Effects of Twice-Weekly Intense Aerobic Exercise in Early Subacute Stroke: A Randomized Controlled Trial

Publication date: Available online 20 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Klas Sandberg, Marie Kleist, Lars Falk, Paul Enthoven
ObjectiveTo examine the effects of 12 weeks of twice-weekly intensive aerobic exercise on physical function and quality of life after subacute stroke.DesignRandomized controlled trial.SettingAmbulatory care.ParticipantsFifty-six patients (28 women) aged ≥50 years who had a mild stroke (98% ischemic) and were discharged to independent living and enrolled 20 days (median) after stroke onset.InterventionsSixty minutes of group aerobic exercise, including 2 × 8 minutes of exercise with intensity up to exertion level 14–15/20 on the Borg rating of perceived exertion scale, twice weekly for 12 weeks (n=29). Controls (n=27) received no organized rehabilitation or scheduled physical exercise.Main Outcome MeasuresPrimary outcome measures: Aerobic capacity: Standard ergometer exercise stress test (peak work rate (WR)). Walking distance: 6-Minute Walk Test (6MWT). Secondary outcomes measures: Maximum Walking Speed 10 meters (MWS10m). Balance: Timed Up and Go (TUG), Single Leg Stance (SLS). Health-related quality of life: Euroqol-5D (EQ-5D). Participation and recovery after stroke: Stroke Impact Scale 2.0 (SIS) domains 8 and 9. Participants were evaluated pre-intervention and post-intervention; patient-reported measures were also evaluated at a 6-month follow-up.ResultsThe following improved significantly more in the intervention group (pre- to post-intervention): peak WR (group x time interaction P=.006), 6MWT (P=.011), MWS10m (P<.001), TUG (P<.001), SLS right and left (eyes open) (P<.001 and P=.022 respectively), and SLS right (eyes closed) (P=.019). Aerobic exercise was associated with improved EQ-5D VAS; P=.008) and perceived recovery (SIS domain 9; P=.002). These patient-reported improvements persisted at the 6-month follow-up.ConclusionsIntensive aerobic exercise twice weekly early in subacute mild stroke improved aerobic capacity, walking, balance, health-related quality of life, and patient-reported recovery.



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Home-based versus laboratory-based robotic ankle training for children with cerebral palsy: A pilot randomized comparative trial

Publication date: Available online 20 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Kai Chen, Yi-Ning Wu, Yupeng Ren, Lin Liu, Deborah Gaebler-Spira, Kelly Tankard, Julia Lee, Weiqun Song, Maobin Wang, Li-Qun Zhang
ObjectiveTo examine the outcomes of a home-based robotic rehabilitation and compare it to a laboratory-based robotic rehabilitation for the treatment of impaired ankles in children with cerebral palsyDesignA randomized comparative trial design comparing a home-based training group and a laboratory-based training group.SettingHome versus a laboratory within a research hospitalParticipantsForty-one children with cerebral palsy with Gross Motor Function Classification System level I, II or III were randomly assigned to two groups. The children in the home-based and laboratory-based groups were 8.7±2.8 (mean±standard deviation) (n=23) and 10.7±6.0 (n=18) years old, respectively.InterventionsSix-week combined passive stretching and active movement intervention of impaired ankle in a laboratory or home environment with a portable rehabilitation robot.Primary outcome measuresActive dorsiflexion range of motion (as the primary outcome), mobility (6-minute walk test and timed up and go), balance (Pediatric Balance Scale), Selective Motor Control Assessment of the Lower Extremity (SCALE), spasticity Modified Ashworth Scale (MAS), passive range of motion, strength and joint stiffness.ResultsSignificant improvements were found for the home-based group in all biomechanical outcome measures except for passive range of motion and all clinical outcomes except the MAS. The laboratory-based group also showed significant improvements in all of the biomechanical outcome measures and all clinical outcome measures except the MAS. There were no significant differences in the outcome measures between the two groups.ConclusionThese findings suggest that translation of repetitive, goal directed, biofeedback training through motivating games from the laboratory into the home environment is feasible. The benefits of home-based robotic therapy were similar to those of laboratory-based robotic therapy.



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Swimming Improves Pain and Functional Capacity of Patients with Fibromyalgia: A Randomized Controlled Trial

Publication date: Available online 20 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Giovana Fernandes, Fabio Jennings, Michele Vieira Nery Cabral, Ana Letícia Pirozzi Buosi, Jamil Natour
Objectiveto evaluate the effect of swimming on pain, functional capacity, aerobic capacity and quality of life on patients with fibromyalgia (FM).DesignRandomized controlled trial (RCT).SettingRheumatology outpatient clinics of a university hospital.ParticipantsSeventy-five female patients, aged 18 to 60 years, with FM randomly assigned to a swimming group (SG; n = 39) or a walking group (WG; n = 36).InterventionThe SG performed 50 minutes of swimming 3 times a week for 12 weeks, with a heart rate at 11 beats under the anaerobic threshold (AT). The WG performed walking with heart rate at the AT, with the same duration and frequency of SG.Main Outcome MeasuresParticipants were evaluated prior to the exercise protocols (T0), at six weeks (T6) and at 12 (T12) weeks after the onset of the protocols. The primary outcome measure was VAS for pain. The secondary measurements were: Fibromyalgia Impact Questionnaire and SF-36 questionnaire for quality of life; spiroergometric test for cardiorespiratory variables; and Timed Up-and-Go Test for functional performance.ResultsPatients in both groups experienced improvement in pain after the 12-week program, however with no difference between groups (p= 0,658). The same results were found regarding functional capacity and quality of life. Moreover, no statistical difference between groups was found regarding aerobic capacity over time.ConclusionSwimming, like walking, is an effective method for reducing pain and improving both functional capacity and quality of life in patients with FM.



