Chilaiditi syndrome is a rare condition, reported in 0.025%-0.28% of the population, in which bowel interposition between the liver and the right hemidiaphragm becomes symptomatic. A male patient in his 60s with hypertension, hypothyroidism, ischaemic cardiomyopathy, chronic kidney disease and a 40-pack-year smoking history presented with progressive abdominal distension, nausea and vomiting for 3 days. He underwent urgent laparotomy with repair of a proximal jejunal perforation. After tracheal intubation, peak airway pressure increased to 50 cmH2O. Lung-protective ventilation with low tidal volumes, permissive hypercapnia, head-up positioning and nasogastric decompression improved compliance and reduced airway pressures to 36 cmH₂O. In the intensive care unit (ICU), staged ventilatory adjustments facilitated gradual weaning to bilevel positive airway pressure (BiPAP) by postoperative day 3. This case shows how Chilaiditi syndrome, complicated by bowel obstruction, can impair respiratory mechanics and create major intraoperative ventilatory challenges. Careful airway pressure interpretation and planned postoperative ventilatory support were central to safe management.
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This study evaluated whether the SCN9A rs6746030 (G>A; R1150W) polymorphism is associated with the clinical success or failure of pulpal anaesthesia following an inferior alveolar nerve block (IANB). In this prospective clinical genetic association study, 320 patients with symptomatic irreversible pulpitis in mandibular molars were recruited. Each patient received a standardized IANB with 2% lidocaine and 1:80000 epinephrine. Anaesthesia was considered successful if the Heft-Parker Visual Analogue Scale (HP-VAS) score was below 54 mm during access cavity preparation/instrumentation; scores of 54 mm or higher were classified as failures. Buccal swab samples were collected for genotyping of rs6746030 using a TaqMan SNP assay. Genotype distributions were compared between the success and failure groups. Statistical analysis included Hardy-Weinberg equilibrium testing, chi-square comparisons, and binary logistic regression with genotype, age and gender as predictors. Out of 320 patients analysed, 199 experienced failed anaesthesia, while 121 achieved successful outcomes. A significant deviation from Hardy-Weinberg equilibrium was found in the failed anaesthesia group (p < 0.05), suggesting potential genetic influence, while the successful group showed no deviation (p = 0.99). Logistic regression revealed that patients with the AA genotype had significantly lower odds of successful anaesthesia (OR = 0.22; 95% CI: 0.049-0.993). No significant associations were observed for the GA genotype, age, or gender. The model's predictive ability was limited, with an AUC of 0.53. The rs6746030 polymorphism of SCN9A in its AA form is associated with a higher likelihood of IANB failure in mandibular molars with symptomatic irreversible pulpitis.
The carotid body is a parasympathetic paraganglion located at the carotid bifurcation. A carotid body tumor is a rare paraganglioma arising from the carotid body. They are benign tumors that often present as slow-growing, painless lateral neck masses. We present a 45-year-old woman with a 6-year history of a slowly progressive left lateral neck swelling, which was initially painless but subsequently became associated with intermittent, non-radiating, dull-aching pain. Examination showed a hemodynamically stable woman with an ovoid-shaped left lateral neck swelling extending from below the angle of the mandible to the supraclavicular region measuring 3cm x 5cm. A contrast-enhanced cervical computed tomography (CT) scan showed an intensely enhancing soft tissue within the left carotid sheath, which splays the internal and external carotid arteries and also encases the carotid bifurcation and internal jugular vein, making it a Shamblin 3 carotid body tumor, which is difficult to resect. She was worked up for neck exploration and excision biopsy under general anaesthesia. Post-operatively, there was no report of injuries to the spinal accessory, hypoglossal, or vagus nerves. She made an uneventful recovery and was discharged home. Complete surgical resection of carotid body tumors with no postoperative complications is feasible even in a low-resource setting.
