Local Wound Infiltration for Thyroidectomized Patients in the Era of Multimodal Analgesia.

The first few hours following thyroidectomy are the most crucial for pain management. Adequate postoperative pain control, reduction in opioid abuse and the possibility of implementing one-day operations are the considered parameters when developing the postoperative analgesic strategy. A study of the available literature was conducted, exploring the efficacy of (open) thyroidectomy wound infiltration. Seventeen full-text RCTs were extracted. Local anesthetics and non-steroidal anti-inflammatory drugs were infiltrated. Emphasis was given to postoperative pain scores and requirements for rescue analgesia with opioids. Most authors agree that local wound infiltration for thyroidectomized patients is effective in the management of postoperative pain parameters. In the era of multimodal analgesia, thyroidectomy wound infiltration could represent an essential adjunct contributing to lower VAS scores and reduced opioid requirements.

Phase Angle and Handgrip Strength as Complements to Body Composition Analysis for Refining Prognostic Accuracy in Cardiac Surgical Patients.

OBJECTIVE: This study aimed to benchmark the prognostic validity of nutritional status, body composition, phase angle, and muscle strength assessment on the basis of morbidity and mortality in the cardiac surgery population. DESIGN: Prospective, cohort study. SETTING: Tertiary university hospital. PARTICIPANTS: Patients undergoing cardiac surgery procedures. INTERVENTIONS: Demographic, anthropometric, and clinical data registration, handgrip strength (HGS) measurement, and body composition assessment were performed the day before the scheduled surgery in a cohort of 179 cardiac surgery patients. Body composition parameters and HGS were reassessed on postoperative day seven (POD7). The study endpoints were the hospital length of stay (LOS) and in-hospital mortality. RESULTS: Data from a cohort of 179 patients were analyzed. Significant impairment of nutritional status, body composition parameters, and HGS were recorded on POD seven (p < 0.001), which was associated with prolonged hospital LOS (p < 0.05). Postoperative low phase angle (PhA) (odds ratio [OR] 4.366; 95% confidence interval [CI] 1.859-10.255; p = 0.001), reduced fat-free mass index (OR 1.077; 95% CI 1.020-1.137; p = 0.008), and expanded extracellular water (ECW) (OR 1.230; 95% CI 1.080-1.401; p = 0.002) were the most powerful predictors of prolonged hospital LOS, with PhA (hazard ratio [HR] 1.228; 95% CI 1.074-1.403; p = 0.003) and ECW (HR 0.945; 95% CI 0.909-0.982; p = 0.004) serving as predictors of in-hospital mortality. Postoperative PhA, ECW, and total body water presented superior or at least equivalent discrimination of morbidity or mortality to EuroSCORE II. CONCLUSIONS: Cardiac surgery patients are at risk of nutritional status deterioration during their hospitalization course, which, in turn, exerts an adverse effect on the outcome. Attenuation of PhA, deterioration of fat-free mass index, and edema development constitute potential surrogates to the prediction of morbidity and mortality.

Levetiracetam as preventive treatment in adults with migraine: an up-to-date systematic review and quantitative meta-analysis.

PURPOSE: The aim of this systematic review was to evaluate current evidence on the efficacy and safety of levetiracetam as migraine prophylaxis in adult patients suffering from migraine attacks. METHODS: PubMed, Scopus, Cochrane Central Register of Controlled Trials, and International Web of Science were searched (last search in August 2018) for studies investigating levetiracetam for migraine prophylaxis in adults. Both randomized and non-randomized trials were eligible. Efficacy was the primary outcome, but tolerability was also investigated. The study is registered on PROSPERO, number CRD42018088900. RESULTS: Nine studies, enrolling 215 patients, were included. Levetiracetam decreased the frequency of attacks with headache in all studies, with a pooled mean difference of -3.02 (95% CI: -4.59 to -1.45; I2 = 0%), -4.65(-7 to -2.3; I2 = 0%), and -5.71 (-8.60 to -2.82; I2 = 0%) at 1, 3, and 6 months compared with baseline. Three randomized controlled trials were included, and levetiracetam was superior to placebo in two but was inferior to sodium valproate in reducing headache frequency. Similar results were found in the other indices of efficacy, and levetiracetam was generally well tolerated. CONCLUSION: Levetiracetam may be a relatively safe and efficacious treatment for the prophylaxis of migraine based on limited evidence, most from uncontrolled studies. Further evidence from randomized controlled trials is necessary.

