Performance of Electrical Velocimetry for Noninvasive Cardiac Output Measurements in Perioperative Patients After Subarachnoid Hemorrhage

Background: Fluid therapy guided by cardiac output measurements is of particular importance for adequate cerebral perfusion and oxygenation in neurosurgical patients. We examined the usefulness of a noninvasive electrical velocimetry (EV) device based on the thoracic bioimpedance method for perioperative hemodynamic monitoring in patients after aneurysmal subarachnoid hemorrhage. Patients and Methods: In total, 18 patients who underwent surgical clipping or endovascular coiling for ruptured aneurysms were examined prospectively. Simultaneous cardiac index (CI) measurements obtained with EV (CIEV) and reference transpulmonary thermodilution (CITPTD) were compared. A total of 223 pairs of data were collected. Results: A significant correlation was found between CIEV and CITPTD (r=0.86; P

https://ift.tt/2MTM48A

Dilated Pupil as a Diagnostic Component of Brain Death—Does it Really Matter?

No abstract available

https://ift.tt/2KcleXn

Clinical and circulating biomarkers of survival and recurrence after radiofrequency ablation in patients with hepatocellular carcinoma

Publication date: Available online 23 June 2018
Source:Critical Reviews in Oncology/Hematology
Author(s): Matteo Canale, Paola Ulivi, Francesco Giuseppe Foschi, Emanuela Scarpi, Serena De Matteis, Gabriele Donati, Giorgio Ercolani, Mario Scartozzi, Luca Faloppi, Alessandro Passardi, Emiliano Tamburini, Martina Valgiusti, Giorgia Marisi, Giovanni Luca Frassineti, Andrea Casadei Gardini
Radiofrequency ablation (RFA) is an effective local treatment for curative intent in patients with cirrhosis of the liver and hepatocellular carcinoma (HCC) with diameter < 3 cm. Several meta-analyses have shown that RFA and surgical resection are comparable in terms of their impact on overall survival. The only clinical data available on markers that are predictive of recurrence and survival after RFA treatment are based on retrospective observational studies. Prospective randomized trials are thus needed to further research in this area.In the present review we analyzed a number of clinical factors that are considered to predict recurrence or survival in HCC patients treated with RFA. We also discussed in detail the circulating biomarkers investigated to date, together with their potential to predict prognosis and recurrence after RFA therapy.Overall survival rates of patients with HCC are significantly affected by liver function, defined as Child-Pugh class, high baseline serum alpha-fetoprotein levels, and the presence of portosystemic collaterals. However, the development of local tumor progression does not significantly affect overall survival. This result is achieved by the effective therapies in patients who relapse after treatment with RFA. For this reason there is an urgent need to identify new circulating biomarkers.



https://ift.tt/2MSkrN5

Do SABR-related toxicities for lung cancer depend on treatment delivery?

Publication date: Available online 23 June 2018
Source:Critical Reviews in Oncology/Hematology
Author(s): Stamati Morias, Loredana Gabriela Marcu, Michala Short, Eileen Giles, Eva Bezak
Stereotactic ablative radiation therapy for lung cancer is an advanced technique where tumours are ablated with hypofractionated radiation doses, with a high degree of accuracy. The aim of this paper is to review the available literature and to discuss the SABR-induced toxicities for lung malignancies as a function of radiation delivery technique.A Medline search was conducted to identify the appropriate literature to fulfil the aim of this review and data from all applicable papers were collated and analysed.The most common techniques of SABR delivery employ linear accelerators, CyberKnife robotic radiosurgery system, TomoTherapy and the Novalis beam surgery system. Linear accelerator-based treatments give rise to a variety of toxicities that are strongly dependent on both patient-related factors and planning/dosimetry-related factors. The limited number of studies using CyberKnife reported low grade toxicities. Grade three toxicities mainly include fatigue and chest pain, usually in less than 10% of patients.All treatment techniques presented show efficiency in SABR delivery with various toxicities which, at this stage, cannot render one technique better than the other. For more conclusive results, well-designed phase three randomised clinical trials are required with better patient selection criteria, including dose and fractionation, treatment machine and technique, along with the consistent selection of a common toxicity grading criterion.

Graphical abstract

https://ift.tt/2tyXMwe

Critical review of axillary recurrence in early breast cancer

Publication date: Available online 23 June 2018
Source:Critical Reviews in Oncology/Hematology
Author(s): Carlos A. Castaneda, Pamela Rebaza, Miluska Castillo, Henry H. Gomez, Miguel de La Cruz, Gabriela Calderon, Jorge Dunstan, Jose Manuel Cotrina, Julio Abugattas, Tatiana Vidaurre
Around 2% of early breast cancer cases treated with axillary lymph node dissection (ALND) underwent axillary recurrence (AR) and it has a deleterious effect in prognosis. Different scenarios have incorporated Sentinel Lymph Node (SLN) Biopsy (SLNB) instead of ALND as part of the standard treatment and more effective systemic treatment has also been incorporated in routine management after first curative surgery and after regional recurrence. However, there is concern about the effect of SLNB alone over AR risk and how to predict and treat AR. SLN biopsy (SLNB) has been largely accepted as a valid option for SLN-negative cases, and recent prospective studies have demonstrated that it is also safe for some SLN-positive cases and both scenarios carry low AR rates. Different studies have identified clinicopathological factors related to aggressiveness as well as high-risk molecular signatures can predict the development of locoregional recurrence. Other publications have evaluated factors affecting prognosis after AR and find that time between initial treatment and AR as well as tumor aggressive behavior influence patient survival. Retrospective and prospective studies indicate that treatment of AR should include local and systemic treatment for a limited time.



