Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial.

OBJECTIVES: Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery. DESIGN: This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022). SETTINGS: This study was conducted in a single institution, which is an academic university hospital. PARTICIPANTS: Eighty-six elective cardiac surgical patients with median sternotomy were recruited. INTERVENTIONS: Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry. CONCLUSIONS: Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

Preemptive deep parasternal intercostal plane block for perioperative analgesia in coronary artery bypass grafting with sternotomy: a randomized, observer-blind, controlled study.

OBJECTIVE: The precise characteristics of deep parasternal intercostal plane block (DPIP), which is useful for providing analgesia during open heart surgery, have not yet been thoroughly elucidated. In this study, we aimed to establish the efficacy, define the cutaneous sensory block area, and determine the duration of preemptive DPIP block at the T3-4 or T4-5 intercostal spaces in patients undergoing coronary artery bypass grafting (CABG) via sternotomy. DESIGN: A prospective, single-blind, randomized controlled trial. SETTING: Patients were randomly divided into three cohorts, each containing thirty patients. PARTICIPANTS: Ninety patients who underwent elective CABG via sternotomy were included in this study. INTERVENTIONS: The T3-4 and T4-5 groups received a preoperative single-shot DPIP block at the respective intercostal spaces. The principal objective of the study was to ascertain the optimal dosage of sufentanil administered during surgical procedures involving either a DPIP block or its absence, and to conduct a comparative analysis thereof across distinct injection sites, specifically T3-4 and T4-5. Secondary factors considered were the dosage of postoperative analgesics, the extent of sensory block on the skin, pain levels after extubation, time of recovery from anesthesia (time to extubation), duration of the block, and the occurrence of nausea and vomiting. MEASUREMENTS & MAIN RESULTS: Preemptive DPIP block significantly reduced intraoperative sufentanil requirement compared to the control group (T3-4:0.38 ± 0.1, T4-5:0.32 ± 0.10, vs. Control:0.88 ± 0.3 µg/kg/h, p < 0.001). It also resulted in decreased analgesic consumption and numeric rating scale scores on the day of surgery (p < 0.01 compared to the control group). The DPIP block provided accurate anesthetic coverage of the dermatomes in the sternal region and reduced the time to extubation and postoperative nausea. However, the injection point (either via the T3-4 intercostal or the T4-5 intercostal) did not affect the efficacy. Preoperative DPIP block failed to provide adequate analgesia beyond 24 h post-surgery. CONCLUSION: Preemptive bilateral DPIP block provided effective analgesia in patients undergoing CABG during surgery and in the early postoperative period. The analgesic effects of the DPIP block in the T3-4 and T4-5 intercostal spaces were comparable.

Thin-section multiplanar reformats from multidetector-row CT data: utility for assessment of regional tumor extent in non-small cell lung cancer.

PURPOSE: To determine the clinical utility of thin-section multiplanar reformats (MPRs) from multidetector-row CT (MDCT) data sets for assessing the extent of regional tumors in non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS: Sixty consecutive NSCLC patients, who were considered candidates for surgical treatment, underwent contrast-enhanced MDCT examinations, surgical resection and pathological examinations. All MDCT examinations were performed with a 4-detector row computed tomography (CT). From each raw CT data set, 5mm section thickness CT images (routine CT), 1.25 mm section thickness CT images (thin-section CT) and 1.25 mm section thickness sagittal (thin-section sagittal MPR) and coronal images (thin-section coronal MPR) were reconstructed. A 4-point visual score was used to assess mediastinal, interlobar and chest wall invasions on each image set. For assessment of utility in routine clinical practice, mean reading times for each image set were compared by means of Fisher's protected least significant difference (PLSD) test. A receiver operator characteristic (ROC) analysis was performed to determine the diagnostic capability of each of the image data sets. Finally, sensitivity, specificity and accuracy of the reconstructed images were compared by McNemar test. RESULTS: Mean reading times for thin-section sagittal and coronal MPRs were significantly shorter than those for routine CT and thin-section CT (p<0.05). Areas under the curve (Azs) showing interlobar invasion on thin-section sagittal and coronal MPRs were significantly larger than that on routine CT (p=0.03), and the Az on thin-section sagittal MPR was also significantly larger than that on routine CT (p=0.02). Accuracy of chest wall invasion by thin-section sagittal MPR was significantly higher than that by routine CT (p=0.04). CONCLUSION: Thin-section multiplanar reformats from multidetector-row CT data sets are useful for assessing the extent of regional tumors in non-small cell lung cancer patients.

Use of oral cholecystography agents in the treatment of hyperthyroidism of subacute thyroiditis.

AIM: In this study, we describe our experience in treating subacute thyroiditis patients with 2 OCAs (sodium ipodate and sodium iopanoate). METHODS: We studied 10 consecutive patients with subacute thyroiditis treated with 1 of the 2 oral cholecystography agents (OCAs). RESULTS: Hyperthyroidism was controlled and symptoms improved markedly in each case without any evidence of subsequent relapse of thyroiditis after withdrawal of OCAs. Three of the 10 patients had been treated previously with corticosteroids and had demonstrated relapse of thyroiditis and hyperthyroidism after tapering or withdrawal of steroids. We observed no side effects of treatment with OCAs. CONCLUSION: Our data suggest that OCAs are effective and safe agents for management of hyperthyroidism in patients with subacute thyroiditis, even when they have relapsed after treatment with corticosteroids.

Recombinant lysine:N(6)-hydroxylase: effect of cysteine-->alanine replacements on structural integrity and catalytic competence.

