Σάββατο, 5 Νοεμβρίου 2016

A systematic review and meta-analysis of the association between long non-coding RNA polymorphisms and cancer risk

Publication date: Available online 5 November 2016
Source:Mutation Research/Reviews in Mutation Research
Author(s): Zhi Lv, Qian Xu, Yuan Yuan
It has been suggested that long non-coding RNA (lncRNA) gene polymorphisms are associated with cancer risk. In this article, we conducted a systematic review related to studies on the association between lncRNA single-nucleotide polymorphisms (SNPs) and the overall risk of cancer. A total 17 SNPs in four common lncRNA genes were included in the meta-analysis. In the lncRNA H19, the rs2735971A/G, rs2839698C/T, and rs3024270G/C polymorphisms, but not rs217727C/T, were correlated with overall cancer risk. The results also suggested that other SNPs were correlated with overall cancer risk, namely, two in HOTAIR (HOX transcript antisense RNA: rs920778C/T and rs7958904G/C) and two in PRNCR1 (rs1016343C/T and rs16901946A/G). No association was found between the three ZNRD1-AS1 (ZNRD1 antisense RNA 1) SNPs and the risk of cancer. In summary, our findings suggest that quite a few studied lncRNA SNPs are associated with overall cancer risk; therefore, they are potential predictive biomarkers for the risk of cancer. Moreover, other lncRNA SNPs investigated were also relevant to cancer but studies on them are limited, and they were also briefly reviewed as candidate cancer markers.



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Perceived Emotional and Psychological Impact of Ulcerative Colitis on Outpatients in Spain: UC-LIFE Survey

Abstract

Background

Ulcerative colitis (UC) negatively impacts patients' health-related quality of life (HRQoL).

Aim

The UC-LIFE survey aimed to evaluate the perceived everyday and emotional impact of UC on patients attending outpatient clinics in Spain and explored patient–physician communication.

Methods

Gastroenterologists handed the survey to consecutive unselected UC patients aged ≥18 years. Patients described their perception on the burden of symptoms and disease severity, social and emotional impact of UC on everyday life, disease knowledge and sources of information about the disease, and patient–physician communication.

Results

A total of 585 patients received the survey, and 436 returned it (74.5% response rate; mean age 46 years, 53% men). Most patients perceived that UC prevented them from leading a normal life (79.3%) and impaired sleep quality (76.1%). Most patients described an emotional impact due to UC, mainly feelings of depression and anxiety, and some 38% perceived that UC decreased their self-confidence. Despite most patients believing that their physician listened/asked about UC symptoms, many perceived that emotional/psychological support was lacking.

Conclusions

Findings support the need for a more patient-centered approach to the care of UC patients, to include psychological, emotional, and social aspects. Improved patient–physician communication would be beneficial and may contribute to better HRQoL in UC patients.



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Driving license class 160:

14 inntense days. Theory: Driving Technique, Physical laws, traffic regulations, Trafkk -psykologi, road constructions, Strategic thinking, more. And many, many kilometers in the car with an instructor. Weekend on ice-track first winter coming, -if you pass the test. You can only test three times in life. Mantra: Line of sight. (How far can you see? -and be seen!) Highest health -demands,-same as a passenger bus. ## What`s behind the next hill --? ## Recertification every second year, health check every 5 years. More from innside car -Konstant hints,tasks to improve,strategy,more: https://youtu.be/97xRZ9fBli4 Nephew - Igen Og Igen (-Again and again ) From Denmark: https://youtube/SMaVOcLHygE ExEMTNor

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Driving license class 160:

14 inntense days. Theory: Driving Technique, Physical laws, traffic regulations, Trafkk -psykologi, road constructions, Strategic thinking, more. And many, many kilometers in the car with an instructor. Weekend on ice-track first winter coming, -if you pass the test. You can only test three times in life. Mantra: Line of sight. (How far can you see? -and be seen!) Highest health -demands,-same as a passenger bus. ## What`s behind the next hill --? ## Recertification every second year, health check every 5 years. More from innside car -Konstant hints,tasks to improve,strategy,more: https://youtu.be/97xRZ9fBli4 Nephew - Igen Og Igen (-Again and again ) From Denmark: https://youtube/SMaVOcLHygE ExEMTNor

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The role of stents in the management of colorectal complications: a systematic review

Abstract

Background

Complications in colorectal surgery include a wide range of clinical conditions, which increase mortality, morbidity, hospital stay and costs. In some cases, the placement of a self-expanding metal stent may represent a possible therapeutic strategy, avoiding further surgery.

Methods

In order to verify the feasibility and safety of the technique, we reviewed the medical literature, between January 1997 and 2015, selecting 32 studies. Inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations.

Results

The estimated rate of early success was 73.3% (95% CI 66.3–79.3), raising from 25 to 68% in the time frame 1997–2007. The rate of early complications was 31.4% (95% CI 25.3–38.3%), progressively decreasing from 75 to 43% up to 2009. The rate of surgery for acute complication was 9.3% (95% CI 6.0–14.2%), reduced on time course from 25 to 9%. The rate of closure of dehiscence was 74.5% (95% CI 62.8–83.5%), while the rate of long-lasting success was 57.3% (95% CI 50.3–64.0%).

Conclusions

Endoscopic stenting in the early postoperative management of anastomotic complications after colorectal surgery should be considered in patients with minimal risk for sepsis, as a safe and often effective alternative to surgery. However, in order to establish the safety and efficacy of this technique, prospective studies involving a larger cohort of patients are required.



