Comparing right colon adenoma detection rate during water exchange and air insufflation: a double-blind randomized controlled trial

BACKGROUND

Randomized controlled trials (RCTs) have reported that water exchange (WE) produced the highest adenoma detection rate (ADR) but did not evaluate right colon adenoma detection rate (rADR) as a primary outcome and only one of the trials employed blinded colonoscopists. The aim of our study was to determine whether, compared with air insufflation, WE significantly increases rADR and right colon serrated lesion detection rate (rSLDR) and decreases adenoma miss rate (rAMR).

METHODS

This prospective, double-blind RCT was conducted at a regional hospital in Taiwan between December 2015 and February 2020. Standard WE and air insufflation were performed. After cecal intubation, the second blinded endoscopist examined the right colon and obtained rADR (primary outcome) and rSLDR. Then, the primary colonoscopist reinserted the scope to the cecum with WE in both groups and performed a tandem examination of the right colon to obtain rAMR.

RESULTS

There were 284 patients (50.9% male, mean age 58.9 ± 9.4 years) who were randomized to WE (n = 144) or air insufflation (n = 140). The baseline characteristics were similar. The rADR (34.7% vs. 22.3%, p = 0.025), Boston Bowel Preparation Scale scores (mean, 2.6 ± 0.6vs. 2.2 ± 0.6, p < 0.001), rSLDR (18.1% vs. 7.1%, p = 0.007), and rAMR (31.5% vs. 45.2%, p = 0.038) were significantly different between WE and air insufflation.

CONCLUSIONS

The current study demonstrated a significantly higher rADR and rSLDR with the WE method performed by blinded colonoscopists. The impact of the significant findings in this report on the occurrence of interval cancers deserves to be studied.

Higher risk of incident ankylosing spondylitis in patients with uveitis: a secondary cohort analysis of a nationwide, population-based health claims database

OBJECTIVES

Ankylosing spondylitis (AS) is a progressive, systemic, inflammatory autoimmune disease that typically affects young adults. Uveitis is a common extra-articular manifestation of AS. Nevertheless, the magnitude of the risk of AS among patients with uveitis is not clear. The aim of this secondary retrospective cohort study was to investigate the risk of incident AS in patients with uveitis using data from a nationwide, population-based health claims research database.

METHOD

Using Taiwan's National Health Insurance Research Database, we identified 6637 patients with uveitis between 2000 and 2012. A comparison cohort was assembled, which consisted of five patients without uveitis, based on frequency matching for gender, 10 year age interval, and index year, for each patient with uveitis. Both groups were followed until diagnosis of AS or the end of the follow-up period. A Poisson regression model was used to calculate the incidence rate ratio for AS between the uveitis cohort and the comparison cohort.

RESULTS

Patients with uveitis exhibited a significantly higher incidence of AS than the comparison cohort (adjusted incidence rate ratio = 2.57, p < 0.001). Subgroup analysis with stratification by the interval between the diagnosis of uveitis and AS indicated that the adjusted incidence rates were significantly higher in the uveitis cohort with an interval of up to 7.9 years.

CONCLUSION

A significant increased risk in AS among patients with uveitis was observed, with a time lag of up to 7.9 years between the diagnosis of uveitis and subsequent diagnosis of AS.

Immunopathogenesis of systemic lupus erythematosus and rheumatoid arthritis: the role of aberrant expression of non-coding RNAs in T cells

Non-coding RNAs (ncRNAs), including microRNAs (miRNAs) and long non-coding RNAs (lncRNAs), are RNA molecules that do not translate into protein. Both miRNAs and lncRNAs are known to regulate gene expression and to play an essential role in T cell differentiation and function. Both systemic lupus erythematosus (SLE), a prototypic systemic autoimmune disease, and rheumatoid arthritis (RA), a representative disease of inflammatory arthritis, are characterized by a complex dysfunction in the innate and adaptive immunity. T cells play a central role in cell-mediated immune response and multiple defects in T cells from patients with SLE and RA have been observed. Abnormality in T cell signalling, cytokine and chemokine production, T cell activation and apoptosis, T cell differentiation and DNA methylation that are associated closely with the aberrant expression of a number of miRNAs and lncRNAs have been implicated in the immunopathogenesis of SLE and RA. This review aims to provide an overview of the current state of research on the abnormal expression of miRNAs and lncRNAs in T cells and their roles in the immunopathogenesis of SLE and RA. In addition, by comparing the differences in aberrant expression of miRNAs and lncRNAs in T cells between patients with SLE and RA, controversial areas are highlighted that warrant further investigation.

The High Mobility Group A1 (HMGA1) Transcriptome in Cancer and Development

BACKGROUND & OBJECTIVES

Chromatin structure is the single most important feature that distinguishes a cancer cell from a normal cell histologically. Chromatin remodeling proteins regulate chromatin structure and high mobility group A (HMGA1) proteins are among the most abundant, nonhistone chromatin remodeling proteins found in cancer cells. These proteins include HMGA1a/HMGA1b isoforms, which result from alternatively spliced mRNA. The HMGA1 gene is overexpressed in cancer and high levels portend a poor prognosis in diverse tumors. HMGA1 is also highly expressed during embryogenesis and postnatally in adult stem cells. Overexpression of HMGA1 drives neoplastic transformation in cultured cells, while inhibiting HMGA1 blocks oncogenic and cancer stem cell properties. Hmga1 transgenic mice succumb to aggressive tumors, demonstrating that dysregulated expression of HMGA1 causes cancer in vivo. HMGA1 is also required for reprogramming somatic cells into induced pluripotent stem cells. HMGA1 proteins function as ancillary transcription factors that bend chromatin and recruit other transcription factors to DNA. They induce oncogenic transformation by activating or repressing specific genes involved in this process and an HMGA1 "transcriptome" is emerging. Although prior studies reveal potent oncogenic properties of HMGA1, we are only beginning to understand the molecular mechanisms through which HMGA1 functions. In this review, we summarize the list of putative downstream transcriptional targets regulated by HMGA1. We also briefly discuss studies linking HMGA1 to Alzheimer's disease and type-2 diabetes.

