2016-09-20T22-59-58Z
Source: National Journal of Physiology, Pharmacy and Pharmacology
Sarma Nursani Lumbanraja.
Background: Early intervention of low birth weight (LBW) should reduce maternal and fetal morbidity. In underserved areas, with inadequacy of health technologies, it was very important to develop a simple scoring system based on the LBW risk factors. Aims and Objective: The aim of this study is to develop a scoring system to predict LBW in underserved area. Materials and Methods: This casecontrol study enrolled total of women with a singleton LBW in Padang Sidempuan General Hospital. For every case, the subsequent woman who delivered a baby weighing ≥2500 g acted as control. All data were by Chi-square or Fishers exact test. Significant variables were taken to be analyzed in backward stepwise binary regression. Then, receiver operating characteristic curve was developed to determine cutoff point and diagnostic value. This was done by SPSS (Statistical Product and Service Solutions, Chicago, IL, USA) 22.0 with 95% confidence interval significant value. Results: This study involved 62 LBW and 62 normal birth weight newborns. Among all variables, only four variables were found to be significant, such as employment, antenatal care, history of anemia in pregnancy, and history of placenta previa in pregnancy. The placenta previa, anemia, care in antenatal, employment (PACE) score was obtained as score for employment was +1, antenatal care was −2, history of anemia in pregnancy was +2, and history of placenta previa was +3. The cutoff point was determined as 0, where a positive score will predict fetal with LBW and total score ≤0 (negative) will predict fetal with normal weight. This model had sensitivity of 88.7%, specificity of 66.1%, and area under curve 0.844 (P
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Τρίτη 20 Σεπτεμβρίου 2016
Placenta previa, anemia, care in antenatal, employment score: Development of a scoring system to predict low birth weight in underserved area in Indonesia
Understanding location- and feature-based processing along the human intraparietal sulcus
Based on different cognitive tasks and mapping methods, the human intraparietal sulcus (IPS) has been subdivided according to multiple different organizational schemes. The presence of topographically organized regions throughout IPS indicates a strong location-based processing in this brain region. However, visual short-term memory (VSTM) studies have shown that while a region in the inferior IPS region (inferior IPS) is involved in object individuation and selection based on location, a region in the superior IPS (superior IPS) primarily encodes and stores object featural information. Here, we determined the localization of these two VSTM IPS regions with respect to the topographic IPS regions in individual participants and the role of different IPS regions in location- and feature-based processing. Anatomically, inferior IPS showed an 85.2% overlap with topographic IPS regions, with the greatest overlap seen in V3A and V3B, and superior IPS showed a 73.6% overall overlap, with the greatest overlap seen in IPS0-2. Functionally, there appeared to be a partial overlap between IPS regions involved in location- and feature-based processing, with more inferior and medial regions showing a stronger location-based processing and more superior and lateral regions showing a stronger feature-based processing. Together, these results suggest that understanding the multiplex nature of IPS in visual cognition may not be reduced to examining the functions of the different IPS topographic regions, but rather, it can only be accomplished by understanding how regions identified by different tasks and methods may colocalize with each other.
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Glutamatergic drive facilitates synaptic inhibition of dorsal vagal motor neurons after experimentally induced diabetes in mice
The role of central regulatory circuits in modulating diabetes-associated glucose dysregulation has only recently been under rigorous investigation. One brain region of interest is the dorsal motor nucleus of the vagus (DMV), which contains preganglionic parasympathetic motor neurons that regulate subdiaphragmatic visceral function. Previous research has demonstrated that glutamatergic and GABAergic neurotransmission are independently remodeled after chronic hyperglycemia/hypoinsulinemia. However, glutamatergic circuitry within the dorsal brain stem impinges on GABAergic regulation of the DMV. The present study investigated the role of glutamatergic neurotransmission in synaptic GABAergic control of DMV neurons after streptozotocin (STZ)-induced hyperglycemia/hypoinsulinemia by using electrophysiological recordings in vitro. The frequency of spontaneous inhibitory postsynaptic currents (sIPSCs) was elevated in DMV neurons from STZ-treated mice. The effect was abolished in the presence of the ionotropic glutamate receptor blocker kynurenic acid or the sodium channel blocker tetrodotoxin, suggesting that after STZ-induced hyperglycemia/hypoinsulinemia, increased glutamatergic receptor activity occurs at a soma-dendritic location on local GABA neurons projecting to the DMV. Although sIPSCs in DMV neurons normally demonstrated considerable amplitude variability, this variability was significantly increased after STZ-induced hyperglycemia/hypoinsulinemia. The elevated amplitude variability was not related to changes in quantal release, but rather correlated with significantly elevated frequency of sIPSCs in these mice. Taken together, these findings suggest that GABAergic regulation of central vagal circuitry responsible for the regulation of energy homeostasis undergoes complex functional reorganization after several days of hyperglycemia/hypoinsulinemia, including both glutamate-dependent and -independent forms of plasticity.
