Effect of glycopyrrolate on the postoperative urine output of patients following kidney transplantation: a retrospective observational study.

OBJECTIVES: To compare the urine output and estimated glomerular filtration rate (eGFR) of patients postoperatively administered sugammadex or glycopyrrolate 7 days following kidney transplantation (KT). METHODS: We retrospectively enrolled 134 consecutive patients who underwent KT under general anesthesia. Their urine output and eGFR were recorded every 24 hours between postoperative day (POD) 1 and 7. We used regression analysis to evaluate the relationship between the reversal agent administered and the outcomes of the participants. RESULTS: The urine output and eGFR of the participants did not differ between the two groups. Multivariate analysis showed that body mass index (BMI) (odds ratio (OR) 1.21; 95% confidence interval (CI) 1.05-1.40), diabetes mellitus (OR 3.14; 95% CI 1.07-9.16), neurovascular disease (OR 7.00; 95% CI 1.61-30.42), and the duration of surgery (OR 1.01; 95% CI 1.00-1.01) were associated with lower urine output on POD 7. In addition, only BMI (OR 1.25; 95% CI 1.09-1.42) was associated with low eGFR on POD 7. CONCLUSIONS: The urine output and eGFR of patients administered sugammadex or glycopyrrolate following KT did not differ 7 days later. Moreover, glycopyrrolate does not affect urine output or eGFR on POD 7, according to multivariate regression analysis.

Efficacy of preoxygenation with end-tidal oxygen when using different oxygen concentrations in patients undergoing general surgery: a single-center retrospective observational study.

BACKGROUND: Preoxygenation is a simple but very important procedure for preventing arterial desaturation. A higher fraction of inspired oxygen (FiO2) increases atelectasis and 80% oxygen results in significantly less atelectasis than 100% oxygen. We investigated whether there was a difference in the duration of adequate preoxygenation when using 100% and 80% oxygen. The proportion of patients for whom >3 min was required to achieve adequate preoxygenation was also investigated. METHODS: The VitalDB database of patients underwent general surgery between February 1, 2021 and November 12, 2021 was reviewed. The time between the start of preoxygenation and the point where a 10% difference between FiO2 and end-tidal oxygen (EtO2) was defined as the preoxygenation time. The patients were classified into 100% and 80% groups according to the oxygen concentration. Propensity score matching (PSM) was performed to control for potential confounding factors. RESULTS: Only 330 of the 1,377 patients had sufficient data for analysis: 179 in the 80% group and 151 in the 100% group. After PSM, 143 patients in each group were analyzed. The median preoxygenation time was 143 s [interquartile range (IQR): 120.5-181.5 s] and 144 s (IQR: 109.75-186.25 s) in the 80% and 100% groups, respectively [P=0.605; median difference =-1 s; 95% confidence interval (CI): -13 to 10]. Of the patients, 27% required >3 min for adequate preoxygenation. CONCLUSIONS: No difference in preoxygenation time was found between the 80% and 100% groups. For some patients, breathing for 3 min is not sufficient for adequate preoxygenation. EtO2 monitoring aids evaluation of whether preoxygenation was adequate.

Successful extracorporeal membrane oxygenation in a patient with central airway obstruction due to an endotracheal mass.

Extracorporeal membrane oxygenation (ECMO) assists blood circulation and gas exchange via a heart-lung machine. ECMO is used mainly in intensive care units as bridging therapy until heart and respiratory failure can be addressed or until transplantation can be performed. ECMO is sometimes used during surgery under general anaesthesia, depending on the patient's underlying diseases and the nature of the operation. If the oxygen supply and carbon dioxide removal capacity are limited, venovenous (VV)-ECMO can be helpful. Here, we describe the use of VV-ECMO for surgical resection of an endotracheal mass through rigid bronchoscopy in a patient who developed decompensating dyspnoea due to central airway obstruction (CAO).

Prediction of blood pressure changes associated with abdominal pressure changes during robotic laparoscopic low abdominal surgery using deep learning.

