Preoperative anterior thigh temperature does not correlate with perioperative temporal hypothermia during cesarean delivery with spinal anesthesia: Secondary analysis of a randomized control trial

BackgroundCore-to-peripheral redistribution of heat, secondary to sympathetic-mediated vasodilation, is the major mechanism leading to early perioperative hypothermia after neuraxial anesthesia. The study aim was to determine if preoperative anterior thigh (peripheral lower extremity) temperature predicted perioperative temporal (core) temperature decrease during cesarean delivery with spinal anesthesia.MethodsSecondary analysis of data derived from a prospective, randomized study of 46 healthy women undergoing scheduled cesarean delivery with spinal anesthesia was performed. Anterior thigh temperature was measured preoperatively prior to spinal anesthesia. The primary outcome was maximum perioperative temporal temperature decrease. Secondary outcomes included incidence of temporal hypothermia (temperature <36°C), shivering, and thermal comfort scores. This study ran concurrently with a previously published trial comparing no active intraoperative warming with active warming.ResultsThere was no correlation between preoperative anterior thigh temperature and maximum perioperative temporal temperature decrease (r=−0.049, P=0.751). The mean ± standard deviation preoperative anterior thigh temperature of women who developed temporal hypothermia compared to those who did not was 32.4 ± 0.8°C versus 32.4 ± 0.70°C respectively (P=0.995). Preoperative anterior thigh temperature did not correlate with the incidence of shivering (r=0.267, P=0.080) or thermal comfort scores (r=0.233, P=0.129).ConclusionPreoperative anterior thigh temperature does not correlate with the degree of perioperative temporal temperature decrease, likelihood of developing hypothermia, shivering, or thermal comfort during cesarean delivery with spinal anesthesia. Although core-to-peripheral redistribution of heat after neuraxial anesthesia is a major mechanism of perioperative heat loss, a lower extremity temperature prediction hypothesis was not confirmed in this population.     

The effect of bupivacaine with fentanyl temperature on initiation and maintenance of labor epidural analgesia: a randomized controlled study

BackgroundLabor epidural analgesia is highly effective, but can be limited by slow onset and incomplete blockade. The administration of warmed, compared to room temperature, bupivacaine has resulted in more rapid onset epidural anesthesia. We hypothesized that the administration of bupivacaine with fentanyl at 37°C versus 20°C would result in improved initial and ongoing labor epidural analgesia.MethodsIn this prospective, randomized, doubled blinded study, 54 nulliparous, laboring women were randomized to receive epidural bupivacaine 0.125% with fentanyl 2 μg/mL (20 mL initial and 6 mL hourly boluses) at either 37°C or 20°C. Pain verbal rating scores (VRS), sensory level, oral temperature, and side effects were assessed after epidural loading (time 0), at 5, 10, 15, 20, 30, 60 min, and at hourly intervals. The primary outcome was the time to achieve initial satisfactory analgesia (VRS ⩽3). Secondary outcomes included ongoing quality of sensory blockade, body temperature and shivering.ResultsThere were no differences between groups in patient demographics, initial pain scores, cervical dilatation, body temperature or mode of delivery. Epidural bupivacaine at 37°C resulted in shorter mean (±SD) analgesic onset time (9.2 ± 4.7 vs. 16.0 ± 10.5 min, P = 0.005) and improved analgesia for the first 15 min after initial bolus (P = 0.001–0.03). Although patient temperature increased during the study (P < 0.01), there were no differences between the groups (P = 0.09). Six (24%) and 10 (40%) patients experienced shivering in the 37°C and 20°C groups, respectively (P = 0.23).ConclusionsThe administration of epidural 0.125% bupivacaine with fentanyl 2 μg/mL at 37°C versus 20°C resulted in more rapid onset and improved labor analgesia for the first 15 min. There was no evidence of improved ongoing labor analgesia or differences in side effects between groups.     

