Rationale and study design for an Individualized PeriopeRative Open lung VEntilatory approach in Emergency Abdominal Laparotomy/scopy: study protocol for a prospective international randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPC) are the most frequent postoperative complications, with an estimated prevalence in elective surgery ranging from 20% in observational cohort studies to 40% in randomized clinical trials. However, the prevalence of PPCs in patients undergoing emergency abdominal surgery is not well defined. Lung-protective ventilation aims to minimize ventilator-induced lung injury and reduce PPCs. The open lung approach (OLA), which combines recruitment manoeuvres (RM) and positive end-expiratory pressure (PEEP) titration, aims to minimize areas of atelectasis and the development of PPCs; however, there is no conclusive evidence in the literature that OLA can prevent PPCs. The purpose of this study is to compare an individualized perioperative OLA with conventional standardized lung-protective ventilation in patients undergoing emergency abdominal surgery with clinical signs of intraoperative lung collapse.

METHODS

Randomized international clinical trial to compare an individualized perioperative OLA (RM plus individualized PEEP and individualized postoperative respiratory support) with conventional lung-protective ventilation (standard PEEP of 5 cmH2O and conventional postoperative oxygen therapy) in patients undergoing emergency abdominal surgery with clinical signs of lung collapse. Patients will be randomised to open-label parallel groups. The primary outcome is any severe PPC during the first 7 postoperative days, including: acute respiratory failure, pneumothorax, weaning failure, acute respiratory distress syndrome, and pulmonary infection. The estimated sample size is 732 patients (366 per group). The final sample size will be readjusted during the interim analysis.

DISCUSSION

The Individualized Perioperative Open-lung Ventilatory Strategy in emergency abdominal laparotomy (iPROVE-EAL) is the first multicentre, randomized, controlled trial to investigate whether an individualized perioperative approach prevents PPCs in patients undergoing emergency surgery.

Aortic valve surgery in octogenarians: Risk factors and long-term impact

BACKGROUND AND OBJECTIVES

To understand the risk factors and long-term impact and results of aortic valve surgery in patients over age 80.

PATIENTS AND METHODS

We consecutively evaluated 255 octogenarians who were operated on between 2000 and 2013 and referred for aortic valve disease (isolated or combined with coronary artery disease), which, even when associated with other diseases, was the primary cause of the patient's functional limitation.

RESULTS

The mortality rate decreased from 14.08% (2000-2004) to 7.7% (isolated valve surgery, 4.4%; with coronary bypass, 3.3%) (2010-2013). The independent risk factors associated with mortality were urgent surgery, combined procedures, peripheral vascular disease, a postsurgery hematocrit level <24% and the need for transfusion. More than 50% of the patients experienced a postoperative complication. Blood product transfusions were associated with renal and respiratory failure, and preoperative anemia was associated with an increased rate of myocardial infarction and stroke. Survival at 1, 3, 5 and 10 years was 79.5, 74.3, 63.6 and 30.5%, respectively, with 91.5% of patients in NYHA functional class I-II. Long-term survival was lower for cases of preoperative left ventricular dysfunction. The EuroSCORE I logistics score was not useful for our population as a predictor of mortality or of medium to long-term survival.

CONCLUSIONS

The morbidity and mortality of aortic valve surgery for patients over age 80 has decreased in recent years, although it remains higher when valve surgery is combined with coronary surgery. The presence of preoperative left ventricular dysfunction decreases long-term survival.

First Ocurrence of a Rhabdovirus Infecting Maize in Argentina

Maize (Zea mays) plants showing symptoms of shortened internodes, dwarfism, panicle sterility, and a mosaic of coarse and fine yellow stripes on leaf blades and sheaths, were found from December to March in experimental maize plantings in every crop year since 2000-01. Although the disease appeared at a very low incidence (estimates less than 1%), it was found in several locations such as Santa Isabel and Venado Tuerto, Santa Fe Province; Río Cuarto, Colonia Caroya, Río Segundo, and Sampacho, Córdoba Province; and Pedro Luro, Buenos Aires Province. Leaf tissue from eight symptomatic plants collected in Colonia Caroya in December 2011 was used to perform "leaf dips" and ultrathin sections. Electron microscopy of these preparations revealed membrane-bound bullet-shaped particles characteristic of the Rhabdoviridae family in mesophyll cytoplasm and vascular bundle parenchyma. The virus was experimentally transmitted to healthy 9-day-old corn plants, with Peregrinus maidis (order Hemiptera, family Delphacidae) raised under laboratory conditions using acquisition, latency, and inoculation vector periods of 7, 21, and 7 days, respectively. The field observed symptoms were replicated in the transmitted plants. Total RNA was extracted from symptomatic and asymptomatic plants with the RNeasy Plant Mini Kit (Qiagen, Germany), and one step RT-PCR (Access RT-PCR Kit, Promega, Madison, WI) was performed, using two sets of degenerate primers targeting conserved regions of rhabdovirus L polymerase gene, primers PVO (1) and Rhab (2). The agarose gel bands shown only in symptomatic samples were 450 bp (1) and 1,000 bp (2), as expected. The approximately 1 kb amplicon, which includes that of 450 bp, was cloned into pGEM-T Easy Vector System (Promega). Five independent clones were sequenced in both directions with M13 F/R universal primers to generate a consensus sequence (GenBank Accession No. JQ715419), which was compared to similar plant rhabdovirus sequences available on GenBank. The partial L polymerase gene sequence of the corn rhabdovirus, Maize yellow striate virus had 73% and 71% sequence identity with the members of the Cytorhabdovirus genus Barley yellow striate mosaic virus isolate Zanjan-1 (BYSMV; GenBank Accession No. FJ665628) and Northern cereal mosaic virus (NCMV; GenBank Accession No. NC002251), respectively. A phylogenetic tree from the partial nucleotide L polymerase sequence indicates that the rhabdovirus infecting maize in Argentina is closely related to the cytorhabdovirus members and is separated from the nucleorhabdovirus group. To our knowledge, this is the first mention of a Rhabdoviridae family virus infecting maize detected in Argentina. References: (1) H. Bourhy et al. J. Gen. Virol. 86:2849, 2005. (2) R. L. Lamprecht et al. Eur. J. Plant Pathol. 123:105, 2009.

En bloc kidney and bladder transplantation from an anencephalic donor into an adult recipient

The visceral block, composed of both kidneys and their vascular pedicles, inferior vena cava, ureters and bladder, was removed from a 3-day-old male anencephalic donor and transplanted into a 32-year-old adult in chronic renal failure. The urinary tract was reconstructed by vesicovesicostomy for technical ease, and prevention of reflux and ureteral stenosis. Maximum urine output was 150 ml. per day and the kidney grafts were lost owing to rejection 5 months after transplantation.