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Vestibular and oculomotor influences on visual dependency
The degree to which a person relies on visual stimuli for spatial orientation is termed visual dependency (VD). VD is considered a perceptual trait or cognitive style influenced by psychological factors and mediated by central reweighting of the sensory inputs involved in spatial orientation. VD is often measured with the rod-and-disk test, in which participants align a central rod to the subjective visual vertical (SVV) in the presence of a background that is either stationary or rotating around the line of sight—dynamic SVV. Although this task has been employed to assess VD in health and vestibular disease, what effect torsional nystagmic eye movements may have on individual performance is unknown. Using caloric ear irrigation, 3D video-oculography, and the rod-and-disk test, we show that caloric torsional nystagmus modulates measures of VD and demonstrate that increases in tilt after irrigation are positively correlated with changes in ocular torsional eye movements. When the direction of the slow phase of the torsional eye movement induced by the caloric is congruent with that induced by the rotating visual stimulus, there is a significant increase in tilt. When these two torsional components are in opposition, there is a decrease. These findings show that measures of VD can be influenced by oculomotor responses induced by caloric stimulation. The findings are of significance for clinical studies, as they indicate that VD, which often increases in vestibular disorders, is modulated not only by changes in cognitive style but also by eye movements, in particular nystagmus.
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Velocity dependence of vestibular information for postural control on tilting surfaces
Vestibular information is known to be important for postural stability on tilting surfaces, but the relative importance of vestibular information across a wide range of surface tilt velocities is less clear. We compared how tilt velocity influences postural orientation and stability in nine subjects with bilateral vestibular loss and nine age-matched, control subjects. Subjects stood on a force platform that tilted 6 deg, toes-up at eight velocities (0.25 to 32 deg/s), with and without vision. Results showed that visual information effectively compensated for lack of vestibular information at all tilt velocities. However, with eyes closed, subjects with vestibular loss were most unstable within a critical tilt velocity range of 2 to 8 deg/s. Subjects with vestibular deficiency lost their balance in more than 90% of trials during the 4 deg/s condition, but never fell during slower tilts (0.25–1 deg/s) and fell only very rarely during faster tilts (16–32 deg/s). At the critical velocity range in which falls occurred, the body center of mass stayed aligned with respect to the surface, onset of ankle dorsiflexion was delayed, and there was delayed or absent gastrocnemius inhibition, suggesting that subjects were attempting to actively align their upper bodies with respect to the moving surface instead of to gravity. Vestibular information may be critical for stability at velocities of 2 to 8 deg/s because postural sway above 2 deg/s may be too fast to elicit stabilizing responses through the graviceptive somatosensory system, and postural sway below 8 deg/s may be too slow for somatosensory-triggered responses or passive stabilization from trunk inertia.
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A simple approach to ignoring irrelevant variables by population decoding based on multisensory neurons
Sensory input reflects events that occur in the environment, but multiple events may be confounded in sensory signals. For example, under many natural viewing conditions, retinal image motion reflects some combination of self-motion and movement of objects in the world. To estimate one stimulus event and ignore others, the brain can perform marginalization operations, but the neural bases of these operations are poorly understood. Using computational modeling, we examine how multisensory signals may be processed to estimate the direction of self-motion (i.e., heading) and to marginalize out effects of object motion. Multisensory neurons represent heading based on both visual and vestibular inputs and come in two basic types: "congruent" and "opposite" cells. Congruent cells have matched heading tuning for visual and vestibular cues and have been linked to perceptual benefits of cue integration during heading discrimination. Opposite cells have mismatched visual and vestibular heading preferences and are ill-suited for cue integration. We show that decoding a mixed population of congruent and opposite cells substantially reduces errors in heading estimation caused by object motion. In addition, we present a general formulation of an optimal linear decoding scheme that approximates marginalization and can be implemented biologically by simple reinforcement learning mechanisms. We also show that neural response correlations induced by task-irrelevant variables may greatly exceed intrinsic noise correlations. Overall, our findings suggest a general computational strategy by which neurons with mismatched tuning for two different sensory cues may be decoded to perform marginalization operations that dissociate possible causes of sensory inputs.