Effects of thermoregulatory vasoconstriction on pulse hemoglobin measurements using a co-oximeter in patients undergoing surgery

Study ObjectiveTo validate intraoperative pulse hemoglobin (SpHb) measurements in anesthetized patients with large forearm temperature – fingertip temperature gradients.Designprospective and observational study.SettingOperating room of a university hospital.Patients28 patients undergoing surgery during general anesthesia, requiring arterial blood withdrawal.InterventionsRadial arterial blood pressure, forearm and fingertip skin surface temperatures, and SpHb were monitored.MeasurementsPaired SpHb and arterial hemoglobin (Hb) measurements at different skin-surface temperature gradients.Main ResultsA total of 175 paired SpHb and arterial Hb measurements were analyzed. The mean SpHb to arterial Hb differences in each group were 0.33 ± 1.41 g/dL in the < 1°C group of the forearm temperature – fingertip temperature gradient, -0.31 ± 1.24 g/dL in the 1 - 2°C group, - 0.59 ± 1.11 g/dL in the 2 - 3°C group, and - 0.53 ± 0.87 g/dL in the > 3°C group (P < 0.05). The percentage of nonmeasurable SpHb due to low perfusion state was 0% (0 of 115 paired measurements) in the < 1°C group, 6.7% (2 of 30 pairs) in the 1 - 2°C group, 16.7% (3 of 18 pairs) in the 2 - 3°C group, and 66.7% (8 of 12 pairs) in the > 3°C group.ConclusionSpHb measured at fingertip was significantly affected by the perfusion state, with lower perfusion associated with lower SpHb. Thermoregulatory vasoconstriction affects measurement of SpHb.     

Accuracy of liver ablation zone prediction in a single 2450 MHz 100 Watt generator model microwave ablation system: An in human study

PurposeTo compare manufacturer provided predictions and realized ablation dimensions in the liver using one 2450 MHz 100 Watt generator model microwave ablation (MWA) system.Materials and methodBetween 1/1/2015 and 2/1/2018, MWAs were performed in 86 patients who underwent a total of 103 MWAs with a single MWA system. There were 64 men and 22 women with a mean age of 63.9 ± 9.9 (SD) years (range: 30–88 years). Demographic, procedural, and outcomes data was recorded. The manufacturer predicted ablation zone sizes in three dimensions (anterior-posterior [AP], transverse [TR], and cranial caudal [CC]) were recorded and then compared to the actual ablation zone sizes at one month follow-up imaging.ResultsMWAs were most commonly performed to treat hepatocellular carcinoma (92/103, 89.3%). Dividing the actual ablation size by the manufacturer prediction in the AP, TR, and CC directions resulted in a mean of 88.3 ± 20.6 (SD) % (range: 33.3–156.4%), 80.2 ± 26.5 (SD) % (range: 29.6–182.9%), and 86.7 ± 25.1 (SD) % (range: 37–186.1%), respectively. The realized AP direction was statistically closer to the manufacturer prediction than the TR (P < 0.01). Ablation Watt setting of 100 Watts resulted in more accurate predictions than the 75 or 45 Watt settings in the AP direction (P = 0.03).ConclusionsThis 2450 MHz 100 Watt generator MWA system manufacturer provided model fairly accurately predicts ablation zone dimensions, but tends to over predict realized dimensions in this mainly hepatocellular carcinoma, and therefore cirrhotic, cohort. The TR is the most inaccurately predicted dimension and manufacturer predictions appear to be best in the 100 W setting, important aspects for interventionalists to consider during ablation planning and execution.     

Biomechanical comparison of conventional versus modified technique in distal chevron osteotomies of the first metatarsal: A cadaver study

BackgroundDistal chevron osteotomy can be performed using a conventional or a modified technique. The aim of this biomechanical study was to compare the stability of the two techniques.MethodsEighteen first metatarsals from nine pairs of fresh frozen human cadaver feet were used. A distal chevron osteotomy was performed using the conventional technique in group 1 (n = 9) and using the modified technique in group 2 (n = 9). The head of the first metatarsals was loaded in two different configurations (cantilever and physiological), using a materials testing machine.ResultsIn the cantilever configuration, the relative stiffness of the osteosynthesis in comparison with intact bone was 60% (±21%) in group 1 and 65% (±25%) in group 2 (p = 0.61). In the physiological configuration, it was 47% (±29%) in group 1 and 47% (±21%) in group 2 (p = 0.98). The failure strength in the cantilever configuration was 235 N (±128 N) in group 1 and 210 N (±107 N) in group 2 (p = 0.47).ConclusionsThe conventional and the modified technique for distal chevron osteotomy in the treatment of hallux valgus show a comparable biomechanical loading capacity in this cadaver study.     

