Hypertriglyceridemia Induced Pancreatitis: plasmapheresis or conservative management?

INTRODUCTION: Hypertriglyceridemia-induced acute pancreatitis (HIAP) may result in severe morbidity and mortality. The most effective management strategy is unknown. While plasmapheresis is often performed, it is possible that a conservative approach which includes fasting, intravenous fluids and high-dose insulin, may be successful. OBJECTIVES: To compare the 28 day mortality and morbidity parameters among patients admitted to the intensive care unit (ICU) due to HIAP when treated conservatively, as compared to patients who were treated with plasmapheresis. MATERIALS AND METHODS: A retrospective study was performed, including all patients at least 18 years of age who were admitted to the ICU between the years 2010 to 2020 with diagnosis of HIAP. Patients underwent plasmapheresis or were managed conservatively. Collected data included patient demographics, chronic illness and medications, hospital and ICU admission times, 28-day mortality, need for ventilation, number of ventilation days, need for inotropic support, daily triglyceride levels, APACHE II score, lactate on admission, need for dialysis, antibiotic treatment, surgical or percutaneous intervention. RESULTS: The study included 29 patients. Twenty two patients were treated conservatively and 7 patients with plasmapheresis. There were no significant statistical differences between the groups regarding demographic parameters, chronic disease and medications. Furthermore, on ICU admission and during the subsequent 4 days APACHE score, serum lactate and triglyceride levels were similar between the groups. There was no significant difference in mortality. However, plasmapheresis was associated with greater morbidity (longer admission times, need for ventilation and number of ventilation days, need for inotropic support and dialysis, and invasive surgical intervention). Finally, when compared to conservative management, the rate of serum triglyceride decrease was not improved following plasmapheresis. CONCLUSION: Efficacy of conservative treatment in lowering the serum triglyceride level in HIAP is similar to plasmapheresis. Due to the small patient cohort further prospective studies are needed to confirm these findings.

Chlorophyll metabolism in pollinated vs. parthenocarpic fig fruits throughout development and ripening.

MAIN CONCLUSION: Expression of 13 genes encoding chlorophyll biosynthesis and degradation was evaluated. Chlorophyll degradation was differentially regulated in pollinated and parthenocarpic fig fruits, leading to earlier chlorophyll degradation in parthenocarpic fruits. Varieties of the common fig typically yield a commercial summer crop that requires no pollination, although it can be pollinated. Fig fruit pollination results in larger fruit size, greener skin and darker interior inflorescence color, and slows the ripening process compared to non-pollinated fruits. We evaluated the effect of pollination on chlorophyll content and levels of transcripts encoding enzymes of the chlorophyll metabolism in fruits of the common fig 'Brown Turkey'. We cloned and evaluated the expression of 13 different genes. All 13 genes showed high expression in the fruit skin, inflorescences and leaves, but extremely low expression in roots. Pollination delayed chlorophyll breakdown in the ripening fruit skin and inflorescences. This was correlated with the expression of genes encoding enzymes in the chlorophyll biosynthesis and degradation pathways. Expression of pheophorbide a oxygenase (PAO) was strongly negatively correlated with chlorophyll levels during ripening in pollinated fruits; along with its high expression levels in yellow leaves, this supports a pivotal role for PAO in chlorophyll degradation in figs. Normalizing expression levels of all chlorophyll metabolism genes in the pollinated and parthenocarpic fruit skin and inflorescences showed three synthesis (FcGluTR1, FcGluTR2 and FcCLS1) and three degradation (FcCLH1, FcCLH2 and FcRCCR1) genes with different temporal expression in the pollinated vs. parthenocarpic fruit skin and inflorescences. FcCAO also showed different expressions in the parthenocarpic fruit skin. Thus, chlorophyll degradation is differentially regulated in the pollinated and parthenocarpic fruit skin and inflorescences, leading to earlier and more sustained chlorophyll degradation in the parthenocarpic fruit.

