Continuous infusion of lipo-prostaglandin E1 for Takayasu’s arteritis with heart failure in an 11-month-old baby: a case report

Takayasu's arteritis is extremely rare in children aged below 6 years. At the onset of Takayasu's arteritis in children, symptoms are varied but differ from those in adults. Corticosteroids are the mainstay of...

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Pediatric lung adenocarcinoma presenting with brain metastasis: a case report

Diagnosis and treatment of primary lung adenocarcinoma in children remains challenging given its rarity. Here we highlight the clinical history, pathological evaluation, genomic findings, and management of a v...

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Rare association of tetralogy of Fallot with absent pulmonary valve syndrome with anomalous origin of right pulmonary artery from ascending aorta

Description 

A 2-month-old boy presented to the paediatric cardiology department with cyanosis and feeding difficulties. Chest radiograph revealed cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus (figure 1A). A diagnosis of tetralogy of Fallot (TOF) with absent pulmonary valve syndrome was made on transthoracic echocardiogram; however, origin of right pulmonary artery (RPA) was not well visualised. The patient further underwent CT angiography (CTA) to delineate the cardiac as well as any extracardiac abnormalities.

Figure 1

Frontal chest radiograph (A) reveals cardiomegaly, right-sided aortic knuckle and dilated pulmonary artery segment along with mild indentation on the lower trachea and diffusely narrowed left main bronchus. Sagittal oblique maximum intensity projection (B) shows presence of features of tetralogy of Fallot, that is, right ventricular hypertrophy, perimembranous ventricular septal defect and pulmonary annular stenosis....

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Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis

Despite being straightforward to collect and key to providing patient-centred, individualised care, the routine use of patient reported outcome measures (PROMs) remains limited in the National Health Service. Herein is described the case of a 69-year-old woman who presented to secondary care with osteoarthritis. Web-based PROMs were used to track the patient's symptoms and function. Lifestyle changes were recommended to manage the osteoarthritis. Monitoring enabled the patient to take control of her disease management. Two years later, she continues to manage her knee symptoms conservatively, recording progress by using a web-based system. This case illustrates how web-based PROMs can be used to support conservative management of knee osteoarthritis by both empowering patients and minimising the burden on secondary care outpatient services.

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New endoscopic technique for retrieval of large colonic foreign bodies and an endoscopy-oriented review of the literature

Colorectal foreign bodies (FB) are challenging issues for the endoscopist especially if the mostly used methods (polypectomy snare, biopsy forceps or wire-guided 40 mm dilation balloon) failed. We report a case of a 31-year-old man who was admitted in the emergency department for the impaction of a 60 cm long and large-size FB in the sigmoid colon. We failed to remove the FB using several different standard technique because of the rigidity, the smoothness and the size of the object. After all these attempts, we built up a 'home-made' device inserting a 0.035 inch non-hydrophilic guidewire (Metro WireGuide, Cook Medical) doubled into an 8.5 Fr stent-pusher-catheter (Cook Medical) serving as an outer sheet in order to create a noose and we finally succeeded in the endoscopic extraction of the device. We suggest this new technique as a valid option to remove large FBs from the colon and rectum when standard endoscopic methods for FB's extraction fail.

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Acute regrowth and dissemination of a mature spinal cord teratoma after partial resection

A 23-year-old man presented with difficulty walking and leg pain and numbness. MRI revealed a cystic mass at Th11–12 and a pineal-region tumour. The patient underwent surgery to resect the thoracic-level mass. The tumour adhered strongly to the neural tissue and could only be partially resected. On pathological examination, the resected tumour was diagnosed as a mature teratoma. The tumour regrew and disseminated within 3 months after resection. Both the spinal cord tumour and the tumour in the pineal region shrank significantly after chemotherapy and radiotherapy. Although the tumour was pathologically diagnosed as a mature teratoma, we suspect that the residual tumour contained an immature or malignant component. Thus, careful follow-up observation is mandatory after partial resection of a mature teratoma. In addition, because teratomas can disseminate in the central nervous system, the presence of teratoma should prompt an examination of both the spinal cord and brain.

