Left Ventricular Strain Rate for Intraoperative Evaluation of Cardiac Diastolic Function by Transesophageal Echocardiography: The Correlation Between Late Diastolic Peak Longitudinal Strain Rate and the Severity of Diastolic Dysfunction.

OBJECTIVES: Speckle-tracking echocardiography is a promising tool for evaluating cardiac diastolic dysfunction. A correlation between left atrial strain rate during atrial contraction and the severity of diastolic dysfunction previously has been demonstrated. Because visualization of the left atrial walls is difficult with transesophageal echocardiography, the authors evaluated the use of left ventricular strain rate during atrial contraction as a substitute for left atrial strain rate to intraoperatively measure the extent of cardiac diastolic dysfunction. DESIGN: Retrospective clinical study. SETTING: Single institutional study. PARTICIPANTS: Sixty-six patients who underwent cardiac surgery between January 2018 and January 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preoperative echocardiographic reports and intraoperative echocardiographic images of the participants were studied. The correlation of cardiac diastolic dysfunction stage with the peak longitudinal strain rate during late diastole and the time to peak value were evaluated. The late diastolic peak longitudinal strain rate was correlated significantly with the stage of diastolic dysfunction (r = -0.64, p < 0.0001). There was no significant correlation between the stage of diastolic dysfunction and the time to peak value (r = -0.17, p = 0.18). A late diastolic peak longitudinal strain rate <0.68 1/s had a sensitivity of 80% and specificity of 81% for predicting grade 2 or 3 diastolic dysfunction. CONCLUSIONS: The late diastolic peak longitudinal strain rate correlates with the severity of diastolic dysfunction in patients undergoing cardiac surgery.

Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review.

OBJECTIVE: To identify factors associated with work productivity in adults with migraine, and accommodations or interventions to improve productivity or the workplace environment for them. METHODS: We conducted a scoping review by searching MEDLINE, Embase, PsycINFO, Cumulative Index of Nursing and Allied Heath Literature, and Web of Science from their inception to 14 October 2019 for studies of any design that assessed workplace productivity in adults with migraine. RESULTS: We included 26 articles describing 24 studies after screening 4139 records. Five prospective cohort studies showed that education on managing migraine in the workplace was associated with an increase in productivity of 29-36%. Two studies showed that migraine education and management in the workplace were associated with increased productivity (absenteeism decreased by 50% in one study). One prospective cohort study showed that occupational health referrals were associated with more than 50% reduction in absenteeism. Autonomy, social support, and job satisfaction were positively associated with productivity, while quantitative demands, emotional demands, job instability, and non-conducive work environment triggers are negatively associated with productivity in workers with migraine. CONCLUSION: Despite migraine being the second leading cause of disability worldwide, there is a paucity of strong data on migraine-related work factors associated with productivity.Registration: None (scoping review).

Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting.

Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.

Speckle- Tracking Echocardiography for the Staging of Diastolic Dysfunction: The Correlation Between Strain-Based Indices and the Severity of Left Ventricular Diastolic Dysfunction.

OBJECTIVES: Left ventricular diastolic function can be assessed by various methods. Tissue Doppler imaging is among the most commonly used techniques. However, this imaging is angle- dependent, affected by loading conditions, and susceptible to myocardial tethering. Speckle- tracking echocardiography also can measure strain-based indices to assess diastolic function, and it has fewer limitations than tissue Doppler imaging. Using speckle- tracking echocardiography, the authors evaluated the correlation between the stage of diastolic dysfunction and strain-based indices in patients undergoing cardiac surgery to determine whether strain-based indices can be used intraoperatively to identify the extent of left ventricular diastolic dysfunction. DESIGN: Retrospective clinical study. SETTING: Single university hospital. PARTICIPANTS: Fifty-eight patients undergoing cardiac surgery (December 2017 to December 2019). INTERVENTIONS: None. Measurement and Main Result: Preoperative echocardiographic reports and intraoperative echocardiographic images of the participants were studied. The correlation between the stage of left ventricular diastolic dysfunction and strain-based indices (including early diastolic peak longitudinal strain and tissue deceleration time) were evaluated. Early diastolic peak longitudinal strain rate significantly correlated with the stage of diastolic dysfunction (r = -0.7 and p < 0.0001). Tissue deceleration time significantly correlated with the stage of diastolic dysfunction in patients with diastolic abnormality (r = -0.4 and p = 0.02). When patients with normal diastolic function were included, this correlation was not significant (r= -0.25 and p = 0.05). CONCLUSIONS: Intraoperatively measured early diastolic peak longitudinal strain rate and tissue deceleration time correlated with the severity of diastolic dysfunction in patients undergoing cardiac surgery.

