Effects of preoperative nutritional status on disability-free survival after cardiac and thoracic aortic surgery: a prospective observational study.

PURPOSE: Preoperative malnutrition is associated with postoperative complications, prolonged intensive care unit stay, and mortality, leading to functional disability after non-cardiac surgery. However, its effects on cardiac and thoracic aortic surgery outcomes remain unknown. We examined the effects of preoperative malnutrition on disability-free survival after surgery and assessed the perioperative 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS2.0) score based on the preoperative nutritional status. METHODS: We included individuals aged ≥ 55 years who underwent elective cardiac and/or thoracic aortic surgery between April 1, 2016 and December 28, 2018 in a tertiary center. The nutritional status was assessed preoperatively using the Mini Nutritional Assessment Short Form, with scores < 12 points indicating a poor nutritional status. The JapanSCORE2 was calculated for surgical risk prediction. Our primary outcome was disability-free survival 1 year after surgery (WHODAS2.0 score: < 16%). The odds ratio of poor nutritional status for disability-free survival was calculated using multiple logistic regression analysis after adjusting for age, JapanSCORE2, and duration of surgery. RESULTS: One hundred patients were followed up for 1 year. Preoperatively, 41 of them had a poor nutritional status. The disability-free survival rates 1 year postoperatively were 46.3% (19/41) and 64.4% (38/59) in patients with and without poor preoperative nutritional status, respectively. The adjusted odds ratio of poor nutritional status for disability-free survival at 1 year after surgery was 0.42 (95% confidence interval, 0.17-0.99). CONCLUSION: Patients with a poor preoperative nutritional status had less likely to show disability-free survival 1 year after cardiac and thoracic aortic surgery.

Application of laser speckle flowgraphy to evaluate cerebral perfusion after carotid endarterectomy.

Cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy (CEA) is devastating, and postoperative monitoring of cerebral perfusion is essential to prevent CHS. We report two cases of successful measurement of ocular blood flow using laser speckle flowgraphy (LSFG) for bedside assessment of the changes in cerebral perfusion after CEA. An 18.7% (case 1) and 47.7% (case 2) increase in ocular blood flow were measured postoperatively using LSFG compared with the baseline. LSFG might be applicable to evaluate cerebral perfusion after CEA.

Effects of a False Window on the Change of Cognitive Function in Patients Admitted to a Neurological Ward.

False windows can display a variety of outdoor scenery in rooms without real windows. We aimed to assess the effects of three different hospital beds on the change in the frontal assessment battery scores in patients aged ≥ 20-year-old admitted in our neurological ward. We included 24 patients on the window side, 12 patients on the aisle side with a false window, and 12 patients on the aisle side without a false window. There were no statistical differences in the change of cognitive function among the three hospital beds. Only the length of hospital stay was a significant associated factor.

Efficacy of modified thoracoabdominal nerves block through perichondrial approach in open gynecological surgery: a prospective observational pilot study and a cadaveric evaluation.

BACKGROUND: Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) was first described as a peripheral nerve block by Tulgar in 2019. This technique provides an analgesic effective range from Th7-11 with a single puncture per side. Although the efficacy and effective duration of M-TAPA have been reported, further examination is required. Therefore, this study aimed to evaluate the analgesic range and effective duration of M-TAPA in open gynecologic surgery. METHODS: Following approval, 10 adult female patients scheduled for open radical hysterectomy via a vertical incision or laparotomy using a midline incision from under the xiphoid process to the symphysis pubis were enrolled. The primary outcome was the number of anesthetized dermatomes at 2 and 24 h postoperatively. Secondary outcomes included numerical rating scale scores and the total amount of fentanyl used. Cadaveric evaluation was performed to assess the spread of the dye. RESULTS: The median numbers (interquartile range) of anesthetized dermatomes at 2 and 24 h postoperatively were 6 (5-7) and 6.5 (5-7) in the anterior cutaneous branch area and 5 (4-7) and 7 (5-7) in the lateral cutaneous branch area, respectively. There was an 85% chance of simultaneously acquiring analgesia in areas innervated by Th8-11, including complete block in areas innervated by the anterior cutaneous branches of Th9-10. Cadaveric evaluation showed the spread of the dye in Th8-11. CONCLUSIONS: M-TAPA may have analgesic effects in the areas supplied by the anterior cutaneous branches of Th8-11. TRAIL REGISTRATION: IRB approval (No.2700; registered on July 10, 2020) and registration (UMIN Clinical Trials Registry: UMIN000041137 ; registered on July 17, 2020).

