Reactive stepping with functional neuromuscular stimulation in response to forward-directed perturbations

Implanted motor system neuroprostheses can be effective at increasing personal mobility of persons paralyzed by spinal cord injuries. However, currently available neural stimulation systems for standing employ...

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No difference between noxious and innocuous thermal stimulation on motor recovery of upper extremity in patients with acute stroke: a randomized controlled trial with 6-month follow-up

Thermal stimulation (TS) have been developed and incorporated in stroke rehabilitation. However, whether noxious and innocuous TS induce the same effects on motor function recovery after stroke is still unknown. A comparative study of different temperature combination regimens is needed.

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Embryonic expression patterns of Eukaryotic EndoU ribonuclease family gene endouC in zebrafish

Publication date: Available online 10 June 2017
Source:Gene Expression Patterns
Author(s): Hung-Chieh Lee, Chuan-Yang Fu, Chih-Wei Zeng, Huai-Jen Tsai
Endou proteins belong to the Eukaryotic EndoU ribonuclease family of enzymes that present high sequence homology with the founding member XendoU domain. The enzymatic activity and three-dimensional structure of some Endou proteins have been previously reported. However, their molecular structure and gene expression patterns during embryogenesis remain to be elucidated. Therefore, we took zebrafish (Danio rerio) endouC as the model to study molecular structure and gene expression dynamics at different developmental stages. Zebrafish endouC cDNA contains 930 base pairs encoding 309 amino acid residues, sharing 27%, 27%, 27%, and 25% identity with that of human, mouse, chicken and frog, respectively. A phylogenetic tree showed that zebrafish EndouA was clustered with vertebrate Endou groups, while zebrafish EndouB and EndouC were found to belong to a unique monophyletic group. Furthermore, the endouC transcript was detected in one-cell embryos, suggesting that it is a maternal gene. While the endouC transcript was only weakly present at early developmental stages, its expression was greatly increased in embryos from 18 to 48 h post-fertilization (hpf) and then decreased after 72 hpf. Finally, endouC was ubiquitously expressed throughout the whole embryo during early embryogenesis, but its expression was enriched in brain, eyes and fin buds from 24 to 96 hpf.



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U-series dating and classification of the Apidima 2 hominin from Mani Peninsula, Southern Greece

Publication date: August 2017
Source:Journal of Human Evolution, Volume 109
Author(s): Antonis Bartsiokas, Juan Luis Arsuaga, Maxime Aubert, Rainer Grün
Laser ablation U-series dating results on a human cranial bone fragment from Apidima, on the western cost of the Mani Peninsula, Southern Greece, indicate a minimum age of 160,000 years. The dated cranial fragment belongs to Apidima 2, which preserves the facial skeleton and a large part of the braincase, lacking the occipital bone. The morphology of the preserved regions of the cranium, and especially that of the facial skeleton, indicates that the fossil belongs to the Neanderthal clade. The dating of the fossil at a minimum age of 160,000 years shows that most of the Neanderthal traits were already present in the MIS 6 and perhaps earlier. This makes Apidima 2 the earliest known fossil with a clear Neanderthal facial morphology. Together with the nearby younger Neanderthal specimens from Lakonis and Kalamakia, the Apidima crania are of crucial importance for the evolution of Neanderthals in the area during the Middle to Late Pleistocene. It can be expected that systematic direct dating of the other human fossils from this area will elucidate our understanding of Neanderthal evolution and demise.



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Autonomic specificity in emotion: The induction method matters

Publication date: Available online 9 June 2017
Source:International Journal of Psychophysiology
Author(s): Jared J. McGinley, Bruce H. Friedman
Research on the autonomic specificity of emotion has spanned decades, yet the findings of this research are still highly debated. Although many studies have explored the autonomic specificity of emotions, few have concurrently explored the influence by which the induction methods themselves have had in directing autonomic change. The current study was conducted to assess whether the methods for emotion elicitation could be meaningfully captured by multivariate pattern classification techniques that have been previously used to explore autonomic specificity of emotion. This aim was achieved by using three separate emotion-elicitation methods to elicit five separate emotions. A sample of 64 college-aged students watched film clips, read imagery scripts, and recalled personal memories for five emotion states. Using multivariate pattern classification analysis, the evidence from the current study lends further support for autonomic specificity of emotion, but also highlights the role that the specific induction technique contributes to autonomic changes that accompany emotions in the laboratory.



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Impact of anxiety symptoms and problematic alcohol use on error-related brain activity

Publication date: Available online 9 June 2017
Source:International Journal of Psychophysiology
Author(s): Stephanie M. Gorka, K. Luan Phan
Anxiety disorders are associated with enhanced defensive reactivity to errors, measured via the error-related negativity (ERN). There is some evidence to suggest that problematic alcohol use is also associated with an enhanced ERN; although prior studies have been almost exclusively in men and have yet to examine the potential interactive effects of anxiety and alcohol abuse symptoms. The aim of the current study was to address the gaps in this literature by examining the unique and interactive effects of anxiety symptoms and problematic alcohol use on the ERN in a sample of 79 heterogeneous internalizing disorder patients. All participants completed a flanker task designed to robustly elicit the ERN and questionnaires assessing current internalizing symptoms and problematic alcohol use. As expected, results revealed that greater anxiety symptoms, but not depressive symptoms, were associated with a more enhanced ERN. There was no main effect of problematic alcohol use but there was a significant anxiety by problematic alcohol use interaction. At high anxiety symptoms, greater problematic alcohol use was associated with a more enhanced ERN; at low anxiety symptoms, alcohol use was unrelated to the ERN. There was no depression by alcohol abuse interaction. The findings suggest that within anxious individuals, heightened reactivity to errors/threat may be related to risk for alcohol abuse. The findings also converge with a broader literature suggesting that heightened reactivity to threat may be a shared vulnerability factor for anxiety and alcohol abuse and a novel prevention and intervention target for anxiety-alcohol abuse comorbidity.



