Utility of transesophageal echocardiography during orthotopic liver transplantation: A narrative review

Orthotopic liver transplantation (OLT) is the standard of care for patients suffering from end stage liver disease (ESLD). This is a high-risk procedure with the potential for hemorrhage, large shifts in preload and afterload, and release of vasoactive mediators that can have profound effects on hemodynamic equilibrium. In addition, patients with ESLD can have preexisting coronary artery disease, cirrhotic cardiomyopathy, porto-pulomary hypertension and imbalanced coagulation. As cardiovascular involvement is invariable and patient are at an appreciable risk of intraoperative cardiac arrest, Trans esophageal echocardiography (TEE) is increasingly becoming a routinely utilized monitor during OLT in patients without contraindications to its use. A comprehensive TEE assessment performed by trained operators provides a wealth of information on baseline cardiac function, while a focused study specific for the ESLD patients can help in prompt diagnosis and treatment of critical events. Future studies utilizing TEE will eventually optimize examination safety, quality, permit patient risk stratification, provide intraoperative guidance, and allow for evaluation of graft vasculature.

Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect: A case report

BACKGROUND

The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) frequently encounters hemodynamic instability after reperfusion of the new liver graft. The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance. In the presence of a left to right intracardiac shunt, this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.

CASE SUMMARY

A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT. A bedside transthoracic echocardiography (TTE) was performed immediately before the procedure and unexpectedly identified a ventricular septal defect (VSD). The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death. We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support, optimized mechanical ventilation, and used transesophageal echocardiography (TEE) for intraoperative monitoring. During reperfusion, considerable turbulent flows with air were noted in the right ventricle, but no air was visualized in the left ventricle. Color flow Doppler showed no reversal flow in the VSD. At the end of the procedure, the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.

CONCLUSION

Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation. The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.

Ubrogepant to treat migraine

Migraine is the primary headache disorder affecting a significant population worldwide. Ubrogepant is an orally bioavailable calcitonin gene-related peptide (CGRP) receptor antagonist (gepant) approved by the U.S. Food and Drug Administration (FDA) for the acute treatment of migraine headaches with or without aura in adults. Ubrogepant is the first oral CGRP receptor antagonist approved for the acute treatment of migraine. CGRP is an important key mediator of migraine pain; CGRP levels have been shown to be significantly higher during a migraine attack. Two pivotal phase III clinical trials (ACHIEVE I and ACHIEVE II) demonstrated effectiveness and safety of ubrogepant in acute migraine attacks. Ubrogepant can be administered as 50- and 100-mg tablets, with a maximum dose of 200 mg within 48 h. Besides minimizing pain, the drug is equally effective in alleviating migraine-associated symptoms such as nausea, photophobia and sound sensitivity. Unlike other gepants, ubrogepant is free from hepatotoxicity at the therapeutic doses. In certain cases (1 in 5), a full relief of pain was achieved with a single dose of the drug. The molecule is not effective as a preventive migraine therapy. The present review discusses the background, preclinical and clinical pharmacology, indication and safety of ubrogepant for the treatment of migraine attacks.

Cardiovascular Risk Assessment for Noncardiac Surgery: Are We Ready for Biomarkers?

Biomarkers aided perioperative cardiac assessment is a relatively new concept. Cardiac biomarkers with historical significance (aspartate transaminase, dehydrogenase, creatinine kinase and myoglobin) have paved the way for traditional biomarkers (cardiac troponin, C-reactive protein, lipoprotein). Contemporary biomarkers like natriuretic peptides (BNP and ProBNP) are validated risk markers in both acute and chronic cardiac diseases and are showing remarkable promise in predicting serious cardiovascular complications after non-cardiac surgery. This review is intended to provide a critical overview of traditional and contemporary biomarkers for perioperative cardiovascular assessment and management. This review also discusses the potential utility of newer biomarkers like galectin-3, sST-2, GDF-15, TNF-alpha, MiRNAs and many others that can predict inflammation, cardiac remodeling, injury and endogenous stress and need further investigations to establish their clinical utility. Though promising, biomarker led perioperative care is still in infancy and it has not been determined that it can improve clinical outcomes.

