Min In Patients Research Articles

Time to CT scan for patients with acute severe neurological symptoms: a quality assurance study

Emergent brain computed tomography (CT) scan allows for identification of patients presenting with acute severe neurological symptoms in whom medical and surgical interventions may be lifesaving. The aim of this study was to evaluate if time to CT from arrival at the emergency department exceeded 30 min in patients admitted with acute severe neurological symptoms. This was a retrospective register-based quality assurance study. We identified patients admitted to the emergency department with acute severe neurological symptoms between April 1st, 2016 and September 30th, 2020. Data were retrieved from the registry of acute medical team activations. We considered that time to CT from arrival at the emergency department should not exceed 30 min in more than 10% of patients. A total of 559 patients were included. Median time from arrival at the emergency department until CT scan was 24 min (IQR 16–35) in children (< 18 years), 10 min (IQR 7–17) for adults (18–59 years), and 11 min (IQR 7–16) for elders (> 60 years). This time interval exceeded 30 min for 8.2% (95% CI 6.1–10.9) of all included patients, 35.3% of children, 5.9% of adults, and 8.6% of elders. No children died within 30 days. The 30-day mortality was 21.3% (95% CI 16.4–27) in adults, and 43.9% (95% CI 38.2–49.8) in elders. Time from arrival at our emergency department until brain CT scan exceeded 30 min in 8.2% of all included patients but exceeded the defined quality aim in children and could be improved.

Pancreatic fluorescence using continuous indocyanine greeninfusion.

Pancreatic fluorescence using continuous indocyanine greeninfusion.

Trans-arterial positive ICG staining-guided laparoscopic liver watershed resection for hepatocellular carcinoma.

IntroductionAnatomical liver resection is the optimal treatment for patients with resectable hepatocellular carcinoma (HCC). Laparoscopic Couinaud liver segment resection could be performed easily as liver segments could be stained by ultrasound-guided indocyanine green (ICG) injection into the corresponding segment portal vein. Several smaller liver anatomical units (liver watersheds) have been identified (such as S8v, S8d, S4a, and S4b). However, since portal veins of liver watersheds are too thin to be identified under ultrasound, the boundaries of these liver watersheds could not be stained intraoperatively, making laparoscopic resection of these liver watersheds demanding. Digital subtraction angiography (DSA) could identify arteries of liver watersheds with a diameter of less than 2 mm. Yet, its usage for liver watershed staining has not been explored so far.PurposeThe aim of this study is to explore the possibility of positive liver watershed staining via trans-arterial ICG injection under DSA examination for navigating laparoscopic watershed-oriented hepatic resection.MethodsWe describe, in a step-by-step approach, the application of trans-arterial ICG injection to stain aimed liver watershed during laparoscopic anatomical hepatectomy. The efficiency and safety of the technique are illustrated and discussed in comparison with the laparoscopic anatomical liver resection via ultrasound-guided liver segment staining.ResultsEight of 10 HCC patients received successful trans-arterial liver watershed staining. The success rate of the trans-artery staining approach was 80%, higher than that of the ultrasound-guided portal vein staining approach (60%). Longer surgical duration was found in patients who underwent the trans-artery staining approach (305.3 ± 23.2 min vs. 268.4 ± 34.7 min in patients who underwent the ultrasound-guided portal vein staining approach, p = 0.004). No significant difference was found in major morbidity, reoperation rate, hospital stay duration, and 30-day and 90-day mortality between the 2 groups.ConclusionsTrans-arterial ICG staining is safe and feasible for staining the aimed liver watershed, navigating watershed-oriented hepatic resection under fluorescence laparoscopy for surgeons.

Closed reduction and percutaneous pinning versus open reduction and internal fixation for Jakob type 3 lateral condyle fractures in children.

