The Evaluation Value of Diffusion-Weighted Imaging for Brain Injury in Patients after Deep Hypothermic Circulatory Arrest.

Objective: Cerebral complications may occur after surgery with deep hypothermic circulatory arrest (DHCA). Diffusion-weighted imaging (DWI) has shown promising results in detecting early changes of cerebral ischemia. However, studies in human models are limited. Here, we examined the significance of DWI for detecting brain injury in postoperative patients after DHCA. Methods: Twelve patients who had undergone selective cerebral perfusion with DHCA were enrolled. All patients underwent magnetic resonance imaging (MRI) examinations before and after the operation with T1-weighted phase (T1W) and T2-weighted phase (T2W). Magnetic resonance angiography (3D TOF) was applied to observe intracranial arterial communication situations. DWI was employed to calculate the apparent diffusion coefficient (ADC) values. The neurocognitive function of patients was assessed preoperatively and postoperatively using the Montreal Cognitive Assessment Scale (MoCA), Hamilton Depression Scale (HAMD), and Hamilton Anxiety Scale (HAMA). Results: The ADC values of the whole brain of patients after surgery were significantly higher than before surgery (P = 0.003). However, no significant difference in the ADC values of other regions before and after the operation was observed. There was no significant effect on the postoperative cognitive function of patients after surgery, but visual-spatial and executive abilities were significantly reduced, while psychological anxiety (P = 0.005) and depression levels (P < 0.05) significantly increased. Correlation analysis revealed a significant association between ADC change values and depression change values (P < 0.05). Conclusion: DHCA demonstrated no significant effect on the cognitive function of patients but could affect the mood of patients. On the other hand, DWI demonstrated promising efficiency and accuracy in evaluating brain injury after DHCA.

Fentanyl inhibits acute myeloid leukemia differentiated cells and committed progenitors via opioid receptor-independent suppression of Ras and STAT5 pathways.

Fentanyl is a common sedative/analgesic used for intrathecal chemotherapy injection in children with acute leukemia. Given the contradictory findings that fentanyl has both inhibitory and stimulatory activities in cancer cells, we investigated the biological effects of fentanyl alone and its combination with standard of care in acute myeloid leukemia (AML) cells at all stages of development. We showed that fentanyl at clinically relevant concentration inhibited growth and colony formation of AML differentiated cells and committed progenitors without affecting their survival. Compared to AML cells without FLT3 mutation, cells harboring FLT3-ITD mutation are likely to be more sensitive to fentanyl. However, fentanyl did not affect the most primitive AML stem cells. Fentanyl significantly augmented the efficacy of cytarabine but not midostaurin in AML differentiated cells and committed progenitors. We further demonstrated that fentanyl inhibited AML cells via suppressing Ras/Raf/MEK/ERK and STAT5 pathway, and this was not dependent on opioid receptor system. Our findings demonstrate the anti-leukemia activity of fentanyl and synergistic effects between fentanyl and cytarabine in AML, via opioid receptor-independent suppression of Ras and STAT5 pathways. Our work is the first to suggest the beneficial effects of fentanyl in children with leukemia.

Impact of ultrasound-guided erector spinae plane block on postoperative quality of recovery in video-assisted thoracic surgery: A prospective, randomized, controlled trial.

STUDY OBJECTIVE: Regional anesthesia improves postoperative analgesia and enhances the quality of recovery (QoR) after surgery. We examine the efficacy of ultrasound-guided erector spinae plane block (ESPB) on QoR after video-assisted thoracic surgery (VATS). DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Single institution, tertiary university hospital. PATIENTS: Adult patients who scheduled for VATS under general anesthesia were enrolled in the study. INTERVENTIONS: We randomly allocated patients to receive preoperative ultrasound-guided ESPB with 25 ml of either 0.5% ropivacaine (ESPB group) or normal saline (Control group). MEASUREMENTS: The primary outcome was QoR as measured by the 40-item QoR questionnaire (QoR-40) score at postoperative day 1. Secondary results were post-anesthesia care unit (PACU) discharge time, acute postoperative pain, cumulative opioid consumption, the incidence of postoperative nausea or vomiting (PONV), and patient satisfaction. MAIN RESULTS: The global QoR-40 score at postoperative day 1 (median, interquartile range) was significantly higher in the ESPB group (174, 170 to 177) than the control group (161.5, 160 to 165), estimated median difference 11 (95% CI 9 to 13, P < 0.001). Compared with the control group, single-injection of ESPB reduced PACU discharge time, acute postoperative pain, and cumulative opioid consumption. Correspondingly, the median patient satisfaction scores were higher in the ESPB group than the control group (9 versus 7, P < 0.001). CONCLUSION: Preoperative single-injection thoracic ESPB with ropivacaine improves QoR, postoperative analgesia, and patient satisfaction after VATS.

