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Fairfax S.T.,Biomedical science | Holwerda S.W.,Medical Pharmacology and Physiology | Credeur D.P.,Medical Pharmacology and Physiology | Zuidema M.Y.,Internal Medicine | And 7 more authors.
Journal of Physiology | Year: 2013

Sympathetic vascular transduction is commonly understood to act as a basic relay mechanism, but under basal conditions, competing dilatory signals may interact with and alter the ability of sympathetic activity to decrease vascular conductance. Thus, we determined the extent to which spontaneous bursts of muscle sympathetic nerve activity (MSNA) mediate decreases in forearm vascular conductance (FVC) and the contribution of local α-adrenergic receptor-mediated pathways to the observed FVC responses. In 19 young men, MSNA (microneurography), arterial blood pressure and brachial artery blood flow (duplex Doppler ultrasound) were continuously measured during supine rest. These measures were also recorded in seven men during intra-arterial infusions of normal saline, phentolamine (PHEN) and PHEN with angiotensin II (PHEN+ANG). The latter was used to control for increases in resting blood flow with α-adrenergic blockade. Spike-triggered averaging was used to characterize beat-by-beat changes in FVC for 15 cardiac cycles following each MSNA burst and a peak response was calculated. Following MSNA bursts, FVC initially increased by +3.3 ± 0.3% (P= 0.016) and then robustly decreased to a nadir of -5.8 ± 1.6% (P < 0.001). The magnitude of vasoconstriction appeared graded with the number of consecutive MSNA bursts; while individual burst size only had a mild influence. Neither PHEN nor PHEN+ANG infusions affected the initial rise in FVC, but both infusions significantly attenuated the subsequent decrease in FVC (-2.1 ± 0.7% and -0.7 ± 0.8%, respectively; P < 0.001 vs. normal saline). These findings indicate that spontaneous MSNA bursts evoke robust beat-by-beat decreases in FVC that are exclusively mediated via α-adrenergic receptors. © 2013 The Physiological Society.

Dughera L.,Digestive Motility and Endoscopy | Rotondano G.,Gastroenterology and Digestive Endoscopy | De Cento M.,Anesthesiology | Cassolino P.,Emergency Surgery | Cisaro F.,Pediatric Gastroenterology
Gastroenterology Research and Practice | Year: 2014

From June 2002 to March 2013 26 patients that underwent Stretta procedure (16 females, 10 males) reached to date an eight-year follow-up. Primary end point of the study was to verify the durability of the procedure at this time. All patients underwent clinical evaluation by upper endoscopy, oesophageal pressure, and pH studies. For each patient 8-year data were compared to those recorded at baseline and at 4 years. There was a significant decrease in both heartburn and GERD HRQL scores at 4 years (P = 0.001) and at 8 years (P = 0.003) as well as a significant increase of QoL scores at each control time (mental SF-36 and physical SF-36, P = 0.001). After 4 and 8 years, 21 patients (80.7%, P = 0.0001) and 20 patients (76.9%, P = 0.0001) were completely off PPIs. Median LES pressure did not show significant amelioration at 4 and 8 years and mean oesophageal acid exposure significantly improved at 4 years (P = 0.001) but returned to baseline values after 8 years. This further follow-up study of ours from four to eight years confirms that RF energy delivery for GERD provides durable improvement in symptoms and in quality of life and reduces antireflux drugs consumption. © 2014 Luca Dughera et al.

