Effect of Low-pressure Pulmonary Recruitment Maneuver on Postlaparoscopic Shoulder Pain: Randomized Controlled Trial.

STUDY OBJECTIVE: Postlaparoscopic shoulder pain (PLSP) is effectively reduced by a pulmonary recruitment maneuver (PRM). The goal of this study is to assess the efficacy of a PRM using maximal inspiratory pressure of 30 cm H2O, which is lower than previously studied pressure for reducing PLSP. DESIGN: Randomized controlled trial. SETTING: University hospital. PATIENTS: Eighty-four patients who were undergoing elective gynecologic laparoscopy. INTERVENTIONS: Patients were randomly assigned to the control (n = 42) or the PRM (n = 42) group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the intensity of the shoulder pain using the visual analog scale (VAS). The VAS score of shoulder pain (median [interquartile range]) was significantly lower in the PRM group than in the control group at 24 hours (0 [0-0] vs 1.5 [0-4.0], p <.001) and 48 hours (0 [0-0] vs 1.0 [0-2.0], p <.001) after surgery. Other variables, including surgical pain score and vital signs, were similar between the 2 groups. CONCLUSION: The PRM with 30 cm H2O can be a simple method to reduce PLSP. Therefore, it would be helpful to perform the PRM with 30 cm H2O routinely.

Comparison of Carbon Dioxide Absorption Rates in Gynecologic Laparoscopy with a Valveless versus Standard Insufflation System: Randomized Controlled Trial.

STUDY OBJECTIVE: The primary objective was to compare carbon dioxide (CO2) absorption rates in patients undergoing gynecologic laparoscopy with a standard versus valveless insufflation system (AirSeal; ConMed, Utica, NY) at intra-abdominal pressures (IAPs) of 10 and 15 mm Hg. Secondary objectives were assessment of surgeons' visualization of the operative field, anesthesiologists' ability to maintain adequate end-tidal CO2 (etCO2), and patients' report of postoperative shoulder pain. DESIGN: A randomized controlled trial using an equal allocation ratio into 4 arms: standard insufflation/IAP 10 mm Hg, standard insufflation/IAP 15 mm Hg, valveless insufflation/IAP 10 mm Hg, and valveless insufflation/IAP 15 mm Hg. SETTING: Single tertiary care academic institution. PATIENTS: Women ≥ 18 years old undergoing nonemergent conventional or robotic gynecologic laparoscopic surgery. INTERVENTIONS: A standard or valveless insufflation system at IAPs of 10 or 15 mm Hg. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients were enrolled and randomized with 33 patients per group. There were 84 robotic cases and 47 conventional laparoscopic cases. CO2 absorption rates (mL/kg*min) did not differ across groups with mean rates of 4.00 ± 1.3 in the valveless insufflation groups and 4.00 ± 1.1 in the standard insufflation groups. The surgeons' rating of overall visualization of the operative field on a 10-point Likert scale favored the valveless insufflation system (median visualization, 9.0 ± 2.0 cm and 9.5 ± 1.8 cm at 10 and 15 mm Hg, respectively) over standard insufflation (7.0 ± 3.0 cm and 7.0 ± 2.0 cm at 10 and 15 mm Hg, respectively; p <.001). The anesthesiologists' ability to maintain adequate etCO2 was similar across groups (p = .417). Postoperative shoulder pain scores were low overall with no significant difference across groups (p >.05). CONCLUSION: CO2 absorption rates, anesthesiologists' ability to maintain adequate etCO2, and postoperative shoulder pain did not differ based on insufflation system type or IAP. Surgeons' rating of visualization of the operative field was significantly improved when using the valveless over the standard insufflation system.