CONCLUSION

Further elucidation of HMGA1 function should lead to novel therapeutic strategies for cancer and possibly for other diseases associated with aberrant HMGA1 expression.

Increased risk of pulmonary and extra-pulmonary tuberculosis in patients with rheumatic diseases

SETTING

Impaired immunity in patients with rheumatic diseases can increase the risk of pulmonary tuberculosis (PTB). However, it is less clear whether rheumatic diseases affect the risk of extra-pulmonary tuberculosis (EPTB).

OBJECTIVE

To investigate the risk of PTB and EPTB in patients with rheumatic diseases using a population-based database.

DESIGN

From Taiwan's National Health Insurance Research Database, 8536 patients with tuberculosis (TB) were frequency-matched with 42,680 controls for sex, 10-year age group and index year. Subjects were retrospectively traced back for their first diagnosis of rheumatic diseases. The association between TB and rheumatic diseases was assessed using multivariate logistic regression analyses.

RESULTS

The risk of developing PTB was significantly higher in patients with systemic lupus erythematosus (adjusted odds ratio [aOR] 4.90, P < 0.001), rheumatoid arthritis (RA) (aOR 2.00, P < 0.001) and Sjögren's syndrome (aOR 6.11, P < 0.001). In addition, the risks of developing EPTB were significantly higher in RA patients (aOR 4.67, P < 0.001), those with Sjögren's syndrome (aOR 5.94, P < 0.001), and the group comprising progressive systemic sclerosis, polymyositis or dermatomyositis (aOR 8.31, P = 0.021).

CONCLUSION

Elevated risks of PTB and EPTB were associated with various rheumatic diseases. Rheumatologists should be vigilant to the possibility of TB, and particularly EPTB, in their patients.

The High Mobility Group A1 (HMGA1) gene is highly overexpressed in human uterine serous carcinomas and carcinosarcomas and drives Matrix Metalloproteinase-2 (MMP-2) in a subset of tumors

OBJECTIVES

Although uterine cancer is the fourth most common cause for cancer death in women worldwide, the molecular underpinnings of tumor progression remain poorly understood. The High Mobility Group A1 (HMGA1) gene is overexpressed in aggressive cancers and high levels portend adverse outcomes in diverse tumors. We previously reported that Hmga1a transgenic mice develop uterine tumors with complete penetrance. Because HMGA1 drives tumor progression by inducing MatrixMetalloproteinase (MMP) and other genes involved in invasion, we explored the HMGA1-MMP-2 pathway in uterine cancer.

METHODS

To investigate MMP-2 in uterine tumors driven by HMGA1, we used a genetic approach with mouse models. Next, we assessed HMGA1 and MMP-2 expression in primary human uterine tumors, including low-grade carcinomas (endometrial endometrioid) and more aggressive tumors (endometrial serous carcinomas, uterine carcinosarcomas/malignant mesodermal mixed tumors).

RESULTS

Here, we report for the first time that uterine tumor growth is impaired in Hmga1a transgenic mice crossed on to an Mmp-2 deficient background. In human tumors, we discovered that HMGA1 is highest in aggressive carcinosarcomas and serous carcinomas, with lower levels in the more indolent endometrioid carcinomas. Moreover, HMGA1 and MMP-2 were positively correlated, but only in a subset of carcinosarcomas. HMGA1 also occupies the MMP-2 promoter in human carcinosarcoma cells.

CONCLUSIONS

Together, our studies define a novel HMGA1-MMP-2 pathway involved in a subset of human carcinosarcomas and tumor progression in murine models. Our work also suggests that targeting HMGA1 could be effective adjuvant therapy for more aggressive uterine cancers and provides compelling data for further preclinical studies.

Percutaneous Ventricular Assist Devices and ECMO in the Management of Acute Decompensated Heart Failure

The successful treatment of acute decompensated heart failure continues to evolve with an increasing utilization of nondurable mechanical support devices. Indications for acute support have broadened to include their use as a bridge to recovery or decision (for durable ventricular assist devices [VADs] or heart transplant). Available devices have improved in terms of effectiveness, ease of insertion, and reduction in complications. The commonly used devices (intra-aortic balloon pump, TandemHeart, Impella, and extracorporeal membrane oxygenation circuit), together with their mechanisms of action, are reviewed. Current considerations for support, specific to each device, are examined and future directions and indications for percutaneous VADs are explored.

Impact of a compulsory final year medical student curriculum on junior doctor prescribing

BACKGROUND

Attendance at face-to-face sessions and completion of online components of the National Prescribing Curriculum was made compulsory for final year medical students at the University of Adelaide in 2010.

