Transient Tachypnea of Newborns Is Associated With Maternal Spinal Hypotension During Elective Cesarean Delivery: A Retrospective Cohort Study

BACKGROUND: The risk for transient tachypnea of newborns, a common cause of respiratory distress in the neonatal period, is 2- to 6-fold higher during elective cesarean delivery compared to vaginal delivery. Here, we evaluated the association between transient tachypnea of newborns and the degree and duration of predelivery maternal hypotension during spinal anesthesia for elective cesarean delivery. METHODS: Demographic data, details of anesthetic management, blood pressure measurements, and vasopressor requirement preceding delivery were compared between transient tachypnea newborns (n = 30) and healthy neonates (n = 151) with normal respiratory function born via elective cesarean delivery between July 2015 and February 2016. The degree and duration of hypotension were assessed using area under the curve for systolic blood pressure (SBP) ≤90 mm Hg and area under the curve for mean arterial pressure ≤65 mm Hg. After adjusting for confounders, multivariable logistic regression was used to evaluate the association between area under the curve for SBP and transient tachypnea of newborns. RESULTS: The median area under the curve for SBP was higher in cases of transient tachypnea of newborns (0.94; interquartile range, 0–28.7 mm Hg*min) compared to healthy controls (0; interquartile range, 0–3.30 mm Hg*min; P = .001). Similarly, median area under the curve for mean arterial pressure was also higher in cases of transient tachypnea of newborns (0; interquartile range, 0–18.6 mm Hg*min) compared to controls (0; interquartile range, 0–1.1 mm Hg*min; P = .01). Mothers of transient tachypnea newborns received significantly higher amounts of phenylephrine and ephedrine compared to controls (P = .001 and 0.01, respectively). Hence, the total vasopressor dose given to mothers in the transient tachypnea of newborn group was much higher than for the control group (P = .001). In the multivariable logistic regression, area under the curve for SBP was significantly associated with transient tachypnea of newborns (odds ratio, 1.02; 95% CI, 1.01–1.04, P = .005) after adjusting for gravidity and the type of anesthetic (spinal versus combined spinal epidural). CONCLUSIONS: Our results suggest that the degree and duration of maternal SBP

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Consensus Statement of the Malignant Hyperthermia Association of the United States on Unresolved Clinical Questions Concerning the Management of Patients With Malignant Hyperthermia

At a recent consensus conference, the Malignant Hyperthermia Association of the United States addressed 6 important and unresolved clinical questions concerning the optimal management of patients with malignant hyperthermia (MH) susceptibility or acute MH. They include: (1) How much dantrolene should be available in facilities where volatile agents are not available or administered, and succinylcholine is only stocked on site for emergency purposes? (2) What defines masseter muscle rigidity? What is its relationship to MH, and how should it be managed when it occurs? (3) What is the relationship between MH susceptibility and heat- or exercise-related rhabdomyolysis? (4) What evidence-based interventions should be recommended to alleviate hyperthermia associated with MH? (5) After treatment of acute MH, how much dantrolene should be administered and for how long? What criteria should be used to determine stopping treatment with dantrolene? (6) Can patients with a suspected personal or family history of MH be safely anesthetized before diagnostic testing? This report describes the consensus process and the outcomes for each of the foregoing unanswered clinical questions. Accepted for publication December 2, 2018. Funding: Travel, hotel, and some food expenses for the attendees at the consensus meeting were paid by the Malignant Hyperthermia Association of the United States The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Ronald S. Litman, DO, ML, Department of Anesthesiology & Critical Care, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to litmanr@email.chop.edu. © 2019 International Anesthesia Research Society

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In Response

No abstract available

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Perioperative Epidural Use and Risk of Delirium in Surgical Patients: A Secondary Analysis of the PODCAST Trial

BACKGROUND: Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3. METHODS: This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding. RESULTS: In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32–1.35]; P= .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17–0.78]; P= .009). Adjusted pain scores (visual analog scale, 0–100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, −16 [95% CI, −26 to −7], P

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Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring

No abstract available

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Gender Inequality in Anesthesiology Research: An Overview of 2018

No abstract available

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Clot Retraction: Lost in Interpretation?

