The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study

Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients.

Processing and production of pellets from poor-grade manganese-containing raw materials

there is a review of current researches in the processing of poor-grade manganese raw materials. The variety of manganese minerals caused by the valent state of metal in compounds is demonstrated. Different processing methods for manganese-containing mineral and technogenic raw materials are considered. The process of extraction of manganese from ferruginous manganese ore using reduction roasting and magnetic separation, beneficiation technology of poor-grade manganese ore to improve the ratio of Mn/Fe; processes of beneficiation and sintering of fine ferruginous manganese ore with low manganese content; production of agglomerate from the concentrate of manganese poor-grade ore to produce ferrosilicon manganese are described. Results of the authors researches intended to obtain concentrate from manganese-containing sludge and to produce hardened pellets suitable for melting into ferromanganese on its basis using a new component of the binder are presented.

Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism

Background and purpose Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. Materials and methods We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. Results Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. Conclusions Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

804 The Role of Kono-S Anastomosis and Mesenteric Resection in Reducing Recurrence After Surgery for Crohn’s Disease: A Systematic Review

Aim Recurrence after surgery for Crohn’s disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key.The Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques. Method We searched MEDLINE, Embase and the Cochrane Library for, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn’s disease. We assessed methodological quality and risk of bias using the Cochrane tool for randomized controlled trials and the JBI tool for nonrandomized trials. A narrative synthesis was used to summarize the findings. Results Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%–3.4% vs 15%–24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor-quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation. Conclusions The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.

Intracerebral Iron Accumulation may be Associated with Secondary Brain Injury in Patients with Poor Grade Subarachnoid Hemorrhage

Background The amount of intracranial blood is a strong predictor of poor outcome after subarachnoid hemorrhage (SAH). Here, we aimed to measure iron concentrations in the cerebral white matter, using the cerebral microdialysis (CMD) technique, and to associate iron levels with the local metabolic profile, complications, and functional outcome. Methods For the observational cohort study, 36 patients with consecutive poor grade SAH (Hunt & Hess grade of 4 or 5, Glasgow Coma Scale Score ≤ 8) undergoing multimodal neuromonitoring were analyzed for brain metabolic changes, including CMD iron levels quantified by graphite furnace atomic absorption spectrometry. The study time encompassed 14 days after admission. Statistical analysis was performed using generalized estimating equations. Results Patients were admitted in a poor clinical grade (n = 26, 72%) or deteriorated within 24 h (n = 10, 28%). The median blood volume in the subarachnoid space was high (SAH sum score = 26, interquartile range 20–28). Initial CMD iron was 44 µg/L (25–65 µg/L), which significantly decreased to a level of 25 µg/L (14–30 µg/L) at day 4 and then constantly increased over the remaining neuromonitoring days (p < 0.01). A higher intraventricular hemorrhage sum score (≥ 5) was associated with higher CMD iron levels (Wald-statistic = 4.1, df = 1, p = 0.04) but not with the hemorrhage load in the subarachnoid space (p = 0.8). In patients developing vasospasm, the CMD iron load was higher, compared with patients without vasospasm (Wald-statistic = 4.1, degree of freedom = 1, p = 0.04), which was not true for delayed cerebral infarction (p = 0.4). Higher iron concentrations in the brain extracellular fluid (34 µg/L, 36–56 µg/L vs. 23 µg/L, 15–37 µg/L) were associated with mitochondrial dysfunction (CMD lactate to pyruvate ratio > 30 and CMD-pyruvate > 70 µM/L, p < 0.001). Brain extracellular iron load was not associated with functional outcome after 3 months (p > 0.5). Conclusions This study suggests that iron accumulates in the cerebral white matter in patients with poor grade SAH. These findings may support trials aiming to scavenger brain extracellular iron based on the hypothesis that iron-mediated neurotoxicity may contribute to acute and secondary brain injury following SAH.

Surgical Compliance and Survival Outcomes For Patients With Osteosarcoma: A Population-Based Database Study

PurposeWe aimed to determine the effect of surgical compliance on prognosis in patients with osteosarcoma and the risk factors leading to surgical noncompliance.MethodsWe analyzed the date collected 3412 osteosarcoma patients from the Surveillance Epidemiology and End Results (SEER) databases between 1973 and 2015. Cox analyses were used to identify the independent prognostic factors. Logistic regression model was conducted to clear the factors associated to surgical compliance; Kaplan-Meier estimator method was adopted to analyze the Overall survival (OS) and Cancer-specific survival (CSS). ResultsAmong 3412 eligible osteosarcoma patients, the poor surgical compliance of patients with osteosarcoma is associated with the earlier time of diagnosis, advanced age, lower economic income, poor grade, distant stage, accepting radiotherapy and refusing chemotherapy. There were significant differences in the effects of diagnostic time, age, grade, radiotherapy, chemotherapy, tumor stage and economic income on surgical compliance (All P < 0.05). Patients’ compliance was an independent prognostic factor for OS and CSS of osteosarcoma patients. ConclusionsOsteosarcoma patients with good surgical compliance have favorable survival. This can help clinicians effectively realize patients' views on surgery and guide patients to learn the signification of surgery.