Spinal metastases treated with bipolar radiofrequency ablation with increased (> 70 °C) target temperature: Pain management and local tumor control

PurposeTo investigate the safety and clinical efficacy of bipolar radiofrequency ablation (b-RFA) with increased (> 70 °C) target temperature for the treatment of spine metastases with the intent of achieving pain relief or local tumor control.Materials and methodsThirty-one patients with a total of 37 metastases who were treated with b-RFA with increased temperature and vertebroplasty from January 2016 to May 2019 were retrospectively included. There were 20 women and 11 men with a mean age of 62.4 ± 10.5 (SD) years (range: 40–78 years). Patients and metastases characteristics, procedure details and clinical outcomes were analyzed.ResultsMetastases were predominantly located in lumbar (22/37; 59.5%) or thoracic spine (13/37; 35.1%). Mean target temperature was 88.4 ± 3.5 (SD) °C (range: 70–90 °C). Technical success was 100% (37/37 metastases). One (1/37; 2.7%) major complication unrelated to b-RFA was reported. One (1/37; 2.7%) metastasis was lost to follow-up. Favorable outcome was noted in patients receiving b-RFA for pain management (16/20 metastases; 80%; mean follow-up, 3.4 ± 2.9 [SD] months) or with oligometastatic/oligoprogressive disease (6/6 metastases; 100%; mean follow-up, 5.0 ± 4.6 [SD] months). In patients receiving b-RFA to prevent complications, favorable outcome was noted in 6/10 metastases (60%; mean follow-up, 3.8 ± 4.8 [SD] months).ConclusionsB-RFA with increased target temperature has an excellent safety profile and results in high rates of pain relief and local metastasis control in patients with oligometastatic/oligoprogressive disease. Suboptimal results are achieved in patients receiving b-RFA to prevent complications related to the growth of the index tumor.     

Mild hypothermia attenuate kidney injury in canines with oleic acid-induced acute respiratory distress syndrome

BackgroundHypothermia may attenuate ventilator induced-lung injury in acute respiratory distress syndrome (ARDS). However, the impact of hypothermia on extra-pulmonary organ injury in ARDS remains unclear. The purpose of this study was to investigate whether hypothermia affects extra-pulmonary organ injury in a canine ARDS model induced by oleic acid.ObjectivesTwelve anesthetized canines with oleic acid-induced ARDS were randomly divided (n = 6 per group) into a hypothermia group (core temperature of 33 ± 1 °C, HT group) and a normothermia group (core temperature of 38 ± 1 °C, NT group) and treated for four hours. The liver, small intestine and kidney were assessed by evaluating biochemical parameters, plasma and tissue cytokine levels, and tissue histopathological injury scores.ResultsThe HT group showed a lower plateau pressure, lung elastance and pulmonary vascular resistance. Hypothermia was associated with lower oxygen consumption (138.4 ± 55.0 ml min⁻¹ vs. 72.0 ± 11.2 ml min⁻¹, P < 0.05) and higher oxygen saturation of mixed venous blood (62.8% ± 8.0% vs. 77.5% ± 10.1%, P < 0.05). Both groups had similar levels of tumour necrosis factor-α in the plasma and extra-pulmonary organ, however, plasma interleukin-10 (97.1 ± 25.0 pg ml⁻¹ vs. 131.4 ± 27.0 pg ml⁻¹, P < 0.05) was higher in the HT group. Further, the animals in the HT group had a lower levels of plasma creatinine (54.6 ± 19.1 U L⁻¹ vs. 29.1 ± 8.0 U L⁻¹, P < 0.05), and lower renal histopathological injury scores [4.0(3.5;7.0) vs. 1.5(0.8;3.0), P < 0.05]. Hypothermia did not affect the histopathological injury of the liver and small intestine.ConclusionsShort-term mild hypothermia can reduce lung elastance and pulmonary vascular resistance, increase the systemic anti-inflammatory response and attenuate kidney histopathological injury in a canine ARDS model induced by oleic acid.     