No abstract available

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American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes. Accepted for publication December 11, 2018. Conflicts of Interest: See Disclosures at the end of the article. Funding: D.A.E. has received research support from Semnur Inc and Grunenthal for research unrelated to the topic or production of this manuscript. T.E.M. received research funding and is a consultant for Edwards Lifesciences and for Mallinckrodt. M.D.E. received research funding from the GE Foundation, Edwards Lifesciences, and Cheetah Medical for projects unrelated to this manuscript. The Perioperative Quality Initiative-4 consensus conference was supported by unrestricted educational grants from the American Society for Enhanced Recovery and the Perioperative Quality Initiative, which have received grants from Baxter, Bev MD, Cadence, Cheetah Medical, Edwards, Heron Pharmaceutical, Mallinckrodt, Medtronic, Merck, Trevena, and Pacira 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 (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to David A. Edwards, MD, PhD, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN. Address e-mail to david.a.edwards@vanderbilt.edu. © 2019 International Anesthesia Research Society

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Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients With Normal Airways

BACKGROUND: During induction of general anesthesia, it is common practice to delay neuromuscular blockade until the ability to deliver mask ventilation has been confirmed. However, the benefits of this approach have never been scientifically validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the efficiency of mask ventilation and the time to tracheal intubation in patients with normal airways. METHODS: Patients (n = 114) were randomized to receive IV rocuronium either before (early rocuronium group, n = 58) or after (late rocuronium group, n = 56) checking mask ventilation. Expiratory tidal volumes (VTs) were measured at 10, 20, 30, 40, 50, and 60 seconds after apnea during mask ventilation. We graded the ease of mask ventilation and measured the time from apnea to tracheal intubation. The primary outcome was the average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea. The main secondary outcome was the time from apnea to tracheal intubation. STATA was used for statistical analysis. RESULTS: The average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea was larger in the early rocuronium group than in the late rocuronium group (552 mL breath−1 [165 mL breath−1] vs 393 mL breath−1 [165 mL breath−1], mean difference, 160 mL breath−1; 95% CI, 98−221 mL breath−1; P

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Managing Complications in Paediatric Anaesthesia

No abstract available

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Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors

BACKGROUND: Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS: With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS: A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P

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Linezolid Consumption Facilitates the Development of Linezolid Resistance in Enterococcus faecalis in a Tertiary-Care Hospital: A 5-Year Surveillance Study

Microbial Drug Resistance, Ahead of Print.


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A Distinct Geographic Variant of sasX in Methicillin-Resistant Staphylococcus aureus ST239 and ST368 Lineage from South India

Microbial Drug Resistance, Ahead of Print.


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Asymptomatic giant cell hepatitis: a subtype of post-infantile giant cell hepatitis?

Abstract

Giant cell hepatitis in adults is considered a rapidly progressive and life-threatening disease, but there are few descriptions of a prolonged disease course. A 36-year-old Japanese man was referred to our hospital for further evaluation of abnormal liver function test results. Although asymptomatic, he had undergone follow-up for 9 years with these abnormalities. Because the cause of liver injury was not identified despite extensive noninvasive examinations, the patient underwent needle biopsy. He was finally diagnosed with post-infantile giant cell hepatitis (PIGCH) based on the presence of small numbers of giant multinucleated hepatocytes scattered primarily around the portal area. Necroinflammatory changes were very mild in the portal tracts and hepatic parenchyma. According to the histological findings as well as the accepted international diagnostic scoring system for autoimmune hepatitis (AIH), which is closely related to PIGCH, AIH was unlikely, although antinuclear antibody was positive at a titer of 1:160. The present case may describe an unknown subtype of PIGCH, characterized by insidious disease onset and progression with concurrent, mildly active underlying hepatitis, which is in contrast with the well-documented aggressive nature of PIGCH.

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Hepatic angiomyolipoma with early drainage veins into the hepatic and portal vein

Abstract

Hepatic angiomyolipoma (AML) is a rare stromal tumor composed of variable admixtures of thick-walled vessels, smooth muscles and adipose tissue. One of the specific radiological findings of hepatic AML is an early drainage vein noted via enhanced computed tomography (CT). We report a case of hepatic AML showing early drainage veins into both the hepatic and portal vein. The case involved a 46-year-old woman who was referred to our hospital because of a giant hepatic tumor. CT revealed well-enhanced 14 cm and 1 cm tumors in the left and right lobes, respectively. Magnetic resonance imaging demonstrated the existence of adipose tissues in the larger tumor. Hepatic arteriography revealed early drainage veins draining into both the hepatic and portal vein. Based on a diagnosis of hepatic AML, left hepatectomy and partial hepatectomy were performed. Pathology revealed both tumors as hepatic AML based on human melanoma black-45 immuno-positivity. Hepatic AML with early drainage veins into both the hepatic and portal vein is rare. The dilated and retrogressive vein drains the abundant arterial blood flow of the tumor. The finding of early drainage veins into not only the hepatic vein but also the portal vein should be helpful for diagnosing hepatic AMLs.

