Anterior lumbar interbody fusion: single institutional review of complications and associated variables

BACKGROUND CONTEXTAs more patients undergo anterior lumbar interbody fusion (ALIF) procedures and more devices are created for that purpose, it is important to understand the complications that can arise and the variables that mitigate risk for major and minor complications.PURPOSETo assess complication rates after ALIF with or without posterior instrumentation and variables associated with increased likelihood of postoperative complications. We aim to provide this data as benchmarking to improve patient safety and surgical care.STUDY DESIGNA single-center retrospective cohort study.PATIENT SAMPLEAll adult patients who underwent ALIF between 2017 and 2019 was performedOUTCOME MEASURESPost-operative major and minor complications were evaluated.METHODSComplications were recorded and presented as percentages. Patient demographics, perioperative, and postoperative data were also collected and analyzed between patients who had no complications and those that had any complication. Subgroup analysis of surgical complications were performed by nonparametric Chi-square tests. Continuous variables were compared using Mann-Whitney U tests.RESULTSNinty-five of three hundred sixty-two (26.2%) of patients experienced a minor or major complication. Among the most common complications found were surgical site infections (5.8%), neurological complications (4.1%), vascular complications (3.6%), and urinary tract infections (3.3%). Patients undergoing ALIF alone with post-operative complications had higher mean age, higher BMI, higher ASA status, and experienced higher estimated blood loss. Patients undergoing ALIF and posterior instrumentation with post-operative complications were more likely to have diabetes and had a higher ASA status. Patients with any complications from both groups had longer length of stay, discharge to a non-home setting and were more likely to be readmitted or return to the operating room.CONCLUSIONOur study reveals variables associated with complications at our institution, including age of the patient, BMI, and ASA status leading to higher complications and greater LOS, higher readmission rates, and disposition to skilled facilities.     

FNDC5 attenuates adipose tissue inflammation and insulin resistance via AMPK-mediated macrophage polarization in obesity

BackgroundObesity-induced chronic inflammation is critical in the pathogenesis of insulin resistance, and the recruitment and proinflammatory activation of adipose tissue macrophages (ATMs) is important for the development of this process. Here, we examined the effects of fibronectin type III domain-containing 5 (FNDC5) on inflammation and insulin resistance in high-fat diet-induced obese mice.Materials and MethodsMale wild-type (WT) and FNDC5^−/− mice were fed with standard chow (Ctrl) or high fat diet (HFD) for 20 weeks to induce obesity and insulin resistance. Firstly, effects of FNDC5 gene deletion on obesity, insulin resistance, macrophage accumulation and polarization and adipose tissue inflammation were determined in mice. Secondly, the macrophage polarity shift was further examined with flow cytometry in isolated stromal vascular fraction (SVF). Thirdly, the effects of exogenous FNDC5 on lipopolysaccharide (LPS)-induced macrophage polarization, inflammation and the underlying signaling mechanism were investigated in RAW264.7 macrophages and primary mouse peritoneal cavity macrophages (PMs). Finally, the therapeutic effects of FNDC5 overexpression were examined in HFD-induced obese WT and FNDC5^−/− mice.ResultsFNDC5 gene deletion aggravated obesity, insulin resistance, fat accumulation and inflammation accompanied with enhanced AMPK inhibition, macrophages recruitment and M1 polarization in mice fed with HFD. Exogenous FNDC5 inhibited LPS-induced M1 macrophage polarization and inflammatory cytokine production via AMPK phosphorylation in both RAW264.7 macrophages and PMs. FNDC5 overexpression attenuated insulin resistance, AMPK inhibition, M1 macrophage polarization and inflammatory cytokine production in adipose tissue of obese WT and FNDC5^−/− mice.ConclusionsFNDC5 attenuates adipose tissue inflammation and insulin resistance via AMPK-mediated macrophage polarization in HFD-induced obesity. FNDC5 plays several beneficial roles in obesity and may be used as a therapeutic regimen for preventing inflammation and insulin resistance in obesity and diabetes.     