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis was to appraise clinical evidence of the impact of peritonsillar infiltration of tramadol, on postoperative pain control and the occurrence of adverse effects in children undergoing tonsillectomy. METHODS: A database search was conducted to identify randomized controlled trials (RCTs) pertinent to peritonsillar infiltration of tramadol compared to no treatment (placebo) or other analgesic regimens. The outcomes of interest were postoperative pain intensity, time to first analgesic demand, rescue analgesic consumption up to 24 hours after intervention, and the occurrence of adverse events. RESULTS: Twelve RCTs enrolling 972 pediatric patients were selected for qualitative analysis, among which eight were suitable for meta-analysis. Tramadol infiltration induced a significant reduction of pain intensity up to 24 hours post-tonsillectomy (mean difference [MD], -2.31; 95% confidence interval [CI], -3.49 to -1.12; P < 0.001; I2  = 97%) and time to first analgesic (MD 180.54; 95% CI, 56.91 to 304.18; P = 0.004; I2  = 99%), with no profound impact on postoperative nausea and vomiting (risk ratio [RR] 0.98; 95% CI, 0.73 to 1.32; P = 0.90; I2  = 0%) compared to the placebo group. The analgesic efficacy of tramadol infiltration was equivalent to the local or systematic use of ketamine or infiltration with local anesthetics. This effect was further enhanced when tramadol infiltration served as an adjunct to other analgesic interventions. No serious adverse events were reported. CONCLUSIONS: In children undergoing tonsillectomy, peritonsillar infiltration of tramadol is associated with a postoperative analgesic benefit when compared to placebo, with negligible adverse events. Yet, no definite conclusion can be drawn due to the low quality, considerable heterogeneity, and paucity of the available data.

Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature.

AIM: Osmotherapy constitutes a first-line intervention for intracranial hypertension management. However, hyperosmolar solutes exert various systematic effects, among which their impact on systemic haemodynamics is poorly clarified. This review aims to appraise the clinical evidence of the effect of mannitol and hypertonic saline (HTS) on cardiac performance in neurosurgical and neurocritical care patients. METHOD: A database search was conducted to identify randomized clinical trials and observational studies reporting HTS or mannitol use in acute brain injury setting. The primary end-points were alterations of cardiac output (CO) and other haemodynamic variables, while the impact of osmotic agents on intracranial pressure, brain relaxation, plasma osmolality, electrolyte levels and urinary output constituted secondary outcomes. RESULTS: Eight studies, enrolling 182 patients in total, were included. HTS exerted a more profound cardiac output augmentation than mannitol, but no distinct difference between groups occurred. Central venous pressure, stroke volume and stroke volume variation were favourably affected by both osmotic agents, whilst the reported changes in blood pressure were inconclusive. HTS infusion yielded a larger intracranial pressure reduction than mannitol but had an equivalent effect on brain relaxation. Mannitol presented a more potent diuretic effect than HTS. Effect on serum osmolality was alike in both osmotic agents, but contrary to HTS-promoted hypernatraemia, mannitol use induced transient hyponatraemia. CONCLUSIONS: Mannitol or HTS administration seems to induce an enhancement of cardiac performance; being more prominent after HTS infusion. This effect combined with mannitol-induced enhancement of diuresis and HTS-promoted increase of plasma sodium concentration could partially explain the effects of osmotherapy on cerebral haemodynamics.

