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Zeng S, Qing Q, Xu W, Yu S, Zheng M, Tan H, Peng J, Huang J. Personalized anesthesia and precision medicine: a comprehensive review of genetic factors, artificial intelligence, and patient-specific factors. Front Med (Lausanne) 2024; 11:1365524. [PMID: 38784235 PMCID: PMC11111965 DOI: 10.3389/fmed.2024.1365524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Precision medicine, characterized by the personalized integration of a patient's genetic blueprint and clinical history, represents a dynamic paradigm in healthcare evolution. The emerging field of personalized anesthesia is at the intersection of genetics and anesthesiology, where anesthetic care will be tailored to an individual's genetic make-up, comorbidities and patient-specific factors. Genomics and biomarkers can provide more accurate anesthetic protocols, while artificial intelligence can simplify anesthetic procedures and reduce anesthetic risks, and real-time monitoring tools can improve perioperative safety and efficacy. The aim of this paper is to present and summarize the applications of these related fields in anesthesiology by reviewing them, exploring the potential of advanced technologies in the implementation and development of personalized anesthesia, realizing the future integration of new technologies into clinical practice, and promoting multidisciplinary collaboration between anesthesiology and disciplines such as genomics and artificial intelligence.
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Affiliation(s)
- Shiyue Zeng
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Qi Qing
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Wei Xu
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Simeng Yu
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Mingzhi Zheng
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Hongpei Tan
- Department of Radiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Junmin Peng
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Jing Huang
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
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Macnamara EF, Loydpierson A, Latour YL, D'Souza P, Murphy J, Wolfe L, Estwick T, Johnston JM, Yang J, Acosta MT, Lee PR, Pierson TM, Soldatos A, Toro C, Markello T, Adams DR, Gahl WA, Yousef M, Tifft CJ. Risks and benefits of anesthesia for combined pediatric procedures in the NIH undiagnosed diseases program. Mol Genet Metab 2023; 140:107707. [PMID: 37883914 DOI: 10.1016/j.ymgme.2023.107707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE The NIH Undiagnosed Diseases Program (UDP) aims to provide diagnoses to patients who have previously received exhaustive evaluations yet remain undiagnosed. Patients undergo procedural anesthesia for deep phenotyping for analysis with genomic testing. METHODS A retrospective chart review was performed to determine the safety and benefit of procedural anesthesia in pediatric patients in the UDP. Adverse perioperative events were classified as anesthesia-related complications or peri-procedural complications. The contribution of procedures performed under anesthesia to arriving at a diagnosis was also determined. RESULTS From 2008 to 2020, 249 pediatric patients in the UDP underwent anesthesia for diagnostic procedures. The majority had a severe systemic disease (American Society for Anesthesiology status III, 79%) and/or a neurologic condition (91%). Perioperative events occurred in 45 patients; six of these were attributed to anesthesia. All patients recovered fully without sequelae. Nearly half of the 249 patients (49%) received a diagnosis, and almost all these diagnoses (88%) took advantage of information gleaned from procedures performed under anesthesia. CONCLUSIONS The benefits of anesthesia involving multiple diagnostic procedures in a well-coordinated, multidisciplinary, research setting, such as in the pediatric UDP, outweigh the risks.
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Affiliation(s)
- Ellen F Macnamara
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Amelia Loydpierson
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Yvonne L Latour
- Medical Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD, United States of America; Department of Pathology, Immunology, and Microbiology, Vanderbilt University, Nashville, TN, United States of America
| | - Precilla D'Souza
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; Hummingbird House Children's Hospice, 60 Curwen Terrace, Chermside, Queensland 4032, Australia
| | - Jennifer Murphy
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; Hummingbird House Children's Hospice, 60 Curwen Terrace, Chermside, Queensland 4032, Australia
| | - Lynne Wolfe
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Tyra Estwick
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, United States of America
| | - Jean M Johnston
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - John Yang
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Maria T Acosta
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Paul R Lee
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; Division of Neurology 2, Office of Neuroscience, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Tyler Mark Pierson
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; Departments of Pediatrics and Neurology & The Board of Governors, Regenerative Medicine Institute and the Cedars Sinai Center for the Undiagnosed Patient, Cedars Sinai Medical Center, Los Angeles, CA, United States of America
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, United States of America
| | - Camilo Toro
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Tom Markello
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - David R Adams
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; National Human Genome Research Institute, NIH, Bethesda, MD, United States of America
| | - William A Gahl
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America
| | - Muhammad Yousef
- National Institutes of Health Clinical Center, Department of Perioperative Medicine, Pediatric Anesthesiology, Bethesda, MD, United States of America
| | - Cynthia J Tifft
- National Institutes of Health Undiagnosed Diseases Program, Common Fund, Office of the Director, NIH, Bethesda, MD, United States of America; National Human Genome Research Institute, NIH, Bethesda, MD, United States of America.
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Yeh J, Ashi AA, Hernandez J, Seaver C. An Unusual Combination of Arthrogryposis, Gastroschisis, Cecal Volvulus, and Malignant Hyperthermia in a Young Woman: A Case Report. Am J Case Rep 2023; 24:e938031. [PMID: 36635941 PMCID: PMC9847307 DOI: 10.12659/ajcr.938031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The purpose of this study is to discuss a patient with a history of conditions, including arthrogryposis, gastroschisis, and malignant hyperthermia, who presented with cecal volvulus requiring urgent surgical intervention. CASE REPORT A 29-year-old woman with a history of arthrogryposis, gastroschisis, malignant hyperthermia, and multiple childhood abdominal surgeries presents to the Emergency Department (ED) with 2 days of abdominal pain and bloody diarrhea. A CT abdomen/pelvis revealed findings concerning for a cecal volvulus. The patient was premedicated and monitored closely by the anesthesia team due to her history of malignant hyperthermia. She underwent an exploratory laparotomy, where a dilated cecum and proximal ascending colon were found to be completely volvulized around the mesentery. Manual bowel detorsion was performed, which resulted in reperfusion of the ischemic-appearing bowel, which then appeared viable. She recovered well after the procedure and was discharged on postoperative day 5. CONCLUSIONS This case highlights a patient who presented with a combination of 4 findings: arthrogryposis, gastroschisis, malignant hyperthermia, and cecal volvulus. With arthrogryposis reported to be associated with gastroschisis and malignant hyperthermia, this report not only corroborates this association, but also aims to draw attention to the fact that these conditions have potential to occur jointly with cecal volvulus. Given the patient's history of gastroschisis requiring extensive abdominal surgeries that contribute as risk factors for cecal volvulus, it is possible there may be other arthrogryposis patients who present with cecal volvulus similar to that seen in this patient.
