bluuebunny/crossref_metadata_2025 huggingface dataset:
Erythropoietin measurements in severely traumatized patients
Authors: VIALET R. , VENTRÉ C. , LEONE M. , CONFORTO C. , MARTIN C.
Published: August 2010

Background:Despite numerous studies in critically ill patients, physiological adaptation to acute anaemia and the pattern of erythropoietin (EPO) secretion has not been well described in severely injured patients. The aim of this study was to describe EPO secretion and its relationship with haemoglobin (Hb) levels in severely injured patients.

Methods:We performed an observational, prospective clinical study in our intensive care unit (ICU). For all patients with severe trauma (Injury Severity Score>15), EPO measurement was obtained on admission, during the first 3 days and then when Hb level was measured. Maximal EPO level (EPOmax) and minimal Hb level (Hbmin) during the ICU stay was determined for all patients.

Results:One hundred and seventy‐one consecutives patients were included (440 EPO measurements). Seventy‐nine patients (46.2%) showed an increased value (≥25 UI/l) EPOmax value. Most EPOmax values were observed early after the trauma [within 4 days for 63 patients (82.8%)].

Plotting EPOmax to Hbmin values show that a threshold Hbmin value of 105 g/l best discriminated patients with and without an elevated EPO secretion. Less than 10% of the patients with Hbmin<105 g/l did not increase their EPO secretion.

Conclusion:In severely traumatized patients a marked response to acute anaemia is observed in most patients. In our study, Hb threshold for a significant EPO secretion following post‐traumatic acute anaemia was 105 g/l. The peak level was achieved early in the course of the anaemia.
Influence of acute normovolaemic haemodilution on bispectral index monitoring and propofol dose requirements
Authors: DAHABA A. A. , RINNHOFER S. , WANG G. , XU X. , LIU X. Y. , WU X. M. , REHAK P. H. , METZLER H.
Published: August 2010

Background: Numerous medical and physiological conditions that might alter electroencephalography (EEG), such as hypoglycaemia, hypothermia or hypovolaemia, were shown to result in the bispectral Index (BIS) indicating an incorrect hypnotic state. Recently, acute normovolaemic haemodilution (ANH) was shown to be associated with significant impairment of cognitive functions that could alter EEG and consequently BIS monitoring, an EEG derived parameter.

Methods: In a randomised clinical study, we assessed the effect of ANH on BIS monitoring before induction and after propofol target controlled infusion (TCI) anaesthesia in 45 unmedicated patients randomly allocated to ANH with oxygen insufflation (oxygen group), ANH with air insufflation (air group), or control group.

Results: With ANH, mean BIS values briefly declined in the oxygen group (82±4) and air group (84±3) before returning to baseline values. The loss of consciousness time was significantly shorter, with fewer propofol TCI dose requirements, and BIS was significantly higher in the oxygen group (1.3±0.5 min, 2.41±0.15 μg/ml, 73±7) and air group (1.2±0.6 min, 2.44±0.17 μg/ml, 75±5), compared with the control group (1.7±0.4 min, 2.75±0.17 μg/ml, 61±5), respectively. Whereas, there was no significant difference in BIS values between the oxygen group (38±7), air group (36±5) and control group (40±6) at propofol TCI 4 μg/ml anaesthesia maintenance.

Conclusions: BIS values briefly declined with ANH before returning to baseline values before anaesthesia induction. Despite transient ANH enhancement of propofol effect during induction, there was no significant difference in BIS values with or without ANH during propofol maintenance of anaesthesia.
Process of foregoing life‐sustaining treatment: a survey among Scandinavian intensivists
Authors: Hynninen M. , Klepstad P. , Petersson J. , Skram U. , Tallgren M.
Published: August 2010

Background: How ethical issues are dealt with varies considerably depending on the geographic and religious background of individuals. The views of Scandinavian physicians on end‐of‐life care were studied using a survey. The aim of this study was to clarify the actual processes of foregoing life‐sustaining treatment in Scandinavia.

Methods:

A questionnaire was developed and sent to 78 intensive care physicians working in Denmark, Finland, Norway and Sweden.

Results: Forty‐four responses were obtained (13 from Denmark, eight from Finland, 12 from Norway and 11 from Sweden); 89% of the respondents were from University Hospitals. Withholding and withdrawing of treatment were practiced in all intensive care units (ICUs) concerned, but written guidelines on end‐of‐life care existed in only one ICU. End‐of‐life care is usually arranged in the ICU. Religious support is available in most hospitals during office hours, but lacking in 26% of ICUs outside office hours. Vasoactive medication, renal replacement therapy, and artificial nutrition are among the therapies most likely to be discontinued during withdrawal of life support. Certain types of monitoring and organ support are still continued in many centers during end‐of‐life care.

Conclusion: Local written guidelines on end‐of‐life care are scarce in Scandinavian ICUs, which may explain the observed variability in the practices. Development of guidelines and monitoring how these instructions are carried out may help to improve the quality of care of dying ICU patients.
Increased plasma glutamate, glycine, and arginine levels in complex regional pain syndrome type 1
Authors: WESSELDIJK F. , FEKKES D. , HUYGEN F. J. P. M. , VAN DE HEIDE‐MULDER M. , ZIJLSTRA F. J.
Published: August 2010

Background: Various inflammatory mediators have been identified as potential contributors to complex regional pain syndrome type 1 (CRPS1), but these mediators do not entirely explain certain manifestations of the syndrome, such as pain. The objective of this study was to investigate the role of amino acids in the pathogenesis of CRPS1.

