Τετάρτη, 31 Αυγούστου 2016

THERAPEUTIC MANAGEMENT OF STAGE II MILK FEVER WITH RETAINED PLACENTA IN A COW

2016-08-31T23-52-20Z
Source: International Journal of Livestock Research
Faez Firdaus Abdullah Jesse, Eric Lim Teik Chung, Yusuf Abba, Muhammad Abubakar Sadiq, Lawan Adamu, Idris Umar Hambali, Asinamai Athliamai Bitrus, Nur Syamila Zabri, Mohd Azmi Mohd Lila, Abd Wahid Haron, Abdul Aziz Saharee.
Milk fever is a condition where the animals body fails to maintain the calcium homeostasis following an upsurge demand of calcium during gestation or lactation. This case reports the clinical management of suspected stage II milk fever with retained placenta in a Friesian cow after parturition of twin calves. A four-year-old Friesian cow weighing 400kg was presented with primary complaint of weakness and inability to stand a day after parturition of two calves. Physical examination revealed that the cow was on sternal recumbency and unable to stand, while the placenta was seen hanging from the vulva region. All vital parameters were normal but the cow was having a weak cardiac rythm. The differential diagnoses at this point of time were milk fever, downers cow syndrome and hypophosphatemia. The cow was diagnosed with suspected milk fever based on the history of parturition of two calves and thus leading to hypocalcaemia. The cow was treated with flunixin meglumine 1.1mg/kg once intravenously as anti-inflammatory, anti-pyrexic and analgesic. Then, 500mL of calcium borogluconate (23%) was administered intravenously slowly at the rate of 1drop/second as a source of calcium. The cow responded well to treatment after 10 minutes of administration. In addition, 0.9% normal saline was lavaged into the uterus to irrigate the retained placenta. Subsequently, 20mL of oxytetracycline (20mg/kg) was infused into the uterine body as the final lavage. Finally, broad spectrum long acting oxytetracycline (20mg/kg) antibiotic was given once intramuscularly to prevent secondary bacterial infections. Therapeutic treatment to restore the calcium level in the blood should be the main focus during the management of milk fever.


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A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation

Abstract

The Clubhouse Model has been in existence for over sixty-five years; however, a review that synthesizes the literature on the model is needed. The current study makes use of the existing research to conduct a systematic review of articles providing a comprehensive understanding of what is known about the Clubhouse Model, to identify the best evidence available, as well as areas that would benefit from further study. Findings are summarized and evidence is classified by outcome domains. Fifty-two articles met the selection criteria of Randomized Clinical Trials (RCT's), quasi-experimental studies, or observational studies for domains of employment (N = 29); quality of life/satisfaction (N = 10); reductions in psychiatric hospitalization(s) (N = 10); social relationships (N = 10); education (N = 3); and health promotion activities (N = 2). RCT results support the efficacy of the Clubhouse Model in promoting employment, reducing hospitalization(s), and improving quality of life. Quasi-experimental and observational studies offer support in education and social domains. The findings from this review indicate that Clubhouses are a promising practice but additional studies using rigorous methods that report the strength of the outcomes are needed to evaluate Clubhouse programs with fidelity to the Clubhouse Model.



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Proper Sterol Distribution Is Required for Candida albicans Hyphal Formation and Virulence

Candida albicans is an opportunistic fungus responsible for the majority of systemic fungal infections. Multiple factors contribute to C. albicans pathogenicity. C. albicans strains lacking CaArv1 are avirulent. Arv1 has a conserved Arv1 homology domain (AHD) that has a zinc-binding domain containing two cysteine clusters. Here, we explored the role of the CaAHD and zinc-binding motif in CaArv1-dependent virulence. Overall, we found that the CaAHD was necessary but not sufficient for cells to be virulent, whereas the zinc-binding domain was essential, as Caarv1/Caarv1 cells expressing the full-length zinc-binding domain mutants, Caarv1C3S and Caarv1C28S, were avirulent. Phenotypically, we found a direct correlation between the avirulence of Caarv1/Caarv1, Caar1AHD, Caarv1C3S, and Caarv1C28S cells and defects in bud site selection, septa formation and localization, and hyphal formation and elongation. Importantly, all avirulent mutant strains lacked the ability to maintain proper sterol distribution. Overall, our results have established the importance of the AHD and zinc-binding domain in fungal invasion, and have correlated an avirulent phenotype with the inability to maintain proper sterol distribution.



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Marker-Based Estimates Reveal Significant Non-additive Effects in Clonally Propagated Cassava (Manihot esculenta): Implications for the Prediction of Total Genetic Value and the Selection of Varieties

In clonally propagated crops, non-additive genetic effects can be effectively exploited by the identification of superior genetic individuals as varieties. Cassava (Manihot esculenta Crantz) is a clonally propagated staple food crop that feeds hundreds of millions. We quantified the amount and nature of non-additive genetic variation for three key traits in a breeding population of cassava from sub-Saharan Africa using additive and non-additive genome-wide marker-based relationship matrices. We then assessed the accuracy of genomic prediction for total (additive plus non-additive) genetic value. We confirmed previous findings based on diallel populations, that non-additive genetic variation is significant for key cassava traits. Specifically, we found that dominance is particularly important for root yield and epistasis contributes strongly to variation in CMD resistance. Further, we showed that total genetic value predicted observed phenotypes more accurately than additive only models for root yield but not for dry matter content, which is mostly additive or for CMD resistance, which has high narrow-sense heritability. We address the implication of these results for cassava breeding and put our work in the context of previous results in cassava, and other plant and animal species.



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Dexmedetomidine versus fentanyl as adjuvant to epidural 0.5% levobupivacaine for transurethral prostate resection in elderly patients: a comparative evaluation

Kumkum Gupta, Prashant K Gupta, Bhawana Rastogi, Manish Jain, Deepak Sharma, Mahesh Narayan Pandey

Ain-Shams Journal of Anaesthesiology 2016 9(3):398-402

Background Regional anesthesia is the technique of choice for patients undergoing transurethral resection of the prostate (TURP), but anesthetic management of elderly patients is challenging due to compromised organ function. The present study aimed to evaluate the relative efficacy and safety of dexmedetomidine versus fentanyl in the enhancement of the quality and duration of epidural anesthesia with 0.5% levobupivacaine and hemodynamic stability during TURP in elderly patients. Patients and methods Sixty elderly consented patients were randomized into two equal groups of 30 patients each in a double-blind manner. They were given 15 ml of 0.5% levobupivacaine (75 mg) either with 1 ml (50 μg) dexmedetomidine (group LD) or with 1 ml (50 μg) fentanyl (group LF) using an epidural catheter. The primary endpoints were the onset and duration of sensory and motor blockade, duration of sensory analgesia, hemodynamic variability, respiratory adequacy, and any adverse effect. Results Demographic data were comparable in both groups. Onset of sensory and motor blockade was faster in patients of group LD than in patients of group LF, with a statistically significant difference (P < 0.05). Duration of motor blockade and sensory analgesia was longer in patients of group LD than in patients of group LF (P < 0.05). Intraoperative heart rate and mean arterial blood pressure were significantly lower in patients of group LD, but no intervention was required. Surgical bleeding was reduced in patients of group LD. Conclusion Dexmedetomidine as an adjuvant to epidural levobupivacaine for TURP has shortened onset time of anesthesia and prolonged duration of sensory analgesia. The surgical field vision was improved due to reduced bleeding.

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Management of perioperative bleeding associated with the use of selective serotonin reuptake inhibitors

Lobna A Saleh, Ahmed N Hassan, Amr Sobhy

Ain-Shams Journal of Anaesthesiology 2016 9(3):449-451

Increased bleeding tendency is associated with the use of selective serotonin reuptake inhibitors. In this study, we report a case of perioperative bleeding in patient on selective serotonin reuptake inhibitors. The management options for such cases are discussed.

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Methylene blue versus vasopressin in sepsis-induced vasoplegia

Mostafa ElAdawy, Ahmed S Omran

Ain-Shams Journal of Anaesthesiology 2016 9(3):319-324

Background Septic shock is one of the biggest causes of mortality in intensive care settings, and, despite all the recent advances in pharmacological and mechanical support therapies, is the second leading cause of death among ICU patients. Although vasopressors have been widely used in these situations, where keeping the hemodynamic stability is of utmost importance, a detailed study of their effects is undoubtedly needed. Objective Our study compared the effect of methylene blue (MB) in the vasoplegic situation associated with sepsis with that of vasopressin. Patients and methods We randomized 40 patients into two groups (20 patients each); patients in the first group received MB, whereas patients in the second group received vasopressin as a hemodynamic support. Results In the present study, mean arterial blood pressure was found to be significantly higher in the MB group compared with the vasopressin group, whereas within the MB group, it was significantly higher after 6 h compared with the baseline level. The systemic vascular resistance showed no difference between the two groups at the start but a marked difference only after 2 h, being higher for the MB group — that is, there was a significant decrease in the vasopressors and inotropes needed in the MB group. There was no significant difference between the two groups regarding the ICU length of stay, the central venous pressure, pulmonary artery pressure, and oxygen extraction ratio. Conclusion The use of MB in sepsis-induced refractory vasoplegic situations remains one of the salvage management strategies; however, the practice of its routine use is yet to be established and needs further investigation.

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Dexamethasone added to levobupivacaine prolongs ultrasound-guided interscalene brachial plexus blockade: a prospective, randomized, controlled study

Ahmed M Abd El-Hamid, Mohamed A. I. Alrabiey

Ain-Shams Journal of Anaesthesiology 2016 9(3):422-425

Objectives This study aimed to evaluate the effect of the addition of dexamethasone to levobupivacaine on the duration of analgesia in forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients and methods This prospective randomized controlled, double-blind clinical trial was conducted on 60 patients who underwent elective forearm surgeries under ultrasound-guided interscalene brachial plexus block. Patients in the levobupivacaine group (group L) received 25 ml of 0.5% levobupivacaine plus 2 ml of normal saline 0.9%. Patients in the levobupivacaine dexamethasone group (group LD) received 25 ml of 0.5% levobupivacaine plus 2 ml of dexamethasone (8 mg). The onset of sensory and motor block, duration of the sensory block, time to first analgesic request, the number of failed block, total morphine consumption, side effects, and complications were recorded and compared. Results Onset of sensory block and motor block was significantly earlier in group LD compared with group L. Duration of sensory block and time to first analgesic request were significantly longer in group LD compared with group L. Total morphine consumption was significantly lower in group LD in comparison with group L. The number of failed blocks was nonsignificantly lower in group LD. The incidence of side effects and complications was low and comparable in both groups. Conclusion Addition of dexamethasone to levobupivacaine significantly shortens the onset of sensory and motor block, prolongs the duration of analgesia, decreases the 24 h morphine consumption, and prolongs the time to first analgesic request with minimal side effects.