Modifications to the PREEMPT Protocol for OnabotulinumtoxinA Injections for Chronic Migraine in Clinical Practice.

OBJECTIVE: To assess the PREEMPT protocol modifications that have developed in clinical practice over time. BACKGROUND: The United States Food and Drug Administration approved the 155-unit fixed-dose, fixed-site PREEMPT protocol of onabotulinumtoxinA (BoNT-A) injections for migraine prevention 9 years ago. METHODS: This is an anonymous survey with free text response options of Headache Medicine clinicians. RESULTS: Out of the 878 contacted Headache Medicine clinicians, 182 (20.7%) completed the survey. Of the 182 respondents, 141 (77.5%) reported that they did not always follow the PREEMPT protocol. Of the 182 respondents, 128 (70%) changed the number of injections, 115 (63%) changed the total units of BoNT-A injected, 105 (57.7%) altered the location of injection sites (58%); 101 (55.5%) do not aspirate to ensure the absence of blood return; 22 (12.1%) changed the dilution; and 4 (2.2%) added lidocaine. The main reported reasons for changes in number, dose, and location of injections included adapting to the patients' pain, anatomy, and preferences. CONCLUSIONS: The wide inter- and intra-personal variations in BoNT-A injections for chronic migraine prevention seen in this survey raise concerns about the standardization of the procedure and suggest that an advisory protocol containing more evidence and discussion of the reasoning behind the recommendations might be more helpful than the current prescriptive protocol.

Intraoperative Assessment of Coronary Artery Stenosis by 2D Speckle-Tracking Echocardiography: The Correlation Between Peak Strain Rate During Early Diastole and the Severity of Coronary Artery Stenosis in Patients Undergoing Coronary Artery Bypass Grafting.

OBJECTIVES: The effects of inhalation anesthetics on cardiac function and the low correlation between transthoracic and transesophageal echocardiographic measurements may alter the ability of transesophageal echocardiography-derived strain rate during early diastole to detect coronary artery stenosis in anesthetized patients. The authors assessed the correlation between coronary artery stenosis and strain-based parameters during early diastole in heart failure patients with preserved ejection fraction undergoing coronary artery bypass grafting. DESIGN: Retrospective clinical study. SETTING: Single university hospital. PARTICIPANTS: Thirty-two adult patients with preserved ejection fraction undergoing coronary artery bypass grafting between December 2016 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography images and coronary artery angiographies of the participants were studied. The correlation between the severity of coronary artery stenosis and strain-based indices measured in the corresponding left ventricular segments were assessed. Receiver operating characteristic curve analysis of strain rate during early diastole was used to predict the presence of coronary artery stenosis ≥70%. Regarding the severity of coronary artery stenosis, it demonstrated a strong and inverse correlation with strain rate during early diastole (r = -0.71, p < 0.001), but showed no significant correlation with time to peak strain rate during early diastole (r = 0.19, p = 0.18). Strain rate during early diastole ≤1.5 s-1 had a sensitivity of 77% and a specificity of 87% for predicting coronary artery stenosis ≥70% (area under the curve, 0.88). CONCLUSIONS: Strain rate during early diastole significantly correlates with the severity of coronary artery stenosis in anesthetized patients suffering from heart failure with preserved ejection fraction.

Intraoperative assessment of left-ventricular diastolic function by two-dimensional speckle tracking echocardiography: relationship between pulmonary capillary wedge pressure and peak longitudinal strain rate during isovolumetric relaxation in patients undergoing coronary artery bypass graft surgery.

