QT prolongation under sevoflurane in infants

Introduction   QT interval prolongation may cause the potentially lethal tachyarrhythmia torsades de pointes ( 1 ). The cause of the QT interval prolongation may be a congenital mutation in genes encoding cardiac potassium and sodium channels ( 2 ) or be acquired following drug administration ( 3 ) or metabolic disorders ( 4 ). Among a few other drugs volatile anaesthetics prolong the QT interval. During the last few years sevoflurane has become the most used volatile anaesthetic for the induction of anaesthesia in infants.
Methods   This investigation, on infants aged from 1 to 6 months, was approved by the institutional ethic committee. Thirty-six otherwise healthy infants due to elective surgery were included in our study The patients were randomly assigned to one of two treatment groups. Group S ( n  = 24) was anaesthetised with sevoflurane, Group H was anaesthetised with halothane. ECG recordings were taken before the anaesthesia onset, 15 min after the first contact with the volatile anaesthetic and 60 min after the ending of the volatile gas exposition. QTc interval was calculated using the Bazett's formula ( 5 ).
Results   QTc interval was significantly ( P < 0.0002) (Table 1) lengthened 15 min after anaesthesia induction with sevoflurane as well as 60 min ( P < 0.01) after the ending of the gas exposition without any difference in age and gender. The QTc interval in patients anaesthetised with halothane did not show any significant change.  

  Table 1     

122.

Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes     

DS Keller  RN Tahilramani  JR Flores-Gonzalez  S. Ibarra  EM Haas 《Surgical endoscopy》2016,30(6):2192-2198

Background

Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay.

Methods

Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay.

Results

Fifty patients were analyzed—25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality.

Conclusions

Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.

     

123.

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model     

McVay MR  Boneti C  Habib CM  Keller JE  Kokoska ER  Jackson RJ  Smith SD 《Journal of pediatric surgery》2008,43(1):25-29

Background/Purpose

Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets.

Methods

One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using χ² tests.

Results

NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both).

Conclusion

Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.     

124.

Evaluation of abduction range of motion and avoidance of inferior scapular impingement in a reverse shoulder model     

Gutiérrez S  Levy JC  Frankle MA  Cuff D  Keller TS  Pupello DR  Lee WE 《Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]》2008,17(4):608-615

The purpose of this study was to determine the effects of prosthetic design and surgical technique of reverse shoulder implants on total abduction range of motion and impingement on the inferior scapular neck. Custom implants in three glenosphere diameters (30, 36, and 42 mm), with 3 different centers of rotation offsets (0, +5, and +10 mm), were placed into a Sawbones scapula (Pacific Research Laboratories, Vashon, WA) in 3 different positions: superior, center, and inferior glenoid. Humeral sockets were manufactured with a 130 degrees , 150 degrees , and 170 degrees neck-shaft angle. Four independent factors (glenosphere diameter, center of rotation offset, glenosphere position on the glenoid, and humeral neck-shaft angle) were compared with the 2 dependent factors of range of motion and inferior scapular impingement. Center of rotation offset had the largest effect on range of motion, followed by glenosphere position. Neck-shaft angle had the largest effect on inferior scapular impingement, followed by glenosphere position. This information may be useful to the surgeon when deciding on the appropriate reverse implant.     

125.

SOST is a target gene for PTH in bone   总被引：9，自引：0，他引：9  

Keller H  Kneissel M 《BONE》2005,37(2):148-158

     

126.

