External Validation of the Revised Cardiac Risk Index and the Geriatric-Sensitive Perioperative Cardiac Risk Index in Oldest Old Patients Following Surgery Under Spinal Anaesthesia; a Retrospective Cross-Sectional Cohort Study

Background

The Revised Cardiac Risk Index (RCRI) and the Geriatric Sensitive Cardiac Risk Index (GSCRI) estimate the risk of postoperative major adverse cardiac events (MACE) regardless of the type of anesthesia and without specifying the oldest old patients. Since spinal anesthesia (SA) is a preferred technique in geriatrics, we aimed to test the external validity of these indices in patients ≥ 80 years old who underwent surgery under SA and tried to identify other potential risk factors for postoperative MACE.

Methods

The performance of both indices to estimate postoperative in-hospital MACE risk was tested through discrimination, calibration, and clinical utility. We also investigated the correlation between both indices and postoperative ICU admission and length of hospital stay (LOS).

Results

The MACE incidence was 7.5%. Both indices had limited discriminative (AUC for RCRI and GSCRI were 0.69 and 0.68, respectively) and predictive abilities. The regression analysis showed that patients with atrial fibrillation (AF) were 3.77 and those with trauma surgery were 2.03 times more likely to exhibit MACE, and the odds of MACE increased by 9% for each additional year above 80. Introducing these factors into both indices (multivariable models) increased the discriminative ability (AUC reached 0.798 and 0.777 for RCRI and GSCRI, respectively). Bootstrap analysis showed that the predictive ability of the multivariate GSCRI but not the multivariate RCRI improved. Decision curve analysis (DCA) showed that multivariate GSCRI had superior clinical utility when compared with multivariate RCRI. Both indices correlated poorly with postoperative ICU admission and LOS.

Conclusion

Both indices had limited predictive and discriminative ability to estimate postoperative in-hospital MACE risk and correlated poorly with postoperative ICU admission and LOS, following surgery under SA in the oldest-old patients. Updated versions by introducing age, AF, and trauma surgery improved the GSCRI performance but not the RCRI.

Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation

BACKGROUND

The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients.

METHODS

The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period.

RESULTS

Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements.

CONCLUSION

Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.

Effect of perioperative terlipressin infusion on systemic, hepatic, and renal hemodynamics during living donor liver transplantation

BACKGROUND

End-stage liver disease is associated with marked hemodynamic disturbances that are further aggravated during liver transplantation. Terlipressin has been shown to be effective in the management of sepsis-induced hypotension and hepatorenal syndrome and recently has been tried as infusion during liver transplantation. This study assessed the effect of intraoperative and postoperative terlipressin infusion on systemic, hepatic, and renal hemodynamics during adult living donor liver transplantation.

METHODS

Eighty recipients were randomly allocated into control (C group; n=40) and terlipressin (TP group; n=40), in which, terlipressin infusion was started at the beginning of surgery at a dose of 3 μg kg(-1) h(-1) to be reduced to 1.5 μg kg(-1) h(-1) after reperfusion and continued for 3 postoperative days; vasoactive agents were used as appropriate in all patients. Systemic hemodynamics, hepatic and renal arterial resistive indices (HARI, RARI), and portal venous blood flow (PBF) were compared between both groups intraoperatively and for 5 postoperative days.

RESULTS

With terlipressin infusion, there were significant increases in both mean arterial pressure and systemic vascular resistance (P<.001), whereas heart rate and cardiac output decreased significantly (P<.001) throughout the study period compared with the C group. Vasoconstrictor drugs required during reperfusion were significantly lower in the TP group. There was a significant decrease in HARI, RARI, and portal venous blood flow in the TP group compared with the C group throughout the study period. There was no significant difference between both groups regarding liver function tests and serum lactate, whereas renal function tests were significantly better in the TP group.

CONCLUSION

Terlipressin infusion significantly decreased HARI, RARI, and portal vein flow and improved low systemic vascular resistance and mean arterial pressure. It helped to reduce intraoperative vasoactive support and might improve postoperative renal function.