BACKGROUND: Intraoperative hypertension and blood pressure (BP) fluctuation are known to be associated with negative patient outcomes. During robotic lower abdominal surgery, the patient's abdominal cavity is filled with CO2, and the patient's head is steeply positioned toward the floor (Trendelenburg position). Pneumoperitoneum and the Trendelenburg position together with physiological alterations during anesthesia, interfere with predicting BP changes. Recently, deep learning using recurrent neural networks (RNN) was shown to be effective in predicting intraoperative BP. A model for predicting BP rise was designed using RNN under special scenarios during robotic laparoscopic surgery and its accuracy was tested. METHODS: Databases that included adult patients (over 19 years old) undergoing low abdominal da Vinci robotic surgery (ovarian cystectomy, hysterectomy, myomectomy, prostatectomy, and salpingo-oophorectomy) at Soonchunhyang University Bucheon Hospital from October 2018 to March 2021 were used. An RNN-based model was designed using Python3 language with the PyTorch packages. The model was trained to predict whether hypertension (20% increase in the mean BP from baseline) would develop within 10 minutes after pneumoperitoneum. RESULTS: Eight distinct datasets were generated and the predictive power was compared. The macro-average F1 scores of the datasets ranged from 68.18% to 72.33%. It took only 3.472 milliseconds to obtain 39 prediction outputs. CONCLUSIONS: A prediction model using the RNN may predict BP rises during robotic laparoscopic surgery.

Intraoperative use of noninvasive ventilation during spinal anaesthesia in patients with severe chronic obstructive pulmonary disease undergoing orthopaedic surgery: A case report.

Compared with invasive mechanical ventilation, noninvasive ventilation (NIV) improves patient comfort and neurocognitive function; and reduces the likelihood of nosocomial infections and the need for sedation. NIV can also be used perioperatively to prevent postoperative pulmonary complications. This current report describes a case of a 64-year-old female patient with chronic obstructive pulmonary disease and chronic respiratory failure that underwent spinal anaesthesia during surgery. She was sedated with propofol. She brought her home ventilator equipment to the operating room and it was used in biphasic-positive airway pressure mode for immediate treatment of respiratory depression.

Impact of Bilateral Subcostal Plus Lateral Transversus Abdominis Plane Block on Quality of Recovery After Laparoscopic Cholecystectomy: A Randomized Placebo-Controlled Trial.

BACKGROUND: Previous research has not evaluated the potential effect of transversus abdominis plane (TAP) block on quality of recovery following laparoscopic cholecystectomy. Therefore, we investigated whether addition of the bilateral subcostal and lateral TAP (bilateral dual TAP [BD-TAP]) blocks to multimodal analgesia would improve the quality of recovery as assessed with the Quality of Recovery-40 (QoR-40). METHODS: Patients age 18 to 60 years who were scheduled to undergo elective laparoscopic cholecystectomy were randomized to the BD-TAP or control group. The BD-TAP group received the BD-TAP block with multimodal analgesia under general anesthesia, using 0.25% ropivacaine, and the control group was treated with the same method, except that they received the sham block using 0.9% normal saline. Both groups had the same multimodal analgesia regimen, consisting of intravenous dexamethasone, propacetamol, ibuprofen, and oxycodone. The primary outcome was the QoR-40 score at 24 hours after surgery. Data were analyzed using the independent t test, Mann-Whitney U test, χ2 test, and Fisher exact test. RESULTS: Thirty-eight patients in each group were recruited. The mean QoR-40 score decreased by 13.6 (95% confidence interval [CI], 8.3-18.8) in the BD-TAP group and 15.6 (95% CI, 6.7-24.5) in the control group. The postoperative QoR-40 score at 24 hours after surgery did not differ between the 2 groups (BD-TAP group, median [interquartile range], 170.5 [152-178]; control group, 161 [148-175]; median difference, 3 [95% CI, -5 to 13]; P = .427). There were no differences between the 2 groups in the pain dimension of the QoR-40: 30.5 (95% CI, 27-33) in the BD-TAP group and 31 (95% CI, 26-32) in the control group; median difference was 0 (95% CI, -2 to 2); P = .77. CONCLUSIONS: Our results indicate that the BD-TAP block does not improve the quality of recovery or analgesic outcomes following laparoscopic cholecystectomy. Our results do not support the routine use of the BD-TAP block for this surgery.

Ultrasound-guided pulsed radiofrequency treatment for distal suprascapular neuropathy: A case report.