Development and Validation of a Natural Language Processing Tool to Identify Injuries in Infants Associated With Abuse

ObjectivesMedically minor but clinically important findings associated with physical child abuse, such as bruises in pre-mobile infants, may be identified by frontline clinicians yet the association of these injuries with child abuse is often not recognized, potentially allowing the abuse to continue and even to escalate. An accurate natural language processing (NLP) algorithm to identify high-risk injuries in electronic health record notes could improve detection and awareness of abuse. The objectives were to: 1) develop an NLP algorithm that accurately identifies injuries in infants associated with abuse and 2) determine the accuracy of this algorithm.MethodsAn NLP algorithm was designed to identify ten specific injuries known to be associated with physical abuse in infants. Iterative cycles of review identified inaccurate triggers, and coding of the algorithm was adjusted. The optimized NLP algorithm was applied to emergency department (ED) providers’ notes on 1344 consecutive sample of infants seen in 9 EDs over 3.5 months. Results were compared with review of the same notes conducted by a trained reviewer blind to the NLP results with discrepancies adjudicated by a child abuse expert.ResultsAmong the 1344 encounters, 41 (3.1%) had one of the high-risk injuries. The NLP algorithm had a sensitivity and specificity of 92.7% (95% confidence interval [CI]: 79.0%–98.1%) and 98.1% (95% CI: 97.1%–98.7%), respectively, and positive and negative predictive values were 60.3% and 99.8%, respectively, for identifying high-risk injuries.ConclusionsAn NLP algorithm to identify infants with high-risk injuries in EDs has good accuracy and may be useful to aid clinicians in the identification of infants with injuries associated with child abuse.     

Effects of mild and moderate hypothermia on apoptosis in neuronal PC12 cells

Background. There is still a possibility that mild hypothermictherapy may be useful as a neuroprotective tool during the intraoperativeperiod, although the mechanism of cerebral protection by mildhypothermia is not well understood. We hypothesized that mildhypothermia may be protective against cerebral ischaemia byinhibiting post-ischaemia apoptosis. In this study, we usedserum-deprived PC12 cells as the neuronal apoptotic model andexamined the direct effects of mild and moderate hypothermia. Methods. Apoptosis was induced by depriving the cell culturemedium of serum, which is one of the most representative methodsto induce apoptosis, but not necrosis, in PC12 cells. Effectsof mild (35 and 33°C) and moderate (31 and 29°C) hypothermiaon apoptosis were evaluated. Cytotoxicity (lactate dehydogenaseleakage) and the percentage of apoptotic cells (calculated byflow cytometry with propidium iodide) were evaluated 4 daysafter induction of apoptosis. As a control, cells without inductionof apoptosis were incubated under the same conditions as theapoptosis group. Results. Without induction at 37°C, cytotoxicity and thepercentage of apoptotic cells were over 60 and 90%, respectively.At each temperature examined below 35°C, significant decreasesin cytotoxicity and the percentage of apoptotic cells were observed.Mean cytotoxicity at 31 and 29°C was 50.2 (SD 4.2)% and47.9 (4.4)%, respectively. The percentage of apoptotic cellsat 31 and 29°C was 42.5 (7.4)% and 36.5 (7.3)%, respectively.In the control group, cytotoxicity and the percentage of apoptoticcells were significantly higher at 29°C than at 37°C. Conclusions. Mild and moderate hypothermia (29–35°C)inhibited apoptosis, although hypothermia below 30°C mayinduce apoptosis in intact cells. Br J Anaesth 2002; 89: 301–5     

Comparison of relaxant effects of propofol on methacholine-induced bronchoconstriction in dogs with and without vagotomy

Propofol has been suggested to have in vivo airway relaxanteffects, although the mechanism is still unclear. In this study,we determined whether propofol could antagonize methacholine-inducedbronchoconstriction and determined whether vagotomy modifiesthis relaxant effect. Fourteen mongrel dogs anaesthetized withpentobarbital and pancuronium were assigned to a control group(n=7) and a vagotomy group (n=7). The trachea was intubatedwith a special endotracheal tube that had a second lumen forinsertion of the bronchoscope. Bronchial cross-sectional area,which was monitored continuously through the bronchoscope, wasmeasured with image analysis software. Bronchoconstriction waselicited with methacholine (0.5 µg kg^–1 + 5.0 µg kg^–1 min^–1)until the end of the experiment. Thirty minutes after the startof methacholine infusion, propofol 0, 0.2, 2.0 and 20 mg kg^–1was administered. Changes in bronchial cross-sectional areawere expressed as percentages of the basal area. Plasma concentrationsof propofol and catecholamine were measured by high-performanceliquid chromatography. Maximal inhibition (bronchoconstriction= 0%, baseline = 100%) and IC₅₀ (concentration producing 50%inhibition of maximal effect) produced by propofol was obtainedfrom each concentration–response curve using a curve-fittingprogram. Methacholine decreased bronchial cross-sectional areato 49.3% (95% confidence interval 38.5–60.1%) and 45.3%(34.8–55.7%) of the baseline value. Propofol 20 mg kg^–1significantly reversed this effect: bronchial cross-sectionalarea was reduced to 77.8% (66.2–89.6%) and 75.9% (64.0–87.9)in the control and vagotomy groups respectively. The two groupsdid not differ significantly in the maximal inhibitory effectof propofol [control group, 61.1% (46.3–75.9%), vagotomygroup, 64.2% (40.1–88.3%)] or pIC₅₀ [control group 5.03(4.55–5.51), vagotomy group 4.86 (4.49–5.24)]. Therefore,the relaxant effects of propofol on methacholine-induced bronchoconstrictionmay not be mediated centrally. Propofol may relax airway smoothmuscles directly or through the peripheral vagal pathway. Br J Anaesth 2001; 86: 249–53     

