Bupivacaine Toxicity Increases Transmural Dispersion of Repolarization, Developing of a Brugada-like Pattern and Ventricular Arrhythmias, Which is Reversed by Lipid Emulsion Administration. Study in an Experimental Porcine Model.

Unintentional administration of bupivacaine may be associated with electrocardiogram changes that promote the development cardiac arrhythmias. Ventricular repolarization markers (corrected QT, QT dispersion, Tpeak-Tend and Tpeak-Tend dispersion) are useful to predict cardiac arrhythmias. We aim to investigate the effects of bupivacaine on the transmural dispersion of repolarization and their reversion following intravenous lipid emulsion (ILE) administration. Fourteen pigs were anaesthetized with thiopental and sevoflurane and underwent tracheal intubation. After instrumentation, a 4 mg kg-bolus of bupivacaine was administrated followed by an infusion of 100 µg kg-1 min-1. QT interval, QTc:QT corrected by heart rate, Tpeak-to-Tend interval and QT and Tpeak-to-Tend dispersion were determined in a sequential fashion: after bupivacaine (at 1 min, 5 min and 10 min) and after ILE (1.5 mL kg-1 over 1 min followed by an infusion of 0.25 mL kg-1 min-1). Three additional animals received only ILE (control group). Bupivacaine significantly prolonged QT interval (∆:36%), QT dispersion (∆:68%), Tpeak-to-Tend (∆:163%) and Tpeak-to-Tend dispersion (∆:98%), from baseline to 10 min. Dispersion of repolarization was related to lethal arrhythmias [three events, including asystole, sustained ventricular tachycardia (VT)] and repeated non-sustained VT (4/14, 28%). A Brugada-like-ECG pattern was visualized at V1-4 leads in 5/14 pigs (35%). ILE significantly decreased the alterations induced by bupivacaine, with the termination of VT within 10 min. No ECG changes were observed in control group. Bupivacaine toxicity is associated with an increase of transmural dispersion of repolarization, the occurrence of a Brugada-like pattern and malignant VA. ILE reverses the changes in dispersion of repolarization, favouring the disappearance of the Brugada-like pattern and VT.

La resonancia magnética multiparamétrica predice la presencia de cáncer de próstata en pacientes con biopsia prostática negativa / Multiparametric magnetic resonance imaging predicts the presence of prostate cancer in patients with negative prostate biopsy

Objetivo: Evaluar el papel del estudio multiparamétrico mediante imagen por resonancia magnética (mpMRI) de próstata para detectar cáncer de próstata en pacientes con biopsia prostática transrectal (BPTR) negativa previa. Material y métodos: Se practicó una mpMRI (secuencias TSE-T2-w, DWI y DCE) de la próstata con equipo de 1.5 T (Magnetom Avanto; Siemens Healthcare Solutions) a 150 pacientes con sospecha previa de cáncer de próstata y BPTR negativa. Se aplicaron criterios de European Society of Urogenital Radiology (ESUR) (1: muy posiblemente benigno, 2: posiblemente benigno, 3: dudoso, 4: posiblemente maligno, y 5: muy posiblemente maligno). A todos los pacientes se les realizó PSA (total y libre), tacto rectal (TR), ecografía transrectal (ETR) y segunda BPTR de, al menos, 14 cilindros. Las variables fueron analizadas de forma ciega independiente. Se estudió la exactitud de cada prueba y se evaluó un modelo de selección de variables stepwise para predecir cáncer en la segunda BPTR. Resultados: La edad media ± desviación estándar fue 66,2 ± 5 (51-77) años, el PSA 11,3 ± 9,6 (0,9-75) ng/mL y el volumen prostático 82,2 ± 42 (20-250) cc. El TR fue sospechoso en 11(7,3%) pacientes. La segunda BPTR muestreó 17,6 ± 2,7 (14-22) cilindros por caso y resultó positiva en 28 (18,7%) pacientes. La mpMRI se consideró positiva (3-5) en 102 (68%), siendo la sensibilidad de la prueba del 92,9% y el VPN del 95,8%. Modifican riesgo de cáncer en segunda BPTR: velocidad de PSA > 0,75 (OR 1,04 [0,99-1,08]); p = 0,06), PSA libre/total < 15% (OR 0,37 [0,13-1,05]; p = 0,06), cada cc de volumen prostático (OR 0,98 [0,97-1]; p = 0,017) y mpMRI 3-5 (OR 7,87 [1,78-34,7]; p = 0,006). El análisis multivariante reveló que mpMRI (OR 7,41 [1,65-33,28]; p = 0,009) y volumen prostático (OR 0,31 [0,12-0,78]; p = 0,01) definen riesgo de cáncer de forma independiente. Conclusiones: La mpMRI según criterios ESUR es una herramienta de gran valor para predecir la presencia de cáncer en la segunda BPTR en pacientes con biopsia previa negativa y resulta más fiable en próstatas de menor volumen