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Affiliation(s)
- Justin Yeh
- Department of Translational Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA
| | - Amro Al Ashi
- Department of Translational Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA
| | - Jennifer Hernandez
- Division of General Surgery, Memorial Healthcare System, Pembroke Pines, FL, USA,Corresponding Author: Jennifer Hernandez, e-mail:
| | - Christopher Seaver
- Department of Translational Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA,Division of General Surgery, Memorial Healthcare System, Pembroke Pines, FL, USA
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Aires CCG, de Souza RRL, Amorim JA, Santos FG, Diniz DA, Carneiro SCDAS, Vasconcellos RJDH. Malignant hyperthermia in maxillofacial surgery: Literature review supported by case presentation. SPECIAL CARE IN DENTISTRY 2023; 43:99-108. [PMID: 35667046 DOI: 10.1111/scd.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/24/2022] [Accepted: 05/13/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Malignant hyperthermia (MH) is characterized by a state of hypermetabolism after exposure to halogenated inhalational anesthetics or succinylcholine. The aims of this study were to carry out an updated review on the subject and report an illustrative case of MH in urgent maxillofacial surgery. MATERIAL AND METHODS A search of the PubMed/MEDLINE database using the keyword "malignant hyperthermia" was performed including articles published over the last 11 years in English, Spanish or Portuguese. Exclusion criteria were similar presentations but not associated with MH and cases not related to the use of anesthetic drugs as a trigger of the condition. CASE REPORT A 45-year-old man (75 kg, ASA status IE) with a negative family history for neuromuscular diseases, victim of a car accident with a facial fracture, underwent surgery under balanced general anesthesia and developed signs of MH 4 h after anesthesia induction. In our patient, the causative agent was sevoflurane and the diagnosis of MH was confirmed, subsequently, by muscle biopsy. RESULTS/DISCUSSION Overall, 44 cases of MH were found. According to the recent literature, MH shows a male predilection (3:1) and the mean age of patients is 32.2 ± 22.2 years. The most frequently cited causative agents were sevoflurane (30.5%), isoflurane (22.2%), and sevoflurane + succinylcholine (13.8%). The most common clinical indicators included hypercarbia (88.8%), hyperthermia (86.1%), and tachycardia (63.8%). Dantrolene was administered in 24 cases. The outcome was favorable in 31 cases (86.1%). The in vitro muscle contracture test (IVCT) was performed in only 15 patients and all of them tested positive. In our patient, the causative agent was sevoflurane and the diagnosis of MH was confirmed by muscle biopsy. CONCLUSION The mortality from MH is still high and an early clinical diagnosis and specific treatment with dantrolene are necessary for a favorable outcome. A complete understanding will allow better management of patients with MH. At present, the best management is to identify susceptible patients and to avoid triggering agents, combined with vigilant monitoring.
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Affiliation(s)
- Carolina Chaves Gama Aires
- Department of Oral and Maxillofacial Surgery, Dental School of Pernambuco, University of Pernambuco (FOP/UPE), Recife, Pernambuco, Brazil
| | - Rosa Rayanne Lins de Souza
- Department of Oral and Maxillofacial Surgery of the Hospital da Restauração (HR), Recife, Pernambuco, Brazil
| | - Jane Auxiliadora Amorim
- Department of Anesthesiology of the Hospital da Restauração (HR), Recife, Pernambuco, Brazil
| | - Fabiano Gouveia Santos
- Department of Anesthesiology of the Hospital da Restauração (HR), Recife, Pernambuco, Brazil
| | - Demóstenes Alves Diniz
- Department of Oral and Maxillofacial Surgery of the Hospital da Restauração (HR), Recife, Pernambuco, Brazil
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Cirino G, Szabo C, Papapetropoulos A. Physiological roles of hydrogen sulfide in mammalian cells, tissues and organs. Physiol Rev 2022; 103:31-276. [DOI: 10.1152/physrev.00028.2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
H2S belongs to the class of molecules known as gasotransmitters, which also includes nitric oxide (NO) and carbon monoxide (CO). Three enzymes are recognized as endogenous sources of H2S in various cells and tissues: cystathionine g-lyase (CSE), cystathionine β-synthase (CBS) and 3-mercaptopyruvate sulfurtransferase (3-MST). The current article reviews the regulation of these enzymes as well as the pathways of their enzymatic and non-enzymatic degradation and elimination. The multiple interactions of H2S with other labile endogenous molecules (e.g. NO) and reactive oxygen species are also outlined. The various biological targets and signaling pathways are discussed, with special reference to H2S and oxidative posttranscriptional modification of proteins, the effect of H2S on channels and intracellular second messenger pathways, the regulation of gene transcription and translation and the regulation of cellular bioenergetics and metabolism. The pharmacological and molecular tools currently available to study H2S physiology are also reviewed, including their utility and limitations. In subsequent sections, the role of H2S in the regulation of various physiological and cellular functions is reviewed. The physiological role of H2S in various cell types and organ systems are overviewed. Finally, the role of H2S in the regulation of various organ functions is discussed as well as the characteristic bell-shaped biphasic effects of H2S. In addition, key pathophysiological aspects, debated areas, and future research and translational areas are identified A wide array of significant roles of H2S in the physiological regulation of all organ functions emerges from this review.
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Affiliation(s)
- Giuseppe Cirino
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Csaba Szabo
- Chair of Pharmacology, Section of Medicine, University of Fribourg, Switzerland
| | - Andreas Papapetropoulos
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece & Clinical, Experimental Surgery and Translational Research Center, Biomedical Research Foundation of the Academy of Athens, Greece
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Foo CTY, To YH, Irwanto A, Ng AYJ, Yan B, Chew STH, Liu J, Ti LK. Variant landscape of the RYR1 gene based on whole genome sequencing of the Singaporean population. Sci Rep 2022; 12:5429. [PMID: 35361824 PMCID: PMC8971428 DOI: 10.1038/s41598-022-09310-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
The RYR1 gene codes for a ryanodine receptor which is a calcium release channel in the skeletal muscle sarcoplasmic reticulum. It is associated with Malignant Hyperthermia (MH) and congenital myopathies including Central Core Disease (CCD), Multiminicore Disease (MMD) and Congenital Fibre-Type Disproportion (CFTD). There is currently little information on the epidemiology of RYR1 variants in Asians. Our study aims to describe the RYR1 variant landscape in a Singapore cohort unselected for RYR1-associated conditions. Data was retrieved from the SG10K pilot project, where whole genome sequencing was performed on volunteers unselected and undetermined for RYR1-associated conditions. Variants were classified based on pathogenicity using databases ClinVar and InterVar. Allele frequencies of pathogenic variants were compared between Chinese, Indians and Malays. Using databases ExAC, GnomAD and GenomeAsia 100k study, we further compared local allele frequencies to those in Europe, America and Asia. Data was analysed using R Commander. Significant P value was set at p < 0.05. Majority of the RYR1 variants were missense mutations. We identified four pathogenic and four likely pathogenic RYR1 variants. All were related to the aforementioned RYR1-associated conditions. There were 6 carriers of RYR1 pathogenic variants amongst 4810 individuals, corresponding to an allele frequency of 0.06%. The prevalence of pathogenic variants was the highest amongst Indians (4 in 1127 individuals) (p = 0.030). Majority of pathogenic and likely pathogenic mutations were missense and located in mutational hotspots. These variants also occurred at higher frequencies in Asians than globally. This study describes the variant landscape of the RYR1 gene in Singapore. This knowledge will facilitate genetic screening for RYR1-related conditions.
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Affiliation(s)
- Claribel Tian Yu Foo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yi Hui To
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Astrid Irwanto
- Nalagenetics Pte. Ltd, Singapore, Singapore.,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Alvin Yu-Jin Ng
- Molecular Diagnosis Centre, Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Benedict Yan
- Molecular Diagnosis Centre, Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | | | - Jianjun Liu
- Agency for Science, Technology and Research, Genome Institute of Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lian Kah Ti
- Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Department of Anaesthesia, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.
