The constant work rate critical power protocol overestimates ramp incremental exercise performance

Abstract

Purpose

The parameters of the power-duration relationship (i.e., the critical power, CP, and the curvature constant, W′) may theoretically predict maximal performance capability for exercise above the CP. The CP and Wʹ are associated with the parameters of oxygen uptake ( \({\dot{\text{V}}}\) O₂) kinetics, which can be altered by manipulation of the work-rate forcing function. We tested the hypothesis that the CP and Wʹ derived from constant work-rate (CWR) prediction trials would overestimate ramp incremental exercise performance.

Methods

Thirty subjects (males, n = 28; females, n = 2) performed a ramp incremental test, and 3–5 CWR prediction trials for the determination of the CP and Wʹ. Multiple ramp incremental tests and corresponding CP and Wʹ estimates were available for some subjects such that in total 51 ramp test performances were predicted.

Results

The ramp incremental test performance (729 ± 113 s) was overestimated by the CP and Wʹ estimates derived from the best (751 ± 114 s, P < 0.05) and worst (749 ± 111 s, P < 0.05) individual fits of CWR prediction trial data. The error in the prediction was inversely correlated with the magnitude of the Wʹ for the best (r = −0.56, P < 0.05) and worst individual fits (r = −0.36, P < 0.05).

Conclusions

The overestimation of ramp incremental performance suggests that the CP and Wʹ derived from different work-rate forcing functions, thus resulting in different \({\dot{\text{V}}}\) O₂ kinetics, cannot be used interchangeably. The present findings highlight a potential source of error in performance prediction that is of importance to both researchers and applied practitioners.

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Ada County Paramedics ABC PSA

According to Ada County Paramedics call 911 call volume records, there were 15 infant sleep-related deaths since 2010, which is roughly two infant deaths each year.

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Ada County Paramedics ABC PSA

According to Ada County Paramedics call 911 call volume records, there were 15 infant sleep-related deaths since 2010, which is roughly two infant deaths each year.

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Substance abuse programs: What EMTs and paramedics need to know

Don Prince is a former fire chief, firefighter and EMS provider. He's also a recovering alcoholic, which is why he's a former fire chief, no longer a fire department member and not providing EMS care. In an article Prince wrote:

"One of the biggest things I could not let go of was my embarrassment, disappointment in myself and shame of having to resign my position as chief and my membership after almost 17 years of being a part of something that meant so much to me and for which I was not willing or able to make a choice to correct in order to try and save. Drinking was more important than my career and family at that time. I now see that if I had addressed my addiction years ago and sought the help that was offered to me none of this would have happened [1]."

Some EMS providers just like the patients they serve struggle with alcoholism and addiction. The daily stress of EMS work, as well as some cultural norms, may cause some EMS providers to unwind with friends and colleagues in situations where alcohol flows freely.

Research on alcohol use in EMS and fire
Science defines binge drinking as five or more servings for men or four or more servings for women. The definition is based on blood alcohol content — that consuming that many drinks within two hours typically raises BAC to 0.08 g/dL or higher [2].

In a study, funded by a grant from Federal Emergency Management Agency's Research and Development, firefighters were asked about their alcohol use. Data was collected from 656 male firefighters from 24 departments in the Missouri Valley region [3].

• Of the firefighters surveyed, 85 percent of career and 71 percent of volunteer firefighters reported drinking alcohol in the past 30 days.
• Approximately half of career and volunteer firefighters reported binge drinking in the past month.
• Career firefighters reported drinking 10 days per month, which is about half their off-duty days in most departments.
• Volunteer firefighters reported drinking an average of 12 days a month.

So, how do firefighters compare to the general male population in the United States" According to the 2013 National Survey on Drug Use and Health, 62 percent of males reported consuming alcohol in the past month — significantly lower than the fire service [4].

In 2010, the Centers for Disease Control and Prevention published data on binge drinking from more than 176,000 males. They found that 23 percent of males reported binge drinking in the month previous — half the rate of binge drinking reported in the fire service research [5].

We also know from anecdotal news reports, social media sharing and personal observation that EMS providers and firefighters seek solitude in the privacy of their own home in the company of a bottle of wine, beer or spirits. For a handful of addicts, the access to patient and agency medications can lead to a downward spiral of narcotics abuse, addiction and theft.

Substance treatment programs
The goal of substance abuse treatment is to stop drug or alcohol abuse and allow addicts to lead active lives in their family, workplace and community. One continual challenge, however, is keeping patients in treatment long enough for them to achieve this goal. That is why finding the right treatment for a person's specific needs is critical.

Drug abuse treatment is not one size fits all. Treatment outcomes depend on the [7]:

• Extent and nature of the person's problems
• Appropriateness of treatment
• Availability of additional services such as after-care
• Quality of interaction between the person and his or her treatment providers

To help addicts find appropriate care, the National Institute on Drug Abuse created a brief guide that asks five questions to answer when searching for a treatment program [8]:

1. Does the program use treatments backed by scientific evidence"
2. Does the program tailor treatment to the needs of each patient"
3. Does the program adapt treatment as the patient's needs change"
4. Is the duration of treatment sufficient"
5. How do 12-step or similar recovery programs fit into drug addiction treatment"

Information resources on drug and alcohol addiction
The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

One of SAMHSA's programs is the National Registry of Evidence-based Programs and Practices, a repository and review system designed to provide the public with reliable information on mental health and substance abuse interventions. All interventions in the registry have met NREPP's minimum requirements for review. The programs' effects on individual outcomes have been independently assessed and rated by certified NREPP reviewers [9].

