Purpose of review Enhanced Recovery After Thoracic Surgery (ERATS) has gained momentum over the past few years, although the evidence base and expert recommendations lag behind other specialties. This review will present and examine key points from the first guidelines for enhanced recovery after lung surgery, released in 2018, jointly sponsored by the European Society of Thoracic Surgeons and the Enhanced Recovery After Surgery Society. Recent findings The recently released guidelines present core components of enhanced recovery as they pertain to lung resection surgery. Although evidence is still sparse in some areas, the guidelines summarize the available literature and incorporate levels of recommendation based upon the strength of available data as well as expert consensus. As of yet, the relative contribution of individual ERATS components to improvement in outcomes is unclear, but overall compliance does seem to be linked to positive results. Since the creation of the guidelines, additional literature related to ERATS has been released, and it will be incorporated and discussed into our review. Summary The creation of guidelines for enhanced recovery after lung resection will provide the thoracic anesthesiologist a framework upon which to build a comprehensive perioperative anesthetic plan. Correspondence to Emily G. Teeter, MD, FASE, Department of Anesthesiology, University of North Carolina at Chapel Hill, N2198 UNC Hospitals, CB #7010, Chapel Hill, NC 27599-7010, USA. Tel: 1 (919) 966 5136; E-mail: Emily_Teeter@med.unc.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Σάββατο 1 Δεκεμβρίου 2018
Neuromonitoring in the elderly
Purpose of review To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. Recent findings The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0–100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. Summary Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly. Correspondence to Claudia Spies, Department of Anesthesiology and Operative Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany. Tel: +49 30 450 651 001; e-mail: claudia.spies@charite.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Incremental value of noncerebral somatic tissue oxygenation monitoring for patients undergoing surgery
Purpose of the review There is increasing interest in the use of noncerebral somatic tissue oxygen saturation (SstO2) monitoring on the basis of near-infrared spectroscopy in patients undergoing surgery or residing in intensive care unit. The relevant question is whether SstO2 monitoring can improve the quality of care. In this article, we reviewed the clinical application of SstO2 monitoring in acute care, focusing on its use in patients undergoing surgery. Recent findings Multiple small cohort studies conducted on pediatric patients reported close associations of SstO2 measurements over different regions such as the splanchnic and renal tissue beds with systemic oxygenation, transfusion, hemodynamic indices, morbidity, and mortality. Conversely, there is paucity of literature on SstO2 monitoring in adult patients. The limited number of reports suggests that SstO2 levels over bulk muscles such as the thenar eminence, forearm, and lower leg during surgery are correlated with postoperative outcomes including postoperative nausea and vomiting and the length of hospital stay in adult patients undergoing surgery. The only pilot, randomized interventional study based on 50 patients undergoing surgery did not find a difference in outcomes on the basis of the use of SstO2 monitoring. Summary Somatic tissue oxygenation may represent an essential aspect of human physiology in acute care, and it is likely outcome-relevant based on observational cohort studies. Future research should examine whether SstO2-guided care can further improve patient outcomes using randomized controlled trials. Correspondence to Lingzhong Meng, MD, Professor and Division Chief, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, PO Box 208051, New Haven, CT 06520, USA. Tel: +1 203 785 2802; e-mail: lingzhong.meng@yale.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Spinal cord perfusion protection for thoraco-abdominal aortic aneurysm surgery
Purpose of Review Spinal cord ischemia (SCI) is a devastating complication after open or endovascular aortic repair for thoracoabdominal aortic disease. The underlying pathogenesis is not fully understood but appears multifactorial. Multiple spinal cord protection strategies and monitoring techniques are currently utilized with variable results seen. The purpose of this review is to summarize important and recent findings related to cause, monitoring and impact of multiple spinal cord protection strategies. Recent Findings Recent data suggests collateral blood flow as the major determinant of spinal cord perfusion instead of individual intercostal vessels, potential role of transcutaneous near-infrared spectroscopy for monitoring of spinal cord perfusion and positive impact of implementing multimodal spinal cord protection strategies on reducing the risk of SCI. Summary SCI leading to paraplegia is a multifactorial complication that remains a major concern in complex aortic surgeries. Although there are no sufficient data to document the efficacy of spinal cord protection techniques individually, their effect on lowering the risk of SCI is most evident when used concomitantly using a multimodal approach that encompasses the perioperative and early postoperative period. Correspondence to Lovkesh Arora, MD, 200 Hawkins drive, 6JCP, Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1079, USA. Tel: +1 319 384 6079; e-mail: Lovkesh-arora@uiowa.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Prehabilitation is better than cure
