Anesthetic care for electroconvulsive therapy

Counselling and medication are often thought of as the only interventions for psychiatric disorders, but electroconvulsive therapy (ECT) has also been applied in clinical practice for over 80 years. ECT refers to the application of an electric stimulus through the patient’s scalp to treat psychiatric disorders such as treatment-resistant depression, catatonia, and schizophrenia. It is a safe, effective, and evidence-based therapy performed under general anesthesia with muscle relaxation. An appropriate level of anesthesia is essential for safe and successful ECT; however, little is known about this because of the limited interest from anesthesiologists. As the incidence of ECT increases, more anesthesiologists will be required to better understand the physiological changes, complications, and pharmacological actions of anesthetics and adjuvant drugs. Therefore, this review focuses on the fundamental physiological changes, management, and pharmacological actions associated with various drugs, such as anesthetics and neuromuscular blocking agents, as well as the comorbidities, indications, contraindications, and complications of using these agents as part of an ECT procedure through a literature review and our own experiences

Epigenetic modification of mesenchymal stromal cells enhances their suppressive effects on the Th17 responses of cells from rheumatoid arthritis patients

Abstract Background The aim of this study was to investigate if epigenetically modified human mesenchymal stromal cells (hMSCs) can regulate the Th17-related immune responses. Methods We tested epigenetic drug combinations at various doses and selected the four combinations that resulted in maximal interleukin (IL)-10 and indoleamine 2,3-dioxygenase gene expression in hMSCs. We examined the effects of epigenetically modified hMSCs (epi-hMSCs) on CD4+ T-cell proliferation and inflammatory cytokine secretion under Th0- and Th17-polarizing conditions using mixed lymphocyte reactions and enzyme-linked immunosorbent assays (ELISAs). We determined Th17 cytokine levels and the percentage of Th17 cells among synovial fluid mononuclear cells (SFMCs) from rheumatoid arthritis (RA) patients by ELISA and flow cytometry. Results Epi-hMSCs inhibited the development of IL-17-producing cells in culture. The percentages of IL-17+ and interferon (IFN)-γ+ cells among peripheral blood mononuclear cells from healthy donors were lower under both the Th0 and Th17 conditions in the presence of epi-hMSCs than in the presence of no or untreated hMSCs. Epi-hMSC-treated RA patient SFMCs secreted lower levels of IL-17 and IFN-γ than RA patient SFMCs cultured without hMSCs or with untreated hMSCs. Conclusions An optimal combination of hypomethylating agents and histone deacetylase inhibitors can enhance the immunomodulatory potential of hMSCs, which may be useful for RA treatment

Preoperative dexamethasone for acute post-thoracotomy analgesia: a randomized, double-blind, placebo-controlled study

Abstract Background The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy. Methods Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 μg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. Results No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h (63.6 [55.9–72.7] vs. 68.5 [60.2–89.0] ml, P = 0.281) and 72 h (199.4 [172.4–225.1] vs. 194.7 [169.1–252.2] ml, P = 0.890). Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. Conclusion A single intravenous administration of dexamethasone during the preoperative period does not reduce opioid consumption and post-thoracotomy pain. Trial registration The study was registered at http://cris.nih.go.kr (KCT0000359) and was conducted from December 2011 to October 2012

Predictive Model for the Assessment of Preoperative Frailty Risk in the Elderly

Adequate preoperative evaluation of frailty can greatly assist in the efficient allocation of hospital resources and planning treatments. However, most of the previous frailty evaluation methods, which are complicated, time-consuming, and can have inter-evaluator error, are difficult to apply in urgent situations. Thus, the authors aimed to develop and validate a predictive model for pre-operative frailty risk of elderly patients by using diagnostic and operation codes, which can be obtained easily and quickly from electronic records. We extracted the development cohort of 1762 people who were hospitalized for emergency operations at a single institution between 1 January 2012 and 31 December 2016. The temporal validation cohort from 1 January 2017 to 31 December 2018 in the same center was set. External validation was conducted on 6432 patients aged 75 years or older from 2012 to 2015 who had emergency surgery in the Korean national health insurance database. We developed the Operation Frailty Risk Score (OFRS) by assessing the association of Operation Group and Hospital Frailty Risk Score with the 90-day mortality through logistic regression analysis. We validated the OFRS in both the temporal validation cohort and two external validation cohorts. In the temporal validation cohort and the external validation cohort I and II, the c-statistics for OFRS to predict 90-day mortality were 0.728, 0.626, and 0.619, respectively. OFRS from these diagnostic codes and operation codes may help evaluate the peri-operative frailty risk before emergency surgery for elderly patients where history-taking and pre-operative testing cannot be performed

