Effects of tapentadol on pain, motor symptoms and cognitive functions in Parkinson\u2019s disease

Background: Pain is a common and undertreated non-motor symptom in patients with Parkinson\u2019s disease (PD). Opioids have been seldom used in PD because they could worsen cognitive and motor functions. Objective: We aimed to assess efficacy and tolerability of tapentadol in PD patients. Methods: We retrospectively reviewed 21 PD patients treated with tapentadol extended release (ER) for chronic pain. Patients were evaluated before treatment and at 3 and 6 months during treatment for pain intensity (current, 24-hour average, and minimum and worst) with a 0-10 Numerical Rating Scale and the painDETECT questionnaire; for motor symptom severity with the Unified Parkinson\u2019s Disease Rating Scale part III and the Hoehn and Yahr scale; for cognitive functions with MiniMental Status Examination, Corsi\u2019s Block Tapping test, Digit Span, Digit-Symbol Substitution test, FAS test, Rey\u2019s Auditory Verbal Learning test, Trail Making-A and -B, and the 9 Hole-Peg Test; for anxiety and depression with the Hospital Anxiety and Depression Scale; and for the quality of life with the Short Form-12 for Quality of Life. Data were analyzed by one-way ANOVA and paired t-test, and by Friedman\u2019s and Wilcoxon\u2019s test. Statistical significance was taken in all cases as P < 0,05. Results: Pain intensity decreased over the course of treatment. No differences were found in PD symptom severity and dopaminergic drug dosages between pretreatment and treatment evaluations . No decrement in cognitive neuropsychological performances was found and an improvement was observed in Digit Span, Digit-Symbol Substitution test and FAS test. The levels of anxiety, depression and of quality of life improved. Overall tapentadol ER was well tolerated and most patients reported no or mild and short-lived gastroenterological and neurological side effects. Conclusions: These results indicate the potential efficacy and tolerability of medium-high dose of tapentadol ER for the treatment of pain in PD

Sugammadex for reversal of neuromuscular blockade: A retrospective analysis of clinical outcomes and cost-effectiveness in a single center

OBJECTIVE: The aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen for neuromuscular block (NMB) management. METHODS: We conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium-sugammadex) and as rescue therapy after neostigmine reversal (rocuronium-neostigmine-sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen was carried out. To such purpose, two periods were compared: 2011-2012, without sugammadex available; 2013-2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective. RESULTS: The introduction of a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P<0.001) and were discharged to the surgical ward (P<0.001) more rapidly than controls. The cost-saving of sugammadex as first-choice reversal drug has been estimated to be €2.9/case. Patients receiving sugammadex as rescue therapy after neostigmine reversal (3.2%) showed no difference in time to discharge to the surgical ward (P=0.44) compared to controls. No unplanned intensive care unit (ICU) admissions with rocuronium-neostigmine-sugammadex strategy were observed. The potential economic benefit in avoiding postoperative residual curarization (PORC)-related ICU admission in the 2013-2014 period was estimated at an average value of €13,548 (€9,316-€23,845). CONCLUSION: Sugammadex eliminated PORC and associated morbidities. In our center, sugammadex reduced the costs of NMB management and promoted rapid turnover of patients in operating rooms, with total cost-effectiveness that counteracts the disadvantages of its high cost

Isolated forearm technique: a meta-analysis of connected consciousness during different general anaesthesia regimens

BACKGROUND: General anaesthesia should prevent patients from experiencing surgery, defined as connected consciousness. The isolated forearm technique (IFT) is the current gold standard for connected consciousness monitoring. We evaluated the efficacy of different anaesthesia regimens in preventing IFT responses. METHODS: We conducted a systematic review with meta-analysis of studies evaluating IFT in adults. Proportions of IFT-positive patients were compared for inhalational versus intravenous anaesthesia and anaesthesia brain monitor (ABM)-guided versus non-ABM-guided. RESULTS: Of 1131 patients in 22 studies, 393 (34.8%) had an IFT response during induction or maintenance. IFT-positive patients were less frequent during induction (19.7% [95% CI, 17.5-22.1]) than during maintenance (31.2% [95% CI, 27.8-34.8]). Proportions of IFT-positive patients during induction and maintenance were similar for inhalational (0.51 [95% CI, 0.38-0.65]) and intravenous (0.52 [95% CI, 0.26-0.77]) anaesthesia, but during maintenance were lower with inhalational (0.18 [95% CI, 0.08-0.38]) than with intravenous (0.48 [95% CI, 0.24-0.73]) anaesthesia. Proportions of IFT-positive patients during induction and maintenance were not significantly different for ABM-guided (0.64 [95% CI, 0.39-0.83]) and non-ABM-guided (0.48 [95% CI, 0.34-0.62]) anaesthesia but during maintenance were lower with non-ABM-guided (0.19 [95% CI, 0.09-0.37]) than with ABM-guided (0.57 [95% CI, 0.34-0.77]). Proportions of IFT-positive patients decreased significantly with increasing age and premedication use. Of the 34 anaesthesia regimens, 16 were inadequate. Studies had low methodological quality (only seven randomised controlled trials) and significant heterogeneity. CONCLUSIONS: Standard general anaesthesia regimens might not prevent connected consciousness. More accurate anaesthesia brain monitor methodology to reduce the likelihood of connected consciousness is desirable

