An in vitro and in vivo validation of a novel color-coded syringe device for measuring the intracuff pressure in cuffed endotracheal tubes

BACKGROUND

The clinical practice of pediatric anesthesiology has changed with a transition to the use of cuffed endotracheal tubes (ETTs) in infants and children. The monitoring of intracuff pressure has been suggested as one means to limit the potential for damage to the tracheal mucosa. The current study evaluates the accuracy of a novel, color-coded syringe device which provides three zones (green, clear, and red) to estimate the intracuff pressure.

METHOD

The study was conducted in two phases. Phase 1 was an in vitro study where cuffed ETTs of sizes 4.0 mm, 5.0 mm and 6.0 mm ID were placed into polyvinylchloride tubing of appropriate sizes. A manometer and the syringe device were simultaneously attached to measure the intracuff pressure at the middle of the 3 different zones on the device (red, clear, and green). Phase 2 was an in vivo study where the syringe device and the manometer were simultaneously attached to the pilot balloon to measure the intracuff pressure and the corresponding zone on the color-coded syringe following endotracheal intubation. Statistical analysis included a descriptive reporting of the mean ± SD, median, range, and 95% confidence intervals (CI) of the actual intracuff pressure readings at the three zones of the syringe device during both its in vitro and in vivo use.

RESULTS

For phase 1 of the study, the 95% CI for the green, clear, and red zones were 21.5-21.8, 29.2-29.5, and 46.5-47.4 cmH2O respectively. This correlated well with the manufacturer reported values of 20-30, 30-40, and 40-60 cmH2O for the 3 zones (green, clear, and red respectively). Phase 2 of the study included 200 patients ranging in age from 0.1 to 21.8 years (6.7 ± 5.1 years) and in weight from 4.0 to 129.1 kilograms (29.4 ± 23.3 kgs). The size of the ETTs ranged from 3.0 to 7.0 mm ID. The intracuff pressure measured by the manometer ranged from 4 to 65 cmH2O (27.6 ± 9.7 cmH2O). The 95% CI for the green, clear, and red zones were 20.5-21.7, 27.7-29.1, and 41.2-46.5 cmH2O respectively. There was no significant differences noted when comparing different patient ages or sizes of ETT.

CONCLUSION

The current study demonstrates a clinically acceptable correlation between the zones on this novel, color-coded syringe device and the actual measurement of the intracuff pressure obtained by a manometer for both in vitro and in vivo use. This device is a simple, reliable, portable and affordable method to monitor intracuff pressure.

Serum IL-33 levels are increased in patients with psoriasis

BACKGROUND

Interleukin (IL)-33 is a recently identified cytokine, which is a member of the IL-1 family and binds to a heterodimeric receptor comprising ST2 (suppression of tumorigenicity 2) and IL-1 receptor accessory protein. Serum levels of IL-33 have been reported to be upregulated in various T helper (Th)1/Th17-mediated diseases, such as rheumatoid arthritis and inflammatory bowel disease. IL-33 expression is increased in lesional skin in patients with psoriasis, but serum levels in patients with psoriasis have not yet been studied.

AIM

To study serum IL-33 levels in patients with psoriasis, a Th1/Th17-mediated skin disease, before and after anti-tumour necrosis factor (TNF)-α therapy.

METHODS

Serum IL-33 levels were measured in patients with psoriasis vulgaris (PV), psoriatic arthritis (PsA) or pustular psoriasis (PP), and compared with those of healthy controls. Associations between serum IL-33 levels and serum TNF-α, IL-6, vascular endothelial growth factor and C-reactive protein levels were also studied. In addition, the effect of IL-33 stimulation on IL-6, IL-8, TNF-α and VEGF secretion by human keratinocyte was analysed.

RESULTS

Serum IL-33 levels in patients with PV, PsA and PP were significantly higher than those in healthy controls. Serum IL-33 levels correlated with serum TNF-α levels in patients with psoriasis, and decreased after anti-TNF-α therapy. IL-33 stimulated IL-6 and IL-8 secretion by human keratinocytes.

CONCLUSIONS

These results suggest that serum IL-33 levels generally reflect increased inflammation in patients with psoriasis.

Predictive factors for pericardial effusion identified by heart dose-volume histogram analysis in oesophageal cancer patients treated with chemoradiotherapy

OBJECTIVE

To identify predictive factors for the development of pericardial effusion (PCE) in patients with oesophageal cancer treated with chemotherapy and radiotherapy (RT).

METHODS

From March 2006 to November 2012, patients with oesophageal cancer treated with chemoradiotherapy (CRT) using the following criteria were evaluated: radiation dose >50 Gy; heart included in the radiation field; dose-volume histogram (DVH) data available for analysis; no previous thoracic surgery; and no PCE before treatment. The diagnosis of PCE was independently determined by two radiologists. Clinical factors, the percentage of heart volume receiving >5-60 Gy in increments of 5 Gy (V5-60, respectively), maximum heart dose and mean heart dose were analysed.