Dexmedetomidine as a sedative and analgesic adjuvant in spine surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: This systematic review and meta-analysis appraise the clinical evidence on efficacy and safety of dexmedetomidine (DEX), as a sedative and analgesic adjunct in adult patients undergoing spine surgery. METHODS: A database search was conducted to identify randomized clinical trials (RCTs) pertinent to the perioperative use of DEX in spine surgery. Sedative and analgesic efficacy of DEX constituted the primary outcomes, whilst the incidence of hemodynamic changes, quality of recovery and occurrence of adverse events served as secondary ones. RESULTS: Fifteen studies enrolling a total of 913 patients were selected for qualitative analysis, among which eight RCTs incorporating a placebo comparison group were included in the meta-analysis. Most of the retrieved studies were of moderate to good quality and demonstrated an acceptable risk of bias. DEX-treated patients showed a significant reduction of both propofol [mean difference (MD), -214.47 mg; 95%CI, -253.16 to -175.78; P < 0.001] and morphine equivalents consumption both intraoperatively and postoperatively (MD, -2.69; 95% CI, -3.05 to -2.33; P < 0.001 and MD, -4.36 mg; 95%CI, -6.93 to -1.79; P < 0.001, respectively) compared to those assigned to placebo. Postoperative nausea and vomiting incidence were comparable between DEX and placebo groups, whilst other adverse events were not consistently reported. CONCLUSIONS: DEX emerges as an attractive alternative to standard sedative and analgesic modalities applied in spine surgery, by attaining a notable sedative and opioid-sparing effect, which goes with an enhanced safety profile. Yet, no definite conclusion can be drawn due to the considerable heterogeneity of available data. TRIAL REGISTRATION: PROSPERO CRD42015029537.

Combined Enteral and Parenteral Glutamine Supplementation in Endotoxemic Swine: Effects on Portal and Systemic Circulation Levels.

OBJECTIVE: To measure plasma glutamine (GLN) levels in systemic and portal circulation after combined enteral and parenteral administration in early endotoxemic swine. We hypothesized that this combination will be more efficient than intravenous administration alone in restoring plasma levels during the course of endotoxemia. MATERIALS AND METHODS: Endotoxemia was induced with Escherichia coli O111:B4 lipopolysaccharide (LPS) (250 µg/kg body weight) in 16 anes-thetized, fasted swine and maintained by constant infusion (2 µg/kg/h) over 180 min. Another 16 swine served as controls. After infusion with LPS or placebo, GLN was administered intravenously, enterally or in combination (0.5 g/kg i.v. plus 0.5 g/kg enterally) over 30 min. At 0, 15, 30, 45, 60, 120 and 180 min, blood was drawn from the systemic and portal circulation for colorimetric assessment of GLN. RESULTS: In healthy, placebo-alone swine, GLN levels remained stable throughout the study. Intravenous and combined infusion increased systemic levels (p = 0.001), but after enteral administration alone, a smaller effect was observed (p = 0.026). Portal levels were increased after combined, enteral and intravenous administration (p = 0.001). In endotoxemia, systemic and portal levels decreased significantly. Intravenous and, to a greater extent, combined administration increased systemic levels (p = 0.001), while enteral administration only had a small effect (p = 0.001). In the portal vein, intravenous and combined treatment increased plasma levels (p = 0.001), whereas enteral supplementation alone had again a small, yet significant effect (p = 0.001). CONCLUSIONS: The findings indicate that combined GLN supplementation is superior to intravenous treatment alone, in terms of enhanced availability in systemic and portal circulations. Thus, combined treatment at the onset of endotoxemia is a beneficial practice, ensuring adequate GLN to compensate for the resulting intracellular shortage.

Benchmarking the Applicability of Four Methods of Endotracheal Tube Cuff Inflation for Optimal Sealing: A Randomized Trial.

PURPOSE: To assess the comparable applicability of four methods of endotracheal tube cuff (ETTc) inflation on the basis of optimal level of intracuff pressure and presence of intubation-related complications. DESIGN: Double-blind, randomized trial. METHODS: A total of 139 adult surgical patients scheduled to undergo nitrous oxide-free general anesthesia were assigned into one of four groups according to the method used for ETTc inflation. The cuff pressure and air volume applied in each method, and laryngotracheal complications were recorded. FINDINGS: The highest and lowest ETTc pressure and air volume values were recorded in palpation and minimum leak technique group, respectively. Laryngotracheal complaints were maximized in palpation and minimized in minimal occlusive volume and minimum leak techniques. CONCLUSIONS: The air-return back into the syringe method emerges as an attractive and simple-to-perform alternative regarding effective ETTc sealing and low incidence of intubation-related morbidity when a cuff manometer is not readily available. STUDY REGISTRATION: ACTRN12615000699561.