Methods: We used HPLC to determine plasma concentrations of 16 amino acids, especially those related to the NMDA receptor (e.g., glutamate and glycine) and nitric oxide (NO) synthesis (e.g., arginine and citrulline) in patients with CRPS1 (n=64) and age‐ and sex‐matched healthy controls (n=51). Patients rated pain intensity (visual analog scale) and the subjective experience of pain intensity (McGill Pain Questionnaire). Psychological dysfunction was assessed using the SCL‐90.

Results: Relative to controls, in CRPS1 patients, plasma levels of glutamate, arginine, taurine, and glycine were increased, and plasma levels of glutamine and the ratio of citrulline to arginine were decreased. Remarkably, in CRPS1 patients there was a highly significant inverse correlation between glutamine and glutamate, although the sum of molar concentrations of glutamate and glutamine remains unchanged. Subjective measures of pain and indicators of psychoneuroticism and emotional instability did not correlate with amino acid levels.

Conclusion: This study shows for the first time a pronounced increase in amino acid levels in this chronic pain syndrome. The marked differences in glutamate, glutamine, glycine, taurine and arginine levels between patients and controls suggest the involvement of both the NDMA receptor and the endothelium‐dependent arginine‐NO system in CRPS1.
Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia
Authors: HANS G. A. , SENARD M. , LEDOUX D. , GRAYET B. , SCHOLTES F. , CREEMERS E. , LAMY M. L.
Published: August 2010

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.
Physiological effects of a lung‐recruiting strategy applied during one‐lung ventilation
Authors: CINNELLA G. , GRASSO S. , NATALE C. , SOLLITTO F. , CACCIAPAGLIA M. , ANGIOLILLO M. , PAVONE G. , MIRABELLA L. , DAMBROSIO M.
Published: August 2010

Background: One‐lung ventilation (OLV) affects respiratory mechanics and ventilation/perfusion matching, reducing functional residual capacity of the ventilated lung. While the application of a lung‐recruiting manoeuvre (RM) on the ventilated lung has been shown to improve oxygenation, data regarding the impact of RM on respiratory mechanics are not available.

Methods: Thirteen patients undergoing lung resection in lateral decubitus were studied. During OLV, a lung‐recruiting strategy consisting in a RM lasting 1 min followed by the application of positive end‐expiratory pressure 5 cmH2O was applied to the ventilated lung. Haemodynamics, gas exchange and respiratory mechanics parameters were recorded on two‐lung ventilation (TLVbaseline), OLV before and 20 min after the RM (OLVpre‐RM, OLVpost‐RM, respectively) and TLVend. Haemodynamics parameters were also recorded during the RM.

Results: The PaO2/FiO2 ratio was 358±126 on TLVbaseline; it decreased to 235±113 on OLVpre‐RM (P<0.01) increased to 351±120 on OLVpost‐RM (P<0.01 vs. OLVpre‐RM), and remain stable thereafter. During the RM, CI decreased from 3.04±0.7 l/m2 OLVpre‐RM to 2.4±0.6 l/m2 (P<0.05), and returned to baseline on OLVpost‐RM (3.1±0.7 l/m2, NS vs. OLVpre‐RM). The RM resulted in alveolar recruitment and caused a significant decrease in static elastance of the dependent lung (16.6±8.9 cmH2O/ml OLVpost‐RM vs. 22.3±8.1 cmH2O/ml OLVpre‐RM) (P<0.01).

Conclusions: During OLV in lateral decubitus for thoracic surgery, application to the dependent lung a recruiting strategy significantly recruits the dependent lung, improving arterial oxygenation and respiratory mechanics until the end of surgery. However, the transient haemodynamic derangement occurring during the RM should be taken into account.
Comparison of nerve stimulation vs. ultrasound‐guided lateral sagittal infraclavicular block
Authors: GÜRKAN Y. , ACAR S. , SOLAK M. , TOKER K.
Published: August 2010

Background: A nerve stimulation‐guided lateral sagittal infraclavicular block (LSIB) has been proven to be an effective block. The purpose of this study was to evaluate whether the use of ultrasound (US) guidance would further improve the block quality of LSIB.

Methods: In a prospective manner, 80 adult patients scheduled for hand, wrist and forearm surgery were randomly allocated to US or nerve stimulation (NS) groups. A needle was inserted into a sagittal plane, 20° dorsally, until muscle twitches were observed in synchrony with the stimulation. In the US group, the block was performed using the same puncture site but under ultrasonic guidance. The final position of the needle was verified with the use of a nerve stimulator. A local anesthetic mixture of 20 ml of levobupivacaine, 5 mg/ml and 20 ml of lidocaine and 20 mg/ml with 5 μg/ml epinephrine (total 40 ml) was administered in both groups.

Results: The block was successful in 37 patients in the NS group and 38 patients in the US group. Block efficacy was better in the US group than the group NS in radial nerve distribution at 20 min (P<0.05). In the US group, there was a slight tendency toward better block density in other nerve areas also but these differences were not significant. Vascular puncture was noted in three patients in the NS group and none in the US group.