The management of type 3 lateral condyle fractures (LCFs) remains controversial. The main goal of this study was to evaluate the feasibility of closed reduction and percutaneous pinning (CRPP) in patients with type 3 LCFs and to assess the outcome of such injuries according to the type of treatment, CRPP, or open reduction and internal fixation (ORIF). This is a retrospective review of prospectively enrolled children with type 3 LCF managed by CRPP or ORIF between 2018 and 2021. All patients were followed for at least 12months. Patients were divided into two groups according to the type of treatment, CRPP or ORIF. Demographic characteristics were recorded for all patients. Standard radiographs were used to identify, evaluate, and classify each fracture and to detect the presence of other concomitant bone lesions. The clinical outcome was assessed according to the Hardacre et al. criteria. Seventy-eight children with type 3 LCF were included; 42 were treated by CRPP (53.8%) and 36 by ORIF (46.2%); the mean follow-up time was 17.7months (range, 12.3-40.9). The baseline characteristics did not differ between the two groups of patients. Overall, successful CRPP could be achieved in 39 out of 42 patients (92.9%). The mean surgical time was 63.4 and 84.5min in patients treated by CRPP and ORIF, respectively (p = 0.01). Fluoroscopy time was significantly shorter in patients managed by ORIF than in those treated by CRPP (12 versus 40s, respectively; p < 0.001). Clinical outcome according to the Hardacre et al. criteria was excellent in 37 out of 39 (94.4%) and in 35 out of 36 patients (97.2%) treated by CRPP and ORIF, respectively (p = 0.09). CRPP management of paediatric type 3 LCF has clinical and radiographic outcomes similar to ORIF; if satisfactory reduction cannot be achieved by CRPP, conversion to ORIF should be considered.

This Month in Anesthesiology

This Month in Anesthesiology

Evaluating the analgesic and sedative effects of intravenous ketamine versus morphine administration on relieving long/short bone-fracture pain in the upper/ lower limbs; a phase II clinical trial

Introduction: The importance of pain control in patients with limb trauma admitted to emergency departments as well as its complications is among the main concerns in post-emergency care, which contributes to the accelerated improvement of patients’ conditions in a significant manner. Objectives: The present study was to evaluate the analgesic and sedative effects of intravenous (IV) ketamine versus morphine administration on relieving long/short bone-fracture pain in the upper/lower limbs. Patients and Methods: The present study is as a double-blind randomized clinical trial. For this purpose, the effect of ketamine and morphine were initially examined using IV ketamine and morphine administration, respectively, at the doses of 0.4 and 0.1 mg/kg/IV/10 min in patients, aged 18-65 years with limb trauma, and admitted to hospital emergency departments. Afterward, the duration of the analgesic effect, the amount of pain relief, according to the visual analog scale (VAS) outcomes, and the complications for each drug, including apnea, bradycardia, tachycardia, altered level of consciousness, nausea, vomiting, hypertension/hypotension, seizures and disturbed sleep were compared, and then the preferred method was introduced. Results: In this study, 120 patients in total, including 60 cases receiving ketamine and 60 individuals receiving morphine, were recruited. The participants’ age range was between 19 -70 years. The patients’ mean age was 47.04±12.57 years of whom 89 patients (74.2%) were male. The study results indicated that the potency of the low-dose ketamine infusion in relieving pain in patients was comparable to that of morphine. Conclusion: It was concluded that ketamine could be administered as an alternative to IV morphine to reduce long/short bone-fracture pain in the upper/lower limbs. Trial Registration: The trial protocol was authorized by the Iranian Registry of Clinical Trials, (identifier: IRCT20170716035105N3; https://en.irct.ir/trial/26628, ethical code: IR.AJUMS.REC.1396.248).

Quality of documentation and treatment in the non-physician staffed ambulance: aretrospective analysis of emergency protocols from the city of Aachen