Purpose of review With a continuously growing number of older patients undergoing major surgical procedures, reliable parameters practicable in perioperative routine revealing those patients at risk are urgently needed. Recently, the concept of 'prehabilitation' with its key elements exercise, nutrition and psychological stress reduction especially in frail patients is attracting increasing attention. Recent findings Literature search revealed a huge amount of publications in particular within the last 12 months. Although a single definition of both frailty and prehabilitation is still to be made, various players in the perioperative setting obviously are becoming increasingly convinced about a possible benefit of the program – referring to different components and measures performed. Although physiologically advantages seem obvious, there is hardly any reliable data on clinical outcomes resulting from properly performed studies. This applies especially to octogenarians; thus those at risk for adverse events the concept originally addresses. Summary Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients. However, further studies on effectiveness in a highly heterogeneous population and agreement on a common concept are mandatory before a final judgement can be given. Correspondence to Simone Gurlit, MD, Department of Anesthesiology and operative Intensive Care, St. Franziskus-Hospital Muenster, Hohenzollernring 70, 48145 Muenster, Germany. Tel: +49 251 935 3936; fax: +49 251 935 4077; e-mails: simonegurlit@aol.com, simone.gurlit@sfh-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Extravascular lung water monitoring for thoracic and lung transplant surgeries
Purpose of review Excessive accumulation of extravascular lung water (EVLW) resulting in pulmonary edema is the most feared complication following thoracic surgery and lung transplant. ICUs have long relied on chest radiography to monitor pulmonary status postoperatively but the increasing recognition of the limitations of bedside plain films has fueled development of newer technologies, which offer earlier detection, quantitative assessments, and can aide in preoperative screening of surgical candidates. In this review, we focus on the emergence of transpulmonary thermodilution (TPTD) and lung ultrasound with a focus on the clinical integration of these modalities into current intraoperative and critical care practices. Recent findings Recent studies demonstrate transpulmonary thermodilution and lung ultrasound provide greater sensitivity and earlier detection of lung water accumulation and are useful to guide clinical management. Assessments from these techniques have predictive value of postoperative outcome. Further, EVLW assessment shows promise as a preoperative screening tool in lung transplant patients. Summary Monitoring EVLW in the perioperative period offers clinicians a powerful tool to guide fluid therapy and manage pulmonary edema. Both TPTD and lung ultrasound have unique attributes in the care of thoracic surgery and lung transplant patients. Correspondence to Sherif Assaad, MD, Department of Anesthesiology, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA. Tel: +1 203 932 5711; fax: +1 203 937 4803; e-mail: sherif.assaad@yale.ed Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Biomarkers and postoperative cognitive function: could it be that easy?
Purpose of review Neurocognitive dysfunction after surgery is highly relevant in the elderly. The multifactorial manner of this syndrome has made it hard to define an ideal biomarker to predict individual risk and assess diagnosis and severity of delirium [postoperative delirium (POD)] and subsequent postoperative cognitive decline (POCD). This review summarizes recent literature on blood biomarkers for POD/POCD. Recent findings Markers for delirium have been searched for in the cerebrospinal fluid to examine the pathologic cascade. However, cerebrospinal fluid cannot be easily obtained in the perioperative setting. Thus, attention shifts toward prediction markers from patients' blood to determine the individual risk. In this regard, three major groups of peripheral blood markers could be distinguished: first, global, but unspecific markers associated with POD/POCD; second, specific and established markers related to neurocognitive function; and third, upcoming or newly described markers with less evidence. Solely neuron-specific enolase is an adequate biomarker based on recent literature. Summary Single markers for postoperative cognitive impairment cannot predict POD/POCD in geriatric patients. However, a wisely arranged battery of promising biomarkers might achieve a satisfying sensitivity and specificity for the preoperative assessment of subsequent cognitive decline. Adequately powered studies to prove this hypothesis are required. Correspondence to Simon T. Schaefer, Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany. Tel: +49 89 440 013 181 142; fax: +49 89 440 078 886; e-mail: simon.schaefer@med.uni-muenchen.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/1qR4umk). Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Delayed recovery following thoracic surgery: persistent issues and potential interventions
Purpose of review Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges. Recent findings Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes. Summary Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions. Correspondence to Alessia Pedoto, MD FASA, Department of Anesthesiology and Critical Care Medicine, 1275 York Ave. Room M301, New York, NY 10065, USA. Tel: +1 212 639 6840; e-mail: pedotoa@mskcc.org Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
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Amplification of endothelium‐dependent vasodilatation in contracting human skeletal muscle: role of KIR channels
Key points
In humans, the vasodilatory response to skeletal muscle contraction is mediated in part by activation of inwardly rectifying potassium (KIR) channels. Evidence from animal models suggest that KIR channels serve as electrical amplifiers of endothelium‐dependent hyperpolarization (EDH). We found that skeletal muscle contraction amplifies vasodilatation to the endothelium‐dependent agonist acetylcholine (ACh), whereas there was no change in the vasodilatory response to sodium nitroprusside, an endothelium‐independent nitric oxide donor. Blockade of KIR channels reduced the exercise‐induced amplification of ACh‐mediated vasodilatation. Conversely, pharmacological activation of KIR channels in quiescent muscle via intra‐arterial infusion of KCl independently amplified the vasodilatory response to ACh. This study is the first in humans to demonstrate that specific endothelium‐dependent vasodilatory signalling is amplified in the vasculature of contracting skeletal muscle and that KIR channels may serve as amplifiers of EDH‐like vasodilatory signalling in humans.