RATIONALE: Suprascapular neuropathy is a rare cause of shoulder pain, and patients usually presents with posterosuperior shoulder pain and weakness on forward flexion and external rotation. Suprascapular neuropathy associated with rotator cuff pathology has received attention as an emerging cause of this condition. Suprascapular nerve (SSN) block can be used in these patients, and pulsed radio frequency (PRF) can be applied to achieve a long-term effect. Several studies have reported on PRF treatment of the SSN for shoulder pain, but most applied treatment to the nerve trunk under the transverse scapular ligament. This report describes a patient with suprascapular neuropathy treated with selective application of PRF to the distal SSN under ultrasound guidance. PATIENT CONCERNS: A 68-year-old woman suffered from right posterior shoulder pain after traumatic full thickness rotator cuff tear. Her pain was not diminished despite of 2 surgeries. DIAGNOSES: She was diagnosed with entrapment of the distal SSN in the spino-glenoid (SGN) notch and suprascapular neuropathy. INTERVENTIONS: She underwent surgery to decompress the entrapped SSN in the SGN. After that, we applied PRF on the distal SSN under ultrasound guidance for persistent pain. This treatment was repeated 3 times. OUTCOMES: PRF treatment resulted in a slight reduction in the visual analogue scale (VAS) pain score from 7-8/10 to 5-6/10 at the 2 weeks follow-up, and to 2-3/10 at the 1 month follow-up. The reduction in pain was maintained at the 1 year follow-up. LESSONS: PRF treatment of the SSN is typically approached from the main branch in the suprascapular notch. We selectively applied PRF to the distal SSN close to the SGN. This technique was safe and effective.

A case of one-lung ventilation using a single-lumen tube placed under fiberoptic bronchoscopic guidance in a 4-year-old child: A case report.

RATIONALE: One-lung ventilation (OLV) is essential for adequate visualization and exposure of the surgical site via a videoscopic approach. Although many instruments facilitating OLV are available, the choice is limited in pediatric patients. PATIENT CONCERNS: A 4-year-old female (weight: 18.6 kg, height: 100 cm) was admitted via our pediatric outpatient clinic because of recurrent hemoptysis, 2 weeks in duration. She had no medical or surgical history. DIAGNOSIS: Contrast-enhanced computed tomography (CT) revealed a 4.5-cm-diameter mass in the left, lower lung lobe. She was diagnosed with a congenital pulmonary airway malformation (CPAM). INTERVENTIONS: She was scheduled for emergency lobectomy via video-assisted thoracoscopic surgery (VATS). To ensure successful VATS, OLV was essential. As our hospital lacked a small-diameter fiberoptic bronchoscope and a proper bronchial blocker, we decided to use single-lumen tube (SLT) with adult fiberoptic bronchoscope. OUTCOMES: We performed successful bronchoscopic-guided OLV using a SLT. We aligned the tube to the right upper lobar bronchus and Murphy eye to prevent obstruction of the right upper lobe bronchus. At the end of surgery, the endotracheal tube lumen had been narrowed by blood clots, we decided to exchange the tracheal tube. The tube was immediately exchanged. After re-intubation, the pulse oximetry (SpO2) then gradually increased. LESSONS: Appropriate preparation and careful management should be considered to perform OLV in pediatric patients without significant complications.

Analysis of caudal epidurogram in single center: A preliminary study of lumbar radiculopathy management.

A caudal epidural block involves placing a needle through the sacral hiatus and delivering medication into the epidural space. The procedure is safe and simple, but failure rates can be as high as 25%. The purpose of this study was to investigate the success rate of caudal epidural block by analyzing needle placement and dye flow pattern.We retrospectively analyzed the medical records of patients who underwent caudal epidural block under spinal stenosis. A case was defined as a failure if it met at least one of the following four criteria: the epidural needle was not placed correctly inside the caudal canal; blood regurgitation or aspiration in the needle was observed; the contrast dye was injected into a blood vessel; or a large amount of the dye leaked into the sacral foramen or did not reach the L5-S1 level.At least 1 failure criterion was observed in 14 cases (17.7%), while none of the failure criteria were satisfied in 65 successful cases (82.3%).No matter how experienced the anesthesiologist may be, delivery of adequate therapeutic agent is not achieved in approximately 20% of cases. Therefore, we recommend fluoroscopy-guided needle placement and confirmation by radio-contrast epidurograpy as the best choice.