Prophylaxis of postoperative complications after craniotomy.

PURPOSE OF REVIEW: This review reports an update of the evidence on practices applied for the prevention and management of the most common complications after craniotomy surgery. RECENT FINDINGS: Latest guidelines support the combined thromboprophylaxis with the use of both mechanical and chemical modalities, preferably applied within 24 h after craniotomy. Nevertheless, a heightened risk of minor hemorrhagic events remains an issue of concern. Postoperative nausea and vomiting (PONV) and pain constitute the complications most commonly encountered during the first 24 h postcraniotomy. Recently, neurokinin type-1 receptor antagonists have been tested as adjuncts for PONV prophylaxis with encouraging results, whereas dexmedetomidine and gabapentinoids emerge as promising alternatives for postcraniotomy pain management. The available data for seizure prophylaxis following craniotomy lacks scientific quality; thus, this remains still a debatable issue. Significantly, a growing body of evidence supports the superiority of levetiracetam over the older antiepileptic drugs (AEDs), in terms of efficacy and safety. SUMMARY: Optimum management of postoperative complications is incorporated as an integral part of the augmented quality of care in patients undergoing craniotomy surgery, aiming to improve outcomes. This review may serve as a benchmark for neuroanesthetists for heightened clinical awareness and prompt institution of well-documented practices.

Postoperative Pain Control Following Craniotomy: A Systematic Review of Recent Clinical Literature.

BACKGROUND: Pain intensity after craniotomy is considered to be moderate to severe during the first 2 postoperative days. The ideal pain treatment to facilitate a rapid postoperative recovery and optimize outcome is unknown. OBJECTIVES: This systematic review aims to report current clinical evidence related to pharmacological and adjuvant analgesic modalities for postcraniotomy pain control. DESIGN: Systematic review of randomized controlled trials (RCTs). DATA SOURCES: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (January 2011 to April 2016). ELIGIBILITY CRITERIA: Original research involving the use of any analgesic drug, analgesic method, or nonpharmacological intervention for postcraniotomy pain relief, as assessed by pain scores up to 48 hours postoperatively, supplemental analgesic requirements, or occurence of adverse events. RESULTS: Nineteen RCTs enrolling a total of 1,805 patients were included. Most of the retrieved studies were of moderate-to-good methodological quality. Systemic pharmacological intervention was assessed in 14 RCTs. Opioids (5 RCTs) provided superior pain relief to other analgesics with no significant side effects, but the quality of studies was low. Diclofenac (3 RCTs) presented adequate craniotomy pain control without any adverse effects, while the use of parecoxib is not supported. Dexmedetomidine (3 RCTs) provided adequate transitional analgesia, but further research is needed. Data on the analgesic efficacy of gabapentin, pregabalin, and intravenous lidocaine are very limited (1 RCT for each). Scalp infiltration/block (3 RCTs) provided adequate analgesia in the early postoperative period, while more studies are needed to verify the analgesic benefit obtained from nonpharmacological interventions, such as multipoint electro-acupuncture, in craniotomy surgery (2 RCTs). CONCLUSIONS: No definite recommendations can be made based on this systematic review of pharamacological interventions following craniotomy due to significant divergence in the methodology of available studies. Limited evidence on scalp infiltration/block suggests an adequate analgesic effect in the early postoperative period. Analgesic efficacy of dexmedetomidine and multipoint electro-acupuncture needs further evaluation.

