Annual Review Clinic improves care in children with cystic fibrosis

BackgroundIt is unclear whether annual multidisciplinary reviews in cystic fibrosis (CF) patients should be conducted in dedicated annual review (AR) clinics or during continuous assessments throughout the year. Our aim was to assess the effect of introducing an AR clinic.MethodsA retrospective written and electronic record review of CF patients was carried out for 2007 (no AR Clinic) and 2010 (established AR Clinic) calendar years. An internet-based satisfaction survey was distributed to families attending the AR clinic.ResultsIn total, 123 children (mean age 9.5 years, range 1.32–18.8 years) and 141 children (8.3 years, 1.1–18.3 years) were included in 2007 and 2010 respectively. There was a significant increase in multidisciplinary reviews (documented annual review 28% vs 85%, P < 0.001; dietary assessment 46% vs 92%, P < 0.001) and investigations (OGTT 2% vs 74%, P < 0.001; abdominal ultrasound 35% vs 85%, P < 0.001) conducted after the introduction of AR clinic. The majority of the families surveyed (85%) were satisfied or very satisfied with the AR clinic.ConclusionsCF AR clinic significantly improves the number of annual investigations and multidisciplinary reviews performed. Families were satisfied with this new process.     

Pulmonary artery pressure in cystic fibrosis adults: Characteristics,clinical correlates and long-term follow-up

BackgroundWe examined pulmonary artery pressure (PAP) characteristics of CF adults, studied clinical correlates and long-term survival.MethodsComprehensive clinical data were collected and Doppler echocardiography was used to estimate PAP in 109 stable CF adults and 50 healthy controls.ResultsCF patients had lower day and night-time oxygen status, elevated CRP and BNP, and elevated PAP (27.7(13.2, 62.8) mmHg patients v 17.9(11.3, 30.9) mmHg controls, p < 0.001). Even patients with mild pulmonary disease had raised PAP. PAP measurements strongly correlated with arterial partial pressure of oxygen (PaO₂, r = − 0.673, p < 0.001), and FEV₁ percentage predicted (FEV₁%, r = − 0.642, p < 0.001) which were both independent predictors of PAP. At 10 year follow up PAP measurements were related to survival but FEV₁% and PaO₂ were both stronger predictors of death.ConclusionsPAP is raised in CF adults and correlates with pulmonary disease severity. Unlike PaO₂ and FEV₁%, it does not appear to be an independent prognostic marker.     

Plasma ghrelin and leptin in adult cystic fibrosis patients

BackgroundWeight loss in cystic fibrosis (CF) may be associated with altered levels of appetite stimulating peptide ghrelin and the appetite decreasing peptide leptin. However, prior data on leptin in CF are conflicting, while the data on ghrelin are scarce. We hypothesized that weight loss in CF is associated with low levels ghrelin and elevated levels of leptin.MethodsPlasma ghrelin, leptin, TNF-α, IL-1 and IL-6, BMI, fat free mass (FFM), fat mass (FM) were measured in 74 CF adults and 20 controls. CF subjects were divided into 3 groups based on lung disease: mild (n = 19), moderate (n = 30) and severe (n = 25).ResultsSevere CF patients (% predicted FEV1 27 ± 7; median BMI 21 kg/m²) had significantly elevated ghrelin and decreased leptin compared to controls and other CF subjects. Ghrelin correlated (r value, p value) with BMI (− 0.35,< 0.001), FFM (− 0.22,< 0.05), FM (− 0.41,< 0.0001), FEV1 (− 0.62,< 0.001), TNF-α (0.51,< 0.0001), IL-1 (0.56,< 0.0001), and IL-6 (0.33,< 0.01). Leptin correlated (r value, p value) with BMI (0.40,< 0.0001), FM (0.56,< 0.0001), FEV1 (0.34,< 0.05), IL-1 (− 0.51,< 0.05) and TNF-α (− 0.43,< 0.0001). BMI and FEV1 were independent predictors of ghrelin (− 0.35,< 0.05;−0.59,< 0.001). FM was a predictor of leptin (0.56,< 0.0001). Cytokines were elevated only in severe CF (severe CF vs. controls, pg/ml): TNF-α (3.4 ± 0.6 vs. 1.2 ± 0.4), IL-1 (3.5 ± 1 vs. 0.2 ± 0.1), IL-6 (17.4 ± 4 vs. 2.4 ± 2).ConclusionsElevated ghrelin and decreased leptin levels are a consequence rather than a cause of weight loss in advanced CF.     