The Joint Commission is an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. The Joint Commission accreditation and certification of substance abuse treatment centers is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards [10].

Addiction treatment programs
A variety of treatment options are available. Some treatment programs serve a diverse patient population while others focus their efforts on the specific characteristics of public safety personnel.

The Watershed is an addiction treatment program, licensed by the Florida Department of Children and Families, Substance Abuse Program Office and accredited by the Better Business Bureau. The Watershed also maintains Gold Seal accreditation through The Joint Commission. The Watershed has provided inpatient addiction, detoxification and rehabilitation services for over 14 years and successfully treated over 35,000 people [11].

The Watershed Addiction Treatment Programs website includes a wealth of resource including links for treatment programs in each of the 50 U.S. states.

In just three years, the Brattleboro Retreat Uniformed Service Program in Vermont has helped about 1,200 uniformed service professionals deal with issues including stress, substance abuse, trauma and depression [12]. Participants come to Brattleboro from throughout the United States, as well as military bases in Europe.

The Brattleboro Uniformed Service Program is a rigorous, brief — average stay is 10 days — partial hospitalization program for active or retired members of a uniformed service, such as police, fire, corrections, military and emergency medical service. Its structured and supervised psychotherapy program focuses on rapid clinical change, reduction of symptoms and stabilization and transitioning to outpatient service providers [13].

American Addiction Centers owns and operates adult drug and alcohol treatment and rehabilitation facilities nationwide. AAC has treatment facilities located in California, New Jersey, Florida, Texas, Nashville and Las Vegas [14].

The Rosecrance Florian Program for firefighters and paramedics incorporates occupational factors into the treatment process. The program's director is an active-duty Battalion Chief/EMT with more than 25 years of experience with the Chicago Fire Department. Operational medical control is provided by a board-certified psychiatrist and addictionologist who is trained and experienced in treating firefighters and paramedics for co-occurring disorders [15].

Do your research
Don Prince, the former fire chief, took his new "lease on life" as a recovering alcoholic and sought training and education from The Addictions Academy to become a Certified Recovery Coach and Interventionist through. The Addictions Academy is one of the nation's leading and accredited centers for individuals seeking training and certification in the fields of addiction treatment services, recovery/sober coaching and intervention.

During my e-mail exchange with Prince, he expressed the need for EMS providers looking for substance abuse treatment options to be cautious. "I would like to share with you my opinion of what the truth is as far as what is out there for one of us who needs help. It is not a very good situation given the current state of the substance abuse industry." [16].

Regarding some residential treatment facilities, Prince wrote, "The idea that a majority of the providers are in it to save lives and help you is not their primary intended mission. That comes secondary to filling beds and making a profit. What suffers is the quality of care during your stay at a facility and, even more importantly, is the lack of aftercare when you leave and get home and back on the job."

According to Prince, 80 percent of people leaving an addiction treatment center relapse within the first year of discharge. Nine out of ten of the addicts who relapse do so within their first 90 days after discharge. "Working with a Recovery Coach can significantly reduce the likelihood of relapse during this crucial period," wrote Prince. "Recovery Coaching is often the missing link, bridging the gap between an individual leaving a treatment center and maintaining long term sobriety."

References
1. Prince, D. Fighting the Devil Within. [Available: On-line] http://ift.tt/2fj3rlF"trk=mp-reader-card

2. FireRescue1. Firefighters and alcohol, what the data says. http://ift.tt/2ePVZLS

3. Ibid.

4. Ibid.

5. Ibid.

6. National Institute on Drug Abuse (NIDA/NIH). Anyone Can Become Addicted to Drugs. YouTube. https://youtu.be/SY2luGTX7Dk

7. National Institute on Drug Abuse. Seeking Drug Abuse Treatment: Know What to Ask. http://ift.tt/24uY7io

8. Ibid.

9. Substance Abuse and Mental Health Services Administration. National Registry of Evidence-based Programs and Practices. http://ift.tt/1SIOoyj

10. The Joint Commission. About The Joint Commission. http://ift.tt/1kWWHXK

11. The Watershed Addiction Treatment Programs. Frequently Asked Questions. http://ift.tt/2ePXb1W

12. Brattleboro Retreat. Uniformed Service Program. http://ift.tt/2fj7vC8

13. New England Psychologist. Program helps service professionals. http://ift.tt/2ePZNgm

14. American Addiction Centers. Frequently Asked Questions. http://ift.tt/2fj3wph

15. Rosecrance Florian Program. Firefighter & Paramedic Substance Abuse Treatment Program. http://ift.tt/2ePZa6r

16. Prince, D. Personal Communication via LinkedIn. April 14, 2016.

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When EMS calls leave you with a feeling of emptiness

By Anonymous Paramedic, Sacramento, Calif.

Some days it's a lot to handle. It's a hard thing to describe. I've never been one for talking about my feelings. The more important it is, the more powerful the feeling, the less I will say about it. The best I can do is to say that it is a feeling of crushing emptiness.

There is always a lot of talk about how this job can effect us. People die while we try to keep them from doing so. That is definitely a humbling feeling. I have worn other people's blood on my skin. I have heard the last words of people I have just met. I have felt my paradigm shift, and my ego crumble when I realize that I cannot help my patient and I do not know why.

