Possible venous air embolism during open eye surgery in a child

PURPOSE: Although venous air embolism is a well recognized complication within most surgical subspecialties, it has only been reported recently during eye surgery in one adult, and never before in a child. We describe the case of a 17-month-old boy who sustained a possible air embolism during repair of an open trauma of his right eye. CLINICAL FEATURES: A vitrectomy through the pars plana with air-fluid exchange of the posterior chamber was performed under general anesthesia to remove a foreign body which had impaled the optic nerve. A few minutes after removal of the foreign body, a notable decrease in end-tidal CO(2), oxygen saturation and arterial blood pressure occurred, requiring administration of a high inspired oxygen fraction and vasopressors. Venous air embolism was strongly suspected after other causes of a decrease of end-tidal CO(2) and hypoxemia had been excluded. An arterial blood gas confirmed hypoxemia and respiratory acidosis. CONCLUSION: Although venous air embolism is a rare complication of eye surgery, it should nevertheless be considered as a possible complication during air-fluid exchange vitrectomy in children.     

Expression and carbonylation of creatine kinase in the quadriceps femoris muscles of patients with chronic obstructive pulmonary disease

Oxidative protein modification involving carbonylation has recently been identified as an important factor in skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease (COPD). However, the exact identity of modified proteins inside limb muscles of patients with COPD remains unknown. We used 2D electrophoresis, immunoblotting, and mass spectrometry to identify carbonylated proteins in the vastus lateralis muscle of 12 patients with COPD and 6 control subjects. Both creatine kinase (CK) and carbonic anhydrase III (CAIII) were identified as being strongly carbonylated in this muscle in both groups of subjects. Total CK activity, CK protein expression, and the intensity of CK carbonylation were significantly greater in the muscles of patients with COPD as compared with control subjects, whereas CAIII protein expression and intensity of carbonylation were similar in the two groups. In patients with COPD, CK activity and protein expression correlated positively with FEV(1) and V O(2)max, whereas the intensity of CK carbonylation correlated negatively with the same parameters. These results indicate that oxygen radicals selectively target CK and CAIII inside limb muscles of humans. The observation that the intensity of CK carbonylation correlates negatively with CK activity in limb muscles of patients with COPD suggests that carbonylation may have a deleterious effect on CK activity, and may contribute to impaired CK function in the limb muscles of these patients.     

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

BackgroundPulmonary metastases are a poor prognostic factor in patients with osteosarcoma; however, the clinical significance of subcentimeter lung nodules and whether they represent a tumor is not fully known. Because the clinician is faced with decisions regarding biopsy, resection, or observation of lung nodules and the potential impact they have on decisions about resection of the primary tumor, this remains an area of uncertainty in patient treatment. Surgical management of the primary tumor is tailored to prognosis, and it is unclear how aggressively patients with indeterminate pulmonary nodules (IPNs), defined as nodules smaller than 1 cm at presentation, should be treated. There is a clear need to better understand the clinical importance of these nodules.Questions/purposes(1) What percentage of patients with high-grade osteosarcoma and spindle cell sarcoma of bone have IPNs at diagnosis? (2) Are IPNs at diagnosis associated with worse metastasis-free and overall survival? (3) Are there any clinical or radiologic factors associated with worse overall survival in patients with IPN?MethodsBetween 2008 and 2016, 484 patients with a first presentation of osteosarcoma or spindle cell sarcoma of bone were retrospectively identified from an institutional database. Patients with the following were excluded: treatment at another institution (6%, 27 of 484), death related to complications of neoadjuvant chemotherapy (1%, 3 of 484), Grade 1 or 2 on final pathology (4%, 21 of 484) and lack of staging chest CT available for review (0.4%, 2 of 484). All patients with abnormalities on their staging chest CT underwent imaging re-review by a senior radiology consultant and were divided into three groups for comparison: no metastases (70%, 302 of 431), IPN (16%, 68 of 431), and metastases (14%, 61 of 431) at the time of diagnosis. A random subset of CT scans was reviewed by a senior radiology registrar and there was very good agreement between the two reviewers (κ = 0.88). Demographic and oncologic variables as well as treatment details and clinical course were gleaned from a longitudinally maintained institutional database. The three groups did not differ with regard to age, gender, subtype, presence of pathological fracture, tumor site, or chemotherapy-induced necrosis. They differed according to local control strategy and tumor size, with a larger proportion of patients in the metastases group presenting with larger tumor size and undergoing nonoperative treatment. There was no differential loss to follow-up among the three groups. Two percent (6 of 302) of patients with no metastases, no patients with IPN, and 2% (1 of 61) of patients with metastases were lost to follow-up at 1 year postdiagnosis but were not known to have died. Individual treatment decisions were determined as part of a multidisciplinary conference, but in general, patients without obvious metastases received (neo)adjuvant chemotherapy and surgical resection for local control. Patients in the no metastases and IPN groups did not differ in local control strategy. For patients in the IPN group, staging CT images were inspected for IPN characteristics including number, distribution, size, location, presence of mineralization, and shape. Subsequent chest CT images were examined by the same radiologist to reevaluate known nodules for interval change in size and to identify the presence of new nodules. A random subset of chest CT scans were re-reviewed by a senior radiology resident (κ = 0.62). The association of demographic and oncologic variables with metastasis-free and overall survival was first explored using the Kaplan-Meier method (log-rank test) in univariable analyses. All variables that were statistically significant (p < 0.05) in univariable analyses were entered into Cox regression multivariable analyses.ResultsFollowing re-review of staging chest CTs, IPNs were found in 16% (68 of 431) of patients, while an additional 14% (61 of 431) of patients had lung metastases (parenchymal nodules 10 mm or larger). After controlling for potential confounding variables like local control strategy, tumor size, and chemotherapy-induced necrosis, we found that the presence of an IPN was associated with worse overall survival and a higher incidence of metastases (hazard ratio 1.9 [95% CI 1.3 to 2.8]; p = 0.001 and HR 3.6 [95% CI 2.5 to 5.2]; p < 0.001, respectively). Two-year overall survival for patients with no metastases, IPN, or metastases was 83% [95% CI 78 to 87], 65% [95% CI 52 to 75] and 45% [95% CI 32 to 57], respectively (p = 0.001). In 74% (50 of 68) of patients with IPNs, it became apparent that they were true metastatic lesions at a median of 5.3 months. Eighty-six percent (43 of 50) of these patients had disease progression by 2 years after diagnosis. In multivariable analysis, local control strategy and tumor subtype correlated with overall survival for patients with IPNs. Patients who were treated nonoperatively and who had a secondary sarcoma had worse outcomes (HR 3.6 [95% CI 1.5 to 8.3]; p = 0.003 and HR 3.4 [95% CI 1.1 to 10.0]; p = 0.03). The presence of nodule mineralization was associated with improved overall survival in the univariable analysis (87% [95% CI 39 to 98] versus 57% [95% CI 43 to 69]; p = 0.008), however, because we could not control for other factors in a multivariable analysis, the relationship between mineralization and survival could not be determined. We were unable to detect an association between any other nodule radiologic features and survival.ConclusionThe findings show that the presence of IPNs at diagnosis is associated with poorer survival of affected patients compared with those with normal staging chest CTs. IPNs noted at presentation in patients with high-grade osteosarcoma and spindle cell sarcoma of bone should be discussed with the patient and be considered when making treatment decisions. Further work is required to elucidate how the nodules should be managed.Level of EvidenceLevel III, prognostic study.     

