A novel method to measure margin reflex distance using the autorefractometer

International Ophthalmology - To determine the margin reflex distance (MRD) in healthy subjects using autorefractometer front monitor images (ARFMI) and validate the accuracy of this method by...     

The effect of acute normovolaemic haemodilution on blood gas parameters: a case report

Introduction Increased awareness of the risks related to homologous blood transfusions such as immunological reactions, transmission of infections, and immunosuppression, has necessitated exploration of alternative techniques to deal with the needs of intra-operative blood transfusion. Strategies that reduce or remove the risks associated with allogeneic transfusion include pre-operative autologous donation, peri-operative cell-salvage techniques, deliberate hypotension, and pharmacological interventions. Acute normovolaemic haemodilution is another such technique. Methods The effect of acute normovolaemic haemodilution on haemodynamics and blood gas parameters was studied in a male patient (58 y, 94 kg, American Society of Anesthesiologists physical status I) undergoing an orthopaedic surgical procedure for joint arthroplasty. After induction of general anaesthesia, 1600 ml of blood was collected and replaced with an equal volume of 6% hexaethyl starch. Results Haemoglobin and haematocrit concentrations were significantly lower following haemodilution (14.9 and 9.2 g/dl for haemoglobin versus 45.0% and 31.7% for haematocrit). There was no significant change in the heart rate, blood pressure or end-tidal carbon dioxide tension throughout the operation period. Central venous pressure increased marginally from 5 to 90 min, but was within normal limits. There was no significant change in blood gas parameters following haemodilution. Platelet count decreased following haemodilution but the values were within normal limits. Conclusion Acute normovolaemic haemodilution with 6% hexaethyl starch is a safe procedure for blood conservation in selected operations. It did not cause any haemodynamic or blood gas parameters to change. It did not have any adverse effect on haemostatic mechanisms that could enhance the risk of bleeding at surgery.     

Intrahepatic cholestasis occurring with prurigo of pregnancy

A 23-year-old woman presented to our polyclinic complaining of itching, generalized dermatitis, and jaundice. She was in her 31st gestational week and had developed pruritus and the dermatitis since the first month of pregnancy; her jaundice started about a month before presentation. Her history included similar complaints in a previous pregnancy, which resulted in premature birth of a baby with a permanent brain defect. One of her sisters had had jaundice and itching in her 27th gestational week and delivered a healthy baby; a second sister had experienced itching and dermatitis in her second trimester and delivered a healthy baby. Physical examination of the patient showed that her eyes were jaundiced (Figure 1); skin examination revealed generalized erythematous excoriated papules, symmetrically distributed all over her body (Figure 2 Figure 3). Laboratory analyses revealed the following results: leukocyte count, 14.30/mm(3) (3.8-10.3/mm(3)); erythrocyte sedimentation rate, 25 mm/h (<20 mm/h); aspartate aminotransferase, 44 U/L (5-40 U/L); alanine aminotransferase, 63 U/L (5-40 U/L); lactate dehydrogenase, 1158 U/L (220-450 U/L); total bilirubin, 6.88 mg/dL (<1.10 mg/dL); and direct bilirubin, 3.27 mg/dL (<0.35 mg/dL). Urinalysis results were positive for bilirubin and urobilinogen. Positive serologic findings included rubella immunoglobulin G, 93 AU/mL (<15) and cytomegalovirus, 188 AU/mL (<10); negative findings included herpes simplex virus type 2 and hepatitis. Histopathologic examination of material collected from the left breast via punch biopsy showed parakeratosis, acanthosis, and perivascular lymphocyte infiltration in dermal vessels. Treatment with 2 g/d cholestyramine and a topical corticosteroid was effective in the patient, who was diagnosed with intrahepatic cholestasis of pregnancy and prurigo of pregnancy based on the clinical, histopathologic, and laboratory findings. To the authors' knowledge, this is the first such reported case in the literature.     