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Physiological effects of anterior repositioning splint on Temporomandibular joint disc displacement: A quantitative analysis

Abstract

Background

Anterior repositioning splints (ARS) are used primarily for the management of temporomandibular joint (TMJ) anterior disc displacement with reduction (ADDwR). However, the exact physiological effects of ARS are still unclear.

Objective

This study investigated the short and long-term effects of ARS on disc and condyle angles / positions by metric analysis.

Methods

22 subjects diagnosed with ADDwR were recruited. Maxillary full-coverage ARS were fabricated and MRI of TMJs were obtained before splint treatment, immediate post-insertion and 6 months after splint treatment. Disc-condyle relation was determined by disc-condyle angle measurement. Disc and condyle positions were described as X-Y coordinates with the summit of glenoid fossa as the origin of the coordinates.

Results

32 TMJs were classified as ADDwR and 12 were normal. Upon ARS insertion, all TMJs with ADDwR got normal disc-condyle relations. The condyles moved significantly forward and downward while the discs moved significantly backward and upward. MRI at 6 months after treatment (without ARS insertion) indicated that only 40.6% (13/32) of the joints were maintained in the normal disc-condyle relationship. The majority of condyles returned to their pre-treatment positions while the discs generally moved anteriorly again.

Conclusion

The use of ARS resulted in forward and downward condyle movement and a concurrent backward movement of the disc resulting in ideal spatial disc-condyle relationship. The stability of this relationship, however, could not be maintained in the majority of TMJs upon ARS removal. Findings explain the good short-term clinical outcomes with ARS and their relatively lower efficacy in the long-term.

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Postoperative pulmonary complications following non-cardiothoracic surgery

1H022A073A03

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An in vitro experimental model for analysis of central control of sympathetic nerve activity

Abstract

Newborn rat brainstem-spinal cord preparations are useful for in vitro analysis of various brainstem functions including respiratory activity. When studying the central control of sympathetic nerve activity (SNA), it is important to record peripheral outputs of the SNA. We developed an in vitro preparation in which neuronal connections between the cardiovascular center in the medulla and SNA peripheral outputs are preserved. Zero- to 1-day-old rats were deeply anesthetized with isoflurane, and the brainstem and spinal cord were isolated with a partial right thoracic cage to record sympathetic nerve discharge from the right thoracic sympathetic nerve trunk (T9–T11). SNA in this preparation was strongly modulated by inspiratory activity. Single-shot electrical stimulation of the ipsilateral rostral ventrolateral medulla (RVLM) induced a transient increase of SNA. Bath application of angiotensin II induced an increase of SNA, and local ipsilateral microinjection of angiotensin II to the RVLM induced a transient increase of SNA. This preparation allows analysis of the central control of the SNA in vitro.

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Acupuncture stimulation at GB34 suppresses 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced oxidative stress in the striatum of mice

Abstract

Recent studies have suggested that increased oxidative stress is a potential etiology in Parkinson's disease (PD). In this study, we investigated whether acupuncture regulates antioxidants in the striatum (ST) of a PD mouse model. Male C57BL/6 mice were administered 30 mg/kg of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) intraperitoneally once a day for 5 days and given acupuncture stimulation at SI3 or GB34 (Yanglingquan) was for 12 consecutive days. Dopaminergic neuronal survival in the nigrostriatal pathway and DJ-1 expression in the ST was evaluated by immunostaining, and the activities of superoxide dismutase (SOD) and catalase (CAT) in the ST was by enzyme-linked immunosorbent assay. MPTP administration induced dopaminergic neuronal death in the nigrostriatal pathway, which was suppressed by acupuncture stimulation at GB34. MPTP administration also suppressed DJ-1 expression and SOD and CAT activities in the ST, which were restored by acupuncture stimulation at GB34. These results indicate that the neuroprotective effect of acupuncture stimulation is due to regulation of the antioxidants.

