Effects of intravenous single-bolus lidocaine infusion versus intravenous single-bolus magnesium sulfate infusion on postoperative pain, emotional status, and quality of life in patients undergoing spine fusion surgery: a randomized study.

BACKGROUND: We assessed the efficiency of intravenous adjuvants in decreasing opioid intake and pain scores after spine fusion surgery. METHODS: This study included 120 patients aged 18-60 listed for spine fusion surgery under general anesthesia. Patients were randomly assigned to four groups: Group (Lidocaine): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min. Group (Magnesium): received IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (combined Lidocaine and Magnesium): received IV lidocaine 4 mg/kg in 50 mL volume over 30 min.+IV magnesium sulfate 30mg/kg in 50 mL volume over 30 min. Group (Control): received IV saline 50 mL. The time to the first request analgesia, the postoperative pain score, total analgesic use, patient satisfaction, anxiety, depression, mental state, quality of life, and side effects were measured. RESULTS: The combined group had more extended time for the first analgesic request and fewer rescue analgesia doses than the other groups. NRS scores at rest or movement were statistically significantly lower in the lidocaine group and the combined group compared to the control group (P1, P3<0.05) at almost all times. This combination reduces anxiety and depression and improves overall health up to three months after a single infusion. The combined group had higher patient satisfaction. CONCLUSIONS: A synergistic effect of a combination of lidocaine and magnesium sulfate on perioperative pain was found. It reduces analgesic consumption, depression, and anxiety and improves overall health up to three months after a single infusion dose.

Intraoperative tourniquet-induced hyperthermia in a pediatric patient: a forgotten association -a case report.

BACKGROUND: The intraoperative use of tourniquets is associated with several complications, including hyperthermia. We present the first documented case of tourniquet-induced hyperthermia in a pediatric patient at our institution. CASE: A 5-year-old female with no past medical history underwent tendon release surgery for congenital talipes equinovarus under general anesthesia. Following inflation of a pneumatic tourniquet to a pressure of 250 mmHg on her left thigh, the patient experienced a gradual increase in body temperature. Despite the implementation of cooling measures, the temperature continued to increase until it plateaued. The hyperthermia gradually resolved upon deflation of the tourniquet. CONCLUSIONS: Tourniquet-induced hyperthermia should be considered as a potential cause of intraoperative hyperthermia, particularly in the absence of typical signs of malignant hyperthermia. Early recognition and appropriate management, including deflation of the tourniquet and implementation of cooling measures, are crucial for preventing potential complications associated with hyperthermia.

The Importance of Serum Homocysteine as a Biomarker in Diabetic and Obese COVID-19 Patients.

Homocysteine is a possible risk marker in hematological complications of COVID-19 infection. This study aimed to elucidate the significance of homocysteine as a biomarker for COVID-19 infection, and the relation of homocysteine with COVID-19 severity in obese people and diabetic patients.  The study groups were 1- COVID-19 patients + Diabetic + Obese (CDO), 2- COVID-19 patients + Diabetic (CD), 3- COVID-19 patients + Obese (CO), 4- Healthy Group (HG). Serum levels of homocysteine, IL-6, D-dimer, vitamin B12, and folate were measured by a fully automated biochemistry device Cobas 6000 analyzer series. The mean serum concentration of homocysteine in the COD, CD, CO and H groups were 32.0114, 23.604, 19.4154, and 9.3206 umol/l respectively. The mean concentration of homocysteine levels between every two groups was statistically significant differences (P<0.05) except for the CD and the CO group (P=0.957). In the CDO group, the males have higher mean concentrations than females (P<0.05). The means of homocysteine concentrations in the CDO group among different age groups were different (P <0.001). The serum homocysteine level in the CDO group has a strong positive correlation (R=0.748) with D-dimer and a strong negative correlation (R= - 0.788) with serum folate, while its correlation with serum vitamin B12 is moderate negative (-0.499) and its correlation with serum IL-6 is weakly positive (R=0.376). The AUC value for homocysteine in predicting COVID-19 in the CDO group was 0.843, while 0.714 for the CD group, and 0.728 for the CO group. The serum homocysteine concentration test for all study groups was compared to the serum IL-6 test and the sensitivity was equal to 95% and its specificity was 67.5%. Serum homocysteine has potential predictive power in COVID-19 patients, and the severity of COVID-19 infection and the type of comorbidity is associated with higher sensitivity and specificity of homocysteine serological tests.

Effect of Elevated Temperature on Rhyolitic Rocks' Properties.