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Correction: Spontaneous ovarian heterotopic pregnancy

Stanley R, Nair A, Fiallo F. Spontaneous ovarian heterotopic pregnancy. BMJ Case Rep 2018.doi: 10.1136/bcr-2018-225619 [Epub ahead of print 9 Aug 2018].

This article contains an error in the authors list. The correct order of authors is:

Russell Stanley, Francisco Fiallo, and Anjana Nair.

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The changing face of cancer treatments

This case demonstrates the effectiveness and ongoing potential of novel lung cancer therapies, specifically immunotherapy agents such as nivolumab, a T-cell programmed death 1 (PD-1) receptor inhibitor. In this case study, our patient had a significant burden of disease with nodal involvement above and below the diaphragm at the time of diagnosis. They were commenced on standard of care therapy: cisplatin and pemetrexed. Despite five cycles of treatment with these agents, their disease progressed significantly with the development of brain metastasis. The patient was switched to a novel immunotherapy agent, nivolumab, and had a complete response to it. Currently, there is no active disease—the lymph nodes have all regressed, the brain metastases have disappeared (with the help of stereotactic surgery) and no further metastases have developed. The patient is tolerating the treatment well and has had no significant adverse reactions to the immunotherapy agent.

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Rapidly growing cardiac tumour in the right ventricle

Description 

A 77-year-old man with a history of Her2 negative, pancytokeratin-positive gastric cancer and synchronous grade 3a stage 2a follicular lymphoma (FLIPI score 3 at presentation) treated with chemotherapy was referred for transthoracic echocardiography (TTE) after a CT of the abdomen demonstrated an incidental low-density lesion in the right ventricle (RV) concerning for malignancy or thrombus. There was no mass present on TTE 2 months prior. Repeat TTE (figure 1) demonstrated a large echogenic mass causing right ventricular inflow and outflow tract (RVOT) obstruction. A cardiac MRI (figure 2) confirmed the presence of a heterogeneous mass with adherent superficial thrombus in the RV and extending into the RVOT, consistent in appearance with a tumour. On further review, a PET/CT performed 1 month prior to presentation showed a hypermetabolic node at the RV apex (maximum Standardized Uptake Value 5.7) felt to represent an initial metastatic focus, with...

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Klebsiella oxytoca tricuspid valve endocarditis in an elderly patient without known predisposing factors

A 73-year-old man with history of nephrolithiasis was admitted after a witnessed cardiac arrest. In the emergency department, the patient had several runs of ventricular fibrillation treated with defibrillation and amiodarone infusion. Echocardiography revealed reduced ejection fraction with multiple mobile structures attached to the tricuspid valve leaflets. Due to concern for possible endocarditis, the patient was started on broad-spectrum antibiotics. On the following day, a renal ultrasound was performed for acute kidney injury followed by a non-contrast CT scan that revealed an obstructing 21 mm left-sided ureteral stone with pyohydronephrosis. He underwent emergent nephrostomy tube placement. Blood and urine cultures subsequently demonstrated the growth of Klebsiella oxytoca. A follow-up transoesophageal echocardiogram confirmed multiple mobile, hyperechoic masses consistent with vegetations. The suspected source for the endocarditis was from the pyelonephritis. The patient's clinical condition improved after a course of intravenous antibiotics and was discharged on oral antibiotics.

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Pathological complete response in pancreatic adenocarcinoma with FOLFIRINOX

The report describes a patient who presented to our centre with abdominal pain and significant weight loss due to adenocarcinoma of the tail of the pancreas. The cancer was deemed as 'resectable disease associated with morbid surgical outcomes' due to the local involvement of the vessels and adjacent organs. Given the patient's excellent performance status, the patient underwent neoadjuvant chemotherapy with folinic acid, fluorouracil, irinotecan and oxaliplatin to downstage the tumour for less morbid surgical resection. The patient underwent 12 cycles of chemotherapy with serial imaging which demonstrated positive response to treatment and surgical resection was performed. Surgical pathology revealed no residual tumour and imaging was negative for any extrapancreatic tumour metastasis. This is an unusual case as pancreatic malignancy is usually lethal with poor survival outcomes.

