Neonates as intrinsically worthy recipients of pain management in neonatal intensive care

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate’s family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

     

The effect of cardiovascular morbidity on clinical response provided by tadalafil in patients with erectile dysfunction

We aimed to investigate the association between erectile dysfunction and severity of cardiovascular morbidity and to assess clinical responses to tadalafil of patients in different cardiovascular risk groups. Between November 2019 and August 2020, a total of 258 male patients aged 45–70 years with ED were included. They were divided into three groups according to the Framingham risk score: low-risk (n: 86, 33.3%), intermediate-risk (n: 103, 39.9%) and high-risk (n: 69, 26.8%). At admission, all domains of the International Index of Erectile Function score were worse in high-risk group compared to other risk groups (p < .001). After a 12-week follow-up, a more significant improvement was observed in all domains of erectile function in all risk groups, but high-risk group had lower sexual scores (p < .001). The lowest rate for complete responsiveness to tadalafil was observed in the high-risk group (37.7%). The rate of failure in complete responsiveness was found to be 4.127 times greater with higher Framingham score and 3.102 times greater with higher erectile dysfunction severity at admission. Our preliminary findings show that more severe sexual disorders are observed in high-risk patients with cardiovascular morbidity. Individualised treatment may be important in high-risk group since they may benefit less from tadalafil, and failure in complete responsiveness can be more common in this group.     

Selective decontamination of the digestive tract helps prevent bacterial infections in the early postoperative period after liver transplant

In liver transplant (LTx) recipients, gut-associated bacterial and fungal organisms produce significant postoperative morbidity and mortality. We sought to assess the role of selective digestive decontamination (SDD) in preventing postoperative infections in a large single-center cohort of liver recipients transplanted under two non-simultaneous protocols. In 212 consecutive patients transplanted between 1/1/91 and 7/31/92, SDD (gentamicin 80 mg, polymyxin B 100 mg, nystatin suspension 10 mL) was employed, starting after induction of anesthesia and continued until POD 21 (SDD Group). In 157 consecutive patients transplanted between 1/1/93 and 12/31/93, SDD was not used (non-SDD Group). Both groups received IV vancomycin and cefotaxime prophylaxis. All culture-positive infections within the first 30 days post-LTx were recorded and classified as bacterial or fungal. Infection-related mortality (patients who died of infectious complications without any technical complication) was recorded. Groups did not differ in patient demographics, United Network for Organ Sharing (UNOS) status, use of veno-venous bypass, total/warm ischemia, or length of ICU stay. Infections developed in fewer SDD patients (56/212; 26%) than non-SDD patients (69/157; 44%) (p<0.001). The incidence of gram-negative infection was less in the SDD group (11% vs. 26%, p<0. 001) as was gram-positive infection (16% vs. 26%, p<0.001). Among patients who developed infection, there was no difference between groups in infections per patient. Primary graft non-function (PNF) developed in 20 SDD patients (7/20 had infections) and 8 non-SDD patients (6/8 had infections) (p=0.06). There were no differences in incidence of fungal infections or of infection-related mortality between groups. In the SDD group, there were fewer abdominal (p<0. 001), lung (p<0.001), wound (p<0.01), and urinary tract infections (p<0.05). CONCLUSION: Use of SDD in liver recipients early after transplant was associated with significantly fewer infections in the early postoperative period.     

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND: The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. PATIENTS AND METHODS: Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. RESULTS: The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up. CONCLUSION: Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.     

Ginkgo biloba extract ameliorates ischemia reperfusion-induced renal injury in rats.

There is increasing evidence to suggest that reactive oxygen metabolites (ROMs) play a role in the pathogenesis of ischemia/reperfusion injury (I/R) in the kidney. This study was designed to determine the possible protective effect of Ginkgo biloba extract (EGb) on renal ischemia/reperfusion (I/R) injury. Wistar albino rats were unilaterally nephrectomized, and 15 days later they were subjected to 45 min of renal pedicle occlusion followed by 6 h of reperfusion. Ginkgo biloba extract (EGb) (50 mg kg(-1) day(-1)) or saline was administered twice, 15 min prior to ischemia and immediately before the reperfusion period. At the end of the treatment period, all rats were decapitated. Kidney samples were taken for histological examination or determination of the renal malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity and collagen content. Production of reactive oxidants was monitored by chemiluminescence (CL) assay. Creatinine and urea concentrations in blood were measured for the evaluation of renal function. Tumor necrosis factor-alpha (TNF-alpha) and lactate dehydrogenase (LDH) were also assayed in serum samples. Ischemia/reperfusion caused a significant decrease in GSH level, which was accompanied with significant increases in MDA level, MPO activity and collagen content of kidney tissues. Similarly, serum BUN and creatinine levels, as well as LDH and TNF-alpha, were elevated in the I/R group as compared to control group. On the other hand, EGb treatment reversed all these biochemical indices, as well as histopathological alterations, which were induced by I/R. The findings imply that ROMs play a causal role in I/R-induced renal injury and EGb exerts renoprotective effects probably by the radical scavenging and antioxidant activities.     

Contact-Free Support Structures for the Direct Metal Laser Melting Process

Although Direct Metal Laser Melting (DMLM), a powder bed fusion (PBF) Additive Manufacturing (AM) for metallic materials, provides many advantages over conventional manufacturing such as almost unlimited design freedom, one of its main limitations is the need for support structures beneath overhang surfaces. Support structures are generally in contact with overhang surfaces to physically prop them up; therefore, they need to be removed after manufacturing due to not constituting a part of the main component design. The removal of supports is a process sequence adding extra time and cost to the overall manufacturing process and could result in damaging the main component. In this study, to examine the feasibility of contact-free supports for overhang surfaces in the DMLM process, coupons with these novel types of supports were prepared from CoCrMo alloy powder. This study aims to understand the effect of two parameters: the gap distance between supports and overhang surfaces and the inclination angle of overhang surfaces, on the surface topography and microstructural properties of these surfaces. Visual inspection, roughness measurements, and optical microscopy were utilized as characterization methods The roughness parameters (Ra, Rq, and Rz) were obtained using the focus variation method, and optical microscope analysis was performed on the cross-sections of the overhang surfaces to investigate the sub-surface microstructure and surface topology. Results showed that contact-free supports have a positive effect on decreasing surface roughness at all build angles when the gap distance is correctly set to avoid sintering of the powder in between the overhang and supports or to avoid too large gaps eliminating the desired effect of the higher thermal conductivity.