Recombinant lysine:N(6)-hydroxylase, rIucD, catalyzes the hydroxylation of L-lysine to its N(6)-hydroxy derivative, with NADPH and FAD serving as cofactors in the reaction. The five cysteine residues present in rIucD can be replaced, individually or in combination, with alanine without effecting a major change in the thermal stability, the affinity for L-lysine and FAD, as well as the k(cat) for mono-oxygenase activity of the protein. However, when the susceptibility to modification by either 5,5'-dithiobis(2-nitrobenzoic acid) (DTNB) or 2,6-dichlorophenol indophenol (DPIP) serves as the criterion for monitoring conformational change(s) in rIucD and its muteins, Cys146-->Ala and Cys166-->Ala substitutions are found to induce an enhancement in the reactivity of one of the protein's remaining cysteine residues with concomitant diminution of mono-oxygenase function. In addition, the systematic study of cysteine-->alanine replacement has led to the identification of rIucD's Cys166 as the exposed residue which is detectable during the reaction of the protein with DTNB but not with iodoacetate. Substitution of Cys51 of rIucD with alanine results in an increase in mono-oxygenase activity (approx. 2-fold). Such replacement, unlike those of other cysteine residues, also enables the covalent DPIP conjugate of the protein to accommodate FAD in its catalytic function. A possible role of rIucD's Cys51 in the modulation of its mono-oxygenase function is discussed.

Incorporation of an (125)I-labeled hexa-iodinated diglyceride analog into low-density lipoprotein and high specific uptake by cells of cervical carcinoma cell lines.

The feasibility of using low-density lipoprotein (LDL) to deliver cytotoxic drugs to tumor cells has been explored since the 1980s, when cells of a number of cancer cell lines were found to have higher LDL receptor activity than normal cells. Such differential uptake between tumor and normal cells may provide a unique opportunity to use LDL as a tumor-specific carrier of radiopharmaceuticals for the clinical management of cancer. In this study, an (125)I-labeled hexa-iodinated diglyceride analog, 1, 3-dihydroxypropan-2-one 1,3-diiopanoate (DPIP), was synthesized and incorporated into LDL using a fusion technique. It was found that approximately 500 [(125)I] DPIP molecules were incorporated into each LDL particle. Cells of three human cervical tumor cell lines, HeLa, SiHa and C-33A, were used to examine the cellular uptake of the [(125)I]DPIP-LDL conjugate. It was shown that the [(125)I]DPIP-LDL conjugate was specifically bound to and taken up by cervical tumor cells through an LDL receptor-mediated endocytosis pathway. The results suggest that LDL may be a selective carrier for delivering hydrophobic radiopharmaceuticals to cancer cells and particularly for the diagnosis of cervical tumors.

Diagnostic and therapeutic potential of poly(benzyl L-glutamate).

Poly(benzyl L-glutamate) (PBLG) microcapsules, prepared by a solvent evaporation technique for intravenous injection, are evaluated for their potential use in diagnostic computed tomographic enhancement of liver images. The smaller microcapsules, < 3 microns, loaded with a radiopaque contrast material, ethyl iopanoate (IOPAE), produced prolonged opacification of the liver when delivered intravenously. In vivo tissue distribution studies of PBLG-131I-IOPAE (5 microCi/rat, iv) showed that liver had the highest uptake (percent of injected dose/g of tissue) among other organs 24 h postinjection. An in vitro estrogen receptor assay in pig uteri indicated that PBLG conjugated with estrone did not interfere with estrogen receptor affinity, suggesting the estrogen therapy potential of PBLG-estrone.

Esters of iopanoic acid as liver-specific CT contrast agents: biodistribution and CT evaluation.

The synthesis and preliminary biodistribution data for a series of sterol-like esters of iopanoic acid having potential value as liver-specific CT contrast agents are described. Structural modification of the sterol portion of the iopanoate ester afforded a group of compounds that displayed tissue specificity similar to cholesteryl iopanoate, the prototype ester of this series, but were rapidly cleared from the target tissues after hydrolysis. From the biodistribution data, the most promising of these agents, pregnenolone iopanoate (PI), was evaluated by CT in rabbits receiving a radiologic dose equivalent to 30 mg I/kg. The hepatic parenchyma was enhanced within 2 h of infusion to a maximal level of 31 HU above precontrast values. Hepatic CT attenuation returned to normal within 24 h. However, CT performed after PI infusion into Vx2 tumor-bearing rabbits failed to provide superior images compared with those acquired following bolus administration of urographic contrast.

Potential tumor- or organ-imaging agents. 23. Sterol esters of iopanoic acid.

A series of sterol esters of iopanoic acid was synthesized and evaluated for their potential to selectively localize in liver and steroid-secreting tissues for possible application in either computed tomography or nuclear medicine imaging. Unlike free iopanoic acid (1), which was rapidly cleared following intravenous administration to rats, cholesteryl iopanoate (2) was found to accumulate in liver, adrenal cortex, and ovary. At 24 h, the ovary was found to contain the highest concentration of 2. The ability of 2 to accumulate in the above tissues was attributed to its resistance to hydrolysis. Pregnenolone iopanoate (3) and dehydroepiandrosterone iopanoate (4), on the other hand, were shown to reach unusually high concentrations in the adrenal cortex within 0.5 h of administration but declined to much lower levels by 24 h. Lipid extraction of tissues showed 3 and 4 to be susceptible to in vivo hydrolysis, which undoubtedly was a major factor in their clearance from adrenal tissue.