The role of exhaled nitric oxide in patients with chronic obstructive pulmonary disease undergoing laparotomy surgery - The noxious study.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) has been associated with major perioperative morbidities or mortalities, especially in surgical patients receiving general anesthesia. The severity of the COPD and the degree of bronchial hyperreactivity can determine the perioperative anesthetic risk; therefore they have to be assessed by a thorough preoperative evaluation in order to give the rationale on which to decide for optimum anesthetic management. OBJECTIVE: Aim of the study was to assess the predictive applicability of exhaled Nitric Oxide (NO) in smoking surgical population with COPD, on the basis of morbidity and mortality. METHODS: A prospective, observational study was undertaken in 70 smoking patients diagnosed with COPD scheduled for laparotomy surgery under general anesthesia COPD was evaluated with the GOLD Classification of Air Flow Limitation, the Modified MRC Dyspnoea Scale (mMRC), the BODE Index score and the 6 Minutes Walk Distance (6MWD) using spirometry parameters. All patients were observed for presenting perioperative and postoperative respiratory complications. A cut off value of 19 ppb was determined for fractional exhaled nitric oxide measured at expiratory flow of 50 mL/s (FENO50) to differentiate patients poor prognosis from those with favorable outcome. RESULTS: Patients with severe COPD had high BODE index score as well as FENO50. Elevated FENO50 is significantly related to multiple complications (p = 0.004) and postoperative cough (p < 0.001). Patients from the high FENO50 group that were not treated with steroids had a statistically significant higher incidence of extra hospital care need (p < 0.001). Increased FENO50 and ABCD classification are both related with the presentation of multiple complications (Odds ratio = 2.5, 95% CI 1.1 to 5.7, p = 0.028 for ABCD and Odds ratio = 6.39, 95% CI 1.33 to 30.5, p = 0.020 for FENO50). Increased FENO50 and ABCD are related with extra hospital care (p = 0.001 and p = 0.002 respectively) and combined with corticosteroid administration could predict the necessity for extra hospital care (Odds ratio 4.09, 95% CI 1.1 to 15.3, p = 0.036 for corticosteroid treatment, odds ratio 2.4, 95% CI 1.1 to 5.1, p = 0.029 for ABCD and odds ratio 7.93, 95% CI 1.7 to 35.3, p = 0.007 for FENO50). CONCLUSION: The FENO50 may identify high risk smoking surgical patients with COPD receiving general anesthesia. Perioperative and postoperative complications in COPD smoking patients undergoing abdominal surgery can be predicted using not only ABCD GOLD 2011 classification but also the FENO50 as a preoperative marker.

Efficacy and safety of prophylactic levetiracetam in supratentorial brain tumour surgery: a systematic review and meta-analysis.

AIMS: The aim of this study was to perform an up-to-date systematic review and meta-analysis on the efficacy and safety of prophylactic administration of levetiracetam in brain tumour patients. METHOD: A systematic review of studies published until April 2015 was conducted using Scopus/Elsevier, EMBASE and MEDLINE. The search was limited to articles reporting results from adult patients, suffering from brain tumour, undergoing supratentorial craniotomy for tumour resection or biopsy and administered levetiracetam in the perioperative period for seizure prophylaxis. Outcomes included the efficacy and safety of levetiracetam, as well as the tolerability of the specific regimen, defined by the discontinuation of the treatment due to side effects. RESULTS: The systematic review included 1148 patients from 12 studies comparing levetiracetam with no treatment, phenytoin and valproate, while only 243 patients from three studies, comparing levetiracetam vs phenytoin efficacy and safety, were included in the meta-analysis. The combined results from the meta-analysis showed that levetiracetam administration was followed by significantly fewer seizures than treatment with phenytoin (OR = 0.12 [0.03-0.42]: χ(2) = 1.76: I(2) = 0%). Analysis also showed significantly fewer side effects in patients receiving levetiracetam, compared to other groups (P < 0.05). The combined results showed fewer side effects in the levetiracetam group compared to the phenytoin group (OR = 0.65 [0.14-2.99]: χ(2) = 8.79: I(2) = 77%). CONCLUSIONS: The efficacy of prophylaxis with levetiracetam seems to be superior to that with phenytoin and valproate administration. Moreover, levetiracetam use demonstrates fewer side effects in brain tumour patients. Nevertheless, high risk of bias and moderate methodological quality must be taken into account when considering these results.

Interaction of a Cannabinoid-2 Agonist With Tramadol on Nociceptive Thresholds and Immune Responses in a Rat Model of Incisional Pain.

