Postoperative analgesia by femoral nerve block with ropivacaine 0.2% after major knee surgery: continuous versus patient-controlled techniques

BACKGROUND AND OBJECTIVES: This prospective study compared the efficacy and adverse effects after knee surgery of ropivacaine 0.2% administered as patient-controlled femoral analgesia (PCFA), as a continuous femoral infusion (Inf), or as both (PCFA+Inf). METHODS: Before general anesthesia, 140 adults scheduled to undergo major knee surgery received a sciatic/fascia iliaca nerve block with 0.75% ropivacaine (40 mL). After surgery, they were randomly assigned to receive, through the femoral catheter, an infusion of 0.2% ropivacaine administered as PCFA (boluses of 10 mL with a lockout time of 60 minutes), Inf (10 mL/h), or PCFA + Inf (5 mL/h plus boluses of 5 mL with a lockout time of 60 minutes). Pain was assessed at rest, on mobilization, and during physiotherapy using a visual analog scale (VAS). Additional use of intravenous (IV) analgesics was noted. RESULTS: Patients in all 3 groups experienced similar pain relief at rest, on mobilization, and after physiotherapy (P >.05). Additional use of analgesics and overall patient satisfaction (excellent or good in 80% of cases) were also similar in all groups. However, total postoperative ropivacaine consumption was lower in the PCFA group, 150 mL/48 h (90.5 to 210); than in the Inf group, 480 mL/48 h (478 to 480); and the PCFA + Inf group, 310 mL/48 h (280 to 340) (P <.05). Adverse events were similar in all 3 groups (hypotension, vomiting, insomnia). No paresthesia or motor block were observed. CONCLUSION: All 3 strategies provided effective pain relief. PCFA resulted in a lower consumption of ropivacaine (toxic and financial impact). PCFA + Inf does not improve postoperative analgesia.     

Forearm reactive hyperemia and mortality in end-stage renal disease

BACKGROUND: Reports on the general population indicated that decreased endothelial-mediated vasodilation has a prognostic impact on cardiovascular (CV) morbidity and mortality. Flow-dependent vasodilation of conduit arteries and ischemia-induced forearm reactive hyperemia are impaired in end-stage renal disease (ESRD). Whether deterioration of vasodilator function in ESRD patients has a prognostic impact has not been documented. The aim of this study was to determine whether the impaired forearm postischemic vasodilation is an independent predictor of mortality in ESRD patients, independently from CV end-organ damages, which are usually associated with decreased vasodilatory response. METHODS: Common carotid artery intima-media thickness (CCA-IMT), aortic stiffness (pulse wave velocity-PWV), and LV mass (LVM) were determined for 78 stable ESRD patients on hemodialysis. Forearm postischemic vasodilation [flow debt repayment (FDR)] was measured by venous plethysmography. All-cause mortality served as the outcome variable over a median follow-up of 60 +/- 27 months. RESULTS: Twenty-four deaths occurred (16 of CV origin). According to Cox regression adjusted for age, CCA-IMT, LVM, and PWV, all-cause mortality was independently associated with decreased FDR (RR 0.69 for every 10% increase; 95% CI 0.56-0.85; P= 0.0006) and increased aortic PWV (RR 1.16 for 1 m/s increase; 95% CI 1.04-1.29; P= 0.0091). CONCLUSION: Our data indicate that lower postischemic forearm reactive hyperemia is associated with all-cause mortality of ESRD patients, independently of the presence of end-organ damage such as LVH or arteriosclerosis.     

Characterization of microbial metabolism of Syrah grape products in an in vitro colon model using targeted and non-targeted analytical approaches

Purpose

Syrah red grapes are used in the production of tannin-rich red wines. Tannins are high molecular weight molecules, proanthocyanidins (PAs), and poorly absorbed in the upper intestine. In this study, gut microbial metabolism of Syrah grape phenolic compounds was investigated.

Methods

Syrah grape pericarp was subjected to an enzymatic in vitro digestion model, and red wine and grape skin PA fraction were prepared. Microbial conversion was screened using an in vitro colon model with faecal microbiota, by measurement of short-chain fatty acids by gas chromatography (GC) and microbial phenolic metabolites using GC with mass detection (GC–MS). Red wine metabolites were further profiled using two-dimensional GC mass spectrometry (GCxGC-TOFMS). In addition, the effect of PA structure and dose on conversion efficiency was investigated by GC–MS.

Results

Red wine exhibited a higher degree of C1–C3 phenolic acid formation than PA fraction or grape pericarp powders. Hydroxyphenyl valeric acid (flavanols and PAs as precursors) and 3,5-dimethoxy-4-hydroxybenzoic acid (anthocyanin as a precursor) were identified from the red wine metabolite profile. In the absence of native grape pericarp or red wine matrix, the isolated PAs were found to be effective in the dose-dependent inhibition of microbial conversions and short-chain fatty acid formation.

