Analgesic Effects of Continuous Wound Infusion Combined with Intravenous Patient-Controlled Analgesia for Thoracic Surgery: A Retrospective Study

Continuous wound infusion analgesia (CWA) with local anesthetics is a loco-regional anesthetic approach for multimodal analgesia management in surgical procedures. This study analyzed whether the combination of intravenous patient-controlled analgesia (PCA) and CWA would be more effective than PCA alone for postoperative analgesia and in preventing chronic postsurgical pain syndrome (PSPS) after thoracic surgeries. We enrolled 166 patients after propensity score matching, the PCA alone (PCA group, n = 83) and the combination of PCA and CWA (PCA-CWA group, n = 83), through a review of electronic medical records. The primary endpoint was the numeric rating scale (NRS) at postoperative days 1, 2, 3, 4, and 5. The secondary endpoint was the presence of PSPS at 3 and 6 months postoperatively. The NRS were lower in the PCA-CWA group than in the PCA group throughout the postoperative period (p < 0.001). The sedation incidence was lower in the PCA-CWA group (1.2%) than in the PCA group (9.6%) (p = 0.034), and there was no significant difference in other postoperative complications or in the incidence of PSPS (p = 1.000). The combination of intravenous PCA and CWA is an effective postoperative analgesic modality for thoracic surgery.

Development and validation of a web-based headache diagnosis questionnaire

Information technology advances may help in conducting epidemiological studies using web-based surveys. Questionnaire-based headache diagnosis should be validated against the doctor’s diagnosis. This study aimed to develop and validate a web-based diagnostic questionnaire for migraine, probable migraine (PM), and tension-type headache (TTH). We constructed a seven-item questionnaire for diagnosing migraine, PM, and TTH. A web-based survey was conducted among adults aged 20–59 years; migraine, PM, and TTH were diagnosed based on the responses. Validation interview was performed via telephone by a neurologist within 1 month after the web-based interview. Finally, 256 participants completed both web-based survey and validation interview. Of them, 121 (47.3%), 65 (25.4%), 61 (23.8%), and 9 (3.5%) were diagnosed with migraine, PM, TTH, and unclassified headache (UH), respectively in the web-based survey, whereas 119 (46.5%), 60 (23.4%), 74 (28.9%), 2 (0.8%), and 1 (0.4%) were diagnosed with migraine, PM, TTH, UH, and primary stabbing headache, respectively in the validation interview. The best agreement was found in migraine (sensitivity: 92.6%; specificity: 94.8%; kappa coefficient: 0.875), followed by TTH (sensitivity: 78.4%; specificity: 98.4%; kappa coefficient: 0.809). PM showed the least agreement (sensitivity: 85.0%; specificity: 92.9%; kappa coefficient: 0.757). In conclusion, our questionnaire is valid in identifying these headache disorders.

Association of Prophylactic Anti-Hepatitis B Virus Therapy With Improved Long-term Survival in Patients With Hepatocellular Carcinoma Undergoing Transarterial Therapy

BACKGROUND

The effect of prophylactic antiviral therapy (AVT) on survival of patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains unknown. This study aimed to determine whether prophylactic AVT could improve long-term survival in patients undergoing transarterial chemotherapy (TAC).

METHODS

Between 2002 and 2016, 2860 newly diagnosed HBV-related patients with HCC treated with TAC were screened to analyze 2 groups based on prophylactic use of antivirals. Treatment effects were analyzed using propensity score (PS) matching (1:1) separately for the entire cohort and each subgroup. The primary endpoint was overall survival.

RESULTS

A total of 1547 patients met the inclusion criteria and 1084 were PS matched for the 2 groups. Median follow-up duration was 16.55 months. In the entire unmatched cohort, patients receiving prophylactic AVT survived significantly longer than those who did not. Among AVT-untreated patients, baseline high viremia and HBV reactivation during treatment were significantly associated with shorter survival. Regarding types of antivirals, survival was significantly longer for patients receiving high-potency antivirals than those receiving low-potency antivirals. Survival differed with antiviral response. In the PS-matched cohort, the prophylactic AVT group survived significantly longer than the nonprophylactic group, irrespective of viral status or tumor stage. Prophylactic AVT remained an independent factor for survival. The association of prophylactic AVT with decreased risk of mortality persisted in patient subgroups after adjusting for baseline risk factors. Sensitivity analyses also confirmed estimated treatment effects.

