Postoperative Management after Pneumonectomy for Blunt Thoracic Trauma

Abstract Pneumonectomy for blunt thoracic injury carries a high mortality rate. We present a case of severe bilateral blunt thoracic injury in which left pneumonectomy was done. The immediate postoperative measures were directed to maintain right heart performance by minimizing hypoxia, avoiding fluid overload and limiting pulmonary hypertension. We believe that this approach contributed to the favorable outcome of this patient.     

Oxidative stress, induced by 6-hydroxydopamine, reduces proteasome activities in PC12 cells

Mutations in familial Parkinson’s disease (PD) have been associated with the failure of protein degradation through the ubiquitin-proteasome system (UPS). Impairment of proteasome function has also been suggested to play a role in the pathogenesis of sporadic PD. We examined the proteasome activity in PC12 cells treated with 6-hydroxydopamine (6-OHDA), the dopamine synthetic derivate used in models of PD. We found that 6-OHDA treatment increased protein oxidation, as indicated by carbonyl group accumulation, and increased caspase-3 activity. In addition, there was an increase in trypsin-, chymotrypsin-, and postacidic-like proteasome activities in cells treated with 10–100 μM 6-OHDA, whereas higher doses caused a marked decline. 6-OHDA exposure also increased mRNA expression of the 19S regulatory subunit in a dose-dependent manner, whereas the expression of 20S- and 11S-subunit mRNAs did not change. Administration of the antioxidant N-acetylcysteine to 6-OHDA-treated cells prevented the alteration in proteasome functions. Moreover, reduction in cell viability owing to administration of proteasome inhibitor MG132 or lactacystin was partially prevented by the endogenous antioxidant-reduced glutathione. In conclusion, our data indicate that mild oxidative stress elevates proteasome activity in response to increase in protein damage. Severe oxidative insult might cause UPS failure, which leads to protein aggregation and cell death. Moreover, in the case of UPS inhibition or failure, the blockade of physiological reactive oxygen species production during normal aerobic metabolism is enough to ameliorate cell viability. Control of protein clearance by potent, brain-penetrating antioxidants might act to slow down the progression of PD.     

Single-dose intravenous valproate in acute mania

OBJECTIVE: High-dose loading with oral and intravenous valproate has been reported to be therapeutic in mania over 48 to 72 hours. We hypothesized that very high dose intravenous (IV) valproate might have even more rapid effects equivalent to effects in status epilepticus that occur within 20 minutes. METHOD: Seven patients with mania (Young Mania Rating Scale score > 20) and minimal prior drug treatment were given valproate 20 mg/kg IV over 30 minutes. RESULTS: No antimanic effects were observed during 120 minutes of observation. There were no side effects. CONCLUSION: Slowly evolving biochemical changes, perhaps at the gene level, may be required for the antimanic effect of anticonvulsants.     

Comparison of Baseline Characteristics and Outcome of Patients with Chest Pain Brought to the Hospital by Private Versus Public Mobile Intensive Care Units

The baseline characteristics and outcome of patients with acute chest pain who were brought to the hospital by public versus private mobile intensive care units were compared. Of 283 patients brought to the Department of Emergency Medicine at the Tel Aviv Sourasky Medical Center by mobile units in July and September of 1995, 163 were transported by the private service and 120 by the public service. Patients who were brought by the private service were older and had significantly more comorbidities, especially cardiac history. However, a significantly higher proportion of patients brought by the public service suffered confirmed myocardial infarction, and were hospitalized in the intensive coronary care unit. In addition, mortality in this group was significantly higher (4.0% vs. 2.2%). Possible explanations for this finding are greater accessibility or bias in the prehospital management of patients channeled through the private mobile service.     

Anti-Rnp antibodies in chronic liver diseases

Antinuclear antibodies are commonly observed in chronic liver disorders. Sera from 87 patients with various chronic liver diseases were tested for the presence of antibodies against two extractable nuclear antigens (ENA) - RNP and Sm. Using an enzyme-linked immunosorbent assay (ELISA) anti-RNP antibodies were detected in 13 patients (15%) most of whom had cryptogenic or primary biliary cirrhosis. When the sera were further tested by ELISA for the presence of anti-Sm antibodies no antibody binding could be detected. These findings support the notion that anti-RNP (but not anti-Sm) antibodies are included among the autoantibodies shared by systemic lupus erythematosus and chronic liver diseases.     