Avaliação do crescimento de micro-organismos fotossintetizantes em fotobiorreator tubular empregando nutrientes provenientes da vinhaça tratada / Evaluation of the growth of photosynthetic microorganisms in tubular photobioreactor using nutrients from treated vinasse

vinhaça é resultante da produção de álcool, após a fermentação do mosto e destilação do vinho. É um resíduo rico em nutrientes, principalmente matéria orgânica, nitrogênio, fósforo e potássio. Para ser despejado em rios e lagos, esse efluente deve passar por tratamentos para remoção desses nutrientes, pois o excesso desses elementos nos corpos hídricos poderia levar a grandes problemas ambientais, de modo que tem sido utilizado em fertirrigação. Microorganismos fotossintetizantes absorvem nutrientes inorgânicos, podendo absorver nutrientes de águas residuais. Se for removida a parte orgânica da vinhaça, a fração inorgânica ou com baixa carga orgânica pode ser a base ou o próprio meio de cultivo destes micro-organismos, que absorvem gás carbônico e sua biomassa é de interesse industrial. Neste contexto, foi estudado o cultivo de Monoraphidium contortum e Synechocystis salina, oriundos de água de mangue, em frascos de Erlenmeyer e em fotobiorreatores tubulares por processo descontínuo, empregando a vinhaça proveniente do tratamento aeróbio (biológico), acoplada a processos físico-químicos, com diferentes diluições. As características físico-químicas das vinhaças tratadas foram avaliadas. Além disso, foram comparados os crescimentos celulares nas diferentes condições experimentais adotadas para o crescimento da microalga M. contortum e da cianobactéria S. salina na vinhaça tratada com e sem diluição. Em cultivos em frascos de Erlenmeyer, em meio proveniente de tratamento biológico, o crescimento celular não diferiu do cultivo em meio padrão, com diluições de 5 e 2 vezes da vinhaça tratada para M. contortum e S. salina, respectivamente. Em fotobiorreator tubular, independente do tratamento ser apenas biológico ou também com carvão ativado, as concentrações celulares máximas (Xm) de M. contortum e S. salina foram da ordem de 1,86x107 células mL-1 e 7,90x106 células mL-1, respectivamente, valores esses menores que os obtidos em meio padrão, com valores de Xm de 2,69x107 células mL-1 e 1,27x106 células mL-1 para M. contortum e S. salina, respectivamente. Em fotobiorreatores tubulares, os teores de mínimos de lipídios de M. contortum e S. salina foram de 33,4 % e 11,0 %, respectivamente. Adicionalmente, os teores mínimos de proteínas da microalga foram de 15,1 % e da cianobactéria foi de 23,2 %

The vinasse is the result of the production of alcohol after the fermentation of the mash and the distillation of the wine. It is a waste rich in nutrients, mainly organic matter, nitrogen, phosphorus and potassium. To be discharged into rivers and lakes, this effluent must be treated in order to remove nutrients, because the excess of these elements in water bodies can lead to major environmental problems, so that it has been used in fertigation. Photosynthetic microorganisms absorb inorganic nutrients and they can absorb nutrients from wastewater. If the organic fraction of vinasse is removed, the inorganic or low organic fraction may be the basis or a medium of cultivation of these microorganisms, which absorb carbon dioxide and its biomass is of industrial interest. In this context, Monoraphidium contortum and Synechocystis salina from mangrove water were cultivated in Erlenmeyer flasks and in tubular photobioreactors by batch process using vinasse from aerobic biological treatment, coupled to physicochemical treatments with different dilutions. The physicochemical characteristics of the treated vinasse were evaluated. In addition, cell growth was compared under different experimental conditions adopted for growth of microalgae M. contortum and cyanobacteria S. salina in vinasse treated with and without dilution. In Erlenmeyer flask cultivations, in medium from the biological treatment, the cell growth was not different of that one in standard medium cultivation, with dilutions of 5 and 2 times the vinasse treated for M. contortum and S. salina, respectively. In the tubular photobioreactor, irrespective if the treatment is only biological or also is carried out treatment with activated charcoal, they were obtained maximum cell concentrations (Xm) of M. contortum and S. salina of 1.86x107 cells mL-1 and 7.90x106 cells. mL-1 , respectively, lower than the standard, whose Xm values were 2.69x107 cells mL-1 and 1.27x106 cells mL-1 for M. contortum and S. salina, respectively. In tubular photobioreactors, the minimum lipid contents of M. contortum and S. salina were 33.4 % and 11.0 %, respectively. In addition, the minimum protein content of microalgae was 15.1 % and cyanobacterium was 23.2 %

The Effect of Carbogen Breathing on 18F-FDG Uptake in Non-Small-Cell Lung Cancer.