The effect of high temperatures on rock's thermophysical and mechanical properties is critical to the design of underground geotechnical applications. The current work investigates the impact of temperature on rhyolitic turf rock's physical and mechanical properties. Intact cylindrical core rock samples were heated to different temperatures (200, 400, 600, and 800 °C). The uniaxial compressive strength (UCS) and elastic modulus of unheated and heated samples were determined as important mechanical properties. In addition, the effect of temperature on the physical properties of rhyolite rock (density, color, and absorption) was investigated in conjunction with its microstructural properties. The hardening of the rhyolitic rock samples was observed below 600 °C, at which point the UCS and elastic modulus decreased to 78.0% and 75.9%, respectively, at 800 °C. The results also show that heating does not significantly affect the density and volume of permeable pore space, but a color change can be observed at 400 °C and above. A microscopic analysis shows the change in microstructural properties of rhyolite rock after heating to 600 °C. Furthermore, the SEM observations of heated materials show structural particle displacements and microcracking, leading to apparent surface cracks.

Influence of Friction Stir Process on the Physical, Microstructural, Corrosive, and Electrical Properties of an Al-Mg Alloy Modified with Ti-B Additives.

In this study, two successive methods were used to improve the grain structure and the mechanical and physical properties of Al 5052 aluminum alloy. The modifying elements, 0.99 wt.% of titanium (Ti) and 0.2 wt.% of boron (B), were added during the casting process. After solidification, single- and double-pass friction stir processing (FSP) were performed to achieve additional grain refinement and disperse the newly formed phases well. The addition of Ti-B modifiers significantly improved the mechanical and physical properties of the Al 5052 aluminum alloy. Nevertheless, only a 3% improvement in microhardness was achieved. The ultimate strength (US), yield strength (YS), and elastic modulus were investigated. In addition, the electrical conductivity was reduced by 56% compared to the base alloys. The effects of grain refinement on thermal expansion and corrosion rate were studied; the modified alloy with Ti-B in the as-cast state showed lower dimension stability than the samples treated with the FSP method. The grain refinement significantly affected the corrosion resistance; for example, single and double FSP passes reduced the corrosion rate by 11.4 times and 19.2 times, respectively. The successive FSP passes, resulting in a non-porous structure, increased the bulk density and formed precipitates with high bulk density.

Inflammatory Myofibroblastic Tumor of the Porta Hepatis: A Case Report.

A 43-year-old man presented with painless jaundice. Imaging revealed a porta hepatis mass compressing the common bile duct. Endoscopic biopsy was negative for malignancy. Complete surgical resection was performed. Pathological assessment showed IGg4 negative inflammatory myofibroblastic tumor.

Functional capacity and quality of life in the postural tachycardia syndrome: A retrospective cross-sectional study.

BACKGROUND: Postural tachycardia syndrome (POTS) is a complex syndrome of orthostatic intolerance that significantly affects quality of life. The relationship between functional capacity, quality of life, and age remains poorly understood in this patient population. The purpose of this cross-sectional study was to assess the clinical and exercise characteristics of patients with POTS who underwent exercise stress testing as part of cardiac rehabilitation, and to evaluate the relationships between functional capacity with age and sex, as well as the relationship between functional capacity and quality of life. METHODS: We included 255 consecutive adult patients with the diagnosis of POTS, by tilt table testing, who underwent exercise stress testing between 2012 and 2017. Clinical and stress test data were obtained from electronic medical records. RESULTS: Of the 255 patients, 232 (91%) were women, with median age 33.5 years. Prevalence of traditional CAD risk factors was low (2% diabetes, 13% hypertension, 7% hyperlipidemia, and 26% smoking history). Mean resting BP was 114 ± 13 mmHg systolic, resting HR was 76 ± 13 bpm, METs achieved 9.2 ± 2.2, and 1 min HR recovery 32 ± 17 bpm. 113 patients (44%) had abnormal functional capacity for age and sex. When analyzed by age groups, younger POTS patients had increasingly lower than expected functional capacity (compared to predicted normals) than did older patients (ANOVA P = 0.0017). The SF-36 physical component of patients with abnormal functional capacity was significantly lower than those with normal functional capacity. (p = 0.006). CONCLUSIONS: In this large cohort, patients with POTS were predominantly female (91%) and relatively young. The novel findings are that younger patients with POTS were more likely to have lower-than-average functional capacity for their age and sex compared to older patients, and that abnormal functional capacity was associated with lower quality of life by SF-36 physical component.

Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity, mortality, and healthcare use. Great strides have been made in stroke prevention and rhythm control strategies, yet reducing the incidence of AF has been slowed by the increasing incidence and prevalence of AF risk factors, including obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, and other modifiable lifestyle-related factors. Fortunately, many of these AF drivers are potentially reversible, and emerging evidence supports that addressing these modifiable risks may be effective for primary and secondary AF prevention. A structured, protocol-driven multidisciplinary approach to integrate lifestyle and risk factor management as an integral part of AF management may help in the prevention and treatment of AF. However, this aspect of AF management is currently underrecognized, underused, and understudied. The purpose of this American Heart Association scientific statement is to review the association of modifiable risk factors with AF and the effects of risk factor intervention. Implementation strategies, care pathways, and educational links for achieving impactful weight reduction, increased physical activity, and risk factor modification are included. Implications for clinical practice, gaps in knowledge, and future directions for the research community are highlighted.

Familial hypercholesterolemia: Detect, treat, and ask about family.

Familial hypercholesterolemia is an autosomal dominant disorder that affects the metabolism of low-density lipo-protein cholesterol (LDL-C) through mutations in the gene for LDL receptor (LDLR), and less commonly in those for apolipoprotein B (APOB), proprotein convertase subtili-sin-kexin type 9 (PCSK9), and others. Patients with these mutations have elevated plasma levels of LDL-C and, as a result, an increased risk of atherosclerotic cardiovascular disease beginning in childhood, leading to significant risk of illness and death.

High Submaximal Exercise Heart Rate Impacts Exercise Intolerance in the Postural Orthostatic Tachycardia Syndrome.

PURPOSE: Exercise intolerance is a hallmark of the postural orthostatic tachycardia syndrome (POTS). However, no data are available on the implications of an exaggerated submaximal heart rate (HR) on exercise intolerance in patients. We investigated whether exaggerated HR responses occurring early on during incremental stress testing relate with increased odds of POTS and exercise intolerance. METHODS: Clinical characteristics and stress test HRs were compared between adults with POTS achieving ≥85% predicted metabolic equivalents (METs) (EX-TL, n = 101; body mass index [BMI] 24 ± 5 kg·m; 95% women) or <85% (EX-INTL, n = 71; BMI 28 ± 7 kg·m; 79% women) and sedentary controls (n = 30; BMI 36 ± 3 kg·m; 87% women). Multivariate logistic regressions were performed to estimate ORs and the probability of POTS and exercise intolerance associated with exercise HRs. RESULTS: Exercise tolerance was increased in EX-TL, but not in EX-INTL (10.0 ± 1.3 and 8.3 ± 1.5 METs vs 8.0 ± 1.6 METs, respectively) versus controls. Absolute peak HR was increased in EX-TL and EX-INTL versus controls (P < .01), whereas percent predicted did not differ. Exercise within the first-to-second stress stages was performed at exaggerated HRs (122 ± 17 bpm vs 103 ± 15 and 113 ± 15 bpm, P < .001) and percent HR reserve in EX-INTL versus controls and EX-TL (49% ± 12% vs 34% ± 11% and 41% ± 11%, P < .001), respectively. In multivariate analyses, peak HR was not significant, whereas increased submaximal HR (either variable) was associated with increased odds of EX-TL or EX-INTL. Lastly, odds of EX-INTL increased as METs decreased, whereas METs was not a predictor of EX-TL. CONCLUSIONS: An exaggerated submaximal exercise HR is predictive of POTS and exercise intolerance, and this chronotropic phenotype is exacerbated in patients achieving <85% predicted METs.

Correction to: ST­segment changes during tilt table testing for postural tachycardia syndrome: correlation with exercise stress test results.

Unfortunately, the 3rd author name was incorrectly published in the original publication. The complete correct name is given below.

ST-segment changes during tilt table testing for postural tachycardia syndrome: correlation with exercise stress test results.

BACKGROUND: Prior studies have reported ECG (Electrocardiogram) changes during tilt table testing (TTT), specifically during repolarization with ST-segment and T-wave changes. The correlation with ischemic evaluation remains unclear. The purpose of this study was to analyze the prevalence of ST-segment changes during TTT in a young, otherwise healthy population of patients with postural tachycardia syndrome (POTS), and correlate them with exercise stress test results. METHODS: Two hundred and fifty-five patients with POTS who underwent TTT and an exercise treadmill test (ETT) were analyzed. RESULTS: Forty-five had ST-segment changes/depressions during TTT (91% female, average age 36 years). Of the 45, three had ST-segment depression during ETT; all three had negative exercise stress echocardiograms (ESEs). Two others had ST-segment depressions on ETT (but not TTT), with negative ESEs. CONCLUSION: In a cohort of young, female, otherwise healthy patients with POTS, ST-segment changes occurred in a significant portion (18%) of patients during TTT. When evaluated with exercise stress testing, these patients had no evidence of underlying ischemia on ETT or ESE.