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures

PurposeTo determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes.MethodsSkeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts.ResultsThirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0−18], and 15 ± 7.9° [range 2−27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p > 0.05). Patients with at least 20° (n = 7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p = 0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p = 0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p < 0.05 for all).ConclusionResidual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.     

Prospective observational study of serial cardiac output by transthoracic echocardiography in healthy pregnant women undergoing elective caesarean delivery

BackgroundAn understanding of cardiovascular changes in parturients is crucial for their anaesthetic management, but few studies have examined the effect of posture on cardiac output in the peripartum period.MethodCardiac output was measured in four different positions by transthoracic echocardiography (Doppler) in 30 term women undergoing elective caesarean delivery. These positions were left lateral level (P1), left lateral with 20° head up (P2), left lateral with 10° head down (P3) measured preoperatively and supine (P4) measured postoperatively.ResultsMean ± SD cardiac output was 4407 ± 1109 mL/min (P1), 4182 ± 825 mL/min (P2), 4031 ± 798 mL/min (P3) and 4641 ± 1064 mL/min (P4). Cardiac output was significantly less in P3 than in P1 (P = 0.049) due to a lower P3 velocity time integral compared with P1 (P = 0.020). Postoperatively, in the supine position, there was no difference in cardiac output, although there was a lower heart rate (P = <0.001) and increased velocity time integral (P = <0.001) compared with P1. The mean differences in interobserver measurements were 0.02 cm (left ventricular outflow tract) and -1.06 cm (velocity time integral). The mean differences in intraobserver measurements were 0.00 cm (left ventricular outflow tract) and -0.22 cm (velocity time integral). Echocardiography was well accepted by all women. Eight women found the left lateral 10° head-down position (P3) uncomfortable due to dizziness, headache, or increased abdominal pressure.ConclusionsCardiac output showed large variability and was lower than previously reported. Cardiac output decreased with the left lateral 10° head-down position due to a reduction in stroke volume that has not previously been reported. The transthoracic examination was acceptable to all women.     

Anterior debridement and bone grafting with posterior single-segment internal fixation for the treatment of mono-segmental spinal tuberculosis

BackgroundsShort-segment or long-segment fixation is the most commonly used method for treating spinal tuberculosis with damage to a single motor segment (mono-segmental spinal tuberculosis). However, these methods incorporate several of the normal adjacent motor segments surrounding the damaged motor segments during surgery and subsequent healing, leaving them prone to adjacent segment degeneration. A single-segment fixation approach may offer an alternative solution for the surgical treatment of mono-segmental spinal tuberculosis.Patients and methods102 Retrospectively studied patients with mono-segmental spinal tuberculosis were divided into two groups: single-segment (the fixed/fused range was limited to only one damaged motion segment n = 54) and short-segment (the fixed/fused range included both the damaged segment and the normal motion segment located above and below the damaged motion segment, respectively n = 48). Responses to postoperative chemotherapy and changes in the Cobb angle for kyphosis, fusion time, and Frankel grading were recorded. Each patient's quality of life and ability to return to work, as determined by the Oswestry Disability Index (ODI), were also evaluated.ResultsAt the end of the final follow-up, the degree of correction was 12.69 ± 4.56° and 13.44 ± 4.53° for the single-segment and short-segment groups, respectively, with a loss of 1.80 ± 1.19° and 1.60 ± 1.16°, respectively. The differences between the two groups were not significant (P > 0.05). The average bone healing time was 4.4 ± 0.9 months in the single-segment group and 4.4 ± 1.0 months in the short-segment group. The Frankel grade for neurologic function returned to normal in >94% of patients. The ODI was 13.5 ± 2.8 and 14.1 ± 3.7 for the single-segment and short-segment groups, respectively. The rates of improvement were 64.0 ± 5.5% and 65.9 ± 4.9% for the single-segment and short-segment groups, respectively. The differences between the two groups were not significant (P > 0.05).ConclusionAfter bone fusion, single-segment fixation is effective in restoring and maintaining spinal stability and retains normal motion segment more than short-segment fixation approach. Strict adherence to the clinical indications must occur in order to optimize the overall outcome.     

