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1. Comparison of Postoperative Respiratory Monitoring by Acoustic and Transthoracic Impedance Technologies in Pediatric Patients at Risk of Respiratory Depression

Author

Lili Ding, C. Dean Kurth, Timothy Williams, Mohamed Mahmoud, Stacey L. Ishman, Abu Minhajuddin, Peter Szmuk, Allison Griffin, Megan Kalin, and Mario Patino

Subjects
Male, medicine.medical_specialty, Percentile, Time Factors, Adolescent, Respiratory rate, Transducers, Pilot Projects, Respiratory monitoring, 03 medical and health sciences, 0302 clinical medicine, Respiratory Rate, Predictive Value of Tests, 030202 anesthesiology, Electric Impedance, medicine, Humans, False Positive Reactions, Plethysmography, Impedance, Prospective Studies, 030212 general & internal medicine, Child, Psychiatry, Prospective cohort study, False Negative Reactions, Lung, Monitoring, Physiologic, Ohio, Tonsillectomy, Capnography, medicine.diagnostic_test, business.industry, Reproducibility of Results, Acoustics, Texas, Confidence interval, Treatment Outcome, Anesthesiology and Pain Medicine, Child, Preschool, Clinical Alarms, Predictive value of tests, Anesthesia, Female, Respiratory Insufficiency, business
Abstract

Background In children, postoperative respiratory rate (RR) monitoring by transthoracic impedance (TI), capnography, and manual counting has limitations. The rainbow acoustic monitor (RAM) measures continuous RR noninvasively by a different methodology. Our primary aim was to compare the degree of agreement and accuracy of RR measurements as determined by RAM and TI to that of manual counting. Secondary aims include tolerance and analysis of alarm events. Methods Sixty-two children (2-16 years old) were admitted after tonsillectomy or receiving postoperative patient/parental-controlled analgesia. RR was measured at regular intervals by RAM, TI, and manual count. Each TI or RAM alarm resulted in a clinical evaluation to categorize as a true or false alarm. To assess accuracy and degree of agreement of RR measured by RAM or TI compared with manual counting, a Bland-Altman analysis was utilized showing the average difference and the limits of agreement. Sensitivity and specificity of RR alarms by TI and RAM are presented. Results Fifty-eight posttonsillectomy children and 4 patient/parental-controlled analgesia users aged 6.5 ± 3.4 years and weighting 35.3 ± 22.7 kg (body mass index percentile 76.6 ± 30.8) were included. The average monitoring time per patient was 15.9 ± 4.8 hours. RAM was tolerated 87% of the total monitoring time. The manual RR count was significantly different from TI (P = .007) with an average difference ± SD of 1.39 ± 10.6 but were not significantly different from RAM (P = .81) with an average difference ± SD of 0.17 ± 6.8. The proportion of time when RR measurements differed by ≥4 breaths was 22% by TI and was 11% by RAM. Overall, 276 alarms were detected (mean alarms/patient = 4.5). The mean number of alarms per patient were 1.58 ± 2.49 and 2.87 ± 4.32 for RAM and TI, respectively. The mean number of false alarms was 0.18 ± 0.71 for RAM and 1.00 ± 2.78 for TI. The RAM was found to have 46.6% sensitivity (95% confidence interval [CI], 0.29-0.64), 95.9% specificity (95% CI, 0.90-1.00), 88.9% positive predictive value (95% CI, 0.73-1.00), and 72.1% negative predictive value (95% CI, 0.61-0.84), whereas the TI monitor had 68.5% sensitivity (95% CI, 0.53-0.84), 72.0% specificity (95% CI, 0.60-0.84), 59.0% positive (95% CI, 0.44-0.74), and 79.5% negative predictive value (95% CI, 0.69-0.90). Conclusions In children at risk of postoperative respiratory depression, RR assessment by RAM was not different to manual counting. RAM was well tolerated, had a lower incidence of false alarms, and had better specificity and positive predictive value than TI. Rigorous evaluation of the negative predictive value is essential to determine the role of postoperative respiratory monitoring with RAM.