AIMS

To determine the impact of a compulsory prescribing curriculum for final year medical students on their prescribing competencies at the start of clinical practice. Graduates' attitudes to their medical school training in prescribing were also surveyed.

METHODS

Two cohorts of medical graduates from the University of Adelaide who commenced medical practice in 2010 and 2011 were required to complete a prescribing task using the National Inpatient Medication Chart (NIMC) at orientation and after 6 months of clinical practice. The main outcome measure was a performance in a scenario-based prescribing test, as determined by test scores and overall safety of prescriptions at orientation and 6 months of clinical practice.

RESULTS

There was a small difference in the average total score for the prescribing task between the 2010 and 2011 cohorts at orientation (P = 0.0007). The 2011 cohort had a higher number of safer charts at commencement of practice. We found no difference between the 2010 and 2011 cohorts in attitudes towards their undergraduate pharmacology education, and new graduates feel poorly prepared.

CONCLUSION

Medical graduates who are required to complete a practically oriented prescribing curriculum in final year perform slightly better on a prescribing assessment at commencement of practice. More work on preparing graduates for this complex task before graduation is needed.

Ultrasound-guided saphenous nerve block is an effective technique for perioperative analgesia in ambulatory arthroscopic surgery of the internal knee compartment

OBJECTIVES

Arthroscopic knee surgery is a minimally invasive technique with moderate pain during the first 24h. Our main objective was to evaluate the efficacy of ultrasound guided saphenous nerve block as a method of pain control intraoperatively and postoperatively for this surgery.

MATERIAL AND METHODS

A prospective and observational study. All patients received general anesthesia with laryngeal mask in the saphenous group, nerve block was performed with 10 ml ropivacaine 0.475%. Location of the surgery (external compartment group/internal compartment group), morphine consumption, VAS for pain at 5, 30, 60 and 120 min and 24 h after surgery, need for rescue medication, onset of nausea and vomiting, length of stay in PACU, delayed discharge and satisfaction were evaluated.

RESULTS

The study included 73 patients. Of these, 46 received saphenous nerve block and 27 didn't receive it. Consumption of intraoperative, postoperative and total morphine was significantly lower in the saphenous group as well as VAS at 24h. In the subgroup of internal compartment surgery differences in VAS 24 h, morphine consume and lenght of stay in PACU were mantained.

CONCLUSIONS

The ultrasound-guided block of saphenous nerve, particularly in the internal compartment arthroscopic knee surgery, decreases analgesic requirements, obtaining more effective pain control in the first 24 h postoperatively and without any known side effects.

Increased prevalence of JC polyomavirus viruria was associated with arthritis/arthralgia in patients with systemic lupus erythematosus

OBJECTIVE

The objective of this paper is to investigate the prevalence of reactivation of the human polyomavirus John Cunningham virus (JCV) in patients with systemic lupus erythematosus (SLE) and its associated clinical manifestations.

METHODS

Sixty-one patients with SLE and 22 controls were enrolled. Urine JCV viral load was quantified by real-time polymerase chain reaction (PCR). Length variants of the VP1 gene were analyzed using capillary electrophoresis.

RESULTS

The prevalence of JCV viruria (63.9% vs. 18.2%, p < 0.001) and urine JCV viral load (2.92 ± 2.76 vs. 0.81 ± 1.85 copies/ml by log10 scale, p < 0.001) were significantly higher in patients with SLE compared with controls. JCV viruria (+) SLE patients had a higher occurrence of arthritis/arthralgia compared with JCV viruria (-) SLE patients (64.1% vs. 22.7%, p = 0.003). In SLE patients, the urine JCV viral load was significantly associated with the occurrence of arthritis/arthralgia. SLE patients with urine JCV viral load >10,000 copies/ml exhibited a 12.75-fold (95% confidence interval 2.88-56.40) risk in clinical arthritis/arthralgia, 18.90-fold (95% confidence interval 2.10-170.39) risk in persistent arthritis, and significantly greater number of length variants in the VP1 gene of JCV compared with JCV viruria (-) SLE patients.

CONCLUSION

Reactivation of JCV in the urinary tract of SLE patients was very common. Both JCV viruria and urine JCV viral load were associated with the occurrence of arthritis/arthralgia in patients with SLE. High urine JCV viral load also was associated with the genetic variant in the VP1 gene.

Molecular regulation of autophagy and its implications for metabolic diseases

PURPOSE OF REVIEW

Autophagy is an evolutionarily conserved cellular programme for the turnover of organelles, proteins, and other macromolecules, involving the lysosomal degradation pathway. Emerging evidence suggests that autophagy can play a central role in human metabolism as well as impact diverse cellular processes including organelle homeostasis, cell death and proliferation, lipid and glycogen metabolism, and the regulation of inflammation and immune responses. The purpose of this review is to examine recent evidence for the role of autophagy in cellular metabolism, and its relevance to select human diseases that involve disorders of metabolism.

RECENT FINDINGS

Recent studies suggest that autophagy may play multiple roles in metabolic diseases, including diabetes and its complications, metabolic syndrome and obesity, myopathies and other inborn errors of metabolism, as well as other diseases that may involve altered mitochondrial function.

SUMMARY

Strategies aimed at modulating autophagy may lead to therapies for diseases in which altered cellular and tissue metabolism play a key role.