It has been reported that 18F-FDG uptake is higher in hypoxic cancer cells than in well-oxygenated cells. We demonstrated that 18F-FDG uptake in lung cancer would be affected by high concentration oxygen breathing. Methods. Overnight fasted non-small-cell lung cancer A549 subcutaneous (s.c.) xenografts bearing mice (n = 10) underwent 18F-FDG micro-PET scans, animals breathed room air on day 1, and same animals breathed carbogen (95% O2 + 5% CO2) on the subsequent day. In separated studies, autoradiography and immunohistochemical staining visualization of frozen section of A549 s.c. tumors were applied, and to compare between carbogen-breathing mice and those with air breathing, a combination of 18F-FDG and hypoxia marker pimonidazole was injected 1 h before animal sacrifice, and 18F-FDG accumulation was compared with pimonidazole binding and glucose transporter 1 (GLUT-1) expression. Results. PET studies revealed that tumor 18F-FDG uptake was significantly decreased in carbogen-breathing mice than those with air breathing (P < 0.05). Ex vivo studies confirmed that carbogen breathing significantly decreased hypoxic fraction detected by pimonidazole staining, referring to GLUT-1 expression, and significantly decreased 18F-FDG accumulation in tumors. Conclusions. High concentration of O2 breathing during 18F-FDG uptake phase significantly decreases 18F-FDG uptake in non-small-cell lung cancer A549 xenografts growing in mice.

Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations.

BACKGROUND: Capnography has many uses in the emergency department (ED) and critical care setting, most commonly cardiac arrest and procedural sedation. OBJECTIVE OF THE REVIEW: This review evaluates several indications concerning capnography beyond cardiac arrest and procedural sedation in the ED, as well as limitations and specific waveforms. DISCUSSION: Capnography includes the noninvasive measurement of CO2, providing information on ventilation, perfusion, and metabolism in intubated and spontaneously breathing patients. Since the 1990s, capnography has been utilized extensively for cardiac arrest and procedural sedation. Qualitative capnography includes a colorimetric device, changing color on the amount of CO2 present. Quantitative capnography provides a numeric value (end-tidal CO2), and capnography most commonly includes a waveform as a function of time. Conditions in which capnography is informative include cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Patients with seizure, trauma, and respiratory conditions, such as pulmonary embolism and obstructive airway disease, can benefit from capnography, but further study is needed. Limitations include use of capnography in conditions with mixed pathophysiology, patients with low tidal volumes, and equipment malfunction. Capnography should be used in conjunction with clinical assessment. CONCLUSIONS: Capnography demonstrates benefit in cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Further study is required in patients with seizure, trauma, and respiratory conditions. It should only be used in conjunction with other patient factors and clinical assessment.

Oxygen consumption and carbon-dioxide recovery kinetics in the prediction of coronary artery disease severity and outcome.

BACKGROUND: Revascularization appears to be beneficial only in patients with high levels of ischemia. This study examined the utility of gas analysis during the recovery phase of cardiopulmonary exercise testing (CPET) in predicting coronary artery disease (CAD) severity and prognosis. METHODS: 40 Caucasian patients (21.2% females), mean age 63.5±7.6 with significant coronary artery lesions (≥50%) were studied. Within two months of coronary angiography, CPET on a treadmill (TM) and recumbent ergometer (RE) were performed on two visits 2-4days apart; subjects were subsequently followed 32±10months. Myocardial wall motion was recorded by echocardiography at rest and peak exercise. Ischemia was quantified by the wall motion score index (WMSI). RESULTS: Mean ejection fraction was 56.7±9.6%. Patients with 1-2 stenotic coronary arteries (SCA) showed a poorer CPET response during the recovery phase than patients with 3-SCA. ROC analysis revealed the change of carbon-dioxide output (∆VCO2) recovery/peak (area under ROC curve 0.77, p=0.02, Sn=87.5%, Sp=70.4%) and oxygen uptake (∆VO2) recovery/peak during TM CPET (area under ROC curve 0.76, p=0.03, Sn 75.0%, Sp 77.8%) were significant in distinguishing between 1-2-SCA and 3-SCA. The same variables predicted ΔWMSI peak/rest on univariate analysis (p<0.05). Multivariate Cox analysis revealed a high predictive value of ∆VO2 recovery/peak obtained during TM CPET for composite endpoint of cumulative cardiac events (HR=1.27, CI=1.07-1.51, p=0.008). CONCLUSIONS: The current study suggests CPET parameters in recovery hold predictive value for CAD severity and prognosis. TM testing seems to be a better approach in the assessment of CAD severity and prognosis.