Prevalence and associated factors of disability in patients with chronic pain: An observational study.

ABSTRACT: The primary treatment goal of patients experiencing chronic pain has shifted from pain reduction to functional status improvement. However, the prevalence of disability and its associated factors in patients with chronic pain remain unknown.Individuals aged ≥50 years who visited the Pain Center at Nara Medical University with chronic pain from June 2019 to May 2020 were eligible for enrollment. Patients were asked to complete the Japanese version of the 12-item World Health Organization Disability Assessment Schedule 2.0. Patient demographics, pain intensity, level of catastrophizing, anxiety, depression, and exercise habits were assessed. Multivariate logistic regression analysis was used to identify the factors associated with disability.Of the 551 patients with a median age of 73 years, 51.5% experienced disability. Fixed factors such as age (odds ratio [OR], 1.03; 95% confidence interval [CI] 1.01-1.06, P = .002) and lumbar and lower limb pain (OR, 3.10; 95% CI, 1.83-5.24, P < .001) and some modifiable factors, including anxiety (OR, 2.06; 95% CI, 1.06-3.98, P = .03), depression (OR, 3.62; 95% CI, 1.92-6.82, P < .001), pain catastrophizer (OR, 2.94; 95% CI, 1.88-4.61, P < .001), numeric rating scale at the most painful site (OR, 1.29; 95% CI, 1.18-1.42, P < .001), exercise habits (walking (OR, 0.52; 95% CI, 0.33-0.83, P = .006) and working out (OR, 0.58; 95% CI, 0.34-0.99, P = .046), were found to be independently associated with disability.This cross-sectional study revealed a high prevalence of disability in patients with chronic pain and identified the factors associated with disability.

The short-term effect of COVID-19 pandemic on disability, pain intensity, psychological status, and exercise habits in patients with chronic pain.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has affected the lives of people worldwide. The first declaration of a state of emergency in Japan, based on the Act on Special Measures for the Prevention and Control of the Novel Coronavirus, was issued from 16 April 2020 to 14 May 2020 to reduce person-to-person contact. Restrictions on going out, participating in community activities, and visiting hospitals were in place. This study investigates the short-term effects of the COVID-19 pandemic on patients with chronic pain. METHODS: This study included outpatients with chronic pain undergoing treatment at the Pain Center of Nara Medical University Hospital. The patients had completed questionnaires for a disability during the study period, from 1 July to 30 September 2019 (baseline), 1 October to 31 December 2019 (pre-pandemic), and 1 July to 30 September 2020 (during the pandemic). The questionnaire covered changes in disability, pain intensity, health-related quality of life (QOL), anxiety, depression, catastrophic thinking, and the presence/absence of exercise habits at baseline, pre-pandemic, and during the pandemic. RESULTS: Of the 245 eligible patients, there was no significant disability difference between baseline, pre-pandemic, and during the pandemic (p = 0.14). Similarly, pain intensity, health-related QOL, anxiety, depression, and the presence/absence of exercise habits did not significantly differ between baseline, pre-pandemic, and during the pandemic either. The current study observed significant differences in terms of catastrophic thinking (p = 0.02). CONCLUSION: The effects of the COVID-19 pandemic on patients with chronic pain were not apparent in the short-term. Clinical trail registration: UMIN000043174.

Current Status of Clinical Engineer Anesthesia Assistants and Their Effect on Labor Task Shifting in Japan: A Prospective Observational Study in a Single Institute.