The aim of this study was to elucidate the antinociceptive interaction between cannabinoids and tramadol and their impact on proinflammatory response, in terms of serum intereleukin-6 (IL-6) and interleukin-2 (IL-2) release, in a rat model of incisional pain. Prospective randomized trial assessing the individual or combined application of intraperitoneal tramadol (10 mg/kg) and the selective cannabinoid-2 (CB-2) agonist (R,S)-AM1241 (1 mg/kg) applied postsurgical stress stimulus. Pharmacological specificity was established by antagonizing tramadol with naloxone (0.3 mg/kg) and (R,S)-AM1241 with SR144528 (1 mg/kg). Thermal allodynia was assessed by hot plate test 30 (T30), 60 (T60), and 120 (T120) minutes after incision. Blood samples for plasma IL-6 and IL-2 level determination were obtained 2 hours after incision. Data from 42 rats were included in the final analyses. Significant augmentation of thermal threshold was observed at all time points, after administration of either tramadol or (R,S)-AM1241 compared with the control group (P = 0.004 and P = 0.015, respectively). The combination of (R,S)-AM1241 plus tramadol promoted the induced antinociception in an important manner compared with control (P = 0.002) and (R,S)-AM1241 (P = 0.022) groups. Although the antiallodynic effect produced by tramadol was partially reversed by naloxone 30 and 60 minutes after incision (P = 0.028 and P = 0.016, respectively), SR144528 blocked the effects of (R,S)-AM1241 administration in a significant manner (P = 0.001) at all time points. Similarly, naloxone plus SR144528 also blocked the effects of the combination of (R,S)-AM1241 with tramadol at all time points (P = 0.000). IL-6 level in (R,S)-AM1241 plus tramadol group was significantly attenuated compared with control group (P = 0.000). Nevertheless, IL-2 levels remained unchanged in all experimental groups. It seems that the concomitant administration of a selective CB-2 agonist with tramadol in incisional pain model may improve antinociceptive effects and immune responses of cannabinoids, but this effect does not seem to be superior to that of tramadol alone.

Impact of anesthetic technique on the stress response elicited by laparoscopic cholecystectomy: a randomized trial.

The aim of this randomized, double-blind clinical trial was to elucidate the impact of general anesthesia alone (GA) or supplemented with epidural anesthesia (EpiGA) on surgical stress response during laparoscopic cholecystectomy, using stress hormones, glucose, and C-reactive protein (CRP), as potential markers. Sixty-two patients scheduled to undergo elective laparoscopic cholecystectomy were randomly assigned into two groups to receive either GA or EpiGA. Stress hormones [cortisol (COR), human growth hormone (hGH), prolactine (PRL)], glucose, and CRP were determined 1 day before surgery, intraoperatively, and upon first postoperative day (POD1). Plasma COR, hGH, PRL, and glucose levels were maximized intraoperatively in GA and EpiGA groups and reverted almost to baseline on POD1. Significant between-group differences were detected for COR and glucose either intraoperatively or postoperatively, but this was not the case for hGH. PRL was elevated in GA group only intraoperatively. Although, CRP was minimally affected intraoperatively, a notable augmentation on POD1, comparable in both groups, was recorded. These results indicate that hormonal and metabolic stress response is slightly modulated by the use of epidural block supplemented by general anesthesia, in patients undergoing laparoscopic cholecystectomy cholecystectomy. Nevertheless, inflammatory reaction as assessed by CRP seems to be unaffected by the anesthesia regimen.

A Four-Probiotics Regimen Reduces Postoperative Complications After Colorectal Surgery: A Randomized, Double-Blind, Placebo-Controlled Study.

