bluuebunny/crossref_metadata_2025 huggingface dataset:
Pharmacological Characteristics of the Inhibition of Nondepolarizing Neuromuscular Blocking Agents at Human Adult Muscle Nicotinic Acetylcholine Receptor
Authors: Fagerlund Malin Jonsson , Dabrowski Michael , Eriksson Lars I.
Published: May 2009

Background

Nondepolarizing neuromuscular blocking agents (NMBAs) are classic competitive-inhibitors at the muscle nicotinic acetylcholine receptor (nAChR). Although the fetal subtype muscle nAChR has been extensively studied at a molecular level, less is known about the interaction between nondepolarizing NMBAs and the human adult muscle nAChR. The aim of this study was to investigate the effect of clinically used nondepolarizing NMBAs at human adult muscle nAChRs and the mechanisms behind the inhibition.

Methods

Human subunits for the adult alpha(1)beta(1)delta(epsilon) muscle nAChR were cloned and expressed into Xenopus oocytes and thereafter studied with two-electrode voltage clamp. The effect of the clinically used nondepolarizing NMBAs, including atracurium, cis-atracurium, mivacurium, pancuronium, rocuronium, vecuronium, and d-tubocurarine, on acetylcholine-induced and dimethylphenylpiperazinium-induced currents were investigated.

Results

All nondepolarizing NMBAs tested inhibited acetylcholine- and dimethylphenylpiperazinium-induced currents in human adult alpha(1)beta(1)delta(epsilon) muscle nAChRs, and no receptor activation was seen. Interestingly, acetylcholine desensitized the human adult alpha(1)beta(1)delta(epsilon) muscle type receptor and attenuated the inhibition caused by nondepolarizing NMBAs, as evident by lack of increase in IC(50) values for the nondepolarizing NMBAs with increased concentrations of acetylcholine. In contrast, dimethylphenylpiperazinium-induced currents were competitively inhibited by the nondepolarizing NMBAs.

Conclusions

This study demonstrates that nondepolarizing NMBAs inhibit human adult muscle nAChRs expressed in Xenopus oocytes by mixed mechanisms. When using the nondesensitizing agonist dimethylphenylpiperazinium, inhibition by the NMBA is competitive, whereas activation with high concentrations of acetylcholine in combination with NMBA induces a noncompetitive inhibition, which the authors speculate can involve receptor desensitization similar to that observed in the neuromuscular junction.
Does a Higher Positive End Expiratory Pressure Decrease Mortality in Acute Respiratory Distress Syndrome?
Authors: Phoenix Susan I. , Paravastu Sharath , Columb Malachy , Vincent Jean-Louis , Nirmalan Mahesh
Published: May 2009

Background

Positive end expiratory pressure (PEEP) is an important component of therapy in patients with acute lung injury or acute respiratory distress syndrome. The independent effect of PEEP on mortality is currently unknown.

Methods

A systematic review and meta-analysis of randomized controlled clinical trials comparing the use of higher and lower levels of PEEP.

Results

Six trials with a total of 2,484 patients from 102 intensive care units and 9 countries met the eligibility criteria. In three trials, the effect of different levels of PEEP was compared in groups receiving comparable tidal volumes. Three trials accounted for more than 85% of total weighting in the meta-analyses. The pooled relative risk obtained from these three trials showed a trend towards improved mortality with high PEEP, even though the difference did not reach statistical significance: Pooled cumulative risk of 0.90 (95% CI 0.72-1.02, P = 0.077). The reduction in absolute risk of death was approximately 4%. There was no evidence of a significant increase in baro-trauma in patients receiving high PEEP, with a pooled risk of 0.95 (95% CI 0.62-1.45, P = 0.81).

Conclusion

High PEEP strategy may have a clinically relevant independent mortality benefit. Despite a possible increase in baro-trauma, the benefits far outweigh potential risks. Current evidence therefore favors the use of high PEEP as the preferred option when ventilating patients with severe acute respiratory distress syndrome. As the reduction in absolute risk of death is less than 5%, a future clinical trial aimed at demonstrating statistical significance is likely to pose considerable financial and ethical burdens.
Hypoxemia during One-lung Ventilation
Authors: Karzai Waheedullah , Schwarzkopf Konrad
Published: May 2009

When switching from two-lung to one-lung ventilation (OLV), shunt fraction increases, oxygenation is impaired, and hypoxemia may occur. Hypoxemia during OLV may be predicted from measurements of lung function, distribution of perfusion between the lungs, whether the right or the left lung is ventilated, and whether the operation will be performed in the supine or in the lateral decubitus position. Hypoxemia during OLV may be prevented by applying a ventilation strategy that avoids alveolar collapse while minimally impairing perfusion of the dependent lung. Choice of anesthesia does not influence oxygenation during clinical OLV. Hypoxemia during OLV may be treated symptomatically by increasing inspired fraction of oxygen, by ventilating, or by using continuous positive airway pressure in the nonventilated lung. Hypoxemia during OLV may be treated causally by correcting the position of the double-lumen tube, clearing the main bronchi of the ventilated lung from secretions, and improving the ventilation strategy.
Experimental Ventilator-induced Lung Injury
Authors: Villar Jesús , Herrera-Abreu Maria Teresa , Valladares Francisco , Muros Mercedes , Pérez-Méndez Lina , Flores Carlos , Kacmarek Robert M.
Published: May 2009

Background

Previous experimental studies of ventilator-induced lung injury have shown that positive end-expiratory pressure (PEEP) is protective. The authors hypothesized that the application of PEEP during volume-controlled ventilation with a moderately high tidal volume (VT) in previously healthy in vivo rats does not attenuate ventilator-induced lung injury if the peak airway pressure markedly increases during the application of PEEP.