INTRODUCTION: Anesthesiologists are in short supply across the world, resulting in perpetually long working hours. To reduce the burden on anesthesiologists, tasks that can be performed by non-physicians must be shifted to other medical staff. In hospitals, clinical engineers can work as anesthesia assistants and perform some of the duties of anesthesiologists. This study aimed to evaluate the effect of task shift performed by clinical engineer anesthesia assistants (CEAAs). METHODS: This was a 1-month prospective observational study that included 33 anesthesiologists (11 fellows and 22 certified anesthesiologists) and 11 CEAAs. The total activity and anesthesia times were extracted from the attendance record as indices of the anesthesiologists' work status. The CEAAs recorded the duration of work performed on behalf of the anesthesiologists as task shift time. The task shift rate was evaluated as follows: task shift time/(task shift time + total activity time) and task shift time/(task shift time) + (total anesthesia time). RESULTS: The study period consisted of 19 weekdays. The average daily activity time of the anesthesiologists was 10.1 h, and the average anesthesia time was 8.5 h. The CEAAs performed a total of 546.8 h of task shift. The defined task shift rate was 20.1% when the total activity time was the denominator and 23.1% when the anesthesia time was the denominator. CONCLUSIONS: CEAAs might be effective in reducing the working hours of anesthesiologists through task shift. Their taking over a portion of the anesthesiologists' duties may allow the anesthesiologists to work more efficiently.

Ocular blood flow by laser speckle flowgraphy to detect cerebral ischemia during carotid endarterectomy.

Laser speckle flowgraphy (LSFG) is a noninvasive technique that can measure relative blood flow velocity in the optic fundus contributed by the ophthalmic artery, the main first branch originating from the internal carotid artery (ICA). The aim of this study was to assess the feasibility of ocular blood flow measurement by LSFG to detect ischemic stress due to carotid clamping during carotid endarterectomy (CEA). Nineteen patients undergoing CEA with ocular blood flow measurement by LSFG and intraoperative monitoring (IOM) were prospectively enrolled between August 2016 and March 2019. The mean blur rate (MBR) of ocular blood flow by LSFG, representing relative blood flow of the branch of the retinal artery originating from the optic nerve head, was compared between before and after carotid clamping during CEA. The correlation between the reduction ratio of MBR and the regional saturation oxygen (rSO2) index by near infrared spectroscopy was investigated. Ocular blood flow measurement by LSFG could not be performed in one patient with a severe cataract. In the other 18 patients, LSFG could be performed in all 106 sessions during surgery. The MBR reduction ratio between before and after carotid clamping ranged from - 12 to 100%. The MBR reduction ratio was positively correlated with the rSO2 index (r = 0.694, 95% confidence interval: 0.336-0.877, p = 0.001). The MBR reduction ratio of ocular blood flow by LSFG after carotid clamping was significantly correlated with the rSO2 index. The ocular blood flow by LSFG could be considered an adjunct modality for evaluating cerebral ischemic tolerance during CEA.

Association Between Optic Nerve Head Blood Flow Measured Using Laser Speckle Flowgraphy and Radial Arterial Pressure During Aortic Arch Surgery.

OBJECTIVE: This study was designed to investigate the association between ocular blood flow measured using laser speckle flowgraphy (LSFG) and radial arterial pressure during aortic arch surgery. DESIGN: A prospective study. SETTING: A single university hospital. PARTICIPANTS: This study included 24 patients undergoing aortic arch surgery with cardiopulmonary bypass (CPB) using antegrade selective cerebral perfusion (SCP). INTERVENTIONS: Measurement of optic nerve head blood flow using LSFG and radial arterial pressure via a catheter in the radial artery METHODS AND MAIN RESULTS: Antegrade SCP was managed with 24℃ and 40-to-60 mmHg at the right radial artery, which usually corresponds to a flow rate of 10 mL/kg/min. Optic nerve head blood flow using LSFG and radial arterial blood pressure were evaluated simultaneously at the right side and recorded at the following 4 points: after the induction of anesthesia (phase 1), after the beginning of CPB (phase 2), after the beginning of antegrade SCP (phase 3), and after cessation of CPB (phase 4). A moderate positive correlation between %change of mean blur rate in the optic nerve head measured using LSFG and %change of radial mean arterial pressure was identified (r = 0.604, p < 0.001). Bland-Altman analysis showed that the bias (mean difference) was -1.2% (95% limits of agreement -47.4% to 45.0%), indicating good agreement between %changes of the values recorded using the 2 measurements. CONCLUSIONS: Intraoperative monitoring of optic nerve head blood flow using LSFG can be used as an additional cerebral perfusion parameter during aortic arch surgery with CPB using antegrade SCP.

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia.