[Hypoglossal nerve neuropraxia after shoulder hemiarthroplasty]

We report a case of hypoglossal nerve damage after shoulder hemiarthroplasty with the patient in "beach chair" position, performed with general anesthesia with orotracheal intubation, and without complications. An ultrasound-guided interscalene block was previously performed in an alert patient. After the intervention, the patient showed clinical symptomatology compatible with paralysis of the right hypoglossal nerve that completely disappeared after 4 weeks. Mechanisms such as hyperextension of the neck during intubation, endotracheal tube cuff pressure, excessive hyperextension, or head lateralization during surgery have been described as causes of this neurological damage. We discuss the causes, the associated factors and suggest preventive measures.

Low plasma fibrinogen levels and blood product transfusion in liver transplantation

BACKGROUND

Risk of bleeding in liver transplantation is determined by surgical technique, preoperative hemoglobin and antifibrinolitic therapy. We hypothesized that keeping these confounders factors identical, preoperative plasma fibrinogen level of ≤2 g/L influenced on blood product requirements.

METHODS

Adult patients underwent orthotropic liver transplantation (LT) during the period between January 1998 and December 2009. Cases were selected according to a propensity matching analysis meeting the following criteria: surgical vena cava preservation, tranexamic acid administration and hemoglobin range between 90 to 120 g/L. Intraoperative management was protocolized. The main variable was the percentage of patients that did not require red blood cells (RBC's).

RESULTS

Six hundred sixty-four patients with LT, 208 excluded, 266 who cannot be matched, the analysis was performed on 190 patients. Two cohorts: Low fibrinogen (≤2 g/L) (61 cases) and standard fibrinogen (>2 g/L) (129 cases) were analyzed. Preoperative platelet count (73.5±52 vs. 104±65; 103/mm3) was different in contrast to the hemoglobin (104.2±8.6 vs. 105.6±8.3; g/L). Use of RBC's resulted significantly higher in the low fibrinogen group (median, 3 vs. 2). The number of patients with no blood product requirements was fewer in the low fibrinogen group (8 cases, 13% vs. 45 cases, 35%). The critical level of plasma fibrinogen (1 g/L) was reached after graft reperfusion in 7 cases (5.5%) in the standard fibrinogen group vs. 24 cases (39%) in the low fibrinogen group.

CONCLUSION

Our data suggest that preoperative plasma fibrinogen level of ≤2 g/L increases requirements for blood products during the surgical procedure of liver transplantation.

The use of granulocyte colony-stimulating factors in a Canadian outpatient setting

BACKGROUND

Data on real-life utilization of granulocyte colony-stimulating factors (g-csfs) in Canada are limited. The objective of the present study was to describe the reasons for, and the patterns of, g-csf use in selected outpatient oncology clinics in Ontario and Quebec.

METHODS

In a retrospective longitudinal cohort study, a review of medical records from 9 Canadian oncology clinics identified patients being prescribed filgrastim (fil) and pegfilgrastim (peg). Patient characteristics, reasons for g-csf use, and treatment patterns were descriptively analyzed.

RESULTS

Medical records of 395 patients initiating g-csf therapy between January 2008 and January 2009 were included. Of this population, 80% were women, and breast cancer was the predominant diagnosis (59%). The most commonly prescribed g-csf was fil (56% in Ontario and 98% in Quebec). The most frequent reason for g-csf use was primary prophylaxis (42% for both fil and peg), followed by secondary prophylaxis (37% fil, 41% peg). Those proportions varied by tumour type and chemotherapy regimen. Delayed g-csf administration (more than 1 day after the end of chemotherapy) was frequently observed for fil, but rarely reported for peg, and that finding was consistent across tumours and concurrent chemotherapy regimens.

CONCLUSIONS

The use of g-csf varies with the malignancy type and the provincial health care setting. The most commonly prescribed g-csf agent was fil, and most first g-csf prescriptions were for primary prophylaxis. Delays were frequently observed for patients receiving fil, but were rarely reported for those receiving peg.

Meaningful inclusion of consumers in research and service delivery

OBJECTIVE

Although participatory methods have become increasingly popular, people with lived experience of mental illness and homelessness have been historically excluded from service planning and research. To better plan for meaningful inclusion of consumers, this study examines lessons learned from the People with Lived Experience Caucus in the Toronto Site of the At Home/Chez Soi Research Demonstration Project on Homelessness and Mental Health.

METHOD

The inclusion of the People with Lived Experience Caucus was evaluated using qualitative methods and multiple data sources, including review of 42 documents, 11 individual interviews, and three focus groups. Caucus members were included in the study team. Transcripts were analyzed using grounded theory methodology.

RESULTS

Findings revealed a complex story of Caucus engagement: Facing time constraints and given little direction, the Caucus developed through a tumultuous process related to both internal and external barriers to meaningful inclusion. Despite the challenges, the Caucus contributed meaningfully to various aspects of the research demonstration project.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It is possible to successfully integrate psychiatric consumers with experience of homelessness in many aspects of research and service planning. Suggestions for future initiatives hoping to engage consumers include: early involvement, purposeful selection of members, clear communication of roles and responsibilities, a consumer coordinating group, and space for critical dialog throughout the process. Lessons learned can inform the inclusion of consumers in similar endeavors in other jurisdictions.

[Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital]

OBJECTIVES

The incidence of postoperative neurological symptoms after performing interscalene block varies between 4 and 16%. The majority of cases are resolved spontaneously within a year, but some patients have their symptoms permanently. Our objective was to assess the incidence of postoperative neurological symptoms after performing the ultrasound-assisted interscalene and supraclavicular anaesthetic blocks.