Conclusions: The block success rate was high and comparable in both groups. There was a trend toward improved block quality in the US group, although not significant.
Apolipoprotein E polymorphism and gender difference in outcome after severe traumatic brain injury
Authors: ÖST M. , NYLÉN K. , CSAJBOK L. , BLENNOW K. , ROSENGREN L. , NELLGÅRD B.
Published: August 2010

Background: Traumatic brain injury (TBI) is one of the most common causes of death and dismal outcome among children and young adults. The morbidity and mortality differ but more aggressive monitoring and more designated neuro intensive care units have improved the results. Studies have demonstrated a connection between apolipoprotein E (APOE) genotype and outcome after TBI, but few are prospective and none is from northern Europe. APOE has three alleles: ɛ2, ɛ3 and ɛ4.

Methods: A total of 96 patients with Glasgow coma score (GCS) ≤8 were prospectively and consecutively included. APOE genotypes were all analyzed at the same laboratory from blood samples by polymerase chain reaction‐restriction fragment length polymorphism.

Results: All patients were assessed at 1 year with Glasgow outcome scale extended (GOSE), National Institute of Health Stroke Scale (NIHSS) and the Barthel daily living index. The genotype was available in all patients. Twenty‐six patients expressed APOE ɛ4 while 70 patients did not. Outcome demonstrated that patients with APOE ɛ4 had worse outcome vs. those lacking this allele. When subdividing patients into gender, males with APOE ɛ4 did worse, a difference not detected among female patients.

Conclusions: APOE ɛ4 correlated to worse outcome in TBI patients. We also found that males with APOE ɛ4 had poor outcome while females did not. Thus, the results indicate that genetic polymorphism may influence outcome after TBI.
Use of an endotoxin adsorber in the treatment of severe abdominal sepsis
Authors: KULABUKHOV V. V.
Published: August 2010

Methods for lipopolysaccharide (LPS) (endotoxin) reduction have been proposed as one way to improve the treatment of Gram‐negative sepsis. Here we present a case with severe Gram‐negative sepsis, treated with a novel device for LPS adsorption (Alteco® LPS Adsorber, Alteco Medical AB, Lund, Sweden). After LPS adsorption, the level of LPS in the patient's bloodsteam was almost eliminated: from 1.44 EU/ml before treatment to 0.03 EU/ml post treatment). The procalcitonin level and inflammatory cytokines were concurrently reduced. Also, an obvious improvement in the status of the patient's hemodynamics was seen. Forty‐five days after treatment the patient is still alive. In conclusion, LPS adsorption may represent a significant improvement in the treatment of Gram‐negative sepsis and further studies are planned.
Cardiac surgery patients present considerable variation in pre‐operative hemodynamic variables
Authors: SLOTH E. , LINDSKOV C. , LORENTZEN A.‐G. , NYGAARD M. , KURE H. H. , JAKOBSEN C.‐J.
Published: August 2010

Background: It is essential to control hemodynamics in cardiac surgery. Patients are often monitored extensively in order to optimize hemodynamic performance. However, pre‐operative values are normally unknown. Furthermore, hemodynamic goals may seem arbitrary and the lack of an evidence‐based consensus may lead to both under‐ and over‐treatment. The aim of this study was to evaluate the variables most commonly used for hemodynamic guidance in the post‐operative period.

Methods: Ten patients scheduled for elective cardiac surgery were followed with invasive hemodynamic monitoring the night before surgery. All data were recorded automatically and electronically.

Results: We found considerable inter‐patient differences and intra‐patient variation. The greatest intra‐patient variation was found in the cardiac index (CI), ranging from 1.9 to 5.3 l/min/m2. Four patients had periodic CI <2.4 l/min/m2. Eight patients showed SpO2 values ≤92, four of them in more than 15% of the observations. Six patients had an SvO2 <70% in more than 40% of the observations and two an SvO2<64% in more than 20% of the observations.

Conclusions: This study is unique because hemodynamic reference data in cardiac surgery patients have not been published previously. The intra‐patient variations were unexpectedly high in most hemodynamic variables and demonstrate the difficulties of using hemodynamic parameters as a guidance for treatment and indicate that goal‐oriented therapy using currently accepted values may result in over‐treatment in some patients.
Hypotension in anaesthetized patients during aneurysm clipping: not as bad as expected?
Authors: HOFF R. G. , VAN DIJK G. W. , METTES S. , VERWEIJ B. H. , ALGRA A. , RINKEL G. J. E. , KALKMAN C. J.
Published: August 2010

Background: Patients with aneurysmal subarachnoid haemorrhage (SAH) often have disturbed autoregulation of cerebral blood flow. A reduction in systemic blood pressure during surgery may therefore lead to delayed cerebral ischaemia (DCI). To assess the incidence and severity of intra‐operative hypotension, we performed a retrospective cohort study in 164 patients with recent SAH and surgical clipping of the aneurysm.

Methods: Intra‐operative hypotension was defined in three levels of severity, as a decrease in mean arterial pressure (ΔMAP) of more than 30%, 40% or 50% compared with the pre‐operative pressure. For each patient the total amount of time with intra‐operative hypotension was retrieved. Logistic regression analysis was performed to study the relation between intra‐operative hypotension and the occurrence of DCI and poor outcome.

Results: A period with ΔMAP>30% occurred in 128 patients (78%) with a median duration of this period of 105 min (25–75‰ 50–171 min). ΔMAP>40% occurred in 88 patients (54%) and ΔMAP>50% occurred in 22 patients (13%). In univariate analysis, ΔMAP>50% was associated with poor outcome. After adjusting for age and World Federation of Neurological Surgeons grade, the association with poor outcome was no longer statistically significant [odds ratio (OR) 1.018; 95% CI 0.996–1.041].

