Continuous Metabolic Monitoring in Infant Cardiac Surgery: Toward an Individualized Cardiopulmonary Bypass Strategy

Cardiopulmonary bypass (CPB) in infants is associated with morbidity due to systemic inflammatory response syndrome (SIRS). Strategies to mitigate SIRS include management of perfusion temperature, hemodilution, circuit miniaturization, and biocompatibility. Traditionally, perfusion parameters have been based on body weight. However, intraoperative monitoring of systemic and cerebral metabolic parameters suggest that often, nominal CPB flows may be overestimated. The aim of the study was to assess the safety and efficacy of continuous metabolic monitoring to manage CPB in infants during open‐heart repair. Between December 2013 and October 2014, 31 consecutive neonates, infants, and young children undergoing surgery using normothermic CPB were enrolled. There were 18 male and 13 female infants, aged 1.4 ± 1.7 years, with a mean body weight of 7.8 ± 3.8 kg and body surface area of 0.39 m². The study was divided into two phases: (i) safety assessment; the first 20 patients were managed according to conventional CPB flows (150 mL/min/kg), except for a 20‐min test during which CPB was adjusted to the minimum flow to maintain MVO₂ >70% and rSO₂ >45% (group A); (ii) efficacy assessment; the following 11 patients were exclusively managed adjusting flows to maintain MVO2 >70% and rSO2 >45% for the entire duration of CPB (group B). Hemodynamic, metabolic, and clinical variables were compared within and between patient groups. Demographic variables were comparable in the two groups. In group A, the 20‐min test allowed reduction of CPB flows greater than 10%, with no impact on pH, blood gas exchange, and lactate. In group B, metabolic monitoring resulted in no significant variation of endpoint parameters, when compared with group A patients (standard CPB), except for a 10% reduction of nominal flows. There was no mortality and no neurologic morbidity in either group. Morbidity was comparable in the two groups, including: inotropic and/or mechanical circulatory support (8 vs. 1, group A vs. B, P = 0.07), reexploration for bleeding (1 vs. none, P = not significant [NS]), renal failure requiring dialysis (none vs. 1, P = NS), prolonged ventilation (9 vs. 4, P = NS), and sepsis (2 vs. 1, P = NS). The present study shows that normothermic CPB in neonates, infants, and young children can be safely managed exclusively by systemic and cerebral metabolic monitoring. This strategy allows reduction of at least 10% of predicted CPB flows under normothermia and may lay the ground for further tailoring of CPB parameters to individual patient needs.     

Economic Cost of Treating the Patient With Asthma in Spain: The AsmaCost Study

ObjectiveThis analysis of the cost of asthma in Spain includes both direct health care costs and indirect costs arising from illness.Patients and MethodsProspective, 12-month observational cohort study of adult patients with asthma diagnosed according to the guidelines of the Global Initiative for Asthma (GINA) and the adapted Spanish criteria (GEMA). We recorded information on health care resources utilized (medications, medical visits, emergency care, hospital admissions, and tests) and indirect costs (patient travel or transfer costs and workdays lost).ResultsA total of 627 patients throughout Spain were studied. Of these, 21.2% had intermittent asthma, 24.6% mild asthma, 27.6% moderate asthma, and 26.6% severe asthma. The total societal cost of asthma (including indirect costs) was €1726 (95% confidence interval [CI], €1314-€2154) per patient annually. Indirect costs accounted for 11.2% of the total. The cost to the National Health Service was €1533 (95% CI, €1133-€1946) per patient annually. The cost of asthma was higher for patients older than 65 years (€2079) and for those with more severe disease (€959 for intermittent asthma; €1598, mild asthma; €1553, moderate asthma; and €2635 severe asthma). Based on these findings, the total annual cost of asthma in Spain is estimated to be €1480 million (95% CI, €382-€2565 million) for patients with demonstrated bronchial hyperreactivity and €3022 million (95% CI, €2472-€3535 million) for patients diagnosed based on symptoms alone.ConclusionsThe average annual cost of asthma in adults in Spain comes to €1726 per patient, considering both direct and indirect costs from a societal perspective. The average annual cost per patient to the National Health Service is €1533.     

Bariatric Surgery Outcomes in Sarcopenic Obesity

Background

Sarcopenic obesity is the combination of low muscle mass and strength with increased fat mass. This condition is associated with negative health outcomes. We hypothesized that sarcopenia could be a pejorative factor on surgical weight loss.