Gastrointestinal and hepatic manifestations of COVID-19 infection: Lessons for practitioners

Originating from Wuhan in China, coronavirus disease 2019 (COVID-19) spread globally within months and was declared a pandemic by World Health Organization in March 2020, making it one of the biggest healthcare calamities of our time. As more data on COVID-19 infection became available, what was initially thought to be a simple respiratory illness was found to be more complex. Many extra-pulmonary manifestations are now frequently reported for COVID-19 in available literature, most commonly gastrointestinal and hepatopancreato-biliary manifestations. Due to early scarcity of data, extra pulmonary manifestations were initially overlooked and may have contributed to nosocomial spread of the infection. Practitioners, especially gastroenterologists, who frequently encounter patients with these symptoms, need to be aware of them. This can not only help minimize the nosocomial spread, ensure safety of provider but also help conserve already stretched-thin healthcare resources. A tremendous amount of COVID-19 related literature is getting added to the growing pool every day, making it difficult for providers to follow. The aim of our review is to summarize the available evidence for gastrointestinal and hepatopancreatobiliary manifestations of COVID-19. We here briefly discussed the possible pathophysiologic mechanism for these manifestations and summarized the recommendations put forward by multiple gastrointestinal societies regarding safe and effective clinical practice during the ongoing pandemic.     

Effect of continuous positive airway pressure on the rapid shallow breathing index in patients following cardiac surgery

OBJECTIVES: To compare the rapid shallow breathing index (RSBI) under different ventilatory support settings prior to extubation trials. DESIGN: Prospective study. SETTING: Cardiac surgery unit at a university hospital. PATIENTS: A total of 33 coronary artery bypass grafting patients ready for extubation. INTERVENTIONS: Enrolled patients received a continuous positive airway pressure (CPAP) trial of 5 cm H(2)O and fraction of inspired oxygen (FIO(2)) of 40% (condition 1), a CPAP trial of 5 cmH(2)O and FIO(2) of 21% (condition 2), and a 1-min spontaneously breathing room air trial without ventilatory support (condition 3). These trials were applied in random order. Measurements and main results: Average values of respiratory frequency and tidal volume were measured under the three experimental conditions in all patients immediately prior to extubation. The RSBIs were determined for each patient under each condition; the average RSBIs under conditions 1, 2, and 3 were compared for significance. The average RSBIs (+/- SD) were significantly smaller under condition 1 (34 +/- 13) and condition 2 (36 +/- 14) compared to condition 3 (71 +/- 24). There was no significant difference in RSBI between conditions 1 and 2. CONCLUSIONS: The administration of 5 cm H(2)O of CPAP can influence the determination of the RSBI. In contrast, changes in FIO(2) have no effect on RSBI determination. We speculate that using the RSBI during CPAP may mislead the clinician into premature discontinuation of mechanical ventilation. Consequently, different threshold values for the RSBI should be derived for different ventilatory support levels.