Published
2017
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2. Myocardial Injury after Noncardiac Surgery

Author

Pierre Coriat, Patricia Cruz, Bogusz Kaczmarek, Gabriel Cusati, Wendy Lim, Saeed Darvish-Kazim, Rupert Pearse, Finlay A. McAlister, Cheryl Ramballi, Robert C M Stephens, R.M. Pearse, Jeff Weitz, Germán Málaga, Alexander Y. Fu, Eleanor McAlees, Alberto Varela, Maria Palencia, James Zacharias, Ryan J. J. Amadeo, Bruce M Biccard, Janet Woods, Catherine M. Clase, Patrick S Finnegan, Laura Gallego Paredes, Alistair Hall, Mariana Vargas Furtado, Alben Sigamani, José Villamor, Alex Torborg, Maria De Los Angeles Lazo, Tony Gin, Pavel S Roshanov, Carmen Fernández, Andrea Kurz, Hertzel C. Gerstein, Stephen Li, R.N. Rodseth, P. Naidoo, Mitchell Winemaker, Parminder Raina, Gordon Y.S. Choi, Lalita Afzal, Richard Mizera, Sean M. Bagshaw, Marta Januszewska, Yannick LeManach, Sultana Furruqh, Robert J. Sapsford, Peter Lovrics, B M Biccard, Cecilia Martínez, Faisal Siddiqui, J. Mooney, Carisi Anne Polanczyk, Ina Ismiarti Shariffuddin, Mark Crowther, Elizabeth Ling, Adrià Font, Mark Soth, Maria Stella Chaparro, Maria José Membrillo, Ekaterina Popova, Denis Monneret, Richard P. Whitlock, Amit Garg, Andrew Archbold, Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (Vision) Investigators, M Leuwer, Vincent W. Lee, Zhuo Sun, Patricia Piñeiro, César A. Jardim, Clare D. Ramsey, Krit Panjasawatwong, James Paul, David W. Gibson, Philip St John, Peter Nagele, Jose Amalth do Espirirto Santo, Pablo Alonso-Coello, Jacek Musial, Jacques G. Tittley, Fernando Botto, Georges Daas, Hou Yee Lai, Ana Gutierrez del Arroyo, Edmunds Reineks, Martin Leuwer, Clive Kearon, Jane Blood, Mari Luz Maestre, Neesh Pannu, Marta De Antonio, Ameen Patel, Aida Rotta-Rotta, Noorjahan Haneem Md Hashim, Amal Bessissow, Hélio Penna Guimarães, Norman Buckley, Mateusz Kózka, Maria José Ferré, Gerard Urrútia, Lydia C.W. Lit, Matthew T. V. Chan, Philip J. Devereaux, Ushananthini Ki, Jesús Alvarez García, Shaveta Mala, Juan Carlos Villar, Andrew McKay, Silvia Moreira Ayub Ferreira, Angeles de Miguel, Gordon H. Guyatt, David Orozco, A. Rushton, Michael J Jacka, Holger J Schünemann, Diane Heels-Ansdell, Guillaume Paré, Stephen Hill, Amit X Garg, Hooman Honar, Pervez Sultan, Miquel Santaló, Zubin Punthakee, Sihe Wang, Katia R. M. Leite, Holger Schünemann, Hilary P Grocott, Aram Shahinyan, Sebastian Ribas, Jackie Bosch, Amanda Smith, Giovanna Luratibuse, Joseph Cherian, Maciej Chwała, Heather McDonald, Rey R. Acedillo, Manuel Muñoz, Sally Benton, Michael Walsh, Vikas Tandon, Shirley Pettit, Javier D Loza-Herrera, Paul M. O'Bryne, Joanne Fletcher, Richard Halliwell, Clara K Chow, Jacek Górka, Michelle M. Graham, Alvaro Castañeda, Ainslie Hildebrand, Patrick Magloire, Skarlett Vásquez, Gareth L Ackland, P. George, Sergio Mazzadi, Susannah Howard, Simon J. Howell, Rubeshan Naidoo, William Orovan, Megan Kalin, Anna Reyes, Anthony Adili, Frederick A. Spencer, Laurel Thorlacius, Jehonathan H. Pinthus, Michaela Lobley, Justin DeBeer, Theroshnie Kisten, Dean Gopalan, John W. Eikelboom, Eliana Vieira Santucci, Derek R. Townsend, Raúl Gonzalez, Tomas VanHelder, Sean McMurtry, Susana Díaz, Catherine Royer, Hussein Cassimjee, James D. Douketis, Ahsun Khan, V Vasanthan, Chew Yin Wang, Sadeesh Srinathan, A. Wahab Undok, Deven Reddy, Paola Muti, Paul Jackson, Javier Ganame, Danielle MacNeil, Pilar Paniagua, Graham S. Hillis, Wojciech Szczeklik, Azim S. Gangji, Stephen D. Walter, Andrew Worster, Matthew B. McQueen, Sadeesh K Srinathan, Otavio Berwanger, Cameron Egan, Aine Mugabi, Neil MacDonald, Erica Aranha Suzumura, Matthew J. McQueen, Reitze N. Rodseth, Maria Del Barrio, Peter A. Kavsak, Cristina Ibanez Esteve, David Szalay, Olga L. Cortés, Fidel Reyes, John Whittle, Gracie Ong, Troy S. Wildes, Ngan N. Lam, Karen Raymer, C. Williams, G.L. Ackland, Enrico Vizza, Salim Yusuf, Wan Azman Ahmad, Radhika Dhanpal, Barbara Sokołowska, David Cain, Andre Lamy, Alexandre Biasi Cavalcanti, Marko Mrkobrada, James Hankinson, Emmanuelle Duceppe, Julian Scott, Maria Tiboni, Tomasz Mrowiecki, Vanessa Valderrama-Victoria, Paweł Iwaszczuk, Robert Sapsford, Andrew Wragg, Atiya Faruqui, Edyta Niebrzegowska, Mohit Bhandari, Teresa Del Castillo, Jean Pierre Goarin, Marko Simunovic, Omid Salehian, Smitha Almeida, Ingeborg Welters, Lehana Thabane, D.L. Skinner, Tej Sheth, Alvin S.B. Tan, Ignacio Garutti, Daniel I. Sessler, Sabu Thomas, Sarah D. McDonald, Trevor W R Lee, Marzida Mansor, Julian H. Barth, Nikki Dewhirst, Xavier Pelaez, Valsa Abraham, Jill Rudkowski, Sanjit S. Jolly, Azad Hassan Abdul Razack, Marcin Raczek, Duane J. Funk, Deborah J. Cook, Martin O'Donnell, and Denis Xavier