Objective

The objectives of the study are to determine the influence of sarcopenic obesity on gastric bypass and sleeve gastrectomy results regarding weight loss and comorbidities resolution at 3, 6, and 12 months.

Setting

The study was conducted at the University Hospital.

Methods

Sixty-nine obese patients who benefited from bariatric surgery were included. Skeletal muscle mass was determined by the Janssen’s equation. Physical performance and muscle strength were determined using the 6-min walk test and the wall sit test. Obese subjects from the lowest tertile of the Skeletal Muscle mass Index (SMI) of Baumgartner were set as sarcopenic.

Results

Weight loss outcomes and rate of weight loss failure were not influenced by sarcopenia. At 1 year, mean EBMIL% was 75.4 %?±?5 in sarcopenic subjects vs 67.8 % ±4 in the non-sarcopenic subjects (p?=?0.242). Improvement rates of co-morbidities were similar between groups. Skeletal muscle mass was no more different between groups at 1 year after surgery. There was no patient lost to follow-up.

Conclusions

Bariatric surgery remains effective in achieving weight loss target in sarcopenic patients, with similar remission rates of main comorbidities and similar safety profile than in the non-sarcopenic group. Whether bariatric surgery could result in improvement or deterioration of daily living activities disabilities and functional autonomy in sarcopenic obese patients still have to be evaluated.

     

Treatment of Bowen's disease of the penis with imiquimod 5% cream

We present an alternative treatment of the intraepithelial neoplasms of penis (Bowen's disease), the topical application of imiquimod 5% cream. It was applied 3 times weekly for 5 weeks. Imiquimod is an imidazoquinolone immune response modifier that has been shown to have indirect antiviral and antitumor effects with few adverse effects. Imiquimod 5% cream may represent an alternative treatment option for Bowen's disease.     

Secondary obstructive uropathy to inverted papilloma of the ureter

We report a new case of inverted papilloma of the ureter, with an uncommon clinic manifestation as a obstructive uropathy. In spite of the bening nature the inverted papilloma of the urinary tract, it can be multifocal and relapsing and it may be associated with low rate urothelial carcinomas. A precise pre-operative diagnosis is necessary for a conservative or endourologic treatment. The followup of these cases with periodic urography and cystoscopy is mandatory.     

Comparison of R2* correction methods for accurate fat quantification in fatty liver

Purpose:

To compare the performance of fat fraction quantification using single‐R₂* and dual‐R₂* correction methods in patients with fatty liver, using MR spectroscopy (MRS) as the reference standard.

Materials and Methods:

From a group of 97 patients, 32 patients with hepatic fat fraction greater than 5%, as measured by MRS, were identified. In these patients, chemical shift encoded fat‐water imaging was performed, covering the entire liver in a single breathhold. Fat fraction was measured from the imaging data by postprocessing using 6 different models: single‐ and dual‐R₂* correction, each performed with complex fitting, magnitude fitting, and mixed magnitude/complex fitting to compare the effects of phase error correction. Fat fraction measurements were compared with co‐registered spectroscopy measurements using linear regression.

Results:

Linear regression demonstrated higher agreement with MRS using single‐R₂* correction compared with dual‐R₂* correction. Among single‐R₂* models, all 3 fittings methods performed similarly well (slope = 1.0 ± 0.06, r² = 0.89–0.91).

Conclusion:

Single‐R₂* modeling is more accurate than dual‐R₂* modeling for hepatic fat quantification in patients, even in those with high hepatic fat concentrations. J. Magn. Reson. Imaging 2013;37:414–422. © 2012 Wiley Periodicals, Inc.     

