Risk factors and neonatal outcomes of pulmonary air leak syndrome in extremely preterm infants: A nationwide descriptive cohort study.

Most extremely preterm infants (EPIs), who were born before 28 weeks of gestation, with pulmonary air leak syndrome (ALS) are symptomatic, often severe, and require drainage. EPIs with severe air leak syndrome (sALS) that require tube drainage or needle aspiration are at high risk of morbidities and mortality. This study aimed to investigate perinatal characteristics, morbidities, and mortality in EPIs with sALS, and to estimate the risk of mortality according to gestational age (GA). A prospective cohort study conducted from 2013 to 2020 compiled the Korean Neonatal Network database to evaluate the incidence, perinatal characteristics, and outcomes of sALS in EPIs born before 28 weeks of gestation. Among 5666 EPIs, the incidence of sALS was 9.4% and inversely related to GA. From this cohort, we compared 532 EPIs with sALS to 1064 EPIs without sALS as controls, matching the subjects by GA and birth weight. Preterm premature rupture of membranes, oligohydramnios, resuscitation after birth, low Apgar scores, repeated surfactant administration, persistent pulmonary hypertension of the newborn, and pulmonary hemorrhage were associated with the development of pneumothorax. The sALS group required a higher fraction of inspired oxygen and more invasive respiratory support at both 28 days of life and 36 weeks of postmenstrual age. The sALS group had a higher incidence of bronchopulmonary dysplasia and major brain injury. The mortality rate was higher in the sALS group than in the control group (55.3% vs 32.5%, P < .001), and the ALS group had a 1.7 times risk of mortality than the control group. More attention should be paid to sALS in EPIs because the frequency of sALS increased as GA decreased, and the risk of mortality was more significant at lower GA.

Opioid sparing effect and safety of nefopam in patient controlled analgesia after laparotomy: A randomized, double blind study.

OBJECTIVES: A double-blind randomised study to evaluate the opioid sparing effect and safety of nefopam when administered via intravenous patient controlled analgesia (PCA) with fentanyl. METHODS: Patients planned for elective open laparotomy, were randomly assigned to receive into fentanyl 25 µg/ml (SF group) or nefopam 2.4 mg/ml plus fentanyl 25 µg/ml (NF group). Patients were assessed before surgery and for 24 h postoperatively. RESULTS: Total PCA fentanyl consumption was significantly lower in the NF group (n = 35) than the SF group (n = 36). Pain scores were significantly lower and patients' satisfaction with treatment significantly better in the NF group than the SF group. Dry mouth and dizziness were significantly more frequent in the NF group than the SF group. There were no other statistically significant between-group differences in the incidence of adverse events. CONCLUSIONS: Intravenous PCA using nefopam + fentanyl following laparotomy has an opioid sparing effect and is associated with a low incidence of some of the typical opioid related adverse events. TRIAL REGISTRY: Clinicaltrials.gov Registration No: NCT02596269.

Is Whole Exome Sequencing Clinically Practical in the Management of Pediatric Crohn's Disease?

BACKGROUND/AIMS: The aim of this study was to identify the profile of rare variants associated with Crohn's disease (CD) using whole exome sequencing (WES) analysis of Korean children with CD and to evaluate whether genetic profiles could provide information during medical decision making. METHODS: DNA samples from 18 control individuals and 22 patients with infantile, very-early and early onset CD of severe phenotype were used for WES. Genes were filtered using panels of inflammatory bowel disease (IBD)-associated genes and genes of primary immunodeficiency (PID) and monogenic IBD. RESULTS: Eighty-one IBD-associated variants and 35 variants in PID genes were revealed by WES. The most frequently occurring variants were carried by nine (41%) and four (18.2%) CD probands and were ATG16L2 (rs11235604) and IL17REL (rs142430606), respectively. Twenty-four IBD-associated variants and 10 PID variants were predicted to be deleterious and were identified in the heterozygous state. However, their functions were unknown with the exception of a novel p.Q111X variant in XIAP (X chromosome) of a male proband. CONCLUSIONS: The presence of many rare variants of unknown significance limits the clinical applicability of WES for individual CD patients. However, WES in children may be beneficial for distinguishing CD secondary to PID.