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Community-acquired fulminant colitis caused by binary toxin-producing Clostridium difficile in Japan

Abstract

We report a case of community-acquired fulminant colitis caused by Clostridium difficile in Japan. A 46-year-old woman was diagnosed with severe infectious enterocolitis and was admitted at another hospital. The stool culture was positive for toxigenic C. difficile. Since the patient presented with fulminant C. difficile infection (CDI) with toxic megacolon, respiratory insufficiency, and circulatory failure, she was transferred to Kyorin University Hospital for intensive care. Intubation and antibiotic therapy were performed. The general condition improved with conservative treatment, and she was discharged without sequelae. While the recovered isolate was toxin A and B-positive and binary toxin-positive, it was identified as polymerase chain reaction (PCR) ribotype ts0592 and slpA sequence type ts0592. The isolate was different from PCR ribotype 027 epidemic in Europe and North America. In Japan, binary toxin-producing strains are rare and have not caused an epidemic to date. Furthermore, there are few data on community-acquired CDI in Japan. In this case, a non-elderly woman with no major risk factors such as antibiotic use, administration of proton pump inhibitor and history of gastrointestinal surgery developed community-acquired fulminant CDI caused by the binary toxin-positive strain, and ICU treatment was required. Further studies focusing on the role of binary toxin-positive C. difficile in the severity of community-acquired CDI are necessary.

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5 ways to bring a culture of celebration to your EMS agency

Regardless of size or service model, here are a few ways your department can honor its employees throughout the year

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NAEMSP commends new 'Emergency Triage, Treat and Transport' model

The model policy will reimburse EMS agencies for the cost of providing Medicare beneficiaries with treatment-without-transportation and transporting patients to alternative destinations

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Emergency Triage, Treatment and Transport reimbursement model is a watershed moment in modern EMS

EMS leaders react to ET3, HHS reimbursement model that recognizes the value of community paramedicine and emphasizes quality and outcomes

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CMS announces Medicare reimbursement for certain non-transport treatment

The Emergency Triage, Treat and Transport Model makes Medicare reimbursement available for treatment without transport

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4 effective strategies to cope with drug shortages in EMS

Pharmaceutical shortages are an ongoing challenge for EMS providers, but agencies can take proactive steps to address the issue

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5 ways to bring a culture of celebration to your EMS agency

Regardless of size or service model, here are a few ways your department can honor its employees throughout the year

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Recent understanding of the pathophysiology of functional dyspepsia: role of the duodenum as the pathogenic center

Abstract

Over almost 30 years since functional dyspepsia (FD) was defined, researchers have endeavored to elucidate the pathophysiology of functional gastrointestinal disorders. Now a consensus is emerging that the gastric symptoms of FD are caused mainly by gastric motility abnormalities and gastric hypersensitivity. The involvement of other causative factors including acid, Helicobacter pylori, psychological factors, and diet has been debated, but how they are involved in the manifestation of dyspeptic symptoms remains unclear. We believe that most of those factors cause FD symptoms by inducing gastric motility abnormalities and gastric hypersensitivity via the duodenum. Here, we discuss 2 possible reasons why patients with FD experience chronic upper abdominal symptoms: (1) the possibility that the contents of the duodenum of patients with FD differ from those of healthy persons and the different contents stimulate the duodenum, and (2) the possibility that the duodenum of patients with FD is more sensitive to noxious stimuli because of low-grade inflammation and increased mucosal permeability.

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Genome Analyses of a New Mycoplasma Species from the Scorpion Centruroides vittatus

Arthropod Mycoplasma are little known endosymbionts in insects, primarily known as plant disease vectors. Mycoplasma in other arthropods such as arachnids are unknown. We report the first complete Mycoplasma genome sequenced, identified, and annotated from a scorpion, Centruroides vittatus, and designate it as Mycoplasma vittatus. We find the genome is at least a 683,827 bp single circular chromosome with a GC content of 42.7% and with 987 protein-coding genes. The putative virulence determinants include 11 genes associated with the virulence operon associated with protein synthesis or DNA transcription and ten genes with antibiotic and toxic compound resistance. Comparative analysis revealed that the M. vittatus genome is smaller than other Mycoplasma genomes and exhibits a higher GC content. Phylogenetic analysis shows M. vittatus as part of the Hominis group of Mycoplasma. As arthropod genomes accumulate, further novel Mycoplasma genomes may be identified and characterized.

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Reply to: “The crucial need of internal control validation in the normalization of circulating microRNAs”

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O6-methylguanine-DNA methyltransferase (MGMT) status in neuroendocrine tumors: a randomized phase II study (MGMT-NET)

Neuroendocrine tumors (NETs) are rare, but their incidence is rising. Alkylating agents (ALKY), temozolomide and streptozotocin, are the main chemotherapies used for advanced pancreatic NETs. According to retrospective data, O6-methylguanine-DNA methyltransferase (MGMT) status appears to be a predictive factor of the response to ALKY.