MATERIAL AND METHODS

A prospective and observational study was conducted on consecutive patients who had undergone upper extremity surgery with an interscalene or supraclavicular block as an isolated technique, or as a complement to general anaesthesia. Seven days after the intervention, a telephone interview was conducted that focused on the detection of neurological symptoms in the operated limb. Further serial interviews were conducted on patients with symptoms (after the first, the third and the sixth month, and one year after surgery) until resolution of symptoms. Neurological evaluation was offered to those patients with persistent symptoms after one year.

RESULTS

A total of 121 patients were included, on whom 96 interscalene blocks and 22 supraclavicular blocks were performed. Postoperative neurological symptoms were detected in 9.9% (95% CI, 5-15%) of patients during the first week. No significant differences were observed between interscalene (9%) and supraclavicular block (14%). After 3 months the symptoms persisted in 9 patients (7.4%), with symptoms remaining in 4 patients (3.3%) after 1.5 years. Electromyogram was performed on 3 patients who tested positive for nerve damage.

CONCLUSIONS

A high incidence of postoperative neurological symptoms was observed, and a worrying percentage of permanence of them. There were no significant differences in incidence according to the type of block, or any features of the patient or the anaesthesia technique that were associated with the incidence of these symptoms, except a marginal relationship with age. These complications must be clearly explained to the patients before performing these blocks.

Coagulopathy management in liver transplantation

Risk of bleeding and transfusion in liver transplantation is determined by age, severity of liver disease, as well as hemoglobin and plasma fibrinogen values. During the hepatectomy and the anhepatic phase, the coagulopathy is related to a decrease in clotting factors caused by surgical bleeding, facilitated by the increased portal hypertension and esophageal-gastric venous distension. Corrections of hematologic disturbances by administration of large volumes of crystalloid, colloid, or blood products may worsen the coagulopathy. Also, impaired clearance of fibrinolytic enzymes released from damaged cells can lead to primary fibrinolysis. At time of graft reperfusion further deterioration may occur as characterized by global reduction among all coagulation factors, decreased plasminogen activator inhibitor factors, and simultaneous generation of tissue plasminogen activator. In situations with inherent risk of bleeding, hypofibrinogenemia must be corrected. Concern about unwanted events is a major limitation of preventive therapy. There is some evidence for the efficacy of antifibrinolytic drugs to reduce red blood cell requirements. A guide for antifibrinolytic therapy are clot firmness in trhomboelastometry or alternatively, diffuse bleeding associated to a fibrinogen value less than 1 g/L. Because thrombin generation is limited in severe thrombocytopenia, platelet administration is recommended when active bleeding coexists with a platelet count below 50,000/mm(3). When the administration of hemoderivates and antifibrinolytic drugs does not correct severe bleeding, consumption coagulopathy and secondary fibrinolysis should be suspected. Treatment of affected patients should be based upon correcting the underlying cause, mostly related to tissue hypoxia due to critical hypoperfusion.

[Anesthesia in the patient with impaired liver function]

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

[Multidisciplinary protocol for computed tomography imaging and angiographic embolization of splenic injury due to trauma: assessment of pre-protocol and post-protocol outcomes]

OBJECTIVES

To assess conservative treatment of splenic injury due to trauma, following a protocol for computed tomography (CT) and angiographic embolization. To quantify the predictive value of CT for detecting bleeding and need for embolization.

MATERIAL AND METHODS

The care protocol developed by the multidisciplinary team consisted of angiography with embolization of lesions revealed by contrast extravasation under CT as well as embolization of grade III-V injuries observed, or grade I-II injuries causing hemodynamic instability and/or need for blood transfusion. We collected data on demographic variables, injury severity score (ISS), angiographic findings, and injuries revealed by CT. Pre-protocol and post-protocol outcomes were compared. The sensitivity and specificity of CT findings were calculated for all patients who required angiographic embolization.

RESULTS

Forty-four and 30 angiographies were performed in the pre- and post-protocol periods, respectively. The mean (SD) ISSs in the two periods were 25 (11) and 26 (12), respectively. A total of 24 (54%) embolizations were performed in the pre-protocol period and 28 (98%) after implementation of the protocol. Two and 7 embolizations involved the spleen in the 2 periods, respectively; abdominal laparotomies numbered 32 and 25, respectively, and 10 (31%) vs 4 (16%) splenectomies were performed. The specificity and sensitivity values for contrast extravasation found on CT and followed by embolization were 77.7% and 79.5%.

CONCLUSIONS

The implementation of this multidisciplinary protocol using CT imaging and angiographic embolization led to a decrease in the number of splenectomies. The protocol allows us to take a more conservative treatment approach.

Cost effectiveness of TAC versus FAC in adjuvant treatment of node-positive breast cancer

Background

This economic analysis aimed to determine, from the perspective of a Canadian provincial government payer, the cost-effectiveness of docetaxel (Taxotere: Sanofi–Aventis, Laval, QC) in combination with doxorubicin and cyclophosphamide (tac) compared with 5-fluorouracil, doxorubicin, and cyclophosphamide (fac) following primary surgery for breast cancer in women with operable, axillary lymph node–positive breast cancer.