I have experienced many of the stereotypical, harrowing experiences associated with this profession. I do not mean to underestimate the effects that those experiences can have on us, but for me personally it feels a little self-aggrandizing.

Those are the stories people expect.

When someone sees me staring into space, lost in my thoughts, it's easy for them to imagine those things running through my mind. I wish that were the case.

Make no mistake, I am struggling.

This job does eat away at me every day. There have been days that the toll is taken in one fell swoop, with a fast-paced, high pressure, traumatizing call.

Most days that isn't the case. Most days I don't have such a convenient target to point at when those feelings hit me. Most days it comes down like a light rain all around me.

There is no big wave. There is no crashing and breaking. Just a slow, steady rain, soaking into everything.

I see death every day, but it doesn't always make for a thrilling story. I see elderly patients over and over, slightly worse each day. I see demanding, high maintenance patients who really only called because they needed someone to talk to, someone to focus on them for a while. I see patients ashamed of themselves. Ashamed of their size, their appearance, or their hygiene. Ashamed that they need us. I see so much sadness. Not the potent sadness of an acute pain or loss. Not the sadness that allows for catharsis. I see a chronic sadness. Less a sharp stab, more a dull ache. A sadness that I don't realize is there until I begin to bend under the weight. Now I'm left searching for the source.

I do look back on certain calls and feel the twinge of the intense feelings that they evoked. I feel regret. I feel guilt. I feel incompetent. At least I feel a sense of understanding. I can understand the hurt of those calls. I can paint a picture in my mind. I can quantify the pain.

Those are not the thoughts running through my mind when I am lost in it all. Instead, I am left here wondering what is causing this. Why am I feeling this way" Why do the highs seem so much lower than they used to be" When did my life become the sum of so many minor injuries"

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When EMS calls leave you with a feeling of emptiness

By Anonymous Paramedic, Sacramento, Calif.

Some days it's a lot to handle. It's a hard thing to describe. I've never been one for talking about my feelings. The more important it is, the more powerful the feeling, the less I will say about it. The best I can do is to say that it is a feeling of crushing emptiness.

There is always a lot of talk about how this job can effect us. People die while we try to keep them from doing so. That is definitely a humbling feeling. I have worn other people's blood on my skin. I have heard the last words of people I have just met. I have felt my paradigm shift, and my ego crumble when I realize that I cannot help my patient and I do not know why.

I have experienced many of the stereotypical, harrowing experiences associated with this profession. I do not mean to underestimate the effects that those experiences can have on us, but for me personally it feels a little self-aggrandizing.

Those are the stories people expect.

When someone sees me staring into space, lost in my thoughts, it's easy for them to imagine those things running through my mind. I wish that were the case.

Make no mistake, I am struggling.

This job does eat away at me every day. There have been days that the toll is taken in one fell swoop, with a fast-paced, high pressure, traumatizing call.

Most days that isn't the case. Most days I don't have such a convenient target to point at when those feelings hit me. Most days it comes down like a light rain all around me.

There is no big wave. There is no crashing and breaking. Just a slow, steady rain, soaking into everything.

I see death every day, but it doesn't always make for a thrilling story. I see elderly patients over and over, slightly worse each day. I see demanding, high maintenance patients who really only called because they needed someone to talk to, someone to focus on them for a while. I see patients ashamed of themselves. Ashamed of their size, their appearance, or their hygiene. Ashamed that they need us. I see so much sadness. Not the potent sadness of an acute pain or loss. Not the sadness that allows for catharsis. I see a chronic sadness. Less a sharp stab, more a dull ache. A sadness that I don't realize is there until I begin to bend under the weight. Now I'm left searching for the source.

I do look back on certain calls and feel the twinge of the intense feelings that they evoked. I feel regret. I feel guilt. I feel incompetent. At least I feel a sense of understanding.  I can understand the hurt of those calls. I can paint a picture in my mind. I can quantify the pain.

Those are not the thoughts running through my mind when I am lost in it all. Instead, I am left here wondering what is causing this. Why am I feeling this way? Why do the highs seem so much lower than they used to be? When did my life become the sum of so many minor injuries?

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Carcinoma ovary with carcinoma cervix - A rare case of synchronous malignancy

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Ashwini Arvind Natekar, Gautam Kr Mandal, Subhasis Basu.
Synchronous malignancies of genital tract are rare. Case report We report a case of carcinoma ovary with incidentally diagnosed carcinoma cervix. The patient had undergone total abdominal hysterectomy with bilateral salpingo-opherectomy with omentectomy and pelvic lymph node dissection for a right ovarian tumor which was reported as borderline malignancy on frozen section. On histological examination the ovarian malignancy was diagnosed as borderline papillary serous carcinoma. The cervix section showed in situ squamous cell carcinoma. Pelvic lymph nodes and omentum were free of tumor. The postoperative period was uneventful and the patient has no signs of malignancy on follow up till date. Conclusion Synchronous malignancies are associated with better prognosis with surgical resection being the treatment of choice. Since synchronous malignancies are rare it has to be reported.


