Contralateral surgery in patients scheduled for total thyroidectomy with initial loss or absence of signal during neural monitoring

BACKGROUND

Staged total thyroidectomy has been advised to prevent bilateral recurrent laryngeal nerve paralysis when loss of the signal from neural monitoring is observed after dissection of the initial thyroid lobe. This is supported by expert opinion but hard evidence is lacking. A lost signal can return during surgery or, even if it persists, its positive predictive value is only in the range 60-70 per cent. The aim of the present study was to investigate the clinical outcome of patients in whom total thyroidectomy was performed following loss of signal after dissection of the first thyroid lobe.

METHODS

This was a prospective observational study of adult patients scheduled for neural monitoring during total thyroidectomy. The prevalence of first-side absence or loss of signal was recorded. The contralateral thyroid lobe was approached routinely. The vagus and recurrent laryngeal nerves on the first side were retested during and at the end of the contralateral procedure.

RESULTS

Some 462 patients were included. Loss (32 patients) or initial absence (8) of signal at dissection of the first thyroid lobe was noted in 40 patients (8·7 per cent). Total thyroidectomy was completed in 29 patients, and a change of surgical strategy adopted in 11 patients with benign disease. At retesting, 15 of 37 initially silent nerves recovered electromyographic signal after a mean(s.d.) interval of 30(14) min. Postoperative vocal cord palsy/paresis was demonstrated in 24 of 40 patients. One patient developed a bilateral paresis that could be managed conservatively.

CONCLUSION

After an absence or loss of signal of the recurrent laryngeal nerve following dissection of the first thyroid lobe, contralateral thyroidectomy can be performed safely, avoiding the expense, psychological burden and potential complications of a second procedure.

Repetitive Transcranial Magnetic Stimulation with Resting-State Network Targeting for Treatment-Resistant Depression in Traumatic Brain Injury: A Randomized, Controlled, Double-Blinded Pilot Study

Repetitive transcranial magnetic stimulation (rTMS) has demonstrated antidepressant efficacy but has limited evidence in depression associated with traumatic brain injury (TBI). Here, we investigate the use of rTMS targeted with individualized resting-state network mapping (RSNM) of dorsal attention network (DAN) and default mode network (DMN) in subjects with treatment-resistant depression associated with concussive or moderate TBI. The planned sample size was 50 with first interim analysis planned at 20, but only 15 were enrolled before the study was terminated for logistical reasons. Subjects were randomized to 20 sessions of bilateral rTMS (4000 left-sided excitatory pulses, 1000 right-sided inhibitory pulses) or sham. Treatment was targeted to the dorsolateral prefrontal cluster with maximal difference between DAN and DMN correlations based on resting-state functional magnetic resonance imaging with individualized RSNM. Mean improvement in the primary outcome, Montgomery-Asberg Depression Rating Scale (MADRS), was 56% ± 14% (n = 9) with active treatment and 27% ± 25% (n = 5) with sham (Cohen's d = 1.43). One subject randomized to sham withdrew before starting treatment. There were no seizures or other significant adverse events. MADRS improvement was inversely correlated with functional connectivity between the right-sided stimulation site and the subgenual anterior cingulate cortex (sgACC; r = -0.68, 95% confidence interval 0.03-0.925). Active treatment led to increased sgACC-DMN connectivity (d = 1.55) and increased sgACC anti-correlation with the left- and right-sided stimulation sites (d = -1.26 and -0.69, respectively). This pilot study provides evidence that RSNM-targeted rTMS is feasible in TBI patients with depression. Given the dearth of existing evidence-based treatments for depression in this patient population, these preliminarily encouraging results indicate that larger controlled trials are warranted.

From genes to treatments: a systematic review of the pharmacogenetics in smoking cessation

Smoking cessation treatment outcomes may be heavily influenced by genetic variations among smokers. Therefore, identifying specific variants that affect response to different pharmacotherapies is of major interest to the field. In the current study, we systematically review all studies published in or after the year 1990 which examined one or more gene-drug interactions for smoking cessation treatment. Out of 644 citations, 46 articles met the inclusion criteria for the systematic review. We summarize evidence on several genetic polymorphisms (CHRNA5-A3-B4, CYP2A6, DBH, CHRNA4, COMT, DRD2, DRD4 and CYP2B6) and their potential moderating pharamacotherarpy effects on patient cessation efficacy rates. These findings are promising and call for further research to demonstrate the effectiveness of genetic testing in personalizing treatment decision-making and improving outcome.

