Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia.

BACKGROUND: Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR). MATERIALS AND METHOD: s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (n = 188) and nonmannitol (n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p < 0.05. RESULTS: Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18-0.89; p = 0.02). CONCLUSION: Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Comparison of the Newborn Infant Parasympathetic Evaluation (NIPE™) index to changes in heart rate to detect intraoperative nociceptive stimuli in healthy and critically ill children below 2 years: An observational study.

BACKGROUND: The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown. AIM: Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium. METHODS: Fifty-one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens- und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium. RESULTS: In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%-30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p = .004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p = .04), but not with intraoperative NIPE depression. CONCLUSION: The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive.

Extended neuromonitoring in aortic arch surgery : A case series.

BACKGROUND: Aortic arch repair for aortic dissection is still associated with a high mortality rate. Providing adequate means of neuromonitoring to guide cerebral hemodynamics is advantageous, especially during selective anterior cerebral perfusion (SACP). OBJECTIVE: We aimed to investigate an easy multimodal neuromonitoring set-up consisting of processed electroencephalography (EEG), near infrared spectroscopy (NIRS), and transcranial doppler sonography (TCD). MATERIAL AND METHODS: We collected intraoperative data from six patients undergoing surgery for aortic dissection. In addition to standard hemodynamic monitoring, patients underwent continuous bilateral NIRS, processed EEG with bispectral index (BIS), and intermittent transcranial doppler sonography of the medial cerebral artery (MCA) with a standard B­mode ultrasound device. Doppler measurements were taken bilaterally before cardiopulmonary bypass (CPB), during CPB, and during SACP at regular intervals. RESULTS: Of the patients four survived without neurological deficits while two suffered fatal outcomes. Of the survivors two suffered from transient postoperative delirium. Multimodal monitoring led to a change in CPB flow or cannula repositioning in three patients. Left-sided mean flow velocities of the MCA decreased during SACP, as did BIS values. CONCLUSION: Monitoring consisting of BIS, NIRS, and TCD may have an impact on hemodynamic management in aortic arch operations.

Dynamic changes of angiopoietins and endothelial nitric oxide supply during fluid resuscitation for major gyn-oncological surgery: a prospective observation.

BACKGROUND: Despite goal-directed hemodynamic therapy, vascular function may deteriorate during surgery for advanced abdominal tumor masses. Fluid administration has been shown to be associated with distinct changes in serum levels of functional proteins. We sought to determine how serum total protein and angiopoietin (ANG) levels change during major abdominal tumor surgery. In addition, ex vivo endothelial nitric oxide synthase (eNOS) activation as well as NO bioavailability in vivo were assessed. METHODS: 30 patients scheduled for laparotomy for late-stage ovarian or uterine cancer were prospectively included. Advanced hemodynamic monitoring as well as protocol-driven goal-directed fluid optimization were performed. Total serum protein, ANG-1, -2, and soluble TIE2 were determined pre-, intra-, and postoperatively. Phosphorylation of eNOS was assessed in microvascular endothelial cells after incubation with patient serum, and microvascular reactivity was determined in vivo by near-infrared spectroscopy and arterial vascular occlusion. RESULTS: Cardiac output as well as preload gradually decreased during surgery and were associated with a median total fluid intake of 12.8 (9.7-15.4) mL/kg*h and a postoperative fluid balance of 6710 (4113-9271) mL. Total serum protein decreased significantly from baseline (66.5 (56.4-73.3) mg/mL) by almost half intraoperatively (42.7 (36.8-51.5) mg/mL, p < 0.0001) and remained at low level. While ANG-1 showed no significant dilutional change (baseline: 12.7 (11.9-13.9) ng/mL, postop.: 11.6 (10.8 -13.5) ng/mL, p = 0.06), serum levels of ANG-2 were even increased postoperatively (baseline: 2.2 (1.6-2.6) ng/mL vs. postop.: 3.4 (2.3-3.8) ng/mL, p < 0.0001), resulting in a significant shift in ANG-2 to ANG-1 ratio. Ex vivo phosphorylation of eNOS was decreased depending on increased ANG-2 levels and ANG-2/1 ratio (Spearman r = - 0.37, p = 0.007). In vivo, increased ANG-2 levels were associated with impaired capillary recruitment and NO bioavailability (Spearman r = - 0.83, p = 0.01). CONCLUSIONS: Fluid resuscitation-associated changes in serum vascular mediator profile during abdominal tumor surgery were accompanied by impaired eNOS activity ex vivo as well as reduced NO bioavailability in vivo. Our results may explain disturbed microvascular function in major surgery despite goal-directed hemodynamic optimization.

