Objective Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature. Study design A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded. Results A 34-year-old woman at her 25 weeks’ gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55–2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%). Conclusion Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

BACKGROUND:The main purpose of the study was to test whether the combination of gabapentin (600 mg 4 hours before surgery, 600 mg after 24 hours), ketamine (0.3 mg/kg before anesthesia), lornoxicam (8 mg before anesthesia and 8 mg/12 hours), and local ropivacaine (5 mL 7.5% at insertion sites) provides superior analgesia to each of these drugs alone in the first 24 hours after laparoscopic cholecystectomy. The secondary purpose was to examine whether this combination has less opioid-related side effects. METHODS:This was a 2-center randomized placebo-controlled trial. One hundred forty-eight patients, between 18 and 70 years of age, were randomly assigned to 6 groups (28 in each group) with the use of computer software: A(gabapentin/ketamine/lornoxicam/ropivacaine); B(gabapentin/placebo/placebo/placebo); C (placebo/ketamine/placebo/placebo); D (placebo/placebo/lornoxicam/placebo); E (placebo/placebo/placebo/ropivacaine); and F (placebo/placebo/placebo/placebo). Only the principal investigator was aware of patients' allocation and provided drugs and placebo in covered prefilled syringes. The primary outcome of the study was the 24-hour morphine consumption. Secondary outcomes were frequency of opioid-related side effects (nausea, vomiting, sedation, pruritus, and dysuria). RESULTS:Only groups A (6.4 mg), B (9.46 mg), and D (9.36 mg) had lower morphine consumption than control group (20.29 mg) (P < 0.001, P = 0.01, and P = 0.008, respectively). Group A was not different from B and D (P = 0.92, P = 0.93). The only difference was in episodes of nausea between groups A (n = 5) and the control group (n = 12) (P = 0.018). CONCLUSION:The combination of gabapentin, ketamine, lornoxicam, and local ropivacaine does not provide superior analgesia than gabapentin alone or lornoxicam alone after laparoscopic cholecystectomy. The combination reduces only the frequency of postoperative nausea, but larger studies are needed for safer results.

BACKGROUND Although damage of the heart vessels is a possible complication of blunt thoracic trauma, occlusion of the right coronary artery is rare and demands high level of suspicion by the emergency physicians. OBJECTIVE Our objective is to present a case of fatal acute occlusion of the right coronary artery after blunt thoracic trauma due to vehicle accident and conduct a brief review of the current literature. CASE REPORT A 58-year-old sustained chest trauma after a vehicle accident, complicated by acute occlusion of the right coronary artery. Despite invasive intervention the patient deteriorated and died due to multi-organ failure. CONCLUSION Acute occlusion of the right coronary artery is a rare complication of blunt chest trauma. Early diagnosis and intervention, collaboration between different specialties and proper hospitalization are vital for the outcome of the patient.

BACKGROUND:Ropivacaine is commonly used as local anesthetic for postoperative analgesia through an epidural catheter. Data show that several adjuvants influence the analgesic effect of local anesthetic potency.OBJECTIVE:The aim of the study was to compare fentanyl and clonidine as adjuvants to 1.5 mg ml(-1) ropivacaine in terms of motor blockade, pain relief and side effects.METHODS:In this single center, randomized, clinical trial, 52 patient scheduled for arthroscopic anterior cruciate ligament reconstruction were radomly allocated in two groups. At twenty-six patient a solution with ropivacaine 1.5 mg ml(-1) plus fentanyl 2 microg ml(-1) (group F) was administered through patient controlled epidural analgesia (PCEA) as postoperative analgesia and ropivacaine 1.5 mg ml(-1) plus clonidine 1 microg ml(-1) (group C) was administered at the remaining twenty-six patients. The VAS score, the Bromage scale and total solution consumption were documented and compared between the two groups for 24 hours after the end of the operation.RESULTS:The mean patient control consumption of the solution was higher at group C respect group F (p = 0.007). At the 8th hour after the operation we register a statistical significant difference at the mean VAS score between the two groups (p < 0.05) with clonidine group achieving a higher score. At the 8th and 12th hour clonidine group register a lower Bromage score than fentanyl group (p < 0.005 and p = 0.002).CONCLUSION:Ropivacaine 1.5 mg ml(-1) plus fentanyl 2 microg ml(-1) administred through PCEA compared with ropivacaine 1.5 mg ml(-1) plus clonidine 1 microg ml(-1) h guarantee higher quality analgesia after ACL reconstruction.

BACKGROUND:The Airtraq Optical Laryngoscope is a new type of laryngoscope that provides a direct view of the glottis without alignment of the mouth, pharynx and trachea. Data show that it has advantages over the Macintosh laryngoscope. OBJECTIVE:The aim of this study was to compare the use of the Airtraq laryngo-scope versus the No. 3 Macintosh blade for routine airway management in terms of intubation time, complications during and after laryngoscopy, and ease of use. METHODS:In this single-center, randomized, clinical trial, 63 patients scheduled for elective operation were randomly allocated to two groups. Thirty-five patients were intubated with the Airtraq laryngoscope and 28 with the traditional Macintosh laryngoscope. All intubations were performed by experienced anesthesiologists who had a similar level of experience with the Airtraq laryngoscope. The time needed for intubation, any assistance required, complications during and after laryngoscopy and intubation, and the number of unsuccessful intubation attempts were documented and compared between the groups. RESULTS:Intubation with the Macintosh laryngoscope was quicker (mean+/-standard deviation: 23.7+/-5.9 seconds) than with the Airtraq laryngoscope (29.6+/-8.5 seconds). Although the difference (5.9 seconds) was statistically significant (p<0.05), it was not clinically significant. The anesthesiologists who used the Airtraq laryngo-scope less frequently required assistance (p<0.05) to place the endotracheal tube. No differences were found regarding complications during and after laryngoscopy and intubation. There were no differences in any of the outcomes in patients with Mallampati class > 2. CONCLUSION:The Airtraq laryngoscope is easier to use but it does not have any significant advantages compared with the Macintosh laryngoscope for routine airway management. More studies are needed to evaluate its use in patients with a difficult airway, and in emergency procedures.