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Erratum to: Diclofenac sodium versus ceftazidime for preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a prospective, randomized, controlled trial



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Gastric Perforation After Incidental Ingestion Of Datun: Report Of An Unusual Case

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Pal Naresh, Griwanmahavir S , Singhbikram J .
Gastric perforation is an extremely rare complication of foreign body ingestion, which usually presents with peritonitis. Ingestion of foreign bodies is a fairly common presentation and most of these cases can be managed conservatively. Larger foreign bodies however, can sometimes be difficult to manage. We present a peculiar case of gastric perforation following involuntary ingestion of a large foreign body i.e. Datun (It is a tree twig commonly used for cleaning teeth in rural India). A 57-year male presented to our accident and emergency department with complaints of pain in upper abdomen following involuntary ingestion of Datun while brushing his teeth 7-8 days back. During this period the patient was passing flatus and stools normally. He also had history of smoking and occasional consumption of alcohol. On examination of the abdomen the patient was found to have tenderness and guarding in upper abdomen. He was investigated further with a provisional diagnosis of perforation peritonitis. Free air under the diaphragm was evident on chest X ray. Upon exploratory laparotomy the patient was found to have a perforation in the body of the stomach with one half of the Datun protruding out of it. Primary closure of perforation was done after removal of the foreign body. Postoperative period was uneventful and the patient was discharged on the 5th post operative day. Symptomatic giant ingested FBscan be challenging to manage and may even require urgent surgical intervention if perforation is suspected. Although ingested foreign bodies are rarely symptomatic they should be considered in differential diagnosis of abdominal pain as well as possible cause of acute abdomen.


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Amyand’s Hernia: An incidental Diagnosis

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Manish Swarnkar, Gaurav Pal, Raju Shinde.
Inguinal hernia repair is commonplace in general surgery practice. Amyands hernia is an extremely rare condition in which the appendix is positioned in the inguinal hernia sac. We report the intra-operative findings of a standard inguinal hernia repair and discuss the management of the Amyands hernia.


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World’s Heaviest Spleen Removed

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Arjun Goel, Brahm Dutt Pathak, Vikrant Singh Chauhan, Laxmi Goel.
A 33 yr old man with hepatosplenomegaly, presented with abdominal pain and distension. After establishing the diagnosis of type I Gauchers disease, splenectomy was done which weighed a massive 14.96 kilograms. The heaviest spleen reported till date. A case report of splenectomy for massive splenomegaly with comparison of other reports is presented. Splenectomy in gaucherss disease have been reported in the past for hypersplenism and splenomegaly. Splenomegaly and hypersplenism causes poor quality of life with abdominal distension and discomfort, recurrent blood transfusions, increased risk of bleeding, pancytopenia. The main indication in our case was massive splenomegaly extending well below the umbilicus and reaching upto the opposite iliac fossa (Hacketts grade V). Such massive sized spleens have never been reported in the past as patients present before reaching this level. Performing splenectomy in this case was in itself an arduous task. Our patient was operated by conventional midline laparotomy and recovered well after surgery.


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A Comparative Evaluation Of Intravenous Ranitidine And Rabeprazole On Gastric Volume And Ph In Patients Undergoing Surgery Under General Anaesthesia

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Sumit Kumar Singh, Mukesh Kumar, Usha Suwalka.
Introduction: The morbidity and mortality associated with the complication of Acid aspiration syndrome increases with the volume and acidity of gastric aspirates. Objective: Routine practice often includes use of pharmacological agents to reduce gastric volume and increase gastric pH. The aim of the study was to compare the effectiveness of intravenous Rabeprazole and intravenous Ranitidine on gastric fluid volume and pH in patients undergoing elective surgery under general anesthesia. Material and Methods: This prospective randomised double blind study was conducted on 90 healthy adult patients of either sex undergoing elective surgery under general anesthesia of age group 18-60 years and three groups were assigned with, Group 1 received intravenous Ranitidine 50 mg, Group 2 received intravenous Rabeprazole 20 mg, Group 3 received 5ml of normal saline(control group) before one hr, on the day of surgery and gastric volume and pH estimated just before induction of anaesthesia. Results: Volume of the gastric aspirates in preintubation was 15.8±2.73 ml in Group 1 (Ranitidine), 14.2±2.93 ml in Group 2 (Rabeprazole) and 20.8±2.81 ml in Group 3 (Control). There was significant (p=0.03) decrease in gastric volume with Rabeprazole compared to Ranitidine. The pH values determined in preintubation was 3.21±0.68 in Group 1 (Ranitidine), 3.66±0.79 in Group 2 (Rabeprazole) and 2.62±0.79 in Group 3 (Control). There was significant (p=0.018) increase in pH with Rabeprazole compared to Ranitidine. Conclusion: From present study it may be concluded that Ranitidine and Rabeprazole both are effective in reducing gastric volume and pH. As compared to Rabeprazole, Ranitidine is less effective in reducing gastric volume and pH but still more commonly used due to its cost effectiveness.


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Immune thrombocytopenia and its association with lymph node tuberculosis – A dilemma!

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Sangita Deepak Kamath, Neeraj Jain, Saurabh Pathak, Ballamudi Srinivas Rao.
Background: Although various hematologic abnormalities are known to occur with tuberculosis, association of immune mediated thrombocytopenia with tuberculosis is uncommon. Newly diagnosed immune thrombocytopenia in TB is rare; only 27 cases have been reported so far. Case: We report a case of axillary lymph node tuberculosis who presented with immune thrombocytopenia. An eighteen year old girl was admitted to our hospital with excessive vaginal bleed of one week duration followed by the development of petechial lesions and ecchymosis over legs, hands and mouth. She also had solitary, firm, left axillary lymphadenopathy. A diagnosis of immune mediated thrombocytopenia (ITP) was made from peripheral blood smear and bone marrow examination. Intravenous methylprednisolone (30mg/kg body weight) followed by oral prednisolone (1mg/kg) failed to elicit any sustained platelet response. Fine needle aspiration cytology of the left axillary lymphadenopathy done later revealed tuberculosis. After two weeks of starting anti-tuberculous therapy, the platelet count returned to normal and she was off all therapy for ITP thereby suggesting likely association between tuberculosis and immune thrombocytopenia. Conclusion: This case report illustrates the causal association between immune thrombocytopenia and tuberculosis.


