PUSH). Results: Based on the experiments, the homemade poultice mixture was found contaminated with Gram-positive microbial factors, but when the poultice mixture was prepared seven times in the laboratory, no microbial load was found (above USP standard). The mean area of the ulcer was 13.41 before the study, but in the last evaluation, value decreased to 2.21. PUSH mean score from the 1st day until the 4th week reduced from 13.42 to 5.85. It was shown that the ulcer recovery trend decreased considerably. Furthermore, regarding the tissue surveys through observing the samples at the end of intervention, it was seen that the ulcer was free of necrosis and granulated tissues were visible on the ulcer. Conclusion: The aseptic specimen was found in an standard level in terms of microbial load and practically caused effective recovery of the pressure ulcer through increasing the circulation in blood veins, reducing the secretions and edema, and is not indicative of traces of any infection; thus the consumption of this poultice was recognized as safe in improving the pressure ulcers.

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Expanding the coverage of preventive chemotherapy for the prevention and control of neglected tropical diseases

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1415-1416

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Using of Cornell measuring tool (Cornell musculoskeletal discomfort questionnaires) for assessment of the musculoskeletal disorders prevalence among Ilam teaching hospitals nurses: Cross-sectional study in 2016

Maryam Omidi, Mohsen Jalilian, Meghdad Kazemi, Maedeh Kamalvandi, Maryam Jamshidzad, Nematullah Kurd

Annals of Tropical Medicine and Public Health 2017 10(6):1729-1734

Introduction: Nurses in compare of other health practitioners have a greater risk for musculoskeletal injuries due to high physical activity together with bending, twisting, prolonged standing, patient moving, and lifting heavy objects. Therefore, the aim of this study was to evaluate musculoskeletal disorders by Cornell measuring tool among Ilam teaching hospitals nurses. Materials and Methods: This study was a cross-sectional analysis in 2016. A total of 120 people of Ilam teaching hospitals nurses randomly interred the study. Participants completed the questionnaire set for assess demographic characteristics (employment, working hours, shift work, and work experience) and musculoskeletal disorders (Cornell musculoskeletal discomfort questionnaires). Data collected were analyzed using SPSS version 21 software and with the conduct of Pearson's correlation test and independent sample t test. Results: The results showed that 52 cases (3.43%) of participants were male and 68 (7.56%) were female. The highest discomfort incidence was reported to the lower back (70%) and neck (69.2%), respectively. Pearson's correlation test showed statistically significant relationship between the age, gender, and work experience with discomfort (P 0.05). Discussion: According to the high prevalence of musculoskeletal disorders in the lower back and neck in the population studied, ergonomic interventions suggested. Conclusion: The use of appropriate educational programs, ergonomic intervention, and the use of health and safety equipment can reduce MSDs and increase productivity of nurses.

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Implementing mTobacco Cessation program in India to assist users in quitting tobacco: World Health Organization

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1417-1418

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A comparison of cognitive emotion regulation, lifestyle, and dimensions of adjustment in 3 groups of patients with multiple sclerosis, patients with cancer under chemotherapy and patients relieved from brain tumor

Khadijeh Jahan Miri, Siamak Samani

Annals of Tropical Medicine and Public Health 2017 10(6):1774-1778

The purpose of the present study WAS to compare cognitive emotion regulation, lifestyle, and dimensions of adjustment in 3 groups of patients with multiple sclerosis (MS), patients with cancer under chemotherapy and patients relieved from brain tumor. The statistical sample included 72 patients that were all selected by convenience sampling method. They filled out the questionnaires of cognitive emotion regulation questionnaire, multidimensional adjustment scales, and lifestyle questionnaire. The results showed that in the score of positive and negative cognitive emotion regulation, the mean score of the MS group was significantly more than the cancer group. In lifestyle, the mean score of the brain tumor group was significantly more than the other two groups. In adjustment and personal, social, job, and family dimensions, the scores of the cancer group were significantly more than the other two groups.

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Streamlining efforts to fight against the global problem of malnutrition in the 2016-2025 decade of action on nutrition

Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy

Annals of Tropical Medicine and Public Health 2017 10(6):1419-1420

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Atherosclerosis-induced leg ulcers in a young female unassociated with risk factors: A rare presentation of a systemic disease

Angoori Gnaneshwar Rao, Uday Deshmukh Reddy, Aparna Karanam, Amit Kolli, Kranthi Javadevapuram, Ruhi Hakkani, Saba Syeda Farheen

Annals of Tropical Medicine and Public Health 2017 10(6):1820-1823

The occurrence of arterial leg ulcers due to atherosclerosis is common among old individuals. However, the development of leg ulcers due to atherosclerosis in a young female unassociated with risk factors like hyperlipidemia is rare. Herein, we present a case of leg ulcers consequent to atherosclerosis in a young female having normal lipid profile and unassociated with other risk factors. Characteristic morphology and site of the ulcers along with supportive investigations such as color Doppler study and histopathology of ulcer corroborated in establishing the diagnosis.

