Effect of tranexamic acid on blood loss reduction in patients undergoing orthognathic surgery under hypotensive anesthesia: a single-center, retrospective, observational study.

Objectives: Orthognathic surgery is a surgical procedure performed by intraoral approach with established and safe techniques; however, excessive blood loss has been reported in rare cases. In response, investigative efforts to identify methods to reduce the amount of blood loss have been made. Among such methods, the administration of tranexamic acid was reported to reduce the amount of intraoperative blood loss. However, few studies to date have reported the effect of tranexamic acid in orthognathic surgery under hypotensive anesthesia. The present study aimed to investigate the effect of the administration of tranexamic acid on intraoperative blood loss in patients undergoing bimaxillary (maxillary and mandibular) orthognathic surgery under hypotensive anesthesia. Patients andMethods: A total of 156 patients (mean age, 27.0±10.8 years) who underwent bimaxillary orthognathic surgery under hypotensive anesthesia performed by the same surgeon between June 2013 and February 2022 were included in this study. The following data were collected from the medical records of each patient: background factors (age, sex, and body mass index), use of tranexamic acid, surgical procedures, previous medical history, duration of surgery, American Society of Anesthesiology physical status findings before surgery, intraoperative blood loss as a primary outcome, in-out balance, and blood test results. Descriptive statistics were calculated for statistical analysis, and a t -test and the chi-squared test were used for between-group comparisons. Group comparisons were performed after 1:1 propensity score matching to adjust for confounding factors. Statistical significance was set at P<0.05. Results: Comparison between the groups based on the use of tranexamic acid revealed a significant difference in operation time. Propensity score matching analysis revealed that intraoperative blood loss was significantly lower in the tranexamic acid group. Conclusion: The administration of tranexamic acid was effective in reducing intraoperative blood loss in patients undergoing bimaxillary orthognathic surgery under hypotensive anesthesia.

Accuracy of diagnosing acute kidney injury by assessing urine output within the first week of life in extremely preterm infants.

BACKGROUND: Neonatal acute kidney injury (AKI) is associated with increased mortality and is often assessed with the neonatal modified Kidney Disease: improving Global Outcomes (KDIGO) classification, which uses changes in serum creatinine levels. However, because this classification has many drawbacks, a novel method, the neonatal Risk, Injury, Failure, Loss, and End-Stage Kidney Disease (nRIFLE) classification for diagnosing neonatal AKI according to urine output (UO), was recently proposed. To date, no data on the incidence of AKI according to nRIFLE are available for extremely preterm infants (born at gestational age less than 28 weeks). This study was conducted to clarify the association between incidence of AKI and in-hospital mortality in extremely preterm infants. METHODS: Of 171 extremely preterm infants hospitalized from 2006 to 2020, 84 in whom indwelling bladder catheters were placed for UO measurements within 24 h of life were included. The incidence of AKI was assessed using the nRIFLE classification. In-hospital mortality was compared between patients with AKI and those without it. RESULTS: The incidence of AKI during the first week of life was 56% and that of in-hospital mortality was significantly higher in patients with AKI (25.5%) than in those without it (2.8%). The odds ratio was 12.3 with 95% confidence interval ranging from 1.5 to 100.0. CONCLUSION: The incidence of AKI according to nRIFLE was higher than reported in most previous studies using the neonatal modified KDIGO classification, suggesting that assessment by nRIFLE criteria using UO may improve diagnostic accuracy of AKI in extremely preterm infants.

Association of Neonatal Jaundice with Gut Dysbiosis Characterized by Decreased Bifidobacteriales.

