Prognostic value of suPAR and hsCRP on acute kidney injury after cardiac surgery.

BACKGROUND: Acute kidney injury (AKI) represents a serious complication following cardiac surgery. Adverse outcome after cardiac surgery has been observed in the presence of elevated levels of soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitivity C-Reactive Protein (hsCRP). The aim of study was (i) to investigate the relationship between preoperative elevated levels of suPAR and hsCRP and postoperative AKI in unselected cardiac surgery patients and (ii) to assess whether the concentration of the biomarkers reflected severity of AKI. METHODS: In a retrospective observational study, biobank blood plasma samples (n = 924) from patients admitted for elective on-pump cardiac surgery were analysed for suPAR and hsCRP levels. The relation between suPAR and hsCRP-values and AKI (any stage), defined by the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, was assessed using adjusted logistic regression. Further, the association between biomarkers and severity (KDIGO 1, KDIGO 2-3 and renal replacement therapy (RRT)) was assessed using adjusted logistic regression. RESULTS: Postoperative AKI (any stage) was observed in 327 patients (35.4 %). A doubling of preoperative suPAR corresponded to an adjusted odds ratio (OR) for postoperative AKI (any stage) of 1.62 (95 % CI 1.26-2.09, p < 0.001). Furthermore, a doubling of suPAR had an adjusted OR of 1.50 (95 % CI 1.16-1.93, p = 0.002), 2.44 (95 % CI 1.56-3.82, p < 0.001) and 1.92 (95 % CI 1.15-3.23, p = 0.002), for KDIGO 1, KDIGO 2-3 and need for RRT, respectively. No significant association was found between elevated levels of hsCRP and any degree of AKI. CONCLUSIONS: Increasing levels of suPAR, but not hsCRP, were associated with development and severity of AKI following on-pump cardiac surgery.

Prognostic Value of Soluble Urokinase-Type Plasminogen Activator Receptor and High-Sensitivity C-Reactive Protein on Postoperative Mortality in Patients Undergoing Elective On-Pump Cardiac Surgery.

OBJECTIVES: Elevated soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitivity C-reactive protein (hsCRP) have been associated with increased mortality in patients with cardiovascular disease. The aim of the present study was to explore the relationship between suPAR and hsCRP values and associated mortality after elective cardiac surgery. A secondary aim was to assess whether a combined risk model of European System for Cardiac Operative Risk Evaluation (EuroSCORE II), suPAR, and/or hsCRP would improve the prognostic accuracy compared with EuroSCORE II alone. DESIGN: Retrospective observational study. SETTING: Single-center, university hospital. PARTICIPANTS: Adult patients admitted for elective on-pump cardiac surgery were included. Biobank blood samples were obtained from previous research projects at a tertiary heart center from 2012 to 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 931 patients were included. Kaplan-Meier and Cox proportional hazard analyses were used to explore a potential association between preoperative suPAR and hsCRP values and all-cause mortality up to one year after surgery. Thirty-day mortality was predicted from suPAR, hsCRP, and EuroSCORE II by logistic regression and compared using area under the receiver operating characteristics curve and Brier scores. After adjustment for known confounders, a doubling of suPAR and hsCRP corresponded to a hazard ratio for all-cause mortality of 2.27 (95% confidence interval 1.65-3.11; p < 0.001) and 1.26 (95% confidence interval 1.07-1.49; p = 0.005), respectively. However, adding the biomarkers to EuroSCORE II did not improve prediction/discrimination with respect to 30-day mortality. CONCLUSIONS: Elevated preoperative levels of suPAR and hsCRP were associated with all-cause mortality in elective cardiac surgery patients. However, inclusion of biomarkers did not improve the prognostic accuracy of EuroSCORE II.

The effect of preoperative dexamethasone on pain 1 year after lumbar disc surgery: a follow-up study.

BACKGROUND: It has been hypothesized that dexamethasone can inhibit persistent postoperative pain, but data on humans is lacking and results from animal studies are conflicting. We explored the effect of 16 mg dexamethasone IV administered preoperatively on persistent pain 1 year after lumbar discectomy. METHODS: This is a prospective 1-year follow-up on a single-centre, randomized, and blinded trial exploring the analgesic effect of 16 mg IV dexamethasone or placebo after lumbar discectomy. One year follow-up was a written questionnaire including back and leg pain (VAS 0-100 mm), Short Form 36 survey (SF-36), EuroQol 5D (EQ-5D), OSWESTRY Low Back Pain Questionnaire, duration of sick leave, working capability, contentment with surgical result. RESULTS: Response rate was 71% (55 patients) in the dexamethasone group, 58% (44 patients) in the placebo group. Leg pain (VAS) was significantly lower in the placebo group compared to the dexamethasone group: 17 (95% CI 10-26) vs 26 (95% CI 19-33) mm, respectively (mean difference 9 mm (95% CI -1 to 0), (P = 0.03). No difference regarding back pain. The placebo group reported significantly more improvement of leg pain and were significantly more satisfied with the surgical result. Patients in the dexamethasone group reported significantly higher pain levels in EQ-5D- and Oswestry questionnaires. No difference in the SF-36 survey or daily analgesic consumption. CONCLUSIONS: We found significantly higher pain levels in the dexamethasone group compared to placebo 1 year after lumbar disc surgery. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT01953978 ). Registered 26 Sep 2013.