Liver transplantation in Jehovah's Witnesses: two cases report.

Liver transplantation is especially challenging in patients who are Jehovah's Witnesses because their religious beliefs prohibit the receipt of blood products. We present two cases of living donor liver transplantation performed in adult Jehovah's Witnesses in South Korea without the use of blood products. In the first case, preoperative erythropoiesisstimulation therapy increased hemoglobin levels from 8.1 to 13.1 g/dl after 9 weeks. In the second case, hemoglobin levels increased from 7.4 to 10.8 g/dl after 6 months of erythropoiesis-stimulation therapy. With the combination of acute normovolemic hemodilution, intraoperative cell salvage, and use of transfusion alternatives, liver transplantation was successfully performed without transfusion of blood products.

Development of the Geop-Pain questionnaire for multidisciplinary assessment of pain sensitivity.

BACKGROUND: To assess the multidisciplinary aspects of pain, various self-rating questionnaires have been developed, but there have not been sufficient relevant studies on this topic in South Korea. The aim of this study was to develop a new pain sensitivity-related questionnaire in the Korean language that would be simple and would well reflect Koreans' senses. METHODS: A new pain assessment questionnaire was developed through a pre-survey on "geop", which is the Korean word expressing fear, anxiety, or catastrophizing. We named the new assessment questionnaire the Geop-Pain Questionnaire (GPQ). The GPQ was composed of 15 items divided into three categories and rated on a 5-point scale. As a preliminary study, internal consistency and test-retest reliability analyses were conducted. Subsequently, 109 individuals completed the GPQ along with three pain-related questionnaires translated into Korean (Pain Sensitivity Questionnaire [PSQ], Pain Anxiety Symptoms Scale [PASS], and Pain Catastrophizing Scale [PCS]), and the correlations were analyzed. RESULTS: All items in the GPQ showed appropriate internal consistency, and the test-retest reliability analysis showed no statistically significant differences. The correlations between the GPQ and the existing questionnaires revealed that the GPQ scores had mid-positive correlations with the PSQ scores and strong positive correlations with the PASS and PCS scores. CONCLUSIONS: This study attempted to develop a questionnaire assessing pain sensitivity multidimensionally using the Korean word geop for the first time. The self-rating GPQ showed high correlations with the existing questionnaires and demonstrated potential to be utilized as a pain prediction index in clinical practice.

A novel family VIII carboxylesterase hydrolysing third- and fourth-generation cephalosporins.

A metagenomic library was constructed from a soil sample of spindle tree-rhizosphere. From this library, one clone with esterase activity was selected. The sequence analysis revealed an open reading frame (EstSTR1) encoded protein of 390 amino acids. EstSTR1 is a family VIII carboxylesterase and retains the S-X-X-K motif conserved in both family VIII carboxylesterases and class C ß-lactamases. The estSTR1 gene was overexpressed in E. coli and the recombinant protein was purified by purified by metal chelating affinity chromatography and size-exclusion chromatography. EstSTR1 hydrolysed p-nitrophenyl esters, exhibited the highest activity toward p-nitrophenyl butyrate. Furthermore, EstSTR1 could hydrolyse third- and fourth-generation cephalosporins (cefotaxime and cefepime) as well as first-generation cephalosporin (cephalothin). Site-directed mutagenesis studies revealed that a catalytic residue, Ser71, of EstSTR1 plays an essential role in hydrolysing both antibiotics and p-nitrophenyl esters. We demonstrate that a metagenome-derived carboxylesterase displays ß-lactam-hydrolysing activities toward third- and fourth-generation cephalosporins.

Identification of a novel alkaline amylopullulanase from a gut metagenome of Hermetia illucens.

A novel pullulanase gene, PulSS4, was identified from the gut microflora of Hermetia illucens by a function-based metagenome screening. The PulSS4 gene had an open reading frame of 4455 base pairs, and encoded a mature protein of 1484 amino acids, with a signal peptide sequence of 44 amino acids. The deduced amino acid sequence of PulSS4 gene showed 51% identity with that of the amylopullulanase of Amphibacillus xylanus, exhibiting no significant sequence homology to already known pullulanases. A conserved domain analysis revealed it to be a pullulanase type II with respective active sites at the N-terminal pullulanase and C-terminal amylase domain. PulSS4 was active in the temperature range of 10-50°C, with an optimum activity at 40°C. It was active in the pH range of 6.5-10.5, with optimum pH at 9.0, and retained more than 80% of its original activity in a broad pH range of 5-11 for 24h at 30°C. Also, PulSS4 was highly stable against many different chemical reagents, including 10% polar organic solvents and 1% non-ionic detergents. Overall, PulSS4 is expected to have the strong potential for application in biotechnological industries that require high activity at moderate temperature and alkaline conditions.