Expression of the human isoform of glutamate dehydrogenase, hGDH2, augments TCA cycle capacity and oxidative metabolism of glutamate during glucose deprivation in astrocytes.

A key enzyme in brain glutamate homeostasis is glutamate dehydrogenase (GDH) which links carbohydrate and amino acid metabolism mediating glutamate degradation to CO2 and expanding tricarboxylic acid (TCA) cycle capacity with intermediates, i.e. anaplerosis. Humans express two GDH isoforms, GDH1 and 2, whereas most other mammals express only GDH1. hGDH1 is widely expressed in human brain while hGDH2 is confined to astrocytes. The two isoforms display different enzymatic properties and the nature of these supports that hGDH2 expression in astrocytes potentially increases glutamate oxidation and supports the TCA cycle during energy-demanding processes such as high intensity glutamatergic signaling. However, little is known about how expression of hGDH2 affects the handling of glutamate and TCA cycle metabolism in astrocytes. Therefore, we cultured astrocytes from cerebral cortical tissue of hGDH2-expressing transgenic mice. We measured glutamate uptake and metabolism using [3 H]glutamate, while the effect on metabolic pathways of glutamate and glucose was evaluated by use of 13 C and 14 C substrates and analysis by mass spectrometry and determination of radioactively labeled metabolites including CO2 , respectively. We conclude that hGDH2 expression increases capacity for uptake and oxidative metabolism of glutamate, particularly during increased workload and aglycemia. Additionally, hGDH2 expression increased utilization of branched-chain amino acids (BCAA) during aglycemia and caused a general decrease in oxidative glucose metabolism. We speculate, that expression of hGDH2 allows astrocytes to spare glucose and utilize BCAAs during substrate shortages. These findings support the proposed role of hGDH2 in astrocytes as an important fail-safe during situations of intense glutamatergic activity. GLIA 2017;65:474-488.

[Extracorporeal CO2 removal as life support system for a severe organizing pneumonia]. / Épuration extracorporelle du CO2 pour suppléance d'une pneumonie organisée sévère.

INTRODUCTION: Acute lung injuries are usually found in intensive care unit. The diffuse alveolar damage (DAD) is the associated histological pattern and the most severe end-stage of the disease. Organizing pneumonia (OP), for which corticosteroids are the reference therapy, can mimic DAD. While postponing the response to treatment, to limit mechanical ventilation side effects, extracorporeal membrane oxygene can be proposed. We present a case of a severe OP for which extracorporeal CO2 removal (ECCO2R) is used as a bridge to recovery under corticosteroid therapy. CASE REPORT: In the context of a flu-like syndrome, the non-recovery of a lung impairment is reported to a severe OP. ECCO2R is applied when using an ultraprotective ventilation and while waiting for lung healing under corticosteroid. This strategy allowed successful recovery, early physical therapy and active mobilization. CONCLUSION: This observation presents the diagnostic and therapeutic difficulties of the lung parenchymental disease in intensive care. OP must be recognized. ECCO2R can be used in severe OP as a bridge to recovery while waiting for the corticosteroid efficacy.

Evaluation of renal oxygenation change under the influence of carbogen breathing using a dynamic R2 , R2 ' and R2 * quantification approach.

The purpose of this study is to demonstrate the feasibility of dynamic renal R2 /R2 '/R2 * measurements based on a method, denoted psMASE-ME, in which a periodic 180° pulse-shifting multi-echo asymmetric spin echo (psMASE) sequence, combined with a moving estimation (ME) strategy, is adopted. Following approval by the institutional animal care and use committee, a block design of respiratory challenge with interleaved air and carbogen (97% O2 , 3% CO2 ) breathing was employed in nine rabbits. Parametrical R2 /R2 '/R2 * maps were computed and average R2 /R2 '/R2 * values were measured in regions of interest in the renal medulla and cortex. Bland-Altman plots showed good agreement between the proposed method and reference standards of multi-echo spin echo and multi-echo gradient echo sequences. Renal R2 , R2 ' and R2 * decreased significantly from 16.2 ± 4.4 s-1 , 9.8 ± 5.2 s-1 and 25.9 ± 5.0 s-1 to 14.9 ± 4.4 s-1 (p < 0.05), 8.5 ± 4.1 s-1 (p < 0.05) and 23.4 ± 4.8 s-1 (p < 0.05) in the cortex when switching the gas mixture from room air to carbogen. In the renal medulla, R2 , R2 ' and R2 * also decreased significantly from 12.9 ± 4.7 s-1 , 15.1 ± 5.8 s-1 and 27.9 ± 5.3 s-1 to 11.8 ± 4.5 s-1 (p < 0.05), 14.2 ± 4.2 s-1 (p < 0.05) and 25.8 ± 5.1 s-1 (p < 0.05). No statistically significant differences in relative R2 , R2 ' and R2 * changes were observed between the cortex and medulla (p = 0.72 for R2 , p = 0.39 for R2 ' and p = 0.61 for R2 *). The psMASE-ME method for dynamic renal R2 /R2 '/R2 * measurements, together with the respiratory challenge, has potential use in the evaluation of renal oxygenation in many renal diseases.