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Neutral zone or conventional mandibular complete dentures: a randomized cross-over trial comparing oral-health related quality of life

Abstract

There is widespread consensus that the neutral zone (NZ) concept contributes to improved stability for mandibular complete dentures (CDs). However, little is known about its impact on oral health-related quality of life (OHRQoL) of edentulous patients compared to conventionally (CV) manufactured dentures. In this prospective cross-over trial, performed at the Oral Health Centre of the University of the Western Cape, CV and NZ mandibular dentures were made for each patient. Scores from the 20-item oral health impact profile (OHIP-20) for both types of dentures were compared with pre-treatment scores using paired t-tests. Treatment effect size (ES) was established. Associations of OHIP-20 scores and several patient variables (age, gender, period of edentulousness, quality of the denture-bearing tissue, denture dimensions, preference) were performed using the generalised linear model. Significance was set at p=0.05. Records of thirty five participants were included in the study (mean age of 62.3 years, (range 47-85 years). There were highly significant differences between pre-treatment and both post-treatment OHIP-20 scores with t=6.470 for CV and t=6.713 for NZ. Treatment ES was large for both types of dentures (>0.8). Difference of ES between NZ and CV dentures was small (ES<0.2). None of the patient variables showed significant associations with OHIP-20 scores of the two types of dentures, except for preference and NZ OHIP-20 scores. For this group of patients, both treatment methods improved OHRQoL significantly and patient-related factors did not influence impact on OHRQoL differently for both interventions.

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Temporomandibular dysfunction in adult patients with myotonic dystrophy (DM1)

Summary

Myotonic muscle dystrophy is a systemic disease with early engagement of the facial muscles. Our aim was to study dysfunction of the temporomandibular system in patients with 'classic' dystrophia myotonica (DM1) and compare it with TMD patients and healthy controls. The study included 27 referred patients with DM1, 18 women and 9 men, aged 30-62 years, and two matched control groups: patients with temporomandibular disorders symptoms (TMD) and healthy controls, both groups were consecutive patients. The patients answered questions regarding facial pain, jaw function and dysfunction. A clinical examination of the temporomandibular system including the occlusion was performed, and the maximum bite force and finger forces were measured. Among the DM1 patients, 33% reported difficulty biting off, and 22% had difficulty chewing, avoiding foods like meat and raw vegetables, and 37% of the DM1 patients scored their pain and discomfort as moderate to fairly severe. Their main complaints were TMJ clicking and locking, difficulty opening wide, and tiredness. They had more clinical signs of dysfunction compared with the controls (p < .001), but no statistically significant difference to the TMD patients. The maximum bite force in DM1 patients was impaired compared to both the TMD patients and the controls (p < .001). Significantly more occlusal interferences were found in DM1 patients, and were associated with chewing difficulties (p < .001). In conclusion, patients suffering from DM1 had an increased prevalence of TMD symptoms, reported impaired chewing function and had a decreased maximum bite force.

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The influence of oral health on patients’ food perception: a systematic review

Summary

Oral food perception depends on somato-sensory information that includes taste and can be modified by oral components and/or functions such as mastication. The purpose of this study is to describe the interplay between oral health, mastication and taste. A review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was conducted on 615 publications found by both pubmed and backward research. Thirty-one studies have been included. The results showed that the decline in taste ability observed during the healthy aging process could be potentiated by the deterioration of oral health and poor oral hygiene. Prosthetic treatment could modify taste ability and oral food perception. A palatal covering with removable dentures can have an impact on taste perception which may depend on taste modality. During the mastication sequence, taste is apparently scattered throughout the oral cavity, probably through saliva. The deterioration of masticatory function modifies taste perception. Oral health and oral care should consider factors influencing patients' food perception and relations between taste and mastication. Therefore, dentists may modulate these factors to improve food perception and patients' eating pleasure and quality of life.

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Temporomandibular disorders and dental occlusion. A systematic review of association studies: end of an era?

Abstract

Aim

To answer a clinical research question: "is there any association between features of dental occlusion and temporomandibular disorders (TMD)?"

Methods

A systematic literature review was performed. Inclusion was based on: 1. the type of study, viz., clinical studies on adults assessing the association between TMD (e.g., signs, symptoms, specific diagnoses) and features of dental occlusion by means of single or multiple variable analysis, and 2. their internal validity, viz., use of clinical assessment approaches to TMD diagnosis.

Results

The search accounted for 25 papers included in the review, 10 of which with multiple variable analysis. Quality assessment showed some possible shortcomings, mainly related with the unspecified representativeness of study populations. Seventeen (N=17) articles compared TMD patients with non-TMD individuals, whilst 8 papers compared the features of dental occlusion in individuals with TMD signs/symptoms and healthy subjects in non-patient populations. Findings are quite consistent toward a lack of clinically-relevant association between TMD and dental occlusion. Only 2 (i.e., centric relation [CR]-maximum intercuspation [MI] slide and mediotrusive interferences) of the almost forty occlusion features evaluated in the various studies were associated with TMD in the majority (e.g., at least 50%) of single variable analyses in patient populations. Only mediotrusive interferences are associated with TMD in the majority of multiple variable analyses. Such association does not imply a causal relationship and may even have opposite implications than commonly believed (i.e., interferences being the result, and not the cause, of TMD).

Conclusions

Findings support the absence of a disease-specific association. Based on that, there seems to lack ground to further hypothesize a role for dental occlusion in the pathophysiology of TMD. Clinicians are encouraged to abandon the old gnathological paradigm in TMD practice.

This article is protected by copyright. All rights reserved.

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New tests identify patterns of vestibular loss

Publication date: Available online 10 June 2017
Source:Clinical Neurophysiology
Author(s): L. Manzari, I.S. Curthoys




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Power training-induced increases in muscle activation during gait in old adults.