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Vellecco V, Panza E, Bibli SI, Casillo GM, Raucci F, Manzo OL, Smimmo M, Villani R, Cavezza MR, Fleming I, d'Emmanuele di Villa Bianca R, Maione F, Cirino G, Bucci M. Phosphodiesterases S-sulfhydration contributes to human skeletal muscle function. Pharmacol Res 2022; 177:106108. [PMID: 35121122 DOI: 10.1016/j.phrs.2022.106108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
The increase in intracellular calcium is influenced by cyclic nucleotides (cAMP and cGMP) content, which rating is governed by phosphodiesterases (PDEs) activity.Despite it has been demonstrated a beneficial effect of PDEs inhibitors in different pathological conditions involving SKM, not much is known on the role exerted by cAMP-cGMP/PDEs axis in human SKM contractility. Here, we show that Ssulfhydration of PDEs modulates human SKM contractility in physiological and pathological conditions. Having previously demonstrated that, in the rare human syndrome Malignant Hyperthermia (MH), there is an overproduction of hydrogen sulfide (H 2S) within SKM contributing to hyper-contractility, here we have used MH negative diagnosed biopsies (MHN) as healthy SKM, and MH susceptible diagnosed biopsies (MHS) as a pathological model of SKM hypercontractility. The study has been performed on MHS and MHN human biopsies after diagnosis has been made and on primary SKM cells derived from both MHN and MHS biopsies. Our data demonstrate that in normal conditions PDEs are S-sulfhydrated in both quadriceps' biopsies and primary SKM cells. This post translational modification (PTM) negatively regulates PDEs activity with consequent increase of both cAMP and cGMP levels. In hypercontractile biopsies, due to an excessive H2S content, there is an enhanced Ssulfhydration of PDEs that further increases cyclic nucleotides levels contributing to SKM hyper-contractility. Thus, the identification of a new endogenous PTM modulating PDEs activity represents an advancement in SKM physiopathology understanding.
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Affiliation(s)
- Valentina Vellecco
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Elisabetta Panza
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Sofia-Iris Bibli
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University, Frankfurt am Main, Germany; German Center of Cardiovascular Research (DZHK), Partner site RheinMain, Frankfurt am Main, Germany
| | - Gian Marco Casillo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Federica Raucci
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Onorina Laura Manzo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy; Center for Vascular Biology, Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Martina Smimmo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Romolo Villani
- U.O.C. Terapia Intensiva Grandi Ustionati (T.I.G.U.) Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli"
| | | | - Ingrid Fleming
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University, Frankfurt am Main, Germany; German Center of Cardiovascular Research (DZHK), Partner site RheinMain, Frankfurt am Main, Germany
| | | | - Francesco Maione
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Giuseppe Cirino
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Mariarosaria Bucci
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy.
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Jamaleddin Surani SA, Budiman M, Azman M, Abdul Rahman R. Assessment of Awareness of Local Anaesthetic Systemic Toxicity (LAST) among Postgraduate Trainees. Int J Clin Pract 2022; 2022:4090444. [PMID: 36458263 PMCID: PMC9675600 DOI: 10.1155/2022/4090444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Although uncommon, local anaesthetic systemic toxicity (LAST) may impose fatal risk to the patients. We investigated the awareness of LAST and knowledge on local anaesthetics among our postgraduate trainees. MATERIALS AND METHODS A total of 134 postgraduate trainees from the departments of general surgery (Surgical), orthopaedic surgery (Ortho), otorhinolaryngology (ENT), obstetrics and gynaecology (OBGYN), as well as anaesthesiology and intensive care (Anaesth) were recruited. A validated questionnaire was used to assess awareness and knowledge. All participants attended a medical-education session and completed the questionnaire as preassessment and postassessment. Data were analysed, and comparisons between disciplines were conducted. RESULTS The trainees' awareness of LAST was overall poor at preassessment which improved almost 6-folds at postassessment. Surprisingly, only 20 (45.5%) participants from the anaesthesiology group had awareness of LAST at preassessment, and none of the participants were from surgical, orthopaedic, and obstetrics and gynaecology departments. Preassessment scores were significantly higher in the anaesth group as compared to all other groups; with a difference in the average score for Anaesth vs Surgical of 3.46 (95%, CI:2.17, 4.74), Anaesth vs Ortho of 3.64 (95%, CI:2.64, 4.64), Anaesth vs ENT of 3.43 (95%, CI:2.20, 4.67), and Anaesth vs OBGYN of 6.93 (95%, CI:5.64, 8.21). However, there was no significant difference of awareness scores between all participants at postassessment scores. CONCLUSION The overall level of awareness was poor. However, the implementation of an education session significantly improved the knowledge and awareness across all disciplines.
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Affiliation(s)
- Shafiq Ali Jamaleddin Surani
- Department of Anaesthesiology & Intensive Care, Penang General Hospital, Jalan Residensi, 10990 George Town, Penang, Malaysia
| | - Maryam Budiman
- Department of Anaesthesiology & Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
| | - Mawaddah Azman
- Department of Otorhinolaryngology-Head, and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
| | - Raha Abdul Rahman
- Department of Anaesthesiology & Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
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Su IM, Wang PK, Chen CY, Huang HT, Day YJ. Rapid screening for mutations associated with malignant hyperthermia using high-resolution melting curve analysis. Tzu Chi Med J 2021; 33:399-405. [PMID: 34760638 PMCID: PMC8532588 DOI: 10.4103/tcmj.tcmj_271_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The diagnosis of malignant hyperthermia (MH) is based on clinical signs or laboratory testing. The gold standard laboratory test is the in vitro contracture test, although it is invasive, expensive, and only performed at specialized centers. Genetic diagnosis is another option, although direct mutation screening is a laborious task. Therefore, we evaluated whether high-resolution melting (HRM) curve analysis could be used as a rapid screening tool to target MH-associated mutations. MATERIALS AND METHODS The feasibility of HRM analysis was evaluated using plasmids that were constructed by cloning wild-type or mutated versions of the ryanodine receptor 1 (RYR1) gene into the pCR2.1 plasmid. We obtained engineered plasmids and patient DNA extracted from blood samples with known wild-type or mutated sequences that are associated with MH. Amplicon lengths were kept relatively short (<250 bp) to improve discrimination between the engineered and patient plasmids. Real-time polymerase chain reaction (PCR) cycling and HRM analysis of the engineered plasmids and patient DNA were performed using the LightCycler 480 System (Roche). RESULTS The HRM results were clearly different from those obtained using real-time PCR. Furthermore, the HRM analysis provided sufficient resolution to identify two single-nucleotide variants in the tested RYR1 exons. CONCLUSION We conclude that HRM analysis can provide high resolution for identifying single-nucleotide variants in RYR1, which might be useful for predicting the risk of MH in the preanesthesia setting.
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Affiliation(s)
- I-Min Su
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Po-Kai Wang
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsien-Tse Huang
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yuan-Ji Day
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Anesthesiology, Tung's Taichung MetroHarbor Hospital, Taichung, Taiwan
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Kermad A, Speltz J, Danziger G, Mertke T, Bals R, Volk T, Lepper PM, Meiser A. Comparison of isoflurane and propofol sedation in critically ill COVID-19 patients-a retrospective chart review. J Anesth 2021; 35:625-632. [PMID: 34169362 PMCID: PMC8225486 DOI: 10.1007/s00540-021-02960-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/06/2021] [Indexed: 02/07/2023]
Abstract
Purpose In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients with ARDS (Acute Respiratory Distress Syndrome). Methods Charts of all 20 patients with COVID-19 ARDS admitted to the ICU of a German University Hospital during the first wave of the pandemic between 22/03/2020 and 21/04/2020 were reviewed. Among screened 333 days, isoflurane was used in 97 days, while in 187 days, propofol was used for 12 h or more. The effect and dose of these two sedatives were compared. Mixed sedation days were excluded. Results Patients’ age (median [interquartile range]) was 64 (60–68) years. They were invasively ventilated for 36 [21–50] days. End-tidal isoflurane concentrations were high (0.96 ± 0.41 Vol %); multiple linear regression yielded the ratio (isoflurane infusion rate)/(minute ventilation) as the single best predictor. Infusion rates were decreased under ECMO (3.5 ± 1.4 versus 7.1 ± 3.2 ml∙h−1; p < 0.001). In five patients, the maximum recommended dose of propofol of 4 mg∙hour−1∙kg−1ABW was exceeded on several days. On isoflurane compared to propofol days, neuro-muscular blocking agents (NMBAs) were used less frequently (11% versus 21%; p < 0.05), as were co-sedatives (7% versus 31%, p < 0.001); daily opioid doses were lower (720 [720–960] versus 1080 [720–1620] mg morphine equivalents, p < 0.001); and RASS scores indicated deeper levels of sedation (− 4.0 [− 4.0 to − 3.0] versus − 3.0 [− 3.6 to − 2.5]; p < 0.01). Conclusion Isoflurane provided sufficient sedation with less NMBAs, less polypharmacy and lower opioid doses compared to propofol. High doses of both drugs were needed in severely ill COVID-19 patients.