Simultaneous multi-slice (SMS) acquisition enhances the sensitivity of hemodynamic mapping using gas challenges.

Hemodynamic mapping using gas inhalation has received increasing interest in recent years. Cerebrovascular reactivity (CVR), which reflects the ability of the brain vasculature to dilate in response to a vasoactive stimulus, can be measured by CO2 inhalation with continuous acquisition of blood oxygen level-dependent (BOLD) magnetic resonance images. Cerebral blood volume (CBV) can be measured by O2 inhalation. These hemodynamic mapping methods are appealing because of their absence of gadolinium contrast agent, their ability to assess both baseline perfusion and vascular reserve, and their utility in calibrating the functional magnetic resonance imaging (fMRI) signal. However, like other functional and physiological indices, a major drawback of these measurements is their poor sensitivity and reliability. Simultaneous multi-slice echo planar imaging (SMS EPI) is a fast imaging technology that allows the excitation and acquisition of multiple two-dimensional slices simultaneously, and has been shown to enhance the sensitivity of several MRI applications. To our knowledge, the benefit of SMS in gas inhalation imaging has not been investigated. In this work, we compared the sensitivity of CO2 and O2 inhalation data collected using SMS factor 2 (SMS2) and SMS factor 3 (SMS3) with those collected using conventional EPI (SMS1). We showed that the sensitivity of SMS scans was significantly (p = 0.01) higher than that of conventional EPI, although no difference was found between SMS2 and SMS3 (p = 0.3). On a voxel-wise level, approximately 20-30% of voxels in the brain showed a significant enhancement in sensitivity when using SMS compared with conventional EPI, with other voxels showing an increase, but not reaching statistical significance. When using SMS, the scan duration can be reduced by half, whilst maintaining the sensitivity of conventional EPI. The availability of a sensitive acquisition technique can further enhance the potential of gas inhalation MRI in clinical applications.

High energy ball milling and supercritical carbon dioxide impregnation as co-processing methods to improve dissolution of tadalafil.

Tadalafil (TD) is a crystalline drug of a high melting point (Tm=299°C) and limited solubility in water (<5µg/mL). These properties may result in reduced and variable bioavailability after oral administration. Since the melting of TD is followed by its decomposition, the drug processing at high temperatures is limited. The aim of the research is, therefore, to improve the dissolution of TD by its co-processing with the hydrophilic polymer Soluplus® (SL) at temperatures below 40°C. In this study, two methods, i.e. high energy ball-milling and supercritical carbon dioxide impregnation (scCO2) are compared, with the aim to predict their suitability for the vitrification of TD. The influence of the amount of SL and the kind of co-processing method on TD thermal properties is analyzed. The results show that only the high energy ball milling process makes it possible to obtain a completely amorphous form of TD, with the characteristic X-ray 'halo' pattern. The intensity of the Bragg peaks diminishes for all the formulations treated with scCO2, but these samples remain crystalline. The MDSC results show that high energy ball milling is capable of forcing the mixing of TD and SL at a molecular level, providing a homogeneous amorphous solid solution. The glass transition temperatures (Tg), determined for the co-milled formulations, range from 79°C to 139°C and they are higher than Tg of pure SL (ca. 70°C) and lower than Tg of pure TD (ca. 149°C). In contrast to the co-milled formulations which are in the form of powder, all the formulations after scCO2 impregnation form a hard residue, sticking to the reaction vessel, which needs to be ground before analysis or further processing. Finally, the dissolution studies show that not only has SL a beneficial effect on the amount of TD dissolved, but also both co-processing methods make the dissolution enhancement of TD possible. After co-processing by scCO2, the amount of TD dissolved increases with the decreasing amount of SL, whereas in the case of the co-milled formulations, the higher the amount of SL in the glassy solution is, the higher the amount of TD dissolved.