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Human albumin 4% versus hydroxyethyl starch 6% for fluid resuscitation in sepsis

Heba F Toulan, Eman M Kamal

Ain-Shams Journal of Anaesthesiology 2016 9(3):325-329

Background Early fluid resuscitation is vital to patients with sepsis. However, the choice of fluid has been a hot topic of discussion. The objective of this study was to compare hydroxyethyl starch (HES) 6% (130/0.4) with albumin 4% as a resuscitation fluid in septic patients. Patients and methods In this prospective randomized study, 80 patients aged 20–60 years of both sexes with sepsis were assigned to receive either HES (130/0.4) in 0.9% saline or human albumin 4% as a resuscitation fluid. Mortality rate after 28 days, need for renal replacement therapy, and duration of ICU stay were compared between the two groups. Results The mortality rate in the albumin group (22.5%) was lower than in the HES 6% group (40%) with significant P value (0.033). Also, the need for renal replacement therapy (RRT) and length of ICU stay were significantly higher in the HES 6% group compared with the albumin group. Conclusion Use of human albumin 4% has a significant effect in reducing mortality rates in the ICU in patients with severe sepsis compared with HES 6%.

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Innovative use of damaged fiberoptic bronchoscope

Senthil Kumar Kaliannan, Khaja Mohideen Sherfudeen, Pavan Kumar Dammalapati

Ain-Shams Journal of Anaesthesiology 2016 9(3):463-464

Flexible fiberoptic bronchoscope is a delicate instrument that can get damaged due to improper handling. Once damaged, this costly instrument becomes useless. We reported a case in which we used a damaged flexible fiberoptic bronchoscope in overcoming a difficulty in advancing the endotracheal tube after visualization of the vocal cord with TruviewPCD in a patient with cervical spine injury.

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A comparative study between terlipressin alone and dobutamine and terlipressin in septic shock patients

Waleed Abdalla, F Kamel, Naglaa M Ali, Tarek Shabana

Ain-Shams Journal of Anaesthesiology 2016 9(3):330-336

Background The use of terlipressin, a long-acting synthetic analog of vasopressin, is associated with reduction in cardiac output and oxygen delivery. The present study was designed to determine whether dobutamine may reverse the terlipressin-induced depression in central venous oxygen saturation (SvO2) in patients with catecholamine-dependent septic shock. Patients and methods This clinical trial was conducted in Ain Shams University hospital's surgical ICU. In total, 90 septic shock patients requiring a continuous infusion of norepinephrine reaching 0.6 µg/kg/min to maintain mean arterial pressure at greater than or equal to 65 mmHg were randomly allocated to three groups be treated as follows: (i): group I, treated with norepinephrine infusion (control); (ii) group II, treated with a single bolus of terlipressin 1 mg, intravenous; (iii) and group III, treated with a single bolus of terlipressin 1 mg, followed by a dobutamine infusion. Results The use of terlipressin (with and without dobutamine) resulted in maintaining mean arterial pressure above 65 mmHg with reduction in norepinephrine requirements to 0.2 (0.1) µg/kg/min in group II and 0.15 (0.1) µg/kg/min in group III (P in each <0.001 vs. control at 2, 4, and 6 h). The use of terlipressin alone in group II resulted in a drop in central SvO2 to 58 (3)% (P<0.001 vs. control at 2, 4, and 6 h) and a decrease in heart rate to 105 beat/minute (7) (P vs. control=0.013 at 2 h, 0.001 at 4 h, and 0.01 at 6 h). The addition of dobutamine in group III resulted in an increase in central SvO2 to 70 (3)% (P<0.001 vs. group II at 2, 4, and 6 h). Conclusion Administration of terlipressin bolus was effective in increasing mean arterial blood pressure and reducing norepinephrine requirements in catecholamine-dependant septic shock patients. Its use was associated with significant reductions in central SvO2, which was reversed by using dobutamine.

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The effect of adding magnesium to bupivacaine for popliteal nerve block on anesthesia and postoperative analgesia in achilles tendon repair patients: a randomized double-blinded study

Ayman A El Sayed

Ain-Shams Journal of Anaesthesiology 2016 9(3):409-415

Purpose The aim of this prospective randomized double-blind study was to investigate the effect of adding magnesium to bupivacaine on the onset and duration of sensory and motor block, postoperative visual analog scale (VAS), and total opioid consumption in patients following Achilles tendon repair surgery with popliteal-sciatic nerve blockade. Patients and methods A total of 60 patients who underwent Achilles tendon repair surgery and were of American Society of Anesthesiologist I or II physical status with age between 18 and 50 years of age were included in the study. The patients were randomly assigned into two groups: group bupivacaine–magnesium (BM) (n=29) received 30 ml of 0.25% bupivacaine and 2 ml of 10% magnesium sulfate, and group bupivacaine (B) (n=28) received 30 ml of 0.25% bupivacaine and 2 ml of normal saline for popliteal-sciatic blockade using the nerve stimulator technique. We evaluated the patients as regards the onset and duration of sensory and motor block, postoperative VAS scores, and total opioid consumption. Results The onset of motor block in group B was significantly longer in comparison with group BM (14.2±2 and 11.9±1.5 min, respectively). At the same time, the duration of sensory and motor block in group BM was significantly longer in comparison with group B (P<0.001). As regards total opioid consumption (tramadol) during the first 12 h postoperatively, it was significantly less in group BM in comparison with group B (190.67±21.8 and 237.86±25.8 mg, respectively). As regards VAS, it was significantly lower in group BM in comparison with group B at 4, 6, 8, 10, and 12 h postoperatively. Conclusion The addition of magnesium to bupivacaine prolonged the motor and sensory block duration without increasing side effects, and enhanced the quality of postoperative analgesia, which was manifested by lower VAS and less total opioid consumption. Moreover, the addition of magnesium speeds up the onset of motor block.

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Effect of high fractional inspiratory oxygen on postoperative pulmonary function: a randomized–controlled study

Gad S Gad

Ain-Shams Journal of Anaesthesiology 2016 9(3):337-342

Background Although a high fraction of inspired oxygen (FiO2) could reduce surgical site infection, there is a concern that it could increase postoperative pulmonary complications, including hypoxemia. However, there is an advantage for preoperative high FiO2 before induction of anesthesia as it decreases the incidences of desaturation and wound infection. Our aim was to assess whether different levels of FiO2 affect pulmonary function tests. Patients and methods Ninety patients scheduled for elective abdominal hysterectomy were randomized to receive either preoxygenation with 1.0 FiO2 for 3 min, then continued on 1.0 FiO2 till the end of surgery (group A), or preoxygenation with 1.0 FiO2 for 3 min, then continued on 0.4 FiO2 till the end of surgery (group B), or preoxygenation with 0.4 FiO2 then continued on 0.4 FiO2 till the end of surgery (group C). The oxygenation index (PaO2/FiO2) was measured every 30 min during anesthesia and 2 h after extubation. Pulmonary function test was measured on the morning of surgery and 2 h after extubation. Results Five minutes after intubation, the median PaO2/FiO2 was 483 (371–490) mmHg in group A, 420 (336–490) mmHg in group B, and 450 (350–485) mmHg in group C (P = 0.24). Two hours after extubation, the PaO2/FiO2 was reduced to 333 (314–342) mmHg in group A, 328 (311–357) mmHg in group B, and 342 (303–316) mmHg in group C (P = 0.55). The median functional vital capacity were 1950 (1600–2120), 1850 (1570–2250), and 1900 (1490–2020) ml at baseline and 1650 (1370–1953), 1670 (1340–2350), and 1711 (1412–2410) ml 2 h after extubation in groups A, B, and C, respectively (P = 0.66). Conclusion We found no significant difference in the oxygenation index or pulmonary function tests between patients administered different levels of FiO2.

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Comparative study of intrathecal midazolam versus fentanyl as adjuvants to ropivacaine for lower-limb surgery

Sanaa M Elfawal, Aktham A Shoukry, Walid H Nofal

Ain-Shams Journal of Anaesthesiology 2016 9(3):432-439

Background The current prospective randomized double-blind study was designed to compare the clinical efficacy of intrathecal midazolam versus fentanyl when added to hyperbaric ropivacaine, evaluating the effect of each on the duration and quality of spinal blockade produced by hyperbaric ropivacaine. Patients and methods The study was conducted on 90 patients of both sexes, aged 20-60 years, of class I or II of the American Society of Anesthesiologists classification, who were undergoing elective lower-limb surgery. Patients were randomly assigned to three groups (30 patients each): group R (control group) received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of normal saline (0.9%) at a total volume of 3.5 ml intrathecally, whereas group RF received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of 25 μg fentanyl (50 μg/ml) at a total volume of 3.5 ml intrathecally and group RM received 3 ml (15 mg) of hyperbaric ropivacaine plus 0.5 ml of 1 mg midazolam (2 mg/ml) at a total volume of 3.5 ml intrathecally. The onset and duration of sensory and motor blockade, postoperative pain, and the time to first rescue analgesia request were noted. Patients were observed for hypotension, bradycardia, sedation, respiratory depression, pruritus, and postoperative nausea and vomiting. Results The onset times and the duration of motor blockade were comparable among groups, whereas the time to sensory block regression was longer in group RM and group RF as compared with group R (P < 0.001). The duration of postoperative analgesia was significantly longer in group RM and group RF as compared with group R (P < 0.001), whereas there was no difference between group RM and group RF. The incidence of pruritus and vomiting was higher in group RF. Conclusion Adding midazolam to hyperbaric ropivacaine in spinal anesthesia for lower-limb surgeries is considered a good alternative for improving the duration of sensory block and decreasing the analgesic requirement in the early postoperative period with minimal side effects compared with hyperbaric ropivacaine alone or fentanyl combined with hyperbaric ropivacaine.