Maffezzini M.,Urology | Campodonico F.,Urology | Capponi G.,Urology | Manuputty E.,Urology | Gerbi G.,Anesthesiology
Surgical Oncology | Year: 2012

Objectives: With the purpose to reduce the complications of radical cystectomy and intestinal urinary reconstruction a perioperative protocol based on fast-track surgery principles and technical modifications of the original surgical technique was applied to patient candidates for etherotopic bladder substitution. Our protocol included pre-, intra-, and postoperative interventions. The technical variations of the modified Indiana pouch technique were focused on intestinal anastomosis to restore bowel continuity, uretero-colonic anastomoses, and capacity of the reservoir. Results and limitations: From 2003 to 2010, 68 consecutive patients participated in the study. Two patients died due to surgical complications (2.9%). Overall, 24 of 68 patients experienced complications (35.3%). Surgery was needed under general anaesthesia for seven patients (10.2%) and under local anaesthesia for four (5.9%). Medical complications were encountered in 13 of 68 patients (19.1%). According to Clavien grading, complications were grade 5 in two patients, grade 4 in two patients, grade 3b in five patients, grade 3a in four patients, grade 2 in nine patients, and grade 1b in two patients. A limitation of our series is that patients were recruited at a single urologic centre and were operated by a single surgeon. Findings need validation. Conclusions: Progress in the perioperative management of major surgery and technical refinements can contribute to reduced complications. In addition, the use of objective reporting tools will facilitate comparison of studies. © 2012 Elsevier Ltd. All rights reserved.

Rominger M.,University of Zürich | Berg D.,Anesthesiology | Frauenfelder T.,University of Zürich | Ramaswamy A.,University of Marburg | Timmesfeld N.,University of Marburg
European Radiology | Year: 2016

Objectives: To assess MRI-pathology concordance and factors influencing tumour size measurement in breast cancer. Materials and methods: MRI tumour size (greatest diameter in anatomical planes (MRI-In-Plane) and greatest diameter along main tumour axis (MRI-MPR)) of 115 consecutive breast lesions (59 invasive lobular carcinoma, 46 invasive ductal carcinoma, and 10 ductal carcinoma in situ) was retrospectively compared to size measured at histopathology (pT size (Path-TNM) and greatest tumour diameter as relevant for excision (Path-Diameter; reference standard)). Histopathological tumour types, preoperative palpability, surgical management, additional high-risk lesions, and BI-RADS lesion type (mass versus non-mass enhancements) were assessed as possible influencing factors. Results: Systematic errors were most pronounced between MRI-MPR and Path-TNM (7.1 mm, limits of agreement (LoA) [-21.7; 35.9]), and were lowest between MRI-In-Plane and Path-Diameter (0.2 mm, LoA [-19.7; 20.1]). Concordance rate of MRI-In-Plane with Path-Diameter was 86 % (97/113), overestimation 9 % (10/113) and underestimation 5 % (6/113); BI-RADS mass lesions were overestimated in 7 % (6/81) versus 41 % (13/32) for non-mass enhancements. On multivariate analysis only BI-RADS lesion type significantly influenced MRI-pathology concordance (p < 0.001). 2/59 (3 %) ILC did not enhance. Conclusion: Concordance rate varies according to the execution of MRI and histopathological measurements. Beyond this only non-mass enhancement significantly predicted discordance. Key Points: • Execution and scope of MRI and histopathological size measurements influence concordance rate. • Non-mass like enhancement predicts discordance. • Additional high-risk lesions in proximity of tumour do not cause measurement discordance. • Low percentage of ILC do not enhance at all. © 2015, European Society of Radiology.

Furuno T.,Medicine and Geriatrics | Yamasaki F.,Clinical Laboratory | Yokoyama T.,Anesthesiology | Sato K.,Medicine and Geriatrics | And 3 more authors.
Heart and Vessels | Year: 2011

Although aspirin has become an established medicine for cardiac and cerebrovascular diseases, the optimal dose remains unknown. We evaluated the optimal dose of aspirin on platelet activity and endothelial function by administering 11 healthy male volunteers (32 ± 6 years of age) doses of aspirin that were increased in a stepwise manner (0, 81, 162, 330 and 660 mg/day) every 3 days. Platelet activity was assessed as surface P-selectin expression (%) measured by flow cytometry and the platelet aggregation ratio. Endothelial function in the brachial artery was assessed by measuring flow-mediated dilation (FMD) before and after reactive hyperemia. Platelet aggregation and P-selectin expression were significantly and dose-dependently suppressed (81-660 mg), and the FMD ratio tended to increase from 0 to 162 mg, but decreased significantly at 660 mg. In conclusion, although aspirin suppressed platelet activity and even surface P-selectin expression, higher doses worsened endothelial-mediated arterial dilation. © 2010 Springer.