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Decreased cerebellar-cerebral connectivity contributes to complex task performance
The cerebellum's role in nonmotor processes is now well accepted, but cerebellar interaction with cerebral targets is not well understood. Complex cognitive tasks activate cerebellar, parietal, and frontal regions, but the effective connectivity between these regions has never been tested. To this end, we used psycho-physiological interactions (PPI) analysis to test connectivity changes of cerebellar and parietal seed regions in complex (2-digit by 1-digit multiplication, e.g., 12 x 3) vs. simple (1-digit by 1-digit multiplication, e.g., 4 x 3) task conditions ("complex – simple"). For cerebellar seed regions (lobule VI, hemisphere and vermis), we found significantly decreased cerebellar-parietal, cerebellar-cingulate, and cerebellar-frontal connectivity in complex multiplication. For parietal seed regions (PFcm, PFop, PFm) we found significantly increased parietal-parietal and parietal-frontal connectivity in complex multiplication. These results suggest that decreased cerebellar-cerebral connectivity contributes to complex task performance. Interestingly, BOLD activity contrasts revealed partially overlapping parietal areas of increased BOLD activity but decreased cerebellar-parietal PPI connectivity.
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Spike synchrony generated by modulatory common input through NMDA-type synapses
Common excitatory input to neurons increases their firing rates and the strength of the spike correlation (synchrony) between them. Little is known, however, about the synchronizing effects of modulatory common input. Here, we show that modulatory common input with the slow synaptic kinetics of N-methyl-d-aspartate (NMDA) receptors enhances firing rates and also produces synchrony. Tight synchrony (correlations on the order of milliseconds) always increases with modulatory strength. Unexpectedly, the relationship between strength of modulation and strength of loose synchrony (tens of milliseconds) is not monotonic: The strongest loose synchrony is obtained for intermediate modulatory amplitudes. This finding explains recent neurophysiological results showing that in cortical areas V1 and V2, presumed modulatory top-down input due to contour grouping increases (loose and tight) synchrony but that additional modulatory input due to top-down attention does not change tight synchrony and actually decreases loose synchrony. These neurophysiological findings are understood from our model of integrate-and-fire neurons under the assumption that contour grouping as well as attention lead to additive modulatory common input through NMDA-type synapses. In contrast, circuits with common projections through model α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors did not exhibit the paradoxical decrease of synchrony with increased input. Our results suggest that NMDA receptors play a critical role in top-down response modulation in the visual cortex.
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Liver research in the International Space Station
Publication date: Available online 19 September 2016
Source:Arab Journal of Gastroenterology
Author(s): Hanaa Gaber, Akram Abdellatif
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A case of hepatic portal venous gas after colonoscopy
Publication date: Available online 19 September 2016
Source:Arab Journal of Gastroenterology
Author(s): Tevfik Solakoglu, Sevil O. Sari, Huseyin Koseoglu, Murat Basaran, Mustafa Akar, Semnur Buyukasik, Osman Ersoy
Hepatic portal venous gas (HPVG) is a rare radiologic finding that is usually precipitated by intestinal ischaemia, intra-abdominal abscesses, necrotising enterocolitis, abdominal trauma, infectious enteritis, and inflammatory bowel disease. In this study, we present a case of HPVG in a 66-year-old female patient who underwent colonoscopy for evaluation of haematochezia and a review of the literature focused on HPVG following colonoscopy.
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Acute vanishing bile duct syndrome after the use of ibuprofen
Publication date: Available online 19 September 2016
Source:Arab Journal of Gastroenterology
Author(s): Ahmet Basturk, Reha Artan, Aygen Yılmaz, Mustafa T. Gelen, Ozgur Duman
We present a case report of a 7-year-old patient who developed toxic epidermal necrolysis (TEN) and vanishing bile duct syndrome (VBDS) after oral ibuprofen intake. Acute VBDS is a rare disease with unknown aetiology, often presenting with progressive loss of the intrahepatic biliary tract. TEN is an immune complex-mediated hypersensitivity reaction involving the skin and mucosa, which is induced by drugs or infectious diseases, sometimes leading to systemic symptoms. The patient in this case report was treated with supportive care, a steroid and ursodeoxycholic acid, with complete recovery observed by the end of the 8th month. This case report suggests that ibuprofen can cause acute vanishing duct syndrome.