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Measuring Access to Information and Technology: Environmental Factors Affecting Persons with Neurological Disorders

Publication date: Available online 20 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Elizabeth A. Hahn, Sofia F. Garcia, Jin-Shei Lai, Ana Miskovic, Sara Jerousek, Patrick Semik, Alex Wong, Allen W. Heinemann
ObjectiveTo develop and validate a patient-reported measure of Access to Information and Technology (AIT) for persons with spinal cord injury, stroke or traumatic brain injury.DesignA mixed-methods approach was used to develop items, refine them through cognitive interviews, and evaluate their psychometric properties. Item responses were evaluated with the Rasch rating scale model. Correlational and analysis of variance methods were used to evaluate construct validity.SettingCommunity-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place.ParticipantsParticipants had a diagnosis of spinal cord injury, stroke or traumatic brain injury. They were age 18 or older and English-speaking.InterventionsNot applicable.Main Outcome MeasuresA set of items to measure AIT for people with disabilities.ResultsTwelve individuals participated in cognitive interviews, 305 participated in field testing of the items, and 604 participated in validation testing of the final set of items. A user-friendly multimedia touchscreen was used for self-administration of the items. A 23-item AIT measure demonstrated good evidence of internal consistency reliability, and content and construct validity.ConclusionsThis new AIT measure will enable researchers and clinicians to determine to what extent environmental factors influence health outcomes and social participation in people with disabilities. The AIT measure could also provide disability advocates with more specific and detailed information about environmental factors to lobby for elimination of barriers.



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What are the determinants of specialized outpatient and dental care use among adults with disabilities living in institutions? Findings from a National Survey in France

Publication date: Available online 20 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Diane Naouri, Clémence Bussière, Nathalie Pelletier-Fleury
ObjectiveTo explore the determinants of specialized outpatient care use (general practitioners excluded) among disabled people living in institutions.ParticipantsPeople living in institution for adults with cognitive, sensory, and mobility disabilities.DesignCross sectional studySettingFrench National Health and Disability Survey – Institution SectionInterventionNot applicableMain outcome measuresWe used different measures of disability severity, available in the survey: 1) the continuous score of limitations based on a measure we constructed according to self-reported level of difficulty performing 18 tasks without aid; 2) the Katz Index; and 3) the respondent's self-reported perception of functional limitation. Logistic regressions were performed to examine the determinants of the likelihood of having consulted a specialized outpatient care physician or a dentist at least once in the past year.ResultsAmong the 2528 individuals, 45% and 28% had respectively consulted a specialized outpatient care physician or a dentist at least once in the previous year. After adjusting for health care needs, higher functional limitation scores, dependency in all six activities of daily living and self-reported perceptions of severe functional limitation were significantly associated with a lower likelihood of having consulted a specialized outpatient care physician (respectively AOR=0.95 (0.94-0.96), AOR=0,29 (0.23-0.38) and AOR=0.51 (0.42-0.62)) or a dentist (respectively AOR=0.95 (0.94-0.96), AOR=0.29 (0.21-0.39) and AOR=0.55 (0.44-0.67)) at least once in the previous year. Being a male, reporting a lack of family support, and having a low socio-economic status also significantly influenced specialized outpatient care use.ConclusionsRegardless of the method used to define and measure disability, a high degree of disability negatively influence specialized outpatient care use after adjusting for health care need. Further studies are needed to better understand the reasons why this association between the degree of functional limitation and unmet medical needs is also a reality among people with disabilities living in institutions.



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Beta-defensin gene ( DEFB1 ) polymorphisms are associated with the susceptibility to chronic respiratory diseases

Abstract

In the present study, we aim to investigate the correlations between polymorphisms in the DEFB1 gene and the susceptibility to chronic respiratory diseases (CRDs). Electronic searches in multiple scientific literature databases (PubMed, EBSCO, Ovid, Springerlink, Wiley, Web of Science, Wanfang database, China National Knowledge Infrastructure database and VIP database) were made to retrieve studies on the associations between DEFB1 gene polymorphisms and CRDs. We used strict inclusion criteria in the present meta-analysis. Data analyses were performed with STATA software (version 12.0; Stata Corp, College Station, TX, USA). Of 76 initially-retrieved articles, 11 were finally incorporated into our meta-analysis, enrolling 1343 patients with CRDs (477 with chronic obstructive pulmonary disease (COPD), 305 with asthma, 286 with cystic fibrosis (CF), 130 with ventilator-associated pneumonia (VAP), 145 with pulmonary tuberculosis, and 1261 healthy controls into our meta-analysis. Our study showed that −44 C/G (rs1800972) and 1654 G/A (rs2738047) in DEFB1 are strongly associated with the increased susceptibility to CRDs. The subgroup analysis on disease types showed that the −44 C/G (rs1800972) in DEFB1 is associated with the susceptibility to COPD, VAP and CF, and the 1654 G/A (rs2738047) associated with the susceptibility to COPD and asthma. Subgroup analyses based on ethnicity indicated that −44 C/G (rs1800972) may confer increased susceptibility to CRDs in Asians but not in Caucasians. Taken together, −44 C/G (rs1800972) and 1654 G/A (rs2738047) are strongly associated with CRD susceptibility, while associations of SNPs −52 G/A (rs1799946) and −20 G/A (rs11362) with CRDs needs further investigation.