INTRODUCTION: The use of both pulse oximetry (SpO2) and respiration rate (RR) monitoring is recommended to prevent the development of respiratory deterioration, particularly after extubation and narcotic analgesic use for pain management. In this study, we investigated the factors contributing to the development of bradypnea in surgical patients receiving fentanyl-based intravenous analgesia after general anesthesia. METHODS: This study involved a historical chart review of postoperative patients outside an intensive care unit setting. We divided the patients according to the data collected during the first hour postoperatively, into those developing bradypnea (RR < 8 breaths per min for > 2 min) and those with normal RR under oxygen administration. We defined oxygen desaturation as SpO2 < 90% for > 10 s. We calculated the effect-site concentrations for fentanyl at the end of surgery and 1 h postoperatively using custom-made software based on chart records. A multivariable analysis was used to determine bradypnea-associated explanatory factors. RESULTS: For the final analysis, we included 258 patients. We detected bradypnea in 125 patients (48%) and oxygen desaturation in 46 patients (18%). We found no difference in the effect-site fentanyl concentrations between patients with and without bradypnea. The logistic regression model revealed that liver dysfunction [odds ratio (OR), 2.918; 95% confidence interval (CI), 1.329-6.405], renal dysfunction (OR, 0.349; 95% CI, 0.128-0.955), and smoking history (OR, 0.236; 95% CI, 0.075-0.735) were independently associated with bradypnea. We found similar incidences of oxygen desaturation between the groups. CONCLUSIONS: Bradypnea was observed in 48% of postoperative patients receiving fentanyl-based intravenous analgesia under oxygen therapy. According to our results, impaired liver function associated positively, whereas smoking history associated negatively with its development. Renal dysfunction was paradoxically associated with less incidence of bradypnea.

Impact of absence of critical respiratory rate change on oxygen desaturation following tracheal extubation after general anaesthesia: a propensity score-matched analysis.

BACKGROUND: It has been suggested that oxygen desaturation may be paradoxically related to the absence of an abnormal respiratory rate (RR) during acoustic respiratory rate (RRa) monitoring in a postoperative setting. We retrospectively compared the incidence of desaruration in patients without an abnormal RR with that in patients with an abnormal RR using propensity scorer matching. We also explored the factors contributing to oxygen desaturation without an RR monitoring alert. METHODS: We used ≤ 8 h postoperative data of the first 935 patients. Outcomes of patients with and without critical RR changes (RR > 30 or < 8 beats per min for > 2 min) (critical RR change vs. noncritical RR change) were first compared according to oxygen desaturation levels (SpO2< 90% for > 10 s). Multivariate analysis was used to determine oxygen desaturation-associated explanatory factors. RESULTS: Propensity score matching yielded 259 patients without critical RR changes and 259 patients with critical RR changes, respectively. Oxygen desaturation rates were higher in patients without critical RR changes [noncritical RR change vs. critical RR change: 39/220 (15.1%) vs. 16/243 (6.2%)]. An odds ratio and 95% CI for the noncritical RR change was 2.56 (1.38-4.55, P = 0.002). A critical change in the RRa was not observed in 576 patients; of these, oxygen desaturation was observed in 76 (13.2%) patients. Surgery duration (OR, 1.018 per 10 min increase; 95% CI, 1.002 to 1.035) was independently associated with oxygen desaturation without critical RR change. CONCLUSION: Postoperative oxygen desaturation paradoxically occurred more frequently in patients without critical RR changes, whose RR was monitored by the RRa under oxygen therapy. The duration of surgery may explain the possibility of postoperative oxygen desaturation without an RRa device alert.

A Retrospective Analysis of Oxygen Desaturation during Acoustic Respiratory Rate Monitoring in Non-ICU Patients following Tracheal Extubation after General Anesthesia.