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Oesophageal narrowing during combination chemotherapy in Ewings sarcoma: Is vincristine a culprit?

Vincristine is a widely used chemotherapeutic agent in paediatric oncology. A 7-year-old boy was diagnosed with non-metastatic Ewing's sarcoma of the pelvis. He was started on chemotherapy with vincristine–cyclophosphamide–adriamycin alternate with ifosfamide–etoposide. He developed recurrent vomiting after three cycles of chemotherapy. Evaluation showed oesophageal stricture involving the middle and lower third part. Biopsy was non-conclusive. His symptoms improved with dilatation. A chemotherapy-induced neuropathic dysmotility was suspected, and his chemotherapy was continued with serial dilatation. Vincristine, being neurotoxic, was suspected to be the reason of this morbidity. His need of dilatation decreased, and symptoms improved remarkably after completion of chemotherapy.

Vincristine-induced oesophageal dysmotility is a rare side effect. There is no consensus on management. Omission of this effective agent in such situation is debatable.

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Simultaneous occurrence of hepatic hydatid cyst and mucinous cystadenoma of the liver in a middle-aged female patient: report of a rare case

We present a rare case of simultaneous occurrence of mucinous cystadenoma of the liver (MCN-L) and a hepatic hydatid cyst (HD-L) in a middle-aged female patient. This is the first case report of a common disease (HD-L) and a rare condition (MCN-H) occurring concurrently. MCN-H of the left lobe was inadequately resected in a rural centre leading to recurrence. She presented with a large upper abdominal lump and upper gastrointestinal symptoms. Radiological investigations and an ultrasound revealed a multilobulated cyst involving both lobes of the liver. There was no ascites. Liver function, basic haematology and renal function were normal. The recurrent MCN-L was removed totally. There was no communication between the MCN-L and the right lobe cyst, which turned out to be a hydatid cyst. The hydatid cyst was evacuated. She was discharged on albendazole and is asymptomatic with no recurrence at 8 months.

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Mitotane-induced dyspnoea: an unusual side effect

Mitotane is a cytostatic antineoplastic agent that is used in the treatment of adrenocortical carcinoma and Cushing's syndrome. The commonly reported side effects associated with mitotane are anorexia, nausea, vomiting, diarrhoea, decreased memory, rash, gynaecomastia, arthralgias and leucopenia. We present a case of a 68-year-old female who developed gradual dyspnoea concurrent with the use of mitotane for the treatment of adrenocortical carcinoma. To the best of our knowledge and literate review, this is the first reported case of dyspnoea associated with the use of this medication. The purpose of this case report is to raise awareness about this uncommon adverse effect of mitotane that may have gone unrecognised on postmarketing surveillance because of under-reporting, lack of case follow-up or other comorbidities masking shortness of breath.

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NUT carcinoma: a rare and devastating neoplasm

Description 

A 45-year-old woman with no significant medical history had 1 month of productive cough empirically treated with azithromycin and dyspnoea on exertion. She was never a smoker and denied any constitutional symptoms, including unexpected weight loss. A CT of the chest was performed after she developed haemoptysis, which demonstrated a 6.3x4.6 cm right hilar mass with hilar, subcarinal and cardiophrenic adenopathy (figure 1A). She underwent bronchoscopy which revealed complete occlusion of the right middle lobe by a tumour extending into the bronchus intermedius. Debridement of this mass was performed, with re-establishment of airway patency to the right lower lobe. Pathology from the debrided tumour as well as the subcarinal lymph node was consistent with poorly differentiated non-small cell lung carcinoma with Thyroid Transcription Factor 1 (TTF-1) and Programmed Death-Ligand 1 (PD-L1) negativity. Due to high clinical suspicion, the tissue samples were transferred to another facility for additional assessment. MRI...