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Gamma emitters in atmospheric precipitation in Krakow (Southern Poland) during the years 2005–2015

Publication date: Available online 20 February 2016
Source:Journal of Environmental Radioactivity
Author(s): Jerzy W. Mietelski, Ewa Nalichowska, Ewa Tomankiewicz, Kamil Brudecki, Paweł Janowski, Renata Kierepko
The results of the sum of dry and wet activity deposition for naturally occurring ⁷Be, ²¹⁰Pb, ⁴⁰K, ²²Na and anthropogenic ¹³⁷Cs radionuclides in Krakow (Southern Poland) for the samples collected over 10 years (from August 2005 to July 2015) are presented and discussed. The radionuclides were determined using low background gamma spectrometry with HPGe detectors. Additionally, in this paper there are shown the results of activity concentrations in water from air precipitation for ⁷Be, ²¹⁰Pb, ²²Na, ⁴⁰K and ¹³⁷Cs radioisotopes from the period of 7 years (from August 2008 to July 2015). For all these series the statistical analysis including Spearman correlations, effects of seasonal variation and multiple regression models were conducted. After excluding two months from 2011 affected by the Fukushima accident, high Spearman correlation factors (R > 0.5) for activity deposition were noticed for the pair of the cosmogenic radionuclides ⁷Be and ²²Na (R = 0.508) and between ²¹⁰Pb and ⁷Be (R = 0.570). High correlation was noted between activity deposition and amount of precipitation for ⁷Be (R = 0.677). The seasonal correlations between ⁷Be–²²Na, ⁴⁰K–¹³⁷Cs, ²¹⁰Pb–¹³⁷Cs and ⁷Be–²¹⁰Pb were investigated and the highest correlation coefficient R = 0.731 for the ⁴⁰K–¹³⁷Cs pair was in the spring season. High correlations were observed also between ²¹⁰Pb and ⁷Be for autumn (R = 0.594), ⁴⁰K–¹³⁷Cs in summer (R = 0.582), ⁷Be–²²Na in spring (R = 0.635) and ²¹⁰Pb–¹³⁷Cs in autumn (R = 0.672). The multiple regression approach showed the interesting difference in scavenging mechanisms of cosmogenic and terrestrial radionuclides. According to that model, the deposition of cosmogenic nuclides was noticeably related to the amount of precipitation, while the deposition of terrestrial radionuclides did not show such dependence.



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Editorial board

Publication date: March 2016
Source:Journal of Environmental Radioactivity, Volume 153





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The risk factors for postoperative pulmonary complications after head and neck cancer surgery

The recent article by Damian et al [1] assessing incidence, outcome, and risk factors for postoperative pulmonary complications (PPCs) in 110 head and neck cancer surgery patients with free flap reconstructions was of great interest. They showed that 32.7% of patients developed PPCs, but no perioperative parameters including intraoperative fluid administration or preoperative pulmonary comorbidity were identified as a predictor for PPCs. In this study, we noted that patients underwent surgery for a primary tumor (76.4%), a recurrence (21.8%), or metastasis (1.8%).

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Classic transcrural celiac plexus block simulated on 100 computed tomography images

To evaluate intra-abdominal needle trajectories of the classic transcrural celiac plexus block (tCPB) with a simulation technique.

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Preventable drug waste among anesthesia providers: opportunities for efficiency

Health care service bundling experiments at the state and regional levels have showed reduced costs by providing a single lump-sum reimbursement for anesthesia services, surgery, and postoperative care. Potential for cost savings related to the provision of anesthesia care has the potential to significantly impact sustainability. This study defines and quantifies routine and preventable anesthetic drug waste and the patient, procedure, and anesthesia provider characteristics associated with increased waste.

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Postoperative conversion disorder

Conversion disorder is a psychiatric disorder in which psychological stress causes neurologic deficits. A 28-year-old female surgical patient had uneventful general anesthesia and emergence but developed conversion disorder 1 hour postoperatively. She reported difficulty speaking, right-hand numbness and weakness, and right-leg paralysis. Neurologic examination and imaging revealed no neuronal damage, herniation, hemorrhage, or stroke. The patient mentioned failing examinations the day before surgery and discontinuing her prescribed antidepressant medication, leading us to diagnose conversion disorder, with eventual confirmation by neuroimaging and follow-up examinations.

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A randomized trial examining preoperative sedative medication and postoperative sleep in children

Midazolam has been found to have beneficial effects on anxiety in children in the preoperative setting. Prior studies have examined various postoperative behaviors of children, but little research has examined the effects of preoperative use of midazolam with postoperative sleep. The purpose of this investigation was to compare postoperative sleep in children as a function of preoperative sedative medication use.