Rotational thromboelastometry and standard coagulation tests for live liver donors

PURPOSE

To study coagulation of live liver donors with standard coagulation tests (SCT) and rotational thromboelastometry (ROTEM) and investigate their relationship.

METHODS

A descriptive prospective study involving 50 right hepatotomy donors with epidural catheters. ROTEM (EXTEM, INTEM, and FIBTEM represent extrinsic and intrinsic pathways of coagulation and fibrinogen activity, respectively) was measured perioperatively and on days 1, 3, 5, 10, and 30. SCTs include prothrombin time (PT), international normalized ratio (INR) of PT, activated partial thromboplastin time (aPPT), fibrinogen, and platelets.

RESULTS

PT and INR reflect hypocoagulability reaching maximum on day one (16.9 ± 2.5 s, 1.4 ± 0.2, p < 0.05 compared with baseline). ROTEM was in normal ranges till day 30 with no hypercoagulability. Fibrinogen showed no correlation with maximum clot firmness (MCF) of FIBTEM (r = 0.35, p > 0.05). CFT of EXTEM was not in significant correlation with PT and INR (r = 0.16, 0.19, p > 0.05), respectively. Significant correlation between platelets and both MCF (EXTEM; r = 0.59, p = 0.004) and MCF (INTEM; r = 0.48, p = 0.027).

CONCLUSION

ROTEM disagreed with SCTs and did not show the temporary hypocoagulability suggested by SCTs. Both ROTEM and SCTs showed no signs of hypercoagulability. Future studies involving ROTEM could help develop new guidelines for coagulation monitoring.

Live donor hepatectomy for liver transplantation in Egypt: Lessons learned

PURPOSE

To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011.

METHODS

After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed.

RESULTS

One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of (50.1%). The most frequent complication was infection (21.1%) (intraabdominal collections), followed by biliary leak (18.2%). Two donors had major complications: one had portal vein thrombosis (PVT) treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely (n=90) with no epidural hematoma despite significantly elevated prothrombin time (PT) and international normalization ratio (INR) postoperatively, reaching the maximum on Day 1 (16.9±2.5 s and 1.4±0.2, P<0.05 when compared with baseline). Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05±0.18 mg/dL on Day 1 and 2.3±0.83 mg/dL on Day 3 postoperatively.

CONCLUSIONS

Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting.

Brain dysfunction in fibromyalgia and somatization disorder using proton magnetic resonance spectroscopy: a controlled study

OBJECTIVE

To evaluate the brain metabolite patterns in patients with fibromyalgia (FM) and somatization disorder (STD) compared with healthy controls through spectroscopy techniques and correlate these patterns with psychological variables.

METHOD

Design. Controlled, cross-sectional study. Sample. Patients were recruited from primary care in Zaragoza, Spain. The control group was recruited from hospital staff. Patients were administered questionnaires on pain catastrophizing, anxiety, depression, pain, quality of life, and cognitive impairment. All patients underwent Magnetic Resonance Imaging and magnetic resonance spectroscopy (MRS).

RESULTS

A significant increase was found in the glutamate + glutamine (Glx) levels in the posterior cingulate cortex (PCC): 10.73 (SD: 0.49) for FM and 9.67 (SD: 1.10) for STD 9.54 (SD: 1.46) compared with controls (P = 0.043). In the FM + STD group, a correlation between Glx and pain catastrophizing in PCC (r = 0.397; P = 0.033) and between quality of life and the myo-inositol/creatine ratio in the left hippocampus (r = -0.500; P = 0.025) was found. To conclude Glutamate seems to be relevant in the molecular processes involved in FM and STD. It also opens the door for Proton MRS ((1) H-MRS) in STD and suggests that reducing glutamatergic activity through pharmacological treatment could improve the outcome of patients with FM and STD.

CONCLUSION

Glutamate seems to be relevant in the molecular processes involved in FM and STD. It also opens the door for Proton MRS ((1) H-MRS) in STD and suggests that reducing glutamatergic activity through pharmacological treatment could improve the outcome of patients with FM and STD.