Conclusion: Hypotension during surgical clipping of intracranial aneurysms occurred frequently. In our study population of patients mostly in good clinical condition, hypotension was not confirmed as an independent risk factor for DCI or poor outcome. Anaesthesia may have had a cerebral protective effect.
Racemic, S(+)‐ and R(−)‐ketamine do not increase elevated intracranial pressure
Authors: SCHMIDT A. , ØYE I. , ÅKESON J.
Published: August 2010

Background: There is controversy regarding the influence of ketamine and its enantiomers on cerebral haemodynamics at increased intracranial pressure (ICP). This study was designed to compare cerebrovascular responses, with particular respect to ICP, to bolus injections of racemic, S(+)‐ and R(−)‐ketamine in an experimental model of intracranial hypertension.

Methods: Nine pigs were anaesthetised with fentanyl and vecuronium during mechanical normoventilation. The ICP was raised with extradural balloon catheters to 23 mmHg. The intra‐arterial xenon clearance technique was used to determine cerebral blood flow (CBF). Three 60‐s bolus injections of racemic ketamine (10 mg/kg), S‐ketamine (5 mg/kg) and R‐ketamine (20 mg/kg) were given in a randomised sequence. Cerebral and systemic haemodynamic responses were evaluated before and at 1, 5, 10, 15, 30 and 45 min after each injection.

Results: Racemic ketamine decreased ICP (P=0.026) by maximally 10.8%, whereas there was no effect on ICP of S‐ (P=0.178) or R‐ketamine (P=0.15). All study drugs had similar biphasic effects on CBF, with maximal initial decreases by 25–29%, followed by transient increases by 7–15%, and a reduction of mean arterial pressure by maximally 22–37%.

Conclusions: A decrease or a lack of an increase in ICP in response to intravenous bolus injections of racemic, S‐ or R‐ketamine suggests that the administration of racemic or S‐ketamine might be safe in patients with intracranial hypertension due to a space‐occupying lesion. The ICP‐lowering effect indicates that racemic ketamine might offer a therapeutic advantage over S‐ketamine.
Nosocomial infections and infection control in regional anesthesia
Authors: SCHULZ‐STÜBNER S. , POTTINGER J. M. , COFFIN S. A. , HERWALDT L. A.
Published: August 2010

Background: Although rare, infectious complications from regional anesthesia and analgesia can be devastating. The literature on this topic consists primarily of surveys, case reports, case series, and studies in which used supplies were cultured. We derived infection control recommendations from the existing literature and compared these recommendations with existing guidelines.

Methods: Structured literature search of the Cochrane Central Register of Controlled Trials, MEDLINE, including old MEDLINE and EMBASE until 2005. Descriptive statistics were cited when applicable.

Main results: Incidence rates for infectious complications vary substantially between studies and range from 3.7 to 7.2/100,000 for spinal anesthesia‐associated meningitis and from 0.2 to 83/100,000 for epidural anesthesia‐associated epidural abscesses. Few comprehensive prospective trials have been conducted and most case reports do not provide complete information about infection control practices.

Conclusion: Studies using more robust methods are necessary to define the rates of infection after different regional anesthesia procedures and to identify risk factors for infections. Data on risk factors would allow anesthesiologists to develop evidence‐based guidelines for placement and care of catheters used for regional anesthesia. A multicenter surveillance system may help anesthesiologists address some of the unanswered questions and to develop evidence‐based infection control recommendations.
Effect of fentanyl on heart rate variability during spontaneous and paced breathing in healthy volunteers
Authors: VETTORELLO M. , COLOMBO R. , DE GRANDIS C. E. , COSTANTINI E. , RAIMONDI F.
Published: August 2010

Background:Many studies have been conducted to assess the effects of fentanyl on the autonomic nervous system (ANS) by heart rate variability (HRV) analysis, but disagreement on the results is still present due to confounding influences introduced by concomitant administration of other drugs or opioid‐related transitory respiratory depression. We performed a single‐drug controlled‐breathing study on healthy volunteers to assess the impact of fentanyl on ANS.

Methods:HRV as a measure of sympathovagal balance was prospectively analyzed with an autoregressive model in 11 subjects during spontaneous and paced breathing (PB) at 20 breaths/min both before and after fentanyl 1 mcg/kg administration. HRV total power, sympathovagal balance (low‐frequency/high‐frequency ratio) and normalized spectral powers were considered (LFnu, HFnu).

Results:Fentanyl led to a reduction of LFnu (from 55.2±23.3 to 43.2±24.1,P<0.05) without HFnu increase during PB. A decrease inR–Rinterval variance (from 3345.6±3333.4 to 1806.9±1328.6 ms2,P<0.05) was shown after fentanyl administration during spontaneous but not PB. PB alone decreased the HRV total power andR–Rinterval variance.

Conclusions:Low‐dose fentanyl administration in healthy volunteers leads to sympathetic and overall ANS modulation decrease, with a trend toward vagal activation.
Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload?
Authors: BARTHA E. , RUDIN Å. , FLISBERG P. , LUNDBERG C. J. , CARLSSON P. , KALMAN S.
Published: August 2010

Background: A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post‐operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high‐risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post‐operative costs of intensive care in patients receiving epidural or intravenous analgesia.

Methods: Clinical data and rates of post‐operative complications were extracted from a previously reported trial following thoraco‐abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care.

