Spinal anaesthesia with Chloroprocaine HCl 1% for elective lower limb procedures of short duration: a prospective, randomised, observer-blind study in adult patients.

BACKGROUND: This prospective, randomised, observer-blinded study has been conducted in patients undergoing procedures of the lower extremities to evaluate the time to complete block resolution of 2-chloroprocaine 1% at three intrathecal doses (30, 40 and 50 mg). METHODS: After informed consent, we enrolled 45 male and female patients, aged 18-65 years, ASA score I-II, BMI 18-32 kg/m2, undergoing elective lower limb procedures lasting ≤40 min and with a requested dermatomeric level of sensory block ≥ T12. The patients were randomised in a 1:1:1 ratio to receive Chloroprocaine HCl 1% at one of the three different intrathecal doses (Group 30 = 30 mg, Group 40 = 40 mg or Group 50 = 50 mg). The progression and regression of both sensory and motor blocks were evaluated blindly. Urine and venous blood samples were collected for pharmacokinetic analysis. RESULTS: Times to regression of spinal blocks were 1.76 ± 0.35 h, 2.13 ± 0.46 h and 2.23 ± 0.38 h, in Group 30, 40 and 50 respectively: the 30 mg dose showed a significantly faster resolution of spinal block than the 40 mg (p = 0.034) and the 50 mg (p = 0.006). Time to readiness for surgery was significantly reduced with the dose of 50 mg when compared to dose of 30 mg (p = 0.0259). CONCLUSIONS: The doses of 50 mg and 40 mg yielded a longer resolution of spinal block than the dose of 30 mg. Nevertheless, the dose of 30 mg resulted in a higher secondary failure rate. TRIAL REGISTRATION: Registration of clinical trial: clinicaltrials.gov ( NCT02481505 ).

Tapia's syndrome as an uncommon complication after cervical spine surgery with tracheostomy: a case report and literature review.

PURPOSE: The aim of the present work is to present a rare case of Tapia's syndrome (hypoglossal and recurrent laryngeal nerve apraxia) following cervical spine surgery with tracheostomy. METHODS: Clinical data were collected from patient's medical records. RESULTS: After uneventful cervical spine surgery with tracheostomy, the patient reported mild dysphagia and dysphonia. Clinical examination and electromyography confirmed unilateral hypoglossal and recurrent laryngeal disfunction, contralateral to surgical access. Neural damage was transitory and full functional recovery was achieved within 12 months. CONCLUSION: Tapia's syndrome can be a rare complication of cervical spine surgery with tracheostomy, due to multiple factors, including tracheostomy cuffed cannula and cervical spine position during surgery.

Non-invasive haemodynamic monitoring with Clearsight in patients undergoing spinal anaesthesia for total hip replacement. A prospective observational cohort study.

BACKGROUND: Patients undergoing elective primary total hip replacement and spinal anesthesia may encounter significant hemodynamic instability Objective: The study is aimed at observing the haemodynamic modifications after spinal anaesthesia during total hip replacement in patients managed to "preload independence" with goal directed fluid therapy (GDFT) and monitored non-invasively with Clearsight. METHODS: Thirty patients, aged 50-80 years, with an American Society of Anaesthesiologists' (ASA) score II-III, undergoing elective primary total hip replacement and spinal anaesthesia were enrolled. Patients were monitored with the EV1000 platform and the Clearsight finger-cuff and managed with a goal directed fluid therapy. RESULTS: The 79% of the population showed preload independence at baseline. After spinal, the 93% did not show a significant mean arterial pressure reduction. In our population, 79% reported a decrease >10% of the stroke volume during surgery, while 66% in the Recovery Room. Patients showed an improvement in mean arterial pressure, systemic vascular resistances indexed (SVRI), stroke volume (SV) and stroke volume indexed (SVI) at spinal resolution compared to baseline. CONCLUSIONS: Our cohort population showed hemodynamic stability throughout the study period, with increased SV and decreased SVRI at spinal resolution compared to basal values. Further randomized prospective studies are advocated in the same setting.

A randomized comparison between Accuro and palpation-guided spinal anesthesia for obese patients undergoing orthopedic surgery.