The effects of a resistive warming mattress during caesarean section: a randomised,controlled trial

BackgroundThe adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section.MethodsA total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0°C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded.ResultsThe incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P = 0.043); mean temperatures differed between the two groups, 36.5°C and 36.3°C, respectively (P = 0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at −1.1 ± 0.9 g/dL versus −1.6 ± 0.9 g/dL in the control group (P = 0.007). There was no difference in shivering (P = 0.798).ConclusionsA resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.     

Computer-assisted surgery (CAS) based correction of posttraumatic ankle and hindfoot deformities—Preliminary results

The first clinical experiences with a computer assisted surgery based (CAS) guided correction arthrodeses at ankle, hindfoot and midfoot were evaluated.MethodsTime spent, accuracy, surgeons’ rating (Visual Analogue Scale [VAS], 0–10 points) were analyzed. The accuracy was assessed by ISO-C 3D (Siremobile™, Siemens, Germany).Results10 patients were included (ankle, n = 3; subtalar joint, n = 6; ankle and subtalar joint, n = 2; Lisfranc joint, n = 1). Time needed for preparation was 500 s (400–900). The correction process took 45 s (30–60). All angles/translations were achieved as planned before surgery (≤ ±1°/±1 mm). The ratings of the three involved surgeons were: feasibility, 9.5 (9–10); accuracy 9.8 (9.5–10); clinical benefit 9 (8–10).ConclusionsCAS guided correction of posttraumatic deformities of the ankle and hindfoot region provides very high accuracy and a fast correction process. The significance of the introduced method may be high in those cases, because the improved accuracy may lead to an improved clinical outcome.     

Temporal evaluation of the microwave ablation zone and comparison of CT and gross sizes during the first month post-ablation in swine lung

Purpose

The purpose of this study was to investigate the development and evolution of the microwave ablation (MWA) lesion in the normal lung by using a swine model at various time points and to compare post-procedural computed tomography (CT) and gross pathologic findings during the first month post-ablation.

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice

ObjectivesTo report our experience with rituximab therapy in patients with rheumatoid arthritis (RA) and a history of severe or recurrent bacterial infections.Patients and methodsRetrospective observational study in five rheumatology departments experienced in the use of biotherapies. Patients were included if they had RA and a history of severe or recurrent bacterial infection (requiring admission and/or intravenous antimicrobial therapy) that contraindicated the introduction or continuation of TNFα antagonist therapy.ResultsOf 161 RA patients given rituximab in the five study centers, 30 met the inclusion criteria, 23 females and seven males with a mean age of 58.4 ± 11.8 years and a mean disease duration of 11.4 ± 13.9 years. Among them, 22 had rheumatoid factors and 21 had received TNFα antagonist therapy (one agent in 15 patients, two in five patients and three in one patient). Prior infections were as follows: septicemia, n = 2; lower respiratory tract infection or lung abscess, n = 12; prosthesis infection, n = 3; septic arthritis, n = 3; endocarditis, n = 1; pyelonephritis, n = 2; osteitis, n = 4; and various skin infections (erysipelas, cellulitis or skin abscess), n = 6. Of these 33 infections, 21 occurred during TNFα antagonist therapy. During rituximab therapy, all patients received concomitant glucocorticoid therapy (mean dosage, 12 ± 7.9 mg/day). The number of rituximab cycles was one in 13 patients, two in seven patients and three or more in 10 patients. Mean time from the single or last serious infection and the first rituximab infusion was 20.1 ± 18.7 months. Mean follow-up since the first rituximab infusion was 19.3 ± 7.4 months. During follow-up, six (20%) patients experienced one infection each. Immunoglobulin levels after rituximab therapy were within the normal range.ConclusionRituximab therapy was well tolerated in 24 (80%) of 30 patients with RA and a history of severe or recurrent bacterial infection. In everyday practice, rituximab therapy seems safe with regard to the recurrence of infectious episodes. However, longer follow-ups are needed.     