Neonatal jaundice, caused by excess serum bilirubin levels, is a common condition in neonates. Imbalance in the gut microbiota is believed to play a role in the development of neonatal jaundice. Thus, we aimed to reveal the gut microbiota characteristics in neonates with jaundice. 16S rRNA gene sequencing was performed on stool samples collected on day 4 from 26 neonates with jaundice (serum total bilirubin > 15.0 mg/dL) and 17 neonates without jaundice (total serum bilirubin < 10.0 mg/dL). All neonates were born full term, with normal weight, by vaginal delivery, and were breastfed. Neonates who were administered antibiotics, had serum direct bilirubin levels above 1 mg/dL, or had conditions possibly leading to hemolytic anemia were excluded. The median serum bilirubin was 16.0 mg/dL (interquartile range: 15.5-16.8) and 7.4 mg/dL (interquartile range: 6.8-8.3) for the jaundice and non-jaundice groups, respectively. There was no difference in the alpha diversity indices. Meanwhile, in the jaundice group, linear discriminant analysis effect size revealed that Bifidobacteriales were decreased at the order level, while Enterococcaceae were increased and Bifidobacteriaceae were decreased at the family level. Bifidobacteriaceae may act preventatively because of their suppressive effect on beta-glucuronidase, leading to accelerated deconjugation of conjugated bilirubin in the intestine. In summary, neonates with jaundice had dysbiosis characterized by a decreased abundance of Bifidobacteriales.

Prophylactic Pentazocine Reduces the Incidence of Pruritus After Cesarean Delivery Under Spinal Anesthesia With Opioids: A Prospective Randomized Clinical Trial.

BACKGROUND: The incidence of pruritus after cesarean delivery under spinal anesthesia with opioids is high, ranging from 50% to 100%. Pruritus is difficult to prevent; however, pentazocine has been shown to be an effective treatment. Despite this, the prophylactic effect of pentazocine on pruritus has not been defined. This randomized double-blind trial aimed to evaluate the effect of intraoperative IV pentazocine on the incidence of opioid-induced pruritus within the first 24 hours after administration of neuraxial opioids. METHODS: We obtained institutional review board approval and written informed consent from the 122 patients (American Society of Anesthesiologists [ASA] physical status II; aged 20-40 years) scheduled for elective cesarean delivery who were included in this study. Spinal anesthesia was performed with 10 mg of 0.5% hyperbaric bupivacaine, 10 µg of fentanyl, and 100 µg of morphine. After delivery of the baby and placenta, the parturient women were randomized to intravenously receive 15 mg (1 mL) of pentazocine or 1 mL of saline. All women received postoperative analgesia with the epidural infusion of 0.15% levobupivacaine. The presence of pruritus within the first 24 hours after intrathecal administration of opioids was recorded, and severity of itch, numerical rating scale (NRS) for pain, and adverse effects were also recorded at the time of the arrival on the ward, as well as 3, 6, 12, and 24 hours after the intrathecal administration of opioids. RESULTS: A total of 119 women completed the study. IV pentazocine reduced the overall incidence of pruritus within the first 24 hours compared to IV saline, with an estimated relative risk of 69% (95% confidence interval [CI], 52%, 90%; P = .007). IV pentazocine also reduced the severity of pruritus. The incidence of nausea and vomiting was not significantly different. There were no significant differences in postoperative NRS scores. CONCLUSIONS: A single 15-mg dose of IV pentazocine after delivery can reduce both the incidence and severity of pruritus in women who have received subarachnoid opioids during cesarean delivery.

The Diagnostic Significance of Comorbidities of Congenital Heart Diseases, Low-Set Ears, and Intrauterine Growth Restriction in Neonates With Trisomies 13 and 18.

BACKGROUND: Trisomies 13 and 18 (T13/18) are autosomal trisomy syndromes with dismal prognoses. Deciding whether to perform a chromosomal analysis for the definitive diagnosis is often difficult (even for experienced pediatricians) because representative clinical signs may not be found in all T13/18 neonates. OBJECTIVES: This study aimed to investigate any clinical signs that could be useful for screening for T13/18 in participants without the representative clinical signs traditionally found in odd-looking neonates with malformation syndromes. PATIENTS AND METHODS: We retrospectively analyzed 15 T13/18 patients, 33 trisomy 21 patients, and 48 controls with other malformation syndromes, for apparent clinical signs during the neonatal period. All participants had been admitted to the neonatal intensive care unit of Kansai Medical University over a nine-year period. RESULTS: The three leading clinical signs in patients with T13/18 were congenital heart diseases (CHD; 100%), low-set ears (LSE; 80%), and intrauterine growth restriction (IUGR; 73.3%). A comorbidity of these two leading non-specific clinical signs was CHD with LSE, which showed the highest diagnostic accuracy between T13/18 and controls with a sensitivity of 80.0% and a negative predictive value of 92.5%. The chi-square test among these three groups (P < 0.01) and multiple comparison tests of proportional differences showed that the comorbidity of CHD with LSE was specific for autosomal trisomy syndromes. A comorbidity of CHD with IUGR also revealed a similar diagnostic accuracy with a sensitivity of 73.3% and a negative predictive value of 90.9% as well as a specificity for T13/18. CONCLUSIONS: The comorbidities of either CHD with LSE or CHD with IUGR should be suspected in neonates with autosomal trisomy syndromes, particularly T13/18 without the expected representative clinical signs.