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Serum metabolomics analysis for early detection of colorectal cancer
Abstract
Background
Although colorectal cancer (CRC) is one of the most common causes of cancer mortality, early-stage detection improves survival rates dramatically. Because cancer impacts important metabolic pathways, the alteration of metabolite levels as a potential biomarker of early-stage cancer has been the focus of many studies. Here, we used CE-TOFMS, a novel and promising method with small injection volume and high resolution, to separate and detect ionic compounds based on the different migration rates of charged metabolites in order to detect metabolic biomarkers in patients with CRC.
Methods
A total of 56 patients with CRC (n = 14 each of Stages I-IV), 60 healthy controls, and 59 patients with colonic adenoma were included in this study. Metabolome analysis was conducted by CE-TOFMS on serum samples of patients and controls using the Advanced Scan package (Human Metabolome Technologies).
Results
We obtained 334 metabolites in the serum, of which 139 were identified as known substances. Among these 139 known metabolites, 16 were correlated with CRC stage by upregulation and 44 by downregulation, with benzoic acid (r = −0.649, t = 11.653, p = 6.07599E−24), octanoic acid (r = 0.557, t = 9.183, p = 7.9557E−17), decanoic acid (r = 0.539, t = 8.749, p = 1.24352E−15), and histidine (r = −0.513, t = 8.194, p = 3.90224E−14) exhibiting significant correlation.
Conclusions
To the best of our knowledge, this is the first report to determine the correlation between serum metabolites and CRC stage using CE-TOFMS. Our results show that benzoic acid exhibited excellent diagnostic power and could potentially serve as a novel disease biomarker for CRC diagnosis.
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Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan
Abstract
Background
The aim of the present study was to examine the technical and oncological feasibility of laparoscopic surgery (LAP) in elderly patients with a history of abdominal surgery.
Methods
We conducted a propensity score-matched case–control study of colorectal cancer (CRC) patients aged ≥80 years that were treated at 41 hospitals between 2003 and 2007. We included 601 patients who had a history of abdominal surgery and underwent curative and elective surgery for stage 0 to III CRC. After the matching procedure, 153 patients were included in each cohort. The surgical outcomes of LAP and open surgery (OS) were compared. P-values of <0.05 were considered statistically significant.
Results
LAP resulted in a significantly longer surgical time (220 vs. 170 min, p < 0.001), but significantly less intraoperative blood loss (39 vs. 100 ml, p < 0.001). A number of postoperative recovery-related parameters, including the length of the hospitalization period (12 vs. 14 days, p = 0.002), and the days to the resumption of fluid (2 vs. 3 days, p < 0.001) and solid food intake (4 vs. 5 days, p < 0.001), were significantly better in the LAP group. Moreover, the overall morbidity rate (43 vs. 66 %, p = 0.009) and the frequency of postoperative ileus (7 vs. 19 %, p = 0.023) were significantly lower in the LAP group, while the frequencies of other morbidities did not differ significantly between the groups. In the survival analyses, overall survival and disease-free survival did not differ between the two groups.
Conclusions
In this population, LAP can be performed safely in elderly CRC patients with a history of abdominal surgery, and LAP resulted in a lower postoperative morbidity rate than OS.
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Top 9 lies everyone new to EMS should ignore
By Michael Morse, EMS1 Contributor
Most of us begin a career in EMS not knowing what to expect. "Expect the unexpected," those who came before us would say with a knowing grin. It doesn't take long before the lies we believed about the job are unveiled by reality.
Here are nine things I thought I knew, that turned out to be not quite true.
1. EMS is easy. Anybody can do it.
Easy" Nothing is easy if you're doing it right. An EMT doing things incorrectly kills people. Very few people are willing to bear the weight of responsibility for somebody else's life, especially a stranger. Put a patient in the truck, and it's you and them, and fifty MPH of road beneath you. Don't screw up.