Intraoperative S-ketamine for the reduction of opioid consumption and pain one year after spine surgery: A randomized clinical trial of opioid-dependent patients.

BACKGROUND: We aimed to explore the effect of intraoperative S-ketamine on analgesic consumption and pain one year after spine surgery in chronic opioid-dependent patients undergoing spinal fusion surgery. METHODS: Single-centre, randomized, blinded trial of 147 patients. INTERVENTION: Perioperative S-ketamine bolus 0.5 mg/kg followed by S-ketamine 0.25 mg kg-1  hr-1 infusion or placebo. MAIN OUTCOMES: Analgesic use, pain (visual analogue scale 0-100 mm [VAS]) and labour market attachment one year after surgery assessed by written questionnaires. RESULTS: Response rate was 67%. One year after surgery, the daily use of oral morphine equivalents was lower in the ketamine group versus the placebo group: 0 (0-20) mg versus 20 (0-62) mg, (p = 0.02), and fewer patients had a daily use of any analgesics in the ketamine group versus placebo group, 42% (95% CI 23-61) versus 74% (95% CI 58-87), (p = 0.04). Mobilization pain was lower in the ketamine group compared to the placebo group: Median difference 17 mm (95% CI -30 to -3), (p = 0.02). Pain at rest was lower in the ketamine group compared to the placebo group with median difference: 13 mm (95% CI -23 to -3), (p = 0.01). Further, labour market attachment was better in the ketamine group, (p = 0.02). CONCLUSION: Intraoperative ketamine may reduce analgesic use, pain, and improve labour market attachment one year after spine surgery in a chronic opioid-dependent population. SIGNIFICANCE: This randomized clinical trial shows that intraoperative ketamine may reduce opioid use and pain and improve labour market attachment one year after spine surgery in an opioid-dependent population.

Adjuvant analgesics for spine surgery.

Increasing evidence indicate that pain is insufficiently treated following surgical procedures. It is essential that pain treatment is effective with a minimum of side effects in order to promote postoperative rehabilitation. Multimodal analgesia is most likely an important strategy in reducing postoperative pain. Combinations of different analgesics with different mechanisms of action may have an additive analgesic effect with fewer side effects compared to using a single drug. However, there is still a pronounced lack of documentation for the effect and side effects of these multimodal analgesic regimes. More than 6,000 spine surgeries are performed annually in Denmark and spine surgery has been associated with high levels of pain compared to other surgical procedures. Therefore, we considered spine surgery to pose a group of well-defined surgical procedures and we used this model to investigate the efficacy of 3 adjuvant analgesics aiming to improve the multimodal approach in pain management.
 
In study I and II we hypothesized that preoperative IV dexamethasone 16 mg would reduce acute postoperative pain, opioid consumption and persistent pain after lumbar disk surgery. We found that dexamethasone significantly reduced acute pain during mobilization. The clinical relevance is however debatable and we could not demonstrate an opioid sparing effect. Further, we discovered significantly higher pain levels in the dexamethasone group compared to placebo 1 year postoperatively.
 
In study III we explored the effect of 500 mg of oral chlorzoxazone on acute postoperative pain and opioid consumption in patients with moderate to severe pain after spine surgery and found no effect of chlorzoxazone compared to placebo.
 
In study IV we hypothesized that intraoperative ketamine would reduce postoperative opioid consumption and persistent pain after spinal fusion surgery in chronic pain patients with opioid dependency. We found a significantly reduced opioid consumption in the ketamine group and a reduced level of persistent pain 6 months postoperatively.
 
In conclusion, dexamethasone and ketamine are potential adjuvant analgesics for postoperative pain. Possibly ketamine also inhibits the development of persistent pain. Chlorzoxazone has no immediate effect as an adjuvant in acute pain management.

Postoperative complications and survival after surgical resection of esophageal squamous cell carcinoma.

BACKGROUND: Resection of esophageal squamous cell carcinoma (SCC) is associated with a frequent occurrence of postoperative complications. Previously, the impact of complications on long-term survival has been explored primarily in mixed squamous cell and adenocarcinoma (AC) populations with conflicting results. In the present study, the influence of postoperative complications on survival following open esophageal resection was investigated exclusively in a western population with SCC. METHODS: In a retrospective observational study, all patients undergoing open surgical resection for esophageal SCC at our centre between February 2010 and December 2015 were consecutively included. Pre- and perioperative clinical information, mortality and complications were registered. RESULTS: In the study cohort, 133 patients were enrolled. Eighty-nine patients (67%) experienced one or more postoperative complications. The estimated 5-year survival on the entire population was 57%. Patients without complications had a long-term survival of 52%, whereas in patients with one or more complications survival was reduced to 30% (log rank P=0.039). Cox regression analysis revealed that postoperative complications were associated with an increased mortality risk with an adjusted hazard ratio (HR) of 2.02 (95% CI: 1.1-3.7, P=0.025), specifically sepsis/septic shock and anastomotic leakage significantly reduced long-term survival. CONCLUSIONS: We found an improved 5-year survival in patients undergoing surgical resection for SCC compared to previous studies with mixed populations, despite a more frequent occurrence of complications. The presence of postoperative complications significantly reduced the long-term survival with 42%.

