Needle infiltration assisted explantation technique for peripheral nerve stimulator leads.

INTRODUCTION: Peripheral nerve stimulation is a neuromodulation modality that is increasing used to treat chronic pain. The permanent peripheral nerve stimulator systems, while easy to place are designed to stay in place and scar at the implantation site. There is a paucity of literature on explantation techniques for peripheral nerve stimulators. METHODS: In this report describe a needle infiltration assisted technique for lead explantation. This novel technique is minimally invasive, cost effective and utilizes a combination of fluoroscopy and ultrasound imaging. We describe the successful use of this technique in 3 cases in our practice without any adverse events. CONCLUSION: There are many situations which might require a permanent peripheral nerve stimulator to be explanted such as infection, lead erosion, patient request or need for patient to undergo magnetic resonance imaging (MRI). In these scenarios, we propose a novel needle infiltration assisted technique of explantation that is safe, effective and easy to replicate.

Prevalence of methicillin-sensitive, methicillin-resistant Staphylococcus aureus, and extended-spectrum beta-lactamase-producing Escherichia coli in newborns: a cross-sectional study.

BACKGROUND: The prevalence of antimicrobial-resistant bacteria and methicillin-sensitive Staphylococcus aureus (MSSA) in healthy newborns and the role of maternal transmission are scarcely discussed. OBJECTIVES: The objective of this study was to evaluate the prevalence of MSSA, MRSA, and ESBL among healthy newborns. Additionally, mother-to-newborn transmission rates were investigated as well as antibiotic susceptibility of MSSA, MRSA, and ESBL isolates. METHODS: Swabs of 658 newborns and their mothers were collected to investigate the presence of MSSA, MRSA, and ESBL. Swabs were taken from the nose and umbilicus immediately after birth. Additional swabs were taken from the nose, perianal area, and umbilicus 3 days after birth. Samples were screened and further characterized using culture and molecular methods. RESULTS: Prevalence of MSSA, MRSA, and ESBL colonization was 10.9, 0.5, and 2.6%, respectively. There was no association between the colonization status of the newborn and infections at any time point. Mother-to-newborn transmission rates (confirmed by PFGE) were 53.6% for MSSA/MRSA and 100% for ESBL. Maternal carriage of MSSA, MRSA, or ESBL was a risk factor for colonization of the newborn. Some isolates were resistant to the antibiotics recommended for therapy, including clindamycin and daptomycin for MSSA/MRSA isolates and ertapenem, fosfomycin, and tigecyclin for ESBL isolates. CONCLUSION: No association between infections and the newborns' colonization status could be detected. Maternal colonization played an important role in newborn colonization, but not every case of colonization could be explained by mother-to-newborn transmission. General screening of pregnant women and healthy newborns in the absence of other risk factors is not necessary. To prevent the possibility of transmission in the healthcare setting, professionals, pregnant women, parents, hospital visitors, and obstetricians should receive regular training on appropriate hygiene measures. With regard to the emergence of resistance to recommended antibiotics, an antibiogram should be conducted before treating MSSA/MRSA/ESBL infections to ensure the efficacy of the antibiotics.

BaxdelaTM (Delafloxacin): A Novel Fluoroquinolone for the Treatment of Acute Bacterial Skin and Skin Structure Infections.

Baxdela (delafloxacin) for treatment of acute bacterial skin and skin structure infections.

Hospitalization cost at childbirth: Health parameters and colonization with antimicrobial resistant bacteria and methicillin susceptible Staphylococcus aureus.

OBJECTIVE: Antimicrobial resistant bacteria (AMR) are of public health and economic relevance. However, there is a lack of data regarding AMR colonization in pregnant women and in newborns. Furthermore, there are few studies analyzing hospital's net income (revenues and costs). STUDY DESIGN: The cross-sectional study took place in two Bavarian clinics. Available data regarding women and newborns were collected using a standardized questionnaire, personal IDs and medical records in addition to AMR/MSSA screening. Economic data consisted of estimated hospitalization costs, calculated using a billing system called G-DRG (German-Diagnosis Related Groups) as well as real hospitalization costs (e.g. staff, medical and non-medical infrastructure costs). RESULTS: Data from 635 pregnant women and 566 newborns were included. While AMR colonization has shown no significant association with clinical complications, or net hospital income; primipara status and medical condition during pregnancy did. AMR colonization did not have a significant influence on the health status of pregnant women or of the newborns. Net hospital income for pregnant women was mostly negative in 2014. In 2014 and 2015 the majority of the cases had a net income between ±€ 1000. Newborns with clinical complications differed significantly in Apgar score at 1min, weight, body length and AMR colonization of the pregnant woman and/or the newborn (p<=0.05). CONCLUSION: Results indicate that colonization does not lead to increased costs during hospitalization considering real hospitalization costs as well as G-DRG estimated costs. Both DRG groups had similar MSSA and AMR prevalence and health status. In future studies, a Centralized Cost Accounting as billing method and an improved possibility of AMR coding in G-DRG catalog would be desirable.