Validation and psychometric properties of the Delirium Motor Subtype Scale in elderly hip fracture patients (Dutch version)

The Delirium Motor Subtype Scale (DMSS) was developed to capture all the previous different approaches to delirium motor subtyping into one new instrument and emphasize disturbances of motor activity rather than associated psychomotoric symptoms. We investigated reliability and validity of the DMSS Dutch version. Elderly patients who had undergone hip fracture surgery received the DMSS and the Delirium Rating Scale Revised-98 (DRS-R-98). A diagnosis of delirium was defined according to the Confusion Assessment Method (CAM). Among 146 patients, 46 (32%) patients were diagnosed with delirium (mean age 86.3 years; SD 5.2). The internal consistency of the DMSS was acceptable (Cronbach's alpha = 0.72). If an item was removed at random the internal consistency of the scale remained the same. Similarly the concurrent validity of DMSS was good (Cohen's kappa = 0.73) while for each motor subtype the Cohen's kappa ranged from 0.58 to 0.85. The sensitivity and specificity of DMSS to detect each subtype ranged from 0.56 to 1 and from 0.88 to 0.98, respectively. This study suggests that the Dutch version of the DMSS is a reliable and valid instrument. The DMSS has scientific validity that could allow for greater precision in further research on motor subtypes.     

Heparin-free management of intra-aortic balloon pump after cardiac surgery

Abstract Background : Anticoagulation with heparin is recommended in patients with an intra‐aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in the early postoperative period after cardiac surgery. We investigated the safety of heparin‐free management after IABP insertion in patients who underwent cardiac surgery. Methods : We studied 203 consecutive patients who received perioperative IABP support between August 2004 and December 2011. All patients were managed without heparin and were followed for thrombotic and/or hemorrhagic complications. Results : Patients were divided into two groups, according to time of IABP treatment following surgery. Group I, 81 patients (39.9%) were treated less than 24 hours following surgery and Group II, 122 patients (60.1%) were treated more than 24 hours following surgery. Vascular complications developed in seven patients (3.4%), two in Group I and five in Group II. Three patients had major and four had minor limb ischemia. There were no major bleeding complications, but minor bleeding complications were observed in eight patients (4.2%). Conclusion : In patients undergoing cardiac surgery with IABP support, the rate of thromboembolic complications was relatively low compared to historical controls. Heparin‐free management may reduce the risk of hemorrhagic complications, with a low risk of thrombotic complications. Heparin should not be routinely used in patients requiring IABP after cardiac surgery. (J Card Surg 2012;27:434‐437)     

Psychosocial Adaptation to Disability Within the Context of Positive Psychology: Philosophical Aspects and Historical Roots

Purpose The purpose of this article is to review the conceptual and clinical similarities that exist between the principles of positive psychology and those underlying rehabilitation counseling and psychology, occupational rehabilitation, and those espoused by the field of psychosocial adaptation to chronic illness and disability (CID). Methods Three themes were selected for review. These included the historical contributions of early scholars in the area of psychosocial adaptation to CID that later were indirectly infused into mainstream positive psychology; state and trait constructs that constitute much of the infrastructure of positive psychology and psychosocial adaptation to CID; and, finally, the philosophical congruencies between positive psychology and psychosocial adaptation to CID. Conclusion The existing literature indicates that there is a substantial philosophical and conceptual overlap between the fields of positive psychology and psychosocial adaptation to CID. Since theoreticians and researchers, from both fields, often use differing terminology and definitions to describe similar concepts, as well as seek similar research goals, it would behoove both fields to seek a closer partnership in order to establish a meaningful dialogue that focuses on human strengths and virtues in the lives of people with CID.     

Disease-Related Mortality within the First Year after Subtotal Esophagectomy for Cancer

Background

Esophageal carcinoma has poor prognosis. Surgery is still considered to be the mainstay of treatment. The mortality rate within the first year after surgery is unknown, but identifying risk factors for early mortality would increase our ability to predict the outcome of these patients and might improve patient selection.

Methods

All patients who had undergone subtotal esophagectomy for cancer between 2003 and 2008 were included in this retrospective series. Patients with less than 12 months follow-up, perioperative mortality, and death from unrelated causes were excluded. Patients were divided into two groups. Group A included all oncological mortality cases within 12 months of surgery. Group B included all patients who survived longer than 12 months following surgery.

Results

Of 81 patients who met the inclusion criteria, group A included 18 patients and group B included 63 (median survival 10 and 25 months, respectively). A higher proportion of patients were operated for pN1 disease in group A (72% versus 33%, p = 0.0004). R₀ esophagectomy rate was lower in group A (39% versus 76%, p = 0.03). Metastatic lymph node ratio (LNR) was higher in group A (mean: 46% versus 10%, p = 0.0003). Multivariate analysis identified LNR as an independent risk factor for first-year oncological mortality [odds ratio (OR) = 1.04, p = 0.0001; 95% confidence interval (CI): 1.02–1.06]. No differences were found in preoperative variables including age, gender, tumor histology, type of operation, and administration of or response to neoadjuvant therapy. Response to neoadjuvant therapy was associated with R₀ resection.

Conclusions

pN1 disease, resection margin involvement, and high LNR were found to be risk factors for first-year oncological mortality after esophagectomy for cancer.