Optimization of procedural sedation and analgesia during atrial fibrillation ablation

PURPOSE OF REVIEW

This mini-review is aimed to provide an overview and discuss procedural sedation and analgesia for atrial fibrillation (AF) ablation with focus at qualification of staff, patient evaluation, monitoring, medication and postprocedural care.

RECENT FINDINGS

Sleep-disordered breathing is highly prevalent in patients with AF. Impact of often used STOP-BANG questionnaire to detect sleep-disordered breathing in AF patients is limited due to its restricted validity. Dexmedetomidine is a commonly used drug in sedation, but is shown not to be superior to propofol in sedation during AF-ablation. Alternatively use of remimazolam has characteristics that makes it a promising drug for minimal to moderate sedation for AF-ablation. High flow nasal oxygen (HFNO) has shown to reduce the risk of desaturation in adults receiving procedural sedation and analgesia.

SUMMARY

An optimal sedation strategy during AF ablation should be based on AF patient characteristics, the level of sedation needed, the procedure (duration and type of ablation) and the education and experience of the sedation provider. Patient evaluation and post procedural care are part of sedation care. More personalized care based on use of various sedation strategies and types of drugs as related to the type of AF-ablation is the way to further optimize care.

Robot-Assisted Minimally Invasive Surgery: First Report from the Caribbean

Although advanced minimally invasive surgery and robotic surgery were well accepted in developed countries by the turn of the 21st century, they did not enjoy the same popularity in the Anglophone Caribbean. Advanced minimally invasive surgery only became available in select Caribbean countries from the year 2010. And up to the year 2021, robotic surgery was completely non-existent in the Anglophone Caribbean.

Surgical leaders in the Anglophone Caribbean recognized a need to encourage the introduction of advanced surgical techniques in the region and engaged local and international stakeholders in an attempt to stimulate this development. In the year 2021, through a collaborative effort by a local medical university, a government-funded hospital, and industry partners in the United Kingdom, robot-assisted minimally invasive surgery was successfully introduced to the Caribbean.

We report our experience of introducing robot-assisted minimally invasive surgery in the Eastern Caribbean. By discussing the pitfalls and successes from our experience, we hope that the lessons can be used to guide the introduction of robot-assisted minimally invasive surgery in other resource-poor countries in the Caribbean.​

Identification and Antimicrobial Resistance of Dermatophilus congolensis from Cattle in Saint Kitts and Nevis

Dermatophilosis is a form of dermatitis caused by the bacterium Dermatophilus congolensis. The disease usually presents as localized purulent dermatitis, crusty hair masses or widespread matting of the hair. This condition is most common in domestic ruminants; but it can also affect other wild animals and humans. Antimicrobial therapy is used in many regions to treat clinical dermatophilosis with varying results. In this study, we aimed to assess the antimicrobial susceptibility of D. congolensis isolates. Fifty-two isolates were obtained from animals showing clinical signs of the disease at farms in St. Kitts. The isolates were then confirmed as D. congolensis by phenotypic tests, PCR and MALDI-TOF Mass Spectrometry. Furthermore, minimum inhibitory concentrations (MIC) of 16 antimicrobial agents were determined, using the broth microdilution method. Although most antimicrobials showed MICs in line with published values, the tetracycline results displayed a clear bimodal distribution over the tested range, with most isolates showing low MICs and 6 isolates much higher values (+/− 100-fold increase). These results indicate the presence of acquired tetracycline resistance in D. congolensis on the island of St. Kitts. Whether the current observation has implications for efficacy of treating the disease must be confirmed in further research.

A possible mechanism of hyperlipidemia in a patient with metastatic non-small cell lung cancer on lorlatinib therapy

INTRODUCTION

We report the case of a woman who developed hyperlipidemia on lorlatinib therapy found to have minimal change disease. We review therapies for cancer known to alter the lipid profile, in addition to reviewing secondary hyperlipidemia workup. We also propose a mechanism for lorlatinib-induced hyperlipidemia.

CASE REPORT

A 63 year old woman with non-small cell lung adenocarcinoma on lorlatinib therapy develops marked hyperlipidemia.Management & outcome: A secondary hyperlipidemia workup is performed which reveals nephrotic range proteinuria. Minimal change disease is found on renal biopsy. The hyperlipidemia was initially responsive to statin therapy, then required addition of ezetimibe.

DISCUSSION

This is a case of hyperlipidemia in a patient on lorlatinib. The case highlights that therapies for lung cancer and other malignancies have the potential to alter the lipid profile. We propose minimal change disease as a possible mechanism for lorlatinib-induced dyslipidemia. Additionally, we discuss the crucial aspects of secondary hyperlipidemia workup.

Measurable residual disease in multiple myeloma and light chain amyloidosis: more than meets the eye

The emergence of highly effective multiple myeloma (MM) treatments may bring cure within reach and highlights the need for highly sensitive measurable residual disease (MRD) techniques to replace conventional response assessments. MRD is being incorporated as an endpoint in an increasing number of studies and had been repeatedly shown to be both a predictive marker of response to treatment and a prognostic marker for future relapse. However, those results should be cautiously interpreted due to non-uniform reporting and the need for longer follow up to assess for sustained MRD negativity. This review aims to critically analyze the key MRD aspects including the current evidence supporting the use of MRD in clinical practice and the pitfalls of the various methods used to assess MRD. The utility of MRD for light chain (AL) amyloidosis will also be discussed.