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Needlescopic surgery for broad ligament hernia: A case report

Broad ligament hernia is a rare type of internal hernia. We herein report a case of broad ligament hernia successfully treated by needlescopic surgery. A 41‐year‐old woman was referred to our hospital with a complaint of nausea and vomiting. Abdominal contrast‐enhanced computed tomography showed diffuse dilatation of the small bowel accompanied by a caliber change at the right side of the uterus. She was thus diagnosed with small bowel obstruction due to incarceration through right broad ligament hernia. After bowel decompression, she underwent elective needlescopic surgery using 2‐ and 3‐mm instruments. The defect in the right broad ligament was closed with sutures, and she was discharged 2 days after surgery. In the treatment of broad ligament hernia without bowel ischemia, neither an abdominal incision nor any energy devices are required. In this respect, needlescopic surgery seems to be a promising approach among minimally invasive surgeries.

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Emergency Triage, Treatment and Transport reimbursement model is a watershed moment in modern EMS

EMS leaders react to ET3, HHS reimbursement model that recognizes the value of community paramedicine and emphasizes quality and outcomes

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4 effective strategies to cope with drug shortages in EMS

Pharmaceutical shortages are an ongoing challenge for EMS providers, but agencies can take proactive steps to address the issue

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5 ways to bring a culture of celebration to your EMS agency

Regardless of size or service model, here are a few ways your department can honor its employees throughout the year

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Association between MRI findings and back pain after osteoporotic vertebral fractures: a multicenter prospective cohort study

Osteoprotic vertebral fractures(OFV) are common in elderly people. The association between back pain due to OVF with MRI signal change is unclear. In this study we hypothesized that MRI findingswould be a predictive factor for back pain measured by VAS at 6 months follow-up.

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Genetic risk score combining six genetic variants associated with the cellular NRF2 expression levels correlates with Type 2 diabetes in the human population

Abstract

Background

Type 2 diabetes (T2D) is known as an inflammatory disease. NRF2 (Nuclear Factor Erythroid 2 Like2) encodes a transcription factor that binds to antioxidant response elements (AREs) and regulates the expression of genes involved in many antioxidant responses.

Objective

This study aimed to gain insight into individual anti-inflammatory activity to prevent T2D development in humans.

Methods

We performed a genome-wide association study (GWAS) to identify genetic variants influencing NRF2 expression in LCLs (lymphoblastoid cell lines) generated from 74 different individuals. Association analyses between T2D or its related traits and genetic risk score (GRS) calculated by combining genetic variants detected from GWAS for cellular NRF2 expression were performed using data from 8715 subjects. The T2D prediction model using GRS was evaluated by measuring the area under the curve (AUC) of the receiver operating characteristics (ROC) curve.

Results

Our GWAS identified six genetic variants (SNP) showing suggestive evidence of associations with cellular NRF2 expression (P < 10^− 6). Logistic regression analysis demonstrated that GRS was associated with an increased risk of T2D (P value = 0.003, OR = 1.13). In addition, linear regression analyses showed positive associations between GRS and fasting glucose (P value = 0.028, β = 0.62), 2-h glucose (P value = 0.0004, β = 1.13) and HbA1C (P value = 0.033, β = 0.03). In the T2D prediction model using GRS, the AUC of the ROC curve was 0.69.

Conclusion

This study highlights genetic variants associated with cellular NRF2 expression and suggests that the GRS of NRF2 expression-associated variants is likely to be a useful indicator of T2D development in the human population.

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Molt-dependent transcriptome analysis of claw muscles in Chinese mitten crab Eriocheir sinensis

Abstract

Background

Molting is a critical developmental process for crustaceans, during which the claw muscles undergo periodic atrophy and restoration. But the mechanism underlying this special muscle reshuffle around ecdysis is not yet thoroughly understood.

Objective

To investigate the molecular mechanism underlying the muscle's reshuffle over the molting cycle of Chinese mitten crab Eriocheir sinensis.

Methods

The Illumina high-throughput sequencing technique were used to sequence the transcriptome of the whole claw muscles from Chinese mitten crab Eriocheir sinensis in three molting stages (inter-molt C stage, pre-molt D₃₋₄ and post-molt A–B stage); the de novo assembly, annotation and functional evaluation of the contigs were performed with bioinformatics tools.

Results

Totally 129,149 unigenes, 128,190 CDS, 33,770 SSRs and a large number of SNP sites were obtained, and 3700 and 12,771 differentially expressed genes (DEGs) were identified respectively in A–B and D₃₋₄ stage compared with that in C stage. The identified DEGs were enriched to 746 and 1 408 GO terms respectively in A–B and D_3–4 stage compared with C stage (p ≤ 0.05). KEGG pathway analysis showed that the DEGs were significantly enriched in 14 and 11 pathways in A–B vs C comparison and D₃₋₄ vs C comparison (p ≤ 0.05), respectively. These DEGs are involved in several biological processes critical for the animal's growth and development, such as gene expression, protein synthesis, muscle development, new cuticle reconstruction, oxidation–reduction process and glycolytic process.