HintergrundDer deutsche Rettungsdienst wird jährlich zu ca. 7,3 Mio. Einsätzen alarmiert, welche zu einem Großteil (ca. 59 %) ohne Arzt ablaufen. Da kaum Daten zur Qualität der medizinischen Versorgung und Dokumentation von Rettungsdiensteinsätzen ohne Arzt vorliegen, sollen diese anhand der Einsatzprotokolle im Rahmen dieser Studie überprüft werden.MethodeEs erfolgte eine retrospektive Analyse von Protokollen der Rettungsdiensteinsätze ohne Arzt aus den Monaten Juni und Juli 2018. Unter Einbezug von Verfahrensanweisungen wurden die Dokumentations- und Behandlungsqualität der Einsätze analysiert. Primäre Endpunkte waren Dokumentationshäufigkeit, Vollständigkeit, die korrekte Notarzt- oder Telenotarztindikationsstellung, die Entwicklung von kritischen Vitalparametern im Einsatzverlauf sowie die mediane Behandlungszeit.ErgebnisseInsgesamt wurden 1935 Protokolle ausgewertet. Die Verdachtsdiagnose wurde in 1323 (68,4 %), die Anamnese in 456 (23,6 %), der Erstbefund in 350 (18,1 %) und der Letztbefund in 52 (2,7 %) der Fälle vollständig dokumentiert. Anhand der Dokumentation bestand bei 531 (27 %) Patienten eine Telenotarzt- bzw. Notarztindikation, jedoch kein Arztkontakt. Bei diesen Patienten wurden 410 kritische Vitalparameter im Erstbefund dokumentiert. Von diesen Vitalwerten verbesserten sich 69 (16,8 %); bei 217 (52,9 %) wurde kein Übergabebefund dokumentiert. Die mediane Behandlungsdauer vor Ort war bei Patienten mit eigentlicher Notarztindikation (15:02 min) signifikant länger als bei Patienten ohne Indikation (13:05 min).SchlussfolgerungDie Dokumentation der Einsätze ist defizitär. Zudem könnte ein Viertel der Patienten von einem prähospitalen Arztkontakt profitieren. Eine juristisch bedenkliche Übergabedokumentation besteht bei ca. der Hälfte aller Protokolle.

Sudden-onset sleep in patients with Parkinson’s disease

Sudden-onset sleep (SOS) is one of the manifestations of excessive daytime sleepiness (ЕDS) in Parkinson’s disease (PD).Aim: сlarify the clinical and polysomnographic characteristics of patients with SOS at the expanded (2 and 3 stages according to Hoehn–Yahr) stages of PD.Material and methods. 42 patients (18 men and 24 women, average age 66.5 ± 7.9 years, duration of PD 8.9 ± 4.6 years, Hoehn–Yahr stage of PD 2.6 ± 0.5) who received combined dopaminergic therapy with levodopa and dopamine agonist were examined. 32 patients had ЕDS, 10 patients did not have it. The Unified Parkinson’s disease rating scale (UPDRS parts II, III in “on” state of dopaminergic medication), the diary of the assessment of the waking period, the Epworth Sleepiness Scale, the Parkinson Disease Sleep Scale I (PDSS I), the Sсales for Outcomes of Parkinsons disease-Cognition (SCOPA-Cog), the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Apathy Scale, the Stroop test. Objective sleep-wake assessment: standard nocturnal video-polysomnography (PSG), multiple sleep latency test (MSLT).Results. SOS was detected in 69% of patients with complaints of ЕDS. Patients with SOS had a shorter latency of falling asleep according to MSLT data (8.1 ± 5.9 min versus 14.2 ± 3.9 min in patients without of ЕDS, p &lt; 0.05).Patients with SOS had a high severity of motor function disorders, apathy and depression (p &lt; 0.05). Рatients with SOS had no significant differences in the main PSG characteristics of night sleep.Conclusion. SOS can be considered as one of the manifestations of a more severe course of PD. A decrease in the effectiveness of night sleep and a change in its structure are not a determining factor in the development of SOS.

Clinical characterization and possible pathophysiological causes of the Deventilation Syndrome in COPD

In daily routine, many COPD patients report early onset augmented dyspnea following use of NIV (Deventilation Syndrome, DVS) as a negative side-effect. The aim of this study is the clinical characterization and concrete definition of DVS. This monocenter prospective observational study collected demographic, physiologic and symptomatic data from 67 in-patients with severe COPD Gold III–IV and chronic hypercapnic failure before, during and after use of an established NIV. During their inpatient follow-up, we examined patients during the first hour after termination of nocturnal NIV. DVS was defined by the authors as an increase of ≥ 2 points on the Borg scale during the first 30 min in patients who reported repeated dyspnea after the use of NIV. We monitored cardiovascular and respiratory data and measured diaphragm excursion. Subjective dyspnea was documented by use of the Borg scale and questionnaires. In addition, respirator and demographic data were collected. DVS occurred in 58% of our COPD patient collective, showing predominant emphysema phenotype. Patients with DVS were more severely ill than non-DVS concerning bronchial obstruction (FEV1 0.6 vs. 0.8 l, p < 0.05) and hypercapnia during spontaneous breathing (pre NIV pCO2: 54.5 vs. 49.3 mmHg, p < 0.02). DVS patients showed significantly higher respiratory rates (RR) (20.1 vs. 18.1/min p < 0.05) after termination of NIV. This trial characterizes and defines early onset augmented dyspnea after the use of NIV, referred to as DVS. It is hereby brought to attention as a frequent side effect of long-term home ventilation and possible pathophysiologic mechanisms are elucidated.