Early Management of Esophageal Leak in Esophageal Atresia: Changing Paradigms

Introduction: A leak at the esophageal anastomosis can occur in 10%-20% of cases of esophageal atresia (EA). Thoracoscopic repair is trans-pleural, with the potential development of an empyema. Standard treatment of an anastomotic leak in a stable patient is often nonoperative, which can lead to prolonged parenteral nutrition and hospitalization. Our objective is to show that early thoracoscopic redo anastomosis management is safe and feasible. Materials and Methods: Retrospective study of a case series of four infants, diagnosed with EA and treated with early thoracoscopic esophageal leak repair between 2013 and 2018. Variables analyzed included age, weight, type of EA, day of leak, surgical approach, time to start feeding, surgical complications, and follow-up. Results: Three patients were type III, and one was type I originally repaired with a thoracoscopic approach. Leaking of the anastomosis was found the second postoperative day in one patient, third day in two patients, and the fifth day in the last one. All were confirmed with an esophagogram. All patients were operated in the first 24 hours after diagnosis by the thoracoscopic approach. The site of leak was found and re-sutured. Patients started feeding between the third and fourth day through a transanastomotic tube, starting oral feeding at the seventh day after an esophagogram did not show a leak. No complications were found. Mean time to complete oral feeding was 10 days. Two patients needed esophageal dilations. Mean time of follow-up has been 33 months. Conclusion: Early thoracoscopic repair of an anastomotic leak can be considered an alternative to the standard nonsurgical management. The early re-suture of the area of leak is a change in paradigm, but it offers the benefits of preservation of the native esophagus, early resumption of enteral feedings, and a shorter length of parental nutrition and hospitalization. Level of Evidence: IV.

Effect of Partial Pars Plana Vitrectomy in Two Cases: Removal of Intraocular Foreign Body and Intraocular Lens Dropped Into Vitreous

The aim of this case study was to present the effect of partial pars plana vitrectomy (PPV) in two cases that is due to the presence of an intraocular foreign body (IOFB) and intraocular lens (IOL) that has dropped into the intravitreal area. The first case was a 30-year-old man with IOFB in the right eye, and the second case was a 34-year-old woman whose IOL was dropped into vitreous after trauma. In cases, IOFB and IOL were extracted from vitreous performed by partial PPV without complication. Partial PPV was effective despite without complete vitrectomy. With minimal/partial vitrectomy approach, most of the vitreous tissues was left in place. We believe that this approach will reduce the rate of complications, such as cataract and retinal detachment.

Applications of Laparoscopic Transperitoneal Surgery of the Pediatric Urinary Tract

Application of laparoscopy in pediatric urology has evolved over more than 30 years coming from a merely diagnostic use for non-palpable testes to "interventional" laparoscopy to extirpative surgery and finally to the era of reconstructive pediatric laparoscopic urology, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic surgery in pediatric urology became implemented increasingly in the twenty-first century with now present-day applications including the complete variety of all kind of indications for surgery for pediatric urological pathology. This article aims to provide a comprehensive overview of current indications, techniques, and outcomes of laparoscopic transperitoneal surgery of the upper as well as of the lower urinary tract for urological pathology in the pediatric patient population.

MHE Testing in Real World Scenario

Professional MHE awareness is high but when it comes to psychometric testing for MHE the real world scenario is characterized by hesitation and testing is offered only to selected cirrhosis patients. The hesitation is rooted in doubts about which tests to use, lack of knowledge about treatment benefits, and uncertainty about the tests' ability to identify patients who will benefit from anti-HE treatment. Thus, the majority of MHE patients do not receive the available efficient anti-HE treatment. This mini-review attempts to quell some of these doubts.

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Impact of a medical university on laparoscopic surgery in a service-oriented public hospital in the Caribbean

INTRODUCTION

The Caribbean lags behind global trends for volume and complexity of laparoscopic operations. In an attempt to promote laparoscopy at a single facility, a partnership was formed between the University of the West Indies (UWI) and the Port of Spain General Hospital in Trinidad and Tobago. This study seeks to document the effect of this partnership on laparoscopic practice.

MATERIALS AND METHODS

In this partnership, the UWI took the bold step of volunteering to staff a surgical team if the Ministry of Health provided the necessary legislative changes. On August 1, 2013, a UWI team was introduced with a mandate to optimize teaching and promote laparoscopic surgery. The UWI team had a similar staff complement to the existing service-oriented teams. There was no immediate investment in equipment, hospital beds, ICU beds, or operating room space. Therefore, the new team was introduced with limited change in existing conditions, resources, and equipment.