BACKGROUND: Heterogeneous results of published studies led to conduct a randomized clinical trial to assess the efficacy of a new formulation of four probiotics as prophylaxis for complications after colorectal surgery. METHODS: A double-blind, placebo-controlled randomized study was conducted enrolling patients undergoing colorectal surgery for cancer. Capsules of placebo or of a formulation containing Lactobacillus acidophilus, L. p lantarum, Bifidobacterium lactis and Saccharomyces boulardii were administered starting one day before operation and continuing for another 15 days postoperatively. Patients were followed up for 30 days with the development of postoperative complications as the primary outcome. Gene expression and serum levels of cytokines were measured on postoperative day 4 ( www.clinicaltrials.gov NCT02313519). RESULTS: The study was prematurely stopped after enrolment due to efficacy in the primary outcome. Administration of probiotics significantly decreased the rate of all postoperative major complication (28.6 vs. 48.8 % of the placebo arm, p 0.010, odds ratio 0.42). Major benefit was found in the reduction of the rate of postoperative pneumonia (2.4 vs. 11.3 %, p 0.029), of surgical site infections (7.1 vs. 20.0 %, p 0.020) and of anastomotic leakage (1.2 vs. 8.8 %, p 0.031). The time until hospital discharge was shortened as well. Gene expression of SOCS3 was positively related with gene expression of TNF and of circulating IL-6 in the probiotic group but not in the placebo group. CONCLUSIONS: The studied probiotic formulation significantly decreased the risk of postoperative complications, namely mechanical ventilation, infections and anastomotic leakage. Modulation of the gene expression of SOCS3 is one suggested mechanism ( www.clinicaltrials.gov NCT02313519).

Pressure ulcers and malnutrition: results from a snapshot sampling in a university hospital.

OBJECTIVE: We aimed to ascertain the factors potentially contributing to the manifestation of pressure ulcers (PU) due to poor nutritional status in a nonselected hospitalized population. SUBJECTS AND METHODS: This is a prospective cohort study of 471 adult inpatients treated at our university hospital. Study parameters included anthropometric data, demographics, medical history, mood status, diet-related factors and self-perception of health status. For each participant, the body mass index (BMI) was calculated, and a malnutrition universal screening tool (MUST) was used to screen for nutritional deficiencies, with the presence of PU constituting the outcome of interest. An independent-samples t test, χ(2) analysis and logistic regression analysis were performed. RESULTS: The overall prevalence of PU in our cohort was 14.2%. Advanced age, low BMI, poor health status by self-assessment, serious mood disorders, malnutrition, abnormal appetite status, a quantity of food intake half of normal, an artificial diet, limited or no autonomy in everyday activities (p < 0.01 for all) and recent weight loss (p < 0.05) were identified as important determinants for the manifestation of PU. Multivariate analysis highlighted limited autonomy in everyday activities (OR 6.456 and 95% CI 3.212-12.973; p = 0.000), MUST score (OR 3.825 and 95% CI 1.730-8.455; p = 0.001) and artificial diet (OR 1.869 and 95% CI 1.247-2.802; p = 0.018) as the most powerful predictors of PU development. CONCLUSION: Poor nutritional status, limited autonomy in everyday activities and artificial nutrition seemed to confer noteworthy prognostic value regarding PU development in the acute-care setting.

Influence of apneic oxygenation on cardiorespiratory system homeostasis.

PURPOSE: The aim of this study was to elucidate the magnitude of variations in oxygenation indices and the pattern of hemodynamic changes in response to the net effect of tracheal apneic oxygenation (AO) with a view to define the safe time limit of its application. METHODS: After obtaining Animal Research Ethics Committee approval, AO was applied in 12 piglets for 40 min. Arterial (a) and mixed venous (v) blood samples for oxygen (O2) and carbon dioxide (CO2) tension (PaO2/PvO2, PaCO2/PvCO2), O2 saturation (SaO2/SvO2), pHa, base excess (BEa), and bicarbonate (HCO3a) determination and for alveolar O2 tension (PAO2), PaO2/FiO2 and PaO2/PAO2 ratio, arterial-mixed venous O2 content (AVDO2), and O2 extraction ratio (O2ER) estimation were collected on anesthesia induction, 10, 20, 30, and 40 min during AO and 10 and 20 min after reconnection to the ventilator. Concomitant hemodynamic data were obtained. RESULTS: Besides PvO2 and PAO2, AO adversely influenced PaO2 (248-113 mmHg), PaCO2 (35-145 mmHg), PvCO2, PaO2/FiO2, and PaO2/PAO2 in a time-depended fashion, whereas SvO2, AVDO2, and O2ER were minimally affected. P(a - v)CO2 was reversed throughout AO. Acid-base status derangement, consisting of HCO3a elevation, BEa widening, and acidemia (pH 6.9) maximized 40 min after AO. During AO, heart rate, systemic and pulmonary circulation pressures, and cardiac output were progressively elevated, whereas systemic vascular resistance was reduced. All the studied parameters reverted almost to baseline within the 20-min period of ventilator reconnection. CONCLUSION: Tracheal AO for 40 min ensures acceptable blood oxygenation, promotes notable hypercapnic acidosis, and consequent transient hemodynamic alterations, which are almost completely reversible after reconnection to the ventilator.