The ambiguous ripening nature of the fig (Ficus carica L.) fruit: a gene-expression study of potential ripening regulators and ethylene-related genes.

The traditional definition of climacteric and non-climacteric fruits has been put into question. A significant example of this paradox is the climacteric fig fruit. Surprisingly, ripening-related ethylene production increases following pre- or postharvest 1-methylcyclopropene (1-MCP) application in an unexpected auto-inhibitory manner. In this study, ethylene production and the expression of potential ripening-regulator, ethylene-synthesis, and signal-transduction genes are characterized in figs ripening on the tree and following preharvest 1-MCP application. Fig ripening-related gene expression was similar to that in tomato and apple during ripening on the tree, but only in the fig inflorescence-drupelet section. Because the pattern in the receptacle is different for most of the genes, the fig drupelets developed inside the syconium are proposed to function as parthenocarpic true fruit, regulating ripening processes for the whole accessory fruit. Transcription of a potential ripening regulator, FcMADS8, increased during ripening on the tree and was inhibited following 1-MCP treatment. Expression patterns of the ethylene-synthesis genes FcACS2, FcACS4, and FcACO3 could be related to the auto-inhibition reaction of ethylene production in 1-MCP-treated fruit. Along with FcMADS8 suppression, gene expression analysis revealed upregulation of FcEBF1, and downregulation of FcEIL3 and several FcERFs by 1-MCP treatment. This corresponded with the high storability of the treated fruit. One FcERF was overexpressed in the 1-MCP-treated fruit, and did not share the increasing pattern of most FcERFs in the tree-ripened fig. This demonstrates the potential of this downstream ethylene-signal-transduction component as an ethylene-synthesis regulator, responsible for the non-climacteric auto-inhibition of ethylene production in fig.

Factors associated with empyema in children with community acquired pneumonia.

AIM: Empyema is a potential complication of community acquired pneumonia but factors predicting this complication are lacking. METHODS: A retrospective study of all previously healthy pediatric patients admitted between January 2007 and July 2009 with CAP. Patients with non-lobar pneumonia, RSV bronchiolitis, underlying chronic disease, or hospital-acquired pneumonia were excluded. Preadmission, clinical characteristics on admission, and outcome were compared between patients with and without empyema. Management strategies in patients with empyema were also compared. RESULTS: Overall 356 patients were included. Median age was 3.8 ± 3.54 years and 60.7% were males. A total of 43 patients (12%) were diagnosed with empyema. The development of empyema was independently associated, on multivariate analysis, with older age, female gender and antibiotic therapy prior to admission, and with dyspnea, thrombocytopenia and involvement of more than one lobe on chest radiograph on admission. Patients who developed empyema had a longer and more complicated course. Hypoxemia on admission was significantly less frequent in patients with empyema who were treated with antibiotic therapy alone, compared to those treated with chest tube or video-assisted thoracoscopic surgery. CONCLUSION: Early identification of dyspnea and thrombocytopenia in patients with community acquired pneumonia could alert physicians on the potential development of empyema. Antibiotic therapy alone may be sufficient in patients with empyema who are mildly hypoxemic on admission.

Reevaluation of presentation and course of idiopathic intracranial hypertension--a large cohort comprehensive study.