Abstract
The local vasodilatory response to muscle contraction is due in part to the activation of inwardly rectifying potassium (KIR) channels. Evidence from animal models suggest that KIR channels function as "amplifiers" of endothelium‐dependent vasodilators. We tested the hypothesis that contracting muscle selectively amplifies endothelium‐dependent vasodilatation via activation of KIR channels. We measured forearm blood flow (Doppler ultrasound) and calculated changes in vascular conductance (FVC) to local intra‐arterial infusion of ACh (endothelium‐dependent dilator) during resting conditions, handgrip exercise (5% maximum voluntary contraction), or sodium nitroprusside (SNP; endothelium‐independent dilator) which served as a high‐flow control condition (n = 7, young healthy men and women). Trials were performed before and after blockade of KIR channels via infusion of barium chloride. Exercise augmented peak ACh‐mediated vasodilatation (ΔFVC saline: 117 ± 14; exercise: 236 ± 21 ml (min)−1(100 mmHg)−1; P<0.05), whereas SNP did not impact ACh‐mediated vasodilatation. Blockade of KIR channels attenuated the exercise‐induced augmentation of ACh. In 8 additional subjects, SNP was administered as the experimental dilator. In contrast to ACh, exercise did not alter SNP‐mediated vasodilatation (ΔFVC saline: 158 ± 35; exercise: 121 ± 22 ml (min)−1(100 mmHg)−1; NS). Finally, in a subset 6 subjects, direct pharmacological activation of KIR channels in quiescent muscle via infusion of KCl amplified peak ACh‐mediated vasodilatation (ΔFVC saline: 97 ± 15, KCl: 142 ± 16 ml (min)−1(100 mmHg)−1; respectively; P<0.05). These findings indicate that skeletal muscle contractions selectively amplify endothelium‐dependent vasodilatory signalling via activation of KIR channels, and this may be an important mechanism contributing to the normal vasodilatory response to exercise in humans.
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The impact of age and egg-laying cycle on female grasshoppers’ preference functions for acoustic signals
Abstract
Female responsiveness and the shape of preference functions for male signal traits are important determinants for male mating success. We observed the responsiveness and the selectivity of virgin grasshopper females (Chorthippus biguttulus L.) for different features of males' acoustic signals throughout their life span to detect possible influences of age on the females' preference functions. In particular, we explored the hypothesis that the females may become less selective with increasing age and, therefore, would start to accept songs that are normally rejected. Such an age effect could relieve the selection pressure on male signal traits. In the majority of animals tested, the general responsiveness decreased with age although a few individuals exhibited an opposite trend. Contrary to the above expectation, there was no indication of a loss of selectivity in older females or an increased acceptance of normally unattractive song models. The timing within the oviposition cycle had a strong effect on responsiveness: near oviposition the general responsiveness increased and with it also the half width of the preference functions. However, highly unattractive song models remained unattractive also near oviposition.
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Highlights from Gastro Update Europe – Prague, June 2018
Publication date: Available online 30 November 2018
Source: Arab Journal of Gastroenterology
Author(s): Guido N.J. Tytgat
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Correlation between expression of MMP-9 and MMP-3 in Helicobacter pylori infected patients with different gastroduodenal diseases
Publication date: Available online 30 November 2018
Source: Arab Journal of Gastroenterology
Author(s): Nader Bagheri, Marzieh Sadeghiani, Ghorbanali Rahimian, Majid Mahsa, Mohammedhadi Shafigh, Mahmoud Rafieian-kopaei, Hedayatollah Shirzad
Abstract
Background and study aims
Helicobacter pylori (H. pylori) has been implicated in the pathogenesis of most important gastro-duodenal diseases, such as gastritis, peptic ulcer disease (PUD) and gastric cancer. H. pylori upregulates the expression and activity of several matrix metalloproteinases (MMPs) in the gastric mucosa, but the role of MMP-3 and MMP-9 in infected patients with H. pylori have not been clearly defined yet. We examined mucosal MMP-3 and MMP-9 mRNA levels in gastric mucosa of H. pylori infected patients and evaluated the effects of virulence factors cagA and vacA allelic variants on these levels. We also determined correlation between mucosal MMP-3 and MMP-9 mRNA levels and types of disease.