Prager J.,University of California at Los Angeles | Deer T.,Center for Pain Relief | Levy R.,Jacksonville University | Bruel B.,University of Texas M. D. Anderson Cancer Center | And 7 more authors.
Neuromodulation | Year: 2014

Objective The objective of this study was to identify best practices and provide guidance to clinicians to ensure safety and optimize intrathecal drug delivery for chronic intractable pain. Methods Twelve experienced pain medicine practitioners - eight anesthesiologists, one neurosurgeon, one physiatrist, one clinical psychologist, and one advanced practice registered nurse - from the United States, Australia, and Europe gathered to identify and publish consensus on best practices in three areas related to safe intrathecal therapy for pain: safety and monitoring, patient and device management, and patient selection and trialing. Conclusions Intrathecal drug delivery is a valuable alternative drug delivery system for many patients with severe chronic or end-of-life pain. While device-related complications (mostly with catheters) and surgical-site infections can occur, the main therapy-related safety issues associated with intrathecal drug delivery arise primarily with inadequate patient monitoring (e.g., respiratory depression), inflammatory mass (e.g., high doses and concentrations of opioids), wound healing, dosing errors (e.g., medication concentration and pump programming), pump fills or refills (e.g., pocket fills), and interaction with concomitant systemic medications (e.g., opioids and benzodiazepines). Many of the reported adverse events and complications of intrathecal drug delivery can be prevented by adequate clinician training, implementation of best practices, and experience. In adopting the therapy, patients must be apprised of its risks and benefits. Physicians and patients must partner to achieve both safety and effectiveness. © 2014 International Neuromodulation Society.

Urbanski P.P.,Cardiovascular Surgery | Lenos A.,Cardiovascular Surgery | Lindemann Y.,Cardiovascular Surgery | Zacher M.,Cardiovascular Surgery | And 2 more authors.
Thoracic and Cardiovascular Surgeon | Year: 2010

Background: Cannulation of arch arteries (innominate, axillary or carotid) for arterial return during cardiopulmonary bypass is increasingly being used; however, the flow and pressure profile in the cannulated arteries remains unclear. The aim of this study was to evaluate the flow and pressure characteristics of arterial inflow through a carotid artery, especially with regard to operative and technical aspects, clinical outcomes, and side-related differences. Methods: Between January 2005 and April 2008, 200 consecutive patients underwent elective aortic arch surgery at our facility. One hundred patients were assigned to undergo cannulation of the left and another 100 to undergo cannulation of the right carotid artery. Both groups were similar in terms of age, sex, and type of surgery. In all patients, arterial return was through a side-graft anastomosed to the carotid artery. The arterial line was also used for unilateral cerebral perfusion for brain protection during mild hypothermic circulatory arrest. The flow and pressure profiles in the arterial line and in the carotid artery were evaluated with regard to cardiopulmonary bypass flow rate and side of cannulation. Results: No complications related to the cannulation of a carotid artery were observed. The arterial return was adequate in all patients, regardless of the side being cannulated. Because of low resistance (mean pressure <50mmHg) in the carotid artery proximal to the inflow side-graft, the flow toward the aortic arch averaged 87 ± 2% (range 84.492%) of the total flow volume (4.6 ± 0.5L/min), without a significant difference between the sides. However, the perfusion pressure in the arterial line was significantly higher when the left carotid artery was cannulated (216 ± 30mmHg vs. 205 ± 30mmHg; p=0.013). There was also a significant difference in the pressure in the distal carotid arteries, which, compared to the systolic blood pressure prior to cardiopulmonary bypass, increased by 30 ± 24mmHg on the left and decreased by 16 ± 21mmHg on the right (p<0.001). Conclusions: Both common carotid arteries are suitable for arterial cannulation; however, left-sided cannulation is associated with an increase in the pressure profile. Therefore, if vascular pathology does not dictate cannulation of the left carotid artery, the right carotid artery should be considered the site of choice. © Georg Thieme Verlag KG Stuttgart - New York.