Introduction/Purpose: Aging modifies neuromuscular activation of agonist and antagonist muscles during walking. Power training can evoke adaptations in neuromuscular activation that underlie gains in muscle strength and power but it is unknown if these adaptations transfer to dynamic tasks such as walking. We examined the effects of lower extremity power training on neuromuscular activation during level gait in old adults. Methods: Twelve community dwelling old adults (age >= 65 years) completed a 10-week lower extremity power-training program and thirteen old adults completed a 10-week control period. Before and after the interventions, we measured maximal isometric muscle strength and electromyographic (EMG) activation of the right knee flexor, knee extensor, and plantarflexor muscles on a dynamometer and we measured EMG amplitudes, activation onsets and offsets, and activation duration of the knee flexors, knee extensors, and plantarflexors during gait at habitual, fast, and standardized (1.25+/-0.6m/s) speeds. Results: Power training-induced increases in EMG amplitude (~41%; 0.47

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Cardiorespiratory Reference Data in Older Adults: The Generation 100 Study.

Purpose: Cardiorespiratory fitness (CRF) is regarded a clinical vital sign, and accurate reference values for all age groups are essential. Little data exist on CRF and cardiorespiratory function in older adults. The aim of this study was to provide normative values for CRF and cardiorespiratory function in older adults, including people with history of cardiovascular diseases. Methods: In total, 1537 (769 women) participants aged 70-77 underwent clinical examinations and cardiopulmonary exercise tests. Peak oxygen uptake (VO2peak), ventilation (VEpeak), expiration of carbon dioxide (VCO2peak), breathing frequency (BFpeak), tidal volume (VTpeak), oxygen pulse (O2-pulsepeak), ventilatory efficiency (EqVO2peak and EqVCO2peak), and 1-minute heart rate recovery were assessed. Results: Men compared to women had higher VO2peak (31.3+/- 6.7 versus 26.2+/-5.0 mL/min/kg), BFpeak (41.8+/-8.0 versus 39.7+/-7.1 breath/min), VTpeak (2.3+/-0.5 versus 1.6+/-0.3), O2-pulsepeak (16.4+/-3.2 versus 11.3+/-2.0), VCO2peak (2.9+/-0.2 and 1.9+/-0.1 L/min), VEpeak (96.2+/-21.7 versus 61.1+/-21.6 L/min), EqVO2peak (38.0+/-6.9 versus 35.1+/-5.6), and EqVCO2peak (33.5+/-5.7 versus 31.9+/-4.5). Women and men with CVD had lower VO2peak (14% and 19%), HRpeak (5% and 6 %), VEpeak (8% and 10%), VTpeak (7% and 4 %), and lower EqVCO2peak (4% and 6%) compared to their healthy counterparts, respectively. Compared to healthy women and men, 1-minute heart rate recovery was 12% and 16% lower for women and men with CVD. Conclusion: This study represents the largest reference material on directly measured CRF and cardiorespiratory function in older men and women, with and without CVD. Novel information will help researchers and clinicians to interpret data form cardiopulmonary testing in older adults. (C) 2017 American College of Sports Medicine

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Xenon as an Adjuvant to Propofol Anesthesia in Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery: A Pragmatic Randomized Controlled Clinical Trial.

BACKGROUND: Xenon was shown to cause less hemodynamic instability and reduce vasopressor needs during off-pump coronary artery bypass (OPCAB) surgery when compared with conventionally used anesthetics. As xenon exerts its organ protective properties even in subanesthetic concentrations, we hypothesized that in patients undergoing OPCAB surgery, 30% xenon added to general anesthesia with propofol results in superior hemodynamic stability when compared to anesthesia with propofol alone. METHODS: Fifty patients undergoing elective OPCAB surgery were randomized to receive general anesthesia with 30% xenon adjuvant to a target-controlled infusion of propofol or with propofol alone. The primary end point was the total intraoperative dose of norepinephrine required to maintain an intraoperative mean arterial pressure >70 mm Hg. Secondary outcomes included the perioperative cardiorespiratory profile and the incidence of adverse and serious adverse events. RESULTS: Adding xenon to propofol anesthesia resulted in a significant reduction of norepinephrine required to attain the predefined hemodynamic goals (cumulative intraoperative dose: median [interquartile range]: 370 [116-570] vs 840 [335-1710] [micro]g, P = .001). In the xenon-propofol group, significantly less propofol was required to obtain a similar depth of anesthesia as judged by clinical signs and the bispectral index (propofol effect site concentration [mean +/- SD]: 1.8 +/- 0.5 vs 2.8 +/- 0.3 mg, P

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Perioperative Temperature Measurement Considerations Relevant to Reporting Requirements for National Quality Programs Using Data From Anesthesia Information Management Systems.

