Humans manage to live under the sun, and are repeatedly exposed to gross and extensive changes in low-level visual information in daily life. For example, you might remember that the sunlight dazzled your eyes when you stepped out from a movie theater. Experimental studies using visual-evoked potentials (VEP) and electrical stimulation suggest that such visual perception is associated primarily with neural processing in the medial-occipital region (Barett et al., 1976; Ducati et al., 1988; Winawer and Parvizi, 2016; Bosking et al., 2017).
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Παρασκευή 3 Νοεμβρίου 2017
Four-dimensional map of the human early visual system
Does Azathioprine induce endoscopic and histologic healing in Pediatric Inflammatory Bowel Disease? A prospective, observational study
The new concept of disease remission for pediatric inflammatory bowel diseases (IBD) implies the achievement of mucosal healing.
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Does Azathioprine induce endoscopic and histologic healing in Pediatric Inflammatory Bowel Disease? A prospective, observational study
The new concept of disease remission for pediatric inflammatory bowel diseases (IBD) implies the achievement of mucosal healing.
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Minimally invasive surgical approaches offer earlier time to adjuvant chemotherapy but not improved survival in resected pancreatic cancer
Abstract
Background
Pancreatic surgery encompasses complex operations with significant potential morbidity. Greater experience in minimally invasive surgery (MIS) has allowed resections to be performed laparoscopically and robotically. This study evaluates the impact of surgical approach in resected pancreatic cancer.
Methods
The National Cancer Data Base (2010–2012) was reviewed for patients with stages 1–3 resected pancreatic carcinoma. Open approaches were compared to MIS. A sub-analysis was then performed comparing robotic and laparoscopic approaches.
Results
Of the 9047 patients evaluated, surgical approach was open in 7511 (83%), laparoscopic in 992 (11%), and robotic in 131 (1%). The laparoscopic and robotic conversion rate to open was 28% (n = 387) and 17% (n = 26), respectively. Compared to open, MIS was associated with more distal resections (13.5, 24.3%, respectively, p < 0.0001), shorter hospital length of stay (LOS) (11.3, 9.5 days, respectively, p < 0.0001), more margin-negative resections (75, 79%, p = 0.038), and quicker time to initiation of chemotherapy (TTC) (59.1, 56.3 days, respectively, p = 0.0316). There was no difference in number of lymph nodes obtained based on surgical approach (p = 0.5385). When stratified by type of resection (head, distal, or total), MIS offered significantly shorter LOS in all types. Multivariate analysis demonstrated no survival benefit for any MIS approach relative to open (all, p > 0.05). When adjusted for patient, disease, and treatment characteristics, TTC was not an independent prognostic factor (HR 1.09, p = 0.084).
Conclusion
MIS appears to offer comparable surgical oncologic benefit with improved LOS and shorter TTC. This effect, however, was not associated with improved survival.
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Comparison of clinical efficacies and safeties of lumen-apposing metal stent and conventional-type metal stent-assisted EUS-guided pancreatic wall-off necrosis drainage: a real-life experience in a tertiary hospital
Abstract
Background
Endoscopic ultrasound (EUS)-guided drainage of pancreatic wall-off necrosis (WON) with transmural stent is regarded as firstline therapy. We aimed at comparing its efficacy and safety with using fully covered self-expandable metal stent (FCSEMS) and lumen-apposing metal stent (LAMS).
Methods
A retrospective review was performed on all consecutive patients with pancreatic WONs who underwent EUS-guided drainage by either FCSEMS or LAMS.