OBJECTIVES: We analyzed the clinical and ophthalmological findings in a large group of patients with idiopathic intracranial hypertension (IIH) trying to find factors that might influence the course of the disease. MATERIALS AND METHODS: Medical records of patients with IIH were retrospectively reviewed. The patients included were women after menarche and men older than 18 years of age who were followed up for at least 1 year. RESULTS: Eighty-two patients (89% women) with a mean age of 30.2 ± 12.0 years were included. The prevailing complaint was headache and transient visual obscurations followed by tinnitus and double vision. Eighty-two percent of patients were overweight at the time of diagnosis. Overweight patients had higher opening cerebrospinal fluid (CSF) pressure than patients with normal weight did. The grade of papilledema correlated with the CSF opening pressure. Inverse correlation was found between the depression of the visual field sensitivity and the grade of papilledema. The mean follow-up time was 61.3 ± 62.3 months. Eighty-four percent of the patients have improved while in 22% CSF diversion procedures or optic nerve decompression was required. The mean body mass index (BMI) at the end of follow-up decreased significantly. Sixty-seven percent of the patients suffered a recurrence of IIH. The number of recurrences inversely correlated with weight loss. Visual field defects on presentation were encountered more frequently in patients with recurrence. Women with recurrence had a history of more pregnancies. CONCLUSIONS: Our results confirm the strong association between overweight and IIH. The recurrence rate seemed to be influenced by the obstetrical history and the severity of visual field defects at presentation. In contrast to some previous studies, we have found an interrelation between the CSF opening pressure, grade of papilledema and depression of the visual field sensitivity.

Mucosal Adenoviral-vectored Vaccine Boosting Durably Prevents XBB.1.16 Infection in Nonhuman Primates.

Waning immunity and continued virus evolution have limited the durability of protection from symptomatic infection mediated by intramuscularly (IM)-delivered mRNA vaccines against COVID-19 although protection from severe disease remains high. Mucosal vaccination has been proposed as a strategy to increase protection at the site of SARS-CoV-2 infection by enhancing airway immunity, potentially reducing rates of infection and transmission. Here, we compared protection against XBB.1.16 virus challenge 5 months following IM or mucosal boosting in non-human primates (NHP) that had previously received a two-dose mRNA-1273 primary vaccine regimen. The mucosal boost was composed of a bivalent chimpanzee adenoviral-vectored vaccine encoding for both SARS-CoV-2 WA1 and BA.5 spike proteins (ChAd-SARS-CoV-2-S) and delivered either by an intranasal mist or an inhaled aerosol. An additional group of animals was boosted by the IM route with bivalent WA1/BA.5 spike-matched mRNA (mRNA-1273.222) as a benchmark control. NHP were challenged in the upper and lower airways 18 weeks after boosting with XBB.1.16, a heterologous Omicron lineage strain. Cohorts boosted with ChAd-SARS-CoV-2-S by an aerosolized or intranasal route had low to undetectable virus replication as assessed by levels of subgenomic SARS-CoV-2 RNA in the lungs and nose, respectively. In contrast, animals that received the mRNA-1273.222 boost by the IM route showed minimal protection against virus replication in the upper airway but substantial reduction of virus RNA levels in the lower airway. Immune analysis showed that the mucosal vaccines elicited more durable antibody and T cell responses than the IM vaccine. Protection elicited by the aerosolized vaccine was associated with mucosal IgG and IgA responses, whereas protection elicited by intranasal delivery was mediated primarily by mucosal IgA. Thus, durable immunity and effective protection against a highly transmissible heterologous variant in both the upper and lower airways can be achieved by mucosal delivery of a virus-vectored vaccine. Our study provides a template for the development of mucosal vaccines that limit infection and transmission against respiratory pathogens.

Effects of partial maize silage substitution with microalgae on viscosity and biogas yields in continuous AD trials.