Forty month follow-up of persistent and difficultly controlled acromegalic patients treated with depot long acting somatostatin analog octreotide

The objective of the present study was to investigate the effects of octreotide long acting release (S-LAR) preparation on GH and IGF-1 serum concentrations and pituitary tumor size in patients with persistent and difficultly controlled acromegaly even after adjuvant irradiation and/or dopamine agonists. Thirty-three patients with active acromegaly (26 female and 7 male, mean age; 43.94 +/- 14.01 SD years) were included in this study. Patients were evaluated at baseline and at 6, 12, 30 and 40 months for GH, IGF-1, and GH response to OGTT and biliary ultrasonography. Sella MRI was performed at initial and at 40 months. All patients received 20 mg S-LAR. Afterwards, the dosage was titrated to improve individual GH response and reduction of IGF-1 into normal ranges. Basal serum IGF-1 levels decreased from median: 530 microg/l [IQR: 420-600] to 340 microg/l [IQR: 230-460] at 6 months (p = 0.01), to 400 microg/l [IQR: 222.4-600] at 12 months (p = 0.48), to 396 microg/l [IQR: 318-468] at 30 months (p = 0.49), to 482 microg/l [308-580] at 40 months (p = 0.47). Nadir GH levels in OGTT fell from 2.70 ng/ml [IQR: 1.35-6.90] to 1.60 ng/ml [IQR: 0.36-4.10] at 6 months (p = 0.03), to 0.31 ng/ml [IQR: 0.18-0.65] at 12 months (p<0.0001), to 1.50 ng/ml [IQR: 0.83-4.00] at 30 months (p = 0.398) and to 0.89 ng/ml [IQR: 0.58-1.35] at 40 months (p<0.0001). Initially, pituitary adenoma volume was median: 1.18 ml [IQR: 0.08-3.50] and it shrank to 0.21 ml [IQR: 0-2.1] at 40 months (p = 0.08). Gallstones were detected in 12 patients and six of them underwent cholecystectomy. S-LAR is an effective treatment regimen in reducing GH and IGF-1 concentrations and as well as in shrinking tumor volume in persistent and difficultly controlled acromegalic patients.     

Additive effect of dabigatran and high-dose aspirin in the development of haemorrhagic pleural effusion in a patient with tuberculous pleuritis

Tuberculous pleuritis can rarely cause haemorrhagic pleural effusion. Dabigatran etexilate can have an additive effect on increasing the risk of haemorrhage. Aspirin cannot cause major haemorrhage, but in the elderly it can cause gastrointestinal bleeding via ulceration of the gastrointestinal mucosa. We report here the case of a 77-year-old male who presented to the hospital with a 2-month history of progressive dyspnoea. He had been taking dabigatran etexilate (220 mg) and high-dose acetylsalicylic acid (aspirin; 300 mg) daily for chronic atrial fibrillation. A chest X-ray revealed a moderately sized right pleural effusion confirmed by a computed tomography scan, which also showed bronchiectasis of both lungs. Dabigatran was discontinued and aspirin was decreased to the minimal therapeutic dose of 100 mg before thoracentesis was performed. Lymphocyte-predominant (50%) haemorrhagic fluid of 500 ml was drained, positive for acid-fast bacilli smear and polymerase chain reaction of Mycobacterium tuberculosis. A chest tube was placed and an additional 1250 ml of haemorrhagic exudate drained out. We treated the patient with a routine regimen of antituberculous medication and the infection resolved without complications other than the bronchiectasis present before treatment. We think that the combination of dabigatran etexilate and high doses of aspirin increased the risk of pleural haemorrhage in this patient with tuberculous pleuritis.     