Results
From 2011 to 2016, 68 patients (66.2% male, median age, 66.5 years) underwent WON drainage (22/68 (32.4%) using FCSEMSs of size 10 × 60 mm (14/22, Hanarostent; 8/22 Wallflex); 46/68 (67.6%) using LAMSs (38/46 and 8/46 with AXIOS of size 15 × 10 mm and 10 × 10 mm, respectively). These two groups were matched for age (66 vs. 70 years, p 0.514), APACHE II (11.5 vs. 10, p 0.693), causes [72.7 vs. 80.4% by gallstone pancreatitis (p 0.472); 9.1 vs. 10.9% by alcoholism (p 0.818)], WON size (8.5 vs. 9 cm, p 0.322), location (36.4 vs. 26.1% at pancreatic head, p 0.384; 54.5 vs. 65.2% at body/tail, p 0.395), and enterostomy site [63.6 vs. 76.1% via transgastric (p 0.285); 31.8 vs. 19.6% via transduodenal (p 0.267)] and their number of necrosectomy (p 0.978). The technical (100 vs. 93.5%, p 0.219) and clinical (95.5 vs. 93.5%, p 0.749) success and adverse event (22.7 vs. 39.1%, p 0.180; 9.1 vs. 19.6% with bleeding, p 0.271; 4.5 vs. 13% with spontaneous stent migration, p 0.28; 9.1 vs. 6.5% with dislodgement during necrosectomy, p 0.704) of the two groups were comparable without significant different. However, the LAMS group associated with early stent revision compared with FCSEMS group (log rank p 0.048).
Conclusions
EUS-guided drainage of WON using FCSEMSs and LAMSs are comparable in efficacy and safety; however, the latter is associated with early stent revision.
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Vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection
Abstract
Background
Conventional open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD) result in poor quality of life because of damage to the vagal nerve. We have developed vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (VLSD). This study aimed to evaluate whether VLSD is effective and safe, and to determine whether a reduction in the incidence of postoperative complications improves postoperative quality of life compared with CLSD.
Methods
We retrospectively evaluated outcomes in 72 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent CLSD (n = 40) or VLSD (n = 32) between April 2015 and December 2016. Their demographic, intraoperative, and postoperative variables were compared.
Results
No patients required conversion to laparotomy in CLSD and VLSD. There was no difference in estimated intraoperative blood loss, volume of intraoperative blood transfused, time to first flatus, time to off-bed activity, and postoperative hospital stay between the two groups. VLSD was associated with a shorter operation time (P = 0.020) and less postoperative complications (P < 0.0001), including less diarrhea (P < 0.0001), epigastric fullness (P < 0.0001), and delayed gastric emptying (P < 0.0001), compared with CLSD. With VLSD, there was a significant increase in body weight and plasma albumin levels at 6 months postoperatively compared with preoperative values (all P < 0.05). The curative effect of improving esophageal/gastric variceal bleeding was similar in the groups.
Conclusions
VLSD is effective and safe for reducing the incidence of postoperative complications, contributing to improving postoperative quality of life.
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Non-exposure simple suturing endoscopic full-thickness resection (NESS-EFTR) versus laparoscopic wedge resection: a randomized controlled trial in a porcine model
Abstract
Background
Current endoscopic full-thickness resection (EFTR) methods produce transmural communication and expose the tumor to the peritoneum. An EFTR method with a simple suturing technique that does not expose the gastric mucosa to the peritoneum (non-exposure simple suturing, NESS) was recently developed. To date, there have been no prospective studies that compare EFTR with laparoscopic wedge resection in human or animal. The aim of this study was to compare outcomes between NESS-EFTR and laparoscopic wedge resection (LWR) using the linear staplers in a randomized animal study.
Methods
NESS-EFTR includes steps of laparoscopic seromuscular suturing, EFTR of the inverted stomach wall, and endoscopic mucosal suturing with endoloops and clips. Sixteen pigs underwent NESS-EFTR (n = 8) or LWR (n = 8). The resected locations were the cardia, fundus, upper body anterior and greater curvature, antrum lesser and greater curvature side. The pigs were killed 3 weeks after surgery. Rates of successful complete resection (en-bloc resection with clear margins), successful closure, and complications were evaluated.
Results
The complete resection rates in the NESS-EFTR and LWR groups were 100 and 75%, respectively (P = 0.467). All wounds were successfully closed in both groups. Resected tissues were significantly larger in the LWR group (mean ± SD: 8.0 ± 0.8 cm vs. 4.4 ± 0.5 cm, P < 0.001). Procedure time was significantly shorter in the LWR group (31.7 ± 10.0 min vs. 118.1 ± 23.4 min, P < 0.001). Early deaths due to complications only occurred in the LWR group (a leakage at cardia and a stenosis at the antrum lesser curvature side).
Conclusions
Incomplete resection and complications were occurred in only LWR group. NESS-EFTR was feasible and safe in animal.
