Δευτέρα, 15 Μαΐου 2017

A rounded opacity silhouetting the left heart border and hilum

A 73-year-old woman with hypertension and atrial fibrillation presented with head and neck injury after mechanical fall. During workup, chest X-ray anteroposterior view (figure 1) revealed a rounded opacity silhouetting the left heart border and hilum. Subsequent contrast-enhanced CT of the chest showed single, 6.4 cm, rounded, well-defined, thin-walled, non-enhanced, low attenuated (–20 and 20 Hounsfield Unit) and homogenous cyst-like structure at the left mediastinum connected to pericardial recesses and not attached to adjacent structures (figure 2A–C). Transthoracic echocardiogram ruled out left ventricular aneurysm, aortic aneurysm, solid tumour and outflow tracts obstruction. Although bronchogenic cyst, oesophageal duplication cyst, thymic tumour and mediastinal lymphoma were considered as possible differentials, radiological features such as CT appearance, homogenous attenuation, unrelated to the underlying structures favoured pericardial cyst. Since patient was asymptomatic, patient and family member were unwilling to undergo surgical removal and pathological confirmation. Follow-up with non-enhanced CT of...

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Transient hemiparaesthesias and dysarthria

A previously healthy 29-year-old Mexican woman presented to an emergency department with transient hemiparaesthesias and dysarthria. There was no evidence of stroke on cross-sectional imaging of the head, and she was discharged without a clear diagnosis. Two days later, she returned with acute abdominal pain. Abdominal imaging revealed complete occlusion of the right renal artery, prompting emergency embolectomy. Following the procedure, she developed acute haemoptysis, dyspnoea and hypoxaemia. Chest imaging demonstrated evidence of pulmonary venous hypertension. Cardiac auscultation revealed an opening snap followed by a diastolic murmur with presystolic accentuation. These sounds were better appreciated in combination with phonocardiography, a technique supplanted by echocardiography in the 1970s1 that visualised heart sounds (video 1). An echocardiogram confirmed the presence of mitral stenosis (MS), unifying the syndrome of embolic phenomena, haemoptysis and pulmonary hypertension. She underwent successful mitral valve replacement and has since returned to normal...


Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182
6948891480

Induction of hibernation-like hypothermia by central activation of the A1 adenosine receptor in a non-hibernator, the rat

Abstract

Central adenosine A1-receptor (A1AR)-mediated signals play a role in the induction of hibernation. We determined whether activation of the central A1AR enables rats to maintain normal sinus rhythm even after their body temperature has decreased to less than 20 °C. Intracerebroventricular injection of an adenosine A1 agonist, N6-cyclohexyladenosine (CHA), followed by cooling decreased the body temperature of rats to less than 20 °C. Normal sinus rhythm was fundamentally maintained during the extreme hypothermia. In contrast, forced induction of hypothermia by cooling anesthetized rats caused cardiac arrest. Additional administration of pentobarbital to rats in which hypothermia was induced by CHA also caused cardiac arrest, suggesting that the operation of some beneficial mechanisms that are not activated under anesthesia may be essential to keep heart beat under the hypothermia. These results suggest that central A1AR-mediated signals in the absence of anesthetics would provide an appropriate condition for maintaining normal sinus rhythm during extreme hypothermia.



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Construction Site RN / LVN / LPN / Paramedic / EMT - Medcor Inc.

To apply click http://bit.ly/Nantucket_Medical_Administrator Sick of riding in the back of an ambulance" Tired of the 24 hour shifts in the ER" Do you routinely engage in conversations with everyone you meet" Do you treat your patients as good, if not better than you would treat yourself" Do you like job perks, good pay, and great benefits" If so this may very well be the last job application you'll ...

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Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long segment fusion for adult spinal deformity

Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology.

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Comparison of the osteogenesis and fusion rates between activin a / BMP-2 chimera (AB204) and rhBMP-2 in a beagle's posterolateral lumbar spine model

Activin A/BMP-2 chimera (AB204) could promote bone healing more effectively than recombinant bone morphogenetic protein 2 (rhBMP-2) with much lower dose in rodent model, but there is no report about the effectiveness of AB204 in a large animal model.

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The Labor Analgesia Requirements in Nulliparous Women Randomized to Epidural Catheter Placement in a High or Low Intervertebral Space.

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BACKGROUND: We hypothesized that an epidural catheter placed in a lower vertebral interspace will require less medication for labor analgesia. METHODS: Nulliparous women requesting neuraxial labor analgesia were randomized to epidural catheter placement at the ultrasound-confirmed L1-2 or L4-5 interspace. Patient-controlled epidural analgesia and breakthrough manual epidural boluses of 10 mL of 0.125% bupivacaine with 50 [micro]g of fentanyl or 8 mL of 2% lidocaine were utilized. Abdominal and perineal pain scores were assessed at 30 and 60 minutes after standardized initiation of epidural analgesia. Pain scores during pushing were assessed after delivery. The primary outcome was the proportion of patients requiring manual boluses and was compared using a [chi]2 test. Secondarily, we analyzed the number of boluses given in early (up to 4 hours before delivery) versus late labor using [chi]2 tests and the pain scores using Mann-Whitney U tests, with adjustment of P values for multiple testing. RESULTS: We analyzed 148 patients. Overall, the percentage of patients in the low versus high groups who required manual boluses was 46% vs 51% (P = 1.0). For the 56 patients in each group who delivered vaginally, 22 (52%) vs 20 (48%) manual boluses were given to the low epidural group in early versus late labor, compared to 9 (20%) vs 36 (80%) in the high epidural group (P = .014). There was no statistical difference in patient-controlled epidural analgesia requirements or patient satisfaction. Comparing the low versus high groups, the median (interquartile range) pain scores were: 3 (1, 6) vs 0 (0, 2) (P = .013) at 30 minutes and 1 (1, 3) vs 0 (0, 1) (P = .013) at 60 minutes for abdominal pain; 0 (0, 2) vs 1 (1, 3) (P = .36) and 0 (0, 1) vs 1 (1, 3) (P = .014) at these same time points for perineal pain; and 1 (0, 5) vs 0 (0, 3) (P = .9) for abdominal and 2 (0, 5) vs 4 (1, 8) (P = .025) for perineal pain during pushing. The percentage of patients who underwent instrumental delivery was 15% vs 5% (P = .06) for the low versus high group. CONCLUSIONS: An L4-5 epidural catheter initially provides less relief of abdominal pain but more relief of perineal labor pain. Patients with an L4-5 catheter require more manual boluses during early labor but less during late labor. The possible association of low epidural catheters with instrumental delivery merits further investigation. (C) 2017 International Anesthesia Research Society