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Modeling Radiation Effects of Ultrasoft X Rays on the Basis of Amorphous Track Structure

Radiation Research, Volume 189, Issue 1, Page 32-43, January 2018.

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R. J. Michael Fry, MD; 1925–2017

Radiation Research, Volume 189, Issue 1, Page 1-4, January 2018.

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Radiation- and Age-Associated Changes in Peripheral Blood Dendritic Cell Populations among Aging Atomic Bomb Survivors in Japan

Radiation Research, Volume 189, Issue 1, Page 84-94, January 2018.

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Improved Total-Body Irradiation Survival by Delivery of Two Radiation Mitigators that Target Distinct Cell Death Pathways

Radiation Research, Volume 189, Issue 1, Page 68-83, January 2018.

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Second-order Kinetics of DTPA and Plutonium in Rat Plasma

Radiation Research, Volume 189, Issue 1, Page 64-67, January 2018.

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Rescue Effect Inherited in Colony Formation Assays Affects Radiation Response

Radiation Research, Volume 189, Issue 1, Page 44-52, January 2018.

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Gilbert W. Beebe Symposium on 30 Years after the Chernobyl Accident: Current and Future Studies on Radiation Health Effects

Radiation Research, Volume 189, Issue 1, Page 5-18, January 2018.

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Effects of 1H + 16O Charged Particle Irradiation on Short-Term Memory and Hippocampal Physiology in a Murine Model

Radiation Research, Volume 189, Issue 1, Page 53-63, January 2018.

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Activation of the TRPV1 Thermoreceptor Induced by Modulated or Unmodulated 1800 MHz Radiofrequency Field Exposure

Radiation Research, Volume 189, Issue 1, Page 95-103, January 2018.

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Super-Resolution Nanoscopy Imaging Applied to DNA Double-Strand Breaks

Radiation Research, Volume 189, Issue 1, Page 19-31, January 2018.

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A Microdosimetric-Kinetic Model of Cell Killing by Irradiation from Permanently Incorporated Radionuclides

Radiation Research, Volume 189, Issue 1, Page 104-116, January 2018.

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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

AnnCardAnaesth_2018_21_1_103_223029_f1.j

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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Caffeine Intake and Its Association with Body Composition Measures and Macronutrient Intakes in People Living with HIV in the Miami Adult Studies on HIV Cohort

Journal of Caffeine Research , Vol. 0, No. 0.

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Caffeine Intake and Its Association with Body Composition Measures and Macronutrient Intakes in People Living with HIV in the Miami Adult Studies on HIV Cohort

Journal of Caffeine Research , Vol. 0, No. 0.

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EEG synchronization measures predict epilepsy-related BOLD-fMRI fluctuations better than commonly used univariate metrics

Because of their complementary properties, the simultaneous acquisition of the electroencephalogram (EEG) and blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) has been actively pursued. This is particularly important in the field of epilepsy, motivated by the need to map epileptic activity, as accurately as possible, in the brain of patients with drug-resistant focal epilepsy undergoing pre-surgical evaluation (Hoffmann et al., 2000; Ives et al., 1993; Lemieux et al., 2001; LeVan and Gotman, 2009; Salek-Haddadi et al., 2006).

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Epileptiform and periodic EEG activities induced by rapid sevoflurane anaesthesia induction

Sevoflurane is a fluorinated inhalated anaesthetic introduced into clinical practice in the 1990's. It is now widely used in both adults and children because of its rapid onset and short-lasting activity, pleasant odour and non-pungency (Eger 1994; Lerman et al., 1994). A rapid increase in the inspiratory concentration of sevoflurane, however, has been demonstrated to be associated with a transient hyperdynamic reaction in adult patients during controlled mild hypocapneic hyperventilation (Vakkuri et al., 1999).

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Testing - Praetorian Digital

Testing Functionality

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Quiz: Understanding acid-base issues in EMS

How well do you know the conditions associated with pH imbalances?

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Paramedics - Crozer Keystone Health Network

Paramedics Crozer Keystone Health System is hiring paramedics at Crozer-Chester Medical Center (PT & Per Diem Rotating) and Delaware County Memorial Hospital (FT & PT Rotating). Requirements: High school diploma or GED Graduate of an approved school of paramedic training National Registry Paramedic preferred Pennsylvania EMT-Paramedic certficiation Must be able to obtain Crozer Medical Command ...