Conclusion

The data generated in this study is the first transcriptomic resource from the muscles of Chinese mitten crab, which would facilitate to characterize key molecular processes underlying crab muscle's growth and development during the molting cycles.

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Mechanisms of age and race differences in receiving minimally invasive inguinal hernia repair

Abstract

Background

Black patients and older adults are less likely to receive minimally invasive hernia repair. These differences by race and age may be influenced by surgeon-specific utilization rate of minimally invasive repair. In this study, we explored the association between race, age, and surgeon utilization of minimally invasive surgery (MIS) with the likelihood of receiving MIS inguinal hernia repair.

Methods

A retrospective cohort study was performed in patients undergoing elective primary inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a 72-hospital clinical registry. Surgeons were stratified by proportion of MIS performed. Using hierarchical logistic regression models, we investigated the association between receiving MIS repair and race, age, and surgeon MIS utilization rate.

Results

Out of 4667 patients, 1253 (27%) received MIS repair. Out of 190 surgeons, 81 (43%) performed only open repair. Controlling for surgeon MIS utilization, race was not associated with MIS receipt (OR 0.93, p = 0.775), but older patients were less likely to receive MIS repair (OR 0.41, p < 0.001).

Conclusions

Race differences were explained by surgeon MIS utilization, implicating access to MIS-performing surgeon as a mediator. Conversely, age disparity was independent of MIS utilization, even after adjusting for comorbidities, indicating some degree of provider bias against performing MIS repair in older patients. Interventions to address disparities should include systematic efforts to improve access, as well as provider and patient education for older adults.

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2018 Acknowledgment of reviewers

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Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis

Abstract

Background

Achalasia is a rare primary esophageal dysmotility disorder in children. Peroral endoscopic myotomy (POEM) is a novel endoscopic technique which has shown promising results for treating achalasia in adults. However, limited data on efficacy and safety in pediatric patients are available. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in pediatric achalasia.

Methods

We searched MEDLINE, Embase, PubMed, and Web of Science databases through July 2018. Studies were eligible for inclusion if they conducted POEM in pediatric patients. Main outcomes were Eckardt score and lower esophageal sphincter (LES) pressure before and after POEM. Secondary outcomes were clinical success rate and adverse events associated with POEM. Two reviewers independently reviewed the studies, collected data, and assessed quality of evidence using Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias.

Results

A total of 12 studies with 146 pediatric patients (53.68% female) underwent POEM for the treatment of achalasia (mean duration of disease of 19.48 months). There was a significant reduction in Eckardt score by 6.88 points (Mean Difference (MD) 6.88, 95% confidence interval (CI), 6.28–7.48, P < .001) and LES pressure by 20.73 mmHg (MD 20.73, 95% CI, 15.76–25.70, P < .001) following POEM. At least 93% of the patients experienced improvement or resolution of achalasia symptoms both short and long terms after POEM, with small proportion of patients experiencing minor adverse effects which could be managed conservatively.

Conclusions

POEM is efficacious and safe for treating achalasia in pediatric populations. Large comparative or randomized trials are warranted to confirm the efficacy and safety of POEM compared to other surgical procedures for achalasia.

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Predicting Youth Improvement in Community-Based Residential Settings with Practices Derived from the Evidence-Base

Abstract

The current investigation conducted descriptive analyses on key variables in community-based residential (CBR) settings and investigated the extent to which disruptive youth between the ages of 13 and 17 years improved based on therapists' reported alignment with using practices derived from the evidence-base (PDEBs). Results from both the descriptive analyses and multilevel modeling suggested that therapists are using practices that both do and do not align with the evidence-base for disruptive youth. In addition, both PDEBs and practices with minimal evidence-support predicted or marginally predicted final average progress rating for these youth. Findings are discussed as they relate to the importance of continued exploration of treatment outcomes for CBR youth.

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Prevalence of pathogenic and likely pathogenic variants in the RASopathy genes in patients who have had panel testing for cardiomyopathy

RASopathies are a group of developmental disorders caused by pathogenic variants in the RAS‐MAPK pathway. Cardiomyopathy is a major feature of this group of disorders, specifically hypertrophic cardiomyopathy (HCM). HCM can be the first presenting feature in individuals with RASopathies. We conducted a retrospective study of all individuals who have had a cardiomyopathy gene panel ordered through our institution to determine the prevalence of pathogenic or likely pathogenic variants in RAS pathway genes in individuals with cardiomyopathy. We evaluated variants in the following genes: BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NF1, NRAS, PTPN11, RAF1, SHOC2, and SOS1. We reviewed 74 cases with cardiomyopathy, including 32 with HCM, 24 with dilated cardiomyopathy (DCM), nine with both left ventricular noncompaction (LVNC) and DCM, four with LVNC only, two with arrhythmogenic right ventricular cardiomyopathy (ARVC) and three with unspecified cardiomyopathy. We identified four patients (5.41%) with pathogenic or likely pathogenic variants in HRAS, PTPN11 and RAF1 (two individuals). Indication for testing for all four individuals was HCM. The prevalence of pathogenic or likely pathogenic variants in RASopathy genes in our HCM patient cohort is 12.5% (4/32). We conclude that the RASopathy genes should be included on multi‐gene panels for cardiomyopathy to increase diagnostic yield for individuals with HCM.