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Elbow instability following lateral collateral ligament complex avulsion fracture and joint interposition: an uncommon presentation

The lateral collateral ligament (LCL) complex of the elbow is a capsuloligamentous structure, critical for elbow stability. Though isolated ligamentous injuries have been reported in literature, there are no studies reporting avulsion fractures of the lateral ligamentous complex of the elbow with joint incarceration in a child. An 11-year-old boy presented to the emergency department after a fall from height, with pain and swelling to the lateral side of his left elbow. Radiographs established a fracture of the lateral condyle and CT imaging confirmed an avulsion of the lateral ligamentous complex, with fragments in the inferior radiocapitellar joint. Examination under anaesthesia revealed an unstable elbow with restricted extension, and the child underwent joint debridement and open reduction internal fixation of LCL complex with cannulated screws. At the final follow-up at 15 months, the child regained preinjury level of function.

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Association of giant retinal tear with iridofundal coloboma in a case of paediatric retinal detachment

Description 

A 6-year-old boy presented with history of sudden-onset painless diminution of vision oculus dexter (OD) since the last six hours. The vision loss was preceded by a sudden shower of floaters. There was no history of recent or remote trauma, and no positive family history of ocular illness could be elicited from the parents. Visual acuity was perception of light with accurate projection of rays OD and 20/20 oculus sinister (OS). A typical and complete iris coloboma with keyhole pupil was noted OD. There was no sign of trauma in either eye. Intraocular pressures measured to 6 mm Hg OD and 13 mm Hg OS. Dilated fundus examination showed type II choroidal coloboma involving the macula (Ida Mann classification) with total rhegmatogenous retinal detachment OD. Peripheral examination revealed a giant retinal tear (GRT), extending almost five clock hours, with a posterior flap falling over the posterior pole (figure 1). OS was...

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Infective endocarditis due to Atopobium vaginae: a rare association between genital infection and endocarditis of the tricuspid valve

Atopobium vaginae is an anaerobic gram-positive organism associated with genitourinary infections. Bacteraemia is rare, with only two cases reported in the literature. This case describes an 18-year-old type 1 diabetic, presenting with sepsis and haemoptysis, on a background of poor dental hygiene and recurrent hospital admissions. Blood cultures grew A. vaginae and echocardiogram revealed a large tricuspid valve lesion. Despite medical therapy, symptoms of pulmonary emboli continued and she therefore underwent surgical resection of the lesion. Histopathological findings were of a vegetation; culture of the lesion was negative but 16S ribosomal PCR was positive, detecting 16S rRNA of A. vaginae. The patient was treated with 4 weeks of vancomycin and made a good recovery. To our knowledge, this represents the first report of infective endocarditis due to this organism. We also provide a review of the literature, including comparing published drug susceptibility data with consensus breakpoints for antimicrobial agents.

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Early warning scores in the perioperative period: applications and clinical operating characteristics

Purpose of review Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. Recent findings Early warning scores can be used to screen for postoperative deterioration and surgical complications. We describe a framework to evaluate the balance between missed events and warning signals that are not followed by an adverse event (nonevents). In large surgical cohort studies, the missed event rates ranged between 19 and 69% and the nonevent rates ranged between 72 and 99% for 'optimal' threshold early warning sores. Recent investigations have shown that there may be a substantial discrepancy between the theoretical benefits shown in validation studies and the practical clinical implementation of early warning scores, which may partly explain the absence of measurable benefit from these systems. Summary Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness. Correspondence to Harm-Jan de Grooth, MD, Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. Tel: +31 6 46 37 15 07; e-mail: h.degrooth@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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What we can learn from Big Data about factors influencing perioperative outcome

Purpose of review This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. Recent findings The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. Summary Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising. Correspondence to Jurgen C. de Graaff, MD, Department of Anesthesiology, Medical Center, SB-3646, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 10 704 34964; e-mail: j.degraaff@erasmusmc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Perioperative cognitive evaluation