Quantitative mapping of cerebrovascular reactivity using resting-state BOLD fMRI: Validation in healthy adults.

In conventional neuroimaging, cerebrovascular reactivity (CVR) is quantified primarily using the blood-oxygenation level-dependent (BOLD) functional MRI (fMRI) signal, specifically, as the BOLD response to intravascular carbon dioxide (CO2) modulations, in units of [%ΔBOLD/mmHg]. While this method has achieved wide appeal and clinical translation, the tolerability of CO2-related tasks amongst patients and the elderly remains a challenge in more routine and large-scale applications. In this work, we propose an improved method to quantify CVR by exploiting intrinsic fluctuations in CO2 and corresponding changes in the resting-state BOLD signal (rs-qCVR). Our rs-qCVR approach requires simultaneous monitoring of PETCO2, cardiac pulsation and respiratory volume. In 16 healthy adults, we compare our quantitative CVR estimation technique to the prospective CO2-targeting based CVR quantification approach (qCVR, the "standard"). We also compare our rs-CVR to non-quantitative alternatives including the resting-state fluctuation amplitude (RSFA), amplitude of low-frequency fluctuation (ALFF) and global-signal regression. When all subjects were pooled, only RSFA and ALFF were significantly associated with qCVR. However, for characterizing regional CVR variations within each subject, only the PETCO2-based rs-qCVR measure is strongly associated with standard qCVR in 100% of the subjects (p≤0.1). In contrast, for the more qualitative CVR measures, significant within-subject association with qCVR was only achieved in 50-70% of the subjects. Our work establishes the feasibility of extracting quantitative CVR maps using rs-fMRI, opening the possibility of mapping functional connectivity and qCVR simultaneously.

Dynamic oxygen challenge evaluated by NMR T1 and T2*--insights into tumor oxygenation.

There is intense interest in developing non-invasive prognostic biomarkers of tumor response to therapy, particularly with regard to hypoxia. It has been suggested that oxygen sensitive MRI, notably blood oxygen level-dependent (BOLD) and tissue oxygen level-dependent (TOLD) contrast, may provide relevant measurements. This study examined the feasibility of interleaved T2*- and T1-weighted oxygen sensitive MRI, as well as R2* and R1 maps, of rat tumors to assess the relative sensitivity to changes in oxygenation. Investigations used cohorts of Dunning prostate R3327-AT1 and R3327-HI tumors, which are reported to exhibit distinct size-dependent levels of hypoxia and response to hyperoxic gas breathing. Proton MRI R1 and R2* maps were obtained for tumors of anesthetized rats (isoflurane/air) at 4.7 T. Then, interleaved gradient echo T2*- and T1-weighted images were acquired during air breathing and a 10 min challenge with carbogen (95% O2 -5% CO2). Signals were stable during air breathing, and each type of tumor showed a distinct signal response to carbogen. T2* (BOLD) response preceded T1 (TOLD) responses, as expected. Smaller HI tumors (reported to be well oxygenated) showed the largest BOLD and TOLD responses. Larger AT1 tumors (reported to be hypoxic and resist modulation by gas breathing) showed the smallest response. There was a strong correlation between BOLD and TOLD signal responses, but ΔR2* and ΔR1 were only correlated for the HI tumors. The magnitude of BOLD and TOLD signal responses to carbogen breathing reflected expected hypoxic fractions and oxygen dynamics, suggesting potential value of this test as a prognostic biomarker of tumor hypoxia.

[Reduction of omalgia in laparoscopic cholecystectomy: clinical randomized trial ketorolac vs ketorolac and acetazolamide]. / Reducción de omalgia en colecistectomía laparoscópica: ensayo clínico aleatorizado con ketorolaco vs ketorolaco y acetazolamida.

