Preoperative hydroperoxide concentrations are associated with a risk of postoperative complications after cardiac surgery

This study aimed to assess whether preoperative oxidative stress levels can predict postoperative complications in patients undergoing cardiac surgery. Ninety-five cardiac surgery patients received an assessment of preoperative oxidative stress by measurement of hydroperoxide values in blood via the d-Rom test. Area under the receiver operating characteristic curve and also multivariate logistic regression were used to evaluate the prognostic significance of preoperative hydroperoxide concentrations in predicting the occurrence of major organ morbidity and mortality (MOMM). MOMM included death, deep sternal infection, reoperation, stroke, renal failure requiring haemodialysis and prolonged ventilation (>48 hours). The ability of preoperative hydroperoxide concentrations to predict MOMM was not significantly different from that of the European system for cardiac operative risk evaluation (EuroSCORE) (area under the receiver operating characteristic curve 0.822 versus 0.821 respectively, P=0.983). The optimal threshold value of hydroperoxide concentration to differentiate between patients with and without MOMM was 450 UCarr (sensitivity, 87.0%; specificity, 81.9%). Duration of intensive care unit stay, mechanical ventilation time and hospital stay were significantly longer in patients with preoperative hydroperoxide concentrations ≥450 UCarr (H group) compared to those patients with preoperative hydroperoxide concentrations <450 UCarr (L group). An increase in preoperative hydroperoxide concentrations remained associated with an increased risk of MOMM (odds ratios: 1.01, 95% confidence interval: 1.00 to 1.03) and prolonged intensive care unit stay (odds ratio 1.01, 95% confidence interval: 1.00 to 1.02), after adjusting for age, gender and EuroSCORE. In conclusion, an increased hydroperoxide concentration before cardiac surgery is an independent risk factor for severe postoperative complications.

Ultrasound-guided single shot caudal block anesthesia reduces postoperative urinary catheter-induced discomfort

BACKGROUND

Urinary catheter-induced discomfort during the postoperative period can be distressing, and sometimes results in severe restlessness and agitation, especially in middle-aged and elderly male patients. Recent advances in ultrasound technology have increased the consistency, safety, and ease of a caudal block even in older patients. We speculated that an ultrasound-guided caudal block would be reliable and safe as treatment for such postoperative discomfort.

METHODS

Adult male patients (ASA I-II) undergoing cervical laminoplasty were allocated to either the caudal block (CB, N.=24) or non-block (NB, N.=24) group. Following anesthesia induction, urinary catheterization was performed using a 16 French Foley catheter. Thereafter, an ultrasound-guided caudal block was performed with 8 ml of 0.3% ropivacaine and 100 µg of fentanyl for patients in group CB, while group NB did not receive a caudal block. We assessed urinary catheter-induced discomfort as mild, moderate, or severe at 0, 2, 6, 10, and 18 hours after surgery, and compared the incidence and severity of discomfort between the groups using a randomized double-blind design.

RESULTS

All caudal blocks were successfully performed with 1 or 2 needle insertions. The incidence of urinary catheter-induced discomfort was significantly reduced in group CB as compared to NB at 0, 2, and 6 hours, while severity was also reduced at 0 and 2 hours. No patient required re-catheterization due to urinary retention after catheter removal. There were no other complications related to the caudal block.

CONCLUSION

Preoperative ultrasound-guided single shot caudal block anesthesia safely reduced postoperative urinary catheter-induced discomfort in our male patients.

The factors associated with pain severity in patients with knee osteoarthritis vary according to the radiographic disease severity: a cross-sectional study

OBJECTIVES

Knee osteoarthritis (OA) pain is suggested to be associated with inflammation and detrimental mechanical loading across the joint. In this cross-sectional study, we simultaneously examined the inflammation and alignment of the lower limb and examined how the pain components varied depending on the disease progression.

DESIGN

One-hundred sixty female medial type of early- [n = 74 in Kellgren-Lawrence (K/L) 2] to advanced-stage (n = 96 in K/L >2) knee OA subjects (70.5 years on average) were enrolled. Knee pain was evaluated using a pain visual analog scale (VAS) and the pain-related subcategory of the Japanese Knee Osteoarthritis Measure (JKOM-pain). The serum interleukin (sIL)-6 level reflecting synovitis, and the high sensitivity C-reactive protein (hs-CRP) level were measured to evaluate the severity of inflammation. The anatomical axis angle (AAA) was measured as an alignment index. The β-coefficient was estimated after adjusting for age and the body mass index (BMI) using a multiple linear regression analysis.