The microalga Acutodesmus obliquus was investigated as a feedstock in semi-continuously fed anaerobic digestion trials, where A. obliquus was co-digested with pig slurry and maize silage. Maize silage was substituted by both 10% and 20% untreated, and 20% ultrasonicated microalgae biomass on a VS (volatile solids) basis. The substitution of maize silage with 20% of either ultrasonicated and untreated microalgae led to significantly lower biogas yields, i.e., 560 dm³ kg-1 VScorr in the reference compared to 516 and 509 dm³ kg-1VScorr for untreated and ultrasonicated microalgae substitution. Further, the viscosities in the different reactors were measured at an OLR of 3.5 g VS dm-3 d-1. However, all treatments with microalgae resulted in significantly lower viscosities. While the mean viscosity reached 0.503 Pa s in the reference reactor, mean viscosities were 53% lower in reactors where maize was substituted by 20% microalgae, i.e. 0.239 Pa s, at a constant rotation speed of 30 rpm. Reactors where maize was substituted by 20% ultrasonicated microalgae had a 32% lower viscosity, for 10% microalgae substitution a decrease of 8% was measured. Decreased viscosities have beneficial effect on the bioprocess and the economy in biogas plants. Nonetheless, with regard to other parameters, no positive effect on biogas yields by partial substitution with microalgae biomass was found. The application of microalgae may be an interesting option in anaerobic digestion when fibrous or lignocellulosic substances lead to high viscosities of the digested slurries. High production costs remain the bottleneck for making microalgae an interesting feedstock.

Tissue-Specific Transcriptome and Hormonal Regulation of Pollinated and Parthenocarpic Fig (Ficus carica L.) Fruit Suggest that Fruit Ripening Is Coordinated by the Reproductive Part of the Syconium.

In the unconventional climacteric fig (Ficus carica) fruit, pollinated and parthenocarpic fruit of the same genotype exhibit different ripening characteristics. Integrative comparative analyses of tissue-specific transcript and of hormone levels during fruit repining from pollinated vs. parthenocarpic fig fruit were employed to unravel the similarities and differences in their regulatory processes during fruit repining. Assembling tissue-specific transcripts into 147,000 transcripts with 53,000 annotated genes provided new insights into the spatial distribution of many classes of regulatory and structural genes, including those related to color, taste and aroma, storage, protein degradation, seeds and embryos, chlorophyll, and hormones. Comparison of the pollinated and parthenocarpic tissues during fruit ripening showed differential gene expression, especially in the fruit inflorescence. The distinct physiological green phase II and ripening phase III differed significantly in their gene-transcript patterns in both pulp and inflorescence tissues. Gas chromatographic analysis of whole fruits enabled the first determination of ripening-related hormone levels from pollinated and non-pollinated figs. Ethylene and auxin both increased during fruit ripening, irrespective of pollination, whereas no production of active gibberellins or cytokinins was found in parthenocarpic or pollinated ripening fruit. Tissue-specific transcriptome revealed apparent different metabolic gene patterns for ethylene, auxin and ABA in pollinated vs. parthenocarpic fruit, mostly in the fruit inflorescence. Our results demonstrate that the production of abscisic acid (ABA), non-active ABA-GE conjugate and non-active indoleacetic acid (IAA)-Asp conjugate in pollinated fruits is much higher than in parthenocarpic fruits. We suggest that fruit ripening is coordinated by the reproductive part of the syconium and the differences in ABA production between pollinated and parthenocarpic fig fruit might be the key to their different ripening characteristics.

Video-assisted transthoracic sympathectomy in the treatment of primary hyperhidrosis: friend or foe?

The authors hypothesize that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function; consequently, thoracoscopic sympathectomy to alleviate symptoms in the hands may result in heat dissipation because sweating is transferred to other sites. To investigate this phenomenon and to determine whether it adversely affects patient satisfaction, a standard questionnaire was administered to 626 patients who underwent sympathectomy at a university-associated public hospital between 1991 and 1998; only patients treated at least 6 months before questionnaire distribution were included in the study. Replies were received from 336 (53.7%) individuals. The surveyed patients underwent bilateral T2, T3 (palmar sweating), or T3, T4 (axillary sweating) sympathectomy by a standard video-assisted transthoracic technique. Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed. After sympathectomy, 97.3% (P < 0.0001) and 29.2% (P < 0.001) of patients reported significant improvement in palmar hyperhidrosis and axillary sweating, respectively. Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure. In contrast, 25% and 64% of patients were either satisfied or very satisfied with the outcome of the procedure. From the survey results, the authors conclude that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function and that thoracic sympathectomy may alleviate symptoms in a large proportion of patients. However, for some individuals, compensatory sweating may prove to be an equally troublesome handicap. Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.