Epiduroscopic Removal of a Lumbar Facet Joint Cyst.

Facet joint synovial cysts are usually associated with osteoarthritis of the adjacent facet joint and/or spondylolisthesis. In between the conservative and operative ends of the treatment spectrum lie minimally invasive techniques such as cyst rupture using epiduroscopy. In this report, we describe an 82-year-old male patient presenting with low back pain radiating to his lower left extremity and associated paresthesia. Magnetic resonance imaging of the lumbar spine revealed a synovial cyst at left L4/5 facet joint. Using epiduroscopy, the cyst was mechanically ruptured by popping it with the tip of the scope. The patient remained symptom-free at his successive visits until 12 months after the procedure, and was opened for desired follow up.

Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus.

BACKGROUND: A high incidence of diabetes mellitus has been reported among patients diagnosed with lumbar degenerative spinal diseases. Although epidural steroid injections are known to increase the postprocedure blood glucose level, it has not been investigated whether a lower steroid dose can reduce blood glucose excursions and still be effective in controlling patients' subjective pain. OBJECTIVE: We compared the effects of 2 common doses of triamcinolone administered via epidural steroid injections on blood glucose levels and pain control in patients with diabetes mellitus to determine an adequate epidural steroid dose. STUDY DESIGN: A prospective observational study. METHODS: One hundred patients with diabetes mellitus were enrolled. They received lumbar transforaminal, lumbar interlaminar, or caudal epidural triamcinolone for radiculopathy, spinal stenosis, or failed back surgery syndrome. After the type of procedure was clinically determined, the doses of triamcinolone given were randomly chosen, either 40 mg (Group 40) or 20 mg (Group 20). The patients were asked to measure their finger stick blood glucose level twice daily (fasting and postprandial) for 3 days before the injection, on the day of the injection, for 7 days after the injection, and at 14 days after the injection. They also kept a blood glucose diary. Employment status and clinical outcome were evaluated at 8 weeks after the procedure. RESULTS: There were significant increases in fasting blood glucose (FBG) level on postprocedure day (PPD) #1 to PPD #3 in Group 40, but on PPD #1 in Group 20. Moreover, there was a significant difference in FBG between groups on PPD #1 and PPD #2 (FBG on PPD #1: 179 [51]) mg/dL in Group 40 versus 146 [50] mg/dL in Group 20, P < 0.001]. Postprandial blood glucose (PBG) level was significantly elevated in both groups from PPD #0 to PPD #3. Notably, the increase in PBG was significantly greater in Group 40 than Group 20 on PPD #0 and #1 (PBG on PPD #0: 288 [57] mg/dL versus 242 [94] mg/dL in Groups 40 and 20, respectively, P = 0.004). The numeric rating scale for pain reported by the patients decreased for 2 weeks after treatment with no difference between groups. Employment status and clinical outcome was not different between groups. LIMITATIONS: The patients who chose to participate in this study may be a cohort of well-controlled patients with diabetes mellitus. The type of procedure performed was determined by a clinical decision and not randomized. The different routes of administration and diagnosis of failed back surgery syndrome can result in different levels of systemic absorption, thereby influencing the degree and duration of hyperglycemia. In patients with FBSS, the epidural space may be destructed by surgery and adhesive changes in epidural space could be extensive. Therefore, we thought that the absorption of epidural space in these patients would be incomplete or slow compared with those without FBSS. CONCLUSION: Epidural steroid injections were associated with statistically significant elevations in PBG in patients with diabetes for up to 4 days after the procedure. The higher dose of triamcinolone increased FBG and PBG greater than a lower dose did without affecting pain control, employment status, or clinical outcome. Thus, with respect to glucose and pain control, 20 mg of triamcinolone appears to be recommended rather than 40 mg in patients with diabetes. Clinical Trials registration : NCT01435707.

