Does the Current American Society of Anesthesiologists Physical Status Classification Represent the Chronic Disease Burden in Children Undergoing General Anesthesia?

No abstract available

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Pain Management: A Problem-Based Learning Approach

No abstract available

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Handbook of Sepsis

No abstract available

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A Comparison of Spinal Anesthesia Versus Monitored Anesthesia Care With Local Anesthesia in Minimally Invasive Fetal Surgery

BACKGROUND: Minimally invasive fetal surgery is commonly performed to treat twin-to-twin transfusion syndrome with selective fetoscopic laser photocoagulation and twin-reversed arterial perfusion sequence using radiofrequency ablation. Although an increasing number of centers worldwide are performing these procedures, anesthetic management varies. Both neuraxial anesthesia and monitored anesthesia care with local anesthesia are used at different institutions. We sought to determine the efficacy and outcomes of these 2 anesthetic techniques for fetal procedures at our institution. METHODS: All patients undergoing minimally invasive fetal surgery for twin-to-twin transfusion syndrome or twin-reversed arterial perfusion sequence over a 6-year time period (2011–2016) were reviewed. Patients receiving monitored anesthesia care with local anesthesia were compared with those receiving spinal anesthesia in both selective fetoscopic laser photocoagulation and radiofrequency ablation fetal procedures. The primary outcome examined between the monitored anesthesia care and spinal anesthesia groups was the difference in conversion to general anesthesia using a noninferiority design with a noninferiority margin of 5%. Secondary outcome measures included use of vasopressors, procedure times, intraoperative fluids administered, maternal complications, and unexpected fetal demise within 24 hours of surgery. RESULTS: The difference in failure rate between monitored anesthesia care and spinal was −0.5% (95% CI, −4.8% to 3.7%). Patients receiving monitored anesthesia care plus local anesthesia were significantly less likely to need vasopressors, had a shorter presurgical operating room time, and received less fluid (P

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Speaker Gender Representation at the American Society of Anesthesiology Annual Meeting: 2011–2016

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011–2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%–27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%–28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed vs 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed vs 25.9% expected; P

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General Anesthesia Alters the Diversity and Composition of the Intestinal Microbiota in Mice

Dysbiosis of the intestinal microbiota has been shown to result in altered immune responses and increased susceptibility to infection; as such, the state of the intestinal microbiome may have profound implications in the perioperative setting. In this first-in-class study, we used 16s ribosomal RNA sequencing and analysis in a mouse model of general anesthesia to investigate the effects of volatile anesthetics on the diversity and composition of the intestinal microbiome. After 4-hour exposure to isoflurane, we observed a decrease in bacterial diversity. Taxonomic alterations included depletion of several commensal bacteria including Clostridiales. These data identify volatile anesthetics as potential contributors to microbial dysbiosis in the postoperative patient. Accepted for publication October 17, 2018. Funding:This work was supported by grants from the National Institutes of Health (R01 GM120519-01). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Cyrus D. Mintz, MD, PhD, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370, Baltimore, MD 21205. Address e-mail to Cmintz2@jhmi.edu. © 2018 International Anesthesia Research Society

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The Impact of Postoperative Intensive Care Unit Admission on Postoperative Hospital Length of Stay and Costs: A Prespecified Propensity-Matched Cohort Study

BACKGROUND: In this prespecified cohort study, we investigated the influence of postoperative admission to the intensive care unit versus surgical ward on health care utilization among patients undergoing intermediate-risk surgery. METHODS: Of adult surgical patients who underwent general anesthesia without an absolute indication for postoperative intensive care unit admission, 3530 patients admitted postoperatively to an intensive care unit were matched to 3530 patients admitted postoperatively to a surgical ward using a propensity score based on 23 important preoperative and intraoperative predictor variables. Postoperative hospital length of stay and hospital costs were defined as primary and secondary end points, respectively. RESULTS: Among patients with low propensity for postoperative intensive care unit admission, initial triage to an intensive care unit was associated with increased postoperative length of stay (incidence rate ratio, 1.69 [95% CI, 1.59–1.79]; P

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Remote Surveillance Technologies: Realizing the Aim of Right Patient, Right Data, Right Time

The convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist's practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication October 18, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jeanine P. Wiener-Kronish, MD, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, GRB 4–444, Boston, MA 02114. Address e-mail to jwiener-kronish@partners.org. © 2018 International Anesthesia Research Society

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Optimal Muscle Selection for OnabotulinumtoxinA Injections in Post-stroke Lower-Limb Spasticity: A Randomized Trial

OBJECTIVE To identify optimal muscle selection patterns for onabotulinumtoxinA treatment of post-stroke lower-limb spasticity (PSLLS). DESIGN Adults with PSLLS (ankle Modified Ashworth Scale [MAS] ≥3) were randomized to onabotulinumtoxinA (300 U, mandatory ankle plantar flexors; ≤100 U, optional lower-limb muscles) or placebo. Post hoc analysis assessed the impact of muscle selection patterns on ankle MAS and physician-assessed Clinical Global Impression of Change (CGI) based on change from baseline to average of weeks 4/6 versus placebo. RESULTS Among 468 patients randomized, onabotulinumtoxinA improved ankle MAS (–0.81 vs –0.61; P=0.01) and CGI (0.86 vs 0.65; P=0.012) versus placebo. Injection of mandatory muscles alone was not sufficient in improving ankle MAS (P=0.255) or CGI (P=0.576) versus placebo but was adequate ≤24 months post-stroke (MAS, –1.13 vs –0.62, P=0.019; CGI, 1.24 vs 0.68, P=0.006). Additional injections into toe muscles (flexor digitorum longus, flexor hallucis longus) improved ankle MAS (–0.98 vs –0.52; P=0.002) and CGI (0.80 vs 0.38; P=0.023) versus placebo regardless of time since stroke. OnabotulinumtoxinA was well tolerated, with no new safety findings. CONCLUSIONS Post hoc analyses suggested additional injections of onabotulinumtoxinA into toe flexors improved ankle MAS and CGI scores versus mandatory muscles alone overall and with treatment initiation >24 months post-stroke. Address correspondence to: Alberto Esquenazi, MD, Department of Physical Medicine and Rehabilitation, MossRehab Gait and Motion Analysis Laboratory, 60 Township Line Road, Elkins Park, PA 19027. Phone: 215-663-6676. Fax: 215-663-6686. aesquena@einstein.edu Disclosures: Competing Interests: Alberto Esquenazi, MD: Dr Esquenazi has received research support from and acted as a consultant for Allergan and Ipsen. Theodore H. Wein, MD, FRCPC: Dr Wein has received research funds from Allergan plc, Merz, National Institutes of Health, Accorda, and Boehringer Ingelheim; acted as a consultant for Allergan plc and Ispen; and received honoraria for accredited CME from Bayer and Boehringer Ingelheim. Anthony B. Ward, MD, FRCP: Dr Ward is a speaker and consultant for Allergan plc and Ipsen. Carolyn Geis, MD: Dr Geis has received research support from and is a speaker/consultant for Allergan plc. Chengcheng Liu, PhD, and Rozalina Dimitrova, MD, MPH, are employees of Allergan plc and Rozalina Dimitrova holds stock in the company. Study funding: This study and analysis were sponsored by Allergan plc (Dublin, Ireland). The study sponsor was involved in the study design, data collection, data analysis, data interpretation, and writing of the article. Assistance with medical writing was provided by Complete Healthcare Communications, LLC (West Chester, PA). Details of Previous Presentations: The REFLEX Study subanalysis on muscle selection patterns for onabotulinumtoxinA has been presented at the following conferences: Wein T, Esquenazi A, Ward A, Geis C, Liu C, Dimitrova R. Muscle Selection Patterns for Injection of OnabotulinumtoxinA in Adult Patients With Post-Stroke Lower-Limb Spasticity Influence Outcome: Results From a Double-Blind, Placebo-Controlled Phase 3 Clinical Trial. American Academy of Neurology 2016 - 68th Annual Meeting. 2016. Wein T, Esquenazi A, Ward A, Geis C, Liu C, Dimitrova R. Muscle Selection Patterns for Injection of OnabotulinumtoxinA in Adult Patients With Post-Stroke Lower-Limb Spasticity Influence Outcome: Results From a Double-Blind, Placebo-Controlled Phase 3 Clinical Trial. World Federation for NeuroRehabilitation - 9th World Congress for NeuroRehabilitation. 2016. Wein T, Esquenazi A, Ward A, Geis C, Liu C, Dimitrova R. Muscle Selection Patterns for Injection of OnabotulinumtoxinA in Adult Patients With Post-Stroke Lower-Limb Spasticity Influence Outcome: Results From a Double-Blind, Placebo-Controlled Phase 3 Clinical Trial. Movement Disorder Society - 20th International Congress of Parkinson's Disease and Movement Disorder. 2016. Wein T, Esquenazi A, Ward A, Geis C, Liu C, Dimitrova R. Muscle Selection Patterns for Injection of OnabotulinumtoxinA in Adult Patients With Post-Stroke Lower-Limb Spasticity Influence Outcome: Results From a Double-Blind, Placebo-Controlled Phase 3 Clinical Trial. American Academy of Physical Medicine and Rehabilitation. 2016. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Letter to the Editor Re: Comorbidities and Mobility in Lower Limb Prosthesis Users