Os efeitos do aquecimento de cristaloides sobre a temperatura corporal materna e nas condições fetais: ensaio clínico randômico

Background and objectives

Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia.

Effects of candidaemia on outcome of burns

AimTo evaluate the diversity and antifungal susceptibilities of Candida isolates from wounds and blood of burn victims, and the associated mortality rates compared with those of controls without candidaemia.MethodsWe performed a nested case-control study within a database of clinical data for all patients admitted to our burn unit from January 2001 to December 2005. Each candidaemic patient was compared with two matched controls. Bloodstream cultures were performed if the core temperature was >39 °C, and three sites were cultured weekly for fungal identification (burn wound, pharynx, urinary tract).ResultsAt least one episode of candidaemia was diagnosed among 20 of 851 persons admitted during the study period. Isolates in bloodstream infection were Candida albicans (65%), C. parapsilosis (25%) and C. tropicalis (10%). The median time between admission and onset of candidaemia was greater with C. albicans infection (42.6 ± 31 days) than with infection by other yeasts (18 ± 12 days). Candidaemia was associated with more extensive burn and longer duration of hospital stay but with similar mortality, compared with controls.ConclusionCandidaemia in burn cases is mostly due to fluconazole-susceptible C. albicans and is not associated with increased mortality.     

Neutrophil elastase-mediated increase in airway temperature during inflammation

BackgroundHow elevated temperature is generated during airway infections represents a hitherto unresolved physiological question. We hypothesized that innate immune defence mechanisms would increase luminal airway temperature during pulmonary infection.MethodsWe determined the temperature in the exhaled air of cystic fibrosis (CF) patients. To further test our hypothesis, a pouch inflammatory model using neutrophil elastase-deficient mice was employed. Next, the impact of temperature changes on the dominant CF pathogen Pseudomonas aeruginosa growth was tested by plating method and RNAseq.ResultsHere we show a temperature of ~ 38 °C in neutrophil-dominated mucus plugs of chronically infected CF patients and implicate neutrophil elastase:α₁-proteinase inhibitor complex formation as a relevant mechanism for the local temperature rise. Gene expression of the main pathogen in CF, P. aeruginosa, under anaerobic conditions at 38 °C vs 30 °C revealed increased virulence traits and characteristic cell wall changes.ConclusionNeutrophil elastase mediates increase in airway temperature, which may contribute to P. aeruginosa selection during the course of chronic infection in CF.     

Patient versus anesthesiologist controlled analgesia in cirrhotic patients undergoing percutaneous radiofrequency ablation of hepatic tumors

Background and aimsPatients may experience pain during Radiofrequency thermal ablation (RFTA) of hepatic tumors. The aim was to compare the use of fentanyl administered through the patient controlled analgesia (PCA) machine with the same drug given intermittently by the anesthesiologist.MethodsIn this prospective, randomized, double-blind study, eighty cirrhotic patients underwent RFTA of hepatic tumors were enrolled. All patient received midazolam 10 μg/kg and fentanyl 1 μg/kg IV, then 5–10 mL of 2% lidocaine were injected from the skin to the liver capsule along a specified insertion route, then the RFTA electrode was advanced into the tumor. For maintenance of analgesia bolus doses of fentanyl were then administered either by patient himself (PCA group, n = 40) with each bolus dose contained 10 μg of fentanyl with a 1 min lock-out time or by the anesthesiologist (ACA group, n = 40).ResultsPCA group received significantly higher doses of fentanyl with a mean value of 53.5 ± 13.5 μg/session, while it was 36.7 ± 13.4 μg/session in the ACA group. Patient satisfaction rates were higher in the PCA than ACA with mean values of 8.32 ± 0.62 and 7.85 ± 0.73, respectively. The mean pain score was statistically lower in the PCA group than the ACA group with mean value 3.37 ± 0.70 and 3.97 ± 0.89, respectively. There was significant difference in the mean values of the demand/ delivered ratio between groups to be 1.47 ± 0.28 and 2.50 ± 0.73 in PCA and ACA groups, respectively.ConclusionPCA with fentanyl proved to be a better alternative than ACA in terms of patient comfort and satisfaction.     