The effect of anesthetic techniques on neutrophil-to-lymphocyte ratio after laparoscopy-assisted vaginal hysterectomy.

BACKGROUND: Surgical stress can induce postoperative systemic leukocytic alterations, including leukocytosis, neutrophilia, or lymphopenia. The present study investigated whether the anesthetic technique could affect the leukocytic alterations, including neutrophil-to-lymphocyte (N/L) ratio, after gynecologic laparoscopy. METHODS: Forty patients scheduled for laparoscopy-assisted vaginal hysterectomy were randomly assigned into two groups: PR group, which received total intravenous anesthesia with propofol and remifentanil, and S group, which received inhalational anesthesia with sevoflurane. Differential counts of leukocytes with N/L ratio of peripheral blood were obtained just before induction (T1), at the end of surgery (T2), 2 hours after surgery (T3), and 24 hours (T4) after surgery. RESULTS: Significant increase in total leukocytic count, neutrophil count, and N/L ratio, and decrease in lymphocytic count were observed at all time points after surgery in both groups. N/L ratio was significantly lower in group PR compared with group S at T3. The increase of N/L ratio in contrast to the value at T1 was significantly lower at T2 and T3 in group PR compared with that of group S. CONCLUSION: Total intravenous anesthesia with propofol and remifentanil resulted in transient but salient leukocytic alterations in the peripheral blood in terms of N/L ratio compared with inhalational anesthesia with sevoflurane in laparoscopy-assisted vaginal hysterectomy.

Early changes in SOFA score as a prognostic factor in pediatric oncology patients requiring mechanical ventilatory support.

PURPOSE: To evaluate whether changes in outcome prediction scores during the first 72 hours after admission to a pediatric intensive care unit (PICU) are more predictive of outcome than single assessments at admission in pediatric oncology patients requiring mechanical ventilatory support for more than 3 days. PATIENTS AND METHODS: The medical records of 54 consecutive pediatric oncology patients requiring mechanical ventilation over 72 hours in the PICU of the Asan Medical Center, Seoul, Korea, between January 2006 and December 2008, were retrospectively reviewed. RESULTS: Although both initial Sequential Organ Failure Assessment (SOFA) score and change in SOFA score (Δ-SOFA) correlated well with mortality, Δ-SOFA score showed a significantly stronger correlation (P<0.001) and a larger area under the receiver operating characteristic curve than did initial SOFA score. Patients with positive and negative Δ-SOFA scores showed statistically significant differences in mortality (18.5% vs. 88.2%, P<0.001). In addition, early changes in respiratory parameters, such as PaO2/FiO2 (P/F) ratio, oxygenation index (OI), and ventilation index (VI), evaluated serially during the first 3 days, also correlated with mortality. Patients showing improvement in these respiratory parameters displayed significantly lower mortality than did patients with worsening of these parameters (P<0.01). CONCLUSIONS: Serial evaluation of SOFA score during the first few days after PICU admission was a good predictor of prognosis in pediatric oncology patients mechanically ventilated over 3 days. Independent of initial SOFA score, Δ-SOFA score during the first 72 hours closely correlated with outcome. Early changes in respiratory parameters, such as P/F ratio, OI, and VI, may also provide valuable prognostic information in such patients.

Endotracheal intubation in a patient with an almost complete obstruction of the glottis due to a movable supraglottic tumor: A case report.

Intubation in patients with an obstruction of the glottis due to a large mass may present great challenge to most anesthesiologists. If tracheostomy is not available, flexible fiberscope guided endotracheal intubation is now the part of the standard management in these cases, but difficulty in advancing the tracheal tube over the fiberscope and into the trachea may be encountered. In this case, a 60-year-old male with a huge supraglottic mass was given general anesthesia for laryngomicroscopic surgery and debulking of the mass lesion. We planned an awake flexible fiberoptic intubation but failed to railroad the tube over the fiberscope even after successfully placing the scope inside the trachea. During various attempts to pass the tracheal entrance, the patient coughed and the tube slid into the trachea as mass moved aside and we could successfully secure the airway.