Comparison of laryngeal mask airway CTrach™ and Airtraq® videolaryngoscopes as conduits for endotracheal intubation in patients with simulated limitation of cervical spine movements by manual in-line stabilization.

BACKGROUND AND AIMS: Laryngeal mask airway (LMA) CTrach™ and Airtraq® videolaryngoscopes are useful for endotracheal intubation in patients with limited cervical spine movements and other predicted difficult airways. We aimed to compare LMA CTrach™ and Airtraq® videolaryngoscopes as conduits for endotracheal intubation in patients with simulated limitation of cervical spine movements by manual in-line stabilization (MILS). MATERIAL AND METHODS: This was a prospective, randomized study including 50 patients undergoing elective surgeries under general anesthesia. Patients were assigned to undergo intubation using Airtraq® (n = 25) or LMA CTrach™ (n = 25) by an experienced anesthesiologist, while MILS was provided. Laryngoscopy and intubation were compared in terms of time taken to obtain optimal laryngeal view, successful intubation, total time, percentage of glottis opening (POGO) score, maneuvers required for optimal laryngeal view and alignment of endotracheal tube, and number of attempts and complications. An integrated score was calculated to classify the attempt as good, restricted, or poor. RESULTS: Time taken to obtain optimal laryngeal view, successful intubation, and total time in both groups were comparable. POGO score >50% was seen in 25 and 21 patients in Groups A and C. Seventy-six percent and ninety-six percent in Groups A and C, respectively, had a good integrated score; 6% and 1% had restricted score; none had a poor score; and the difference between them was statistically significant (P = 0.042). CONCLUSIONS: LMA CTrach™ and Airtraq® are similar with respect to time taken for obtaining optimal laryngeal view, successful intubation, and total time when used for intubation in patients with simulated limitation of cervical spine movements.

Effect of air, anesthetic gas mixture, saline, or 2% lignocaine used for tracheal tube cuff inflation on coughing and laryngotracheal morbidity after tracheal extubation.

BACKGROUND AND AIMS: Coughing and sore throat postoperatively are common clinical problems during general anesthesia which can be avoided by various methods including topicalization of airway with local anesthetics, endotracheal tube cuff (ETT) inflation with local anesthetics, use of intravenous drugs such as dexamethasone, maintaining ETT cuff pressure, intubation by an experienced anethesiologist, etc. The aims of the study were to compare postextubation coughing response, mean number of cuff deflations required intraoperatively, and postoperative airway morbidity in terms of sore throat (2 h and 18-24 h), hoarseness of voice, and dysphagia following inflation of ETT cuff with air, anesthetic gas mixture, saline, and 2% lignocaine during general anesthesia. MATERIAL AND METHODS: One hundred and four patients were randomized into 1 of 4 groups depending on whether air, anesthetic gas mixture, saline, or 2% lignocaine was used to inflate the cuff of ETT using computer-generated randomization table. RESULTS: There was no significant difference in the postextubation cough response among the four groups. The mean number of times the ETT cuff was deflated was significantly in favor of liquid media comapred to gaseous media (P < 0.001). The incidence of sore throat at 2 h and at 18-24 h, hoarseness of voice, and dysphagia were comparable in all groups. CONCLUSION: ETT cuff inflation with air, anesthetic gas mixture, 2% lignocaine, and saline are comparable in terms of incidence of postextubation cough and postoperative airway morbidity symptoms such as sore throat, hoarseness of voice, and dysphagia.

Evaluation of effect of entropy monitoring on isoflurane consumption and recovery from anesthesia.

