Metabolic Signatures: Pioneering the Frontier of Rectal Cancer Diagnosis and Response to Neoadjuvant Treatment with Biomarkers-A Systematic Review.

Colorectal cancer (CRC) is one of the most aggressive, heterogenous, and fatal types of human cancer for which screening, and more effective therapeutic drugs are urgently needed. Early-stage detection and treatment greatly improve the 5-year survival rate. In the era of targeted therapies for all types of cancer, a complete metabolomic profile is mandatory before neoadjuvant therapy to assign the correct drugs and check the response to the treatment given. The aim of this study is to discover specific metabolic biomarkers or a sequence of metabolomic indicators that possess precise diagnostic capabilities in predicting the efficacy of neoadjuvant therapy. After searching the keywords, a total of 108 articles were identified during a timeframe of 10 years (2013-2023). Within this set, one article was excluded due to the use of non-English language. Six scientific papers were qualified for this investigation after eliminating all duplicates, publications not referring to the subject matter, open access restriction papers, and those not applicable to humans. Biomolecular analysis found a correlation between metabolomic analysis of colorectal cancer samples and poor progression-free survival rates. Biomarkers are instrumental in predicting a patient's response to specific treatments, guiding the selection of targeted therapies, and indicating resistance to certain drugs.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report.

Importance: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective: To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review: With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings: After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance: Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group.

INTRODUCTION: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Medication-induced mood disorders following epidural steroid injections in patients with pain: A case series.

Key Clinical Message: Medication-induced mood disorders following epidural steroid injections are possible therefore should be disclosed to the patient. Abstract: Medication-induced mood disorders have been rarely reported following epidural steroid injections (ESI). This case series presents three patients who met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for substance/medication-induced mood disorder after an ESI. In considering a candidacy for ESI, the rare but significant, side effects of psychiatric side effects should be disclosed to patients.

Exploratory Evaluation of Neopterin and Chitotriosidase as Potential Circulating Biomarkers for Colorectal Cancer.

Chronic inflammation is demonstrated to play a direct role in carcinogenesis. Our exploratory study aimed to assess the potential added value of two inflammation biomarkers, chitotriosidase and neopterin, in follow-up evaluation of patients with colorectal cancer (CRC). An observational exploratory study was conducted. Patients with CRC and matched controls (1:1, age, sex, and living environment) were evaluated. The patients with CRC (CRC group) and controls were assessed at baseline (before surgical intervention for patients with CRC). Patients with CRC were also evaluated at 1-year follow-up. Significantly more patients with blood group A (54.5% vs. 25.0%) and smokers (50.0% vs. 22.7%) were in the CRC group. The serum values of chitotriosidase and neopterin were higher in CRC patients than in controls, but only neopterin reached the conventional level of statistical significance (p-value = 0.015). The circulating chitotriosidase and neopterin values decreased significantly at 1-year follow-up (p-value < 0.0001). Patients with higher N- and M-stage showed statistically significant higher levels of chitotriosidase and neopterin at baseline and 1-year follow-up (p-values < 0.03). Circulating chitotriosidase levels also showed statistically significant differences regarding baseline and 1-year follow-up on patients with CRC and different differentiation grades (p-values < 0.02). The circulating levels of neopterin significantly decreased at 1-year follow-up, indicating its potential as a prognostic marker. The circulating values of chitotriosidase and neopterin exhibit significant differences in patients with than without recurrences. Our results support further evaluation of chitotriosidase and neopterin as prognostic markers in patients with CRC.

Left atrial geometric and functional remodeling parameters measured by cardiac magnetic resonance imaging and outcome prediction in patients with severe aortic stenosis.

