Why is the Long-Run Tax on Capital Income Zero? Explaining the Chamley-Judd Result

Why is it optimal not to tax capital income in the long-run in Chamley (1986) and Judd (1985)? This paper demonstrates that the answer follows standard intuitions from the commodity tax literature. In the steady state, Engel curves for consumption are linear in labour earnings, irrespective of the utility function adopted. Thus, in the steady state, consumption demands in each period become equally complementary to leisure over time. This renders taxes on capital income redundant, since they cannot alleviate distortions from taxing labour income. The argument that taxes on capital income should be zero because distortions explode in finite time is relevant only if restrictions are imposed on the utility function. We show how these restrictions imply that consumption demands in each period are equally complementary to leisure over time. We also demonstrate that the optimal tax on capital income is zero irrespective of whether the gross interest rate is endogenous. This contradicts arguments that the entire burden of capital income taxes is shifted to labour through general equilibrium effects on the interest rate

Cytokine storm in severe patient COVID-19 and curative plasmapheresis

Background: In the intensive care unit, the curative plasmapheresis technique is widely applied among severe patients, who show signs of both endogenous and exogenous intoxication. The impact of isovolemic isooncotic curative plasmapheresis on the status of hemoleukogram and immunological markers has not been studied yet. Material and methods: The study is retrospective, observational. The medical records of 34 COVID-19 patients from the COVID intensive care units of Timofei Mosneaga Republican Clinical Hospital who benefited from isovolemic, curative isooncotic plasmapheresis were analyzed. There were 25 complete, analyzed data sets. General data were recorded: preplasmapheresis, postplasmaphesis hemoleukogram. Results: Isovolemic, isooncotic plasmapheresis, performed in patients with severe COVID-19, SARS-CoV2 showed effects of improving the status of laboratory indices that denote the evolution and favorable prognosis of the disease. The activity of the cytokine storm decreased in both groups of patients, both in those with a mean age of up to 60 years and in those over 60 years of age, with p = 0.001. Patients over 60 years of age had a marked improvement in serum ferritin index, compared to patients in the age group up to 60 years, in the period after plasmapheresis, p = 0.043. Analogously, the level of C-reactive protein was analyzed, which clearly decreases in patients 60 years of age, p = 0.037 Conclusions: Isovolemic, isooncotic plasmapheresis is a procedure performed in severe COVID-19 (SARS-CoV-2) patients to improve the status of the cytokine storm. Moreover, the performance of the procedure in different age groups induced an improvement in the satiety of hemoleukogram and proinflammatory indices

Managementul anestezic în chirurgia laparoscopică

Introducere. În ultimii ani, chirurgia laparoscopică ocupă un loc centrat în progresul actului chirurgical, oferind posibilități noi în tratamentul minim-invaziv, dezvoltarea chirurgiei de o zi și recuperarea postoperatorie precoce a pacientului. O data cu evoluția chirurgiei laparoscopice apare necesitatea adaptării managementului anestezic al pacientului supus chirurgiei laparoscopice. Studiile recente, confi rmă legătura strînsă dintre modifi cările fiziologice ale organismului în cadrul pneumoperitoneum și ajustarea tehnicii anestezice. Material și metode. Au fost evaluate datele literaturii disponibile în baza de date PubMed, cuprinse între anii 2002-2017. Tatonarea a fost efectuată utilizându-se cuvintele cheie “chirurgie laparoscopică”, “management anestezic”, “pneumoperitoneum”. Informația articolului a inclus analiza calitativă și sinteza recomandărilor literaturii de specialitate în vederea managementului anestezic în chirurgia laparoscopică. Rezultate. O importanță deosebită în managementul anestezic al pacientului în chirurgia laparoscopică o are stratifi carea riscului perioperator de rând cu patologia concomitentă a acestuia. Deasemenea dereglările fi ziologice în organe și sisteme cu importanță vitală legate de pneumoperitoneum și poziționarea pacientului, influențează stratifi carea riscului și modifi ca rezultatul scontat. Concluzii. Modificările în fiziologia organelor vitale, legate de pneumoperitoneu, necesită un management anestezic subtil, care ar oferi siguranța maximă a pacientului pe durata intervenției, o restabilire postanestezică precoce și minimizarea complicațiilor postanestezice. Odata cu tendințele dezvoltării chirurgiei de o zi, reintegrarea pacientului în postoperator necesită o tactică anestezică optim