Ascending monoaminergic systems alterations in Alzheimer's disease. translating basic science into clinical care

Extensive neuropathological studies have established a compelling link between abnormalities in structure and function of subcortical monoaminergic (MA-ergic) systems and the pathophysiology of Alzheimer's disease (AD). The main cell populations of these systems including the locus coeruleus, the raphe nuclei, and the tuberomamillary nucleus undergo significant degeneration in AD, thereby depriving the hippocampal and cortical neurons from their critical modulatory influence. These studies have been complemented by genome wide association studies linking polymorphisms in key genes involved in the MA-ergic systems and particular behavioral abnormalities in AD. Importantly, several recent studies have shown that improvement of the MA-ergic systems can both restore cognitive function and reduce AD-related pathology in animal models of neurodegeneration. This review aims to explore the link between abnormalities in the MA-ergic systems and AD symptomatology as well as the therapeutic strategies targeting these systems. Furthermore, we will examine possible mechanisms behind basic vulnerability of MA-ergic neurons in AD.

Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy

Background

Staged thyroidectomy has been recommended when loss of the signal from intraoperative nerve monitoring is observed after first-side dissection of the recurrent laryngeal nerve. There is no high-quality evidence supporting this recommendation. In addition, it is not clear whether signal loss predicts postoperative vocal cord paralysis.

Methods

This was a prospective observational study of consecutive adult patients undergoing neuromonitored total thyroidectomy for either malignancy or multinodular goitre. The prevalence of first-side loss of signal was recorded. Surgery was completed, and vagus and laryngeal nerves on the first side were rechecked at the end of the procedure.

Results

Two-hundred and ninety patients were included. Loss of signal on the first side was noted in 16 procedures (5·5 per cent). Thyroidectomy was completed and, at retesting, 15 of 16 initially silent nerves recovered an electromyographic signal with a mean(s.d.) amplitude of 132(26) mcV. Mean time to recovery was 20·2 (range 10–35) min. In no patient was the signal lost on the opposite side. Only three of 15 nerves with a recovered signal were associated with transient vocal cord dysfunction.

Conclusion

After loss of signal of the recurrent laryngeal nerve dissected initially, there was a 90 per cent chance of intraoperative signal recovery. In this setting, judicious bilateral thyroidectomy can be performed without risk of bilateral recurrent nerve paresis.

Low- vs high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation

BACKGROUND

Almitrine combined with inhaled nitric oxide (NO) can prevent hypoxia during one-lung ventilation (OLV). The optimal dose of almitrine that would provide therapeutic advantage with few side-effects during open-chest OLV has not been established.

METHODS

Forty-two patients undergoing thoracotomy were randomly allocated to three groups: placebo, almitrine 4 microg kg(-1) min(-1) and inhaled NO 10 p.p.m. (ALM4+NO), and almitrine 16 microg kg(-1) min(-1) and inhaled NO 10 p.p.m. (ALM16+NO). Gas exchange, haemodynamic and respiratory variables and plasma concentrations of almitrine and lactate were monitored. Measurements were obtained with the patient awake (baseline), after induction of anaesthesia with two-lung ventilation (control 2LV), 20 min after treatment (2LV+T), and then at 10, 20 and 30 min of OLV (OLV10', OLV20' and OLV30') with FI(O2)1.

RESULTS

In the placebo group, OLV impaired Pa(O2) and increased pulmonary shunt [16 (SD 7) kPa and 42 (10)% respectively]. These improved with ALM4+NO [26 (10) kPa and 31 (7)%; P<0.001]. ALM16+NO further improved PaO2) to 36 (13) kPa (P<0.0001) but gave no improvement in the shunt. Mean pulmonary artery pressure was similar in the placebo and ALM4+NO groups [20 (4) vs 23 (5) mm Hg], whereas it was increased in the ALM16+NO group to 28 (8) mm Hg (P<0.01). Plasma concentrations of almitrine and lactate were unaltered by the treatments.

CONCLUSIONS

Low-dose almitrine (4 microg kg(-1) min(-1)) together with inhaled NO significantly improves oxygenation during open-chest OLV, without modifying pulmonary haemodynamics. An increased dose of almitrine (16 microg kg(-1) min(-1)) with inhaled NO further improves arterial oxygenation, but also increases mean pulmonary artery pressure.

[Failure in the functioning of an implanted automatic defibrillator due to pneumothorax occurring during its implantation ]

A 67-year-old man with chronic bronchitis and coronary artery disease was scheduled to receive an implantable cardioverter defibrillator (ICD) after an episode of sustained monomorphic ventricular tachycardia. During implantation through the left subclavian vein, oxygen saturation decreased to slightly below baseline. Nevertheless, the procedure continued, given that the patient experienced neither breathing difficulties nor pain. When the ICD failed to reverse ventricular fibrillation induced to test the device, an external defibrillator was used. At that point, left-sided pneumothorax was observed by x-ray. Air in the pleural cavity caused an increase in the defibrillation threshold. After insertion of a thoracic drain, the ICD implantation procedure was completed successfully.