Efficacy and Safety of Magnesium Sulfate as an Adjunct to Ropivacaine Wound Infiltration in Thyroid Surgery: A Prospective, Double-Blind, Randomized Controlled Trial.

Background/Objective: Wound infiltration with local anesthetics emerges as a promising modality for postoperative pain alleviation. However, such strategies in neck surgery have not been a well-established practice. To assess wound infiltration with ropivacaine plus magnesium sulfate for pain relief following thyroid surgery. Methods: This prospective, double-blind, randomized study enrolled 68 patients who underwent thyroid surgery. Concerning the solution used for surgical wound infiltration, the study participants were randomly allocated into three groups: (1) 100 mg of ropivacaine (Group R); (2) 100 mg of ropivacaine plus magnesium sulfate 10 mg/kg (Group RMg); and (3) normal saline which served as a placebo (Group P). Pain perception both at rest and at movement, was measured using the Visual Analogue Scale (VAS) at 30 min, as well as at 1, 2, 4, 6, 12, and 24 h postoperatively. The total consumption of analgesics in morphine equivalents was also recorded. Moreover, adverse effects and patient satisfaction were recorded. Cortisol, TNF-α, and IL-6 levels were measured 30 min before infiltration and 6 h and 24 h postoperatively. Results: Demographics and clinical characteristics were similar between the groups. The VAS scores at rest and during movement were significantly lower in the RMg group compared to the saline or ropivacaine groups. Total analgesic consumption was also significantly lower in the RMg group. No operation-, wound-, or infiltration-related adverse effects were recorded in the study groups. Better overall satisfaction was obtained for the RMg group. Conclusions: Ropivacaine plus magnesium sulfate wound infiltration provided better pain control and the analgesic effect was more significant, contributing to effective postoperative analgesia in patients undergoing thyroid surgery.

Identification of Key Genes Associated with Tumor Microenvironment Infiltration and Survival in Gastric Adenocarcinoma via Bioinformatics Analysis.

OBJECTIVE: Gastric carcinoma (GC) is the fifth most commonly diagnosed cancer and the third leading cause of cancer-related deaths globally. The tumor microenvironment plays a significant role in the pathogenesis, prognosis, and response to immunotherapy. However, the immune-related molecular mechanisms underlying GC remain elusive. Bioinformatics analysis of the gene expression of GC and paracancerous healthy tissues from the same patient was performed to identify the key genes and signaling pathways, as well as their correlation to the infiltration of the tumor microenvironment (TME) by various immune cells related to GC development. METHODS: We employed GSE19826, a gene expression profile from the Gene Expression Omnibus (GEO), for our analysis. Functional enrichment analysis of Differentially Expressed Genes (DEGs) was conducted using the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes database. RESULTS: Cytoscape software facilitated the identification of nine hub DEGs, namely, FN1, COL1A1, COL1A2, THBS2, COL3A1, COL5A1, APOE, SPP1, and BGN. Various network analysis algorithms were applied to determine their high connectivity. Among these hub genes, FN1, COL1A2, THBS2, COL3A1, COL5A1, and BGN were found to be associated with a poor prognosis for GC patients. Subsequent analysis using the TIMER database revealed the infiltration status of the TME concerning the overexpression of these six genes. Specifically, the abovementioned genes demonstrated direct correlations with cancer-associated fibroblasts, M1 and M2 macrophages, myeloid-derived suppressor cells, and activated dendritic cells. CONCLUSION: Our findings suggest that the identified hub genes, particularly BGN, FN1, COL1A2, THBS2, COL3A1, and COL5A1, play crucial roles in GC prognosis and TME cell infiltration. This comprehensive analysis enhances our understanding of the molecular mechanisms underlying GC development and may contribute to the identification of potential therapeutic targets and prognostic markers for GC patients.