Relative cerebral hyperperfusion during cardiopulmonary bypass is associated with risk for postoperative delirium: a cross-sectional cohort study.

BACKGROUND: Our objective was to evaluate if changes in on-pump cerebral blood flow, relative to the pre-bypass baseline, are associated with the risk for postoperative delirium (POD) following cardiac surgery. METHODS: In 47 consecutive adult patients, right middle cerebral artery blood flow velocity (MCAV) was assessed using transcranial Doppler sonography. Individual values, measured during cardiopulmonary bypass (CPB), were normalized to the pre-bypass baseline value and termed MCAVrel. An MCAVrel > 100% was defined as cerebral hyperperfusion. Prevalence of POD was assessed using the Confusion Assessment Method for the Intensive Care Unit. RESULTS: Overall prevalence of POD was 27%. In the subgroup without POD, 32% of patients had experienced relative cerebral hyperperfusion during CPB, compared to 67% in the subgroup with POD (p < 0.05). The mean averaged MCAVrel was 90 (±21) % in the no-POD group vs. 112 (±32) % in the POD group (p < 0.05), and patients developing delirium experienced cerebral hyperperfusion during CPB for about 39 (±35) min, compared to 6 (±11) min in the group without POD (p < 0.001). In a subcohort with pre-bypass baseline MCAV (MCAVbas) below the median MCAVbas of the whole cohort, prevalence of POD was 17% when MCAVrel during CPB was kept below 100%, but increased to 53% when these patients actually experienced relative cerebral hyperperfusion. CONCLUSIONS: Our results suggest a critical role for cerebral hyperperfusion in the pathogenesis of POD following on-pump open-heart surgery, recommending a more individualized hemodynamic management, especially in the population at risk.

Network of Mediators for Vascular Inflammation and Leakage Is Dysbalanced during Cytoreductive Surgery for Late-Stage Ovarian Cancer.

BACKGROUND: Cytoreductive surgery (CS) in late-stage ovarian cancer patients is often challenging due to extensive volume shifts, and high fluid intake may provoke postoperative complications. Expression of vasoactive mediators is altered in cancer patients, which may affect systemic vascular function. We sought to assess how serum levels of vasoactive markers and mediators change during CS in ovarian cancer. METHODS: Following IRB approval and informed consent, pre- and postoperative serum samples were analyzed in 26 late-stage ovarian cancer patients using multiplex protein arrays and ELISA. RESULTS: The proinflammatory cytokines and chemokines IL-6, IL-8, and CCL2 were significantly elevated after 24 hrs compared to the baseline values, with IL-6 and IL-8 being most prominently increased. While ANGPT1 remained unchanged after surgery, its competitive antagonist ANGPT2 was significantly increased. In contrast, serum levels of the ANGPT receptor TIE2 were decreased to 0.6 of the baseline values. While VEGF-D, E-selectin, P-selectin, ICAM-1, and PECAM-1 remained unchanged, serum activity of both thrombomodulin and syndecan-1 was significantly increased following surgery. CONCLUSION: We identified a regulatory network of acute-phase reaction during CS in late-stage ovarian cancer. This suggests that IL-6 exerts positive regulation of other proinflammatory mediators and, by upregulating ANGPT2 and suppressing ANGPT1, induces a serum profile that promotes vascular leakage. This may contribute to the observed hemodynamic alterations during CS procedures.

Synthetic CpG oligonucleotides induce a genetic profile ameliorating murine myocardial I/R injury.

We previously demonstrated that pre-conditioning with CpG oligonucleotide (ODN) 1668 induces quick up-regulation of gene expression 3 hours post-murine myocardial ischaemia/reperfusion (I/R) injury, terminating inflammatory processes that sustain I/R injury. Now, performing comprehensive microarray and biocomputational analyses, we sought to further enlighten the "black box" beyond these first 3 hours. C57BL/6 mice were pretreated with either CpG 1668 or with control ODN 1612, respectively. Sixteen hours later, myocardial ischaemia was induced for 1 hour in a closed-chest model, followed by reperfusion for 24 hours. RNA was extracted from hearts, and labelled cDNA was hybridized to gene microarrays. Data analysis was performed with BRB ArrayTools and Ingenuity Pathway Analysis. Functional groups mediating restoration of cellular integrity were among the top up-regulated categories. Genes known to influence cardiomyocyte survival were strongly induced 24 hours post-I/R. In contrast, proinflammatory pathways were down-regulated. Interleukin-10, an upstream regulator, suppressed specifically selected proinflammatory target genes at 24 hours compared to 3 hours post-I/R. The IL1 complex is supposed to be one regulator of a network increasing cardiovascular angiogenesis. The up-regulation of numerous protective pathways and the suppression of proinflammatory activity are supposed to be the genetic correlate of the cardioprotective effects of CpG 1668 pre-conditioning.