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Spontaneous Perinephric Haematoma In An Otherwise Healthy Adult Female

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Amit Sharma, Mukund Andankar, Hemant Pathak.
Spontaneous perinephric haematoma is a rare urologic entity. Tumours (both benign and malignant) are the most common causes. Several other causes have also been reported. However, in some patients, no apparent underlying etiology could be found and are described as having idiopathic spontaneous perinephric hematoma. We report a case of idiopathic spontaneous perinephric haematoma in a 38 year-old female who was successfully managed conservatively.


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Papillary Renal Cell Carcinoma Presenting As Pyonephrosis In A Young Adult.

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Amit Sharma, Mukund Andankar, Hemant Pathak.
Papillary Renal Cell Carcinoma is the second most common type of renal malignancy in adults. It presents in fifth to seventh decade of life and is commoner in patients with End Stage Renal Disease and acquired renal cystic diseases. The presentation is similar to the clear cell type of Renal Cell Carcinoma and is asymptomatic usually. We report a case of Papillary Renal Cell Carcinoma in a young adult who presented with pyonephrosis.


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Primary Low Grade Spindle Cell Sarcoma Of The Breast

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Anne Wilkinson, Radhika Mhatre, Anjali Patrikar.
Spindle cell sarcomas of the breast are very rare accounting for 0.2 to 1 % of all breast malignancies. Sarcomas of the breast differ from the invasive epithelial cancers in their presentation, behavior, management, staging and prognosis. Hence it is important to be aware of these rare lesions. This article describes a case of primary low grade spindle cell sarcoma of the breast in a 70 year old female patient.


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Parous Septate uterus: to treat or not to?

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Ushakiran T.S, Rajshree Dayanand Katke.
Mullerian duct anomalies are the most common congenital anomalies of the reproductive system and septate uterus is the most frequently diagnosed Mullerian anomaly. The true incidence of Mullerian duct anomalies is difficult to state because some cases may be asymptomatic and there are pitfalls associated with various diagnostic methods.(1)Septate uterus is the most common cause of uterine anamoly and has the highest reproductive failure rate. In this study, we have 4 case reports of patients presenting with different problems in the OPD of Cama and Albless hospital in whom septate uterus was incidently diagnosed during various operative procedures . Septate uterus may present with altogether different symptoms. To treat or not to is the dilemma we are addressing in this presentation


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Unavoidable Caesarian Myomectomy In A Case Of Transverse Lie With Huge Fibroid At Incision

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Rajshree Dayanand Katke, Shubhangi Nawarange, Nishtha Tripathi.
Myomectomy during caesarean delivery may lead to hemorrhage and uterine atony ,hence it is not recommended. Myomectomy has been reported during cesarean section in recent studies. We presented a patient who was 30 yr old, primigravida with 40wks gestation with transverse lie in prelabour, taken for emergency lower segment caesarian section, and was accidentally found to have a huge myoma in the incision site. As uterine incision could not be closed because of the myoma, myomectomy was performed during caesarean section unavoidably. A single 760 g and 9 cmx 7 cm sized and another fibroid of 4cm x3cm myoma was removed. The physical examinations were unremarkable in the postoperative period. If myomectomy during caesarean delivery becomes a widespread practice, it could potentially eliminate multiple surgeries for both indications. Many surgeons have been reluctant to adopt this policy without conclusive evidence demonstrating its safety. However, most of the authors suggested that the complications and morbidity following caesarean myomectomy do not significantly differ from those occurring during caesarean section alone, while fertility is apparently not compromised by this treatment.


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Patent Vitellointeststinal duct with prolapsed and gangrenous small bowel.

2016-10-27T04-43-16Z
Source: The Southeast Asian Journal of Case Report and Review
Yadvendra Dheer, Anand Pandey, Archika Gupta, Shiv Narayan.
A wide variety of anomalies may occur as a result of the vitellointestinal duct (VID) failing to obliterate completely. Most reports on symptomatic VID focus on Meckel's diverticulum, while other anomalies are given little attention. We report a case of a baby of 2 months who presented with prolapsed intestinal loop through umbilicus with gangrenous changes. The gangrenous part of intestine was resected and end to end anastomosis was done.


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Effects of perioperative supplementation with pro-/synbiotics on clinical outcomes in surgical patients: A meta-analysis with trial sequential analysis of randomized controlled trials

Clinical Nutrition

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Influence of successful chronic hepatitis C virus treatment with ledipasvir/sofosbuvir on warfarin dosing requirements in four veterans

Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy

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Apical membrane expression of distinct sulfated glycans represents a novel marker of cholangiolocellular carcinoma

Laboratory Investigation

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Efficacy and safety of sofosbuvir/simeprevir plus flat dose ribavirin in genotype-1 elderly cirrhotic patients: A real life study

Liver International

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Characterization of resident lymphocytes in human pancreatic islets

Clinical and Experimental Immunology

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The prevalence of steatohepatitis in chronic hepatitis B patients and its impact on disease severity and treatment response

Liver International

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Outcomes in colorectal surgeon-driven management of obstructing colorectal cancers

Diseases of the Colon and Rectum

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Can we eliminate neoadjuvant chemoradiotherapy in favor of neoadjuvant multiagent chemotherapy for select stage II/III rectal adenocarcinomas: Analysis of the National Cancer Database

Cancer

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The “left ureteral triangle” as an anatomic landmark for the identification of the left ureter in laparoscopic distal colectomies

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques

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Mendelian randomisation suggests no beneficial effect of moderate alcohol consumption on the severity of nonalcoholic fatty liver disease

Alimentary Pharmacology and Therapeutics

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Enhanced recovery implementation in colorectal surgery--Temporary or persistent improvement?