Interaction of TNFi and conventional synthetic DMARD in SARS-CoV-2 vaccine response in axial spondyloarthritis and psoriatic arthritis

ObjectivesTo evaluate humoral responses to three doses of the inactivated SARS-CoV-2 vaccine (CoronaVac) in patients with spondyloarthritis (SpA) and the effect of therapy, compared with a control group (CG).MethodsProspective cohort of axial SpA/psoriatic arthritis patients and age/sex-balanced CG from the CoronavRheum phase 4 trial (NCT04754698). CoronaVac was given in two doses (28-days interval) with a booster at day 210. Blood samples were collected in the days 0/28 (D28)/69 (D69) and 240 (D240) to evaluate anti-SARS-CoV-2 IgG seropositivity (SP) and neutralising antibodies (NAb).ResultsOne hundred and ninety-four SpA patients were enrolled and 183 patients were age/sex-balanced with 183 CG. At D69, SpA patients showed a high SP (80.2% vs. 95.7%, P < 0.001) and moderate NAb positivity (61.6% vs. 82.7%, P < 0.001), but lower than CG. In patients, older age   prednisone (P < 0.001), methotrexate (MTX) (P < 0.001) and TNF inhibitors (TNFi) (P < 0.001) were independently associated with lower SP, while Caucasian ethnicity (P < 0.05) and prednisone (P < 0.01) were associated with diminished NAb. In contrast, sulfasalazine (SSZ) use was associated with NAb presence (P < 0.05). In monotherapy, only TNFi was also associated with absence of SP (P < 0.05). Further comparison with CG revealed that TNFi and/or MTX negatively impacted SP/NAb (P < 0.05). In contrast, patients under SSZ monotherapy achieved 100% SP (P > 0.999) and 83.3% NAb positivity (P > 0.999). SSZ + TNFi combination resulted in a similar response than CG [SP (P = 0.153) and NAb (P = 0.715)]. After third dose (D69–D240), a major increment occurred for SP (81.3% to 93.1%, P < 0.001) and NAb (63.2% to 86.1%, P < 0.001), but still lower than CG (P < 0.05), and only TNFi impaired both SP (P = 0.016)/NAb (P = 0.002).ConclusionsWe provided novel data demonstrating that TNFi attenuates immunogenicity in SpA patients while SSZ has a positive impact on vaccine antibody production. We also confirmed that MTX in combination with TNFi had a major negative impact in vaccine humoral response (CoronavRheum clinicaltrials.gov #NCT04754698).     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Development of a quantitative immunofluorescence assay for detection of Stenotrophomonas maltophilia antibodies in patients with cystic fibrosis

BackgroundTo describe a simple quantitative immunofluorescence assay (IFA) for the detection of specific Stenotrophomonas maltophilia antibodies in serum of CF patients.MethodsA total of 100 sera (64 CF patients and 36 healthy subjects) were collected over a period of 2 years at the University Hospital Essen, Germany. Sputum culture status classified CF patients into groups. Serologic response was determined after Pseudomonas aeruginosa absorption by indirect IFA to Sm whole cell.ResultsCF patients with “chronic S. maltophilia” showed significantly higher S. maltophilia antibody levels compared with healthy individuals (P < 0.0001) and CF patients with “intermittent” (P = 0.0315) or “never S. maltophilia/P. aeruginosa” (P = 0.0002). A discriminant cut-off value of > 1:120 titre was established to differentiate “CF chronic S. maltophilia” from the other groups. For “CF chronic S. maltophilia”, the IFA showed sensitivity and specificity values of 70.7% and 84.7%, respectively.ConclusionOur data demonstrated that quantitative IFA is a simple serological assay for the detection of specific S. maltophilia antibodies, which could be useful as a diagnostic tool for monitoring immune response of CF patients to S. maltophilia.     