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Pleural effusion in advanced liver disease

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Cyriac Abby Philips Lovkesh Anand and Apurva Pande.
We present the case of a decompensated cirrhotic in whom localized pleural effusion was managed on the lines of tubercular effusion inadvertently, with use of catheter drainage, leading to fatal complications. Pleural effusion in advanced cirrhosis must be evaluated in a step wise manner to minimize interventional treatments.


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Anaesthetic Management of Hunter Syndrome with AmbuLMA

2016-11-05T05-14-52Z
Source: The Southeast Asian Journal of Case Report and Review
Shwetha Seetharamaiah, Neisevilie Nisa, Lokesh Kashyap.
Patients with Hunter Syndrome have multisystem involvement and difficult airway due to infiltration of tissues with mucopolysaccharides. A eight year old, male child with Hunter Syndrome weighing 20 kg was admitted for repair of umbilical hernia and right inguinal hernia. Anaesthetic management was planned with IV induction and a 2.5 size Ambu Laryngeal Mask Airway (LMA). Post-operatively child was observed for 24 hrs and LMA was removed when the child was fully awake. Children with mucopolysaccharidosis are prone to atlantoaxial subluxation. Airway management with AmbuLMA in this case demonstrated safe alternative to endotracheal intubation.


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Single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural and spinal needle: excellent results in 1464 children with inguinal hernia/hydrocele

Abstract

Background

Laparoscopic percutaneous extraperitoneal closure (LPEC) of the internal ring is a well-developed procedure for pediatric inguinal hernia and hydrocele. To reduce the skin incisions and improve the cosmesis, single-site LPEC (SLPEC) has been developed with numerous techniques and instruments. In this study, we described our modifications of SLPEC using an epidural and spinal needle in a large pediatric population.

Methods

From February 2013 to February 2016, 1464 pediatric patients who underwent SLPEC in our hospital were retrospectively reviewed. A 5-mm laparoscope was introduced at the subumbilicus. An 18-gauge epidural needle with a silk suture loop was introduced into the corresponding skin of the internal ring. The needle was advanced extraperitoneally on the medial side of the ring. The suture loop was pushed into peritoneal cavity by the spinal needle. The epidural needle was withdrawn to the roof of the internal ring and then kept advancing along the lateral side. Aided by the spinal needle and laparoscope, a long suture loop was sent into the first loop in peritoneal cavity. The long suture loop was pulled out of the abdominal wall by picking up the first loop, and the internal ring was closed by knotting the suture extracorporeally. The contralateral patent processus vaginalis (CPPV) was simultaneously repaired if present.

Results

In total, 981 patients presented with inguinal hernia and 483 with hydrocele. A CPPV was present in 483 patients with unilateral pathology and thus simultaneously repaired. The hydrodissection technique and grasping forceps were used in 290 and 113 patients, respectively. The median operation time was 11 min (7–18 min) and 18 min (10–30 min) for unilateral and bilateral inguinal hernias/hydroceles, respectively. There was no development of intra- or postoperative complications.

Conclusions

SLPEC using an epidural and spinal needle can be performed with excellent results in pediatric inguinal hernias and hydroceles.



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A Study on Clinical Profile and Antimicrobial Drug Resistance in Infection with Stenotrophomonas maltophilia at a Tertiary Care Hospital of Rural Gujarat, India.

2016-11-05T03-09-14Z
Source: National Journal of Integrated Research in Medicine
Disha Sharma*, Yagnesh Pandya**, Chirag Modi***, Suman Singh****.
Background & objectives: Stenotrophomonas maltophilia causes opportunistic infections and is emerging as an important hospital-acquired pathogen. Present study was undertaken to investigate the prevalence, clinical profile, associated factors and antimicrobial susceptibility of S. maltophilia. Methods: Cross sectional retrospective study was conducted whereby patients details including type of infection, hospital stay, indwelling devices, co-morbid conditions and outcome till discharge were collected from January 2012 to March 2016. Identification and antimicrobial susceptibility were done by using Vitek2-compact-microbiological system. Results: 45 (0.17%) S.maltophilia strains were isolated from 27,132 samples received, forming 1.63% of total non-fermenters. Prevalence of S.maltophilia infection ranged from 0.06% in 2012 to 0.26% in 2015. Common sites involved were respiratory tract i.e. 55.5%, followed by bloodstream (20%), urinary tract (13.3%) and soft tissue (11.1%). 64.4% patients were male, and adults (26.7%) between 51-60 years of age. 66.7% of the isolates were from critical care units followed by wards (33.3%). Co-morbid conditions observed were COPD with respiratory complications i.e. 26.7% followed by cardiovascular diseases 22.2%, malignancy 11.1%, post surgical patients 11.1%, complicated UTI and trauma 8.8% each, CNS complications 6.7%, burns and cellulitis 2.2% each. All patients had exposure to broad-spectrum antibiotics and 66.6% had indwelling devices. 17.8% isolates were resistant to trimethoprim-sulfamethoxazole. Mortality observed was 20%. Interpretation & conclusion: S maltophilia is an emerging pathogen and its prevalence has gradually increased at our hospital. ICUs are the main hospital sites and respiratory infections main clinical condition. [Disha S NJIRM 2016; 7(5):5-8]


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Evaluation of protein: creatinine ratio on random urine samples in assessment of proteinuria

