Local warming at injection site helps alleviate pain after rocuronium administration

Purpose

Various strategies have been proposed to reduce discomfort of pain after rocuronium injection. These studies have shown pretreatment of drugs such as fentanyl and lidocaine to be effective. In a prospective randomized study, we evaluated whether pretreatment with local warming at injection site using an air-warming device could effectively alleviate pain induced by rocuronium.

Methods

Ninety patients undergoing spinal surgeries were randomly divided into two groups: group C (control) and group T (treatment). Patients in group T were subjected to warming at 40°C for 1 min prior to injecting 1 ml (10 mg) of rocuronium at the site of venous access. Patients were then assessed for any discomfort and to quantify their discomfort on a 5-point scale.

Results

Age, sex, and weight were comparable between the two groups. Pain on rocuronium administration was reported by 88.9% patient in group C versus 66.7% in group T (p < 0.05). Severe pain was significantly less in group T (35.6% vs. 8.9%).

Conclusion

Application of warmth over the vascular access prior to rocuronium administration effectively reduces injection-related pain.     

Review article: Renal support in critical illness

Purpose

This review provides a focused and comprehensive update on established and emerging evidence in acute renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI).

Principal findings

There have been considerable technological innovations in the methods and techniques for provision of extracorporeal RRT in critical illness. These have greatly expanded our capability to provide both renal and non-renal life-sustaining organ support for critically ill patients. Recent data suggest earlier initiation of RRT in AKI may confer an advantage for survival and renal recovery. Two large trials have recently shown no added benefit to augmented RRT dose delivery in AKI. Observational data have also suggested that fluid accumulation in critically ill patients with AKI is associated with worse clinical outcome. However, several fundamental clinical questions remain to be answered, including issues regarding the time to ideally initiate/discontinue RRT, the role of high-volume hemofiltration or other blood purification techniques in sepsis, and extracorporeal support for combined liver-kidney failure. Extracorporeal support with RRT in sepsis, rhabdomyolysis, and liver failure are discussed, along with strategies for drug dosing and management of RRT in sodium disorders.

Conclusions

We anticipate that this field will continue to expand to promote research and innovation, hopefully for the benefit of sick critically ill patients.     

NGAL is an early predictive biomarker of contrast-induced nephropathy in children

We hypothesized that neutrophil gelatinase-associated lipocalin (NGAL) is an early predictive biomarker of contrast-induced nephropathy (CIN). We prospectively enrolled 91 children (age 0–18 years) with congenital heart disease undergoing elective cardiac catheterization and angiography with contrast administration (CC; Ioversol). Serial urine and plasma samples were analyzed in a double-blind fashion by NGAL enzyme-linked immunosorbent assay (ELISA). CIN, defined as a 50% increase in serum creatinine from baseline, was found in 11 subjects (12%), but detection using increase in serum creatinine was only possible 6–24 h after CC. In contrast, significant elevation of NGAL concentrations in urine (135 ± 32 vs. 11.6 ± 2 ng/ml without CIN, p < 0.001) and plasma (151 ± 34 vs. 36 ± 4 without CIN, p < 0.001) were noted within 2 h after CC in those subjects. Using a cutoff value of 100 ng/ml, sensitivity, specificity, and area under the receiver-operating characteristic (ROC) curve for prediction of CIN were excellent for the 2-h urine NGAL (73%, 100%, and 0.92, respectively) and 2-h plasma NGAL (73%, 100%, and 0.91, respectively). By multivariate analysis, the 2-h NGAL concentrations in the urine (R ² = 0.52, p < 0.0001) and plasma (R ² = 0.72, p < 0.0001) were found to be powerful independent predictors of CIN. Patient demographics and contrast volume were not predictive of CIN.     

Anisomycin activates p38 MAP kinase to induce LTD in mouse primary visual cortex

Anisomycin is both a well-established protein synthesis inhibitor and a potent activator of the p38/JNK MAPK pathway. It has been used to block the late phase of long-term potentiation (LTP) and long-term depression (LTD) in hippocampus. In this study, we have found that anisomycin produces a time-dependent decline in the magnitude of the field EPSP (fEPSP) in acute brain slices of mouse primary visual cortex. This anisomycin-mediated fEPSP depression occludes NMDA receptor-dependent LTD induced by low-frequency stimulation (LFS). In contrast, two other protein synthesis inhibitors, emetine and cycloheximide, have no effect either on baseline synaptic transmission or on LTD. Moreover, the decline of the fEPSP caused by anisomycin can be rescued by the application of the p38 inhibitor SB203580 but not by the JNK inhibitor SP600125. These results indicate that activation of p38 MAPK by anisomycin induces LTD and subsequently occludes electrically induced LTD. Also, the occlusion of LFS-LTD by anisomycin suggests that common mechanisms may be shared between the two forms of synaptic depression. Consistent with this view, bath application of a membrane permeant peptide derived from the carboxyl tail of GluR2 subunit of AMPA receptor, which specifically blocks regulated AMPA receptor endocytosis, thereby preventing the expression of LFS-induced LTD, significantly reduced the anisomycin-induced decline of the fEPSP. In conclusion, our results indicate that anisomycin produces long-lasting depression of AMPA receptor-mediated synaptic transmission by activating p38 MAPK-mediated endocytosis of APMA receptors in mouse primary visual cortex.     