Diffusion-weighted imaging detects early brain injury after hypothermic circulatory arrest in pigs.

OBJECTIVES: Cerebral injury is a complication of surgery with deep hypothermic circulatory arrest (DHCA). This study aimed to evaluate diffusion-weighted imaging (DWI) for the early detection of brain injury after DHCA in an animal model. METHODS: Twelve healthy, adult, male miniature pigs were randomly divided into the DHCA (to receive DHCA; n = 6) and the control (sham surgery under anaesthesia; n = 6) groups. All animals received DWI, T1-weighted imaging (T1WI) and T2WI the day before surgery, 7 h postoperatively and 24 h postoperatively. Histopathological evaluation of the brain tissues was performed in the DHCA group using the Fluoro-Jade C staining to detect neuronal degeneration, the Nissl staining to show neuronal morphology and the TUNEL assay for apoptosis. The Cohen's kappa coefficient was used to compare the results of DWI with those of the histopathological evaluation. RESULTS: All animals survived surgery. In the control group, no new focal brain lesions were detected by postoperative DWI, T1WI or T2WI. In the DHCA group, new focal brain lesions were detected as early as 7 h postoperatively by DWI but not T1WI or T2WI. All three imaging sequences revealed abnormalities 24 h after surgery. In sections from areas showing abnormalities on DWI, the Fluoro-Jade C staining detected neuronal degeneration, the Nissl staining showed morphological abnormalities and the TUNEL assay demonstrated apoptotic cells. The Cohen's kappa statistics showed agreement between DWI findings and the results of all 3 histopathological examinations (TUNEL: kappa = 0.553; Nissl: kappa = 0.652; Fluoro-Jade C: kappa = 0.778; all P < 0.001). CONCLUSIONS: DWI is superior to T1WI or T2WI for the early detection of neurological lesions after DHCA in pigs.

The feasibility of measuring renal blood flow using transesophageal echocardiography in patients undergoing cardiac surgery.

BACKGROUND: There is no reliable method to monitor renal blood flow intraoperatively. In this study, we evaluated the feasibility and reproducibility of left renal blood flow measurements using transesophageal echocardiography during cardiac surgery. METHODS: In this prospective noninterventional study, left renal blood flow was measured with transesophageal echocardiography during three time points (pre-, intra-, and postcardiopulmonary bypass) in 60 patients undergoing cardiac surgery. Sonograms from 6 subjects were interpreted by 2 blinded independent assessors at the time of acquisition and 6 mo later. Interobserver and intraobserver reproducibility were quantified by calculating variability and intraclass correlation coefficients. RESULTS: Patients with Doppler angles of >30 degrees (20 of 60 subjects) were eliminated from renal blood flow measurements. Left renal blood flow was successfully measured and analyzed in 36 of 60 (60%) subjects. Both interobserver and intraobserver variability were <10%. Interobserver and intraobserver reproducibility in left renal blood flow measurements were good to excellent (intraclass correlation coefficients 0.604-0.999). Left renal arterial luminal diameter for the pre, intra, and postcardiopulmonary bypass phases, ranged from 3.8 to 4.1 mm, renal arterial velocity from 25 to 35 cm/s, and left renal blood flow from 192 to 299 mL/min. CONCLUSION: In patients undergoing cardiac surgery, it was feasible in 60% of the subjects to measure left renal blood flow using intraoperative transesophageal echocardiography. The interobserver and intraobserver reproducibility of renal blood flow measurements was good to excellent.