2016-11-05T02-58-35Z
Source: International Journal of Research in Medical Sciences
Vyankatesh T. Anchinmane, Shilpa V. Sankhe.
Background: Significant proteinuria (>300mg/day) may indicate the presence of important renal disease. Quantitative estimation of urinary protein over 24 hours is the gold standard test for detection of proteinuria. However, 24 hours urine collection method is inconvenient and cumbersome to patients. The present study was undertaken to determine diagnostic accuracy of random urine protein: creatinine ratio for the diagnosis of proteinuria among patients with renal diseases. Methods: The prospective study was done in 200 nephropathy cases. The 24 hours urinary protein test used as gold standard test and compared with their random urine sample protein: creatinine ratio (cut off >0.3). The data analyzed for sensitivity, specificity and accuracy of random urine sample protein: creatinine ratio test. Results: Random urine sample protein: creatinine ratio test showed sensitivity, specificity and accuracy of 95.6%, 94.4% and 95.5% respectively Conclusions: The convenient and accurate protein: creatinine ratio method on random urine samples is reliable method for estimation and screening the proteinuria cases over quantification of proteinuria by collection of 24 hours urine samples and hence, a wider application of this method is recommended.


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Clinico-pathological profile of abdominal tuberculosis and their treatment response in a tertiary care centre

2016-11-05T02-58-35Z
Source: International Journal of Research in Medical Sciences
Rajani Mavila, Manoj D. Kottarath, Niyas Naseer, Neethu Thambi, Vinayak Mohan.
Background: Abdominal tuberculosis is an important clinical entity having varied mode of clinical presentation. So the diagnosis of abdominal TB is difficult and careful approach to the patients and supportive investigation data are necessary to make the final diagnosis. Objectives of the study were to evaluate the clinic-pathological profile of patients with abdominal TB in a tertiary care centre in northern Kerala and to assess their response to anti-tubercular therapy under DOTS. Methods: This was a retrospective follow up study conducted in the department of Pulmonary Medicine in association with the department of Gastro-medicine and Surgery, and medical college DOTS centre Pariyaram Medical College, Pariyaram Kannur districtKerala, India. Total 55 patients with abdominal TB diagnosed on the basis of clinical profile and supported investigation data like gross morphological findings at endoscopy, colonoscopy, diagnostic laparoscopy, laparotomy or histologically proven caseating granulomas were selected for this study. Results: Out of the 55 patients, 31 were males and 24 females with age ranging 16-80 (Mean 30.01±11.7) years. Abdominal pain was the most common presenting symptom in 45 (81.81%). The diagnosis of abdominal TB was confirmed histopathologically in 42 (76.36%). Remaining 13 (23.64%) cases were diagnosed microscopically and with supportive clinical and imaging background. All the patients were treated under DOTS. Conclusions: Neither clinical features, laboratory, radiological and Endoscopic methods nor bacteriological and histopathological findings by themselves provide a gold standard in the diagnosis of abdominal TB. If diagnosed early, it can be treated successfully with anti-TB drugs.


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Diaphragmatic and intercostal electromyographic activity during neostigmine, sugammadex and neostigmine-sugammadex-enhanced recovery after neuromuscular blockade: A randomised controlled volunteer study.

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BACKGROUND: Electromyographic activity of the diaphragm (EMGdi) during weaning from mechanical ventilation is increased after sugammadex compared with neostigmine. OBJECTIVE: To determine the effect of neostigmine on EMGdi and surface EMG (sEMG) of the intercostal muscles during antagonism of rocuronium block with neostigmine, sugammadex and neostigmine followed by sugammadex. DESIGN: Randomised, controlled, double-blind study. SETTING: Intensive care research unit. PARTICIPANTS: Eighteen male volunteers. INTERVENTIONS: A transoesophageal EMGdi recorder was inserted into three groups of six anaesthetised study participants, and sEMG was recorded on their intercostal muscles. To reverse rocuronium, volunteers received 50 [mu]g kg-1 neostigmine, 2 mg kg-1 sugammadex or 50 [mu]g kg-1 neostigmine, followed 3 min later by 2 mg kg-1 sugammadex. MAIN OUTCOME MEASURES: We examined the EMGdi and sEMG at the intercostal muscles during recovery enhanced by neostigmine or sugammadex or neostigmine-sugammadex as primary outcomes. Secondary objectives were the tidal volume, PaO2 recorded between the onset of spontaneous breathing and extubation of the trachea and SpO2 during and after anaesthesia. RESULTS: During weaning, median peak EMGdi was 0.76 (95% confidence interval: 1.20 to 1.80) [mu]V in the neostigmine group, 1.00 (1.23 to 1.82) [mu]V in the sugammadex group and 0.70 (0.91 to 1.21) [mu]V in the neostigmine-sugammadex group (P

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JNA Journal Club.

No abstract available

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Extradural Hematoma With Unanticipated Difficult Intubation Due to Rhinoscleromatosis.

No abstract available

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JNA Journal Club.

No abstract available

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Serum Lactate is a Biomarker of Brain Tumor Metabolism.

No abstract available

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Neonatal Sevoflurane Exposure Induces Adulthood Fear-induced Learning Disability and Decreases Glutamatergic Neurons in the Basolateral Amygdala.