Purpose of review This article reviews the recent clinical evidence published between January 2017 and June 2018 – related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. Recent findings Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. Summary Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care. Correspondence to Federico Bilotta, MD, PhD, Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University, Rome, Italy. Tel: +39 6 8608273; fax: +39 6 8608273; e-mail: bilotta@tiscali.it Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Case 27-2018: A 3-Year-Old Boy with Seizures

Presentation Of Case. Dr. Caitlin E. Naureckas Li (Pediatrics): A 3-year-old boy was admitted to this hospital during the summer because of a seizure. The patient had been well until 3 days before admission, when one episode of emesis occurred. The following evening, he was fussy, and on the third…

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Case 26-2018: A 48-Year-Old Man with Fever, Chills, Myalgias, and Rash

Presentation of Case. Dr. William G. Tsiaras: A 48-year-old man was evaluated at this hospital because of fever, chills, myalgias, diarrhea, and a diffuse rash. The patient had been in his usual state of good health until about 3 weeks before admission, in the late spring, when he noted the onset…

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Case 25-2018: A 63-Year-Old Man with Syncope

Presentation of Case. Dr. William J. Hucker: A 63-year-old man was evaluated at this hospital because of syncope. Approximately 13 years before admission, the patient had an out-of-hospital cardiac arrest and was found to have multivessel coronary artery disease. He underwent coronary-artery bypass…

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Case 24-2018: A 71-Year-Old Man with Acute Renal Failure and Hematuria

Presentation of Case. Dr. Joshua Z. Drago (Medicine): A 71-year-old man was transferred to this hospital because of worsening renal function and hematuria. Three weeks before this admission, the patient's wife became ill with chills, fatigue, and myalgias, and she thought she had influenza. A few…

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Mesenteric fibromatosis in a patient with a history of neuroblastoma: a case report

Abstract

Mesenteric fibromatosis (MF) is a locally aggressive proliferative spindle cell lesion of the mesentery. A 34-year-old male presented with increasing abdominal pain and constipation. On workup, patient was found to have a large pelvic mass on CT A/P concerning for cancer. The patient underwent surgical excision of >15 cm intra-abdominal tumor along with adherent small bowel section. Histology of the tumor showed a spindle cell lesion consistent with MF. Previous reports have shown association of MF with Gardner syndrome and familial adenomatous polyposis. We present the first reported case of MF in a patient with previous neuroblastoma.

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A Prospective Observational Cohort Study of Calls for Help in a Tertiary Care Academic Operating Room Suite

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1–1.8), corresponding to a rate of 5.0 (3.8–6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR. Accepted for publication June 11, 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 Cameron J. Ricks, MD, Department of Anesthesiology and Perioperative Care, University of California, Irvine School of Medicine, 333 The City Blvd W, Suite 2150, Orange, CA 92868. Address e-mail to cricks@uci.edu. © 2018 International Anesthesia Research Society

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Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents

BACKGROUND: Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Secondgeneration drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS: The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS: A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0.90, 91–180, 181–365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0–90 days and 3.4 (0.8 to 15.3) at 91–180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS: The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT. Accepted for publication March 9, 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 Gregory A. Nuttall, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Address e-mail to Gnuttall@mayo.edu. © 2018 International Anesthesia Research Society

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Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial

BACKGROUND: Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. METHODS: This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. RESULTS: Visual analog scale scores were significantly better (P2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P

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Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures

No abstract available

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Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex: A Randomized, Double-Blind, Noninferiority Trial