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The effects of coinduction with sevoflurane–propofol and sevoflurane–ketofol in patients undergoing radiofrequency ablation of hepatocellular carcinoma

Rania M Ali, Marwa A Khairy

Ain-Shams Journal of Anaesthesiology 2016 9(3):343-348

Background Radiofrequency ablation (RFA) is a minimally invasive and effective method for local tumor destruction in nonsurgical patients with early-stage hepatocellular carcinoma (HCC). General anesthesia (GA) has been used for RFA. GA can decrease the hepatic blood flow and cause more hepatic dysfunction. This study aimed to compare the hemodynamic response, recovery characteristics, and postprocedural analgesia after induction of GA with either sevoflurane–propofol or sevoflurane–ketofol in liver patients undergoing RFA of HCC. Patients and methods Eighty patients with hepatic cirrhosis scheduled for RFA of HCC were randomly allocated into two groups. In group PS, induction of anesthesia was achieved using sevoflurane with propofol (1%). In group KPS, induction of anesthesia was achieved using sevoflurane with ketofol (prepared at a ratio of 1: 2). Results Regarding the induction time, the laryngeal mask airway (LMA) insertion time, the percentage of LMA insertions from the first attempt, time to removal of LMA, and time to emergence were comparable between the two groups. However, the rescue analgesia time was longer in group KPS compared with group PS (P < 0.001). The number of episodes during which blood pressure was below 20% of baseline blood pressure, as well as the highest and the lowest mean arterial pressure, was comparable between the two groups. Postoperative levels of liver enzymes were comparable between the two groups. In the recovery unit, only one patient (2.5%) in group KPS suffered from postoperative emergence agitation, and three patients (7.5%) suffered from nausea. Conclusion Either sevoflurane–propofol or sevoflurane–ketofol may be used as alternatives in liver patients undergoing RFA of HCC as both techniques have favorable anesthetic profiles and provide hemodynamic stability. However, when choosing sevoflurane–ketofol, the advantage of its enhanced analgesic effect must be weighed against the increased risk for postoperative nausea and vomiting.

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Copper and anesthesia − a surprising connection

Pradnya M Bhalerao, Kalpana V Kelkar, Anand H Pande, Bapu P.G. Kakade

Ain-Shams Journal of Anaesthesiology 2016 9(3):455-457

A 28-year-old female presented with complaints of fever with chills and dizziness on and off for the last 3 months. On admission, she was investigated and found to have anemia and thrombocytopenia. On examination, the patient was pale and had a palpable huge spleen. Past history revealed a diagnosis of Wilson's disease 15 years ago. This disease, due to altered copper metabolism, may influence the conduct and outcome of anesthesia secondary to abnormalities in hemopoietic, cardiovascular, connective tissue, immune, and nervous systems. In this study, we present a patient, a diagnosed case of Wilson's disease, with massive splenomegaly posted for splenectomy under general anesthesia and the concerns involved therein.

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Prophylactic dexamethasone or pethidine for the prevention of postoperative shivering during transurethral resection of the prostate under spinal anesthesia

Abd El Azeem A El Bakry, Ezzeldin S Ibrahim

Ain-Shams Journal of Anaesthesiology 2016 9(3):349-352

Background Shivering is a common complication in elderly patients undergoing urologic operations under spinal anesthesia. The present study compares the effect of prophylactic dexamethasone and pethidine on shivering during transurethral resection of the prostate (TURP) under spinal anesthesia. Patients and methods This random prospective double-blinded controlled study was conducted on 90 patients scheduled for TURP operations under spinal anesthesia. Patients were allocated into three groups: in the C group, patients were administered intravenous 10 ml normal saline before spinal anesthesia. In the P group, patients were administered 25 mg pethidine in 10 ml normal saline. In the D group, patients were administered 0.1 mg/kg dexamethasone in 10 ml normal saline. Core body temperature, mean arterial blood pressure, respiratory rate, oxygen saturation, incidence and severity of shivering, nausea, vomiting, and pruritus were recorded. Results The incidence and severity of shivering were low in the pethidine and dexamethasone groups compared with the control group (P < 0.05), with no significant difference between the pethidine and dexamethasone groups (P > 0.05). Conclusion Prophylactic dexamethasone is as effective as pethidine in reducing the incidence and severity of shivering in TURP patients under spinal anesthesia.

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Global burden of diabetes: action for anesthesia

Sukhminder Jit Singh Bajwa, Sanjay Kalra, Manash Baruah

Ain-Shams Journal of Anaesthesiology 2016 9(3):317-318



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A randomized study comparing the efficacy and safety of epidural anesthesia versus general anesthesia in patients undergoing percutaneous nephrolithotomy

Tanuj Kumawat, Varsha Kothari, Shivam Priyadarshi, Tuhin Mistry, Sanjay Morwal

Ain-Shams Journal of Anaesthesiology 2016 9(3):353-357

Background Percutaneous nephrolithotomy (PCNL) is the preferred surgical technique for large renal stones (>2 cm in diameter), which involves keyhole surgery through a 1 cm incision on the skin overlying the kidney. It can be performed under local, regional, as well as general anesthesia (GA). We have compared the efficacy and safety of regional epidural anesthesia (EA) and GA in patients undergoing PCNL. Patients and methods In this prospective study, a total of 112 patients of American Society of Anesthesiologists physical status I and II undergoing PCNL were randomized into two groups. Patients in group A (n=56) received regional EA (with lignocaine and bupivacaine), and group B (n=56) patients received standard GA. The postoperative visual analog scale (VAS) score, amount of postoperative analgesic use, adverse effects, operative time, and blood loss were evaluated and compared between the two groups. Results The mean VAS score at 1 h was 1.25 in group A and 5.21 in group B (P<0.001), at 3 h it was 3.05 in group A and 5.04 in group B (P<0.001), and at 6 h it was 3.04 in group A and 4.79 in group B (P<0.001). Less analgesia was required in the EA group compared with the GA group (P<0.001). Five (8.92%) patients in group A and 21 (37.50%) patients in group B had postoperative nausea (P<0.05). Pain score at 18 and 24 h, operative time, postoperative hemoglobin level, and adverse effects were not significantly different between the two groups. Conclusion EA is a good alternative anesthetic technique for PCNL with less analgesic consumption and fewer complications as compared to GA.

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Ultrasound-guided rectus sheath block for pediatric patients undergoing elective abdominal midline operations: a randomized controlled trial

Mostafa M Hussein Khalil

Ain-Shams Journal of Anaesthesiology 2016 9(3):403-408

Background Under high-resolution ultrasonic guidance, bilateral rectus sheath block (RSB) can be performed with higher success rate and fewer complications. RSB results in blocking the anterior branches of the lower thoracic spinal nerves supplying the central portion of the anterior abdominal wall. Objective The aim of the study was to assess the effectiveness of bilateral ultrasound-guided RSB in children undergoing elective midline abdominal operations. Patients and methods Fifty-six patients of both sexes between 2 and 10 years of age, of American Society of Anesthesiologists physical status I–II, undergoing elective midline abdominal procedures were involved in this randomized controlled trial. Patients were randomly allocated to one of two groups: 27 patients in group R (RSB group) and 29 patients in group C (control group). Both groups received general anesthesia. Group R received bilateral RSB with 0.3/ml/kg bupivacaine 0.25% under ultrasound guidance, and group C received regular analgesics. The primary outcome measure was degree of pain assessed using the Objective Pain Scale. The secondary outcome measures were hemodynamic parameters, intraoperative fentanyl requirement, and postoperative need for analgesia. Results Demographic and hemodynamic parameters were similar in both groups. Total intraoperative fentanyl requirement was significantly lower in group R compared with group C. Group R had a significantly lower pain score up to 24/h postoperatively compared with group C. The mean time to first postoperative rescue analgesia was significantly longer in group R (120.8±4.7/min) than in group C (48±3.6/min). The number of rescue doses of analgesia was significantly lower in group R [1 (0–1)] than in group C [3 (2–3)]. Conclusion Bilateral RSB under ultrasound guidance provides effective intraoperative and postoperative analgesia with more stable hemodynamics in pediatric patients undergoing elective midline abdominal procedures.

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Comparative study evaluating the efficacy of ultrasound-guided transversus abdominis plain block versus intraperitoneal injection of local anesthetics in pain control following laparoscopic colectomy

Aktham A Shoukry, Waleed H Nofal, Sanaa M Elfawal

Ain-Shams Journal of Anaesthesiology 2016 9(3):358-365

Background Laparoscopic surgeries are being widely conducted nowadays for its well-known advantages such as less postoperative pain, shorter length of hospital stay, decreased morbidity and mortality, and reduced healthcare costs. Many analgesic modalities have been applied for this type of surgery, of which we have chosen the intraperitoneal injection (IP) of local anesthetics and the transversus abdominis plane (TAP) block. We studied the effect of both techniques on postoperative pain scores and their effect on abdominal and shoulder pain after laparoscopic colectomy. Patients and methods Fifty patients were enrolled in the study. All of them were of American Society of Anesthesiology (ASA) physical status I or II and scheduled for elective laparoscopic colectomy surgery. Patients were randomly allocated into one of two groups (25 patients each): the TAP block group (TAP group) and the IP of local anesthetics group (IP group). Pain score using the numerical rating scale (NRS), hemodynamic parameters, amount of consumption of rescue analgesia, shoulder pain, and adverse reactions were recorded. Results The main outcome variable was the pain score in the immediate postoperative period and the next 3 h; the mean NRS scores were lower in the TAP group than in the IP group in the previously mentioned time periods, with a highly significant difference. Also, there was a significant difference in the NRS score at the fourth hour postoperatively; however, the subsequent NRS scores at the different time intervals showed no significant difference until the end of the 24th hour postoperatively. In the TAP group, 20 patients (80%) complained of abdominal pain at least once in the first 24 h after surgery, whereas all the patients in the IP group experienced abdominal pain, with a significant difference between the two groups. The overall analgesic consumption in milligrams and the total number of analgesic doses were found to be less in the TAP group, with a highly significant difference. Conclusion The results of this study demonstrated that the TAP block is a more effective analgesic modality for abdominal pain than the IP local anesthetic during the early postoperative period after laparoscopic colectomy but IP is more effective in relieving postoperative shoulder pain.