BACKGROUND: Although obese patients benefit from neuraxial anesthesia, technical difficulties often discourage its use. The current randomized trial compared Accuro, a hand-held, battery-operated ultrasound (US) device, and conventional palpation for spinal anesthesia in obese patients undergoing orthopedic surgery. We hypothesized that Accuro would decrease the number of needle redirections. METHODS: We enrolled 130 men and women with a body mass index ≥30 kg/m2, scheduled for lower limb surgery under spinal block. Patients were randomized either to the Control group (group C: spinal block after palpation of cutaneous landmarks) or to the Accuro group (group A: preprocedural US scan with Accuro to identify the needle insertion point). The procedural time, the number of skin passes and of needle redirections, the occurrence of failure and adverse events were recorded. RESULTS: Ninety-nine patients completed the study. Patients in group Accuro showed a median (IQR) number of redirections of 3 (0-9) and a median (IQR) number of needle passes through the skin of 1 (1-2) versus 6 (1-16) and 1 (1-3), respectively, in group Control (p=0.008, p=0.019). The performance time was 558±232 s in group Accuro versus 348±255 s in group Control (p<0.001). There were no intergroup differences in terms of failed blocks and adverse events. CONCLUSIONS: The use of Accuro reduced the number of needle redirections and passes through the skin when performing spinal anesthesia, but required a longer procedural time. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registry (NCT03075488).

Effect of different anaesthetic techniques on gene expression profiles in patients who underwent hip arthroplasty.

OBJECTIVES: To investigate the modulation of genes whose expression level is indicative of stress and toxicity following exposure to three anaesthesia techniques, general anaesthesia (GA), regional anaesthesia (RA), or integrated anaesthesia (IA). METHODS: Patients scheduled for hip arthroplasty receiving GA, RA and IA were enrolled at Rizzoli Orthopaedic Institute of Bologna, Italy and the expression of genes involved in toxicology were evaluated in peripheral blood mononuclear cells (PBMCs) collected before (T0), immediately after surgery (T1), and on the third day (T2) after surgery in association with biochemical parameters. RESULTS: All three anaesthesia methods proved safe and reliable in terms of pain relief and patient recovery. Gene ontology analysis revealed that GA and mainly IA were associated with deregulation of DNA repair system and stress-responsive genes, which was observed even after 3-days from anaesthesia. Conversely, RA was not associated with substantial changes in gene expression. CONCLUSIONS: Based on the gene expression analysis, RA technique showed the smallest toxicological effect in hip arthroplasty. TRIAL REGISTRATION: ClinicalTrials.gov number NCT03585647.

Acute pancreatitis after major spine surgery: a case report and literature review.

BACKGROUND: Acute pancreatitis has been described as potential complication of both abdominal and non-abdominal surgeries. The pathogenetic mechanism underlying acute pancreatitis in spine surgery may include intraoperative hemodynamic instability causing prolonged splanchnic hypoperfusion, as well as mechanical compression of the pancreas due to scoliosis correction, with a higher risk in cases of more extended fusions, especially in young adults with lower body mass index (BMI). CASE PRESENTATION: We report here a case of postoperative acute pancreatitis with benign evolution in a young female patient after the first and second surgery of a two-stage correction of right thoracic idiopathic scoliosis.In December 2017, the patient underwent first-stage T4-L3 posterior arthrodesis with T7-T12 osteotomies and temporary magnetic bar. Intraoperative blood loss required massive transfusion. In the immediate postoperative period, the patient started reporting nausea/vomiting, abdominal pain at pressure, moderate meteorism, abdominal distension, hypoactive bowel sounds, and fever. Laboratory tests indicated a progressive increase in aspartate aminotransferase, alanine aminotransferase, serum amylase, lipase, phospho-creatine kinase, and reactive C-protein. A CT scan showed free abundant abdominal fluid in the hepatic, renal, pancreatic, and pelvic regions. After the diagnosis, a hypolipidic diet was initiated, and good hydration per os was maintained. After gastroenterologic consultation, somatostatin, rifaximin, and ursodehoxycholic acid were initiated and maintained for 8 days. In the following days, laboratory tests showed a slow but consistent decrease in liver and pancreatic enzymes until normalization. In January 2018, the patient underwent second-stage surgery with removal of magnetic bar, definitive posterior fusion, and instrumentation T4-L3. Laboratory tests showed a second, even more significant, increase in the amylase and lipase level and a moderate increase in the reactive C-protein. Therapy was maintained until complete normalization of amylase and lipase levels. CONCLUSIONS: Early recognition of symptoms plays a key role in preventing severe morbidity after scoliosis surgery. When symptoms suggest abdominal complication, pancreatic and liver enzymes are to be evaluated for posing prompt diagnosis. Gastroenterologic consultation and eventual imaging are further steps in differential diagnosis and treatment of this rare complication.