Osteointegration of hydroxyapatite-titanium implants coated with nonglycosylated recombinant human bone morphogenetic protein-2 (BMP-2) in aged sheep   总被引：2，自引：0，他引：2  

Sachse A  Wagner A  Keller M  Wagner O  Wetzel WD  Layher F  Venbrocks RA  Hortschansky P  Pietraszczyk M  Wiederanders B  Hempel HJ  Bossert J  Horn J  Schmuck K  Mollenhauer J 《BONE》2005,37(5):699-710

Osteointegration of metal implants into aged organisms can be severely compromised due to reduced healing capacity of bone, lack of precursor cells for new bone formation, or osteoporosis. Here, we report on successful implant healing in a novel model of aged sheep in the presence of nonglycosylated bone morphogenetic protein 2 (BMP-2). Ewes of 8 to 12 years with significant radiologic and histologic signs of osteoporosis and adipocytic bone marrow received a cylindrical hydroxyapatite-titanium implant of 12 x 10 mm. BMP-2 has been produced as a bacterial recombinant fusion protein with maltose-binding protein and in vitro generation of mature BMP-2 by renaturation and proteolytic cleavage. A BMP-2 inhibition ELISA was developed to measure the in vitro release kinetics of bioactive human BMP-2 from immersed solid implant materials by using Escherichia coli expressed and biotinylated recombinant human BMP-2 receptor IA extracellular domain (ALK-3 ECD). The implants were placed laterally below both tibial plateaus, with the left leg implant carrying 380 microg BMP-2. Both implant types became integrated within the following 20 weeks. The control implant only integrated at the cortical bone, and little new bone formation was found within the pre-existing trabecular bone or the marrow cavity. Marrow fat tissue was partially replaced by unspecific connective tissue. In contrast, BMP-2-coated implants initiated significant new bone formation, initially in trabecular arrangements to be replaced by cortical-like bone after 20 weeks. The new bone was oriented towards the cylinder. Highly viable bone marrow appeared and filled the lacunar structures of the new bone. In mechanical tests, the BMP-2-coated implants displayed in average 50% higher stability. This animal model provided first evidence that application of nonglycosylated BMP-2 coated on solid implants may foster bone healing and regeneration even in aged-compromised individuals.     

127.

Lingual nerve injury associated with the ProSeal laryngeal mask airway: a case report and review of the literature     

Brimacombe J  Clarke G  Keller C 《British journal of anaesthesia》2005,95(3):420-423

We present a case of lingual nerve injury that was associated with use of the ProSeal laryngeal mask airway during shoulder replacement in a 61-yr-old male. We also review other cases of cranial nerve injury, most of which were associated with use of the classic laryngeal mask airway. In principle, the frequency of cranial nerve injuries can be reduced by avoiding insertion trauma, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.     

128.

Survival of severe congenital diaphragmatic hernia has morbid consequences     

Cortes RA  Keller RL  Townsend T  Harrison MR  Farmer DL  Lee H  Piecuch RE  Leonard CH  Hetherton M  Bisgaard R  Nobuhara KK 《Journal of pediatric surgery》2005,40(1):36-46

Background/Purpose

Fetal tracheal occlusion (TO) was developed in an attempt to enhance prenatal lung growth and improve survival in fetuses with severe congenital diaphragmatic hernia (CDH). We conducted a randomized, controlled clinical trial in 24 fetuses with severe left CDH (liver herniated into the thorax and low lung-to-head ratio) to compare survival after endoscopic fetal TO vs standard perinatal care (control) and prospectively followed up the 16 survivors (9 control, 7 TO) to compare neurodevelopmental, respiratory, surgical, growth, and nutritional outcomes.

Methods

At 1 and 2 years old, subjects underwent evaluation consisting of medical and neurological history and physical, developmental testing, nutritional assessment, oxygen saturation and pulmonary function testing, chest radiograph, and echocardiogram. Growth and developmental measures were corrected for prematurity. Data were analyzed by Mann-Whitney rank sum test, Fisher's Exact test, and logistic and linear regression.

Results

Infants with TO were significantly more premature at birth (control vs TO, 37.4 ± 1.0 vs 31.1 ± 1.7 weeks; P < .01). Growth failure (z score for weight <2 SDs below mean) was severe in both groups at 1 year of age (control vs TO, 56% vs 86%; P = .31). There was considerable catch-up growth by age 2 years (growth failure: control vs TO, 22% vs 33%; P = .19). There were no differences in other growth parameters. There were also no differences in neurodevelopmental outcome at 1 and 2 years. Supplemental oxygen at hospital discharge was a significant predictor of worse neurodevelopmental outcome at 1 and 2 years old (P = .05 and P = .02, respectively). Hearing loss requiring amplification has been diagnosed in 44% of the group (control vs TO, 44% vs 43%; P = 1.0).

