Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study

Background

Postoperative pulmonary complications (PPCs) are the most commonly reported complications after esophagectomy. The aim of this study was to examine the effect and feasibility of preoperative inspiratory muscle training-high intensity (IMT-HI), and IMT-endurance (IMT-E) on the incidence of PPCs in patients following esophagectomy for esophageal cancer (EC).

Method

A single-blind, randomized, clinical pilot study was conducted between 2009 and 2012. Forty-five participants were assigned to either IMT-HI or IMT-E. Effectiveness was assessed by analyzing PPCs, length of hospital stay (LOS), duration of mechanical ventilation, stay on the intensive care unit, and number of reintubations. Maximal inspiratory pressure and lung function changes were recorded pre- and post-training. Feasibility was assessed by IMT-related adverse events, training compliance, and patients’ satisfaction.

Results

Thirty-nine patients could be analyzed, 20 patients in the IMT-HI arm and 19 patients in the IMT-E arm. The incidence of PPCs differed significantly between groups and was almost three times lower for the IMT-HI group (4 vs. 11 patients; p = 0.015). Other differences in favor of the IMT-HI group were LOS (13.5 vs. 18 days; p = 0.010) and number of reintubations (0 vs. 4 patients; p = 0.030). Both interventions proved to be equally feasible.

Conclusion

Preoperative IMT-HI showed to be a promising, effective, and feasible intervention to reduce PPCs in EC patients undergoing esophagectomy. Further research with a larger sample size is recommended.     

Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR)

Background

Ventral hernias are a common, challenging, and expensive problem for both the general and reconstructive surgeons; therefore, the aim of this study is to critically assess perioperative factors related to cost in abdominal wall reconstructions (AWR).

Methods

A retrospective review of AWR patients from 2007 and 2012 was performed. Analysis of perioperative factors associated with total cost of reconstruction was performed. Linear regression analyses were used to assess independent predictors of total cost.

Results

134 consecutive AWR performed by a single surgeon over a 5-year period at an academic teaching center were included. The average total cost of AWR was $61,251 ± 55,624. Linear regression analysis demonstrated that diabetes (P = 0.026), increased American Society of Anesthesiologists score (P = 0.002), preoperative anemia (P = 0.001), and hernias derived from trauma (P = 0.015) were independently associated with added cost in AWR when controlling for confounding variables. In addition, patients requiring intra-abdominal procedures (P = 0.012) and those receiving an AWR using Acellular Dermal Matrix (P = 0.015) accrued significantly greater cost. Interestingly, preoperative placement of an epidural (P = 0.011) was independently associated with significant cost savings and reduced medical morbidity. Major surgical complications (P < 0.001) and length of stay (P < 0.001) were independently associated with increased cost following AWR.

Conclusion

We present a critical assessment of cost in AWR at a major academic teaching hospital and quantify the impact of reconstruction in the setting of medical morbidities and reconstructive complexities. The data from this study can be used to adjust reimbursement schemes and to critically assess the cost–benefit of performing AWR.     

Qualitative and quantitative evaluation of human dental enamel after bracket debonding: a noncontact three-dimensional optical profilometry analysis

Objectives

The aim of this study was to undertake a qualitative and quantitative evaluation of changes on enamel surfaces after debonding of brackets followed by finishing procedures, using a high-resolution three-dimensional optical profiler and to investigate the accuracy of the technique.

Materials and methods

The labial surfaces of 36 extracted upper central incisors were examined. Before bonding, the enamel surfaces were subjected to profilometry, recording four amplitude parameters. Brackets were then bonded using two types of light-cured orthodontic adhesive: composite resin and resin-modified glass ionomer cement. Finishing was performed by three different methods: pumice on a rubber cup, fine and ultrafine aluminum oxide discs, and microfine diamond cups followed by silicon carbide brushes. The samples were subsequently re-analyzed by profilometry.

Results

Wilcoxon signed-rank test, Kruskal–Wallis test (p?U test with Bonferroni correction (p?Conclusions The 3D optical profilometry technique was able to provide accurate qualitative and quantitative assessment of changes on the enamel surface after debonding.

Clinical relevance

Morphological changes in the topography of dental surfaces, especially if related to enamel loss and roughness, are of considerable clinical importance. The quantitative evaluation method used herein enables a more comprehensive understanding of the effects of orthodontic bonding on teeth.     

The experience of the nurse at triage influences the timing of CPAP intervention

Increasing attention in the last decade has shown that intervention of continuous positive airway pressure therapy (CPAP) in cardiogenic pulmonary oedema (CPO) markedly improves the outcome of patients presenting with acute respiratory failure. This study used a non-experimental correlational design to research the relationship between the experience of the nurse, with the application of CPAP to patients presenting to a metropolitan emergency department with CPO and to establish what difference, if any, CPAP made to outcomes. A retrospective audit of records was used to extract data on all 54 patients that received CPAP over a 12-month period. The primary outcome measures were off CPAP within 2 h, transfer to intensive care unit (ICU) or cardiac care unit (CCU) and secondary outcome measures were length of hospital stay and death. There was a trend towards more experienced nurses attending patients who required immediate treatment or treatment within 10 min. These patients were more likely to be recognised at triage as requiring CPAP therapy. The early application of CPAP reduced hospital mortality, length of stay, and the need for intubation and ventilation. Attention needs to be given on how best to educate nurses so that more patients presenting with acute respiratory failure can benefit from nurses' decision-making regarding the commencement of CPAP.     

Crystal structure of the TRANCE/RANKL cytokine reveals determinants of receptor-ligand specificity

RANK, the receptor activator of NF-kappaB, and its ligand RANKL (initially termed TRANCE, also termed ODF and OPGL), are a TNF superfamily receptor-ligand pair that govern the development and function of osteoclasts, lymphoid tissue, and mammary epithelium. While TNF family cytokines share a common structural scaffold, individual receptor-ligand pairs associate with high specificity. Given the low level of amino acid conservation among members of the TNF superfamily, the means by which these molecules achieve specificity cannot be completely understood without knowledge of their three-dimensional structures. To determine the elements of RANKL that mediate RANK activation, we have crystallized the ectodomain of murine RANKL and solved its structure to a resolution of 2.6 A. RANKL self-associates as a homotrimer with four unique surface loops that distinguish it from other TNF family cytokines. Mutagenesis of selected residues in these loops significantly modulates RANK activation, as evidenced by in vitro osteoclastogenesis, thereby establishing their necessity in mediating the biological activities of RANKL. Such structural determinants of RANKL-RANK specificity may be of relevance in the pharmacologic design of compounds to ameliorate osteopenic disorders of bone.