RESULTS

There were 252 laparoscopic operations performed over the study period. After introduction of the UWI team, there was an increase in the mean number of unselected laparoscopic operations (3.17 vs 10.83 cases per month; P<0.001; 95% confidence interval [95% CI] -8.5 to -6.84; standard error of the difference [SED] 0.408), the mean number of basic laparoscopic operations (3.17 vs 6.94 cases per month; P<0.0001; 95% CI -4.096 to -3.444; SED 0.165), the mean number of advanced laparoscopic operations (0 vs 3.89; P<0.0001), the number of teams undertaking unselected laparoscopic operations (2 vs 5), and the number of teams independently performing advanced laparoscopic operations (0 vs 4).

CONCLUSION

At this facility, we have demonstrated a significant increase in laparoscopic case volume and complexity when partnerships were formed between the UWI and this service-oriented hospital. Continued cross-fertilization and distribution of skill sets across the surgical community can reasonably be expected. We also identified maneuvers that can be used as a template to build laparoscopic services in other service-oriented hospitals in developing nations.

Advancement of laparoscopic surgery in Guyana: a working model for developing countries

In the late 20th century, the volume and complexity of laparoscopic operations being performed have increased worldwide. However, surgical practice lagged behind in the Caribbean region. This article reports a tailored approach to initiate advanced laparoscopy in Guyana, which can be used as a model to initiate laparoscopic services in other developing nations. This can be achieved in four stages: 1) relying on regional proctors to teach laparoscopic techniques adapted to resource-poor environments, 2) focusing on developing skill sets such as laparoscopic suturing in order to rely less on expensive consumables, 3) creating partnerships that include all stakeholders, and 4) collaborating with regional experts as a valuable resource for continued medical education, multidisciplinary support, and sharing learning experiences.

Principles of minimal residual disease detection for hematopoietic neoplasms by flow cytometry

Flow cytometry has become an indispensible tool for the diagnosis and classification of hematopoietic neoplasms. The ability to rapidly distinguish cellular subpopulations via multiparametric assessment of quantitative differences in antigen expression on single cells and enumerate the relative sizes of the resulting subpopulations is a key feature of the technology. More recently, these capabilities have been expanded to include the identification and enumeration of rare subpopulations within complex cellular mixtures, for example, blood or bone marrow, leading to the application for post-therapeutic monitoring or minimal residual disease detection. This review will briefly present the principles to be considered in the construction and use of flow cytometric assays for minimal residual disease detection including the use of informative antibody combinations, the impact of immunophenotypic instability, enumeration, assay sensitivity, and reproducibility.

Reflections concerning triply-periodic minimal surfaces

In recent decades, there has been an explosion in the number and variety of embedded triply-periodic minimal surfaces (TPMS) identified by mathematicians and materials scientists. Only the rare examples of low genus, however, are commonly invoked as shape templates in scientific applications. Exact analytic solutions are now known for many of the low genus examples. The more complex surfaces are readily defined with numerical tools such as Surface Evolver software or the Landau-Ginzburg model. Even though table-top versions of several TPMS have been placed within easy reach by rapid prototyping methods, the inherent complexity of many of these surfaces makes it challenging to grasp their structure. The problem of distinguishing TPMS, which is now acute because of the proliferation of examples, has been addressed by Lord & Mackay (Lord & Mackay 2003 Curr. Sci. 85, 346-362).

Unilateral and mild bilateral hearing loss in children: past and current perspectives

Since the early 1980s, audiologists have become increasingly aware of the potential effect of even mild degrees of hearing loss on the psychoeducational and psychosocial outcomes of children. This review describes some of the key research findings during the past several decades that have led us to our current thinking about unilateral and mild bilateral hearing loss in children. The first section addresses unilateral hearing loss. This is followed by a review of the literature on mild bilateral hearing loss. Specifically, the issues addressed include the significance of permanent mild degrees of hearing loss on children's psychoeducational and psychosocial development and the speech, language, and auditory characteristics of children with mild degrees of hearing loss. Finally, some recommendations regarding the direction of future research are offered. This review is followed by 2 articles summarizing the proceedings of a 2005 workshop convened by the Centers for Disease Control and Prevention (CDC), Early Hearing Detection and Intervention (EHDI) program, and the Marion Downs Hearing Center to address concerns about the underidentification of-- and professionals' apparent lack of awareness of-- permanent unilateral and minimal to mild hearing loss in children.

Selection of the simplest RNA that binds isoleucine

We have identified the simplest RNA binding site for isoleucine using selection-amplification (SELEX), by shrinking the size of the randomized region until affinity selection is extinguished. Such a protocol can be useful because selection does not necessarily make the simplest active motif most prominent, as is often assumed. We find an isoleucine binding site that behaves exactly as predicted for the site that requires fewest nucleotides. This UAUU motif (16 highly conserved positions; 27 total), is also the most abundant site in successful selections on short random tracts. The UAUU site, now isolated independently at least 63 times, is a small asymmetric internal loop. Conserved loop sequences include isoleucine codon and anticodon triplets, whose nucleotides are required for amino acid binding. This reproducible association between isoleucine and its coding sequences supports the idea that the genetic code is, at least in part, a stereochemical residue of the most easily isolated RNA-amino acid binding structures.