Assessing the perioperative timeline and incidence of postoperative complications to optimize care for pediatric surgery patients from Northern Quebec.

BACKGROUND: Patients from remote communities often require relocation to urban centres to receive surgical care. This study examines the timeline of care for pediatric surgical patients presenting to the Montreal Children's Hospital from two remote communities in Quebec serving largely Indigenous populations. It aims to identify factors contributing to length of stay, including the incidence of post-operative complications and risk factors for complications. METHODOLOGY: This was a single-center retrospective study of children from Nunavik and Terres-Cries-de-la-Baie-James who underwent general or thoracic surgery between 2011 and 2020. Patient characteristics, including risk factors for complications, and any postoperative complications were summarized descriptively. The timeline of the patient's stay from consultation to post-operative follow-up was determined through chart review, identifying the dates and modality of post-operative follow up. RESULTS: There were 271 eligible cases, including 213 urgent (79.8%) and 54 elective (20.2%) procedures. In total, four patients (1.5%) experienced a postoperative complication at follow-up. All complications occurred among patients who underwent urgent surgery. Three complications (75%) were surgical site infections, managed conservatively. Among patients who underwent elective surgery, 20% waited over 5 days prior to operation The average length of time between discharge and follow-up was one week, regardless of surgical urgency. This was the main contributor to the total time in Montreal. CONCLUSION: Postoperative complications identified at one-week follow-up were rare and only seen following urgent surgery, suggesting that telemedicine can safely replace many in-person post-surgical follow up visits. In addition, there is room to improve wait times for those from remote communities by prioritizing displaced patients where possible.

The utility of transthoracic echocardiography to confirm central line placement: an observational study.

BACKGROUND: Ultrasound visualization of neck vessels is the standard method used to assist with internal jugular vein (IJV) central line placement. Nevertheless, this practice has not eliminated the risk of carotid puncture and/or inadvertent arterial cannulation. Transesophageal echocardiography (TEE) effectively verifies wire placement within the heart but is invasive and not always available. We examined the feasibility and potential utility of using transthoracic echocardiography (TTE) to verify the distal wire in the right atrium (RA) before dilation and cannulation of the IJV. METHODS: Following institutional Research Ethics Board approval and signed consent, 100 patients scheduled for elective cardiac surgery were recruited. As per standard practice at our institution, all patients were to have a central line inserted under general anesthesia with TEE visualization of the guidewire. Transesophageal echocardiography (apical or subcostal four-chamber images) was performed by one of four operators while another anesthesiologist performed central line placement. Following IJV puncture, blood was rapidly aspirated and reinjected to produce microbubbles. Subsequently, a 0.035-inch j-tipped flexible guidewire was inserted and visualized with TEE. The wire was then reinserted into the RA under TTE visualization. RESULTS: Overall, the RA was viewed 94% (95% confidence interval [CI] 87 to 98) of the time with TTE, and both the microbubbles and guidewire were detected 91% (95% CI 84 to 96) of the time. The subjects in whom the guidewire could not be well visualized had a higher mean body mass index (33.6 vs 28.8; P = 0.01). CONCLUSIONS: Transthoracic echocardiography [corrected] is a feasible, noninvasive, and potentially useful method to confirm appropriate placement of the guidewire before dilation and cannulation of the IJV.

Amino-terminal cysteine residues differentially influence RGS4 protein plasma membrane targeting, intracellular trafficking, and function.

Regulator of G-protein signaling (RGS) proteins are potent inhibitors of heterotrimeric G-protein signaling. RGS4 attenuates G-protein activity in several tissues. Previous work demonstrated that cysteine palmitoylation on residues in the amino-terminal (Cys-2 and Cys-12) and core domains (Cys-95) of RGS4 is important for protein stability, plasma membrane targeting, and GTPase activating function. To date Cys-2 has been the priority target for RGS4 regulation by palmitoylation based on its putative role in stabilizing the RGS4 protein. Here, we investigate differences in the contribution of Cys-2 and Cys-12 to the intracellular localization and function of RGS4. Inhibition of RGS4 palmitoylation with 2-bromopalmitate dramatically reduced its localization to the plasma membrane. Similarly, mutation of the RGS4 amphipathic helix (L23D) prevented membrane localization and its G(q) inhibitory function. Together, these data suggest that both RGS4 palmitoylation and the amphipathic helix domain are required for optimal plasma membrane targeting and function of RGS4. Mutation of Cys-12 decreased RGS4 membrane targeting to a similar extent as 2-bromopalmitate, resulting in complete loss of its G(q) inhibitory function. Mutation of Cys-2 did not impair plasma membrane targeting but did partially impair its function as a G(q) inhibitor. Comparison of the endosomal distribution pattern of wild type and mutant RGS4 proteins with TGN38 indicated that palmitoylation of these two cysteines contributes differentially to the intracellular trafficking of RGS4. These data show for the first time that Cys-2 and Cys-12 play markedly different roles in the regulation of RGS4 membrane localization, intracellular trafficking, and G(q) inhibitory function via mechanisms that are unrelated to RGS4 protein stabilization.