Results: Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros/patient, were outweighed by lower post‐operative costs of intensive care 5,571 vs. 7,921 Euros/patient (NS).

Conclusion: Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post‐operative care following major surgery.
Comparative evaluation of ultrasound‐guided continuous infraclavicular brachial plexus block with stimulating catheter and traditional technique: a prospective‐randomized trial
Authors: DHIR S. , GANAPATHY S.
Published: August 2010

Background: Secondary catheter failure has been reported in up to 40% of patients with continuous peripheral nerve blocks resulting in failure to provide pain relief after the initial block wears off. Introduction of stimulating catheters as well as ultrasound for regional anaesthesia has facilitated correct placement of catheter tip, closer to the plexus. This randomized study was conducted to compare the efficacy of continuous infraclavicular brachial plexus blocks using non‐stimulating catheter, stimulating catheter and ultrasound‐guided catheter placement with nerve stimulation assistance.

Methods: Patients undergoing elective hand surgery were randomly allocated to receive continuous infraclavicular brachial plexus block using non‐stimulating catheter [group traditional nerve stimulation (TR)], stimulating catheter [group stimulating catheter (ST)] or ultrasound‐guided catheter placement with nerve stimulation assistance [group ultrasound guidance with nerve stimulation assistance (US)]. Motor and sensory blocks were assessed every 5 min and primary block success was determined at 30 min. After resolution of the primary block, threshold stimulating current and resulting response, spread of drug on re‐injection as seen ultrasonographically and the capacity to re‐establish block was documented. Complications and need for supplement was noted.

Results: The primary block success was significantly higher in the US group [96% US, 58% ST, 59% TR (P=0.0005)]. Secondary catheter failure was significantly lower in the US group [9% US, 17% ST, 86% TR (P<0.0001)]. Axillary nerve was blocked more predictably in the US group (100% US, 79% ST, 50% TR (P=0.0003).

Conclusion: In this study, ultrasound guidance with nerve stimulation assistance significantly improved primary success and reduced secondary catheter failure in continuous infraclavicular brachial plexus blocks.
Impaired myocardial t‐PA release in patients with coronary artery disease
Authors: ÖSTERLUND B. , JERN S. , JERN C. , SEEMAN‐LODDING H. , ÖSTMAN M. , JOHANSSON G. , BIBER B.
Published: August 2010

Aims: Myocardial ischemia remains a significant perioperative complication in coronary artery disease (CAD) patients. We hypothesized that noxious stimuli during major surgery are associated with an acute release of tissue‐type plasminogen activator (t‐PA) into the coronary circulation, and that this response is reduced by CAD.

Methods and results: Two patient groups, with (n=14) and without (n=8) CAD, were studied during the initial phase of heart surgery. After retrograde great cardiac vein catheterizations during closed‐chest conditions, coronary arterial–venous concentration gradients of t‐PA and plasminogen activator inhibitor type‐1 (PAI‐1) were measured together with coronary blood flow measurements, allowing derivation of coronary net release rates. Pre‐surgery atrial pacing, performed to evaluate the influence of increases in heart rate (+40 beats/min) and coronary blood flow (+80 ml/min), did not significantly alter coronary net release of t‐PA or PAI‐1 in either patient group. Sternotomy induced a prominent increase in coronary net release of both total and active t‐PA in the non‐CAD group. This response was considerably reduced in the CAD group.

Conclusions: This study provides the first analysis of coronary t‐PA release during major surgery and demonstrates a deficient local endothelial t‐PA release in patients with CAD. This suggests a reduced local fibrinolytic capacity in CAD patients, which may explain the increased risk for coronary thrombosis in this patient group.
Effect of pulsed radiofrequency for postherpetic neuralgia
Authors: Kim Y. H. , Lee C. J. , Lee S. C. , Huh J. , Nahm F. S. , Kim H. Z. , Lee M. K.
Published: August 2010

Background: Postherpetic neuralgia (PHN) is one of the most intractable pain disorders, particularly among elderly patients. Lesioning of dorsal root ganglion (DRG) using pulsed radiofrequency (PRF) has shown pain reduction for PHN. We assessed the efficacy of PRF lesioning of DRG for PHN via an open, nonrandomized study.

Methods: Forty‐nine patients with PHN refractory to conservative therapy were involved. After impedance and sensory electrical nerve stimulation thresholds were assessed, PRF was performed three times adjacent to the DRG of corresponding levels at 42 °C for 120 s under the fluoroscopic guidance. Pain ratings were conducted on a visual analogue scale at 4‐, 8‐ and 12‐week follow‐up. The data were analyzed using the one‐way ANOVA test. P<0.05 was considered to be statistically significant.

Results: There was excellent pain relief (about 55%) at 4 weeks after PRF lesioning adjacent to the DRG and the effectiveness was maintained at the subsequent 12‐week follow‐up. The pain duration, age and stimulation level did not influence the outcome. There were no procedure‐related complications.

Conclusions: PRF lesioning of DRG showed significant pain relief compared with the conventional treatments in patients with intractable PHN. In order to elucidate the mode of action of PRF, further research is needed and the optimal electrical parameters of PRF have to be determined.
Early time course of altered leukocyte response to lipopolysaccharide and peptidoglycan in porcine gunshot injury
Authors: GUNDERSEN Y. , VAAGENES P. , THRANE I. , OS Ø. , PILLGRAM‐LARSEN J. , SUNDNES K. O. , AASEN A. O. , OPSTAD P. K.
Published: August 2010

Background: Penetrating injuries are frequently combined with polybacterial soiling. Clearance of the microorganisms depends on the ability to activate immune responses, but post‐traumatic hyporeactivity of immune cells is almost universal. The aim of this study was to map the early time course of this altered leukocyte reactivity, and to compare the reactions to subsequent Gram‐positive or Gram‐negative challenges.

