Functionally characterized arthropod pest and pollinator cytochrome P450s associated with xenobiotic metabolism.

The cytochrome P450 family (P450s) of arthropods includes diverse enzymes involved in endogenous essential physiological functions and in the oxidative metabolism of xenobiotics, insecticides and plant allelochemicals. P450s can also establish insecticide selectivity in bees and pollinators. Several arthropod P450s, distributed in different phylogenetic groups, have been associated with xenobiotic metabolism, and some of them have been functionally characterized, using different in vitro and in vivo systems. The purpose of this review is to summarize scientific publications on arthropod P450s from major insect and mite agricultural pests, pollinators and Papilio sp, which have been functionally characterized and shown to metabolize xenobiotics and/or their role (direct or indirect) in pesticide toxicity or resistance has been functionally validated. The phylogenetic relationships among these P450s, the functional systems employed for their characterization and their xenobiotic catalytic properties are presented, in a systematic approach, including critical aspects and limitations. The potential of the primary P450-based metabolic pathway of target and non-target organisms for the development of highly selective insecticides and resistance-breaking formulations may help to improve the efficiency and sustainability of pest control.

Transcriptomic analysis of s-methoprene resistance in the lesser grain borer, Rhyzopertha dominica, and evaluation of piperonyl butoxide as a resistance breaker.

BACKGROUND: The lesser grain borer, Rhyzopertha dominica is a serious pest of stored grains. Fumigation and contact insecticides play a major role in managing this pest globally. While insects are developing genetic resistance to chemicals, hormonal analogues such as s-methoprene play a key role in reducing general pest pressure as well as managing pest populations that are resistant to fumigants and neurotoxic contact insecticides. However, resistance to s-methoprene has been reported in R. dominica with some reports showing a remarkable high resistance, questioning the use of this compound and other related analogues in grain protection. The current study attempts to identify possible molecular mechanisms that contribute in resistance to s-methoprene in R. dominica. RESULTS: Transcriptome analysis of resistant and susceptible strains of this pest species identified a set of differentially expressed genes related to cytochrome P450s, indicating their potential role in resistance to s-methoprene. Laboratory bioassays were performed with s-methoprene treated wheat grains in presence and absence of piperonyl butoxide (PBO), a cytochrome P450 inhibitor. The results indicate that PBO, when applied alone, at least at the concentration tested here, had no effect on R. dominica adult emergence, but has a clear synergistic effect to s-methoprene. The number of produced progeny decreased in presence of the inhibitor, especially in the resistant strain. In addition, we also identified CYP complement (CYPome) of R. dominica, annotated and analysed phylogenetically, to understand the evolutionary relationships with other species. CONCLUSIONS: The information generated in current study suggest that PBO can effectively be used to break resistance to s-methoprene in R. dominica.

Development of efficient RNAi in Nezara viridula for use in insecticide target discovery.

Stink bugs are an emerging pest in many regions of the world but their molecular biology is still poorly understood. While several transcriptomes are available, the lack of validated gene manipulation tools like RNA interference (RNAi) in species such as the southern green stinkbug Nezara viridula precludes the characterization of individual genes in vivo. Such tools are particularly useful in performing high-throughput screens to search for essential genes that can be prioritized as potential insecticide targets. Here, we developed and optimized an efficient RNAi in N. viridula for use in insecticide target discovery and beyond. The visible marker Sex combs reduced and the essential gene Actin were used to verify the usability and efficiency of RNAi by microinjection at both the adult and nymphal stages, respectively, with nymphal approach presenting significant advantages. Following validation, RNAi was then used to measure lethality following the knockdown (KD) of two genes that are known insecticide targets, Chitin synthase, and Acetyl-CoA carboxylase. The KD of each gene resulted in >75% corrected mortality. These results indicate that RNAi is an effective tool in N. viridula and set a benchmark to evaluate potential targets in future RNAi screens aimed at insecticide target discovery.

Disruption of a horizontally transferred phytoene desaturase abolishes carotenoid accumulation and diapause in Tetranychus urticae.