Delivery room analgesia: an analysis of maternal satisfaction.

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.

Alternating patient position following the induction of obstetric epidural analgesia does not affect local anaesthetic spread.

To assess the influence of gravity on epidural-induced sensory blockade during the first stage of labour, 60 parturients were recruited to a randomized, controlled, single-blinded study. In all cases an epidural catheter was placed with the patient in the left lateral position. Thereafter, patients were randomized to one of three groups. In group supine (S), the epidural injection was performed in the supine position with a 15-20 degrees right flank elevation and the patient remained supine. In group left (L) patients remained in the left lateral position for 10 min after injection. In group left and right (L+R) patients remained in the left lateral position for 5 min and then assumed the right lateral position for 5 min. Thereafter, in groups L and L+R patients lay supine with a 15-20 degrees right flank elevation. All patients received 50 microg fentanyl in 10 ml of 0.125% bupivacaine. Ten minutes after injection loss of pinprick and temperature sensation were assessed and pain scores measured. Height of sensory deficit 10 min after injection and after maximal blockade were unaffected by patient position. In all cases maximal blockade reached T8 or higher. Time to maximal block was 14.7 +/- 2.3 min, 14.1 +/- 1.6 min and 13.9 +/- 1.5 min for groups L, L+R and S respectively. After maximal blockade, pain scores were significantly (P<0.0001) decreased in all groups, with no differences between them. We conclude that position immediately following local anaesthetic drug administration has little effect on onset and distribution of epidural analgesia.

Continuous intravenous diclofenac does not induce opioid-sparing or improve analgesia in geriatric patients undergoing major orthopedic surgery.

STUDY OBJECTIVE: To assess the analgesic efficacy and perioperative opioid-sparing effects of adjuvant intravenous (IV) diclofenac. DESIGN: Prospective, controlled, double-blind study. SETTING: Large referral hospital. PATIENTS: 40 ASA physical status I, II, and III geriatric patients (>65 years) undergoing open reduction and internal fixation of subcapital fracture of the femur. INTERVENTIONS: A standardized general anesthetic was administered. On induction of anesthesia, patients in the diclofenac group received an IV bolus of diclofenac (0.7 mg/kg) followed by a constant infusion (0.15 mg/kg/hr) until the end of surgery. In the saline group, an equal volume of saline was administered. "Rescue" fentanyl was administered in response to an increase in mean arterial pressure or heart rate (exceeding 20% of the patient's preinduction "baseline" values) that did not respond to a 30% increase in the inspired isoflurane concentration. Postoperative pain was assessed using a four-point patient-generated pain score (1 = none, 2 = mild, 3 = moderate, 4 = severe) as well as number of attempts and actual morphine delivered via a patient-controlled analgesia (PCA) device. MEASUREMENTS AND MAIN RESULTS: The two treatment groups were demographically comparable. The perioperative hemodynamic variables, as well as the induction and "rescue" fentanyl dosages, were unaffected by the treatment modality. Pain scores, PCA attempts, and actual morphine delivered were statistically similar between the two groups. CONCLUSIONS: Adjuvant IV diclofenac does not improve intraoperative stability or decrease postoperative opioid requirements in geriatric patients undergoing internal fixation of subcapital fracture of the femur.

Effect of spinal versus general anesthesia on bladder compliance and intraabdominal pressure during transurethral procedures.

STUDY OBJECTIVE: To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN: Prospective, randomized, open-label study. SETTING: Teaching hospital. PATIENTS: 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS: According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS: The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Student's t-test (p < 0.05 was considered statistically significant). CONCLUSION: Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.

Influence of thiopental and propofol on postoperative cognitive recovery in the elderly patient undergoing general anesthesia.