Serotonin Syndrome: The Potential for a Severe Reaction Between Common Perioperative Medications and Selective Serotonin Reuptake Inhibitors.

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to patients of all ages. Although generally considered safe, therapy with SSRIs can be complicated by serotonin syndrome (SS), a life-threatening condition. We present a case of SS that developed in a young man who was receiving a stable dose of fluoxetine and then received several commonly used medications during an emergent appendectomy. Because polypharmacy in the perioperative setting may trigger SS, it is important for anesthesiologists to be cognizant of the interactions between SSRIs and common perioperative medications to formulate anesthetic plans that optimize patient safety.

Traumatic carotid artery dissection during acrobatic flight associated with -G(z) acceleration.

BACKGROUND: A 38-yr-old man developed the acute onset of expressive aphasia and right hemiparesis during the performance of an advanced aerobatic flight maneuver. CASE REPORT: Magnetic resonance imaging (MRI) demonstrated patchy infarction in the territory of the left middle cerebral artery. Magnetic resonance, angiography (MRA) revealed a dissection of the left internal carotid artery. He had flown an aerobatic routine with multiple abrupt transitions from +8 G(z) to -6 G(z) 4 d prior with no ill effects. He had no risk factors for dissection or stroke. The patient recovered full neurological function within several hours. DISCUSSION: We propose that the arterial dissection occurred during the patient's preceding aerobatic flight, leading to an embolic stroke 4 d later. The most likely mechanism was sustained -G(z) acceleration combined with flexion and rotation of his neck during abrupt transition from +G(z) to -G(z), causing stretching of the internal carotid artery at the point of entry to the skull base and development of an intimal tear.

Microalbuminuria in HIV disease.

BACKGROUND/AIMS: Microalbuminuria is a marker for early kidney disease and cardiovascular risk. The purposes of this study were to determine the prevalence of microalbuminuria in an HIV-infected clinic population, to test the predictive value of a single urine albumin/creatinine ratio (ACR) to identify persistent microalbuminuria and to examine covariates of microalbuminuria. METHODS: We conducted a prospective cohort study of HIV-infected subjects (n = 182) without proteinuria (urine protein/creatinine ratio ≥0.5 g/g), elevated serum creatinine, diabetes, or chronic inflammatory conditions. Subjects completed three research visits within 9 months. Microalbuminuria was defined as the geometric mean ACR of 25-355 mg/g for females and 17-250 mg/g for males. RESULTS: The prevalence of microalbuminuria was 14%. The negative predictive value of a single urine ACR determination was 98%, whereas the positive predictive value was only 74%. Microalbuminuria was similar among Black (15%) and non-Black (14%) subjects (p = 0.8). Subjects with microalbuminuria were more likely to have hypertension (p = 0.02) and metabolic syndrome (p = 0.03). While duration of HIV infection and the level of HIV viremia were similar between groups, those with microalbuminuria were more likely to have a CD4 count <200 cells/µl (p = 0.0003). In a multivariate logistic regression analysis, the only significant independent predictors of microalbuminuria were low CD4 count (p = 0.018) and current ritonavir exposure (p = 0.04). CONCLUSION: The prevalence of microalbuminuria in an HIV-infected clinic population was similar to earlier reports, and was associated with hypertension and impaired immune function. A single normal ACR determination effectively excludes microalbuminuria, whereas an elevated ACR requires confirmation.

Oxidative stress in the developing brain: effects of postnatal glucocorticoid therapy and antioxidants in the rat.

In premature infants, glucocorticoids ameliorate chronic lung disease, but have adverse effects on long-term neurological function. Glucocorticoid excess promotes free radical overproduction. We hypothesised that the adverse effects of postnatal glucocorticoid therapy on the developing brain are secondary to oxidative stress and that antioxidant treatment would diminish unwanted effects. Male rat pups received a clinically-relevant tapering course of dexamethasone (DEX; 0.5, 0.3, and 0.1 mg x kg(-1) x day(-1)), with or without antioxidant vitamins C and E (DEXCE; 200 mg x kg(-1) x day(-1) and 100 mg x kg(-1) x day(-1), respectively), on postnatal days 1-6 (P1-6). Controls received saline or saline with vitamins. At weaning, relative to controls, DEX decreased total brain volume (704.4±34.7 mm(3) vs. 564.0±20.0 mm(3)), the soma volume of neurons in the CA1 (1172.6±30.4 µm(3) vs. 1002.4±11.8 µm(3)) and in the dentate gyrus (525.9±27.2 µm(3) vs. 421.5±24.6 µm(3)) of the hippocampus, and induced oxidative stress in the cortex (protein expression: heat shock protein 70 [Hsp70]: +68%; 4-hydroxynonenal [4-HNE]: +118% and nitrotyrosine [NT]: +20%). Dexamethasone in combination with vitamins resulted in improvements in total brain volume (637.5±43.1 mm(3)), and soma volume of neurons in the CA1 (1157.5±42.4 µm(3)) and the dentate gyrus (536.1±27.2 µm(3)). Hsp70 protein expression was unaltered in the cortex (+9%), however, 4-HNE (+95%) and NT (+24%) protein expression remained upregulated. Treatment of neonates with vitamins alone induced oxidative stress in the cortex (Hsp70: +67%; 4-HNE: +73%; NT: +22%) and in the hippocampus (NT: +35%). Combined glucocorticoid and antioxidant therapy in premature infants may be safer for the developing brain than glucocorticoids alone in the treatment of chronic lung disease. However, antioxidant therapy in healthy offspring is not recommended.

