EUS to the Rescue: Endoscopic Ultrasound-Guided Transgastric Cholecystostomy in Acute Cholecystitis

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Early Prediction of Persistent Organ Failure by Serum Angiopoietin-2 in Patients with Acute Pancreatitis

Abstract

Background

Biomarkers for the early prediction of the severity of acute pancreatitis (AP) are urgently needed for clinical management of the disease. Angiopoietin-2 (Ang-2), one of the autocrine peptides that reduce endothelial permeability, has been found to be associated with various diseases, including inflammatory disorders.

Aims

This study aimed to determine whether serum Ang-2 could serve as a noninvasive biomarker for the early prediction of persistent organ failure (POF) in acute pancreatitis.

Methods

A total of 120 AP patients were prospectively enrolled at Jinling Hospital. Serum samples were collected on admission. Clinical and laboratory data were recorded. Ang-2 levels were measured by enzyme-linked immunosorbent assay.

Results

A total of 37 patients developed POF and were classified as having severe AP (SAP). Ang-2 was significantly higher on admission in patients who developed POF than in those who did not (p < 0.001 for all). Furthermore, receiver operating characteristic (ROC) curve analysis revealed that Ang-2 could distinguish patients who developed POF from mild AP (MAP, area under ROC curve [AUC] = 0.88, 95 % CI 0.78–0.94) and moderately severe AP patients (MSAP, AUC = 0.74, 95 % CI 0.63–0.83). In addition, multivariate logistic regression showed that increased Ang-2 was an independent predictor of developing POF between subgroups with MSAP and SAP (OR 7.2, 95 % CI 2.7–19.4) and among all AP patients (OR 12.1, 95 % CI 4.8–30.3).

Conclusions

Elevated serum Ang-2 levels on admission may be a promising biomarker for the prediction of POF in AP.

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Incorporating Clinical Research into a Career in Gastroenterology and Hepatology

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Predictive Factors for Pain After Endoscopic Resection of Gastric Tumors

Abstract

Background

Abdominal pain is a common complaint following endoscopic resection (ER).

Aims

To investigate the predictive factors for abdominal pain after ER.

Methods

Patients who were scheduled to undergo endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain scores were checked every 6 h after ER and whenever patients complained of pain by using a 0–10 pain scale. If the pain score exceeded 5, 25 mg of intravenous (IV) pethidine was administered.

Results

Among 156 patients who underwent ER, 66 (42.3 %) received IV pethidine due to moderate/severe abdominal pain. Both the number of patients complaining of abdominal pain and the pain scores decreased with time following the procedure, with only a few patients complaining of mild abdominal pain 2 days after ER. Multivariate analysis showed that female sex [odds ratio (OR) 2.88; confidence interval (CI) 1.31–6.33], tumor location in the lower third of the stomach (OR 5.46; CI 2.31–12.92), and procedures time more than 60 min (OR 2.96; CI 1.26–6.98) were significant predictive factors for developing pain after ER.

Conclusions

Female sex, tumor location in the lower third of the stomach, and longer procedure time were significantly associated with pain after ER. Close monitoring and active management of pain is recommended for patients who have these risk factors. With these efforts, the majority of patients could experience pain relief within 2 days after the procedure.

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Intra- and inter-regional cortical interactions related to sharp wave ripples and dentate spikes

The hippocampus generates population events termed sharp-wave ripples (SWRs) and dentate spikes (DSs). While little is known about DSs, SWR-related hippocampal discharges during sleep are thought to replay prior waking activity, reactivating the cortical networks that encoded the initial experience. During slow-wave sleep, such reactivations likely occur during up-states, when most cortical neurons are depolarized. However, most studies have examined the relationship between SWRs and up-states measured in single neocortical regions. As a result, it is currently unclear whether SWRs are associated with particular patterns of widely distributed cortical activity. Additionally, no such investigation has been carried out for DSs. The present study addressed these questions by recording SWRs and DSs from the dorsal hippocampus simultaneously with prefrontal, sensory (visual and auditory), perirhinal and entorhinal cortices in naturally sleeping rats. We found that SWRs and DSs were associated with up-states in all cortical regions. Up-states coinciding with DSs and SWRs exhibited increased unit activity, power in the gamma band, and intra-regional gamma coherence. Unexpectedly, inter-regional gamma coherence rose much more strongly in relation to DSs than SWRs. Whereas the increase in gamma coherence was time-locked to DSs, that seen in relation to SWRs was not. These observations suggest that SWRs are related to the strength of up-state activation within individual regions throughout the neocortex, but not so much to gamma coherence between different regions. Perhaps more importantly, DSs coincided with stronger periods of inter-regional gamma coherence, suggesting that they play a more important role than previously assumed.