Subjects
medicine.medical_specialty, biology, Troponin T, business.industry, Hazard ratio, Infarction, Perioperative, medicine.disease, Troponin, Surgery, Anesthesiology and Pain Medicine, Internal medicine, medicine, biology.protein, Cardiology, Myocardial infarction, Prospective cohort study, business, Cohort study
Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Published
2014
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3. Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

Author

Fernando, Botto, Pablo, Alonso-Coello, Matthew T V, Chan, Juan Carlos, Villar, Denis, Xavier, Sadeesh, Srinathan, Gordon, Guyatt, Patricia, Cruz, Michelle, Graham, C Y, Wang, Otavio, Berwanger, Rupert M, Pearse, Bruce M, Biccard, Valsa, Abraham, German, Malaga, Graham S, Hillis, Reitze N, Rodseth, Deborah, Cook, Carisi A, Polanczyk, Wojciech, Szczeklik, Daniel I, Sessler, Tej, Sheth, Gareth L, Ackland, Martin, Leuwer, Amit X, Garg, Yannick, Lemanach, Shirley, Pettit, Diane, Heels-Ansdell, Giovanna, Luratibuse, Michael, Walsh, Robert, Sapsford, Holger J, Schünemann, Andrea, Kurz, Sabu, Thomas, Marko, Mrkobrada, Lehana, Thabane, Hertzel, Gerstein, Pilar, Paniagua, Peter, Nagele, Parminder, Raina, Salim, Yusuf, P J, Devereaux, Matthew J, McQueen, Mohit, Bhandari, Jackie, Bosch, Norman, Buckley, Clara K, Chow, Richard, Halliwell, Stephen, Li, Vincent W, Lee, John, Mooney, Mariana V, Furtado, Erica, Suzumura, Eliana, Santucci, Katia, Leite, Jose Amalth do Espirirto, Santo, Cesar A P, Jardim, Alexandre Biasi, Cavalcanti, Helio Penna, Guimaraes, Michael J, Jacka, Finlay, McAlister, Sean, McMurtry, Derek, Townsend, Neesh, Pannu, Sean, Bagshaw, Amal, Bessissow, Emmanuelle, Duceppe, John, Eikelboom, Javier, Ganame, James, Hankinson, Stephen, Hill, Sanjit, Jolly, Andre, Lamy, Elizabeth, Ling, Patrick, Magloire, Guillaume, Pare, Deven, Reddy, David, Szalay, Jacques, Tittley, Jeff, Weitz, Richard, Whitlock, Saeed, Darvish-Kazim, Justin, Debeer, Peter, Kavsak, Clive, Kearon, Richard, Mizera, Martin, O'Donnell, Matthew, McQueen, Jehonathan, Pinthus, Sebastian, Ribas, Marko, Simunovic, Vikas, Tandon, Tomas, Vanhelder, Mitchell, Winemaker, Sarah, McDonald, Paul, O'Bryne, Ameen, Patel, James, Paul, Zubin, Punthakee, Karen, Raymer, Omid, Salehian, Fred, Spencer, Stephen, Walter, Andrew, Worster, Anthony, Adili, Catherine, Clase, Mark, Crowther, James, Douketis, Azim, Gangji, Paul, Jackson, Wendy, Lim, Peter, Lovrics, Sergio, Mazzadi, William, Orovan, Jill, Rudkowski, Mark, Soth, Maria, Tiboni, Rey, Acedillo, Amit, Garg, Ainslie, Hildebrand, Ngan, Lam, Danielle, Macneil, Pavel