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Affiliation(s)
- Azzeddine Kermad
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany.
| | - Jacques Speltz
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Guy Danziger
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thilo Mertke
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Robert Bals
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V-Pulmonology, Allergology and Intensive Care Medicine, Saarland University Hospital Medical Center, Homburg, Saarland, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Medicine, Saarland University Hospital Medical Center, Kirrberger Str. 100, 66421, Homburg, Saarland, Germany
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11
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Beebe D, Puram VV, Gajic S, Thyagarajan B, Belani KG. Genetics of Malignant Hyperthermia: A Brief Update. J Anaesthesiol Clin Pharmacol 2021; 36:552-555. [PMID: 33840940 PMCID: PMC8022069 DOI: 10.4103/joacp.joacp_360_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/02/2020] [Accepted: 02/24/2020] [Indexed: 11/25/2022] Open
Abstract
Malignant hyperthermia susceptibility (MHS) and the associated condition malignant hyperthermia (MH) are rare but well-known disorders in the field of anesthesiology. MHS is usually determined by a history of a family member developing a positive episode during general anesthesia and then confirmed by an invasive caffeine halothane contracture test (CHCT). More recently, within the context of MH as a pharmacogenetic disorder, the question of whether or not MHS can be principally genetically determined is of high importance as knowledge of detailed pathogenesis may prevent against its largely invariable lethality if untreated. Thus, in this brief report, genetic terms, as well as updates in the genetics of MHS, will be reviewed in order to better understand both the condition and the current research.
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Affiliation(s)
- David Beebe
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Vikram V Puram
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Srdjan Gajic
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Bharat Thyagarajan
- Department of Lab Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Kumar G Belani
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
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12
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Samiotis I, Papakonstantinou NA, Dedeilias P, Vasileiadis I, Papalois A, Deftereos S, Kotanidou A. Dantrolene Induces Mitigation of Myocardial Ischemia-Reperfusion Injury by Ryanodine Receptor Inhibition. Semin Thorac Cardiovasc Surg 2021; 34:123-132. [PMID: 33460764 DOI: 10.1053/j.semtcvs.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
The impairment of intracellular calcium homeostasis plays an essential role during ischemia-reperfusion injury. Calcium release from sarcoplasmic reticulum which is triggered by myocardial ischemia is mainly mediated by ryanodine receptors. Dantrolene sodium is a ryanodine receptor antagonist. The objective of the present study was to evaluate the in-vivo impact of dantrolene sodium on myocardial ischemia-reperfusion injury in swine models. An in vivo, experimental trial comparing 10 experimental animals which received dantrolene sodium with 9 control swine models was conducted. Their left anterior descending coronary artery was temporarily occluded for 75 minutes via a vessel tourniquet, which was then released. Myocardial reperfusion was allowed for 24 hours. Dantrolene was administered at the onset of the reperfusion period and levels of troponin, creatine phosphokinase and creatine kinase myocardial band between the two groups were compared. Additionally, various other hemodynamic parameters and left ventricular morphology and function were examined. There were significantly lower values of troponin, creatine phosphokinase and creatine kinase myocardial band in the dantrolene group indicating less ischemia-reperfusion injury. Moreover, the postischemic cardiac index was also greater in the dantrolene group, whereas viable myocardium was also better preserved. In conclusion, the in vivo cardioprotective role of dantrolene sodium against ischemia-reperfusion injury in swine models was indicated in this study. Therefore, dantrolene sodium administration could be a promising treatment against ischemia-reperfusion injury in humans. However, large randomized clinical studies should be firstly carried out to prove this hypothesis.
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Affiliation(s)
- Ilias Samiotis
- Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos'', Greece
| | | | - Panagiotis Dedeilias
- Cardiovascular and Thoracic Surgery Department, General Hospital of Athens "Evangelismos'', Greece
| | - Ioannis Vasileiadis
- 1st Respiratory Medicine Department, Hospital for Diseases of the Chest "Sotiria", National and Kapodistrian University of Athens, Greece
| | - Apostolos Papalois
- Experimental, Educational and Research Center, ELPEN Pharmaceuticals, Athens, Greece; School of Medicine European University of Cyprus, Nicosia, Cyprus
| | - Spyridon Deftereos
- 2nd Department of Cardiology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine, General Hospital of Athens "Evangelismos'', School of Medicine, National and Kapodistrian University of Athens, Greece
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13
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Lawal TA, Todd JJ, Witherspoon JW, Bönnemann CG, Dowling JJ, Hamilton SL, Meilleur KG, Dirksen RT. Ryanodine receptor 1-related disorders: an historical perspective and proposal for a unified nomenclature. Skelet Muscle 2020; 10:32. [PMID: 33190635 PMCID: PMC7667763 DOI: 10.1186/s13395-020-00243-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022] Open
Abstract
The RYR1 gene, which encodes the sarcoplasmic reticulum calcium release channel or type 1 ryanodine receptor (RyR1) of skeletal muscle, was sequenced in 1988 and RYR1 variations that impair calcium homeostasis and increase susceptibility to malignant hyperthermia were first identified in 1991. Since then, RYR1-related myopathies (RYR1-RM) have been described as rare, histopathologically and clinically heterogeneous, and slowly progressive neuromuscular disorders. RYR1 variants can lead to dysfunctional RyR1-mediated calcium release, malignant hyperthermia susceptibility, elevated oxidative stress, deleterious post-translational modifications, and decreased RyR1 expression. RYR1-RM-affected individuals can present with delayed motor milestones, contractures, scoliosis, ophthalmoplegia, and respiratory insufficiency. Historically, RYR1-RM-affected individuals were diagnosed based on morphologic features observed in muscle biopsies including central cores, cores and rods, central nuclei, fiber type disproportion, and multi-minicores. However, these histopathologic features are not always specific to RYR1-RM and often change over time. As additional phenotypes were associated with RYR1 variations (including King-Denborough syndrome, exercise-induced rhabdomyolysis, lethal multiple pterygium syndrome, adult-onset distal myopathy, atypical periodic paralysis with or without myalgia, mild calf-predominant myopathy, and dusty core disease) the overlap among diagnostic categories is ever increasing. With the continuing emergence of new clinical subtypes along the RYR1 disease spectrum and reports of adult-onset phenotypes, nuanced nomenclatures have been reported (RYR1- [related, related congenital, congenital] myopathies). In this narrative review, we provide historical highlights of RYR1 research, accounts of the main diagnostic disease subtypes and propose RYR1-related disorders (RYR1-RD) as a unified nomenclature to describe this complex and evolving disease spectrum.
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Affiliation(s)
- Tokunbor A Lawal
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA.
| | - Joshua J Todd
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Jessica W Witherspoon
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Carsten G Bönnemann
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - James J Dowling
- Departments of Paediatrics and Molecular Genetics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Susan L Hamilton
- Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, USA
| | - Katherine G Meilleur
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Robert T Dirksen
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, NY, USA
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14
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Cost-benefit relationship of keeping dantrolene stocks from the point of view of healthcare institutions. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction:
Malignant hyperthermia (MH) is an acute syndrome triggered by certain anesthetic medications. Dantrolene is the only specific treatment for MH crises. Without treatment, lethality may be as high as 80%. In Colombia, it is not mandatory to keep dantrolene supplies in stock.
Objective:
To establish the cost-benefit ratio, from the perspective of healthcare institutions, of keeping dantrolene supplies in stock in the operating theater.
