Effect of postoperative landiolol administration for atrial fibrillation after off pump coronary artery bypass surgery.

AIM: Atrial fibrillation is one of the most common postoperative arrhythmias following cardiac surgery. Despite many clinical studies, there is still no consensus on the most appropriate prevention strategy for atrial arrhythmia. A randomized prospective trial was conducted to determine the efficacy of intravenous landiolol administration in the early period after off-pump coronary artery bypass grafting (CABG) followed by treatment with carvedilol for prevention of atrial fibrillation. METHODS: Seventy consecutive patients were enrolled in the study prospectively. Patients in the treated group received landiolol intravenously (5 µg/kg/min) in the ICU immediately after surgery. Heart rate was maintained at 60-80 bpm and intravenous landiolol was continued at 0-10 µg/kg/min until oral drug administration was possible. All patients received oral carvedilol (2.5-5 mg/day) after extubation and this was continued postoperatively. The primary endpoint was the overall development of postoperative atrial fibrillation. RESULTS: Postoperative atrial fibrillation occurred in 4 (11.1%) of the 36 patients in the landiolol group, compared with 11 (32.3%) of the 34 patients in the control group, indicating that development of atrial fibrillation was significantly inhibited by landiolol (P=0.042). No major postoperative complications occurred in the landiolol group. CONCLUSION: Postoperative intravenous landiolol therapy followed by oral carvedilol may be more effective than oral carvedilol alone for prevention of atrial fibrillation after off-pump CABG. We also found that intravenous landiolol is well tolerated after cardiac surgery.

Adult-onset leukoencephalopathy with vanishing white matter with a missense mutation in EIF2B5.

We report of a woman aged 52 years born to consanguineous parents and seeking treatment for progressive dementia and delusion. Neurologic examination revealed dementia and emotional instability, indifference, and confabulation. There was also mild spasticity of the bilateral lower limbs. MRI revealed diffuse white matter hyperintensity on T2-weighted images accompanied by hypointense areas on fluid-attenuated inversion recovery images. A homozygous missense mutation was identified in EIF2B5.

Haemodynamic effects of volume resuscitation by hypertonic saline-dextran (HSD) in porcine acute cardiac tamponade.

BACKGROUND: Hypertonic saline-dextran (HSD) has been utilized for small-volume resuscitation in acute circulatory shock. However, HSD has also been reported to induce myocardial depression. The aim of this study was to examine the effects of HSD on cardiac performance and splanchnic perfusion in a low cardiac output model based on experimental cardiac tamponade. METHODS: Seven anaesthetized, mechanically ventilated pigs of both sexes (weight 24 +/- 2 kg, mean +/- SEM) completed a randomized, cross-over protocol. A low cardiac output state was established by intrapericardial infusion of dextran. Animals were resuscitated by bolus infusions (4 ml kg(-1) in 2 min) of either 7.5% hypertonic saline-dextran or Ringer's acetated solution (RAc) and then observed during tamponade (20 min) and following its release (40 min). Central haemodynamics, portal venous (QPV) and renal arterial (QRA) flows were measured together with gastric, jejunal, hepatic and renal laser-Doppler flowmetry. RESULTS: Resuscitation using HSD in a low cardiac output state completely restored QPV and improved gastric, jejunal, hepatic and renal microcirculation as assessed by laser-Doppler flowmetry while no significant effect was observed in QRA. No such beneficial effects could be observed when animals were resuscitated using RAc. The improved haemodynamic state by HSD was maintained following release of cardiac tamponade while perfusion in RAc resuscitated animals returned to baseline or even remained depressed (hepatic and renal microcirculation). No signs of cardiodepression by HSD were observed. CONCLUSION: Resuscitation using HSD in a low cardiac output state restored splanchnic perfusion and microcirculation without any signs of cardiodepression.

Citation classics in anaesthesia and pain journals: a literature review in the era of the internet.

BACKGROUND: The number of citations an article receives reflects its scientific impact. The introduction of internet-based resources to search and access articles has made it possible to review even whole scientific areas. This study identifies the top 50 most-cited articles over the last 25 years in specialty journals dedicated to anaesthesia and pain, respectively. METHODS: Twenty-two journals listed in The Science Citation Index Expanded in the field of anaesthesiology and nine major medical journals were screened using the cited reference option to identify articles cited more than 100 times between 1986 and 2002. The top 50 articles in specialty journals and the top 10 articles in major medical journals concerning anaesthesia and pain were retrieved for further analysis. RESULTS: The most-cited articles in specialty journals were published from 1986 to 1997 and received a mean of 222 (anaesthesia) and 279 (pain) citations. Sixty-seven institutions produced the most-cited articles and of those 28 were located outside North America. The articles were published in six journals led by the Journal of Pain (50 articles) and Journal of Anaesthesiology (39 articles). Forty-seven articles were classified as related to clinical experience, 33 were review articles, and 20 discussed basic science. CONCLUSION: To make an article a possible 'citation classic' in anaesthesiology, it should be published in one of six leading journals and originate from an established institute in North America. Internet resources to publish and cite the literature have to date not advanced any article published in the last 5 years to the top 100 list.