Conclusions

In this group of infants with severe CDH, there were no differences in outcome at 2 years old despite significant prematurity in the TO group. Oxygen supplementation at hospital discharge identified the most vulnerable group with respect to neurodevelopmental outcome, but all infants had significant growth failure, and hearing impairment is a substantial problem in this population. Severe CDH carries significant risk of chronic morbidity.     

129.

Prime the ProSeal™ drain tube with lube from a tube!     

Joseph Brimacombe  Christian Keller 《Journal canadien d'anesthésie》2005,52(3):338-339

     

130.

Increased risk of psoriasis following chronic rhinosinusitis without nasal polyps: a population‐based matched‐cohort study     

J.J. Keller  C.‐S. Wu  H.‐C. Lin 《The British journal of dermatology》2013,168(2):289-294

Background Although chronic rhinosinusitis without nasal polyps (CRSsNP) and psoriasis both share immunological disturbances as pathological factors, no prior study has investigated the risk for psoriasis among patients with CRSsNP. Objectives To investigate the subsequent risk for psoriasis following a diagnosis of CRSsNP by utilizing a cohort study design and a population‐based dataset in Taiwan. Methods In total, 13 242 subjects with CRSsNP were included in the study cohort and 39 726 subjects were randomly extracted for the comparison cohort. We individually tracked each individual in this study (n = 52 968) for a 5‐year period following their index date to identify those subjects who received a subsequent diagnosis of psoriasis. Cox proportional hazards regression analysis was conducted to calculate the 5‐year risk of subsequent psoriasis following a diagnosis of CRS among the sampled subjects. Results The incidence rate of psoriasis during the 5‐year follow‐up period was 1·41 [95% confidence interval (CI) 1·14–1·71] per 1000 person‐years and 0·69 (95% CI 0·59–0·81) per 1000 person‐years for the study and comparison cohort, respectively. Stratified Cox proportional hazards regression revealed that the hazard ratio for psoriasis during the 5‐year follow‐up period for subjects with CRSsNP compared with the control group was 2·01 (95% CI 1·54–2·62) after adjusting for monthly income, geographical region, hypertension, diabetes, coronary heart disease and hyperlipidaemia, and censoring the cases who died during the 5‐year follow‐up period. Conclusion This study detected an increased risk for psoriasis among patients with CRSsNP.     

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Pilot study of a novel pain management strategy: evaluating the impact on patient outcomes

Background

Our objective was to evaluate the impact of a novel multimodal pain management strategy on intraoperative opioid requirements, postoperative pain, narcotic use, and length of stay.

Methods

Consecutive patients undergoing elective laparoscopic colorectal resection were managed with an experimental protocol. The protocol uses a post-induction, pre-incision bilateral TAP block and local peritoneal infiltration at port sites with long-acting liposomal bupivacaine (20 mL long-acting liposomal bupivacaine, 30 mL 0.25 % bupivacaine, 30 mL saline). Experimental patients were matched on age, body mass index, gender, comorbidity, diagnosis, and procedure to a control group that received no block or local wound infiltration. Both groups followed a standardized enhanced recovery pathway. Demographics, perioperative, and postoperative outcomes were evaluated. The main outcome measures were intraoperative opioids, postoperative pain, opioid use, and length of stay.

Results

Fifty patients were analyzed—25 experimental and 25 controls. Patients were well matched on all demographics. In both cohorts, the main diagnosis was colorectal cancer and primary procedure performed a segmental resection. Operative times were similar (p = 0.41). Experimental patients received significantly less intraoperative fentanyl (mean 158 mcg experimental vs. 299 mcg control; p < 0.01). The experimental group had significantly lower initial (p < 0.01) and final PACU pain scores (p = 0.04) and shorter LOS (3.0 vs. 4.1 days, p = 0.04) compared to controls. Experimental patients trended toward shorter PACU times and lower opioid use and daily pain scores throughout the hospital stay. Postoperative complication and readmission rates were similar across groups. There were no reoperations or mortality.

