The latest medical research on Anesthesiology

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Neutrophil Extracellular Traps Are Elevated in Patients with Pneumonia-related Acute Respiratory Distress Syndrome.


Neutrophil extracellular traps are increasingly recognized as pathogenic in acute injury, but their role in sepsis-related acute respiratory distress syndrome is unknown WHAT THIS ARTICLE TELLS US THAT IS NEW:: In 35 patients with acute respiratory distress syndrome secondary to pneumonia, neutrophil extracellular traps were elevated in the blood and bronchoalveolar fluid, and associated with interleukin-8 and neutrophil levels; however, higher (vs. lower) levels of neutrophil extracellular traps were not associated with mortality or duration of mechanical ventilation BACKGROUND:: Neutrophil extracellular traps have been associated with tissue damage. Whether these are involved in the pathogenesis of human acute respiratory distress syndrome (ARDS) and could be a potential therapeutic target is unknown. The authors quantified bronchoalveolar and blood neutrophil extracellular traps in patients with pneumonia-related ARDS and assessed their relationship with ventilator-free days.

Immunocompetent patients with pneumonia and moderate or severe ARDS (n = 35) and controls (n = 4) were included in a prospective monocentric study. Neutrophil extracellular trap concentrations were quantified (as DNA-myeloperoxidase complexes) in bronchoalveolar lavage fluid and serum by enzyme-linked immunosorbent assay. The relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and the primary clinical endpoint (i.e., the number of live ventilator-free days at day 28) was assessed using linear regression analyses.

There was no significant relationship between bronchoalveolar lavage neutrophil extracellular trap concentrations and ventilator-free days by multiple regression analysis (β coefficient = 2.40; 95% CI, -2.13 to 6.92; P = 0.288). Neutrophil extracellular trap concentrations were significantly higher in bronchoalveolar lavage than in blood of ARDS patients (median [first to third quartiles]:154 [74 to 1,000] vs. 26 [4 to 68] arbitrary units, difference: -94; 95% CI, -341 to -57; P < 0.0001). Bronchoalveolar concentrations of patients were higher than those of controls (154 [74 to 1,000] vs. 4 [4 to 4] arbitrary units, difference: -150; 95% CI, -996 to -64; P < 0.001) and associated with bronchoalveolar interleukin-8 (Spearman's ρ = 0.42; P = 0.012) and neutrophil concentrations (ρ = 0.57; P < 0.0001). Intensive care unit mortality (12%, n = 2 of 17 vs. 17%, n = 3 of 18; P > 0.99) and the number of ventilator-free days at day 28 (22 [14 to 25] vs. 14 [0 to 21] days; difference: -5; 95% CI, -15 to 0; P = 0.066) did not significantly differ between patients with higher (n = 17) versus lower (n = 18) bronchoalveolar neutrophil extracellular trap concentrations.

Bronchoalveolar neutrophil extracellular trap concentration was not significantly associated with mechanical ventilation duration in pneumonia-related ARDS.

Elevation of Transient Receptor Potential Vanilloid 1 Function in the Lateral Habenula Mediates Aversive Behaviors in Alcohol-withdrawn Rats.


Chronic alcohol use and withdrawal leads to increased pain perception, anxiety, and depression. These aberrant behaviors are accompanied by increased excitatory glutamatergic transmission to, and activity of, the lateral habenula neurons.Vanilloid type 1, or TRPV1, channels are expressed in the habenula and they facilitate glutamatergic transmission. Whether TRPV1 channel plays a role in habenula hyperactivity is not clear.

Glutamatergic transmission in the lateral habenula was inhibited by TRPV1 channel antagonists. In vivo, local administration of TRPV1 antagonists into the lateral habenula attenuated hyperalgesia, anxiety, and relapse-like drinking in rats who chronically consumed alcohol.The data suggest that enhanced TRPV1 channel function during withdrawal may contribute to aberrant behavior that promotes relapse alcohol consumption.

Recent rat studies indicate that alcohol withdrawal can trigger a negative emotional state including anxiety- and depression-like behaviors and hyperalgesia, as well as elevated glutamatergic transmission and activity in lateral habenula neurons. TRPV1, a vanilloid receptor expressed in the habenula, is involved in pain, alcohol dependence, and glutamatergic transmission. The authors therefore hypothesized that TRPV1 contributes to the changes in both the behavioral phenotypes and the habenula activity in alcohol-withdrawn rats.

Adult male Long-Evans rats (n = 110 and 280 for electrophysiology and behaviors, respectively), randomly assigned into the alcohol and water (Naïve) groups, were trained to consume either alcohol or water-only using an intermittent-access procedure. Slice electrophysiology was used to measure spontaneous excitatory postsynaptic currents and firing of lateral habenula neurons. The primary outcome was the change in alcohol-related behaviors and lateral habenula activity induced by pharmacologic manipulation of TRPV1 activity.