Methods

Sixty healthy, male Sprague-Dawley rats were anesthetized and randomized to be mechanically ventilated for 4 h at (1) VT of 6 ml/kg, (2) VT of 20 ml/kg, or (3) VT of 20 ml/kg plus 10 cm H2O of PEEP. Peak airway pressures, gas exchange, histologic evaluation, mortality, total lung tissue cytokine gene expression, and serum cytokine concentrations were analyzed.

Results

Peak airway pressures exceeded 30 cm H2O with high VT plus PEEP. All lungs ventilated with high VT had perivascular edema and inflammatory infiltrates. In addition, those ventilated with PEEP had small hemorrhages foci. Five animals from the high VT plus PEEP group died (P = 0.020). Animals ventilated with high VT (with or without PEEP) had a substantial increase in serum interleukin-6 (P = 0.0002), and those ventilated with high VT plus PEEP had a 5.5-fold increase in systemic levels of tumor necrosis factor-alpha (P = 0.007).

Conclusions

In contrast to previous reports, PEEP exacerbated lung damage and contributed to fatal outcome in an in vivo, mild overdistension model of ventilator-induced lung injury in previously healthy rats. That is, the addition of high PEEP to a constant large VT causes injury in previously healthy animals.
Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device
Authors: Koff Matthew D. , Loftus Randy W. , Burchman Corey C. , Schwartzman Joseph D. , Read Megan E. , Henry Elliot S. , Beach Michael L.
Published: May 2009

Background

Hand hygiene is a vital intervention to reduce health-care associated infections, but compliance remains low. The authors hypothesized that improvements in intraoperative hand hygiene compliance would reduce transmission of bacteria to surgical patients and reduce the incidence of postsurgical healthcare-associated infections.

Methods

The authors performed a controlled before-and-after study over 2 consecutive months. One hundred fourteen operative cases were enrolled. Two predesignated sites on the anesthesia machine were selected, decontaminated, and cultured via aseptic technique. These sites and the peripheral intravenous stopcock were cultured again after completion of the surgery. The treatment phase used a novel personal hand-decontamination device capable of recording hand-decontamination events.

Results

There were no significant differences in patient location, age, or case duration and procedure type between groups. Use of the Sprixx GJ device (Harbor Medical Inc., Santa Barbara, CA) increased hourly hand decontamination events by 27-fold as compared with baseline rates (P < 0.002; 95% confidence interval, 3.3-13.4). Use of the device was associated with a reduction in contamination in the anesthesia work area and peripheral intravenous tubing. Intravenous tubing contamination was identified in 32.8% of cases in the control group versus 7.5% in the treatment group (odds ratio, 0.17; 95% confidence interval, 0.06-0.51; P < 0.01). Healthcare-associated infections rates were reduced in the device group (3.8%) as compared with the control group (17.2%) (odds ratio, 0.19; 95% confidence interval, 0.00-0.81; P = 0.02).

Conclusions

Improved hand hygiene compliance through the use of a novel hand sanitation strategy reduces the risk of intraoperative bacterial transmission. The intervention was associated with a reduction in healthcare-associated infections.
Perioperative Drug Therapy in Elderly Patients
Authors: Rivera Richard , Antognini Joseph F. , Riou Bruno
Published: May 2009

Advances in modern medicine and public health have resulted in increased longevity, which in turn has resulted in more elderly patients (arbitrarily defined as aged 65 yr or older) coming to the operating room for a variety of surgical procedures. Even in the absence of comorbidities, these patients, as compared with their younger cohorts, respond differently to various perioperative physiologic trespasses and pharmacologic interventions. In this clinical commentary, we focus on the altered pharmacologic responses elderly patients have during the perioperative period. In many instances, elderly patients are more sensitive to drugs, and for the purposes of this clinical commentary, we use the word sensitivity in its general clinical meaning, i.e., an enhanced response for a given dose of drug that might have a pharmacokinetic or pharmacodynamic explanation.
Circadian Disruption of Body Core Temperature and Rest–Activity Rhythms after General (Propofol) Anesthesia in Rats
Authors: Dispersyn Garance , Pain Laure , Touitou Yvan
Published: May 2009

Background

General anesthesia is commonly associated with sleep disorders, fatigue, drowsiness, and mood alterations in patients. The authors examined whether general (propofol) anesthesia can impact the circadian temporal structure by disturbing circadian rest-activity and body temperature rhythms under normal light-dark conditions (light-dark 12:12 h) in rats.

Methods

A group of rats was anesthetized with propofol, and another was injected with 10% Intralipid, which was used as a control lipidic solution. The authors examined six groups of rats according to the Zeitgeber time of intraperitoneal administration (ZT6, ZT10, ZT16) and the substance injected (propofol or Intralipid).

Results

On the day after anesthesia, propofol induced a significant 60- to 80-min phase advance of both rest-activity and body temperature rhythms. A significant 45- to 60-min phase advance of body temperature and a significant 20-min phase advance of rest-activity were still observed on the second day after anesthesia. The amplitudes of both rest-activity and body temperature rhythms were decreased on the first and second days after anesthesia. The 24-h mean rest-activity rhythm was decreased on the day after anesthesia, whereas the 24-h mean body temperature rhythm was not modified.