Carotenoids underlie many of the vibrant yellow, orange, and red colors in animals, and are involved in processes ranging from vision to protection from stresses. Most animals acquire carotenoids from their diets because de novo synthesis of carotenoids is primarily limited to plants and some bacteria and fungi. Recently, sequencing projects in aphids and adelgids, spider mites, and gall midges identified genes with homology to fungal sequences encoding de novo carotenoid biosynthetic proteins like phytoene desaturase. The finding of horizontal gene transfers of carotenoid biosynthetic genes to three arthropod lineages was unprecedented; however, the relevance of the transfers for the arthropods that acquired them has remained largely speculative, which is especially true for spider mites that feed on plant cell contents, a known source of carotenoids. Pigmentation in spider mites results solely from carotenoids. Using a combination of genetic approaches, we show that mutations in a single horizontally transferred phytoene desaturase result in complete albinism in the two-spotted spider mite, Tetranychus urticae, as well as in the citrus red mite, Panonychus citri Further, we show that phytoene desaturase activity is essential for photoperiodic induction of diapause in an overwintering strain of T. urticae, consistent with a role for this enzyme in provisioning provitamin A carotenoids required for light perception. Carotenoid biosynthetic genes of fungal origin have therefore enabled some mites to forgo dietary carotenoids, with endogenous synthesis underlying their intense pigmentation and ability to enter diapause, a key to the global distribution of major spider mite pests of agriculture.

Functional characterization of CYP6A51, a cytochrome P450 associated with pyrethroid resistance in the Mediterranean fruit fly Ceratitis capitata.

Overexpression of the cytochrome P450 monooxygenase CYP6A51 has been previously associated with pyrethroid resistance in the Mediterranean fruit fly (medfly) Ceratitis capitata, an important pest species worldwide; however, this association has not been functionally validated. We expressed CYP6A51 gene in Escherichia coli and produced a functional enzyme with preference for the chemiluminescent substrate Luciferin-ME EGE. In vitro metabolism assays revealed that CYP6A51 is capable of metabolizing two insecticides that share the same mode of action, λ-cyhalothrin and deltamethrin, whereas no metabolism or substrate depletion was observed in the presence of spinosad or malathion. We further expressed CYP6A51 in vivo via a GAL4/UAS system in Drosophila melanogaster flies, driving expression with detoxification tissue-specific drivers. Toxicity bioassays indicated that CYP6A51 confers knock-down resistance to both λ-cyhalothrin and deltamethrin. Detection of CYP6A51 - associated pyrethroid resistance in field populations may be important for efficient Insecticide Resistance Management (IRM) strategies.

Tetranychus urticae mites do not mount an induced immune response against bacteria.

The genome of the spider mite Tetranychus urticae, a herbivore, is missing important elements of the canonical Drosophila immune pathways necessary to fight bacterial infections. However, it is not known whether spider mites can mount an immune response and survive bacterial infection. In other chelicerates, bacterial infection elicits a response mediated by immune effectors leading to the survival of infected organisms. In T. urticae, infection by either Escherichia coli or Bacillus megaterium did not elicit a response as assessed through genome-wide transcriptomic analysis. In line with this, spider mites died within days even upon injection with low doses of bacteria that are non-pathogenic to Drosophila Moreover, bacterial populations grew exponentially inside the infected spider mites. By contrast, Sancassania berlesei, a litter-dwelling mite, controlled bacterial proliferation and resisted infections with both Gram-negative and Gram-positive bacteria lethal to T. urticae This differential mortality between mite species was absent when mites were infected with heat-killed bacteria. Also, we found that spider mites harbour in their gut 1000-fold less bacteria than S. berlesei We show that T. urticae has lost the capacity to mount an induced immune response against bacteria, in contrast to other mites and chelicerates but similarly to the phloem feeding aphid Acyrthosiphon pisum Hence, our results reinforce the putative evolutionary link between ecological conditions regarding exposure to bacteria and the architecture of the immune response.

Differences in the suppression of distortion product otoacoustic emissions by contralateral white noise between patients with acute or chronic tinnitus.