Sports interest mediating exercise and compulsive internet use among undergraduates

With the massive growth in Internet technologies, people have become wary of excessive Internet usage, known as compulsive Internet usage or Internet addiction. This study looks into how exercise is related to compulsive Internet usage. Previous research showed varying results regarding the relationship between sports habit and Internet usage; this project clarifies the relationship by investigating mediating variables in terms of interest in different aspects of sports, such as physical education, mastering sport skills, sports participation, and watching sports. Two survey studies were conducted. The participants were 232 male and 107 female Taiwanese undergraduate students in the first survey, totaling 339 students. The second survey had 233 males, 98 female students, and 2 who did not disclose their gender, with a final total of 333. The results reveal that interest in physical education (IPE) mediates sports habit and compulsive Internet usage. As long as the student had a habit of doing sports that increased IPE, this would in turn decrease compulsive Internet use. The importance of igniting students' IPE is discussed.

Experimental investigation of performance and emissions characteristics of waste cooking oil biodiesel and n-butanol blends in a compression ignition engine

Experimental investigations were conducted to evaluate the effects of n-butanol in biodiesel–diesel blends on the performance and emissions characteristics of a constant speed, direct injection diesel engine.

Vortioxetine for the treatment of major depression

Vortioxetine (Lu-AA-21004; 1-[2-(2,4-dimethylphenylsulfanyl)phenyl]piperazine hydrobromide) is a novel orally active molecule that is being investigated by Lundbeck and Takeda for the treatment of major depression and generalized anxiety disorders. Vortioxetine has a unique "multi-modal" mechanism of action. It inhibits the activity of serotonin transporters and is an agonist of serotonin 5-HT1A receptor, partial agonist of 5-HT1B and antagonist of 5-HT3A, 5-HT7 and 5-HT1D receptors. Vortioxetine has been effective in various animal models of depression and anxiety and clinical studies have shown the antidepressant and antianxiety properties of vortioxetine in a dose range of 5-20 mg/day. Vortioxetine reverses cognitive decline in patients with depression making it a unique molecule. The molecule lacks any serious side effects and drug-drug interactions. However, dose adjustments are required if vortioxetine is co-administered with rifampicin or bupropion. The molecule is under review by various regulatory agencies around the world for the treatment of major depression.

Anesthesia for Liver Transplantation

Orthotopic liver transplantation is the only definitive treatment for end-stage liver disease. More than 6000 procedures are performed in the United States annually with excellent survival rates. The shortage of donor organs leads to continued interest in techniques to enlarge the potential donor pool. Patients presenting for liver transplant suffer from important cardiovascular, respiratory, renal, neurological, and gastroenterological comorbidity. In the Western world, liver failure is increasingly caused by steatohepatitis, and transplant candidates are thus becoming older and more comorbid. The role of the transplant anesthesiologist is highly important in the preoperative assessment, intraoperative management, and postoperative care of these complex and sick patients. Appropriate investigation and management of comorbidities such as coronary artery disease and portopulmonary hypertension is controversial and differs between programs. The transplant procedure is a major surgery, and although massive transfusion is no longer commonplace, there is potential for significant hemodynamic instability, coagulopathy, and metabolic disturbance. Liver transplant surgery can be divided into the preanhepatic phase, the anhepatic phase, and the reperfusion phase, with important anesthetic considerations at each point.  An understanding of the surgical techniques used for vascular exclusion of the liver and the role of venovenous bypass is crucial for the anesthesiologist. Recent trends in perioperative care include the use of antifibrinolytic drugs and point-of-care coagulation tests, intraoperative renal replacement therapy, and “fast-track” extubation and postoperative care. Care of patients with fulminant hepatic failure or those receiving split-liver grafts requires special consideration.