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Magnesium sulfate at two different doses as an adjuvant to bupivacaine in infraumblical (below knee) orthopedic surgeries under spinal anesthesia

Sudarshan Kumar Chaudhary, Ravinder Kumar Verma, Shelly Rana, Jai Singh, Amruth Danesh

Ain-Shams Journal of Anaesthesiology 2016 9(3):416-421

Background The use of magnesium sulfate as an adjuvant in neuraxial block has gained popularity, with the aim of improving and enhancing the quality and duration of anesthesia, delaying the onset of postoperative pain, and thus reducing the demand for postoperative rescue analgesics. However, until today, there has been no consensus as regards the ideal dose of magnesium sulfate as an adjuvant in the subarachnoid block. The present study was designed to examine whether the addition of intrathecal magnesium sulfate (50 and 100 mg) would enhance the analgesic efficacy of intrathecal bupivacaine. We hypothesized that the additive effect of magnesium sulfate as an adjuvant to bupivacaine in subarachnoid block is dose dependent. Materials and methods This study was carried out on 90 American Society of Anesthesiology I and II patients of both sexes in the age group of 20–60 years scheduled for below knee surgeries under subarachnoid block. Group 1 (n = 30) patients received intrathecal 0.5% heavy bupivacaine (2.8 ml) +0.2 ml normal saline; group 2 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml) +50 mg (0.1 ml) magnesium sulfate +0.1 ml normal saline; and group 3 (n = 30) received intrathecal 0.5% heavy bupivacaine (2.8 ml)+100 mg (0.2 ml) magnesium sulfate. The primary outcome measure was the duration of postoperative analgesia, and secondary outcomes included the number of supplemental analgesic requirements, block characteristics, and hemodynamic stability. Results The onset of sensory and motor block was delayed in the magnesium group (100 mg>50 mg). There was a significant prolongation of postoperative analgesia in the magnesium group in a dose-dependent manner, and total dose of rescue analgesic requirement was found to be significantly delayed in the 100 mg group. Patients in all groups remained hemodynamically stable without any adverse effects. Conclusion Magnesium sulfate (100 mg) as an adjuvant to bupivacaine in subarachnoid block prolongs the duration of analgesia and decreases the demand for rescue analgesics compared with the control and the magnesium sulfate 50 mg group.

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The role of granisetron in the enhancement of recovery and home discharge in ambulatory surgery performed under spinal anesthesia

Ayman Kasem

Ain-Shams Journal of Anaesthesiology 2016 9(3):366-370

Background The popularity of day-care surgery has increased worldwide due to reduced costs and remarkable safety profile. Neuraxial anesthesia is a popular technique for day-case surgeries. Anesthetist should modify his/her techniques to optimize patient's chance of early discharge. 5-Hydroxytryptamine type 3 receptor antagonists used to prevent and treat postoperative nausea and vomiting may affect the course of spinal anesthesia and prevent its associated hypotension. Aim The aim of this study was to evaluate the effects of granisetron in the reversal of hyperbaric bupivacaine spinal anesthesia and enhancement of home discharge in day surgeries. Patients and methods Sixty adult patients scheduled for elective day surgery under spinal anesthesia were randomly divided into two equal groups to receive either 1 mg of granisetron (the G group) intravenously diluted in 5 ml normal saline over 30 s, 5 min before spinal anesthesia, or an equal volume of intravenous normal saline (the S group) at the same time. Heart rate, mean arterial pressure, oxygen saturation, and sensory and motor block levels were monitored and recorded. Results Time to regression of sensory level by two dermatomes, time to regression of sensory level to S2, time to first void, and time to discharge readiness were significantly lower in group G. Moreover, the incidence of nausea and shivering was significantly lower in group G. Conclusion Administration of 1 mg of granisetron before spinal anesthesia in ambulatory surgeries resulted in a statistically faster sensory regression and earlier home discharge from the day-surgery unit.

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Preservative-free racemic ketamine with bupivacaine: a desirable option for extended caudal analgesia in pediatric surgery

Deepa Chandramohan, Shirley A D'Souza

Ain-Shams Journal of Anaesthesiology 2016 9(3):426-431

Introduction Caudal epidural block is a commonly performed procedure in pediatric anesthesia worldwide. Ketamine is used as an adjuvant in single-shot caudal blocks to prolong postoperative analgesia. Aims of the study This randomized double-blind study was carried out to evaluate the effect of the addition of preservative-free racemic ketamine 0.5 mg/kg to 0.25% bupivacaine (1 ml/kg) in caudal block on the duration of postoperative analgesia in pediatric patients and to observe adverse effects, if any. Materials and methods Sixty children, aged 2–9 years, undergoing infraumbilical surgical procedures were assigned randomly to one of two groups, B or BK, to receive 1 ml/kg of 0.25% bupivacaine or a mixture of 0.5 mg/kg of preservative-free racemic ketamine with 1 ml/kg of 0.25% bupivacaine, respectively, for single-shot caudal anesthesia. The postoperative pain score was assessed. Sedation, motor weakness, and other adverse effects were also observed. Observations and results The mean duration of analgesia was significantly longer (P < 0.01) in group BK (12.933 h) than in group B (3.467 h). The incidences of adverse effects such as urinary retention, vomiting, and motor weakness were comparable in the two groups (P > 0.05). Conclusion Preservative-free racemic ketamine at a dose of 0.5 mg/kg may be used as a safe and reliable adjunct to caudal bupivacaine for prolongation of postoperative analgesia in children. As racemic ketamine is less expensive and more easily available than S(+)-ketamine, further studies comparing their cost-effectiveness may help to establish the racemic preparation as an appropriate adjuvant for single-shot caudal analgesia, especially in nations where cost constraints exist.

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Sepsis and the orexin system



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How receptive are patients with late stage cancer to rehabilitation services and what are the sources of their resistance?

Publication date: Available online 31 August 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Andrea L. Cheville, Lori Rhudy, Jeffrey R. Basford, Joan M. Griffin, Ann Marie Flores
ObjectiveTo describe the proportion and characteristics of patients with late stage cancer that are and are not receptive to receiving rehabilitation services, as well as the rationale for their level of interest.SettingA comprehensive cancer center in a Northcentral US quaternary medical centerDesignA prospective mixed methods studyParticipants311 adults with Stage IIIC or IV non-small cell or extensive stage small cell lung cancer.InterventionsNot applicableMain Outcome MeasuresTelephone acquired responses to the administration of: 1) the Activity Measure for Post Acute Care Computer Adaptive Test (AM-PAC-CAT); 2) Numerical rating scales for pain, dyspnea, fatigue, general emotional distress, and distress associated with functional limitations; 3) a query regarding receptivity to receipt of rehabilitation services, and 4) a query about rationale for non-receptivity.ResultsOverall 99 (31.8%) of the study's 311 participants expressed interest in receiving rehabilitation services; 38 at the time of enrollment and an additional 61 during at least one subsequent contact. Participants expressing interest were more likely to have a child as primary caregiver (18.18% vs. 9.91%, p = 0.04) and a musculoskeletal comorbidity (42.4% vs. 31.6%, p = 0.05). Function-related distress was highly associated with receptivity, as were lower AM-PAC-CAT scores. Reasons provided for lack of interest in receiving services included a perception of their limited benefit, being too busy, and prioritization below more pressing tasks/concerns.ConclusionsOne-third of patients with late stage lung cancer are likely to be interested in receiving rehabilitation services despite high levels of disability and related distress. These findings suggest that patient misperception of the role of rehabilitation services may be a barrier to improved function and quality of life. Efforts to educate patients on the benefits of rehabilitation and to more formally integrate rehabilitation as part of comprehensive care may curb these missed opportunities.



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Safe landing strategies during a fall: Systemic review and meta-analysis

Publication date: Available online 31 August 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Yaejin Moon, Jacob J. Sosnoff
ObjectiveTo systematically synthesize information on safe landing strategies for a fall and quantitatively examine the effects of the strategies to reduce risk of injury from a fall.Data SourcesPubMed, Web of science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane LibraryStudy SelectionDatabases were searched using the combinations of keywords of "falls", "strategy", "impact" and "load". Randomized control trials, cohort studies, pre-post studies, or cross-sectional studies were included.Data ExtractionThe fall strategies were extracted and categorized by falling direction. Measurements of impact loads that reflect the risk of injuries were extracted (e.g. impact velocity, impact force, fall duration, and impact angle). Hedges g was used as effect size to quantify effect of a protective landing strategy to reduce the impact load.Data SynthesisA total of seven landing strategies (squatting, elbow flexion, forward rotation, martial arts rolling, martial arts slapping, relaxed muscle, and stepping) in 13 studies were examined. In general, all strategies, except for the martial arts slapping technique, significantly reduced impact load (g's=0.73 to 2.70). Squatting was an efficient strategy to reduce impact in backward falling (g=1.77) while elbow flexion with outstretched arms was effective in forward falling (g=0.82). Also, in sideways falling strategies, martial arts rolling (g=2.70) and forward rotation (g=0.82) were the most efficient strategies to reduce impact load.ConclusionsThe result showed that landing strategies have significant effect on reducing impact load during a fall and might be effective to reduce impact load of falling. The current study also highlighted limitations of the previous studies which focused on a young population and self-initiated falls. Further investigation with elderly individuals and unexpected falls is necessary to verify effectiveness and suitableness of the strategies to at-risk population in real-life falls.



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Psychometric properties of the 30-meter walking test in patients with degenerative cervical myelopathy: results from two prospective multicenter cohort studies

The timed 30-meter walking test (30MWT) is used in clinical practice and in research to objectively quantify gait impairment. The psychometric properties of 30MWT have not yet been rigorously evaluated.

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A simple scoring system to assess the need for an endoscopic intervention in suspected upper gastrointestinal bleeding: A prospective cohort study

Assessment of the emergent endoscopy for upper gastrointestinal bleeding (UGIB) patients has important clinical implications. There is no validated criterion to triage.