Optimal cardiopulmonary resuscitation duration for favorable neurological outcomes after out-of-hospital cardiac arrest

BackgroundA favorable neurological outcome is closely related to patient characteristics and total cardiopulmonary resuscitation (CPR) duration. The total CPR duration consists of pre-hospital and in-hospital durations. To date, consensus is lacking on the optimal total CPR duration. Therefore, this study aimed to determine the upper limit of total CPR duration, the optimal cut-off time at the pre-hospital level, and the time to switch from conventional CPR to alternative CPR such as extracorporeal CPR.MethodsWe conducted a retrospective observational study using prospective, multi-center registry of out-of-hospital cardiac arrest (OHCA) patients between October 2015 and June 2019. Emergency medical service–assessed adult patients (aged ≥ 18 years) with non-traumatic OHCA were included. The primary endpoint was a favorable neurological outcome at hospital discharge.ResultsAmong 7914 patients with OHCA, 577 had favorable neurological outcomes. The optimal cut-off for pre-hospital CPR duration in patients with OHCA was 12 min regardless of the initial rhythm. The optimal cut-offs for total CPR duration that transitioned from conventional CPR to an alternative CPR method were 25 and 21 min in patients with initial shockable and non-shockable rhythms, respectively. In the two groups, the upper limits of total CPR duration for achieving a probability of favorable neurological outcomes < 1% were 55–62 and 24–34 min, respectively, while those for a cumulative proportion of favorable neurological outcome > 99% were 43–53 and 45–71 min, respectively.ConclusionsHerein, we identified the optimal cut-off time for transitioning from pre-hospital to in-hospital settings and from conventional CPR to alternative resuscitation. Although there is an upper limit of CPR duration, favorable neurological outcomes can be expected according to each patient’s resuscitation-related factors, despite prolonged CPR duration.

COMPARISON OF HAEMODYNAMIC STABILITY WITH 0.5% AND 0.75% HYPERBARIC BUPIVACAINE DURING SPINAL ANAESTHESIA IN WOMEN UNDERGOING CAESAREAN SECTION

Objective: To compare the effect of 0.5% and 0.75% hyperbaric Bupivacaine on haemodynamic stability in terms of mean systolic blood pressure and heart rate recorded at 4 min in patients undergoing caesarian section in spinal anesthesia.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital, Malir, from Jul to Dec 2018.&#x0D; Methodology: The patients were assigned in two groups (A and B) using lottery method. Group A received 0.5% hyperbaric Bupivacaine solution. Group B received 0.5% hyperbaric Bupivacaine solution. Spinal anaesthesia was given, blood pressure and heart rate were recorded. Data were analyzed in SPSS version 23. Both groups were compared for mean systolic blood pressure and heart rate by using independent sample t-test.&#x0D; Results: The mean age of patients was 29.62 ± 6.21 years in 0.75% Bupivacaine group while 29.31 ± 6.20 years in 0.5% Bupivacaine group. The mean systolic blood pressure of patients was 111.63 ± 5.96 mmHg in 0.75% Bupivacaine group while 117.16 ± 7.12 mmHg in 0.5% Bupivacaine group. The difference was significant in both groups (p-value &lt;0.05). The mean heart rate of patients was 92.27 ± 4.71 beats per min (bpm) in 0.75% Bupivacaine group while 97.68 ± 4.58 bpm in 0.5% Bupivacaine group. The difference was significant in both groups (p-value &lt;0.05).&#x0D; Conclusion: 0.5% hyperbaric Bupivacaine was better than 0.75% hyperbaric Bupivacaine solution in spinal anaesthesia during caesarean section.

Impact of the duration of normothermic regional perfusion on the results of liver transplant from controlled circulatory death donors: A retrospective, multicentric study.