Conclusions

Our multimodal pain management strategy reduced intraoperative opioid administration. Postoperatively, improvements in PACU time, postoperative pain and narcotic use, and lengths of stay were seen in the experimental cohort. With the favorable finding from the pilot study, further investigation is warranted to fully evaluate the impact of this pain management protocol on patient satisfaction, clinical and financial outcomes.

     

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model

Background/Purpose

Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets.

Methods

One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using χ² tests.

Results

NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both).

Conclusion

Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.     

Evaluation of abduction range of motion and avoidance of inferior scapular impingement in a reverse shoulder model

The purpose of this study was to determine the effects of prosthetic design and surgical technique of reverse shoulder implants on total abduction range of motion and impingement on the inferior scapular neck. Custom implants in three glenosphere diameters (30, 36, and 42 mm), with 3 different centers of rotation offsets (0, +5, and +10 mm), were placed into a Sawbones scapula (Pacific Research Laboratories, Vashon, WA) in 3 different positions: superior, center, and inferior glenoid. Humeral sockets were manufactured with a 130 degrees , 150 degrees , and 170 degrees neck-shaft angle. Four independent factors (glenosphere diameter, center of rotation offset, glenosphere position on the glenoid, and humeral neck-shaft angle) were compared with the 2 dependent factors of range of motion and inferior scapular impingement. Center of rotation offset had the largest effect on range of motion, followed by glenosphere position. Neck-shaft angle had the largest effect on inferior scapular impingement, followed by glenosphere position. This information may be useful to the surgeon when deciding on the appropriate reverse implant.     

Osteointegration of hydroxyapatite-titanium implants coated with nonglycosylated recombinant human bone morphogenetic protein-2 (BMP-2) in aged sheep

Osteointegration of metal implants into aged organisms can be severely compromised due to reduced healing capacity of bone, lack of precursor cells for new bone formation, or osteoporosis. Here, we report on successful implant healing in a novel model of aged sheep in the presence of nonglycosylated bone morphogenetic protein 2 (BMP-2). Ewes of 8 to 12 years with significant radiologic and histologic signs of osteoporosis and adipocytic bone marrow received a cylindrical hydroxyapatite-titanium implant of 12 x 10 mm. BMP-2 has been produced as a bacterial recombinant fusion protein with maltose-binding protein and in vitro generation of mature BMP-2 by renaturation and proteolytic cleavage. A BMP-2 inhibition ELISA was developed to measure the in vitro release kinetics of bioactive human BMP-2 from immersed solid implant materials by using Escherichia coli expressed and biotinylated recombinant human BMP-2 receptor IA extracellular domain (ALK-3 ECD). The implants were placed laterally below both tibial plateaus, with the left leg implant carrying 380 microg BMP-2. Both implant types became integrated within the following 20 weeks. The control implant only integrated at the cortical bone, and little new bone formation was found within the pre-existing trabecular bone or the marrow cavity. Marrow fat tissue was partially replaced by unspecific connective tissue. In contrast, BMP-2-coated implants initiated significant new bone formation, initially in trabecular arrangements to be replaced by cortical-like bone after 20 weeks. The new bone was oriented towards the cylinder. Highly viable bone marrow appeared and filled the lacunar structures of the new bone. In mechanical tests, the BMP-2-coated implants displayed in average 50% higher stability. This animal model provided first evidence that application of nonglycosylated BMP-2 coated on solid implants may foster bone healing and regeneration even in aged-compromised individuals.     

Lingual nerve injury associated with the ProSeal laryngeal mask airway: a case report and review of the literature

We present a case of lingual nerve injury that was associated with use of the ProSeal laryngeal mask airway during shoulder replacement in a 61-yr-old male. We also review other cases of cranial nerve injury, most of which were associated with use of the classic laryngeal mask airway. In principle, the frequency of cranial nerve injuries can be reduced by avoiding insertion trauma, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.     