Intraoperative ketamine reduces immediate postoperative opioid consumption after spinal fusion surgery in chronic pain patients with opioid dependency: a randomized, blinded trial.

Perioperative handling of surgical patients with opioid dependency represents an important clinical problem. Animal studies suggest that ketamine attenuates central sensitization and hyperalgesia and thereby reduces postoperative opioid tolerance. We hypothesized that intraoperative ketamine would reduce immediate postoperative opioid consumption compared with placebo in chronic pain patients with opioid dependency undergoing lumbar spinal fusion surgery. Primary outcome was morphine consumption 0 to 24 hours postoperatively. Secondary outcomes were acute pain at rest and during mobilization 2 to 24 hours postoperatively (visual analogue scale), adverse events, and persistent pain 6 months postoperatively. One hundred fifty patients were randomly assigned to intraoperative S-ketamine bolus 0.5 mg/kg and infusion 0.25 mg·kg·h or placebo. Postoperatively, patients received their usual opioids, paracetamol and IV patient-controlled analgesia with morphine. In the final analyses, 147 patients were included. Patient-controlled analgesia IV morphine consumption 0 to 24 hours postoperatively was significantly reduced in the ketamine group compared with the placebo group: 79 (47) vs 121 (53) mg IV, mean difference 42 mg (95% confidence interval -59 to -25), P < 0.001. Sedation was significantly reduced in the ketamine group 6 and 24 hours postoperatively. There were no significant differences regarding acute pain, nausea, vomiting, hallucinations, or nightmares. Back pain at 6 months postoperatively compared with preoperative pain was significantly more improved in the ketamine group compared with the placebo group, P = 0.005. In conclusion, intraoperative ketamine significantly reduced morphine consumption 0 to 24 hours after lumbar fusion surgery in opioid-dependent patients. The trend regarding less persistent pain 6 months postoperatively needs further investigation.

Transorbital impalement by a wooden stick in a 3-year-old child.

We present a case of a 3-year-old girl with a transorbital impalement injury due to a wooden stick penetrating the lower inferior palpebra and progressing through the orbita, after the child jumped from a table and hit a wooden basket containing pieces of exposed stick. CT revealed the stick progressing transorbitally through the medial wall and terminating just below the sella turcica. The stick was successfully removed by neurosurgical and ophthalmological specialists. The eye was subsequently inspected, and showed no pathological findings. The girl was treated with topical chloramphenicol and discharged 2 days later. Follow-up examination 2 months after the trauma demonstrated normal visual acuity and ocular motility, with no diplopia, tearing or pain.

Insufficient pain management after spine surgery.

INTRODUCTION: A prospective observational quality assurance study was performed at Glostrup Hospital, Denmark, to describe patients undergoing spine surgery with regard to perioperative analgesic management, post-operative pain, opioid consumption and side effects. MATERIAL AND METHODS: Patients eligible for the study were identified consecutively from the operation chart. The following data were registered: post-operative visual analogue (VAS) pain score at rest and during mobilisation, opioid consumption for the first 24 h, other analgesics administered and side effects. RESULTS: A total of 87 patients were included. For instrumented lumbar fusion patients (n = 24), the VAS pain scores at 1, 4 and 24 h after surgery were (median (interquartile range)) 5 (0-7), 2.5 (0-8) and 5.5 (0-9) at rest and 5 (0-8), 3 (0-9) and 7 (3-9) during mobilisation, respectively. The other surgical subgroups generally experienced VAS ≤ 3. For instrumented lumbar fusion, the total 0-24 h consumption of intravenous morphine equivalents was 39.1 (27.5-62.7) mg. Only eight of 87 patients received the entire scheduled standard post-operative pain treatment. Adverse events were rare. CONCLUSION: Most patients experienced acceptable pain levels, but instrumented lumbar fusion leads to moderate to severe pain levels and a relatively high opioid consumption. The scheduled standard pain management protocols were sparsely followed. Challenges exist in post-operative pain management as observed in previous surveys, especially for instrumented lumbar fusion surgery. Future work should focus on optimising treatment plans. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Urological problems in pregnancy, birth, and puerperium--a systematic review]. / Urinvejsproblemer under graviditet, fødsel og puerperium.

Urological problems in pregnancy represent a diagnostic and therapeutic challenge. Urinary tract symptoms in pregnant women comprise urinary tract infections, urolithiasis, hydronephrosis, urinary retention, urinary frequency and urinary incontinence. The primary purpose of this paper was to link our current understanding of the urinary tract anatomy and physiology to urinary tract symptoms in pregnancy and puerperium and the secondary purpose was to provide a review on diagnosis and management of these.