The patient with congenital heart disease in ambulatory surgery

The number of patients with congenital heart disease (CHD) undergoing ambulatory surgery is increasing. Deciding whether a CHD patient is suitable for an ambulatory procedure is still challenging. Several factors must be considered, including the type of planned procedure, the complexity of the underlying pathology, the American Society of Anesthesiologists' Physical Status classification of the patient, and other patient-specific factors, including comorbidity, chronic complications of CHD, medication, coagulation disorders, and issues related to the presence of a pacemaker (PM) or cardioverter-defibrillator. Numerous studies reported higher perioperative mortality and morbidity rates in surgical patients with CHD than non-CHD patients. However, most of these studies were conducted in a cohort of hospitalized patients and may not reflect the ambulatory setting. The current review aims to provide the anesthesiologist with an overview and practical recommendations on selecting and managing a CHD patient scheduled for an ambulatory procedure.

Towards a fasting-mimicking diet for critically ill patients: the pilot randomized crossover ICU-FM-1 study

BACKGROUND

In two recent randomized controlled trials, withholding parenteral nutrition early in critical illness improved outcome as compared to early up-to-calculated-target nutrition, which may be explained by beneficial effects of fasting. Outside critical care, fasting-mimicking diets were found to maintain fasting-induced benefits while avoiding prolonged starvation. It is unclear whether critically ill patients can develop a fasting response after a short-term nutrient interruption. In this randomized crossover pilot study, we investigated whether 12-h nutrient interruption initiates a metabolic fasting response in prolonged critically ill patients. As a secondary objective, we studied the feasibility of monitoring autophagy in blood samples.

METHODS

In a single-center study in 70 prolonged critically ill patients, 12-h up-to-calculated-target feeding was alternated with 12-h fasting on day 8 ± 1 in ICU, in random order. Blood samples were obtained at the start of the study, at the crossover point, and at the end of the 24-h study period. Primary endpoints were a fasting-induced increase in serum bilirubin and decrease in insulin requirements to maintain normoglycemia. Secondary outcomes included serum insulin-like growth factor I (IGF-I), serum urea, plasma beta-hydroxybutyrate (BOH), and mRNA and protein markers of autophagy in whole blood and isolated white blood cells. To obtain a healthy reference, mRNA and protein markers of autophagy were assessed in whole blood and isolated white blood cells of 23 matched healthy subjects in fed and fasted conditions. Data were analyzed using repeated-measures ANOVA, Fisher's exact test, or Mann-Whitney U test, as appropriate.

RESULTS

A 12-h nutrient interruption significantly increased serum bilirubin and BOH and decreased insulin requirements and serum IGF-I (all p ≤ 0.001). Urea was not affected. BOH was already increased from 4 h fasting onwards. Autophagic markers in blood samples were largely unaffected by fasting in patients and healthy subjects.

CONCLUSIONS

A 12-h nutrient interruption initiated a metabolic fasting response in prolonged critically ill patients, which opens perspectives for the development of a fasting-mimicking diet. Blood samples may not be a good readout of autophagy at the tissue level.

TRIAL REGISTRATION

ISRCTN, ISRCTN98404761. Registered 3 May 2017.

Docetaxel and cisplatin: an active regimen in patients with locally advanced, recurrent or metastatic squamous cell carcinoma of the head and neck. Results of a phase II study of the EORTC Early Clinical Studies Group

BACKGROUND

Docetaxel and cisplatin are among the most active antitumor agents in head and neck cancer, and phase I studies found the combination of the two drugs to be feasible. The EORTC ECSG performed a multicenter phase II study in patients with locally advanced, recurrent or metastatic squamous cell carcinoma of the head and neck to evaluate the antitumor efficacy and toxicity of this combination.

PATIENTS AND METHODS

Eligibility criteria included written informed consent, a WHO performance status < 2, life expectancy of > 12 weeks, and adequate bone marrow, liver and renal function. Neoadjuvant pretreatment with cisplatin-based chemotherapy or prior radiotherapy were allowed. Patients were ineligible if pretreated with taxoids, had CNS involvement, concurrent malignancy, peripheral neuropathy, or no measurable disease. Treatment consisted of docetaxel 100 mg/m2 (one-hour i.v. infusion), followed by cisplatin 75 mg/m2 (three-hour i.v. infusion), repeated every three weeks. Supportive care included hydration, 5HT3-antagonists, and corticosteroids.