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A local structured training program with live pigs allows performing ESD along the gastrointestinal tract with results close to those of Japanese experts

The high specific skill needed by ESD limit its widespread use in Europe and animal training is recommended in Europe to improve the results of ESD that are far from Japanese at present. We create a local training program using live pigs as models, along with our human cases, to provide continuous exposure to the technique.

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Preventing Long-Term Cardiac Damage in Pediatric Patients With Kawasaki Disease

Kawasaki disease is currently the leading cause of long-term cardiac damage in pediatric patients in the United States. Kawasaki disease is diagnosed based on symptomatology and by ruling out other etiology. There is a significant need for an improved, standardized treatment protocol for patients diagnosed with Kawasaki disease and a more rapid initiation of treatment for these patients. Decreasing the cardiac damage caused by Kawasaki disease with timely diagnosis and treatment needs be a principal goal.

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Clostridium difficile infection is associated with lower inpatient mortality when managed by GI surgeons

Diseases of the Colon and Rectum

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METASTATIC OVARIAN CYSTOSARCOMA PHYLLOIDES OF BREAST

2016-08-31T02-06-07Z
Source: International Journal of Current Research and Review
Papa Dasari, Haritha Sagili, Priyanka Yoga Purani.
Background: Cystosarcoma Phylloides is a rare breast neoplasm constituting ≤ 1% of all breast neoplasms. These are mostly benign and reccur. Malignant cystosarcoma Phylloides can recur and metastasize to lung, bone and abdominal viscera. Metastasis to Ovary is not reported in literature. Case: A 46 year old multiparous lady was diagnosed with a recurrent cystosarcoma of right breast and a large Ovarian mass which was causing her dyspnoea. The mass was of 30 weeks size and was firm and tender. CECT showed a large solid abdominopelvic mass with irregular enhancing septate extending from pelvis to infracolic area with minimal free fluid. Uterus and Ovaries could not be delineated. FNAC from the mass was reported as low-grade malignant mesenchymal tumour. CA 125 was within normal range. Laparotomy revealed a large fleshy mass with jelly like material which was adherent to intestines and pelvic and parietal peritoneum. Right ovary is not visualized. Left ovary parially visualised and incorporated into the mass. Excision of the mass with TAH and BSO was carried out. There was diffuse ooze from the pelvic and peritoneal cavity which was managed by packing, blood product transfusion and tranexamic acid. She received massive transfusion and survived. Later she developed haemoptysis and underwent tracheostomy and feeding ileostomy and was managed in ICU for 8 weeks. Palliative mastectomy and adjuvant Radiotherapy and chemotherapy were differed by Oncologists and hence she was discharged after 4 months of admission. Conclusion: Managing ovarian metastasis from cystosarcoma phylloids can be challenging and the quality of life is poor when the primary disease is not managed adequately.


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Emergency Ventriculo-Pleural Shunt in Pregnancy.

No abstract available

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ANAESTHETIC MANAGEMENT OF A PARTURIENT WITH EISENMENGER’S SYNDROME POSTED FOR EMERGENCY CAESAREAN SECTION

2016-08-31T00-10-36Z
Source: International Journal of Current Research and Review
M. S. Prasanth Kumar, A. K. Kavitha, S. Mushahida, S. Giridharan.
Physiological changes in pregnancy is poorly tolerated in patients with Eisenmenger syndrome (ES) thus increasing the maternal mortality to 30-50%. We describe the management of a 34 years old primigravida with Eisenmengers syndrome with pre eclampsia who was posted for emergency caesarean section.


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MORPHOLOGY OF PSOAS MINOR MUSCLE- A CADAVERIC STUDY

2016-08-31T00-10-36Z
Source: International Journal of Current Research and Review
Parveen Ojha, Seema Prakash, Anjali Jain.
Aim: To study prevalence of psoas minor muscle and its morphology Material and Method: The study was conducted at R.N.T. Medical College, Udaipur (Rajasthan) in thirty adult embalmed cadavers (23 males and 7 females) of the age group 50 to 60 years. Results: Psoas minor muscle was present in eight (26.66%) cases. Morphology of muscle showed a wide variation its muscle belly and its tendinous mode of insertion on either pecten pubis (in five cases) or as merging with obturator fascia and iliac fascia (in three cases). Psoas minor muscle though an inconstant muscle, if present is of clinical importance to radiologists, surgeons and physiotherapists as it can mimic certain abdominal emergencies.


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EVALUATION OF POST OPERATIVE COMPLAINTS IN FIXED PARTIAL DENTURE WEARERS AND THOSES WITH CROWNS: A QUESTIONNAIRE BASED STUDY

2016-08-31T00-10-36Z
Source: International Journal of Current Research and Review
Nandhini G. Ashok, Sangeetha S..
Aim: To evaluate the post-operative complaints of patients having crowns and fixed partial dentures by means of a simple questionnaire. Methodology: A sample questionnaire with 15 questions was prepared, pertained to the period of the prosthesis in place, the nature of complaint as told by patient in his or her own words, number of units involved, and the type of materials used in fabrication of prosthesis. The study was carried out in patients who visited Saveetha Dental College and Hospitals as outpatients from January 2016 to April 2016. A total of One hundred patients were randomly selected and interviewed. Objective: All the patients of our dental college who underwent tooth replacement by means of a fixed partial denture and crowns were included in the study to evaluate the problems encountered after post-operative insertion of the prosthesis. Reason: To create an awareness among the dentists about the problems encountered with our patients and to manage them accordingly as patients comfort is of at most importance to us. Result: Most of the failures are due to poor patient care after insertion while the others occur as a result of defective design and inadequate execution of clinical and laboratory procedures. In this study, clinic survey was undertaken to access the patients discomfort after cementation of prosthesis. The most common problem encountered was looseness and repeated dislodgement. Other complains such as food impaction, inability to maintain oral hygiene, sensitivity, pain and esthetic issues were also encountered. Conclusion: The knowledge regarding the clinical Fixed Partial Denture complications enhances students ability to complete a through diagnosis, developed most appropriate to patients and communicate realistic expectations to patients and plan time internals needed for post-treatment care in the dental institutions


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Ultrasound to Improve Target Site Identification for Proximal Humerus Intraosseous Vascular Access.

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No abstract available

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Development of a Pediatric Risk Assessment Score to Predict Perioperative Mortality in Children Undergoing Noncardiac Surgery.

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BACKGROUND: Although there have been numerous attempts to predict perioperative mortality in adults, an objective model to predict mortality in children has not been developed. In this study, we aimed to develop a Pediatric Risk Assessment (PRAm) score to predict perioperative mortality in children undergoing noncardiac surgery. METHODS: We included all children recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric databases in a derivation cohort and those from the 2014 database in a validation cohort. The primary outcome was the incidence of in-hospital mortality. A total of 115,229 (63%) were included in the derivation cohort and 68,194 (37%) in the validation cohort. We used multivariable logistic regression to determine the predictors for mortality and designed the PRAm score. RESULTS: On the basis of the multivariable regression model, we created a simplified risk assessment tool (PRAm score) ranging from 0 to >=9, including the presence of any comorbidities, factors of critical illness, age =4, there is wide variability in objectively obtained PRAm scores. (C) 2016 International Anesthesia Research Society

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Further Clarification of Postoperative Anemia and Its Effects on the Kidney.

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No abstract available

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A STUDY OF SHORT-TERM OUTCOME OF ACUTE CORONARY SYNDROME PATIENTS WITH SPECIAL REFERENCE TO SERUM URIC ACID AT PRESENTATION

2016-08-30T22-15-54Z
Source: International Journal of Current Research and Review
Kapildev Mondal, Soumabrota Dutta.
Background: Acute coronary syndrome is very common course of death worldwide. It is the most common life Threatening cardiological disease. Assessment of prognosis of acute coronary syndrome patient with respect of Uric acid level as a risk factor to prevent mortality & morbidity have great impact on public health. Aim of the study: Very few Literatures are available regarding this. Our objective is to find out the Effect of Serum Uric acid level on short term outcome of acute coronary syndrome patient. Materials & Methods: We did retrospective study in general medicine department of SSKM HOSPITAL; Kolkata, with acute coronary syndrome patients on 2009-2010. Our study included 100 patients of acute coronary syndrome of various severity. We also proposed to do a detailed laboratory investigation including serum uric acid level in every patient. We did Detailed Clinical Examination & Relevant laboratory investigation. We collected Data according to Hospital regulation after approval by Hospital authorities. Then we analyzed data with help of statistical method BY using software. Results: In our study serum uric acid levels correlate with severity of cardiac failure. There was statistically significant correlation found between serum uric had higher levels of uric acid as compared to patients of class l and ll. Discussion: Out of 100 patients, six expired during 7 day follow up. Patients who had myocardial infarction in past have higher serum uric acid levels and are in higher Killip class. Combination of Killip class and serum uric acid level after acute myocardial infarction is a good predictor of mortality after ami. Conclusion: Hyperurecemia is found to be associated with less chance of good outcome of acute coronary syndrome patients.


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GOVERNMENT AND SOCIAL CONFLICTS BETWEEN TRADITIONAL RULERS AND PRESIDENTS-GENERAL OF TOWN UNIONS (TUS) IN ANAMBRA STATE, NIGERIA

2016-08-30T22-15-54Z
Source: International Journal of Current Research and Review
Andrew O. Obiajulu, Makodi Biereenu-Nnabugwu.
This paper has investigated how financial releases and creation of care-taker committees by Anambra state government influence social conflicts between Traditional rulers and Presidents-General of TUs in some communities. About 524 respondents given the quantitative tool for this study were drawn from members of TUs within the three communities used for the study: Nri,Isi-agu and Amansea. Qualitatitve data were also derived for the study from: victims of TU conflict, members of the vigilante, government officials involved in resolving TU conflicts and community leaders. Findings showed that the state government is a pronounced source of social conflict between the institutions. It does that through her financial releases; creation of care-taker committees and fermenting conflict even in peaceful communities that are seen as her political opponents. Government officials associated with fermenting TU conflict should be prosecuted (Word count: 131).