Dexmedetomidine is an effective adjuvant to subtenon block in phacoemulsification cataract surgery

BackgroundResearches to find a better adjuvant in regional anesthesia are still continued until now.Dexmedetomidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the onset of sensory and motor block. The objective of the present study was to evaluate the effect of adding dexmedetomidine to local anesthetics on the sensory and motor block of the subtenon block in patients undergoing phacoemulsification cataract surgery.MethodsSixty patients of American Society of Anaesthesiologists (ASA) grade I–III, aged between 18 and 70 years, scheduled for phacoemulsification cataract surgery were randomly assigned to two equal groups. Group C (control group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine and Group D (dexmedetomidine group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine plus dexmedetomidine (0.5 μg/kg). Onset and duration of sensory and motor block was recorded. Pain during administration of anesthesia and during surgery was graded using the verbal analogue scale and recorded. Intraocular pressure, hemodynamic, and sedation parameters were recorded before and after surgery.ResultsOnset of both sensory and motor block was significantly decreased in group D (P < 0.001, P = 0.004 respectively), and duration of sensory and motor block was more prolonged in group D than in group C (P < 0.001, P = 0.961). Pain during administration of anesthesia was significantly lower in group I compared with group II, and more patients in group I compared with group II were pain free, without a significant difference between the two groups. Intraocular pressure was significantly decreased in group D (P < 0.001). More sedation score was observed in group D (P = 0.022). Heart rate and mean arterial blood pressure were insignificantly decreased in group D more than in group C.ConclusionDexmedetomidine is a safe and effective adjuvant to subtenon block in phacoemulsification cataract surgery.     

Changing thresholds and incidence of antibiotic treatment of cystic fibrosis pulmonary exacerbations, 1995–2005

BackgroundIncreased chronic therapy use and improved cystic fibrosis (CF) patient health should be accompanied by reduced pulmonary exacerbation-associated antibiotic treatment incidence.MethodsTreatment incidence rates and associated sign/symptom scores from 1995–2005 were studied in Epidemiologic Study of CF patients by route (± IV) and age (< 6, 6–12, 13–17, ≥ 18 years).ResultsOverall treatment incidence rate fell 0.0165 events/patient-year/year (P = .006); IV incidence fell 0.0179 (P < .001). Non-IV incidence increased in children ≤ 12 years (P ≤ .002) while significantly decreasing in older patients. Mean IV (P = .046) and non-IV (P = .004) treatment-associated clinical scores decreased in children < 6 years. Non-IV (but not IV) clinical scores decreased in older patients.ConclusionsIV incidence fell for all ages from 1995–2005; non-IV incidence increased in patients ≤ 12 years and fell in others. Average clinical treatment thresholds fell in children < 6 years; IV thresholds were unchanged in older patients; non-IV thresholds fell for patients ≥ 13 years. Decreases in treatment incidence were likely partially offset by lower treatment thresholds.     