OBJECTIVE: The mechanisms underlying the shift from acute tinnitus to chronic remain obscure. An association between tinnitus and medial olivocochlear bundle (MOCB) reflex dysfunction has been hypothesised by several studies. The differences between participants with acute and chronic tinnitus have not yet been investigated. DESIGN: Participants were examined with distortion product otoacoustic emissions (DPOAEs) suppression elicited by contralateral white noise. They were compared in terms of frequency regions with non-recordable DPOAEs, suppression amplitudes and the presence of DPOAE enhancement. STUDY SAMPLE: Eighteen participants with acute tinnitus, 40 age-matched adults with chronic tinnitus and 17 controls were included. All participants (aged 34.7 ± 9.6years; mean ± Standard deviation) had normal hearing. Tinnitus was bilateral in 22 participants and unilateral in 36. RESULTS: Ears with chronic tinnitus presented significantly lower DPOAE suppression amplitudes than ears with acute tinnitus (p < 0.0001). Both acute and chronic tinnitus ears present a high prevalence of enhancement, significantly different from controls (p < 0.0001, p = 0.0002, respectively). Non-recordable DPOAEs were significantly more frequent in the chronic than in the acute tinnitus and control groups (p < 0.0001). CONCLUSIONS: The differences between study groups indicate that when tinnitus becomes chronic, DPOAEs suppression presents changes that might reveal corresponding steps in tinnitus pathophysiology. Treatment implications are discussed.

Impact of coronary artery stent edge dissections on long-term clinical outcome in patients with acute coronary syndrome: an optical coherence tomography study.

AIMS: The purpose of the present study was to assess the incidence, predictors and long term prognosis of stent edge dissections identified by (OCT) after the implantation of bare metal (BMS) and drug eluting stents (DES). METHODS AND RESULTS: We studied 74 patients who underwent percutaneous coronary intervention (PCI) because of an acute coronary syndrome. Edge dissections were found in 29 of 74 patients (39.1%). Independent predictors of edge dissections were: the presence of ST-elevation myocardial infarction (STEMI) (P = 0.005, odds ratio 11.78; 95% Cl 2.06-67.10), the small reference lumen diameter (P = 0.009, odds ratio 0.11; 95% Cl 0.02-0.58) and the short stents implanted (P = 0.013, odds ratio 0.83; 95% Cl 0.72-0.96). During a follow-up period of 25.6 ± 9.4 months 11 patients presented with at least one major adverse cardiac event. Event free survival was significantly decreased in patients with edge dissection with a flap thickness >0.31 mm compared to patients with thinner flap or without any dissection (P < 0.001). CONCLUSIONS: OCT frequently detects edge dissections, usually related to STEMI presentation and to PCI technique. Deep vessel wall injury at stent edges with a dissection flap thickness more than 0.31mm carries an adverse clinical impact on long-term clinical outcome.

Hyposmia: an underestimated and frequent adverse effect of chemotherapy.

OBJECTIVES: Optimal function of both the olfactory sensory neurons and the olfactory mucosa is a prerequisite for normal olfactory perception. Both the olfactory neurons and mucosa might be subjects to the neurotoxic and mucotoxic effects of chemotherapy. Despite the recognized importance of olfaction in nutrition and quality of life, the potential olfactory toxicity of chemotherapy regimens has not been adequately assessed. The aim of this study is to investigate whether mucotoxic and/or neurotoxic drugs compromise olfactory performance. PATIENTS AND METHODS: Forty-four consecutive patients completed the "Sniffin' Sticks" test, an objective quantitative/qualitative method to assess olfactory function, at diagnosis and immediately before the infusion of the last session of three to four chemotherapy cycles, according to the therapeutic protocol. The patients underwent therapy containing oxaliplatin and antimetabolites (5-FU or capecitabine; O+A group), taxanes and platinum analogues (cisplatin and carboplatin; T+P group), or taxanes and anthracyclines (doxorubicin or liposomal doxorubicin; T+A group). RESULTS: A significant decrease was noted for olfactory threshold (OT), olfactory discrimination (OD), olfactory identification (OI), and the composite threshold-discrimination-identification (TDI) score. A significant deterioration of all olfactory indices was found for each chemotherapy group. Pairwise comparisons revealed significant differences between the O+A and the T+P group regarding OT and TDI. TDI scores were significantly lower after chemotherapy in all age groups. Patients older than 50 years were found to be more susceptible to olfactory toxicity than younger patients. CONCLUSIONS: Patients who undergo chemotherapy experience significant compromise in their olfactory function. A grading system for olfactory toxicity is proposed.