No abstract available

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ANALYSIS OF CELL VIABILITY AND GENE EXPRESSION AFTER CONTINUOUS ULTRASOUND THERAPY IN L929 FIBROBLAST CELLS

Objective This study aimed to analyze cell viability and gene expression IL-6 (interleukin-6) and VEGF (vascular endothelial growth factor) after continuous ultrasound therapy of 1 and 3 MHz on L929 fibroblast cells. Design The L929 cells were cultivated in 12-well plates and divided into 5 groups: G1: non-irradiated, G2: 0.2 W/cm2-1 MHz, G3: 0.5 W/cm2-1 MHz, G4: 0.2 W/cm2-3 MHz and G5: 0.5 W/cm2-3 MHz. The cells were irradiated at 24 hours and 48 hours. Cell viability was evaluated using the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) method. The gene expression analysis was assessed using real-time PCR. Results The G2 and G3 groups showed a decrease in cell viability when compared to the G1 at 48 hours (p

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Effects of Carbohydrate Mouth Rinse on Cycling Time Trial Performance: A Systematic Review and Meta-Analysis

Abstract

Background

Despite the growing number of studies reporting carbohydrate mouth rinse effects on endurance performance, no systematic and meta-analysis review has been conducted to elucidate the level of evidence of carbohydrate mouth rinse effects on cycling trial performance such as time-, work-, and distance-based trials.

Objectives

The objective of this study were to establish the effect of a carbohydrate mouth rinse on cycling performance outcomes such as mean power output and time to complete a trial, together with the risk of bias in the cycling-carbohydrate mouth rinse literature.

Methods

We systematically reviewed randomized placebo-controlled trials that assessed carbohydrate mouth rinse effects on mean power output and time to complete the trial. A random-effects meta-analysis assessed the standardized mean difference between carbohydrate and placebo mouth rinses.

Results

Thirteen studies (16 trials) were qualitatively (systematic review) and quantitatively (meta-analysis) analyzed with regard to mean power output (n = 175) and time to complete the trial (n = 151). Overall, the reviewed studies showed a low risk of bias and homogeneous results for mean power output (I² = 0%) and time to complete the trial (I² = 0%). When compared with placebo, the carbohydrate mouth rinse improved mean power output (standardized mean difference = 0.25; 95% confidence interval 0.04–0.46; p = 0.02), but not the time to complete the trial (standardized mean difference = − 0.13; 95% confidence interval − 0.36 to 0.10; p = 0.25).

Conclusion

The present systematic and meta-analytic review supports the notion that a carbohydrate mouth rinse has the potential to increase mean power output in cycling trials, despite showing no superiority over placebo in improving time to complete the trials.

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Prevalence and Clinical Features of Community-Acquired Pneumonia Caused by Macrolide-Resistant Mycoplasma pneumoniae Isolated from Adults in Jeju Island

Microbial Drug Resistance, Ahead of Print.


