Hemodynamics and gas exchange during carbon dioxide insufflation for totally endoscopic coronary artery bypass grafting

BACKGROUND: In addition to single-lung ventilation (SLV), positive-pressure CO2 insufflation is mandatory for totally endoscopic coronary artery bypass grafting. Studies on the effects of unilateral CO2 insufflation on hemodynamics produced controversial results, and bilateral insufflation has not been studied to our knowledge. The present study sought to investigate hemodynamics and gas exchange during unilateral and bilateral CO2 insufflation in patients who underwent totally endoscopic coronary artery bypass grafting. METHODS: Eleven hemodynamic and gas exchange variables were monitored during 22 totally endoscopic coronary artery bypass grafting procedures with unilateral (n = 17) or bilateral (n = 5) CO2 insufflation at a pressure of 10 to 12 mm Hg. Data were obtained at baseline with double-lung ventilation, after institution of SLV, during insufflation, after cardiopulmonary bypass during SLV, and after return to double-lung ventilation. RESULTS: Arterial oxygen tension decreased significantly during SLV, whereas the peak inspiratory pressure increased. In addition, central venous pressure and heart rate increased significantly during insufflation, but mean arterial pressure remained unchanged. Although the end-tidal CO2 pressure did not change, arterial carbon dioxide tension increased progressively to a maximum of 44.6 +/- 5.9 mm Hg during unilateral insufflation, and 55.7 +/- 14.6 mm Hg during bilateral insufflation (p < 0.05 versus baseline and between groups). Mixed venous oxygen saturation declined during SLV regardless of CO2 insufflation and recovered to baseline once double-lung ventilation was restarted. Left and right ventricular ejection fractions remained unaltered. No patient required inotropic or vasopressor support. CONCLUSIONS: Carbon dioxide insufflation for totally endoscopic coronary artery bypass grafting with SLV had no adverse effects on hemodynamics. In contrast to a moderate increase of arterial carbon dioxide tension during unilateral insufflation, markedly elevated arterial carbon dioxide tension levels remain a cause of concern during bilateral insufflation.     

Promoter polymorphisms of the genes encoding tumor necrosis factor-alpha and interleukin-1beta are associated with different subtypes of psoriasis characterized by early and late disease onset

The psoriatic inflammatory process is characterized by an overexpression of pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-1beta compared with a relative deficiency of anti-inflammatory factors such as interleukin-10 and the interleukin-1 receptor antagonist (interleukin-1Ra). Gene polymorphisms that affect cytokine production may contribute to the disease-associated cytokine imbalance and influence susceptibility to psoriasis. Here, we investigated the relationship between polymorphisms in the genes encoding for tumor necrosis factor-alpha (G-238A, G-308A), interleukin-1beta (C-511T, T+3953C), and interleukin-1Ra (intron 2), and cytokine production in peripheral blood mononuclear cells of healthy donors, and analyzed the distribution of these polymorphisms in patients with psoriasis vulgaris (n = 231) and healthy controls (n = 345). Carriage of tumor necrosis factor A-238 allele 2 (-238*A) was associated with increased production of tumor necrosis factor-alpha in response to lipopolysaccharide in vitro, and with early onset disease (< 40 y), especially in male patients with psoriasis [32% vs 7% in male controls; odds ratio = 6.78, 95% confidence interval = (3.18-15.15), p(adjusted) = 2 x 10(-7)]. Carriage of the interleukin-1B-511*1 (-511*C) homozygous genotype was associated with increased production of interleukin-1Ra in response to lipopolysaccharide and interleukin-10, and with late onset psoriasis [> or = 40 y; 61% vs 44% in controls; odds ratio = 2.04, 95% confidence interval = (1.19-3.53), p(adjusted) = 0.0419]. These findings indicate that gene polymorphisms associated with altered cytokine responses in vitro may modify age of onset of psoriasis. They also provide further evidence that patients with early and late onset psoriasis differ in their genetic background.     

Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: A systematic review and meta-analysis

IntroductionChronic depression represents a substantial portion of depressive disorders and is associated with severe consequences. This review examined the efficacy and acceptability of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in the treatment of chronic depression. Additionally, the comparative effectiveness of the two types of antidepressants has been examined.MethodsA systematic search was conducted in the following databases: CENTRAL, MEDLINE, EMBASE, ISI Web of Science, BIOSIS, PsycINFO, and CINAHL. Primary efficacy outcome was a response to treatment; primary acceptance outcome was dropping out of the study. Only randomized controlled trials were considered.ResultsWe identified 20 studies with 22 relevant comparisons. 19 studies focused on samples with a majority of dysthymic patients. Both SSRIs and TCAs are efficacious in terms of response rates when compared to placebo (Benefit Ratio [BR]=1.49; p<0.001 for SSRIs and BR=1.74; p<0.001 for TCAs) and no statistically significant differences between the active drugs and placebo in terms of dropout rates could be found. No differences in effectiveness were found between SSRIs and TCAs in terms of response rates (BR=1.01; p=0.91), yet, SSRIs showed statistically better acceptability in terms of dropout rates than TCAs (Odds Ratio [OR]=0.41; p=0.02).LimitationsThe methodological quality of the primary studies was evaluated as unclear in many cases and more evidence is needed to assess the efficacy of SSRIs and TCAs in patients suffering from chronic forms of depression other than dysthymia.ConclusionsThis systematic review provides evidence for the efficacy of both SSRIs and TCAs in the treatment of chronic depression and showed a better acceptability of SSRIs.     

A comparison between flexible electrogoniometers,inclinometers and three-dimensional video analysis system for recording neck movement

This study compared neck range of movement recording using three different methods goniometers (EGM), inclinometers (INC) and a three-dimensional video analysis system (IMG) in simultaneous and synchronized data collection. Twelve females performed neck flexion-extension, lateral flexion, rotation and circumduction. The differences between EGM, INC, and IMG were calculated sample by sample. For flexion-extension movement, IMG underestimated the amplitude by 13%; moreover, EGM showed a crosstalk of about 20% for lateral flexion and rotation axes. In lateral flexion movement, all systems showed similar amplitude and the inter-system differences were moderate (4–7%). For rotation movement, EGM showed a high crosstalk (13%) for flexion-extension axis. During the circumduction movement, IMG underestimated the amplitude of flexion-extension movements by about 11%, and the inter-system differences were high (about 17%) except for INC–IMG regarding lateral flexion (7%) and EGM–INC regarding flexion-extension (10%). For application in workplace, INC presents good results compared to IMG and EGM though INC cannot record rotation. EGM should be improved in order to reduce its crosstalk errors and allow recording of the full neck range of movement. Due to non-optimal positioning of the cameras for recording flexion–extension, IMG underestimated the amplitude of these movements.