Predictors of quality of life improvement in allergic rhinitis patients after sublingual immunotherapy.

OBJECTIVES: Sublingual immunotherapy (SLIT) has been described as a significant intervention in the treatment of allergic rhinitis (AR). However, factors that may predict treatment outcomes with respect to quality of life (QoL) results and mainly the role of olfactory function are still being underestimated. In this study, we investigated determinants that best predict treatment outcomes for QoL, exploring mainly the role of olfaction. METHODS: One hundred forty-five patients following SLIT, 45 placebo-controls, and 48 healthy subjects were studied. Olfactory function was objectively evaluated using "Sniffin' Sticks" test pre- and post-cessation of SLIT. Three categories of validated QoL questionnaires were filled out by all subjects: questionnaire specific for olfaction (Questionnaire of Olfactory Deficits), questionnaires for assessing psychology (Beck Depression Inventory, Zung Depression Scale, State & Trait Anxiety Inventory), general Short Form-36 health survey. RESULTS: Statistically significant improvement of olfactory function by 11.1% and of all QoL questionnaires results (all P<.001) was observed on final evaluation. Anosmia, asthma history, and the severity of symptoms-expressed by the Total Symptoms Score-were proven independent determinants of clinically significant improvement in patients' QoL. CONCLUSIONS: Several factors were found that may predict QoL outcomes in AR patients following SLIT.

Functional characterization of glutathione S-transferases associated with insecticide resistance in Tetranychus urticae.

The two-spotted spider mite Tetranychus urticae is one of the most important agricultural pests world-wide. It is extremely polyphagous and develops resistance to acaricides. The overexpression of several glutathione S-transferases (GSTs) has been associated with insecticide resistance. Here, we functionally expressed and characterized three GSTs, two of the delta class (TuGSTd10, TuGSTd14) and one of the mu class (TuGSTm09), which had been previously associated with striking resistance phenotypes against abamectin and other acaricides/insecticides, by transcriptional studies. Functional analysis showed that all three GSTs were capable of catalyzing the conjugation of both 1-chloro-2,4 dinitrobenzene (CDNB) and 1,2-dichloro-4-nitrobenzene(DCNB) to glutathione (GSH), as well as exhibiting GSH-dependent peroxidase activity toward Cumene hydroperoxide (CumOOH). The steady-state kinetics of the T. urticae GSTs for the GSH/CDNB conjugation reaction were determined and compared with other GSTs. The interaction of the three recombinant proteins with several acaricides and insecticides was also investigated. TuGSTd14 showed the highest affinity toward abamectin and a competitive type of inhibition, which suggests that the insecticide may bind to the H-site of the enzyme. The three-dimensional structure of the TuGSTd14 was predicted based on X-ray structures of delta class GSTs using molecular modeling. Structural analysis was used to identify key structural characteristics and to provide insights into the substrate specificity and the catalytic mechanism of TuGSTd14.

Glottic and supraglottic pT3 squamous cell carcinoma: outcomes with transoral laser microsurgery.