Langenbeck's Archives of Surgery

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Screening for celiac disease in irritable bowel syndrome: An updated systematic review and meta-analysis

The American Journal of Gastroenterology

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Comparable outcomes of the consistent use versus switched use of anti- tumor necrosis factor agents in postoperative recurrent Crohn's disease following ileocolonic resection

International Journal of Colorectal Disease

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Inflammatory bowel disease is associated with hidradenitis suppurativa: Results from a multicenter cross-sectional study

Journal of the American Academy of Dermatology

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Thyroid dysfunction in primary biliary cholangitis: A comparative study at two European centers

The American Journal of Gastroenterology

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Therapeutic reversal of food allergen sensitivity by mature retinoic acid–differentiated dendritic cell induction of LAG3+CD49b-Foxp3- regulatory T cells

The Journal of Allergy and Clinical Immunology

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Short leukocyte telomere length, alone and in combination with smoking, contributes to increased risk of gastric cancer or esophageal squamous cell carcinoma

Carcinogenesis

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The role of oral antibiotics prophylaxis in prevention of surgical site infection in colorectal surgery

International Journal of Colorectal Disease

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Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology

British Journal of Surgery

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Alterations of pulmonary function in patients with inflammatory bowel diseases

Annals of Thoracic Medicine

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Prevalence of hepatitis A virus as cause of acute viral hepatitis in central Karnataka, India

2016-10-27T01-44-05Z
Source: International Journal of Contemporary Pediatrics
Manjunatha Sarthi, K. G. Raghu Kumar, V. L. Jayasimha, C. S. Vinod Kumar, Satish S. Patil, K. R. Shama Taj, K. G. Basavarajappa.
Background: Hepatitis A is a preventable infectious disease with global distribution. Knowledge about the epidemiology of hepatitis A in a particular region will helpful for appropriate management of cases as well as preventive strategies for that region or area could be planned. The aim of the present study was to determine the prevalence of hepatitis A virus (HAV) as cause of acute viral hepatitis (AVH) in Central Karnataka, India. Methods: Blood samples were collected from AVH cases over a period of six months from June 2015 to November 2015 among patients attending a tertiary care centre, Davangere, Karnataka, India. Samples were tested for HAV IgM antibody (anti-HAV IgM) using a commercially available immunochromatographic assay. Results: Out of 51 samples tested, 19 (37.25%) were positive for anti-HAV IgM. Seropositivity for HAV was higher in females (43.75%) than males (34.29%). Agewise anti-HAV IgM positivity showed highest rate in 1-5 years age group (50.0% ), followed by 6-10 years group (42.86%) with a decline in older age groups (> 15 years). Conclusions: HAV causes AVH most commonly in early childhood and a small number of adolescents and adults. Females are more commonly infected than males. The preventive strategies and control measures of hepatitis A will be determined by future definition of HAV epidemiology in the Central Karnataka region, India.


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Pancreas with Multiple Cysts.

No abstract available

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Predictive Serum Markers of Gallstone Disease: Gazing Into A Crystal Ball.

No abstract available

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Enteral Iron Supplementation in Preterm Infants: Response to Letter to the Editor.

No abstract available

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Using the Objective Structured Clinical Exam (OSCE) to Assess ACGME Competencies in Pediatric Gastroenterology Fellows.

Background: The Accreditation Council for Graduate Medical Education (ACGME) has described six core competencies with which trainees should demonstrate proficiency. Using the Objective Structured Clinical Exam (OSCE), we aimed to assess four of these competencies among Pediatric GI fellows (PG). Methods: Eight first-year PG's from six medical centers in the New York area participated in a four-station OSCE with trained standardized patient (SP) actors. The cases included an "ED Consult" for lower GI bleeding; "Breaking Bad News" focusing on CF nutritional complications; "Second Opinion" for abdominal pain; "Transition of Care" for inflammatory bowel disease. At each station, attending faculty (FO) observed the encounters behind a one-way mirror. SPs and FOs provided immediate feedback to the examined fellows. Previously validated OSCE checklists were used to assess performance. On completion, fellows attended debriefing sessions and completed surveys about the educational value. Results: Median overall milestone competency scores were 6.9 (PC1), 4.8 (PC2), 5.9(MK1), 5.7(MK2), 6.4(ICS1), 6.9(Prof1), 6.7(Prof3). Overall, fellows score highest (7/9) on the IBD "Transition of Care" case, found the "Breaking Bad News" Cystic Fibrosis OSCE to be the most challenging, and were most comfortable with the "ED Consult" OSCE, as a commonly encountered scenario. Overall, the fellows rated the educational value of the program highly. Conclusions: To our knowledge, while the OSCE has been validated in other medical fields, this is the first OSCE program developed for Pediatric GI fellows. These OSCEs have included ACGME competencies, serving to assess fellows' skills in these areas while exposing them to challenging medical and psychosocial cases that they may not frequently encounter. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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The Causal Evaluation of Acute Recurrent and Chronic Pancreatitis in Children: Consensus From the INSPPIRE Group.

Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) have been diagnosed in children at increasing rates over the past decade. However, as pediatric ARP and CP are still relatively rare conditions, little quality evidence is available on which to base the diagnosis and determination of etiology. Objectives: To review the current state of the literature regarding the etiology of these disorders and to developed a consensus among a panel of clinically active specialists caring for children with these disorders to help guide the diagnostic evaluation and identify areas most in need of future research. Methods: A systematic review of the literature was performed and scored for quality, then consensus statements developed and scored by each individual in the group for level of agreement and strength of the supporting data using a modified Delphi method. Scores were analyzed for the level of consensus achieved by the group. Results: The panel reached consensus on 27 statements covering the definitions of pediatric ARP and CP, evaluation for potential etiologies of these disorders, and long-term monitoring. Statements for which the group reached consensus to make no recommendation or could not reach consensus are discussed. Conclusion: This consensus helps define the minimal diagnostic evaluation and monitoring of children with ARP and CP. Even in areas in which we reached consensus, the quality of the evidence is weak, highlighting the need for further research. Improved understanding of the underlying cause will facilitate treatment development and targeting. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Disruption of Memory Consolidation May Explain Patterns of Memory Better Than Emotion-Induced Retrograde Amnesia in Study by Chen et al.

No abstract available

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Intraoperative Hyperoxemia: An Unnecessary Evil?.

No abstract available

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Preoperative Three-Dimensional Strain Imaging Identifies Reduction in Left Ventricular Function and Predicts Outcomes After Cardiac Surgery.

BACKGROUND: Echocardiography-based speckle-tracking strain imaging is an emerging modality to assess left ventricular function. The aim of this study was to investigate the change in left ventricular systolic function after cardiac surgery with 3-dimensional (3D) speckle-tracking strain imaging and to determine whether preoperative 3D strain is an independent predictor of acute and long-term clinical outcomes after aortic valve, mitral valve, and coronary artery bypass grafting operations. METHODS: In total, 163 adult patients undergoing aortic valve, mitral valve, and coronary artery bypass surgeries were enrolled prospectively and had complete data sets. Demographic, operative, and outcome data were collected. 3D transthoracic echocardiograms were preformed preoperatively and on second to fourth postoperative day. Blinded off-line analysis was performed for left ventricular 2-dimensional (2D) ejection fraction (EF2D) and 3D ejection fraction (EF3D) and global peak systolic area, longitudinal, circumferential, and radial strain. RESULTS: 3D global strain correlated well with EF3D. Ventricular function as measured by strain imaging decreased significantly after all types of cardiac surgery. When preoperative EF3D was used, receiver operating characteristic curves identified reference values for 3D global strain corresponding to normal, mildly reduced, and severely reduced ventricular function. Normal ventricular function (EF3D >= 50%) corresponded to 3D global area strain -25%, with area under curve = 0.86 (0.81-0.89). Patients with reduced preoperative 3D global area strain had worse postoperative outcomes, including length of intensive care unit stay (4 vs 3 days, P = .001), major adverse events (27% vs 11%, P = .03), and decreased 1-year event-free survival (69% vs 88%, P = .005). After we controlled for baseline preoperative risk models including European System for Cardiac Operative Risk Evaluation score and surgery type, preoperative strain was an independent predictor of both short- and long-term outcomes, including length of intensive care unit stay, postoperative inotrope score, and 1-year event-free survival. CONCLUSIONS: This study shows that cardiac surgery was associated with an acute reduction in postoperative left ventricular function, when evaluated with 3D strain imaging. In addition, preoperative 3D strain was demonstrated to be an independent predictor of acute and long-term clinical outcomes after cardiac surgery. The use of noninvasive 3D transthoracic echocardiogram strain imaging before cardiac surgery may provide added information to aid in perioperative risk stratification and management for these high-risk patients. (C) 2016 International Anesthesia Research Society

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Chronic Sciatic Neuropathy in Rat Reduces Voluntary Wheel-Running Activity With Concurrent Chronic Mechanical Allodynia.