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BDNF Effects on Functional Recovery across Motor Behaviors after Cervical Spinal Cord Injury

Unilateral C₂ cervical spinal cord hemisection (SH) disrupts descending excitatory drive to phrenic motor neurons, thereby paralyzing the ipsilateral diaphragm muscle (DIAm) during ventilatory behaviors. Recovery of rhythmic DIAm activity ipsilateral to injury occurs over time, consistent with neuroplasticity and strengthening of spared synaptic inputs to phrenic motor neurons. Localized intrathecal delivery of brain-derived neurotrophic factor (BDNF) to phrenic motor neurons after SH enhances recovery of eupneic DIAm activity. However, the impact of SH and BDNF treatment on the full range of DIAm motor behaviors has not been fully characterized. We hypothesized that all DIAm motor behaviors are affected by SH and that intrathecal BDNF enhances the recovery of both ventilatory and higher force non-ventilatory motor behaviors. An intrathecal catheter was placed in adult, male Sprague-Dawley rats at C₄ to chronically infuse artificial CSF (aCSF) or BDNF. DIAm EMG electrodes were implanted bilaterally to record activity across motor behaviors, i.e., eupnea, hypoxia-hypercapnia (10% O₂ and 5% CO₂), sighs, airway occlusion and sneezing. After SH, ipsilateral DIAm EMG activity was evident in only 43% of aCSF-treated rats during eupnea and activity was restored in all rats after BDNF treatment. The amplitude of DIAm EMG (RMS) was reduced following SH during eupnea and hypoxia-hypercapnia in aCSF-treated rats, and BDNF treatment promoted recovery in both conditions. The amplitude of DIAm RMS EMG during sighs, airway occlusion and sneezing was not affected by SH or BDNF treatment. We conclude that the effects of SH and BDNF treatment on DIAm activity depend on motor behavior.

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Cocaine sensitization increases sub-threshold activity in dopamine neurons from the ventral tegmental area

The progressive escalation of psychomotor responses that results from repeated cocaine administration is termed sensitization. This phenomenon alters the intrinsic properties of dopamine (DA) neurons from the ventral tegmental area (VTA) leading to enhanced dopaminergic transmission in the mesocorticolimbic network. The mechanisms underlying this augmented excitation are nonetheless poorly understood. DA neurons display the hyperpolarization-activated non-selective cation current dubbed Ih. We recently demonstrated that Ih and membrane capacitance are substantially reduced in VTA DA cells from cocaine sensitized rats. The present study shows that 7 days of cocaine withdrawal did not normalize Ih and capacitance. In cells from cocaine sensitized animals the amplitude of excitatory synaptic potentials, at -70mV, was ~39% larger in contrasts to controls. Raise and decay phases of the synaptic signal were faster under cocaine, a result associated with a reduced membrane time constant. Synaptic summation was paradoxically elevated by cocaine exposure as it consisted of a significantly reduced summation indexed but a considerably increased depolarization. These effects are at least a consequence of the reduced capacitance. H-conductance attenuation is unlikely to explain such observations since at -70mV no statistical differences exist in Ih or input resistance. The neuronal shrinkage associated with a diminished capacitance may help to understand two fundamental elements of drug addiction: incentive sensitization and negative emotional states. A reduced cell size may lead to substantial enhancement of cue-triggered bursting which underlies drug-craving and reward anticipation while it could also result in dopamine depletion as smaller neuron might express low levels of tyrosine hydroxylase.

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Parietal Area BA7 Integrates Motor Programs for Reaching, Grasping, and Bimanual Coordination

Skillful interaction with the world requires that the brain uses a multitude of sensorimotor programs and subroutines such as for reaching, grasping, and the coordination of the two body halves. However, it is unclear how these programs operate together. Networks for reaching, grasping, and bimanual coordination might converge in common brain areas. For example, Brodmann Area 7 (BA7) is known to activate in disparate tasks involving the three types of movements separately. Here we asked whether BA7 plays a key role in integrating coordinated reach-to-grasp movements for both arms together. To test this, we applied transcranial magnetic stimulation (TMS) to disrupt BA7 activity in the left and right hemispheres, while human participants performed a bimanual size-perturbation grasping task using the index and middle fingers of both hands to grasp a rectangular object whose orientation (and thus grasp-relevant width dimension) might or might not change. We found that TMS of the right BA7 during object perturbation disrupted the bimanual grasp and transport/coordination components, and TMS over the left BA7 disrupted unimanual grasps. These results show that right BA7 is causally involved in the integration of reach-to-grasp movements of the two arms.