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Adopting the American anesthesia oral examination in China: value and roadblocks

The quality and standardized training and certification of young physicians is key to the quality of health care in the future. In contrast to the American system, there is no nationwide and standardized oral examination in the training and certification process for anesthesiologists in China. The adoptability of the American anesthesia oral examination in China, as well as potential roadblocks, has not been specifically discussed. In this commentary, we share our experience of introducing the American oral examination to an audience of Chinese anesthesiologists and propose a pragmatic approach for adopting the anesthesia oral examination in China.

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A clinical study of cardiac rhythm disturbance in patients with chronic obstructive pulmonary disease using 24 hour Holter monitoring

2016-02-20T06-12-32Z
Source: International Journal of Research in Medical Sciences
Varsha S. Dabadghao*, Rajsinh Patil, Suresh K. Sharma, Arjun L. Kakrani.
Background: Chronic obstructive pulmonary disease (COPD) has been defined by GOLD (guidelines for obstructive lung disease) as a disease state characterised by airflow limitation that is not fully reversible, with FEV1/FVC


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Psychosocial Factors Associated with Subclinical Atherosclerosis in South Asians: The MASALA Study

Abstract

South Asians have the highest rates of premature atherosclerotic cardiovascular disease amongst all ethnic groups in the world; however this risk cannot be fully explained by traditional risk factors. Participants from the Mediators of Atherosclerosis in South Asians Living in America Study were included in this cross-sectional analysis. The purpose of this study was to investigate the association of psychosocial factors (including anger, anxiety, depressive symptoms, current and chronic stress, and everyday hassles) with carotid intima-media thickness (CIMT). Three multivariate models were examined to evaluate the association between the psychosocial factors and CIMT. Findings suggest that the impact of psychosocial factors on subclinical atherosclerosis is differential for South Asian men and women. For men, anxiety and depression were associated; while for women, stress was associated with common carotid intima media thickness, independent of traditional CVD risk factors, diet and physical activity.

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Hematological spectrum in patients with alcoholic liver cirrhosis: a model of end-stage liver disease score based approach

2016-02-20T04-57-46Z
Source: International Journal of Advances in Medicine
Deepak Jain, H. K. Aggarwal, Avinash Rao, Shaveta Dahiya, Suhas Singla.
Background: Patients with alcoholic liver cirrhosis have anaemia, leucocytosis as well as leukopenia and thrombocytopenia in various proportions, which are, to a greater extent, determine mortality and morbidity among them. There is a growing need of a scale to determine the stages at which these hematological parameters could be corrected so as to decrease their adverse impacts on the patients lives. The model of end-stage liver disease (MELD) score is built to predict survival in cirrhotic patients undergoing transplantation and to assign priority for liver transplantation. To simplify the task of early identification and management of patients with deranged blood indices, we studied the relationship between various hematological parameters and MELD score. Methods: This was a prospective observational study in which spectrum of various hematological indices and complications of alcoholic liver disease were observed in 88 patients with stigmata of chronic liver failure on clinical examination substantiated by histopathological evidence and imaging. Hematological parameters including anaemia, leukocyte count and platelet count were assessed in the subjects and were categorized under the different groups of MELD score. The relationship of these variables with MELD score was studied and statistical analysis was done. Results: We observed a progressive fall in hemoglobin levels with the increase in MELD score. All the patients in group 1 had normal leukocyte count. Leukocytosis predominated in MELD group 2 and 3 patients. In group 4, leukopenia was more prevalent. All the patients in group 5 had leukopenia. Group 1 and 2 patients did not have thrombocytopenia. Thrombocytopenia started occurring in MELD group 3 patients, while involving all the patients of group 4 and 5. Conclusions: The statistically significant association between the variables and the groups shows that MELD score grouping system could be an important tool in the assessment of these patients. This association strongly depicts that the clinicians could effectively apply the classification in predicting the hematological complications in these patients and take precautions early in preventing the further progression of the disease thus decreasing the mortality in these patients.


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Xenon Anesthesia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND: Xenon anesthesia has been studied for decades. However, no meta-analysis of randomized controlled trials (RCTs) on xenon anesthesia has been conducted. The aim of this study was to systematically review all available evidence from RCTs comparing xenon and other inhaled and IV anesthetics on anesthetic outcomes. Our meta-analysis attempted to quantify the effects of xenon anesthesia on clinical outcomes in relation to other anesthetics. METHODS: We found 43 RCTs from PubMed, MEDLINE, CENTRAL, EMBASE, and CINAHL (until January 2015). A total of 31 studies comparing xenon (841 patients) with other inhaled agents (836 patients) and 12 studies comparing xenon (373 patients) with propofol (360 patients) were found. We evaluated clinical outcomes, such as intraoperative hemodynamics, emergence, and postoperative nausea and vomiting (PONV). RESULTS: Patients undergoing xenon anesthesia had a lower heart rate and higher mean arterial pressure (MAP) intraoperatively than those receiving volatile anesthesia (mean difference = −6 min−1 [99% confidence interval {99% CI} −10.0 to −2.3]; mean difference = 9 mm Hg [99% CI 3.1–14.4]) and propofol anesthesia (mean difference = −10 min−1 [99% CI −12.4 to −6.6]; mean difference = 7 mm Hg [99% CI 0.85–13.2]). Compared with baseline, intraoperative MAP remained relatively stable (change

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The Physiology of Cardiopulmonary Resuscitation

Outcomes after cardiac arrest remain poor more than a half a century after closed chest cardiopulmonary resuscitation (CPR) was first described. This review article is focused on recent insights into the physiology of blood flow to the heart and brain during CPR. Over the past 20 years, a greater understanding of heart–brain–lung interactions has resulted in novel resuscitation methods and technologies that significantly improve outcomes from cardiac arrest. This article highlights the importance of attention to CPR quality, recent approaches to regulate intrathoracic pressure to improve cerebral and systemic perfusion, and ongoing research related to the ways to mitigate reperfusion injury during CPR. Taken together, these new approaches in adult and pediatric patients provide an innovative, physiologically based road map to increase survival and quality of life after cardiac arrest.