BACKGROUND: Animal models of peripheral neuropathy produced by a number of manipulations are assessed for the presence of pathologic pain states such as allodynia. Although stimulus-induced behavioral assays are frequently used and important to examine allodynia (ie, sensitivity to light mechanical touch; von Frey fiber test), other measures of behavior that reflect overall function are not only complementary to stimulus-induced responsive measures, but are also critical to gain a complete understanding of the effects of the pain model on quality of life, a clinically relevant aspect of pain on general function. Voluntary wheel-running activity in rodent models of inflammatory and muscle pain is emerging as a reliable index of general function that extends beyond stimulus-induced behavioral assays. Clinically, reports of increased pain intensity occur at night, a period typically characterized with reduced activity during the diurnal cycle. We therefore examined in rats whether alterations in wheel-running activity were more robust during the inactive phase compared with the active phase of their diurnal cycle in a widely used rodent model of chronic peripheral neuropathic pain, the sciatic nerve chronic constriction injury (CCI) model. METHODS: In adult male Sprague Dawley rats, baseline (BL) hindpaw threshold responses to light mechanical touch were assessed using the von Frey test before measuring BL activity levels using freely accessible running wheels (1 hour/day for 7 sequential days) to quantify the distance traveled. Running wheel activity BL values are expressed as total distance traveled (m). The overall experimental design was after BL measures, rats underwent either sham or CCI surgery followed by repeated behavioral reassessment of hindpaw thresholds and wheel-running activity levels for up to 18 days after surgery. Specifically, separate groups of rats were assessed for wheel-running activity levels (1 hour total/trial) during the onset (within first 2 hours) of either the (1) inactive (n = 8/group) or (2) active (n = 8/group) phase of the diurnal cycle. An additional group of CCI-treated rats (n = 8/group) was exposed to a locked running wheel to control for the potential effects of wheel-running exercise on allodynia. The 1-hour running wheel trial period was further examined at discrete 20-minute intervals to identify possible pattern differences in activity during the first, middle, and last portions of the 1-hour trial. The effect of neuropathy on activity levels was assessed by measuring the change from their respective BLs to distance traveled in the running wheels. RESULTS: Although wheel-running distances between groups were not different at BL from rats examined during either the inactive phase of the diurnal cycle or active phase of the diurnal cycle, sciatic nerve CCI reduced running wheel activity levels compared with sham-operated controls during the inactive phase. In addition, compared with sham controls, bilateral low-threshold mechanical allodynia was observed at all time points after surgical induction of neuropathy in rats with free-wheel and locked-wheel access. Allodynia in CCI compared with shams was replicated in rats whose running wheel activity was examined during the active phase of the diurnal cycle. Conversely, no significant reduction in wheel-running activity was observed in CCI-treated rats compared with sham controls at any time point when activity levels were examined during the active diurnal phase. Finally, running wheel activity patterns within the 1-hour trial period during the inactive phase of the diurnal cycle were relatively consistent throughout each 20-minute phase. CONCLUSIONS: Compared with nonneuropathic sham controls, a profound and stable reduction of running wheel activity was observed in CCI rats during the inactive phase of the diurnal cycle. A concurrent robust allodynia persisted in all rats regardless of when wheel-running activity was examined or whether they ran on wheels, suggesting that acute wheel-running activity does not alter chronic low-intensity mechanical allodynia as measured using the von Frey fiber test. Overall, these data support that acute wheel-running exercise with limited repeated exposures does not itself alter allodynia and offers a behavioral assay complementary to stimulus-induced measures of neuropathic pain. (C) 2016 International Anesthesia Research Society

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Remote Effects of Electromagnetic Millimeter Waves on Experimentally Induced Cold Pain: A Double-Blinded Crossover Investigation in Healthy Volunteers.

BACKGROUND: The hypoalgesic effect of electromagnetic millimeter waves (MW) is well studied in animal model; however, the results of human research are controversial. The aim of this study was to evaluate the effects of various frequency ranges of MW on hypoalgesia using the cold pressor test (CPT). METHODS: Experimental pain was induced using standardized CPT protocols in 20 healthy male volunteers. The skin of the lower part of sternum was exposed to MW with a frequency of 42.25 GHz (active generator); MW within 50-75 GHz frequency range (noise generator); or an inactive MW device (placebo generator) in a random crossover double-blinded manner. Pain threshold, measured using the CPT, was the primary outcome. Other CPT parameters, heart rate, blood pressure, incidence of subjective sensations (paresthesia) during exposure, as well as quality of volunteers' blinding were also recorded. The end points of the condition with exposure to 42.25 GHz, were compared with baseline; exposure to noise 50-75 GHz; and placebo generators. RESULTS: Pain threshold increased during exposure to the 42.25 GHz generator when compared with baseline: median difference (MD), 1.97 seconds (95% confidence interval [CI], 0.35-3.73) and noise generator: MD, 1.27 seconds (95% CI, 0.05-2.33) but not compared with the placebo generator. Time to onset of cold and increasing pain sensations as well as diastolic blood pressure increased under the exposure to the 42.25 GHz generator when compared with baseline and noise generator. Other outcome measures were comparable among the study conditions. CONCLUSIONS: We were able to partially confirm the previously suggested hypoalgesic effects of low-intensity electromagnetic MW. However, the effect was indistinguishable from the placebo condition in our investigation. (C) 2016 International Anesthesia Research Society

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In Response.

No abstract available

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Prediction of Outcome After Emergency High-Risk Intra-abdominal Surgery Using the Surgical Apgar Score.

BACKGROUND: With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never been validated exclusively in an emergency setting. METHODS: A consecutive prospective single-center cohort study of 355 adults undergoing emergency high-risk abdominal surgery between June 2013 and May 2014 is presented. The primary outcome measure was 30-day mortality. Secondary outcome measures were postoperative major complications, defined according to the Clavien-Dindo scale as well as the American College of Surgeons' National Surgical Quality Improvement Program guidelines, and intensive care unit admission. The SAS was calculated postoperatively. Cochran-Armitage test for trend was used to evaluate the incidence of both outcomes. Area under the curve was used to demonstrate the scores' discriminatory power. RESULTS: One hundred eighty-one (51.0%) patients developed minor or no complications. The overall incidence of major complications was 32.7% and the overall death rate was 16.3%. Risk of major complications, death, and intensive care unit admission increased significantly with decreasing SAS (P

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Sevoflurane Abolishes Oxygenation Impairment in a Long-Term Rat Model of Acute Lung Injury.