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Academic status does not affect outcome following complex hepato-pancreato-biliary procedures
Abstract
Introduction
There is a growing debate regarding outcomes following complex hepato-pancreato-biliary (HPB) procedures. The purpose of our study is to examine if facility type has any impact on complications, readmission rates, emergency department (ED) visit rates, and length of stay (LOS) for patients undergoing HPB surgery.
Methods
The SPARCS administrative database was used to identify patients undergoing complex HPB procedures between 2012 and 2014 in New York. Univariate generalized linear mixed models were fit to estimate the marginal association between outcomes such as overall/severe complication rates, 30-day and 1-year readmission rates, 30-day and 1-year ED-visit rates, and potential risk factors. Univariate linear mixed models were used to estimate the marginal association between possible risk factors and LOS. Facility type, as well as any variables found to be significant in our univariate analysis (p = 0.05), was further included in the multivariable regression models.
Results
There were 4122 complex HPB procedures performed. Academic facilities were more likely to have a higher hospital volume (p < 0001). Surgery at academic facilities were less likely to have coexisting comorbidities; however, they were more likely to have metastatic cancer and/or liver disease (p = 0.0114, < 0. 0001, and = 0.0299, respectively). Postoperatively, patients at non-academic facilities experienced higher overall complication rates, and higher severe complication rates, when compared to those at academic facilities (p < 0.0001 and = 0.0018, respectively). Further analysis via adjustment for possible confounding factors, however, revealed no significant difference in the risk of severe complications between the two facility types. Such adjustment also demonstrated higher 30-day readmission risk in patients who underwent their surgery at an academic facility.
Conclusion
No significant difference was found when comparing the outcomes of academic and non-academic facilities, after adjusting for age, gender, race, region, insurance, and hospital volume. Patients from academic facilities were more likely to be readmitted within the first 30-days after surgery.
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Laparoscopic modified mesocolic excision with central vascular ligation in right-sided colon cancer shows better short- and long-term outcomes compared with the open approach in propensity score analysis
Abstract
Background
The introduction of complete mesocolic excision (CME) with central vessel ligation (CVL) for right-sided colon cancer has improved oncologic outcomes. However, there is controversy over the oncologic safety of laparoscopic CME with CVL. This study compared short-term and long-term oncologic outcomes between laparoscopic and open modified CME (mCME) with CVL in patients with right-sided colon cancer.
Methods
We enrolled 1239 patients who underwent open mCME with CVL and 1010 patients treated by a laparoscopic approach for right-side colon cancer between 2000 and 2013 and used 1:1 propensity score matching to adjust for potential baseline confounders between two groups.
Results
After propensity score matching, 683 patients who underwent open mCME with CVL were compared with 683 patients treated with a laparoscopic approach. There were no significant differences between these groups in age, sex, ASA score, TNM stage, tumor size, lymphovascular invasion, and perineural invasion. Comparison of open and laparoscopic mCME groups showed no significant difference in postoperative morbidity (21.4 vs. 18.3%, p = 0.175) and mortality (0.1 vs. 0%, p = 1.000). The laparoscopic mCME group showed shorter length of hospital stay. The 5-year overall survival rate was 83.7% in the open group and 94.7% in the laparoscopic group (p < 0.001). The laparoscopic group also showed a significantly better 5-year disease-free survival rate (82.7 vs. 88.7%, p = 0.009) and 5-year disease-specific survival rate (83.7 vs. 94.7%, p < 0.001).
Conclusion
Laparoscopic modified mesocolic excision with central vascular ligation is a safe and feasible approach with better short-term recovery profiles and potential oncologic benefits than the open approach for right-sided colon cancer.
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Intra-corporeal hand-sewn esophagojejunostomy is a safe and feasible procedure for totally laparoscopic total gastrectomy: short-term outcomes in 100 consecutive patients
Abstract
Background
An optimal method for intracorporeal esophagojejunostomy has not yet been standardized. This study sought to introduce intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy.
Methods
The author conducted a consecutive series of 100 intracorporeal hand-sewn esophagojejunostomies after totally laparoscopic total gastrectomy for upper third gastric cancer from September 2012 to December 2016.