CONCLUSIONS

Prophylactic AVT is associated with significantly improved long-term survival among patients undergoing TAC. High-potency antivirals are indicated for this approach.Hepatitis B virus-associated morbidity is a well-known complication during transarterial chemotherapy (TAC). Our large-scale study demonstrated that prophylactic therapy with high-potency antivirals provides a significantly better survival in TAC-treated patients, irrespective of baseline viremia status or tumor stage.

Effective dose of intravenous oxycodone depending on sex and age for attenuation of intubation-related hemodynamic responses

Background/aim

Preoperative intravenous oxycodone may help to prevent or attenuate intubation-related hemodynamic responses (IRHRs), but its pharmacokinetics differs according to age and sex. Therefore, we investigated the 95% effective dose (ED₉₅) of intravenous oxycodone for attenuating all IRHRs, depending on the age and sex of the study population.

Materials and methods

All patients were allocated to one of 6 groups: 1) 20–40 year old males, 2) 41–65yearold males, 3) 66–80 year old males, 4) 20–40 year old females, 5) 41–65yearold females, and 6) 66–80 year old females (groups YM, OM, EM, YF, OF, and EF, respectively). Using Dixon’s up-and-down method, the first patient in each group was slowly injected with intravenous oxycodone (0.1 mg kg^-1) 20 min before intubation. The subsequent patient received the next oxycodone dose, which was decreased or increased by 0.01 mg kg^-1, depending on the “success” or “failure” of attenuation of all IRHRs to within 20% of the baseline values at 1 min after intubation in the previous patient. After obtaining 8 crossover points, predictive ED₉₅ was estimated with probit regression analysis.

Results

ED₉₅ varied greatly according to age and sex. ED₉₅was 0.133 mg kg^-1, 0.181 mg kg^-1, 0.332 mg kg^-1, 0.183 mg kg^-1, 0.108 mg kg^-1, and 0.147 mg kg^-1in groups YM, OM, EM, YF, OF, and EF, respectively.

Conclusion

ED₉₅ is higher in males with increasing age but is ambiguous for females. ED₉₅ is higher in males than in females over 40 years of age but is higher in females than in males under 41 years of age. However, after considering the age and sex of the study population, these results can be used as reference doses for further studies to verify the clinical effects of oxycodone for attenuating all IRHRs.

Clinically relevant concentrations of dexmedetomidine may reduce oxytocin-induced myometrium contractions in pregnant rats

BACKGROUND

Recently, there have been some trials to use dexmedetomidine in the obstetric field but concerns regarding the drug include changes in uterine contractions after labor. We aimed to evaluate the effects of dexmedetomidine on the myometrial contractions of pregnant rats.

METHODS

In a pilot study, the contraction of the myometrial strips of pregnant Sprague-Dawley rats in an organ bath with oxytocin at 1 mU/ml was assessed by adding dexmedetomidine from 10-6 to 10-2 M accumulatively every 20 min, and active tension and the number of contractions were evaluated. Then, changes in myometrial contractions were evaluated from high doses of dexmedetomidine (1.0 × 10-4 to 1.2 × 10-3 M). The effective concentrations (EC) for changes in uterine contractions were calculated using a probit model.

RESULTS

Active tension and the number of contractions were significantly decreased at 10-3 M and 10-4 M dexmedetomidine, respectively (P < 0.05). A complete loss of contractions was seen at 10-2 M. Dexmedetomidine (1.0 × 10-4 to 1.2 × 10-3 M) decreased active tension and the number of contractions in a concentration-dependent manner. The EC95 of dexmedetomidine for inhibiting active tension and the number of contractions was 5.16 × 10-2 M and 2.55 × 10-5 M, respectively.

CONCLUSIONS

Active tension of the myometrium showed a significant decrease at concentrations of dexmedetomidine higher than 10-3 M. Thus, clinical concentrations of dexmedetomidine may inhibit uterine contractions. Further research is needed for the safe use of dexmedetomidine in the obstetrics field.

