Acid-base status is an important factor for inflammation,but don’t forget CO2!

Zampieri and colleagues used sophisticated statistical methods to create a picture of acid-base pattern and inflammation relationship in a clinical context. The observed independent relationship between acidosis and albumin concentration and inflammatory pattern opens up a new area for research. It has become clear that, in addition to the characterization of mediators, receptors, and cellular phenotypes, the inflammatory response has to be interpreted in light of acid-base status, albumin concentration, and probably also carbon dioxide level.Until now, the interplay between acid-base status and inflammation has received little attention, especially in a clinical context. The article by Zampieri and colleagues [1] in a previous issue of Critical Care is a pioneering study analyzing the relationship between acidosis variables, inflammatory mediators, and end-organ failures (acute kidney injury and shock). Since the metabolic and inflammatory reactions are simultaneous, the demonstration of interplay that is more than a simultaneous modification remains a difficult challenge. Because of this, the authors used three different statistical methods to separate the confounding factors. First, they developed a generalized linear model using the measured mediator as a dependent variable and components of acid-base status as variables. Second, they performed a multivariate adaptive regression with splines in order to evaluate the association of selected cytokines and acid-base components. Third, they performed a principal component analysis using Simplified Acute Physiology Score 3 as a way of quantifying illness severity in order to assess the independent association of acid-base variables and cytokine levels. The authors found that, in 87 prospective unselected patients, the level of strong anion gap (SIG) was positively associated with TNFα and IL-6, IL-8, and IL-10. A negative association was found between albumin level and TNFα and IL-6, IL-7, IL-8, and IL-10 and IFNγ. The conclusion drawn from these results opens up a new route for research to understand the mechanisms that link acid-base variables, albumin level, and immunological activation.Such a topic is important and clinically relevant since plasma and interstitial fluid constitute the microenvironment for immune and tissue cells. Acid-base and albumin characteristics may then interfere with the cell response to different signals such as endotoxin. In addition, both fluid resuscitation and capillary leak may largely influence the composition of the cell microenvironment, especially when a crystalloid such as saline or a balanced crystalloid such as Ringer’s lactate is used. The role of surrounding cell pH could be seen as a result of metabolic acidosis and carbon dioxide (CO₂) level, an aspect that was not investigated in the study [2,3]. Given the picture presented in this article, some approaches might be tested to clarify the mechanisms involved in immune modifications induced by acid-base changes. First, immune cells should be drawn from septic patients that have been incubated in the septic plasma or drawn after replacement of septic plasma by healthy plasma; both acid-base conditions or albumin concentration can then be modified to test their impact on immune cells phenotype. This might help to clarify how the pH, the SIG, and albumin concentration change the immune cell phenotypes. Second, similar experiments with healthy cells incubated in plasma from acutely injured patients could be performed to demonstrate the role of physicochemical plasma patterns. Mediators and cell functions then could be evaluated in different acid-base conditions. Until now, few data on alkalosis have been reported in terms of immunity, and the essential information comes from acidosis situations. One author of the study was part of a group [4] that showed that metabolic acidosis induced by hydrochloric acid and lactic acidosis added to culture media of RAW 264.7 cells have opposite effects: hydrochloric acid at a pH of 7 seems essentially pro-inflammatory (nitric oxide level, IL-6/IL-10 ratio, NF-κB DNA binding), whereas lactic acidosis is essentially anti-inflammatory. A group with the same author, using a rat model, confirmed these results in terms of systemic cytokines [5]. In that study, the authors found a positive relationship between SIG and IL-6, IL-8, and IL-10 and TNFα, which was independent of illness severity. Even though albumin was not administered in the presented cohort, it can be discussed in light of immune effects. The authors observed a negative correlation between albumin level and IL-6, IL-8, IL-10, monocyte chemoattractant protein-1 and IFNγ. In addition to its complex effects, albumin was shown to be immunosuppressive for peripheral blood monocytes (IFNγ and TNFα) and also for T lymphocyte clone [6], which confirmed the presented results. Except for specific indications, albumin is not recommended for use in fluid resuscitation, especially after the recent negative results of a randomized clinical trial [7]. Third, the role of hypo- or hypercarbia has to be investigated since elevated CO₂ was shown to modulate mammalian inflammatory and innate immune responses in vitro and in vivo [3], independently of extra- and intra-cellular pH. During a sterile insult of inflammation stimulation, hypercapnia may be of benefit but would be deleterious in the setting of infection due to host immunosuppression. The underlying mechanism implicates the NF-κB signaling pathway as an important hub of CO₂ sensitivity [3,8]. This, in combination with the ability of elevated CO₂ to enhance bacterial and fungal virulence and survival, suggests that hypercapnia may predispose humans to infections or worsen outcomes [3]. Understanding the involved molecular signaling pathways will be of great importance in the identification of new approaches to control infection and inflammation in the clinical setting.     