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Diaphragm Electromyographic Activity following Unilateral Mid-Cervical Contusion Injury in Rats

Contusion type injuries to the spinal cord are characterized by tissue loss and disruption of spinal pathways. Mid-cervical spinal cord injuries impair the function of respiratory muscles and may contribute to significant respiratory complications. This study systematically assessed the impact of a 100-kDy unilateral C4 contusion injury on diaphragm muscle activity across a range of motor behaviors in rats. Chronic diaphragm EMG was recorded prior to injury, and at 1 and 7 days post injury. Histological analyses assessed the extent of perineuronal net formation, white matter sparing and phrenic motoneuron loss. At 7 days post injury, ~45% of phrenic motoneurons were lost ipsilaterally. Relative diaphragm RMS EMG activity increased bilaterally across a range of motor behaviors by 7 days post injury. The increase in diaphragm RMS EMG activity was associated with an increase in neural drive (RMS75) and was more pronounced during higher force, non-ventilatory motor behaviors. Animals in the contusion group displayed a transient decrease in respiratory rate and an increase in burst duration at 1-day post injury. By 7 days following mid-cervical contusion, there was significant perineuronal net formation and white matter loss that spanned 1mm around the injury epicenter. Taken together, these findings are consistent with increased recruitment of remaining motor units including more fatigable, high-threshold motor units during higher force non-ventilatory behaviors. Changes in diaphragm EMG activity following mid-cervical contusion injury reflect complex adaptations in neuromotor control that may increase the risk of motor unit fatigue and compromise the ability to sustain higher force diaphragm efforts.

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Investigation of oxidative stress parameters in different life span erythrocyte fractions in young untrained men after an acute exercise

The objective of study was to establish the role of exercise-induced oxidative stress in the erythrocyte fractions: young (YF), middle-aged (MAF) and old (OF) of young untrained men after acute exercise. Blood samples were collected before exercise, immediately and one hour after exercise. Maximum wattage was 292±27 W and exercise time duration was 8.73±0.9 min. Different optical properties and oxidative stress parameters were found in each erythrocyte fraction. Total thiols in YF and MAF after exercise and after one hour rest were similar to values before exercise, however, in OF (32.7±9.8 nmol/mgHb) the concentration was lower in comparison to YF (55.5±3.2 nmol/mgHb), MAF (56.8±7.7 nmol/mgHb) and increased one hour later (P < 0.0002). The glutathione concentration was higher in OF (8.4±0.4 nmol/mgHb) than in YF (4.5±0.6 nmol/mgHb) and MAF (4.8±0.5 nmol/mgHb) (P < 0.0002) and did not change neither after exercise nor one hour later. In OF, the peroxides level was higher after exercise (1.2±0.2 nmol/mgHb) and one hour later (1.1±0.2 nmol/mgHb), when compared with samples before exercise (0.9±0.1 nmol/mgHb) (P < 0.05). Similar results were observed in YF and MAF. The TBARS (thiobarbituric acid reactive substances) level was approx. 2.5 fold higher in OF (0.19±0.04 nmol/mgHb) when compared with YF (0.07±0.01 nmol/mgHb) and MAF (0.08±0.02 nmol/mgHb) (P < 0.0002) and was increased after exercise remaining unchanged after one hour later. In YF and MAF, no difference in TBARS level was detected after exercise one hour later. No difference in membrane fluidity was observed in all fractions. Erythrocytes OF appeared to be more sensitive for cellular oxidative damages.

This article is protected by copyright. All rights reserved

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Enhancing phosphorus uptake efficiency through QTL-based selection for root system architecture in maize

Publication date: Available online 9 November 2016
Source:Journal of Genetics and Genomics
Author(s): Riliang Gu, Fanjun Chen, Lizhi Long, Hongguang Cai, Zhigang Liu, Jiabo Yang, Lifeng Wang, Huiyong Li, Junhui Li, Wenxin Liu, Guohua Mi, Fusuo Zhang, Lixing Yuan
Root system architecture (RSA) plays an important role in phosphorus (P) acquisition, but enhancing P use efficiency (PUE) in maize via genetic manipulation of RSA has not yet been reported. Here, using a maize recombinant inbred line (RIL) population, we investigate the genetic relationships between PUE and RSA, and develop P-efficient lines by selection of quantitative trait loci (QTLs) that coincide for both traits. In low-P (LP) fields, P uptake efficiency (PupE) is more closely correlated with PUE (r = 0.48–0.54), and RSA in hydroponics is significantly related to PupE (r = 0.25–0.30) but not to P utilization efficiency (PutE). QTL analysis detected a chromosome region where two QTLs for PUE, three for PupE and three for RSA were assigned into two QTL clusters, Cl-bin3.04a and Cl-bin3.04b. These QTLs have favorable effects from alleles coming from the large-rooted and high-PupE parent. Marker-assisted selection (MAS) identified nine advanced backcross-derived lines carrying Cl-bin3.04a or Cl-bin3.04b that displayed mean increases of 22%–26% in PUE in LP fields. Furthermore, a line L224 pyramiding Cl-bin3.04a and Cl-bin3.04b shows enhanced PupE, relying mainly on changes in root morphology, rather than root physiology, under both hydroponic and field conditions. These results highlight the physiological and genetic contributions of RSA to maize PupE, and provide a successful study case of developing P-efficient crops through QTL-based selection.