STUDY OBJECTIVE: To assess mental and psychomotor recovery following induction of anesthesia with thiopental or propofol in elderly patients undergoing general anesthesia. DESIGN: Randomized, prospective, double-blind study. SETTING: Large referral hospital. PATIENTS: 40 elderly patients ASA physical status I-III (> 65 years) undergoing abdominopelvic surgery with an estimated surgical time of at least 90 minutes. INTERVENTIONS: All patients received combined epidural-general anesthesia. After establishing a T6 sensory blockade, patients were randomized to receive either thiopental or propofol for induction of general anesthesia. The induction drug was slowly titrated until loss of eyelash reflex was noted. Thereafter, all patients received desflurane (2% to 3% end-tidal) and 70% nitrous oxide (N2O) in oxygen for maintenance of general anesthesia. To facilitate tracheal intubation, intravenous alfentanil 10 micrograms/kg and atracurium 0.4 mg/kg were administered. Perioperative analgesia was maintained with epidural bupivacaine. MEASUREMENTS AND MAIN RESULTS: A digit substitution test (DSST) and shape-sorter test, as well as patient-generated 100-mm visual analog score (VAS; 0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination, were performed during the preanesthetic interview, on postanesthesia care unit admission, and at 15, 45, 90, and 120 minutes thereafter. To induce loss of consciousness, either thiopental 2.5 +/- 1.0 mg/kg or propofol 1.6 +/- 0.6 mg/kg was administered. The mean anesthetic time was 109 +/- 30 minutes and 114 +/- 38 minutes for the thiopental and propofol groups, respectively. Emergence, extubation, and orientation times, as well as time to follow commands, were unaffected by patient randomization. Similarly, the DSST and shape-sorter tests, in addition to the patient-generated VAS for pain, anxiety, and coordination, were similar among groups. However, irrespective of treatment modality, return to baseline digit substitution and shape-sorter scores were significantly delayed (p < 0.01). CONCLUSION: When compared to thiopental, propofol does not facilitate improved cognitive recovery in geriatric patients undergoing prolonged surgery.

The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement.

STUDY OBJECTIVE: To assess the influence of tourniquet inflation-deflation as well as desmopressin and tranexamic acid (TA) administration on prothrombin fragment 1.2, fibrinogen, plasmin antiplasmin complex, and D-dimer concentrations during total knee replacement. DESIGN: Randomized, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: 30 ASA physical status I, II, and III patients undergoing total knee replacement. INTERVENTIONS: Patients were randomized to one of three treatment groups. Patients received either tranexamic acid, desmopressin, or an equal volume of saline, intravenously. MEASUREMENTS AND MAIN RESULTS: Cubital blood was drawn immediately before induction of anesthesia, 1 hour after tourniquet application, and 2 and 15 minutes after tourniquet deflation. Fibrinogen and D-dimer levels were measured using the Clauss Method and latex agglutination, respectively. Plasmin antiplasmin complex and prothrombin fragment 1.2 levels were measured by enzyme-linked immunosorbent assay (ELISA). All assays were performed in duplicate, and intra-assay variability was documented. No statistically significant difference in fibrinogen, D-dimer, plasmin antiplasmin complex, or prothrombin fragment 1.2 levels was demonstrated among the groups. Similarly, within each group there were no statistically significant differences in the variables studied. However, despite the lack of statistical significance, when compared with their levels during tourniquet application, an increase in D-dimer and plasmin antiplasmin complex levels was observed in all three groups at 2 and 15 minutes after tourniquet release. In contrast, no increase in prothrombin fragment 1.2 generation was noted. Significantly more allogeneic blood was transfused in the Control and Desmopressin Groups when compared with the tranexamic acid group (p< 0.02). CONCLUSIONS: No evidence of tourniquet-induced fibrinolysis or thrombin generation was demonstrated in the systemic circulation. Desmopressin and tranexamic acid had no significant effect on the variables measured.

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients.

