Isolated forearm technique: a meta-analysis of connected consciousness during different general anaesthesia regimens.

BACKGROUND: General anaesthesia should prevent patients from experiencing surgery, defined as connected consciousness. The isolated forearm technique (IFT) is the current gold standard for connected consciousness monitoring. We evaluated the efficacy of different anaesthesia regimens in preventing IFT responses. METHODS: We conducted a systematic review with meta-analysis of studies evaluating IFT in adults. Proportions of IFT-positive patients were compared for inhalational versus intravenous anaesthesia and anaesthesia brain monitor (ABM)-guided versus non-ABM-guided. RESULTS: Of 1131 patients in 22 studies, 393 (34.8%) had an IFT response during induction or maintenance. IFT-positive patients were less frequent during induction (19.7% [95% CI, 17.5-22.1]) than during maintenance (31.2% [95% CI, 27.8-34.8]). Proportions of IFT-positive patients during induction and maintenance were similar for inhalational (0.51 [95% CI, 0.38-0.65]) and intravenous (0.52 [95% CI, 0.26-0.77]) anaesthesia, but during maintenance were lower with inhalational (0.18 [95% CI, 0.08-0.38]) than with intravenous (0.48 [95% CI, 0.24-0.73]) anaesthesia. Proportions of IFT-positive patients during induction and maintenance were not significantly different for ABM-guided (0.64 [95% CI, 0.39-0.83]) and non-ABM-guided (0.48 [95% CI, 0.34-0.62]) anaesthesia but during maintenance were lower with non-ABM-guided (0.19 [95% CI, 0.09-0.37]) than with ABM-guided (0.57 [95% CI, 0.34-0.77]). Proportions of IFT-positive patients decreased significantly with increasing age and premedication use. Of the 34 anaesthesia regimens, 16 were inadequate. Studies had low methodological quality (only seven randomised controlled trials) and significant heterogeneity. CONCLUSIONS: Standard general anaesthesia regimens might not prevent connected consciousness. More accurate anaesthesia brain monitor methodology to reduce the likelihood of connected consciousness is desirable.

Rationale and evidence for the adjunctive use of N-acetylcysteine in multidrug-resistant infections.

Bacterial multidrug resistance has been a serious issue for healthcare systems in recent decades, responsible for many infections and deaths. Due to the increasing incidence of antimicrobial resistance and scarce treatment options, research is focused on finding possible therapeutic adjuvants able to increase the efficacy of antibiotics. The aim of this article is a review of available evidence on the use of N-acetylcysteine (NAC). MEDLINE/PubMed was searched for appropriate keywords. In vitro and in vivo preclinical studies, clinical studies, reviews, and meta-analyses were retrieved and selected based on relevance. A narrative review article was written, reporting published evidence and the expert opinion of the authors. Among possible adjunctive treatments, NAC has attracted the interest of researchers as a candidate for re-purposing. It is a widely used drug with a good tolerability profile, mainly used as a mucolytic agent, with antioxidant, anti-inflammatory properties and antibacterial activity. NAC acts on different mechanisms and stages of infections, resulting in inhibition of biofilm formation, disruption of preformed biofilms, and reduction of bacterial viability. NAC may be administered as an aerosol in many types of infections, including cystic fibrosis, bronchiectasis and infective flare of chronic obstructive pulmonary disease (COPD), and by the intravenous route in severe systemic infections (including septic shock) such as those caused by carbapenemase (KPC)-producing Klebsiella pneumoniae (Kp) and Carbapenem-Resistant Acinetobacter baumannii (CR-Ab). A rationale exists for using NAC as an adjunctive treatment in multidrug-resistant (MDR) infections, based on in vitro, in vivo and clinical evidence, and future research is needed to identify candidate patients and optimal schedules for specific clinical conditions.

Preliminary evidence for reduced preoperative cerebral blood flow velocity as a risk factor for cognitive decline three months after cardiac surgery: an extension study.

This extension study investigated the association between preoperative cerebral blood flow (CBF) velocity and postoperative cognitive decline (POCD) at a three-month follow-up in patients who underwent cardiac surgery. Continuous transcranial Doppler ultrasound on both middle cerebral arteries (MCAs) was used preoperatively in 31 right-handed cardiac surgery patients at rest. Each patient performed a neuropsychological evaluation to assess cognitive performance before surgery, at discharge and at three-month follow-up. Patients with POCD at the three-month follow-up had a marginally significantly lower preoperative CBF velocity in the left MCA than patients without POCD. Moreover, the group with POCD had a significantly lower CBF velocity in the left than in the right MCA, whereas no difference between the left and right CBF velocity was found in the group without POCD. These preliminary findings suggest that reduced preoperative CBF velocity in the left MCA may represent an independent risk factor for cognitive decline in patients three months after surgery.

Upper airway obstruction by retropharyngeal hematoma after cervical spine trauma: report of a case treated with percutaneous dilational tracheostomy.

The authors report the case of a patient affected by a cervical spine trauma who developed upper airway obstruction as a result of a retropharyngeal hematoma. An endotracheal intubation with a small-diameter tube was performed, but ventilation and oxygenation were not adequate. An early Percutaneous Dilational Tracheostomy with the Ciaglia technique was then performed. The risk of upper airway obstruction by retropharyngeal hematoma after cervical spine trauma is discussed in this article, as are the feasibility and benefits of using Percutaneous Dilational Tracheostomy in emergency cases of upper airway obstruction.

Pain-related middle-latency somatosensory evoked potentials in the prognosis of post anoxic coma: a preliminary report.