RESULTS

A total of 143 patients with oesophageal cancer were reviewed retrospectively. The median follow-up by CT was 15 months (range, 2.1-72.6 months) after RT. PCE developed in 55 patients (38.5%) after RT, and the median time to develop PCE was 3.5 months (range, 0.2-9.9 months). On univariate analysis, DVH parameters except for V60 were significantly associated with the development of PCE (p < 0.001). No clinical factor was significantly related to the development of PCE. Recursive partitioning analysis including all DVH parameters as variables showed a V10 cut-off value of 72.8% to be the most influential factor.

CONCLUSION

The present results showed that DVH parameters are strong independent predictive factors for the development of PCE in patients with oesophageal cancer treated with CRT.

ADVANCES IN KNOWLEDGE

A heart dosage was associated with the development of PCE with radiation and without prophylactic nodal irradiation.

Thoracic epidural infusion with chloroprocaine for postoperative analgesia following epicardial pacemaker placement in an infant

In critically ill neonates and infants, major interventions, including thoracotomy, may result in significant postoperative respiratory insufficiency and pain leading to the need for postoperative mechanical ventilation. Although there are many potential options for providing postoperative analgesia, there continues to be expanding use of regional anesthesia in this population. One of the many reported advantages is the provision of postoperative analgesia while avoiding the deleterious effects on respiratory function that may be seen with systemic opioids. We report the use of thoracic epidural anesthesia using a continuous infusion of chloroprocaine to provide analgesia following thoracotomy and epicardial pacemaker placement in an infant. The perioperative plan was complicated by comorbid conditions including congenital complete heart block, recent rhinovirus infection with residual respiratory involvement, and prematurity.

Relationship between leukocyte telomere length and personality traits in healthy subjects

BACKGROUND

It has been shown that certain personality traits are related to mortality and disease morbidity, but the biological mechanism linking them remains unclear. Telomeres are tandem repeat DNA sequences located at the ends of chromosomes, and shorter telomere length is a predictor of mortality and late-life disease morbidity. Thus, it is possible that personality traits influence telomere length. In the present study, we examined the relationship of leukocyte telomere length with personality traits in healthy subjects.

SUBJECTS AND METHODS

The subjects were 209 unrelated healthy Japanese who were recruited from medical students at 4th-5th grade. Assessment of personality traits was performed by the Revised NEO Personality Inventory (NEO-PI-R) and the Temperament and Character Inventory (TCI). Leukocyte relative telomere length was determined by a quantitative real-time PCR method for a ratio of telomere/single copy gene.

RESULTS

In the stepwise multiple regression analysis, shorter telomere length was related to lower scores of neuroticism (P<0.01) and conscientiousness (P<0.05) of the NEO-PI-R, and lower scores of harm avoidance (P<0.05) and reward dependence (P<0.05) of the TCI.

CONCLUSIONS

The present study suggests that leukocyte telomere length is associated with some personality traits, and this association may be implicated in the relationship between personality traits and mortality.

[Anesthetic management of a patient with Fontan circulation with pacemaker failure]

We describe the anesthetic management of a 23-year-old female patient with severe bradycardia due to pacemaker lead disconnection. The pacemaker had been placed due to complete AV block following an extracardiac Fontan operation. She was scheduled for lead repair under general anesthesia. The preoperative HR was only 37 beats x min(-1) of idioventricular rhythm. As further bradycardia was a major concern, we prepared a percutaneous cardiac pacemaker and the catheterization laboratory for transatrial cardiac pacing. After placement of transcutaneous cardiac pacing pads on the chest, we administered isoproterenol at 0.01 microg x kg(-1) x min(-1). We confirmed an increase in HR to 50 beats x min(-1) and induced anesthesia, after which isoproterenol was administered at 0.015 microg x kg(-1) x min(-1). No bradycardia was observed perioperatively. Transvenous cardiac pacing, part of the last step in the ACLS bradycardia algorithm, is inappropriate except in patients with anatomic Fontan circulation. Furthermore, in the case of bradycardia, percutaneous or transesophageal cardiac pacing can be used; however, these are not always effective. Transatrial cardiac pacemakers are probably most effective for bradycardia with Fontan circulation but they should be placed by a catheter specialist, and emergency placement can be difficult. As described here, a special management protocol is necessary to control bradycardia in the face of Fontan circulation.

[Anesthetic management of Jehovah's Witnesses patients undergoing open heart surgery with cardiopulmonary bypass]

BACKGROUND

The anesthetic management of Jehovah's Witnesses (JW) patients undergoing open heart surgery with cardiopulmonary bypass (CPB) is associated with a major risk of anemic hypoxia.

METHODS

Fifteen patients from the community of JW underwent open heart surgery. The surgical procedures undertaken were aortic valve replacement in 7 patients, mitral valve plasty or replacement in 5 patients, repair of congenital heart diseases in 2 patients, and removal of left atrial myxoma in one patient. Hemoglobin values, cardiac output, and oxygen delivery (Do2) as well as consumption (Vo2) were evaluated during and after surgery.