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Ketamine Versus Special K: A Double-Edged Sword

No abstract available

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The Goose and the Gander

No abstract available

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The Role of Ketamine in Low- and Middle-Income Countries: What Would Happen if Ketamine Becomes a Scheduled Drug?

No abstract available

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AIDS Service Organization Access Among African, Caribbean and Other Black Residents of an Average Canadian City

Abstract

Due to heightened vulnerability to HIV/AIDS, African, Caribbean and Black (ACB) communities are priority groups for prevention and intervention services in Canada. However, it is not clear which factors may affect ACB communities' access to these services. We evaluated access to the local AIDS service organization (ASO) in Middlesex-London by using data from the Black, African and Caribbean Canadian Health Study. Modified Poisson regression was used to obtain prevalence risk ratios for factors associated with three measures of access: familiarity with the ASO, willingness to access, and realized access. In adjusted analyses, older ACB community members were more likely to be familiar with the ASO, willing to access it, and have actually gone there. Canadian-born participants were less likely to have been to the ASO than recent immigrants. These results have implications for reaching specific segments of ACB communities for HIV/AIDS-related services in Canada.

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Electroacupuncture Relieves Nerve Injury–Induced Pain Hypersensitivity via the Inhibition of Spinal P2X7 Receptor–Positive Microglia

BACKGROUND: Electroacupuncture (EA) has therapeutic effects on neuropathic pain induced by nerve injury; however, the underlying mechanisms remain unclear. In this study, we examined whether EA treatment relieves pain hypersensitivity via the down-regulation of spinal P2X7 receptor–positive (P2X7R+) microglia-mediated overexpression of interleukin (IL)-1β and/or IL-18. METHODS: Male Sprague-Dawley rats underwent chronic constriction injury (CCI) or 3′-O-(4-benzoylbenzoyl) adenosine 5′-triphosphate (BzATP) intrathecal injection. Von Frey and Hargreaves tests were performed to evaluate the effect of EA on pain hypersensitivity. The spinal P2X7R, IL-1β, and IL-18 expression levels were determined by real-time polymerase chain reaction, Western blot analysis, immunofluorescence staining, and enzyme-linked immunosorbent assay. The selective P2X7R antagonist A-438079 was used to examine the P2X7R+ microglia–dependent release of IL-1β and IL-18. Primary cultures were subsequently used to assess the P2X7R+ microglia–induced IL-1β and IL-18 release. RESULTS: EA treatment significantly improved the pain thresholds and inhibited spinal P2X7R+ microglia activation induced by CCI or BzATP administration, which was accompanied by the suppression of spinal IL-1β and IL-18 overexpression. Moreover, A-438079 also improved pain thresholds and suppressed overexpression of IL-1β in the CCI- and BzATP-injected rats. The analysis of cultured microglia further demonstrated that A-438079 markedly decreased BzATP-induced IL-1β release. CONCLUSIONS: EA treatment relieves nerve injury-induced tactile allodynia and thermal hyperalgesia via the inhibition of P2X7R+ microglia–mediated IL-1β overexpression.

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Decreasing the Hours That Anesthesiologists and Nurse Anesthetists Work Late by Making Decisions to Reduce the Hours of Over-Utilized Operating Room Time

In this special article, we evaluate how to reduce the number of hours that anesthesiologists and nurse anesthetists work beyond the end of their scheduled shifts. We limit consideration to surgical suites where the hours of cases in each operating room (OR) average 8 hours or more per day. Let "allocated hours" refer to the hours into which cases are scheduled, calculated months in advance for each combination of service and day of the week. Over-Utilized time is the OR workload exceeding allocated time. Reducing Over-Utilized time is the key to reducing the hours that anesthesia providers work late. Certain decisions that reduce Over-Utilized time and reduce the hours that anesthesiologists and nurse anesthetists work late are made by the surgical committee or perioperative medical director months in advance. Such decisions include increasing the number of first case starts and planning staffing for turnovers and lunch breaks during the busiest times of the day. However, most decisions substantively influencing Over-Utilized OR time are made within 1 workday before the day of surgery and on the day of surgery, because only then are ORs sufficiently full that changes can be made to minimize Over-Utilized time. Decisions to reduce Over-Utilized time on the day of surgery include targeting ORs with expected Over-Utilized time and taking steps to reduce it, including making effective staff assignments and appropriately scheduling add-on cases.

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Can We Claim Accuracy from a Regional Near-Infrared Spectroscopy Oximeter?