BACKGROUND: Certain surgical interventions may require a deep neuromuscular block (NMB). Reversal of such a block before tracheal extubation is challenging. Because anticholinesterases are ineffective in deep block, sugammadex 4 mg/kg has been recommended for the reversal of rocuronium- or vecuronium-induced deep NMB. However, this recommendation requires opening 2 vials of 200 mg sugammadex, which results in an increase in drug costs. Therefore, we sought a less expensive solution for the induction and reversal of deep NMB. Although the optimal dose of sugammadex for antagonism of deep block from pipecuronium has not been established, data pertaining to moderate block are available. Accordingly, we hypothesized that sugammadex 2 mg/kg would be a proper dose to reverse deep pipecuronium block, enabling us to avoid cost increases. In the present study, we compared sugammadex 2 mg/kg with the standard dose of 4 mg/kg for reversal of deep block from pipecuronium. METHODS: This single-center, randomized, double-blind, 2 parallel-arms, noninferiority study comprised 50 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch SX). Noninferiority margin was specified beforehand as an increase in reversal time of no

https://ift.tt/2LLV9hN

Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case–Control Study

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy. Accepted for publication July 3, 2018. Funding: This work was supported by the University of Michigan Health System Department of Anesthesiology. Support for REDCap (Research Electronic Data Capture) reported in this publication was provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000433. E.A.S.C. is supported by a grant from the Burroughs Wellcome Foundation. P.T. was supported by a grant from the Robert Wood Johnson Foundation (Princeton, NJ), Harold Amos Medical Faculty Development Program (award 69779). B.T.B. is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Bethesda, MD) under Award Number K08HD075831. No source of funding had a role in any stage of the study, analysis, or writing of this manuscript. Conflicts of Interest: See Disclosures at the end of the article. This work was presented, in part, at the 48th Society for Obstetric Anesthesia and Perinatology Annual Meeting, Boston, MA, May 18–22, 2016. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Sydney Behrmann, BS, is currently affiliated with the University of Michigan Medical School, Ann Arbor, Michigan; Anthony Chau, MD, MMSc, is currently affiliated with the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia; Caitlin Clancy, BA, BSN, RN, is currently affiliated with the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Stephanie Lin, MD, is currently affiliated with the Department of Perinatal Medicine, Marian Regional Medical Center, Santa Maria, California; Kristina Priessnitz, BS, is currently affiliated with the Michigan State College of Human Medicine, East Lansing, Michigan; Anuj Shah, MD, is currently affiliated with the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan. Reprints will not be available from the authors. Address correspondence to Melissa E. Bauer, DO, Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to mbalun@med.umich.edu. © 2018 International Anesthesia Research Society

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In Response

No abstract available

https://ift.tt/2NDeLXe

Preoperative Salivary Cortisol AM/PM Ratio Predicts Early Postoperative Cognitive Dysfunction After Noncardiac Surgery in Elderly Patients

BACKGROUND: The diagnosis of postoperative cognitive dysfunction (POCD) requires complicated neuropsychological testing and is often delayed. Possible biomarkers for early detection or prediction are essential for the prevention and treatment of POCD. Preoperative screening of salivary cortisol levels may help to identify patients at elevated risk for POCD. METHODS: One hundred twenty patients >60 years of age and undergoing major noncardiac surgery underwent neuropsychological testing 1 day before and 1 week after surgery. Saliva samples were collected in the morning and the evening 1 day before surgery. POCD was defined as a Z-score of ≤−1.96 on at least 2 different tests. The primary outcome was the presence of POCD. The primary objective of this study was to assess the relationship between the ratio of AM (morning) to PM (evening) salivary cortisol levels and the presence of POCD. The secondary objective was to assess the relationship between POCD and salivary cortisol absolute values in the morning or in the evening. RESULTS: POCD was observed in 17.02% (16 of 94; 95% confidence interval [CI], 9.28%–24.76%) of patients 1 week after the operation. A higher preoperative AM/PM salivary cortisol ratio predicted early POCD onset (odds ratio [OR], 1.56; 95% CI, 1.20–2.02; P = .001), even after adjusting for the Mini-Mental Sate Examination score (odds ratio, 1.55; 95% CI, 1.19–2.02; P = .001). The area under the receiver operating characteristic curve for the salivary cortisol AM/PM ratio in individuals with POCD was 0.72 (95% CI, 0.56–0.88; P = .006). The optimal cutoff value was 5.69, with a sensitivity of 50% and specificity of 91%. CONCLUSIONS: The preoperative salivary cortisol AM/PM ratio was significantly associated with the presence of early POCD. This biomarker may have potential utility for screening patients for an increased risk and also for further elucidating the etiology of POCD. Accepted for publication July 18, 2018. Funding: Supported by the National Natural Science Foundation of China (81720108013, 81571059); Jiangsu Provincial Special Program of Medical Science (BL2014029); Scientific Research Innovation Project for Graduate Students of Jiangsu Universities, Jiangsu, China (SJZZ16_0290); and China Postdoctoral Science Foundation Funded Project (Project No: 2015M580473). 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). Y. Han, L. Han, and M.-M. Dong contributed equally to this work and share first authorship. Reprints will not be available from the authors. Address correspondence to Jun-Li Cao, MD, PhD, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai Rd, Quanshan District, Xuzhou City 221002, Jiangsu Province, China. Address e-mail to caojl0310@aliyun.com. © 2018 International Anesthesia Research Society