Background: Perioperative hypothermia may increase the incidences of wound infection, blood loss, transfusion, and cardiac morbidity. U.S. national quality programs for perioperative normothermia specify the presence of at least 1 "body temperature" >=35.5[degrees]C during the interval from 30 minutes before to 15 minutes after the anesthesia end time. Using data from 4 academic hospitals, we evaluated timing and measurement considerations relevant to the current requirements to guide hospitals wishing to report perioperative temperature measures using electronic data sources. METHODS: Anesthesia information management system databases from 4 hospitals were queried to obtain intraoperative temperatures and intervals to the anesthesia end time from discontinuation of temperature monitoring, end of surgery, and extubation. Inclusion criteria included age >16 years, use of a tracheal tube or supraglottic airway, and case duration >=60 minutes. The end-of-case temperature was determined as the maximum intraoperative temperature recorded within 30 minutes before the anesthesia end time (ie, the temperature that would be used for reporting purposes). The fractions of cases with intervals >30 minutes between the last intraoperative temperature and the anesthesia end time were determined. RESULTS: Among the hospitals, averages (binned by quarters) of 34.5% to 59.5% of cases had intraoperative temperature monitoring discontinued >30 minutes before the anesthesia end time. Even if temperature measurement had been continued until extubation, averages of 5.9% to 20.8% of cases would have exceeded the allowed 30-minute window. Averages of 8.9% to 21.3% of cases had end-of-case intraoperative temperatures

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Anesthetic and Obstetric Management of Syringomyelia During Labor and Delivery: A Case Series and Systematic Review.

BACKGROUND: Syringomyelia is a rare, slowly progressive neurological condition characterized by the presence of a syrinx within the spinal cord. Consensus regarding the safest mode of delivery and anesthetic management in patients with syringomyelia remains controversial and presents management dilemmas. This study reviews the cases of syringomyelia at our institution and provides a systematic review of the literature to guide decisions regarding labor and delivery management. METHODS: A retrospective review of cases at our hospital from 2002 to 2014 and a systematic review of the literature from 1946 to 2014 were undertaken. Hospital records and electronic databases were interrogated using International Classification of Diseases, 10th Revision codes and the keywords "syringomyelia," "syringobulbia," and "pregnancy". Data regarding demographics, diagnosis, radiology reports, neurological symptoms, mode of delivery, anesthetic management, and maternal-fetal outcomes were collected. RESULTS: We collected and analyzed data on a total of 43 pregnancies in 39 patients. The most common location for syrinx was in the cervicothoracic region (41.9%). The large majority of patients (n = 34; 87%) demonstrated signs and symptoms associated with syringomyelia before delivery. Syringomyelia associated with Arnold Chiari malformation was documented in 49% (n = 21) cases. General anesthesia was the most commonly used (n = 21/30, 70%) anesthetic technique for cesarean delivery. The majority (n = 9/13, 69%) of patients had an epidural sited for labor analgesia. There were no maternal or neonatal complications associated with neuraxial anesthesia; however, 3 cases (14%) raised concerns regarding general anesthesia including difficult intubation, transient worsening of neurological symptoms postpartum, and prolonged muscle paralysis after atracurium. CONCLUSIONS: Despite concerns regarding aggravation of the syrinx with vaginal delivery, this mode of delivery has never caused any documented long-term worsening of neurological condition. All techniques of anesthesia have been performed successfully without major lasting complications. All cases necessitate patient counseling and individualized multidisciplinary involvement to ensure maternal safety. (C) 2017 International Anesthesia Research Society

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Protective Lung Ventilation and Morbidity After Pulmonary Resection: A Propensity Score-Matched Analysis.

BACKGROUND: Protective lung ventilation (PLV) during one-lung ventilation (OLV) for thoracic surgery is frequently recommended to reduce pulmonary complications. However, limited outcome data exist on whether PLV use during OLV is associated with less clinically relevant pulmonary morbidity after lung resection. METHODS: Intraoperative data were prospectively collected in 1080 patients undergoing pulmonary resection with OLV, intentional crystalloid restriction, and mechanical ventilation to maintain inspiratory peak airway pressure =8 mL/kg (predicted body weight) mean tidal volume. The primary outcome was the occurrence of pneumonia and/or acute respiratory distress syndrome (ARDS). Propensity score matching was used to generate PLV and non-PLV groups with comparable characteristics. Associations between outcomes and PLV status were analyzed by exact logistic regression, with matching as cluster in the anatomic and nonanatomic lung resection cohorts. RESULTS: In the propensity score-matched analysis, the incidence of pneumonia and/or ARDS among patients who had an anatomic lung resection was 9/172 (5.2%) in the non-PLV compared to the PLV group 7/172 (4.1%; odds ratio, 1.29; 95% confidence interval, 0.48-3.45, P= .62). The incidence of pneumonia and/or ARDS in patients who underwent nonanatomic resection was 3/118 (2.5%) in the non-PLV compared to the PLV group, 1/118 (0.9%; odds ratio, 3.00; 95% confidence interval, 0.31-28.84, P= .34). CONCLUSIONS: In this prospective observational study, we found no differences in the incidence of pneumonia and/or ARDS between patients undergoing lung resection with tidal volumes =8 mL/kg. Our data suggest that when fluid restriction and peak airway pressures are limited, the clinical impact of PLV in this patient population is small. Future randomized trials are needed to better understand the benefits of a small tidal volume strategy during OLV on clinically important outcomes. (C) 2017 International Anesthesia Research Society

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Improving Performance by Monitoring the Success Rate of Peripheral Nerve Blocks.

In our hospital, we introduced a system to measure the collective and individual efficacy of brachial plexus and popliteal nerve blocks with the objective to create transparency as an instrument for monitoring and improvement. Initially, individual results were anonymous, but after 1 year anonymity was lifted within the team of anesthesiologists and results are now discussed quarterly. Collective performance of interscalene, supraclavicular, and popliteal blocks improved significantly over time. Sharing and discussing collective and individual performance has resulted in critical self-appraisal and increased willingness to learn from each other and strengthened the team's ambition for further improvement. (C) 2017 International Anesthesia Research Society

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Falls From the O.R. or Procedure Table.