Patients diagnosed with T3 squamous cell laryngeal carcinomas are nowadays offered either organ-preserving surgical or non-surgical treatment, with the optimum approach remaining undefined. No direct comparison of organ-preserving therapeutical options, stratified by anatomical subsites is available in the literature. The aim of this study is to present institutional treatment outcomes for laser-assisted microsurgery (TLM) of laryngeal T3 squamous cell carcinomas and review the relevant literature. Sixty-four consecutive, previously untreated patients were evaluated. Twenty-four supraglottic and 19 glottic patients were treated with TLM and neck dissection, tumor exposure and postoperative upstaging of the tumors through pathology evaluation of the specimens being the only exclusion criteria. Five-year disease-specific survival and organ preservation rates for supraglottic carcinomas were both 91.7 %. The respective values for glottic carcinomas were 63.2 and 73.3 %. TLM-treated T3 supraglottic tumors seem to attribute better outcomes than T3 glottic tumors in terms of recurrence-free survival, organ preservation and local control (p = 0.01, <0.0001 and 0.01, respectively). The results of this study suggest that TLM-treated T3 supraglottic tumors have a good prognosis, substantially better than that of glottic tumors. A literature review, on the other hand, attributes to chemo-radiation-treated T3 supraglottic tumors a considerably poorer prognosis. Further studies of homogenous populations in terms of anatomical subsites are needed in order to reach a consensus regarding treatment of T3 laryngeal tumors.

Mannitol and renal dysfunction after endovascular aortic aneurysm repair procedures: a randomized trial.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) may result in deterioration of renal function. Mannitol has renovascular and antioxidant properties that could prove beneficial in this respect. DESIGN: A randomized prospective study. SETTING: Attikon University Hospital, single institution. PARTICIPANTS: Eighty-six patients undergoing elective EVAR under regional anesthesia. METHODS: Patients received hydration alone (controls) or hydration plus mannitol (0.5 g/kg). MEASUREMENTS AND MAIN RESULTS: Creatinine, serum cystatin-C, urine neutrophil-gelatinase-associated lipocalin (NGAL), albuminuria and serum urea were measured 24 hours and 72 hours after the procedure (baseline NGAL was measured in 19 randomly selected patients). Serum creatinine also was measured at the followup of the patients. Serum creatinine and cystatin-C were lower in the mannitol group at 24 hours postoperatively (creatinine, mannitol [n=43]; 1.07±0.26 [CI95%: 0.99-1.15] v controls [n=43]; 1.20±0.30 [CI95%: 1.11-1.30]), but not at 72 hours (creatinine, mannitol [n=43]; 1.13±0.29 [CI95%: 1.04-1.22] v controls [n=43]; 1.26±0.41 [CI95% 1.15-1.38]). Urine NGAL increased substantially at 24 hours without differences between groups. At followup (controls: 13±7 months; mannitol: 12±7 months), there were no differences between creatinine or creatinine clearance (creatinine: controls [n=28]; 1.15±0.39 [CI95% 1.02-1.29] v mannitol [n=23]; 1.05±0.27 [CI95%: 0.95-1.17]). The overall changes of creatinine and creatinine clearance with time were significant in controls but not in the mannitol group. The classification according to the RIFLE criteria yielded 4 patients at risk for renal injury and 2 with renal injury in the control group and 6 patients at risk with no patients with injury in the mannitol group, but the difference of renal dysfunction between the 2 groups was not statistically significant. CONCLUSIONS: Mannitol plus hydration during EVAR provides a small but significant benefit for renal function. Future preventive protocols aiming at greater restoration of renal function after EVAR could include mannitol as a useful component.

Development, application and evaluation of three novel TaqMan qPCR assays for phosphine resistance monitoring in major stored product pests Tribolium castaneum and Rhyzopertha dominica.