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Clonal Complexes and Antimicrobial Susceptibility Profiles of Staphylococcus pseudintermedius Isolates from Dogs in the United States

Microbial Drug Resistance , Vol. 0, No. 0.


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Genetic Characterization of vanA-Enterococcus faecium Isolates from Wild Red-Legged Partridges in Portugal

Microbial Drug Resistance , Vol. 0, No. 0.


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Prove It: Dual defibrillation of refractory ventricular fibrillation

What's the evidence that delivery of dual defibrillation improves survival outcomes for patients who suffer out-of-hospital cardiac arrest and fail to respond to conventional therapy?

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Repetitive postoperative extubation failure and cardiac arrest due to laryngomalacia after general anesthesia in an elderly patient: a case report

Abstract

The authors report a case involving an elderly patient who experienced repetitive perioperative cardiac arrest caused by laryngomalacia. The patient underwent surgery under general anesthesia; however, 2 h after initial extubation, he experienced cardiopulmonary arrest. Return of spontaneous circulation was achieved by immediate resuscitation. Four hours later, a second extubation was performed without any neurological complications. However, 2 h later, he experienced cardiopulmonary arrest again. Immediately after the third extubation, 12 h after the second cardiopulmonary arrest, fiberoptic laryngoscopy revealed laryngomalacia. His respiratory condition stabilized after emergent tracheostomy. Laryngomalacia should be considered even in adult cases when signs of upper airway obstruction manifest after extubation.



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EMT program receives new ambulance simulator

An EMT instructor said it would allow students to get real world experience

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Aerobic capacity mediates susceptibility for the transition from steatosis to steatohepatitis

Abstract

Background & aims

Low aerobic capacity increases risk for NAFLD and liver-related disease mortality, but mechanisms mediating these effects remain unknown. We recently reported that rats bred for low aerobic capacity (low capacity runner (LCR)) displayed susceptibility to high-fat diet-induced steatosis in association with reduced hepatic mitochondrial fatty acid oxidation (FAO) and respiratory capacity compared to high aerobic capacity (high capacity runners (HCR)) rats. Here we tested the impact of aerobic capacity on susceptibility for progressive liver disease following a 16 week 'western diet' high in fat (45% kcal), cholesterol (1% w w−1), and sucrose (15% kcal).

Results

Unlike previously with a diet high in fat and sucrose alone, the inclusion of cholesterol in the WD induced hepatomegaly, and steatosis in both HCR and LCR, while producing greater cholesterol ester accumulation in LCR compared to HCR. Importantly, WD-fed low-fit LCR rats displayed greater inflammatory cell infiltration, serum ALT, expression of hepatic inflammatory markers (F4/80, MCP-1, TLR4, TLR2, and IL-1b), and effector caspase (caspase-3 & -7) activation compared to HCR. Further, LCR rats had greater WD-induced decreases in complete FAO and mitochondrial respiratory capacity.

Conclusions

Intrinsic aerobic capacity had no impact on WD-induced hepatic steatosis; however, rats bred for low aerobic capacity developed greater hepatic inflammation which was associated with reduced hepatic-mitochondrial FAO and -respiratory capacity and increased accumulation of cholesterol esters. These results confirm epidemiological reports that aerobic capacity impacts progression of liver disease and suggest that these effects are mediated through alterations in hepatic mitochondrial function.

This article is protected by copyright. All rights reserved



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Starvation, carbohydrate loading, and outcome after major surgery

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Circle systems and low-flow anaesthesia

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Addition of droperidol to prophylactic ondansetron and dexamethasone in children at high risk for postoperative vomiting. A randomized, controlled, double-blind study

Abstract
Background: The combination of dexamethasone (DEX), ondansetron (OND) and droperidol (DRO) is efficacious in preventing postoperative nausea and vomiting in adults, but has not been well assessed in children.Methods: Children undergoing elective surgery under general anaesthesia and considered at high risk for postoperative vomiting (POV) were randomly assigned to receive a combination of DEX, OND and placebo (Group A) or a combination of DEX, OND and DRO (Group B). The primary outcome was the incidence of POV during the first 24 hours after surgery. We hypothesized that the addition of DRO to the standard antiemetic prophylaxis would provide a further 15% reduction in the residual risk for POV. The secondary outcome considered was any adverse event occurring during the study.Results: One hundred and fifty-three children, aged three to 16 years, were randomized to Group A and 162 to Group B. The overall incidence of POV did not differ significantly between the two groups, with 16 patients in Group A (10.5%) and 18 in Group B (11.1%) presenting with one or more episodes of POV, P=0.86. Fewer patients presented with adverse events in Group A (2%) compared with Group B (8%), P=0.01. Drowsiness and headache were the principal adverse events reported.Conclusions: The addition of DRO to a combination of OND and DEX did not decrease POV frequency below that obtained with the two-drug combination in children at high risk of POV, but increased the risk of drowsiness. The combination of DEX and OND should be recommended in children with a high risk of POV.Clinical trial registration. NCT01739985.