https://ift.tt/2MRpTQc

Immune-checkpoint inhibitors in non-small cell lung cancer: a tool to improve patients’ selection

Publication date: Available online 23 June 2018
Source:Critical Reviews in Oncology/Hematology
Author(s): Giuseppe Luigi Banna, Francesco Passiglia, Francesca Colonese, Stefania Canova, Jessica Menis, Alfredo Addeo, Antonio Russo, Diego Luigi Cortinovis
The identification of reliable predictive biomarkers of efficacy or resistance to immune-oncology (I-O) agents is a major issue for translational research and clinical practice. However, along with PDL1 and molecular features other clinical, radiological and laboratory factors can be considered for the selection of those patients who would not be the best candidate for immune-checkpoint inhibitors (ICPIs). We examined these factors, emerging from the results of currently available studies in non-small cell lung cancer (NSCLC), aiming to provide a useful and manageable tool which can help Oncologists in their everyday clinical practice.A thorough patient evaluation and close clinical monitoring, due to limited, early or inconclusive currently available data, should be deserved for patients with a pre-existing symptomatic chronic obstructive pulmonary disease, age >75 years, Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 1, a time to progression (TTP) < three months and progressive disease (PD) as the best response to the previous treatment, hepatitis or HIV-infections, high neutrophil to lymphocyte ratio (NLR), or on treatment with high-dose steroids, when the use of ICPIs is considered. Limited data are available to consider that ICPIs are safe in patients with interstitial lung disease, bronchiolitis obliterans organizing pneumonia and autommune diseases. Early evidence on steroids, vaccinations and antibiotics suggest their possible interaction with ICPIs and need to be more investigated in clinical trials. Oncogene-addicted NSCLC harboring EGFR-mutations and low tumor-infiltrating T-lymphocytes (TILs) seems not to gain benefit from I-O.



https://ift.tt/2yIP190

Giant congenital melanocytic nevus in a Cameroonian child: a case report

Giant congenital melanocytic nevus is a very rare condition characterized by a large skin lesion and an increased risk of complications like neurocutaneous melanosis and malignant transformation. Reports of gi...

https://ift.tt/2tndf3d

A global Unified Dosimetry Index (gUDI) to evaluate simultaneous integrated boost radiotherapy plans in prostate cancer

Formulation of a global Unified Dosimetry Index (gUDI) for the evaluation of prostate simultaneous integrated boost Volumetric Modulated Arc Therapy (VMAT by RapidArc) radiotherapy plans.

https://ift.tt/2txCorv

Mortality of patients examined at a diagnostic centre: A matched cohort study

Publication date: August 2018
Source:Cancer Epidemiology, Volume 55
Author(s): Esben Næser, Henrik Møller, Ulrich Fredberg, Peter Vedsted
Background'Diagnostic Centres' has been established to provide a diagnostic pathway for patients with non-specific, serious symptoms that could be cancer. As little is known about the prognosis, we aimed to 1) analyse mortality of patients examined at the diagnostic centre, stratified on diagnostic outcome (cancer, serious-non-malignant disease, or other/no diagnosis), and 2) compare mortality for cancer patients examined at the diagnostic centre with cancer patients diagnosed through other routes.MethodRetrospective cohort study including 938 patients examined at the Diagnostic Centre, Silkeborg Regional Hospital, Denmark, during 2012–2014. Cancer patients examined at the diagnostic centre were matched (1:10) to a reference group of cancer patients diagnosed through other routes. Information on diagnosis, death, comorbidity and socioeconomic factors was obtained by linkage to national Danish registers. Mortality was assessed by Kaplan Meier mortality survival analysis and hazard ratios of death were estimated using Cox proportional regression analysis while adjusting for confounders.ResultsThe 1-year cumulative mortality was 28% in cancer patients examined at the diagnostic centre. The hazard ratio of death was seven times increased in cancer patients compared to patients with other/no diagnosis. The hazard ratio of death was 0.91 (95% CI: 0.68; 1.22) in cancer patients examined at the diagnostic centre compared to cancer patients diagnosed through other routes.DiscussionThe mortality among cancer patients examined at the diagnostic centre was comparable to cancer patients diagnosed through other routes. The results indicate that cancer patients with non-specific serious symptoms do not have a worse prognosis than other cancer patients.



https://ift.tt/2tw9Aj6

Effects of epidural anesthesia on postoperative nausea and vomiting in laparoscopic gynecological surgery: a randomized controlled trial

Abstract

Purpose

Patients undergoing laparoscopic gynecological surgery are susceptible to postoperative nausea and vomiting (PONV). We hypothesized that a combination of epidural and general anesthesia to minimize intraoperative opioid administration would reduce the incidence of PONV following laparoscopic gynecological surgery.