Dual effects of leptin in perioperative gas exchange of morbidly obese patients

Leptin has shown positive effects on respiratory function in experimental settings. The role of leptin on perioperative respiratory function in morbidly obese patients has not been established. We performed a retrospective analysis of morbidly obese patients undergoing laparoscopic sleeve gastrectomy. Fasting serum leptin and interleukin (IL)-6 were measured preoperatively, and arterial blood gases were obtained pre- and postoperatively. Outcome variables were arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and differences in PaO2 and PaCO2 between pre- and postoperative values (\u394PaO2, \u394PaCO2; postoperative minus preoperative). Patients with lower (<40 \u3bcg/L) and higher ( 6540 \u3bcg/L) leptin levels were compared. Bravais-Pearson's correlation, multiple linear regression, and logistic regression analysis were performed. A total of 112 morbidly obese patients were included. Serum leptin was significantly higher in females than in males (42.86\ub112.89 vs. 30.67\ub113.39 \u3bcg/L, p<0.0001). Leptin was positively correlated with body mass index (r = 0.238; p = 0.011), IL-6 (r = 0.473; p<0.0001), and \u394PaO2 (r = 0.312; p = 0.0008). Leptin was negatively correlated with preoperative PaO2 (r = -0.199; p = 0.035). Preoperative PaO2 was lower, \u394PaCO2 was smaller, and \u394PaO2 was greater in the high leptin group than in the low leptin group. In multiple regression analysis, leptin was negatively associated with preoperative PaO2 (estimate coefficient = -0.147; p = 0.023). In logistic regression analysis, leptin was associated with improved \u394PaO2 (odds ratio [OR] = 1.104; p = 0.0138) and \u394PaCO2 (OR = 0.968; p = 0.0334). Leptin appears to have dual effects related to perioperative gas exchange in obese patients undergoing bariatric surgery. It is associated with worse preoperative oxygenation but improved respiratory function after surgery

Pain-related Somato Sensory Evoked Potentials: A potential new tool to improve the prognostic prediction of coma after cardiac arrest

INTRODUCTION: Early prediction of a good outcome in comatose patients after cardiac arrest still remains an unsolved problem. The main aim of the present study was to examine the accuracy of middle-latency SSEP triggered by a painful electrical stimulation on median nerves to predict a favorable outcome. METHODS: No- and low-flow times, pupillary reflex, Glasgow motor score and biochemical data were evaluated at ICU admission. The following were considered within 72 h of cardiac arrest: highest creatinine value, hyperthermia occurrence, EEG, SSEP at low- (10 mA) and high-intensity (50 mA) stimulation, and blood pressure reactivity to 50 mA. Intensive care treatments were also considered. Data were compared to survival, consciousness recovery and 6-month CPC (Cerebral Performance Category). RESULTS: Pupillary reflex and EEG were statistically significant in predicting survival; the absence of blood pressure reactivity seems to predict brain death within 7 days of cardiac arrest. Middle- and short-latency SSEP were statistically significant in predicting consciousness recovery, and middle-latency SSEP was statistically significant in predicting 6-month CPC outcome. The prognostic capability of 50 mA middle-latency-SSEP was demonstrated to occur earlier than that of EEG reactivity. CONCLUSIONS: Neurophysiological evaluation constitutes the key to early information about the neurological prognostication of postanoxic coma. In particular, the presence of 50 mA middle-latency SSEP seems to be an early and reliable predictor of good neurological outcome, and its absence constitutes a marker of poor prognosis. Moreover, the absence 50 mA blood pressure reactivity seems to identify patients evolving towards the brain death

Veno-Venous ECMO: An Alternative Strategy for Acute Respiratory Failure After High-Voltage Electrocution. The Utility of Point-of-Care Tests

