Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Transesophageal echocardiography during lung transplantation.

Transesophageal echocardiography (TEE) is a semi-invasive monitoring technique increasingly used in cardiac surgery and in major noncardiac surgery for patients with known or supposed cardiac or coronary problems. During lung transplantation (LTx), the close interrelation between heart and lung function makes TEE an invaluable tool for instantly monitoring the physiopathological situation in the subsequent steps of the intervention. In patients scheduled for LTx, induction of anesthesia could be a dangerous moment with the possibility of cardiogenic shock if pulmonary hypertension (PH) exists; pneumatic tamponade is also possible in patients with emphysema caused by alpha(1)-antitrypsin deficiency, with subsequent cardiac insufficiency. One-lung ventilation is a critical phase during LTx; hypoxemia resulting from ventilation of a diseased dependent lung could impair heart oxygenation, particularly if tachycardia is present. Clamping of the pulmonary artery before pneumonectomy could exacerbate cardiac afterload, especially in patients with previous PH. High transmural pressure, linked with low systemic pressure, makes right ventricle (RV) perfusion pressure inadequate. Hypoxemia and PH are the most frequent causes of intraoperative RV decompensation. In this special setting, TEE is irreplaceable in informing the anesthesiologist about the correct time for extracorporeal oxygenation. Lung reperfusion brings with it the possibility of coronary gaseous embolism, easily detected with TEE. After LTx, TEE can be used to detect strictures, thrombi, or permeability of pulmonary venous anastomoses. To summarize, intraoperative TEE during LTx contributes to the immediate recognition of critical events and allows for rapid therapeutic interventions.

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Ulnar neuropathy due to a carpal ganglion: the diagnostic contribution of CT.

Clinical features and electrophysiologic studies indicated a lesion of the ulnar nerve in the wrist of a 50-year-old man. CT of this region revealed a ganglion inside Guyon's canal. Surgical exploration disclosed a carpal ganglion compressing the ulnar nerve just proximal to its division.

Transcranial magnetic stimulation in epileptic patients: usefulness and safety.

We studied 58 patients with partial or generalized epilepsy who had transcranial magnetic stimulation (TMS) of the brain motor regions. Short-term monitoring disclosed that the stimulation did not provoke seizures or EEG changes in any patient. Long-term follow-up disclosed that the epileptic condition was not made worse by TMS. TMS, as currently used for monitoring conduction in central motor pathways, does not induce seizures in drug-treated epileptic patients.

Pregnancy and multiple sclerosis--a 3-year prospective study.

A prospective study of the level of disability, severity and distribution of relapses in 15 women with multiple sclerosis prior to, during and up to 3 years following pregnancy was undertaken. The pregnant group was compared with 22 nulliparous women attending the same clinic and matched for age and severity and duration of disease. In the pregnant group, relapses were more frequent and severe than expected values during the first 6 months post partum, but were below expected values 6-24 months post partum. Over the total study period, therefore, there were no significant differences in relapse number, Expanded Disability Status Score or functional scores between the two groups. Babies born during the study showed normal distributions of weight and head circumference.

Free radical scavengers improve the impaired endothelium-dependent responses in aorta and kidneys of diabetic rabbits.