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Comparative total and unbound pharmacokinetics of cefazolin administered by bolus versus continuous infusion in patients undergoing major surgery: a randomized controlled trial

Abstract
Background. Perioperative administration of cefazolin reduces the incidence of perioperative infections. Intraoperative re-dosing of cefazolin is commonly given between 2 and 5 h after the initial dose. This study was undertaken to determine whether intraoperative continuous infusions of cefazolin achieve better probability of target attainment (PTA) and fractional target attainment (FTA) than intermittent dosing.Methods. Patients undergoing major surgery received cefazolin 2 g before surgical incision. They were subsequently randomized to receive either an intermittent bolus (2 g every 4 h) or continuous infusion (500 mg h−1) of cefazolin until skin closure. Blood samples were analysed for total and unbound cefazolin concentrations using a validated chromatographic method. Population pharmacokinetic modelling was performed using Pmetrics® software. Calculations of PTA and FTA were performed for common pathogens.Results. Ten patients were enrolled in each arm. A two-compartment linear model best described the time course of the total plasma cefazolin concentrations. The covariates that improved the model were body weight and creatinine clearance. Protein binding varied with time [mean (range) 69 (44–80)%] with a fixed 21% unbound value of cefazolin used for the simulations (120 min post-initial dosing). Mean (sd) central volume of distribution was 5.73 (2.42) litres, and total cefazolin clearance was 4.72 (1.1) litres h−1. Continuous infusions of cefazolin consistently achieved better drug exposures and FTA for different weight and creatinine clearances, particularly for less susceptible pathogens.Conclusions. Our study demonstrates that intraoperative continuous infusions of cefazolin increase the achievement of target plasma concentrations, even with lower infusion doses. Renal function and body weight are important when considering the need for alternative dosing regimens.Clinical trial registration. NCT02058979.

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Ransomware cyberattack continues to cripple hospitals

Seven of the 47 affected hospitals and clinics in Britain are still having IT problems; new variants of the rapidly replicating malware were discovered

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Hemodynamic responses and plasma phenylephrine concentrations associated with intranasal phenylephrine in children

Summary

Introduction

Intranasal phenylephrine, an alpha-1 adrenergic agonist, causes vasoconstriction of the nasal mucosa and is used to reduce bleeding associated with nasotracheal intubation or endoscopic sinus surgery. The purpose of this study was to describe the hemodynamic effects associated with plasma phenylephrine concentrations following topical intranasal administration of 0.25% and 0.5% phenylephrine in children.

Methods

After Institutional Review Board and parental approval, 77 children between the ages of 2 and 12 years were studied in a prospective, double-blind manner and randomized into three groups. Group 1 received intranasal saline, while groups 2 and 3 received 0.1 mL/kg of 0.25% or 0.5% phenylephrine, respectively. All received the same anesthetic of halothane, N2O, O2, and vecuronium. After inhalation induction, endtidal halothane and PaCO2 were maintained at 1.5% and 35 mm Hg, respectively. Heart rate and rhythm, systolic, diastolic, and mean, noninvasive arterial blood pressures were recorded and venous blood was obtained for measurement of plasma phenylephrine concentration by high-performance liquid chromatography at baseline and at 2, 5, 10, and 20 minutes following intranasal spray application of the study drug. Nasotracheal intubation was performed immediately following the 5-minute measurements, and the presence of bleeding was assessed. Hemodynamic data were compared by analysis of variance for repeated measures. Bleeding and arrhythmia incidence among groups were analyzed using chi-squared tests. Phenylephrine levels were correlated with hemodynamic values via regression analysis.

Results

Fifty-two patients received intranasal phenylephrine. Increases in blood pressure correlated with increasing plasma phenylephrine concentration. Systolic blood pressure increased 8%, and mean blood pressure increased 14%, which were statistically significant but clinically insignificant. Heart rate did not change, and the incidence of arrhythmia was low and similar among groups. Bleeding following nasotracheal intubation was less frequent in Group 3 (11/27 subjects) than in Group 1 (17/25). Peak plasma phenylephrine concentrations were observed by 14±7 minutes following intranasal administration, and were highly variable among individuals (37.8±39.7 and 49.6±93.9 ng/mL [mean±SD] in Groups 2 and 3).

Discussion

Administration of intranasal phenylephrine, 0.25% and 0.50%, results in rapid but highly variable systemic absorption that is associated with mild increases of blood pressure that are clinically insignificant. Bleeding associated with nasotracheal intubation was less following administration of 0.5% intranasal phenylephrine than following intranasal saline.



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Preoperative colonization in pediatric cardiac surgery and its impact on postoperative infections

Summary

Background

Patients with congenital heart defects are frequently hospitalized before surgery. This exposes them to a high risk for pathogen colonization. There are limited data on colonization prevalence in the pediatric cardiac population, and limited data concerning its potential role in the risk of developing infections after cardiac surgery.

Aim

This study aimed to verify the impact of preoperative colonization on postoperative infections in a population of pediatric cardiac surgery patients coming from Italy and developing countries.

Methods

This was a retrospective study conducted in all the patients aged ≤18 years who underwent pediatric open-heart surgery in the year 2015. Clinical data were retrieved from the institutional database for cardiac surgery patients. Data on swab cultures were retrieved from the laboratory database. Swab colonization was tested for association with infection and other outcomes.