RESULTS

Multiple linear regression analyses showed that the sIL-6 levels, but not AAA, associated with the pain VAS [β = 10.77 (95% confidence interval (CI): 4.14-17.40), P < 0.01] and JKOM-pain scores [β = 3.19 (95% CI: 1.93-4.44), P < 0.001] in the early stage. Conversely, AAA, but not the sIL-6 levels, was found to be associated with the pain VAS [β = -1.29 (95% CI: -2.51 to -0.08), P < 0.05] and JKOM-pain scores [β = -0.49 (95% CI: -0.82 to -0.16), P < 0.01] in the advanced stage.

CONCLUSIONS

The presence of a higher level of sIL-6 and the varus alignment of the joint is associated with pain in early- and advanced-stage knee OA patients, respectively.

Transversus abdominis plane block in combination with general anesthesia provides better intraoperative hemodynamic control and quicker recovery than general anesthesia alone in high-risk abdominal surgery patients

BACKGROUND

Patients with severe cardiovascular disease are frequently hemodynamically unstable during abdominal surgery. Improving the safety of such patients by stabilizing intraoperative hemodynamics remains a major concern for anesthesiologists. Transversus abdominis plane (TAP) block in combination with general anesthesia may facilitate optimum anesthetic management of these high-risk patients.

METHODS

Patients with cardiovascular disease classified as American Society of Anesthesiologists (ASA) physical status 3 were enrolled. The patients were undergoing elective abdominal surgery and were randomized to a group receiving general anesthesia and TAP block (Group T, N.=33) or a group receiving general anesthesia alone (Group G, N.=35). We compared the groups for intraoperative hemodynamic stability, anesthesia emergence time, amounts of anesthetics and opioids given, and frequency of emergency treatment with cardiovascular agents. A preliminary study demonstrated that systolic blood pressure and heart rate were maintained stable within 70-110% of their preanesthesia values throughout surgery in ASA 1 elderly patients without cardiovascular disease. Thus, the hemodynamically stable time was defined as the time when systolic blood pressure and heart rate were 70-110% of their preanesthesia values. The ratio of hemodynamically stable time to total operative time was used as an index of hemodynamic stability.

RESULTS

The median (minimum-maximum) percentage of hemodynamically stable time was longer in Group T (91[50-100]%) than Group G (79[40-91]%, P<0.01). The mean sevoflurane concentration, amount of fentanyl given and frequency of vasopressor use were lower in Group T than Group G (P<0.05). Anesthesia emergence time was shorter in Group T (14[4-30] min) than Group G (18[9-52] min, P<0.01). No worsening of cardiovascular complications was observed.

CONCLUSION

For abdominal surgery in patients with severe cardiovascular disease, combining TAP block with general anesthesia promotes intraoperative hemodynamic stability and early emergence from anesthesia.

Is the 7/2(1)- isomer state of 43S spherical?

We report on the spectroscopic quadrupole moment measurement of the 7/2(1)(-) isomeric state in (16)(43)S(27) [E*=320.5(5) keV, T(1/2)=415(3) ns], using the time dependent perturbed angular distribution technique at the RIKEN RIBF facility. Our value, |Q(s)|=23(3) efm(2), is larger than that expected for a single-particle state. Shell model calculations using the modern SDPF-U interaction for this mass region reproduce remarkably well the measured |Q(s)|, and show that non-negligible correlations drive the isomeric state away from a purely spherical shape.

Pleth variability index predicts hypotension during anesthesia induction

BACKGROUND

The pleth variability index (PVI) is a new algorithm used for automatic estimation of respiratory variations in pulse oximeter waveform amplitude, which might predict fluid responsiveness. Because anesthesia-induced hypotension may be partly related to patient volume status, we speculated that pre-anesthesia PVI would be able to identify high-risk patients for significant blood pressure decrease during anesthesia induction.

METHODS

We measured the PVI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in 76 adult healthy patients under light sedation with fentanyl to obtain pre-anesthesia control values. Anesthesia was induced with bolus administrations of 1.8 mg/kg propofol and 0.6 mg/kg rocuronium. During the 3-min period from the start of propofol administration, HR, SBP, DBP, and MAP were measured at 30-s intervals.

RESULTS

HR, SBP, DBP, and MAP were significantly decreased after propofol administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre-anesthesia control values. Linear regression analysis that compared pre-anesthesia PVI with the decrease in MAP yielded an r value of -0.73. Decreases in SBP and DBP were moderately correlated with pre-anesthesia PVI, while HR was not. By classifying PVI >15 as positive, a MAP decrease >25 mmHg could be predicted, with sensitivity, specificity, positive predictive, and negative predictive values of 0.79, 0.71, 0.73, and 0.77, respectively.

