Effect of smoking on treatment outcome among tuberculosis patients in Malaysia; a multicenter study.

BACKGROUND: Smoking plays a key role in the development of tuberculosis (TB) infection and is also a predictor of poor TB treatment prognosis and outcomes. The current study was conducted to determine the prevalence of smoking and to assess the effects of smoking on treatment outcomes among TB patients. METHODS: A multi-center retrospective study design was used to collect data from TB patients in four different states of Malaysia, namely Penang, Sabah, Sarawak, and Selangor. The study included medical records of TB patients admitted to the selected hospitals in the period from January 2006 to March 2009. Medical records with incomplete data were not included. Patient demographics and clinical data were collected using a validated data collection form. RESULTS: Of all patients with TB (9337), the prevalence of smokers was 4313 (46.2%). Among smokers, 3584 (83.1%) were associated with pulmonary TB, while 729 (16.9%) were associated with extrapulmonary TB. Male gender (OR = 1.43, 95% CI 1.30-1.58), Chinese ethnicity (OR = 1.23, 95% CI 1.02-1.49), Sarawak indigenous ethnicity (OR = 0.74, 95% CI 0.58-0.95), urban residents (OR = 1.46, 95% CI 1.33-1.61), employed individuals (OR = 1.21, 95% CI 1.09-1.34), alcoholics (OR = 4.91, 95% CI 4.04-5.96), drug abusers (OR = 7.43, 95% CI 5.70-9.60) and presence of co-morbid condition (OR = 1.27, 95% CI 1.16-1.40) all showed significant association with smoking habits. This study found that 3236 (75.0%) patients were successfully treated in the smokers' group, while 4004 (79.7%) patients were non-smokers. The proportion of deaths (6.6%, n = 283), defaulters (6.6%, n = 284) and treatment interruptions (4.7%, n = 204) was higher in the smokers' group. CONCLUSIONS: Smoking has a strong influence on TB and is a major barrier towards treatment success (OR = 0.76, 95% CI 0.69-0.84, p < 0.001). Therefore, the findings indicate that smoking cessations are an effective way to decrease treatment failure and drug resistance.

The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications.

OBJECTIVE: Over 150,000 carotid endarterectomy (CEA) procedures are performed each year. Perioperative anesthetic management may be complex due to multiple patient and procedure-related risk factors. The authorsaimed to determine whether the use of general anesthesia (GA), when compared with regional anesthesia (RA), would be associated with reduced perioperative morbidity and mortality in patients undergoing a CEA. DESIGN: Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SETTING: The authors evaluated patients undergoing a CEA at multiple university- and community-based settings. PARTICIPANTS: A total of 43,463 patients were identified; 22,845 patients were propensity matched after excluding for missing data. INTERVENTIONS: The study population was divided into 2 groups: patients undergoing RA or GA. The RA group included regional anesthesia performed by the anesthesiologist or surgeon, monitored anesthesia care, and local infiltration. METHODS: The primary endpoint was 30-day mortality. Secondary endpoints included surgical site infection, pulmonary complications, return to the operating room, acute kidney injury, cardiac arrest, urinary tract infection, myocardial infarction, thromboembolism, perioperative transfusion, sepsis, and days to discharge. MEASUREMENTS AND MAIN RESULTS: Younger age, Hispanic ethnicity, body mass index <18.5, dyspnea, chronic obstructive pulmonary disease, and smoking history were associated with receiving GA. Patients with low hematocrit and low platelets were more likely to get RA. There was no mortality difference. GA was associated with a significantly higher rate of perioperative transfusions (p = 0.037) and perioperative pneumonia (p = 0.027). CONCLUSION: The use of RA over GA in CEA is associated with decreased risk of postoperative pneumonia and a reduced need for perioperative blood transfusions.

Chemical Sensing Employing Plant Electrical Signal Response-Classification of Stimuli Using Curve Fitting Coefficients as Features.

In order to exploit plants as environmental biosensors, previous researches have been focused on the electrical signal response of the plants to different environmental stimuli. One of the important outcomes of those researches has been the extraction of meaningful features from the electrical signals and the use of such features for the classification of the stimuli which affected the plants. The classification results are dependent on the classifier algorithm used, features extracted and the quality of data. This paper presents an innovative way of extracting features from raw plant electrical signal response to classify the external stimuli which caused the plant to produce such a signal. A curve fitting approach in extracting features from the raw signal for classification of the applied stimuli has been adopted in this work, thereby evaluating whether the shape of the raw signal is dependent on the stimuli applied. Four types of curve fitting models-Polynomial, Gaussian, Fourier and Exponential, have been explored. The fitting accuracy (i.e., fitting of curve to the actual raw signal) depicted through R-squared values has allowed exploration of which curve fitting model performs best. The coefficients of the curve fit models were then used as features. Thereafter, using simple classification algorithms such as Linear Discriminant Analysis (LDA), Quadratic Discriminant Analysis (QDA) etc. within the curve fit coefficient space, we have verified that within the available data, above 90% classification accuracy can be achieved. The successful hypothesis taken in this work will allow further research in implementing plants as environmental biosensors.