A retrospective analysis of biofilm antibiotic susceptibility testing: A better predictor of clinical response in cystic fibrosis exacerbations

BackgroundBacteria grow as biofilms within CF airways. However, antibiotic susceptibility testing is routinely performed on planktonically-growing bacteria. This study assessed whether CF patients infected with multiresistant organisms had improved clinical outcomes if given antibiotics that inhibited their biofilm-grown bacteria.Methods110 patients with pulmonary exacerbations were treated with intravenous antibiotics based on susceptibility testing of planktonically-growing bacteria. A retrospective analysis was done using bacterial isolates grown from their sputum at exacerbation. Each isolate was grown as a biofilm and combination antibiotic susceptibility testing was performed. Clinical outcomes in patients treated with biofilm-susceptible antibiotics were compared to those that were not.Results66 of 110 patients (60%) were treated with antibiotic combinations that inhibited all of their planktonically-grown bacterial isolates, however, when the same isolates were grown as biofilms, only 24 patients (22%) had all of their biofilm-grown isolates remaining susceptible to the antibiotics (P = < 0.001 ). When patients with at least one biofilm-grown susceptible isolate (n = 61) were compared to those with none (n = 49), there was a significant decrease in sputum bacterial density (P = 0.02) and length of stay (P = 0.04) and a non-significant decrease in treatment failure. Survival analyses of time to next exacerbation showed non-significant trends favoring patients treated with biofilm-effective antibiotics.ConclusionsMost patients with CF exacerbations do not receive antibiotics that inhibit all biofilm-grown bacteria from their sputum at exacerbation. Patients treated with biofilm-effective therapy seemed to have improved clinical outcomes.     

Nutritional status is associated with health-related quality of life in children with cystic fibrosis aged 9–19 years

BackgroundThe impact of improved nutritional status on health-related quality of life (HRQOL) is unknown for children with cystic fibrosis (CF).MethodsAssociations between nutritional status and HRQOL were examined over 2 years in 95 children, aged 9–19 years, who were followed in the Wisconsin Newborn Screening Project. HRQOL was assessed using the Cystic Fibrosis Questionnaire (CFQ). Associations between height z-score (HtZ), BMI z-score (BMIZ) and seven CFQ dimensions were evaluated.ResultsMean values of at least 80 were observed for all CFQ dimensions except respiratory symptoms and treatment burden. Treatment burden was significantly worse in patients with meconium ileus (57) compared to pancreatic insufficient (65) and sufficient (78) subjects, p < 0.0001. HtZ and BMIZ were positively associated with physical functioning and body image (p < 0.05).ConclusionsBetter nutritional status was associated with increased HRQOL scores. Early diagnosis through newborn screening and improved nutrition provides an opportunity to enhance quality of life and body image perception.     

Health related quality of life in cystic fibrosis: To work or not to work?

BackgroundThe present study investigated whether patients with CF who are studying or working report a better HRQoL in comparison to non-working/studying patients.Methods57 adult CF patients completed the Cystic Fibrosis Questionnaire—Revised, a CF-specific measure of HRQoL. Medical condition was quantified in terms of FEV1 % predicted, BMI, Pseudomonas aer. status, pancreatic status (PS), having an indwelling catheter device (PAC), CF Related Diabetes Mellitus and nutritional status.ResultsMean age was 26.7 years (SD 8.1), mean FEV1 % predicted was 65.09 (SD 22.18), mean BMI was 21.23 (SD 3.45). FEV1 % predicted was related to HRQoL domains Physical Functioning and General Health (r = 0.27 and 0.38 respectively, p < 0.05). A higher BMI was associated with better scores on Eating Disturbances (= fewer problems; r = 0.44, p < 0.01) and a better perception of Weight (r = 0.43, p < 0.01) and Body Image (r = 0.28, p < 0.05). Analysis of variance showed that specific domains of HRQoL were related to diabetes (Weight), taking caloric supplements (Body Image and Weight) and/or PAC (Physical Functioning, Treatment Burden, Role, Weight). Twenty-four patients worked/studied, these patients had a higher FEV1, and fewer had Pseudomonas aer. or a PAC or took high caloric supplements, compared to non-working/studying patients. After controlling for medical parameters, patients who were working/studying scored higher than non-working/studying patients on Physical Functioning, Role Functioning and Social Functioning.ConclusionsCF patients' HRQoL is related to medical status. The non-working/studying CF patients in this sample had greater disease severity and reported a lower quality of life than their working/studying peers, even after controlling for relevant medical parameters. The decision to stop work/study for CF patients is difficult and affects patients' personal, social and financial well-being.     