Cerebral Function and Perfusion during Cardiopulmonary Bypass: A Plea for a Multimodal Monitoring Approach.

BACKGROUND: Postoperative neurological injury still represents a major cause of morbidity after cardiac surgery. Our objective was to compare the limits as well as advantages of routine monitoring tools for the detection of cerebral function and perfusion deficits during cardiopulmonary bypass in a daily clinical setting. METHODS: Adult patients undergoing elective cardiac surgery with use of cardiopulmonary bypass were included. Patients received monitoring comprising Bispectral Index (BIS), Near Infrared Spectroscopy (NIRS) and assessment of middle cerebral artery flow velocity (MCAV) using transcranial Doppler (TCD) sonography. Measurements were taken after anesthesia induction (at baseline) and every 10 minutes during aortic cross-clamping. Relative deviation from baseline values was calculated. Values were compared with predefined, generally accepted threshold values identifying patients at risk for cerebral functional and perfusion deficits. RESULTS: 30 consecutive patients were included into data analysis. Compared to NIRS as well as BIS monitoring, there was a wide interindividual variability in relative MCAV values for the whole cohort (median 0.9, range 0.39-2.19). Out of 229 measurements in total, 82 BIS but only 30 NIRS and 12 TCD values were lying outside predefined limits. TCD monitoring identified two patients with disturbed cerebral autoregulation, while NIRS remained unremarkable. The latter was significantly associated with systemic hemoglobin levels. Finally, patients with relative MCAV values >1.0 had a higher risk of developing postoperative delirium. CONCLUSION: Our findings reveal inherent technical limitations of each individual monitoring component, such as high interindividual variability (TCD), low spatial resolution (NIRS), or interaction with anesthetics (BIS). We therefore argue for a multimodal neuromonitoring that combines several qualities. Such approach would help reducing these limitations while individual components complement each other, thus providing more patient safety during cardiac surgery. Furthermore, such an approach would be easily applicable in a routine clinical setting.

Vendor effects on murine gut microbiota influence experimental abdominal sepsis.

BACKGROUND: Experimental animal models are indispensable components of preclinical sepsis research. Reproducible results highly rely on defined and invariant baseline conditions. Our hypothesis was that the murine gut microbiota varies among different distributors of laboratory animals and that these variations influence the phenotype of abdominal sepsis derived from a bacterial inoculum model (intraperitoneal stool injection). MATERIALS AND METHODS: Male C57BL/6 mice (8-wk old) purchased from Charles River (CR), Janvier (J), and Harlan (H) were sacrificed, and the bacterial composition of feces was analyzed using CHROMagar orientation medium. Stool was injected intraperitoneally into CR mice, followed by clinical observation and gene expression analysis. Experiments were repeated 16 mo later under the same conditions. RESULTS: Stool analysis revealed profound intervendor differences in bacterial composition, mainly regarding Staphylococcus aureus and Bacillus licheniformis. Mice challenged with CR as well as H feces developed significantly higher severity of disease and died within the observation period, whereas stool from J mice did not induce any of these symptoms. Real-time polymerase chain reaction revealed corresponding results with significant upregulation of proinflammatory cytokines and vascular leakage-related mediators in CR and H injected animals. Sixteen months later, the bacterial fecal composition had significantly shifted. The differences in clinical phenotype of sepsis after intraperitoneal stool injection had vanished. CONCLUSIONS: We are the first to demonstrate vendor and time effects on the murine fecal microbiota influencing sepsis models of intraabdominal stool contamination. The intestinal microbiota must be defined and standardized when designing and interpreting past and future studies using murine abdominal sepsis models.

Pulmonary vascular inflammation: effect of TLR signalling on angiopoietin/TIE regulation.