Methods:
Using a decision tree, a Monte Carlo simulation was run with 10,000 scenarios to determine the median annual cost of keeping full or partial stocks (36 or 12 vials x 20 mg, respectively) of dantrolene. For the option of not keeping supplies in stock, the cost threshold was calculated where the expected value of both alternatives of the decision tree is equalized. Indifference curves were constructed for complete and partial supplies.
Results:
The median annual cost was estimated at 6.6 million Colombian pesos (COP) for full dantrolene supplies, and at COP 2.2 million for partial supplies. The median economic consequence threshold for 1 death due to the unavailability of dantrolene was estimated at COP 18.5 million for full supplies, and at COP 57.0 million for partial supplies.
Conclusion:
If, as a result of the unavailability of dantrolene, the economic consequences of a death due to MH exceed the threshold of COP 57.0 or COP 18.5 million, the purchase of full or partial stocks, respectively, is justified.
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Affiliation(s)
- Kyeong Seon M Kim
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Robert Scott Kriss
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Timothy J Tautz
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA.
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16
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Pothen N, Kansal S, Rais T, Doumas S, Solhkhah R. A Look at Genetic Linkage between Clozapine-induced Agranulocytosis, Malignant Hyperthermia, Neuroleptic Malignant Syndrome, and Statin-induced Myopathy. INNOVATIONS IN CLINICAL NEUROSCIENCE 2019; 16:28-31. [PMID: 32082940 PMCID: PMC7006864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clozapine-induced agranulocytosis, malignant hyperthermia (MH), statin-induced myopathy, and neuroleptic malignant syndrome (NMS) are all serious drug reactions with significant overlap in terms of clinical symptomatology. The use of clozapine can lead to neutropenia, as well as the development of NMS; thus, it seemed logical to explore a possible common genetic background for the development of these two adverse effects. Furthermore, due to the overwhelming clinical resemblance between NMS, MH, and statin-induced myopathy, we decided specifically to search for a common genetic background in the development of these conditions. Methods: We searched the PubMed, OMIM, WikiGenes, Medline, and Google Scholar databases to identify articles pertinent to our subject published over the last 30 years. Articles were reviewed according to our inclusion/exclusion criteria, and irrelevant articles were excluded. Results and Conclusions: In our exploration for a common genetic background between clozapine-induced agranulocytosis, MH, NMS, and statin-induced myopathy, we identified the SLCO1B1 gene, which was common to three of these four conditions (MH, statin-induced myopathy, and clozapine-induced agranulocytosis). Although we did not find a gene common among NMS and the other conditions, the overlap of clinical symptoms between NMS, MH, and statin-induced myopathy did not allow us to rule out the possibility of a common factor, in terms of genetic predisposition, between these conditions. Future studies can aid to fill in the gaps of knowledge in terms of any genetic linkage between these three conditions and the mechanism of their associations.
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Affiliation(s)
- Nitin Pothen
- Dr. Pothen and Dr. Kansal are with Ocean Medical Center, Hackensack Meridian Health in Brick, New Jersey
- Dr. Rias is with Firelands Regional Health System-Sandusky in Sandusky, Ohio, and Mercy Health-St. Vincent Medical Center in Toledo, Ohio
- Dr. Doumas is Psychiatry Residency Program Director at Jersey Shore University Medical Center in Neptune, New Jersey
- Dr. Solhkhah is Chairman of Department of Psychiatry at Jersey Shore University Medical Center in Neptune, New Jersey
| | - Shveta Kansal
- Dr. Pothen and Dr. Kansal are with Ocean Medical Center, Hackensack Meridian Health in Brick, New Jersey
- Dr. Rias is with Firelands Regional Health System-Sandusky in Sandusky, Ohio, and Mercy Health-St. Vincent Medical Center in Toledo, Ohio
- Dr. Doumas is Psychiatry Residency Program Director at Jersey Shore University Medical Center in Neptune, New Jersey
- Dr. Solhkhah is Chairman of Department of Psychiatry at Jersey Shore University Medical Center in Neptune, New Jersey
| | - Theodor Rais
- Dr. Pothen and Dr. Kansal are with Ocean Medical Center, Hackensack Meridian Health in Brick, New Jersey
- Dr. Rias is with Firelands Regional Health System-Sandusky in Sandusky, Ohio, and Mercy Health-St. Vincent Medical Center in Toledo, Ohio
- Dr. Doumas is Psychiatry Residency Program Director at Jersey Shore University Medical Center in Neptune, New Jersey
- Dr. Solhkhah is Chairman of Department of Psychiatry at Jersey Shore University Medical Center in Neptune, New Jersey
| | - Stacy Doumas
- Dr. Pothen and Dr. Kansal are with Ocean Medical Center, Hackensack Meridian Health in Brick, New Jersey
- Dr. Rias is with Firelands Regional Health System-Sandusky in Sandusky, Ohio, and Mercy Health-St. Vincent Medical Center in Toledo, Ohio
- Dr. Doumas is Psychiatry Residency Program Director at Jersey Shore University Medical Center in Neptune, New Jersey
- Dr. Solhkhah is Chairman of Department of Psychiatry at Jersey Shore University Medical Center in Neptune, New Jersey
| | - Ramon Solhkhah
- Dr. Pothen and Dr. Kansal are with Ocean Medical Center, Hackensack Meridian Health in Brick, New Jersey
- Dr. Rias is with Firelands Regional Health System-Sandusky in Sandusky, Ohio, and Mercy Health-St. Vincent Medical Center in Toledo, Ohio
- Dr. Doumas is Psychiatry Residency Program Director at Jersey Shore University Medical Center in Neptune, New Jersey
- Dr. Solhkhah is Chairman of Department of Psychiatry at Jersey Shore University Medical Center in Neptune, New Jersey
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17
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Ferhi F, Dardour L, Tej A, Kebaili R, M'aaref S, Jazia KB. Malignant hyperthermia in a 4-year-old girl during anesthesia induction with sevoflurane and succinylcholine for congenital ptosis surgery. Saudi J Ophthalmol 2019; 33:183-187. [PMID: 31384166 PMCID: PMC6664270 DOI: 10.1016/j.sjopt.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/27/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
Abstract
Malignant hyperthermia (MH) is a rare pharmacogenic disorder of skeletal muscle calcium regulation, resulting from general anesthesia that can be fatal. Most cases are caused by administration of volatile anesthetics or depolarizing muscle relaxants. It has been generally reported that both of sevoflurane and succinylcholine can induce the delayed onset of MH. Here, we report a case of malignant hyperthermia in a four-year-old girl during anesthesia induction for unilateral congenital ptosis surgery, two minutes after sevoflurane and succinylcholine administration. The crisis was atypical but early recognized and managed by administration of dantrolene with symptomatic treatment.