Antiplatelet drugs given to high risk patients for secondary prevention of cardiovascular disease are frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This is also the case for many patients undergoing lower limb vascular surgery via spinal or epidural anaesthesia. The aim of this study is to corroborate the clinician's decision for discontinuing or continuing the anti-platelet treatment in these patients perioperatively. We screened MEDLINE and Scopus (January 1980 - July 2007) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines according to Evidence Based Medicine rules. One randomized controlled trial, 2 meta-analyses, 1 prospective and 4 retrospective studies as well as 6 esteemed medical societies'" guidelines all conclude that there is no justification for the discontinuation of aspirin and NSAIDs prior to neuraxial anesthesia. However, for other antiplatelet drugs like ticlopidine, clopidogrel, abciximab, eptifabatide and tirofiban not enough data exist to support their continuation through the procedure. Therefore, their preoperative withdrawal is suggested 8 hours to 14 days prior, accordingly. The existing evidence does not justify the discontinuation of aspirin and NSAIDs before the intended procedure. Anesthesiologists and surgeons should be aware of the cardiovascular risks of withdrawal versus the non - evidence based benefit in hemorrhage complications.

Sepsis and septic shock are great challenges for the doctors who treat critically ill patients. A big part of the scientific community is performing researches about the pathophysiology and treatment of this clinical problem. The endothelium has a very significant role in the alterations that sepsis causes especially to the circulatory system. The disorders of the normal function of the endothelium include derangement of the vascular tone, increase of endothelium permeability, activation of the endothelial cells, production of various regulators and disorders of coagulation. Nitric oxide is the modulator that mediates the action of most vasodilators. The overproduction of nitric oxide during sepsis is possibly the most important cause of the vasopressor-resistant hypotension which characterizes septic shock. The levels of natriuretic peptides are also increased. These peptides act through several ways on the circulatory system both peripherally and directly on the myocardium. Endothelin, vasopressin, adrenomedullin and prostacyclin are vasoactive substances that have their own role in the regulation of the circulatory system during sepsis.

Awareness during surgery is a very serious problem for the anesthetist and the patient as well. Such incidents are the cause for 2% of the legal claims against anesthetists while patients with intraoperative awareness experience describe it as the worst thing they have ever suffered from. Pain, anxiety and inability to react due to muscle paralysis often lead to the situation called posttraumatic stress disorder which demands psychiatric support. The fact that there are patients who report intraoperative experience, even several days after surgery, raises questions about the way the anesthetic drugs interfere with the mechanisms of memory and consciousness while, in bibliography, there are studies proving that even deeply anesthetized patients can be influenced by auditory stimuli without being able to recall them. Intraoperative monitoring of the anesthesia depth is important for the prevention of this problem. From all the available devices only the Bispectral Index Monitoring (BIS) has been proven to be effective for this purpose but the high cost per person and the low specificity in preventing awareness episodes do not allow its everyday use. The surgeon and especially the anesthesiologist must be aware of the risk factors, the prevention measures and the actions that must be taken after an awareness incident in order to minimize the unfortunate complications for both the patient and the doctors.

After a series of experiments, a protein was discovered on the membrane of the red blood cell with water channel characteristics, which was named "aquaporin". This discovery revolutionized the study of water movement between the cells and intercellular spaces of the human body which until then was thought to be carried out only by diffusion. Until today 13 different aquaporins have been identified in cells of various systems. Of special interest is the effort to find the relation between aquaporins and pathological conditions of which the pathophysiology is not clear. The conclusions reached from studies on animal experimental models show a possible relation between aquaporin dysfunction and diseases of the kidney, brain, lungs, eye, ear, the circulatory system, the gastrointestinal system and other systems. Stroke, pulmonary edema, diabetes insipitus, atheromatosis, epilepsy, cystic fibrosis, asthma, obesity, cataract, glaucoma, inflammatory bowel diseases, ascites and hepatorenal syndrome are some of the diseases that are connected with aquaporin disorder, according to present evidence. The possible relation of these water channels with tumor angiogenesis is very challenging. Many researchers have examined the possibility of intervention in the normal aquaporin function for therapeutic purposes, and believe that the discovery of drugs to stimulate or block the water channels will bring a new era in the treatment of many diseases. The purpose of this article is to review the experimental data on the role of aquaporins in water homeostasis and in the pathophysiology of various diseases

The problem of the greater number of people in the waiting list for transplantation compared with the number of the available transplants is very important and worries the universal scientific community. A great part of the organs that are being transplanted yearly come from brain dead patients. The accurate and as well undoubtable diagnosis of brain death is a crucial part of the chain which leads to the successful transplantation of an organ and the treatment of a patient with end stage disease. Very important as well is the appropriate management and support of the vital functions of the patient without brain activity because brain death causes a series of alterations to many systems putting organ viability in danger. Applying the appropriate support to the circulatory, ventilatory, endocrinic and other systems is a very difficult task and requires knowledge and experience. The purpose of this article is the review of the criteria for the diagnosis of brain death, of the dysfunctions that brain death causes to various systems and of the measures which have to be taken for the viability and successful transplantation of the brain dead donor’s vital organs.