Results

Among 169 children who performed the screening for pathogen colonization, 50% had at least one positive swab. Italian patients were (P=.001) less likely to be colonized with respect to foreign patients (relative risk 0.17, 95% CI 0.09-0.35). Postoperative infections in colonized patients occurred at a similar rate as in noncolonized patients (relative risk 1.24, 95% CI 0.64-2.39; P=.532). Colonized patients had a preoperative stay (P=.021) longer than noncolonized patients (mean difference 2 days, 95% CI 0.3-3.8 days).

Conclusion

The results of our study suggest that the impact of preoperative colonization on outcome and postoperative infections may be negligible; larger series are required to clearly define this issue.



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Acute respiratory distress syndrome

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Heart failure—pathophysiology and inpatient management

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Novel psychoactive substances: a practical approach to dealing with toxicity from legal highs

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Uses of capnography in the critical care unit

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Anaesthesia for cardioversion

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CMIP haploinsufficiency in two patients with autism spectrum disorder and co-occurring gastrointestinal issues

Autism spectrum disorder (ASD) is a genetically heterogeneous group of disorders characterized by impairments in social communication and restricted interests. Though some patients with ASD have an identifiable genetic cause, the cause of most ASD remains elusive. Many ASD susceptibility loci have been identified through clinical studies. We report two patients with syndromic ASD and persistent gastrointestinal issues who carry de novo deletions involving the CMIP gene detected by genome-wide SNP microarray and fluorescence in situ hybridization (FISH) analysis. Patient 1 has a 517 kb deletion within 16q23.2q23.3 including the entire CMIP gene. Patient 2 has a 1.59 Mb deletion within 16q23.2q23.3 that includes partial deletion of CMIP in addition to 12 other genes, none of which have a known connection to ASD or other clinical phenotypes. The deletion of CMIP is rare in general population and was not found among a reference cohort of approximately 12,000 patients studied in our laboratory who underwent SNP array analysis for various indications. A 280 kb de novo deletion containing the first 3 exons of CMIP was reported in one patient who also demonstrated ASD and developmental delay. CMIP has previously been identified as a susceptibility locus for specific language impairment (SLI). It is notable that both patients in this study had significant gastrointestinal issues requiring enteral feedings, which is unusual for patients with ASD, in addition to unusually elevated birth length, further supporting a shared causative gene. These findings suggest that CMIP haploinsufficiency is the likely cause of syndromic ASD in our patients.



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Breathing circuit compliance and accuracy of displayed tidal volume during pressure-controlled ventilation of infants: A quality improvement project

Summary

Introduction

Anesthesia machines have evolved to deliver desired tidal volumes more accurately by measuring breathing circuit compliance during a preuse self-test and then incorporating the compliance value when calculating expired tidal volume. The initial compliance value is utilized in tidal volume calculation regardless of whether the actual compliance of the breathing circuit changes during a case, as happens when corrugated circuit tubing is manually expanded after the preuse self-test but before patient use. We noticed that the anesthesia machine preuse self-test was usually performed on nonexpanded pediatric circuit tubing, and then the breathing circuit was subsequently expanded for clinical use. We aimed to demonstrate that performing the preuse self-test in that manner could lead to incorrectly displayed tidal volume on the anesthesia machine monitor. The goal of this quality improvement project was to change the usual practice and improve the accuracy of displayed tidal volume in infants undergoing general anesthesia.

Methods

There were four stages of the project: (i) gathering baseline data about the performance of the preuse self-test and using infant and adult test lungs to measure discrepancies of displayed tidal volumes when breathing circuit compliance was changed after the initial preuse self-test; (ii) gathering clinical data during pressure-controlled ventilation comparing anesthesia machine displayed tidal volume with actual spirometry tidal volume in patients less than 10 kg before (machine preuse self-test performed while the breathing circuit was nonexpanded) and after an intervention (machine preuse self-test performed after the breathing circuit was fully expanded); (iii) performing department-wide education to help implement practice change; (iv) gathering postintervention data to determine the prevalence of proper machine preuse self-test.

Results

At constant pressure-controlled ventilation through fully expanded circuit tubing, displayed tidal volume was 83% greater in the infant test lung (mean±SD TV 15±5 vs 9±4 mL; mean [95% CI] difference=6.3 [5.6, 7.1] mL, P<.0001) and 3% greater in the adult test lung (245±74 vs 241±72 mL; difference=5 [1, 10] mL, P=.0905) when circuit compliance had been measured with nonexpanded tubing compared to when circuit compliance was measured with fully expanded tubing. The clinical data in infants demonstrated that displayed tidal volume was 41% greater than actual tidal volume (difference of 10.4 [8.6, 12.2] mL) when the circuit was expanded after the preuse self-test (preintervention) and 7% greater (difference of 2.5 [0.7, 4.2] mL) in subjects when the circuit was expanded prior to the preuse self-test (postintervention) (P<.0001). Clinical practice was changed following an intervention of departmental education: the preuse self-test was performed on expanded circuit tubing 11% of the time prior to the intervention and 100% following the intervention.

Conclusion

Performing a preuse self-test on a nonexpanded pediatric circuit that is then expanded leads to falsely elevated displayed tidal volume in infants less than 10 kg during pressure-controlled ventilation. Overestimation of reported tidal volume can be avoided by expanding the breathing circuit tubing to the length which will be used during a case prior to performing the anesthesia machine preuse self-test. After department-wide education and implementation, performing a correct preuse self-test is now the standard practice in our cardiac operating rooms.