The basal frequency of spontaneous excitatory postsynaptic currents and firing of lateral habenula neurons in alcohol-withdrawn rats was significantly increased. The TRPV1 antagonist capsazepine (10 µM) induced a stronger inhibition on spontaneous excitatory postsynaptic currents (mean ± SD; by 26.1 ± 27.9% [n = 11] vs. 6.7 ± 18.6% [n = 17], P = 0.027) and firing (by 23.4 ± 17.6% [n = 9] vs. 11.9 ± 16.3% [n = 12], P = 0.025) in Withdrawn rats than Naive rats. By contrast, the TRPV1 agonist capsaicin (3 μM) produced a weaker potentiation in Withdrawn than Naïve rats (spontaneous excitatory postsynaptic currents: by 203.6 ± 124.7% [n = 20] vs. 415.2 ± 424.3% [n = 15], P < 0.001; firing: 38.1 ± 14.7% [n = 11] vs. 73.9 ± 41.9% [n = 11], P < 0.001). Conversely, capsaicin's actions in Naïve but not in Withdrawn rats were significantly attenuated by the pretreatment of TRPV1 endogenous agonist N-Oleoyldopamine. In Withdrawn rats, intra-habenula infusion of TRPV1 antagonists attenuated hyperalgesia and anxiety-like behaviors, decreased alcohol consumption upon resuming drinking, and elicited a conditioned place preference.

Enhanced TRPV1 function may contribute to increased glutamatergic transmission and activity of lateral habenula neurons, resulting in the aberrant behaviors during ethanol withdrawal.

Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function.


Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers...

Survey Research.


Surveys provide evidence on practice, attitudes, and knowledge. However, conducting good survey research is harder than it looks. The authors aim t...

Aquaporin 5 -1364A/C Promoter Polymorphism Is Associated with Pulmonary Inflammation and Survival in Acute Respiratory Distress Syndrome.


Acute respiratory distress syndrome is defined according to clinical criteria, but lack of precise characterization may contribute to negative trials and impede personalized care. Polymorphisms of aquaporin-5, a key mediator of inflammation, may impact outcome.

In acute respiratory distress syndrome attributable to bacterial pneumonia, the C-allele of the aquaporin-5 -1364A/C promoter polymorphism is associated with less pulmonary inflammation and greater survival. This may improve characterization of acute respiratory distress syndrome and ultimately facilitate individualized care.

The aquaporin-5 (AQP5) -1364A/C promoter single-nucleotide polymorphism is associated with an altered AQP5 expression and mortality in sepsis. Because AQP5 expression alters neutrophil cell migration, it could affect pulmonary inflammation and survival in bacterially evoked acute respiratory distress syndrome. Accordingly, the authors tested the hypotheses that the AC/CC genotype in patients with bacterially evoked pneumonia resulting in acute respiratory distress syndrome is associated with (1) attenuated pulmonary inflammation and (2) higher 30-day survival.

In this prospective, observational study, bronchoalveolar lavage and blood sampling were performed within 24 h of intensive care unit admission. In 136 Caucasian patients with bacterially evoked acute respiratory distress syndrome, genotype of the AQP5 -1364A/C promoter polymorphism, bronchoalveolar lavage total protein, albumin, white cell concentrations, and lactate dehydrogenase activity were measured to evaluate the relationship between genotypes and survival.

AC/CC patients as well as survivors showed lower bronchoalveolar lavage protein (0.9 mg/ml vs. 2.3 mg/ml, P < 0.001 and 1.6 mg/ml vs. 2.6 mg/ml, P = 0.035), albumin (0.2 mg/ml vs. 0.6 mg/ml, P = 0.019 and 0.3 mg/ml vs. 0.6 mg/ml, P = 0.028), leukocytes (424 /ml vs. 1,430/ml; P = 0.016 and 768 /ml vs. 1,826/ml; P = 0.025), and lactate dehydrogenase activity (82 U/l vs. 232 U/l; P = 0.006 and 123 U/l vs. 303 U/l; P = 0.020). Thirty-day survival was associated with AQP5 -1364A/C genotypes (P = 0.005), with survival of 62% for AA genotypes (58 of 93) but 86% for C-allele carriers (37 of 43). Furthermore, multiple proportional hazard analysis revealed the AA genotype was at high risk for death within 30 days (hazard ratio, 3.53; 95% CI, 1.38 to 9.07; P = 0.009).

In acute respiratory distress syndrome attributable to bacterial pneumonia, the C-allele of the AQP5 -1364A/C promoter polymorphism is associated with an attenuated pulmonary inflammation and higher 30-day survival. Thus, the AQP5 genotype impacts on inflammation and prognosis in acute respiratory distress syndrome.