Functional evaluation of residues in the herbicide-binding site of Mycobacterium tuberculosis acetohydroxyacid synthase by site-directed mutagenesis.

Mycobacterium tuberculosis acetohydroxyacid synthase (M. tuberculosis AHAS) has been proposed to bean essential target for novel herbicide- and chemical-based antibacterial agents. Therefore, here we investigated the roles of multiple conserved herbicide-binding site residues (R318, A146, Q148, M512, and V513) in M. tuberculosis AHAS through site-directed mutagenesis by characterizing the kinetic parameters and herbicide sensitivities of various point mutants. Interestingly, all mutant enzymes showed significantly altered kinetic parameters, specifically reduced affinity towards both the substrate and cofactor. Importantly, mutation of R318 led to a complete loss of AHAS activity, indicating a key role for this residue in substrate binding. Furthermore, all mutants demonstrated significant herbicide resistance against chlorimuron ethyl (CE), with several-fold higher IC50 than that of wild type AHAS. Docking analysis also indicated that binding of CE was slightly affected upon mutation of these residues. Taken together, these data suggest that the residues examined here mediate CE binding and may also be important for the catalytic activity of AHAS. This study will pave the way for future structure-function studies of CE and will also aid the development of novel anti-tuberculosis agents based on this chemical scaffold.

A Pilot Study of the Correlation between the Numeric Rating Scale used to Evaluate "Geop" and Questionnaires on Pain Perception.

BACKGROUND: The word "geop" is a unique Korean term commonly used to describe fright, fear and anxiety, and similar concepts. The purpose of this pilot study is to examine the correlation between the Numeric Rating Scale (NRS) score of geop and three different questionnaires on pain perception. METHODS: Patients aged 20 to 70 years who visited our outpatient pain clinics were evaluated. They were requested to rate the NRS score (range: 0-100) if they felt geop. Next, they completed questionnaires on pain perception, in this case the Korean version of the Pain Sensitivity Questionnaire (PSQ), the Pain Catastrophizing Scale (PCS), and the Pain Anxiety Symptoms Scale (PASS). The correlations among each variable were evaluated by statistical analyses. RESULTS: There was no statistically significant correlation between the NRS score of geop and the PSQ score (r = 0.075, P = 0.5605). The NRS score of geop showed a significant correlation with the PCS total score (r = 0.346, P = 0.0063). Among the sub-scales, Rumination (r = 0.338, P = 0.0077) and Magnification (r = 0.343, P = 0.0069) were correlated with the NRS score of geop. In addition, the NRS score of geop showed a significant correlation with the PASS total score (r = 0.475, P = 0.0001). The cognitive (r = 0.473, P = 0.0002) and fear factors (r = 0.349, P = 0.0063) also showed significant correlations with the NRS score of geop. CONCLUSIONS: This study marks the first attempt to introduce the concept of "geop." The NRS score of geop showed a moderate positive correlation with the total PCS and PASS score. However, further investigations are required before the "geop" concept can be used practically in clinical fields.

Screening and characterization of a novel cellulase gene from the gut microflora of Hermetia illucens using metagenomic library.

A metagenomic fosmid library was constructed using genomic DNA isolated from the gut microflora of Hermetia illucens, a black soldier fly. A cellulase-positive clone, with the CS10 gene, was identified by extensive Congo-red overlay screenings for cellulase activity from the fosmid library of 92,000 clones. The CS10 gene was composed of a 996 bp DNA sequence encoding the mature protein of 331 amino acids. The deduced amino acids of CS10 showed 72% sequence identity with the glycosyl hydrolase family 5 gene of Dysgonomonas mossii, displaying no significant sequence homology to already known cellulases. The purified CS10 protein presented a single band of cellulase activity with a molecular mass of approximately 40 kDa on the SDS-PAGE gel and zymogram. The purified CS10 protein exhibited optimal activity at 50°C and pH 7.0, and the thermostability and pH stability of CS10 were preserved at the ranges of 20~50°C and pH 4.0~10.0. CS10 exhibited little loss of cellulase activity against various chemical reagents such as 10% polar organic solvents, 1% non-ionic detergents, and 0.5 M denaturing agents. Moreover, the substrate specificity and the product patterns by thinlayer chromatography suggested that CS10 is an endo-ß-1,4-glucanase. From these biochemical properties of CS10, it is expected that the enzyme has the potential for application in industrial processes.