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Changing the paradigm for diagnostic MRI in pediatrics: Don't hold your breath

Summary

Increasingly complex pediatric patients and improvements in technology warrant reevaluation of the risk associated with anesthesia for diagnostic imaging. Although magnetic resonance imaging is the imaging modality of choice for children given the potentially harmful effects of computerized tomography-associated ionizing radiation, we dare to suggest that certain patients would benefit from the liberalization of our current standard. Incorporating the use of newer computerized tomography technology may improve safety for those that are already at higher risk for adverse events. Furthermore, magnetic resonance imaging is not risk-free—what is often overlooked is the need for controlled ventilation and breath-holding to minimize motion artifact. As physicians at the forefront of the development and sustainability of the perioperative surgical home, anesthesiologists must work to not only optimize patients preoperatively but should also act as gatekeepers for procedural safety.



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Racial differences in the pain management of children recovering from anesthesia

Summary

Background

When pain management has been studied in settings such as pediatric emergency departments, racial disparities have been clearly identified. To our knowledge, this has not been studied in the pediatric perioperative setting. We sought to determine whether there are differences based on race in the administration of analgesia to children suffering from pain in the postanesthesia care unit.

Methods

This is a prospective, observational, study of 771 children aged 4-17 years who underwent elective outpatient surgery. Racial differences in probability of receiving analgesia for pain in the recovery room were assessed using bivariable and multivariable logistic regression analyses.

Results

A total of 294 children (38.2%) received at least one class of analgesia (opioid or nonopioid); while 210 (27.2%) received intravenous (i.v.) opioid analgesia in the recovery room. Overall postanesthesia care unit analgesia utilization was similar between white and minority children (white children 36.8% vs minority children 43.4%, OR 1.3; 95% CI=0.92-1.89; P=.134). We found no significant difference by racial/ethnic group in the likelihood of a child receiving i.v. opioid for severe postoperative pain (white children 76.0% vs 85.7%, OR 1.89; 95% CI=0.37-9.67; P=.437). However, minority children were more likely to receive i.v. opioid analgesia than their white peers (white children 24.5% vs minority children 34.2%, OR 1.5; 95% CI=1.04-2.2; P=.03). On multivariable analysis, minority children had a 63% higher adjusted odds of receiving i.v. opioids in the recovery room (OR=1.63; 95% CI, 1.05-2.62; P=.03).

Conclusions

Receipt of analgesia for acute postoperative pain was not significantly associated with a child's race. Minority children were more likely to receive i.v. opioids for the management of mild pain.



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Effect of caudal block using different volumes of local anaesthetic on optic nerve sheath diameter in children: a prospective, randomized trial

Abstract
Background: Caudal block is commonly administered for postoperative analgesia in children. Although caudal block with 1.5 ml kg−1 local anaesthetic has been reported to reduce cerebral oxygenation in infants, the effect of caudal block on intracranial pressure (ICP) in children has not been well investigated. Optic nerve sheath diameter (ONSD) correlates with degree of ICP. This study aimed to estimate the effects of caudal block on ICP according to volume of local anaesthetic using ultrasonographic measurement of ONSD in children.Methods: Eighty patients, 6- to 48-months-old, were randomly allocated to the high-volume (HV) or low-volume (LV) groups for caudal block with ropivacaine 0.15%, 1.5 ml kg−1 or 1.0 ml kg−1, respectively. Measurement of ONSD was performed before (T0), immediately after (T1), and 10 min (T2) and 30 min (T3) after caudal block.Results: The two groups exhibited significant differences in ONSD according to time (PGroup x Time=0.003). The HV group exhibited significantly greater changes in ONSD from T0 to T2 and T3 than the LV group. However, in both groups, ONSDs at T1, T2 and T3 were significantly greater compared with those at T0, with the highest values at T2.Conclusions: Caudal block with a high volume of local anaesthetic can cause a greater increase in ICP than caudal block with a low volume of local anaesthetic. However, caudal block with 1.0 ml kg−1 of local anaesthetic can also result in a significant increase in ICP.Clinical trial registration. NCT02768493.

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Volatile anaesthetics and organ protection in kidney transplantation: finally, a randomized controlled trial!

Many clinical trials have evaluated whether volatile anaesthetics are protective in scenarios of ischaemia–reperfusion (I/R). Although the majority of studies of I/R injury involve cardiac surgery with cardiopulmonary bypass,12 some have been performed in lung surgery with one-lung ventilation,3 liver resection under inflow occlusion,4 or liver transplantation.5 The study by Niewuwenhuijs-Moeke and colleagues6 in this issue of the BritishJournalof Anaesthesia is the first to evaluate direct effects of volatile anaesthetics on kidneys undergoing I/R injury during transplantation (volatile anaesthetic protection of renal transplants, VAPOR-1 trial). The authors are to be congratulated for their efforts. So far, only animal experiments have addressed the impact of volatile anaesthetics on renal I/R injury, or the kidneys were evaluated only as a secondary outcome in clinical trials.2 Therefore, this study increases our knowledge and experience of organ protection and volatile anaesthetics.