Methods

A Markov model looking at two time phases—5-year treatment and long-term follow-up—was constructed. Clinical events included clinical response (based on disease-free survival and overall survival) and rates of febrile neutropenia, stomatitis, diarrhea, and infections. Health states were “no recurrence,” “locoregional recurrence,” “distant recurrence,” and “death.” Costs were based on published sources and are presented in 2006 Canadian dollars. Model inputs included chemotherapy drug acquisition costs, chemotherapy administration costs, relapse and follow-up costs, costs for management of adverse events, and costs for granulocyte colony-stimulating factor (g-csf) prophylaxis. A 5% discount rate was applied to costs and outcomes alike. Health utilities were obtained from published sources.

Results

For tac as compared with fac, the incremental cost was $6921 per life-year (ly) gained and $6,848 per quality-adjusted life-year (qaly) gained. The model was robust to changes in input variables (for example, febrile neutropenia rate, utility). When g-csf and antibiotics were given prophylactically before every cycle, the incremental ratios increased to $13,183 and $13,044 respectively.

Conclusions

Compared with fac, tac offered improved response at a higher cost. The cost-effectiveness ratios were low, indicating good economic value in the adjuvant setting of node-positive breast cancer patients.

Inclined slot-excited annular electron cyclotron resonance plasma source for hyperthermal neutral beam generation

An inclined slot-excited antenna (ISLAN) electron cyclotron resonance (ECR) plasma source is newly designed and constructed for higher flux hyperthermal neutral beam (HNB) generation. The developed ISLAN source is modified from vertical slot-excited antenna (VSLAN) source in two aspects: one is the use of inclined slots instead of vertical slots, and the other is a cusp magnetic field configuration rather than a toroidal configuration. Such modifications allow us to have more uniform arrangement of slots and magnets, then enabling plasma generation more uniform and thinner. Moreover, ECR plasma allows higher ionization rate, enabling plasma density higher even in submillitorr pressures, therefore decreasing the collision rate and∕or the reionization rate of the reflected atoms while passing through the plasma, and eventually getting higher flux of HNBs. In this paper, we report the design features and the plasma characteristics of the ISLAN source by doing plasma measurements and electromagnetic simulations. It was found that ISLAN source can be a high potential source for larger flux HNB generation; the source was found to give higher plasma densities and better uniformities than inductively coupled plasma source, particularly in low pressure ranges. Also, it is important that using ISLAN gives easier matching and better stability, i.e., ISLAN shows similar field patterns and good plasma symmetries irrespective of the variations of the mean diameter of the ring resonator and∕or the presence of a limiter or a reflector, and the operating pressures.

[Mortality in patients with multiple injuries: analysis using the trauma and injury severity score in a referral hospital]

BACKGROUND AND OBJECTIVES

A growing number of patients with multiple injuries are being treated. Injury severity scales can be used to assess outcomes objectively. This study aimed to assess our hospital's cases on the basis of the Trauma and Injury Severity Score (TRISS) and compare outcomes to those reported in the Major Trauma Outcome Study, as well as to determine preventable mortality and analyze causes of death and associated factors.

PATIENTS AND METHODS

Data were extracted from the records of patients admitted with multiple injuries in 2005 and were used to calculate the Revised Trauma Score (RTS), the Injury Severity Score (ISS), and the TRISS or probability of survival. Hospital mortality was also calculated. A TRISS between 25 and 50 was considered to indicate a preventable avoidable death; a TRISS over 50 indicated a preventable death. Logistic regression analysis was used to identify factors associated with mortality.

RESULTS

We studied the cases of 198 patients with a mean (SD) age of 43.9 (19) years. Ninety-three percent had suffered blunt trauma. The mean ISS, the prehospital RTS, and the TRISS were 16.9 (11.2), 10.8 (2.5), and 0.95 (0.2), respectively. Twenty-five patients died. Fifteen deaths were classified as preventable or potentially preventable. Factors related to exitus were head injury and age (odds ratios, 4.6 and 4.0, respectively).

CONCLUSIONS

The rate of preventable death in our hospital was higher than expected. Mortality was strongly associated with head injury and age. The TRISS model can identify preventable deaths objectively.

3-Hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase inhibitory effect of Vitis vinifera

Activity-guided fractionation of the methanol extract of Vitis vinifera bark led to the isolation of epsilon-viniferin, ampelopcin A, vitisin A and vitisin B. Vitisin A and vitisin B showed a remarkable inhibitory activity against 3-hydroxy-3-methylglutaryl-Coenzyme A (HMG-CoA) reductase with IC50 value of 42.1 microM and 23.9 microM, respectively.

[Factors related to renal dysfunction after liver transplantation in patients with normal preoperative function]

OBJECTIVE

To determine perioperative factors related to postoperative renal dysfunction in patients receiving liver transplants who had normal renal function before surgery.

PATIENTS AND METHODS

We analyzed the cases of 189 consecutive patients. Patients with hepatorenal syndrome and previously diagnosed renal insufficiency were excluded, as were patients undergoing a second transplant operation. Postoperative renal dysfunction was diagnosed when creatinine levels exceeded 1.5 mg x dL(-1) in the first postoperative week. Multivariate analysis of preoperative variables (patient characteristics; Child-Pugh score; status with the United Network for Organ Sharing; and sodium, coagulation, hemoglobin, and creatinine levels); intraoperative variables (blood product units required, duration of surgery, reperfusion syndrome, surgical technique, and crystalloids required); and postoperative variables (hemodialysis or filtration, reoperation, mortality, creatinine levels at 6 and 12 months).