Objective: To assess the ability of multiparametric prostate magnetic resonance imaging (mpMRI) to detect prostate cancer in patients with prior negative transrectal prostate biopsy (TPB). Material and methods: mpMRI (TSE-T2-w, DWI and DCE sequences) was performed on 1.5 T (Magnetom Avanto; Siemens Healthcare Solutions) in 150 patients suspicious of prostate cancer and with negative TPB. European Society of Urogenital Radiology (ESUR) criteria were used (score 1: clinically significant disease is highly unlikely to be present; score 2: clinically significant cancer is unlikely to be present; score 3: clinically significant cancer is equivocal; score 4: clinically significant cancer is likely to be present; score 5: clinically significant cancer is highly likely to be present). PSA measurement (total and free), digital rectal examination (DRE), transrectal ultrasound (TRU) and a second TPB (at least 14 cylinders) were performed in all patients. Variables were submitted for independent blind analysis. The accuracy of each test was measured. Stepwise selection model for prediction of prostate cancer in second TPB was developed. Results: Mean age was 66.2± 5 years (51-77), mean PSA 11.3± 9.6 ng/mL (0.9-75) and mean prostatic volume 82.2 ± 42 (20-250) cc. DRE was suspicious in 11 (7.3%) patients. The mean number of cylinders per patient sampled in second TRB was 17.6 ± 2.7(14-22). Second TRB was positive in 28 patients (18.7%). mpMRI was positive (score 3-5) in 102 (68%), test sensibility was 92.9% and the NPV was 95.8%. The risk of prostate cancer diagnosis in second TPB is modified by: PSA velocity > 0.75 (OR 1.04 [0.99-1.08]; P=0.06), free/total ratio PSA <15% (OR 0.37 [0.13-1.05]; P=0.06), each cc. of prostate volume (OR 0.98 [0.97-1]; P=0.017) and mpMRI 3-5 (OR 7.87 [1.78-34.7]; P=0.006). Multivariate analysis reveals that mpMRI (OR 7.41 [1.65-33.28]; P=0.009) and prostatic volume (OR 0.31 [0.12-0.78]; P=0.01) are independent risk predictors of prostate cancer. Conclusions: According to ESUR guidelines and in patients with prior negative prostate biopsy, mpMRI is a valuable tool for the prediction of prostate cancer in second TPB. Lower prostate volume, the higher reliability

Multiparametric magnetic resonance imaging predicts the presence of prostate cancer in patients with negative prostate biopsy.

OBJECTIVE: To assess the ability of multiparametric prostate magnetic resonance imaging (mpMRI) to detect prostate cancer in patients with prior negative transrectal prostate biopsy (TPB). MATERIAL AND METHODS: mpMRI (TSE-T2-w, DWI and DCE sequences) was performed on 1.5T (Magnetom Avanto; Siemens Healthcare Solutions) in 150 patients suspicious of prostate cancer and with negative TPB. European Society of Urogenital Radiology (ESUR) criteria were used (score 1: clinically significant disease is highly unlikely to be present; score 2: clinically significant cancer is unlikely to be present; score 3: clinically significant cancer is equivocal; score 4: clinically significant cancer is likely to be present; score 5: clinically significant cancer is highly likely to be present). PSA measurement (total and free), digital rectal examination (DRE), transrectal ultrasound (TRU) and a second TPB (at least 14 cylinders) were performed in all patients. Variables were submitted for independent blind analysis. The accuracy of each test was measured. Stepwise selection model for prediction of prostate cancer in second TPB was developed. RESULTS: Mean age was 66.2± 5 years (51-77), mean PSA 11.3± 9.6ng/mL (0.9-75) and mean prostatic volume 82.2±42 (20-250) cc. DRE was suspicious in 11 (7.3%) patients. The mean number of cylinders per patient sampled in second TRB was 17.6±2.7(14-22). Second TRB was positive in 28 patients (18.7%). mpMRI was positive (score 3-5) in 102 (68%), test sensibility was 92.9% and the NPV was 95.8%. The risk of prostate cancer diagnosis in second TPB is modified by: PSA velocity > 0.75 (OR 1.04 [0.99-1.08]; P=0.06), free/total ratio PSA <15% (OR 0.37 [0.13-1.05]; P=0.06), each cc. of prostate volume (OR 0.98 [0.97-1]; P=0.017) and mpMRI 3-5 (OR 7.87 [1.78-34.7]; P=0.006). Multivariate analysis reveals that mpMRI (OR 7.41 [1.65-33.28]; P=0.009) and prostatic volume (OR 0.31 [0.12-0.78]; P=0.01) are independent risk predictors of prostate cancer. CONCLUSIONS: According to ESUR guidelines and in patients with prior negative prostate biopsy, mpMRI is a valuable tool for the prediction of prostate cancer in second TPB. Lower prostate volume, the higher reliability.