Understanding the Effects of General Anesthetics on Cortical Network Activity Using Ex Vivo Preparations.


General anesthetics have been used to ablate consciousness during surgery for more than 150 yr. Despite significant advances in our understanding o...

A review of ASA physical status - historical perspectives and modern developments.


The American Society of Anesthesiologists (ASA) physical status is a tool commonly used to classify a patient's physical fitness before surgery. Si...

A trial comparing emergency front of neck airway performance in a novel obese-synthetic neck, meat-modified obese neck and conventional slim manikin.


Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have desc...

A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients.


We retrospectively compared patients receiving remifentanil with patients receiving sufentanil undergoing fast-track cardiac surgery. After 1:1 pro...

Using spectral reflectance to distinguish between tracheal and oesophageal tissue: applications for airway management.


Proper placement of the tracheal tube requires confirmation, and the predominant method in addition to clinical signs is the presence of end-tidal ...

Comparison of alteplase and urokinase for pharmacomechanical thrombolysis of clotted hemodialysis access.

J Vasc Access

Percutaneous pharmacomechanical thrombolysis is increasingly used to salvage thrombosed hemodialysis access. We aim to evaluate the effectiveness of alteplase compared to urokinase in percutaneous pharmacomechanical thrombolysis clotted access.

Records of patients who underwent pharmacomechanical thrombolysis at Interventional Nephrology Suite in a tertiary teaching hospital from 1 January 2016 to 31 December 2016 were reviewed. Technical and clinical success rates, thrombosis-free and cumulative survivals, procedure time, and radiation dose imparted to patients were compared for pharmacomechanical thrombolysis with urokinase versus alteplase.

A total of 122 incident patients underwent pharmacothrombolysis (n = 53 for urokinase, n = 69 for alteplase) during the study period. The mean dose of urokinase and alteplase used was 176,897 ± 73,418 units and 3.7 ± 0.8 mg, respectively. Pharmacomechnical thrombolysis using urokinase versus alteplase has similar technical success rate (98.1% vs 97.1%, p = 0.599), clinical success rate (88.7% vs 97.1%, p = 0.068), complication rate (9.4% vs 13.0%, p = 0.373), and primary patency rates at 3 months (57.1% vs 70.1%, p = 0.106). Thrombosis-free survivals of the vascular access were 113.2 (35.3, 196) days versus 122 (84, 239) days (p = 0.168). Cumulative survivals were 239 (116, 320) vs 213 (110.5, 316.5) days (p = 0.801). Procedure time, fluoroscopy time, skin dose, and dose were significantly lower for pharmacomechanical thrombolysis using alteplase compared to urokinase (p = 0.045, p < 0.0001, p = 0.006, p = 0.001, respectively). Stenting was found to be associated with successful dialysis following thrombolysis on univariate analysis (odds ratio: 9.167, 95% confidence interval: 1.391-19.846, p = 0.021), although this was no longer significant in multivariate analysis (p = 0.078).

Alteplase is an effective and safe alternative to urokinase for pharmacomechanical thrombolysis of clotted vascular access.

Survey of non-tunneled temporary hemodialysis catheter clinical practice and training.

J Vasc Access

Nephrologists are placing fewer non-tunneled temporary hemodialysis catheters. Requiring competence for nephrology fellow graduation is controversial.

Anonymous, online survey of all graduates from a single, military nephrology training program (n = 81; 1985-2017) and all US Nephrology program directors (n = 150).

Graduate response and completion rates were 59% and 100%, respectively; 93% agreed they had been adequately trained; 58% (26/45) place non-tunneled temporary hemodialysis catheters, independent of academic practice or time in practice, but 12/26 did ⩽5/year and 23/26 referred some or all. The most common reason for continuing non-tunneled temporary hemodialysis catheter placement was that it is an essential emergency procedure (92%). The single most significant barrier was time to do the procedure (49%). Program director response and completion rates were 50% and 79%, respectively. The single most important barrier to fellow competence was busyness of the service (36%), followed by disinterest (21%); 55% believed that non-tunneled temporary hemodialysis catheter insertion competence should be required, with 81% indicating it was an essential emergency procedure. The majority of graduates and program directors agreed that simulation training was valuable; 76% of programs employ simulation. Graduates who had simulation training and program directors with ⩽20 years of practice were significantly more likely to agree that simulation training was necessary.

Of the graduate respondents from a single training program, 58% continue to place non-tunneled temporary hemodialysis catheters; 55% of program directors believe non-tunneled temporary hemodialysis catheter procedural competence should be required. Graduates who had non-tunneled temporary hemodialysis catheter simulation training and younger program directors consider simulation training necessary. These findings should be considered in the discussion of non-tunneled temporary hemodialysis catheter curriculum requirements.