An overview of curcumin in neurological disorders

Curcumin, the principal curcuminoid found in spice turmeric, has recently been studied for its active role in the treatment of various central nervous system disorders. Curcumin demonstrates neuroprotective action in Alzheimer's disease, tardive dyskinesia, major depression, epilepsy, and other related neurodegenerative and neuropsychiatric disorders. The mechanism of its neuroprotective action is not completely understood. However, it has been hypothesized to act majorly through its anti-inflammatory and antioxidant properties. Also, it is a potent inhibitor of reactive astrocyte expression and thus prevents cell death. Curcumin also modulates various neurotransmitter levels in the brain. The present review attempts to discuss some of the potential protective role of curcumin in animal models of major depression, tardive dyskinesia and diabetic neuropathy. These studies call for well planned clinical studies on curcumin for its potential use in neurological disorders.

Ascorbic Acid inhibits development of tolerance and dependence to opiates in mice: possible glutamatergic or dopaminergic modulation

In a recent study, it has been demonstrated that ascorbic acid possessed antidopaminergic activity and modulate the glutamatergic neurotransmission in mice. With this background, the present study was undertaken to study the effect of ascorbic acid on the development of tolerance and dependence to opiate and its mechanism of action. Male Swiss mice weighing 20-25 g were used in the present study. Mice were made physically dependent on opioid by the chronic administration of morphine (10 mg/kg, twice a day, for 9 days) intraperitoneally. Ascorbic acid, haloperidol (dopamine antagonist) or MK 801 (NMDA receptor antagonist) was administered daily for 9 d before challenging the animals with morphine. The development of tolerance was assessed by noting the tail-flick latency on day 1, 3, 9 and 10. On the 10(th) day after the measurement of tail-flick latency, animals were challenged with naloxone (2 mg/kg., i.p.) and incidence of escape jumps were recorded by placing the animals in 45 cm high plexiglass container. Ascorbic acid (400-1600 mg/kg) dose dependently inhibited development of tolerance and dependence to morphine as noted from tail-flick latency. When given along with MK 801 (0.01 mg/kg., i.p) or haloperidol (0.1 mg/kg i.p.), ascorbic acid (800 mg/kg., i.p.) potentiated the response of MK 801 or haloperidol. In conclusion, it is hypothesized that inhibition of development of tolerance and dependence to morphine by ascorbic acid appears to have two components, namely dopaminergic and glutamatergic.

Effect of various antiepileptic drugs in a pentylenetetrazol-induced seizure model in mice

The present study was undertaken to compare the anticonvulsant effect of various antiepileptic drugs on the intravenous pentylenetetrazol (PTZ)-induced seizure threshold in mice. Minimal doses of PTZ needed to induce different phases (myoclonic jerks, generalized clonus and tonic extensor) of convulsions were recorded as an index of seizure threshold. Furthermore, TID50 (the dose of an anticonvulsant drug required to increase the PTZ seizure threshold for tonic extensor by 50%) was calculated for all drugs, and from these values the potency ratio was determined. Pentobarbital (10-40 mg/kg i.p.), phenobarbital (5-20 mg/kg i.p.), phenytoin (20-40 mg/kg i.p.), carbamazepine (5-20 mg/kg i.p.), diazepam (0.5-2 mg/kg i.p.), chlordiazepoxide (1-4 mg/kg i.p.), triazolam (0.02-0.08 mg/kg i.p.), clonazepam (0.03125-0.25 mg/kg i.p.), GABA (25-100 mg/kg i.p.), ethanol (1000-4000 mg/kg of 10% v/v p.o.), ashwagandha (50-200 mg/kg p.o.), tiagabine (20 and 40 mg/kg i.p.), gabapentin (50-200 mg/kg i.p.), pregabalin (10-40 mg/kg i.p.), progesterone (20-80 mg/kg s.c.), adenosine (25-200 mg/kg i.p.) and rofecoxib (1-4 mg/kg i.p.) exhibited dose-dependent anticonvulsant effects. The TID50 of triazolam was found to be the lowest among all the drugs tested, indicating higher potency. The relative potency of standard drugs to increase the PTZ seizure threshold for tonic extensor was found to be: triazolam > clonazepam > diazepam > rofecoxib > chlordiazepoxide > phenobarbital > carbamazepine > pentobarbital > pregabalin > phenytoin > progesterone > tiagabine > GABA > adenosine > gabapentin > ashwagandha > ethanol. The results of the present study indicate that the intravenous PTZ seizure threshold may be useful for assessing the anticonvulsant effect of drugs effective against different stages of convulsions.