Radiography is frequently used for the evaluation of the musculoskeletal system in domestic and wild animal species. The aim of the study was to document the radiological anatomy of the shoulder, elbow and carpal joints and to provide length measurements of selective forelimb bones in southern giant pouched rats. Forelimb radiographs were obtained in seven adult male and female southern giant pouched rats under general anaesthesia. All rats had a well-developed clavicle, coracoid process and acromion. The minor and major tubercles were located further distally relative to the head of the humerus. The medial epicondyle and lateral supracondylar crest were very prominent. The supracondylar foramen was present in all rats. The radius was relatively smaller than the ulna, and the interosseous space was wide. The carpus had eight carpal bones, and two rudimentary digits were visualised on the palmar side of the manus. Additionally, five slender, widely spaced metacarpal bones, were seen with the third metacarpal bone being relatively the longest and the first metacarpal bone being the shortest. Shoulder joint dysplasia was identified in one female southern giant pouched rat. Radiographic examination of the thoracic limb in southern giant pouched rats allowed evaluation of bones forming the shoulder, elbow and carpal joints. Current information will contribute to the understanding of rodent anatomy and will be useful for scientists researching the forelimb of rodents and related species. Additionally, this information will augment the application of radiography and other related diagnostic imaging modalities in rodents and hence will enhance their welfare.
Cardiac surgery associated acute kidney injury (CSA-AKI) is a common and serious complication following cardiac surgery with cardiopulmonary bypass (CPB), associated with prolonged hospitalization, increased costs, and higher mortality rates. Pathophysiological reasons and preventive strategies remain limited. Preoperative hydration and restriction of fluid fasting represent potentially modifiable factors, yet their association with postoperative CSA-AKI remains poorly understood. To explore the association between preoperative oral hydration and CSA-AKI in patients undergoing elective cardiac surgery with CPB. Prospective, single centre, observational hypothesis-generating study. Preoperative hydration surrogate was estimated based on patient self-reporting of fluid intake between admission and surgery. ROC analysis yielded a Youden Index-derived cut-off of 51.5 ml/h to stratify patients into low and high intake groups. The cut-off was derived within the study sample for exploratory stratification. Primary endpoint was incidence of CSA-AKI within seven postoperative days, defined according to KIDIGO creatinine criteria. Secondary endpoints included incidence of renal replacement therapy (RRT), postoperative renal function parameters, intensive care unit (ICU) and hospital length of stay (LOS), 30-day mortality, and postoperative complications. Secondary endpoints were considered exploratory. Of the 92 patients analysed, 16,3% (15/92) of patients developed postoperative CSA-AKI. Using a data-derived expoloratory threshold of 51.5 ml/h, patients with lower preoperative fluid intake had a higher incidence of CSA-AKI thank patients with higher intake (33.3% [13/39]) vs. (3.8% [2/53]) (p < 0.001) respectively. RRT requirement was higher in the low-intake group (17.9% [7/39] vs. 0% [0/53]). The interval from last oral intake to induction of anaesthesia was significantly longer in the low-intake group (14.6 ± 5.1 vs. 11.5 ± 4.9, p = 0.004). Lower preoperative fluid intake was associated with higher observed rates of postoperative rates of CSA-AKI after applying a data-derived threshold. These exploratory data-driven findings and thresholds require prospective validation studies.
Patients with intellectual disabilities, autism spectrum disorder, and related conditions often require sedation or general anesthesia to receive dental treatment. Many of these patients routinely take multiple medications, including antiepileptic and antipsychotic drugs, which may influence anesthetic management through drug interactions. However, medication use among patients receiving dental anesthesia in special needs dentistry has not been well investigated. This study aimed to clarify patterns of oral medication use in this population. This retrospective descriptive study included patients who underwent dental treatment under general anesthesia or intravenous sedation at Okayama University Hospital, Japan, between April 2022 and March 2025. Demographic characteristics, anesthesia-related variables, and regularly prescribed oral medications were collected from electronic medical records. Medications were categorized by pharmacological class, and descriptive statistical analyses were performed. A total of 424 patients were analyzed. The mean age was 27.6 ± 15.3 years, and 67.4% were male. General anesthesia was used in 70.5% of patients. Overall, 71.0% regularly used oral medications, and polypharmacy, defined as the use of five or more medications, was observed in 23.5%. Antiepileptic drugs (36.8%) and antipsychotics (35.4%) were the most frequently prescribed medication classes. Risperidone and sodium valproate were the most commonly prescribed medications. Despite the relatively young age of the study population, medication use and polypharmacy were highly prevalent. The frequent use of antiepileptic and antipsychotic medications highlights the importance of understanding potential drug interactions during anesthetic management in special needs dentistry.