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Ohio fire dept. hopeful grant will help buy ambulance equipment

The department wants to buy a third power cot and loader and a chest compressor for the city's third ambulance.

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Oxygen signaling: Call for papers

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Cholinergic and {beta}-adrenergic control of cardiovascular reflex responses to brief repeated asphyxia in term-equivalent fetal sheep

The role of cholinergic and β-adrenergic activity in mediating fetal cardiovascular recovery from brief repeated episodes of asphyxia, consistent with established labor, remains unclear. In this study, we tested the effect of cholinergic and β-adrenergic blockade on the fetal chemoreflex and fetal heart rate (FHR) overshoot responses during brief repeated asphyxia at rates consistent with early or active labor. Chronically instrumented fetal sheep at 0.85 of gestation received either intravenous atropine sulfate (cholinergic blockade; n = 7) or vehicle (n = 8) followed by 3 x 1-min umbilical cord occlusions repeated every 5 min (1:5; consistent with early labor), or intravenous propranolol hydrochloride (β-adrenergic blockade; n = 8) or vehicle (n = 6) followed by 3 x 2-min occlusions repeated every 5 min (2:5; consistent with active labor). In vehicle controls, 1:5 occlusions were associated with rapid and sustained FHR decelerations followed by rapid return of FHR to baseline values after release of the occlusion. Cholinergic blockade abolished FHR decelerations during occlusions and caused FHR overshoot after release of the occlusion (P < 0.05 vs. control 1:5). In vehicle controls, 2:5 occlusions caused rapid and sustained FHR decelerations followed by FHR overshoot after release of the occlusion. β-adrenergic blockade was associated with greater reduction in FHR during occlusions and attenuated FHR overshoot (P < 0.05 vs. control 2:5). These data demonstrate that the FHR overshoot pattern after asphyxia is mediated by a combination of attenuated parasympathetic activity and increased β-adrenergic stimulation of the fetal heart.

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Maternal factors influencing exclusive breastfeeding of babies at six weeks of age

2016-11-10T05-21-31Z
Source: International Journal of Contemporary Pediatrics
Purnima Samayam, Pradeep Krishna.
Background: Exclusive breastfeeding for first six months of life has several advantages for babies as well as mothers. However exclusive breastfeeding may not be followed by mothers due to various reasons. The objective of this study was to study the rates of exclusive breastfeeding and mixed feeding in infants at Six weeks of age. Methods: Prospective observational study. 200 mothers and their healthy full term newborns were included. Exclusive and early breastfeeding was initiated with guidance and support for the mothers during their hospital stay. All mothers were given verbal advice about the need and benefits of exclusive breastfeeding for first six months. Primary outcome: number of mothers giving exclusive breastfeeding or mixed feeding at six weeks postnatal age during the first immunisation visit. Results: 92.78% mothers were exclusively breastfeeding their babies at 6 weeks of age. 7.22% had started mixed feeding. 96.23% of multipara and 87.84% of primipara were respectively giving exclusive breastfeeding at 6 weeks. The difference was statistically significant (P value 0.0328). Mothers aged 20-35 years (95.65%) were more likely to continue exclusive breastfeeding than those aged


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A prospective, randomized, double blind, comparative study of intramuscular nalbuphine hydrochloride, butorphanol tartrate and pentazocine lactate for post-operative pain relief following abdominal hysterectomy

2016-11-10T03-12-53Z
Source: International Journal of Basic & Clinical Pharmacology
Praveen P. V. V. S. B., Vijaya Chandra Reddy Konda, Lohit K..
Background: This study aimed to compare the efficacy and safety of intramuscularly administered nalbuphine, butorphanol and pentazocine for post-operative pain relief after abdominal hysterectomy. Methods: Seventy-five adult female patients, aged between 20-50 years, belonging to American Society of Anaesthesiologists (ASA) class 1 and 2, posted for abdominal hysterectomy under spinal anesthesia were included in the study. The subjects were randomly divided into 3 groups (n=25 each) and given Group A: pentazocine lactate (30 mg, 1mL), Group B: butorphanol tartarate (2 mg, 1 ml) and Group C: nalbuphine hydrochloride (10 mg, 1 mL) when post-operative pain intensity reached ≥4 mm on the Visual analogue scale (VAS). The onset, duration, time to peak effect and adverse events were recorded at regular intervals for 24 hours, postoperatively. Results: The mean time to onset of anesthesia was significantly faster (P


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A comparative study of the learning styles among 1st, 2nd and final year MBBS students