OBJECTIVES: Two-dimensional speckle tracking echocardiography has advantages over tissue Doppler imaging during isovolumetric relaxation for predicting left-ventricular end-diastolic pressure in non-surgical patients. Considering the direct and indirect effects of general anesthesia on hemodynamics, we examined correlations between strain-based indices during isovolumetric relaxation and pulmonary capillary wedge pressure in anesthetized patients. Moreover, we determined applicable cut-off values for strain-based indices to predict pulmonary capillary wedge pressure ≥15 mmHg intraoperatively. DESIGN: Retrospective clinical study. SETTING: Single university hospital. PARTICIPANTS: Thirty adult patients with preserved ejection fraction undergoing coronary artery bypass grafting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two-dimensional speckle tracking echocardiography was used to measure strain rate during isovolumetric relaxation (SRIVR) and to calculate the mitral early diastolic inflow (E) to SRIVR ratio (E/SRIVR). Tissue Doppler imaging was used to calculate the E to early diastolic velocity at the lateral mitral annulus ratio (lateral E/e'). SRIVR and E/SRIVR showed strong correlations with pulmonary capillary wedge pressure (r = 0.80 and 0.73, respectively; p < 0.001 and p < 0.001). Lateral E/e' correlated with pulmonary capillary wedge pressure (r = 0.42; p < 0.05). SRIVR predicted high pulmonary capillary wedge pressure better than lateral E/e' did (areas under the receiver operating characteristic curves, 0.94-vs. 0.47, respectively). SRIVR <0.2 s-1 had a sensitivity of 100% and a specificity of 81% for predicting pulmonary capillary wedge pressure ≥15 mmHg. CONCLUSIONS: SRIVR is superior to tissue Doppler indices for predicting pulmonary capillary wedge pressure intraoperatively in patients with coronary artery disease and preserved ejection fraction.

Intestinal alkaline phosphatase decreases intraperitoneal adhesion formation.

BACKGROUND: Damage to the peritoneum initiates an inflammatory response leading to the formation of adhesions, which subsequently cause significant morbidity in some patients. Intestinal alkaline phosphatase (IAP) is a gut enzyme capable of detoxifying various inflammatory mediators such as lipopolysaccharide, lipoteichoic acid, CpG DNA, and adenosine triphosphate. In this study, we aimed to examine the anti-inflammatory effects of IAP on postoperative adhesions in mice. METHODS: C57BL/6 mice were subjected to a midline laparotomy and then six musculoperitoneal buttons (MPBs) were created by pinching and ligating the peritoneum and underlying muscle. The buttons were half-excised and E-cauterized, and then cecal abrasion was performed. Five hundred microliters of vehicle with IAP 5000 U or vehicle alone were applied over the peritoneal cavity. In some experiments, the mice were euthanized on the first and second postoperative day (POD), and cytokines analysis was done on the MPB, peritoneal tissue, and peritoneal fluid. In separate experiments, the mice were sacrificed on the 21st POD, and adhesion to each button was scored based on type and tenacity. RESULTS: IAP group mice had significantly lower adhesion scores compared with controls (21.5 ± 1.7 versus 13.2 ± 1.3; P = 0.0014, n = 15). MPB from IAP group mice had significantly lower interleukin-1ß and tumor necrosis factor-α protein level compared to control mice (105.66 ± 4.5 versus 69.8 ± 4.8 versus pg/mg, P = 0.0001; 45.25 ± 2.8 pg/mg versus 24.88 ± 4.1 pg/mg; P = 0.0007, n = 10). IAP treatment significantly decreased interleukin-1ß and tumor necrosis factor-α mRNA expression in MPB in the first POD (1.14 ± 0.25 versus 0.33 ± 0.07; P = 0.0068; 1.33 ± 0.31 versus 0.33 ± 0.08; P = 0.0064, n = 10). CONCLUSIONS: Application of IAP during laparotomy could represent a novel approach to prevent postoperative adhesions.

Nitric oxide mediates effects of acute, not chronic, naltrexone on LPS-induced hepatic encephalopathy in cirrhotic rats.