Methods

Women undergoing elective laparoscopic gynecological surgery were randomly assigned to receive general anesthesia alone (group G, n = 45) or general anesthesia with epidural anesthesia (group GE, n = 45). Patients in group G received fentanyl and remifentanil for intraoperative analgesia, and those in group GE received single-shot ropivacaine at the time of induction of anesthesia. The primary outcome was the incidence of PONV within 24 h of surgery. Secondary outcomes included the use of rescue metoclopramide within 24 h of surgery and the time to first incidence of PONV and first use of rescue metoclopramide.

Results

The incidence of PONV within 24 h of surgery was 60.0% in group G and 44.4% in group GE [relative risk (RR): 0.53, 95% confidence interval (CI): 0.23–1.23, p = 0.14]. There were no intergroup differences in the use of rescue metoclopramide (40.0% in group G, 24.4% in group GE, RR: 0.49, 95% CI 0.20–1.20, p = 0.11) and the time to first incidence of PONV and first use of rescue metoclopramide (p = 0.20 and 0.12, respectively).

Conclusion

Minimizing intraoperative opioid administration by combining epidural and general anesthesia did not reduce the 24-h incidence of PONV or rescue metoclopramide use after laparoscopic gynecological surgery.

https://ift.tt/2Iis38b

PET imaging of cardiomyocyte apoptosis in a rat myocardial infarction model

Abstract

Cardiomyocyte apoptosis has been observed in several cardiovascular diseases and contributes to the subsequent cardiac remodeling processes and progression to heart failure. Consequently, apoptosis imaging is helpful for noninvasively detecting the disease progression and providing treatment guidance. Here, we tested ¹⁸F-labeled 2-(5-fluoropentyl)-2-methyl-malonic acid (¹⁸F-ML-10) and ¹⁸F-labeled 2-(3-fluoropropyl)-2-methyl-malonic acid (¹⁸F-ML-8) for apoptosis imaging in rat models of myocardial infarction (MI) and compared them with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG). MI was induced in Sprague-Dawley rats by permanent left coronary artery ligation. Procedural success was confirmed by echocardiography and positron emission tomography (PET) imaging with ¹⁸F-FDG. In vivo PET imaging with ¹⁸F-ML-10 and ¹⁸F-ML-8 was performed in the MI models at different time points after operation. Terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) assays and immunohistochemical analyses were used to evaluate myocardial apoptosis. In vitro cell binding assays were performed to validate ¹⁸F-ML-8 binding to apoptotic cardiomyocytes. PET imaging demonstrated high ¹⁸F-ML-10 and ¹⁸F-ML-8 uptake where ¹⁸F-FDG uptake was absent. The focal accumulation of the two tracers was high on days 1 and 3 but was not notable on days 5 and 7 after surgery. The infarct-to-lung uptake ratio was 4.29 ± 0.30 for ¹⁸F-ML-10 and 3.51 ± 0.18 for ¹⁸F-ML-8 (n = 6, analyzed by averaging the uptake ratios on postoperative days 1 and 3, P < 0.05). The TUNEL results showed that myocardial cell apoptosis was closely related to the focal uptake of the apoptotic tracers in the infarct area. In addition, the apoptosis rates calculated from the TUNEL results were better correlated with ¹⁸F-ML-8 uptake than with ¹⁸F-ML-10 uptake. Ex vivo cell binding assays demonstrated that ¹⁸F-ML-8 accumulated in apoptotic cells but not in necrotic or normal cells. PET imaging using ¹⁸F-ML-10 or ¹⁸F-ML-8 allows the noninvasive detection of myocardial apoptosis in the early phase. In addition, ¹⁸F-ML-8 may be better than ¹⁸F-ML-10 for apoptosis imaging. We propose that PET imaging with ¹⁸F-ML-10 or ¹⁸F-ML-8 combined with ¹⁸F-FDG is an alternative for detecting and assessing MI.

https://ift.tt/2Kgf8oO

Macrocephaly, epilepsy and intracranial cysts: an image to remember

Description  

An 11-year-old, developmentally normal girl presented with recurrent seizures for the past 2 years. She was also noted to have progressively increasing head size since early infancy. She was born to non-consanguineous parents from the Aggarwal community in India and had a 7-year-old younger sister with similar problems. There was no associated history of vision impairment, tone abnormalities, cognitive or behavioural problems, extrapyramidal movements or gait changes. Examination showed head circumference of 58 cm (>3 z-scores), a single café-au-lait macule and normal bilateral fundi. The rest of the systemic examination was unremarkable. Parental head circumference was normal. She was evaluated for familial macrocephaly with epilepsy. MRI brain showed diffuse involvement of the subcortical and periventricular white matter with sparing of corpus callosum and formation of subcortical cysts (figure 1A–D). Electroencephalogram showed intermittent spike-slow waves from left temporal and right centroparietal areas and bilateral frontal intermittent rhythmic delta activity. Targeted...