Patient safety secured by constant vigilance remains a primary responsibility of every anesthesia professional. Although significant attention has been focused on patient falls occurring before and after surgery, a potentially catastrophic complication is when patients fall off an operating room or procedure table during anesthesia care. Because such events are (fortunately) uncommon, and because very little information is published in our literature, we queried 2 independent closed claims databases (the American Society of Anesthesiologists Closed Claims Project and the secure records of a private, anesthesia specialty-specific liability insurer) for information. We acquired documentation of patient events where a fall occurred during anesthesia care, noting the surrounding conditions of the provider, the patient, and the environment at the time of the event. We identified 21 claims (1.2% of cases) from the American Society of Anesthesiologists Closed Claims Project, while information from a private liability insurer identified falls in only 0.07% of cases. The percentage of these patients under general, regional, or monitored anesthesia care anesthesia was 71.5%, 19.5%, and 9.5%, respectively. To educate personnel about these uncommon events, we summarized this cohort with illustrative examples in a series of mini-case reports, noting that both inpatients and outpatients undergoing a broad array of procedures with various anesthetic techniques within and outside operating rooms may be vulnerable to patient falls. Based on detailed reports, we created 2 supplementary videos to further illuminate some of the unique mechanisms by which these events and their resulting injuries occur. When such information was available, we also noted the associated liability costs of defending and settling malpractice claims associated with these events. Our goal is to inform anesthesia and perioperative personnel about the common patient, provider, and environmental risk factors that appear to contribute to these mishaps, and suggest key strategies to mitigate the risks. (C) 2017 International Anesthesia Research Society

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Cardiorespiratory Alterations Following Acute Normovolemic Hemodilution in a Pediatric and an Adult Porcine Model: A Prospective Interventional Study.

BACKGROUND: Acute normovolemic hemodilution (ANH) is considered as a blood-sparing intervention during the perioperative management. We aimed at comparing the cardiopulmonary consequences of ANH between adult pigs and weaned piglets to establish the effects of lowering hematocrit in these age groups, and thereby testing the hypothesis that difference in the age-related physiological behavior will be reflected in the cardiorespiratory changes following ANH. METHODS: ANH was achieved in anesthetized, mechanically ventilated adult minipigs and 5-week-old weaned piglets by stepwise blood withdrawal (10 mL/kg) with crystalloids replacement. Cardiorespiratory assessments consisted of measuring airway resistance, respiratory tissue elastance, effective lung volume, extravascular lung water, mean arterial pressure, pulmonary blood flow, and cardiac output. Respiratory and hemodynamic measurements were made at control conditions and following each ANH condition obtained with 5 to 7 steps. RESULTS: ANH induced immediate and progressive increases in airway resistance and tissue elastance in both groups, with more pronounced worsening in adults despite the similar decreases in hematocrit. The increases in extravascular lung water were significantly greater in the adult population with the differences in mean (DM) of 25.1% (95% confidence interval [CI], 5.3%-44.9%). Progressive ANH led to significant decreases in the DM of pulmonary blood flow (45.3%; 95% CI, 19.8%-70.8%) and mean arterial pressure (36.3%; 95% CI, 18.7%-53.9%) only in adults, whereas cardiac output increased significantly only in the piglets (DM, 51.6; 95% CI, 14.2%-89.0%). CONCLUSIONS: While ANH led to mild detrimental cardiorespiratory changes in weaned piglets, gradual developments of bronchoconstriction, lung tissue extravasation and stiffening, and deteriorations in systemic and pulmonary hemodynamics were observed in adults. ANH may exert age-dependent cardiorespiratory effect. (C) 2017 International Anesthesia Research Society

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Aerosolized Vasodilators for the Treatment of Pulmonary Hypertension in Cardiac Surgical Patients: A Systematic Review and Meta-analysis.

BACKGROUND: In cardiac surgery, pulmonary hypertension is an important prognostic factor for which several treatments have been suggested over time. In this systematic review and meta-analysis, we compared the efficacy of inhaled aerosolized vasodilators to intravenously administered agents and to placebo in the treatment of pulmonary hypertension during cardiac surgery. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and clinicaltrials.gov databases from inception to October 2015. The incidence of mortality was assessed as the primary outcome. Secondary outcomes included length of stay in hospital and in the intensive care unit, and evaluation of the hemodynamic profile. METHODS: Of the 2897 citations identified, 10 studies were included comprising a total of 434 patients. RESULTS: Inhaled aerosolized agents were associated with a significant decrease in pulmonary vascular resistance (-41.36 dyne[middle dot]s/cm5, P= .03) and a significant increase in mean arterial pressure (8.24 mm Hg, P= .02) and right ventricular ejection fraction (7.29%, P

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Virtual Reality as an Adjunctive Nonpharmacological Sedative During Orthopedic Surgery Under Regional Anesthesia: A Pilot and Feasibility Study.