Ketamine, a short-acting anesthetic first synthesized in 1962, has long been surrounded by controversy, particularly regarding its use in neurosurgery. The rise in elective surgeries in the early 20th century spurred the development of new anesthetics. Phencyclidine (PCP) was created, which was effective but caused psychotic features. In response, ketamine, a safer PCP derivative was synthesized. Approved by the FDA in 1970, ketamine was widely used during the Vietnam War and gained favor in pediatric neurosurgery due to its rapid onset, lack of intubation requirement, and smooth recovery. It introduced the concept of "dissociative anesthesia." However, the emergence of newer anesthetics, early concerns about ketamine raising intracranial pressure (ICP), and its association with recreational drug use led to a decline in clinical neurosurgical use. This study explores ketamine's history, misconceptions about its safety, its effects on ICP, and its current neurosurgical applications. Reevaluating ketamine's history and its role could improve outcomes in neurological critical care and lead to a greater awareness that is essential to understanding its potential in neurosurgery.
Obese patients are vulnerable to atelectasis, impaired oxygenation, and postoperative pulmonary complications (PPCs) during and after general anesthesia. Driving pressure-guided individualized positive end-expiratory pressure (PEEP) can improve intraoperative respiratory mechanics, but whether these physiological benefits translate into fewer PPCs in bariatric surgery remains uncertain. In this single-center, parallel-group randomized clinical trial, 116 adults with obesity scheduled for elective laparoscopic bariatric surgery were randomized 1:1 to a driving pressure-guided individualized PEEP strategy or a conventional fixed low-PEEP strategy. All patients received volume-controlled ventilation with a tidal volume of 7 ml/kg predicted body weight and an inspired oxygen fraction of 0.50. After a standardized recruitment maneuver, the driving pressure group underwent stepwise PEEP titration to identify the PEEP level associated with the lowest driving pressure; the conventional group received fixed PEEP of 5 cm H2O. The primary endpoint was the severity and incidence of PPCs within the first 5 postoperative days. Secondary endpoints included respiratory mechanics, oxygenation, hospital length of stay, postoperative nausea and vomiting, surgical site infection, and mortality. All 116 randomized patients completed the trial. Any PPC occurred in 41 of 58 patients (70.7%) in the driving pressure group and 44 of 58 patients (75.9%) in the conventional group (odds ratio, 0.77; 95% CI, 0.33 to 1.79; P = 0.68). PPC severity scores were 1.0 ± 0.9 and 1.1 ± 0.8, respectively (mean difference, -0.10; 95% CI, -0.41 to 0.21; P = 0.53). Severe PPCs (grade >  = 3) occurred in 3 patients (5.2%) in each group. Compared with conventional ventilation, driving pressure-guided ventilation produced lower intraoperative driving pressure, higher dynamic compliance, and a higher PaO2/FiO2 ratio 1 h after surgical start; these physiological improvements were not accompanied by shorter hospital stay or fewer postoperative adverse events. In obese patients undergoing laparoscopic bariatric surgery, a driving pressure-guided individualized PEEP strategy improved intraoperative respiratory mechanics and early oxygenation but did not reduce PPCs compared with conventional fixed low-PEEP ventilation. These findings suggest that optimizing respiratory-system driving pressure alone may be insufficient to improve short-term clinical pulmonary outcomes in this surgical population.
Surgery and anesthesia can be associated with postoperative neurological injury, especially in individuals with diminished cognitive reserve. Timely identification of at-risk patients enables deployment of preventive strategies. Despite consistent recommendations, perioperative cognitive risk assessment remains largely overlooked. We explored which dynamic electroencephalogram (EEG) patterns are correlated with cognitive subdomains significantly affected by surgery and anesthesia. This was a secondary analysis of two prospective observational studies that included patients undergoing elective laparoscopic abdominal or pelvic surgery under general anesthesia. Cognition was assessed using the Mini-Mental State Exam, 2nd edition (MMSE-2) and the Montreal Cognitive Assessment (MoCA) within one week before and up to 48 h after surgery. Frontal EEG was recorded pre-induction to extubation. Cognitive subdomains and EEG changes were explored using linear regression and accuracy analyses. Data were obtained from 23 surgical patients (median [IQR] age, 63 [16] years; 52% female). Auditory-verbal delayed recall (MMSE-2, p = 0.001 AUC = 0.76 [0.62-0.89]; MoCA, p < 0.001 AUC = 0.75 [0.6-0.89]) and processing speed (MMSE-2, p < 0.001 AUC = 0.85 [0.72-0.95]) were significantly affected postoperatively. Delta power at the end of maintenance, changes in theta, alpha power, aperiodic slope, offset were correlated with processing speed changes. Dynamic EEG patterns were correlated with processing speed changes. Integrating EEG into perioperative risk assessment may contribute to early identification of vulnerability. This study demonstrates the correlation between changes in perioperative EEG and cognitive subdomains.