Results
All patients were successfully operated on without conversion to open- or laparoscope-assisted surgery. The mean reconstruction time was 45 min, and the time until first flatus was 4 days. The time to start a soft diet was 7 days. The length of postoperative hospital stay was 8 days. The overall postoperative morbidity was 8%, including one anastomotic leak, and the mortality was zero. The median follow-up duration was 13 months; no anastomotic strictures were encountered.
Conclusions
Intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy is a safe and feasible procedure. This method can identify negative margins with intraoperative frozen sections before reconstruction and could be a good option for performing intracorporeal esophagojejunostomy with an advanced endoscopic suture technique.
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The use of high definition colonoscopy versus standard definition: does it affect polyp detection rate?
Abstract
Background
Polyp detection rate (PDR) during lower gastrointestinal endoscopy (LGIE) is of clinical importance. Detecting adenomatous polyps early in the adenoma–carcinoma sequence can halt disease progression, enabling treatment at a favourable stage. High definition colonoscopy (HDC) has been used in our hospital alongside standard definition equipment since 2011. We aim to determine what affect the use of HDC has on PDR.
Methods
Post-hoc analysis of a prospectively maintained database on all patients undergoing LGIE was performed (01/01/2012–31/12/2015), n = 15,448. Analysis tested the primary outcome of HD's effect on PDR across LGIE and secondary outcome stratified this by endoscopist group (Physician (PE), Surgeon (SE) and Nurse Endoscopist (NE)).
Results
Of 15,448 patients, 1353 underwent HDC. Unmatched analysis showed PDR increased by 5.3% in this group (p < 0.001). Matched analysis considered 2288 patients from the total cohort (1144 HDC) and showed an increase of 1% in PDR with HDC (p = 0.578). Further unmatched analysis stratified by endoscopist groups showed a PDR increase of 1.8% (p = 0.375), 5.4% (p = 0.008) and 4.6% (p = 0.021) by PE, SE and NE respectively. Matched analysis demonstrated an increase of 1% (p = 0.734) and 1.5% (p = 0.701) amongst PE and NE, with a decrease of 0.6% (p = 0.883) by SE.
Conclusion
The introduction of HDC increased PDR across all LGIE in our hospital, though this was not clinically significant. This marginal benefit was present across all endoscopist groups with no group benefiting over another in matched analysis.
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Control of inferior vena cava injury during laparoscopic surgery using a double balloon-equipped central venous catheter: proof of concept in a live porcine model
Abstract
Background
Iatrogenic inferior vena cava (IVC) injury is a rare but potentially life-threatening complication during laparoscopic surgery. This experimental study aimed to assess the hemostatic ability of a new device, double balloon-equipped central venous (DB-CV) catheter, for IVC injury.
Methods
The DB-CV catheter comprises a triple-lumen sphincterotome combined with two dilating balloons having a diameter of 25 mm. The experimental procedures were performed in five pigs. The DB-CV catheter was inserted via the right femoral vein. For the IVC occlusion test, correct placement of the balloons was confirmed by indocyanine green fluorescence imaging, and hemodynamic data were recorded. For the IVC injury test, a 3- to 4-mm circumferential incision was created in IVC, and hemostasis was initiated using balloon inflation 5 s after the injury.
Results
Hemodynamic changes were minimal, with a 20 mmHg reduction in the mean arterial pressure because of IVC occlusion. All bleeding from IVC injuries was successfully temporarily stopped by direct balloon compression, with a mean time to hemostasis of 69 s and mean blood loss of 32 ml. Subsequently, the positioning of IVC injuries between two balloons made it possible to suture the injured IVC.
Conclusions
Balloon occlusion using the DB-CV catheter provides a rapid temporal hemostatic effect and can overcome the serious condition of massive hemorrhage from IVC injuries.
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Impact of minimally invasive surgery on short-term outcomes after rectal resection for neoplasm within the setting of an enhanced recovery program
Abstract
Background
Minimally invasive surgery (MIS) for rectal cancer has increased in recent years. Enhanced recovery (ER) protocols are associated with improved outcomes, such as decreased length of stay (LOS). We examined the impact of MIS and ER protocols on outcomes after rectal resection for neoplasm.