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Genetics of anophthalmia and microphthalmia. Part 1: Non-syndromic anophthalmia/microphthalmia

Abstract

Eye formation is the result of coordinated induction and differentiation processes during embryogenesis. Disruption of any one of these events has the potential to cause ocular growth and structural defects, such as anophthalmia and microphthalmia (A/M). A/M can be isolated or occur with systemic anomalies, when they may form part of a recognizable syndrome. Their etiology includes genetic and environmental factors; several hundred genes involved in ocular development have been identified in humans or animal models. In humans, around 30 genes have been repeatedly implicated in A/M families, although many other genes have been described in single cases or families, and some genetic syndromes include eye anomalies occasionally as part of a wider phenotype. As a result of this broad genetic heterogeneity, with one or two notable exceptions, each gene explains only a small percentage of cases. Given the overlapping phenotypes, these genes can be most efficiently tested on panels or by whole exome/genome sequencing for the purposes of molecular diagnosis. However, despite whole exome/genome testing more than half of patients currently remain without a molecular diagnosis. The proportion of undiagnosed cases is even higher in those individuals with unilateral or milder phenotypes. Furthermore, even when a strong gene candidate is available for a patient, issues of incomplete penetrance and germinal mosaicism make diagnosis and genetic counseling challenging. In this review, we present the main genes implicated in non-syndromic human A/M phenotypes and, for practical purposes, classify them according to the most frequent or predominant phenotype each is associated with. Our intention is that this will allow clinicians to rank and prioritize their molecular analyses and interpretations according to the phenotypes of their patients.

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Editorial Board

Publication date: February 2019

Source: Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms, Volume 1862, Issue 2

Author(s):

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Verification of the reliability of current perception threshold and pain threshold testing by application of an electrical current stimulus to mandibular mucosa in young adults

Abstract

Background

There is little evidence regarding the reliability of CPT and PT measurement to gauge mandibular perception. Thus, this study aimed to evaluate the test‐retest reliability of CPT and PT values obtained from the mandibular oral mucosa and to test the bilateral differences in CPT and PT values obtained from the mental foramen region and buccal shelf region by a single operator.

Methods

CPT and PT values were obtained from the mental foramen and buccal shelf regions of 20 volunteers (10 male, 10 female; average age: 26.4 ± 2.6 years) by using the Neurometer CPT/C^® device to deliver electrical stimulation.

Results

Relative and absolute reliability was confirmed over two measurements of CPT and PT over a 7‐10 day measurement interval. Intraclass correlation coefficient (ICC) for CPT and PT Table obtained from the mental foramen region were >0.8, while most ICC for the buccal shelf region were <0.8. Standard error of measurement, minimal detectable change, and Bland‐Altman analyses showed that the CPT and PT measurements had no systematic error and could serve as useful methods. At all frequencies, the bilateral difference in CPT and PT values at the mental foramen and buccal shelf region was not significant.

Conclusion

CPT and PT measurements using a custom‐made device that applied an electrical current to the mental foramen region have appropriate reliability to assess intraoral sensitivity to electrical stimulation in young adults.

This article is protected by copyright. All rights reserved.

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In Appreciation of the Maternal and Child Health Journal’s Peer Reviewers, 2018

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An exploratory study of the relationship between post‐operative nausea and vomiting and post discharge nausea and vomiting in children undergoing ambulatory surgery

Abstract

Background

The factors contributing to postoperative nausea and vomiting in children have been identified, but there have been no reported studies that have studied pediatric post‐discharge nausea and vomiting .

Aims

A preliminary study of the factors affecting post discharge nausea and vomiting in ambulatory children, specifically whether postoperative nausea and vomiting factors are contributory.

Methods

122 pediatric patients aged 5‐10 years undergoing elective ambulatory surgery participated in this institution‐approved study. After obtaining written parental consent and patient assent when indicated, child self‐ratings of nausea and pain were completed pre‐operatively and at discharge, and for 3 days post‐discharge. Questionnaires were returned by mail, with a 64% return rate. Using stepwise logistic regression with backward elimination, three separate analyses were undertaken to predict the following outcomes: nausea present in recovery; nausea present on postoperative day 1 and emesis on day of surgery.