Post-traumatic stress disorder (PTSD) often co-occurs with anxiety and social interaction difficulties, particularly in females. This study examined the effects of voluntary and involuntary exercise, combined with sertraline, on PTSD-like symptoms, anxiety, and social behavior in female rats. PTSD-like symptoms were induced using the Single Prolonged Stress (SPS) model, which involved sequential exposure to restraint stress (2 h), forced swimming (20 min), and ether anesthesia (2-3 min), followed by a 7-day incubation period. A 10-min restraint was then applied as an additional stress event. Afterward, the rats underwent voluntary wheel running or treadmill exercise (5 days per week), with or without sertraline treatment (10 mg/kg/day) for 4 weeks. Behavioral assessments were conducted using the Elevated Plus Maze (EPM) and the Three-Chamber Social Test (3-CST). One day after behavioral testing, estrous cycles were evaluated using vaginal smears, followed by corticosterone analysis in blood samples the next day. Involuntary exercise and sertraline significantly reduced anxiety-like behavior, with involuntary exercise showing a stronger effect than voluntary exercise. Involuntary exercise also improved sociability and social novelty, while sertraline enhanced social novelty. Notably, sertraline reduced corticosterone levels, with the greatest effect observed when combined with involuntary exercise. These findings suggest that combining involuntary exercise with pharmacological treatment may provide synergistic benefits for alleviating anxiety-like behaviors and stress responses in a PTSD-like rat model.
Acute kidney injury (AKI) is a common complication with poor clinical outcomes, and patients with high body mass index (BMI) are particularly vulnerable, especially after major surgical procedures, though the underlying mechanisms remain unclear. In this study, we used a Western diet (WD)-induced obesity model to examine how obesity influences ischemia/reperfusion injury (IRI)-induced AKI and to explore the mechanisms involved. We found that obesity alone did not cause renal damage in healthy mice but markedly worsened kidney injury following IRI. RNA sequencing and bioinformatic analyses identified upregulation of hexokinase-2 as a key mediator of this effect. Notably, pharmacologic inhibition of hexokinase-2 restored metabolic balance in cultured human proximal tubule epithelial cells and alleviated renal injury in obese mice with AKI. Furthermore, clinical data showed that higher BMI and increased hexokinase-2 expression were associated with more severe tubular injury in patients with acute tubular necrosis. These findings demonstrate that obesity aggravates AKI through hexokinase-2-mediated metabolic reprogramming and suggest that targeting hexokinase-2 could be a promising therapeutic strategy for obese individuals at risk of AKI.