BACKGROUND: Laparoscopy cholecystectomy for the surgical treatment of cholelithiasis has been considered the gold standard. The referred pain to the shoulder (omalgia) may be present to 63% of the patients and limits outpatient management. OBJECTIVE: The study was to evaluate the usefulness of acetazolamide associated with ketorolac for reduction of the omalgia to minimally invasive treatment. METHODS: We performed a clinical trial, randomized, double blind in patients undergoing laparoscopic cholecystectomy to assess the reduction of post-operative omalgia comparing ketorolac and ketorolaco+acetazolamida. 31 patients in each group were studied. The study group: 250 mg of acetazolamide before anesthetic induction and 30 mg of ketorolac in the immediate postoperative period. CONTROL GROUP: one tablet of placebo prior to the anesthetic induction and 30 mg of ketorolac in the immediate postoperative. The presence of omalgia was assessed using the analog visual scale. The variables recorded included: age, sex, flow of carbon dioxide intra-abdominal pressure, surgical time, urgent or elective surgery, omalgia, severity of pain evaluated by analog visual scale, addition analgesia. RESULTS: Both groups were homogeneous and statistical analysis showed no differences in the variables studied. The omalgia in the study group was presented at 9.67% and in the group control was the 58.06% (p < 0.001). CONCLUSION: 250 mg oral acetazolamide associated 30 mg of ketorolac reduces significantly the development of omalgia in patients undergoing laparoscopic cholecystectomy.

Antecedentes: la colecistectomía laparoscópica es el patrón de referencia del tratamiento de la colelitiasis sintomática. El 63% de los pacientes operados sufre dolor postquirúrgico referido al hombro (omalgia), circunstancia que limita el tratamiento ambulatorio. Objetivo: evaluar la utilidad de la acetazolamida asociada con ketorolaco para disminuir la omalgia consecutiva al tratamiento de mínima invasión. Material y métodos: ensayo clínico, aleatorizado, doble ciego realizado en pacientes a quienes se efectuó colecistectomía laparoscópica para evaluar la reducción de la omalgia postoperatoria y comparar el efecto de ketorolaco y ketorolaco más acetazolamida. En cada grupo se estudiaron 31 pacientes. El grupo de estudio recibió 250 mg de acetazolamida antes de la inducción anestésica, y 30 mg de ketorolaco en el postoperatorio inmediato. El grupo control recibió una tableta de placebo antes de la inducción anestésica, y 30 mg de ketorolaco en el postoperatorio inmediato. La omalgia se evaluó con la escala visual análoga. Las variables estudiadas incluyeron: edad, sexo, flujo de dióxido de carbono, presión intrabdominal, tiempo quirúrgico, cirugía electiva o urgente, omalgia, intensidad del dolor evaluada con la escala visual análoga y analgesia de rescate. Resultados: los grupos estudiados fueron homogéneos, el análisis estadístico no mostró diferencias en las variables estudiadas. En el grupo de estudio la omalgia coexistió en 9.67% de los pacientes y en el grupo control en 58.06% (p < 0.001). Conclusión: la administración por vía oral de 250 mg de acetazolamida y 30 mg de ketorolaco redujo significativamente la omalgia en los pacientes a quienes se realizó colecistectomía laparoscópica.

Influence of carbon dioxide insufflation of the neck on intraocular pressure during robot-assisted endoscopic thyroidectomy: a comparison with open thyroidectomy.

BACKGROUND: Increased intraocular pressure (IOP) during surgery can result in serious ophthalmic complications. We hypothesized that carbon dioxide (CO2) insufflation of the neck during endoscopic thyroidectomy would constrict the jugular veins mechanically, causing elevated venous pressure and thus elevated IOP. We compared IOP changes at each step of open thyroidectomy (OT) versus robot-assisted endoscopic thyroidectomy (RET) METHODS: Perioperatively, IOP was measured at six time points in patients undergoing OT (n = 18) or RET with CO2 insufflation (n = 19). Anesthesia, ventilatory strategy, intravenous infusions, and surgical positioning were standardized RESULTS: In both groups, induction of anesthesia reduced IOP, but surgical positioning with the neck in extension had no effect on IOP. In the OT group, IOP remained unchanged during anesthesia. In the RET group, CO2 insufflation significantly increased IOP to an average of 3.6 ± 3.0 mmHg higher than the previous measurement (P < 0.001), and this IOP increase persisted immediately before gas deflation. These elevated IOP values during CO2 insufflation in the RET group were significantly higher than those at corresponding time points in the OT group. However, these elevated IOP values were similar to the pre-anesthetic baseline IOP CONCLUSION: CO2 insufflation of the neck at pressure of 6 mmHg increased the IOP significantly compared with open thyroidectomy. However, this increase in IOP could be balanced by an anesthetic-induced IOP-lowering effect, thereby having no clinical significance in patients with normal IOP undergoing robot-assisted endoscopic thyroidectomy.