The effects of two endogenous antioxidants, alpha-lipoic acid and reduced gluthathione (GSH), were evaluated in the response of the renal vasculature and aortic rings ex vivo of 4-week alloxan-diabetic rabbits to the endothelium-dependent agonists bradykinin (BK) and acetylcholine (Ach) or to the endothelium-independent agonist sodium nitroprusside (SNP) and compared with age and sex-matched euglycemic rabbits. The maximal decrease in perfusion pressure (R(max)) after BK infusion in the renal vasculature from diabetic rabbits was 5.4+/-1.3% (PD(2) 8 [12.6-3.4]) compared with 34.2+/-4.2% (PD(2) 9 [11.3-6.7]) (P<0.05) attained in tissues obtained from euglycemic rabbits. The addition of 1 microM lipoic acid or GSH improved (P<0.05) the R(max) to BK to 18.3+/-2.4% (PD(2) 8.6 [12.4-4.8]) and 19.5+/-3.7% (PD(2) 9.1 [13.3-4.9]), respectively. Similarly, the maximal vasorelaxant response to Ach in kidneys from diabetic rabbits was 16+/-2.0% (PD(2) 7.3 [10.4-4.2] whilst the R(max) in kidneys from euglycemic animals was 52.7+/-4.9% (PD(2) 11.3 [16.4-6.2]). Incubation with 1 microM alpha-lipoic acid or GSH restored the R(max) to Ach to 31+/-3.9% (PD(2) 9.8 [14.3-5.3]) and to 23+/-5.4% (PD(2) 7.6 [11.4-3.8], respectively. The vasodilatory response to SNP was unaltered among tissues from diabetic and euglycemic rabbits and was also unaffected by the treatments utilized. In addition, the R(max) to Ach in aortic rings of diabetic rabbits was 28.7+/-2.4% (PD(2) 8.3 [11.7-4.9]) compared with 100% (PD(2) 7.9 [12.1-3.7]) obtained in tissues gathered from euglycemic rabbits. The pretreatment of the tissues with alpha-lipoic acid restores the R(max) to 47.4+/-4% (PD(2) 11.1 [14.3-7.9]) and the pretreatment with GSH to 52+/-3.2% (PD(2) 9.8 [12.7-6.9]). Similarly, the response to SNP was unaltered in all groups. Lipoic acid and reduced gluthatione directly improved the endothelium-dependent response of renal arterioles and aortic rings of diabetic rabbits.

Plasmid-mediated extended-spectrum beta-lactamase-producing strains of Enterobacteriaceae isolated from diabetes foot infections in a Brazilian diabetic center.

We bacteriologically analyzed 156 species of Enterobacteriaceae, isolated from 138 patients with community-acquired diabetic foot ulcers, in a prospective study made at a diabetic center and at the Federal University of Ceará, Brazil, from March, 2000, to November, 2001. The samples were cultured using selective media, and identification, susceptibility tests and detection of plasmid-mediated-extended-spectrum-beta-lactamase (ESBL) producing strains were made with conventional and automated methods. The most frequently occurring pathogens were K. pneumoniae (21.2%), Morganella morganii (19.9%) and E. coli (15.4%). High resistance rates were noted for ampicillin, first generation cephalosporin, trimethoprim/sulfamethoxazole, tetracycline, amoxicillin-clavulanic acid and chloramphenicol. ESBL-producing strains were detected in 6% of the patients. Resistance among gram-negative bacteria has become increasingly common, even in community-acquired infections.

[Ileorectal anastomosis with a B.A.R. A clinical case report. Bowel anastomosis ring]. / Anastomosi ileo rettale con B.A.R. Descrizione di un caso clinico.

The device invented in 1892 by Murphy is now being used again: as a matter of fact, modern technologies allowed for the development of a pressure bowel-anastomosis system with complete reabsorption, whose mechanical structure resembles Murphy's device. In 1987, in digestive anastomosis, the B.A.R. (Bowel Anastomosis Ring) pressure suturing device was successfully used. In this case report, the authors, on the basis of previous experiences concerning pressure bowel anastomosis with biodegradable material, describe the use of the B.A.R. for the performance of an ileo-rectal sub-peritoneal anastomosis in a patient with rectal neoplasia and previous ileorectostomy. In the authors' opinion, the absence of post-surgery complications and the very good functional outcome that was achieved in such a complex case, from a pathological and surgical point of view, is a further contribution to the validity of such methodology, which is also supported by several studies carried out both in the U.S.A. and in Europe on colic and upper digestive surgery. By overcoming the last hindrance represented by the performance of esophageal anastomosis, it will be possible to consider B.A.R. as a useful and proper method to be generally applied in digestive surgery.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

BACKGROUND: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first international consensus conference on this topic. METHODS: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. RESULTS: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. CONCLUSION: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Determination of ten sulphonamides in egg by liquid chromatography-tandem mass spectrometry.