Conclusion

The results demonstrate the disturbing effects of propofol anesthesia on the circadian time structure in rats under normal light conditions.
Coagulopathy during Induced Severe Intracranial Hypertension in a Porcine Donor Model
Authors: Barklin Anne , Tønnesen Else , Ingerslev Jørgen , Sørensen Benny , Fenger-Eriksen Christian
Published: May 2009

Background

Development of coagulopathy is a serious complication arising from isolated traumatic brain injury, and it predicts poor outcome. The underlying mechanism has not yet been established, although coagulopathy arising from brain tissue injury and the release of tissue factor may represent the pathophysiology. The authors investigated dynamic whole-blood clot formation (ROTEM) in a recently developed porcine model of induced severe intracranial hypertension.

Methods

In this prospective, randomized experimental study, 17 pigs were designated for severe intracranial hypertension or sham operation. Intracranial hypertension was induced by inflation of an intracranial balloon. Whole-blood clot formation was assessed by clot initiation, and clot propagation and clot strength through thrombelastometry. The authors also assessed thrombin generation and prothrombin time, which were obtained at baseline, immediately after intervention, and 5 h after intervention.

Results

A dramatic shortening in time to clot initiation and an increase in clot propagation were observed after induction of intracranial hypertension as compared to the control group. These results were further substantiated by a pronounced increase in thrombin generation and a significantly shortened prothrombin time in the intervention group. No difference in clot strength was detected between the groups.

Conclusions

In a porcine model, induction of increased intracranial pressure causing severe intracranial hypertension was associated with a pronounced activation of the coagulation system. Taken together, the various results indicate that tissue factor probably represents the main trigger of hypercoagulopathy found in these pigs.
4G/5G Polymorphism of Plasminogen Activator Inhibitor -1 Gene Is Associated with Mortality in Intensive Care Unit Patients with Severe Pneumonia
Authors: Sapru Anil , Hansen Helen , Ajayi Temitayo , Brown Ron , Garcia Oscar , Zhuo HanJing , Wiemels Joseph , Matthay Michael A. , Wiener-Kronish Jeanine
Published: May 2009

Background

Higher plasma and pulmonary edema fluid levels of plasminogen activator inhibitor-1 (PAI-1) are associated with increased mortality in patients with pneumonia and acute lung injury. The 4G allele of the 4G/5G polymorphism of the PAI-1 gene is associated with higher PAI-1 levels and an increased incidence of hospitalizations for pneumonia. The authors hypothesized that the 4G allele would be associated with worse clinical outcomes (mortality and ventilator-free days) in patients with severe pneumonia.

Methods

The authors enrolled patients admitted with severe pneumonia in a prospective cohort. Patients were followed until hospital discharge. DNA was isolated from blood samples, and genotyping detection for the PAI-1 4G/5G polymorphism was carried out using Taqman-based allelic discrimination.

Results

A total of 111 patients were available for analysis. Distribution of genotypes was 4G/4G 26 of 111 (23%), 4G/5G 59 of 111 (53%), and 5G/5G 26 of 111 (23%). Of 111 patients, 32 (29%) died before hospital discharge and 105 patients (94%) received mechanical ventilation. Patients with the 4G/4G and the 4G/5G genotypes had higher mortality (35% vs. 8%, P = 0.007) and fewer ventilator-free days (median 4 vs. 13, P = 0.04) compared to patients with the 5G/5G genotype.

Conclusions

The 4G allele of the 4G/5G polymorphism in the PAI-1 gene is associated with fewer ventilator-free days and increased mortality in hospitalized patients with severe pneumonia. These findings suggest that PAI-1 may have a role in pathogenesis and that the 4G/5G polymorphism may be an important biomarker of risk in patients with severe pneumonia.
Quality and Safety Indicators in Anesthesia
Authors: Haller Guy , Stoelwinder Johannes , Myles Paul S. , McNeil John
Published: May 2009

Clinical indicators are increasingly developed and promoted by professional organizations, governmental agencies, and quality initiatives as measures of quality and performance. To clarify the number, characteristics, and validity of indicators available for anesthesia care, the authors performed a systematic review. They identified 108 anesthetic clinical indicators, of which 53 related also to surgical or postoperative ward care. Most were process (42%) or outcome (57%) measures assessing the safety and effectiveness of patient care. To identify possible quality issues, most clinical indicators were used as part of interhospital comparison or professional peer-review processes. For 60% of the clinical indicators identified, validity relied on expert opinion. The level of scientific evidence on which prescriptive indicators ("how things should be done") were based was high (1a-1b) for 38% and low (4-5) for 62% of indicators. Additional efforts should be placed into the development and validation of anesthesia-specific quality indicators.
Ethyl Pyruvate Attenuates Spinal Cord Ischemic Injury with a Wide Therapeutic Window through Inhibiting High-mobility Group Box 1 Release in Rabbits
Authors: Wang Qiang , Ding Qian , Zhou Yiming , Gou Xingchun , Hou Lichao , Chen Shaoyang , Zhu Zhenghua , Xiong Lize
Published: May 2009

Background

Ethyl pyruvate (EP) has been reported to offer a protective effect against ischemic injury through its antiinflammatory action. The nuclear protein high-mobility group box 1 (HMGB1) can activate inflammatory pathways when released from ischemic cells. This study was designed to investigate the neuroprotective effect of EP against spinal cord ischemic injury and the potential role of HMGB1 in this process.