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Altered preoperative coagulation and fibrinolysis are associated with myocardial injury after non-cardiac surgery

Abstract
Background. Myocardial injury after non-cardiac surgery (MINS), a complication with unclear pathogenesis, occurs within the first 30 days after surgery and worsens prognosis. Hypercoagulability induced by surgery might contribute to plaque rupture, with subsequent thrombosis and myocardial injury. This study assessed haemostatic markers before surgery and evaluated their association with MINS.Methods. This is a substudy of VISION, a prospective cohort study of perioperative cardiovascular events. Of 475 consecutive vascular surgery patients, 47 (9.9%) developed MINS, defined as postoperative high-sensitivity troponin  ≥50 ng litre−1, with ≥20% elevation from the preoperative concentration. The control group consisted of 84 non-MINS patients matched for patient characteristics and co-morbidities. The following preoperative markers of hypercoagulability and fibrinolysis were measured: antithrombin, factor VIII activity, von Willebrand factor concentration and activity, fibrinogen, D-dimer, plasmin–antiplasmin complex, and tissue plasminogen activator. Moreover, C-reactive protein and CD40L concentrations were measured to assess inflammatory activity.Results. Patients with MINS compared with the non-MINS group had a significantly higher concentration of factor VIII (186 vs 155%, P=0.006), von Willebrand factor activity (223 vs 160%, P<0.001), von Willebrand factor concentration (317 vs 237%, P=0.02), concentrations of fibrinogen (5.6 vs 4.2 g litre−1, P=0.03), D-dimer (1680.0 vs 1090.0 ng ml−1, P=0.04), plasmin–antiplasmin complex (747 vs 512 ng ml−1, P=0.002) and C-reactive protein (10 vs 4.5 mg litre−1, P=0.02) but not antithrombin (95 vs 94%, P=0.89), tissue plasminogen activator (11 vs 9.7 ng ml−1, P=0.06) and CD40L (8790 vs 8580 pg ml−1, P=0.73).Conclusions. Preoperative elevation of blood markers of hypercoagulability in patients undergoing vascular surgery is associated with a higher risk of MINS.Clinical trial registration. NCT00512109.

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‘Failed supraglottic airway’: an algorithm for suboptimally placed supraglottic airway devices based on videolaryngoscopy

Anaesthetists would not accept malpositioned tracheal tubes resulting in leak, inadequate ventilation, high airway pressures, or one-sided lung ventilation. Yet it is our impression that many, if not the majority, of surgeries are conducted with blindly placed and suboptimally sited supraglottic airway devices (SADs). The anaesthetic community appears to accept much lower standards for SAD placement than for tracheal tube placement.

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Neural network imaging to characterize brain injury in cardiac procedures: the emerging utility of connectomics

Abstract
Cognitive dysfunction is a poorly understood but potentially devastating complication of cardiac surgery. Clinically meaningful assessment of cognitive changes after surgery is problematic because of the absence of a means to obtain reproducible, objective, and quantitative measures of the neural disturbances that cause altered brain function. By using both structural and functional connectivity magnetic resonance imaging data to construct a map of the inter-regional connections within the brain, connectomics has the potential to increase the specificity and sensitivity of perioperative neurological assessment, permitting rational individualized assessment and improvement of surgical techniques.

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Critical airways, critical language

The contribution of human factors to adverse outcomes during emergency airway management is well established.1 Effective communication is a core non-technical skill that contributes to minimizing such error.2 The language used must aid rather than hinder communication.

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Total haemoglobin mass, but not haemoglobin concentration, is associated with preoperative cardiopulmonary exercise testing-derived oxygen-consumption variables

Abstract
Background. Cardiopulmonary exercise testing (CPET) measures peak exertional oxygen consumption (V˙O2peak) and that at the anaerobic threshold (V˙O2 at AT, i.e. the point at which anaerobic metabolism contributes substantially to overall metabolism). Lower values are associated with excess postoperative morbidity and mortality. A reduced haemoglobin concentration ([Hb]) results from a reduction in total haemoglobin mass (tHb-mass) or an increase in plasma volume. Thus, tHb-mass might be a more useful measure of oxygen-carrying capacity and might correlate better with CPET-derived fitness measures in preoperative patients than does circulating [Hb].Methods. Before major elective surgery, CPET was performed, and both tHb-mass (optimized carbon monoxide rebreathing method) and circulating [Hb] were determined.Results. In 42 patients (83% male), [Hb] was unrelated to V˙O2 at AT and V˙O2peak (r=0.02, P=0.89 and r=0.04, P=0.80, respectively) and explained none of the variance in either measure. In contrast, tHb-mass was related to both (r=0.661, P<0.0001 and r=0.483, P=0.001 for V˙O2 at AT and V˙O2peak, respectively). The tHb-mass explained 44% of variance in V˙O2 at AT (P<0.0001) and 23% in V˙O2peak (P=0.001).Conclusions. In contrast to [Hb], tHb-mass is an important determinant of physical fitness before major elective surgery. Further studies should determine whether low tHb-mass is predictive of poor outcome and whether targeted increases in tHb-mass might thus improve outcome.

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Engaging in risky business: is it time to rethink risk tolerance in anaesthesia?

In this issue of the British Journal of Anaesthesia, Greig and colleagues1 describe a new study examining risk tolerance amongst a large and diverse group of anaesthetists from across a single National Health Service Trust. Using a validated electronic questionnaire, the authors presented a group of anaesthetists with 11 risky situations and queried respondents as to whether they would proceed with the procedure or not (a go/no-go decision). Importantly, all of the scenarios were drawn from previous instances where a critical incident had occurred and been reported. Among their key findings, the authors reported that a consultant was significantly more likely to proceed with a given scenario than a trainee. Perhaps even more striking was the finding that in no one scenario was there absolute agreement over whether to proceed or not. Even in situations where national guidelines clearly suggest a procedure should be cancelled (i.e. a faulty gas analyser), several individuals responded that they would proceed. Overall, the authors found wide variability in what anaesthetists consider either acceptable or professional behaviour. One might expect that if the study were expanded to include other trusts, or even anaesthetists from other countries, this variability would be likely to persist.

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Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis

Abstract
The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) −150 to − 2, I2=79%] and 74 min (95% CI − 126 to − 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml−1 (95% CI 0.23–1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://ift.tt/2pCmIQf.