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Increasing Prevalence of Group III Penicillin-Binding Protein 3 Mutations Conferring High-Level Resistance to Beta-Lactams Among Nontypeable Haemophilus influenzae Isolates from Children in Korea

Microbial Drug Resistance, Ahead of Print.


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Modified FOLFIRINOX versus CisGem first-line chemotherapy for locally advanced non resectable or metastatic biliary tract cancer (AMEBICA) − PRODIGE 38: study protocol for a randomized controlled multicenter phase II/III study

Combination of cisplatine and Gemcitabine (CisGem) is the reference 1 st line Chemotherapy in patients with advanced biliary cancer. FOLFIRINOX demonstrated an overall survival superiority when compared to gemcitabine in 1 st line for patients with metastatic pancreatic adenocarcinoma. Because of similarities between pancreatic and biliary cancers, we proposed a randomized trial comparing mFOLFIRINOX and CisGEm.

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Chronic Hepatitis C Infection — Noninvasive assessment of Liver Fibrosis in the era of Direct Acting Antivirals

Significant advancements in the diagnosis and treatment of chronic hepatitis C infection and its associated fibrosis have revolutionized treatment of these patients over the last several years. Liver biopsy, the gold standard diagnostic method for evaluating liver fibrosis level, was routinely used prior to initiation of hepatitis C therapy, placing patients at an inherent risk of adverse events. The recent advent of noninvasive serologic and nonserologic measures of hepatic fibrosis level has reduced the need for liver biopsy significantly, thereby minimizing its associated risks.

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A RARE CASE OF SUBMUCOSAL GASTRIC TUMOR.

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Prolonged depression of knee‐extensor torque complexity following eccentric exercise

New Findings

What is the central question of this study?

Does eccentric exercise leading to prolonged knee‐extensor torque depression also result in a prolonged loss of knee‐extensor torque complexity?

What is the main finding and its importance?

The recovery of the loss of torque complexity after eccentric exercise took 24 h, whereas after acute muscle fatigue it took 10 min. The depression of torque complexity after eccentric exercise was prolonged.

Abstract

Neuromuscular fatigue reduces the temporal structure, or complexity, of muscle torque output. Exercise‐induced muscle damage reduces muscle torque output for considerably longer than high‐intensity fatiguing contractions. We hypothesized that muscle‐damaging eccentric exercise would lead to a persistent decrease in torque complexity, whereas fatiguing exercise would not. Ten healthy participants performed five isometric contractions (6 s contraction, 4 s rest) at 50% maximal voluntary contraction (MVC) before, immediately after and 10, 30 and 60 min and 24 h after eccentric (muscle‐damaging) and isometric (fatiguing) exercise. These contractions were also repeated 48 h and 1 week after eccentric exercise. Torque and surface EMG signals were sampled throughout each test. Complexity and fractal scaling were quantified using approximate entropy (ApEn) and the detrended fluctuation analysis α exponent (DFA α). Global, central and peripheral perturbations were quantified using MVCs with femoral nerve stimulation. Complexity decreased after both eccentric [ApEn, mean (SD), from 0.39 (0.10) to 0.20 (0.12), P < 0.001] and isometric exercise [from 0.41 (0.13) to 0.09 (0.04); P < 0.001]. After eccentric exercise, ApEn and DFA α required 24 h to recover to baseline levels, but after isometric exercise they required only 10 min. The MVC torque remained reduced [from 233.6 (74.2) to 187.5 (64.7) N m] 48 h after eccentric exercise, with such changes evident only up to 60 min after isometric exercise [MVC torque, from 246.1 (77.2) to 217.9 (71.8) N m]. The prolonged depression in maximal muscle torque output is therefore accompanied by a prolonged reduction in torque complexity.