BACKGROUND AND AIMS: Entropy monitoring entails measurement of the effect of anesthetic on its target organ rather than merely the concentration of anesthetic in the brain (indicated by alveolar concentration based on which minimum alveolar concentration [MAC] is displayed). We proposed this prospective randomised study to evaluate the effect of entropy monitoring on isoflurane consumption and anesthesia recovery period. MATERIAL AND METHODS: Sixty patients undergoing total abdominal hysterectomy under general anesthesia using an endotracheal tube were enrolled in either clinical practice (CP) or entropy (E) group. In group CP, isoflurane was titrated as per clinical parameters and MAC values, while in Group E, it was titrated to entropy values between 40 and 60. Data including demographics, vital parameters, alveolar isoflurane concentration, MAC values, entropy values, and recovery profile were recorded in both groups. RESULTS: Demographic data and duration of surgery were comparable. Time to eye opening on command and time to extubation (mean ± standard deviation) were significantly shorter, in Group E (6.6 ± 3.66 and 7.27 ± 4.059 min) as compared to Group CP (9.77 ± 5.88 and 11.63 ± 6.90 min), respectively. Mean isoflurane consumption (ml/h) was 10.81 ± 2.08 in Group E and 11.45 ± 2.24 in Group CP and was not significantly different between the groups. Time to readiness to recovery room discharge and postanesthesia recovery scores were also same in both groups. CONCLUSION: Use of entropy monitoring does not change the amount of isoflurane consumed during maintenance of anesthesia or result in clinically significant faster recovery.

Comparison of polyvinyl chloride, curved reinforced, and straight reinforced endotracheal tubes for tracheal intubation through Airtraq™ laryngoscope in anesthetized patients.

BACKGROUND AND AIMS: The Airtraq™ video laryngoscope facilitates tracheal intubations in patients with difficult airway or cervical spine immobilization. However, curved reinforced tracheal tube and straight reinforced tracheal tubes are useful where neck of the patient is likely to be moved or flexed or if patient is in prone position, wherein nonreinforced endotracheal tube (ETT) might get kinked and/or compressed. We compared intubation success rate of curved and straight reinforced tracheal tubes with polyvinyl chloride (PVC) tracheal tube using Airtaq™ laryngoscope in paralyzed and anesthetized patients. MATERIAL AND METHODS: Totally, 120 patients underwent random allocation to one of the three groups using computer-generated randomization table. Patients were intubated with appropriate size and type of ETT using Airtraq™ after obtaining optimal glottis view. Experienced anesthesiologist performed endotracheal intubation and unblinded observer noted down success and ease of intubation. RESULTS: Patients intubated with PVC tube (100%) had higher rates of successful intubation and shorter intubation time (4 s), in comparison to intubation with curved reinforced (92.5%) and straight reinforced tubes (SRTs) (85%) using Airtraq™ laryngoscope (AL). However, there was no statistical difference in the incidence of airway trauma among all the three groups. CONCLUSIONS: PVC tracheal tube is significantly superior to both curved and SRTs for intubation using AL.

Glutathione species and metabolomic prints in subjects with liver disease as biological markers for the detection of hepatocellular carcinoma.

BACKGROUND: The incidence of liver disease is increasing in USA. Animal models had shown glutathione species in plasma reflects liver glutathione state and it could be a surrogate for the detection of hepatocellular carcinoma (HCC). METHODS: The present study aimed to translate methods to the human and to explore the role of glutathione/metabolic prints in the progression of liver dysfunction and in the detection of HCC. Treated plasma from healthy subjects (n = 20), patients with liver disease (ESLD, n = 99) and patients after transplantation (LTx, n = 7) were analyzed by GC- or LC/MS. Glutathione labeling profile was measured by isotopomer analyzes of 2H2O enriched plasma. Principal Component Analyzes (PCA) were used to determined metabolic prints. RESULTS: There was a significant difference in glutathione/metabolic profiles from patients with ESLD vs healthy subjects and patients after LTx. Similar significant differences were noted on patients with ESLD when stratified by the MELD score. PCA analyses showed myristic acid, citric acid, succinic acid, l-methionine, d-threitol, fumaric acid, pipecolic acid, isoleucine, hydroxy-butyrate and glycolic, steraric and hexanoic acids were discriminative metabolites for ESLD-HCC+ vs ESLD-HCC- subject status. CONCLUSIONS: Glutathione species and metabolic prints defined liver disease severity and may serve as surrogate for the detection of HCC in patients with established cirrhosis.

Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment.