Gamma probe radioguided parathyroid forearm surgery in recurrent hyperparathyroidism

A case is described of a successful radioguided forearm graft parathyroidectomy. This is the first report of both pre-operative diagnostic and successful intra-operative localisation during a single procedure, of autologous transplanted parathyroid tissue.

Involvement of sigma (sigma1) receptors in modulating the anti-depressant effect of neurosteroids (dehydroepiandrosterone or pregnenolone) in mouse tail-suspension test

The present study investigated the effects of neurosteroids dehydroepiandrosterone sulfate (DHEAS) or pregnenolone sulfate (PS) on the tail-suspension test (TST) of depression in mice, and also the possible involvement of sigma (sigma) receptors. Immobility time in the TST was measured for a total period of 6 min. DHEAS (10 and 40 mg/kg, s.c.) or PS (40 mg/kg, s.c.) significantly reduced the immobility period without accompanying changes in the locomotor activity in mice. The effect on behavioural despair by DHEAS (10 and 40 mg/kg, s.c.) and PS (40 mg/kg, s.c.) was blocked by BD 1047 (1 mg/kg, s.c.), a novel sigma1-receptor antagonist, progesterone (10 mg/kg, s.c.), a sigma-receptor antagonistic neurosteroid or rimcazole (5 mg/kg, s.c.), another sigma1-receptor antagonistic property, respectively. The treatments and their combination did not alter the motor activity in mice. These data suggested a role for the central sigma receptors particularly sigma-1 (sigma1) receptors in the anti-depressant-like effects of neurosteroids.

Rofecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor potentiates the anticonvulsant activity of tiagabine against pentylenetetrazol-induced convulsions in mice

Numerous studies have implicated prostaglandins as potential modulators in seizure activity. The objective of the present study was to elucidate the effect of rofecoxib (selective COX-2 inhibitor) alone or in combination with newer antiepileptic drug tiagabine (gamma-amino acid reuptake inhibitor) against pentylenetetrazol (PTZ) (80 mg/kg, i.p.)-induced chemoconvulsions in mice. Rofecoxib or tiagabine was administered 45 min prior to the PTZ challenge. In combination study, rofecoxib was administered 10 min before tiagabine and after 35 min the animals were challenged with convulsive dose of PTZ. Mean onset time of jerks, clonus and extensor phases following PTZ challenge was noted. Pretreatment with rofecoxib (1-5.0 mg/kg, i.p.) or tiagabine (1-10 mg/kg, i.p.) dose dependently protected the animals against PTZ-induced convulsions. The mean onset time of jerks, clonus and extensor phase were increased. A subeffective dose of rofecoxib (0.5 mg/kg, i.p.) potentiated the effect of subprotective dose of tiagabine (0.5 mg/kg, i.p.). The results of the present study suggested that the protective effect of rofecoxib, a COX-2 inhibitor against PTZ-induced convulsions may be possibly through the GABAergic modulation. Rofecoxib may have a place as adjuvant therapy with standard antiepileptic drugs such as tiagabine in the treatment of epilepsy.