Structural and functional significance of the highly-conserved residues in Mycobacterium tuberculosis acetohydroxyacid synthase.

Mycobacterium tuberculosis AHAS is a potential target for the development of novel anti-tuberculosis agents. Silico analysis showed that conserved His84 and Gln86 residues lie in the catalytic dimer interface of M. tuberculosis AHAS. Mutational analyses of these invariants led to significant reduction in their activity with reduced affinity toward the substrate. Importantly, mutation of Gln86 to Trp abolished complete activity. Further, molecular dynamics simulation studies suggested that these residues are likely to play a key role in maintaining the Glu85 side chain in the required geometry with N1' atom of ThDP during catalysis. In addition, substitution of essential Glu85 by Ala, Asp, and Gln led to severe drop in catalytic activity with reduced affinity toward ThDP confirming its catalytic role in M. tuberculosis AHAS.

Characterization of a novel cold-active esterase isolated from swamp sediment metagenome.

A functional screen of a metagenomic library from "Upo" swamp sediment in Korea identified a gene EstL28, the product of which displayed lipolytic properties on a tributyrin-supplemented medium. The EstL28 sequence encodes a 290 amino acid protein (designated as EstL28), with a predicted molecular weight of 31.3 kDa. The encoded EstL28 protein exhibited the highest sequence similarity (45 %) to a hydrolase found in Streptococcus sanguinis. Phylogenetic analysis indicated that EstL28 belongs to a currently uncharacterized family of esterases. Within the conserved α/ß-hydrolase 6 domain, the EstL28 retains the catalytic triad Ser103-Asp248-His268 that is typical of esterases. The Ser103 residue in the catalytic triad is located in the consensus pentapeptide motif GXSXG. The purified EstL28 enzyme worked optimally at 35 °C and pH 8.5 and remained stable at temperatures lower than 20 °C. The catalytic activity of EstL28 was maximal with p-nitrophenyl butyrate, indicating that it was an esterase. This enzyme also exhibited stable activity in the presence of methanol, ethanol, isopropanol, and dimethyl sulfoxide. Therefore, the level of stability in organic solvents and cold temperature suggests that EstL28 has potential for many biotechnological applications.

Burkholderia denitrificans sp. nov., isolated from the soil of Dokdo Island, Korea.

A novel, Gram-negative, bacterial strain KIS30-44(T) was identified from wet forest soil collected on the Korean island of Dokdo. Growth of the strain was observed at 15-30°C, pH 5-9, 0-3% NaCl, and 950 mM KNO(3). KIS30-44(T) reduced nitrate to nitrogen gas. Analysis of the 16S rRNA gene sequence showed that KIS30-44(T) was phylogenetically related to Burkholderia sacchari, Burkholderia mimosarum, and Burkholderia oxyphila (98.1%, 98.0%, and 98.0% sequence similarity, respectively). The genomic G+C content was 63.5 mol%. KIS30-44(T) exhibited less than 52% DNA-DNA relatedness with the type strains of 9 closely related Burkholderia species. The major isoprenoid quinone was Q-8. The polar lipid profile consisted of diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylglycerol and two unknown aminolipids. The major fatty acids in KIS30-44(T) were C(16:0), C(18:1) ω7c and summed feature 3 (iso-C(15:0) 2-OH and C(16:1) ω7c), and the strain contained half the amount of C(17:0) cyclo found in the 9 closely related Burkholderia species. The results of these phenotypic, 16S rRNA gene sequence, DNA-DNA hybridization, and chemotaxonomic data indicate that KIS30-44(T) represents a novel species within the genus Burkholderia, for which the name Burkholderia denitrificans (Type strain KIS30-44(T) =KACC 12733(T) =DSM 24336(T)) is proposed.