Elective Cesarean section at 37 weeks is associated with the higher risk of neonatal complications.

Elective Cesarean section performed before 39 weeks of gestation may be associated with increased risk of neonatal complications. We retrospectively investigated differences in the neonatal complication rate between 684 newborns delivered by elective Cesarean section at 37 weeks of gestation (n = 390) and those delivered by the same procedure at 38 weeks (n = 294) between 2006 and 2012 at our hospital in order to ascertain whether adverse outcomes differ between the groups. Newborns delivered at 37 weeks had a significantly higher incidence of neonatal intensive care unit admission (p = 0.03), adverse respiratory complications (p < 0.01), low birth weight (p < 0.001), and hypoglycemia (p < 0.005) than those delivered at 38 weeks. Compared with normal weight neonates, low birth weight neonates were more likely to have hypoglycemia (p < 0.001). Multivariate logistic regression analysis revealed that an adverse respiratory outcome was independently associated with gestational age (p < 0.01; odds ratio [OR], 3.26; 95% confidence interval [CI], 1.36-7.81), while hypoglycemia was independently associated with birth weight (p < 0.01; OR, 16.34; 95% CI, 7.72-34.56). Respiratory disorders were significantly associated with gestational age even in normal birth weight newborns without any other complications such as hyperbirilubinemia, hypoglycemia or bacterial infections. In conclusion, the incidence of neonatal complications was higher in newborns delivered at 37 weeks of gestation than in those delivered at 38 weeks via elective Cesarean section. Thus, the procedure should be scheduled at 38 weeks to improve neonatal outcomes.

[Treatment of intrathecal fentanyl-induced itch with pentazocine: a case report].

Pentazocine has activities both of kappa-opioid receptor agonist and weak micro-opioid receptor antagonist. Recent study has suggested that kappa-opioid receptor agonists have antipruritic effects. We experienced a case of pentazocine inhibiting itch evoked by intrathecal fentanyl in a patient with idiopathic pulmonary fibrosis (IPF). A 50-year-old woman with IPF was diagnosed with fallopian tube abscess and which necessitated emergency surgery. We mainly performed regional anesthetic management to prevent acute exacerbation of IPF by tracheal intubation under general anesthesia. About 30 minutes after intrathecal administration of a combination of bupivacaine and fentanyl, she began to complain of itch. Although propofol was given intravenously, pruritus still recurred. Following that, when pentazocine was administered intravenously, pruritus disappeared immediately and then never recurred. Therefore, it is suggested that pentazocine can be useful in reducing pruritus on intrathecal opioid-induced itch. Future studies are necessary to evaluate the efficacy of pentazocine for the treatment and prevention of opioid-induced itch.

B-type natriuretic peptide for assessment of haemodynamically significant patent ductus arteriosus in premature infants.

AIM: Haemodynamically significant patent ductus arteriosus (hsPDA) is frequently observed in premature infants. This study was conducted to explore whether the blood BNP can be a valuable biomarker to assess the necessity of treatment for hsPDA in premature infants. METHODS: Serial measurements of the blood BNP were performed during the first 5 days of life in premature infants with hsPDA (Group I) and those without hsPDA (Group N). The definition of the hsPDA was the PDA requiring treatment, such as indomethacin administration and/or surgical ligation. RESULTS: Forty-six subjects were enrolled. Compared with Group N, Group I showed significantly higher level of blood BNP at postnatal 24-96 h and demonstrated the peak value at postnatal 24-48 h. With the ROC curve using the data at postnatal 24-48 h in Group I, we deduced the predictive value of 250 pg/mL of blood BNP for indomethacin treatment. Similarly, with the ROC curve using the maximal value of blood BNP within the first 5 days of life, the predictive value of 2000 pg/mL for surgical ligation was deduced. CONCLUSIONS: Blood BNP during early postnatal period can be a useful biomarker to assess the necessity of treatment for hsPDA in premature infants.