Анестезиологическии менеджмент в лапароскопической хирургии

Catedra de anesteziologie şi reanimatologie nr. 1 „Valeriu Ghereg”, IP USMF „Nicolae Testemițanu”Rezumat Introducere. În ultimii ani, chirurgia laparoscopică ocupă un loc centrat în progresul actului chirurgical, oferind posibilități noi în tratamentul minim-invaziv, dezvoltarea chirurgiei de o zi și recuperarea postoperatorie precoce a pacientului. O data cu evoluția chirurgiei laparoscopice apare necesitatea adaptării managementului anestezic al pacientului supus chirurgiei laparoscopice. Studiile recente, confi rmă legătura strînsă dintre modifi cările fiziologice ale organismului în cadrul pneumoperitoneum și ajustarea tehnicii anestezice. Material și metode. Au fost evaluate datele literaturii disponibile în baza de date PubMed, cuprinse între anii 2002-2017. Tatonarea a fost efectuată utilizându-se cuvintele cheie “chirurgie laparoscopică”, “management anestezic”, “pneumoperitoneum”. Informația articolului a inclus analiza calitativă și sinteza recomandărilor literaturii de specialitate în vederea managementului anestezic în chirurgia laparoscopică. Rezultate. O importanță deosebită în managementul anestezic al pacientului în chirurgia laparoscopică o are stratifi carea riscului perioperator de rând cu patologia concomitentă a acestuia. Deasemenea dereglările fi ziologice în organe și sisteme cu importanță vitală legate de pneumoperitoneum și poziționarea pacientului, influențează stratifi carea riscului și modifi ca rezultatul scontat. Concluzii. Modificările în fiziologia organelor vitale, legate de pneumoperitoneu, necesită un management anestezic subtil, care ar oferi siguranța maximă a pacientului pe durata intervenției, o restabilire postanestezică precoce și minimizarea complicațiilor postanestezice. Odata cu tendințele dezvoltării chirurgiei de o zi, reintegrarea pacientului în postoperator necesită o tactică anestezică optima Introduction. During the last years, laparoscopic surgery has gained a central place in the development of surgery, giving possibilities of minimally-invasive treatment, one-day surgery, and fast-track recovery of surgical patient. Once laparoscopic surgery has developed, the necessity to adapt anaesthetic management for these patients arises. Recent studies confirm the connection between physiologic changes during pneumoperitoneum and anaesthesia adapting. Material and methods. There has been scientifically evaluated data from PubMed, 2002-2017. Key words used in search: “laparoscopic surgery”, “anaesthetic management”, “pneumoperitoneum”. The article contains a qualitative analysis and synthesis of the recommendation, concerning anaesthetic management in laparoscopic surgery. Results. Risk stratification in perioperative period in the same time with comorbidities of the patient has a central role in anaesthetic management in laparoscopic surgery. In addition physiologic changes in vital organs and systems, related to pneumoperitoneum and patient’s position can influence risk stratification and change the result. Conclusions. Changes in vital organs physiology related to pneumoperitoneum require a delicate anaesthetic management that ensures intraoperative patient safety, a fasttrack recovery and minimize postanesthetic complications. Developing of one – day laparoscopic surgery, requires an optimal anaesthesia tactics Введение. В последние годы лапароскопическая хирургия занимает центральное место в общей хирургии, которая, в свою очередь, преподносит новые возможности в мини-инвазивном лечении, развитии хирургии одного дня и раннее послеоперационное восстановление больного. Актуальные исследования подтверждают тесную связь между физиологическими изменениями в организме в условиях пневмоперитонеума и подбором анестезиологической техники. Материалы и методы. Были обработаны данные литературы, представленные базой данных PubMed за период 2002-2017 гг. Ключевые слова, использованные в поиске: «лапароскопическая хирургия», «анестезиологический менеджмент», «пневмоперитонеум», «СО2». Составляющими статьи являются качественный анализ и синтез литературных рекомендаций по специальности, относительно анестезиологического менеджмента в лапароскопической хирургии. Результаты. Особое место в анестезиологическом менеджменте больного в хирургической лапароскопии отводится стратификации, наряду с хирургическим риском и сопутствующей патологии. В то же время, изменения в физиологии жизненно важных органах и системах, связанные с пневмоперитонеумом и положением больного, несомненно могут влиять на стратификации риска и модификацию ожидаемого результата. Заключение. Изменения в физиологии жизненно важных органах связанные с пневмоперитонеумом, требуют сбалансированного анестезиологического менеджмента, который обеспечит максимальную защиту больного на протяжении всей операции, быстром послеоперационном восстановлении и минимализации осложнений. Одновременно с развитием хирургии одного дня, реинтеграция пациента требует оптимальной анестезиологической тактики