RESULTS

One hundred fifty patients with normal kidney function were included. Postoperative renal dysfunction developed in 45 (30%). Differences between patients with and without postoperative renal dysfunction were found for weight; sex; Child-Pugh score; blood transfusion requirements (mean [SD] of 2.36 [2.4] units of packed red cells in the group of patients with renal dysfunction vs 1.3 [1.8] in the patients with normal function); and reperfusion syndrome (26 [66.7%] patients with renal dysfunction and 35 [21.5%] without). The last 2 variables continued to be significantly correlated with renal dysfunction in the multivariate analysis with a relative risk of 1.25, (95% confidence interval [CI], 1.01-1.55) for units of blood transfusion and 2.41 (95% CI, 1.04-5.57) for reperfusion syndrome. Renal replacement therapy was used in 4 patients (2.7%). Mortality rates were similar. At 6 and 12 months, 26 (17.3%) and 18 (12%) patients had renal dysfunction.

CONCLUSIONS

Acute renal dysfunction is a frequent complication following a liver transplant and it is associated with transfusion of more units of blood products even when the average transfusion amount is not large.

[Influence of the severity of obesity on morbidity and mortality after gastric bypass surgery]

OBJECTIVE

To determine the influence of severity of obesity on morbidity and mortality following Roux-en-Y gastric bypass and vertical ringed gastroplasty, with severity classified as morbid obesity (MO) defined by a body mass index (BMI) between 35 and 55 Kg/m2 and super-morbid obesity (SMO) defined by a BMI exceeding 55 Kg/m2.

METHOD

A series of patients who underwent the aforementioned type of gastric bypass surgery were followed for 5 years. The patients were classified as to whether they had associated sleep apnea syndrome, alveolar hypoventilation, or "overlap syndrome".

RESULTS

A total of 105 patients were enrolled: 70 (66.7%) classified as having MO and 35 (33.3%) classified as having SMO. Distribution by sex was significantly different in the 2 groups, but respiratory diseases were similar. PaO2 was higher in the MO group, PaCO2 was lower, and the alveolar-arterial gradient was smaller. Duration of surgery was shorter in the MO group (120.43 +/- 32.97 vs. 136.76 +/- 28.28 minutes). The percentage of complications was similar in the 2 groups (32.86% and 45.7% in the MO and SMO groups, respectively), although the incidence of respiratory complications was higher in SMO patients (8.57% vs. 20% in the MO and SMO groups, respectively). No differences were observed in the rates of surgical, hemodynamic, or infectious complications. Length of hospital stay was similar (6.44 vs. 6.69 for MO and SMO patients, respectively).

CONCLUSIONS

More severe obesity can be associated with preoperative arterial blood gas alterations in patients with concomitant respiratory disease and a higher incidence of respiratory complications in the early phase of recovery from gastric bypass surgery.

[Hemothorax as complication of laparoscopic technique]

A 69-year-old woman with a hiatal hernia and esophagitis caused by reflux was scheduled for laparoscopic Nissen fundoplication. Anesthetic induction was accomplished with fentanyl, propofol and rocuronium and maintenance with sevoflurane and rocoronium. Hemodynamics were stable until the end of surgery, when a sudden decrease in blood pressure to 40/20 mm Hg and arterial carbon dioxide tension to 14 mm Hg were observed. Anesthetic insufflation was stopped and physiological saline solution and ephedrine were administered. Hemothorax and air embolism were ruled out. After hemodynamic recovery, renewal of anesthetic insufflation was contraindicated, laparoscopy was halted, and hemoperitoneum was ruled out. After extubation, the patient was transferred to the recovery room, where hemodynamic instability worsened progressively. A chest radiograph suggest left hemothorax and an emergency thoracotomy was performed. After evacuation of multiple clots from the pleural cavity, the point of hemorrhage was located at the right crus of the diaphragm and bleeding was arrested. Postoperative recovery continued with no further events. The most common complications of laparoscopy are pneumothorax, gastroesophageal perforation and hemorrhage. However, given the complexity of the technique, the possibility of bleeding in the pleural cavity, as occurred in this case, should be considered. This case highlights the importance of rigorous intraoperative monitoring and postoperative surveillance by the anesthesiologist.

[Changes in the bispectral index and the spectral edge frequency 90 during different phases of anesthesia with sevoflurane]

INTRODUCTION

Electroencephalographic monitoring is one of the techniques used to measure hypnosis during anesthesia. Efforts to find a means to apply this monitoring function are justified by cases of intraoperative awakening and are in the interest of guaranteeing patient welfare and controlling anesthesia.

OBJECTIVES

To determine the changes in two electroencephalographic parameters, the bispectral index (BIS) and the spectral edge frequency 90 (SEF90), during the different phases of anesthesia. Patients and method. Forty-eight patients undergoing abdominal surgery were studied prospectively. Anesthesia was induced by propofol, fentanyl or sevoflurane. Anesthesia was maintained with sevoflurane and O2/N2O at a concentration of 70% to maintain BIS between 40 and 60. Variables monitored were heart rate, blood pressure, arterial oxygen saturation (with a pulse oximeter), expired CO2 partial pressure, inspired and expired sevoflurane partial pressure, esophageal temperature, SEF90 (defined as the frequency below which 90% of the power in the electroencephalogram resides) and BIS. All variables were recorded during three phases: induction, maintenance and recovery from anesthesia. We then performed an analysis of variance, with p < 0.05 considered significant.