CONCLUSION

Pre-anesthesia PVI can predict a decrease in MAP during anesthesia induction with propofol. Its measurement may be useful to identify high-risk patients for developing severe hypotension during anesthesia induction.

An exploration of unmet information needs among breast cancer patients in Japan: a qualitative study

Informational need assessment has become an important part of health care in order to provide information effectively in clinical settings. Literature on information needs in the West suggests that breast cancer (BC) patients needed more information than doctors had provided, and information that fully met their needs was associated with patients' long-term well-being. Since few studies on this issue have been conducted in Japan, where the general consultation style is less open and more indirect, compared with that in the West, the application of the findings in the West is questionable. The purpose of this qualitative study was to explore perceived information needs among female BC patients in Japan. Twelve Japanese women with BC participated in semi-structured face-to-face interviews. Grounded theory using verbatim transcripts extracted two main themes: information needed to minimize physical and psychological impacts of treatment and information needed for the resumption of normal life. These were closely related at two time points. Physical support after discharge was perceived as relatively insufficient, especially by women experiencing post-operative arm complications. More open and direct communication was preferred between patients and doctors/family members in the recovery phase. Unmet needs for information may lead to patients' distress.

XBP1 may determine the size of the ameloblast endoplasmic reticulum

Ameloblasts progress through defined stages of development as enamel forms on teeth. Pre-secretory ameloblasts give rise to tall columnar secretory ameloblasts that direct the enamel to achieve its full thickness. During the maturation stage, the ameloblasts shorten and direct the enamel to achieve its final hardened form. Here we ask how the volume of selected ameloblast organelles changes (percent volume per ameloblast) as ameloblasts progress through six defined developmental stages. We demonstrate that mitochondria volume peaks during late maturation, indicating that maturation-stage ameloblasts maintain a high level of metabolic activity. Also, the endoplasmic reticulum (ER) volume changes significantly as a function of developmental stage. This prompted us to ask if X-box-binding protein-1 (XBP1) plays a role in regulating ameloblast ER volume, as has been previously demonstrated for secretory acinar cells and for plasma cell differentiation. We demonstrate that Xbp1 expression correlates positively with percent volume of ameloblast ER.

Application of devices for safe laparoscopic hepatectomy

The continuing evolution of a variety of laparoscopic instrument and device has been gradually applied to the laparoscopic hepatectomy in many countries. Recent experience has persuaded us that there are great potential benefits derived from laparoscopic hepatectomy and much has been learned about patient selection, the grade of surgical difficulty with respect to tumor location, and the required instrumentation. Among these efforts, various ways of hepatic parenchymal transection with mechanical devices have been attempted and continuing to innovate to perform safe laparoscopic hepatectomy Important technologic developments and improved endoscopic procedures are being established equipment modifications. For safe laparoscopic hepatectomy, it is important to have all necessary equipment. The intraoperative laparoscopic ultrasonography, microwave coagulators, ultrasonic dissection, argon beam coagulators, laparoscopic coagulation shears, endolinear staplers and TissueLink monopolar sealer are essential. This procedure is in need that well experienced endoscopic surgeon and well-experienced liver surgeon should be collaborated in laparoscopic hepatectomy and the indications are strictly followed based upon the location and size of tumors. Finally critical determinant for success and safe laparoscopic hepatectomy is through familiarity with the relevant laparoscopic instruments and equipments. Laparoscopic hepatectomy is expected to develop further in the future as a new surgical instrument, equipment and method, which improves patients' quality of life.

Continuous intravenous lidocaine controls abdominal pain secondary to peritoneal carcinomatosis as a consequence of diffusion into ascites