Purpose. Acoustic respiratory rate (RRa) monitoring provides an accurate estimation of the respiratory rate (RR). We investigated the incidence of oxygen desaturation under RRa monitoring in a postoperative setting and identified its related factors. Methods. This study was a retrospective chart review of postoperative patients outside an intensive care unit setting. Using the data collected during the first 8 h postoperatively, patients were divided into oxygen desaturated (SpO2 < 90% for >10 s) and nondesaturated groups under oxygen administration. Multivariate analysis was used to determine oxygen desaturation-associated explanatory factors. Results. Oxygen desaturation was detected in 102 of 935 patients (10.9%). % vital capacity [odds ratio (OR), 0.885 per 10% increase; 95% confidence interval (CI), 0.790 to 0.992], coexisting chronic obstructive pulmonary disease (OR, 2.195; 95% CI, 1.088 to 4.428), and absence of a critical RRa change (RR > 30 or <8 beats/min for >2 min) (OR, 1.972; 95% CI, 1.226 to 3.172) were independently associated with oxygen desaturation. Conclusion. Postoperative oxygen desaturation was observed in more than 10% of the patients whose RR was monitored by RRa under oxygen therapy. It is more likely to occur in patients with impaired pulmonary function or morbid pulmonary status and can also occur in the absence of abnormal RR.

Incidence of life-threatening respiratory events after laparoscopic colon surgery with or without continuous respiratory rate monitoring.

BACKGROUND: Respiratory depression (RD) is a critical complication of general anesthesia. The present study investigated the incidence of postoperative life-threatening respiratory events after laparoscopic colon surgery in patients observed using continuous respiratory rate monitoring [RM; with oxygen saturation by pulse oximetry (SpO2)] and traditional respiratory monitoring (TM; SpO2 monitoring only). In addition, postoperative incidence rates of RD and desaturation in the RM group were determined. FINDINGS: In this retrospective observational study, medical records of 214 patients who underwent laparoscopic colon surgery were analyzed. A total of 88 patients with RM were observed and compared with 126 patients with TM. Nineteen patients in the RM group were excluded from the final analyses because of incomplete data. No life-threatening respiratory events were observed in the RM group (0/69), whereas two such events (2/126) occurred in the TM group. Incidence rates of postoperative RD and desaturation within 8 h after surgery were 17.1% (12/69) and 24.3% (17/69), respectively, in the RM group. CONCLUSIONS: No postoperative life-threatening respiratory events were observed in the RM group. Furthermore, the incidence rates of RD and desaturation were noted to be relatively high.

Ocular Blood Flow Measured Using Laser Speckle Flowgraphy During Aortic Arch Surgery With Antegrade Selective Cerebral Perfusion.

OBJECTIVE: The objective of this study was to evaluate the validity of ocular blood flow measured using laser speckle flowgraphy (LSFG) for the assessment of cerebral perfusion during aortic arch surgery. DESIGN: A prospective study. SETTING: A single university hospital. PARTICIPANTS: The study included 17 patients undergoing aortic arch surgery with cardiopulmonary bypass (CPB) using antegrade selective cerebral perfusion (ASCP). INTERVENTIONS: Measurement of ocular blood flow using LSFG. MEASUREMENTS AND MAIN RESULTS: Measurement of ocular perfusion that is supplied mainly from the ophthalmic artery might be useful as an indicator of cerebral blood flow because the ophthalmic artery is the first branch of the internal carotid artery. Recently, LSFG has been developed for noncontact estimation of ocular perfusion using the laser speckle phenomenon. In this study, the LSFG system was used to measure blood flow in the optic nerve head during aortic arch surgery with CPB using ASCP. The blood flow in the optic nerve head during ASCP was statistically significantly reduced by 40.6% compared with the baseline value after anesthetic induction. CONCLUSIONS: Ocular blood flow measured using LSFG showed favorable validity for assessment of cerebral perfusion during aortic arch surgery with ASCP.

Involvement of the endothelin ET(B) receptor in gender differences in deoxycorticosterone acetate-salt-induced hypertension.