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ANATOMIC CONFIGURATIONS OF EXTERNAL BRANCH OF SUPERIOR LARYNGEAL NERVE AND SUPERIOR THYROID ARTERY: A STUDY IN CADAVERS

2016-08-30T22-15-54Z
Source: International Journal of Current Research and Review
Swapnali Shamkuwar, PS Bhuiyan.
Objectives: Thyroidectomy is one of the commonly performed procedures in head and neck surgery. Injury to the external branch of superior laryngeal nerve occurs frequently in thyroid surgery which can result in voice changes in the patient. The aim of the present study is to study the anatomical relationship between external branch of superior laryngeal nerve and superior thyroid artery. Methods: Sixty specimens of the thyroid gland of both sexes were studied. The distance between superior pole of thyroid gland and crossing point of superior thyroid artery and external branch of superior laryngeal nerve was measured and recorded. Results: The external laryngeal nerve was categorized into three types. In 63 (52.5%) cases the nerve crossed the superior thyroid artery more than 1cm (type1) and in 47 (39.16%) cases it crossed the artery less than 1cm (type 2a) above the upper pole of the thyroid gland. In 10 (8.33%) cases the nerve crossed the artery under cover (type 2b) of upper pole of the thyroid gland. Conclusions: A sound knowledge of the anatomy of the external laryngeal nerve and its relation to superior thyroid artery and superior pole of thyroid gland is helpful to minimize lesions of the nerve and perform safe surgery on thyroid gland.


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Combined Multichannel Intraluminal Impedance and pH Measurement in Detecting Gastroesophageal Reflux Disease in Children.

Objective: To evaluate and compare multichannel intraluminal impedance-pH (MII-pH) monitoring with standard investigations including pH testing for detecting gastroesophageal reflux disease (GERD) in children. Methods: A retrospective review of all MII-pH studies performed between July 2007 and March 2013 at Sydney Children's Hospital. Results from MII-pH testing, esophagogastroduodenoscopy (EGD), barium meal and pepsin assay, symptoms, underlying co-morbidities, age, and medication usage were evaluated. Results: An additional 47.18% of children had GERD detected by MII-pH testing, which would have been missed by pH testing alone. Based on symptomatology, 50.49% of children with respiratory symptoms due to GERD and 47.54% of those with gastrointestinal symptoms would have been missed by pH testing alone. GERD was detected in an additional 39.47% of children with neurological impairment, 44.44% for those with cystic fibrosis, and 52.17% for those with esophageal atresia-tracheoesophageal fistula by MII-pH. In patients with persistent symptoms on anti-reflux medication, GERD would have been missed by pH testing alone in 50.40%., GERD was detected in an additional 62.79% of infants and 42.76% of older children by MII-pH compared to pH testing alone. With reference to MII-pH, the sensitivity of other standard investigations, pH testing (32.35%), barium meal (25.00%), EGD (45.26%) and pepsin assay (48.89%), was significantly lower in the detection of GERD in children. Of all abnormal MII-pH results, 51.1% were abnormal due to symptom association alone. Conclusions: Combined MII-pH testing is superior to standard investigations such as 24-hour pH testing, barium meal, EGD, and pepsin assay in detecting GERD in children, particular due to its ability to associate symptoms with acid and non-acid reflux events. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Reply to a Letter to the Editor Regarding the Original Article, Predictors of Pouchitis After Ileal Pouch-Anal Anastomosis in Children.

No abstract available

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Favorable Outcomes of Preterm Infants with PNALD Treated with IV Fish Oil-Based Lipid Emulsion.

Objectives: To study the acute and long-term outcomes of preterm infants treated with an intravenous (IV) fish oil-based lipid emulsion (FishLE) for parenteral nutrition-associated liver disease (PNALD). Methods: Preterm infants 14 days to 24 months of age with anatomic short gut or severe intestinal dysmotility, serum direct bilirubin >=4 mg/dL, and requiring >60% calories from PN were eligible. Enrolled infants received 1 g/kg/day of FishLE until resolution of direct hyperbilirubinemia or return of enteral nutrition. Acute clinical effects and biochemical markers of liver function were monitored. Growth and developmental scores at 6 and 12 months postmenstrual age (PMA) were assessed and compared to controls matched by gestational age (GA). Results: Thirteen patients with mean GA of 28 +/- 4 weeks were treated and compared to 119 GA matched controls. Their mean direct bilirubin was 9.8 +/- 6.4 mg/dL at enrollment. All infants had resolution of cholestasis after study completion. There were no acute adverse events, deaths, or liver/intestinal transplants. Weight and head circumference were similar between FishLE treated patients and controls at 6 and12 month PMA. Cognitive and motor scores were decreased at 6 and 12 months PMA in FishLE treated infants. Logistic regression analysis showed that prolonged hospitalization was detrimental to cognitive and motor development, while treatment was not. Conclusions: The use of IV fish oil-based lipid emulsions in premature infants appears to be safe and reverses PNALD despite significant liver disease and intestinal failure. This therapy should be utilized in preterm infants with PNALD and followed long term to evaluate development. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Celiac Disease and Diabetes: when to test and Treat.

Prevalence studies from around the world have established a substantial increase in the prevalence of celiac disease (CD) in patients with type 1 diabetes (T1DM). About two-thirds of patients with T1DM and CD are asymptomatic for CD at diagnosis. We aim to provide an up-to-date state of the art summary of the recommendations for serologic testing for CD in patients with T1DM, and to clarify the debate on the need for screening and interventions. We searched Medline, and Cochrane databases for studies of celiac autoimmunity and biopsy-proven CD in people with T1DM between January 1 2000 and December 1, 2015. CD was found to be an independent risk factor for microvascular and macrovascular complications, as well as for increased morbidity in patients with T1DM. However, publications reveal controversy regarding the benefits of a gluten free diet (GFD) on glycemic control, bone health and quality of life in individuals with T1DM and asymptomatic CD. A multicenter, prospective randomized controlled trial aimed to investigate this issue is currently ongoing. Until resolution of the pros and cons of screening for CD, and of the benefit versus burden of GFD treatment in T1DM patients with asymptomatic CD, we recommend repeated screening for CD during childhood and adulthood, and treatment with GFD for those with biopsy-proven CD, even if asymptomatic. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Diagnosing Spontaneous Bacterial Peritonitis in Children: Tap-in for Higher Scores.

No abstract available

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Sertraline as an Additional Treatment for Cholestatic Pruritus in Children.

Backgrounds/Aim: Pruritus is a severe symptom accompanying chronic cholestasis. It can be debilitating and difficult to control. In children, first-line treatments are ursodeoxycholic acid and rifampicin. Refractory pruritus may require invasive therapies including liver transplantation. Clinical trials based on small samples of adult patients suggest that serotonin reuptake inhibitors can improve pruritus in cholestatic or uremic disease. We performed a prospective, multicenter study to assess efficiency and safety of the serotonin reuptake inhibitor sertraline in treating children with refractory cholestatic pruritus. Methods: Twenty children suffering from refractory cholestatic pruritus related to Alagille syndrome or PFIC were included from 4 centers between 2007 and 2014, and treated with sertraline at a starting dose of 1 mg.kg-1.d-1 and thereafter individually adapted up to 4 mg.kg-1.d-1. Before and after 3 months with therapy, pruritus was assessed using a visual itching scale graded on 10 points, a skin scratch marks score and a sleeping impairment score. Results: Sertraline was prescribed at a median daily dose of 2.2 mg.kg-1.d-1. After 3 months, pruritus improved in 14 out of 20 treated patients, and the median itching score decreased significantly from 8/10 [5-10] to 5/10 [2-10]. Likewise, skin scratch marks and sleep quality improved in 9 of these 14 patients. Non-severe adverse events were reported in 6 children, leading to treatment discontinuation in 3. Conclusion: Our data suggest that sertraline may constitute a useful drug in the management of refractory cholestatic pruritus in children. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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The Intragastric Pressure Measurement: A Novel Method to Assess Gastric Accommodation in Functional Dyspepsia Children.

Impaired gastric accommodation (GA) is proposed as a main pathophysiological mechanism for functional dyspepsia (FD). At present, the gastric barostat is the gold standard to measure GA. Hence, this procedure is very invasive and it might alter gastric physiology. Recently, we proposed the measurement of intragastric pressure (IGP) by means of high resolution manometry during nutrient intake as a potential alternative for assessing GA in adults. Objectives: Our aim was first to study the feasibility of the IGP measurement with nutrient tolerance in children with FD and second to compare these results with young healthy adults. Methods: A HRM probe and a feeding tube were positioned in the proximal stomach. The IGP was measured before and during intragastric infusion of a nutrient drink (ND, 300 Kcal, 60 ml/min). Subjects were asked to score their satiation and epigastric symptoms. The test ended when the subjects scored maximal satiation. Results: 15 healthy subjects (HVs, 21.7 +/- 4.7 years, 21.1 +/- 0.3 kg.m2) and 17 FD patients (14.4 +/- 0.7 years, 19.6 +/- 0.7 kg.m2) participated. FD patients suffered mainly from postprandial fullness (86%), epigastric pain (71%) and bloating (62%). In both groups, intragastric infusion of ND induced a drop in IGP (AAC FD: -15.5 +/- 3.5 mmHg vs. HVs: -18.0 +/- 8.7 mmHg; p = 0.57). Patients showed impaired nutrient tolerance compared to HVs (587.6 +/- 80.2 Kcal vs. 936 +/- 66.2 Kcal; p = 0.003). All patients and HVs tolerated the catheters and could finalize the study. Conclusion: The measurement of IGP during intragastric nutrient drink infusion was well tolerated in children. Nutrient tolerance was reduced in FD children compared to healthy subjects. In the future, this might be a useful tool to assess GA accommodation and nutrient tolerance in children. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Nutritional Status in Short Stature Children is Related to Both Ghrelin and Insulin-like Growth Factor I Concentrations.