Fermeture percutanée des communications interventriculaires congénitales par la prothèse Amplatzer Duct OccluderII: données préliminaire d’une étude Tunisienne monocentrique

Introduction . Percutaneous closure of congenital ventricular septal defects (VSDs) represents a promising alternative to surgery with lower rate of complications and shorter hospital stay. Its main limitation is the choice of the appropriate device for each type of defect. Aim. To report the experience of the service of cardiology (Sahloul hospital, Sousse, Tunisia) in percutaneous closure of congenital VSDs with Amplatzer Duct Occluder II (ADOII). Methods. This was a retrospective, monocentric study, conducted from January 2013 to December 2017. The study included patients treated by percutaneous closure of congenital VSDs with the ADOII device. Results. Twelve patients (6 boys; 6 girls) were included. The mean±SD of patients’ age and weight were 65±41 months and 23±10 kg, respectively. VSDs were peri-membranous (n=9) and muscular (n=3), and defects were restrictive (n=11) and non-restrictive (n=1). The mean (minimum-maximum) size of VSDs was 4.72 (3-6) mm. Eleven ADOII prostheses were successfully implanted. One failure procedure was noted with migration of the device into the pulmonary artery. A second child with perimembranous defect developed transient atrioventricular block. No deaths occurred. Conclusion. The present early experience shows that percutaneous closure with ADOII device of perimembranous and trabecular VSDs is safe and effective.     

Prevalence of postoperative complications after orthognathic surgery: a 15-year review.

PURPOSE: This study was conducted to determine the prevalence of postoperative complications after orthognathic surgery and evaluate the use of antibiotic prophylaxis in relation to the infection rate. PATIENTS AND METHODS: All patients undergoing orthognathic procedures between 1990 and 2004 were studied retrospectively by retrieving their individual medical records. Demographic data, intraoperative data (specific orthognathic procedures and duration of operation), and postoperative data (type and duration of antibiotic prophylaxis and presence of postoperative complications) were recorded. Patients noted to have suffered any postoperative complications were studied in detail, and various factors, including gender, age, duration of operation, and use of prophylactic antibiotics, were analyzed using statistical tests in relation to postoperative infection. RESULTS: A total of 2,910 orthognathic procedures were performed on 1,294 consecutive patients in the 15-year period, with 1,070 patients undergoing bimaxillary procedures and 224 patients undergoing single-jaw surgery. The orthognathic surgery-related complication rate was 9.7%, of which 7.4% was related to postoperative infection. Of the cases of infection, 58.3% were acute infection and 41.7% were chronic infection. Patients who received a single preoperative dose of antibiotics had a significantly higher infection rate (17.3%) than those who received postoperative antibiotics for various durations. CONCLUSIONS: The prevalence of infection after orthognathic surgery was relatively low given the complexity of the procedures. No particular orthognathic procedure was more susceptible to infection. A preoperative dose of prophylactic antibiotics together with at least 2 days of postoperative doses was useful in reducing the infection rate compared with only a single dose of prophylactic antibiotics.     

Are hearing and middle ear statuses at risk in Chinese patients undergoing orthognathic surgery?1

Orthognathic surgery, which is performed to correct dentofacial abnormalities, has been associated with postoperative reduction in hearing sensitivity and middle ear dysfunction. In this study, the pre‐ and postoperative hearing status and middle ear function of 37 Chinese subjects who underwent orthognathic surgery, as well as subjective reports of aural symptoms, particularly hearing loss, tinnitus, fullness and otalgia, were investigated. There was a significant increase in the number of subjects with measured loss, perceived loss and aural fullness from pre‐surgery to 1 week post surgery. However, the percentage of increase was small compared with previous findings. This difference in findings was attributed to the type of surgical techniques used, and to the fact that the Chinese population appears to be less susceptible to middle ear effusion. Subjective complaints of aural symptoms may not be accompanied by measured loss.     

Titanium miniplate fixation for osteotomies in facial fibrous dysplasia — a histologic study of the screw/bone interface

In four patients who had osteotomies of the jaws affected by fibrous dysplasia (FD), screws embedded in bone blocks were removed at a re-entry operation 20 months postoperatively. Morphometric measurement of the bone density and calculation of the bone contact percentage were performed. Both normal and dysplastic bone were found to have some direct bone contact with the titanium screws. Although the bone contact percentage was higher in the normal bone when compared with FD, statistics failed to show any significant difference (P>0.05). The dysplastic bone healed well around the titanium screws without inflammatory reaction and direct dysplastic bone/screw contact was noted. Longer screws should be used in facial FD in order to compensate for the reduced bone contact percentage.     

An unusual facial sinus

An unusual presentation of a chronic suppurative granuloma on the alar base area originating from a maxillary lateral incisor is reported. Treatment involved adequate endodontic therapy with simultaneous apical surgery and excision of the granuloma and sinus tract. Awareness of the possible dental origin of facial sinuses, despite their unusual location, is emphasized.