Associations between amino acids and bone mineral density in men with idiopathic osteoporosis

Idiopathic osteoporosis in middle-aged men is characterized by low-level bone formation. Inhibited anabolism may be involved in the pathogenesis of the disease and amino acids may be of importance. In the present study fasting amino acid profiles in plasma and erythrocytes were determined in 22 male idiopathic osteoporosis (MIO) patients and in 20 age-matched healthy men and associated with bone mineral density, bone histomorphometry and hormones.The osteoporotic patients had normal plasma essential amino acids but increased non-essential amino acids (p = 0.001), particularly glutamine and glycine. The ratio essential/non-essential amino acids, an index of protein nutritional status, was decreased in the MIO patients (0.59 (0.04) μmol/l, mean (SD)), compared to controls (0.66 (0.05), p = 0.001).In the MIO patients, the ratio essential/non-essential plasma amino acids (r = 0.60, p = 0.003) was positively correlated with lumbar spine bone mineral density.The erythrocyte amino acids represent a large proportion of the free amino acids in blood. A novel finding was the lower levels of erythrocyte tryptophan in MIO (12 (2) μmol/l) compared to controls (16 (3), p = 0.001) and decreased erythrocyte/plasma ratio (0.28 (0.07) vs. 0.33, (0.06), p < 0.01), suggesting an altered amino acid transport of tryptophan between plasma and erythrocytes. In the combined group of MIO and control men (n = 42), bone mineral density was positively correlated with erythrocyte tryptophan in both the lumbar spine (r = 0.45, p = 0.003) and femoral neck (r = 0.56, p < 0.001). The bone histomorphometric variables wall thickness, trabecular thickness and mineral apposition rate were all positively associated with erythrocyte tryptophan levels in the MIO patients.In the combined group of MIO and controls, a multiple regression analysis showed that erythrocyte tryptophan could explain 22% of the variation of lumbar spine and 30% of the variation in femoral neck bone mineral density.We conclude that men with idiopathic osteoporosis have changes in free amino acid profiles which indicate their altered utilization. The correlations between tryptophan and bone mineral density and bone histomorphometry suggest a link between tryptophan and osteoblast function which may be important for bone health.     

Comparison of hepatic epithelioid angiomyolipoma and non-hepatitis B,non-hepatitis C hepatocellular carcinoma on contrast-enhanced ultrasound

PurposeThe purpose of this study was to retrospectively compare the imaging features of hepatic epithelioid angiomyolipoma (HEAML) to those of hepatocellular carcinoma negative for hepatitis B surface antigen and hepatitis C antibody (NBNC-HCC) on contrast-enhanced ultrasound (CEUS) with sulphur hexafluoride microbubbles.Material and methodsTwenty-two patients (4 men, 18 women) with a mean age of 42.6 ± 10.2 (SD) years (range: 22–63 years) with histopathologically confirmed HEMAL were included in the study. Forty-four patients (30 men, 14 women) with a mean age of 57.3 ± 15.9 years (range: 19-85 years) with histopathologically confirmed NBNC-HCC were randomly selected from our institution's database as a control group. The CEUS characteristics of the two groups were compared.ResultsOn conventional ultrasound, significant differences in tumor diameter were found between HEAML (4.0 ± 2.0 [SD] cm; range: 1.3–8.9 cm) and NBNC-HCC (8.4 ± 4.4 [SD] cm; range: 1.6-18 cm) (P < 0.001) as well as in degrees of enhancement during the portal (P = 0.001) and late phases (P = 0.003), contrast distribution (P < 0.001) and absence of pseudocaspule (P < 0.001). On CEUS, hyperenhancement during the arterial phase was observed in 21/22 (95.5%) HEAMLs and in 43/44 (97.7%) NBNC-HCCs (P > 0.999). Homogeneous enhancement was more frequent in HEAMLs (20/22; 90.9%) than in NBNC-HCCs (13/44; 29.6%) (P < 0.001). Pseudocapsule was observed in 0/22 HEAMLs (0.0%) and in 36/44 NBNC-HCCs (81.8%) (P = 0.017). A prolonged enhancement was observed in 5/22 HEAMLs (22.7%) and in 0/44 NBNC-HCCs (0.0%) (P < 0.001) during the late phase.ConclusionCEUS with sulphur hexafluoride microbubbles is helpful in discriminating between HEAML and NBNC-HCC. Homogeneous enhancement and lack of pseudocapsule are suggestive features for the diagnosis of HEAML.     