BACKGROUND: Emerging studies are beginning to describe the role of afflicted left atrium (LA) function and strain in cardiovascular diseases including aortic stenosis (AS), especially for risk stratification and outcome prediction. Cardiac magnetic resonance imaging (CMR) is becoming increasingly useful in determining LA parameters; however, in patients with AS, this approach has not been applied yet. AIMS: This study sought to evaluate the role of CMR in characterizing LA geometry and function in patients with severe AS. METHODS: We prospectively evaluated 70 patients with symptomatic severe AS and 70 controls. LA volumes, function, and strain were determined using CMR. A composite outcome (cardiac death, ventricular tachyarrhythmias, and heart failure hospitalization) was evaluated over a median of 13 months. Time-to-event outcomes were analyzed accordingly. RESULTS: Besides increased LA volumes (LAVs) and LA sphericity index (LASI) (P <0.001), LA phasic functions and strain were considerably defective in patients with AS (all P <0.001). LV mass (LVM), end-diastolic and end-systolic volumes were also significantly associated withal LA strain parameters (P <0.001). Regarding outcome prediction, decreased total (LA-εt), active (LA-εa), and passive strain (LA-εp), along with enhanced LASI were independently associated with outcome (P <0.001). Time-to-event analysis showed a significantly higher risk to reach the composite outcome for LA-εt <31.1% (hazard ratio [HR], 6.981; 95% confidence interval [CI], 2.74-17.77; P <0.001), LA-εp <14.5% (HR, 2.68; 95% CI, 1.00-7.18; P <0.01), and LA-εa <21.2% (HR, 2.02; 95% CI, 1.07-3.83, P <0.03). CONCLUSION: Patients with severe AS have a significantly remodeled LA, with impaired phasic function and strain. Amongst all CMR parameters, LAVmin, LASI, LAPF, and LA-εp appear to be independent predictors for outcomes.

Erector spinae plane block for affective and safe analgesia in a patient with severe penetrating chest trauma caused by an explosion in the battlefield.

The ongoing conflict in Ukraine continues to generate many complex traumatic injuries and provides unique challenges to anaesthesiologists who provide medical care at various levels of medical evacuation. We report the successful use of an ultrasound-guided continuous erector spinae plane (ESP) block in a patient with severe posterolateral chest trauma. The acute perioperative outcome of the patient was improved with the ESP block, the main benefits being excellent analgesia and minimal postoperative morphine requirements without influencing the risk of bleeding and coagulopathy. We conclude that continuous ESP block can be utilized to provide excellent analgesia following massive thoracic trauma. It's ease of placement under ultrasound guidance and low risk of complications makes this technique particularly useful in war medicine.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Cervical ribs-An anatomical obstacle for upper limb regional blocks.

Anatomic variations of the cervical and supraclavicular regions are possible with an impact on regional anesthesia strategy. The presence of cervical ribs may obstruct needle visualization for brachial plexus block in those regions. Preprocedural scan may help in choosing the appropriate technique.

Urinary retention: a possible complication of unilateral continuous quadratus lumborum analgesia - a case report.

OBJECTIVE: Continuous quadratus lumborum (QL) analgesia is a new option for proximal femur surgery considered safe and effective. The purpose of this report was to show that we may not be aware of all the possible complications of this technique, and urinary retention may occur even when the block is performed unilaterally. CASE REPORT: To an obese, intubated, mechanically ventilated, female patient, operated in prone position for removal of a femur tumour, we performed a trans-muscular quadratus lumborum block (TQL). We mounted a catheter and administered continuous infusion of local anaesthetic in the postoperative period. The patient experienced urinary retention. A urinary catheter was placed and it was maintained for the entire period of local anaesthetic infusion. When the catheter was removed, 72 hours after the surgery, the patient resumed normal bladder functions. CONCLUSION: Urinary retention is a possible complication when continuous quadratus lumborum analgesia is used, even when performed unilaterally.

Preoperative difficult airway prediction using suprahyoid and infrahyoid ultrasonography derived measurements in anesthesiology.