Methods

EP was administered at various time points before or after 20 min of spinal cord ischemia in male New Zealand rabbits. All animals were sacrificed at 72 h after reperfusion with modified Tarlov criteria, and the spinal cord segment (L4) was harvested for histopathological examination and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling staining. The HMGB1 levels in serum and spinal cord tissue were analyzed by enzyme-linked immunosorbent assay.

Results

The treatment of EP at 30 min before ischemia or at 6 h after reperfusion significantly improved the hind-limb motor function scores and increased the numbers of normal motor neurons, which was accompanied with reduction of the number of apoptotic neurons and levels of HMGB1 in serum and spinal cord tissue. The HMGB1 contents of spinal cord tissue correlated well with the numbers of apoptotic motor neurons in the anterior spinal cord at 72 h after reperfusion.

Conclusion

These results suggest that EP affords a strong protection against the transient spinal cord ischemic injury with a wide therapeutic window through inhibition of HMGB1 release.
Massive Blood Transfusions
Authors: Miller Ronald D. , Warner David O.
Published: May 2009

To determine the coagulation defects associated with massive blood transfusions, coagulation studies were performed on 21 battle casualties admitted to the US Naval Support Activity Hospital, Da Nang, Vietnam. All but one patient who received less than 20 units of Acid-Citrate-Dextrose blood (7 patients) did not develop a coagulopathy. All patients who received more than 20 units (14 patients) developed a clinically significant coagulation defect. Although the partial thromboplastin and prothrombin times were markedly prolonged (i.e., low Factor V and XIII levels), restoring these times to normal levels by fresh frozen plasma administration did not terminate the clinical coagulopathy.In all 12 patients who had platelet counts less than 60,000/mm(3), a clinical bleeding problem (coagulopathy) developed. The coagulopathy eventually spontaneously resolved (n = 4), was successfully treated with fresh blood (n = 4), or the patients died (n = 4). A mathematical analysis confirmed that the thrombocytopenia is dilutional in origin and is the primary cause of a coagulopathy from massive blood transfusions. The authors conclude that clinically important coagulopathies predictably occur after administration of 20-25 units of stored Acid-Citrate-Dextrose blood in acutely wounded, previously healthy soldiers. Fresh frozen plasma should not be a major therapeutic choice for coagulopathies in massive blood transfusions. Treatment of dilutional thrombocytopenia (50,000/mm(3)) is a primary component of treating coagulopathies associated with massive blood transfusions.
Sevoflurane Preconditioning against Focal Cerebral Ischemia
Authors: Codaccioni Jean-Laurent , Velly Lionel J. , Moubarik Chahrazad , Bruder Nicolas J. , Pisano Pascale S. , Guillet Benjamin A.
Published: May 2009

Background

Preconditioning the brain with volatile anesthetics seems to be a viable option for reducing ischemic cerebral injury. However, it is uncertain whether this preconditioning effect extends over a longer period of time. The purpose of this study was to determine if sevoflurane preconditioning offers durable neuroprotection against cerebral ischemia.

Methods

Rats (Sprague-Dawley) were randomly allocated to two groups: nonpreconditioned control group (n = 44) and preconditioned group (n = 45) exposed to 2.7 vol% sevoflurane (45 min) 60 min before surgery. Animals in both groups were anesthetized with 3.0 vol% sevoflurane and subjected to transient middle cerebral artery occlusion. After 60 min of awake focal ischemia, the filament was removed. Functional neurologic outcome (range 0-18; 0 = no deficit), cerebral infarct size (Nissl staining), and apoptosis (Terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate nick-end labeling; cleaved caspase-3 staining) were evaluated at 3, 7, and 14 days after ischemia.

Results

Sevoflurane preconditioning significantly improved functional outcome and reduced infarct volume (109 +/- 43 vs. 148 +/- 56 mm(3)) 3 days after ischemia compared to the control group. However, after 7- and 14-day recovery periods, no significant differences were observed between groups. The number of apoptotic cells was significantly lower in the preconditioned group than in the control group after 3- and 7-day recovery periods. Fourteen days after ischemia, no differences were observed between groups.

Conclusion

In this model of transient focal cerebral ischemia, sevoflurane preconditioning induced effective but transient neuroprotective effects. Sevoflurane preconditioning also decreased ischemia-induced apoptosis in a more sustained way because it was observed up to 7 days after injury.
Drowning
Authors: Layon A Joseph , Modell Jerome H. , Warner David S. , Warner Mark A.
Published: May 2009

Over the past four decades, we have learned considerably more about the pathophysiology and treatment of drowning. This, coupled with increased emphasis in improvement in water safety and resuscitation, has produced a threefold decrease in the number of deaths, indexed to population, from drowning in the United States yearly. This review presents the current status of our knowledge of the epidemiology, the pathophysiology of drowning and its treatment, updates the definitions of drowning and the drowning process, and makes suggestions for further improvement in water safety.
Mini-epidemic of Erroneous Central Venous Pressure Measurements Resulting from the Malproduction of a Specific Part of a Pressure Transducer System
Authors: Görlinger Klaus , Kehren Clemens J. , Peters Jürgen
Published: May 2009

Electromanometric blood pressure measurements are routine in critically ill patients, and many interventions are based on correct measurements. We report a mini-epidemic of erroneous central venous pressure measurements due to faulty pressure transducer manufacturing resulting in wrong therapeutic decisions.
Feasibility of Tobacco Interventions in Anesthesiology Practices
Authors: Warner David O.
Published: May 2009

Background

Abstinence from smoking can improve postoperative outcomes, and surgery is also an excellent opportunity for smokers to permanently quit. One strategy for perioperative tobacco interventions is that anesthesiologists Ask, Advise, and Refer (AAR) -- Ask their patients about tobacco use, Advise them to abstain, and Refer them to resources such as telephone quit-lines. This pilot project determined the feasibility and acceptability of the AAR strategy in anesthesiology practices.