Use of transesophageal Doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: An observational study

Aims:

To report the use of transesophageal Doppler (TED), a minimally invasive cardiac output (COP) monitor, before, during and after reperfusion and study its effect on anesthetic management during living donor liver transplantation (LDLT).

Setting and Design:

A prospective observational study.

Methods:

A total of 25 consecutive recipients with a MELD score between 15 and 20 were enrolled. Data were recorded at baseline (TB); anhepatic phase (TA); and post-reperfusion — 1, 5, 10 and 30 minutes. Fluid therapy was guided by corrected flow time (FTc) of the TED. Packed red blood cells (RBCs) were only given when hematocrit was less than 25%. Rotational thromboelastometry (ROTEM) and standard laboratory tests were used to guide component blood products requirements.

Results:

Post-reperfusion, the COP, Cardiac Index (CI) and stroke volume (SV) increased significantly at all points of measurements; this was associated with a significant decrease in systemic vascular resistance (SVR) (P ;< .05). Immediately post-reperfusion, for 5 minutes, mean arterial blood pressure (ABP) dropped significantly (P < .05), and 14 out of the 25 patients required boluses of epinephrine (10 μg) to restore the mean ABP; 3 of the 14 patients required norepinephrine infusion till the end of surgery. Central venous pressure (CVP) and urine output (UOP) at all measures were maintained adequately with FTc-guided fluid replacement. Eight out of the 25 patients required no blood transfusion, and 4 of the 8 patients required no catecholamine support.

Conclusion:

TED as a sole monitor for COP was able to present significant and reliable changes in the cardiovascular status of the recipients during reperfusion, which could help to guide fluid- and drug-supportive therapy in this population of patients. This preliminary study needs to be applied on a larger scale.

Clinical and Radiological Differences in Alzheimer's Disease with and without a History of Mild Cognitive Impairment

We assessed the influence of a history of amnesic mild cognitive impairment (MCI) in patients with Alzheimer's disease (AD) at presentation from a clinical and radiological point of view. A consecutive sample of patients fulfilling the criteria of probable Alzheimer's disease according to the NINCDS-ADRDA work group not previously diagnosed nor treated underwent neuropsychological assessment including mini-mental test, Blessed dementia rating scale (BDRS), ADAS-Cog, neuropsychiatric inventory (NPI), and a daily living activities scale (DAD). Radiological evaluation consisted of magnetic resonance imaging, left hippocampal volumetry and magnetic resonance spectroscopy (MRS) of the brain. We divided the patients into two groups according to positive/negative history of MCI for a period longer than one year. The AD patients with a history of MCI were more likely to have a history of depression (OR: 5.5; 95% CI: 1.12-26) and have more depressive symptoms at presentation in the NPI than those without a history of MCI. They also had a history of hypertension more frequently than the remainder. The presence/absence of ApoE4 alleles did not have influence in the clinical course. With regard to radiological findings the patients with previous MCI showed lower values of N-acetyl-aspartate (NAA) in parietal (p=0.0001) temporal (p=0.08) and occipital (p=0.00001) lobes than the other group, as well as a smaller left hippocampus although the difference was not statistically significant. A history of MCI in AD patients represents a form of the disease with slower progression from clinical and radiological viewpoints. These patients present with more depressive symptoms and a history of depression than the remainder. The lower NAA levels on MRS are compatible with a longer disease duration when AD is preceded by amnesic MCI.

An Atlas of Infectious and Parasitic Diseases of the Central Nervous System. A Cooperative Study of SILAN (Sociedad Iberolatinoamericana de Neurorradiologia)

Infectious diseases of the central nervous system vary in frequency in different locations in America and Europe. What is common in Brazil can be a sporadic presentation in Europe. Cooperative work gathering experiences from neuroradiologists working in various places can be achieved and will help to identify uncommon cases that can present in our daily practice.

Memantine versus donepezil in mild to moderate Alzheimer's disease: a randomized trial with magnetic resonance spectroscopy

BACKGROUND AND PURPOSE

To compare memantine with the most prescribed cholinesterase inhibitor (donepezil) from a clinical viewpoint when administered in early phases of Alzheimer disease (AD), and to find out whether memantine may produce changes in brain metabolite concentrations in comparison with donepezil.