In France, the program of controlled donation after circulatory death (cDCD) was established with routine use of in situ normothermic regional perfusion (NRP). There is currently no consensus on its optimal duration. The purpose was to assess the impact of NRP duration on liver graft function and biliary outcomes. One-hundred and fifty-six liver recipients from NRP-cDCD donors from six French centers between 2015 and 2019 were included. Primary endpoint was graft function assessed by early allograft dysfunction (EAD, according to Olthoff's criteria) and MEAF (model for early allograft function) score. Overall, three (1.9%) patients had primary non-function, 30 (19.2%) patients experienced EAD, and MEAF score was 7.3 (±1.7). Mean NRP duration was 179 (±43) min. There was no impact of NRP duration on EAD (170±44min in patients with EAD vs. 181±42min in patients without, P=.286). There was no significant association between NRP duration and MEAF score (P=.347). NRP duration did neither impact on overall biliary complications nor on non-anastomotic biliary strictures (overall rates of 16.7% and 3.9%, respectively). In conclusion, duration of NRP in cDCD donors does not seem to impact liver graft function and biliary outcomes after liver transplantation. A 1 to 4-h perfusion represents an optimal time window.

Does Procedure Time and Size Matter for Office Hysteroscopy Treatment of Retained Products of Conception?

<h3>Study Objective</h3> To establish the procedure time (PT) and mean size of retained products of conception (RPOC) treated in office hysteroscopy (OH). <h3>Design</h3> Retrospective Study (Canadian Task Force II- b). <h3>Setting</h3> Private Office Setting. <h3>Patients or Participants</h3> Patients with RPOC with or without prior treatment. <h3>Interventions</h3> Patients treated with a 5 mm continuous flow office hysteroscope, or Truclear^TM 5C System, or with 16 Fr resectoscope. <h3>Measurements and Main Results</h3> A total of 486 cases were reviewed, and 137 cases were included. 74(54%) patients had a PUS, and adherent RPOC was found in 6 (4.4%) (Chi - square analysis, p=-021) patients, all of which had a PUS. Descriptive analysis found the overall intra-operative visual analogue score (VAS) of pain < 5 to be 96.9 % and the Likert's scale of satisfaction with the procedure to be high (93.4%). The overall mean PT is 14.2±8 (mean±SD) min & the overall mean size is 2.1±.8 cm, and in PUS group it is 15±9 min & 2.2±.8 cm. Independent samples test was applied to variables, and no significant difference was found in VAS or satisfaction rates with or without PUS, but as the overall PT increases, the VAS increases (.307; sig(2-tailed)=.00) and satisfaction rate decreases (-.219; sig(2-tailed)=.01). Truclear had the shortest duration at 10±4 min(p=.00). 127(87.6%) patients who were very satisfied with the procedure, had a PT of 13.6±8 min(p=.064) & size of 2.1±.9 cm. The ROC curve was plotted for the PT and the size of RPOC. The PT was > 6.5 min in patients who had a PUS (86.5% sensitivity), but the specificity is low (14.3%), therefore, even in patients who had no PUS, the PT may be > 6.5 min. A risk of RPOC size > 1.55 cm is higher in PUS with 77% sensitivity and 42.9% specificity. <h3>Conclusion</h3> Women reported highest satisfaction with RPOC of size < 2.1 cm and the procedure time of < 14 min.

Evaluation of estimated glomerular function (eGFR) versus creatinine clearance (CrCl) to predict acute kidney injury when using zoledronate for the treatment of osteoporosis.

Zoledronate is widely used for the treatment of osteoporosis. A potential side effect is acute kidney injury (AKI). Advice from the UK Medicines and Healthcare products Regulatory Agency (MHRA) in 2019 stated that CrCl and not estimated glomerular filtration rate (eGFR) should be used and that treatment should not be given if CrCl < 35ml/min. The objective of this study was to compare our current method of assessing renal function (eGFR) with the method proposed by the MHRA (CrCl) for predicting AKI after zoledronate infusions. The evaluation was performed at the Metabolic Bone Centre in Sheffield Teaching Hospitals, UK. Data on all the patients who had zoledronate from 1/09/2015 to 1/10/2020 were included. Data on 4405 patients were retrieved (total number of infusions 7660). Creatinine in the 14days post-infusion was available for a total of 969 infusions and AKI was observed within 14days following 45 infusions (4.6%). One patient died due to pneumonia. One patient needed continued haemodialysis. Severe AKI (threefold in creatinine and/or eGFR < 15ml/min/173 m2) was observed within 1year following 24 infusions. If the MHRA recommendations had been followed, 996 infusions with baseline CrCl < 35ml/min would not have been given. Of these, follow-up data on serum creatinine within 14days were available for 142 infusions, showing AKI in only four (2.8%). Logistic regression showed that both CrCl and eGFR were significant factors in predicting AKI within 14days, but that the current recommended cut-off of CrCl 35ml/min had poor sensitivity. Since eGFR is at least as good a predictor of AKI as CrCl, and permits the treatment of more patients at high fracture risk, we recommend that eGFR is used to determine renal function for zoledronate treatment. We suggest that the infusion is given over 30min in patients with eGFR < 50ml/min/1.73 m2.