2. "When ya save them with Narcan, they'll puke on ya, then they'll attack ya"
Bringing a person back from the dead is a pretty satisfying experience for even the most jaded EMS person. I've brought hundreds of people back from the brink. With very few exceptions, I've found the newly revived are polite, grateful, embarrassed and cooperative. Giving somebody a second chance; not just correcting a mistake they made, but actually being the person responsible for helping them stay alive for another day, should never be minimized. We got into this vocation for a reason, and that reason is staring you right in the face every time you successfully use Narcan. The start of their new life begins the second they lay eyes on you. Saying something stupid to them cheapens the experience. Saying something brilliant is usually lost in the confusion. Stick to something kind and non-judgmental.
3. A little CPR and presto
CPR is great, no doubt about it. However, the first twenty-five or so times I did it were failures. But when I was able to bring back that twenty-sixth guy three months later, I forgot all about the first twenty-five and was ready for the next one. With experience comes acceptance. A person in cardiac arrest needs CPR, and needs it quick. The event is typically fifteen minutes from onset before we arrive on scene. Bystander CPR and rapid defibrillation is the key. We do the best we can, and sometimes the outcome is truly miraculous.
4. Alcohol is a great way to relax and enjoy life.
When 70 percent of your EMS calls are somehow alcohol-related you see real quick just how obnoxious this myth is. The misery caused by people who shouldn't drink far outweighs the fun to be had by those who can — at least in the eyes of the EMT who has to live with the memories of mangled teens, men in their forties dying from liver disease, assaults, rapes, and other mayhem. Add the risk of the EMT abusing alcohol to deal with the stress, disappointment, and disillusionment that can be a byproduct of an EMS career and the allure of the drink fades away. Be careful, alcohol is a wise and cunning substance waiting to pounce on those of us with addictive tendencies.
5. Every person drives like a moron when an ambulance is approaching.
Actually, the vast majority of people do everything and anything to get out of the way of an approaching emergency vehicle. There are hundreds of vehicles in your path on the way to and from an emergency scene. Try and focus on the vast majority of people who get out of the way, and deal with the few who don't without doing anything ridiculous. You cannot control the actions of people, all you can control is yourself. When I learned that little secret, driving with lights and sirens became enjoyable, rather than torture.
6. Emergency Room personnel are great looking, fun and love seeing EMS.
It doesn't matter if you're the best EMT in the word; we all wear out our welcome, fast. This is especially true if we do our job half-assed and don't respect the people we bring our problems to. Imagine dealing with the public, many of whom are frequent flyers, abusive patients and good, hardworking people cut down in the prime of their life by accidents, medical emergencies and the unknown. Then imagine doing so under bright fluorescent lights without the luxury of leaving, grabbing a coffee on the way back to the station and catching a snooze.
7. EMS = earn money sleeping
If I had a dollar for every hour of uninterrupted sleep I managed in nearly twenty-five years of EMS work, I wouldn't have many dollars.
As for earning money" Most EMTs work for private ambulance companies. The only people earning real money are the people who own them. Fire department-based EMS makes a career out of a job, in most cases. It is far more difficult to make ends meet working for a private company, but it's not impossible.
8. EMTs get hardened by what they see and can handle emotional trauma better than the general public.
Nobody gets used to seeing terrible things. Some people can hide their feelings better than others. Others have no idea that what they are feeling is slowly eating them alive; they think it's normal to feel like the weight of the world is crushing them. It's not normal, and the only "hard" EMT is in all probability more brittle than hard.
9. The most important word in Emergency Medical Services is "emergency."
As long as we believe that our primary reason for being EMTs is responding to emergencies we will have difficulty with this profession. "Mobile" Medical Services is a far more fitting moniker. Every time we respond to a medical call, where we are disappointed at the non-emergent nature of the situation, resentment overtakes compassion.
The best way to find satisfaction with a career in EMS is to eliminate preconceived notions about what the job entails. Nothing is as exciting as we imagine it to be. EMS is real. EMS is mostly boring routine. But sprinkled among that day-to-day grind is people. By focusing on the people that cross our path, and connecting with those who depend on us, EMS becomes far more than a job, and ultimately can, and should be a satisfying experience. What is essential is to keep your expectations grounded in reality.