Postoperative biomarkers predict acute kidney injury and poor outcomes after pediatric cardiac surgery

Acute kidney injury (AKI) occurs commonly after pediatric cardiac surgery and associates with poor outcomes. Biomarkers may help the prediction or early identification of AKI, potentially increasing opportunities for therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 311 children undergoing surgery for congenital cardiac lesions to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. Severe AKI, defined by dialysis or doubling in serum creatinine during hospital stay, occurred in 53 participants at a median of 2 days after surgery. The first postoperative urine IL-18 and urine NGAL levels strongly associated with severe AKI. After multivariable adjustment, the highest quintiles of urine IL-18 and urine NGAL associated with 6.9- and 4.1-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine NGAL levels associated with longer hospital stay, longer intensive care unit stay, and duration of mechanical ventilation. The accuracy of urine IL-18 and urine NGAL for diagnosis of severe AKI was moderate, with areas under the curve of 0.72 and 0.71, respectively. The addition of these urine biomarkers improved risk prediction over clinical models alone as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, urine IL-18 and urine NGAL, but not plasma NGAL, associate with subsequent AKI and poor outcomes among children undergoing cardiac surgery.     

Direct repair of lumbar spondylolysis by Buck��s technique

Background:

The lesion in spondylolysis is a nonunion that follows a fatigue fracture of pars interarticularis. Direct repair of the pars defect is a logical alternative to fusion as it helps to preserve the motion segment and prevents abnormal stresses at the adjacent levels. The purpose of the study is to analyze the clinical and radiological results of direct screw osteosynthesis of the pars defect by the Buck’s method in patients with symptomatic spondylolysis with or without grade 1 spondylolisthesis.

Materials and Methods:

Nine patients (six males, three females, mean age 24 years) with symptomatic spondylolysis with or without grade 1 spondylolisthesis and a normal disc in magnetic resonance imaging (MRI), who failed conservative treatment, underwent surgery between January 2000 and April 2009. Of them five patients had bilateral lysis at one level, one had bilateral lysis at three levels and two levels each and two had unilateral lysis at one level. Direct pars repair by the Buck’s method with internal fixation of the defect using 4.5 mm cortical screws and cancellous bone grafting was done. The mean follow-up period was 45 months. MacNab criteria were used to evaluate the postoperative functional outcome. Healing of the pars defect was assessed by plain radiographs and computed tomography (CT) scan.

Results:

Spondylolysis was bilateral in seven and unilateral in two patients. Two patients had associated grade 1 spondylolisthesis. The mean operative time was 58 minutes (range 45 – 75 minutes) and blood loss was 98 ml (50 – 140 ml). Although radiological fusion was observed in all patients at a mean follow-up of 45 months (range 9 to 108 months), the functional outcome was excellent in two patients and good in five, with one fair and one poor result. The overall result of the procedure was satisfactory in 78% (7/9) of the patients. The two patients with associated grade 1 spondylolisthesis had fair and poor results. No complications were encountered in the perioperative or postoperative period.

Conclusions:

In carefully selected patients, direct repair of the pars defect by the Buck’s technique of internal fixation and bone grafting was a safe and effective alternative to fusion in younger patients with symptomatic spondylolysis, without associated spondylolisthesis, who failed conservative management.     

Computer navigation assisted fixation in neglected C2-C3 dislocation in an adult

A 49-year-old male presented with neck pain and deformity following an industrial accident sustained two months back. His neurology was normal except for a minimal weakness in left biceps (grade 4/5). Radiographs, magnetic resonance imaging and computed tomographic scan revealed fracture dislocation of C2-C3 with significant lateral translation of C2 over C3 without disc herniation. In view of unsuccessful closed reduction and absent disc herniation at the level of dislocation, a posterior only reduction, stabilisation and fusion with Iso-C 3D computer navigation-assisted cervical pedicle screw fixation with transverse rod-screw construct was performed. At 6 months followup the patient was completely relieved of his symptoms and was able to return to his previous occupation. The rare case is reported for the management by Iso-C 3D computer navigation assisted cervical pedicle screw fixation and reduction with transverse rod-screw construct at each involved level.     