Methods

An educational program, including presentations, written materials, and Web-based resources, was developed and disseminated to 14 U.S. anesthesiology practices, representing both academic and private practices, who agreed to implement the AAR strategy as a part of their routine clinical practice. Three months after implementation, a survey was administered to those members of these practices who were instructed in the AAR strategy.

Results

There were 97 respondents (75% response rate). Since the pilot project began, 91%, 79%, and 58% of respondents reported that they frequently or almost always asked, advised, and referred their patients who smoke, respectively. The majority of respondents (56%) agreed that they were responsible for helping patients get the help they need to quit smoking. Most (74%) also agreed that they planned to incorporate the AAR strategy into their routine practice.

Conclusion

These results suggest that the AAR strategy is potentially feasible and well-accepted in anesthesiology clinical practice. Further work will be needed to define whether these practices and attitudes can be sustained and whether they are ultimately effective in modifying perioperative smoking behavior in surgical patients.
Metabolic Myopathies: Update 2009
Authors: van Adel Brian A , Tarnopolsky Mark A
Published: May 2009

Metabolic myopathies are inborn errors of metabolism that result in impaired energy production due to defects in glycogen, lipid, mitochondrial, and possibly adenine nucleotide metabolism. Fatty acid oxidation defects (FAOD), glycogen storage disease, and mitochondrial myopathies represent the 3 main groups of disorders, and some consider myoadenylate deaminase (AMPD1 deficiency) to be a metabolic myopathy. Clinically, a variety of neuromuscular presentations are seen at different ages of life. Newborns and infants commonly present with hypotonia and multisystem involvement (liver and brain), whereas onset later in life usually presents with exercise intolerance with or without progressive muscle weakness and myoglobinuria. In general, the glycogen storage diseases result in high-intensity exercise intolerance, whereas the FAODs and the mitochondrial myopathies manifest predominately during endurance-type activity or under fasted or other metabolically stressful conditions. The clinical examination is often normal, and testing requires various combinations of exercise stress testing, serum creatine kinase activity and lactate concentration determination, urine organic acids, muscle biopsy, neuroimaging, and specific genetic testing for the diagnosis of a specific metabolic myopathy. Prenatal screening is available in many countries for several of the FAODs through liquid chromatography-tandem mass spectrometry. Early identification of these conditions with lifestyle measures, nutritional intervention, and cofactor treatment is important to prevent or delay the onset of muscle weakness and to avoid potential life-threatening complications such as rhabdomyolysis with resultant renal failure or hepatic failure. This article will review the key clinical features, diagnostic tests, and treatment recommendations for the more common metabolic myopathies, with an emphasis on mitochondrial myopathies.
Mutilating Acral Ulcers: The Spectrum of Differential Diagnosis
Authors: Izadyar Shahram , Kwan Justin Y , Gundogdu Betul M , Phan Cecile L , Harati Yadollah
Published: May 2009

Prominent acral mutilating ulcers can be present in sensorimotor neuropathies. Although diabetes mellitus is the most common cause of neuropathic ulcers, these skin lesions may manifest in nondiabetic neuropathies. The dermatologic abnormalities may even precede the onset of typical neuropathic symptoms, leading to diagnostic confusion. Therefore, a broad differential diagnosis of neurological and systemic disorders should be considered when evaluating patients who have acral skin ulcerations. We report 3 cases of mutilating ulcers associated with nondiabetic neuropathies. The first case is a woman with multiple ulcerations on her forearm, hands, and toes. Her nerve biopsy revealed neuropathy with multiple congophilic deposits consistent with amyloid neuropathy. The second case is a woman with necrotic painless ulcer on her heel. Nerve biopsy in this patient revealed features suggestive of vasculitic neuropathy. The third case is a man with multiple ulcers on his extremities. A sural nerve biopsy in this patient was consistent with leprous neuropathy.
The Use of Rapid Endovascular Balloon Occlusion in Unstable Patients with Ruptured Abdominal Aortic Aneurysm
Authors: Philipsen Tine E. , Hendriks Jeroen M. , Lauwers Patrick , Voormolen Maurits , d'Archambeau Olivier , Schwagten Veerle , Fias Lore , Van Schil Paul E.
Published: May 2009

Objective

To present our results and demonstrate advantages of rapid endovascular balloon occlusion (REBO) of the juxtarenal aorta in unstable patients with ruptured abdominal aortic aneurysm (rAAA).

Methods

Since 2006, all unstable patients with rAAA are immediately transferred to the operating room (OR). No computed tomography scan is performed once diagnosis is made on ultrasound examination. Instability is defined as systolic blood pressure less than 60 mm Hg, unconsciousness, cardiac ischemia, or intubation. Once arrived in the OR, a Reliant aortic balloon is introduced and inflated at the level of the renal arteries. Subsequently, an angiogram is made through the contralateral femoral artery in order to decide between open or endovascular repair (EVAR).