Physiologically-based pharmacokinetic model predictions of inter-ethnic differences in imatinib pharmacokinetics and dosing regimens.

This study implements a physiologically-based pharmacokinetic (PBPK) modelling approach to investigate inter-ethnic differences in imatinib pharmacokinetics and dosing regimens. A PBPK model of imatinib was built in the Simcyp Simulator (version 17) integrating in vitro drug metabolism and clinical pharmacokinetic data. The model accounts for ethnic differences in body size and abundance of drug-metabolising enzymes and proteins involved in imatinib disposition. Utility of this model for prediction of imatinib pharmacokinetics was evaluated across different dosing regimens and ethnic groups. The impact of ethnicity on imatinib dosing was then assessed based on the established range of trough concentrations (Css,min ). The PBPK model of imatinib demonstrated excellent predictive performance in describing pharmacokinetics and the attained Css,min in patients from different ethnic groups, shown by prediction differences that were within 1.25-fold of the clinically-reported values in published studies. PBPK simulation suggested a similar dose of imatinib (400-600 mg/d) to achieve the desirable range of Css,min (1000-3200 ng/mL) in populations of European, Japanese and Chinese ancestry. The simulation indicated that patients of African ancestry may benefit from a higher initial dose (600-800 mg/d) to achieve imatinib target concentrations, due to a higher apparent clearance (CL/F) of imatinib compared to other ethnic groups; however, the clinical data to support this are currently limited. PBPK simulations highlighted a potential ethnic difference in the recommended initial dose of imatinib between populations of European and African ancestry, but not populations of Chinese and Japanese ancestry.

Anticoagulant profile of supplementary-dose enoxaparin in patients undergoing prolonged percutaneous coronary intervention

Abstract Background Enoxaparin 0.75 mg/kg, with either a staged-dose regimen (0.5+0.25 mg/dl) or a single-dose regimen (0.75 mg/dl) achieves target anticoagulation for 90 min in patients undergoing percutaneous coronary intervention (PCI). In patients with prolonged procedures (&amp;gt;90 min), a supplementary-dose enoxaparin (0.375 mg/kg) needs to be given at 90 min to maintain target anticoagulation for additional 90 min. However, the actual anticoagulant profile of this supplementary-dose regimen remains unknown because it is recommended only based on pharmacokinetic simulations. Purpose This study directly assessed the anticoagulant profile of supplementary-dose enoxaparin (0.375 mg/kg) in troponin-negative patients undergoing prolonged elective trans-radial PCI who received a total dose of enoxaparin 0.75 mg/kg during the first 90 min of their procedures. Methods In 33 patients with prolonged procedures, 15 patients received enoxaparin 0.5 mg/kg at the beginning of coronary angiography and additional enoxaparin 0.25 mg/kg before PCI (Staged-dose regimen); while, 18 patients received enoxaparin 0.75 mg/kg at the beginning of coronary angiography without additional dose before PCI (Single-dose regimen). A supplementary-dose enoxaparin (0.375 mg/kg) was administered at 90 min after the first dose was given, and every 90 min thereafter until the end of PCI. Anti-Xa levels were assessed at 0 min (immediately before), 10 min and 90 min after each supplementary dose was given (S_0min, S_10min, and S_90min, respectively). Target anticoagulation was defined as anti-Xa level of 0.5–1.8 IU/ml. Results In patients who received only one supplementary dose (n=28), the anti-Xa levels were S1_0min: 0.87±0.19 IU/ml, S1_10min: 1.44±0.21 IU/ml, and S1_90min: 1.10±0.21 IU/ml. In patients who received two supplementary doses (n=5), the anti-Xa levels were S1_0min: 0.86±0.07 IU/ml, S1_10min: 1.27±0.27 IU/ml, and S1_90min: 1.03±0.23 IU/ml, as well as S2_0min: 1.03±0.23 IU/ml, S2_10min: 1.56±0.28 IU/ml, and S2_90min: 1.28±0.18 IU/ml, respectively. No patient received more than two doses of supplementary enoxaparin. All anti-Xa levels were within the range of target anticoagulation except for two patients receiving one supplementary dose (S1_10min: 1.96 IU/ml and 1.81 IU/ml, respectively) and another one receiving two supplementary doses (S2_10min: 1.87 IU/ml). Conclusions In patients undergoing prolonged PCI who received a total dose of enoxaparin 0.75 mg/kg during the first 90 min of their procedures, a supplementary-dose enoxaparin (0.375 mg/kg), which was administered at 90 min and every 90 min thereafter, maintained target anticoagulation for additional 90 min each time it was given. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Peking Union Medical College Hospital (PUMCH) Science Fund for Junior Faculty