Results

Nearly half (47%) of our cohort experienced nausea at the time of discharge; 11% had emesis on day of surgery. On postoperative day 1 there was a 15% incidence of nausea with a 3% incidence of emesis. In the multiple logistic regression analyses, nausea at discharge was predicted by male gender (odds ratio 2.5, 95% CI: 1.0–6.2) and presence of pain on discharge (odds ratio 3.0, 95% CI: 1.0–9.2). Emesis on day of surgery was predicted by presence of nausea at discharge (odds ratio 16.9, 95% CI: 1.8–159.3) and having a family history of nausea/vomiting (odds ratio 8.3, 95% CI: 1.6–43.4). Presence of nausea on postoperative day 1 was predicted only by presence of nausea on discharge (odds ratio 3.7, 95% CI: 1.2–11.1).

Conclusions

Our preliminary data indicate that post‐operative nausea and vomiting may persist into the post‐discharge period and pain may be a contributing factor.

This article is protected by copyright. All rights reserved.

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Anesthesia Outside the Operating Room

No abstract available

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Recent Advances in Anesthesiology

No abstract available

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Ability to control directional lip‐closing force during voluntary lip pursing in healthy young adults

Abstract

Background

It is considered important to evaluate the ability to control lip‐closing force (LCF).

Objective

This study aimed to investigate the ability to control directional LCF.

Methods

The experimental system included an apparatus developed to measure LCF during lip pursing in eight directions (upper, lower, right, left and the four directions in between) and a display showing the exerted LCF and a target value in each direction in real time. Twenty subjects (10 males and 10 females) were instructed to maintain the LCF at a specific target value using visual feedback. Based on our preliminary experiments, the target value was set as 50% of the maximum LCF, and the range was set at the target value ± 8%. The accuracy rate was defined as the ratio of the matched time, in which the subject was able to keep the LCF in the target range, to the total 3 seconds.

Results

The accuracy rate of males was higher than in females in the lower, lower left, and lower right directions. The accuracy rate of the directional LCF differed significantly depending on the direction. In assessing the accuracy rate for each directional LCF, the rates of upper and lower directional LCF were significantly higher than that of oblique directional LCF. No significant relationship was observed between the accuracy rate and the maximum LCF except for one direction in male subjects.

Conclusions

Our findings suggest that the ability to control directional LCF is affected by sex and the force direction.

This article is protected by copyright. All rights reserved.

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Society for Neuroscience in Anesthesiology & Critical Care (SNACC) Neuroanesthesiology Education Milestones for Resident Education

Background: The Accreditation Council for Graduate Medical Education (ACGME) has introduced competency-based assessments (milestones) for resident education. However, the existing milestones for Anesthesiology are not specific to Neuroanesthesiology. The Society for Neuroscience in Anesthesiology & Critical Care (SNACC) commissioned a task force to adapt the ACGME anesthesiology milestones for use in Neuroanesthesiology training, and to provide recommendations for implementing milestones. Methods: A 7-member expert task force supported by an advisory committee developed the initial milestones by consensus. Written permission was given by the ACGME. The milestones were refined following 3-month pilot use in 14 departments across the United States and inputs from SNACC members. Final milestones were approved by the SNACC Board of Directors. Results: Twelve Neuroanesthesiology-specific milestones in 5 major ACGME domains are recommended; these were identified as most pertinent to this subspecialty rotation. These pertain to patient care (7 milestones), medical knowledge (2 milestones), practice-based learning and improvement (1 milestone), and interpersonal and communication skills (2 milestones). Each milestone was described in detail, with clear outline of expectations at various levels of training. Conclusions: The SNACC Neuroanesthesiology milestones provide a framework for reviewing resident performance and are expected to facilitate improved use of ACGME milestones during Neuroanesthesiology subspecialty training. The task force recommends that the target should be to accomplish level 4 or higher milestones by the end of residency training. Individual programs should decide the implications of a resident not meeting the expected milestones. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Deepak Sharma, MD, DM, Departments of Anesthesiology & Pain Medicine and Neurological Surgery, Division of Neuroanesthesiology & Perioperative Neurosciences, University of Washington, Seattle, WA, P.O. Box #359724, 325, 9th Ave., Seattle, WA 98104 (e-mail: dsharma@uw.edu). Received December 15, 2018 Accepted January 7, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

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Cerebrospinal Fluid Glucose and Lactate Levels After Subarachnoid Hemorrhage: A Multicenter Retrospective Study