Evaluation of an acetated Ringer-based contrast material mixture for postmortem computed tomography angiography

PurposeThe purpose of this study was to compare an established postmortem contrast medium mixture based on polyethylene glycol (PEG) to an isotonic crystalloid with acetated Ringer solution (AR) as the base, both mixed with water-soluble iodinated contrast medium for postmortem computed tomography angiography (PMCTA) with the aim to avoid alterations of the corpse during autopsy.Materials and methodsThe study included 20 cadavers; 10 had PMCTA with AR and 10 with PEG. PMCTA images were analyzed with respect to image quality, vascular contrast patterns and artifacts. Autopsy was evaluated for visual, organ, vessel and haptic alterations. The Wilcoxon rank sum test was used to search for differences in image quality between the two groups. Statistical significance was set at P < 0.05.ResultsAR provided excellent contrast within the right coronary artery (P < 0.001) but a lack of contrast within the left coronary artery (P = 0.008) whereas PEG showed the opposite. A better image quality was observed in the PEG group by comparison with the AR group for right common carotid artery (P = 0.03), left common carotid artery (P = 0.01) and left coronary artery (P = 0.008). No differences were found for ascending aorta (P = 0.65), aortic arch (P = 0.09), right circle of Willis (P = 0.17), left circle of Willis (P = 0.08), inferior vena cava (P = 0.07) and abdominal aorta (P = 0.08). Severe extravasation occurred in all (10/10; 100%) cadavers in the AR group but in none (0/10; 0%) in the PEG group (P < 0.001). At autopsy, visual alteration with lilac discoloration of the face was observed in 4/10 cadavers (40%) in the AR group and in 9/10 cadavers (90%) in the PEG group (P = 0.057). Haptic alterations were observed in 3/10 cadavers (30%) in the AR group and 10/10 cadavers (100%) in the PEG group (P = 0.003).ConclusionAR results in contrast medium mixture extravasation in all cadavers, but PEG altered the autopsy more severely. Both carrier substances result in specific substance-related artifacts and dependent opacification of the coronary arteries, but PEG is recommended for PMCTA exclusively with regard to diagnostic imaging.     

Ovarian tumors in children and adolescents: A series of 41 cases

ObjectivePictorial review with a detailed semiological analysis of ovarian tumors in children and adolescents to provide a relevant diagnostic approach.Patients and methodsRetrospective study (2001–2011) of 41 patients under the age of 15 who underwent surgery for an ovarian mass with a definite pathological diagnosis.ResultsSixty-two percent of the lesions were benign, 33% were malignant and 5% were borderline. Germ cell tumors were most frequent (77.5%), followed by sex cord stromal tumors (12.5%) and epithelial tumors (7.5%). Malignant tumors were more frequent in children between 0 and 2 years old. On imaging, calcifications and fat were specific for germ cell tumors; the presence of a mural nodule was predictive of a mature teratoma (P < 0.001). Predictive factors for malignancy were clinical, including abdominal distension (P < 0.01) or a palpable mass (P = 0.05), biological, including increased hCG and/or AFP levels (P < 0.001) and radiological, including tumors larger than 12 cm (P < 0.05), tumoral hypervascularity (P < 0.01) and voluminous ascites (P < 0.01).ConclusionThis semiological analysis confirms the role of imaging in diagnosing the etiology of ovarian lesions in children and adolescents and emphasizes the importance identifying tumoral hypervascularity, which, in addition to classic criteria, is highly predictive of malignancy.     