No abstract available

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Ketamine Versus Special K: A Double-Edged Sword

No abstract available

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The World Congress on Enhanced Recovery 2015 Conference Summary

No abstract available

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Focus on Physiology to Improve Cardiopulmonary Resuscitation

No abstract available

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An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions

BACKGROUND: Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0–21 years) at hospital discharge. METHODS: We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. RESULTS: Patients in the database averaged 9 ± 6.1 (range, 0–21) years of age and 36.7 ± 24.9 (1–195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children 12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2–3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1–1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses 15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). CONCLUSIONS: A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

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Midazolam for Anxiolysis and Postoperative Nausea and Vomiting Prophylaxis: Can We Kill Two Birds with One Stone?

No abstract available

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Will Xenon Be a Valuable Addition in Perioperative and Critical Care Settings?

No abstract available

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Association of Sodium Homeostasis with Blood Transfusions During Liver Transplantation

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Primus Inter Pares? The Angle of View Varies

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The Goose and the Gander

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Evolving Definitions and Pharmacologic Management of Complex Regional Pain Syndrome

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Net Reclassification Improvement

When adding new markers to existing prediction models, it is necessary to evaluate the models to determine whether the additional markers are useful. The net reclassification improvement (NRI) has gained popularity in this role because of its simplicity, ease of estimation, and understandability. Although the NRI provides a single-number summary describing the improvement new markers bring to a model, it also has several potential disadvantages. Any improved classification by the new model is weighted equally, regardless of the direction of reclassification. In prediction models that already identify the high- and low-risk groups well, a positive NRI may not mean better classification of those with medium risk, where it could make the most difference. Also, overfitting, or otherwise misspecified training models, produce overly positive NRI results. Because of the unaccounted for uncertainty in the model coefficient estimation, investigators should rely on bootstrapped confidence intervals rather than on tests of significance. Keeping in mind the limitations and drawbacks, the NRI can be helpful when used correctly.

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Variability of Automated Intraoperative ST Segment Values Predicts Postoperative Troponin Elevation

BACKGROUND: Intraoperative electrocardiographic monitoring is considered a standard of care. However, there are no evidence-based algorithms for using intraoperative ST segment data to identify patients at high risk for adverse perioperative cardiac events. Therefore, we performed an exploratory study of statistical measures summarizing intraoperative ST segment values determine whether the variability of these measurements was associated with adverse postoperative events. We hypothesized that elevation, depression, and variability of ST segments captured in an anesthesia information management system are associated with postoperative serum troponin elevation. METHODS: We conducted a single-institution, retrospective study of intraoperative automated ST segment measurements from leads I, II, and III, which were recorded in the electronic anesthesia record of adult patients undergoing noncardiac surgery. The maximum, minimum, mean, and SD of ST segment values were entered into logistic regression models to find independent associations with myocardial injury, defined as an elevated serum troponin concentration during the 7 days after surgery. Performance of these models was assessed by measuring the area under the receiver operator characteristic curve. The net reclassification improvement was calculated to quantify the amount of information that the ST segment values analysis added regarding the ability to predict postoperative troponin elevation. RESULTS: Of 81,011 subjects, 4504 (5.6%) had postoperative myocardial injury. After adjusting for patient characteristics, the ST segment maximal depression (e.g., lead I: odds ratio [OR], 1.66; 95% confidence interval [CI], 1.26–2.19; P = 0.0004), maximal elevation (e.g., lead I: OR, 1.70; 95% CI, 1.34–2.17; P

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Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs: A Systematic Review and Meta-Analysis

BACKGROUND: Steroids often are administered into the epidural space through the transforaminal epidural (TFE) route to treat lumbosacral radicular pain secondary to herniated intervertebral discs. However, their efficacy and safety compared with transforaminal epidural local anesthetics (LAs) or saline injections is unclear. METHODS: We reviewed randomized controlled trials that compared TFE injections of steroids (with or without LA) with LA or saline in adult outpatients with lumbosacral radicular pain secondary to herniated intervertebral disks. Databases searched included MEDLINE, EMBASE, Cochrane central register of controlled trials, Cochrane database of systematic reviews, and Google Scholar up to February 2015. Data on scores of numerical rating scale for pain, validated scores for measuring physical disability and quality of life, and incidence of surgery measured at 1 month to 2 years after the interventions were meta-analyzed. Strength of evidence was classified with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: Eight randomized controlled trials including 771 patients (366 in steroid and 405 in comparator groups) were included. There was variability in the studies in the dose of TFE steroids, frequency, and number of procedures. Patients who received TFE steroids reported a significant, but clinically modest, reduction in mean pain scores (0–10 scale) compared with LA/saline (−0.97 points; 95% confidence interval, −1.42 to −0.51 points; P

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2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion

BACKGROUND: Stored red blood cells (RBCs) are deficient in 2,3-diphosphoglycerate (2,3-DPG), but it is unclear how autologous salvaged blood (ASB) compares with stored blood and how rapidly 2,3-DPG levels return to normal after transfusion. Therefore, we compared levels of 2,3-DPG in stored versus ASB RBCs and in patients' blood after transfusion. METHODS: Twenty-four patients undergoing multilevel spine fusion surgery were enrolled. We measured 2,3-DPG and the oxyhemoglobin dissociation curve (P50) in samples taken from the ASB and stored blood bags before transfusion and in blood samples drawn from patients before and after transfusion. RESULTS: The mean storage duration for stored RBCs was 24 ± 8 days. Compared with fresh RBCs, stored RBCs had decreased 2,3-DPG levels (by approximately 90%; P