https://ift.tt/2KiS3VK

Pyrexia of unknown origin: inferior vena cava agenesis

A 26-year-old woman presented with a 5-day history of fever after returning from Bali. She denied sexual contact abroad. On examination, there was suprapubic tenderness and a widespread maculopapular rash. Malaria serology was negative and blood tests were normal except for an elevated C reactive protein. Treatment was initially with ceftriaxone, metronidazole and doxycycline, but her symptoms failed to improve. A CT pelvis suggested a possible tubo-ovarian abscess, a suspected inferior vena cava (IVC) anomaly and left internal iliac/femoral venous thrombosis. A gynaecology review demonstrated left tubo-ovarian tenderness and fullness. An MRI suggested pelvic inflammatory disease and thrombophlebitis affecting the pelvic veins; deep vein thrombosis (DVT) treatment was commenced. Further family history revealed thrombosis throughout multiple generations. Further imaging analysis demonstrated agenesis of the IVC with compensatory dilation of pelvic collaterals and an acute DVT of the deep pelvic venous system. The patient was discharged with direct oral anticoagulant therapy.

https://ift.tt/2IjDwEi

Pregnancy and gastric cancer: diagnostic and treatment dilemma

Gastric cancer in pregnancy is an extremely rare entity. The incidence of gastric cancer is more in elderly patients and higher in the male population. Gastric cancer symptoms can be nausea, vomiting and epigastric discomfort which is similar to early pregnancy symptoms. This leads to a misinterpretation and delay in the diagnosis during pregnancy. Gastric cancer in pregnancy is associated with poor prognosis because of its delayed diagnosis at an advance stage. We present our patient here, with this rare clinical diagnosis and with no suspicion in a young healthy woman.

https://ift.tt/2K0Kofz

Delayed leucoencephalopathy after coil embolisation of unruptured cerebral aneurysm

A 56-year-old right-handed woman was successfully treated by coil embolisation for a large unruptured paraclinoid aneurysm of the left internal carotid artery. Though she was discharged on day 3 after the intervention with uneventful clinical course, she was rehospitalised for continuous headache and right upper limb weakness 2 weeks after the treatment. Subsequent progression of cognitive dysfunction and right hemiparesis were observed. Repeated MRI revealed diffuse leucoencephalopathy within the ipsilateral brain hemisphere. Clinical course, serological examination, and radiological findings were consistent with localised hypocomplemental vasculitis caused by delayed hypersensitivity reaction. Immunosuppressive treatments using prednisolone successfully improved her symptoms. After a washout period for immunosuppressant, skin reaction test was performed and revealed polyglycolic-polylactic acid, coating material of the coil, positive for delayed allergic reaction. Given the increased frequency of endovascular treatment for unruptured aneurysms, even such a rare complication should be recognised and treated properly to avoid neurological sequelae.

https://ift.tt/2IngrRm

Pancreatic intraepithelial neoplasia in heterotopic pancreas: incidentally diagnosed on endoscopic mucosal resection of a duodenal polyp

Heterotopic pancreas is the presence of pancreatic tissue outside its normal location. It can develop similar pathological conditions that develop in the normal pancreas, including adenocarcinoma and its precursor lesions. Due to the rarity of the condition, the diagnosis can be challenging, and treatment is not well established. We present a 47-year-old female patient referred for endoscopic resection of a 2 cm polyp in the second part of her duodenum. Complete endoscopic mucosal resection (EMR) was performed, with pathology revealing low-grade pancreatic intraepithelial neoplasia (PanIN) in heterotopic pancreatic tissue. To the best of our knowledge, this is the first case of heterotopic pancreas with low-grade PanIN in the duodenum to be incidentally diagnosed and treated with EMR.

https://ift.tt/2Kfcgfi

Involvement of bilateral posterior limb of internal capsule in hypernatraemic dehydration

Description 

A 3-month-old male infant presented with loose stools and vomiting for the past 2 weeks and altered sensorium for the past 5 days. He was being administered inadequately diluted oral rehydration solution. On examination, he had moderate encephalopathy, depressed anterior fontanel and doughy skin. Laboratory investigations showed serum sodium 200 mEq/L, potassium 6.1 mEq/L, chloride 129 mEq/L, urea 136 mg/dL and creatinine 0.7 mg/dL. MRI of the brain showed predominant involvement of bilateral posterior limbs of internal capsule and genu with diffusion restriction (figure 1A–F). The baby improved with administration of free water, supportive care and gradual reduction of serum sodium. There were no seizures, and encephalopathy improved by day 3 of hospitalisation. At 3-month follow-up, he has normal development, absence of seizures or focal motor deficits.

Figure 1

(A–F) MRI brain on day 4 of illness, axial T2 (A and D), diffusion-weighted (B and E, b...

https://ift.tt/2yD0xCC

Spontaneous intracerebral haemorrhage: a rare complication of aortic aneurysm endoleak

We present a rare case of intracerebral haemorrhage secondary to consumptive coagulopathy in relation to ongoing endoleak after thoracic endovascular aneurysm repair (TEVAR). A 68-year-old man underwent elective TEVAR for an 18 cm diameter Crawford type II thoracoabdominal aneurysm. He was subsequently shown to have a type 1b endoleak and a short episode of disseminated intravascularcoagulation (DIC) perioperatively. Two months after the procedure, he experienced a consumptive coagulopathy leading to intracerebral haemorrhage and ultimately his death. Endoleak-related DIC is an underappreciated phenomenon within the medical literature. Currently, management is reliant on general DIC principles and anecdotal experiences of others within the case report literature.