Methods
A retrospective analysis was performed for patients undergoing elective open (OS) or MIS rectal resection for neoplasm from 2010 to 2015 at a single institution. MIS was defined as any laparoscopic or robotic procedure. An ER protocol was implemented in 8/2013. Regression models were used to estimate outcomes including LOS, 30-day morbidity, readmission, and hospital costs.
Results
Among 325 patients, 252 (77.5%) underwent OS; 73 (22.5%) underwent MIS rectal resection. Prior to ER implementation, only 6.1% underwent MIS, compared to 23.1 and 54.4% in the 2 years following ER implementation (p < 0.001). Prior to ER implementation, median LOS was 7 days (n = 181) with 23.8% 30-day morbidity. Following ER implementation, median LOS was 4 days (n = 144); patients receiving OS had median LOS of 5.5 days (n = 82) and 30-day morbidity of 19.5%. ER patients receiving MIS had median LOS of 3 days (n = 62) and 30-day morbidity of 14.5%. Univariate regression demonstrated <?xm-insertion_mark_start author="0009543" time="20171030T142022+0530"?>that <?xm-insertion_mark_end ?>MIS patients on ER protocol were more likely to have a shortened LOS (< 6 days) compared to OS patients on non-ER protocol (both p < 0.001).
Conclusions
The combination of MIS and ER protocol is significantly associated with reduced LOS for patients undergoing rectal resection for neoplasm. Further research is needed to determine which patients are best suited to MIS from an oncologic standpoint.
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First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device
Abstract
Background
Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology.
Methods
A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction.
Results
Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system.
Conclusion
Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.
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Feasibility and outcomes of underwater endoscopic mucosal resection for ≥ 10 mm colorectal polyps
Abstract
Background
Underwater endoscopic mucosal resection (UEMR) is an emerging strategy for the management of colorectal polyps. We aimed to evaluate the efficacy and safety of UEMR for clinically significant (≥ 10 mm) colorectal polyps.
Methods
We performed a prospective dual-centre study of polyps ≥ 10 mm undergoing UEMR between June 2014 and March 2017. Outcomes measured comprised: (1) completeness of resection at index UEMR, (2) intraprocedural and 30-day complications, (3) rates and predictors of submucosal lift, en bloc resection, polyp/adenoma recurrence and (4) pain score. Endoscopy records were correlated with histology.
Results
85 patients underwent UEMR of 97 polyps. Resection was endoscopically complete at index UEMR in 97.9%. The median pain score was 0 (no pain). Submucosal lift was required in 29.9% and correlated with polyp size ≥ 30 mm (p = 0.03) and clip placement (p = 0.004). En bloc resection was achieved in 45.4%, and inversely correlated with polyp size ≥ 20 mm (p < 0.001). 30-day complications (4.1%) were minor and consisted of intraprocedural bleeding (n = 2) and delayed bleeding (n = 2). 60.8% attended endoscopy post-UEMR after a median interval of 6 months, with 20.3% polyp and 13.6% adenoma recurrence. Polyp recurrence was associated with piecemeal resection (p = 0.04), recurrent polyp (p = 0.02), female sex (p = 0.01) and poor access (p = 0.005). Predictors for adenoma recurrence included female gender (p = 0.01) and difficult access (p < 0.001). Recurrence rates did not differ with polyp size, site, morphology, dysplasia status, submucosal injection, patient age, or study centre.
Conclusions
UEMR is an effective, safe and well tolerated option for significant colorectal polyps. Piecemeal resection, recurrent polyp, female gender, and difficult access are predictors of post-UEMR polyp recurrence.
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Transanal total mesorectal excision: pathological results of 186 patients with mid and low rectal cancer
Abstract
Background
Transanal total mesorectal excision (TaTME) seems to be a valid alternative to the open or laparoscopic TME. Quality of the TME specimen is the most important prognostic factor in rectal cancer. This study shows the pathological results of the largest single-institution series published on TaTME in patients with mid and low rectal cancer.
Methods
We conducted a retrospective cohort study of all consecutive patients with rectal cancer, treated by TaTME between November 2011 and June 2016. Patient data were prospectively included in a standardized database. Patients with all TNM stages of mid (5–10 cm from the anal verge) and low (0–5 cm from the anal verge) rectal cancer were included.
