Lateral spread response monitoring during microvascular decompression for hemifacial spasm

Aim

The aim of the present study was to determine (1) whether successful intraoperative electromyography monitoring for lateral spread response (LSR) is possible with partial neuromuscular blockade (NMB) in subjects undergoing microvascular decompression (MVD) for hemifacial spasm and (2) the adequate level of NMB to achieve that goal.

Material and methods

A total of 61 patients in whom LSR was monitored during MVD were enrolled in the study. Patients were randomly allocated to two groups: group TOF in which the NMB target was maintenance of two train-of-four (TOF) counts and group T1 in which the NMB target was maintenance of a T₁/Tc ratio of 50?% (T₁: first twitch height of TOF and Tc: control twitch height). The adductor pollicis brevis muscle was used to monitor TOF responses. The frequency of successful LSR monitoring, defined as successful baseline establishment and maintenance of LSR until surgical decompression, was compared between the two groups.

Results

Of the 61 patients 2 were excluded from the study so that 30 patients in group TOF and 29 patients in group T1 were analyzed. The success rate of LSR monitoring was clinically acceptable and significantly higher in group T1 than in group TOF, i.e. n?=?15 (50.0?%) in group TOF versus n?=?24 (82.8?%) in group T1 (P?=?0.008), corresponding to a 32.8?% higher success rate in group T1 than group TOF (95?% CI: 13.9–51.7?%). Mean vecuronium infusion dose was smaller and mean TOF count was higher in group T1 than group TOF with a TOF count =?2 (1) in group TOF versus 3 (1) in group T1 (P?=?0.003). Mean sevoflurane and remifentanil infusion doses were not different between groups. There was no incidence of spontaneous movement during microscopy in either group.

Conclusion

Maintenance of partial NMB with a target T₁/Tc ratio of 50?% resulted in a clinically acceptable success rate of LSR monitoring and surgical condition during MVD. Maintenance of partial NMB with a target T₁/Tc ratio of 50?% rather than TOF count of two during LSR monitoring for MVD can therefore be recommended.     

A Critical Role for Thioredoxin-Interacting Protein in Diabetes-Related Impairment of Angiogenesis

Impaired angiogenesis in ischemic tissue is a hallmark of diabetes. Thioredoxin-interacting protein (TXNIP) is an exquisitely glucose-sensitive gene that is overexpressed in diabetes. As TXNIP modulates the activity of the key angiogenic cytokine vascular endothelial growth factor (VEGF), we hypothesized that hyperglycemia-induced dysregulation of TXNIP may play a role in the pathogenesis of impaired angiogenesis in diabetes. In the current study, we report that high glucose–mediated overexpression of TXNIP induces a widespread impairment in endothelial cell (EC) function and survival by reducing VEGF production and sensitivity to VEGF action, findings that are rescued by silencing TXNIP with small interfering RNA. High glucose–induced EC dysfunction was recapitulated in normal glucose conditions by overexpressing either TXNIP or a TXNIP C247S mutant unable to bind thioredoxin, suggesting that TXNIP effects are largely independent of thioredoxin activity. In streptozotocin-induced diabetic mice, TXNIP knockdown to nondiabetic levels rescued diabetes-related impairment of angiogenesis, arteriogenesis, blood flow, and functional recovery in an ischemic hindlimb. These findings were associated with in vivo restoration of VEGF production to nondiabetic levels. These data implicate a critical role for TXNIP in diabetes-related impairment of ischemia-mediated angiogenesis and identify TXNIP as a potential therapeutic target for the vascular complications of diabetes.     

Sacrococcygeal teratoma growth rate predicts adverse outcomes

Purpose

The purpose of this study was to characterize the growth rate of sacrococcygeal teratomas (SCTs) and determine its relationship to adverse outcomes.

Methods

A retrospective review of all pathology-confirmed isolated SCT patients evaluated with at least two documented ultrasounds and followed through hospital discharge between 2005 and 2012 was conducted. SCT growth rate was calculated as the difference between tumor volumes on a late- and early-gestation ultrasound divided by the difference in time. Outcomes were death, high-output cardiac failure (HOCF), hydrops, and preterm delivery. Student's t-test, receiver operator characteristics, Fisher's Exact test, and Pearson's correlation were performed.

Results

Of the 28 study subjects, there were 3 in utero demises and 2 neonatal deaths. Significantly faster SCT growth rates were seen in all adverse outcomes, including death (p < 0.0001), HOCF (p = 0.005), and preterm delivery (p = 0.009). There was a significant association with adverse outcomes at > 61 cm³/week (AUC = 0.87, p = 0.001, LR = 4.52). Furthermore, there was an even greater association with death at > 165 cm³/week (AUC = 0.93, p = 0.003, LR = 18.42). Growth rate was directly correlated with the percent of solid tumor (r = 0.60, p = 0.0008).

Conclusion

Faster SCT growth is associated with adverse outcomes. SCT growth rate determined by ultrasound is an effective prognostic indicator for adverse outcomes and easily applied to patient management.     

Increased risk of ischemic stroke in patients with Bell's palsy: A longitudinal follow-up study using a national sample cohort

ObjectiveTo investigate the association between Bell's palsy and stroke according to the different types of stroke, using a sample cohort based on the national Korean population.MethodsIndividuals aged ≥ 20 years were collected from the Korean National Health Insurance Service National Sample Cohort between 2002 and 2013. We extracted the data for Bell's palsy patients (n = 3658) and 1:4 matched controls (n = 14,632) and analyzed the occurrence of hemorrhagic or ischemic stroke in both groups. Matching was performed on the basis of age, gender, income, and region of residence. For Bell's palsy, we included only participants who received the diagnosis (ICD-10 code, G510) 2 or more times via ambulatory visits for the same episode with steroid treatment. Patient admission histories were used to identify occurrences of hemorrhagic stroke (I60, I61 and I62) and ischemic stroke (I63). Adjusted hazard ratios were calculated using stratified Cox proportional hazard models for the Charlson comorbidity index and 95% confidence intervals (CIs). For the subgroup analyses, we divided the participants by age, sex, and each time period after the onset of Bell's palsy (≤1 year, 1 to 2 years, 2 to 3years, > 3years).ResultsThe risk of ischemic stroke was significantly increased in Bell's palsy patients compared to that in the controls (adjusted HR = 1.74, 95% CI = 1.38–2.19, P < 0.001). In the subgroup analyses, a significant association between two clinical disorders was observed in patients aged ≥ 50 years old, regardless of gender. The risk of ischemic stroke was significantly increased, especially within 2 years after Bell's palsy. In contrast, the risk of hemorrhagic stroke was not significantly increased.ConclusionThere is an association of Bell's palsy with ischemic stroke but not with hemorrhagic stroke.