[Development of new hydrophilic catheter kit for self-catheterization: study in pediatric cases].

PURPOSE: To increase the management of self-catheterization in children of school age, a catheter kit consisting of hydrophilic catheter and a packet containing sterilized water was developed. We evaluated the lubricating characteristic and clinical efficacy of this new catheter kit. MATERIALS AND METHODS: The catheter kit used in the study was a pocket-size plastic container in which a polyurethane catheter coated with hydrophilic polymer and a packet containing sterilized water were packed in combination. The lubricating characteristic of catheter was assessed by the measurement of friction value. For clinical assessment, male children aged over 6 years old who were doing self-catheterization at 17 medical institutions nationwide were selected as the subjects. The 32 children who had given informed consent (mean age: 11.6 years old) were asked to use the catheter kit continuously for 1 week. The results were investigated by a questionnaire survey in which the assessment before and after the use was expressed in scores. At the same time, urinalysis and urine culture were examined. RESULTS: The friction value of hydrophilic catheter was equivalent to or less than that observed by applying a lubricant to the conventional catheter. The comparison of conventional catheter with the kit indicated significantly higher scores (assessment in 5 grades expressed in scores) for the portability and operability of the kit. Though there was no significant difference in the ease of insertion between the two catheters, there were several comments that the kit got stuck in the urethra when it was withdrawn. The global assessment gave a significantly higher score to the kit and 30 (94%) of the 32 children wanted to use the kit continuously. No increase in hematuria which caused a clinical problem or no new apparent urinary tract infection occurred after the use of the kit. CONCLUSIONS: Compared with the conventional catheter, the hydrophilic catheter kit highly satisfied a large number of children at the time of self-catheterization. Depending on the condition of children, the kit is considered useful for continued self-catheterization for a long term.

Myocardial dysfunction associated with proinflammatory cytokines after esophageal resection.

UNLABELLED: Proinflammatory cytokines have been implicated in mediating myocardial dysfunction associated with major surgery. We investigated the profile of proinflammatory cytokines and the association of cytokine levels with myocardial function after esophagectomy. We studied 12 patients who underwent subtotal esophagectomy. One patient died of multiple organ failure. This patient had the largest interleukin-6 (IL-6) level of all the subjects. IL-6 levels increased from 14.9 +/- 8.7 pg/mL to 498.4 +/- 294.3 pg/mL (P < 0.05) at 6 h postoperatively. Interleukin-8 (IL-8) levels also significantly increased postoperatively. Right ventricular ejection fraction (RVEF) decreased from 44% +/- 1% to 36% +/- 2% (P < 0.05) and 37% +/- 2% (P < 0.05) at 6 h and 12 h postoperatively. Stroke volume index (SVI) decreased significantly at the end of operation and at 6 h and 12 h postoperatively. The changes of RVEF and SVI showed an independent negative correlation with the IL-6 level (r = -0.70, P < 0.001 and r = -0.62, P < 0.001, respectively). In contrast, the change of RVEF and SVI was not correlated with the IL-8 level. Esophagectomy is associated with transient depression of myocardial function. IL-6 may contribute to this postoperative myocardial dysfunction. IMPLICATIONS: We examined the association between myocardial function and proinflammatory cytokines after esophagectomy. Interleukin-6 may be the cytokine that most sensitively reflects the postoperative myocardial dysfunction.

Minor cardiac troponin T release in patients undergoing coronary artery bypass graft surgery on a beating heart.

OBJECTIVES: To determine whether and to what extent coronary artery bypass graft (CABG) surgery without extracorporeal circulation is associated with cardiac troponin T (TnT) release. DESIGN: Prospective study. SETTING: A single university hospital. PARTICIPANTS: Twenty-three patients scheduled for minimally invasive CABG surgery. Sixteen patients received one coronary anastomosis, and seven received two. INTERVENTIONS: TnT and creatine kinase-MB (CK-MB) levels were determined immediately before induction of anesthesia (baseline) and at 0, 12, and 24 hours after surgery. Hemodynamic measurements were made, and 5-lead electrocardiograms with continuous automated ST-segment trends were analyzed. MEASUREMENTS AND MAIN RESULTS: All patients had a good cardiac outcome. Median cumulative coronary artery occlusion time was 27 minutes (range, 10 to 49 minutes). TnT levels were undetectable in 91.3% of patients at baseline when a detection limit of 0.01 ng/mL was employed. TnT and CK-MB showed significant elevations at 12 and 24 hours versus baseline. Postoperatively, TnT was detectable in 91.3% of patients, and 17.4% suffered minor myocardial damage, as evidenced by an abnormal increase in TnT greater than 0.2 ng/mL, excluding those exhibiting myocardial infarction. ST segment changes developed in seven patients, persisting for 13.0 minutes (range, 9.5 to 15.8 minutes) and disappearing immediately after coronary artery clamp release. There were no significant correlations between cumulative coronary occlusion time and peak TnT or CK-MB levels. CONCLUSIONS: TnT was detected after surgery in most patients, and significant TnT levels indicative of myocardial injury (>0.2 ng/mL) were detected in only 17% of patients, probably as a result of brief periods of coronary artery occlusion.