Conclusions

Metabolite profiling was complementary to targeted analysis. The identified metabolites had biological relevance, because the structures of the metabolites resembled fragments of their grape phenolic precursors or were in agreement with literature data.     

Comprehensive phenotyping of salt-induced hypertensive heart disease in living mice using cardiac magnetic resonance

Objectives

To characterise the effects of high-salt diet (HSD) on left ventricular (LV) mass, systolic function and coronary reserve in living mice using cardiac magnetic resonance imaging (MRI).

Methods

Thirty C57BL/6 1-month-old female mice were fed either a control (n?=?15) or an HSD (n?=?15). After 3 months, LV volumes, ejection fraction and mass were assessed using time-resolved three-dimensional (3D) black-blood manganese-enhanced MRI, and coronary flow velocity reserve (CFVR) was assessed using dynamic MR angiography at rest and during adenosine-induced hyperaemia. Hearts were excised to assess LV wet mass and micro-vascular remodelling at histology.

Results

Micro-vascular remodelling was found at histology in all investigated hearts from the HSD group and none from the control group. No difference between the HSD and control groups was found in terms of heart weight, LV volumes and ejection fraction. Heart to body weight ratio was higher in the HSD group (4.39?±?0.24 vs 4.02?±?0.16 mg/g, P?<?0.001), because of lower body weight (22.3?±?0.9 vs 24.0?±?1.4 g, P?<?0.001). CFVR was lower in the HSD group (1.73?±?0.11 vs 1.94?±?0.12, P?<?0.001).

Conclusions

Phenotyping of hypertensive heart disease is feasible in living mice using dynamic MR angiography and time-resolved 3D black-blood manganese-enhanced MRI. HSD is associated with early impairment of coronary reserve, before the onset of significant hypertrophy.

Key Points

? In vivo phenotyping of hypertensive heart disease is feasible in mice using MRI ? HSD in mice is associated with early impairment of coronary reserve ? Dietary salt in mice alters coronary reserve before the onset of ventricular hypertrophy     

Comparison between stress myocardial perfusion SPECT recorded with cadmium-zinc-telluride and Anger cameras in various study protocols

Purpose

The results of stress myocardial perfusion SPECT could be enhanced by new cadmium-zinc-telluride (CZT) cameras, although differences compared to the results with conventional Anger cameras remain poorly known for most study protocols. This study was aimed at comparing the results of CZT and Anger SPECT according to various study protocols while taking into account the influence of obesity.

Methods

The study population, which was from three different institutions equipped with identical CZT cameras, comprised 276 patients referred for study using protocols involving ²⁰¹Tl (n?=?120) or ^99mTc-sestamibi injected at low dose at stress (^99mTc-Low; stress/rest 1-day protocol; n?=?110) or at high dose at stress (^99mTc-High; rest/stress 1-day or 2-day protocol; n?=?46). Each Anger SPECT scan was followed by a high-speed CZT SPECT scan (2 to 4 min).

Results

Agreement rates between CZT and Anger SPECT were good irrespective of the study protocol (for abnormal SPECT, ²⁰¹Tl 92 %, ^99mTc-Low 86 %, ^99mTc-High 98 %), although quality scores were much higher for CZT SPECT with all study protocols. Overall correlations were high for the extent of myocardial infarction (r?=?0.80) and a little lower for ischaemic areas (r?=?0.72), the latter being larger on Anger SPECT (p?<?0.001). This larger extent was mainly observed in 50 obese patients who were in the ²⁰¹Tl or ^99mTc-Low group and in whom stress myocardial counts were particularly low with Anger SPECT (228?±?101 kcounts) and dramatically enhanced with CZT SPECT (+279?±?251 %).

Conclusion

Concordance between the results of CZT and Anger SPECT is good regardless of study protocol and especially when excluding obese patients who have low-count Anger SPECT and for whom myocardial counts are dramatically enhanced on CZT SPECT.

     

Automated Surveillance of Outpatients with Pneumonia: A Performance Evaluation

Objective

To determine if influenza surveillance should target all patients with acute respiratory infections (ARI) or only track pneumonia cases.

Introduction

Effective responses to epidemics of infectious diseases hinge not only on early outbreak detection, but also on an assessment of disease severity. In recent work, we combined previously developed ARI case-detection algorithms (CDA) [1] with text analyses of chest imaging reports to identify ARI patients whose providers thought had pneumonia. In this work, we asked if a surveillance system aimed at patients with pneumonia would outperform one that monitors the full severity spectrum of ARI.