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Human Lumbar Ligamentum Flavum Anatomy for Epidural Anesthesia: Reviewing a 3D MR-Based Interactive Model and Postmortem Samples

The ligamentum flavum (LF) forms the anatomic basis for the loss-of-resistance technique essential to the performance of epidural anesthesia. However, the LF presents considerable interindividual variability, including the possibility of midline gaps, which may influence the performance of epidural anesthesia. We devise a method to reconstruct the anatomy of the digitally LF based on magnetic resonance images to clarify the exact limits and edges of LF and its different thickness, depending on the area examined, while avoiding destructive methods, as well as the dissection processes. Anatomic cadaveric cross sections enabled us to visually check the definition of the edges along the entire LF and compare them using 3D image reconstruction methods. Reconstruction was performed in images obtained from 7 patients. Images from 1 patient were used as a basis for the 3D spinal anatomy tool. In parallel, axial cuts, 2 to 3 cm thick, were performed in lumbar spines of 4 frozen cadavers. This technique allowed us to identify the entire ligament and its exact limits, while avoiding alterations resulting from cutting processes or from preparation methods. The LF extended between the laminas of adjacent vertebrae at all vertebral levels of the patients examined, but midline gaps are regularly encountered. These anatomical variants were reproduced in a 3D portable document format. The major anatomical features of the LF were reproduced in the 3D model. Details of its structure and variations of thickness in successive sagittal and axial slides could be visualized. Gaps within LF previously studied in cadavers have been identified in our interactive 3D model, which may help to understand their nature, as well as possible implications for epidural techniques.

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Risk Factors Involved in Central-to-Radial Arterial Pressure Gradient During Cardiac Surgery

BACKGROUND: A central-to-radial arterial pressure gradient may occur after cardiopulmonary bypass (CPB), which, in some patients, may last for a prolonged time after CPB. Whenever there is a pressure gradient, the radial artery pressure measure may underestimate a more centrally measured systemic pressure, which may result in a misguided therapeutic strategy. It is clinically important to identify the risk factors that may predict the appearance of a central-to-radial pressure gradient, because more central sites of measurements might then be considered to monitor systemic arterial pressure in high-risk patients. The objective of this study was to assess preoperative and intraoperative risk factors for central-to-radial pressure gradient. METHODS: Seventy-three patients undergoing cardiac surgery using CPB were included in this prospective observational study. A significant central-to-radial arterial pressure gradient was defined as a difference of 25 mm Hg in systolic pressure or 10 mm Hg in mean arterial pressure for a minimum of 5 minutes. Preoperative data included demographics, presence of comorbidities, and medications. Intraoperative data included type of surgery, CPB and aortic clamping time, use of inotropic drugs, and vasodilators or vasopressors agents. The diameter of the radial and femoral artery was measured before the induction of anesthesia using B-mode ultrasonography. RESULTS: Thirty-three patients developed a central-to-radial arterial pressure gradient (45%). Patients with a significant pressure gradient had a smaller weight (71.0 ± 16.9 vs 79.3 ± 17.3 kg, P = 0.041), a smaller height (162.0 ± 9.6 vs 166.3 ± 8.6 cm, P = 0.047), a smaller radial artery diameter (0.24 ± 0.03 vs 0.29 ± 0.05 cm, P 90 minutes (OR, 8.521; 95% CI, 1.917–37.870, P = 0.005), and patient height (OR, 0.933, 95% CI, 0.876–0.993, P = 0.029). The relative risk (RR) estimates remained statistically significant for the Parsonnet score and the aortic clamping time ≥90 minutes (RR, 1.010; 95% CI, 1.003–1.018, P = 0.009 and RR, 2.253; 95% CI, 1.475–3.443, P

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Opioids and Sleep Apnea: More Than Perioperative Impact

No abstract available

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Environmental Endocrine Disruptor Affects Voluntary Physical Activity in Mice.

INTRODUCTION: Voluntary physical activity levels are regulated by sex hormones. The purpose of this study was to determine the effect of the endocrine disruptor benzyl butyl phthalate (BBP) on the regulation of physical activity in mice. METHODS: Mouse dams were treated with 500 mg[BULLET OPERATOR]kg-1[BULLET OPERATOR]day-1 of BBP or vehicle on gestation days 9-16. Pups were weaned and analyzed for voluntary physical activity levels, puberty development, sex hormone levels, and body composition over a 20 week period. RESULTS: Seventy-three offspring from BBP treated dams were studied (n=43 males, n=30 females). Endocrine disruption was indicated by decreased anogenital distances in BBP-treated male offspring at 10 (p=0.001) and 20 weeks (p=0.038) and delayed vaginal openings in BBP-treated female offspring (p=0.001). Further, there was a significant decrease in serum testosterone concentration in male mice between control and BBP at 10 weeks (p=0.039) and at 20 weeks (p=0.022). In female mice there was a significant increase in serum testosterone concentration in BBP mice at 20 weeks (p=0.002), and a significant increase in estrogen (estradiol) concentrations at 20 weeks in the control female mice (p=0.015). Overall, BBP mice ran significantly less distance (males, p=0.008; females, p=0.042) than controls. Other than a significant increase in BBP-treated males in fat mass at 20 weeks (p=0.040), there was no significant decrease in weight, lean mass, or fat mass in either female or male mice, regardless of treatment. CONCLUSION: Maternal endocrine disruption altered hormone response, but not body composition in either sex of offspring, with a corresponding decreased activity throughout early adulthood in all offspring. These results suggest that exposure to common environmental endocrine disruptors in utero, can reduce and alter physical activity levels in offspring. (C) 2016 American College of Sports Medicine

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Exercise Reduces Lung Fibrosis Involving Serotonin/Akt Signaling.