https://ift.tt/2ouybTe

Anticipated Rates and Costs of Guideline-Concordant Preoperative Stress Testing

BACKGROUND: Current guidelines recommend that patients have preoperative assessment of cardiac risk and functional status, and that patients at "elevated" cardiac risk with poor or unknown functional status be referred for preoperative stress testing. Little is known about current rates of testing or resultant medical costs. We set out to estimate the expected rates of preoperative stress testing and resultant costs if physicians in the United States were to follow current guidelines and to investigate differences that would arise from 2 risk prediction methods included in current guidelines. METHODS: We applied 2 risk prediction tools (Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest) included in current American College of Cardiology/American Heart Association guidelines to a multicenter prospective registry of patients undergoing surgery in the United States in 2009. We then calculated expected rates of preoperative cardiac stress testing if physicians were to follow American College of Cardiology/American Heart Association guidelines, expected nationwide direct medical expenditures that would result (in 2017 US dollars), and agreement beyond chance between the 2 risk prediction tools. RESULTS: Current guidelines recommend considerable spending on preoperative stress testing. Guideline-recommended spending would differ substantially depending on the risk prediction tool used and the reliability of the functional status assessment. Rates of testing and resultant spending are likely much greater among patients at "elevated" risk, compared with patients at "low" risk. Two guideline-recommended risk assessment tools, Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest, have poor agreement beyond chance across the currently recommended risk threshold. CONCLUSIONS: Preoperative stress testing is likely a considerable source of medical spending, despite unproven benefit. Which perioperative risk assessment tool clinicians should use, what risk thresholds are appropriate for patient selection, and the reliability of the functional status assessment all warrant further attention. Accepted for publication July 23, 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 Matthew A. Pappas, MD, MPH, Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Stop G-10, Cleveland, OH 44195. Address e-mail to pappasm@ccf.org. © 2018 International Anesthesia Research Society

https://ift.tt/2LOVosm

Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields. Accepted for publication July 3, 2018. M. M. Longacre, MD, MM, and A. M. Bader, MD, MPH, are currently affiliated with the Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, Boston, Massachusetts. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Mckenna M. Longacre, MD, MM, Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to mmlongacre@partners.org. © 2018 International Anesthesia Research Society

https://ift.tt/2osLH9P

Use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator During Preoperative Risk Discussion: The Patient Perspective

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk. METHODS: Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions. RESULTS: Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P

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Traumatic Brain Injury in Flies

No abstract available

https://ift.tt/2osLyDj

Observation of Complement Protein Gene Expression Before and After Surgery in Opioid-Consuming and Opioid-Naive Patients