Background: In patients with subarachnoid hemorrhage (SAH), abnormalities in glucose and lactate metabolism have been described using cerebral microdialysis. Glucose and lactate concentrations in cerebrospinal fluid (CSF) are more easily accessible, but scarce data are available in this setting. The aim of this study is to assess the relationship of CSF glucose and lactate with blood concentrations and with unfavorable neurological outcome after SAH. Methods: A retrospective cohort study was conducted in 5 European University intensive care units. Patients aged 18 years and above who were admitted after a nontraumatic SAH over a 4-year period (2011 to 2014) were included if they had an external ventricular drain placed, daily analysis of CSF including glucose (±lactate) concentrations for 1 to 4 consecutive days, and concomitant analysis of glucose and lactate concentrations in the arterial blood. Results: A total of 144 patients were included in the final analysis (median age: 58 [49 to 66] y; male sex: 77/144). Median time from admission to external ventricular drain placement was 1 (0 to 3) day; median Glasgow Coma Scale on admission was 10 (7 to 13), and CT-scan Fisher scale was 4. A total of 81 (56%) patients had unfavorable neurological outcome at 3 months (Glasgow Outcome Scale ≤3). There was a weak correlation between blood and CSF glucose (r2=0.07, P=0.007), and between blood and CSF lactate levels (r2=0.58, P

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International Multicenter Survey of Perioperative Management of External Ventricular Drains: Results of the EVD Aware Study

Introduction: The perioperative management of patients with external ventricular drains (EVDs) is not well defined, and adherence to published management guidelines unknown. This study investigates practice, patterns, and variability in the perioperative management of patients with EVDs. Methods: A 31-question survey was sent to 1830 anesthesiologists from 27 institutions in North America, Europe, and Asia. A perioperative EVD Guideline Adherence Score was calculated for the preoperative, transport and intraoperative periods. Differences in management practices between neuroanesthesiologists and non-neuroanesthesiologists, and factors affecting EVD guideline adherence, were examined using bivariate significance tests and linear regression. Results: Among a sample of 599 anesthesiologists (survey response rate, 32.7%), compared with non-neuroanesthesiologists, neuroanesthesiologists were more likely to include baseline neurological examination (P=0.023), hourly cerebrospinal fluid output (P=0.006) and color (P

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Glucose and Lactate Concentrations in Cerebrospinal Fluid After Traumatic Brain Injury

Background: Studies in which brain metabolism has been monitored using microdialysis have indicated decreases in cerebral glucose concentration and increases in lactate concentration in patients with traumatic brain injury (TBI). However, few data are available on glucose and lactate concentrations in the cerebrospinal fluid (CSF) of TBI patients. This study investigates the relationship between CSF glucose and lactate concentrations and outcomes after TBI. Methods: Consecutive adult (>18 y) TBI patients were admitted to our 35-bed medicosurgical between 2011 and 2014 and were included in the study if they met the following inclusion criteria: presence of an external ventricular drain (EVD) for intracranial pressure monitoring, daily analysis of CSF glucose and lactate concentrations for 4 consecutive days, and concomitant measurements of blood glucose/lactate concentrations. Neurological outcome was assessed at 3 months using the extended Glasgow Outcome Scale (GOS), and unfavorable outcome defined as a GOS 1 to 4. Results: Of 151 TBI patients who had an EVD, 56 met the inclusion criteria. Most EVDs were placed on the day of intensive care unit admission, and maintained for 10 (interquartile range: 6 to 14) days. On day 1, there was a weak but significant correlation between blood and CSF glucose concentrations (R2=0.07, P=0.04), and a greater correlation between blood and CSF lactate (R2=0.32, P

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Intubating Laryngeal Mask Airway-assisted Flexible Bronchoscopic Intubation is Associated With Reduced Cervical Spine Motion When Compared With C-MAC Video Laryngoscopy-guided Intubation: A Prospective Randomized Cross Over Trial

Background: In the evolving research into cervical spine mechanics during airway intervention, new devices are being constantly added to the armamentarium of anesthesiologists. In this study we compared cervical spine movement during orotracheal intubation using an intubating laryngeal mask airway (LMA Fastrach) assisted flexible bronchoscope or video laryngoscope. Materials and Methods: In total, 40 consenting patients without history of abnormalities of cervical spine and planned for elective neuroradiologic interventions in the angiography suite were enrolled in this randomized crossover trial. Every patient was subjected to LMA Fastrach-guided flexible bronchoscopic as well as video laryngoscopy guided intubation. Cervical spine motion at the occipital bone, C1-C5 vertebrae, the occiput-C1, C1-C2, C2-C3 and C4-C5 junctions was investigated using continuous fluoroscopy during intubation. The primary outcome of the study was combined craniocervical motion from occiput to C5 between the 2 intubation techniques. Results: There was less (62%) combined craniocervical movement from occiput to C5 during the LMA Fastrach-flexible bronchoscopy-guided technique as compared with video laryngoscopy-guided intubation (17.55±14.23 vs. 28.95±11.58 degrees, respectively; P

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