Recent studies suggest endogenous opioids and nitric oxide (NO) are involved in the pathophysiology of hepatic encephalopathy (HE). In this study, the interaction between the opioid receptor antagonist and NO was investigated on lipopolysaccharide (LPS)-induced HE in cirrhotic rats. Male rats were divided in the sham- and bile duct ligation (BDL)-operated groups. Animals were treated with saline; naltrexone (10 mg/kg, i.p.); or L-NAME (3 mg/kg, i.p.), alone or in combination with naltrexone. To induce HE, LPS (1 mg/kg, i.p.) was injected 1 h after the final drug treatment. HE scoring, hepatic histology, and plasma NO metabolites levels and mortality rate were recorded. Deteriorated level of consciousness and mortality after LPS administration significantly ameliorated following both acute and chronic treatment with naltrexone in cirrhotic rats. However, acute and chronic administration of L-NAME did not change HE scores in cirrhotic rats. The effects of acute but not chronic treatment of naltrexone on HE parameters were reversed by L-NAME. Plasma NOx concentrations elevated in BDL rats, which were decreased after acute and chronic treatment by naltrexone or L-NAME, significantly. We suggest both acute and chronic treatment with naltrexone improved LPS-induced HE. But, only acute treatment with naltrexone may affect through NO pathway.

A novel approach to maintain gut mucosal integrity using an oral enzyme supplement.

OBJECTIVE: To determine the role of intestinal alkaline phosphatase (IAP) in enteral starvation-induced gut barrier dysfunction and to study its therapeutic effect as a supplement to prevent gut-derived sepsis. BACKGROUND: Critically ill patients are at increased risk for systemic sepsis and, in some cases, multiorgan failure leading to death. Years ago, the gut was identified as a major source for this systemic sepsis syndrome. Previously, we have shown that IAP detoxifies bacterial toxins, prevents endotoxemia, and preserves intestinal microbiotal homeostasis. METHODS: WT and IAP-KO mice were used to examine gut barrier function and tight junction protein levels during 48-hour starvation and fed states. Human ileal fluid samples were collected from 20 patients postileostomy and IAP levels were compared between fasted and fed states. To study the effect of IAP supplementation on starvation-induced gut barrier dysfunction, WT mice were fasted for 48 hours +/- IAP supplementation in the drinking water. RESULTS: The loss of IAP expression is associated with decreased expression of intestinal junctional proteins and impaired barrier function. For the first time, we demonstrate that IAP expression is also decreased in humans who are deprived of enteral feeding. Finally, our data demonstrate that IAP supplementation reverses the gut barrier dysfunction and tight junction protein losses due to a lack of enteral feeding. CONCLUSIONS: IAP is a major regulator of gut mucosal permeability and is able to ameliorate starvation-induced gut barrier dysfunction. Enteral IAP supplementation may represent a novel approach to maintain bowel integrity in critically ill patients.

The role of different serotonin receptor subtypes in seizure susceptibility.

5-Hydroxytryptamine (5-HT) has the most diverse set of receptors in comparison with any other neurotransmitter or hormone in the body. To date, seven families of 5-HT receptors have been characterized. A great number of studies have been published regarding the role of 5-HT and its receptors in seizures. However, with a few exceptions, the net effect of activating or inhibiting each 5-HT receptor subtype on the development or severity of seizures remains controversial. Additionally, the results of studies, which have used knockout animals to investigate the role of 5-HT receptors in seizures, have sometimes been contradictory to those which have used pharmacological tools. The present study aims to review the available data regarding the influence of each receptor subtype on seizure development and, when possible, reconcile between the apparently different results obtained in these studies.

Antinociceptive and antidiarrheal effects of pioglitazone in a rat model of diarrhoea-predominant irritable bowel syndrome: role of nitric oxide.