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Spotlight: Braun Ambulances 'built for life' to protect, serve responders

Braun Industries prides itself on producing safe, quality ambulances for those who serve

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Yellow ambulance uses Binder Lift on 500lb patient wedged in tub

DAVIESS COUNTY, Ky. — The Situation: When Dinah Chapman of Yellow Ambulance responded to a call of a man stuck in a tub, she didn't realize just how stuck he was. When she and the rest of her crew arrived in the patient's bathroom, they found a 500-pound man wedged in the bottom of his Jacuzzi-style tub." Not only was he naked, he was also wet," Chapman recalled. "We had ...

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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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Active and Inactive Leg Hemodynamics during Sequential Single-Leg Interval Cycling

AbstractIntroductionLeg order during sequential single-leg cycling (i.e. exercising both legs independently within a single session) may affect local muscular responses potentially influencing adaptations. This study examined the cardiovascular and skeletal muscle hemodynamic responses during double-leg and sequential single-leg cycling.MethodsTen young healthy adults (28 ± 6 y) completed six 1-min double-leg intervals interspersed with one minute of passive recovery and, on a separate occasion, 12 (six with one leg followed by six with the other leg) 1-min single-leg intervals interspersed with one minute of passive recovery. Oxygen consumption, heart rate, blood pressure, muscle oxygenation, muscle blood volume and power output were measured throughout each session.ResultsOxygen consumption, heart rate and power output were not different between sets of single-leg intervals but the average of both sets was lower than the double-leg intervals. Mean arterial pressure was higher during double-leg compared with sequential single-leg intervals (115 ± 9 mmHg vs. 104 ± 9 mmHg; p

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Whole-genome methylation profiling of peripheral blood mononuclear cell for acute exacerbations of chronic obstructive pulmonary disease treated with corticosteroid

Objective Although association studies in the general population may be relevant for determining susceptibility to chronic obstructive pulmonary disease (COPD), they may be less applicable for pharmacogenetics research in participants who have already acquired the disease. Patients and methods A genome-wide methylation profiling (generated by HumanMethylation450 BeadChips study was performed on peripheral blood mononuclear cells of 24 patients with AECOPD (acute exacerbation COPD), with good and poor responsiveness to standard corticosteroid treatment. Pyrosequencing was used to replicate the selected CpG sites in 50 patients with AECOPD with standard corticosteroid treatment. Results The results showed the patients with AECOPD with good and poor response to standard corticosteroid treatment have a distinct DNA methylation pattern. A total of 23 CpG loci located in 19 known gene regions, including gene-body and promoter, appeared to be significantly differentially methylated. Replication by pyrosequencing revealed that one CpG site in PSMD8 showed the same trend of differential methylation and reached to statistical significance as the microarray result. Conclusion Our preliminary findings provide evidence for molecular heterogeneity in patients with AECOPD, which may contribute to significant differences in their response to COPD treatment. * Chung-Hsuan Chen and Lawrence Shih-Hsin Wu contributed equally to the writing of this article. Correspondence to Lawrence Shih-Hsin Wu, PhD, Institute of Medical Sciences, Tzu Chi University, No. 701, Zhongyang Road, Sec. 3, Hualien 97004, Taiwan Tel: 886 927 588 999; fax: 886 3857 3053; e-mail: lshwu@hotmail.com Received May 1, 2017 Accepted December 9, 2017 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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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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The effects of a single session of spinal manipulation on strength and cortical drive in athletes

Abstract

Purpose

The primary purpose of this study was to investigate whether a single session of spinal manipulation (SM) increases strength and cortical drive in the lower limb (soleus muscle) of elite Taekwondo athletes.

Methods

Soleus-evoked V-waves, H-reflex and maximum voluntary contraction (MVC) of the plantar flexors were recorded from 11 elite Taekwondo athletes using a randomized controlled crossover design. Interventions were either SM or passive movement control. Outcomes were assessed at pre-intervention and at three post-intervention time periods (immediate post, post 30 min and post 60 min). A multifactorial repeated measures ANOVA was conducted to assess within and between group differences. Time and session were used as factors. A post hoc analysis was carried out, when an interactive effect was present. Significance was set at p ≤ 0.05.

Results

SM increased MVC force [F(3,30) = 5.95, p < 0.01], and V-waves [F(3,30) = 4.25, p = 0.01] over time compared to the control intervention. Between group differences were significant for all time periods (p < 0.05) except for the post60 force measurements (p = 0.07).

Conclusion

A single session of SM increased muscle strength and corticospinal excitability to ankle plantar flexor muscles in elite Taekwondo athletes. The increased MVC force lasted for 30 min and the corticospinal excitability increase persisted for at least 60 min.

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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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Πληροφορίες

Πέμπτη 11 Ιανουαρίου 2018

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