Chronic low back pain (cLBP) is the most frequently reported cause of years lived with disability. Identifying the anatomical structures or dysfunction contributing to patients' symptoms is critical to guiding treatment. The etiology of back pain and differential diagnosis is often broad, ranging from non-degenerative cLBP (trauma, tumor, inflammation, infection, etc.) to degenerative (also described as nonspecific) cLBP. After eliminating suspicion for more insidious causes of cLBP, a thorough investigation can be conducted in an attempt to identify a source of degenerative cLBP. Degenerative cLBP can originate from many sources, and a detailed understanding of the structures potentially involved is invaluable for an accurate diagnosis. This review article aims to provide a broad overview of the utility of clinical history, physical exam findings, imaging findings, and diagnostic procedures in identifying the cause of patients' cLBP. We provide a framework to help guide clinicians by dividing the structures into groups as follows: anterior vertebral column, posterior vertebral column, and extra-vertebral pain. For each condition listed, we touch on the treatment options that can be considered.

Evolution of lumbar degenerative spondylolisthesis with key radiographic features.

Spondylolisthesis is a common finding in middle-aged and older adults with back pain. The pathophysiology of degenerative spondylolisthesis is a subject of controversy regarding not only its etiology but also the mechanisms of its progression. It is theorized that degeneration of the facets and discs can lead to segmental instability, leading to displacement over time. Kirkaldy-Willis divided degenerative spondylolisthesis into three phases: dysfunction, instability, and finally, restabilization. There is a paucity of literature on the unification of the radiological hallmarks seen in spondylolisthesis within these phases. The radiographic features include (1) facet morphology/arthropathy, (2) facet effusion, (3) facet vacuum, (4) synovial cyst, (5) interspinous ligament bursitis, and (6) vacuum disc as markers of dysfunction, instability, and/or restabilization. We discuss these features, which can be seen on X-ray, CT, and MRI, with the intention of establishing a timeline upon which they present clinically. Spondylolisthesis is initiated as either degeneration of the intervertebral disc or facet joints. Early degeneration can be seen as facet vacuum without considerable arthropathy. As the vertebral segment becomes increasingly dynamic, fluid accumulates within the facet joint space. Further degeneration will lead to the advancement of facet arthropathy, degenerative disc disease, and posterior ligamentous complex pathology. Facet effusion can eventually be replaced with a vacuum in severe facet osteoarthritis. Intervertebral disc vacuum continues to accumulate with further cleft formation and degeneration. Ultimately, autofusion of the vertebra at the facets and endplates can be observed. With this review, we hope to increase awareness of these radiographical markers and their timeline, thus placing them within the framework of the currently accepted model of degenerative spondylolisthesis, to help guide future research and to help refine management guidelines.

The therapeutic effectiveness of fluoroscopically guided intra-articular sacroiliac joint injections in patients with sacroiliac joint dysfunction, an observational study.

Objective: The goal of this project is to evaluate the therapeutic effectiveness of fluoroscopically guided intra-articular sacroiliac (SI) joint injections in patients with diagnosed SI joint dysfunction. Patient reported outcomes related to pain and quality of life measures were evaluated. Design: This is a retrospective observational study of patients receiving intra-articular SI joint injections under a single provider at the Cleveland Clinic from September 2013 to April 2019. Three hundred fifty-one patients received injections and were administered patient reported outcomes (PROs) including the Numeric Rating Scale, Patient Health Questionnaire, Pain Disability Questionnaire, EuroQol-5 Dimensions Questionnaire, and PROMIS-GH Physical and Mental Health at baseline and approximately 1-, 3-, 6-, 12-, and 24-month time points during follow-up appointments. The primary outcome measure was the percentage of patients receiving their first injection who achieved minimal clinically important difference (MCID) in these PROs at each follow-up time point. Secondary outcomes were the percentage of patients achieving MCID in each PRO for each injection analyzed (including patients who received repeat injections) and average change in these PROs at each time point for first and all injections. Results: A total of 351 patients were included in the analysis, with varying time points of follow-up. The average patient age was 52.3 (±14.9) years with 74.9% female and 59.0% white. For first time injections, the MCID was achieved for Numeric Rating Scale in 60.6%, 42.1%, 47.5%, and 32.5% of patients at 1-, 3-, 6-, and 12-month follow-up, respectively. There was significant improvement in PROMIS-GH Physical Health at 3-month, 6-month, and 1-year follow-up. There was no significant improvement in PROMIS-GH Mental Health at any follow-up time points. Conclusions: Fluoroscopically guided intra-articular SI joint injection for SI joint dysfunction is effective in providing therapeutic pain relief exceeding MCID values in greater than 60% of patients at 1 month and greater than 40% at 3- and 6- months after injection. However, while this intervention may provide significant pain relief and improvement in function, it may not address the psychosocial aspect of chronic pain to the same extent.