Novel variations in the signal peptide region of transforming growth factor beta1 gene in patients with hepatitis: a brief report from India

Genotypic status of the signal peptide region of transforming growth factor beta1 (TGF-beta1) showed a significant difference in C/C-genotype frequency at +29 position (codon 10) between a range of viral hepatitis patients and controls (P = 0.009, OR = 3.15, CI = 1.29-7.678), contributed by those who were infected with hepatitis B virus (HBV) alone or HBV + hepatitis delta virus (HDV) (P = 0.003, OR = 5.0, CI = 1.78-13.97).

Minimal access surgery for hydatid cyst disease: laparoscopic, thoracoscopic, and retroperitoneoscopic approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.

A successful PPMC (physician practice management company) acquisition strategy: vision, focus and discipline

Acquisitions have become increasingly necessary for managed care organizations to create product value and operating synergies. Physician practice management companies (PPMCs) that have successfully acquired and consolidated group practices and IPAs have a clear vision of their mission, focus on their target markets, and adhere to a disciplined methodology of financial evaluation, negotiation, and transition. Growing a PPMC entails risks, but expectations are for continued expansion of these organizations. The vision-focus-discipline method can help buyers adhere to a successful strategy during the acquisition process.

Basal cell carcinoma on the scalp of an Indian patient

BACKGROUND

Basal cell carcinoma (BCC) is the most common malignancy in whites, but it rarely occurs in dark persons.

OBJECTIVE

To report a BCC on the hairy scalp of an Asian Indian female with no obvious risk factors except previous scalp trauma.

METHODS

We review the English literature concerning BCC in Indians, and compare this with data for North American blacks and whites; and reports of BCC arising in areas of prior trauma.

RESULTS/CONCLUSION

Skin cancer accounts for 1-2% of malignancies in blacks and Indians, compared with one-third of neoplasms in whites. BCC comprises 75% of skin cancers in whites, but squamous cell carcinoma represents 60-65% of skin cancers in blacks and Indians. Although most BCCs occur in sun-exposed areas in whites, blacks, and Indians, a significant percentage also develop in photoprotected areas. Trauma may be a significant risk factor for BCC, either with actinic damage or alone, as in our case.

Vancomycin penetration into biofilm covering infected prostheses and effect on bacteria

To evaluate the adequacy of penetration of antibiotics into biofilm, a novel in vitro model for prosthesis-related infection was developed. Sterile stainless steel orthopedic nuts were incubated with slime-producing Staphylococcus epidermidis. Biofilm-covered nuts were exposed to varying concentrations of vancomycin; then biofilms were harvested. Vancomycin levels in biofilm, as measured by fluorescent polarization immunoassay, far exceeded the MIC and MBC of vancomycin for the organism. Bacterial growth in biofilm was inversely related to vancomycin concentration in biofilm, but even extremely high drug concentrations did not eradicate bacteria embedded in biofilm. The MICs and MBCs for bacteria recovered from biofilm did not differ from those for incubating organisms. Thus, failure of glycopeptide antibiotics to cure prosthesis-related infection is not due to poor penetration of drugs into biofilm but likely due to diminished antimicrobial effect on bacteria in the biofilm environment.

Snowmobile injuries in northern Newfoundland and Labrador: an 18-year review

The charts of 310 consecutive patients with snowmobile injuries admitted to Charles S. Curtis Memorial Hospital, St. Anthony, Newfoundland, during the years 1969 through 1986 were reviewed in order to determine the causes and possible ways of prevention of these injuries. There were 237 males and 73 females. Most patients were less than 30 years of age (73%). Drivers represented 57% of the injured. Falling off the machine and collisions were responsible for 60% of the injuries; 3.0% were due to mechanical failure of the snowmobile. The lower limbs and head and neck regions were most commonly affected (42.6 and 27.6%, respectively); less than 10% of the patients were wearing helmets at the time of the accident. We conclude that the human factor was responsible for the majority of the injuries. We recommend enforcement of legislation, intensification of public education about the hazards of driving snowmobiles, and modifications in the design of the engine, especially to provide increased protection for the lower limbs.