Results

Twelve patients with rAAA were defined as unstable. REBO was installed within 10 minutes after arrival in the OR. Aortic occlusion resulted in immediate hemodynamic stability. Five patients were suitable for EVAR. Seven patients had open repair. For these abdominal dissection was more careful since no instability was encountered. All patients survived the procedure except one. Mean stay on intensive care unit was 19.7 days for open group and 8.4 for EVAR.

Conclusions

REBO of the juxtarenal abdominal aorta by pc technique in unstable patients with rAAA resulted in a 17% 30-day mortality and a 100% 1-year event-free follow-up for survivors. With this technique, EVAR exclusion is still a valuable treatment. Exposure and decision making for the open group is easier to perform with less risk for additional damaging to neighboring structures during dissection since urgent cross-clamping is not necessary.
Complex Aortic Valve Surgery for Endocarditis Using the Beating-Heart Technique
Authors: Ricci Marco , Suarez Maria R. , Panos Anthony L. , Macedo Francisco Igor B. , Brown Michael , Alba Julia , Salerno Tomas A.
Published: May 2009

Objective

Surgical outcomes of aortic valve surgery for endocarditis are poor. Postoperative deterioration of left ventricular (LV) function may contribute to this process. To enhance preservation of myocardial function during aortic valve surgery, we have used a beating-heart technique of myocardial protection without cardioplegic arrest. The aim of this article is to report our initial clinical experience with this technique.

Methods

We identified 30 consecutive patients with endocarditis who underwent aortic valve repair (one patient) or replacement using either a mechanical prosthesis (four patients) or a biologic prosthesis (25 patients) with beating-heart technique. There were 22 men and eight women (mean age 52.8 ± 16.1 years). There were one elective, 22 urgent/emergent, and seven “salvage” operations. Two patients had preoperative stroke, five respiratory failure, three renal failure, 12 congestive heart failure, eight septic shock, and one previous coronary artery bypass grafting. The etiology of the infection was identified in 15 patients (50%). Ten patients had severe, seven moderate, and four mild aortic insufficiency. All patients had vegetations, four had annular abscesses, and two had intracardiac fistulas.

Results

Eight patients (26.6%) had redo procedures. Concomitant procedures included aortic and mitral valve procedure (14 patients), tricuspid valve procedure (two patients), and coronary artery bypass grafting (one patient). Aortic annular reconstruction was required in four patients (13.2%). Total CPB time was 125 ± 67 minutes. Intra-aortic balloon pump was needed in one patient. Two patients (6.6%) had a stroke unrelated to air embolism. Mean follow-up was 7.9 ± 12 months. Early mortality (30 days) was 13.3% (four patients), and late mortality was 10% (three patients). Total mortality was 18% in urgent/emergent cases, and 42% in salvage operations. There was no statistical difference between preoperative and postoperative echocardiographic values of LV function (ejection fraction and fractional shortening). LV end-diastolic dimension decreased postoperatively (P = 0.03), whereas LV end-systolic dimension and left atrial size were unchanged.

Conclusions

Our study did not show improved survival benefits of beating-heart aortic valve surgery compared with historical series in which conventional myocardial protection was used. However, our findings suggest that beating-heart technique is an alternative strategy of myocardial protection that may contribute to preservation of LV function in patients undergoing complex operations for aortic valve endocarditis.
Intraoperative Epiaortic Ultrasound Scanning Guides Operative Strategies and Identifies Patients at High Risk during Coronary Artery Bypass Grafting
Authors: Lyons Jefferson M. , Thourani Vinod H. , Puskas John D. , Kilgo Patrick D. , Baio Kim T. , Guyton Robert A. , Lattouf Omar M.
Published: May 2009

Objective

Epiaortic ultrasound (EU) reliably reveals ascending aortic atherosclerosis (AAA), allowing strategies to minimize the risk of embolization or plaque disruption during coronary artery bypass grafting. Our objective was to delineate if EU-guided intervention improved outcomes.

Methods

Patients undergoing coronary artery bypass grafting (2004–2007) were categorized by EU grade (grade 1–2 [mild] vs. 3–5 [moderate/severe]) and the use of an aortic clamp. A propensity score estimated probability of clamp use was based on 45 risk factors. Multiple logistic regression models measured the association between outcomes—death, stroke, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE)—and the primary variables (grade and clamp use), adjusted for propensity score.

Results

Grade was available in 4278 patients. Patients with grade 3 to 5 AAA had an increased risk of death (adjusted odds ratios (AOR) 3.11; P < 0.001), stroke (AOR 2.12; P < 0.001), and MACCE (AOR 2.58; P < 0.001). Aortic clamping (any clamp, all grades) led to a higher risk of stroke (AOR 2.77; P = 0.032). EU altered aortic manipulation in 530 patients (12.4%). In this group, patients with high grade aortas had similar rates of death, stroke or MACCE, when compared with patients with low-grade aortas.

Conclusions

EU alters surgical strategy. Patients with grade 3 to 5 AAA are at increased risk of death, stroke, and MACCE compared with patients with grade 1 to 2 AAA. Clamping the aorta (any grade) increases the risk for stroke. Aortic clamping should be avoided in patients with grade 3 to 5 AAA, but EU may minimize morbidity and mortality if a clamp must be used.
Effects of Ultrasonic Skeletonization of the Gastroepiploic Artery on Endothelial Nitric Oxide Production
Authors: Terada Takuro , Tomita Shigeyuki , Asaumi Yoshihide , Koshida Yoshinao , Ishikawa Nobuki , Watanabe Go
Published: May 2009

Objective

The right gastroepiploic artery (GEA) is a reliable conduit for coronary artery bypass grafting. Recently, ultrasonic skeletonization in graft harvesting has attracted attention as an alternative technique to increase the length and caliber size of grafts. The influence of GEA skeletonization using an ultrasonically activated device with that using an electrosurgical unit was compared from the viewpoint of production of nitric oxide (NO).