Increased pulmonary vascular resistance is a critical complication in sepsis. Toll-like receptor (TLR) as well as angiopoietin (ANG) signalling both contribute to the emergence of pulmonary arterial hypertension. We hypothesized that TLR stimulation by bacterial ligands directly affects expression and secretion of ligands and receptors of the angiopoietin/TIE axis. Microvascular endothelial (HPMEC) and smooth muscle cells (SMC) of pulmonary origin were incubated with thrombin and with ligands for TLR2, -4, -5, and -9. Expression and secretion of ANG1, -2, TIE2 and IL-8 were determined using quantitative real-time PCR and ELISA. TLR stimulation had no impact either on the expression of ANG2 and TIE2 in HPMEC or on that of ANG1 in SMC. However, overall levels of both released ANG1 and -2 were halved upon stimulation with the TLR9 ligand CpG, and ANG2 release was significantly enhanced by TLR4 activation when initially provoked by sequentially performed stimulation. Furthermore, enhanced ANG2 activity increased endothelial permeability, as demonstrated in an in vitro transwell assay. We conclude that sole TLR stimulation by bacterial ligands plays no significant role for altered expression and secretion of ANG1, -2 and TIE2 in human pulmonary vascular cells. The interplay between various stimuli is required to induce imbalances between ANG1 and -2.

Endothelial permeability following coronary artery bypass grafting: an observational study on the possible role of angiopoietin imbalance.

BACKGROUND: Unresolved inflammation resulting in capillary leakage with endothelial barrier dysfunction is a major contributor to postoperative morbidity and mortality after coronary artery bypass graft (CABG). Angiopoietins (ANGs) are vascular growth factors, also mediating inflammation and disruption of the endothelium, thus inducing capillary leakage. We hypothesized that changes in the relative serum levels of ANG1 and ANG2 influence endothelial barrier function and perioperative morbidity after CABG. METHODS: After approval and informed consent, serum samples (n = 28) were collected pre CABG surgery, 1, 6, and 24 h after aortic de-clamping. ANG1, ANG2, soluble ANG receptor TIE2 (sTIE2), and IL-6 serum concentrations were analyzed by ELISA. Human pulmonary microvascular endothelial cells (HPMECs) were incubated with patient serum and FITC-dextran permeability was assessed. Furthermore, ANG2 secretion of HPMECs was analyzed after incubation with IL-6-containing patient serum. RESULTS: CABG induced an early and sustained increase of ANG2/ANG1 ratio (5-fold after 24 h compared to pre-surgery). These changes correlated with elevated serum lactate levels, fluid balance, as well as the duration of mechanical ventilation. Permeability of HPMECs significantly increased after incubation with post-surgery serum showing a marked shift of ANG2/ANG1 balance (18-fold) compared to serum with a less pronounced increase (6-fold). Furthermore, CABG resulted in increased IL-6 serum content. Pre-incubation with serum containing high levels of IL-6 amplified the ANG2 secretion by HPMECs; however, this was not influenced by blocking IL-6. CONCLUSIONS: CABG affects the balance between ANG1 and ANG2 towards a dominance of the barrier-disruptive ANG2. Our data suggest that this ANG2/ANG1 imbalance contributes to an increased postoperative endothelial permeability, likewise being reflected by the clinical course. The results strongly suggest a biological effect of altered angiopoietin balance during cardiac surgery on endothelial permeability.

The Use of Internal Jugular Vein Ultrasonography to Anticipate Low or High Central Venous Pressure During Mechanical Ventilation.

BACKGROUND: Critically low or high central venous pressure (CVP) values, together with systemic hypotension, can indicate hypovolemia or acute heart failure. However, measuring CVP requires the insertion of a central venous catheter, a time-consuming procedure that can be associated with severe complications. OBJECTIVE: We sought to evaluate the use of ultrasonography of the internal jugular vein (IJV) to estimate low or high CVP values in patients who were on ventilation. METHODS: Ultrasonography of IJV dimensions and the collection of hemodynamic data was performed in 47 patients, and the ratio between IJV diameter in the 30° and 0° position was calculated (ratio(30/0)). The predictive value of ratio(30/0) for estimating low and high CVP levels was analyzed using receiver operating characteristic curves. RESULTS: The median IJV diameter ratio(30/0) was 0.49. CVP ranged from 1 to 13 mm Hg (median 7 mm Hg). Seventeen patients had a CVP ≤ 5 mm Hg or lower (defined as "low"), and in 11 patients, values of ≥ 10 mm Hg were measured (defined as "high"). The corresponding IJV diameter ratios increased significantly from 0.34 (in the low CVP group) to 0.9 (in the high CVP group). Receiver operating characteristic analysis revealed a good predictive value of the ratio(30/0) for the prediction of low or high CVP values, respectively. A ratio(30/0) of < 0.45 optimally indicated a low CVP, while > 0.65 was the cutoff value to detect a CVP ≥ 10 mm Hg. CONCLUSION: The estimation of low or high CVP values by IJV ultrasonography in different patient positions can be a helpful instrument for the rapid hemodynamic assessment of the critically ill patient.