Surfactant alterations following donation after cardiac death donor lungs

The use of lungs from donation after cardiac death (DCD) donors is one of the strategies to increase the donor pool. The aim of this study was to assess the surfactant alterations in DCD donor lungs. Pigs were sacrificed and left untouched for 1 (DCD1), 2 (DCD2) and 3 (DCD3) h. Lungs were then topically cooled with saline for 1, 2 or 3 h to reach a total ischemic time of 4 h. Heart‐beating donors (HBD) served as control group. Bronchoalveolar lavage (BAL) samples were assessed for protein levels and surfactant function. Left lungs were prepared for ex‐vivo evaluation. Pulmonary vascular resistance (PVR), oxygenation, airway pressure (AWP) and wet‐to‐dry weight ratio were significantly different between HBD and DCD3 groups (P < 0.05). BAL protein levels were statistically higher in DCD3 compared with HBD group (P < 0.05). Surface tension and surface tension measured at minimal bubble diameter (adsorption) were lower in HBD compared with DCD groups (P < 0.05). Adsorption was also lower in DCD1 compared with DCD2 (P < 0.05). Adsorption and surface tension were correlated with oxygenation and AWP (P < 0.05). This study has shown that lung function deteriorates with increasing warm ischemic time intervals. BAL protein, surface tension, adsorption, peak AWP and PVR increase significantly after 2 h of warm ischemia together with a significant reduction of the ratio PaO₂/FiO₂.     

Decreased serotonin 5-HT2A receptor-stimulated phosphoinositide signaling in fibroblasts from melancholic depressed patients.

Abnormalities in serotonin (5-HT) receptors and 5-HT receptor-mediated signal transduction systems have been widely reported in mood disorders. This study was intended to evaluate 5-HT(2A) receptor-coupled activation of phosphatidylinositol (PI) hydrolysis in subtypes of depression. Samples for fibroblast culture were obtained from patients with major depression with or without melancholia, and normal controls. Dose response curves were determined for 5-HT-induced PI hydrolysis. PI response was determined for bradykinin and l-alpha-lysophosphatidic acid (LPA), alternative Gq-coupled receptor agonists. [125I]LSD binding for 5-HT(2A) also was conducted. Finally, Western blot analysis was performed for phospholipase Cbeta1 (PLCbeta1) and Galpha(q/11) proteins. The maximum PI response observed with 5-HT was significantly lower in melancholics but not nonmelancholic patients relative to controls. Activation of PI hydrolysis by bradykinin and LPA was not reduced in melancholic vs melancholics and controls; responses to both agonists actually were increased in the melancholic group. [125I]LSD binding, PLCbeta1, and Galpha(q/11) protein levels did not differ between groups. The data raise the possibility that the reduced 5-HT(2A) receptor-induced PI hydrolysis is intrinsic to the receptor itself or its coupling to Gq protein, and is not related to altered availability of the 5-HT(2A) receptor, Gq or PLC.     

Is general anesthesia a risk for myocardium? Effect of anesthesia on myocardial function as assessed by cardiac troponin-i in two different groups (isofluran+N2O inhalation and propofol+fentanyl iv anesthesia)

Background and objectives

Peroperative myocardial infarction (MI) is the most common cause of morbidity and mortality. What is the role of general anesthesia in this process? Is general anesthesia a risk for myocardial infarction? The present study was designed to determine whether the measurement of serum levels of cardiac troponin I (cTnI), a highly sensitive and specific marker for cardiac injury, would help establish the diagnosis of myocardial infarction in two different types of anesthesia.

Method

Elective abdominal hysterectomy was planned with the permission of the ethic committee in 40 patients who were 20–45 years range, in ASA-I group, and have a Goldman Cardiac Risk Index-0. The patients were divided into two groups. Isoflurane + N₂O was administrated to first group, and Propofol + Fentanyl to second group. cTnI levels were determined before anesthesia, after induction before surgery and 9 hours after the second period respectively.

Results

There was no significant difference between the groups by the means of demographic properties, hemodynamic parameters and cTnI levels, and the cTnI levels were determined under the basal levels in all samples.

Conclusion

General anesthesia is not a risk for myocardial infarction to state eliminating risk factors and protection hemodynamia cardiac.     

Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome

BACKGROUND: Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS: The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS: Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION: PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.