Methods: Twelve juvenile pigs sustained two standardized rounds, one through the right femur and one through the left upper abdomen. First aid treatment and acute surgery were started immediately. Blood samples were drawn before trauma and after 10, 30, 60, and 90 min, and thereafter stimulated in ex vivo whole blood for 3 h with lipopolysaccharide (LPS, 10 ng/ml), peptidoglycan (PepG, 1 μg/ml), or an equivalent amount of normal saline. The leukocyte response was evaluated by measurement of tumor necrosis factor (TNF)‐α, interleukin (IL)‐1 β, IL‐6, IL‐8, and IL‐10 in the supernatant.

Results: In the post‐traumatic in vivo serum, the concentration of TNF‐α increased steadily (significant after 60 min). A reduced ex vivo reaction to LPS was evident after 10 min, and was statistically significant after 30 min. The lowest levels were reached after 90 min. The ex vivo synthesis of TNF‐α after stimulation with PepG remained unaltered. A similar development was seen for IL‐6. IL‐1 β levels did not change, while IL‐8 increased significantly only after 60 and 90 min.

Conclusions: Trauma almost instantaneously reprogrammed circulating leukocytes. As measured with TNF‐α, a profound hyporeactivity to LPS, but not to PepG, was induced. In addition, no global down‐regulation of leukocyte function was found after stimulation with LPS.
Comparison of etoricoxib vs. ketorolac in postoperative pain relief
Authors: LENZ H. , RAEDER J.
Published: August 2010

Background: COX‐2 inhibitors have been claimed to have equal analgesic efficacy as non‐selective nonsteroidal anti‐inflammatory drugs, but this has been disputed in animal experiments.

Methods: One hundred thirty‐three women scheduled for ambulatory, laparoscopic gynaecological surgery were included in this randomised, double‐blind study. Group E received 120 mg etoricoxib orally as premedication. Group K received 30 mg ketorolac i.v. after induction of anaesthesia. General anaesthesia was induced and maintained with propofol and remifentanil. Fentanyl 0.5 μg/kg i.v. and local wound anaesthesia was administered at the end of surgery. Postoperatively, the patients received fentanyl 0.5 μg/kg i.v. if visual analogue scale (VAS) ≥30 mm. Before discharge, Group K received 30 mg ketorolac i.v. Twenty‐four hours postoperatively, Group E received 120 mg etoricoxib.

Results: The first 4 h postoperatively, Group K required 83±65 μg and Group E required 123±91 μg fentanyl [mean (SD), P=0.004]. After 30 min VAS in Group K was 31.3±19.7 mm and 43.8±16.9 mm in Group E [mean (SD), P<0.001]. Discharge readiness was significantly shorter in Group K (222±40 min) compared with Group E (244±47 min) [mean (SD), P=0.004]. There were no differences in pain scores or rescue pain medication at 24 or 48 h postoperatively. Less nausea was observed in the 4–24‐h period in Group E.

Conclusions: Thirty milligram ketorolac i.v. after induction of anaesthesia resulted in significantly less immediate pain and opioid consumption during the first 4 h postoperatively compared with 120 mg etoricoxib preoperatively.
Risk factors and outcome in ICU‐acquired infections
Authors: MAGNASON S. , KRISTINSSON K. G. , STEFANSSON T. , ERLENDSDOTTIR H. , JONSDOTTIR K. , KRISTJANSSON M. , JONMUNDSSON E. , BALDURSDOTTIR L. , SIGVALDASON H. , GUDMUNDSSON S.
Published: August 2010

Background: Nosocomial infections are common in intensive care units (ICU). The objectives of this study were to determine risk factors of ICU‐acquired infections, and potential mortality attributable to such infections.

Methods: An observational study was performed in a 10‐bed multidisciplinary ICU. For a period of 27 months, all patients admitted for ≥48 h were included. Infections were diagnosed according to Centers for Disease Control and Prevention definitions. Airway colonization was explored by molecular typing. Risk factors for infection were determined by multivariable logistic regression. Survival was analyzed with time‐varying proportional hazards regression.

Results: Of 278 patients, 81 (29%) were infected: urinary tract infections in 39 patients (14%), primary bloodstream infections in 25 (9%), surgical site infections in 22 (8%) and pneumonia in 21 (8%). Of the total of 147 episodes, Gram‐negative bacilli were isolated in 90, Gram‐positive cocci in 49 and Candida sp. in 25. Risk factors for pneumonia were mechanical ventilation [odds ratio (OR=7.9, CI 1.8–35), lack of enteral nutriment (OR=8.0, CI 1.4–45) and length of time at risk (OR=1.8, CI 1.2–2.8), while gastric acid inhibitors did not affect the risk (OR=0.99, CI 0.32–3.0). Transmission of bacteria from the stomach to the airway was not confirmed. The risk of death was increased as patients were infected with pneumonia [hazard ratio (HR)=3.6; CI: 1.6–8.1], or primary bloodstream infection (HR=2.5; CI: 1.2–5.4), independent of age and disease severity.