Production of nitric oxide is lower in Shiga toxin-stimulated neutrophils of infants compared to those of children or adults.

Hemolytic uremic syndrome (HUS) in infants is mainly caused by the Shiga toxin (Stx), which is produced by pathogenic Escherichia coli O157:H7. Infants are prone to develop HUS in comparison to older children and adults, but its underlying mechanism remains unknown. Recent observations suggest that reactive oxygen species (ROS) and reactive nitrogen species (RNS) including nitric oxide (NO) may be involved in the pathogenesis of HUS. We therefore measured NO production by neutrophils prepared from infants (6-27 months old), children (5.3-11 years old) or adults (25-47 years old). The NO production was measured by a flow cytometric analysis with a fluorescent indicator (expressed as mean fluorescence intensity), and mRNA expression of inducible NO synthase (iNOS) was analyzed by reverse transcription-polymerase chain reaction (RT-PCR). The amount of NO produced was significantly lower in Stx-stimulated neutrophils prepared from infants (45.8 ± 23.3) than that in those from children (120.5 ± 81.5) or adults (127.7 ± 45.8) (n = 10 each group, P < 0.05). The expression level of iNOS mRNA was lower in Stx-stimulated neutrophils of the infants than the level in those of children or adults. In conclusion, Stx increased NO production in neutrophils probably via iNOS. Importantly, the degree of the Stx-mediated increase in NO production was lower in neutrophils of infants compared to those of children or adults, which may explain the higher incidence of HUS in infants. These results suggest that NO may contribute to the cellular defense mechanisms against Stx.

Increased urinary calcium excretion caused by ceftriaxone: possible association with urolithiasis.

The administration of ceftriaxone is known to be associated with biliary pseudolithiasis, although the development of urolithiasis has only rarely been reported. We treated a young male with bacterial meningitis complicated by urinary precipitates composed of ceftriaxone-calcium salt, which prompted us to study whether ceftriaxone administration predisposes children to the formation of urinary precipitates. The case-control study reported here included 83 children with bacterial pneumonia aged from 3 months to 8.9 years. The children were divided into one group of 43 children who received ceftriaxone (group A) and a second group of 40 children who received amoxicillin (group B). Paired samples of serum and urine before and after treatment were obtained from the patients in each group. There were no significant differences in demographic characteristics and blood biochemistry between the groups. However, the mean urinary calcium to creatinine ratio (uCa/Cr; mg/mg) was significantly higher in group A patients than in group B patients after treatment (0.19 vs. 0.09, respectively; p < 0.001), and analysis of the paired urine samples revealed that the uCa/Cr significantly increased after treatment only in group A patients(p < 0.001). There was a weak but non-significant relationship between the dose of ceftriaxone and the uCa/Cr in group A (p = 0.10, r = 0.24). Our results are the first to demonstrate that ceftriaxone has the potential to significantly increase urinary excretion of calcium, which may be linked to ceftriaxone-related urolithiasis or sludge. We therefore suggest that it is worthwhile monitoring the uCa/Cr levels in patients on ceftriaxone as they may be at greater risk for developing large stones and renal damage.

Immunoglobulin preparations affect hyponatremia in Kawasaki disease.

Hyponatremia frequently occurs in Kawasaki disease (KD). The aim of this study was to investigate the effect of Na content of the intravenous immunoglobulin (IVIG) preparation on serum Na levels in KD. Seventy-eight subjects, of whom 27 had hyponatremia, were split up into two groups: group A receiving IVIG preparations containing high Na (0.9%) and group B receiving IVIG preparations containing trace Na. While the data before IVIG therapy revealed no significant differences in the median serum Na between the groups, an administration of IVIG preparations increased the serum levels of Na in group A (P < 0.01) but not in group B (P > 0.05). Furthermore, the median serum Na level was significantly higher in group A than that in group B (139.0 vs 137.0 mEq/L, respectively, P < 0.01). No significant difference was found in the prevalence of coronary artery lesions between the groups. In conclusion, we should keep it in mind that the IVIG products without Na have an adverse affect on hyponatremia in KD though their efficacy seems to be equivalent to those containing high Na.