Purpose: Idiopathic pulmonary fibrosis (IPF) is a chronic fibrosing interstitial pneumonia, which involves aberrant serotonin (5-HT) and Akt signaling. As protective effects of chronic aerobic training (AT) have been demonstrated in the context of lung injury, this study investigated whether AT attenuates bleomycin-induced lung fibrosis partly via a reduction of 5-HT and AKT signaling. Methods: Seventy-two C57Bl/6 male mice were distributed in Control (Co), Exercise (Ex), Fibrosis (Fi) and Fibrosis+Exercise (Fi+Ex) groups. Bleomycin (1.5UI/Kg) was administered on day 1 and treadmill AT began on day 15 and continued for 60 min a day, 5 days a week for 4 weeks. We evaluated total and differential cell counts in BAL, IL-1beta, IL-6, CXCL1/KC, IL-10, TNF-alpha and TGF-beta levels in BAL, collagen content in lung parenchyma, 5-HT levels in BAL fluid and in serum, the expression of 5HT2B receptor and Akt phosphorylation in lung tissue. Results: AT reduced bleomycin-increased number of total cells (p

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Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial.

BACKGROUND: The aim of this study was to apply both IV fluid and forced-air warming to decrease perioperative hypothermia in women undergoing cesarean delivery with spinal anesthesia. The authors hypothesize that combined-modality active warming (AW) would increase maternal temperature on arrival at the postanesthesia care unit (PACU) and decrease the incidence of maternal perioperative hypothermia (

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Estimated Maximal Safe Dosages of Tumescent Lidocaine.

BACKGROUND: Tumescent lidocaine anesthesia consists of subcutaneous injection of relatively large volumes (up to 4 L or more) of dilute lidocaine (30 mg/kg), serum lidocaine concentrations would be below levels associated with mild toxicity and that the concentration-time profile would be lower after liposuction than without liposuction. METHODS: Volunteers participated in 1 to 2 infiltration studies without liposuction and then one study with tumescent liposuction totally by local anesthesia. Serum lidocaine concentrations were measured at 0, 2, 4, 6, 8, 10, 12, 14, 16, 18, and 24 hours after each tumescent lidocaine infiltration. Area under the curve (AUC[infinity]) of the serum lidocaine concentration-time profiles and peak serum lidocaine concentrations (Cmax) were determined with and without liposuction. For any given milligram per kilogram dosage, the probability that Cmax >6 [mu]g/mL, the threshold for mild lidocaine toxicity was estimated using tolerance interval analysis. RESULTS: In 41 tumescent infiltration procedures among 14 volunteer subjects, tumescent lidocaine dosages ranged from 19.2 to 52 mg/kg. Measured serum lidocaine concentrations were all

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A Randomized Comparison Between Conventional and Waveform-Confirmed Loss of Resistance for Thoracic Epidural Blocks.

Background and Objectives: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. In this randomized trial, we compared conventional and EWA-confirmed LOR in 2 teaching centers. Our research hypothesis was that EWA-confirmed LOR would decrease the failure rate of thoracic epidural blocks. Methods: One hundred patients undergoing thoracic epidural blocks for thoracic surgery, abdominal surgery, or rib fractures were randomized to conventional LOR or EWA-LOR. The operator was allowed as many attempts as necessary to achieve a satisfactory LOR (by feel) in the conventional group. In the EWA-LOR group, LOR was confirmed by connecting the epidural needle to a pressure transducer using a rigid extension tubing. Positive waveforms indicated that the needle tip was positioned inside the epidural space. The operator was allowed a maximum of 3 different intervertebral levels to obtain a positive waveform. If waveforms were still absent at the third level, the operator simply accepted LOR as the technical end point. However, the patient was retained in the EWA-LOR group (intent-to-treat analysis). After achieving a satisfactory tactile LOR (conventional group), positive waveforms (EWA-LOR group), or a third intervertebral level with LOR but no waveform (EWA-LOR group), the operator administered a 4-mL test dose of lidocaine 2% with epinephrine 5 [mu]g/mL. Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Results: Compared with LOR, EWA-LOR resulted in a lower rate of primary failure (2% vs 24%; P = 0.002). Subgroup analysis based on experience level reveals that EWA-LOR outperformed conventional LOR for novice (P = 0.001) but not expert operators. The performance time was longer in the EWA-LOR group (11.2 +/- 6.2 vs 8.0 +/- 4.6 minutes; P = 0.006). Both groups were comparable in terms of operator's level of expertise, depth of the epidural space, approach, and LOR medium. In the EWA-LOR group, operators obtained a pulsatile waveform with the first level attempted in 60% of patients. However, 40% of subjects required performance at a second or third level. Conclusions: Compared with its conventional counterpart, EWA-confirmed LOR results in a lower failure rate for thoracic epidural blocks (2% vs 24%) in our teaching centers. Confirmatory EWA provides significant benefits for inexperienced operators. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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