Background: Neonatal mice exposed to sevoflurane show certain cognitive and behavioral impairments in adulthood. However, the mechanisms underlying long-term cognitive deficits induced by sevoflurane exposure remain unknown. The present study was performed to investigate whether there is differential neuronal activation between naive mice and sevoflurane-exposed neonates in fear-conditioning tests based on immediate early gene (c-Fos) expression. Methods: Male mice were exposed to 3% sevoflurane (SEVO group) or carrier gas alone (no anesthesia, NA group) for 6 hours on postnatal day 6. The mice were allowed to mature before performing the contextual fear-conditioning test. A reduced freezing response was confirmed in the SEVO group. Neural activation in the regions of the medial prefrontal cortex, hippocampus, and amygdala was investigated using c-Fos immunostaining 2 hours after the test. The types of neurons activated were also identified. Results: The number of c-Fos-positive cells decreased by 27% in the basolateral amygdala in the SEVO group, while no significant changes were observed in other regions. Furthermore, glutamatergic, but not [gamma]-aminobutyric acid (GABA)ergic, neurons expressed c-Fos after the contextual fear-conditioning test in both groups. The number of glutamatergic neurons in the basolateral amygdala in the SEVO group was reduced by 27%. Conclusions: Decreased neural activation in the basolateral amygdala may be associated with reduced freezing time in neonatal sevoflurane-exposed mice. Fewer glutamatergic neurons responding to fear stimuli in the basolateral amygdala may contribute to decreased neural activation and learning deficits in mice exposed to sevoflurane as neonates. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved

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Assessment of health related quality of life in patients with cervical dystonia and writer’s cramp

2016-11-05T01-00-09Z
Source: International Journal of Research in Medical Sciences
Pavan Kumar Singh, Reeta Singh.
Background: There is paucity of literature regarding data about clinical and demographic factors affecting HRQoL with assessment with validated specific tool in patients with CD and WC especially from India. Methods: Demographic, clinical details, SF-36 and BDI score were noted in included patients. CD and WC severity scale were assessed by TWSTRS and BFM scale respectively. Disease specific quality of life in patients with CD was assessed by CDQ-24. Results: All 32 patients with CD scored significantly worse in all the eight domains of the SF-36. Patients with CD had significantly worse (mean BDI 12.14±6.7 versus 5.09±4.8; P


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Operating Room Anesthesia Subspecialization Is Not Associated With Significantly Greater Quality of Supervision of Anesthesia Residents and Nurse Anesthetists.

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BACKGROUND: Supervision of anesthesia residents and nurse anesthetists is a major responsibility of faculty anesthesiologists. The quality of their supervision can be assessed quantitatively by the anesthesia residents and nurse anesthetists. Supervision scores are an independent measure of the contribution of the anesthesiologist to patient care. We evaluated the association between quality of supervision and level of specialization of anesthesiologists. METHODS: We used two 6-month periods, one with no feedback to anesthesiologists of the residents' and nurse anesthetists' evaluations, and the other with feedback. Supervision scores provided by residents and nurse anesthetists were considered separately. Sample sizes among the 4 combinations ranged from n = 51 to n = 62 University of Iowa faculty. For each supervising anesthesiologist and 6-month period, we calculated the proportion of anesthetic cases attributable to each anesthesia Current Procedural Terminology code. The sum of the square of the proportions, a measurement of diversity, is known as the Herfindahl index. The inverse of this index represents the effective number of common procedures. The diversity (degree of specialization) of each faculty anesthesiologist was measured attributing each case to: (1) the anesthesiologist who supervised for the longest total period of time, (2) the anesthesiologist who started the case, or (3) the anesthesiologist who started the case, limited to cases started during "regular hours" (defined as nonholiday Monday to Friday, 07:00 AM to 02:59 PM). Inferential analysis was performed using bivariate-weighted least-squares regression. RESULTS: The point estimates of all 12 slopes were in the direction of greater specialization of practice of the evaluated faculty anesthesiologist being associated with significantly lower supervision scores. Among supervision scores provided by nurse anesthetists, the association was statistically significant for the third of the 6-month periods under the first and second ways of attributing the cases (uncorrected P

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Does Only Size Matter or Is There Still a Place for Single-Center Studies in the Era of Big Data?.

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No abstract available

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Performance of the Angle Labor Pain Questionnaire During Initiation of Epidural Analgesia in Early Active Labor.

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BACKGROUND: The Angle Labor Pain Questionnaire (A-LPQ) is a new, 22-item multidimensional psychometric questionnaire that measures the 5 most important dimensions of women's childbirth pain experiences using 5 subscales: The Enormity of the Pain, Fear/Anxiety, Uterine Contraction Pain, Birthing Pain, and Back Pain/Long Haul. Previous work showed that the A-LPQ has overall good psychometric properties and performance during early active labor in women without pain relief. The current study assessed the tool's sensitivity to change during initiation of labor epidural analgesia with the standardized response mean (SRM, primary outcome). METHODS: Two versions of the A-LPQ were administered once, in each of 2 test sessions, by the same trained interviewer during early active labor. The sequence of administration was randomized (ie, standard question order version [Test 1] followed by mixed version [Test 2] or vice versa). Test 1 was completed before epidural insertion; Test 2 commenced 20 to 30 minutes after the test dose. Providers assessed/treated pain independently of the study. Sensitivity to change was assessed using SRMs, Cohen's d, and paired t tests. Overall pain intensity was concurrently examined using Numeric Rating Scale and the Verbal Rating Scale (VRS); coping was assessed with the Pain Mastery Scale. Changes in pain were measured with the Patient Global Impression of Change Scale. Internal consistency was assessed with Cronbach's [alpha]. Concurrent validity with other tools was assessed using Spearman's rank correlation coefficient. RESULTS: A total of 51 complete datasets were analyzed. Most women reported moderate (63%, 32/51) or severe (18%, 9/51) baseline pain on VRS scores during Test 1; 29% (15/51) reported mild pain, and 6% (3/51) reported moderate pain during Test 2. Approximately 90% (46/51) of women reported much or very much improved pain at the end of testing. Cronbach's [alpha] for A-LPQ summary scores was excellent (0.94) and ranged from 0.78 (acceptable) to 0.92 (excellent) for subscales (Test 1). Large SRMs were found for A-LPQ summary scores (1.6, 95% CI: 1.2, 2.1) and all subscales except the Birthing Pain subscale (moderate, 0.60, 95% CI: 0.23, 0.97). Significant (P 0.73), correlations were moderate ([rho] > 0.5) with VRS scores and coping scores ([rho] > 0.67). CONCLUSIONS: Findings support A-LPQ use for measurement of women's childbirth pain experiences during initiation of labor epidural analgesia during early active labor. Combined with our previous work, they also support the use of the A-LPQ in late labor and at delivery. (C) 2016 International Anesthesia Research Society

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Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study.