BACKROUND: Stored product protection from insect pests relies heavily on the use of phosphine. The most serious drawback of phosphine is the development of resistance in major stored product insects worldwide, including the red flour beetle, Tribolium castaneum (Herbst) and the lesser grain borer, Rhyzopertha dominica (F.). Two genetic loci are responsible for phosphine resistance: the rph1 (S349G mutation in the cyt-b5-r homolog) in T. castaneum and the rph2 (P45/49S mutation in the dihydrolipoamide dehydrogenase (dld) gene) in T. castaneum and R. dominica. RESULTS: In this study, we have developed and applied high-throughput, practical and specific molecular diagnostics (TaqMan qPCR) for monitoring mutations S349G, P45S and P49S. In our pilot monitoring application, we have included phosphine-resistant and susceptible populations from different parts of the world (USA, Australia, Brazil) and European strains from Greece and Serbia. Our results for the resistant T. castaneum showed a P45S mutant allele frequency (MAF) of 100% and 75.0% in the populations from Serbia and Brazil, respectively. Regarding the susceptible T. castaneum, P45S was detected in Greece (MAF = 62.5%) and was absent in Australia (MAF = 0.0%). Additionally, the S349G mutation was found to be fixed in all resistant populations, while it was also detected in susceptible ones (frequencies: 65.0% and 100.0%). The only case where both mutations were fixed (100%) was a resistant population from Serbia. In R. dominica, the P49S mutation was found only in the two resistant R. dominica populations from Serbia and Greece (50.0% and 100%) and was absent from the susceptible one from Greece; thus, P49S seems to be a satisfactory indicator for monitoring phosphine resistance. CONCLUSIONS: Our P49S detection assay in R. dominica seems to be a viable option in this direction, yet its utilization needs additional large-scale confirmatory work. The identification of additional resistance markers also should be prioritized. © 2023 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Unsupervised Screen Exposure and Poor Language Development: A Scoping Review to Assess Current Evidence and Suggest Priorities for Research.

Screen exposure has both negative and positive effects on the level of language skills a child acquires. The purpose of this review is to address current literature on the possible relationship between unsupervised screen exposure and language development in children and to provide recommendations to caregivers regarding screen exposure of children, taking into consideration the possible effects. A scoping review was conducted using the PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) database. A total of 590 articles were retrieved and considered for inclusion. Twenty-one articles were finally included and reviewed with an emphasis on language, communication, and executive skills as well as cognitive development. The negative effects of screen exposure for children outweigh the positive effects. The largest number of studies demonstrate that unsupervised screen exposure may negatively impact a child's language usage and cognitive and executive skills, disrupt playtime, and affect the quality of sleep. On the other hand, supervised screen use is associated with improved language skills. More evidence is needed on unsupervised exposure in children to new types of screens. As technology could play a significant role in schools in the future, additional research is required to create educational media for schoolchildren with specific guidelines.

Cochlear dysfunction in patients with acute hypothyroidism.

The effect of acute hypothyroidism on the cochlear function was studied prospectively, in a group of 52 patients with thyroid carcinoma who underwent total thyroidectomy. All patients were examined before surgery and 6-8 weeks postoperatively. During this period there was no replacement with levothyroxine and the magnitude of thyroxin depletion was monitored by serum thyroid-stimulating hormone levels. Pure-tone audiometry, tympanometry and transiently evoked otoacoustic emissions were performed. A group of healthy volunteers of similar age and sex were used as controls. Tympanograms were normal, either on initial or on repeat testing. Audiometry showed elevation of all postoperative hearing thresholds, whereas the thresholds varied significantly across frequency. Transiently evoked otoacoustic emission testing showed response signal-to-noise ratios lower in the postoperative session (hypothyroid state) than in the preoperative session on all measured frequencies. Emission levels varied significantly across frequency, with maximum response observed at 2 kHz. Comparison of significant pure-tone and otoacoustic emission shifts for individual ears showed more ears affected in otoacoustic emission testing, indicating subclinical involvement. Comparing hearing thresholds and otoacoustic emission levels between patients and controls showed significant differences on postoperative testing. It may be thus concluded that acute hypothyroidism causes elevation of hearing thresholds in humans and to a greater degree subclinical damage of the cochlear function.

Influence of cochlear implantation on the vestibular function.