Irritable bowel syndrome (IBS) is a prevalent disease characterized by abdominal pain and abnormal bowel habits. Pioglitazone is a peroxisome proliferator-activated receptor (PPAR) γ agonist and, although it is mostly used as an antidiabetic agent, it has been reported to have analgesic effects. Nitric oxide (NO), a gaseous molecule that mediates many of the effects of pioglitazone, has been implicated in the pathophysiology of IBS. The aim of the present study was to investigate the effects of pioglitazone on symptoms in a rat model of diarrhoea-predominant IBS (D-IBS).and to determine the role of NO in these effects. Diarrhoea-predominant IBS was induced by intracolonic instillation of acetic acid. Pioglitazone (2 mg/kg, i.p.) was administered on Days 7, 9 and 11 after acetic acid instillation. To investigate the mechanism involved in pioglitazone action, rats were also administered either the PPARγ antagonist GW9662 (3 mg/kg, i.p.), the NO synthase (NOS) inhibitor N(G) -nitro-l-arginine methyl ester (l-NAME; 10 mg/kg, i.p.) or the NO precursor l-arginine (250 mg/kg, i.p.) along with pioglitazone. Visceral hypersensitivity, nociceptive thresholds, defecation frequency, stool form, serum and colon NO production and inducible (i) NOS activity were assessed 1 h after the final injection of pioglitazone or dimethylsulphoxide (used as the vehicle). Pioglitazone reduced visceral hypersensitivity and defecation frequency, increased nociceptive thresholds, NO production and iNOS activity and shifted stool form towards hard stools in D-IBS rats. These effects of pioglitazone were significantly reversed by l-NAME, but not GW9662. l-Arginine augmented the effects of pioglitazone. In conclusion, pioglitazone alleviates symptoms in a rat model of D-IBS through an NO-dependent mechanism.

Estradiol reduces depressive-like behavior through inhibiting nitric oxide/cyclic GMP pathway in ovariectomized mice.

Estradiol decline has been associated with depressive-like behavior in female mice and NO has been suggested to play a major role in the pathogenesis of major depression. This study was conducted to investigate the antidepressant-like effects of acute estradiol administration in female ovariectomized (OVX) mice and the possible role of nitric oxide (NO)/cyclic GMP (cGMP) pathway. To this end, bilateral ovariectomy was performed in female mice and different doses of estradiol were injected alone or in combination with non-specific NO synthase (NOS) inhibitor (L-NAME), selective neural NOS (nNOS) inhibitor (7-NI), an NO precursor (L-arginine) or selective phosphodiesterase type 5 inhibitor (sildenafil). The duration of immobility was recorded in the forced swimming test (FST) to assess the depressive behavior. Moreover, hippocampal levels of NO were determined in select groups. 10 days following the procedure, OVX mice showed significantly prolonged immobility time in comparison with the sham group. Estradiol (3, 10, and 30 µg/kg, s.c.), when injected 1 h prior to FST, exerted antidepressant-like effects in OVX mice. Both L-NAME (30 mg/kg, i.p.), and 7-NI (50 mg/kg, i.p.) significantly reduced the immobility times of OVX mice. Administration of a sub-effective dose of L-NAME (10mg/kg), 15 min after a sub-effective dose of estradiol (1 µg/kg, s.c.) had a robust antidepressant-like effect in OVX mice. Also a sub-effective dose of 7-NI (25 mg/kg), 30 min after a sub-effective dose of estradiol (1 µg/kg, s.c.) showed antidepressant-like effect in OVX mice. Both the NO precursor L-arginine (750 mg/kg, i.p.) and the cGMP-specific phosphodiesterase type 5 inhibitor sildenafil (5 mg/kg, i.p.), 30 min before estradiol treatment, prevented the antidepressant-like effect of a potent dose of estradiol (10 µg/kg, s.c.) in OVX mice. The present findings suggest that suppression of the NO synthase/NO/cGMP pathway may be involved in the antidepressant-like effects of estradiol in OVX mice.

Targeting the gut to prevent sepsis from a cutaneous burn.

Severe burn injury induces gut barrier dysfunction and subsequently a profound systemic inflammatory response. In the present study, we examined the role of the small intestinal brush border enzyme, intestinal alkaline phosphatase (IAP), in preserving gut barrier function and preventing systemic inflammation after burn wound infection in mice. Mice were subjected to a 30% total body surface area dorsal burn with or without intradermal injection of Pseudomonas aeruginosa. Mice were gavaged with 2000 units of IAP or vehicle at 3 and 12 hours after the insult. We found that both endogenously produced and exogenously supplemented IAP significantly reduced gut barrier damage, decreased bacterial translocation to the systemic organs, attenuated systemic inflammation, and improved survival in this burn wound infection model. IAP attenuated liver inflammation and reduced the proinflammatory characteristics of portal serum. Furthermore, we found that intestinal luminal contents of burn wound-infected mice negatively impacted the intestinal epithelial integrity compared with luminal contents of control mice and that IAP supplementation preserved monolayer integrity. These results indicate that oral IAP therapy may represent an approach to preserving gut barrier function, blocking proinflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival after severe burn injuries.