Benefit of pain and function after cervical transforaminal epidural steroid injections, an observational study.

Objective: To evaluate the improvement of pain and function after cervical transforaminal epidural steroid injections (CTFESI) for radicular pain. Design: This is a retrospective observational study of patients receiving fluoroscopically-guided cervical transforaminal epidural steroid injections under a single provider at a tertiary referral center from December 2013 to December 2020. Primary outcome measures were Numeric Rating Scale (NRS), patient reported percent of pain relief, the Patient Health Questionnaire, the Patient Reported Outcome Measurement Information System (PROMIS) Global Health Physical and Mental Health score, and the Pain Disability Questionnaire. Results: A total of 219 individual patients underwent 261 CTFESI and were included in the analyses. The average subject age was 51.9 years (SD = 11.3) and 50.9 % were male. Following the intervention, average pain relief by NRS at 3 months, 6 months, 1 year, and 2 years was -4.07, -3.82, -4.20, and -4.45, respectively. The average functional improvement with PROMIS-GH physical at 3-months, 6-months, 1- year, and 2-years was 2.23, 2.35, 3.15, and 3.29, respectively. Conclusions: Our results suggest that patients with cervical radiculopathy report significant pain relief and functional improvement following CTFESI. They can also report clinically important improvement in their health-related quality of life.

Stereotactic body radiation therapy for nonresectable tumors of the pancreas.

BACKGROUND: Stereotactic body radiation therapy (SBRT) has emerged as a potential treatment option for local tumor control of primary malignancies of the pancreas. We report on our experience with SBRT in patients with pancreatic adenocarcinoma who were found not to be candidates for surgical resection. METHODS: The prospective database of the first 20 consecutive patients receiving SBRT for unresectable pancreatic adenocarcinomas and a neuroendocrine tumor under an IRB approved protocol was reviewed. Prior to SBRT, cylindrical solid gold fiducial markers were placed within or around the tumor endoscopically (n = 13), surgically (n = 4), or percutaneously under computerized tomography (CT)-guidance (n = 3) to allow for tracking of tumor during therapy. Mean radiation dose was 25 Gray (Gy) (range 22-30 Gy) delivered over 1-3 fractions. Chemotherapy was given to 68% of patients in various schedules/timing. RESULTS: Patients had a mean gross tumor volume of 57.2 cm(3) (range 10.1-118 cm(3)) before SBRT. The mean total gross tumor volume reduction at 3 and 6 mo after SBRT were 21% and 38%, respectively (P < 0.05). Median follow-up was 14.57 mo (range 5-23 mo). The overall rate of freedom from local progression at 6 and 12 mo were 88% and 65%. The probability of overall survival at 6 and 12 mo were 89% and 56%. No patient had a complication related to fiducial markers placement regardless of modality. The rate of radiation-induced adverse events was: grade 1-2 (11%) and grade 3 (16%). There were no grade 4/5 adverse events seen. CONCLUSION: Our preliminary results showed SBRT as a safe and likely effective local treatment modality for pancreatic primary malignancy with acceptable rate of adverse events.

Radiographic mislead: apparent arterial placement of subclavian central venous catheter due to mediastinal shift.

Optimal placement of central venous catheters (CVC) is essential for accurate monitoring of central venous pressure (CVP) in major surgeries and ensuring long-term use of the catheter for managing the critically ill patient. Accidental subclavian artery catheterization is one of the most serious complications of the procedure. Radiography is commonly used to ensure optimal placement of CVC tip and rule out subclavian artery catheterization in the absence of Doppler ultrasound and a pressure transducer. We present a case of a haemodynamically unstable and hypoxaemic patient with mediastinal shift, in which the anaesthesiologist was in a dilemma about the arterial placement of the right subclavian CVC. The CVC crossing the midline due to mediastinal shift gave the false impression of it being placed in subclavian artery rather than the vein. Subsequently, it was proved to be correctly placed in the subclavian vein.

Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3-year follow-up.

OBJECTIVES: To evaluate the long-term effect and safety of sildenafil citrate for the treatment of erectile dysfunction after radical prostatectomy (RP). METHODS: The study consisted of 91 patients with erectile dysfunction from our institution who received oral sildenafil citrate after RP. We surveyed these patients using a self-administered questionnaire during the first year of sildenafil citrate use to determine treatment satisfaction, patient compliance, and safety. Those who had responded positively to the drug were surveyed again 3 years later (n = 48). Sildenafil citrate was prescribed at a dose of 50 mg and increased to 100 mg if needed. Data were collected from a self-administered questionnaire using the abridged five-item version of the International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory of Men, and the Erectile Dysfunction Inventory of Treatment Satisfaction. The patients were stratified according to the type of nerve-sparing (NS) RP procedure they underwent: bilateral NS, unilateral NS, and non-NS. RESULTS: At 3 years, 31 (71%) of the 43 patients who had returned the second surveys were still responding to sildenafil. Of these 31 respondents, 10 (31%) had augmented their dose from 50 to 100 mg. The dropout rate was 27%; 6 of 12 had discontinued because of the return of natural erections, 5 because of a loss of efficacy, and 1 because his spouse had died. No differences were found in the 1-year and 3-year five-item International Index of Erectile Function (Sexual Health Inventory of Men) and Erectile Dysfunction Inventory of Treatment Satisfaction scores between the NS groups. The most common side effects at 3 years were headache (12%), flushing (10%), and blue or blurred vision (2%). No patient discontinued the drug at 3 years because of side effects. CONCLUSIONS: The results of this study indicate that the vast majority of patients with erectile dysfunction after RP who initially respond to sildenafil continue to do so at 3 years and are satisfied and compliant with the treatment regimen.

Long-term potency after iodine-125 radiotherapy for prostate cancer and role of sildenafil citrate.

OBJECTIVES: To assess the long-term sexual potency and attrition in sexual function after iodine-125 ((125)I) seed radiotherapy and the effect of sildenafil on radiation-induced erectile dysfunction (ED). METHODS: This prospective study consisted of 86 sexually active patients (mean age 63.5 +/- 7.7 years) who underwent (125)I seed implantation from 1997 to 1999 to treat low-volume prostate cancer (prostate-specific antigen less than 10 ng/mL, Gleason score 6 or less, stage T1-T2). All patients were followed up every 6 to 8 months for 4 years. Patients prescribed sildenafil citrate for ED completed the abridged five-item version of the International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires. RESULTS: The median follow-up was 49.7 months (range 36 to 66). Of 86 patients, 43 (50%) did not initiate drug therapy; and only 36 (83.7%) of the 43 were interviewed at 4 years. Twenty-three (63.8%) of the 36 patients had erections sufficient for vaginal penetration, with a total mean +/- SD IIEF-5 score of 15.76 +/- 1.13. The other 50% (43 of 86) initiated sildenafil citrate for treatment of ED after seed implantation, with a minimal follow-up of 6 months. At 4 years, 32 (74%) of the 43 were responding positively to sildenafil citrate, with a total IIEF-5 score of 18.3 +/- 1.2. The mean EDITS +/- SD score was 76.5 +/- 3.2, and the spousal satisfaction rate was 72% (31 of 43). The dropout rate was 37% (16 of 43); 10 (63%) of the 16 discontinued because of a lack of efficacy, 3 (19%) because of a return of natural erections sufficient for vaginal penetration, and 3 (19%) discontinued because of side effects (headaches). CONCLUSIONS: ED is a major long-term issue after (125)I seed radiotherapy, with a long-term potency rate of 29%. Sildenafil citrate improves erections in most patients after (125)I seed implantation.