2016-11-10T03-12-53Z
Source: International Journal of Basic & Clinical Pharmacology
Nagesh Raju G., Manjunath S. M., Dharmaraj B., Shrish Patil.
Background: Learning style is the way students begin to focus, internalize and remember new and difficult information. Identifying the learning styles of medical students will enable the faculty to use appropriate T/L method to increase the grasping ability of their subject/ learning. Purpose of the study was to assess and compare the learning styles of 1st, 2nd and final MBBS students by using VARK questionnaire. Methods: This was an observational, cross-sectional study based on the questionnaire, conducted by the department of Pharmacology at Basaveshwara Medical College and Hospital, Chitradurga. The VARK learning styles assessment questionnaire was administered to 1st (96 students), 2nd (60 students) and Final year (49 students). The students were categorized as auditory, kinaesthetic, visual learner or read/write depending on the predominant option they chose. Independent sample 't' test was used to compare the mean scores between the two groups using the software SPSS v22. Results: 40% of students had unimodal and 60% had multimodal learning style. Final year MBBS students had higher percentage of multimodal learning style (73%). The most preferred style of learning among all the medical students was kinesthetic (6.6), followed by aural (5.5), visual (4.0) and read/write (3.5). There was significant difference between the learning styles of 1st and Final year MBBS students in Visual (p=0.01) and Read /Write (p= 0.008). Conclusions: Knowing that students have different learning styles and kinesthetic being the most preferred mode of learning will help medical faculty to develop teaching/learning strategies for better outcomes.


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Issue Information

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Caregiver burden in caregivers of elderly registered in Armed Forces Hospital and King Fahad Military Medical Complex Home Care Services in Dhahran

2016-11-10T02-36-25Z
Source: International Journal of Medical Science and Public Health
Rana Alshehri, Fadwa Alohali, Bader Almutairi.
Background: Worldwide, there is a dramatic shift in the distribution of population toward older ages. Family caregivers are playing a major role in keeping ongoing care for this age group. Moreover, they are saving tremendous costs on healthcare systems. Unfortunately, caregivers throughout their experience are facing difficulties, suffering and are subjected to caregiver burden. Objectives: To estimate the prevalence of caregiver burden and to identify its predictive factors. Materials and Methods: A cross-sectional descriptive study was conducted in two conveniently selected home care registered elderly in two military hospitals in the Eastern Province, Saudi Arabia. In a structured interview setting, a constructed questionnaire and Zarit Burden Interview were used to collect data from primary caregivers. Results: A total of 117 caregivers for functionally impaired elderly people were included in the study. The overall estimated prevalence was 65%. Furthermore, severe, moderate, and mild burden were 15%, 18%, and 30%, respectively. Longer duration of caregiving, unavailability of secondary caregiver, and female care recipient were positively associated with the burden. Conclusions: Results of the present study show a respectable prevalence of burden among Saudi caregivers. Effective counseling, education, and multidisciplinary support are needed for caregivers of an elderly population. Further studies are needed to explore the burnout among Saudi caregivers.


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Evaluation of anti-Cathepsin L1: A more reliable method for serodiagnosis of human fasciolosis

Transactions of the Royal Society of Tropical Medicine and Hygiene

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Phase II study of chemoselection with docetaxel plus cisplatin and 5-fluorouracil induction chemotherapy and subsequent conversion surgery for locally advanced unresectable oesophageal cancer

British Journal of Cancer

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Neonatal gastrointestinal perforations: The 10-year experience of a reference hospital

Indian Journal of Surgery

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Estimating the time to diagnosis and the chance of spontaneous clearance during acute hepatitis C in HIV-infected individuals

Open Forum Infectious Diseases

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PD-1 inhibitor gastroenterocolitis case series and appraisal of immunomodulatory gastroenterocolitis

Histopathology

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Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis

Alimentary Pharmacology and Therapeutics

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Value of treating all stages of chronic hepatitis C: A comprehensive review of clinical and economic evidence

Infectious Diseases and Therapy

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Randomised clinical trial: Exploratory phase 2 study of ONO-2952 in diarrhoea-predominant irritable bowel syndrome

Alimentary Pharmacology and Therapeutics

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An S100P-positive biliary epithelial field is a pre-invasive intraepithelial neoplasm in nodular-sclerosing cholangiocarcinoma

Human Pathology

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Antithrombotic treatment with direct-acting oral anticoagulants (DOACs) in patients with splanchnic vein thrombosis and cirrhosis

Liver International

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Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis

Asian Journal of Endoscopic Surgery

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Pharmacokinetic dose adjustment of 5-FU in modified FOLFOX7 plus bevacizumab for metastatic colorectal cancer in Japanese patients: a-JUST phase II clinical trial