METHODS

In this comparative rater-blinded parallel group randomized trial we recruited a consecutive sample of patients with probable mild to moderate AD. At baseline we carried out neuropsychological assessment with mini-mental, Clinical Dementia Rating Scale (CDR), Blessed Dementia Rating Scale, Alzheimer's Disease Assessment Scale, cognitive part (ADAS-cog), neuropsychiatric inventory (NPI), and disability assessment for dementia (DAD), as well as (1)H magnetic resonance spectroscopy (MRS) in several areas of the brain. Patients were randomized to receive either donepezil or memantine for 6 months. After this elapse of time we repeated the same procedures and observed the changes in clinical scales (ADAS-cog, NPI, DAD), as well as the changes in metabolite levels in every area of exploration (temporal, pre-frontal, posterior cingulated (PCG), and occipital), especially those of N-acetyl-aspartate (NAA) which is regarded as a surrogate marker of neuronal density.

RESULTS

A total of sixty-three patients completed the trial. We did not see significant differences in clinical scales and metabolite levels between those on donepezil (n = 32) and those on memantine (n = 31). In general, more patients worsened than improved on either of the drugs. The changes in the NAA/creatine ratio in the PCG correlated significantly with the changes in the ADAS-cog (P = 0.004).

CONCLUSIONS

Donepezil and memantine have similar modest clinical and spectroscopic effect on mild to moderate AD. MRS could be useful to monitor progression of the disease.

Fahr's syndrome presenting with pure and progressive presenile dementia

Fahr's syndrome involves calcification of basal ganglia and dentate nuclei of the cerebellum. Clinically it may present with an array of movement disorders, dementia and other behavioural disturbances. Sporadic and familial cases have been reported with or without calcium/phosphorus metabolism. A rare form of frontotemporal dementia with neurofibrillary tangles and Fahr-type calcifications (DNTC) has been observed mainly in Japan. We report the singular case of a 50-year-old woman with progressive dementia but neither extrapyramidal symptoms nor a metabolic disorder. Brain CT showed Fahr-type calcifications in the basal ganglia, cerebellum and centrum semiovale as well as temporal atrophy; MRI showed diffuse atrophy predominantly in parietotemporal regions. The clinical and radiological features of our patient point to this uncommon form of dementia.

[Hypoxic encephalopathy and cortical laminar necrosis]

INTRODUCTION

Cortical laminar necrosis is characterized by destruction of the cerebral cortex, mainly of the third layer, in situations of reduced energy supply to the brain. The cerebral lesions caused are known through studies made at autopsies, but there are few descriptions in the literature of the neuroimaging changes. We report the case of a patient who suffered hypoxic encephalopathy secondary to prolonged status epilepticus, and in whom cerebral MR showed changes compatible with cortical laminar necrosis.

CLINICAL CASE

A 16 year old girl who had been epileptic since infancy presented with a state of generalized tonic-clonic convulsions followed by coma. Three weeks later she was mute, had a blink reflect to threats and followed visual stimuli with eye movements but no voluntary motor or verbal response. She also showed generalized hypertonia and fine tremor of her arms, which she moved spontaneously with no asymmetry. After two months her clinical condition became stable. Cerebral MR at this time showed diffuse hypersignal of the cortex and basal ganglia in T2 and FLAIR sequences and hyposignal of the subcortical white matter associated with a marked hypersignal delimiting the grooves of convexity in T1 sequences.

CONCLUSIONS

Situations of prolonged hypoxia, such as in status epilepticus, lead to necrosis of layers of the cerebral cortex. Clinically this is seen as the appearance of hypoxic encephalopathy and radiologically as characteristic alterations of neuroimaging known as cortical laminar necrosis.