Methods

Fourteen pigs were used in this study. The GEA were harvested using an ultrasonically activated device (group ultrasonically activated device [USAD], n = 7) or electrocautery (group E, n = 7). Blood sampling was performed at the following three times from the distal end of the GEA: (1) preskeletonization, (2) pedicle, and (3) postskeletonization. Plasma NOx (NO metabolites) levels were measured by chemiluminescent assay. Moreover, in excised specimens, the expression of nitric oxide synthase was examined immunohistologically.

Results

In group USAD, the preskeletonization basal level of plasmaNOx in GEA was 25.7 ± 10.9 μmol/L, which then increased to 26.9 ± 10.5 μmol/L (pedicle) and 32.2 ± 12.1 μmol/L (postskeletonization). In group E, the preskeletonization basal plasma NOx level in GEA was 28.9 ± 11.4 μmol/L, which changed to 27.5 ± 8.9 μmol/L (pedicle) and 21.8 ± 8.3 μmol/L (postskeletonization). The results of multivariate analysis indicated that the patterns of changes in plasma NOx level were significantly different in both groups (P = 0.024). In group USAD, post hoc multiple comparison tests revealed a significant difference between preskeletonization and postskeletonization (P = 0.037).

Conclusions

Ultrasonically skeletonized GEA showed increased effective graft length, higher free flow capacity, and increased endothelial NO production than that prepared using an electrosurgical unit.
Stentless versus Stented Bioprosthetic Aortic Valves
Authors: Pepper John , Cheng Davy , Stanbridge Rex , Ferdinand Francis D. , Jamieson W. R. Eric , Stelzer Paul , Berg Geoffrey , Sani Guido , Martin Janet
Published: May 2009

Objective

The purpose of this consensus conference was to determine whether stentless bioprosthetic valves improve clinical and resource outcomes compared with stented valves in patients undergoing aortic valve replacement, and to outline evidence-based recommendations for the use of stentless and stented bioprosthetic valves in adult aortic valve replacement.

Methods

Before the consensus conference, the best available evidence was reviewed in that systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of validity and importance. At the consensus conference, evidence-based statements were created, and consensus processes were used to determine the ensuing recommendations. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of recommendation.

Results and Recommendations

Seventeen randomized studies published in 23 articles involving 1317 patients, and 14 nonrandomized trial published in 18 articles involving 2485 patients were included in the meta-analysis and consensus conference. All randomized trials inserted the stentless bioprosthetic valves in the subcoronary configuration. The consensus panel agreed upon the following statements and recommendations in patients undergoing aortic valve replacement: 1. Stentless and stented valves both provide an excellent valve substitute for aortic valve disease (class I, level A). 2. In certain situations, the early superior hemodynamic performance of stentless bioprosthesis offers advantages over stented valves (class IIa, level A). Because there were no randomized control trial comparing subcoronary stentless prosthetic valve and root replacement, the following recommendations are derived from expert opinion: 1. In the absence of aortic root disease and with an annulus greater than or equal to 21 mm, either stentless or stented valves are acceptable alternatives for the majority of patients when a current (second or third) generation bioprosthesis is indicated (class I, level C). 2. In the presence of an aortic annulus <21 mm, the use of a freestanding bioprosthetic root can be considered as an alternative to enhanced diameter stented bioprosthesis or a root enlargement procedure (class I, level C).
Epicardial Ablation on the Beating Heart
Authors: Lee Anson M. , Aziz Abdulhameed , Sakamoto Shun-Ichiro , Schuessler Richard B. , Damiano Ralph J.
Published: May 2009

Objective

To perform a minimally invasive procedure for atrial fibrillation without cardiopulmonary bypass, it is necessary to create transmural lesions on the beating heart. Although bipolar radiofrequency clamps can isolate the pulmonary veins, they have difficulty in performing any other left atrial lesions, particularly those of the traditional Cox-Maze procedure. This study examined the performance of an internally cooled, bipolar radiofrequency device designed for such an application.

Methods

Eleven domestic pigs underwent median sternotomy. Five animals had eight atrial lesions created with the radiofrequency device at times of 20, 30, 40, and 50 seconds. In six other pigs, the device was compared with another technology that has been used clinically for epicardial, beating heart ablation, the Guidant Flex 4 microwave device. The tissue was stained with 2,3,5-triphenyltetrazoluim chloride, and the lesions were sectioned at 5-mm intervals. Lesion width, depth, and transmurality were evaluated.

Results

The radiofrequency device had a linear dose-response relationship. Lesions were wider and deeper with increasing ablation times. A total of 40%, 45%, 60%, and 67% of lesions were transmural at times of 20, 30, 40, and 50 seconds, respectively. Ninety-one percent of lesions in tissue up to 4-mm thick were transmural after 50 seconds. However, performance in thicker tissue was poor. Lesions created by the device were deeper and more likely to be transmural than the Flex 4.