Investigation of the use of antioxidants to diminish the adverse effects of postnatal glucocorticoid treatment on mortality and cardiac development.

BACKGROUND: In premature infants, glucocorticoids ameliorate chronic lung disease, but have adverse effects on growth and the cardiovascular system. Glucocorticoid excess promotes free radical overproduction and vascular dysfunction. OBJECTIVES: We hypothesized that the adverse effects of postnatal glucocorticoid therapy are secondary to oxidative stress and that antioxidant treatment would diminish unwanted effects. METHODS: Male rat pups received a clinically relevant course of dexamethasone (Dex), or Dex with vitamins C and E (DexCE), on postnatal days 1-6 (P1-6). Controls received saline (Ctrl) or saline with vitamins (CtrlCE). RESULTS: At P21, Dex reduced survival (Ctrl: 96 vs. Dex: 70%) and promoted asymmetric growth restriction (ponderal index, Ctrl: 6.3 +/- 0.1 g . mm(-3) x 10(-5) vs. Dex: 7.4 +/- 0.2 g . mm(-3) x 10(-5)), both p < 0.05. Dex increased cardiac oxidative stress (protein expression: 4-HNE +20%, Hsp90 -42% and eNOS -54%), induced left ventricle (LV) wall thinning (LV wall volume: Ctrl: 47.2 +/- 1.2 mm(3) vs. Dex: 38.9 +/- 1.7 mm(3)) and decreased the ratio of the aortic lumen:total vessel area (Ctrl: 0.74 +/- 0.01 vs. Dex: 0.66 +/- 0.02), all p < 0.05. DexCE restored towards control values survival, growth symmetry the aortic lumen:total vessel area, and increased the cardiac expression of Hsp90 relative to Dex. In addition, relative to controls, the decrease in the cardiac expression of eNOS was no longer significant in DexCE animals (-20.3 +/- 14.4%, p > 0.05). However, DexCE did not prevent growth retardation, cardiac 4-HNE upregulation (DexCE: +29%) or LV thinning (DexCE: 40.1 +/- 1.1 mm(3)). Treatment of neonates with vitamins alone affected somatic growth and promoted thinner LV walls (CtrlCE: 39.9 +/- 0.5 mm(3), p < 0.05). CONCLUSIONS: Combined glucocorticoid and antioxidant therapy in premature infants may be safer than glucocorticoids alone in the treatment of chronic lung disease. However, antioxidant therapy in healthy offspring is not recommended.

Hyperhomocysteinemia, a cardiac metabolic disease: role of nitric oxide and the p22phox subunit of NADPH oxidase.

BACKGROUND: Hyperhomocysteinemia (HHcy) is a reliable indicator of cardiovascular disease, in part because of the production of superoxide and scavenging of nitric oxide (NO). The present study assessed the impact of HHcy on the NO-dependent control of cardiac O2 consumption and examined enzymatic sources of superoxide. METHODS AND RESULTS: Rats and mice were fed methionine in drinking water for 5 to 9 weeks to increase plasma homocysteine, a process that did not cause significant changes in hemodynamic function. The ability of the NO agonists bradykinin and carbachol to reduce myocardial O2 consumption in vitro was impaired by approximately 40% in methionine-fed rats, and this impairment was proportional to their individual plasma homocysteine concentration. However, responses were restored in the presence of ascorbic acid, tempol, and apocynin, which inhibits NADPH oxidase assembly. Western blots showed no difference in Cu/Zn or Mn superoxide dismutase, endothelial NO synthase, or inducible NO synthase protein, but HHcy caused a 100% increase in the p22phox subunit of NADPH oxidase. Western blots with plasma membrane-enriched fractions of cell lysate detected elevated levels of p22phox, p67phox, and rac-1, which indicates increased oxidase assembly. Finally, mice lacking a functional gp91phox subunit of NADPH oxidase demonstrated normal NO-dependent regulation of myocardial O2 consumption after methionine feeding. CONCLUSIONS: In HHcy, superoxide produced by NADPH oxidase reduces the ability of NO to regulate mitochondrial function in the myocardium. The severity of this effect is proportional to the increase in homocysteine.