To evaluate the accuracy of the EOlife X, a ventilation feedback device for training, during regular ventilation and during intra-arrest ventilation with ongoing chest compressions. In this prospective experimental method-comparison study in a porcine cardiac arrest model, EOlife X-derived inspiratory tidal volume (Vti), expiratory tidal volume (Vte), and respiratory rate (f) were compared with sensor-based reference computations. Data were extracted by optical character recognition from screen recording of the EOlife X. Reference metrics were computed from continuous airflow and airway pressure measurements. For each animal, a two-minute-long period before cardiac arrest and a two-minute-long period of cardiopulmonary resuscitation (CPR) were analysed. The animals were mechanically ventilated via an endotracheal tube. Agreement was assessed using Bland-Altman analysis with linear mixed model derived bias and limits of agreement to account for repeated measures. Clinically acceptable differences were prespecified as ±50mL for tidal volumes and ±3/min for respiratory rate. Data from 11 animals, yielding 821 paired ventilations (581 regular, 240 intra-arrest), were analysed. During regular ventilation, EOlife X measurements were within the prespecified clinically acceptable difference for all metrics, while exceeding it for all metrics during intra-arrest ventilation: Bias for Vtiwas -26mL with limits of agreement (LoA) ranging from -355 to 304mL, for Vtebias was -281mL (LoA -599 to 37mL), and for f23.8/min (LoA -50.2 to 97.8/min). The proportions of measurements outside the prespecified clinically acceptable difference during intra-arrest ventilation were 37.1% for Vti, 86.2% for Vte, and 60.4% forf. Waveform inspection suggested that chest compression-induced reverse airflow affects airflow-based measurements. EOlife X showed agreement within predefined clinically acceptable limits during regular ventilation, but not during intra-arrest ventilation with ongoing chest compressions. Chest compression-induced reverse airflow appears to compromise airflow-based calculation of tidal volume and respiratory rate. Devices for ventilatory monitoring should be validated specifically under CPR conditions.
This study estimated the economic benefits of robotic-assisted ventral hernia repair (RVHR) using individual patient data (IPD) from a prospective multicenter study, the ASPIRE INDIA. The 30-day quality-adjusted life-years (QALY) gain was estimated from the EuroQol five-dimension three-level questionnaire scores (EQ-5D-3L), with uncertainty quantified via non-parametric bootstrap resampling. Productivity gains were estimated by wages drawn from a lognormal distribution fitted to Periodic Labour Force Survey (PLFS) 2023-24 data, adjusted to FY2026-27. A joint Monte Carlo (MC) simulation propagated uncertainty across all stochastic inputs. The results were scaled to an annual cohort of 300,000 cases. All assumptions were tested through sensitivity analyses. At 300,000 annual cases, the mean total benefit of RVHR over laparoscopic VHR (LVHR) was INR 2,799 million (95% confidence interval [CI]: INR 846-5,001) at 1x willingness-to-pay (WTP; INR 210,000/QALY) and INR 2,959 million (95% CI: INR 1,010-5,154 million) at 2x WTP. Post-anesthesia care unit (PACU) time saved represented the largest component of estimated economic benefit, which accounted for 65.8% of the total benefit at 1x WTP, followed by patient productivity (19.0%), caregiver productivity (9.5%), and QALY gain (5.7%). These findings identify the principal economic benefit dimensions for RVHR and provide a quantitative basis for structured value discussions at the institutional level regarding robotic-assisted surgery (RAS) adoption that should be considered alongside cost data in future comprehensive economic evaluations.
There are very few reports describing to which extent sex, age, dose and time from dose intake affect the enantiomeric distribution during treatment with citalopram. The aim of the present study was to quantify the impact of these factors on the active S-enantiomer during treatment with citalopram. Samples analysed for citalopram in a routine therapeutic drug monitoring setting were included. The analytical method consisted of enantiomeric separation and quantification of R- and S-citalopram. We employed a linear mixed model to account for multiple samples from the same patient. A total of 305 samples was included. The mean (± SD) proportion of S-citalopram in the total sample was 34.2 ± 8.1%, corresponding to a mean S/R ratio of 0.52 ± 0.17. According to the linear mixed model, the proportion of S-citalopram increased with 0.69 percentage points per decade of age. Increasing the time interval from dose intake to sampling reduced this proportion with 1.10 percentage points every 6 h. For example, if the sample was obtained 24 h after intake in a person aged 40, the proportion of S-citalopram was 32.7%; while if the sample was obtained 12 h after intake the proportion was 34.9%. Sex and dose did not impact significantly. The percentage of S-citalopram in plasma during treatment with citalopram increased with patient age and decreased with the time from dose intake. In contrast, sex and dose did not significantly affect the percentage of S-citalopram.