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Anesthesia for Patients with Traumatic Brain Injuries
Source:Anesthesiology Clinics
Author(s): Bishwajit Bhattacharya, Adrian A. Maung
Teaser
Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.from Anaesthesiology via xlomafota13 on Inoreader http://ift.tt/2cBss6y
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5 things you need to know to survive a Medicare audit
The following is paid content sponsored by EMS Management & Consultants. By EMS1 BrandFocus Staff Ambulance providers are more likely than ever to face Medicare audits. Most challenged claims are flagged because of incorrect or incomplete documentation, and it's important to train medics as well as billing staff on the latest regulations to maximize coding and billing compliance, enlisting ...
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Clinical usefulness of pectoral nerve block for the management of zoster-associated pain: case reports and technical description
Abstract
The recently introduced pectoral nerve (Pecs) block is a simple alterative to the conventional thoracic paravertebral block or epidural block for breast surgery. It produces excellent analgesia and can be used to provide balanced anesthesia and as a rescue block in cases where performing a neuraxial blockade is not possible. In the thoracic region, a neuraxial blockade is often used to manage zoster-associated pain. However, this can be challenging for physicians due to the increased risk of hemodynamic instability in the upper thoracic level, and comorbid and contraindicated medical conditions such as coagulopathy. Here, we introduce an ultrasound-guided Pecs block for the management of herpes zoster-associated pain, which could be an effective alternative to other interventional options in the thoracic region.
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A randomized, double-blind trial evaluating the efficacy of palonosetron with total intravenous anesthesia using propofol and remifentanil for the prevention of postoperative nausea and vomiting after gynecologic surgery
Abstract
Purpose
Palonosetron has potent and long-acting antiemetic effects for postoperative nausea and vomiting (PONV). The aim of this study was to prospectively evaluate the efficacy of palonosetron when used with total intravenous anesthesia (TIVA) using propofol and remifentanil for the prevention of PONV in patients undergoing laparoscopic gynecologic surgery.
Methods
This prospective double-blind study comprised 100 female American Society of Anesthesiologist physical status I and II patients who were undergoing laparoscopic gynecologic surgery under TIVA. The patients were randomly assigned to two groups—the palonosetron plus TIVA group (palonosetron 0.075 mg i.v., n = 50) and the TIVA group (normal saline 1.5 ml i.v., n = 50). The treatments were given before the induction of anesthesia. The incidence of PONV, severity, number of rescue antiemetics, adverse effects, and patient satisfaction during the first 24 h after surgery were evaluated.
Results
The demographic profiles of the patients in the two groups were comparable. The overall incidence of PONV (0–24 h) was significantly lower in the TIVA plus palonosetron group than in the TIVA group (34 vs 58 %, p = 0.027). In particular, during the 6–24 h after surgery, the incidence of PONV (14 vs 30 %, p = 0.03) and the incidence of moderate to severe nausea (6 vs 22 %, p = 0.041) were significantly lower in the TIVA plus palonosetron group than in the TIVA group. There were no significant differences in adverse effects, use of rescue antiemetics or patient satisfaction.
Conclusion
Combining palonosetron with TIVA can be considered as a good method to prevent PONV, not only during the short postoperative period but also especially during the 6–24-h period after anesthesia.
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4 lessons for EMS providers from Urban Shield
Collapsed concrete, smoke and screams greeted our triage team. Our team leader quickly surveyed the width of the rubble pile and pointed each of us to an area of the incident to begin patient triage, initiate control of life-threatening hemorrhage and manage compromised patient airways. I was directed to the furthest left side of the incident and told to work my way toward the middle of the clustered patient.
My first patient was supine and only responsive to verbal stimulus. His breathing was labored and blood was spurting from the pulsing end of his femoral artery. His right leg was fully amputated above the knee.
"Tourniquet, high and tight. Stop the bleeding," echoed in my head as I rummaged through the trauma kit around my waist.
I applied a tourniquet as tight as I could around the patient's leg and the bleeding slowed. I quickly swept the patient for other injuries. It was hard to leave him, but knew that my assignment was triage, not treatment.
Urban Shield MCI and tactical training
"Hey brother, that's a little tight," the patient whispered to me.
My patient, who really has a high right leg amputation, was one of more than 30 volunteers pretending to be injured in the first EMS exercise at Urban Shield 2016.