Endocardial endothelium in the avascular frog heart: role for diffusion of NO in control of cardiac O2 consumption.

We investigated the role of nitric oxide (NO) in the control of myocardial O(2) consumption in the hearts of female Xenopus frogs, which lack a coronary vascular endothelium and in which the endocardial endothelium is the only source of NO to regulate cardiac myocyte function. Hence, frogs are an ideal model in which to explore the role of diffusion of NO from the endocardial endothelium (EE) without vascular endothelial or cardiac cell NO production. In Xenopus hearts we examined the regulation of cardiac O(2) consumption in vitro at 25 degrees C and 37 degrees C. The NO-mediated control of O(2) consumption by bradykinin or carbachol was significantly (P < 0.05) lower at 25 degrees C (79 +/- 13 or 73 +/- 11 nmol/min) than at 37 degrees C (159 +/- 26 or 201 +/- 13 nmol/min). The response to the NO donor S-nitroso-N-acetyl penicillamine was also markedly lower at 25 degrees C (90 +/- 8 nmol/min) compared with 37 degrees C (218 +/- 15 nmol/min). When Triton X-100 was perfused into hearts, the inhibition of myocardial O(2) consumption by bradykinin (18 +/- 2 nmol/min) or carbachol (29 +/- 4 nmol/min) was abolished. Hematoxylin and eosin slides of Triton X-100-perfused heart tissue confirmed the absence of the EE. Although endothelial NO synthase protein levels were decreased to a variable degree in the Triton X-100-perfused heart, NO(2) production (indicating eNOS activity) decreased by >80%. It appears that the EE of the frog heart is the sole source of NO to regulate myocyte O(2) consumption. When these cells are removed, the ability of NO to regulate O(2) consumption is severely limited. Thus our results suggest that the EE produces enough NO, which diffuses from the EE to cardiac myocytes, to regulate myocardial O(2) consumption. Because of the close proximity of the EE to underlying myocytes, NO can diffuse over a distance and act as a messenger between the EE and the rest of the heart to control mitochondrial function and O(2) consumption.

NAD(P)H oxidase-generated superoxide anion accounts for reduced control of myocardial O2 consumption by NO in old Fischer 344 rats.

We investigated the role of nitric oxide (NO) in the control of myocardial O2 consumption in Fischer 344 rats. In Fischer rats at 4, 14, and 23 mo of age, we examined cardiac function using echocardiography, the regulation of cardiac O2 consumption in vitro, endothelial NO synthase (eNOS) protein levels, and potential mechanisms that regulate superoxide. Aging was associated with a reduced ejection fraction [from 75 +/- 2% at 4 mo to 66 +/- 3% (P < 0.05) at 23 mo] and an increased cardiac diastolic volume [from 0.60 +/- 0.04 to 1.00 +/- 0.10 ml (P < 0.01)] and heart weight (from 0.70 +/- 0.02 to 0.90 +/- 0.02 g). The NO-mediated control of cardiac O2 consumption by bradykinin or enalaprilat was not different between 4 mo (36 +/- 2 or 34 +/- 3%) and 14 mo (29 +/- 1 or 25 +/- 3%) but markedly (P < 0.05) reduced in 23-mo-old Fischer rats (15 +/- 3 or 7 +/- 2%). The response to the NO donor S-nitroso-N-acetyl penicillamine was not different across groups (35%, 35%, and 44%). Interestingly, the eNOS protein level was not different at 4, 14, and 23 mo. The addition of tempol (1 mmol/l) to the tissue bath eliminated the depression in the control of cardiac O2 consumption by bradykinin (25 +/- 3%) or enalaprilat (28 +/- 3%) in 23-mo-old Fischer rats. We next examined the levels of enzymes involved in the production and breakdown of superoxide. The expression of Mn SOD, Cu/Zn SOD, extracellular SOD, and p67phox, however, did not differ between 4- and 23-mo-old rats. Importantly, there was a marked increase in gp91phox, and apocynin restored the defect in NO-dependent control of cardiac O2 consumption at 23 mo to that seen in 4-mo-old rats, identifying the role of NADPH oxidase. Thus increased biological activity of superoxide and not decreases in the enzyme that produces NO are responsible for the altered control of cardiac O2 consumption by NO in 23-mo-old Fischer rats. Increased oxidant stress in aging, by decreasing NO bioavailability, may contribute not only to changes in myocardial function but also to altered regulation of vascular tone and the progression of cardiac or vascular disease.