STUDY OBJECTIVE: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN: Randomized, prospective, open-label study. SETTING: Large referral hospital. PATIENTS: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

The effect of repeated epidural sympathetic nerve block on "failed back surgery syndrome" associated chronic low back pain.

STUDY OBJECTIVE: To assess the therapeutic benefits of repeated epidural local anesthetic administration on pain perception and straight leg raise (SLR) in patients suffering from chronic low back pain. DESIGN: Prospective, randomized, controlled, single-blind study protocol. PATIENTS: 50 ASA physical status I, II, and III patients at least 18 years of age, who had previously undergone spine surgery. INTERVENTIONS: All participants were admitted to hospital for the 5-day duration of the study. Following epidural catheterization, fluoroscopy was performed to verify correct placement of the epidural catheter. On the first study day, all patients received depomedrol 80 mg, in 10-ml 1% lidocaine, epidurally. Thereafter, patients were randomized into two equal groups. In Group Bupivacaine (B) 10-ml 0.125% bupivacaine was administered. In Group Saline (S), an equal volume of saline was administered. Epidural injections were performed twice daily (09H00 and 14H00) for 4 days. Sympathetic blockade was confirmed by the presence of peripheral vasodilatation. Sensory blockade was assessed using loss of pin prick and temperature sensation. SLR as well as patient-generated 100-mm visual analog score (VAS) for pain were performed prior to each injection, at 15 minutes after injection, and hourly for 2 hours thereafter. Similar parameters were measured 1 week, 1 month, and 3 months after discharge. MEASUREMENTS AND MAIN RESULTS: 46 patients completed the study. VAS for pain was marginally lower in Group B. However, statistical significance was not demonstrated. During the hospitalization period, the SLR in both study groups significantly (0.008) improved with time. However, no difference between the groups was demonstrated. In both groups, 1 week, 1 month, and 3 months after discharge, the SLR was comparable to prestudy recordings. In Group B, at 1 week, 1 month, and 3 months after discharge, patient-generated VAS for pain were significantly (p = 0.002) higher when compared to pain scores at the time of patient discharge.

The analgesic efficacy of patient-controlled ropivacaine instillation after Cesarean delivery.

To assess the efficacy and safety of wound instillation of ropivacaine, when administered via a patient-controlled elastometric pump, 50 term parturients undergoing cesarean delivery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard spinal anesthetic was administered. After the surgery, a multihole 20-gauge epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point that demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to the elastometric pump. According to a computer-generated randomization schedule, the pump was filled with either ropivacaine 0.2% (Ropivacaine Group) or an equal volume of sterile water (Control Group). Postoperatively, patient-controlled analgesia was administered via the elastometric pump. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, IV). Thereafter, "rescue" dipyrone (1 g) was administered on patient request. In a subset of 10 patients, blood ropivacaine levels were assessed. Compared with the Control Group, significantly fewer patients in the Ropivacaine Group received "rescue" morphine (92% vs. 48%, respectively) (P<0.01). The total "rescue" morphine administered during the first 6 postoperative hours was 2+/-3 mg vs. 10+/-5 mg (P<0.01) for the Ropivacaine and Control Groups, respectively. Patient-generated resting pain scores were similar between the groups. However, pain scores generated after coughing and leg raise were significantly (P<0.04) less in the Ropivacaine Group. More patients in the Ropivacaine Group than in the Control Group described their analgesia as good or excellent. In the subset of patients (n = 10) studied, unbound ropivacaine blood levels were below the toxic threshold (600 ng/mL). However, blood ropivacaine accumulation was noted. All patients stated that the elastometric pump was easy to use. Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery.

Diclofenac does not decrease renal blood flow or glomerular filtration in elderly patients undergoing orthopedic surgery.