9031

Background: Our team reported at the 42nd ASCO meeting that continuous, low-dose intravenous (IV) lidocaine is an effective method for pain relief in terminal patients with peritoneal carcinomatosis. Our aim was to explore the mechanism by which abdominal pain of terminally-ill patients with peritoneal carcinomatosis was improved by continuous IV lidocaine. Methods: 48 patients with peritoneal carcinomatosis due to GI (46) and GYN (2) malignancies were administered lidocaine at low-doses (0.4 and/or 0.8mg/kg- h) for >24 hours, because opiates, NSAIDs, and other adjuvants were ineffective in relieving their abdominal pain. Pain (faces rating scale; 0-no pain, 5-worst pain), oral intake, side effects, and activities of daily life were quantified. Two days after beginning lidocaine, ascites was sampled to measure ascitic concentration of lidocaine, tumor markers and cytology. Results: Mean age (±SE) was 60±2. The volume of ascites was estimated to be 2,700±400ml by the ultrasound 5 points methodology. Abdominal symptoms improved in 1.5±0.2days after beginning lidocaine, and the pain scale decreased from 1.9±0.2 to 0.5±0.1; p<0.001; 75% of patients had improvement in pain of whom 78% had complete relief of pain. Oral intake increased from 18% to 49% of baseline (p<0.001), and 67% in those with improvement in pain had an increased volume of oral intake. There were no obvious differences in response to 0.4 and 0.8 mg/kg-h in patients receiving both doses. Serum concentrations of lidocaine at 0.4 and 0.8 mg/kg-h were 1.7±0.2 and 3.2±0.2 μg/ml, respectively; lidocaine concentrations in the ascites were 1.2±0.2 and 2.1±0.2 μg/ml. No patient complained of pain at the time of peritoneal puncture. Side effects included bradycardia of <60 beats per minutes (3 patients). The duration of lidocaine administration was 23±3 days; 43% of patients were able to be discharged home for end-of-life care, with parenteral nutrition and continuation of lidocaine administration or oral mexiletine (300–450 mg/day) for adjuvant analgesia. Conclusions: Lidocaine diffuses into ascites and almost equilibrates with serum concentrations acting as a peritoneal anesthesia which, as a result, controls abdominal pain in patients with peritoneal carcinomatosis.

No significant financial relationships to disclose.

In vivo suppression of mafA mRNA with siRNA and analysis of the resulting alteration of the gene expression profile in mouse pancreas by the microarray method

Maf is a family of transcription factor proteins that is characterized by a typical bZip structure, and one of the large mafs, mafA is a strong transactivator of insulin. To explore the role of mafA in the pancreas, we modified the mafA mRNA level in vivo in mice by the RNA interference (siRNA) technique and analyzed the resulting alteration of the expressed gene profile with a microarray system. The mafA expression level in siRNA-treated mice was reduced approximately 60% compared with control-siRNA-treated animals. Microarray analysis revealed changes in the expression level of several genes in the siRNA-treated mice, with prominent down-regulated expression of the genes encoding insulin, glucagon, and adipocytokines, suggesting possible role of mafA in the pathophysiological states of impaired metabolic responses or inflammatory reactions.

Bacterial translocation in small intestinal ischemia-reperfusion injury and efficacy of Anti-CINC antibody treatment

The involvement of bacterial translocation in small intestinal ischemia-reperfusion injuries and the efficacy of using anti-CINC antibodies for treatment were investigated. A model for ischemia-reperfusion injury of the small intestine was constructed by clamping the supramesenteric artery (for 90 min) in rats. Anti-CINC antibodies and saline were given just before the induction of ischemia in the treatment group and the control group, respectively. Six hours after reperfusion, bacteria were detected in the mesenteric lymph nodes, but the 'bacteria-positive' rate was significantly lower in the treatment group than in the control group. Bacterial cultures and endotoxins in the blood were negative in both groups up to 24 h later. The plasma cytokine levels showed similar variations, although the increases were significantly lower after reperfusion in the treatment group. In addition, the degrees of neutrophil infiltration and mucosal injury were attenuated in the small intestine, and the structure of the liver was maintained. Furthermore, the 1-week survival was improved. These results suggest that bacterial translocation occurred predominantly via the lymphatic system and that anti-CINC antibody treatment exerted a protective effect against small intestinal ischemia-reperfusion injury.

Origin, splicing, and expression of rodent amelogenin exon 8

Amelogenin RNA transcripts undergo extensive alternative splicing, and MMP-20 processes the isoforms following their secretion. Since amelogenins have been ascribed cell-signaling activities, we asked if a lack of proteolytic processing by MMP-20 affects amelogenin signaling and consequently alters amelogenin splice site selection. RT-PCR analyses of amelogenin mRNA between control and Mmp20(-/-)mice revealed no differences in the splicing pattern. We characterized 3 previously unidentified amelogenin alternatively spliced transcripts and demonstrated that exon-8-encoded amelogenin isoforms are processed by MMP-20. Transcripts with exon 8 were expressed approximately five-fold less than those with exon 7. Analyses of the mouse and rat amelogenin gene structures confirmed that exon 8 arose in a duplication of exons 4 through 5, with translocation of the copy downstream of exon 7. No downstream genomic sequences homologous to exons 4-5 were present in the bovine or human amelogenin genes, suggesting that this translocation occurred only in rodents.