https://ift.tt/2MUn6WC

A migratory shark bone

Fish bone ingestion is a common presentation in ENT. If not managed correctly, it can cause serious complications for the patient and dilemmas for the clinician. A 49-year-old Sri Lankan woman presented to the emergency department following shark bone ingestion with a 'pricking' sensation in her throat. After initial investigation, the bone migrated through to the sternocleidomastoid muscle. After surgical removal of the shark bone she went on to develop a large neck collection, which required surgical drainage. The careful attention to the patient's history and use of imaging facilitated treatment in this case of fish bone ingestion and management of the sequelae.

https://ift.tt/2twIZ5s

Antibody-dependent cell-mediated cytotoxicity induced by active immunotherapy based on racotumomab in non-small cell lung cancer patients

Abstract

Antitumor strategies based on positive modulation of the immune system currently represent therapeutic options with prominent acceptance for cancer patients' treatment due to its selectivity and higher tolerance compared to chemotherapy. Racotumomab is an anti-idiotype (anti-Id) monoclonal antibody (mAb) directed to NeuGc-containing gangliosides such as NeuGcGM3, a widely reported tumor-specific neoantigen in many human cancers. Racotumomab has been approved in Latin American countries as an active immunotherapy for advanced non-small cell lung cancer (NSCLC) treatment. In this work, we evaluated the induction of Ab-dependent cell-mediated cytotoxicity (ADCC) in NSCLC patients included in a phase III clinical trial, in response to vaccination with racotumomab. The development of anti-NeuGcGM3 antibodies (Abs) in serum samples of immunized patients was first evaluated using the NeuGcGM3-expressing X63 cells, showing that racotumomab vaccination developed antigen-specific Abs that are able to recognize NeuGcGM3 expressed in tumor cell membranes. ADCC response against NeuGcGM3-expressing X63 (target) was observed in racotumomab-treated- but not in control group patients. When target cells were depleted of gangliosides by treatment with a glucosylceramide synthase inhibitor, we observed a significant reduction of the ADCC activity developed by sera from racotumomab-vaccinated patients, suggesting a target-specific response. Our data demonstrate that anti-NeuGcGM3 Abs induced by racotumomab vaccination are able to mediate an antigen-specific ADCC response against tumor cells in NSCLC patients.

https://ift.tt/2K0xzlr

A small compound spindlactone A sensitizes human endometrial cancer cells to TRAIL-induced apoptosis via the inhibition of NAD(P)H dehydrogenase quinone 1

https://ift.tt/2KeSTDa

MYO5A inhibition by miR-145 acts as a predictive marker of occult neck lymph node metastasis in human laryngeal squamous cell carcinoma

https://ift.tt/2IiQoL0

TRIM44, a crucial target of miR-410, functions as a potential oncogene in osteosarcoma

https://ift.tt/2K4w2eb

Eligibility of real-world patients with chemo-refractory, K-RAS wild-type, metastatic colorectal cancer for palliative intent regorafenib monotherapy

Abstract

The CORRECT trial demonstrated survival benefits with regorafenib monotherapy in patients with treatment-refractory, metastatic colorectal cancer (mCRC). However, the trial's stringent eligibility criteria for regorafenib may limit its external validity. We aimed to examine treatment attrition rates and eligibility for regorafenib in routine practice. We identified patients at the British Columbia Cancer Agency diagnosed with mCRC who demonstrated disease progression or intolerable toxicity on 2 or more lines of systemic therapy. During the study timeframe, panitumumab and cetuximab were only used in the chemo-refractory setting. Data on clinicopathologic variables and patient outcomes were ascertained and analyzed. Eligibility was determined using the CORRECT trial criteria. A total of 391 patients were identified, among whom only 39% were eligible for regorafenib: 35% in the panitumumab group and 51% in the cetuximab group. The main reasons for ineligibility in all patients were Eastern Cooperative Oncology Group Performance Status (ECOG PS) > 1 (69%), an elevated total bilirubin (21%), and thromboembolic events in the past 6 months (10%). No difference in eligibility for regorafenib was observed between patients previously receiving panitumumab or cetuximab (P = 0.914; 95% CI 0.550–1.951). Kaplan–Meier analyses showed that regorafenib-eligible compared to regorafenib-ineligible patients had an increased median overall survival of 5.3 versus 2.1 months, respectively (P < 0.001). However, Cox proportional hazard analyses showed that only ECOG PS rather than trial eligibility was correlated with outcomes. The strict eligibility criteria disqualify most patients with treatment-refractory mCRC for regorafenib therapy. Future trials should broaden the eligibility criteria to improve external validity.

https://ift.tt/2KfcQcL

The impact of low body mass index on postoperative outcomes in pancreatectomy patients: a retrospective analysis of Japanese administrative data

Abstract

Purpose

To comparatively examine in-hospital mortality among different underweight body mass index (BMI) categories in pancreatic cancer patients after pancreatectomy in Japan.

Methods

We conducted a large-scale multi-center retrospective cohort study of adult patients with pancreatic cancer who underwent pancreatectomy between April 1, 2010 and March 31, 2016. Patients were classified according to BMI as follows: normal BMI (18.50–24.99 kg/m²), mild thinness (17.00–18.49 kg/m²), moderate thinness (16.00–16.99 kg/m²), and severe thinness (< 16.00 kg/m²). A multivariable logistic regression analysis was performed with in-hospital mortality as the dependent variable and BMI groups as the main independent variable of interest.