Effects of differential-phase remote ischemic preconditioning intervention in laparoscopic partial nephrectomy: A single blinded,randomized controlled trial in a parallel group design

Study ObjectiveThere are two windows of protection for remote ischemic preconditioning (RIPC), an early (ERIPC) and a late-phase (LRIPC). While ERIPC has been well studied, works on LRIPC are relatively scarce, especially for the kidneys. We aimed to compare the effects of early-phase versus late-phase RIPC in patients with laparoscopic partial nephrectomy (LPN).DesignA randomized controlled studySettingThe Second Affiliated Hospital of Anhui Medical University, 1 May 2012 to 30 October 2013PatientsSixty-five ASA 1 to 2 patients scheduled for LPN were located randomly to ERIPC group, LRIPC group and CON group (control).InterventionsThree five-minute cycles of right upper limb ischaemia and reperfusion were performed after induction of anesthesia in ERIPC group. Patients in LRIPC group received similar treatment 24 h before surgery, while control patients were not subjected to preconditioning.MeasurementsSerum neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C (CysC) were evaluated before the induction of anesthesia (0h), 2 h (2 h) and 6 h (6 h) after surgery. Unilateral glomerular filtration rates (GFR) were assessed before and after surgery to evaluate overall renal function.Main ResultsSerum NGAL and CysC were significantly lower in ERIPC and LRIPC groups at 2h post-operation (P < 0.001), 6h post-operation (P < 0.001). Additionally, The GFR were significantly lower in ERIPC and LRIPC groups than in CON group at the 3rd month after surgery (P = 0.019; P < 0.001). Moreover, compared to the ERIPC group, concentration of NGAL and CysC in LRIPC group decreased to a greater extent, while GFR and the percentage of decrement was significantly less in the LRIPC group (P = 0.016; P < 0.001).ConclusionsRegardless of early-phase or late-phase intervention, limb remote ischemic preconditioning confers protection on renal ischemia-reperfusion injury in patients with laparoscopic partial nephrectomy, and the late-phase protection is more prominent.     

Residual neuromuscular block as a risk factor for critical respiratory events in the post anesthesia care unit

ObjectiveResidual neuromuscular block is an important postoperative complication associated to the use of neuromuscular blocking drugs. The purpose of this study was to access the incidence of residual neuromuscular block in a post-anesthesia care unit and to evaluate its association with critical respiratory events.Material and methodsProspective cohort study was conducted in a Post Anesthetic Care Unit (PACU) for a period of 3 weeks. Two hundred two adult patients who submitted to scheduled non-cardiac and non-intracranial surgery were eligible to the study. The primary outcome variable was residual neuromuscular block after arrival to PACU that was defined as train-of-four ratio <0.9 and objectively quantified using acceleromyography. Demographic data, perioperative variables, lengths of hospital and recovery room stay and critical respiratory events were recorded. Inadequate emergence was classified in its different forms according to the Richmond agitation and sedation scale 10 min after admission to the recovery room.ResultsResidual neuromuscular block incidence in the post-anesthesia care unit was 29.7% (95% confidence interval: 23.4, 36.1). Patients with residual neuromuscular block had more frequently overall critical respiratory events (51% versus 16%, P < 0.001), airway obstruction (10% versus 2%, P = 0.029), mild-moderate hypoxemia (23% versus 4%, P < 0.001), severe hypoxemia (7% versus 1%, P = 0.033), respiratory failure (8% versus 1%, P = 0.031), inability to breathe deeply (38% versus 12%, P < 0.001) and muscular weakness (16% versus 1%, P < 0.001). Residual neuromuscular block was more common after high-risk surgery (53% versus 33%, P = 0.011) and was more often associated with post-operative hypoactive emergence as defined by the Richmond Agitation and Sedation Scale (21% versus 6%, P = 0.001).ConclusionsThis study suggests that residual neuromuscular block is common in the PACU and is associated with more frequent critical respiratory events.     

Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis

ObjectiveMany clinical studies have been carried out to investigate the relationship between periodontitis and rheumatoid arthritis (RA). Owing to limited evidence and inconsistent findings among these studies, it is unclear whether periodontitis would increase the risk for RA. This meta-analysis was performed to evaluate whether periodontitis represents a risk factor for RA.MethodsPubMed, Cochrane Library, Embase, Web of Science, and Wanfang were searched for eligible studies that compared periodontitis patients with controls. A pooled odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the association between periodontitis and RA.ResultsThirteen studies including a total of 706611 periodontitis patients and 349983 control subjects were included. The pooled OR of RA risk between periodontitis and controls was (OR: 1.69; 95% CI: 1.31–2.17; P < 0.0001), indicating that the patients in periodontitis group had a 69% greater risk for RA than people in control group. When stratified by disease type, the pooled results showed periodontitis represents a risk factor for incident RA (OR = 1.70, 95%CI: 0.75–3.85, P < 0.001) and mixed RA (OR = 1.61, 95%CI: 1.26–2.06; P < 0.001). When stratified by disease duration, the pooled results showed periodontitis represents a risk factor for RA disease duration > 5 years (OR = 2.88, 95%CI: 0.66–12.62, P = 0.018), disease duration < 5 years (OR = 2.59, 95%CI: 0.83–8.11, P < 0.001), mixed disease duration (OR = 1.53; 95%CI: 1.05–2.22, P < 0.001).ConclusionOur meta-analysis revealed an increased risk of RA in patients with periodontitis compared to healthy controls. Moreover, when stratified by disease type, there was a higher risk between incident RA and periodontitis. When stratified by disease duration, the patients with periodontitis might be more closely associated with the RA patients with disease duration >5 years.     

Daily serum creatinine monitoring promotes earlier detection of acute kidney injury in children and adolescents with cystic fibrosis

BackgroundThe epidemiology of aminoglycoside-associated acute kidney injury (AG-AKI) has not been well described in pediatric patients with cystic fibrosis (CF). We aimed to assess the impact of daily serum creatinine (SCr) measurement on detection of AG-AKI at our institution.MethodsWe examined a cohort of hospitalized patients with CF who received an intravenous (IV) aminoglycoside for ≥ 3 days. We compared the rate, timing, and medical management surrounding detection of AG-AKI during 2 periods: January 2010–May 2011 (Era 1, SCr measured at the discretion of the medical team, N = 124) and June 2011–June 2012 (Era 2, SCr measured daily, N = 103). Our primary outcome was detection of AG-AKI defined as ≥ 50% increase in SCr from baseline (lowest value in prior 6 months), or ≥ 0.3 mg/dL rise within 48 h, occurring after day 2.ResultsThe use of once daily tobramycin (p = 0.02) and IV fluids (p < 0.001) was higher during Era 2, while AG courses were shorter (p = 0.04), and fewer concomitant nephrotoxins (p = 0.04) were given; higher daily tobramycin doses (p < 0.001) were administered. Although the rate of AG-AKI was not significantly different (12% during Era 1 vs. 20% during Era 2, p = 0.09), the number of AG-AKI days detected increased (5.5 vs. 2.9 per 100 AG days, p = 0.003), and detection occurred earlier (median 6 vs. 9 days, log rank test p = 0.02) during the daily SCr period.ConclusionsDaily SCr measurement promoted earlier and increased detection of AG-AKI in patients with CF at our institution. We suggest systematic evaluation for AKI during aminoglycoside administration in patients with CF.