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Rare Pelvic Malignant Tumors in Adults: Treatment Features and Clinical Outcome in Nonmetastatic Disease (Single Institution Experience)

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Novel KIAA1109 variants affecting splicing in a Russian family with ALKURAYA‐KUČINSKAS syndrome

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A Comparative Effectiveness Trial to Reduce Burnout and Improve Quality of Care

Abstract

Clinician burnout is presumed to negatively impact healthcare quality; yet scant research has rigorously addressed this hypothesis. Using a mixed-methods, randomized, comparative effectiveness design, we tested two competing approaches to improve care—one addressing clinician burnout and the other addressing how clinicians interact with consumers—with 192 clinicians and 469 consumers at two community mental health centers. Although qualitative reports were promising, we found no comparative effectiveness for either intervention on burnout, patient-centered processes, or other outcomes. Discussion includes identifying ways to strengthen approaches to clinician burnout.

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Acetaminophen pharmacokinetics in severely obese adolescents and young adults

Abstract

Background

Intravenous acetaminophen is commonly administered as an adjunctive to opioids during major surgical procedures, but neither the correct pharmacokinetic size descriptor nor the dose is certain in severely obese adolescents undergoing bariatric surgery.

Methods

Adolescents, 14‐20 years of age, with a body mass index (BMI) ≥95th percentile for age and sex or BMI ≥40 kg·m⁻², presenting for laparoscopic or robotic assisted or vertical sleeve gastrectomy were administered intravenous acetaminophen (1000 mg) following completion of the surgical procedure. Venous blood was drawn for acetaminophen assay at eight time points, starting 15 minutes after completion of the infusion and up to 12 hours afterward. Time‐concentration data profiles were analyzed using nonlinear mixed effects models. Parameter estimates were scaled to a 70‐kg person using allometry. Normal fat mass was used to assess the impact of obesity on pharmacokinetic parameters.

Results

The study cohort comprised 11 female patients, age 17 SD 2 years with a weight of 125 SD 19 kg and a mean BMI of 46 SD 5 kg·m⁻². The plasma acetaminophen serum concentration was 17 (SD 4) μg·mL⁻¹ at 10‐20 minutes after completion of the infusion and 5 (SD 6) μg·mL⁻¹ at 80‐100 minutes. A two‐compartment model, used to investigate pharmacokinetics, estimated clearance 10.6 (CV 72%) L·h·70 kg⁻¹, intercompartment clearance 37.3 (CV 63%) L·h·70 kg⁻¹, central volume of distribution 20.4 (CV 46%) L·70 kg⁻¹, and peripheral volume of distribution 16.8 (CV 42%) L·70 kg⁻¹. Clearance was best described using total body weight. Normal fat mass with a parameter that accounts for fat mass contribution (Ffat) of 0.88 best described volumes.

Conclusion

Current recommendations of acetaminophen to a maximum dose of 1000 mg resulted in serum concentrations below detection limits in all patients within 2 hours after administration. Dose is better predicted using total body mass with allometric scaling.

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WDR74 functions as a novel coactivator in TGF-β signaling

Publication date: Available online 27 November 2018

Source: Journal of Genetics and Genomics

Author(s): Jinquan Liu, Meiling Zhao, Bo Yuan, Shuchen Gu, Mingjie Zheng, Jian Zhou, Jianping Jin, Ting Liu, Xin-Hua Feng

Abstract

Smads are critical intracellular signal transducers for transforming growth factor-β (TGF-β) in mammalian cells. In this study, we have identified WD repeat-containing protein 74 (WDR74) as a novel transcriptional coactivator for Smads in the canonical TGF-β signaling pathway. Through direct interactions with Smad proteins, WDR74 enhances TGF-β-mediated phosphorylation and nuclear accumulation of Smad2 and Smad3. Consequently, WDR74 enables stronger transcriptional responses and more robust TGF-β-induced physiological responses. Our findings have elucidated a critical role of WDR74 in regulating TGF-β signaling.

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Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) in Pragmatic Clinical Trials of Mental Health Services Implementation: Methods and Applied Case Study

Abstract

Pragmatic clinical trials of mental health services are increasingly being developed to establish comparative effectiveness, influence sustainable implementation, and address real world policy decisions. However, use of time and resource intensive qualitative methods in pragmatic trials may be inconsistent with the aims of efficiency and cost minimization. This paper introduces a qualitative method known as Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) that combines the techniques of Rapid Assessment Procedures with clinical ethnography. A case study is presented to illustrate how RAPICE can be used to efficiently understand pragmatic trial implementation processes and associated real world policy implications.

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