S, Roshanov, Sadeesh K, Srinathan, Clare, Ramsey, Philip St, John, Laurel, Thorlacius, Faisal S, Siddiqui, Hilary P, Grocott, Andrew, McKay, Trevor W R, Lee, Ryan, Amadeo, Duane, Funk, Heather, McDonald, James, Zacharias, Olga Lucía, Cortés, Maria Stella, Chaparro, Skarlett, Vásquez, Alvaro, Castañeda, Silvia, Ferreira, Pierre, Coriat, Denis, Monneret, Jean Pierre, Goarin, Cristina Ibanez, Esteve, Catherine, Royer, Georges, Daas, Gordon Y S, Choi, Tony, Gin, Lydia C W, Lit, Alben, Sigamani, Atiya, Faruqui, Radhika, Dhanpal, Smitha, Almeida, Joseph, Cherian, Sultana, Furruqh, Lalita, Afzal, Preetha, George, Shaveta, Mala, Holger, Schünemann, Paola, Muti, Enrico, Vizza, G S Y, Ong, Marzida, Mansor, Alvin S B, Tan, Ina I, Shariffuddin, V, Vasanthan, N H M, Hashim, A Wahab, Undok, Ushananthini, Ki, Hou Yee, Lai, Wan Azman, Ahmad, Azad H A, Razack, Vanessa, Valderrama-Victoria, Javier D, Loza-Herrera, Maria, De Los Angeles Lazo, Aida, Rotta-Rotta, Barbara, Sokolowska, Jacek, Musial, Jacek, Gorka, Pawel, Iwaszczuk, Mateusz, Kozka, Maciej, Chwala, Marcin, Raczek, Tomasz, Mrowiecki, Bogusz, Kaczmarek, Bruce, Biccard, Hussein, Cassimjee, Dean, Gopalan, Theroshnie, Kisten, Aine, Mugabi, Prebashini, Naidoo, Rubeshan, Naidoo, Reitze, Rodseth, David, Skinner, Alex, Torborg, Gerard, Urrutia, Mari Luz, Maestre, Miquel, Santaló, Raúl, Gonzalez, Adrià, Font, Cecilia, Martínez, Xavier, Pelaez, Marta, De Antonio, Jose Marcial, Villamor, Jesús Alvarez, García, Maria José, Ferré, Ekaterina, Popova, Ignacio, Garutti, Carmen, Fernández, Maria, Palencia, Susana, Díaz, Teresa, Del Castillo, Alberto, Varela, Angeles, de Miguel, Manuel, Muñoz, Patricia, Piñeiro, Gabriel, Cusati, Maria, Del Barrio, Maria José, Membrillo, David, Orozco, Fidel, Reyes, Robert J, Sapsford, Julian, Barth, Julian, Scott, Alistair, Hall, Simon, Howell, Michaela, Lobley, Janet, Woods, Susannah, Howard, Joanne, Fletcher, Nikki, Dewhirst, C, Williams, A, Rushton, I, Welters, M, Leuwer, Rupert, Pearse, Gareth, Ackland, Ahsun, Khan, Edyta, Niebrzegowska, Sally, Benton, Andrew, Wragg, Andrew, Archbold, Amanda, Smith, Eleanor, McAlees, Cheryl, Ramballi, Neil, Macdonald, Marta, Januszewska, Robert, Stephens, Anna, Reyes, Laura Gallego, Paredes, Pervez, Sultan, David, Cain, John, Whittle, Ana Gutierrez, Del Arroyo, Zhuo, Sun, Patrick S, Finnegan, Cameron, Egan, Hooman, Honar, Aram, Shahinyan, Krit, Panjasawatwong, Alexander Y, Fu, Sihe, Wang, Edmunds, Reineks, Jane, Blood, Megan, Kalin, David, Gibson, and Troy, Wildes