Conclusions

This internally cooled, bipolar radiofrequency device can reliably create transmural lesions on tissue up to 4-mm thick and performs better than a microwave device.
Epidemiology of Pediatric Chronic Inflammatory Bowel Disease in Central and Western Slovenia, 1994–2005
Authors: Orel Rok , Kamhi Tina , Vidmar Gaj , Mamula Petar
Published: May 2009

Background:

The aim of this study was to determine the epidemiological and clinical characteristics of inflammatory bowel disease (IBD) in children in central and western Slovenia during a 12‐year period (1994–2005).

Materials and Methods:

The medical records of patients with newly diagnosed IBD during the period of 1994–2005 were retrospectively reviewed.

Results:

In the 12‐year study period, 137 children received new diagnoses of IBD, 60% had Crohn disease (CD), 28% had ulcerative colitis (UC), and 12% had indeterminate colitis (IC). The mean annual incidence of IBD for the whole 12‐year period was 4.03/100,000 children; for CD 2.42, for UC 1.14, and for IC 0.47. The annual incidence of IBD rose from 3.04 in the period 1994–1999 to 5.14 in the period 2000–2005. The incidences of CD, UC, and IC rose from 1.99, 0.77, and 0.28, respectively, in the first 6 years to 2.88, 1.57, and 0.69, respectively, in the second 6‐year period. The most common type of CD at presentation was inflammatory. Pancolitis was the most frequent form of UC. Almost half of the patients had a severe form of CD at its onset.

Conclusions:

The incidence of total pediatric IBD in central and western Slovenia is high and seems to be still rising. CD is the most prevalent form of IBD; its incidence is comparable with that reported in other central and western European countries. The incidences of UC and IC are rising more rapidly than the incidence of CD.
Oats Do Not Induce Systemic or Mucosal Autoantibody Response in Children With Coeliac Disease
Authors: Koskinen Outi , Villanen Mikko , Korponay‐Szabo Ilma , Lindfors Katri , Mäki Markku , Kaukinen Katri
Published: May 2009

Objectives:

A gluten‐free diet omitting wheat, rye, and barley is the only effective treatment for coeliac disease. The necessity of excluding oats from the diet has remained controversial. We studied the toxicity of oats in children with coeliac disease during a 2‐year follow‐up by investigating jejunal transglutaminase 2 (TG2)‐targeted IgA‐class autoantibody deposits, a potentially more sensitive disease marker than serum antibodies or conventional histology.

Patients and Methods:

Twenty‐three coeliac children in remission were randomized to undergo oat or gluten challenge with wheat, rye, barley, and oats. When jejunal histological relapse was evident after gluten challenge, patients excluded wheat, rye, and barley but continued with oats. Mucosal morphology and TG2‐targeted autoantibody deposits were studied in jejunal biopsies taken at baseline and after 6 and 24 months. Furthermore, serum IgA‐class TG2 antibodies were measured.

Results:

At baseline, serum TG2 antibodies were negative in all 23 patients, but 7 of them had minor mucosal deposits. In the oats group, there was no significant change in the intensity of the deposits within 2 years. In contrast, during the gluten challenge, the intensity of the deposits clearly increased and decreased again when wheat, rye, and barley were excluded but consumption of oats was continued; this was in line with serum autoantibodies. The intensity of the mucosal deposits correlated well with both villous morphology and serum autoantibody levels.

Conclusions:

Consumption of oats does not induce TG2 autoantibody production at mucosal level in children with coeliac disease. Measurement of small‐intestinal mucosal autoantibody deposits is suitable for monitoring treatment in coeliac patients.
Bowel Habits and Toilet Training in a Diverse Population of Children
Authors: Wald Ellen R , Di Lorenzo Carlo , Cipriani Lynne , Colborn D Kathleen , Burgers Rosa , Wald Arnold
Published: May 2009

Objectives:

To gather data concerning bowel habits and toilet training of developmentally normal children ages 5 to 8 years.

Methods:

A questionnaire containing information on age, race, and sex was completed anonymously by a parent in 9 pediatric practices. Recall information was elicited about onset and completion of toilet training, frequency and quality of stooling, size of bowel movements, and behavioral components of defecation.

Results:

Questionnaires were completed for 1142 children. When all of the children were considered together, toilet training started at a mean of 27.2 months and was completed at a mean of 32.5 months. It began and was completed nearly 3 months earlier for girls than for boys (P < 0.001). African American children started and completed toilet training at least 6 months earlier than white children (P < 0.001). Of the children, 95% defecated either daily or every other day. Straining at defecation and infrequent stooling were reported significantly more often for girls, whereas staining of underclothes and passage of large bowel movements were reported more often in boys. Approximately 10% of children fulfilled criteria for functional constipation.

Conclusions:

Most of the children between 5 and 8 years of age have a medium‐size bowel movement daily or every other day without straining or withholding. Although African American children toilet train at an earlier age than do white children, bowel habits appear to be similar. A sizeable subgroup of children presenting to primary care providers have a history that is consistent with constipation.
Pruritus Ani: An Approach to an Itching Condition
Authors: Stermer Edy , Sukhotnic Igor , Shaoul Ron
Published: May 2009

Pruritus ani is frequently encountered in children by the primary care physician and the pediatrician. It is mainly due to an infection with pinworms, but fecal soiling, poor hygiene, local irritation, and dietary agents should also be considered. Treatment should be directed at the underlying etiology. Once these have been excluded, both general and specific measures must be initiated. There is almost no experience for local treatment modalities in children, and they cannot currently be recommended.