Objectives: Ghrelin plays an important role in the growth processes in children, additionally, it regulates appetite. The aim of the study was to assess ghrelin and insulin-like growth factor type I (IGF-I) concentrations in children with idiopathic short stature (ISS), dependent on nutritional status. Methods: The study group included 116 children, aged 10.6 +/- 3.5 years (mean +/- SD), with ISS [height below -2.0 standard deviation scores (SDS), maximal growth hormone (GH) secretion during two GH-stimulating tests - over 10 ng/ml]. In each child, fasting ghrelin, IGF-I, insulin-like growth factor binding protein 3 (IGFBP-3), glucose, insulin, lipids, leptin, adiponectin and resistin concentrations were assessed. The IGF-I/IGFBP-3 molar ratio was calculated to determine the IGF-I bioavailability. According to body mass index SDS calculated for height age (BMI SDS for HA), the children were divided into 3 groups: poorly nourished (thin), normal and obese. The control group consisted of 19 healthy children, aged 11.0 +/- 3.5 years, with normal body weight and height. Results: Ghrelin concentration was significantly higher in short, thin children than in short, obese children (1458.3 +/- 798.5 vs. 917.2 +/- 303.0 pg/ml; p

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Τρίτη, 30 Αυγούστου 2016

Continuous ambulatory adductor canal catheters for patients undergoing knee arthroplasty surgery

To determine after knee arthroplasty surgery the feasibility of discharging patients home on postoperative day 1 with continuous adductor canal blocks.

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Variations in the distance between the cricoid cartilage and targets of stellate ganglion block in neutral and extended supine positions: an ultrasonographic evaluation

Abstract

Purpose

Anatomic variations complicate surface landmark-guided needle placement, thereby increasing nerve blockade failure rate. However, little is understood about how anatomic distances change under different clinical conditions. As the cricoid cartilage is an easy and accurate landmark, we investigated changes in distance between the sixth or seventh cervical transverse processes (C6TP or C7TP) and the cricoid cartilage in neutral and extended supine positions.

Methods

Forty-two patients (16 men, 26 women) were included in this study. Distances between the cricoid cartilage and C6TP/C7TP were measured using ultrasonography with the patient in neutral and extended supine positions.

Results

C6TP and C7TP were caudally located at 6.0 ± 8.1 and 15.1 ± 7.2 mm, respectively, from the cricoid cartilage in the neutral supine position, and at 15.2 ± 8.0 and 25.3 ± 8.0 mm, respectively, in the extended supine position. In the extended supine position, the cricoid cartilage was more cephalad than C6TP and C7TP in all patients. The distance from the cricoid cartilage to C6TP was 12.1 ± 7.6 mm in men and 17.2 ± 7.7 mm in women.

Conclusion

C6TP and C7TP are located approximately 15 and 25 mm, respectively, caudal to the cricoid cartilage in the extended supine position. Our results highlight the fact that there can be significant anatomic variation between the extended and neutral supine positions used in stellate ganglion block, which should be kept in mind when devising easily identifiable and palpable surface landmarks.



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Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death among Medicare Beneficiaries Over Two Years

Publication date: Available online 30 August 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Hillary R. Bogner, Heather F. de Vries McClintock, Jibby E. Kurichi, Pui L. Kwong, Dawei Xie, Sean Hennessy, Joel E. Streim, Margaret G. Stineman
ObjectiveTo examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults.DesignA national representative sample with two year follow-up.SettingMedicare Current Beneficiary Survey (MCBS) from calendar years 2001-2008.ParticipantsOur study sample included 23,470 community-dwelling adults aged 65 years and older followed for two years.InterventionsNot applicable.Main Outcome Measure(s)A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activity of daily living (ADL) stage transitions, institutionalization, or death after two years, adjusting for baseline socioeconomics and health-related characteristics.ResultsOut of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2,508 (10.7% weighted) improved, 3,210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2,281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio (RRR) = 0.68, 95% confidence interval (CI): 0.54-0.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR = 0.87, 95% CI: 0.79-0.97), be institutionalized (adjusted RRR = 0.72, 95% CI: 0.56-0.92), or die (adjusted RRR = 0.86, 95% CI: 0.75-0.98).ConclusionsKnowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related healthcare disparities and the impact of ongoing policy changes among Medicare beneficiaries.



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High rate of hepatitis B viral breakthrough in elderly non-Hodgkin lymphomas patients treated with Rituximab based chemotherapy

Rituximab-containing chemotherapies are offered to elderlies for treatment of non-Hodgkin lymphomas (NHL). From 0.7 to 27% of patients with "resolved" HBV infection develop HBV reactivation and related hepatitis during Rituximab-containing chemotherapies. Currently, several antiviral drugs are available for the prophylaxis of patients at risk for HBV reactivation, which include lamivudine, tenofovir, entecavir, and adefovir. Viral breakthrough may occur during therapy, which is defined as an abrupt increase in serum HBV DNA levels after a period of persistent suppression.

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The multidisciplinary management of gastro-oesophageal junction tumours

The management of GOJ cancers remains controversial and may vary between countries. Evidence-based attitudes and guidelines are not easy to elaborate since most of the trials and studies reported mixed cases of oesophageal (both adenocarcinoma and squamous cell tumours), GOJ and gastric cancers. The aim of this expert discussion and position paper is to elaborate practical recommendations that integrate evidence-reported literature and experience-based attitude covering all clinical aspects of GOJ cancer across different specialities and countries in Europe.

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High rate of hepatitis B viral breakthrough in elderly non-Hodgkin lymphomas patients treated with Rituximab based chemotherapy

Rituximab-containing chemotherapies are offered to elderlies for treatment of non-Hodgkin lymphomas (NHL). From 0.7 to 27% of patients with "resolved" HBV infection develop HBV reactivation and related hepatitis during Rituximab-containing chemotherapies. Currently, several antiviral drugs are available for the prophylaxis of patients at risk for HBV reactivation, which include lamivudine, tenofovir, entecavir, and adefovir. Viral breakthrough may occur during therapy, which is defined as an abrupt increase in serum HBV DNA levels after a period of persistent suppression.

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The multidisciplinary management of gastro-oesophageal junction tumours

The management of GOJ cancers remains controversial and may vary between countries. Evidence-based attitudes and guidelines are not easy to elaborate since most of the trials and studies reported mixed cases of oesophageal (both adenocarcinoma and squamous cell tumours), GOJ and gastric cancers. The aim of this expert discussion and position paper is to elaborate practical recommendations that integrate evidence-reported literature and experience-based attitude covering all clinical aspects of GOJ cancer across different specialities and countries in Europe.

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Chromatin: Xist as a recruitment tool

Nature Reviews Genetics. doi:10.1038/nrg.2016.116

Author: Denise Waldron



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Specification and epigenetic programming of the human germ line

Nature Reviews Genetics. doi:10.1038/nrg.2016.88

Authors: Walfred W. C. Tang, Toshihiro Kobayashi, Naoko Irie, Sabine Dietmann & M. Azim Surani



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Evolution to the rescue: using comparative genomics to understand long non-coding RNAs

Nature Reviews Genetics. doi:10.1038/nrg.2016.85

Author: Igor Ulitsky



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Are EMTs resilient enough?

Improving resiliency through regular exercise and smart nutrition is essential to helping EMS providers cope with traumatic stress.

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Are EMTs resilient enough?

Friese_FC.jpg

By Bryan Fass

While even normal people outside of public safety experience job-related stress as a fact of life, it seems like ours is much worse. Those of us who've in the business for a while can remember a time where the topic of stress and stress management were never discussed. Thankfully, EMS has taken a great leap forward bringing to light the depth and severity of our mental health.

Stress can be good and bad. Exercise induced stress is good. It forces our body to grow, heal and improve. The stress you experience prior to a protocol test increases your mental acuity.

The trouble starts when the stress response is constant and your body has no time to reset and rebalance. As call volumes have increased, so have resiliency issues for EMS providers.

As a paramedic and as a strength coach I have often wondered what has changed.

  • Why has the rate of suicide and mental health issues increased"
  • Is it the call volume, is it the type of calls or have we changed"

Next read these questions. I want to spark a conversation. Share your answers with me in the comments or send me an email. Together, we can hopefully steer the profession in a healthier direction.

  • Is our inability to handle stress because we have lost the ability to separate from the job"
  • Have we lost the ability for physical outlets to help manage the stress"
  • Are we poisoning ourselves with a toxic combination of overtime, poor eating habits and reliance on stimulants"

I can recall as a green medic running my first pediatric traumatic arrest. Sure, I had read about it, studied it and even did hours of training in the NICU. Yet having to manage the scene, intubate the child while en route, start compressions, start an IO and then carry a child I knew was deceased into the emergency department was very foreign to me.

I recall standing there as the trauma team worked the child, being expected to calmly and accurately give a report and then go write my patient care report. I had no training for that and no way to manage those emotions. Yes, that call weighed on me the rest of the shift, but I pushed on.

Exercise to increase resiliency
However as soon as my shift ended I drove right to the gym and hammered myself with an epic workout; that was and is my outlet, my relief valve. Studies show that exercise, any exercise, calms the mind and releases endorphins that help promote wellness [1, 2, 3].

Exercise is by far the best medicine for building resiliency. The data is clear. Any exercise is beneficial with cardiovascular exercise shown to be slightly superior. As I have said in multiple EMS1 columns move well and move often but just move.

Another issue is our addiction to technology. When I was a street medic you were connected only if you had a Nextel phone (the walkie talkie phone). Now there is an app for constant communication. I often wonder if after a series of difficult calls when an EMT should disconnect from the stressor and find an outlet if the news feeds, photos, texts and instant messages that flood in slowly elevate the long-term stress response.

Disconnect from the world and get after it. The stronger you are and the more fit you are, the less pain you experience. Exercise will boost your resiliency and help to improve your sleep and nutrition.

Let's face it: the EMS diet is not so good. Not only do you have to contend with the call volume and missed meals; bringing your food with you will fix that. We also have to deal with stress eating and fatigue eating. There is a reason that you crave the foods that are bad, and understanding why is the first step.

Eat better to improve resiliency
The overconsumption of sugars and caffeine plus a diet devoid of beneficial nutrition when tied into the over stimulation of the stress response throws the serotonin, cortisol, adrenalin response and more importantly the recovery process so far out of whack that we are essentially poisoning ourselves and making ourselves vulnerable to the cumulative dangers of bad stress [4]. Soldiers that died by suicide were 62 percent more likely to have extremely low levels of DHA (the good fat in fish and chia/flax that helps your brain) then soldiers that did not attempt suicide [5].