Cancer Chemotherapy and Pharmacology

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Comparison of endoscopic dilation vs surgery for anastomotic stricture in patients with Crohn's disease following ileocolonic resection

Clinical Gastroenterology and Hepatology

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Overcoming dynamic molecular heterogeneity in metastatic colorectal cancer: Multikinase inhibition with regorafenib and the case of rechallenge with anti-EGFR

Cancer Treatment Reviews

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Liver and spleen stiffness measurements by point shear wave elastography via acoustic radiation force impulse: intraobserver and interobserver variability and predictors of variability in a US population

Journal of Ultrasound in Medicine

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Evaluation of the effectiveness of biofeedback therapy for functional constipation in children

The Turkish Journal of Gastroenterology

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Appendicitis in the HIV Era: A South African perspective

Indian Journal of Surgery

from Gastroenterology via xlomafota13 on Inoreader http://www.mdlinx.com/gastroenterology/medical-news-article/2016/11/10/tbhivappendicitisappendicectomyhaart/6928444/
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Significant increase of synchronous disease in first-line metastatic colorectal cancer trials: Results of a systematic review

European Journal of Cancer

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Prospective randomized controlled study on the validity and safety of an absorbable adhesion barrier (Interceed) made of oxidized regenerated cellulose for laparoscopic colorectal surgery

Asian Journal of Endoscopic Surgery

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Risk stratification for locally advanced hepatocellular carcinoma using pretreatment alpha-fetoprotein and 18F-FDG PET

Liver International

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The effect of prior tetanic stimulation on train-of-four monitoring in paediatric patients: A randomised open-label controlled trial.

BACKGROUND: In clinical research, neuromuscular monitoring must present a stable response for a period of 2 to 5 min before administration of a neuromuscular blocking agent. The time required to reach this stable response may be shortened by applying a 5-s tetanic stimulus. OBJECTIVES: The aim of this study was to test whether tetanic stimulation interferes with onset and recovery times after a single dose of rocuronium 0.6 mg kg-1 followed by spontaneous recovery. DESIGN: A randomised, open-label, controlled trial. SETTING: A single-centre trial, study period from January 2014 to July 2015. PATIENTS: Fifty children aged 2 to 11 years scheduled for elective paediatric surgery. INTERVENTION: Patients were randomly allocated to receive either tetanic stimulation (group T) or not (group C) before calibration of the neuromuscular monitor. MAIN OUTCOME MEASURES: Onset and recovery times. Initial and final T1 height, time to obtain initial T1 height stability and monitor settings were also analysed. RESULTS: There was no significant difference in mean onset time [(C: 57.5 (+/- 16.9) vs. T: 58.3 (+/- 31.2) s; P = 0.917]. Mean times to normalised train-of-four (TOF) ratios of 0.7, 0.8 and 0.9 were significantly shorter in the tetanic stimulation group [C: 40.1 (+/-7.9) vs. T: 34.8 (+/-10) min; P = 0.047, C: 43.8 (+/-9.4) vs. T: 37.4 (+/-11) min; P = 0.045 and C: 49.9 (+/-12.2) vs. T: 41.7 (+/-13.1) min; P = 0.026, respectively]. The mean time required for T1 height stabilisation was similar in the two groups [C: 195.0 (+/- 203.0) vs. T: 116.0 (+/- 81.6) s; P = 0.093], but the initial and final T1 height values were significantly lower in the tetanic stimulation group (C: 98.0 vs. T: 82.7%; P

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Drugs in Anaesthesia and Intensive Care, 5th edn.

No abstract available

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Comparison of Supraclavicular and Infraclavicular Brachial Plexus Block: A Systemic Review of Randomized Controlled Trials.

BACKGROUND: Supraclavicular (SC) and infraclavicular (IC) brachial plexus block (BPB) are commonly used for upper extremity surgery. Recent clinical studies have compared the effect of SC- and IC-BPB, but there have been controversies over spread of sensory blockade in each of the 4 peripheral nerve branches of brachial plexus. METHODS: This study included a systemic review, using the Medline and EMBASE database from their inceptions through March 2016. Randomized controlled trials (RCTs) comparing SC- and IC-BPB were included. The prespecified primary outcome was the incidences of incomplete sensory blockade in each of the 4 terminal nerve branches of brachial plexus. Secondary outcome included the incidence of successful blockade, performance time, onset of sensory block, duration of analgesia, and complication rates. RESULTS: Ten RCTs involving 676 patients were included. Pooled analyses showed the incidence of incomplete block at 30 minutes in radial nerve territory was significantly higher in IC-BPB, favoring SC-BPB (risk ratio 0.39; 95% confidence interval [0.17-0.88], P = .02, I2 = 0%). However, subgroup analysis according to the number of injections of IC-BPB showed that double or triple injections IC-BPB yielded no difference in the incomplete radial block. Furthermore, the incidence of incomplete ulnar block at 30 minutes was significantly lower in IC-BPB when using double or triple injection IC-BPB. There was no difference in the secondary outcomes between SC- and IC-BPB groups, with the exception of complication rates. The incidence of paresthesia/pain on local anesthetic injection, phrenic nerve palsy, and Horner syndrome was significantly higher in the SC group, favoring IC-BPB. CONCLUSIONS: This meta-analysis demonstrated that IC-BPB showed a significantly high incidence of incomplete radial nerve sensory block at 30 minutes, which may be avoided by double or triple injection. Furthermore, IC-BPB with multiple injection technique showed significantly lower incidence of incomplete ulnar block than SC-BPB. There were no differences in the incidence of successful blockade, block onset, and duration of analgesia between SC- and IC-BPB. Procedure-related paresthesia/pain and adjacent nerve-related complications were more frequent in SC-BPB. However, because of the small sample size, publication bias remains a concern when interpreting our results. Further studies with sufficient sample size and reporting large number of outcomes are required. (C) 2016 International Anesthesia Research Society