Improvement of 'dynamic analgesia' does not decrease atelectasis after thoracotomy

There is still controversy concerning the beneficial aspectsof ‘dynamic analgesia’ (i.e. pain while coughingor moving) on the reduction of postoperative atelectasis. Inthis study, we tested the hypothesis that thoracic epiduralanalgesia (TEA) prevents these abnormalities as opposed to multimodalanalgesia with i.v. patient controlled analgesia (i.v. PCA)after thoracotomy. Fifty-four patients undergoing thoracotomy(lung cancer) were randomly assigned to one of the two groups.Clinical respiratory characteristics, arterial blood gas, andpulmonary function tests (forced vital capacity and forced expiratoryvolume in 1 s) were obtained before surgery and on the next3 postoperative days. Atelectasis was compared between the twogroups by performing computed tomography (CT) scan of the chestat day 3. Postoperative respiratory function and arterial bloodgas values were reduced compared with preoperative values (mean(SD) FEV₁ day 0: 1.1 (0.3) litre; 1.3 (0.4) litre) but therewas no significant difference between groups at any time. PCAand TEA provided a good level of analgesia at rest (VAS day0: 21 (15/100); 8 (9/100)), but TEA was more effective for analgesiaduring mobilization (VAS day 0: 52 (3/100); 25 (17/100)). CTscans revealed comparable amounts of atelectasis (expressedas a percentage of total lung volume) in the TEA (7.1 (2.8)%)and in the i.v. PCA group (6.71 (3.2)%). There was no statisticaldifference in the number of patients presenting with at leastone atelectasis of various types (lamellar, plate, segmental,lobar). Br J Anaesth 2001; 87: 564–9     

神经营养因子在抑郁症中的作用

抑郁症是一种常见病和多发病.近年来,随着对抑郁症发病机制和治疗研究的进展,发现神经营养因子(neurotrophic factors,NTF)表达减少及其受体活性降低是抑郁症的一个重要变化,NTF在抑郁症中的作用越来越得到重视.本文对神经营养因子与抑郁症的病理、生理学研究进展进行综述.     

Severe Sequelae of Group B Streptococcal (Streptococcus Agalactiae) Meningitis in an 82-year-old Man

Abstract : Group B Streptococcal (GBS) meningitis is rare in adults, and only 2 cases have been reported in Japan. Here we report GBS meningitis in an 82-year-old man. The patient with a history of colon cancer developed a high fever and severe headache, and was taken to our hospital several hours later. On admission he was semi-comatose, light and corneal reflexes were normal, his neck was only mildly stiff. He was then on a respirator due to status epilepticus. Cerebrospinal fluid examination demonstrated marked pleocytoisis (46,2507/μ1, mostly polymorphonuclear cells) and GBS. With intensive care and antibiotic therapy, he regained consciousness 10 days later. However, he suffered severe dementia, hearing loss, limb muscle atrophy, and urinary retention in the chronic stage of the disease. Although survivors of adult GBS meningitis are reported to be free of severe neurologic sequelae, factors such as being the oldest patient among the reported cases, the premorbid malignancy and the marked inflammation were considered to be related to the severe neurologic sequelae in the present case.     

The use of extracorporeal membrane oxygenation in a child with adult respiratory distress syndrome following post-obstruction pulmonary oedema

The use of extracorporeal membrane oxygenation (ECMO) for post-operative complications is not well described. ECMO, a partial venoarterial cardiopulmonary bypass, may permit the reversal of pulmonary insult from barotrauma and oxygen toxicity. This report concerns an 8-year-old girl who developed post-obstruction pulmonary oedema and adult respiratory distress syndrome (ARDS) after a general anaesthetic for an attempted aspiration of a peritonsillar abscess and demonstrates an effective use of this technique. In this patient, the extreme levels of ventilatory support required post-operatively caused haemodynamic instability and severe barotrauma. The institution of ECMO with accompanying decrease in ventilatory support resulted in rapid resolution of haemodynamic instability, hypoxia, and pulmonary pathology.