This pilot study assessed the feasibility and potential for any possible sedation sparing effect of immersive virtual reality (IVR) therapy on patients undergoing joint replacement surgery under regional anesthesia. Nine participants were given IVR, regional anesthetic, and sedation. Ten received conventional care. Mean propofol usage was 155 +/- 45 mg/h in the conventional care group and 63 +/- 21 mg/h in the IVR group (P = .088, mean difference -91.6 mg/h, 95% confidence interval -200 to 16.87 mg/h). There was no significant difference in postoperative satisfaction between the 2 groups. This pilot study demonstrates that it is possible to safely provide IVR in an operating theater environment and may confer a sedation sparing effect. A larger, more powered, and randomized study is needed to assess this effect. (C) 2017 International Anesthesia Research Society

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Retrograde Type B Aortic Dissection Caused by Intraaortic Balloon Counterpulsation.

No abstract available

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Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs.

BACKGROUND: We consider whether there should be greater priority of information sharing about postacute surgical resources used: (1) at skilled nursing facilities or inpatient rehabilitation hospitals to which patients are transferred upon discharge (when applicable) versus (2) at different hospitals where readmissions occur. Obtaining and storing data electronically from these 2 sources for Perioperative Surgical Home initiatives are dissimilar; both can be challenging depending on the country and health system. METHODS: Using the 2013 US Nationwide Readmissions Database, we studied discharges of surgical diagnosis-related group (DRG) with US national median length of stay (LOS) >= 3 days and >= 10 hospitals each with >= 100 discharges for the Medicare Severity DRG. RESULTS: Nationwide, 16.15% (95% confidence interval [CI], 15.14%-17.22%) of discharges were with a disposition of "not to home" (ie, transfer to a skilled nursing facility or an inpatient rehabilitation hospital). Within 30 days, 0.88% of discharges (0.82%-0.95%) were followed by readmission and to a different hospital than the original hospital where the surgery was performed. Among all discharges, disposition "not to home" versus "to home" was associated with greater odds that the patient would have readmission within 30 days and to a different hospital than where the surgery was performed (2.11, 95% CI, 1.96-2.27; P

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Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technique that allows for temporary occlusion of the aorta in patients with severe, life-threatening, trauma-induced noncompressible hemorrhage arising below the diaphragm. REBOA utilizes a transfemoral balloon catheter inserted in a retrograde fashion into the aorta to provide inflow control and support blood pressure until definitive hemostasis can be achieved. Initial retrospective and registry clinical data in the trauma surgical literature demonstrate improvement in systolic blood pressure with balloon inflation and improved survival compared to open aortic cross-clamping via resuscitative thoracotomy. However, there are no significant reports of anesthetic implications and perioperative management in this challenging cohort. In this narrative, we review the principles, technique, and logistics of REBOA deployment, as well as initial clinical outcome data from our level-1 American College of Surgeons-verified trauma center. For anesthesiologists who may not yet be familiar with REBOA, we make several suggestions and recommendations for intraoperative management based on extrapolation from these initial surgical-based reports, opinions from a team with increasing experience, and translated experience from emergency aortic vascular surgical procedures. Further prospective data will be necessary to conclusively guide anesthetic management, especially as potential complications and implications for global organ function, including cerebral and renal, are recognized and described. (C) 2017 International Anesthesia Research Society

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Endoscopic Sleeve Gastroplasty: A Concern of Anesthesiologists.

No abstract available

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Enhancing Feedback on Professionalism and Communication Skills in Anesthesia Residency Programs.

BACKGROUND: Despite its importance, training faculty to provide feedback to residents remains challenging. We hypothesized that, overall, at 4 institutions, a faculty development program on providing feedback on professionalism and communication skills would lead to (1) an improvement in the quantity, quality, and utility of feedback and (2) an increase in feedback containing negative/constructive feedback and pertaining to professionalism/communication. As secondary analyses, we explored these outcomes at the individual institutions. METHODS: In this prospective cohort study (October 2013 to July 2014), we implemented a video-based educational program on feedback at 4 institutions. Feedback records from 3 months before to 3 months after the intervention were rated for quality (0-5), utility (0-5), and whether they had negative/constructive feedback and/or were related to professionalism/communication. Feedback records during the preintervention, intervention, and postintervention periods were compared using the Kruskal-Wallis and [chi]2 tests. Data are reported as median (interquartile range) or proportion/percentage. RESULTS: A total of 1926 feedback records were rated. The institutions overall did not have a significant difference in feedback quantity (preintervention: 855/3046 [28.1%]; postintervention: 896/3327 [26.9%]; odds ratio: 1.06; 95% confidence interval, 0.95-1.18; P = .31), feedback quality (preintervention: 2 [1-4]; intervention: 2 [1-4]; postintervention: 2 [1-4]; P = .90), feedback utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 1 [1-2]; P = .61), or percentage of feedback records containing negative/constructive feedback (preintervention: 27%; intervention: 32%; postintervention: 25%; P = .12) or related to professionalism/communication (preintervention: 23%; intervention: 33%; postintervention: 24%; P = .03). Institution 1 had a significant difference in feedback quality (preintervention: 2 [1-3]; intervention: 3 [2-4]; postintervention: 3 [2-4]; P = .001) and utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 2 [1-4]; P = .008). Institution 3 had a significant difference in the percentage of feedback records containing negative/constructive feedback (preintervention: 16%; intervention: 28%; postintervention: 17%; P = .02). Institution 2 had a significant difference in the percentage of feedback records related to professionalism/communication (preintervention: 26%; intervention: 57%; postintervention: 31%; P

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Intraoperative "Analgesia Nociception Index"-Guided Fentanyl Administration During Sevoflurane Anesthesia in Lumbar Discectomy and Laminectomy: A Randomized Clinical Trial.