I loosened the tourniquet, called for firefighters to carry the patient to the casualty collection point and moved to the next patient. A woman, likely deafened from ear drum rupture from the explosions pressure wave, was attempting to console a catatonic, shell-shocked patient sitting in the rubble.
Urban Shield is a series of comprehensive, full-scale preparedness exercises to test the capabilities of SWAT, USAR, EMS, explosive ordinance disposal, field hospitals and other supporting agencies. During the Sept. 10-12, 2016 48-hour operational period, teams rotated through a series of exercises in and around Oakland which are planned and coordinated by the Bay Area Urban Areas Security Initiative.
My EMS Branch team started its six-hour rotation at 0600 on Sept. 11 in a dimly lit parking lot at the Alameda County Fire Department Training Division. The sprawling complex of classrooms, fire training towers and simulated disasters hosted two of the three exercises our team completed.
I had a few minutes to meet my teammates, all EMTs with the Berkeley Medical Reserve Corps, before our instructor/proctor lectured us on trauma patient assessment, triage and rapid treatment for hemorrhage and airway emergencies.
Our student to instructor pairing was perfect. The BRMC EMTs are all pre-med and our instructor, Justin Lemieux, is a Stanford Emergency Medicine clinical instructor and SWAT physician. He was eager to teach and we were just as eager to learn from him.
From MCI response to Rescue Task Force
We spent 40 minutes triaging and moving victims to the casualty collection point in our first exercise, the collapsed structure MCI. After we finished, we received a debrief from the exercise observers on what we did well — not much — and where we could improve — lots of areas. The debrief team's assessment was specific, helpful and challenged us to do better.
With only a few minutes to review the incident as a team, we quickly walked to our next exercise, a joint simulation with a tactical team. A briefing video quickly brought us up to speed on a group of terrorists holding hostages inside a three-story building. The terrorists were known to have an explosive device.
Our medical team listened in as the SWAT team received its briefing and asked questions about the terrorist threat and available law enforcement resources. The SWAT team leader and our medical team leader decided the medical personnel would respond as a rescue task force from an armored vehicle at the edge of the hot zone until the threat was neutralized.
For a few nervous minutes, we waited for the tactical team to make entry into the building. We tracked their progress by listening to the start of and quick end of gunfire.
Moments later, two officers threw open the doors of the armored vehicle and instructed us to make entry through a corridor of officers to reach the injured hostages. We moved through a rolling corridor of officers while doing our best to stay in physical contact — hand on the shoulder — with one another.
On the third story of the building, we found our patients huddled in a room designated as a hasty casualty collection point. Our focus, as the rescue task force, was patient triage, treatment of life threats and rapid movement of casualties out of the building and to the armored vehicle, which we had identified as the casualty collection point. The tactical team leader quickly reassigned some of his officers to assist with bleeding control and patient movement, while the remainder provided continuing threat protection.
The exercise was over in minutes. We had made some improvements as a team completing our medical mission.
High-fidelity training
The final exercise, another joint simulation for SWAT and EMS, was at a massive shipping container storage yard. Rusting, once brightly colored shipping containers, were stacked four or five high with a few open lanes and lots of dark, narrow passages.
The scenario was dignitary protection in a four-vehicle convoy traveling to a public venue. A car for private security and a mini-van for the dignitary and his family were followed by an armored vehicle containing the tactical team and an ambulance for our medical team.
As the security car and minivan rounded a corner, BOOM! An explosion echoed through the canyons of containers.
We strained to see through the dust and smoke as the SWAT officers ran towards the explosion and eruption of gunfire. After a few minutes of nervously waiting, we were called to the incident over the radio.
A high-fidelity simulation of overturned vehicles, flames, smoke and multiple blast victims greeted us as we rounded the corner. Even though multiple attackers had been killed this was a very unstable scene and every patient was critical. Only the most minimal care was provided before patients were carried to the casualty collection point.
Video courtesy of Jim Morrissey, Alameda County
Afterwards, Jim Morrissey, paramedic and Urban Shield planner, emphasized the two top priorities. "Tactical stops the killing. And then everyone — tactical and medical — stops the dying."
Morrissey, along with Alameda County Sheriff Gregory Ahern, emphasized the changing emphasis for SWAT once the active threat is neutralized. Not every officer needs to be pointing a rifle down range, in a security stance. Instead, some SWAT officers need to assist with hemorrhage control, patient movement and other lifesaving treatments.