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Delayed coronary stent-related inflammatory complications following percutaneous coronary intervention (PCI) are exceptionally rare, and chronic cutaneous fistulization years after stent implantation has only rarely been described. Such indolent presentations may mimic superficial chest wall infections, making diagnosis challenging. Multimodality imaging is essential for accurate diagnosis and surgical planning. A 53-year-old man with type 2 diabetes mellitus and ischemic heart disease underwent right coronary artery (RCA) stenting in 2018. He presented with recurrent intermittent fever and a persistent draining xiphisternal sinus for seven months following incision and drainage of a presumed chest wall abscess. Ultrasonography demonstrated a localized subcutaneous collection. Contrast-enhanced computed tomography and CT coronary angiography (CTCA) revealed a fractured, chronically occluded RCA stent with extensive peri-stent inflammatory soft tissue extending into the pericardium, diaphragm, and subdiaphragmatic region. Cardiac magnetic resonance imaging confirmed transdiaphragmatic inflammatory extension and a fistulous tract communicating with the overlying skin. Transesophageal echocardiography was not performed because transthoracic echocardiography and cross-sectional imaging adequately delineated the lesion and showed no evidence of endocarditis. Following preoperative and perioperative antibiotic therapy, the patient underwent surgical excision of the fractured stent, chronic fibro-inflammatory tissue, and sinus tract. Intraoperative cultures and GeneXpert testing were negative, possibly reflecting prior prolonged antibiotic therapy. The postoperative course was uneventful, with complete wound healing, resolution of fever, and follow-up transthoracic echocardiography demonstrating no pericardial collection or valvular vegetations. This case highlights an exceptionally rare delayed culture-negative chronic peri-stent inflammatory fistulizing process associated with RCA stent fracture presenting nearly seven years after PCI. It emphasizes the importance of maintaining a high index of suspicion in patients with persistent chest wall sinuses after coronary intervention and demonstrates the complementary role of CTCA and cardiac magnetic resonance imaging in defining disease extent and guiding successful surgical management.
We reported the clinical records of 2 patients each with a foreign body in the urinary bladder admitted to Qingdao Central Hospital, University of Health and Rehabilitation Sciences. The size and shape of each foreign body in the urinary bladder were different, thus we chose different surgical approaches to remove them. Case 1 was a 21-year-old male patient. He presented to the outpatient service with urodynia. The patient currently complained of urodynia, and narrated that a foreign body was self-inserted via the urethra 2 days before. Physical examination revealed suprapubic pain. Ultimately he was admitted to the Department of Urology with a diagnosis of "bladder foreign body". A computed tomography (CT) scan of the pelvis was performed and the results demonstrated a linear metallic structure, mea-suring 4.2 cm in length, within the urinary bladder. Under general anesthesia, the patient was placed in lithotomy position and a rigid cystoscope was inserted into the bladder via urethra. The foreign body was a metal tubular structure and was located within the urinary bladder. Removal by foreign body forceps was attempted and long axis of the foreign body should be parallel to cystoscope. Removal was carefully performed after several attempts due to the smooth surface of the metal foreign body. Case 2 was a 42-year-old male patient. He presented to the outpatient service with dysuria and urodynia and was admitted to the Department of Urology. The patient narrated that a foreign body was self-inserted via the urethra 1 day before, and currently complained of dysuria, urodynia, and slight hematuria. A CT scan of the urologic system was performed and the results demonstrated a metal tubular structure, measuring 21.5 cm in length. The length of the foreign body was long (from top of iliac crest to perineum) and both ends were sharp, thus bladder perforation could not be excluded. Besides, with smooth metal surface, it was difficult to remove via cystoscopy and the risk of iatrogenic bladder perforation would increase simultaneously. Therefore, laparoscopic surgery was chosen to detect whether there would be a bladder perforation and could remove the foreign body. Under general anesthesia, the patient was placed in supine position and supraumbilical incision of 1 cm was performed. Pneumoperitoneum needle was used to establish a pneumoperitoneum and insufflation CO2 pressure was maintained at 12 mmHg. The peritoneum was accessed and a 10-mm trocar and laparoscopic camera were inserted. A 5-mm trocar was inserted at 2 cm below the umbilical level of lateral margin of left rectus abdominis muscle. While a 12-mm trocar was inserted at symmetrical site of his right rectus abdominis muscle. Under laparoscope, dome of the bladder was lifted into the abdominal cavity by the foreign body, then the bladder wall was incised to expose the foreign body. We pushed the bottom of the foreign body from the perineum extracorporally and removed the foreign body from the supraumbilicus trocar.
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