Results
A total of 186 patients were included. Tumor was in the mid and low rectum in, respectively, 62.9 and 37.1%. Neoadjuvant chemoradiotherapy was given in 62.4%, only radiotherapy in 3.2%, and only chemotherapy in 2.2%. Preoperative staging showed T1 in 3.2%, T2 in 20.4%, T3 in 67.7%, and T4 in 7.5%. Mesorectal resection quality was complete in 95.7% (n = 178), almost complete in 1.6% (n = 3), and incomplete in 1.1% (n = 2). Overall positive CRM (≤ 1 mm) and DRM (≤ 1 mm) were 8.1% (n = 15) and 3.2% (n = 6), respectively. The composite of complete mesorectal excision, negative CRM, and negative DRM was achieved in 88.1% (n = 155) of the patients. The median number of lymph nodes found per specimen was 14.0 (IQR 11–18).
Conclusions
The present study showed good rates regarding total mesorectal excision, negative circumferential, and distal resection margins. As the specimen quality is a surrogate marker for survival, TaTME can be regarded as a safe method to treat patients with rectal cancer, from an oncological point of view.
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Rapid in-situ radiometric assessment of the Mrima-Kiruku high background radiation anomaly complex of Kenya
Publication date: Available online 2 November 2017
Source:Journal of Environmental Radioactivity
Author(s): M.I. Kaniu, H.K. Angeyo, I.G. Darby, L.M. Muia
This paper presents the radiometric survey results of the Mrima-Kiruku high background radiation (HBR) anomaly complex of south coastal Kenya. Utilizing a portable γ-ray spectrometer consisting of a 2.0 l NaI(Tl) backpack detector integrated with GPS to perform the relevant in-situ radiometric measurements, a novel geospatial gating method was devised to represent the measurements. The goal of this study was to assess radiation exposure and associated natural radioactivity levels in the complex and to compare the results obtained with those from previous preliminary related studies. Absorbed dose-rates in air were found to range <60–2368 nGy h−1. These rates were observed to correspond with the spatial variability of the underlying geology and terrain, increasing toward the summits of both Mrima and Kiruku Hills which implies that the complex is a geogenic HBR anomaly. The activity concentrations of 232Th in the study area are generally higher than those of 40K and 238U: The means of 40K, 238U and 232Th ranged 235±19–603±28 Bq kg−1, 68±6–326±24 Bq kg−1 and 386±12–1817±51 Bq kg−1 respectively. It was concluded that the high air absorbed dose-rate values that were measured (>600 nGy h−1) are due to elevated activity concentrations of 232Th. Therefore there is significant (>1 mSv/y) radiological hazard to the inhabitants of the area particularly those who reside at the foothills of both Mrima and Kiruku Hills.
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Radiological survey of the covered and uncovered drilling mud depository
Publication date: Available online 2 November 2017
Source:Journal of Environmental Radioactivity
Author(s): Jácint Jónás, János Somlai, Anita Csordás, Edit Tóth-Bodrogi, Tibor Kovács
In petroleum engineering, the produced drilling mud sometimes contains elevated amounts of natural radioactivity. In this study, a remediated Hungarian drilling mud depository was investigated from a radiological perspective. The depository was monitored before and after a clay layer was applied as covering.In this study, the ambient dose equivalent rate H*(10) of the depository has been measured by a Scintillator Probe (6150AD-b Dose Rate Meter). Outdoor radon concentration, radon concentration in soil gas, and in situ field radon exhalation measurements were carried out using a pulse-type ionization chamber (AlphaGUARD radon monitor). Soil gas permeability (k) measurements were carried out using the permeameter (RADON-JOK) in situ device. Geogenic radon potentials were calculated. The radionuclide content of the drilling mud and cover layer sample has been determined with an HPGe gamma-spectrometer. The gamma dose rate was estimated from the measured radionuclide concentrations and the results were compared with the measured ambient dose equivalent rate.Based on the measured results before and after covering, the ambient dose equivalent rates were 76 (67–85) nSv/h before and 86 (83–89) nSv/h after covering, radon exhalation was 9 (6–12) mBq/m2s before and 14 (5–28) mBq/m2s after covering, the outdoor radon concentrations were 11 (9–16) before and 13 (10–22) Bq/m3after covering and the soil gas radon concentrations were 6 (3–8) before and 24 (14–40) kBq/m3 after covering. Soil gas permeability measurements were 1E-11 (7E-12-1E-11) and 1E-12 (5E-13-1E-12) m2 and the calculated geogenic radon potential values were 6 (3–8) and 12 (6–21) before and after the covering. The main radionuclide concentrations of the drilling mud were CU-238 12 (10–15) Bq/kg, CRa-226 31 (18–40) Bq/kg, CTh-232 35 (33–39) Bq/kg and CK-40 502 (356–673) Bq/kg. The same radionuclide concentrations in the clay were CU-238 31 (29–34) Bq/kg, CRa-226 45 (40–51) Bq/kg, CTh-232 58 (55–60) Bq/kg and CK-40 651 (620–671) Bq/kg.According to our results, the drilling mud depository exhibits no radiological risk from any radiological aspects (radon, radon exhalation, gamma dose, etc.); therefore, long term monitoring activity is not necessary from the radiological point of view.