Bunionette deformity corrected with “shortening” scarf osteotomy of the fifth metatarsal: mid-term results of a 34-cases

BackgroundThe aim of this study was to evaluate the clinical and radiological outcomes (in mid-term) after “shortening” scarf osteotomy of the fifth metatarsal for the treatment of bunionette deformity.MethodsWe retrospectively reviewed the functional score — American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale, radiographic results — 4th/5th intermetatarsal angle, varus angle of the 5th metatarsophalangeal joint and complications in a consecutive series of 34 feet (27 patients) with bunionette. Nine males and 18 females (mean age: 45 years) were included in the study. Three males and four females were operated bilaterally The patients were operated on between 2004 and 2015, and evaluated during 2017.ResultsThe average AOFAS score improved from 59.4 to 93 at a mean follow-up of 7.2 years. The 4th/5th intermetatarsal angle and varus angle of the 5th metatarsophalangeal joint decreased from 13.9°/19.5° preoperatively to 6°/5.9° at final follow-up. No neurovascular damage was recorded. Complications arose in five feet (14.7%): delayed union (n = 1), early infection (n = 1), distal screw migration (n = 1), asymptomatic non-union (n = 1), transverse metatarsalgia (n = 1). The osteotomy healed within less than three months except twoo (delayed union, non-union). Three feet needed additional surgery: screw removal (n = 2), Weil osteotomy of 2nd–4th metatarsals (n = 1).Conclusions“Shortening” scarf osteotomy is an acceptable, but not complication-free, treatment option for the bunionette deformity and offers promising results in the mid-term.     

Instability of the extensor digitorum tendons in Jaccoud arthropathy assessed by semi-dynamic MRI of the metacarpophalangeal joints

PurposeThe purpose of this study was to test the hypothesis that Jaccoud arthropathy (JA) in patients with systemic lupus erythematosus (SLE) is associated with instability of the extensor digitorum (ED) tendons during flexion of the metacarpophalangeal (MCP) joints by comparing the position of the ED tendons between SLE patients with JA and control subjects on hand MRI obtained with flexed and extended MCP joints.Materials and methodsThirty-two hands of SLE patients with JA (13 women and 3 men; mean age, 50.0 ± 12.2 [SD] years; age range: 26–68 years) and 24 hands of sex- and age-matched control subjects (20 women and 4 men; mean age, 50.1 ± 13.0 [SD] years; age range: 24–68 years) were included in the study. Axial spin echo T1-weighted MRI images of the second to fifth MCP joints in flexion and in extension were obtained. Two radiologists (R1 and R2) separately measured the amplitude and assessed the direction of the displacement of the ED tendons with respect to the midline at the level of each MCP joint. Statistical analysis included two-way ANOVA with random effects to assess differences in amplitude and Fisher–Freeman–Halton exact test to assess differences in direction with P-values < 0.0083 and < 0.0063 considered as statistically significant respectively.ResultsAmplitude of the displacement of the ED tendons was statistically significantly greater in SLE patients with JA than in control subjects in flexion for both readers (median 58°, 95% confidence interval [CI]: 50°–65° vs. 20°, 95% CI: 16°–24°; P < 0.0001 for R1 and 54°, 95% CI: 47°–61° vs. 25°, 95% CI: 22°–28°; P < 0.0001 for R2) and in extension for one reader (17°, 95% CI: 15°–20° vs. 14°, 95% CI: 11°–16°; P = 0.0048 for R1 and 20°, 95% CI: 15°–25° vs. 16°, 95% CI: 12°–18°; P = 0.0292 for R2). Ulnar deviation of the ED tendons was statistically significantly more frequent in SLE patients with JA than in control subjects in flexion and in extension for both readers (P < 0.0001).ConclusionJA is associated with instability of the ED tendons in patients with SLE best depicted when MCP joints are flexed.