Air-water fluxes of N2O and CH4 during microalgae (Staurosira sp.) cultivation in an open raceway pond.

The industrial-scale production of biofuels from cultivated microalgae has gained considerable interest in the last several decades. While the climate benefits of microalgae cultivation that result from the capture of atmospheric CO(2) are known, the counteracting effect from the potential emission of other greenhouse gases has not been well quantified. Here, we report the results of a study conducted at an industrial pilot facility in Hawaii to determine the air-water fluxes of N(2)O and CH(4) from open raceway ponds used to grow the marine diatom Staurosira sp. as a feedstock for biofuel. Dissolved O(2), CH(4), and N(2)O concentrations were measured over a 24 h cycle. During this time, four SF(6) tracer release experiments were conducted to quantify gas transfer velocities in the ponds, and these were then used to calculate air-water fluxes. Our results show that pond waters were consistently supersaturated with CH(4) (up to 725%) resulting in an average emission of 19.9 ± 5.6 µmol CH(4) m(-2) d(-1). Upon NO(3)(-) depletion, the pond shifted from being a source to being a sink of N(2)O, with an overall net uptake during the experimental period of 3.4 ± 3.5 µmol N(2)O m(-2) d(-1). The air-water fluxes of N(2)O and CH(4) expressed as CO(2) equivalents of global warming potential were 2 orders of magnitude smaller than the overall CO(2) uptake by the microalgae.

A simple method to clamp end-tidal carbon dioxide during rest and exercise.

Carbon dioxide regulates ventilation and cerebral blood flow during exercise. There are significant limitations in breathing systems designed to control end-tidal gas concentrations when used during high-intensity exercise. We designed a simple, inexpensive breathing system which controls end-tidal carbon dioxide (PET CO2) during exercise from rest to peak work capacity (W(max)). The system is operated by an investigator who, in response to breath-by-breath PET CO2, titrates flow of a 10 % CO(2), 21 % O(2) mixture into an open-ended 5-L inspiratory reservoir. To demonstrate system efficacy, nine fit male subjects performed two maximal, incremental exercise tests (25 W min(-1) ramp) on a cycle ergometer: a poikilocapnic control trial in which PET CO2 varied with work intensity, and an experimental trial, in which we planned to clamp PET CO2 at 50 mmHg. With our breathing system, we maintained PET CO2 at 51 ± 2 mmHg throughout exercise (rest, 50 ± 2; W(max), 52 ± 5 mmHg; mean ± SD) despite large changes in ventilation (range 27-65 at rest, 134-185 L min(-1) BTPS at W (max)) and carbon dioxide production (range 0.3-0.7 at rest, 4.5-5.5 L min(-1) at W (max)). This simple, inexpensive system achieves PET CO2 control at rest and throughout exercise.

Liver function assessment with three (13)C breath tests by two-point measurements.

In this study, we performed three breath tests - l-[1-(13)C ]phenylalanine breath test (PBT), l-[1-(13)C ] methionine breath test, and [(13)C]methacetin breath test (MethaBT) - in patients with chronic liver disease to determine the optimal timing of expired air collection for diagnosing chronic liver disease and evaluating the grade of fibrosis. The subjects were 61 adults with normal livers, 98 chronic hepatitis patients, and 91 liver cirrhosis patients. We investigated the relationships of breath test results with routine biochemical tests and the Child-Pugh score, as well as the diagnostic capacities of the breath tests for liver dysfunction/cirrhosis and grade of liver fibrosis. For the diagnosis of liver cirrhosis and correlations with liver fibrosis, the accuracy of the PBT at 30 min (PBT30) was similar to that of the MethaBT at 15 min (Metha15). For liver function assessment by two-point measurement with (13)C breath tests, we recommend the PBT30 and the Metha15.