On top of that, too many first responders are self-medicating with alcohol and drugs. This destroys the allostatic balance leading responders into a deep, dark hole.

A key to boosting resiliency in EMS requires that EMT's have a physical outlet for their stress. Tie in good nutrition that heals, and you can boost your resiliency and wellness at the same time.

References

  1. Perspectives in Rehabilitation. Exercise therapy improves both mental and physical health in patients with major depression. DOI: 10.3109/09638288.2014.972579. Knapen, Davy Vancampfort, Yves Moriën and Yannick Marchal. Pages 1490-1495
  2. Exercise and well-being: a review of mental and physical health benefits associated with physical activity Penedo, Frank J; Dahn, Jason R
  3. http://ift.tt/2bzVlli
  4. http://ift.tt/1GsrWTc
  5. Lewis, Michael et.al. "Suicide of active duty us military and omegs-3 fatty acid status. The Journal of Clinical Psychiatry 72.12 (2011): 1585.


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My children don’t know their father before PTSD

soldier_with_ptsd.jpg

By Lea Farrow, Uniform Stories Contributor

It has been almost five years since my husband was diagnosed with PTSD. In a lot of ways, it feels like a lifetime. And for our children, it has literally been their lifetime.

I knew my husband for nine years before his official diagnosis. However, I really only knew my husband for five years before the signs of the disorder started to show.

My husband has been a paramedic for 15 years. His PTSD didn't arrive overnight. It was an insidious process after years of answering extremely traumatic calls, and receiving very little support or education through the service about ongoing stress management.

Many of the jobs that led to my husband's PTSD were pediatric calls. The job that triggered his major collapse was a horrific pediatric death. At the time, we had two small children of our own, our daughter was almost 3 and our son was not yet 1.

The day my husband came home from work a broken man, he fell to pieces in the kitchen. It wasn't that I hadn't seen him cry before, but we could have both drowned in his tears that night.

Although I tried my best, I couldn't protect our children from every episode that ripped through our house. Sometimes the pain would burst out of my husband so suddenly and ferociously, that all I could do was huddle my kids until the storm passed. Our daughter would ask, "Mommy, what's happening" Daddy is really scaring me…"

I had to accept the reality that my children were not safe alone with their father. One day I was torn away from work by a desperate phone call, and rushed home to a find a shattered man, only barely holding on. I often ask, do our children remember that day" Do they remember the raw anguish coursing wildly out of their father, who scarcely had enough strength left to direct it away from us" I sure do.

We found new ways to manage as a couple and as a family. I helped my husband begin to earn back the trust from his children and he found help for his PTSD (when he was ready to accept it). We have come a long way in the years since, but PTSD is still very much with us. It'll be with us always. And our children sadly bear witness to some of its worst moments. They don't know a life without PTSD overshadowing it.



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EMS needs planning, preparation to mitigate the effects of terrorist attacks

san_bernadino_FC.jpg

In June 2016 the National Academy of Medicine released a discussion paper that looked at the challenges of an EMS response to a major terror attack. In the paper, "Health and Medical Response to Active Shooter and Bombing Events," members of the National Academies of Sciences, Engineering, and Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Disasters described potential best practices on how to respond effectively to sudden, dramatic mass casualty events, based on data gleaned from recent attacks in Europe and the U.S.

Most of us are still relatively complacent about what we would do in case of a Boston or Aurora style attack in our community. Indeed, chances are very remote that such attacks will occur.

However, in such cases, the actions of dispatch centers and field personnel may play a critical role in the victims' chances of survival. It is common sense that EMS, fire and law enforcement personnel should jointly prepare and train for a variety of sudden mass casualty events.

Work together, train together
As the National Academy of Medicine discussion paper implies, a variety of political, fiscal and bureaucratic barriers exist to hinder the development of such plans. Both government and private sector agencies charged with public safety and public health must put aside territorial differences and work together to determine who will respond, how teams will operate and where patients should be transported, all in a very short operational period.

Bleeding control is a major priority when managing large numbers of injured patients after an attack. In many situations, direct pressure bandages and tourniquets can rapidly control bleeding, and free up field providers to provide care to other injured victims.

Unfortunately, ambulances and engine companies often do not carry enough trauma supplies to handle more than a few victims simultaneously. Disaster caches or trailers can be helpful, but only if they can be rapidly moved to the scene within minutes of the initial dispatch.

Rural and remote areas
Rural regions face especially difficult challenges in a mass casualty response. Underfunded agencies and scattered resources can hinder an adequate response.

One simple solution is to have policies in place that initiate mutual aid from neighboring agencies automatically at the initial response, rather than waiting precious minutes for the first responding units to arrive. This would include air medical services, volunteer organizations and even agencies that are a fair distance away from the incident, but would be expected to respond in large scale events.

The delay in sending an appropriate response level can result in lives lost. Dispatch protocols should be developed that result in an adequate number of units and personnel being sent to initial reports of a major event, similar to fire service alarm assignments.

This can reduce the human judgment factor during dispatch and improve the chances of getting off on the right foot early in the incident. If it turns out that the incident is smaller than reported, no harm is created in downgrading the response.

Cooperation with receiving facilities
Emergency departments and hospitals will not be immune to the effects of a large scale event. Not only do such facilities have to be able to rapidly scale up their internal disaster response, they must also work in cooperation with each other to spread the multitude of patients around the region.

While field operations may perform the initial sorting and destination decisions, resources such as staff, blood products and equipment may be rapidly depleted, necessitating a rapid region-wide response by other facilities and organizations. Again, interagency agreements, policies and procedures should be in place to facilitate complex decision making processes.

No one wants to think about a major violent event happening in their community. As EMS providers, we have to prepare for the worst, and hope for the best. As the National Academy of Medicine paper points out, continuous planning and preparation will be the major tools used by field providers and agencies alike in mitigating the effects of a terror attack.

Health and Medical Response to Active Shooter and Bombing Events



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Are EMTs resilient enough?

By Bryan Fass

While even normal people outside of public safety experience job-related stress as a fact of life, it seems like ours is much worse. Those of us who've in the business for a while can remember a time where the topic of stress and stress management were never discussed. Thankfully, EMS has taken a great leap forward bringing to light the depth and severity of our mental health.

Stress can be good and bad. Exercise induced stress is good. It forces our body to grow, heal and improve. The stress you experience prior to a protocol test increases your mental acuity.

The trouble starts when the stress response is constant and your body has no time to reset and rebalance. As call volumes have increased, so have resiliency issues for EMS providers.   

As a paramedic and as a strength coach I have often wondered what has changed.

  • Why has the rate of suicide and mental health issues increased?
  • Is it the call volume, is it the type of calls or have we changed?

Next read these questions. I want to spark a conversation. Share your answers with me in the comments or send me an email. Together, we can hopefully steer the profession in a healthier direction.

  • Is our inability to handle stress because we have lost the ability to separate from the job?
  • Have we lost the ability for physical outlets to help manage the stress?
  • Are we poisoning ourselves with a toxic combination of overtime, poor eating habits and reliance on stimulants?

I can recall as a green medic running my first pediatric traumatic arrest. Sure, I had read about it, studied it and even did hours of training in the NICU. Yet having to manage the scene, intubate the child while en route, start compressions, start an IO and then carry a child I knew was deceased into the emergency department was very foreign to me.

I recall standing there as the trauma team worked the child, being expected to calmly and accurately give a report and then go write my patient care report. I had no training for that and no way to manage those emotions. Yes, that call weighed on me the rest of the shift, but I pushed on.

Exercise to increase resiliency
However as soon as my shift ended I drove right to the gym and hammered myself with an epic workout; that was and is my outlet, my relief valve. Studies show that exercise, any exercise, calms the mind and releases endorphins that help promote wellness [1, 2, 3].

Exercise is by far the best medicine for building resiliency. The data is clear. Any exercise is beneficial with cardiovascular exercise shown to be slightly superior. As I have said in multiple EMS1 columns move well and move often but just move. 

Another issue is our addiction to technology. When I was a street medic you were connected only if you had a Nextel phone (the walkie talkie phone). Now there is an app for constant communication. I often wonder if after a series of difficult calls when an EMT should disconnect from the stressor and find an outlet if the news feeds, photos, texts and instant messages that flood in slowly elevate the long-term stress response. 

Disconnect from the world and get after it. The stronger you are and the more fit you are, the less pain you experience. Exercise will boost your resiliency and help to improve your sleep and nutrition.

Let's face it the EMS diet is not so good. Not only do you have to contend with the call volume and missed meals; bringing your food with you will fix that. We have to deal with stress eating and fatigue eating. There is a reason that you crave the foods that are bad and understanding is the first step.

Eat better to improve resiliency
The overconsumption of sugars and caffeine plus a diet devoid of beneficial nutrition when tied into the over stimulation of the stress response throws the serotonin, cortisol, adrenalin response and more importantly recovery process so far out of whack that we are essentially poisoning ourselves and making ourselves vulnerable to the cumulative dangers of bad stress [4]. Soldiers that died by suicide were 62 percent more likely to have extremely low levels of DHA (the good fat in fish and chia/flax that helps your brain) then soldiers that did not attempt [5].

On top of that too many first responders are self-medicating with alcohol and drugs. This destroys the allostatic balance leading responders into a deep, dark hole.  

A key to boosting resiliency in EMS requires that EMT's have a physical outlet for their stress. Tie in good nutrition that heals, and you can boost your resiliency and wellness at the same time.

References

  1. Perspectives in Rehabilitation. Exercise therapy improves both mental and physical health in patients with major depression. DOI: 10.3109/09638288.2014.972579. Knapen, Davy Vancampfort, Yves Moriën and Yannick Marchal. Pages 1490-1495
  2. Exercise and well-being: a review of mental and physical health benefits associated with physical activity Penedo, Frank J; Dahn, Jason R
  3. http://ift.tt/2bzVlli
  4. http://ift.tt/1GsrWTc
  5. Lewis, Michael et.al. "Suicide of active duty us military and omegs-3 fatty acid status. The Journal of Clinical Psychiatry 72.12 (2011): 1585.


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