Sevoflurane anesthesia: impact on postoperative cognitive dysfunction

Background: Sevoflurane is the inhalational anesthetic agent that is used widely in operating room. It is currently the most commonly used inhalation anesthetic in operating rooms. A series of studies on animal and human model detected the association of intraoperative use of sevoflurane and postoperative cognitive dysfunction (POCD) manifestation. On the other hand other studies demonstrate the same POCD associated with intravenous agents. Relevant multicentric trials got the reasons to suspect other key factors in developing postoperative cognitive dysfunction. Conclusions: The intra-anesthetic use of sevoflurane has been associated for a long time with the higher incidence of POCD. The mechanism was not identified, and the theory of neuroinflammation remained the main key of pathophysiological reaction that leads to cognitive dysfunction. Recent multicentre trial gives reliable information that the use of intravenous anesthetic agents is associated with the same POCD. Neuroinflammation remains to be the mediator of cognitive disorders, and apparently IL-6 keeps a major role in them. Future studies are needed to be conducted to identify the role of anesthetic agents in determining the neuroinflammation

Metabolism and physiological effects of carbon dioxide. Implications in anaesthetic management

Valeriu Ghereg Department of Anesthesiology and Reanimatology, Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of MoldovaBackground: Carbon dioxide is a normal by-product of aerobic metabolism that maintains the equilibrium of respiratory act, being eliminated from the lungs. Despite of an increasing number of researches concerning carbon dioxide metabolism and its effects on human homeostasis, there are still discussions about carbon dioxide metabolism, physiology and its implication in anaesthetic management, ICU, critically ill patient. The use of mild to moderate hypercapnia during general anaesthesia and in mechanically ventilated patients is growing, based on scientifical researches of last years. Material and methods: There has been scientifically evaluated data from PubMed, 2002-2017. Key words used in search are: “carbon dioxide”, “ventilation”, “metabolism”, “gas change”. There were selected articles, taking in consideration their title, and chosen abstracts. The article contains a qualitative analysis and synthesis of the recommendation, concerning anaesthetic management and metabolism of carbon dioxide. Conclusions: Carbon dioxide metabolism and its anaesthetic management, represents a challenge that will be actual for many years in future. The amount of controversial studies about effects of carbon dioxide on patients under general anaesthesia or mechanical ventilation, determined us to perform a review of literature, and evaluate it. There are known facts about carbon dioxide metabolism, such as normal values, how it is produced in human body, how it is evacuated, effects on cardiovascular, nervous systems, and still there are many controversial studies on that topic, that determine to study it more and find new research results

Laparoscopic cholecystectomy and permissive hypercapnic ventilation anesthesia: prospective, randomized study

Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, The 6th International Medical Congress for Students and Young Doctors, May 12-14, 2016Background. Hipercapnic ventilation during general anesthesia was a disputed topic for researchers during last ten years. However there were observed potential beneficial effects of induced mild hypercapnia during the anesthesia on intraoperative and postoperative outcome: lower necessity in opioids, reducing the rate of wound infections,, accelerated wound healing. AIM. Estimation of the effects of intraoperative induced mild hypercapnia (ETCO2=45-50 mmHg), on postoperative recovery after laparoscopic colecistectomy. Materials and methods. Prospective randomized study (normocapnic lot, n=42; hypercapnic lot, n=58), written informed consent. Positive agreement of Ethics Committee. Anesthesia: induction – propofol, fentanyl, maintenance – sevofluran, relaxants – tracrium. Statistics: t-Student, Fisher exact test, Mantel-Cox test and ANOVA. Results. Similar lots in terms of age, BMI, ASA, surgery and hospitalization period. Hypercapnic lot vs. normocapnic lot: length of awakening from anesthesia – median, 15 vs. 20 min (χ2=12,6; p<0,0001); postoperative ileus period – median, 28 vs. 30 hours (χ2=10,8; p=0,001); PONV risk, in favor of hypercapnic lot – OR=0,50 (95CI=0,24-1,05), p=0.0695. Neurocognitive tests (DCT, DSST, Wechsler, Stroop), similar resuls for both lots and for the pre and postoperative periods. Study limits: reduced sample, short period of surgery, mild hypercapnia. Conclusions: The results of our research show a reduced period of awake after anesthesia, also a reduced period of ileus, and a minimized PONV risk, after laparoscopic cholecystectomy with induced mild hipercapnia with no hemodinamic and neurocognitive side effects

Postoperative neurocognitive status of patients in relation with the carbon dioxide endtidal level during anesthesia in laparoscopic cholecystectomy: prospective, randomized, experimental study