Neuromuscular block in patients 80\xa0years and older: a prospective, controlled study

BackgroundAn increasing number of patients older than 80 years are undergoing anesthesia, but little information is available regarding pharmacodynamic effects of myorelaxants in this population. This study aims to compare the time course of rocuronium neuromuscular block in patients ≥ 80 years with those of younger adults.MethodsUnder total intravenous anesthesia with propofol and sufentanil, time course of a bolus of rocuronium 0.6 mg/kg neuromuscular block was assessed with acceleromyography in patients ≥ 80 and in patients 20–50 years old. Onset time, clinical duration, duration until 90% and 100% recovery of baseline were determined.ResultsData from 32 patients were analyzed, 16 were ≥ 80 years and 16 were 20–50 years old. Demographic data are shown in Table 1. In the group ≥ 80, onset time was 190 s ± 46 s compared to 123 s ± 40 s in the group 20–50, P < 0.001 and the clinical duration was 52 [48–69.5] min and 36 [34–41] min, respectively, P < 0.001. Duration to 90% recovery of baseline was 77.5 [71–88.5] min and duration to 100% recovery of baseline was 91.2 [82.2–98] min in patients ≥ 80 years and the corresponding values in the patients 20–50 years old were 53.5 [49–55.5] min and 59.5 [56.5–70.25] min, respectively, P < 0.001.ConclusionCompared to younger adults rocuronium shifted in patients ≥ 80 years from a rapid onset, intermediate acting compound to a slower onset, long-acting compound.Trial registrationClinicalTrials.gov identifier: NCT03551652 (29/05/2018).

The RAI-6 Questionnaire: A New Screening Questionnaire to Monitor Complications of Radioiodine Treatment.

Objective: The aim of this study is to develop a simple and efficient screening questionnaire to be able to routinely monitor potential radioiodine therapy-induced complications.Materials and Methods: A new radioiodine 6 (RAI-6) questionnaire containing six questions adressing salivary, ocular, and nasal symptoms as well as quality of life was developed. Validation of the RAI-6 questionnaire was assessed with a group of fifty-four patients diagnosed with differentiated thyroid carcinoma treated post-operatively with radioiodine therapy, and in a group of fifty healthy volunteers. The patient's group was subdivided into subgroups according to the radioiodine dose received: 23 patients received less or 30 mCi, 28 patients received 100 mCi, and three patients received between 200 and 300 mCi. We asked the patients to complete the RAI-6 questionnaire in a retrospective manner, regarding their situation before radioiodine therapy and regarding their actual symptoms after radioiodine therapy. The time needed to complete the RAI-6 was also assessed both in patients and in healthy volunteers.Results: The mean post radioiodine treatment RAI-6 score were significantly higher than the mean pre radioiodine RAI-6 scores (p < 0.001) and the scores of healthy participants (p < 0.001). The mean total RAI-6 scores increased significantly with increasing radioiodine dose. A total mean RAI-6 score of each question was also analysed and revealed that ocular and nasal discomfort as well as quality of life were the items which affected the patients most after radioiodine treatment. The mean time to fill the RAI-6 questionnaire was 2 min for patients and 49 s for healthy volunteers.Conclusion: The RAI-6 represents a new questionnaire which is easy and quick to complete. This simple screening tool can be recommended for general clinical practise and further epidemiological research.

Oscillatory Pattern of Sympathetic Nerve Bursts Is Associated With Baroreflex Function in Heart Failure Patients With Reduced Ejection Fraction.