Helical computed tomography of liver injuries: A trial of dual phase imaging

This study was performed to evaluate whether consecutive arterial phase and portal venous phase scans of the upper abdomen are contributory in the evaluation of the liver in patients with blunt abdominal trauma. The purpose of the study was to determine whether such dual acquisition using helical computed tomography (HCT) provides improved definition of injuries and significant information about the dynamics of posttraumatic hemorrhage.During a 10-month period, all patients referred for evaluation of blunt abdominal trauma were scanned using a dual phase imaging technique. Two consecutive and comparable scan clusters were programmed to study the upper abdomen, with a slice collimation of 10 mm and a 11 pitch. Intravenous contrast medium was delivered at a rate of 2 ml/sec for a total of 125 ml, with scan delays of 30 and 70 seconds (arterial and venous phases of hepatic enhancement).Thirty-two patients with hepatic lacerations were encountered, and the images from both acquisitions were compared and graded according to lesion conspicuity. The presence of contrast medium extravasation associated with parenchymal injuries was also recorded.In 23 (72%) of the 32 patients, the liver injuries were better defined in the portal venous phase, and in eight (25%) patients, the lesions were equally shown in both phases. In only one case, the lesion was better demonstrated in the arterial phase. Contrast medium extravasation was noted in two patients at the site of liver laceration. In three additional cases, contrast medium extravasation was also noted in associated splenic injuries. In all of these patients, the extravasation (bleeding laceration) was seen only in the images corresponding to the portal venous phase.Dual phase HCT of the upper abdomen does not provide significant additional information in the evaluation of patients with liver injuries resulting from blunt abdominal trauma. With a single scan cluster through the upper abdomen after a 70-second injection-scan delay, lesion definition is optimal, and vascular opacification remains adequate.     

Arteroportal fistulas between the accessory right hepatic, gastroduodenal and superior mesenteric arteries and portal vein: a difficult technical problem to overcome in liver transplantation

BACKGROUND: Fistulous communications between the accessory right hepatic (ARHA), gastroduodenal (GD), and superior mesenteric (SMA) arteries and the portal vein (PV) may represent a contraindication for liver transplantation (LT). MATERIAL: A patient with HCV-related liver cirrhosis and progressive liver decompensation underwent preoperative LT work-up. Doppler ultrasound (DU), Angiography and MRI revealed arteroportal fistulas (APF) and diversion of mesenteric-splenoportal flow through spontaneous splenorenal shunts (SSRS) in the systemic circulation. The patient was transplanted and the ARHA and GDA were distally sectioned; the HA was anastomosed to the donor HA; the superior mesenteric vein (SMV) was detached from the splenopancreatic venous bed by sectioning and ligating the Henle trunk, by ligating an posterior-inferior pancreatic vein and, finally, by positioning an iliac vein interposition graft between the SMV and the donor PV. The postanastomotic SMV trunk and recipient PV were ligated below and above the pancreatic head, respectively. RESULTS: Reperfusion and late liver function were good. DU and MRI studies showed an effective portal flow and the maintenance of a normal splenopancreatic vein outflow through the SSRS. DISCUSSION: APF represent a serious clinical problem, particularly in patients who need LT. The persistence of arterial flow into the PV is dangerous for the long-term liver function. A particular surgical strategy, strictly tailored to the hemodynamic conditions, has to be planned. CONCLUSIONS: Extrahepatic multiple APF would no longer to represent a contraindication to LT, although this claim needs to be confirmed in the light of further experience and a longer-term follow-up.     

Glibenclamide effects on renal function and histology after acute hemorrhage in rats under sevoflurane anesthesia

INTRODUCTION: Hypovolemia from hemorrhage evokes protective compensatory reactions, such as the renin-angiotensin system, which interferes in the clearance function and can lead to ischemia. This study was designed to evaluate the effects of glibenclamide, a K(+)(ATP) channel blocker, on renal function and histology in rats in a state of hemorrhagic shock under sevoflurane anesthesia. MATERIAL AND METHODS: Twenty Wistar rats were randomized into two groups of 10 animals each (G1 and G2), only one of which (G2) received intravenous glibenclamide (1 microg.g(-1)), 60 min before bleeding was begun. Both groups were anesthetized with sevoflurane and kept on spontaneous respiration with oxygen-air, while being bled of 30% of volemia in three stages with 10 min intervals. There was an evaluation of renal function - sodium para-aminohippurate and iothalamate clearances, filtration fraction, renal blood flow, renal vascular resistance - and renal histology. Renal function attributes were evaluated at three moments: M1 and M2, coinciding with the first and third stages of bleeding; and M3, 30 min after M2, when the animals were subjected to bilateral nephrectomy before being sacrificed. RESULTS: Significant differences were found in para-aminohippurate clearance, G1 < G2, and higher renal vascular resistance values were observed in G1. Histological examination showed the greater vulnerability of kidneys exposed to sevoflurane alone (G1) with higher scores of vascular and tubular dilatation. There were vascular congestion and tubular vacuolization only in G1. Necrosis and signs of tubular regeneration did not differ in both groups. CONCLUSION: Treatment with glibenclamide attenuated acutely the renal histological changes after hemorrhage in rats under sevoflurane anesthesia.