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It's not about the bike: enhancing oxygen delivery

It's Not About the Bike was the title of Lance Armstrong's first autobiography, and in the light of subsequent allegations and admissions, it seems indeed that it was not.1 Armstrong's phenomenal Tour de France cycling success was of course multifactorial, an aggregation of gains in several aspects of performance, but an integral factor in his success appears to have been 'blood doping', a fast-track increase in haemoglobin achieved with erythropoietin and autologous blood transfusion.2 In the case of elite athletes, the advantage being sought is an increase in critical power, the highest work rate that can be sustained over a substantial amount of time without an appreciable contribution from anaerobic metabolism.3 Could a similar approach be employed clinically to improve the functional capacity of patients facing major surgery?

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Comparison of preoperative and intraoperative assessment of aortic stenosis severity by echocardiography

Abstract
Background. General anaesthesia and surgically induced changes in cardiac loading conditions may alter flow across the aortic valve. This study examined how echocardiographic assessment of the severity of aortic stenosis (AS) changes during surgery.Methods. Patients who underwent aortic valve replacement for any severity of AS between July 2007 and June 2015 were identified. Peak velocities, mean gradients, and dimensionless indices (DI) measured with preoperative transthoracic echocardiography (TTE) were compared with those measured with intraoperative transoesophageal echocardiography (TOE). Additionally, agreement of preoperative and intraoperative grading of AS based on these measurements was assessed.Results. Data from 319 patients were analysed. On average, intraoperative TOE peak velocity and mean gradient were lower by 0.59 m s−1 and 12.5 mm Hg, respectively (P<0.0001), compared with preoperative TTE measurements, whereas the difference in mean DI was minimal at 0.008. Preoperative and intraoperative grades of AS severity (mild, moderate, and severe) by peak velocity, mean gradient, and DI agreed in 53.3, 53.7, and 83.3% of patients, respectively. The TOE grade of AS severity by peak velocity and mean gradient was at least one lower than the TTE grade in 45.1 and 42.7% of patients, respectively. Significantly fewer patients had their severity of AS reclassified based on DI (P<0.0001).Conclusions. Intraoperative TOE peak velocities and mean gradients are often significantly lower than preoperative TTE measurements, leading to underestimation of AS severity in nearly half of our study patients. The DI is a more reliable measurement of AS severity in the intraoperative setting.

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Medication errors in paediatric anaesthesia: the hidden part of the iceberg

Editor—We read with great interest the recent report by Wahr and colleagues1 about medication safety in the operating room. The authors highlighted several issues, particularly errors attributable to syringe preparation. Paediatric patients are a population particularly exposed to medication errors owing to the fact that drugs on the pharmaceutical market are, for the most part, supplied in adult packaging and dosage. Thus, the drug dilution procedure is a crucial step to obtain accurate concentrations of drugs used for paediatric or neonatal anaesthesia. As few studies have evaluated the accuracy of drug dilution in the paediatric population, we prospectively assessed the content of syringes prepared by nurse anaesthetists in several paediatric operating theatres in France.

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Measuring the anaesthesia clinical learning environment at the department level is feasible and reliable

Abstract
Background. The learning environment describes the context and culture in which trainees learn. In order to establish the feasibility and reliability of measuring the anaesthetic learning environment in individual departments we implemented a previously developed instrument in hospitals across New South Wales.Methods. We distributed the instrument to trainees from 25 anaesthesia departments and supplied summarized results to individual departments. Exploratory and confirmatory factor analyses were performed to assess internal structure validity and generalizability theory was used to calculate reliability. The number of trainees required for acceptable precision in results was determined using the standard error of measurement.Results. We received 172 responses (59% response rate). Suitable internal structure validity was confirmed. Measured reliability was acceptable (G-coefficient 0.69) with nine trainees per department. Eight trainees were required for a 95% confidence interval of plus or minus 0.25 in the mean total score. Eight trainees as assessors also allow a 95% confidence interval of approximately plus or minus 0.3 in the subscale mean scores. Results for individual departments varied, with scores below the expected level recorded on individual subscales, particularly the 'teaching' subscale.Conclusions. Our results confirm that, using this instrument, individual departments can obtain acceptable precision in results with achievable trainee numbers. Additionally, with the exception of departments with few trainees, implementation proved feasible across a training region. Repeated use would allow departments or accrediting bodies to monitor their individual learning environment and the impact of changes such as the introduction of new curricular elements, or local initiatives to improve trainee experience.

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Anaesthetic considerations for hybrid atrial fibrillation surgery

Editor—Hybrid atrial fibrillation surgery consists of simultaneous epicardial and endocardial ablation of the beating heart by thoracoscopy and percutaneous femoral approaches, respectively, without cardiopulmonary bypass support. The epicardial ablation may be bilateral or unilateral. A joint effort of different teams is required: cardiologist, cardiac surgeon, anaesthetists, respiratory therapists, and nurses.1 The cardiopulmonary bypass team is on standby. Anaesthetic considerations for hybrid surgery involve control of perioperative haemodynamic and respiratory stability and postoperative pain control. We review our institutional approach here for the benefit of new programmes.