UNLABELLED: Nonsteroidal antiinflammatory drugs (NSAIDs) have become increasingly popular in the treatment of perioperative pain. Due to concerns that cyclooxygenase inhibition may adversely affect renal function, these drugs are often not used in geriatric surgical patients. However, the perioperative effect of NSAIDs on renal blood flow (RBF) and glomerular filtration rate (GFR) has not been assessed. Therefore, using a prospective, controlled, double-blinded study design, we evaluated the effect of diclofenac on RBF and GFR in 20 patients (>65 yr) undergoing open reduction and internal fixation of the femur. All patients were normovolemic before the study. A standardized general anesthetic was administered. On induction of anesthesia, patients in the diclofenac group received an IV bolus of diclofenac (0.7 mg/kg) followed by a constant infusion (0.15 mg x kg(-1) x h(-1)) until the end of surgery. In the saline group, an equal volume of saline was administered. During four time periods (equilibration, anesthesia, surgical, recovery), GFR and effective renal plasma flow (ERPF) were measured by inulin and paraaminohippurate clearance, respectively. After the induction of anesthesia and throughout the surgical period, ERPF and GFR were significantly decreased compared with preoperative baseline values. However, no difference was demonstrated between the groups. These results suggest that, in geriatric surgical patients, the adjuvant administration of NSAIDs does not adversely affect renal function. IMPLICATIONS: As determined by inulin and paraaminohippurate clearance, the intraoperative administration of diclofenac does not decrease glomerular filtration rate or effective renal plasma flow in normovolemic geriatric patients. Therefore, diclofenac may be administered during the perioperative period.

A comparative study of the postoperative allogeneic blood-sparing effect of tranexamic acid versus acute normovolemic hemodilution after total knee replacement.

UNLABELLED: Both acute normovolemic hemodilution (NVHD) and tranexamic acid (TA) are potentially useful allogeneic blood conservation strategies after total knee replacement. However, the relative efficacy of these blood-sparing techniques is unknown. Therefore, to compare the postoperative allogeneic blood sparing of NVHD and TA after total knee replacement, we investigated 40 patients in a prospective, single-blinded study protocol. In Group TA, 30 min before deflating the limb tourniquet, an IV infusion of TA, 15 mg/kg, was administered over a 30-min period. Thereafter, a constant IV infusion of 10 mg x kg(-1) x hr(-1) was administered until 12 h after deflation of the limb tourniquet. Before induction of anesthesia, NVHD patients were bled to a target hematocrit of approximately 28%. Intravascular blood volume was maintained with lactated Ringer's solution. All autologous blood was transfused at the end of the surgery. Postoperatively, hematocrit was measured daily. In all cases, a hematocrit <27% was the postoperative transfusion trigger. Before discharge, deep vein thrombosis was excluded by Echo Doppler. Three months after surgery, the incidence of delayed thromboembolic events was assessed. The two groups were demographically comparable. In Group NVHD, 843 mL+/-289 of autologous blood was removed. Despite autologous blood transfusion, during the early postoperative period and until the third postoperative day, the NVHD group had significantly (P < 0.01) lower mean hematocrits when compared with the TA group. Thereafter, because of a significantly (P < 0.0008) greater allogeneic blood requirement in the NVHD group, no statistically significant difference in mean hematocrit recordings was noted among the groups. Blood accumulation in the surgical drain 12 h postoperatively, was significantly (P < 0.0008) higher in the NVHD group (259 mL+/-156) when compared with the TA group (110 mL+/-62). Significantly (P < 0.0008) more allogeneic blood was transfused in the NVHD group (19 U/13 patients) when compared with the TA group (2 U/2 patients). No abnormal Echo Doppler studies were reported. During the 3-mo follow-up period, a deep vein thrombosis and pulmonary embolus were documented in one patient in the NVHD group. We conclude that perioperative hemodynamic stability and allogeneic blood sparing is superior after tranexamic acid administration when compared with normovolemic hemodilution. IMPLICATIONS: For total knee replacement, when compared with normovolemic hemodilution, tranexamic acid administration is associated with superior perioperative hemodynamic stability and allogeneic blood sparing.