To describe contrast-enhanced ultrasound (CEUS) patterns of pneumonia, to characterize CEUS patterns and to determine the clinical value of deviant CEUS patterns. N = 50 patients with radiologically diagnosed alveolar pneumonia were investigated by CEUS and retrospectively evaluated. Pulmonary enhancement was differentiated from bronchial arterial enhancement by measurement of time to enhancement from the application of the contrast agent (CA). The echogenicity of the CA enhancement was evaluated (isoechoic/hypoechoic) using the spleen as an "in vivo reference". In addition, the homogeneity of the CA enhancement (homogeneous/ inhomogeneous) was recorded. The patients were divided into two groups according to the CEUS pattern (type 1/type 2) and compared to each other in terms of age, days of hospitalization, comorbidity, rate of complications and the presence of pleural effusion. The majority showed a type 1 CEUS pattern consisting of a pulmonary arterial supply (92 %), an isoechoic extent of enhancement (74 %) and a homogeneous enhancement (78 %) of the CA in the pulmonary lesions. The only significant difference found between the two groups was the average age. Pneumonia most likely shows a type 1 CEUS pattern consisting of a pulmonary arterial supply, an isoechoic extent of enhancement compared to the spleen and a homogeneous enhancement of the CA in the pulmonary lesions. Prognostic value of a type 2 CEUS pattern (bronchial arterial supply and/or hypoechoic extent of enhancement and/or inhomogeneous enhancement) in pneumonia regarding days of hospitalization, comorbidity, rate of complications and the presence of pleural effusion could not be shown. © Georg Thieme Verlag KG Stuttgart · New York.

Flores M.P.,ME3 | de Castro A.P.C.R.,Anesthesiology | Nascimento J.D.S.,Head of the CET SBA
Revista Brasileira de Anestesiologia | Year: 2012

Background and objectives: Pain treatment involves the usage of common and opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and adjuvant analgesics. Traditionally, these drugs are administered systemically or into the neuraxis. However, when analgesics are applied through these pathways, they are associated with significant side effects, which can hinder its use. Topical administration of analgesics is an alternative. The objective of this paper is to discuss topical analgesics, the mechanisms of action and clinical efficacy. Content: This is a review paper addressing the usage of the topical local anesthetics: capsaicin, clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids, discussing mechanism of action and effectiveness. Conclusions: Topical analgesics are promising as a strategy for pain treatment, as they are associated with lower incidence of side effects. The benefit of local anesthetics, NSAID's and capsaicin is well established. However, the efficacy of clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids is still questionable. Studies have shown that the multimodal approach is an alternative, but studies are needed to confirm this hypothesis. © 2012 Elsevier Editora Ltda.

Hoelzer B.C.,Mayo Medical School | Moeschler S.M.,Mayo Medical School | Seamans D.P.,Anesthesiology
Pain Medicine (United States) | Year: 2015

Introduction: Simulation is an evolving aspect of medical education. The role of simulation in training programs is variable, however, in technical specialties such as surgery and anesthesiology its role is quickly becoming a standard part of training programs. Pain fellowship programs must teach clinical diagnostic skills, pharmacology and pathophysiology, in addition to interventional skills to fellows with varying residency backgrounds. Methods: The implementation of a hybrid simulation course into the pain fellowship curriculum allows for active learning as fellows experience challenging patient scenarios, stressful periprocedural events, and cases gone awry that require emergency algorithm recall and action. Conclusion: This report describes the incorporation of simulation and crucial conversations into a pain fellowship curriculum. © Wiley Periodicals, Inc.

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