Methods

Time series of daily casecounts (backgrounds) were created by applying either an ARI CDA (ARI ICD-9 codeset [1]) or a Pneumonia CDA (ARI ICD-9 codes AND chest imaging obtained AND positive results from automated text analysis that identify those chest imaging reports that support the diagnosis of pneumonia) to electronic medical record (EMR) entries related to outpatient encounters at the VA Maryland Health Care System. We used an age-structured metapopulation influenza epidemic model for Baltimore to inject factitious influenza cases into backgrounds. Injections were discounted by the known sensitivity of the ARI CDA [1]. For injections into the pneumonia backgrounds time series, factitious ARI cases were further discounted by the expected pneumonia rate in the modeled influenza epidemic (10%). From the time of injection, EARS or CUSUM statistics [2,3] were applied on each successive day on paired back-ground+injection vs. background-only time series. Each injection-prospective-surveillance cycle was repeated 52 times, each time with the injection shifted to a different week of the one-year study period (2010–11). We computed: 1) the “Detection Delay”, the average time from injection to the first alarm present in the back-ground+injection dataset but absent from the background-only dataset; 2) the “False-Alarm Rate” (FAR), defined as the number of unique false-alarms originating in the background-only dataset during the study year, divided by 365 days. To create activity monitoring operating characteristic (AMOC) curves, we empirically determined the corresponding Delay-FAR pairs over a wide range of alarm thresholds.

Results

The Figure compares AMOC curves for otherwise identical surveillance systems that included either any ARI outpatient visits (red circles, using the EARS W2c statistic [2] and blue triangles, using the CUSUM statistic) or pneumonia (blue triangles, using the CUSUM statistic modified for sparse data [3]). Note that Detection Delay (y-axis) is lower at any given FAR when surveillance aims at patients with pneumonia. Sensitivity analysis suggests that this advantage remains true when pneumonia complicates influenza ≥ 5% of the time.

Conclusions

Our results suggest that EMR-based influenza surveillance that targets patients with pneumonia can outperform systems that monitor all ARI patients.Open in a separate window     

An algorithm combining ultrasound monitoring and urinary luteinizing hormone testing: a novel approach for intrauterine insemination timing

ObjectiveIntrauterine insemination (IUI) is a commonly used treatment for infertility. Optimal timing of insemination is achieved either by ultrasound monitoring of follicular growth followed by the administration of human chorionic gonadotropin (hCG) or by the detection of a luteinizing hormone (LH) surge through urinary LH testing (uLH). However, in cycles where follicular growth is monitored, there is a possibility of a premature LH rise which may affect the outcome of treatment. The objective of the current study was to determine the frequency of spontaneous LH surges in ultrasound-monitored IUI cycles.MethodsOne hundred IUI cycles were followed for this prospective cohort study In combination with ultrasound monitoring, uLH testing was performed twice daily. A serum LH test was performed in the case of an inconclusive uLH test result. IUI was performed either on the day after a positive LH test or, if the diameter of the dominant follicle reached 18 mm and the LH test was still negative, 36 hours after ovulation triggering by administration of hCG.ResultsOf the 87 analyzed cycles, 19 (21.8%) exhibited a premature LH surge as detected by urine testing. Eleven further cycles had an inconclusive urine result, and in six of these (6.9% of cycles) the result was confirmed positive by serum LH testing, giving a total of 25 cycles (28.7%) experiencing a premature LH surge.ConclusionA considerable proportion of patients undergoing ultrasound-monitored IUI cycle had a spontaneous LH surge before ovulation triggering was scheduled This could affect pregnancy rates following IUI.     

Combining MYD88 L265P mutation detection and clonality determination on CSF cellular and cell-free DNA improves diagnosis of primary CNS lymphoma

Diagnosis of primary central nervous system lymphoma (PCNSL) is challenging, and although brain biopsy remains the gold standard, cerebrospinal fluid (CSF) constitutes a less invasive source of lymphomatous biomarkers. In a retrospective cohort of 54 PCNSL cases tested at diagnosis or relapse, we evaluated the contribution of immunoglobulin heavy chain (IGH) gene clonality and MYD88 L265P detection on both CSF cell pellets and supernatants, in comparison with cytology, flow cytometry, interleukin (IL)-10 and IL-6 quantification. Clonality assessment included a new assay to detect partial IGH-DJ rearrangements. Clonal IGH rearrangements and/or MYD88 L265P mutation were detected in 27 (50%) cell pellets and 24 (44%) supernatant cell-free (cf) DNA. Combining analyses on both compartments, 36 (66%) cases had at least one detectable molecular marker, present only in cfDNA for 9 (16%) of them. While cytology and flow cytometry were positive in only 7 (13.0%) and 9 (17.3%) cases respectively, high IL-10 levels were observed in 36 (66.7%) cases. Overall, taking into account molecular and cytokine results, 46/54 (85%) cases had at least one lymphomatous biomarker detectable in the CSF. These results show that this combination of biomarkers evaluated on both cell pellet and supernatant CSF fractions improves significantly the biological diagnosis of PCNSL.