Epinephrine administration via a laryngeal mask airway: what is the optimal dose?

Background. The aim of this animal study was to clarify the effects of laryngeal mask airway (LMA)-administrated epinephrine and to assess the optimal dose. Methods. Thirty pigs were anesthetized and intubated with a cuffed tracheal tube (TT) and an LMA. Then they were assigned to one of five groups. The control group received distilled water 10 mL via the TT; the TT group received epinephrine 50 μg/kg via the TT; and the other three groups received two, four or six times the TT dose of epinephrine via the LMA. Heart rate (HR) and arterial pressure were monitored before and after drug administration for 15 minutes. Results. After epinephrine administration, the LMA-6 and TT groups had elevated systolic, diastolic and mean arterial pressures at 1 min and there was no significant difference between the two groups. In the TT group, these parameters peaked at 2 min then declined rapidly. In the LMA-6 group, they increased more slowly, and then maintained a plateau. The control, LMA-2 and LMA-4 groups failed to display significant persistent (>2 min) hemodynamic changes. Conclusions. We could not identify an optimal LMA-administrated epinephrine dose. The TT route is suitable when a high peak drug effect is required and the LMA route may be preferable if a persistent plateau effect is desired. Effective LMA administration of drugs may require larger doses than those given via TT

The efficacy of four-slice helical CT in evaluating pancreatic trauma: a single institution experience

<p>Abstract</p> <p>Study objective</p> <p>To assess the efficacy of computed tomography (CT) in evaluating patients with pancreatic trauma.</p> <p>Methods</p> <p>We undertook a retrospective review of all blunt trauma patients admitted to the Chi-Mei Medical Center from January 2004 to June 2006. Every patients underwent abdominal CT scan in emergency department and the CT scans were obtained with a four-slice helical CT. Diagnosis of a pancreatic injury in these patients was by surgical observation or by CT findings. Radiographic pancreatic injuries were classified as deep or superficial lesions. Deep lesions were defined as the hematomas or lacerations >50% thickness of the pancreas. Superficial lesions were described as the hematomas or lacerations <50% thickness of the pancreas; pancreatic edema; and focal fluid accumulation around the pancreas</p> <p>Results</p> <p>Nineteen patients with pancreatic trauma, fourteen males and five females, average age 40.6 ± 21.4 years, were included. Most patients (73.7%) with pancreatic trauma had associated organ injuries. CT was performed in all patients and laparotomy in 14 patients. CT was 78.9% sensitive in detecting pancreatic trauma. All deep pancreatic lesions revealed on CT required surgical treatment, and complication was discovered in two patients undergoing delayed surgery. Superficial lesions were managed conservatively.</p> <p>Conclusion</p> <p>Four-slice helical CT can detect most pancreatic trauma and provide practical therapeutic guidance. Delayed operation might result in complications and is associated with prolonged hospital stays.</p

Prognostic Value of Leucocyte Telomere Length in Acute Myocardial Infarction

Introduction: Leucocyte telomere length (LTL) has been described as a marker of biological age, endothelial dysfunction and atherosclerosis. The association between LTL and clinical characteristics of Asian patients, and their outcomes following acute myocardial infarction (AMI) have been inconclusive. Objective: To investigate the relationship between LTL and developing AMI, the association of LTL with inpatient and 30-day mortality, and the comparison to LTL with established AMI risk scores in predicting these outcomes. Methodology: 100 patients aged 30-70 years admitted with an AMI to a tertiary referral center between May-Oct 2017 were enrolled; these were matched with 100 non-AMI ('healthy') controls for gender and age (+/- 1 year). Clinical data was obtained prospectively; inpatient and 30-day outcomes documented. LTL was reflected by a well described variable called a tis ratio (TSR). The TSR was measured at enrolment using a quantitative PCR-based methods (qPCR) and results blinded to the clinician

Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Fish Bone Penetration of the Duodenum: A Rare Cause of Liver Abscess

We present a case of an elderly patient who visited our emergency department owing to a pyogenic liver abscess. A linear calcified object extending from the stomach to the liver was found on images from a computed tomography scan. The patient underwent laparotomy and a retained fish bone and a hepato-duodenal fistula were discovered during surgery. The bacteriological presentation of foreign-body-related liver abscesses are unique and most of the patients require surgical interventions to remove the foreign bodies. However, it is difficult to obtain a reliable history of accidentally swallowed foreign bodies. Physicians should exam the images carefully for any clues of retained foreign bodies in patients with pyogenic liver abscess

Bisoprolol, Known to Be a Selective β₁-Receptor Antagonist, Differentially but Directly Suppresses I_K(M) and I_K(erg) in Pituitary Cells and Hippocampal Neurons

Bisoprolol (BIS) is a selective antagonist of &#946;1 adrenergic receptors. We examined the effects of BIS on M-type K+ currents (IK(M)) or erg-mediated K+ currents (IK(erg)) in pituitary GH3, R1220 cells, and hippocampal mHippoE-14 cells. As GH3 cells were exposed to BIS, amplitude of IK(M) was suppressed with an IC50 value of 1.21 &#956;M. The BIS-induced suppression of IK(M) amplitude was not affected by addition of isoproterenol or ractopamine, but attenuated by flupirtine or ivabradine. In cell-attached current, BIS decreased the open probability of M-type K+ (KM) channels, along with decreased mean opening time of the channel. BIS decreased IK(erg) amplitude with an IC50 value of 6.42 &#956;M. Further addition of PD-118057 attenuated BIS-mediated inhibition of IK(erg). Under current-clamp conditions, BIS depolarization increased the firing of spontaneous action potentials in GH3 cells; addition of flupirtine, but not ractopamine, reversed BIS-induced firing rate. In R1220 cells, BIS suppressed IK(M); subsequent application of ML-213(Kv7.2 channel activator) reversed BIS-induced suppression of the current. In hippocampal mHippoE-14 neurons, BIS inhibited IK(M) to a greater extent compared to its depressant effect on IK(erg). This demonstrated that in pituitary cells and hippocampal neurons the presence of BIS is capable of directly and differentially suppressing IK(M) and IK(erg), despite its antagonism of &#946;1-adrenergic receptors

Assessment of a New Method to Verify Feeding Tube Placement by Syringe Aspiration in a Porcine Model

Background: Malpositioned feeding tubes carry the risk of serious complications. However, common bedside methods of differentiating tracheal from gastric feeding tube placement are neither accurate nor practical. Therefore, we conducted an animal study to verify feeding tube placement by syringe aspiration test. Methods: A total of 26 pigs were anesthetized and intubated with tracheal tubes in the trachea and the esophagus. The animals were divided into two groups. The animals in the mechanical ventilation group were paralysed and received mechanical ventilation. The animals in the spontaneous breathing group maintained spontaneous breathing. The feeding tubes were then inserted through the tracheal tubes, into the trachea and esophagus, so that the anterior openings of the feeding tubes were located in the trachea and esophagus. A feeding syringe was then attached and 30 ml of air was aspirated into the syringe. The ability to aspirate air without resistance was defined as a positive syringe aspiration test. If there was resistance as air was aspirated, it was defined as a negative syringe aspiration test. In the next step, 20 esophageal ventilations were given to create a distended stomach in the experimental animals, and the syringe aspiration test was repeated in the same manner described above. Results: The syringe aspiration test was positive for feeding tubes placed in the trachea and was negative for feeding tubes located in the esophagus in both the mechanical ventilation group and the spontaneous breathing group. Conclusion: The syringe aspiration test is an effective method of differentiating tracheal from esophageal feeding tube placement