Opioids may influence inflammation. We compared genes associated with pain and inflammation in patients who consumed opioids (3–120 mg of oral morphine equivalents per day) with those who did not for differential expression. White blood cells were assayed in 20 patients presenting for total lower extremity joint replacement. We focused on messenger ribonucleic acid expression of complement proteins. We report that the expression of a complement inhibitor, complement 4 binding protein A, was reduced, and the expression of a complement activator, complement factor D, was increased in opioid-consuming patients. We conclude that opioid consumption may influence expression of complement activators and inhibitors. Accepted for publication July 12, 2018. Funding: Supported in part by the Department of Anesthesiology at the University of Utah. 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). Clinical trial number and registry URL: This study is not subject to ClinicalTrials.gov review because the study is not a clinical trial and does not involve an intervention or investigational use of a device or drug. Reprints will not be available from the authors. Address correspondence to Ken B. Johnson, MD, Department of Anesthesiology, University of Utah, 30 N 1900 E RM 3C444, Salt Lake City, UT 84112. Address e-mail to ken.b.johnson@hsc.utah.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2NE2l1p

Intravenous Lidocaine for the Prevention of Cough: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: It remains unclear to what extent intravenous lidocaine prevents cough and whether there is dose-responsiveness and risk of harm. METHODS: We searched electronic databases to January 1, 2017 for randomized trials comparing intravenous lidocaine with placebo for the prevention of cough in surgical patients. Primary outcome was the incidence of cough. Data were analyzed using a random-effects model and were expressed as risk ratio (RR) and number needed to treat (NNT) with 95% confidence interval. RESULTS: In 20 trials in adults (n = 3062) and 5 trials in children (n = 445), intravenous lidocaine 0.5–2 mg·kg−1 was tested for the prevention of intubation-, extubation-, or opioid-induced cough. Twenty-two trials included only American Society of Anesthesiologists I or II patients; 3 trials (n = 99) also included American Society of Anesthesiologists III patients. Lidocaine was associated with a lower incidence of cough compared to placebo in adults and children, irrespective of dosage and cough etiology. Data from adults suggested dose-responsiveness; with 0.5 mg·kg−1, RR was 0.66 (0.50–0.88) and NNT was 8 (5.4–14.3); with 1 mg·kg−1, RR was 0.58 (0.49–0.69) and NNT was 7 (4.6–8.9); with 1.5 mg·kg−1, RR was 0.44 (0.33–0.58) and NNT was 5 (3.3–5.2); and with 2 mg·kg−1, RR was 0.39 (0.24–0.62) and NNT was 3 (2.0–3.4). Adverse effect reporting was sparse. CONCLUSIONS: Within a range of 0.5–2 mg·kg−1, intravenous lidocaine dose dependently prevents intubation-, extubation-, and opioid-induced cough in adults and children with NNTs ranging from 8 to 3. The risk of harm in high-risk patients remains unknown. Accepted for publication April 12, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. 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 Sara Clivio, MD, Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland. Address e-mail to sara.clivio@cardiocentro.org. © 2018 International Anesthesia Research Society

https://ift.tt/2osLofb

Global Anesthesia

No abstract available

https://ift.tt/2wxfR09

Incentive-Based Game for Allaying Preoperative Anxiety in Children: A Prospective, Randomized Trial

BACKGROUND: Induction of anesthesia can be distressing both for children and their parents. Nonpharmacological behavioral interventions can reduce the anxiety of children without significant adverse effects as seen with sedative medications. We hypothesized that the use of incentive-based game therapy in conjunction with parental involvement would be a simple and cost-effective intervention in reducing the preoperative anxiety in children. METHODS: Eighty children between the age group of 4 and 8 years scheduled to undergo surgery were randomly assigned to a control group (n = 40) and intervention group (n = 40). Children in the intervention group participated in an incentive-based game in the preoperative room. Anesthesia was induced with parental presence in both the groups. The modified Yale Preoperative Anxiety Scale (mYPAS) score to measure the anxiety of the children during induction was taken as the primary outcome. Induction Compliance Checklist score and parental satisfaction were assessed as secondary outcomes. RESULTS: The mYPAS score of children in the intervention group was significantly less than the control group during anesthesia induction. The mean difference (95% confidence interval [CI]) of the mYPAS at induction between the 2 groups was 20 (95% CI, 16–24; P

https://ift.tt/2NBLfAZ