1. In the present study, we investigated the role of endothelin ET(B) receptors in gender differences in the development of deoxycorticosterone acetate (DOCA)-salt-induced hypertension by using the spotting-lethal (sl) rat, which carries a naturally occurring deletion in the ET(B) receptor gene. 2. In wild-type rats, the elevation of systolic blood pressure (SBP) by DOCA-salt treatment for 4 weeks was extremely lower in females than in males, but this gender difference was partially attenuated in ovariectomized (OVX) animals. These alterations of SBP corresponded with vascular superoxide () production. 3. In homozygous (sl/sl) group, the SBP of male, intact female and OVX rats was markedly elevated by DOCA-salt treatment to the same extent, indicating that the gender difference in DOCA-salt-induced hypertension was abolished by the genetic ET(B) receptor deficiency. There were similar increases in the vascular endothelin (ET)-1 content in the three DOCA-salt-treated animal groups, but vascular production in male and OVX rats was much higher than that in intact females. 4. Daily oral administration of ABT-627, an ET(A) receptor antagonist, to sl/sl rats for 2 weeks suppressed the DOCA-salt-induced hypertension more efficiently in intact female rats than in male animals. 5. Thus, vascular oxidative stress is related, at least in part, to differences in the development of DOCA-salt-induced hypertension between male and female rats, but this gender difference is abolished by the genetic ET(B) receptor deficiency, suggesting that ET(B) receptor-mediated vasoprotective actions contribute to the gender differences seen. In addition, in both sexes, vascular ET-1 overproduction and the ET(A) receptor-mediated action seem to be responsible for the enhanced susceptibility to DOCA-salt hypertension in genetic ET(B) receptor deficiency.

Antihypertensive effect of angiotensin I-converting enzyme inhibitory peptides from a sesame protein hydrolysate in spontaneously hypertensive rats.

Sesame peptide powder (SPP) exhibited angiotensin I-converting enzyme (ACE) inhibitory activity, and significantly and temporarily decreased the systolic blood pressure (SBP) in spontaneously hypertensive rats (SHRs) by a single administration (1 and 10 mg/kg). Six peptide ACE inhibitors were isolated and identified from SPP. The representative peptides, Leu-Val-Tyr, Leu-Gln-Pro and Leu-Lys-Tyr, could competitively inhibit ACE activity at respective Ki values of 0.92 microM, 0.50 microM, and 0.48 microM. A reconstituted sesame peptide mixture of Leu-Ser-Ala, Leu-Gln-Pro, Leu-Lys-Tyr, Ile-Val-Tyr, Val-Ile-Tyr, Leu-Val-Tyr, and Met-Leu-Pro-Ala-Tyr according to their content ratio in SPP showed a strong antihypertensive effect on SHR at doses of 3.63 and 36.3 microg/kg, which accounted for more than 70% of the corresponding dosage for the SPP-induced hypotensive effect. Repeated oral administration of SPP also lowered both SBP and the aortic ACE activity in SHR. These results demonstrate that SPP would be a beneficial ingredient for preventing and providing therapy against hypertension and its related diseases.

Effects of sesamin on aortic oxidative stress and endothelial dysfunction in deoxycorticosterone acetate-salt hypertensive rats.

In the present study, we evaluated the relationship between the antihypertensive effect of sesamin, a lignan from sesame oil, and its antioxidative activity in deoxycorticosterone acetate (DOCA)-salt hypertensive rats. After a 5-week treatment period, systolic blood pressure was significantly elevated in normal diet-fed DOCA-salt animals compared with cases in sham-operated animals. Sesamin feeding, tempol (a superoxide dismutase mimetic) treatment or antihypertensive drugs combination (triple therapy; reserpine, hydralazine, hydrochlorothiazide) significantly suppressed the development of DOCA-salt-induced hypertension. Compared with sham-operated rats, the normal diet-fed DOCA-salt rats revealed marked increases in aortic superoxide (O(2)(-)) production. These increases in O(2)(-) production were significantly suppressed by sesamin feeding or tempol treatment, but not by triple therapy. Acetylcholine (Ach)-induced endothelium-dependent relaxation was markedly decreased in normal diet-fed DOCA-salt rats, compared with cases in sham-operated rats. Sesamin feeding and triple therapy significantly improved the DOCA-salt-induced impairment of endothelium-dependent relaxation. However, tempol treatment had no effect on the impaired vasodilator responses induced by DOCA-salt treatment. In DOCA-salt rats with or without sesamin feeding, systolic blood pressure significantly correlated with both aortic O(2)(-) production and endothelium-dependent vascular relaxation. These findings suggest that sesamin feeding inhibits the enhancement of aortic O(2)(-) production in DOCA-salt hypertensive rats, and this effect may contribute to the antihypertensive effect of sesamin. Sesamin feeding-induced improvement of endothelial dysfunction seems to result from the above antioxidative and antihypertensive effects.