Performance of closed-loop systems for intravenous drug administration: a systematic review and meta-analysis of randomised controlled trials.

Closed-loop drug delivery systems are autonomous computers able to administer medication in response to changes in physiological parameters (controlled variables). While limited evidence suggested that closed-loop systems can perform better than manual drug administration in certain settings, this technology remains a research tool with an uncertain risk/benefit profile. Our aim was comparing the performance of closed-loop systems with manual intravenous drug administration in adults. We searched MEDLINE, CENTRAL, and Embase from inception until November 2022, without restriction to language. We assessed for inclusion randomised controlled trials comparing closed-loop and manual administration of intravenous drugs in adults, intraoperatively or in the Intensive Care Unit. We identified 32 studies on closed-loop administration of propofol, noradrenaline, phenylephrine, insulin, neuromuscular blockers, and vasodilators. Most studies were at moderate or high risk of bias. The results showed that closed-loop systems reduced the duration of blood pressure outside prespecified targets during noradrenaline (MD 14.9%, 95% CI 9.6-20.2%, I2 = 66.6%) and vasodilators administration (MD 7.4%, 95% CI 5.2-9.7%, I2 = 62.3%). Closed-loop systems also decreased the duration of recovery after propofol (MD 1.3 min, 95% CI 0.4-2.1 min, I2 = 58.6%) and neuromuscular blockers (MD 9.0 min, 95% CI 7.9-10.0 min, I2 = 0%). The certainty of the evidence was low or very low for most outcomes. Automatic technology may be used to improve the hemodynamic profile during noradrenaline and vasodilators administration and reduce the duration of postanaesthetic recovery.Registration: This systematic review was registered with PROSPERO (CRD42022336950) on the 7th of June 2022.

Invasive cutaneous squamous cell carcinoma resulting in arm amputation. Case discussion and literature review.

Skin cancer is one of the most common cancers in the world. Specifically incidence of non-melanoma malignancy in the UK has increased by 56% in the last decade. Cutaneous squamous cell carcinoma (cSCC) is a type of non-melanoma skin cancer that if caught early can be successfully treated. Conservative excision surgery is the most common treatment modality with high cure rates even if tumours are advanced. Radical surgery is rarely required, and amputations, especially when the distal part of the upper extremity is involved, are very uncommon. Here, we describe a case of an invasive cutaneous squamous cell carcinoma of the elbow that required trans-humeral arm amputation.

The management of deep sternal wound infection: Literature review and reconstructive algorithm.

Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.

Extracorporeal membrane oxygenation cannula-related chronic wound with a retained suture in a neonate.

Extracorporeal membrane oxygenation (ECMO) is often employed to manage persistent pulmonary hypertension of the newborn where non-invasive therapies have failed. Delivery of ECMO requires insertion of indwelling catheters into central or peripheral vasculature; and this predisposes the recipient to development of catheter-associated skin infection; however, chronic non-healing wounds with granuloma formation are rare. We describe a case of an 8-month-old child who presented to our Plastic Surgery Services with a chronic left groin wound at ECMO cannula insertion site that failed medical management. The patient underwent wound exploration and debridement during which an old non-absorbable suture localized at the base of the wound was discovered. The foreign material as well as granuloma was removed, leading to the resolution of the chronic skin lesion and patient recovery without major complications. To our knowledge, this is the first case report describing an ECMO-associated paediatric chronic wound.

Do different types of stress differentially alter behavioural and neurobiological outcomes associated with depression in rodent models? A systematic review.

Cataloguing the effects of different types of stress on behaviour and physiology in rodent models has not been comprehensively attempted. Here, we systematically review whether chronic exposure to physical stress, psychosocial stress, or both types of stress can induce different behavioural and neurobiological outcomes in male and female rodents. We found that physical stress consistently increased depressive-like behaviour, impaired social interaction and decreased body weight, while psychosocial stress consistently increased both anxiety- and depressive-like behaviour, impaired social interaction and learning and memory, increased HPA axis activity, peripheral inflammation and microglial activation, and decreased hippocampal neurogenesis in male rodents. Moreover, we found that the combined effect of both stress types resulted in a more severe pathological state defined by increased anxiety- and depressive-like behaviour, impaired social interaction and learning and memory, increased HPA axis activity and central inflammation, and reduced hippocampal neurogenesis and neural plasticity in male rodents. Phenotypes for females were less consistent, irrespective of the type of stress exposure, on account of the limited number of studies using females. This review highlights that the type of stress may indeed matter and will help animal researchers to more appropriately choose a stress/depression model that fits their research purposes.

The type of stress matters: repeated injection and permanent social isolation stress in male mice have a differential effect on anxiety- and depressive-like behaviours, and associated biological alterations.

Chronic stress can alter the immune system, adult hippocampal neurogenesis and induce anxiety- and depressive-like behaviour in rodents. However, previous studies have not discriminated between the effect(s) of different types of stress on these behavioural and biological outcomes. We investigated the effect(s) of repeated injection vs. permanent social isolation on behaviour, stress responsivity, immune system functioning and hippocampal neurogenesis, in young adult male mice, and found that the type of stress exposure does indeed matter. Exposure to 6 weeks of repeated injection resulted in an anxiety-like phenotype, decreased systemic inflammation (i.e., reduced plasma levels of TNFα and IL4), increased corticosterone reactivity, increased microglial activation and decreased neuronal differentiation in the dentate gyrus (DG). In contrast, exposure to 6 weeks of permanent social isolation resulted in a depressive-like phenotype, increased plasma levels of TNFα, decreased plasma levels of IL10 and VEGF, decreased corticosterone reactivity, decreased microglial cell density and increased cell density for radial glia, s100ß-positive cells and mature neuroblasts-all in the DG. Interestingly, combining the two distinct stress paradigms did not have an additive effect on behavioural and biological outcomes, but resulted in yet a different phenotype, characterized by increased anxiety-like behaviour, decreased plasma levels of IL1ß, IL4 and VEGF, and decreased hippocampal neuronal differentiation, without altered neuroinflammation or corticosterone reactivity. These findings demonstrate that different forms of chronic stress can differentially alter both behavioural and biological outcomes in young adult male mice, and that combining multiple stressors may not necessarily cause more severe pathological outcomes.

A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure.

Periorbital necrotizing fasciitis (PNF) is a severe suppurative infection of the subcutaneous tissue and underlying fascia of the periorbital region. Typically, the course of PNF is milder and has a better prognosis than that of necrotizing fasciitis in other parts of the body. As such, this disease is thought to be associated with a significantly smaller risk of morbidity and mortality. Nevertheless, it is a rare and devastating condition that can lead to disfigurement, blindness and death. Early recognition is critical to improved patient outcomes. Here, we describe a case of PNF in a 60-year-old male that rapidly progressed to widespread systemic involvement and severe multiorgan failure requiring ventilatory, cardiovascular and renal support. Treatment included broad-spectrum antibiotics, intravenous immunoglobulin and surgical debridement. This case highlights the life-threatening nature of PNF, as demonstrated by rapid progression to multiorgan dysfunction and the need of an urgent surgical intervention.