Patients and methods
Total RNA was extracted from gastric biopsies of 50 H. pylori-infected patients and 50 H. pylori-negative patients. Mucosal MMP-3 and MMP-9 mRNA expression level in H. pylori-infected and non-infected gastric biopsies were determined by real time-polymerase chain reaction (PCR). Presence of vacA (vacuolating cytotoxin A) and cagA (cytotoxin associated gene A) virulence factors were evaluated using PCR.
Results
The levels of MMP-3 in gastric mucosa were not different between H. pylori-positive and H. pylori-negative patients. There was no correlation between MMP-3 mRNA expression and virulence factor (cagA and vacA allelic variants) and the different types of disease (gastritis and PUD) in infected patients. But MMP-9 mRNA expression was significantly higher in biopsies of H. pylori-infected patients compared to H. pylori-negative patients. Also mucosal MMP-9 mRNA expression in H. pylori-infected patients was significantly associated with cagA status PUD.
Conclusion
Our results suggest that MMP-9 might be involved in the pathogenesis of H. pylori. PUD could be associated with cag PAI-dependent MMP-9 upregulation.
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A positive feedback regulation of Heme oxygenase 1 by CELF1 in cardiac myoblast cells
Publication date: Available online 30 November 2018
Source: Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Yang Liu, Huiwen Wang, Jun Wang, Bin Wei, Xinyi Zhang, Mengqi Zhang, Dong Cao, Jiang Dai, Zhen Wang, Eric Nyirimigabo, Guangju Ji
Abstract
As an RNA binding protein, CUG-BP Elav-like family (CELF) has been shown to be critical for heart biological functions. However, no reports have revealed the function of CELF1 in hypertrophic cardiomyopathy (HCM). Hinted by RNA immunoprecipitation-sequencing (RIP-seq) data, the influence of the CELF protein on heme oxygenase-1 (HO-1) expression was tested by modulating CELF1 levels. Cardiac hypertrophy is related to oxidative stress-induced damage. Hence, the cardiovascular system may be protected against further injury by upregulating the expression of antioxidant enzymes, such as HO-1. During the past two decades, research has demonstrated the central role of HO-1 in the protection against diseases. Thus, understanding the molecular mechanisms underlying the modulation of HO-1 expression is profoundly important for developing new strategies to prevent cardiac hypertrophy.
To elucidate the molecular mechanisms underlying HO-1 regulation by the CELF protein, we performed RNA immunoprecipitation (RIP), biotin pull-down analysis, luciferase reporter and mRNA stability assays. We found that the expression of HO-1 was downregulated by CELF1 through the conserved GU-rich elements (GREs) in HO-1 3′UTR transcripts. Correspondingly, CELF1 expression was regulated by controlling the release of carbon monoxide (CO) in H9C2 cells. The CELF1-HO-1-CO regulation axis constituted a novel positive feedback circuit. In addition, we detected the potential involvement of CELF1 and HO-1 in samples from HCM patients. We found that CELF1 and CELF2, but not HO-1, were highly expressed in HCM heart samples. Thus, a manipulation targeting CELF1 could be developed as a potential therapeutic option for cardiac hypertrophy.
Graphical abstract
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Acknowledgement to Reviewers
Publication date: December 2018
Source: Clinical Neurophysiology, Volume 129, Issue 12
Author(s):
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Editorial Board
Publication date: December 2018
Source: Clinical Neurophysiology, Volume 129, Issue 12
Author(s):
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Effects of deep brain stimulation on the primary motor cortex: Insights from transcranial magnetic stimulation studies
Publication date: Available online 30 November 2018
Source: Clinical Neurophysiology
Author(s): Zhen Ni, Kaviraja Udupa, Mark Hallett, Robert Chen
Abstract
Deep brain stimulation (DBS) implanted in different basal ganglia nuclei regulates the dysfunctional neuronal circuits and improves symptoms in movement disorders. However, the understanding of the neurophysiological mechanism of DBS is at an early stage. Transcranial magnetic stimulation (TMS) can be used safely in movement disorder patients with DBS, and can shed light on how DBS works. DBS at a therapeutic setting normalizes the abnormal motor cortical excitability measured with motor evoked potentials (MEP) produced by primary motor cortical TMS. Abnormal intracortical circuits in the motor cortex tested with paired-pulse TMS paradigm also show normalization with DBS. These changes are accompanied with improvements in symptoms after chronic DBS. Single-pulse DBS produces cortical evoked potentials recorded by electroencephalography at specific latencies and modulates motor cortical excitability at certain time intervals measured with MEP. Combination of basal ganglia DBS with motor cortical TMS at stimulus intervals consistent with the latency of cortical evoked potentials delivered in a repetitive mode produces plastic changes in the primary motor cortex. TMS can be used to examine the effects of open and closed loop DBS. Patterned DBS and TMS delivered in a repetitive mode may be developed as a new therapeutic method for movement disorder patients.
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