Sympathetic hyperactivation and baroreflex dysfunction are hallmarks of heart failure with reduced ejection fraction (HFrEF). However, it is unknown whether the progressive loss of phasic activity of sympathetic nerve bursts is associated with baroreflex dysfunction in HFrEF patients. Therefore, we investigated the association between the oscillatory pattern of muscle sympathetic nerve activity (LFMSNA/HFMSNA) and the gain and coupling of the sympathetic baroreflex function in HFrEF patients. In a sample of 139 HFrEF patients, two groups were selected according to the level of LFMSNA/HFMSNA index: (1) Lower LFMSNA/HFMSNA (lower terciles, n = 46, aged 53 ± 1 y) and (2) Higher LFMSNA/HFMSNA (upper terciles, n = 47, aged 52 ± 2 y). Heart rate (ECG), arterial pressure (oscillometric method), and muscle sympathetic nerve activity (microneurography) were recorded for 10 min in patients while resting. Spectral analysis of muscle sympathetic nerve activity was conducted to assess the LFMSNA/HFMSNA, and cross-spectral analysis between diastolic arterial pressure, and muscle sympathetic nerve activity was conducted to assess the sympathetic baroreflex function. HFrEF patients with lower LFMSNA/HFMSNA had reduced left ventricular ejection fraction (26 ± 1 vs. 29 ± 1%, P = 0.03), gain (0.15 ± 0.03 vs. 0.30 ± 0.04 a.u./mmHg, P < 0.001) and coupling of sympathetic baroreflex function (0.26 ± 0.03 vs. 0.56 ± 0.04%, P < 0.001) and increased muscle sympathetic nerve activity (48 ± 2 vs. 41 ± 2 bursts/min, P < 0.01) and heart rate (71 ± 2 vs. 61 ± 2 bpm, P < 0.001) compared with HFrEF patients with higher LFMSNA/HFMSNA. Further analysis showed an association between the LFMSNA/HFMSNA with coupling of sympathetic baroreflex function (R = 0.56, P < 0.001) and left ventricular ejection fraction (R = 0.23, P = 0.02). In conclusion, there is a direct association between LFMSNA/HFMSNA and sympathetic baroreflex function and muscle sympathetic nerve activity in HFrEF patients. This finding has clinical implications, because left ventricular ejection fraction is less in the HFrEF patients with lower LFMSNA/HFMSNA.

Physical Activity And Cancer-related Outcomes In Patients With Metastatic Renal Cell Carcinoma

PURPOSE: Tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) have revolutionized advanced or metastatic renal cell carcinoma (mRCC). Despite improvements in detection and treatment, mRCC remains a lethal cancer, with 5-year disease-specific mortality ~12%. While physical activity (PA) has been identified as an effective intervention that may improve cancer-related outcomes in patients with other metastatic cancer, there is limited information regarding: 1) the level of physical activity in patients newly diagnosed with mRCC; 2) how this compares to patients with localized renal cell carcinoma (RCC) and healthy controls (HC) and; 3) how it impacts cancer-related outcomes. METHODS: We enrolled 35 consecutive patients with newly diagnosed mRCC who were planning to receive TKI-based systemic therapy with/without ICIs at City of Hope. We also enrolled 29 patients with localized RCC who were scheduled to undergo surgery without systemic therapy. Twenty HC were recruited from acquaintances of patients with RCC. All participants completed a questionnaire about physical activity and demographics at diagnosis. RESULTS: At diagnosis, patients with mRCC were significantly more likely to be older (65.2 vs 52.9 years), have dyslipidemia (31 vs 17%), and a history of coronary artery disease (17 vs 0 %) when compared to HC (P < 0.05). Average minutes of weekly PA was 109.5 min in patients with mRCC, 123.2 min in patients with localized RCC, and 125.8 min in HC. There was no statistically significant difference in the number of participants who met the recommended PA >150 min/week across three groups: 11 patients with mRCC (31%), 8 patients with localized RCC (27%), and 7 HC (35%). In patients with mRCC, there were no statistically significant differences in time to disease progression between patients who met the recommended PA and physically inactive patients (53.7 months [active] vs 48.2 months [inactive]; P = 0.73). CONCLUSIONS: Patients with mRCC have a high burden of chronic comorbidities at diagnosis. In these patients, we found no association between PA and cancer related outcomes, which may be due to the overall low reported PA in this group. Additional studies are needed to examine the impact of increasing PA on health outcomes in patients with mRCC.