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BACKGROUND: Persistent pain after cesarean delivery and vaginal delivery has been the subject of only a few research articles. The primary outcome of our prospective study was the incidence of persistent pain and its association to mode of delivery. We also studied the nature and intensity of pain after delivery. METHODS: A questionnaire was distributed on postpartum day 2 to 1052 women who had given birth vaginally and to 502 who had undergone cesarean delivery in a tertiary maternity hospital in Helsinki, Finland, in 2010. A second questionnaire was mailed to the women 1 year later. We recorded the women's health history, obstetric history and previous pain history, details of cesarean delivery or vaginal delivery, and description of pain, if present. RESULTS: The incidence of persistent pain at 1 year after delivery was greater after cesarean delivery (85/379 [22%]) than after vaginal delivery (58/713 [8%]: P

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Combination of 5-HT3 Antagonist and Dexamethasone Is Superior to 5-HT3 Antagonist Alone for PONV Prophylaxis After Laparoscopic Surgeries: A Meta-analysis.

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INTRODUCTION: 5-Hydroxytryptamine type 3 (5-HT3) receptor antagonists are the most commonly used drugs for postoperative nausea vomiting (PONV) prophylaxis. Dexamethasone is another antiemetic with proven efficacy in reducing PONV. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the combination of dexamethasone and 5-HT3 antagonist versus a 5-HT3 antagonist alone as prophylaxis of PONV in laparoscopic surgical patients. METHODS: PubMed, PubMed Central, and CENTRAL databases were searched to identify those randomized trials that compared a 5-HT3 antagonist with the 5-HT3 antagonist and dexamethasone combination for PONV prophylaxis after laparoscopic surgeries. RESULTS: Data from 17 RCTs that evaluated 1402 patients were included. Results from our meta-analysis show that the combination of dexamethasone and a 5-HT3 receptor antagonist is more effective in preventing PONV than the 5-HT3 antagonist alone (odds ratio 0.38, 95% confidence interval [CI] 0.27-0.54; number needed to treat = 6.6), with no statistical heterogeneity (I2 = 0) among studies. The need for rescue antiemetic is also decreased in patients receiving the combination (odds ratio 0.21, 99% CI 0.10-0.46; number needed to treat = 6), although data are insufficient to detect any significant difference in incidence of adverse effects. In addition, patients in the combination group complained of less pain after 24 hours (Weighted Mean Difference -0.67, 99% CI -1.27 to -0.08). CONCLUSION: Combination of a 5-HT3 receptor antagonist and dexamethasone is significantly more effective than 5-HT3 antagonist alone in preventing PONV after laparoscopic surgeries, with possible improvement in postoperative analgesia. (C) 2016 International Anesthesia Research Society

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Effect of a High-Rate Versus a Low-Rate Oxytocin Infusion for Maintaining Uterine Contractility During Elective Cesarean Delivery: A Prospective Randomized Clinical Trial.

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BACKGROUND: Oxytocin is routinely used as prophylaxis against uterine atony. During elective cesarean delivery (CD), an oxytocin bolus is used to initiate adequate uterine tone, followed by an oxytocin infusion to maintain uterine contractility. However, it is unclear whether oxytocin maintenance infusion rate influences total estimated blood loss (EBL). METHODS: We performed a prospective, randomized, double-blind trial in 51 women undergoing elective CD. Women were randomly assigned to receive an oxytocin maintenance infusion of 2.5 or 15 U/h. All women received an oxytocin 1 U bolus to initiate adequate uterine tone. The primary outcome was EBL. EBL values between groups were compared using a Mann-Whitney U test; P

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Preoxygenation: Physiologic Basis, Benefits, and Potential Risks.

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Preoxygenation before anesthetic induction and tracheal intubation is a widely accepted maneuver, designed to increase the body oxygen stores and thereby delay the onset of arterial hemoglobin desaturation during apnea. Because difficulties with ventilation and intubation are unpredictable, the need for preoxygenation is desirable in all patients. During emergence from anesthesia, residual effects of anesthetics and inadequate reversal of neuromuscular blockade can lead to hypoventilation, hypoxemia, and loss of airway patency. In accordance, routine preoxygenation before the tracheal extubation has also been recommended. The objective of this article is to discuss the physiologic basis, clinical benefits, and potential concerns about the use of preoxygenation. The effectiveness of preoxygenation is assessed by its efficacy and efficiency. Indices of efficacy include increases in the fraction of alveolar oxygen, increases in arterial oxygen tension, and decreases in the fraction of alveolar nitrogen. End points of maximal preoxygenation (efficacy) are an end-tidal oxygen concentration of 90% or an end-tidal nitrogen concentration of 5%. Efficiency of preoxygenation is reflected in the rate of decline in oxyhemoglobin desaturation during apnea. All investigations have demonstrated that maximal preoxygenation markedly delays arterial hemoglobin desaturation during apnea. This advantage may be blunted in high-risk patients. Various maneuvers have been introduced to extend the effect of preoxygenation. These include elevation of the head, apneic diffusion oxygenation, continuous positive airway pressure (CPAP) and/or positive end-expiratory pressure (PEEP), bilevel positive airway pressure, and transnasal humidified rapid insufflation ventilatory exchange. The benefit of apneic diffusion oxygenation is dependent on achieving maximal preoxygenation, maintaining airway patency, and the existence of a high functional residual capacity to body weight ratio. Potential risks of preoxygenation include delayed detection of esophageal intubation, absorption atelectasis, production of reactive oxygen species, and undesirable hemodynamic effects. Because the duration of preoxygenation is short, the hemodynamic effects and the accumulation of reactive oxygen species are insufficient to negate its benefits. Absorption atelectasis is a consequence of preoxygenation. Two approaches have been proposed to reduce the absorption atelectasis during preoxygenation: a modest decrease in the fraction of inspired oxygen to 0.8, and the use of recruitment maneuvers, such as CPAP, PEEP, and/or a vital capacity maneuver (all of which are commonly performed during the administration of anesthesia). Although a slight decrease in the fraction of inspired oxygen reduces atelectasis, it does so at the expense of a reduction in the protection afforded during apnea. (C) 2016 International Anesthesia Research Society