Synergistic Stimulation with Different TLR7 Ligands Modulates Gene Expression Patterns in the Human Plasmacytoid Dendritic Cell Line CAL-1.

OBJECTIVE: TLR7 ligation in plasmacytoid dendritic cells is promising for the treatment of cancer, allergy, and infectious diseases; however, high doses of ligands are required. We hypothesized that the combination of structurally different TLR7 ligands exponentiates the resulting immune response. METHODS: CAL-1 (human pDC line) cells were incubated with the TLR7-specific adenine analog CL264 and single-stranded 9.2s RNA. Protein secretion was measured by ELISA. Microarray technique was used to detect modified gene expression patterns upon synergistic stimulation, revealing underlying functional groups and networks. Cell surface binding properties were studied using FACS analysis. RESULTS: CL264 in combination with 9.2s RNA significantly enhanced cytokine and interferon secretion to supra-additive levels. This effect was due to a stronger stimulation of already regulated genes (by monostimulation) as well as to recruitment of thus far unregulated genes. Top scoring canonical pathways referred to immune-related processes. Network analysis revealed IL-1ß, IL-6, TNF, and IFN-ß as major regulatory nodes, while several minor regulatory nodes were also identified. Binding of CL264 to the cell surface was enhanced by 9.2s RNA. CONCLUSION: Structurally different TLR7 ligands act synergistically on gene expression patterns and on the resulting inflammatory response. These data could impact future strategies optimizing TLR7-targeted drug design.

Influence of Intraoperative Fluid Management on Postoperative Outcome and Mortality of Cytoreductive Surgery for Advanced Ovarian Cancer-A Retrospective Observational Study.

Background: The surgical treatment of advanced ovarian cancer is associated with extensive tissue trauma, prolonged operating times and a considerable volume shift. It, therefore, represents a challenge for anaesthesiological management. Aim: The aim of this single-centre, retrospective, observational study was to investigate whether intraoperative extensive volume supply influences postoperative outcomes and long-term survival. Methods: The study included 73 patients with a mean (SD) age of 63 (13) years who underwent extensive tumour-reducing surgery for ovarian cancer between 2012 and 2015. The effect of the intraoperative fluid balance on postoperative complications, such as anastomotic insufficiency or pleural effusions, was investigated using logistic regression. Further, the influence of fluid balance, lactate and creatinine levels on 5-year survival was analysed in a Cox regression model. Associations between anaesthesia time and the intraoperative fluid balance were examined using Spearman's rank correlation coefficients. Results: The mean (SD) postoperative fluid balance in the considered patient cohort was 9.1 (3.4) litres (l) at a mean (SD) anaesthesia time of 529 (106) minutes. Cox regression did not reveal a statistically significant effect of the fluid balance, but it did reveal a statistically significant association between the lactate level 24 h following surgery and the 5-year survival (HR [95%-CI] fluid balance: 0.97 [0.85, 1.11]; HR [95%-CI] lactate: 1.79 [1.24, 2.58]). According to logistic regression, the intraoperative fluid balance was associated with an increased chance of postoperative complications in the considered patient cohort (OR [95%-CI] 1.28 [1.1, 1.54]). Conclusions: We could not detect a negative impact of an increased fluid balance on 5-year survival, but a negative impact on postoperative complications was found in our patient cohort.

Lower Patient Height and Weight Are Predisposing Factors for Complex Radial Arterial Catheterization.

