Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.     

术前连续股神经阻滞在老年髋部骨折患者救治绿色通道中的应用

目的探讨术前连续股神经阻滞在老年髋部骨折患者救治绿色通道中的应用。方法选取2017年5月至2019年5月髋部骨折患者120例,根据患者镇痛意愿分为静脉镇痛组37例、术后股神经阻滞组41例、术前股神经阻滞组42例。静脉镇痛组接受常规治疗,术前1 h口服塞来昔布,术后传统自控静脉镇痛;术后股神经阻滞组接受绿色通追流程,术前1 h口服塞来昔布,术后连续股神经阻滞镇痛;术前股神经阻滞组接受绿色通道流程,术前和术后均连续股神经阻滞镇痛。比较各組手术等待时间、手术时间、术后首次下床时间及住院时间,拔管时间、清醒时间,比较各组术后6h、12h、24h、48 h、72 h视觉模拟评分法(VAS)评分及住院期间并发症发生情况。结果术前股神经阻滞组、术后股神经阻滞组手术等待时间、术后首次下床时间、住院时间均短于静脉镇痛组(P<0.05);术后不同时间点,术前股神经阻滞组VAS评分均低于静脉镇痛组和术后股神经阻滞组(P<0.05);术前股神经阻滞组、术后股神经阻滞组肺部感染发生率、切口感染发生率均低于静脉镇痛组(P<0.05)。结论绿色通道下行术前连续股神经阻滞镇痛,能有效缩短老年髋部骨折患者手术等待时间,降低术后疼痛程度,降低并发症发生率,,促进患者早期康复。     

Motor abilities and anthropometrics in youth cross‐country skiing

The purposes were to validate whether general motor abilities and anthropometrics are determinants of youth cross‐country (XC) skiing performance; evaluate gender‐specific differences; and to establish noninvasive diagnostics. Fifty‐one youth XC skiers (34 boys; 13.8 ± 0.6 years and 17 girls; 13.4 ± 0.9 years) performed motor skill and laboratory tests, and anthropometric data were collected and correlated with XC skiing performance. Anthropometrics and maturity status were related to boys but not to girls XC skiing performance. Push‐ups and 20‐m sprint were correlated to XC skiing performance in both boys and girls. XC skiing performance of boys was predominantly influenced by upper body and trunk strength capacities (medicine ball throw, push‐ups, and pull‐ups) and jumping power (standing long and triple jump), whereas XC skiing of girls was mainly influenced by aerobic capacities (3000‐m run). Laboratory measures did not reveal greater correlations to XC skiing performance compared with simple test concepts of speed, strength, and endurance. Maturity was a major confounding variable in boys but not girls. Use of noninvasive simple test concepts for determination of upper body strength, speed, and endurance represent practicable support for ski clubs, schools, or skiing federations in the guidance and evaluation of young talent, being aware of the effect of maturity especially in boys.     

Adjuvant/Perioperative Therapy in Pancreatic and Periampullary Cancer

The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic adenocarcinoma was initially shown to be beneficial based on a prospective, randomized trial published 30 years ago. Since then, oncologists have debated whether chemotherapy alone, chemoradiation, or both are optimal adjuvant therapies following pancreatectomy for pancreatic ductal adenocarcinomas (PDAC). No global consensus has emerged, and there is no one superior modality despite randomized trials in part, to poor trial design, poor patient selection, and poor therapy options itself. We need to have a disciplined approach to the selection of patients for pancreatectomy, pathologic assessment of surgical resection margins, and postoperative (pre-treatment) imaging. In the era of the multidetector CT optimized for pancreatic imaging, tumors of “borderline resectability” have emerged as a distinct subset of PDAC. The attempt to standardize the definition of borderline resectable is a work in progress and modified with time. This distinction (between resectable and borderline resectable) is essential to minimize potentially confounding results of clinical trials. Additionally, preoperative therapy is not only preferred but mandatory in a large population of borderline resectable patients. Ultimately, as we develop more effective systemic therapies for PDAC, proceeding with surgery after a period of induction therapy will be even more compelling especially if there is a clear positive impact on overall survival.     

Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

ObjectivesThe influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice.MethodsData were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups.ResultsA total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63–5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21–4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67–8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group.ConclusionsIn this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.     

法洛四联症外科矫治手术前后的介入干预治疗

目的:评价经导管介入治疗措施对法洛四联症(tetralogy of Fallot,TOF)外科矫治术的辅助治疗价值。方法:对我科2010年10月至2013年12月住院的27例,和作者在外院完成的3例TOF经导管介入治疗进行总结分析。结果:男性20例,女性10例,年龄8个月~49岁,平均4.3岁。外科矫治术前行体-肺侧枝血管(major aorto-pulmonary collateral arteries,MAPCAs)栓塞术17例、肺动脉瓣球囊扩张术(percutaneous balloon pulmonary valvuloplasty PBPV)4例;因术后肺出血急诊行MAPCAs栓塞术4例,术后左心衰行MAPCA-肺静脉瘘瘘口封堵1例、肺动脉分支狭窄球囊扩张(percutaneous balloon pulmonary arterioplasty PBPA)3例、PBPV1例。介入治疗均达到预期效果,未发生与操作相关的并发症,1例根治术后,肺出血患者行MAPCAs栓堵术后肺出血改善,但死于感染性心内膜炎,其他病例均痊愈出院。结论:TOF外科矫治术前、术后的介入治疗,可减少TOF根治手术风险并改善预后。     

Early Warning of Acute Altitude Sickness by Physiological Variables and Noninvasive Cardiovascular Indicators

Objective To examine if the variations at sea level would be able to predict subsequent susceptibility to acute altitude sickness in subjects upon a rapid ascent to high altitude.Methods One hundred and six Han nationality male individuals were recruited to this research. Dynamic electrocardiogram, treadmill exercise test, echocardiography, routine blood examination and biochemical analysis were performed when subjects at sea level and entering the plateau respectively. Then multiple regression analysis was performed to construct a multiple linear regression equation using the Lake Louise Score as dependent variable to predict the risk factors at sea level related to acute mountain sickness (AMS).Results Approximately 49.05% of the individuals developed AMS. The tricuspid annular plane systolic excursion (22.0±2.66 vs. 23.2±3.19 mm, t=1.998, P=0.048) was significantly lower in the AMS group at sea level, while count of eosinophil [(0.264±0.393)×10⁹/L vs. (0.126±0.084)×10⁹/L, t=-2.040, P=0.045], percentage of differences exceeding 50 ms between adjacent normal number of intervals (PNN50, 9.66%±5.40% vs. 6.98%±5.66%, t=-2.229, P=0.028) and heart rate variability triangle index (57.1±16.1 vs. 50.6±12.7, t=-2.271, P=0.025) were significantly higher. After acute exposure to high altitude, C-reactive protein (0.098±0.103 vs. 0.062±0.045 g/L, t=-2.132, P=0.037), aspartate aminotransferase (19.7±6.72 vs. 17.3±3.95 U/L, t=-2.231, P=0.028) and creatinine (85.1±12.9 vs. 77.7±11.2 mmol/L, t=-3.162, P=0.002) were significantly higher in the AMS group, while alkaline phosphatase (71.7±18.2 vs. 80.6±20.2 U/L, t=2.389, P=0.019), standard deviation of normal-to-normal RR intervals (126.5±35.9 vs. 143.3±36.4 ms, t=2.320, P=0.022), ejection time (276.9±50.8 vs. 313.8±48.9 ms, t=3.641, P=0.001) and heart rate variability triangle index (37.1±12.9 vs. 41.9±11.1, t=2.020, P=0.047) were significantly lower. Using the Lake Louise Score as the dependent variable, prediction equation were established to estimate AMS: Lake Louise Score=3.783+0.281×eosinophil-0.219×alkaline phosphatase+0.032×PNN50.Conclusions We elucidated the differences of physiological variables as well as noninvasive cardiovascular indicators for subjects after high altitude exposure compared with those at sea level. We also created an acute high altitude reaction early warning equation based on the physiological variables and noninvasive cardiovascular indicators at sea level.