Airway management is one of the most important skills in everyday practice of anesthesia. Improper airway management might contribute to significant morbidity and mortality. In some patients, clinical parameters do not anticipate all difficulties related to airway management. Ultrasonography (US) might confer a potential screening tool for difficult airway. Suprahyoid and infrahyoid US measurements have been investigated for difficult airway prediction in anesthesiology. The most extensively investigated parameter was the anterior neck soft tissue thickness measured at different levels: anterior to the hyoid bone, epiglottis and vocal cords commissure. Hyomental distances measured with the head placed in neutral, sniffing or maximal hyperextended position and the derived hyomental distance ratios have also been evaluated for difficult airway prediction. For the evaluation of the tongue, measurements such as thickness, cross-sectional area, width, volume and tongue-to-oral cavityratio can be used. Thus, anesthesiologists have many available potential US measurements, which could provide information regarding airway anatomy during the preoperative airway assessment and could serve as potential screening parameters for difficult airway. Still, we do not yet know which of these provides optimal predictive accuracy and larger sample size studiesare required to validate their use in the preoperative evaluation of the airway.

Saphenous nerve block as a diagnosis tool for chronic postsurgical pain of the left medial calf.

Ultrasound-guided saphenous nerve block above the knee may be a valuable diagnosis tool in patient presenting chronic pain of the calf.

Effectiveness versus efficiency in a medical skills laboratory.

Medical educators are facing the new challenge of using medical simulation for teaching purposes. The use of simulators seems attractive for trainers and for trainees, but prices of simulators may be prohibitive. In an era of limited resources it is mandatory when using such an expensive tool as simulation, to prove its benefits. Despite the fact that simulation provides opportunity for training, additional advantages are far from being established. The supposed benefits of using medical simulators in teaching and examination needs to be proven regarding two aspects: effectiveness and efficiency.

Clinical aspects and cytokine response in severe H1N1 influenza A virus infection.

INTRODUCTION: The immune responses in patients with novel A(H1N1) virus infection (nvA(H1N1)) are incompletely characterized. We investigated the profile of Th1 and Th17 mediators and interferon-inducible protein-10 (IP-10) in groups with severe and mild nvA(H1N1) disease and correlated them with clinical aspects. METHODS: Thirty-two patients hospitalized with confirmed nvA(H1N1) infection were enrolled in the study: 21 patients with nvA(H1N1)-acute respiratory distress syndrome (ARDS) and 11 patients with mild disease. One group of 20 patients with bacterial sepsis-ARDS and another group of 15 healthy volunteers were added to compare their cytokine levels with pandemic influenza groups. In the nvA(H1N1)-ARDS group, the serum cytokine samples were obtained on admission and 3 days later. The clinical aspects were recorded prospectively. RESULTS: In the nvA(H1N1)-ARDS group, obesity and lymphocytopenia were more common and IP-10, interleukin (IL)-12, IL-15, tumor necrosis factor (TNF)α, IL-6, IL-8 and IL-9 were significantly increased versus control. When comparing mild with severe nvA(H1N1) groups, IL-6, IL-8, IL-15 and TNFα were significantly higher in the severe group. In nonsurvivors versus survivors, IL-6 and IL-15 were increased on admission and remained higher 3 days later. A positive correlation of IL-6, IL-8 and IL-15 levels with C-reactive protein and with > 5-day interval between symptom onset and admission, and a negative correlation with the PaO(2):FiO(2) ratio, were found in nvA(H1N1) groups. In obese patients with influenza disease, a significant increased level of IL-8 was found. When comparing viral ARDS with bacterial ARDS, the level of IL-8, IL-17 and TNFα was significantly higher in bacterial ARDS and IL-12 was increased only in viral ARDS. CONCLUSIONS: In our critically ill patients with novel influenza A(H1N1) virus infection, the hallmarks of the severity of disease were IL-6, IL-15, IL-8 and TNFα. These cytokines, except TNFα, had a positive correlation with the admission delay and C-reactive protein, and a negative correlation with the PaO(2):FiO(2) ratio. Obese patients with nvA(H1N1) disease have a significant level of IL-8. There are significant differences in the level of cytokines when comparing viral ARDS with bacterial ARDS.