Subjects
Male, Myocardial Ischemia, surgical technique, Article, Cohort Studies, Age Distribution, Postoperative Complications, Troponin T, Humans, preoperative care, human, Prospective Studies, outcome assessment, Aged, Hardware_MEMORYSTRUCTURES, troponin T, ComputingMilieux_THECOMPUTINGPROFESSION, predictive value, Research Diagnostic Criteria, heart muscle injury, Middle Aged, Prognosis, major clinical study, mortality, clinical feature, Patient Outcome Assessment, peroperative complication, priority journal, Surgical Procedures, Operative, prognosis, purl.org/pe-repo/ocde/ford#3.02.09 [https]
Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated abnormal laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Published
2014

4. 727 URINARY AQUAPORIN-1 AND PERILIPIN-2: POTENTIAL BIOMARKERS FOR EARLY DETECTION OF RENAL CELL CARCINOMA

Author

Alethea Paradis, Robert S. Figenshau, Evan D. Kharasch, Joseph B. Song, Megan Kalin, Joel Vetter, Sam B. Bhayani, Youssef S. Tanagho, Jonathan M. Mobley, Jeremiah J. Morrissey, and Goutham Vemana

Subjects
medicine.medical_specialty, Bladder cancer, biology, Genitourinary system, business.industry, Urology, medicine.medical_treatment, Urinary system, Perilipin 2, Urine, urologic and male genital diseases, medicine.disease, female genital diseases and pregnancy complications, Nephrectomy, Cystectomy, Renal cell carcinoma, medicine, biology.protein, business, neoplasms
Abstract

INTRODUCTION AND OBJECTIVES: Renal cell carcinoma (RCC) has a higher lethal potential than any other urological malignancy. Currently, no screening marker exists for RCC. Previous studies have found elevated urine concentrations of aquaporin-1 (AQP1) and perilipin-2 (PLIN2) in patients with RCC compared to healthy controls. We compare pre-operative urine concentrations of AQP1 and PLIN2 in RCC patients with pre-operative urine concentrations in prostate cancer (ACP) and bladder cancer (TCC) patients. Our goal is to demonstrate specificity of these markers to detect RCC among the most common genitourinary malignancies. METHODS: Patients were enrolled into the study from February 28, 2012, to October 16, 2012. Pre-operative urine samples were obtained from 35 patients with clear and papillary RCC who underwent either a partial or radical nephrectomy, 27 patients with ACP who underwent a radical prostatectomy, and 28 patients with TCC who underwent either a transurethral resection of bladder tumor or radical cystectomy. Urine AQP1 and PLIN2 concentrations were determined by Western blot procedures normalized to the urinary creatinine excretion. Wilcoxon Rank Sum Test compared urine concentrations of AQP1 and PLIN2 between RCC, TCC, and ACP patients. RESULTS: The median urine AQP1 and PLIN2 for RCC patients were 33 and 37 relative absorbance/mg urinary creatinine. Patients with TCC had median AQP1 and PLIN2 concentrations of 2 and 6, while ACP patients had median AQP1 and PLIN2 of 3 and 5. Using the Wilcoxon Rank Sum test, there was a statistical difference in urinary AQP1 and PLIN2 concentrations between RCC patients and both patients with TCC and ACP (p-value 0.0001 for both). CONCLUSIONS: There is a statistically significant elevation in the pre-operative urine concentrations of AQP1 and PLIN2 in RCC patients compared to patients with TCC and ACP. Knowing that the urinary concentrations of AQP1 and PLIN2 are elevated in patients with RCC compared to healthy controls, we believe that AQP1 and PLIN2 have high potential to be used as screening biomarkers for RCC. Source of Funding: Funding is from two grants: R01CA141521 and the Barnes Jewish Hospital Foundation.

Published
2013
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