RESULTS

Forty-four patients (median age 55 years, range 35-76) entered the trial; 41 patients were eligible, 164 cycles of treatment were evaluable for toxicity, and 31 patients for response. Fourteen patients had undergone prior surgery, 15 had received radiotherapy, and five had had chemotherapy. A median number of four treatment cycles (range 1-6) was given. Hematologic and non-hematologic toxicities were common, but hypersensitivity reactions and fluid retention were very infrequent due to corticosteroid prophylaxis. Four patients were taken off the study due to toxicity, and one toxic death occurred due to pneumonia. Among 41 eligible patients, objective responses as confirmed by independent review included six complete remissions and 16 partial remissions, resulting in an overall response rate of 53.7% (95% confidence interval: 37.4%-69.3%). Responses occurred in locally advanced, recurrent and metastatic disease, both in pre- and non-pretreated patients. Of 22 evaluable, non-pretreated patients with locally advanced or metastatic disease, five achieved complete responses, and 14 partial responses. Observed among nine evaluable pretreated patients with locally advanced or metastatic head and neck cancer were one complete response and two partial responses.

CONCLUSION

The combination of docetaxel and cisplatin is feasible and active in locally advanced, recurrent, and metastatic squamous cell carcinoma of the head and neck.

Studies of osteocalcin function in dentin formation in rodent teeth

Osteocalcin (OC) is a major non-collagenous protein synthesized by osteoblasts, odontoblasts and cementoblasts. We examined the function of OC in dentinogenesis by exposing rat and hamster tooth organ cultures to 1,25(OH)2vit D3 or to bovine OC added to the culture medium. We furthermore examined dentinogenesis in tooth explants cultured in the presence of warfarin (an inhibitor of gamma-carboxylation of OC). Finally, we analyzed dentin from osteocalcin null mutant mice. Exposure to 1,25(OH)2vit D3 increased OC synthesis by odontoblasts in vitro at the transcriptional and protein levels but had no apparent effect on matrix formation or 45Ca uptake. High levels of bovine OC temporarily suppressed the initial formation of dentin and enamel and uptake of 45Ca. This effect was not seen when tooth explants were exposed to thermally decarboxylated OC. Exposure of tooth explants to warfarin had no significant effect on dentinogenesis. Dentin obtained from two-month-old OC null mutants looked structurally normal and did not show marked differences in dentin matrix thickness and mineral content compared to wild type. We concluded that, although OC at supraphysiological levels has the potential to affect dentin mineralization probably through its Gla-residues, the locally produced levels of OC are not sufficient to markedly influence dentinogenesis.

The SIP68: a measure of health-related functional status in rehabilitation medicine

OBJECTIVE

To demonstrate the usefulness of the SIP68, a recently developed short version of the sickness impact profile (SIP), for measuring health-related functional status in rehabilitation medicine.

DESIGN

Survey, oral interviews.

SETTING

Patient's homes.

PATIENTS

315 persons (out of 423 that could be reached) with a spinal cord injury whose mean average age was 39.4 years and who were living in the community at the time of the interview.

MAIN OUTCOME MEASURES

Internal consistency is tested by computing Cronbach's alpha. Construct validity is tested by principal components analysis and computing Cattell's similarity index. Criterion validity is tested by comparing SIP68 results with the level of the spinal cord lesion and with results of specific measures of disability (Barthel Index) and life satisfaction (Life Satisfaction Questionnaire), and with vocational status.

RESULTS

SIP68 scores and subscale scores indicate that our spinal cord injured group falls well within the scope of this instrument. Internal consistency figures are good and the proposed six-dimensional structure is confirmed. Criterion validity figures are also satisfactory. Barthel Index scores show high agreement with the scores of the subscale "somatic autonomy," moderate agreement with the other physically related and socially related subscales, and low agreement with the mentally related subscales of the SIP68. LSQ scores show low agreement with the physically related subscales and moderate agreement with the mentally and socially related subscales. Figures of vocational status show strongest agreement with the socially oriented subscales.

CONCLUSION

The SIP68 is recommended as a useful generic outcome measure for research in rehabilitation medicine.

[Value of computer tomography in the diagnosis of tumors and inflammatory changes in the pelvis]

Report of an investigative study concerning 33 patients suffering from tumors and inflammatory lesions of the pelvis examined by computed tomography. These findings have been compared with the results of conventional radiologic techniques. For many reasons CT of the pelvis shows considerable advantages to all other diagnostic radiologic methods. Therefore CT evaluation is now a standard method before and after surgery.