[Etiology in complex partial epilepsy. I. Neuroimaging studies]

With the appearance of MR, a great advance has been made in the study of the aetiology of epilepsy. This technique can show anomalies not detected in CT scans, obtain images of multiple planes, improve the differentiation of cerebral tissues and allow improved visualization of the temporal lobe, making it very useful in the study of patients with complex partial crises (CPC). We studied 151 epileptics with CPC by means of CT scan and MR in all cases; the anomolous topography was the same in all cases, but the diagnosis was not. In patients with a previously normal CT scan, on MR anomalies were detected in 24 cases. We found a statistical differences on evaluation of the MR anomaly depending on whether the CT scan was normal or abnormal. Statistical differences were also found when there were a greater number of anomalies on MR depending on the frequency of crises at the onset of the disorder.

[Primary T-cell lymphoma in the central nervous system of immunocompetent patients. Clinical and pathological study of two cases]

Primary T-cell lymphoma in the central nervous system has rarely been described in the literature. We report 2 such cases in immunocompetent patients. The first presented with subacute encephalopathy affecting both memory and speech. A CT-scan of the head showed a contrast-enhanced mass around the third ventricle. The second presented with 2 partial seizures with secondary generalization; the CT-scan in this case showed a right temporal lesion. Both underwent surgery for total removal of the masses followed by cranial irradiation. Tissue examination confirmed the diagnosis. The first patient died 14 months after diagnosis. In the second case lymphoma recurred 8 months after surgery.

Modified lingual split technique versus conventional buccal technique in odontectomy of impacted mandibular third molars

This study was conducted to compare two different techniques used in odontectomy of impacted mandibular third molar; the modified lingual split technique and the conventional buccal technique as regarding the duration of surgery as well as the incidence of postoperative sequelae such as pain, edema, and trismus. This study was carried out on thirty adult male patients having class II, position B mesioangular impacted mandibular third molar scheduled for removal, the cases were divided into two equal groups. Group one using the conventional buccal technique and group two using the modified lingual split technique. Pain was categorized into a three grade scale according to the dose of the analgesic taken by the patients postoperatively. The degree of trismus was calculated by measuring the interincisal distance when the mouth was opened at a maximum using a graduated caliper both preoperatively and postoperatively. Edema was measured linearly using a tape between different predetermined facial anatomical landmarks in different planes. All measurements were carried out immediately before surgery and after one, two and seven days postoperatively. The collected data were tabulated and were statistically analyzed. There was a significant difference between the two techniques as regarding the duration of surgery in favour of the modified lingual split technique, with a mean of 36.3 minutes, in group two against a mean of 54.3 minutes in group I. As regarding pain there was no significant difference in the first and the second postoperative days, while there was a significant difference in favour of the modified lingual split bone technique in the seventh postoperative day. Trismus and edema were comparable in both groups.

[Syringomyelia due to arachnoiditis. Clinical-radiological description of 5 patients]

Five patients (mean age 44 years--range 21-67 years) with arachnoiditis of different origin who posteriorly developed syringomyelia are presented. The etiopathogenic mechanism of the arachnoiditis was post injury in one case, 2 patients had history of meningitis (tuberculous and pneumococcic) and in the other two no related factor was found. The period of latency among the causes which originated arachnoiditis and the diagnosis of syringomyelia oscillated between 10 months and 16 years. The localization of the cavity was dorsal in 3 cases, cervical in another and in the last it was extended along the whole spine. No patient demonstrated the Arnold-Chiari malformation nor basilar impression. Analyzing the clinical history, radiologic studies and surgical findings the most probable etiopathogenic mechanism involved in each case is discussed.

[Anterior spinal artery syndrome caused by cervical disc protrusion. Diagnosis by magnetic resonance]

The syndrome of the anterior spinal artery is a rare disease with a diagnosis based an its characteristic clinical features. Until the widespread use of the Magnetic Resonance (MR) the lesional confirmation required an anatomopathological study. We report a 49-years-old male with lacinating interscapular pain and sudden asymmetrical tetraparesia, in whom MR scan disclosed a plurisegmental anterior spinal lesion and a posterolateral disk protrusion at C6-C7 level. We discuss the etiological and pathogenetical relation between degenerative vertebral disk disease and spinal infarctions.