Bipolar hemiarthroplasty versus total hip arthroplasty in allograft-prosthesis composite reconstruction of the proximal femur following primary bone tumour resection.

AIMS: The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods. METHODS: In a retrospective study, 57 patients who underwent APC reconstruction of proximal femur following the primary tumour resection, either using BHA (29) or THA (28), were included. Functional outcome was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and Harris Hip Score (HHS). Postoperative complications of the two techniques were also compared. RESULTS: The mean follow-up of the patients was 8.3 years (standard deviation (SD) 5.5) in the BHA and 6.9 years (SD 4.7) in the THA group. The mean HHS was 65 (SD 16.6) in the BHA group and 88 (SD 11.9) in the THA group (p = 0.036). The mean MSTS score of the patients was 73.3% (SD 16.1%) in the BHA and 86.7% (SD 12.2%) in the THA group (p = 0.041). Limping was recorded in 19 patients (65.5%) of the BHA group and five patients (17.8%) of the THA group (p < 0.001). Dislocation occurred in three patients (10.3%) of the BHA group and two patients (7.1%) of the THA group. CONCLUSION: While the dislocation rate was not higher in THA than with BHA, the functional outcome was significantly superior. Based on our results, we recommend THA in APC reconstruction of the proximal femur. Cite this article: Bone Joint J 2020;102-B(4):524-529.

Anesthetic Management of a Patient with a Giant Pericardial Cyst Compressing the Right Atrium.

Pericardial cysts are rare mediastinal cysts composed of a single fluid-filled mesothelial layer and can be congenital in origin or develop secondary to pericarditis, trauma, or infection. Although most pericardial cysts are asymptomatic, life-threatening complications can occasionally occur. We report on a 57-year-old man with an asymptomatic 9 cm pericardial cyst that was incidentally found as an abnormal cardiac silhouette on routine chest radiography. Further imaging confirmed the presence of a pericardial cyst that was compressing the right atrium. The patient underwent successful video-assisted thoracoscopic removal of the pericardial cyst under general anesthesia. The patient's postoperative course was uneventful and he was discharged on postoperative day 1 in a stable condition. To our knowledge, this is the first report regarding the anesthetic management of a patient with a giant pericardial cyst undergoing thoracic surgery. Knowledge regarding the perioperative challenges associated with the removal of pericardial cysts can prevent complications and improve patient outcomes.

Application of 99mTc-UBI 29-41 scintigraphy in knee periprosthetic infection diagnosis.

AIM: In recent years, the use of total knee arthroplasty (TKA) is considered a safe and cost-effective orthopedic procedure for alleviating the chronic pain and treatment of progressive osteoarthritis. This procedure may have some complications including periprosthetic infection as the most serious and aseptic loosening as the most common one. Differentiating between these entities is important because each has a different therapeutic approach. This study was conducted to investigate the ability of 99mTC-UBI scan to distinguish septic from aseptic loosening in a painful knee prosthesis. METHODS: 34 patients with painful knee prostheses were included. The 99mTC-UBI scan was done immediately after IV administration of 99mTC-UBI in early dynamic and 30-minute static images. Time-activity curve (TAC) was drawn for all patients and target to non-target ratio (T/NT) was calculated on 30-minute images. The final diagnosis was confirmed by surgical findings, microbiologic culture results or active clinical follow up. RESULTS: Using TAC analysis, 24 99mTC-UBI scans were considered negative and 10 positive for an infectious process. Sensitivity, specificity, negative and positive predictive values were 56 %, 80 %, 83 %, and 50 %, respectively. T/NT ratio analysis on 30-minute static images demonstrated 9 positive and 25 negative patterns, with a cut off value of 1.83 for the T/NT ratio. The sensitivity, specificity, negative and positive predictive values, and accuracy of this test modality were all 100 %. CONCLUSIONS: Our findings show 99mTc-UBI scan is an excellent clinical diagnostic test for differentiating septic from aseptic loosening of the knee prostheses with perfect sensitivity and specificity. Highly accurate results were obtained only 30 minutes after injection.

Targeting bacterial quorum sensing shows promise in improving intestinal barrier function following burn­site infection.