Local cardiac wall stabilization influences the reproducibility of regional wall motion during off-pump coronary artery pass surgery.

OBJECTIVE: Myocardial ischemia is a risk factor during off-pump coronary artery bypass procedures. The development of new regional wall motion abnormalities assessed by transesophageal echocardiography (TEE) is a very sensitive sign of myocardial ischemia. To facilitate anastomosis, the epicardial area of the anastomosis site is often immobilized by a "stabilizer." This study was designed to investigate whether cardiac wall stabilization with an epicardial stabilizer could affect the interpretation of wall motion during coronary anastomosis without cardiopulmonary bypass. METHODS: The TEE videotapes of 15 adult patients were investigated. Left ventricular (LV) transgastric short and long axis views were divided according to a modified 16-segment method. LV wall motion was scored using a 5-grade scale by two independent blinded investigators during pre-occlusion, occlusion, and reperfusion of anastomosed coronary arteries. The wall motion scores of a stabilized segment combined with two adjacent segments were compared with those of non-stabilized segments. Interobserver agreement was assessed using the weighted kappa statistic. RESULTS: A total of 216 segments were analyzed by two investigators. The interobserver kappa coefficient in pre-occlusion and reperfusion periods was 0.87, 0.87 and 0.86, 0.87, respectively, indicating high agreements without stabilizer. During the occlusion period in stabilized and non-stabilized segments, it was 0.59 and 0.76, respectively, showing significantly less reproducibility in the presence of stabilizer. CONCLUSION: Cardiac wall stabilization affects the reproducibility in the interpretation of regional wall motion during off-pump coronary artery bypass surgery. Caution should be used when monitoring for myocardial ischemia using TEE during coronary artery bypass surgery with epicardial stabilizer.

Joint proprioception in the elderly with and without hip fracture.

OBJECTIVES: Decreased proprioception may contribute to the risk of falls in elderly patients. The purpose of this study is to determine whether patients with hip fractures have decreased hip proprioception compared with aged-matched controls, and whether hip proprioception differs in patients with repaired fractures compared with patients who have undergone prosthetic hip replacement after hip fracture. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Both hips of twenty-four hip fracture patients and age-matched patients without hip fractures were studied. Hip fracture patients were divided into osteosynthesis (twelve hips) and hemiarthroplasty (twelve hips) groups. INTERVENTION: Reproducibility of index angles (thirty hip flexion and thirty hip abduction) were compared with a six-degree-of-freedom electrogoniometer (instrumented spatial linkage; angular accuracy +/-0.5 degrees). RESULTS: There was no significant difference (flexion, p > 0.20; abduction, p > 0.67) in joint proprioception between fracture and no fracture groups. Likewise, there was no difference (flexion, p > 0.99, abduction; p > 0.74) in joint proprioception between osteosynthesis and hemiarthroplasty groups. CONCLUSIONS: Joint proprioception of hip fracture patients was not found to be diminished compared with age-matched normal controls. Additionally, replacement of the femoral head did not reduce joint proprioception compared with osteosynthesis with an intact femoral head. Maintenance of the femoral head does not seem to be necessary for the maintenance of joint proprioception in elderly hip fracture patients.

What is the optimal dose of glucose administration during minor surgery under sevoflurane anesthesia?

PURPOSE: We attempted to identify the optimal infusion rate of glucose to maintain an appropriate usage of energy sources during minor surgery after an overnight fast. METHODS: Forty patients scheduled for tympanoplasty or skin grafting under sevoflurane anesthesia were assigned to four groups. The patients received a 2-h infusion of either saline or glucose at a rate of 0.1, 0.2, or 0.3 g.kg(-1).h(-1). Blood samples were collected before the induction of anesthesia, and at 1 and 2 h after the start of the saline or glucose infusion. Plasma glucose, free fatty acid, beta-hydroxybutyrate, acetoacetate, and immunoreactive insulin were measured. RESULTS: Plasma glucose concentration increased dose-dependently. Immunoreactive insulin levels increased in the groups receiving 0.2 or 0.3 g.kg(-1).h(-1) of glucose infusion. Free fatty acid and ketone bodies did not increase in any glucose infusion groups. The arterial ketone body ratio increased to over 1.00 in the groups receiving 0.2 or 0.3 g.kg(-1).h(-1) of glucose infusion. Glycorrhea was observed only in the group receiving 0.3 g.kg(-1).h(-1) of glucose. CONCLUSION: The smaller doses of glucose (0.1-0.2 g.kg(-1).h(-1)) prevented lipolysis and hyperglycemia during minor surgery.