RESULTS

During induction mean BIS decreased from 95.6 to 34.7 after intubation, while SEF90 fell from 20.5 Hz to 11.9 Hz. During maintenance BIS, SEF90 and expired sevoflurane partial pressure remained constant. During recovery mean BIS increased from 59.2 to 92.3 upon extubation, and SEF90 went from 15.1 to 22.2 Hz; although heart rate increased, blood pressure did not. The mean electroencephalographic values recorded when movement occurred were 77 for BIS (range 58-96) and 18 for SEF90 (range 13-18).

CONCLUSION

Electroencephalographic monitoring is useful for distinguishing between states of consciousness and unconsciousness during anesthesia, and is valid for the phases of induction and recovery. BIS values over 58 and SEF90 values over 13 may indicate inadequate hypnosis.

Tranexamic acid reduces red cell transfusion better than epsilon-aminocaproic acid or placebo in liver transplantation

We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT.

IMPLICATIONS

In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.

[Electroencephalographic and hemodynamic monitoring at various desflurane concentrations]

OBJECTIVES

To assess the electroencephalographic patterns and hemodynamic changes produced by desflurane at 0.5, 1 and 1.5 MAC.

MATERIAL AND METHODS

Twenty-four patients undergoing gynecological surgery under general anesthesia were enrolled prospectively. We monitored electroencephalographic (EEG) patterns and hemodynamic parameters as well as inspired and expired desflurane fractions. Anesthetic induction was with 2 mg/kg of propofol, 2 to 3 mg/kg of fentanyl and 0.1 mg/kg vecuronium. Spectral edge frequency (SEF90) and the EEG delta ratio were recorded along with mean systolic and diastolic pressures, heart rate, oxygen saturation and expired CO2 fraction during induction, intubation, 5 min after intubation and at 0.5, 1 and 1.5 MAC during weaning from anesthesia and extubation.

RESULTS

Blood pressure fell significantly at 1.5 MAC and increased when anesthesia was withdrawn; heart rate did not change significantly. SEF90 and the delta ratio changed, however, at each phase. SEF90 fell notably at the moment of induction but gradually increased, rising upon intubation, 5 min later, at 0.5 MAC and upon withdrawal of anesthesia. A significant decrease in SEF90 appeared when 1.5 MAC was reached, related to achievement of a deeper plane of anesthesia.

CONCLUSIONS

Automated EEG processing can provide a good measure of depth of anesthesia, as it reflects significant changes related to level of anesthesia at each phase. These differences are not always observable with routine monitoring of hemodynamic parameters.

Protective immunity against murine hepatitis virus (MHV) induced by intranasal or subcutaneous administration of hybrids of tobacco mosaic virus that carries an MHV epitope

Hybrids of tobacco mosaic virus (TMV) were constructed with the use of fusion to the coat protein peptides of 10 or 15 amino acids, containing the 5B19 epitope from the spike protein of murine hepatitis virus (MHV) and giving rise to TMV-5B19 and TMV-5B19L, respectively. The TMV hybrids were propagated in tobacco plants, and the virus particles were purified. Immunogold labeling, with the use of the monoclonal MAb5B19 antibody, showed specific decoration of hybrid TMV particles, confirming the expression and display of the MHV epitope on the surface of the TMV. Mice were immunized with purified hybrid viruses after several regimens of immunization. Mice that received TMV-5B19L intranasally developed serum IgG and IgA specific for the 5B19 epitope and for the TMV coat protein. Hybrid TMV-5B19, administered by subcutaneous injections, elicited high titers of serum IgG that was specific for the 5B19 epitope and for coat protein, but IgA that was specific against 5B19 was not observed. Mice that were immunized with hybrid virus by subcutaneous or intranasal routes of administration survived challenge with a lethal dose (10 x LD50) of MHV strain JHM, whereas mice administered wild-type TMV died 10 d post challenge. Furthermore, there was a positive correlation between the dose of administered immunogen and protection against MHV infection. These studies show that TMV can be an effective vaccine delivery vehicle for parenteral and mucosal immunization and for protection from challenge with viral infection.

[The incidence of intraoperative conciousness in emergency surgery and its possible relation to the post-traumatic stress syndrome. Presentation of three cases]

Intraoperative awakening and recall of specific events is a rare complication (0.2 to 1.3%) of surgery. The possibility of developing serious psychiatric complications, such as posttraumatic stress disorder (PTSD) makes the prevention and detection of intraoperative awareness a subject of special interest. We describe our experience with three patients in whom awareness was detected during emergency surgery under general anesthesia. We conducted two structured interviews with the patients three months after surgery in order to detect the possible development of psychiatric complications. One patient suffered insomnia and reexperience of the event during the first two weeks after surgery. Improvement was spontaneous. None of the patients suffered PTSD. Efforts to decrease the incidence of episodes of intraoperative awakening with specific recall must be based on clinical observation and exhaustive monitoring of the patient, including anesthetic gases, given that no ideal method of monitoring depth of anesthesia exists. Cases should be detected in the first few days after surgery by means of a specific test. Likewise, possible causes for the episode should be explained to the patient, who should be followed for six months so that early diagnosis of PTSD or other psychiatric complications can be made.