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New Applications for Your Mobile Device.

No abstract available

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Surveying the Literature: Synopsis of Recent Key Publications.

No abstract available

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Perioperative Anesthesia Care and Tumor Progression.

This narrative review discusses the most recent up-to-date findings focused on the currently available "best clinical practice" regarding perioperative anesthesia care bundle factors and their effect on tumor progression. The main objective is to critically appraise the current literature on local anesthetics, regional outcome studies, opioids, and nonsteroidal anti-inflammatory drugs (NSAIDs) and their ability to decrease recurrence in patients undergoing cancer surgery. A brief discussion of additional topical perioperative factors relevant to the anesthesiologist including volatile and intravenous anesthetics, perioperative stress and anxiety, nutrition, and immune stimulation is included. The results of several recently published systematic reviews looking at the association between cancer recurrences and regional anesthesia have yielded inconclusive data and provide insufficient evidence regarding a definitive benefit of regional anesthesia. Basic science data suggests an anti tumor effect induced by local anesthetics. New refined animal models show that opioids can safely be used for perioperative pain management. Preliminary evidence suggests that NSAIDs should be an essential part of multimodal analgesia. Volatile anesthetics have been shown to increase tumor formation, whereas preclinical and emerging clinical data from propofol indicate tumor protective qualities. The perioperative period in the cancer patient represents a unique environment where surgically mediated stress response leads to immune suppression. Regional anesthesia techniques when indicated in combination with multimodal analgesia that include NSAIDs, opioids, and local anesthetics to prevent the pathophysiologic effects of pain and neuroendocrine stress response should be viewed as an essential part of balanced anesthesia. (C) 2016 International Anesthesia Research Society

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Individualized Perioperative Bleeding Management.

No abstract available

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Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients.

BACKGROUND: Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray. METHODS: A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasal squeeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90[degrees] elevation) and supine (0[degrees] elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0[degrees], 15[degrees], 30[degrees], 45[degrees], and 90[degrees] to determine the relationship between the angles of administration and the amount of liquid dispensed. RESULTS: The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 +/- 0.22 mL) compared with the upright position (0.041 +/- 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37-0.67 mL, P =45[degrees]; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90[degrees] because only a small change in angle below 45[degrees] will result in a substantial increase in medication delivered. (C) 2016 International Anesthesia Research Society

from Anaesthesiology via xlomafota13 on Inoreader http://pdfs.journals.lww.com/anesthesia-analgesia/9000/00000/Intranasal_Medication_Administration_Using_a.97806.pdf
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Effects of Epidural Labor Analgesia With Low Concentrations of Local Anesthetics on Obstetric Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Low concentrations of local anesthetics (LCLAs) are increasingly popular for epidural labor analgesia. The effects of epidural analgesia with low concentrations of anesthetics on the duration of the second stage of labor and the instrumental birth rate, however, remain controversial. A systematic review was conducted to compare the effects of epidural analgesia with LCLAs with those of nonepidural analgesia on obstetric outcomes. METHODS: The databases of PubMed, Embase, and the Cochrane controlled trials register were independently searched by 2 researchers, and randomized controlled trials that compared epidural labor analgesia utilizing LCLAs with nonepidural analgesia were retrieved. The primary outcomes were the duration of the second stage of labor and the instrumental birth rate; secondary outcomes included the cesarean delivery rate, the spontaneous vaginal delivery rate, and the duration of the first stage of labor. RESULTS: Ten studies (1809 women) were included. There was no significant difference between groups in the duration of the second stage of labor (mean difference = 5.71 minutes, 95% confidence interval [CI]: -6.14 to 17.83; P = .36) or the instrumental birth rate (risk ratio [RR] = 1.52, 95% CI: 0.97-2.4; P = .07). There was no significant difference between groups in the cesarean delivery rate (RR = 0.8, 95% CI: 0.6-1.05; P = .11), the spontaneous vaginal delivery rate (RR = 0.98, 95% CI: 0.91-1.06; P = .62), or the duration of the first stage of labor (mean difference = 17.34 minutes, 95% CI -5.89 to 40.56; P = .14). CONCLUSIONS: Compared with nonepidural analgesia, epidural analgesia with LCLAs is not associated with a prolonged duration of the second stage of labor or an increased instrumental birth rate. The results of this meta-analysis are based on small trials of low quality. These conclusions require confirmation by large-sample and high-quality trials in the future. (C) 2016 International Anesthesia Research Society