RESULTS

After CPB, the mean hemoglobin (Hb) value decreased to 8.2 g x dl(-1) from the baseline level of 11.6 g x dl(-1) (P = 0.0007); however, it increased to 10.5 g x dl(-1) at the end of surgery Cardiac index remained unchanged. Oxygen delivery (Do2) decreased after CPB from its baseline level, whereas oxygen consumption remained unchanged. Twenty-four hours after surgery, Do2 recovered to its baseline level because of an increase in cardiac output with the Hb value of 10.7 g x dl(-1) .

CONCLUSIONS

The decrease in Hb level is unavoidable in cardiac surgery with CPB in these JW patients. This survey showed that the decrease in Hb level may be compensated by conserved cardiac output avoiding the decrease of Do2 to its critical level when hypoxia occurs.

Interaction effects between the brain-derived neurotrophic factor Val66Met polymorphism and parental rearing on personality traits in healthy subjects

Aims

There is a growing body of data suggesting the gene-environment interaction in the characterization of personality traits, but variation in ordinary parental rearing among environmental factors has not been focused yet. We examined the effects of the interaction between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and parental rearing on personality traits.

Methods

Subjects were 710 Japanese healthy volunteers. Perceived parental rearing was assessed by the Parental Bonding Instrument (PBI), which consists of the care and protection factors. Personality assessment was performed by the Temperament and Character Inventory (TCI), which has 7 dimensions, i.e., novelty seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness, and self-transcendence. The BDNF Val66Met polymorphism was detected by the PCR-RFLP method.

Results

Parental rearing has significant main effects on all TCI dimensions except novelty seeking, while no significant main effects of the BDNF genotype on the TCI scores were found. The interaction between the BDNF genotype and maternal care of the PBI had significant effects on harm avoidance and self-directedness of the TCI. Post-hoc analyses showed that decreased maternal care was correlated with increased harm avoidance and decreased self-directedness in most of the genotype groups, and for both personality traits the correlation was highest in the Met/Met genotype and lowest in the Val/Val genotype and that for the Val/Met genotype was in between the two values.

Conclusion

The present study suggests that the BDNF Val66Met polymorphism moderates the effects of parenting rearing, especially maternal care, on harm avoidance and self-directedness in healthy subjects.

THE -1021C/T polymorphism of the dopamine-B-hydroxylase (DBH) gene promoter affects personality traits in healthy subjects

Introduction

Dopamine and norepinephrine are implicated in the characterization of personality traits. Dopamine-β-hydroxylase (DBH) is the enzyme responsible for conversion of dopamine to norepinephrine. Previous studies have shown that the -1021C/T polymorphism of the DBH gene promoter influences plasma DBH activity. Few studies investigated the association between this polymorphism and personality traits.

Aim

To examine the association between the -1021C/T DBH polymorphism and personality traits in healthy volunteers.

Methods

The participants were 627 Japanese unrelated volunteers. The subjects with present psychiatric disorders or past history of psychiatric disorders according to the DSM-IV were excluded. The DBH genotypes were identified by a PCR-RFLP method, and personality traits were assessed by the Temperament and Character Inventory (TCI). The study protocol was approved by the Ethics Committee of Yamagata University School of Medicine, and all subjects provided written informed consent to participate.

Results

In the two-factor analysis of covariance with the DBH genotype and sex as factors and with age as a covariate, there was no main effect of the DBH genotype on any TCI score, while the interaction between the factors was significant in harm avoidance. In the post-hoc analysis, the group with the T allele predictive of lower DBH activity had higher scores of harm avoidance than that without the T allele in females (p=0.006), but not in males.

Conclusion

The present study suggests that the -1021C/T DBH polymorphism affects the personality trait of harm avoidance in healthy females.

The brain-derived neurotrophic factor Val66Met polymorphism modulates the effects of parental rearing on personality traits in healthy subjects

There is a growing body of data suggesting that gene-environment interaction is critical in the characterization of personality traits; however, previous studies have not taken into consideration variability in parental rearing as an environmental factor. In this study, we examined the effects of the interaction between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism and parental rearing on personality traits in 710 healthy Japanese subjects. Perceived parental rearing was assessed by the Parental Bonding Instrument (PBI), which consists of the care and protection factors. Assessment of personality traits was performed by the temperament and character inventory (TCI), which has seven dimensions, i.e. novelty seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness and self-transcendence. Parental rearing has significant main effects on some TCI dimensions, but no significant main effects of the BDNF genotype on the TCI scores were found. The interaction between the BDNF genotype and maternal care of the PBI had significant effects on harm avoidance and self-directedness of the TCI. Post hoc analyses showed that decreased maternal care was correlated with increased harm avoidance and decreased self-directedness, and for both personality traits the partial correlation coefficient was highest in the Met/Met genotype group and lowest in the Val/Val genotype group and the value of the Val/Met genotype group was in the middle. Data from this study suggest that the BDNF Val66Met polymorphism modulates the effects of parental rearing, especially maternal care, on harm avoidance and self-directedness in healthy subjects.