Preoperative Neutrophil-to-Lymphocyte Ratio as a Prognostic Predictor after Curative Resection for Hepatocellular Carcinoma

BACKGROUND: This study was designed to evaluate the impact of an elevated preoperative neutrophil-to-lymphocyte ratio (NLR) on outcome after curative resection for hepatocellular carcinoma (HCC). METHODS: Patients undergoing resection for HCC from January 1994 to May 2007 were identified from the hepatobiliary database. Demographics, laboratory analyses, and histopathology data were analyzed. RESULTS: A total of 96 patients were identified with a median age at diagnosis of 65 (range, 15-85) years. The 1-, 3-, and 5-year overall survival rates were 80%, 58%, and 52%, respectively. Although the presence of microvascular invasion, NLR >or=5, and R1 resection margin were adverse predictors of overall survival, there were no independent predictors identified on multivariate analysis. The 1-, 3-, and 5-year disease-free survival rates were 74%, 63%, and 57%, respectively. Preoperative tumor biopsy, NLR >or= 5, multiple liver tumors, microvascular invasion, and R1 resection margin were all predictors of poorer disease-free survival. Multivariate analysis showed that a NLR >or= 5 and R1 resection margin were independent predictors of poorer disease-free survival. The median disease-free survival of those with a NLR >or= 5 was 8 months compared with 18 months for those with a NLR < 5. CONCLUSION: Preoperative NLR >or= 5 was an adverse predictor of disease-free and overall survival.     

Effects of spinal cord injury on semen parameters

OBJECTIVE/BACKGROUND: Neurogenic reproductive dysfunction in men with spinal cord injury (SCI) is common and the result of a combination of impotence, ejaculatory failure, and abnormal semen characteristics. It is well established that the semen quality of men with SCI is poor and that changes are seen as early as 2 weeks after injury. The distinguishing characters of poor quality are abnormal sperm motility and viability. In the majority of the men with SCI, the sperm count is not abnormal. We elaborate on the effects of the SCI on semen parameters that may contribute to poor motility and poor viability. METHODS: Review. DESIGN: PubMed and MEDLINE databases were searched using the following key words: spinal cord injuries, fertility, sexual dysfunction, and spermatogenesis. All literature was reviewed by the team of authors according to the various stages of sperm development and transport in the male reproductive cycle. FINDINGS: The cause of asthenozoospermia appears to be multifactorial. CONCLUSION: Current literature does not support the preeminence of a single factor relating to neurogenic reproductive dysfunction in men with SCI. After SCI, there is ample evidence of disturbance of sperm production, maturation and storage, and transport due to an abnormal neuroendocrine milieu. Semen quality seems to be primarily affected by changes to the seminal plasma constituents, type of bladder management, and the neurogenic impairment to the ejaculatory function. Further focused and structured studies are required.     

A Perspective on the Surgical Management of Congestive Heart Failure

Surgical treatment of patients with congestive heart failure (CHF) has steadily advanced from rescue procedures such as aneurysmectomy, rupture repair, ventricular assist devices (VADs), and transplantation to procedures that can prevent or delay the progression of cardiac dysfunction and failure. The latter include operations such as coronary artery bypass grafting (CABG) and mitral valve repair for patients with ischemic cardiomyopathy (ICMP) and mitral annular dilatation, ventricular restoration and remodeling, and cardiac resynchronization therapy. As the number of heart transplants reported worldwide continues to decline over the past decade (by over 30%), newer surgical therapies have emerged. A need arises for clinical registries such as the NIH-sponsored LVAD registry and registries for biventricular pacing and AICD implantation, for total artificial heart implants, and for mitral valve repair in patients with ICMP. Prospective trials comparing sole ventricular restoration therapy (SVR) to SVR with concomitant CABG/MVR, coronary sinus versus epicardial LV pacing for ventricular resynchronization therapy, trials comparing LVAD as destination therapy to AICD implants, mitral valve repair versus chordal-sparing valve replacement for ischemic and valvular cardiomyopathy, and off-pump versus on-pump CABG for patients with ICMP are urgently needed. Future research should also be directed toward drugs targeting “B-cell mediated” humeral vascular rejection—the Achilles heel of cardiac transplantation, xenotransplantation, permanently implantable VADs, gene therapy, and myocardial cell regeneration therapy.