BACKGROUND: The "Analgesia Nociception Index" (ANI; MetroDoloris Medical Systems, Lille, France) is a proposed noninvasive guide to analgesia derived from an electrocardiogram trace. ANI is scaled from 0 to 100; with previous studies suggesting that values >=50 can indicate adequate analgesia. This clinical trial was designed to investigate the effect of intraoperative ANI-guided fentanyl administration on postoperative pain, under anesthetic conditions optimized for ANI functioning. METHODS: Fifty patients aged 18 to 75 years undergoing lumbar discectomy or laminectomy were studied. Participants were randomly allocated to receive intraoperative fentanyl guided either by the anesthesiologist's standard clinical practice (control group) or by maintaining ANI >=50 with boluses of fentanyl at 5-minute intervals (ANI group). A standardized anesthetic regimen (sevoflurane, rocuronium, and nonopioid analgesia) was utilized for both groups. The primary outcome was Numerical Rating Scale pain scores recorded from 0 to 90 minutes of recovery room stay. Secondary outcomes included those in the recovery room period (total fentanyl administration, nausea, vomiting, shivering, airway obstruction, respiratory depression, sedation, emergence time, and time spent in the recovery room) and in the intraoperative period (total fentanyl administration, intraoperative-predicted fentanyl effect-site concentrations over time [CeFent], the correlation between ANI and predicted CeFent and the incidence of movement). Statistical analysis was performed with 2-tailed Student t tests, [chi]2 tests, ordinal logistic generalized estimating equation models, and linear mixed-effects models. Bonferroni corrections for multiple comparisons were made for primary and secondary outcomes. RESULTS: Over the recovery room period (0-90 minutes) Numerical Rating Scale pain scores were on average 1.3 units lower in ANI group compared to the control group (95% confidence interval [CI], -0.4 to 2.4; P= .01). Patients in the ANI group additionally had 64% lower recovery room total fentanyl administration (95% CI, -12% to 85%; P= .44, unadjusted P= .026), 82% lower nausea scores (95% CI, -19% to 96%; P= .43, unadjusted P= .03), and a reduced incidence of shivering (ANI 4%, control 27%, P= .80, unadjusted P= .047) compared to the control group. Intraoperatively, ANI group patients had on average 27% higher predicted CeFent levels during the highly nociceptive periods of intubation and first incision (5-30 minutes) compared with control group patients (95% CI, 3%-57%; P= .51, unadjusted P= .03). For a 1-unit decrease in ANI scores, predicted CeFent on average increased by an estimated 1.98% in the ANI group (95% CI, 1.7%-2.26%; P

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Cardiac Output Measurements Based on the Pulse Wave Transit Time and Thoracic Impedance Exhibit Limited Agreement With Thermodilution Method During Orthotopic Liver Transplantation.

BACKGROUND: Orthotopic liver transplantation (OLT) is characterized by significant intraoperative hemodynamic variability. Accurate and real-time cardiac output (CO) monitoring aids clinical decision making during OLT. The purpose of this study is to compare accuracy, precision, and trending ability of CO estimation obtained noninvasively using pulse wave transit time (estimated continuous cardiac output [esCCO; Nihon Kohden, Tokyo, Japan]) or thoracic bioimpedance (ICON; Osypka Medical GmbH, Berlin, Germany) to thermodilution cardiac output (TDCO) measured with a pulmonary artery catheter. METHODS: Nineteen patients undergoing OLT were enrolled. CO measurements were collected with esCCO, ICON, and thermodilution at 5 time points: (T1) pulmonary artery catheter insertion; (T2) surgical incision; (T3) portal reperfusion; (T4) hepatic arterial reperfusion; and (T5) abdominal closure. The results were analyzed with Bland-Altman plot, percentage error (the percentage of the difference between the CO estimated with the noninvasive monitoring device and CO measured with the thermodilution technique), 4-quadrant plot with concordance rate(the percentage of the total number of points in the I and III quadrant of the 4-quadrant plot), and concordance correlation coefficient (a measure of how well the pairs of observations deviate from the 45-degree line of perfect agreement). RESULTS: Although TDCO increased at T3-T5, both esCCO and ICON failed to track the changes of CO with sufficient accuracy and precision. The mean bias of esCCO and ICON compared to TDCO were -2.0 L/min (SD, +/-2.7 L/min) and -3.3 L/min (SD, +/-2.8 L/min), respectively. The percentage error was 69% for esCCO and 77% for ICON. The concordance correlation coefficient was 0.653 (95% confidence interval [CI], 0.283-0.853) for esCCO and 0.310 (95% CI, -0.167 to 0.669) for ICON. Nonetheless, esCCO and ICON exhibited reasonable trending ability of TDCO (concordance rate: 95% [95% CI, 88-100] and 100% [95% CI, 93-100]), respectively. The mean bias was correlated with systemic vascular resistance (SVR) and arterial elastance (Ea) for esCCO (SVR, r = 0.610, 95% CI, 0.216-0.833, P

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