from Anaesthesiology via xlomafota13 on Inoreader http://pdfs.journals.lww.com/anesthesia-analgesia/9000/00000/Effects_of_Epidural_Labor_Analgesia_With_Low.97807.pdf
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A Pilot Assessment of 3 Point-of-Care Strategies for Diagnosis of Perioperative Lung Pathology.

BACKGROUND: Lung ultrasonography is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in the emergency and critical care setting and after cardiothoracic surgery in intensive care. Lung ultrasound may be useful before cardiothoracic surgery and after discharge from intensive care, but the proportion of significant respiratory pathology in this setting is unknown and may be too low to justify its routine use. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. METHODS: In this prospective observational study, patients undergoing elective cardiothoracic surgery who received a CXR as part of standard care preoperatively or after discharge from the intensive care unit received a standardized clinical assessment and then a lung ultrasound examination within 24 hours of the CXR by 2 clinicians. The incidence of collapse/atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion, and pneumothorax were compared between clinical examination, CXR, and lung ultrasound (reference method) based on predefined diagnostic criteria in 3 zones of each lung. RESULTS: In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. With lung ultrasound as a reference, the sensitivity of the 5 different pathologies ranged from 7% to 69% (CXR), 7% to 76% (clinical examination), and 14% to 94% (combined); the specificity of the 5 different pathologies ranged from 91% to 98% (CXR), from 90% to 99% (clinical examination), and from 82% to 97% (combined). For clinical examination and lung ultrasound, intraobserver agreements beyond chance ranged from 0.28 to 0.70 and from 0.84 to 0.97, respectively. The agreements beyond chance of pathologic diagnoses between modalities ranged from 0.11 to 0.64 (CXR and lung ultrasound), from 0.08 to 0.7 (CXR and lung ultrasound), and from 0 to 0.58 (clinical examination and CXR). CONCLUSIONS: Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or postoperative cardiothoracic surgery participants with high estimate of interobserver agreement beyond that expected by chance, and we showed clinically significant diagnoses may be missed by the contemporary practice of clinical examination and CXR. (C) 2016 International Anesthesia Research Society

from Anaesthesiology via xlomafota13 on Inoreader http://pdfs.journals.lww.com/anesthesia-analgesia/9000/00000/A_Pilot_Assessment_of_3_Point_of_Care_Strategies.97808.pdf
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Safety and Efficacy of Volatile Anesthetic Agents Compared With Standard Intravenous Midazolam/Propofol Sedation in Ventilated Critical Care Patients: A Meta-analysis and Systematic Review of Prospective Trials.

BACKGROUND: Inhalation agents are being used in place of intravenous agents to provide sedation in some intensive care units. We performed a systematic review and meta-analysis of prospective randomized controlled trials, which compared the use of volatile agents versus intravenous midazolam or propofol in critical care units. METHODS: A search was conducted using MEDLINE (1946-2015), EMBASE (1947-2015), Web of Science index (1900-2015), and Cochrane Central Register of Controlled Trials. Eligible studies included randomized controlled trials comparing inhaled volatile (desflurane, sevoflurane, and isoflurane) sedation to intravenous midazolam or propofol. Primary outcome assessed the effect of volatile-based sedation on extubation times (time between discontinuing sedation and tracheal extubation). Secondary outcomes included time to obey verbal commands, proportion of time spent in target sedation, nausea and vomiting, mortality, length of intensive care unit, and length of hospital stay. Heterogeneity was assessed using the I2 statistic. Outcomes were assessed using a random or fixed-effects model depending on heterogeneity. RESULTS: Eight trials with 523 patients comparing all volatile agents with intravenous midazolam or propofol showed a reduction in extubation times using volatile agents (difference in means, -52.7 minutes; 95% confidence interval [CI], -75.1 to -30.3; P

from Anaesthesiology via xlomafota13 on Inoreader http://pdfs.journals.lww.com/anesthesia-analgesia/9000/00000/Safety_and_Efficacy_of_Volatile_Anesthetic_Agents.97809.pdf
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