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Affiliation(s)
- Fehmi Ferhi
- Department of Anesthesiology-Intensive Care, University Hospital Farhat Hached, Sousse, Tunisia
- Corresponding author.
| | - Leïla Dardour
- Department of Medical Genetics, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - Amel Tej
- Department of Pediatrics, University Hospital Farhat Hached, Sousse, Tunisia
| | - Raoudha Kebaili
- Department of Pediatrics, University Hospital Farhat Hached, Sousse, Tunisia
| | - Sarra M'aaref
- Department of Anesthesiology-Intensive Care, University Hospital Farhat Hached, Sousse, Tunisia
| | - Khaled Ben Jazia
- Department of Anesthesiology-Intensive Care, University Hospital Farhat Hached, Sousse, Tunisia
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18
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Moshinsky JA, Tutungi E. Malignant Hyperthermia During Sleeve Lobectomy for Resection of a Proximal Endobronchial Tumor. J Cardiothorac Vasc Anesth 2019; 33:3095-3100. [PMID: 31076299 DOI: 10.1053/j.jvca.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 11/11/2022]
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19
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Vellecco V, Martelli A, Bibli IS, Vallifuoco M, Manzo OL, Panza E, Citi V, Calderone V, de Dominicis G, Cozzolino C, Basso EM, Mariniello M, Fleming I, Mancini A, Bucci M, Cirino G. Anomalous K v 7 channel activity in human malignant hyperthermia syndrome unmasks a key role for H 2 S and persulfidation in skeletal muscle. Br J Pharmacol 2019; 177:810-823. [PMID: 31051045 DOI: 10.1111/bph.14700] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/05/2019] [Accepted: 04/16/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Human malignant hyperthermia (MH) syndrome is induced by volatile anaesthetics and involves increased levels of cystathionine β-synthase (CBS)-derived H2 S within skeletal muscle. This increase contributes to skeletal muscle hypercontractility. Kv 7 channels, expressed in skeletal muscle, may be a molecular target for H2 S. Here, we have investigated the role of Kv 7 channels in MH. EXPERIMENTAL APPROACH Skeletal muscle biopsies were obtained from MH-susceptible (MHS) and MH-negative (MHN) patients. Immunohistochemistry, RT-PCR, Western blot, and in vitro contracture test (IVCT) were carried out. Development and characterization of primary human skeletal muscle cells (PHSKMC) and evaluation of cell membrane potential were also performed. The persulfidation state of Kv 7 channels and polysulfide levels were measured. KEY RESULTS Kv 7 channels were similarly expressed in MHN and MHS biopsies. The IVCT revealed an anomalous contractility of MHS biopsies following exposure to the Kv 7 channel opener retigabine. Incubation of negative biopsies with NaHS, prior to retigabine addition, led to an MHS-like positive response. MHS-derived PHSKMC challenged with retigabine showed a paradoxical depolarizing effect, compared with the canonical hyperpolarizing effect. CBS expression and activity were increased in MHS biopsies, resulting in a major polysulfide bioavailability. Persulfidation of Kv 7.4 channels was significantly higher in MHS than in MHN biopsies. CONCLUSIONS AND IMPLICATIONS In skeletal muscle of MHS patients, CBS-derived H2 S induced persulfidation of Kv 7 channels. This post-translational modification switches the hyperpolarizing activity into depolarizing. This mechanism can contribute to the pathological skeletal muscle hypercontractility typical of MH syndrome. LINKED ARTICLES This article is part of a themed section on Hydrogen Sulfide in Biology & Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.4/issuetoc.
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Affiliation(s)
- Valentina Vellecco
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alma Martelli
- Department of Pharmacy, University of Pisa, Pisa, Italy
| | - Iris Sofia Bibli
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,German Center of Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | | | - Onorina L Manzo
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Elisabetta Panza
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | | | | | | | | | | | | | - Ingrid Fleming
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,German Center of Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | - Antonio Mancini
- Center of Biotechnologies, A. Cardarelli Hospital, Naples, Italy
| | - Mariarosaria Bucci
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe Cirino
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
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20
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Zhang Y, Zhou R. Almost-certain malignant hyperthermia during cardiopulmonary bypass: a case report and literature review. Perfusion 2019; 34:490-494. [PMID: 30843472 DOI: 10.1177/0267659119833230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Malignant hyperthermia is a well-known but potentially lethal disorder which is triggered by volatile anesthetics and depolarizing muscle relaxants. Early diagnosis and treatment could save lives. However, during cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of malignant hyperthermia extremely difficult than other surgeries. We report a case of almost-certain malignant hyperthermia, according to the clinical grading scale, in a patient undergoing on-pump coronary artery bypass grafting surgery. The patient underwent difficult weaning from cardiopulmonary bypass until intra-aortic balloon pump and temporary cardiac pacemaker had been implanted. Although dantrolene and corresponding treatments were administered recently, the patient died 12 days after surgery because of acute kidney failure and cardiac arrest. Therefore, it is important for us to previously recognize some specific signs of malignant hyperthermia during cardiopulmonary bypass to avoid severe outcomes.
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Affiliation(s)
- Yan Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Ronghua Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, P.R. China
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21
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Rosen GP, Escobar M, Fumero P, Viswanath O, Wright J. The importance of a prepared and ready malignant hyperthermia response team. J Clin Anesth 2019; 56:109-110. [PMID: 30743151 DOI: 10.1016/j.jclinane.2019.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Gerald P Rosen
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America.
| | | | - Pablo Fumero
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, United States of America; Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America; Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, United States of America
| | - Jennifer Wright
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America
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22
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Xu X. Magnesium sulfate - An effective agent could delay the progression of fulminant malignant hyperthermia. Med Hypotheses 2019; 124:118-120. [PMID: 30798905 DOI: 10.1016/j.mehy.2019.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/12/2018] [Accepted: 02/02/2019] [Indexed: 12/11/2022]
Abstract
Malignant hyperthermia (MH) is a life-threatening disease that occurs during general anaesthesia following exposure to succinylcholine (SCh), a depolarizing muscle relaxant, and volatile anaesthetics. Susceptibility to MH most commonly arises from mutations in the RyR1 gene, the Ca2+ release channel of skeletal muscle. Fulminant MH (f-MH) is the most dangerous form of MH, which presents a hypermetabolic cascade state, including very high temperature and carbon dioxide production, increased heart rate and oxygen consumption, mixed acidosis, rigid muscles, and rhabdomyolysis. Dantrolene is the only specific drug therapy for MH on the market. Without dantrolene, the reported mortality of f-MH is as high as 42.3%. Based on the participation of catecholamine in the hyperhaemodynamic response of f-MH and the demonstrated effective control of catecholamine release of magnesium sulfate, combined with the fact that magnesium and calcium have opposite effects on muscle contraction, I hypothesized that magnesium sulfate could be a choice for delaying the progression of f-MH while waiting for dantrolene treatment.
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Affiliation(s)
- Xuebing Xu
- Department of Anesthesiology, Hongkong University-Shenzhen Hospital, Shenzhen 518053, China.
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Truong KM, Pessah IN. Comparison of Chlorantraniliprole and Flubendiamide Activity Toward Wild-Type and Malignant Hyperthermia-Susceptible Ryanodine Receptors and Heat Stress Intolerance. Toxicol Sci 2019; 167:509-523. [PMID: 30329129 PMCID: PMC6358238 DOI: 10.1093/toxsci/kfy256] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chlorantraniliprole (CP) and flubendiamide (FD) are widely used in agriculture globally to control lepidopteran pests. Both insecticides target ryanodine receptors (RyRs) and promote Ca2+ leak from sarcoplasmic reticulum (SR) within insect skeletal muscle yet are purportedly devoid of activity toward mammalian RyR1 and muscle. RyRs are ion channels that regulate intracellular Ca2+ release from SR during physiological excitation-contraction coupling. Mutations in RYR1 genes confer malignant hyperthermia susceptibility (MHS), a potentially lethal pharmacogenetic disorder in humans and animals. Compared with vehicle control, CP (10 µM) triggers a 65-fold higher rate of Ca2+ efflux from Ca2+-loaded mammalian WT-RyR1 SR vesicles, whereas FD (10 µM) produces negligible influence on Ca2+ leak. We, therefore, compared whether CP or FD differentially influence patterns of high-affinity [3H]ryanodine ([3H]Ry) binding to RyR1 isolated from muscle SR membranes prepared from adult C57BL/6J mice expressing WT, homozygous C-terminal MHS mutation T4826I, or heterozygous N-terminal MHS mutation R163C. Basal [3H]Ry binding differed among genotypes with rank order T4826I ≫R163C∼WT, regardless of [Ca2+] in the assay medium. Both CP and FD (0.01-100 µM) elicited concentration-dependent increase in [3H]Ry binding, although CP showed greater efficacy regardless of genotype or [Ca2+]. Exposure to CP (500 mg/kg; p.o) failed to shift intolerance to heat stress (38°C) characteristic of R163C and T4826I MHS mice, nor cause lethality in WT mice. Although nM-µM of either diamide is capable of differentially altering WT and MHS RyR1 conformation in vitro, human RyR1 mutations within putative diamide N- and C-terminal interaction domains do not alter heat stress intolerance (HSI) in vivo.