Results

We analyzed 6173 patients from 332 hospitals. The results showed that the severe thinness group had a longer postoperative hospital stay (34.4 ± 25.6 days) and higher incidence of postoperative pneumonia (5.5%) than the other groups. The generalized estimating equations accounted for patient demographics, surgical procedure, anesthetic technique, activities of daily living score, and Charlson comorbidity index as covariates. Relative to the normal BMI group, the odds ratios for in-hospital mortality were 0.57 (95% confidence interval: 0.26–1.24; P = 0.16) in the mild thinness group, 1.49 (0.64–3.48; P = 0.36) in the moderate thinness group, and 2.54 (1.05–6.08; P = 0.04) in the severe thinness group.

Conclusion

Severe thinness was significantly associated with a higher risk of mortality, and extremely low BMI should be considered a risk factor in pancreatectomy patients.

https://ift.tt/2tliLU4

Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns

BACKGROUND: Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS: Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS: Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS: Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization. Accepted for publication May 14, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jeron Zerillo, MD, Department of Anesthesiology, Mount Sinai School of Medicine, 1 Gustave L Levy Pl, New York, NY 10029. Address e-mail to jeron.zerillo@mountsinai.org. © 2018 International Anesthesia Research Society

https://ift.tt/2ltuYSg

Variable Ventilation Associated With Recruitment Maneuver Minimizes Tissue Damage and Pulmonary Inflammation in Anesthetized Lung-Healthy Rats

BACKGROUND: Recruitment maneuver and positive end-expiratory pressure (PEEP) can be used to counteract intraoperative anesthesia-induced atelectasis. Variable ventilation can stabilize lung mechanics by avoiding the monotonic tidal volume and protect lung parenchyma as tidal recruitment is encompassed within the tidal volume variability. METHODS: Forty-nine (7 per group) male Wistar rats were anesthetized, paralyzed, and mechanically ventilated. A recruitment maneuver followed by stepwise decremental PEEP titration was performed while continuously estimating respiratory system mechanics using recursive least squares. After a new recruitment, animals were ventilated for 2 hours in volume-control with monotonic (VCV) or variable (VV) tidal volumes. PEEP was adjusted at a level corresponding to the minimum elastance or 2 cm H2O above or below this level. Lungs were harvested for histologic analysis (left lung) and cytokines measurement (right lung). Seven animals were euthanized before the first recruitment as controls. RESULTS: A time-dependent increase in respiratory system elastance was observed and significantly minimized by PEEP (P

https://ift.tt/2ttovKN

High-Fidelity Simulation Nurse Training Reduces Unplanned Interruption of Continuous Renal Replacement Therapy Sessions in Critically Ill Patients: The SimHeR Randomized Controlled Trial

BACKGROUND: Although continuous renal replacement therapy (CRRT) is common, unplanned interruptions (UI) often limit its usefulness. In many units, nurses are responsible for CRRT management. We hypothesized that a nurse training program based on high-fidelity simulation would reduce the rate of interrupted sessions. METHODS: We performed a 2-phase (training and evaluation), randomized, single-center, open study: During the training phase, intensive care unit nurses underwent a 6-hour training program and were randomized to receive (intervention) or not (control) an additional high-fidelity simulation training (6 hours). During the evaluation phase, management of CRRT sessions was randomized to either intervention or control nurses. Sessions were defined as UI if they were interrupted and the interruption was not prescribed in writing more than 3 hours before. RESULTS: Study nurses had experience with hemodialysis, but no experience with CRRT before training. Intervention nurses had higher scores than control nurses on the knowledge tests (grade, median [Q1–Q3], 14 [10.5–15] vs 11 [10–12]/20; P = .044). During a 13-month period, 106 sessions were randomized (n = 53/group) among 50 patients (mean age 70 ± 13 years, mean simplified acute physiology II score 69 [54–96]). Twenty-one sessions were not analyzed (4 were not performed and 17 patients died during sessions). Among the 42 intervention and 43 control sessions analyzed, 25 (59%) and 38 (88%) were labeled as UI (relative risk [95% CI], 0.67 [0.51–0.88]; P = .002). Intervention nurses required help significantly less frequently (0 [0–1] vs 3 [1–4] times/session; P

https://ift.tt/2lxLa5f

Perioperative Hydroxyethyl Starch: A Potential Threat to a Patient Safety

No abstract available

https://ift.tt/2yAVCSL

Propofol Attenuates the Myocardial Protection Properties of Desflurane by Modulating Mitochondrial Permeability Transition