Burn­site infections, commonly due to Pseudomonas aeruginosa, have been associated with deranged intestinal integrity, allowing bacteria and their products to translocate from the gut to the circulatory system. The P. aeruginosa quorum sensing (QS) transcription factor MvfR (PqsR) controls the expression of numerous virulence factors, and the synthesis of several toxic products. However, the role of QS in intestinal integrity alterations, to the best of our knowledge, has not been previously investigated. Using a proven anti­MvfR, anti­virulence agent, the in vivo results of the present study revealed that inhibition of MvfR function significantly decreased Fluorescein Isothiocyanate­Dextran (FITC­Dextran) flow from the intestine to the systemic circulation, diminished bacterial translocation from the intestine to mesenteric lymph nodes (MLNs), and improved tight junction integrity in thermally injured and infected mice. In addition, the MvfR antagonist administration alleviates the intestinal inflammation, as demonstrated by reduced ileal TNF­α and fecal lipocalin­2 concentrations. In addition, it is associated with lower levels of circulating endotoxin and decreased P. aeruginosa dissemination from the burn wound to the ileum. Collectively, these results hold great promise that the inhibition of this QS system mitigates gut hyperpermeability by attenuating the derangement of morphological and immune aspects of the intestinal barrier, suggesting that MvfR function is crucial in the deterioration of intestinal integrity following P. aeruginosa burn­site infection. Therefore, an anti­virulence approach targeting MvfR, could potentially offer a novel therapeutic approach against multi­drug resistant P. aeruginosa infections following thermal injuries. Since this approach is targeting virulence pathways that are non­essential for growth or viability, our strategy is hypothesized to minimize the development of bacterial resistance, and preserve the beneficial enteric microbes, while improving intestinal integrity that is deranged as a result of burn and infection.

Ultrasound as a diagnostic tool in the investigation of patients with carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is reveled to be the most common peripheral nerve entrapment syndrome, estimating for 90% of all compressive. The diagnosis of CTS is based on the use of clinical criteria and imaging technique tests such as ultrasonography (US) and magnetic resonance imaging (MRI). US is a time-saving method in the diagnosis of CTS, which induces less discomfort to the patient and may be a more cost-effective approach to confirm clinical suspicion of this syndrome .The current study was aimed to evaluate the value of US and physical examinations in the diagnosis of CTS. This cross-sectional and cross-sectional prospective case study was conducted to evaluate the usefulness of wrist ultrasonography in diagnosing CTS. Twenty one patients (21 wrists) were invited to participate in the study along with an age- and sex-matched group of participant controls. Physical examination included Phalen, Tinel, Durkan, Tourniquet test. Anteroposterior and mediolateral dimension of carpal tunnel, and the median nerve area at the tunnel were also measured. All the patients underwent the open surgical release of the flexor retinaculum. There was a significant statistical relationship (p=0.05) between anteroposterior diameter of the carpal tunnel and clinical and electro physiologic nerve involvement. Furthermore, some qualitative findings was achieved such as median nerve splitting, hypo echogenicity of the involved nerve, thickening of flexor retinaculum and disappearance of median nerve areas (especially mediolateral direction). In conclusion, ultrasonographic examination of the wrists in the patients with suspected clinical symptoms can improve the diagnostic ability of CTS, especially by improving technology and experience. US can be applied for the median nerve area (MNA) measurement as a first line technique in patients with CTS.

Anaesthetic management of a patient with a unique combination of anti-N-methyl-D-aspartate receptor encephalitis and stiff-person syndrome.

Stiff-person syndrome (SPS) and anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis are rare paraneoplastic syndromes caused by antibodies that target the central nervous system. Here, we describe a 26-year-old woman who presented with psychosis, amnesia, rigidity and fever. After extensive diagnostic and laboratory workup, she was diagnosed with an ovarian teratoma which was causing the symptoms of anti-NMDAR encephalitis and SPS. The patient was successfully treated with laparoscopic removal of the ovarian tumour under general anaesthesia. She was placed on immunosuppressant medications preoperatively and postoperatively, and her symptoms gradually resolved. Although there are case reports regarding the anaesthetic management of SPS and anti-NMDAR encephalitis, our study is the first report of a patient afflicted with both conditions.