Catedra de anesteziologie și reanimatologie „Valeriu Ghereg”, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemiţanu”, Chișinău, Republica Moldova, Spitalul Clinic Municipal „Sfânta Treime”, Chișinău, Republica Moldova, Spitalul Clinic Municipal nr. 1, Chișinău, Republica Moldova, Catedra de anesteziologie și reanimatologie nr. 2, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemiţanu”, Chișinău, Republica MoldovaRezumat Introducere. Capnia este responsabilă de o serie de efecte fiziologice, cu impact clinic important. Ventilarea pulmonară artificială, pe durata anesteziei generale, poate asigura, separat, atât oxigenarea, cât și nivelul de CO2 din sânge. Hipercapnia moderată a fost asociată cu o trezire mai rapidă, cu bronhodilatare, cu reducerea riscului de infecţie de plagă; totodată, hipercapnia a fost asociată cu acidoză respiratorie, vasoconstricţie pulmonară hipoxică, creșterea presiunii intracerebrale. Nu a fost studiat, deocamdată, impactul hipercapniei moderate, induse intraanestezic, asupra funcţiei neurocognitive postoperatorii. Materal și metode. Studiu prospectiv, randomizat (eșantionare simplă, raport 1:2,5), experimental. Acordul Comitetului de Etică a Cercetării și al pacientului eligibil – obţinute. Înrolaţi pacienţii beneficiari de colecistectomie laparoscopică electivă, fără comorbidităţi severe. Seturi de date complete, analizate – 177 (lotul „normocapnie” – 49 de pacienţi; lotul „hipercapnie” – 128 de pacienţi). Hipercapnia asigurată intraanestezic prin creșterea spaţiului mort al circuitului respirator. Au fost înregistraţi parametrii antropometrici, durata anesteziei, durata de spitalizare. Pentru evaluarea statutului neurocogntiv, a fost utilizat testul de conectare a numerelor (NCT). Teste statistice aplicate: t-Student pereche, bicaudal (pentru datele de tip continuu, cu distribuţie normală), testul exact Fisher, pentru datele de tip categorie. Soft statistic utilizat: GraphPad Prism, versiunea 6 (Graph Pad Software Inc, CA, SUA). Rezultate. Loturile de studiu – omogene din punctul de vedere al repartizării pe sexe, masei corporale, înălţimii, duratei anesteziei și celei de spitalizare; eterogene după vârstă. Rezultatele testului NCT (în secunde), în funcţie de valoarea intraanestezică a ETCO2 , respectiv, pentru starea de normocapnie (31,8 [28,8 – 34,8] vs. 33,0 [30,0 – 35,9], p=0,032), hipercapnie ușoară (30,6 [27,9 – 33,3] vs. 31,4 [28,8 – 34,0], p=0,016) și hipercapnie moderată (27,7 [24,5 – 30,8] vs. 28,8 [25,7 – 32,0], p<0,0001). Pacienţii cu un gradient ETCO2 <15 mmHg au prezentat valori ale NCT, postoperator vs. preoperator cu diferenţe statistic semnificative (31,9 [29,6 – 34,1] vs. 32,7 [30,5 – 35,0], p=0,01); în mod analogic – pacienţii care au avut un gradient al ETCO2 ≥15 mmHg (27,0 [23,9 – 30,3] vs. 28,5 [25,1 – 31,8], p=0,0007). Concluzii. Ventilarea pulmonară artificială cu hipercapnie moderată (ETCO2 =45-55 mmHg), indusă și menţinută intraanestezic, nu afectează funcţia neurocognitivă a pacientului postoperatoriu, după colecistectomia laparoscopică. Mai mult decât atât, funcţia neurocognitivă postoperatorie, pe fundal de hipercapnie moderată, indusă intraanestezic, pare să fie ameliorată, probabil din cauza menţinerii unei perfuzii cerebrale sporite.Abstract Introduction. Level of CO2 (capnia) is responsible for several physiological effects, with important clinical impact. Mechanical ventilation during general anesthesia can separately assure both oxygenation and blood levels of CO2. Moderate hypercapnia was associated with a faster wake up, bronchodilation, reduced risk of wound infection; at the same time, hypercapnia was associated with respiratory acidosis, hypoxic pulmonary vasoconstriction and a rise in intracranial pressure. The impact of moderate hypercapnia, induced during anesthesia, on postoperative neurocognitive function has not been studied yet. Material and methods. Prospective, randomized (simple sampling, 1:2.5 ratio), experimental study. Ethics Research Committee’s and patient’s consent have been received. The study enrolled patients scheduled for elective laparoscopic cholecystectomy, without severe comorbidities. Data sets were complete and analyzed – 177 patients, out of which – 49 patients in the “normocapnia” group, and 128 – in the “hypercapnia” group. Hypercapnia was provided during surgery by a rise in dead space. Anthropometric parameters, anesthesia length, length of hospital stay were registered. In order to evaluate the neurocognitive status, the number connection test (NCT) was used. The following statistical tests were applied: two-tailed Student paired test (for continuous type data, with normal distribution), Fisher’s exact test, for category type data. The soft used: GraphPad Prism, version 6 (Graph Pad Software Inc., CA, USA). Results. The study groups were homogenous from the point of view of gender repartition, weight, height, anesthesia length and hospital stay length; heterogeneous regarding age. The results of the NCT (in seconds), depending on ETCO2 values during anesthesia, were distributed for normocapnia (31.8 [28.8 – 34.8] vs. 33.0 [30.0 – 35.9], p=0,032), for mild hypercapnia (30.6 [27.9 – 33.3] vs. 31.4 [28.8 – 34.0], p=0.016) and moderate hypercapnia (27.7 [24.5 – 30.8] vs. 28.8 [25.7 – 32.0], p<0.0001. Patients with an ETCO2 gradient <15 mmHg presented postoperative vs. preoperative NCT values with statistical significance (31.9 [29.6 – 34.1] vs. 32.7 [30.5 – 35.0], p=0.01); in the same way – patients that had an ETCO2 gradient ≥15 mmHg (27.0 [23.9 – 30.3] vs. 28.5 [25.1 – 31.8], p=0.0007). Conclusions. Mechanical ventilation with moderate hypercapnia (ETCO2 =45-55 mmHg), induced and maintained during anesthesia, does not affect the postoperative neurocognitive function of the patient after laparoscopic cholecystectomy. More than that, the postoperative neurocognitive function, on a background of moderate hypercapnia induced during anesthesia, seems to be improved, probably due to a maintained increased cerebral flow