BACKGROUND: Desflurane and propofol are cardioprotective, but relative efficacy is unclear. The aim was to compare myocardial protection of single, simultaneous, and serial administration of desflurane and propofol. METHODS: Sixty New Zealand White rabbits and 65 isolated Sprague Dawley rat hearts randomly received desflurane, propofol, simultaneous desflurane and propofol, or sequential desflurane then propofol. Rabbits were subdivided to receive either ischemia-reperfusion with temporary occlusion of the left anterior descending artery or a time-matched, nonischemic perfusion protocol, whereas rat hearts were perfused in a Langendorff model with global ischemia-reperfusion. End points were hemodynamic, functional recovery, and mitochondrial uptake of 3H-2-deoxy-D-glucose as an indicator of mitochondrial permeability transition. RESULTS: In rabbits, there were minimal increases in preload-recruitable stroke-work with propofol(P

https://ift.tt/2lrW2kT

Electroencephalographic Arousal Patterns Under Dexmedetomidine Sedation

BACKGROUND: The depth of dexmedetomidine-induced sedation is difficult to assess without arousing the patient. We evaluated frontal electroencephalogram (EEG) as an objective measure of dexmedetomidine-induced sedation. Our aims were to characterize the response patterns of EEG during a wide range of dexmedetomidine-induced sedation and to determine which spectral power best correlated with assessed levels of dexmedetomidine-induced sedation. METHODS: Sedline EEG sensor was positioned on the forehead of 16 volunteers. Frontal EEG data were collected at 250 Hz using the Sedline monitor. A computer-controlled infusion pump was used to infuse dexmedetomidine to four 15-minute target plasma concentrations of 0.3, 0.6, 1.2, and 2.4 ng/mL. Arterial blood samples for dexmedetomidine plasma concentration and sedation (self-reported numerical rating scale) and arousal were measured at baseline and at the end of each infusion step. The EEG signal was used to estimate spectral power in sequential 4-second data segments with 75% overlap for 3 power bands: delta = 0.5–1.5 Hz, alpha = 9–14 Hz, beta = 15–24 Hz. We quantified the relationships among the plasma concentrations of dexmedetomidine, level of sedation, and various EEG parameters. RESULTS: EEG data at the end of the dexmedetomidine infusion steps show progressive loss of high frequencies (beta) and increase in alpha and delta powers, with increasing dexmedetomidine concentrations. Beta prearousal spectral power was best in predicting dexmedetomidine-induced level of sedation (R = −0.60, 95% CI, −0.43 to −0.75). The respective values for delta and alpha powers were R = 0.28 (95% CI, 0.03–0.45) and R = 0.16 (95% CI, −0.09 to 0.38). When the beta power has dropped below −16 dB or the delta power is above 15 dB, the subjects show moderate to deep levels of sedation. When awakening the subject, there is a reduction in power in the delta and alpha bands at the 0.6, 1.2, and 2.4 ng/mL dexmedetomidine target levels (P

https://ift.tt/2yAVwun

Spinal Activation of Tropomyosin Receptor Kinase-B Recovers the Impaired Endogenous Analgesia in Neuropathic Pain Rats

BACKGROUND: Although endogenous analgesia plays an important role in controlling pain states, chronic pain patients exhibit decreased endogenous analgesia compared to healthy individuals. In rats, noxious stimulus–induced analgesia (NSIA), which is an indicator of endogenous analgesia, diminished 6 weeks after spinal nerve ligation (SNL6W). A recent study in rats with deleted noradrenergic fibers demonstrated that the noradrenergic fibers were essential to NSIA. It has also been reported that brain-derived neurotrophic factor increased spinal noradrenergic fibers. Therefore, this study examined the effect of TrkB activation, which is the receptor for brain-derived neurotrophic factor, on impaired NSIA in SNL6W rats. In addition, we also examined the effect of endogenous analgesia on acute incisional pain. METHODS: After 5 daily intraperitoneal injections of 7,8-dihydroxyflavone (7,8-DHF, TrkB agonist, 5 mg/kg), NSIA was examined by measuring the withdrawal threshold increment in the left (contralateral to nerve ligation) hindpaw at 30 minutes after capsaicin injection (250 μg) in the forepaw. K252a (TrkB antagonist, 2 μg) was administrated intrathecally for 5 days. Idazoxan (α2 adrenoceptor antagonist, 30 μg), atropine (muscarinic antagonist, 30 μg), and propranolol (nonselective β adrenoceptor antagonist, 30 μg) were administered intrathecally for 15 minutes before capsaicin injection. Microdialysis and immunohistochemistry were performed to examine the noradrenergic plasticity in the spinal dorsal horn. A hindpaw incision was performed on the left (contralateral to nerve ligation) hindpaw. Data were analyzed by 1-way analyses of variance or 2-way repeated-measures 1-way analysis of variance followed by a Student t test with Bonferroni correction. RESULTS: Five daily intraperitoneal injections of 7,8-DHF restored the attenuated NSIA in SNL6W rats (n = 7, P = .002; estimated treatment effect [95% CI]: 62.9 [27.0–98.7] g), with this effect blocked by 5 daily intrathecal coadministrations of K252a (n = 6, P