The Use of Regional or Neuraxial Anesthesia for Below-Knee Amputations May Reduce the Need for Perioperative Blood Transfusions.

BACKGROUND AND OBJECTIVES: Amputations of the lower extremity remain a common procedure in a high-risk population. Perioperative morbidity and mortality reach as high as 14.1% in below-knee amputations. We aimed to determine whether regional, or neuraxial, anesthesia, when compared with general anesthesia (GA), would be associated with reduced perioperative morbidity and mortality. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program data set. The study population was divided into 2 groups: patients undergoing regional anesthesia (RA) and those undergoing GA. The primary end point for our study was 30-day mortality. The secondary end points were return to the operating room, surgical site infections, pulmonary complications, acute kidney injury, urinary tract infection, cardiac arrest, myocardial infarction, perioperative transfusions, thromboembolisms, sepsis, composite measure of postoperative complications, and days from operation to discharge. RESULTS: Twelve thousand seven hundred twenty-three patients were identified. Older patients, white patients, patients with a higher body mass index, patients without dyspnea, patients with independent functional status, smokers, patients with sepsis, and patients with bleeding disorders were associated with receiving GA. Hispanic patients, patients with chronic obstructive pulmonary disease, and patients with congestive heart failure were associated with receiving RA. Our study did not reveal a 30-day mortality difference between RA and GA. Regional anesthesia was associated with a significantly decreased need for perioperative blood transfusions (11.8% vs 16.5%, P < 0.001) and a decrease in the composite measure of postoperative complications (25.7% vs 29.1%, P < 0.04). CONCLUSIONS: Regional anesthesia does not offer a mortality advantage over GA, but RA may reduce the need for perioperative blood transfusions.

Emerging roles of liposomal bupivacaine in anesthesia practice.

Despite advances in drug technology and improvements in technology, including peripheral nerve catheters and ultrasound, postoperative pain is still a significant problem in the clinical setting worldwide. Postoperative pain can have a critical negative impact with regard to physiological consequences to the body and therefore, the role of liposomal bupivacaine as an extended release bupivacaine with approximately 72 h of duration may have far-reaching and significant impact in clinical practice. Liposomal bupivacaine has a DepoFoam multivesicular liposome technology with particle suspension in an isotonic aqueous solution and consists of tiny lipid-based particles, which contain discrete water-filled chambers dispersed through a lipid matrix. Other advantages include a reduction in opioid consumption, while not requiring a catheter or any other device, as well as easy dilution with saline. This review summarizes current research with this novel agent in postsurgical pain, and discusses potential roles in chronic pain states. Further studies are warranted for its use in epidural and intrathecal administration. Moreover, this review will explore the expansion of liposomal bupivacaine's current clinical role.

Perioperative Hyperalgesia and Associated Clinical Factors.

PURPOSE OF REVIEW: Pain has an important evolutionary role because it serves as an essential warning device to damaging stimuli. The perioperative setting is a unique environment where clinicians must accurately diagnose and address the source of pain. Modern-day perioperative pain control continues to be unsatisfactory. Nearly half of all surgical patients have moderate to severe pain postoperatively, and 24% experience inadequate pain relief. Furthermore, over half of the patients develop chronic pain after thoracotomies, mastectomies, and limb amputation surgeries. Hyperalgesia in the perioperative setting is an important and under-recognized source of morbidity during the perioperative course. RECENT FINDINGS: Key sources of perioperative hyperalgesia include nociceptive-induced pain with surgical trauma, opioid-induced hyperalgesia, and inadequate control of pain in the preoperative setting. Research also hints that inhaled anesthetics may also play a role in the development of perioperative hyperalgesia. Despite new evidence, hyperalgesia remains difficult to diagnose and treat. In our manuscript, we aim to help clinicians develop strategies to define, understand, diagnose, and treat perioperative hyperalgesia. Common mechanisms of perioperative hyperalgesia are delineated in an organized fashion with clinicians as the target audience.

Thrombosis during off pump LVAD placement in a patient with heparin induced thrombocytopenia using bivalirudin.

Here we present our attempt at off pump HeartMate II left ventricular assist device (LVAD) implantation using the anticoagulant bivalirudin in a patient with heparin induced thrombocytopenia, which resulted in thrombosis within the LVAD device. This required that our procedure be converted to on pump, and a new HeartMate II LVAD device to be implanted. In our view, this thrombotic event may have been caused by a number of factors that include bivalirudin's (1) short half-life of about 20 minutes, (2) decreased activity with blood stasis, (3) inability to prevent clot propagation, and (4) uncertainty with real-time monitoring of therapeutic levels. To prevent future thrombotic events, it may be beneficial to immediately deair the LVAD device prior to the coring of the left ventricle during off pump LVAD placement. In addition, a solution other than blood may be used for priming. If blood is used for priming of the LVAD device, the duration of blood stasis should not exceed 20 minutes when bivalirudin is being used for anticoagulation. Furthermore, this case emphasizes the importance of having a backup LVAD device available and ready to use during surgical procedures.