BACKGROUND: Regarding hypoxic-ischemic encephalopathy, while the bilateral absence of N20/P25 somatosensory evoked potentials (SEPs) is considered to be the best indicator of adverse outcomes, the presence of middle latency evoked potentials (MLCEPs) is associated with a favourable neurological prognosis. The main aim of the present study was to investigate whether painful electrical stimulation might be considered a provocative test in producing MLCEPs and predictor of patient's outcomes after cardiac arrest. METHODS: Retrospective pilot study. SEPs with and without pain-related electrical stimulation in both median nerves were recorded in 17 patients with post anoxic coma after cardiac arrest. Glasgow Coma Scale, electroencephalograms, heart rate and blood pressure changes were also recorded at the same time. Three months after cardiac arrest the same measures with inclusion of Glasgow Outcome Scale Extended were also performed only in the remaining patients with severe neurological outcome. No one intervention was made. RESULTS: Patients who showed MLCEPs had a good outcome, while patients without N20/P25 SEPs but with increases in blood pressure remained in a vegetative state. Patients who did not show N20/P25 SEPs and increase in blood pressure died within one week. Only one patient who showed N20/P25 SEPs was minimally conscious. CONCLUSION: These preliminary data suggest that MLCEPs elicited by painful electrical stimulation seem to be a sensitive method to predict the neurological outcome of patients in the acute phase of coma. Blood pressure response might be a prognostic physiological measure of survival in the vegetative state in patients without N20/P25 SEPs.

[Surgically treated Zenker diverticulum: a double-contrast radiologic study and videorecording]. / Diverticoli di Zenker operati: studio radiologico a doppio contrasto associato a video-registrazione.

Sixteen patients who had undergone the surgical resection of pharyngoesophageal diverticula were investigated with combined double-contrast radiology and video-recording. In 11 patients morphological or functional anomalies were identified. The authors report their results and stress the high incidence of postoperative stenoses (18%) and recurrences (43%). The combined use of double-contrast examination and video-recording is suggested to detect such functional disorders as those which were identified in 68% of the patients in this series of cases.

Rectocele in males: clinical, defecographic, and CT study of singular cases.

The authors report eight cases of rectocele in male subjects studied with defecography and computed tomography. The pocket is located between the prostatic apex and the urogenital diaphragm. The abnormality has clinical significance.

Paralisia supranuclear progressiva / Progressive supranuclear palsy

A paralisia supranuclear progressiva é uma doença rara com predomínio no sexo masculino descrita entre as patologias conhecidas como parkinsonismo atípico. Y.O.N, 66 anos, branca, feminina, brasileira, residente em São Paulo, nível superior, enfermeira aposentada. Queixava-se de disfonia associada à perda de peso progressiva, dificuldade em iniciar movimentos, lentificação, rigidez, apatia, desmotivação, tonturas e quedas freqüentes há aproximadamente 3 anos. Neste período, refere piora progressiva da marcha. Há 1 ano apresentou queda com luxação de ombro direito sendo submetida a procedimento cirúrgico. No último ano iniciou com quadro de distúrbio comportamental, irritabilidade, desinibição e agressividade. Negava comorbidades prévias. Ao exame físico geral apresentava-se emagrecida, com hiperextensão de tronco e coluna cervical, alteração da marcha com necessidade de auxílio, fáscies de espanto, disartria, perda do olhar vertical para baixo. Força muscular diminuida +/5+ em membros inferiores com atrofia muscular, rigidez, sem tremores de extremidade. MEEM 28/30 FV 8/minuto, Teste do relógio 0. À ressonância magnética apresentou sinais de dilataçãodo sistema ventricular, alargamento dos sulcos corticais, cisternas basais e sylvianas, raras zonas de alteração da intensidade de sinal localizada na substância branca periventricular compatíveis com áreas de glicose. O quadro clínico e a perda do olhar conjugado vertical para baixo sugeriram uma hipótese diagnóstica de possível paralisia supranuclear progressiva. O relato de caso demonstra a dificuldade do diagnóstico de pacientes que apresentam déficit cognitivo, alteração de comportamento e alterações neurológicas e um alerta à comunidade científica da possibilidade desse diagnóstico (AU)

Paralisia supranuclear progressiva

A paralisia supranuclear progressiva é uma doença rara com predomínio no sexo masculino descrita entre as patologias conhecidas como parkinsonismo atípico. Y.O.N, 66 anos, branca, feminina, brasileira, residente em São Paulo, nível superior, enfermeira aposentada. Queixava-se de disfonia associada à perda de peso progressiva, dificuldade em iniciar movimentos, lentificação, rigidez, apatia, desmotivação, tonturas e quedas freqüentes há aproximadamente 3 anos. Neste período, refere piora progressiva da marcha. Há 1 ano apresentou queda com luxação de ombro direito sendo submetida a procedimento cirúrgico. No último ano iniciou com quadro de distúrbio comportamental, irritabilidade, desinibição e agressividade. Negava comorbidades prévias. Ao exame físico geral apresentava-se emagrecida, com hiperextensão de tronco e coluna cervical, alteração da marcha com necessidade de auxílio, fáscies de espanto, disartria, perda do olhar vertical para baixo. Força muscular diminuida +/5+ em membros inferiores com atrofia muscular, rigidez, sem tremores de extremidade. MEEM 28/30 FV 8/minuto, Teste do relógio 0. À ressonância magnética apresentou sinais de dilataçãodo sistema ventricular, alargamento dos sulcos corticais, cisternas basais e sylvianas, raras zonas de alteração da intensidade de sinal localizada na substância branca periventricular compatíveis com áreas de glicose. O quadro clínico e a perda do olhar conjugado vertical para baixo sugeriram uma hipótese diagnóstica de possível paralisia supranuclear progressiva. O relato de caso demonstra a dificuldade do diagnóstico de pacientes que apresentam déficit cognitivo, alteração de comportamento e alterações neurológicas e um alerta à comunidade científica da possibilidade desse diagnóstico