This affirmed my experience just a few minutes earlier. I had looked up from a severely injured casualty and directed two officers to move the patient to the casualty collection point. They readily and willingly moved the patient so I could move to another patient.
Top takeaways from Urban Shield
Our medical team ended its day with a debrief. Lemieux went above and beyond by presenting a bonus trauma resuscitation case review.
I was able to return to the container yard to watch another EMS and tactical team run the dignitary protection scenario. I also had a chance to watch a tactical team complete an active shooter and hostage rescue scenario in a massive airline hangar at the airport.
Urban Shield was an immersive, high-fidelity and full-scale training exercise for individuals and teams. For me it brought MCI response challenges to life. Here are my top takeaways from Urban Shield:
1. Sense of urgency
Everything we did had to be done with urgency. We were pushed by the proctors and observers to spend minimal time on triage, only treat true life threats and rapidly sweep patients for wounds. Other than hemorrhage control, airway positioning and attempting to seal open chest wounds additional treatments were provided in the warm zone casualty collection point, cold zone treatment areas, ambulances or at a field hospital.
Part of working with urgency is being aware of time. It is really hard to triage a patient, quickly assess for life threats and begin lifesaving treatments in less than a minute. It takes regular on-the-clock practice to be ready for this type of work. It wasn't until the third exercise that I felt like I had adjusted my internal motor to work efficiently and with a real sense of urgency.
2. Transport is a treatment
For the walking wounded, the first treatment they receive is "If you can get up and walk, go" with a specific location identified. Any other assessment or treatment is withheld until the walking wounded patient self-transports to the casualty collection point.
The other patients, especially the red tags, have injuries and illnesses that are likely time sensitive. Movement is a treatment and moving a patient towards definitive care is critical to their survival.
Movement might happen in increments. First to a casualty collection point, then to an on-scene treatment area, then into an ambulance, additional triage at the receiving hospital and finally transport into an operating room.
3. SWAT willing and able to help
The SWAT officers we were partnered with and the others I observed were eager and willing to assist with medical. Officers divided patients into injured and not injured, applied tourniquets and carried patients to casualty collection points.
If you want SWAT to help, tell them how with direct and specific instructions. Their mission is to stop the killing. Once that mission is completed they are full partners in the next mission — to stop the dying.
4. Watch and learn from others
I learned a lot by listening to my teammates, our instructor and watching other EMS teams. Our medical team leader divided the triage area into sectors and directed each of us to a sector and to triage towards the middle. A casualty collection point keeps the medical team closer to additional victims and is an intermediary step between the area of injury and the treatment area or ambulance.
EMS Branch Team 19
Consider participating in Urban Shield 2017 or sending personnel from your agency to participate. I am sure anyone who participates is able to have a unique training experience and will bring valuable skills and knowledge back to their agency. Learn more at UrbanShield.org.
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The disappearing San of southeastern Africa and their genetic affinities
Abstract
Southern Africa was likely exclusively inhabited by San hunter-gatherers before ~2000 years ago. Around that time, East African groups assimilated with local San groups and gave rise to the Khoekhoe herders. Subsequently, Bantu-speaking farmers, arriving from the north (~1800 years ago), assimilated and displaced San and Khoekhoe groups, a process that intensified with the arrival of European colonists ~350 years ago. In contrast to the western parts of southern Africa, where several Khoe-San groups still live today, the eastern parts are largely populated by Bantu speakers and individuals of non-African descent. Only a few scattered groups with oral traditions of Khoe-San ancestry remain. Advances in genetic research open up new ways to understand the population history of southeastern Africa. We investigate the genomic variation of the remaining individuals from two South African groups with oral histories connecting them to eastern San groups, i.e., the San from Lake Chrissie and the Duma San of the uKhahlamba-Drakensberg. Using ~2.2 million genetic markers, combined with comparative published data sets, we show that the Lake Chrissie San have genetic ancestry from both Khoe-San (likely the ||Xegwi San) and Bantu speakers. Specifically, we found that the Lake Chrissie San are closely related to the current southern San groups (i.e., the Karretjie people). Duma San individuals, on the other hand, were genetically similar to southeastern Bantu speakers from South Africa. This study illustrates how genetic tools can be used to assess hypotheses about the ancestry of people who seemingly lost their historic roots, only recalling a vague oral tradition of their origin.
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