Clinical Outcomes of Rhythm Control Strategies for Asymptomatic Atrial Fibrillation According to the Quality-of-Life Score: The CODE-AF (Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation) Registry

BACKGROUND: Atrial fibrillation (AF) is associated with an increased risk of poor cardiovascular outcomes; appropriate rhythm control can reduce the incidence of these adverse events. Therefore, catheter ablation is recommended in symptomatic patients with AF. The aims of this study were to compare AF-related outcomes according to a baseline symptom scale score and to determine the best treatment strategy for asymptomatic patients with AF. METHODS AND RESULTS: This study enrolled all patients who completed a baseline Atrial Fibrillation Effect on Quality-of-Life (AFEQT) survey in a prospective observational registry. The patients were divided into 2 groups according to AFEQT score at baseline; scores <= 80 were defined as symptomatic, whereas scores >80 represented asymptomatic patients. The primary outcome was defined as a composite of hospitalization for heart failure, ischemic stroke, or cardiac death. This study included 1515 patients (mean age: 65.7 +/- 10.5 years; 998 [65.9%] men). The survival curve showed a poorer outcome in the symptomatic group compared with the asymptomatic group (log-rank P=0.04). Rhythm control led to a significantly lower risk of a composite outcome in asymptomatic patients (hazard ratio [HR], 0.47 [95% CI, 0.27-0.84], P=0.01). Rhythm control was associated with more favorable composite outcomes in the asymptomatic group with paroxysmal AF, left atrium diameter <= 50 mm, and CHA(2)DS(2)-VASc score >= 3. CONCLUSIONS: Symptomatic patients with AF experienced more adverse outcomes compared with asymptomatic patients. In asymptomatic patients with AF, a strategy of rhythm control improved the outcomes, especially with paroxysmal AF, smaller left atrium size, or higher stroke risk.N

Clinical Outcomes of Rhythm Control Strategies for Asymptomatic Atrial Fibrillation According to the Quality‐of‐Life Score: The CODE‐AF (Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation) Registry

Background Atrial fibrillation (AF) is associated with an increased risk of poor cardiovascular outcomes; appropriate rhythm control can reduce the incidence of these adverse events. Therefore, catheter ablation is recommended in symptomatic patients with AF. The aims of this study were to compare AF‐related outcomes according to a baseline symptom scale score and to determine the best treatment strategy for asymptomatic patients with AF. Methods and Results This study enrolled all patients who completed a baseline Atrial Fibrillation Effect on Quality‐of‐Life (AFEQT) survey in a prospective observational registry. The patients were divided into 2 groups according to AFEQT score at baseline; scores ≤80 were defined as symptomatic, whereas scores >80 represented asymptomatic patients. The primary outcome was defined as a composite of hospitalization for heart failure, ischemic stroke, or cardiac death. This study included 1515 patients (mean age: 65.7±10.5 years; 998 [65.9%] men). The survival curve showed a poorer outcome in the symptomatic group compared with the asymptomatic group (log‐rank P=0.04). Rhythm control led to a significantly lower risk of a composite outcome in asymptomatic patients (hazard ratio [HR], 0.47 [95% CI, 0.27–0.84], P=0.01). Rhythm control was associated with more favorable composite outcomes in the asymptomatic group with paroxysmal AF, left atrium diameter ≤50 mm, and CHA2DS2‐VASc score ≥3. Conclusions Symptomatic patients with AF experienced more adverse outcomes compared with asymptomatic patients. In asymptomatic patients with AF, a strategy of rhythm control improved the outcomes, especially with paroxysmal AF, smaller left atrium size, or higher stroke risk. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02786095