Intracapsular components do not change hip proprioception.

We compared joint proprioception in 12 hips in 12 patients with hemiarthroplasty after fracture of the hip, in 12 hips in 11 patients with total hip arthroplasty because of osteoarthritis and in a control group of 12 age-matched patients with no clinical complaints. There was no significant difference (p = 0.05) in joint proprioception in any of the groups. There was no decrease in joint proprioception in the group with total hip arthroplasty compared with the hemiarthroplasty group or with the control group. Other factors such as stretch receptors in the adjacent tendons and muscles may have a greater influence on proprioception in the hip than the intracapsular components.

Screw home motion after total knee replacement.

The objective of this study was to evaluate the effect of muscle force and the posterior cruciate ligament on screw home motion in patients with total knee replacement in a posterior cruciate ligament retaining prosthesis (10 knees) and a posterior cruciate ligament substituting prosthesis (10 knees). Screw home motion was examined with only active extension and with two types of externally loaded active extension (2 kg and body weight). Screw home motion was measured with a 6 degrees of freedom electrogoniometer (instrumented spatial linkage). Retaining the posterior cruciate ligament maintained screw home motion, with and without external load to muscles, whereas substituting the posterior cruciate ligament maintained screw home motion only under the full external load of body weight. This was not seen with a 2-kg external load. As for the normal knee, it appears that screw home motion of a prosthetic knee is influenced, not only by the presence of ligamentous structures, but also by the activity of the muscles. The activity of the muscles may have a much greater effect on screw home motion with currently used prosthetic designs than does the presence of ligamentous structures.

Gait analysis after total knee arthroplasty. Comparison of posterior cruciate retention and substitution.

: The objective of this study was to measure three-dimensional knee motion during gait in patients with total knee replacements which either retained the posterior cruciate ligament (n = 11), or required sacrifice of the posterior cruciate ligament and replacement of its function with a posterior stabilizing articular surface (n = 9). Clinically meaningful translations (anterior and posterior, medial and lateral, proximal and distal) and rotations (flexion and extension, internal and external rotation, abduction and adduction) were measured using an instrumented spatial linkage. Although patients from both groups were able to achieve passive full extension and a minimum of 95 degrees flexion, some of their translations and rotations during free speed walking were consistently less than those in a group of healthy controls. Motion during the swing phase of gait was similar for both knee replacement groups. However, abduction and adduction and proximal and distal translation were larger (but neither difference was significant) for the patients with implants with a posterior stabilizing surface, which suggests that the stabilizing surface may not reliably provide as much stability in these directions as does retention of the posterior cruciate ligament.

Three-dimensional kinematics of the human knee with intracortical pin fixation.

Knee motion was measured with an instrumented spatial linkage (accuracy, linear +/-500 microns; angular, +/-0.5 degree) fixed with intracortical Kirschner wires in five healthy male volunteers (five knees, judged clinically to be normal). This technique allows an accurate description of the relative angular and linear movements between tibia and femur without the effect of skin movement relative to the bone and without the effect of changing muscle volume. Motion of the tibia relative to the femur was described in terms of three clinically meaningful rotations and three translations between full extension and 60 degrees flexion: (1) abduction and adduction: 3.4 degrees +/- 1.2 degrees; (2) internal and external rotation: 10.6 degrees +/- 2.8 degrees, representing screw home motion; (3) anterior and posterior: 5.2 +/- 1.7 mm, representing roll back phenomenon; (4) proximal and distal: 1.2 +/- 2.7 mm; and (5) medial and lateral: 1.1 +/- 2.6 mm.

Comparison of joint position sense after total knee arthroplasty.

A comparison of joint position sense, determined by reproducibility of index angles and their subsequent change, was performed in 55 knees that had undergoing a semiconstrained total knee arthroplasty. Knees were stratified into groups that represented arthroplasties performed with or without posterior cruciate ligament retention, with or without resurfacing of the patella, and with or without cement for fixation. There was no significant difference in joint position sense among all the arthroplasty groups. Likewise, there was no difference in joint position sense between any of the arthroplasty groups and an age-matched control group of 32 knees in 32 patients who had not previously undergoing a total knee arthroplasty. Knee arthroplasty does not affect joint position sense.