Effect of sugammadex versus neostigmine/atropine combination on postoperative cognitive dysfunction after elective surgery.

This study aimed to assess the effects of sugammadex and neostigmine/atropine on postoperative cognitive dysfunction (POCD) in adult patients after elective surgery. A randomised, double-blind controlled trial was carried out on 160 American Society of Anesthesiologists physical status I to III patients who were >40 years. The Mini-Mental State Evaluation, clock-drawing test and the Isaacs Set test were used to assess cognitive function at three timepoints: 1) preoperatively, 2) one hour postoperatively, and 3) at discharge. The anaesthetic protocol was the same for all patients, except for the neuromuscular block reversal, which was administered by random allocation using either sugammadex or neostigmine/atropine after the reappearance of T2 in the train-of-four sequence. POCD was defined as a decline ≥1 standard deviation in ≥2 cognitive tests. The incidence of POCD was similar in both groups at one hour postoperatively and at discharge (28% and 10%, in the neostigmine group, 23% and 5.4% in the sugammadex group, P=0.55 and 0.27 respectively). In relation to individual tests, a significant decline of clock-drawing test in the neostigmine group was observed at one hour postoperatively and at discharge. For the Isaacs Set test, a greater decline was found in the sugammadex group. These findings suggest that there are no clinically important differences in the incidence of POCD after neostigmine or sugammadex administration.

The Greek version of Shoulder Pain and Disability Index (SPADI): translation, cultural adaptation, and validation in patients with rotator cuff tear.

BACKGROUND: This study aimed to translate and culturally adapt a Greek version of the Shoulder Pain and Disability Index (SPADI) questionnaire and to validate its usage in Greek patients. MATERIALS AND METHODS: A forward and backward translation was performed, and the final version of the Greek questionnaire was administered to 134 outpatients (mean age 47.4 ± 14.5) with rotator cuff tear under conservative treatment. The questionnaire was re-administered 2-5 days later to assess test-retest reliability. Patients completed the Greek SPADI, the Greek version of the Quick DASH (Disability of the Arm, Shoulder and Hand Questionnaire) and the EuroQoL EQ-5D. 102 of the 134 questionnaires were considered valid. RESULTS: The internal consistencies of the SPADI total and its subscales measured with Cronbach's alpha coefficient were high (0.932 for SPADI-Total, 0.899 for SPADI-Disability, 0.905 for SPADI-Pain). Intraclass correlation coefficients showed excellent test-retest reliability (0.899 for Disability, 0.902 for Pain, and 0.929 for total SPADI). A significantly high positive correlation was found between the SPADI total score and its subscales, and Quick DASH for Pain and Disability. Significant correlations were also found between SPADI scales and EQ-5D variables. There was a moderate positive correlation with the variables "self-reliance" (r = 0.66), "common activities" (r = 0.58), and "pain/discomfort" (r = 0.49), and a weaker correlation with the "mobility" variable (r = 0.20). Factor analysis (PAF method) revealed a bidimensional formation of the SPADI. Eight items (five pain/three disability) weighted the first factor by >0.5, and five disability items weighted the second factor. CONCLUSIONS: The Greek SPADI represents a valid and reliable tool for measuring pain and disability in patients with painful shoulder disorders. LEVEL OF EVIDENCE: Level 3.

Cardiopulmonary resuscitation in end-stage cancer patients.

Cardiopulmonary resuscitation (CPR) in patients with end-stage cancer is an issue of significant clinical and ethical importance. In general, the overall survival to discharge in cancer patients is referred to be 6.2% (localised - 9.5% vs. metastatic disease - 5.6%) compared to 15% of unselected in-hospital arrests. However, immediate survival, as well as survival to discharge after a successful CPR is affected by multiple factors. Type and extend of tumor, degree of clinical deterioration, functional status and many other factors do correlate with outcome in different degrees. Critical illness scoring systems are commonly used in order to assess performance status of patients and predict outcome. This article will review all the above mentioned factors, as well as patients' perception about "do-not-resuscitate" orders and palliative care.

Preoperative pulmonary evaluation in patients scheduled for lung operations.

Preoperative pulmonary evaluation is essential in order to identify patients at risk for postoperative pulmonary complications (PPCs). Procedure and patient related risk factors should be assessed and modified if possible in order to reduce the incidence of PPCs. The extent of preoperative pulmonary evaluation testing required depends on whether the operation to be performed is thoracic or non-thoracic, in addition with patients' coexisting diseases and risk factors. Lung cancer resection surgery also requires extended preoperative evaluation, which is guided by functional pulmonary testing, including spirometry, diffusing capacity of the lung to carbon monoxide (DLCO) measurement, split function testing, exercise testing and arterial blood gas analysis according to published guidelines. Strategies to reduce the risk of PPCs should always be applied in patients at risk, beginning preoperatively and continuing during intraoperative and postoperative period.

Cancer cachexia and immunomodulation.

Cachexia is derived from the Greek words "kakos" meaning "bad" and "hexis" meaning "condition". Cachexia is a debilitating state of involuntary weight loss complicating malignant, infectious and inflammatory diseases. Several hypotheses for its etiology have been suggested including cytokines, circulating hormones, neuropeptides, neurotransmitters, and tumor-derived factors. Cachexia syndrome is caused predominantly by cytokines either produced by cancer or released by the immune system cells as a response to the presence of cancer, as well as other tumor products that induce profound lipolysis or protein degradation. Several strategies have been applied in the management of cachexia and related immunodeficiency including: 1.hypercaloric feeding;2.administration of glucocorticoids;3.progrestational drugs;4.cyproheptadine and other antiserotonergic drugs;5.branched-chain aminoacids;6.prokinetic agents;7.eicosapentanoic acid (EPA);8.cannabinoids;9.5'-deoxy-5-fluorouridine;10.emerging drugs: melatonin, thalidomide, beta2-agonists, non-steroidal anti-inflammatory drugs (NSAIDs);11.others:pentoxifylline, hydrazine sulfate, anabolic steroids. Better understanding of the mechanisms underlying cancer and cachexia leading to immune dysfunction has guided immunomodulatory strategies to reverse cachexia and immunodeficiency. The oncept is that the tumor itself may lead to cachexia and immune dysfunction but also cachexia is related and mediated with immune dysfunction. Thus the purpose is to affect the tumor itself and cachexia immune pathways in order to restore immune efficiency. However, more experimental and clinical studies are needed to evaluate the efficacy of immunomodulatory intervention in cancer cachexia and related immunodeficiency.