Background: Radial artery (RA) catheterization for invasive blood pressure monitoring is often performed via palpation, and an ultrasound is used secondarily only in case of multiple unsuccessful attempts. Although more elaborate, it has been shown that primary ultrasound-guided catheterization may be advantageous compared with palpation. The aim of this study was to identify factors associated with difficult RA catheterization. Methods: Left RA ultrasound assessments were performed in patients with indicated invasive blood pressure monitoring the day before surgery. RA catheterization was performed by personnel blinded to the ultrasound results. Based on the number of attempts needed for successful catheter placement, the cohort was divided into uncomplicated (group 1) and difficult (more than one attempt, group 2) catheterization cases. Cases subjected to primary ultrasound were excluded from the analysis. Results: Body weight, height and surface area (BSA) of patients in group 2 (n = 16) were significantly lower than those of patients in group 1 (n = 25), and internal RA diameters were significantly smaller in group 2 patients. In the whole cohort, BSA was significantly associated with distal and proximal internal RA diameters. In contrast, no differences were observed in the skin-to-artery distance, the longitudinal axis deviation (kinking) or blood flow velocity. Median time to successful catheterization was 77 (47-179) s. Prolonged time needed for cannulation was significantly associated with lower body weight, BMI and BSA, and with reduced distal and proximal internal RA diameter. Conclusions: RA catheterization performed through pulse palpation may be difficult, especially in adult patients with lower body weight and height, due to reduced arterial diameters. Initial use of ultrasound in these patients may reduce first-attempt failure, preventing procedural delays and patient discomfort.

The comparison of the morphology of the mid-palatal suture between edentulous individuals and dentate jaws shows morphological differences.

BACKGROUND: A profound understanding of the evolution and anatomy of the viscero- and neurocranium is quintessentially important for orthodontists. This particularly alludes to structures, which are directly targeted by orthodontic therapy such as the maxilla and the mid-palatal suture. The anatomy of the mid-palatal suture of toothed individuals is well described, whereas little is known about sutures' morphological changes after tooth loss. Therefore, the aim of this study was to evaluate the edentulous mid-palatal suture by means of histologic and histomorphometric analysis. METHODS: Ten mid-palatal sutures of edentulous donors as well as six age- and sex matched dentulous controls were examined. For the histological and histomorphometric analysis (sutural width, obliteration, vascularization and interdigitation) conventional staining protocols (HE, Movat-Pentachrome, Sirius Red) and immunofluorescence (vWF, TRAP) were performed. Histomorphometric analysis was carried out using NIS-elements imaging software. RESULTS: When compared to dentulous controls, the edentulous investigation group showed a decreased vascularization and sutural width as well as an increased sutural obliteration. Notably, a high variability and inhomogeneity within regard the histomorphometric parameters was seen in edentulous samples. CONCLUSIONS: The mid-palatal suture of edentulous individuals showed significant morphological differences compared to individuals with toothed jaws. The loss of teeth and thereby functional loading seems to have a considerable impact on sutures' morphology.

PRe-Operative Prediction of postoperative DElirium by appropriate SCreening (PROPDESC) development and validation of a pragmatic POD risk screening score based on routine preoperative data.

STUDY OBJECTIVE: To develop and validate a pragmatic risk screening score for postoperative delirium (POD) based on routine preoperative data. DESIGN: Prospective observational monocentric trial. SETTING: Preoperative data and POD assessment were collected from cardiac and non-cardiac surgical patients at a German university hospital. Data-driven modelling approaches (step-wise vs. component-wise gradient boosting on complete and restricted predictor set) were compared to predictor selection by experts (investigators vs. external Delphi survey). PATIENTS: Inpatients (≥60 years) scheduled for elective surgery lasting more than 60 min. MEASUREMENTS: POD was assessed daily during first five postoperative or post-sedation days with confusion assessment method for intensive and standard care unit (CAM-ICU/CAM), 4 'A's test (4AT) and Delirium Observation Screening (DOS) scale. MAIN RESULTS: From 1023 enrolled patients, 978 completed observations were separated in development (n = 600; POD incidence 22.2%) and validation (n = 378; POD incidence 25.7%) cohorts. Data-driven approaches generated models containing laboratory values, surgical discipline and several items on cognitive and quality of life assessment, which are time consuming to collect. Boosting on complete predictor set yielded the highest bootstrapped prediction accuracy (AUC 0.767) by selecting 12 predictors, with substantial dependence on cardiac surgery. Investigators selected via univariate comparison age, ASA and NYHA classification, surgical risk as well as ´serial subtraction´ and ´sentence repetition´ of the Montreal Cognitive Assessment (MoCA) to enable rapid collection of their risk score for preoperative screening. This investigator model provided slightly lower bootstrapped prediction accuracy (AUC 0.746) but proved to have robust results on validation cohort (AUC 0.725) irrespective of surgical discipline. Simplification of the investigator model by scaling and rounding of regression coefficients into the PROPDESC score achieved a comparable precision on the validation cohort (AUC 0.729). CONCLUSIONS: The PROPDESC score showed promising performance on a separate validation cohort in predicting POD based on routine preoperative data. Suitability for universal screening needs to be shown in a large external validation.