Intraoperative Psoas Compartment Block vs Preoperative Fascia Iliaca Block for Pain Control After Direct Anterior Total Hip Arthroplasty: A Randomized Controlled Trial

Background

Modern joint arthroplasty protocols place an emphasis on minimizing patient-reported postoperative pain while minimizing opioid consumption. The use of multimodal pain management protocols has been reported to improve patient outcomes and satisfaction after total hip arthroplasty.

Pyruvate improves cardiac electromechanical and metabolic recovery from cardiopulmonary arrest and resuscitation

Severe depletion of myocardial energy and antioxidant resources during cardiac arrest culminates in electromechanical dysfunction following recovery of spontaneous circulation (ROSC). A metabolic fuel and natural antioxidant, pyruvate augments myocardial energy and antioxidant redox states in parallel with its enhancement of contractile performance of stunned and oxidant-challenged hearts. This study tested whether pyruvate improves post-arrest cardiac function and metabolism. Beagles were subjected to 5 min cardiac arrest and 5 min open-chest cardiac compression (OCCC: 80 compressions min(-1); aortic pressure 60-70 mmHg), then epicardial dc countershocks (5-10 J) were applied to restore sinus rhythm. Pyruvate was infused i.v. throughout OCCC and the first 25 min ROSC to a steady-state arterial concentration of 3.6+/-0.2 mM. Control experiments received NaCl infusions. Phosphocreatine phosphorylation potential (approximately PCr) and glutathione/glutathione disulfide ratio (GSH/GSSG), measured in snap-frozen left ventricle, indexed energy and antioxidant redox states, respectively. In control experiments, left ventricular pressure development, dP/dt and carotid flow initially recovered upon defibrillation, but then fell 40-50% by 3 h ROSC. ST segment displacement in lead II ECG persisted throughout ROSC. Approximately PCr collapsed and GSH/GSSG fell 61% during arrest. Both variables recovered partially during OCCC and completely during ROSC. Pyruvate temporarily increased approximately PCr and GSH/GSSG during OCCC and the first 25 min ROSC and enhanced pressure development, dP/dt and carotid flow at 15-25 min ROSC. Contractile function stabilized and ECG normalized at 2-3 h ROSC, despite post-infusion pyruvate clearance and waning of its metabolic benefits. In conclusion, intravenous pyruvate therapy increases energy reserves and antioxidant defenses of resuscitated myocardium. These temporary metabolic improvements support post-arrest recovery of cardiac electromechanical performance.     

The virtues of vitamin D—but how much is too much?

Vitamin D deficiency is common in healthy adults and children as well as in the chronic kidney disease (CKD) population. What was once a disease of malnourished children in the developing world has re-emerged and reached pandemic proportions. In parallel with this development, there is a growing awareness that vitamin D is not simply a ‘calcaemic hormone’ but plays an important role in the prevention of cardiovascular disease, infectious and auto-immune conditions, renoprotection, glycaemic control and prevention of some common cancers. Most tissues in the body have a vitamin D receptor and the enzymatic machinery to convert ‘nutritional’ 25-hydroxyvitamin D to the active form 1,25-dihydroxyvitamin D; it is estimated that 3% of the human genome is regulated by the vitamin D endocrine system. Although there are few well-conducted studies on the benefits of vitamin D therapy, an exuberant use of vitamin D is now seen in the general population and at all stages of CKD. There is emerging evidence that vitamin D may in fact have a therapeutic window, and at least from the effects on the cardiovascular system, more is not necessarily better. In this review, we discuss the role of nutritional vitamin D (ergocalciferol or cholecalciferol) supplementation in CKD patients, interpreting the clinical studies in the light of the vitamin D metabolic pathway and its pluripotent effects. While nutritional vitamin D compounds clearly have numerous beneficial effects, randomised controlled studies are required to determine the effectiveness and optimal dose at different stages of CKD, its concurrent use with activated vitamin D compounds and its safety profile.     

Uptake and Transport of Novel Amphiphilic Polyelectrolyte-Insulin Nanocomplexes by Caco-2 Cells—Towards Oral Insulin

Purpose  

The influence of polymer architecture on cellular uptake and transport across Caco-2 cells of novel amphiphilic polyelectrolyte-insulin nanocomplexes was investigated.     

Expression of decorin and collagens I and III in different layers of human skin in vivo: a laser capture microdissection study

Extracellular matrix (ECM) organization is a complex process that requires the coordinated efforts of many molecules. For the regulation of collagen fiber diameter, the proteoglycan decorin appears to be of major relevance. To investigate the role of decorin in the process of (photo-)aging in more detail, full-thickness punch biopsies were isolated from human buttock skin. Single exposure with two minimal erythemal doses of solar simulated irradiation caused down-regulation of decorin mRNA in young (n = 5) and old subjects (n = 5) after 24 h. Interestingly, decorin mRNA was elevated with age. To test the hypothesis that a decreased collagen-to-decorin-ratio impairs collagen structure we also investigated collagens I and III gene expression. Both were down-regulated with increasing age and after single UV-irradiation. As determined by laser capture microdissection-quantitative real time-Polymerase chain reaction (n = 11), decorin is mostly present in the reticular dermis while being absent from the papillary dermis. Minor expression was also observed in the epidermis. However, in contrast to full-thickness skin biopsies age-dependent changes in collagens I, III, and decorin expression could not be observed with this methodology indicating technical limitations. Together with our finding that collagens I and III mRNA are similarly expressed in the reticular and papillary dermis and are down-regulated by UV, our studies support the idea of a major role of decorin in ECM organization. Altered expression of decorin mRNA in the different dermal strata and a decrease in the collagen-to-decorin ratio inflicted by both age and ultraviolet irradiation possibly affect collagen bundle diameter and subsequently the mechanical properties of human skin.     

A randomized trial of a DWI intervention program for first offenders: intervention outcomes and interactions with antisocial personality disorder among a primarily American-Indian sample

BACKGROUND: Randomized trial evidence on the effectiveness of incarceration and treatment of first-time driving while intoxicated (DWI) offenders who are primarily American Indian has yet to be reported in the literature on DWI prevention. Further, research has confirmed the association of antisocial personality disorder (ASPD) with problems with alcohol including DWI. METHODS: A randomized clinical trial was conducted, in conjunction with 28 days of incarceration, of a treatment program incorporating motivational interviewing principles for first-time DWI offenders. The sample of 305 offenders including 52 diagnosed as ASPD by the Diagnostic Interview Schedule were assessed before assignment to conditions and at 6, 12, and 24 months after discharge. Self-reported frequency of drinking and driving as well as various measures of drinking over the preceding 90 days were available at all assessments for 244 participants. Further, DWI rearrest data for 274 participants were available for analysis. RESULTS: Participants randomized to receive the first offender incarceration and treatment program reported greater reductions in alcohol consumption from baseline levels when compared with participants who were only incarcerated. Antisocial personality disorder participants reported heavier and more frequent drinking but showed significantly greater declines in drinking from intake to posttreatment assessments. Further, the treatment resulted in larger effects relative to the control on ASPD than non-ASPD participants. CONCLUSIONS: Nonconfrontational treatment may significantly enhance outcomes for DWI offenders with ASPD when delivered in an incarcerated setting, and in the present study, such effects were found in a primarily American-Indian sample.     

Advanced heart failure: prognosis, uncertainty, and decision making

Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care.