Laparoscopic cholecystectomy and permissive hypercapnic ventilation anesthesia: prospective, randomized study

Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, 6th International Medical Congress for Students and Young Doctors, May 12-14, 2016, Chisinau, Republic of MoldovaBackground. Hipercapnic ventilation during general anesthesia was a disputed topic for researchers during last ten years. However there were observed potential beneficial effects of induced mild hypercapnia during the anesthesia on intraoperative and postoperative outcome: lower necessity in opioids, reducing the rate of wound infections,, accelerated wound healing. AIM. Estimation of the effects of intraoperative induced mild hypercapnia (ETCO2=45-50 mmHg), on postoperative recovery after laparoscopic colecistectomy. Materials and methods. Prospective randomized study (normocapnic lot, n=42; hypercapnic lot, n=58), written informed consent. Positive agreement of Ethics Committee. Anesthesia: induction – propofol, fentanyl, maintenance – sevofluran, relaxants – tracrium. Statistics: t-Student, Fisher exact test, Mantel-Cox test and ANOVA. Results. Similar lots in terms of age, BMI, ASA, surgery and hospitalization period. Hypercapnic lot vs. normocapnic lot: length of awakening from anesthesia – median, 15 vs. 20 min (χ2=12,6; p<0,0001); postoperative ileus period – median, 28 vs. 30 hours (χ2=10,8; p=0,001); PONV risk, in favor of hypercapnic lot – OR=0,50 (95CI=0,24-1,05), p=0.0695. Neurocognitive tests (DCT, DSST, Wechsler, Stroop), similar resuls for both lots and for the pre and postoperative periods. Study limits: reduced sample, short period of surgery, mild hypercapnia. Conclusions: The results of our research show a reduced period of awake after anesthesia, also a reduced period of ileus, and a minimized PONV risk, after laparoscopic cholecystectomy with induced mild hipercapnia with no hemodinamic and neurocognitive side effects

Moderate permissive hypercapnia, induced during general anesthesia and its effects on acid-base balance: prospective, comparative study

Catedra de anesteziologie şi reanimatologie nr. 1 „Valeriu Ghereg”, Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica Moldova, Spitalul Clinic Municipal „Sfânta Treime”, Chişinău, Republica Moldova, Catedra de anesteziologie şi reanimatologie nr. 2, Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaRezumat Introducere. Capnia este responsabilă de o serie de efecte fiziologice, cu impact clinic important. Ventilarea pulmonară artificială, pe durata anesteziei generale, poate asigura, separat, atât oxigenarea, cât și nivelul de CO2 din sânge. Hipercapnia moderată a fost asociată cu o trezire mai rapidă, cu bronhodilatare, cu reducerea riscului de infecţie de plagă; totodată, hipercapnia a fost asociată cu acidoză respiratorie, vasoconstricţie pulmonară hipoxică, creșterea presiunii intracerebrale. Nu a fost studiat, deocamdată, impactul hipercapniei moderate, induse intraanestezic, asupra echilibrului acido-bazic.Abstract Introduction. Capnia is responsible for several physiological effects, with important clinical impact. Mechanical ventilation during general anesthesia can separately assure both oxygenation and blood levels of CO2. Moderate hypercapnia was associated with a faster wake up, bronchodilation, reduced risk of wound infection; at the same time, hypercapnia was associated with respiratory acidosis, hypoxic pulmonary vasoconstriction and a rise in intracranial pressure. The impact of moderate hypercapnia, induced during anesthesia, on acid-base balance has not been studied yet