Conclusions: Mortality was increased by ICU‐acquired pneumonia and primary bloodstream infections. Our findings did not support the gastro‐pulmonary hypothesis of ICU‐acquired pneumonia. The proposition that blood transfusions increase the risk of ICU‐acquired nosocomial infections was not supported.
Job satisfaction or production? How staff and leadership understand operating room efficiency: a qualitative study
Authors: ARAKELIAN E. , GUNNINGBERG L. , LARSSON J.
Published: August 2010

Background: How to increase efficiency in operating departments has been widely studied. However, there is no overall definition of efficiency. Supervisors urging staff to work efficiently may meet strong reactions due to staff believing that demands for efficiency means just stress at work. Differences in how efficiency is understood may constitute an obstacle to supervisors' efforts to promote it. This study aimed to explore how staff and leadership understand operating room efficiency.

Methods: Twenty‐one members of staff and supervisors in an operating department in a Swedish county hospital were interviewed. The analysis was performed with a phenomenographic approach that aims to discover the variations in how a phenomenon is understood by a group of people.

Results: Six categories were found in the understanding of operation room efficiency: (A) having the right qualifications; (B) enjoying work; (C) planning and having good control and overview; (D) each professional performing the correct tasks; (E) completing a work assignment; and (F) producing as much as possible per time unit. The most significant finding was that most of the nurses and assistant nurses understood efficiency as individual knowledge and experience emphasizing the importance of the work process, whereas the supervisors and physicians understood efficiency in terms of production per time unit or completing an assignment.

Conclusions: The concept ‘operating room efficiency’ is understood in different ways by leadership and staff members. Supervisors who are aware of this variation will have better prerequisites for defining the concept and for creating a common platform towards becoming efficient.
Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in children
Authors: CHO J. E. , KIM J. Y. , KIM J. E. , CHUN D. H. , JUN N. H. , KIL H. K.
Published: August 2010

Background: Studies comparing epidural fentanyl and sufentanil in adults reported a similar analgesic effect with variable side effects. We hypothesized that epidural fentanyl and sufentanil will have a similar analgesic effect in children undergoing urological surgery.

Methods: Sixty‐four children undergoing urological surgery were randomized into two groups: fentanyl in ropivacaine (fentanyl group, n=32) and sufentanil in ropivacaine (sufentanil group, n=32). After anaesthesia, an epidural catheter was inserted at the L2–3, L3–4 or L4–5 interspace. For post‐operative pain relief, a solution consisting of fentanyl 0.1 mcg/kg/ml or sufentanil 0.015 mcg/kg/ml in 1.5 mg/ml ropivacaine was infused at a rate of 2 ml/h. To assess post‐operative pain, the faces pain scale and the face, legs, activity, cry, consolability score were recorded at 1, 6, 24, 48 and 72 h after surgery. The incidence of adverse effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was also evaluated.

Results: Pain scores demonstrated no significant difference between the groups. The need for rescue analgesia during 24–72 h was higher in the fentanyl group than in the sufentanil group (6/32 vs. 0/32, P=0.012). The incidence of pruritus was higher in the sufentanil group compared with that in the fentanyl group (5/32 vs. 0/32).

Conclusions: Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in infants and children undergoing urological surgery. The incidence of pruritus in the sufentanil group was higher than that in the fentanyl group.
Vibratory Communication in the Jumping Spider Phidippus clarus: Substrate‐borne Courtship Signals are Important for Male Mating Success
Authors: Elias Damian O. , Sivalinghem Senthurran , Mason Andrew C. , Andrade Maydianne C. B. , Kasumovic Michael M.
Published: August 2010

Recently, work has shown that multimodal communication is common throughout the animal kingdom but the function of multimodal signals is still poorly understood. Phidippus clarus are jumping spiders in which males produce multimodal (visual and vibrational) signals in both male–male (aggressive) and male–female (courtship) contexts. The P. clarus mating system is complex, with sex ratios and the level of male competition changing over the course of the breeding season. Vibrational signal components have been shown to function in male aggressive contests but their role in courtship has not been investigated. Here, we performed an experiment to test the role of vibrational signaling in courtship by observing mating success for males that were experimentally muted. We show that vibratory courtship signals, and in particular signaling rate, is an important component of mating success and potentially a target of female choice. While the ability to produce vibratory signals significantly increased mating success, some muted males were still able to successfully mate. In these trials, signaling rate also predicted mating success suggesting that redundant signal components may compensate for errors and perturbations in signal transmission or that vibratory signals function to enhance the efficacy of visual signals.
Experimental Evidence that Sexual Displays are Costly for Nest Survival
Authors: Dias Raphael I. , Castilho Leonardo , Macedo Regina H.
Published: August 2010