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Patient choice compared with no choice of intrathecal morphine dose for caesarean analgesia: a randomized clinical trial

Abstract
Background: The study aimed to determine whether a patient's choice for their intrathecal morphine (ITM) dose reflects their opioid requirements and pain after caesarean delivery and if giving women a choice of ITM dose would reduce opioid use and improve pain scores compared with women who did not have a choice.Methods: A total of 120 women undergoing caesarean delivery with spinal anaesthesia were enrolled in this randomized, double-blind study. Patients were randomly assigned to a choice of 100 or 200 μg ITM or no choice. The study involved deception, such that all participants were still randomly assigned 100 or 200 μg ITM regardless of choice. Rescue opioid use over the 48-h study period was the primary outcome measure. Pain at rest and movement and side effect (pruritus, nausea, and vomiting) data were collected 3, 6, 12, 24, 36 and 48 h postoperatively. Data are presented as median [95% confidence interval (CI)].Results: Women who requested the larger ITM dose required more supplemental opioid [median 0.8 (95% CI 0.4–1.3)] mg morphine equivalents at each assessment interval; P < 0.001] and reported more pain with movement [median 1.2 (95% CI 0.5–1.9)] verbal numerical rating score of 0–10 points] than patients who requested the smaller ITM dose (P = 0.0008), regardless of the ITM dose given. There was no difference in opioid use whether the patient was offered a perceived choice or not.Conclusions: Women who were given a choice and chose the larger ITM dose correctly anticipated a greater postoperative opioid requirement and more pain compared with women who chose the smaller dose. Simply being offered a choice did not impact opioid use or pain scores after caesarean delivery.Trial Registration: ClinicalTrials.gov (NCT01425762).

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Real-time ultrasound-guided paramedian spinal anaesthesia: evaluation of the efficacy and the success rate of single needle pass

Editor—The ideal way to provide spinal anaesthesia is via a single needle pass (i.e. a successful dural puncture, with a single skin puncture and no needle redirection). This was recommended by the Second American Society of Regional Anesthesia Consensus on Neuraxial Anesthesia and Anticoagulation.1 Multiple puncture attempts are associated with a higher chance of complications.2,3 A paramedian approach has been shown to improve the success rate of spinal anaesthesia, especially in patients who are unable to sit up or those with a degenerative spine condition.4–6 The use of ultrasound has been suggested to increase the efficacy of spinal anaesthesia.7

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Oxford Textbook of Vascular Surgery . M. M. Thompson, R. Fitridge, J. Boyle, M. Thompson, K. Brohi, R. J. Hinchliffe, N. Cheshire, A. R. Naylor, I. Loftus and A. H. Davies (editors)

Oxford Textbook of Vascular Surgery. ThompsonM. M., FitridgeR., BoyleJ., ThompsonM., BrohiK., HinchliffeR. J., CheshireN., NaylorA. R., LoftusI. and DaviesA. H. (editors). eISBN: 9780199658220. Oxford University Press, 800 pp. £44.00 (online), £145.00 (textbook)

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Issue Information



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New insights into Ca2+ channel function in health and disease



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Extracellular vesicles in bile as markers of malignant biliary stenoses

Gastroenterology

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US hepatitis C cases soar on spike in heroin use

Reuters Health News

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Mental illness in bariatric surgery: A cohort study from the PORTAL network

Obesity

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Vaccine alliance says 300,000 doses of Merck's Ebola shot available for emergencies

Reuters Health News

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Management of recurrent bleeding after pancreatoduodenectomy

ANZ Journal of Surgery

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Real-world effectiveness of ombitasvir/paritaprevir/ritonavir ± dasabuvir ± ribavirin in patients with HCV genotype 1 or 4 infection: A meta-analysis

Journal of Viral Hepatitis

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Survival outcomes in patients with neuroendocrine tumors

JAMA Oncology

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Infliximab and adalimumab drug levels in Crohn's disease: Contrasting associations with disease activity and influencing factors

Alimentary Pharmacology and Therapeutics

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Anastomotic complications after laparoscopic total gastrectomy with esophagojejunostomy constructed by circular stapler (OrVil) versus linear stapler (overlap method)

Surgical Endoscopy

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Systematic review with meta-analysis: Risk factors for non-alcoholic fatty liver disease suggest a shared altered metabolic and cardiovascular profile between lean and obese patients

Alimentary Pharmacology and Therapeutics

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Effectiveness of repeat 18F-fluorodeoxyglucose positron emission tomography computerized tomography (PET-CT) scan in identifying interval metastases for patients with esophageal cancer

Annals of Surgical Oncology

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Variation in delayed time to adjuvant chemotherapy and disease-specific survival in stage III colon cancer patients

Annals of Surgical Oncology

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"Ransomware" cyberattack cripples hospitals across England

AP

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Amylase, lipase, and acute pancreatitis in people with type 2 diabetes treated with liraglutide: Results from the LEADER randomized trial

Diabetes Care

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Magnitude and kinetics of decrease in liver stiffness after anti-viral therapy in patients with chronic hepatitis C: A systematic review and meta-analysis

Clinical Gastroenterology and Hepatology

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Accuracy of preoperative tumor localization in large bowel using 3D magnetic endoscopic imaging: Randomized clinical trial

Surgical Endoscopy

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A prospective randomized study of the use of an ultrathin colonoscope versus a pediatric colonoscope in sedation-optional colonoscopy

Surgical Endoscopy

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Histologic scores for fat and fibrosis associate with development of type 2 diabetes in patients with non-alcoholic fatty liver disease

Clinical Gastroenterology and Hepatology

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Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer: A multicenter randomized controlled trial (the BIOPEX-study)

Annals of Surgery

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Phosphate tablets or polyethylene glycol for preparation to colonoscopy? A multicentre non-inferiority randomized controlled trial

Surgical Endoscopy

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Technology: Nucleic acid detection — it's elementary with SHERLOCK!

Nature Reviews Genetics. doi:10.1038/nrg.2017.40

Author: Dorothy Clyde



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The evolutionary significance of polyploidy

Nature Reviews Genetics. doi:10.1038/nrg.2017.26

Authors: Yves Van de Peer, Eshchar Mizrachi & Kathleen Marchal



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