BACKGROUND: Patients experiencing acute lung injury (ALI) often need mechanical ventilation for which sedation may be required. In such patients, usually the first choice an intravenously administered drug. However, growing evidence suggests that volatile anesthetics such as sevoflurane are a valuable alternative. In this study, we evaluate pulmonary and systemic effects of long-term (24-hour) sedation with sevoflurane compared with propofol in an in vivo animal model of ALI. METHODS: Adult male Wistar rats were subjected to ALI by intratracheal lipopolysaccharide (LPS) application, mechanically ventilated and sedated for varying intervals up to 24 hours with either sevoflurane or propofol. Vital parameters were monitored, and arterial blood gases were analyzed. Inflammation was assessed by the analysis of bronchoalveolar lavage fluid (BALF), cytokines (monocyte chemoattractant protein-1 [MCP-1], cytokine-induced neutrophil chemoattractant protein-1 [CINC-1], interleukin [IL-6], IL-12/12a, transforming growth factor-[beta], and IL-10) in blood and lung tissue and inflammatory cells. The alveolocapillary barrier was indirectly assessed by wet-to-dry ratio, albumin, and total protein content in BALF. Results are presented as mean +/- standard deviation. RESULTS: After 9 hours of ventilation and sedation, oxygenation index was higher in the LPS/sevoflurane (LPS-S) than in the LPS/propofol group (LPS-P) and reached 400 +/- 67 versus 262 +/- 57 mm Hg after 24 hours (P

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Effects of Obesity and Leptin Deficiency on Morphine Pharmacokinetics in a Mouse Model.

BACKGROUND: Obesity causes multiorgan dysfunction, specifically metabolic abnormalities in the liver. Obese patients are opioid-sensitive and have high rates of respiratory complications after surgery. Obesity also has been shown to cause resistance to leptin, an adipose-derived hormone that is key in regulating hunger, metabolism, and respiratory stimulation. We hypothesized that obesity and leptin deficiency impair opioid pharmacokinetics (PK) independently of one another. METHODS: Morphine PK were characterized in C57BL/6J wild-type (WT), diet-induced obese (DIO), and leptin-deficient (ob/ob) mice, and in ob/ob mice given leptin-replacement (LR) therapy. WT mice received several dosing regimens of morphine. Obese mice (30 g) received one 80 mg/kg bolus of morphine. Blood was collected at fixed times after morphine injection for quantification of plasma morphine and morphine 3-glucuronide (M3G) levels. PK parameters used to evaluate morphine metabolism included area-under the curve (AUC150), maximal morphine concentration (CMAX), and M3G-to-morphine ratio, and drug elimination was determined by clearance (Cl/F), volume of distribution, and half-life (T1/2). PK parameters were compared between mouse groups by the use of 1-way analysis of variance, with P values less than .05 considered significant. RESULTS: DIO compared with WT mice had significantly decreased morphine metabolism with lower M3G-to-morphine ratio (mean difference [MD]: -4.9; 95% confidence interval [CI]: -8.8 to -0.9) as well as a decreased Cl/F (MD: -4.0; 95% CI: -8.9 to -0.03) Ob/ob compared with WT mice had a large increase in morphine exposure with a greater AUC150 (MD: 980.4; 95% CI: 630.1-1330.6), CMAX (MD: 6.8; 95% CI: 2.7-10.9), and longer T1/2 (MD: 23.1; 95% CI: 10.5-35.6), as well as a decreased Cl/F (MD: -7.0; 95% CI: -11.6 to -2.7). Several PK parameters were significantly greater in ob/ob compared with DIO mice, including AUC150 (MD: 636.4; 95% CI: 207.4-1065.4), CMAX (MD: 5.3; 95% CI: 3.2-10.3), and T1/2 (MD: 18.3; 95% CI: 2.8-33.7). When leptin was replaced in ob/ob mice, PK parameters began to approach DIO and WT levels. LR compared with ob/ob mice had significant decreases in AUC150 (MD: -779.9; 95% CI: -1229.8 to -330), CMAX (MD: -6.1; 95% CI: -11.4 to -0.9), and T1/2 (MD: -19; 95% CI: -35.1 to -2.8). Metabolism increased with LR, with LR mice having a greater M3G-to-morphine ratio compared with DIO (MD: 5.3; 95% CI: 0.3-10.4). CONCLUSIONS: Systemic effects associated with obesity decrease morphine metabolism and excretion. A previous study from our laboratory demonstrated that obesity and leptin deficiency decrease the sensitivity of central respiratory control centers to carbon dioxide. Obesity and leptin deficiency substantially decreased morphine metabolism and clearance, and replacing leptin attenuated the PK changes associated with leptin deficiency, suggesting leptin has a direct role in morphine metabolism. (C) 2016 International Anesthesia Research Society

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New trends in interventional pulmonology.

Purpose of review: As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications. Recent findings: The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia. Summary: The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Single-lung ventilation and oxidative stress: a different perspective on a common practice.

Purpose of review: To summarize what is currently known about the relationship between single-lung ventilation (SLV), oxidative stress, and postoperative disruption of organ function. Recent findings: SLV produces progressive alelectasis that is associated with hypoxic pulmonary vasoconstriction and redistribution of blood flow away from the nonventilated lung. This local tissue hypoxia induces the generation of reactive oxygen and reactive nitrogen species, an effect subsequently amplified by lung re-expansion consistent with well described hypoxia/reperfusion responses. Both experimental and clinical data indicate that the magnitude of oxidative and nitrosative stress is related to the duration of SLV and that these stresses affect not only the collapsed/re-expanded lung, but other organs as well. Summary: SLV and subsequent re-expansion of atelectatic lung are associated with the generation of reactive oxygen and nitrogen species that may modulate persistent systemic effects. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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