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Patient Blood Management: An International Perspective.

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This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country's PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety. (C) 2016 International Anesthesia Research Society

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Interaction of Isoflurane, Tumor Necrosis Factor-[alpha] and [beta]-Amyloid on Long-Term Potentiation in Rat Hippocampal Slices.

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BACKGROUND: The relationship between inhalational anesthetics such as isoflurane and cognitive impairment in the elderly is controversial. Both [beta]-amyloid peptide (A[beta]), associated with Alzheimer disease, and tumor necrosis factor-[alpha] (TNF-[alpha]), a proinflammatory stress-related peptide, impair the synaptic function. We hypothesized that transient exposure to isoflurane and these peptides would impair synaptic function, manifest as a depression of long-term potentiation (LTP) and paired pulse facilitation (PPF), in the rat hippocampus. METHODS: Hippocampal slices were prepared from 3- to 4-week-old male Wistar rats. Preliminary experiments identified minimal concentrations of A[beta]1-42 peptide and TNF-[alpha] that produced statistically detectable suppressing effects on LTP (600 nM A[beta]1-42 and 5 ng/mL TNF-[alpha]). These concentrations of peptides were applied to slices alone, with 1.5% isoflurane, or in combination for 1 hour and then washed out. Measurements of LTP (field excitatory postsynaptic potentials [fEPSPs]) from neurons in the CA1 area by stimulation of the Schaffer-Collateral pathway were made after high-frequency stimulation (100 Hz, 1 second). Analysis of variance with correction for multiple comparisons was used to compare LTP under steady-state conditions and averaged for the 40- to 60-minute period after LTP induction. RESULTS: EPSP amplitude after LTP induction was 155% +/- 9% of baseline and was not affected by isoflurane exposure and washout (150% +/- 4% of baseline, P = .47). Both A[beta]1-42 and TNF-[alpha] reduced LTP by approximately 15% compared with control (129% +/- 7% and 131% +/- 11% of baseline respectively, means +/- SD, both P

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Intraoperative Clinical Decision Support for Anesthesia: A Narrative Review of Available Systems.

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With increasing adoption of anesthesia information management systems (AIMS), there is growing interest in utilizing AIMS data for intraoperative clinical decision support (CDS). CDS for anesthesia has the potential for improving quality of care, patient safety, billing, and compliance. Intraoperative CDS can range from passive and post hoc systems to active real-time systems that can detect ongoing clinical issues and deviations from best practice care. Real-time CDS holds the most promise because real-time alerts and guidance can drive provider behavior toward evidence-based standardized care during the ongoing case. In this review, we describe the different types of intraoperative CDS systems with specific emphasis on real-time systems. The technical considerations in developing and implementing real-time CDS are systematically covered. This includes the functional modules of a CDS system, development and execution of decision rules, and modalities to alert anesthesia providers concerning clinical issues. We also describe the regulatory aspects that affect development, implementation, and use of intraoperative CDS. Methods and measures to assess the effectiveness of intraoperative CDS are discussed. Last, we outline areas of future development of intraoperative CDS, particularly the possibility of providing predictive and prescriptive decision support. (C) 2016 International Anesthesia Research Society

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Incremental Value of Preoperative Copeptin for Predicting Myocardial Injury.

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BACKGROUND: Copeptin, a novel marker of endogenous stress, has shown diagnostic and prognostic value in nonsurgical patients with a suspected coronary event. We aimed to assess the incremental value of copeptin in addition to established preoperative risk indices to predict the occurrence of postoperative myocardial injury. METHODS: This secondary analysis of prospectively collected data included adults undergoing noncardiac surgery with risk factors for adverse perioperative cardiac events based on preoperative risk stratification. We examined preoperative copeptin in patients without elevated preoperative troponin and its association with myocardial injury by receiver operator characteristic curves, logistic regression, and net reassignment indices. RESULTS: Of the 190 patients included, 33 (17.4%) experienced myocardial injury within 48 hours, and 17 (8.9%) experienced cardiac death and/or major adverse cardiac events within the first postoperative year. Preoperative copeptin showed an area under the receiver operator characteristic curve of .66 (95% confidence interval, .55-.76) for myocardial injury and an optimal cutoff of 9.6 pmol/L. This cutoff was an independent predictor of myocardial injury, with an odds ratio of 4.67 (95% confidence interval, 2.06-11.19) when adjusted for age, sex, and the revised cardiac risk index. The net reassignment improvement for myocardial injury was between 39% and 50% for both events and nonevents when adding copeptin to established preoperative risk indices. No significant difference in major adverse cardiac event and/or cardiac death was observed. CONCLUSIONS: Copeptin (>=9.6 pmol/L) was associated with significantly higher rates of myocardial injury and improved risk stratification in patients scheduled for noncardiac surgery with nonelevated preoperative troponin. (C) 2016 International Anesthesia Research Society

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Lidocaine Administration Controls MicroRNAs Alterations Observed After Lung Ischemia-Reperfusion Injury.