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Atmospheric CO 2 concentrations and δ 13 C values between New Zealand and Antarctica, 1998 to 2010: some puzzling results

From 1998 to 2010, during eight cruises of the M/V Italica between New Zealand and Antarctica, sets of flask air samples were collected and atmospheric CO 2 concentrations were recorded. The δ 13 C of CO 2 from the 1998 to 2003 air samples have already been published and show large interannual variability and an increasing frequency of 13 C-depleted samples. These results were related to a mosaic of areas with positive air–sea fluxes. We report here δ 13 C results from air samples collected from four further cruises. δ 13 C values obtained during the 2004/2005 cruise show an inexplicable saw-toothed distribution. Air samples from the 2005/2006 cruise have δ 13 C values which match previous sets of samples (1998 to 2004) and show more frequent and more negative isotopic events. From 2006 until 2009, further samples could not be collected. However, during December 2009 and January 2010, two more sets of air samples were collected, the δ 13 C values of which greatly differ from previous results, being absolutely homogeneous and paralleled by flat CO 2 concentrations. The results of these last two sets of air samples may be due either to fortuitous environmental conditions or to an improbable and substantial change in oceanic and atmospheric conditions in this section of the circumpolar area. Keywords: New Zealand to Antarctica, flask air samples, atmospheric CO 2 concentrations, carbon isotopic composition of CO 2 , puzzling results (Published: 5 December 2012) Citation: Tellus B 2012, 64 , 17472, http://dx.doi.org/10.3402/tellusb.v64i0.1747

Unusual Displacement of a Mobilised Dental Bridge during Orotracheal Intubation

Dental trauma during tracheal intubation mostly happens in case of poor dentition, restricted mouth opening, and/or difficult laryngoscopy. 57-year-old man undergoing laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma had his dental work detached at induction of anesthesia. Oropharyngeal direct view, manual inspection, fibreoptic nosendoscopy, tracheobronchoscopy, and fiberoptic inspection of the esophagus and stomach were unsuccessful in locating the dislodged bridge. While other possible exams were considered, such as lateral and AP x-ray of head and neck, further meticulous manual “sweepings” of the mouth were performed, and by moving the first and second fingers below the soft palate deep towards the posterolateral wall of the pharynx, feeling consistent with a dental prosthesis was detected in the right pharyngeal recess. Only after pulling the palatopharyngeal arch upward was it possible to grasp it and extract it out with the aid of a Magill Catheter Forceps. Even though the preexisting root and bridge deficits were well reported by the consultant dentist, the patient was fully reimbursed. The lack of appropriate documentation of the advanced periodontal disease in the anesthesia records, no mention of potential risks on anesthesia consent, and insufficient protective measures during airway instrumentation reinforced the reimbursement claim

Surfactant disaturated-phosphatidylcholine kinetics in acute respiratory distress syndrome by stable isotopes and a two compartment model

BACKGROUND: In patients with acute respiratory distress syndrome (ARDS), it is well known that only part of the lungs is aerated and surfactant function is impaired, but the extent of lung damage and changes in surfactant turnover remain unclear. The objective of the study was to evaluate surfactant disaturated-phosphatidylcholine turnover in patients with ARDS using stable isotopes. METHODS: We studied 12 patients with ARDS and 7 subjects with normal lungs. After the tracheal instillation of a trace dose of (13)C-dipalmitoyl-phosphatidylcholine, we measured the (13)C enrichment over time of palmitate residues of disaturated-phosphatidylcholine isolated from tracheal aspirates. Data were interpreted using a model with two compartments, alveoli and lung tissue, and kinetic parameters were derived assuming that, in controls, alveolar macrophages may degrade between 5 and 50% of disaturated-phosphatidylcholine, the rest being lost from tissue. In ARDS we assumed that 5–100% of disaturated-phosphatidylcholine is degraded in the alveolar space, due to release of hydrolytic enzymes. Some of the kinetic parameters were uniquely determined, while others were identified as lower and upper bounds. RESULTS: In ARDS, the alveolar pool of disaturated-phosphatidylcholine was significantly lower than in controls (0.16 ± 0.04 vs. 1.31 ± 0.40 mg/kg, p < 0.05). Fluxes between tissue and alveoli and de novo synthesis of disaturated-phosphatidylcholine were also significantly lower, while mean resident time in lung tissue was significantly higher in ARDS than in controls. Recycling was 16.2 ± 3.5 in ARDS and 31.9 ± 7.3 in controls (p = 0.08). CONCLUSION: In ARDS the alveolar pool of surfactant is reduced and disaturated-phosphatidylcholine turnover is altered