The aim of the present study was to examine the influence of cochlear implantation on vestibular function. The function of the horizontal semicircular canal, the saccular function, and the incidence of vestibular symptoms were assessed before and after cochlear implantation. Twenty unilaterally cochlear implant patients were evaluated preoperatively, 1 and 6 months postoperatively, with caloric testing with electronystagmography (ENG) recordings and vestibular evoked myogenic potentials (VEMP) testing. A medical history was taken from every subject, noting the presence or absence of vertigo before and after the operation. A possible correlation between the appearance of postoperative vertigo and age, sex, implant side, preoperative caloric results and VEMP status, and postoperatively recorded changes in caloric and VEMP testing was also investigated. A statistically significant difference was found in the percentages of canal paresis (p = 0.01) and the percentages of VEMP waveform absence (p = 0.002) between the repeated measurements in the implanted side, whereas in the non-implanted side no difference was (p > 0.05) found. Four patients complained of postoperative vestibular symptoms. In three of them the symptoms lasted less than 6 months postoperatively, but the fourth patient was still dizzy 6 months after cochlear implantation. No correlation was found between the above-mentioned factors and the occurrence of postoperative vertigo. In conclusion, although changes of the peripheral vestibular function of the implanted side were recorded in our patients, permanent vertigo was rare. Predictive factors for the occurrence of postoperative vestibular symptoms could not be identified.

Unusual Presentation of Pneumocephalus With Late Onset During Labour Epidural Analgesia.

A 36-year-old woman with no significant medical history was in active labour and requested labour analgesia. While the epidural technique was performed at the L4-L5 interspace, using the loss of resistance to air technique (LORA), inadvertent dural puncture occurred. Since the patient reported no headache or discomfort, the same procedure was repeated at the L3-L4 interspace successfully. Loss of resistance was reported at 3 cm and the epidural catheter was advanced uneventfully at 8 cm. Aspiration was negative for blood or cerebrospinal fluid (CSF) and a test dose of 2 ml lidocaine 2% was administered epidurally. Within five minutes the patient exhibited a mild hypotensive episode successfully treated with 2.5 mg ephedrine IV, a sensory blockade up to T6 level, and a motor blockade up to T10 level. Both the woman's and the baby's vital signs remained stable, no further drugs were administered epidurally and labour progressed painlessly and uncomplicated for 90 minutes with subsequent vaginal delivery of a healthy newborn. During the episiotomy incision repair, the patient complained of light dizziness and nausea. Her vital signs and the arterial blood gases (ABGs) ordered were within normal range, but the neurological examination revealed an isolated Babinski on the right foot. The head CT scan requested indicated a considerable quantity of air within the subarachnoid region. The patient was treated conservatively; symptoms showed steady improvement with total resolution on the sixth day, and the woman was discharged. This case reemphasizes the possibility of pneumocephalus, which may, in reality, occur more frequently than is commonly recognized without a CT confirmation.

Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery.

The enhanced recovery after surgery (ERAS) protocols are a comprehensive therapeutic approach that prioritizes the well-being of patients. It encompasses several aspects such as providing sufficient nutritional support, effectively managing pain, ensuring appropriate fluid management and hydration, and promoting early mobilization after surgery. The advent of ERAS theory has led to a shift in focus within modern ERAS protocols. At present, ERAS protocols emphasize perioperative therapeutic strategies employed by surgeons and anesthesiologists, as well as place increased importance on preoperative patient education, interdisciplinary collaboration, and the enhancement of patient satisfaction and clinical outcomes. This editorial highlights the application of ERAS protocols in the current context of total joint replacement surgery.

IL-6 Serum Levels in COVID-19 Patients With Vertigo.

Introduction Dizziness and vertigo represent well-established symptoms of COVID-19. An overexpression of cytokines, a condition often described with the term "cytokine storm" or "hypercytokinemia", is a key characteristic of SARS-Cov-2 infection and plays a pivotal role in disease progression and prognosis. Among them, IL-6 is of major importance.  Purpose The purpose of this study is to investigate any probable IL-6 serum titer difference in COVID-19 patients with vertigo (V+) or without vertigo (V-) admitted to the COVID-19 internal medicine departments of Attikon University Hospital, Athens, Greece, within 12 months. Methods The sample consisted of 52 COVID-19 patients who were diagnosed between January 1, 2020, and December 31, 2020. Of those, 31 reported vertigos during their admission (V+), while the remaining 21 COVID-19 patients did not complain of such symptoms (V-). Results Higher IL-6 serum levels post-COVID-19 infections lead to higher incidence rates of vertigo symptoms (p<.005), regardless of gender and age (p.005).