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Affiliation(s)
| | - Isaac N Pessah
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California 95616-5270
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Cost-benefit Analysis of Maintaining a Fully Stocked Malignant Hyperthermia Cart versus an Initial Dantrolene Treatment Dose for Maternity Units. Anesthesiology 2019; 129:249-259. [PMID: 29672336 DOI: 10.1097/aln.0000000000002231] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The Malignant Hyperthermia Association of the United States recommends that dantrolene be available for administration within 10 min. One approach to dantrolene availability is a malignant hyperthermia cart, stocked with dantrolene, other drugs, and supplies. However, this may not be of cost benefit for maternity units, where triggering agents are rarely used. METHODS The authors performed a cost-benefit analysis of maintaining a malignant hyperthermia cart versus a malignant hyperthermia cart readily available within the hospital versus an initial dantrolene dose of 250 mg, on every maternity unit in the United States. A decision-tree model was used to estimate the expected number of lives saved, and this benefit was compared against the expected costs of the policy. RESULTS We found that maintaining a malignant hyperthermia cart in every maternity unit in the United States would reduce morbidity and mortality costs by $3,304,641 per year nationally but would cost $5,927,040 annually. Sensitivity analyses showed that our results were largely driven by the extremely low incidence of general anesthesia. If cesarean delivery rates in the United States remained at 32% of all births, the general anesthetic rate would have to be greater than 11% to achieve cost benefit. The only cost-effective strategy is to keep a 250-mg dose of dantrolene on the unit for starting therapy. CONCLUSIONS It is not of cost benefit to maintain a fully stocked malignant hyperthermia cart with a full supply of dantrolene within 10 min of maternity units. We recommend that hospitals institute alternative strategies (e.g., maintain a small supply of dantrolene on the maternity unit for starting treatment).
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Peddyandhari F, Soenarto R, Auerkari A, Lunaesti C, Rahyussalim A. Perioperative management in a malignant hyperthermia susceptible patient. BALI JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.4103/bjoa.bjoa_2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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A 20-Year-Old-Trauma Patient With Suspected Malignant Hyperthermia Following Induction With Succinylcholine. Adv Emerg Nurs J 2018; 40:171-175. [DOI: 10.1097/tme.0000000000000196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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In J, Ahn EJ, Lee DK, Kang H. Incidence of malignant hyperthermia in patients undergoing general anesthesia: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e9115. [PMID: 29245345 PMCID: PMC5728960 DOI: 10.1097/md.0000000000009115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Malignant hyperthermia (MH) continues to be of potential concern for clinicians whenever inhalational anesthetic agents or succinylcholine are used, because MH is a potentially fatal metabolic disorder. METHODS A systematic and comprehensive search will be performed using MEDLINE, EMBASE, and Google Scholar, for studies published up to November 2017. Peer-reviewed prospective cohort studies, retrospective cohort studies, and cross-sectional studies or reports issued by government organizations reporting the incidence or prevalence of MH will be eligible for inclusion. The quality of included studies will be assessed using the Newcastle-Ottawa scale and the modified risk of bias tool. Heterogeneity of estimates across studies as well as publication bias will be assessed. This systematic review and meta-analysis will be performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. All statistical analyses will be conducted using the Stata SE version 15.0. RESULTS The results of this systematic review and meta-analysis will be published in a peer-reviewed journal. CONCLUSION To our knowledge, this systematic review and meta-analysis will be the first to evaluate existing research on the incidence of MH. Our study will provide an overall estimate of the incidence of MH. Subgroup analysis will assess the incidence of MH according to age, gender, geographical region, race, and the provoking agent if possible. The review will benefit patients, healthcare providers, and policymakers. ETHICS AND DISSEMINATION Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care. TRIAL REGISTRATION NUMBER The protocol for this review has been registered in the PROSPERO network (registration number: CRD42017076628).
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Affiliation(s)
- Junyong In
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Gyeonggido
| | - Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University School of Medicine
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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Lilitsis E, Astyrakaki E, Blevrakis E, Xenaki S, Chalkiadakis G, Chrysos E. Anesthetic management of a pediatric patient with Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH) and acute appendicitis: case report and review of the literature. BMC Anesthesiol 2017; 17:116. [PMID: 28851284 PMCID: PMC5576333 DOI: 10.1186/s12871-017-0400-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mitochondria are the energy producing organelles practically in every human cell except erythrocytes. Indeed mitochondria are widespread in high energy requiring organs like brain, heart and muscles. Currently there are no clinical trials supporting with clear evidence which is the most suitable surgical or anesthetic management of a patient with known mitochondrial disease presenting with surgical disorders. This condition poses possible hazardous problems to the medical attention of those patients. CASE PRESENTATION A case of an 8 year old child with known Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH deficiency) requiring surgery for acute appendicitis is presented. Our approach for anesthesia revealed a combination of fentanyl, low dose propofol and nitrous oxide. CONCLUSION The choice of the safest pharmacological anesthetic agents for patients with ETFDH deficiency is challenging given that most of the general anesthetic medications have multiple effects on mitochondria, fatty acids metabolism and striated muscles. Anesthetists are expected to individualize anesthetic care for the patient based on current publications for similar cases, medical history and knowledge of pharmacology and physiology.
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Affiliation(s)
- Emmanuel Lilitsis
- Department of Anesthesiology, University Hospital of Crete, Herakllion, Greece
| | - Elisavet Astyrakaki
- Department of Anesthesiology, University Hospital of Crete, Herakllion, Greece
| | - Evaggelos Blevrakis
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - Sofia Xenaki
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - George Chalkiadakis
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - Emmanuel Chrysos
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece.
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Mullins MF. Malignant Hyperthermia: A Review. J Perianesth Nurs 2017; 33:582-589. [PMID: 30236564 DOI: 10.1016/j.jopan.2017.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 03/19/2017] [Accepted: 04/02/2017] [Indexed: 02/06/2023]
Abstract
Malignant hyperthermia is an uncommon, but potentially lethal condition that may be encountered during the perioperative period. There is wide variability in the manner in which malignant hyperthermia may manifest. For a patient to survive a malignant hyperthermia crisis, prompt recognition and treatment is of paramount importance. Perioperative nurses play a pivotal role in the successful management of malignant hyperthermia. The fictitious case study presented in this paper describes the identification, presentation, pathophysiology, and treatment of a general anesthesia patient with fulminant malignant hyperthermia.
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Beam TA, Loudermilk EF, Kisor DF. Pharmacogenetics and pathophysiology of CACNA1S mutations in malignant hyperthermia. Physiol Genomics 2016; 49:81-87. [PMID: 28011884 DOI: 10.1152/physiolgenomics.00126.2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/14/2016] [Indexed: 12/27/2022] Open
Abstract
A review of the pharmacogenetics (PGt) and pathophysiology of calcium voltage-gated channel subunit alpha1 S (CACNA1S) mutations in malignant hyperthermia susceptibility type 5 (MHS5; MIM #60188) is presented. Malignant hyperthermia (MH) is a life-threatening hypermetabolic state of skeletal muscle usually induced by volatile, halogenated anesthetics and/or the depolarizing neuromuscular blocker succinylcholine. In addition to ryanodine receptor 1 (RYR1) mutations, several CACNA1S mutations are known to be risk factors for increased susceptibility to MH (MHS). However, the presence of these pathogenic CACNA1S gene variations cannot be used to positively predict MH since the condition is genetically heterogeneous with variable expression and incomplete penetrance. At present, one or at most six CACNA1S mutations display significant linkage or association either to clinically diagnosed MH or to MHS as determined by contracture testing. Additional pathogenic variants in CACNA1S, either alone or in combination with genes affecting Ca2+ homeostasis, are likely to be discovered in association to MH as whole exome sequencing becomes more commonplace.