Survival of severe congenital diaphragmatic hernia has morbid consequences

Background/Purpose

Fetal tracheal occlusion (TO) was developed in an attempt to enhance prenatal lung growth and improve survival in fetuses with severe congenital diaphragmatic hernia (CDH). We conducted a randomized, controlled clinical trial in 24 fetuses with severe left CDH (liver herniated into the thorax and low lung-to-head ratio) to compare survival after endoscopic fetal TO vs standard perinatal care (control) and prospectively followed up the 16 survivors (9 control, 7 TO) to compare neurodevelopmental, respiratory, surgical, growth, and nutritional outcomes.

Methods

At 1 and 2 years old, subjects underwent evaluation consisting of medical and neurological history and physical, developmental testing, nutritional assessment, oxygen saturation and pulmonary function testing, chest radiograph, and echocardiogram. Growth and developmental measures were corrected for prematurity. Data were analyzed by Mann-Whitney rank sum test, Fisher's Exact test, and logistic and linear regression.

Results

Infants with TO were significantly more premature at birth (control vs TO, 37.4 ± 1.0 vs 31.1 ± 1.7 weeks; P < .01). Growth failure (z score for weight <2 SDs below mean) was severe in both groups at 1 year of age (control vs TO, 56% vs 86%; P = .31). There was considerable catch-up growth by age 2 years (growth failure: control vs TO, 22% vs 33%; P = .19). There were no differences in other growth parameters. There were also no differences in neurodevelopmental outcome at 1 and 2 years. Supplemental oxygen at hospital discharge was a significant predictor of worse neurodevelopmental outcome at 1 and 2 years old (P = .05 and P = .02, respectively). Hearing loss requiring amplification has been diagnosed in 44% of the group (control vs TO, 44% vs 43%; P = 1.0).

Conclusions

In this group of infants with severe CDH, there were no differences in outcome at 2 years old despite significant prematurity in the TO group. Oxygen supplementation at hospital discharge identified the most vulnerable group with respect to neurodevelopmental outcome, but all infants had significant growth failure, and hearing impairment is a substantial problem in this population. Severe CDH carries significant risk of chronic morbidity.     

Increased risk of psoriasis following chronic rhinosinusitis without nasal polyps: a population‐based matched‐cohort study

Background Although chronic rhinosinusitis without nasal polyps (CRSsNP) and psoriasis both share immunological disturbances as pathological factors, no prior study has investigated the risk for psoriasis among patients with CRSsNP. Objectives To investigate the subsequent risk for psoriasis following a diagnosis of CRSsNP by utilizing a cohort study design and a population‐based dataset in Taiwan. Methods In total, 13 242 subjects with CRSsNP were included in the study cohort and 39 726 subjects were randomly extracted for the comparison cohort. We individually tracked each individual in this study (n = 52 968) for a 5‐year period following their index date to identify those subjects who received a subsequent diagnosis of psoriasis. Cox proportional hazards regression analysis was conducted to calculate the 5‐year risk of subsequent psoriasis following a diagnosis of CRS among the sampled subjects. Results The incidence rate of psoriasis during the 5‐year follow‐up period was 1·41 [95% confidence interval (CI) 1·14–1·71] per 1000 person‐years and 0·69 (95% CI 0·59–0·81) per 1000 person‐years for the study and comparison cohort, respectively. Stratified Cox proportional hazards regression revealed that the hazard ratio for psoriasis during the 5‐year follow‐up period for subjects with CRSsNP compared with the control group was 2·01 (95% CI 1·54–2·62) after adjusting for monthly income, geographical region, hypertension, diabetes, coronary heart disease and hyperlipidaemia, and censoring the cases who died during the 5‐year follow‐up period. Conclusion This study detected an increased risk for psoriasis among patients with CRSsNP.