https://ift.tt/2luOJc6

Driving Under the Influence of Cannabis: A Framework for Future Policy

Marijuana is the most widely consumed illicit substance in the United States, and an increasing number of states have legalized it for both medicinal and recreational purposes. As it becomes more readily available, there will be a concurrent rise in the number of users and, consequently, the number of motor vehicle operators driving under the influence. This article examines the cognitive and psychomotor effects of cannabis, as well as current policy concerning driving under the influence of drugs. The authors performed a MEDLINE search on the epidemiology of cannabis use, its cognitive and psychomotor effects, and policies regarding driving under the influence of drugs. Twenty-eight epidemiological studies, 16 acute cognitive and psychomotor studies, 8 chronic cognitive and psychomotor studies, and pertinent state and federal laws and policies were reviewed. These search results revealed that marijuana use is associated with significant cognitive and psychomotor effects. In addition, the legalization of marijuana varies from state to state, as do the laws pertaining to driving under the influence of drugs. Marijuana is a commonly found illicit substance in motor vehicle operators driving under the influence of drugs. Current evidence shows that blood levels of tetrahydrocannabinol do not correlate well with the level of impairment. In addition, although acute infrequent use of cannabis typically leads to cognitive and psychomotor impairment, this is not consistently the case for chronic heavy use. To establish the framework for driving under the influence of cannabis policy, we must review the current published evidence and examine existing policy at state and federal levels. Accepted for publication May 10, 2018. Funding: This study was partially funded by the Centers for Rehabilitation Sciences Research, US Department of Defense. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Robert M. Chow, MD, Department of Anesthesiology, Yale School of Medicine, 330 Cedar St, TMP-3, New Haven, CT 06520. Address e-mail to Robert.chow@yale.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2tvg0ig

Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures. METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed. RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE's occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed. CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur. Accepted for publication January 19, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Ayesha S. Bryant, MSPH, MD, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 625 19th St S, JT 880A, Birmingham, AL 35249. Address e-mail to asbryant@uabmc.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2ltc5yL

Association Between Intraoperative Oliguria and Acute Kidney Injury After Major Noncardiac Surgery

BACKGROUND: Acute kidney injury (AKI) occurs in 6.1%–22.4% of patients undergoing major noncardiac surgery. Previous studies have shown no association between intraoperative urine output and postoperative acute renal failure. However, these studies used various definitions of acute renal failure. We therefore investigated the association between intraoperative oliguria and postoperative AKI defined by the serum creatinine criteria of the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification. METHODS: In this single-center, retrospective, observational study, we screened 26,984 patients undergoing elective or emergency surgery during the period September 1, 2008 to October 31, 2011 at a university hospital. Exclusion criteria were age

https://ift.tt/2lrQkiV

In Response

No abstract available

https://ift.tt/2txuk9Y

Superficial femoral artery transection following penetrating trauma

Abstract

We describe a patient who sustained a penetrating injury to the posterior right lower extremity just above the popliteal region with transection of the superficial femoral artery (SFA) despite minimal evidence of active bleeding. An on-table angiogram identified flow in the SFA followed by the popliteal artery and into the trifurcation of the right lower extremity. Eventually, a second operation revealed transection followed by end-to-end anastomosis of SFA and stabilization of the patient. The findings of this case highlight the need for a high index of suspicion and persistent clinical investigation to identify vascular injuries in the absence of hard signs of vascular trauma.

https://ift.tt/2tvcQLn

Unusual complication of bladder prolapse with subsequent diagnosis of urothelial carcinoma leading to a necrotizing soft tissue infection after radical cystectomy

Abstract

There is lack of information in the literature on long-term complications of suprapubic catheters. The most common complications include urinary tract infection, bladder calculi, urine leakage and neoplastic changes. We report a case of an unusual complication of bladder prolapse, with subsequent diagnosis of urothelial carcinoma, leading to a necrotizing soft tissue infection after a radical cystectomy in a patient with long-term catheterization and its management. Due to the rarity of this complication, its management has not been well studied. In this particular case, the logical indication was radical cystectomy due to the presence of bladder necrosis.

https://ift.tt/2MNZQcB

Strategy for esophageal non-epithelial tumors based on a retrospective analysis of a single facility

Abstract

Background

Although most esophageal non-epithelial tumors are benign tumors, such as leiomyomas, they also include gastrointestinal tumors (GISTs); thus, a histopathological diagnosis is indispensable to determine the optimal treatment strategy. However, no consensus has been reached as to the diagnostic methods and treatments for esophageal non-epithelial tumors. The purpose of this study was to evaluate the reliability of the diagnostic methods and treatments for esophageal non-epithelial tumors in our hospital.

Methods

All 28 cases of esophageal non-epithelial tumors at Kobe University Hospital from 2008 to 2016 were analyzed retrospectively with respect to the diagnostic methods, histopathological diagnosis, and treatments.

Results

Three diagnostic methods, endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA), endoscopic incisional biopsy, and endoscopic submucosal dissection (ESD)/endoscopic mucosal resection (EMR), were performed in our hospital. All GIST cases could be correctly diagnosed by EUS-FNA. Tumors less than approximately 20 mm in diameter and located in the superficial layer are good indications for ESD/EMR, which both play roles in diagnosis and treatment. The final diagnoses by these methods consisted of the following: 13 leiomyomas, 5 GISTs, 3 schwannomas, 2 liposarcomas, 3 cysts, 1 reactive lymphoid hyperplasia, and 1 granulosa cell tumor. Fifteen cases underwent surgery. Enucleation or partial resection was performed for leiomyomas, schwannomas and liposarcomas, while esophagectomy was performed for GISTs. Thus, sufficient management of non-epithelial tumors is achieved.

Conclusions

Improved endoscopic procedures, including EUS-FNA and ESD/EMR, enabled the appropriate diagnosis and treatment of esophageal non-epithelial tumors.

https://ift.tt/2K9ErJc