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Affiliation(s)
- Teresa A Beam
- Department of Pharmaceutical Sciences, Manchester University College of Pharmacy, Natural and Health Sciences, Fort Wayne, Indiana; and
| | - Emily F Loudermilk
- Department of Pharmaceutical and Biomedical Sciences, Ohio Northern University, College of Pharmacy, Ada, Ohio
| | - David F Kisor
- Department of Pharmaceutical Sciences, Manchester University College of Pharmacy, Natural and Health Sciences, Fort Wayne, Indiana; and
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Belani KG, Cao C, Daugherty D, Guo X, Hu L, Huang J, Liu H, Liu J, Litman RS, Rosenberg H, Stellaccio FS, Wei H, Yu S, Zhang X, Zuo Y. Malignant Hyperthermia Status in China. Anesth Analg 2016. [DOI: 10.1213/ane.0000000000001043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pharmacogenetics and anaesthetic drugs: Implications for perioperative practice. Ann Med Surg (Lond) 2015; 4:470-4. [PMID: 26779337 PMCID: PMC4685230 DOI: 10.1016/j.amsu.2015.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/01/2015] [Accepted: 11/04/2015] [Indexed: 12/13/2022] Open
Abstract
Pharmacogenetics seeks to elucidate the variations in individual's genetic sequences in order to better understand the differences seen in pharmacokinetics, drug metabolism, and efficacy between patients. This area of research is rapidly accelerating, aided by the use of novel and more economical molecular technologies. A substantial evidence base is being generated with the hopes that in the future it may be used to generate personalised treatment regimens in order to improve patient comfort and safety and reduce incidences of morbidity and mortality. Anaesthetics is an area of particular interest in this field, with previous research leading to better informed practice, specifically with regards to pseudocholinesterase deficiency and malignant hyperthermia. In this review, recent pharmacogenetic data pertaining to anaesthetic drugs will be presented and possible future applications and implications for practice will be discussed. Pharmacogenetic variations in anaesthetic drugs affect enzymes, transport proteins and drug receptors. Genotyping may provide more clues as to aetiology of conditions related to usage of anaesthetic drugs e.g. propofol infusion syndrome. Improved and more economical molecular technology will lead to increase in quantity of pharmacogenetic data.
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Cystathionine β-synthase-derived hydrogen sulfide is involved in human malignant hyperthermia. Clin Sci (Lond) 2015; 130:35-44. [PMID: 26460077 DOI: 10.1042/cs20150521] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/12/2015] [Indexed: 12/13/2022]
Abstract
Hydrogen sulfide is an endogenous gasotransmitter and its mechanism of action involves activation of ATP-sensitive K(+) channels and phosphodiesterase inhibition. As both mechanisms are potentially involved in malignant hyperthermia (MH), in the present study we addressed the involvement of the L-cysteine/hydrogen sulfide pathway in MH. Skeletal muscle biopsies obtained from 25 MH-susceptible (MHS) and 56 MH-negative (MHN) individuals have been used to perform the in vitro contracture test (IVCT). Quantitative real-time PCR (qPCR) and Western blotting studies have also been performed. Hydrogen sulfide levels are measured in both tissue samples and plasma. In MHS biopsies an increase in cystathionine β-synthase (CBS) occurs, as both mRNA and protein expression compared with MHN biopsies. Hydrogen sulfide biosynthesis is increased in MHS biopsies (0.128±0.12 compared with 0.943±0.13 nmol/mg of protein per min for MHN and MHS biopsies, respectively; P<0.01). Addition of sodium hydrosulfide (NaHS) to MHS samples evokes a response similar, in the IVCT, to that elicited by either caffeine or halothane. Incubation of MHN biopsies with NaHS, before caffeine or halothane challenge, switches an MHN to an MHS response. In conclusion we demonstrate the involvement of the L-cysteine/hydrogen sulfide pathway in MH, giving new insight into MH molecular mechanisms. This finding has potential implications for clinical care and could help to define less invasive diagnostic procedures.
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Cost-effectiveness analysis of stocking dantrolene in ambulatory surgery centers for the treatment of malignant hyperthermia. Anesthesiology 2014; 120:1333-8. [PMID: 24714119 DOI: 10.1097/aln.0000000000000257] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare hypermetabolic syndrome of the skeletal muscle and a potentially fatal complication of general anesthesia. Dantrolene is currently the only specific treatment for MH. The Malignant Hyperthermia Association of the United States has issued guidelines recommending that 36 vials (20 mg per vial) of dantrolene remain in stock at every surgery center. However, the cost of stocking dantrolene in ambulatory surgery centers has been a concern. The purpose of this analysis is to assess the cost-effectiveness of stocking dantrolene in ambulatory surgery centers as recommended by the Malignant Hyperthermia Association of the United States. METHODS A decision tree model was used to compare treatment with dantrolene to a supportive care-only strategy. Model assumptions include the incidence of MH, MH case fatality with dantrolene treatment and with supportive care-only. Sensitivity analyses were performed to assess the robustness of the estimated cost-effectiveness. RESULTS The estimated annual number of MH events in ambulatory surgery centers in the United States was 47. The incremental effectiveness of dantrolene compared with supportive care was 33 more lives saved per year. The incremental cost-effectiveness ratio was $196,320 (in 2010 dollars) per life saved compared with a supportive care strategy. Sensitivity analysis showed that the results were robust for the plausible range of all variables and assumptions tested. CONCLUSION The results of this analysis suggest that stocking dantrolene for the treatment of MH in ambulatory surgery centers as recommended by the Malignant Hyperthermia Association of the United States is cost-effective when compared with the estimated values of statistical life used by U.S. regulatory agencies.
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Abstract
Evolution has exploited the chemical properties of Ca(2+), which facilitate its reversible binding to the sites of irregular geometry offered by biological macromolecules, to select it as a carrier of cellular signals. A number of proteins bind Ca(2+) to specific sites: those intrinsic to membranes play the most important role in the spatial and temporal regulation of the concentration and movements of Ca(2+) inside cells. Those which are soluble, or organized in non-membranous structures, also decode the Ca(2+) message to be then transmitted to the targets of its regulation. Since Ca(2+) controls the most important processes in the life of cells, it must be very carefully controlled within the cytoplasm, where most of the targets of its signaling function reside. Membrane channels (in the plasma membrane and in the organelles) mediate the entrance of Ca(2+) into the cytoplasm, ATPases, exchangers, and the mitochondrial Ca(2+) uptake system remove Ca(2+) from it. The concentration of Ca(2+) in the external spaces, which is controlled essentially by its dynamic exchanges in the bone system, is much higher than inside cells, and can, under conditions of pathology, generate a situation of dangerous internal Ca(2+) overload. When massive and persistent, the Ca(2+) overload culminates in the death of the cell. Subtle conditions of cellular Ca(2+) dyshomeostasis that affect individual systems that control Ca(2+), generate cell disease phenotypes that are particularly severe in tissues in which the signaling function of Ca(2+) has special importance, e.g., the nervous system.
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Affiliation(s)
- Marisa Brini
- Department of Biology, University of Padova, Via U. Bassi 58/B, I-35131, Padova, Italy,
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Nakhro K, Park JM, Choi BO, Chung KW. Missense mutations ofmitofusin 2in axonal Charcot–Marie–Tooth neuropathy: polymorphic or incomplete penetration? Anim Cells Syst (Seoul) 2013. [DOI: 10.1080/19768354.2013.814587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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