Nest predation is one of the most significant limitations for successful breeding of tropical passerines. Thus, parental strategies may include choosing appropriate nest sites and behaving in ways that minimize predation. Habitat characteristics that may influence nest success include degree of nest concealment, proximity to habitat edge, plant architecture as well as several others cited in the literature. However, few studies have examined display behavior as a factor that could also influence nest survival. We experimentally tested whether sexual motor displays served as a cue for visually oriented predators to locate artificial nests in a population of blue‐black grassquits Volatinia jacarina, a Neotropical passerine that exhibits a complex sexual display and is subjected to elevated rates of nest predation. We also evaluated the effect of nest substrate on survival. Predation rate was higher for nests within territories of displaying males relative to areas without displaying males and for nests placed in shrubs relative to grasses. Predation increased sharply in the third experimental replicate, at the end of the breeding season, which suggests that predators may develop a search image for nests or may become more abundant during specific periods of the season. Avian predators appear to be the most important nest predators. Results suggest that there may be a trade‐off between the increase in fitness derived from sexual displays of males to attract potential mates and the decrease owing to predation of active nests within their territories.
Translation, cultural adaptation assessment, and both validity and reliability testing of the Kidney Disease Quality of Life – Short Form version 1.3 for use with Iranian patients
Authors: PAKPOUR AMIR H , YEKANINEJAD MIRSAEED , MOLSTED STIG , HARRISON ADRIAN P , HASHEMI FARIBA , SAFFARI MOHSEN
Published: August 2010

Aim:  The aims of the study were to translate the Kidney Disease Quality of Life – Short Form version 1.3 (KDQOL‐SF ver. 1.3) questionnaire into Iranian (Farsi), and to then assess it in terms of validity and reliability on Iranian patients.

Methods:  The questionnaire was first translated into Farsi by two independent translators, and then subsequently translated back into English. After translation disparities had been reconciled, the final Iranian questionnaire was tested. An initial test–retest reliability evaluation was performed over a 10 day period on a sample of 20 patients recruited from a larger group (212 patients with end‐stage renal disease on haemodialysis). Afterwards, reliability was estimated by internal consistency, and validity was assessed using known group comparisons and constructs for the patient group as a whole. Finally, the factor structure of the questionnaire was extracted by performing exploratory factor analysis.

Results:  All of the scales in the questionnaire showed good test–retest reliability (i.e. intraclass correlations between test and retest scores were >0.7). All of the scales met the minimal criteria (0.7) for internal consistency and Cronbach's‐α ranged 0.71–0.93. Furthermore, results from a discriminate validity evaluation showed that the questionnaire could be used to discriminate between subgroups of the patients. Finally, a principal component analysis of the disease‐specific scales indicated that this part of the questionnaire could be summarized into an 11 factor structure that jointly accounted for 79.81% of the variance.

Conclusion:  The Iranian version of the KDQOL‐SF questionnaire is both highly reliable and valid for use with Iranian patients on haemodialysis.
RIFLE and Acute Kidney Injury Network classifications predict mortality in leptospirosis‐associated acute kidney injury
Authors: SILVA JÚNIOR GERALDO B , ABREU KRASNALHIA LÍVIA S , MOTA ROSA MS , BARRETO ADLER GC , ARAÚJO SÔNIA MHA , ROCHA HERMANO AL , LIBÓRIO ALEXANDRE B , DAHER ELIZABETH F
Published: August 2010

Aim:  Acute kidney injury (AKI) is a common complication in leptospirosis. The aim of this study is to investigate the association between RIFLE and AKIN classifications with mortality in leptospirosis‐associated AKI.

Methods:  A retrospective study was conducted in patients with leptospirosis admitted to tertiary hospitals in Brazil. The association between RIFLE and AKIN classifications with mortality was investigated. Univariate and multivariate analysis was performed to investigate risk factors for death.

Results:  A total of 287 patients were included, with an average age of 37 ± 16 years, and 80.8% were male. Overall mortality was 13%. There was a significant association between these classifications and death. Among non‐survivors, 86% were in the class ‘failure’ and AKIN 3. Increased mortality was observed according to the worse classifications: ‘risk’ (R; 2%), ‘injury’ (I; 8%) and ‘failure’ (F; 23%), as well as in AKIN 1 (2%), AKIN 2 (8%) and AKIN 3 (23%) (P < 0.0001). The worst classifications were significantly associated with death: RIFLE F (odds ratio = 11.6, P = 0.018) and AKIN 3 (odds ratio = 12.8, P = 0.013). Receiver–operator curve for patients with AKI showed high areas under the curve (0.71, 95% confidence interval = 0.67–0.74) for both RIFLE and AKIN classifications in determining the sensitivity for mortality.

Conclusion:  There is a significant association between RIFLE and AKIN classifications with mortality in patients with leptospirosis. Initiation of dialysis in patients with RIFLE F and AKIN 3 should always be considered.
CHEMICAL and MORPHOLOGICAL PATHOLOGY OF MERCURY DEPOSIT FOLLOWING ADMINISTRATION OF A MERCURIAL ONCOSTATIC*
Authors: Mori Wataru , Tsunakawa Shozo , Oota Kunio , Taguchi Hisako
Published: August 2010

Using autopsy cases with definite history of receiving a mercurial oncostatic, Hg‐Hematoporphyrin‐Na, chemical and morphological pathology of mercury deposit in the kidney and liver was studied. It was proved that mercury was deposited for at least 50 to 70 days in those organs and almost diminished in around 200 days. A very small dose did not cause any deposit. The kidney, especially the cortex, contained much more amount of mercury than the liver, and mercury deposit in the other organs was quite slight.

Moderate number of cases showed remarkable changes of the kidney and liver histologically, degeneration of the tubular epithelium with occasional calcification in the former and central necrosis in the latter. The renal change was most probably related with the mercurials, but the hepatic damage was difficult to be attributed to the agent at the present stage of our study.

Parallelism between the amount of mercury deposit and the grade of histological changes was not always clear, a fact which suggests that the effects of the mercurials varied among different individuals. It is recommended to prescribe strong agents, especially oncostatics, under the repeated control of renal and hepatic function tests.