Association of Maternal Lactation With Diabetes and Hypertension: A Systematic Review and Meta-analysis.

Importance: Lactation has been shown to be associated with lower rates of diabetes and hypertension in mothers. However, the strength of association has varied between studies, and sample sizes are relatively small. Objective: To conduct a systematic review and meta-analysis to determine whether lactation is associated with a lower risk of diabetes and hypertension. Data Sources: Ovid MEDLINE, Ovid Embase, Cochrane CENTRAL, and CINAHL databases were searched from inception to July 2018 with manual search of the references. Study Selection: Studies of adult women that specified duration of breastfeeding for at least 12 months, evaluated primary hypertension and diabetes as outcomes, were full-text articles in English, and reported statistical outcomes as odds ratios were included. Data Extraction and Synthesis: Study characteristics were independently extracted using a standard spreadsheet template and the data were pooled using the random-effects model. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline for reporting was followed. Main Outcomes and Measures: Diabetes and hypertension. Results: The search yielded 1558 articles, from which a total of 6 studies met inclusion criteria for association between breastfeeding and diabetes and/or hypertension. The 4 studies included in the meta-analysis for the association between lactation and diabetes had a total of 206 204 participants, and the 5 studies included in the meta-analysis for the association between lactation and hypertension had a total of 255 271 participants. Breastfeeding for more than 12 months was associated with a relative risk reduction of 30% for diabetes (pooled odds ratio, 0.70 [95% CI, 0.62-0.78]; P < .001) and a relative risk reduction of 13% for hypertension (pooled odds ratio, 0.87 [95% CI, 0.78-0.97]; P = .01). Conclusions and Relevance: This study suggests that education about the benefits of breastfeeding for prevention of diabetes and hypertension in women is a low-risk intervention that can be easily included in daily practice and may have a positive impact on cardiovascular outcomes in mothers.

Temporal trends, ethnic determinants, and short-term and long-term risk of cardiac death in cancer patients: a cohort study.

BACKGROUND: We evaluated the risk of cardiac death in patients with prior cancer diagnoses and compared risk by cancer type and ethnicity in a large US population. METHOD: Utilizing the Surveillance, Epidemiology, and End Results database, data on patients with a cancer diagnosis between 2000 and 2014 were obtained. We calculated the standardized mortality ratio (SMR) of cardiac death after a cancer diagnosis and the excess risk per 10,000 person-years. We stratified the analysis according to the time interval between cancer and cardiac events, cancer site, cancer stage, and race. RESULTS: A total of 4,671,989 patients with a cancer diagnosis were included, of which 163,255 died due to cardiac causes within 10 years of diagnosis. We found a significantly higher rate of cardiac death for cancer patients [SMR=1.16, 95% confidence interval (CI) 1.15-1.16] compared to the general population. When observed for each cancer site, the highest SMR was after a diagnosis of hepatocellular carcinoma (SMR=2.58, 95% CI 2.45-2.72), pancreatic cancer (SMR=2.36, 95% CI 2.25-2.47), and lung cancer (SMR=2.30, 95% CI 2.27-2.34). Patients with metastatic disease had a higher rate of cardiac death (SMR=2.16, 95% CI 2.13-2.19). When stratified by ethnicity, SMR for cardiac death was 1.76, 2.28, 3.68, 2.65, and 1.84 for whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics, respectively. CONCLUSIONS: Cancer patients are more vulnerable to cardiac death than the general population, especially those with nonwhite ethnicity; liver, lung, and pancreatic cancers; and history of metastasis. Healthcare providers should be aware of this risk and pay particular attention to the highest-risk groups.

Visit-to-Visit Blood Pressure Variability, Coronary Atheroma Progression, and Clinical Outcomes.