A precise and reliable method for the determination of 10 sulphonamide antibiotics (sulfadiazine, sulfathiazole, sulfamerazine, sulfamethazine, sulfamethoxypyridazine, sulfachloropyridazine, sulfamethoxazole, sulfamonomethoxine, sulfadimethoxine and sulfaquinoxaline) in egg by liquid chromatography-tandem mass spectrometry (LC-MS/MS) has been developed. Drugs were extracted using a mixture of dichloromethane/acetone (50:50, v/v), acidified with acetic acid and then cleaned-up on a cation-exchange solid-phase extraction (SPE) cartridge. The chromatographic separation was performed by gradient on a C(18) column with a mobile phase of methanol-water containing 0.1% formic acid and 5mM ammonium acetate, then sulphonamides were detected in a triple-quadrupole mass spectrometer operated in positive electrospray ionization mode (ESI(+)). The method was validated at 15, 30 and 45 microgkg(-1). These levels were much lower than the corresponding maximum residue limit of 100 microgkg(-1) set for sulphonamides in several matrices but not in eggs, where the presence of such residues is not permitted. Results were quantitated against the selected internal standard (13)C(6)-sulphamethazine and also according to the matrix-matched approach. The within-laboratory reproducibility, expressed as a relative standard deviation, never exceeded 21%. All decision limit (CCalpha) values lied in the range between 16.1 and 20.5 microgkg(-1) and the corresponding results for detection capability (CCbeta) were 16.9 and 25.7 microgkg(-1). Ruggedness was estimated according to the Youden robustness test.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes.

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: >/=126 mg/dL; 2-h value: >/=140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

[Experience of a peripheral center in the surgical treatment of hepatic metastasis from colorectal cancer]. / Esperienza di un centro periferico nel trattamento chirurgico delle metastasi epatiche da cancro colorettale.

Surgical resection is still the first therapeutic option in patients with resectable colorectal cancer metastatic to the liver. Application of radiofrequency energy has been used in patients who did not meet the criteria for resectability and yet were candidates for a liver-directed procedure based upon the presence of liver-only disease. Hepatic resection has evolved in the last two or three decades from a procedure with associated mortality rate of up to 20% in the early 80s to usually less than 5% in patients undergoing liver resection thereafter. This improvement in morbidity and mortality is multifactorial; despite the increased safety of liver operations, hepatic resection still remains a complex surgical procedure with serious potential morbidity. The experience with liver resections and/or radiofrequency ablations, for colorectal cancer metastatic to the liver, performed at a medium-volume center (15 cases in 4 years) is presented. Some features of the metastatic disease, including the number, size and location of metastases are identified. The perioperative mortality is 0, morbidity for non surgical complications is 40%. In this series the reported overall 1-yr survival is 80%, 2-yr is 67%. This paper reviews the experienced factors that have defined the morbidity and mortality associated with liver surgery.

CT scan and surgical treatment of traumatic iliacus hematoma with femoral neuropathy: case report.

Iliacus hematoma should be suspected as the cause of femoral neuropathy in cases of minor trauma in teenagers, especially when the onset of paralysis is delayed and therefore an acute traction injury of the nerve is unlikely. In our 14-year-old female patient the condition followed minor trauma. In such cases CT scan should be performed. When this reveals a hematoma and the nerve lesion is rapidly progressing or complete, the hematoma should be promptly evacuated.

Alloxan diabetes blocks noradrenergic tachyphylaxis in the isolated rabbit kidney--effects of insulin.

Normal and alloxan treated diabetic rabbit kidneys were perfused with Krebs-Henseleit solution in a non-recirculating system and the effects of norepinephrine (NOR) 10(-6)M were tested by infusion of this drug for three subsequent periods of 20 min each, with an interval of 10 min for drug wash-out. In the control kidneys the infusion of NOR promoted an intense vasoconstriction, which was less intense during the second and the third periods. This was known as tachyphylaxis. In contrast to the controls, kidneys from diabetic animals did not show tachyphylaxis to NOR, but when insulin was added to the perfusate, tachyphylaxis appeared. Normal kidneys perfused with hyperosmolar solutions show, as in controls, the same phenomenon. The data presented here demonstrate a defect of adrenergic vascular receptors in alloxan treated kidneys, which can be acutely reversed by insulin. These facts are of importance for the understanding of the vascular disease in diabetes.