Conus Medullaris Syndrome Due to Missed Thoracolumbar Spinal Fracture in a Patient with Ankylosing Spondylitis who Underwent Hip Surgery

Ankylosing spondylitis (AS) is vulnerable to fracture, and the missed diagnosis can lead to neurological deterioration. Herein, we present the conus medullaris syndrome due to aggravation of the missed spinal fracture in an 85-year-old woman with AS who underwent hip surgery. She underwent osteosynthesis in a supine position with supports under her shoulders and head due to spine deformity with AS, but was fully supine without supports after surgery. She showed complete paraplegia at postoperative 12 h. The re-reading radiological imaging showed the missed spinal fracture, of which the deteriorated dislocation was revealed on the re-examined radiological evaluation. This deterioration was not recovered ultimately despite an emergent surgery. A thorough preoperative assessment is essential to prevent the missed diagnosis of spinal fracture and minimise deterioration due to its dislocation, with specific spine precaution during transport, transfer and positioning.

Effect of antiviral therapy in reducing perinatal transmission of hepatitis B virus and maternal outcomes after discontinuing them

BACKGROUND/AIMS

There have been numerous efforts to reduce mother-to-child transmission (MTCT) of hepatitis B virus (HBV) with antiviral agents during pregnancy. However, there are limited data regarding the outcomes of pregnant women after delivery. This study was performed to evaluate the efficacy of antiviral agents in preventing MTCT of HBV and maternal long-term outcomes.

METHODS

The HBV-infected pregnant women treated with antiviral agents to prevent MTCT were retrospectively reviewed. Forty-one pregnant women who received telbivudine or tenofovir during late pregnancy (28-34 week) were analyzed. Hepatitis B virus surface antibody (HBsAb) positivity was tested in 43 infants after 7 months of birth. Eleven mothers were followed >1 year after delivery.

RESULTS

The mean HBV DNA titer before antiviral therapy was 8.67 (6.60-9.49) log copies/mL, and the median age at delivery was 32 years (range, 22-40). Eleven patients were treated with tenofovir and 30 with telbivudine. The median duration was 57 days (range, 23-100), and the median HBV DNA titer at birth was 5.06 log copies/mL (range, 2.06-6.50). Antiviral treatments were associated with significant HBV DNA reduction (P<0.001). Among 43 infants (two cases of twins), HBsAb was not detected in two, subsequently confirmed to have HBV infection. Biochemical flare was observed in two of 11 mothers followed >12 months, and an antiviral agent was administered.

CONCLUSION

Antiviral treatment during late pregnancy effectively reduced MTCT. Long-term follow-up should be required in such cases. In addition, given that maternal biochemical flare occurred in 18% of mothers, re-administration of antiviral agents might be required.

A case of gabapentin-induced rhabdomyolysis requiring renal replacement therapy

Gabapentin is commonly used for controlling convulsions, restless pain syndrome, and pain in diabetic neuropathy. Common side effects include dizziness, somnolence, ataxia, peripheral edema, and confusion; gabapentin-induced rhabdomyolysis is rarely reported. To date, the reported cases of gabapentin-induced rhabdomyolysis have been associated with patients with multiple underlying diseases and assuming multiple medicines for various reasons. In this report, we describe a case of gabapentin-induced rhabdomyolysis in a 32-year-old woman with no medical history. We also review related literature and discuss the possible mechanism and the association with other factors. This case shows that gabapentin can induce rhabdomyolysis in healthy patients and that clinicians must consider the possible association between gabapentin and rhabdomyolysis.

Percutaneous Management of Coronary Artery-to-pulmonary Artery Fistula Using an Amplatzer Vascular Plug with the Trans-radial Approach

Congenital coronary artery fistulas (CAFs) are rare and asymptomatic, although symptomatic CAFs should be treated with percutaneous intervention or surgery. A 62-year-old woman developed bilateral coronary-to-pulmonary artery fistulas resulting in exertional chest pain. We herein report the successful use of trans-catheter closure of a coronary artery-to-pulmonary artery fistula, which lead to the coronary steal phenomenon, using an Amplatzer vascular plug with the trans-radial approach. After the procedure, the patient remained asymptomatic.

A Case of Disseminated Intra-abdominal Gastrointestinal Stromal Tumor Managed with Low Dose Imatinib

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Imatinib mesylate is recommended as adjuvant therapy for GIST after surgical resection. However, drug-related adverse events are common. A 74-year-old female with metastatic GIST who was managed with imatinib experienced severe adverse events, including skin rashes, tremor, and alopecia, etc. The imatinib dose was reduced and the size of the metastatic GIST continued to decrease and adverse events showed significant improvement.