Injury to the abdominal aorta during laparoscopic surgery: an unusual presentation

IMPLICATIONS

Laparoscopic cholecystectomy is a very common surgical procedure, and vascular injuries account for one third of major complications during this surgery. We describe an unusual presentation of an abdominal aorta injury.

[Study of the squamous cell carcinoma (SCC) antigen in benign diseases]

BACKGROUND

The values of the squamous cell carcinoma (SCC) antigen in benign diseases were studied with the aim of determining false positive values in the study of epidermoid carcinomas.

METHODS

Serum determinations of the SCC antigen were performed by radioimmunoanalysis with the Abbott SCC-RIA kit. The control group was made up of a total of 719 subjects of whom 317 were healthy blood donors and 402 were healthy women with normal cervicovaginal cytology. The study group was made up of 693 women with benign diseases.

RESULTS

Ninety-eight point two percent of the subjects from the control group presented values under 2.5 ng/ml, therefore this value was chosen as the maximum limit of normality. Higher values than this threshold of normality were observed in 11.7% of the 34 patients with chronic disease (0.1-18.2 ng/ml) and in 57.5% of the 40 patients with chronic renal failure (0.5-6.0 ng/ml).

CONCLUSIONS

In patients with chronic liver disease or chronic renal failure, the serum determination of the squamous cell carcinoma antigen loses its value as a tumor marker of epidermoid carcinomas given the risk of obtaining false positive values.

Effects of moclobemide on depressive symptoms and cognitive performance in a geriatric population: a controlled comparative study versus imipramine

Moclobemide, a novel monoamine oxidase-A reversible inhibitor with demonstrated antidepressive efficacy, was administered double-blind versus imipramine to aged depressive subjects. The two drugs were given for 60 days in increasing doses up to 600 mg for moclobemide and 100 mg for imipramine. Fifteen patients received moclobemide and 15 received imipramine. Psychiatric conditions and symptoms were rated at 0, 7, 14, 30, 45, and 60 days after the beginning of the trial by means of the Scale for the Assessment of Psychoorganic Syndromes, Hamilton Rating Scale for Depression, Rome. Depression Inventory, Hamilton Anxiety Rating Scale, State-Trait Anxiety Inventory-X form, and the Clinical Global Impression Scale. Cognition was tested through the Benton visual retention test at days 0, 30, and 60 and the Digit Substitution Test of the Wechsler Adult Intelligence Scale at days 0 and 60. Side effects were assessed through the Dosage Record Emergent Symptoms at days 0, 7, 14, 30, 45, and 60. The dropout rate was significantly greater in the moclobemide group. Both drugs induced an improvement in depressive and anxious symptomatology, with moclobemide showing a faster onset. Furthermore, moclobemide showed an enhancing effect on cognition, which was not shown by imipramine. Such results indicate that moclobemide could prove to be the drug of choice in geriatric depression, given that cognitive effects are prominent in the aged.

Ageing of the human entorhinal cortex and subicular complex

Age-dependent changes in the entorhinal cortex (EC) and subicular complex (SC) were studied in 30 brains of patients who died between 14 and 86 years of age, without CNS impairment, as determined by macro- and microscopic examination. The brains were fixed in 10% formalin and embedded in paraffin. Three series of coronal EC and SC sections (7 microns) were stained by Nissl, PAS or hematoxylin-eosin. Using neuronal count and Kariometry, age-dependent modifications were studied in layers II, III and V of the lateral area of the EC; in the pyramidal layer of the subiculum (S), and in layer II of the presubiculum (PS). All EC layers studied presented a slight (11-20%) although significant reduction up to 35 years, but from 35 to 75 years the decrease was not significant. After 75 years the neuronal loss increased slightly. The nuclear area decreased up to the age of 40-45 years, (10-18%) and augmented from this age up to 75 years (10-14%). During the last period of life, the nuclear area did not change. From 30-60 years, pyramidal layer in the S showed a significant neuronal loss (30%), thereafter, neuronal reduction was less. At early years, the nuclear area decreased insignificantly (15%), and from 35 years up to the most advanced age studied, it increased significantly (13%). In the PS, layer II manifested a cell loss throughout the lifespan (32.9%) and the changes in the nuclear area did not reach statistical significance due to the dispersions of its values.(ABSTRACT TRUNCATED AT 250 WORDS)