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BACKGROUND: Ischemia-reperfusion injury (IRI) is associated with morbidity and mortality. MicroRNAs (miRNAs) have emerged as regulators of IRI, and they are involved in the pathogenesis of organ rejection. Lidocaine has proven anti-inflammatory activity in several tissues but its modulation of miRNAs has not been investigated. This work aims to investigate the involvement of miRNAs in lung IRI in a lung auto-transplantation model and to investigate the effect of lidocaine. METHODS: Three groups (sham, control, and Lidocaine), each comprising 6 pigs, underwent a lung autotransplantation. All groups received the same anesthesia. In addition, animals of lidocaine group received a continuous intravenous administration of lidocaine (1.5 mg/kg/h) during surgery. Lung biopsies were taken before pulmonary artery clamp, before reperfusion, 30 minutes postreperfusion (Rp-30), and 60 minutes postreperfusion (Rp-60). Samples were analyzed for different miRNAs (miR-122, miR-145, miR-146a, miR-182, miR-107, miR-192, miR-16, miR-21, miR-126, miR-127, miR142-5p, miR152, miR155, miR-223, and let7) via the use of reverse-transcription quantitative polymerase chain reaction. Results were normalized with miR-103. RESULTS: The expression of miR-127 and miR-16 did not increase after IRI. Let-7d, miR-21, miR-107, miR-126, miR-145, miR-146a, miR-182, and miR-192 significantly increased at the Rp-60 (control versus sham P

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CXCL12/CXCR4 Signaling Contributes to the Pathogenesis of Opioid Tolerance: A Translational Study.

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BACKGROUND: Long-term opioid therapy for chronic pain may lead to analgesic tolerance, especially when administered intrathecally, thus preventing adequate pain relief. Discovering drug targets to treat opioid tolerance using a mechanism-based approach targeting opioid-induced neuroinflammation provides new therapeutic opportunities. In this study, we provide translational evidence that CXCL12/CXCR4 signaling contributes to the pathogenesis of opioid tolerance. METHODS: The CXCL12 levels in the cerebrospinal fluid of opioid-tolerant patients were compared with those of opioid-naive subjects. For further investigation, a rodent translational study was designed using 2 clinically relevant opioid delivery paradigms: daily intraperitoneal morphine injections and continuous intrathecal morphine infusion. We measured rats' tail flick responses and calculated the percentage of maximum possible effects (%MPE) to demonstrate opioid acute antinociception and the development of analgesic tolerance. The effects of exogenous CXCL12, CXCL12 neutralizing antibody, and receptor antagonist AMD3100 were investigated by intrathecal administration. Data were presented as mean +/- SEM. RESULTS: CXCL12 was significantly upregulated in the cerebrospinal fluid of opioid-tolerant patients for 892 +/- 34 pg/mL (n = 27) versus 755 +/- 33 pg/mL (n = 10) in naive control subjects (P = .03). Furthermore, after 2 and 5 days of intrathecal morphine infusion, rat lumbar spinal cord dorsal horn CXCL12 messenger RNA levels were significantly upregulated by 3.2 +/- 0.7 (P = .016) and 3.4 +/- 0.3 (P = .003) fold, respectively. Results from the daily intraperitoneal morphine injection experiments revealed that administering an intrathecal infusion of CXCL12 for 24 hours before the first morphine injection did not decrease antinociception efficacy on day 1 but accelerated tolerance after day 2 (%MPE 49.5% vs 88.1%, P = .0003). In the intrathecal morphine coinfusion experiments, CXCL12 accelerated tolerance development (%MPE 9.4% vs 43.4% on day 1, P

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Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

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BACKGROUND: The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. METHODS: Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. RESULTS: Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. CONCLUSIONS: An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence). (C) 2016 International Anesthesia Research Society

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Early Detection of Anesthesia Workstation High-Pressure Oxygen Line Leak.

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No abstract available

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Relationship Between Preoperative Anemia and In-Hospital Mortality in Children Undergoing Noncardiac Surgery.

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BACKGROUND: The relationship between preoperative anemia and in-hospital mortality has not been investigated in the pediatric surgical population. We hypothesized that children with preoperative anemia undergoing noncardiac surgery may have an increased risk of in-hospital mortality. METHODS: We identified all children between 1 and 18 years of age with a recorded preoperative hematocrit (HCT) in the 2012, 2013, and 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) pediatric databases. The endpoint was defined as the incidence of in-hospital mortality. Children with preoperative anemia were identified based on their preoperative HCT. Demographic and surgical characteristics, as well as comorbidities, were considered potential confounding variables in a multivariable logistic regression analysis. A sensitivity analysis was performed using propensity-matched analysis. RESULTS: Among the 183,833 children included in the 2012, 2013, and 2014 ACS NSQIP database, 74,508 had a preoperative HCT recorded (41%). After exclusion of all children

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Continuous Renal Replacement Therapy.

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No abstract available

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Clinical Anesthesia Procedures of the Massachusetts General Hospital.

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What's New in Obstetric Anesthesia: The 2016 Gerard W. Ostheimer Lecture.

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This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States. Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care. Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care. (C) 2016 International Anesthesia Research Society

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Proactive Use of Plasma and Platelets in Massive Transfusion in Trauma: The Long Road to Acceptance and a Lesson in Evidence-Based Medicine.

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No abstract available

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