Importance: Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events, but mechanisms and therapeutic implications underlying this association are not well understood. Objective: To examine the association of intraindividual BPV, coronary atheroma progression, and clinical outcomes using serial intravascular ultrasonography. Design, Setting, and Participants: Post hoc patient-level analysis of 7 randomized clinical trials conducted from 2004 to 2016 involving 3912 patients in multicenter, international, clinic-based primary and tertiary care centers. Adult patients with coronary artery disease who underwent serial intravascular ultrasonography in the setting of a range of medical therapies were included. Data were analyzed between November 2017 and March 2019. Exposures: Visit-to-visit BPV measured using intraindividual standard deviation over 3, 6, 12, 18, and 24 months. Main Outcomes and Measures: Percent atheroma volume (PAV) progression and major adverse cardiovascular events (defined as death, myocardial infarction, stroke, urgent revascularization for acute coronary syndrome, and hospitalization for unstable angina). Results: Of 3912 patients, the mean (SD) age was 58 (9) years, 1093 (28%) were women, and 3633 (93%) were white . Continuous change in PAV was significantly associated with systolic BPV (ß, .049; 95% CI, 0.021-0.078; P = .001), diastolic BPV (ß, .031; 95% CI, 0.002-0.059; P = .03), and pulse pressure variability (ß, .036; 95% CI, 0.006-0.067; P = .02), without a signal for differential effect greater than or less than a mean BP of 140/90 mm Hg. The PAV progression as a binary outcome was significantly associated with systolic BPV (odds ratio, 1.09; 95% CI, 1.01-1.17; P = .02) but not diastolic BPV (odds ratio, 1.04; 95% CI, 0.97-1.11; P = .30) or pulse pressure variability (odds ratio, 1.03; 95% CI, 0.96-1.10; P = .47). Survival curves revealed a significant stepwise association between cumulative major adverse cardiovascular events and increasing quartiles of systolic BPV (Kaplan-Meier estimates for quartiles 1-4: 6.1% vs 8.5% vs 10.1% vs 12.0%, respectively; log-rank P <.001). These distinct stepwise associations were not seen with diastolic BPV or pulse pressure variability. Conclusions and Relevance: Greater BPV, particularly systolic BPV, is significantly associated with coronary atheroma progression and adverse clinical outcomes. These data suggest maintaining stable blood pressure levels may be important to further improve outcomes in patients with coronary disease.

Relation of Isolated Low High-Density Lipoprotein Cholesterol to Mortality and Cardiorespiratory Fitness (from the Henry Ford Exercise Testing Project [FIT Project]).

Isolated low high-density lipoprotein cholesterol (HDL-C) is associated with lower fitness and increased mortality. Whether the association between isolated low HDL-C and mortality differs by fitness is uncertain. Patients in the Henry Ford ExercIse Testing Project (FIT Project) completed a physician-referred treadmill stress test and those prescribed lipid-lowering medications or with known cardiovascular disease were excluded. Isolated low HDL-C was defined as HDL-C <40 mg/dl for men and <50 mg/dl for women with low-density lipoprotein cholesterol (LDL-C) and triglycerides <100 mg/dl (n = 688). An optimal lipid panel was defined as HDL-C ≥40 mg/dl for men and ≥50 mg/dl for women with LDL-C and triglycerides <100 mg/dl (n = 2,923). Mortality was ascertained through Social Security Death Index linkage. Patients with isolated low HDL-C had a mean age of 48.9 ± 12.9 years and 62.9% were women. Over a mean follow-up of 10.3 ± 5 years, 12.8% of patients with isolated low HDL-C and 8.7% with optimal lipids died. Compared to individuals with optimal lipids, those with isolated low HDL-C who achieved <6 METs had a lower survival (p = 0.02), whereas there was no mortality difference for those who achieved 6 to 10 METs (p = 0.13) or ≥10 METs (p = 0.66). In adjusted Cox models, the mortality hazard for those with isolated low HDL-C compared with optimal lipids was 1.73 (95% confidence interval [CI] 1.18 to 2.54), 1.90 (95% CI 1.19 to 3.04), and 0.97 (95% CI 0.53 to 1.78) for the METS categories of <6, 6 to 10, and ≥10. In conclusion, individuals with isolated low HDL-C fitness significantly improved risk stratification and only those with lower fitness had an increased totality mortality risk.

Correction: Hypertension guidelines.

In Aleyadeh W, Hutt-Centeno E, Ahmed HM, Shah NP. Hypertension guidelines: treat patients, not numbers. Cleve Clin J Med 2019; 86(1):47-56. doi:10.3949/ccjm.86a.18027, on page 50, the following statement was incorrect: "In 2017, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) recommended a relaxed systolic blood pressure target, ie, below 150 mm Hg, for adults over age 60, but a tighter goal of less than 130 mm Hg for the same age group if they have transient ischemic attack, stroke, or high cardiovascular risk.9" In fact, the ACP and AAFP recommended a tighter goal of less than 140 mm Hg for this higher-risk group. This has been corrected online.

Hypertension guidelines: Treat patients, not numbers.

The updated 2017 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for managing hypertension advocate tighter blood pressure control than previous guidelines. This review summarizes the evidence behind the guidelines, discusses the risks and benefits of stricter blood pressure control, and provides our insights on blood pressure management in clinical practice.