Goal-Directed Fluid Therapy Based on Stroke Volume Variation in Patients Undergoing Major Spine Surgery in the Prone Position: A Cohort Study.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: The aim of this study was to test whether a goal-directed fluid therapy (GDFT) protocol, based on stroke volume variation (SVV), applied in major spine surgery performed in the prone position, would be effective in reducing peri-operative red blood cells transfusions. SUMMARY OF BACKGROUND DATA: Recent literature shows that optimizing perioperative fluid therapy is associated with lower complication rates and faster recovery. METHODS: Data from 23 patients who underwent posterior spine arthrodesis surgery and whose intraoperative fluid administration were managed with the GDFT protocol were retrospectively collected and compared with data from 23 matched controls who underwent the same surgical procedure in the same timeframe, and who received a liberal intraoperative fluid therapy. RESULTS: Patients in the GDFT group received less units of transfused red blood cells (primary endpoint) in the intra (0 vs. 2.0, P = 0.0 4) and postoperative period (2.0 vs. 4.0, P = 0.003). They also received a lower amount of intraoperative crystalloids, had fewer blood losses, and lower intraoperative peak lactate. In the postoperative period, patients in the GDFT group had fewer pulmonary complications and blood losses from surgical drains, needed less blood product transfusions, had a shorter intensive care unit stay, and a faster return of bowel function. We found no difference in the total length of stay among the two groups. CONCLUSION: Our study shows that application of a GDFT based on SVV in major spine surgery is feasible and can lead to reduced blood losses and transfusions, better postoperative respiratory performance, shorter ICU stay, and faster return of bowel function. LEVEL OF EVIDENCE: 3.

mRNA 5' region sequence incompleteness: a potential source of systematic errors in translation initiation codon assignment in human mRNAs.

The amino acid sequence of gene products is routinely deduced from the nucleotide sequence of the relative cloned cDNA, according to the rules for recognition of start codon (first-AUG rule, optimal sequence context) and the genetic code. From this prediction stem most subsequent types of product analysis, although all standard methods for cDNA cloning are affected by a potential inability to effectively clone the 5' region of mRNA. Revision by bioinformatics and cloning methods of 109 known genes located on human chromosome 21 (HC 21) shows that 60 mRNAs lack any in-frame stop upstream of the first-AUG, and that in five cases (DSCR1, KIAA0184, KIAA0539, SON, and TFF3) the coding region at the 5' end was incompletely characterized in the original descriptions. We describe the respective consequences for genomic annotation, domain and ortholog identification, and functional experiments design. We have also analyzed the sequences of 13,124 human mRNAs (RefSeq databank), discovering that in 6448 cases (49%), an in-frame stop codon is present upstream of the initiation codon, while in the other 6676 mRNAs (51%), identification of additional bases at the mRNA 5' region could well reveal some new upstream in-frame AUG codons in the optimal context. Proportionally to the HC 21 data, about 550 known human genes might thus be affected by this 5' end mRNA artifact.

Segmental paralogy in the human genome: a large-scale triplication on 1p, 6p, and 21q.

Few cases of large-scale segmental paralogy have been reported in the human genome. We have identified a large (approximately 500 kb) segment on human chromosome (HC) 21 (21q22) that is triplicated on HC 1 (1p35) and HC 6 (6p12-21). We also identified a new member of CLIC (Chloride Intracellular Channel) family on 21q, namely CLIC6. All three segments appear to include three functional members of three different gene families: DSCR1-like (Down Syndrome Candidate Region 1-like), CLIC, and AML/Runt (Acute Myeloid Leukemia/Runt). Molecular evolution analysis shows a common evolutionary origin for the triplicated regions. This finding of a further large-scale genomic triplication that went undetected at previously systematic automated searches provides a new model for gene divergence study and underlines the need for new tools to effectively detect inter-chromosomal similarity. An algorithm to overcome current limitations is proposed.

Cysteine and tyrosine-rich 1 (CYYR1), a novel unpredicted gene on human chromosome 21 (21q21.2), encodes a cysteine and tyrosine-rich protein and defines a new family of highly conserved vertebrate-specific genes.

A novel human gene has been identified by in-depth bioinformatics analysis of chromosome 21 segment 40/105 (21q21.1), with no coding region predicted in any previous analysis. Brain-derived DNA complementary to RNA (cDNA) sequencing predicts a 154-amino acid product with no similarity to any known protein. The gene has been named cysteine and tyrosine-rich protein 1 gene (symbol cysteine and tyrosine-rich 1, CYYR1). The CYYR1 messenger RNA was found by Northern blot analysis in a broad range of tissues (two transcripts of 3.4 and 2.2 kb). The gene consists of four exons and spans about 107 kb, including a very large intron of 85.8 kb. Analysis of expressed sequence tags shows high CYYR1 expression in cells belonging to the amine precursor uptake and decarboxylation system. We also cloned the cDNA of the murine ortholog Cyyr1, which was mapped by a radiation hybrid panel on chromosome 16 within the region corresponding to that containing the respective human homolog on chromosome 21. Sequence and phylogenetic analysis led to identification of several genes encoding CYYR1 homologous proteins. The most prominent feature identified in the protein family is a central, unique cysteine and tyrosine-rich domain, which is strongly conserved from lower vertebrates (fishes) to humans but is absent in bacteria and invertebrates.