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MIVAT: the last 2 years experience, tips and techniques after more than 10 years
Abstract
Background
Minimally invasive video-assisted thyroidectomy (MIVAT) has been introduced into clinical practice by Miccoli in the late 1990s (Miccoli et al., Am J Surg 181(6):567–570, 2001) and it has become a widespread technique used and welcomed worldwide. In this paper, we present our experience of the last 2 years; we also describe tips and techniques derived from over 460 cases performed in the last 10 years by the same surgical team with the same single operator.
Methods
In the last 10 years, we did about 460 MIVAT procedures. In the last 2 years, we performed MIVAT on 156 consecutive patients at Sant'Andrea University Hospital of Rome "Sapienza" University. of 156 cases performed, we were able to monitor the follow-up in 110 patients.
Results
On 110 cases, the mean surgical time was 74 ± 7.2 min. In our data, we reported: transitory hypoparathyroidism 11 (10%), definitive hypoparathyroidism 4 (3.60%) (this value is inclusive of patients treated with central neck dissection. The value referred only to MIVAT is 1.05%), 2 (1.81%) transitory monolateral nerve palsy, 16 (14.50%) transitory, and 1 (0.9%) definitive nerve palsy. 4 (3.60%) cases of transitory dysphagia and 0 (0%) cases of definitive dysphagia (Table 4). We also had 1 (0.9%) case of surgical scar infection, 0 (0%) postoperative bleeding, and 2 (1.81%) cases of subcutaneous surgical adhesion. Cosmetic results were: 0 (0%) insufficient, 0 (0%) sufficient, 6 (6.30%) passable, 17 (15.50%) good. and 86 (78.20%) excellent. Conversion rate 0 (0%).
Conclusion
MIVAT is a good and safe technique, with similar short-term outcomes and similar costs compared to traditional total thyroidectomy. We hope that the tips and techniques reported in this paper as well as the advices in the use of instruments in MIVAT and open surgery will be useful to improve the skills of young surgeons and make thyroid surgery less invasive.
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Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery
Abstract
Background
Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery.
Methods
The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion.
Results
The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9–7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05).
Conclusions
Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.
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Uncomplicated common bile duct stone removal guided by cholangioscopy versus conventional endoscopic retrograde cholangiopancreatography
Abstract
Background
Although previous studies have reported the possibility of therapeutic ERCP without fluoroscopy, more robust documentation of fluoroscopy-free common bile duct stone (CBDS) clearance is needed. Technically, "digital cholangioscopy" (DCS) may be used to confirm CBDS clearance. We aimed to compare the feasibility, safety, and radiation exposure between patients with CBDS undergoing stone removal by DCS and conventional ERCP (cERCP).
Methods
Fifty (50) consecutive patients with a CBDS size < 15 mm underwent DCS (SpyGlass DS Direct Visualization System, Boston Scientific, Marlboro, MA, USA) between December 2015 and October 2016. Of 202 consecutive patients undergoing cERCP during the same time frame, 50 matched pairs were created using propensity score matching analysis. In the DCS group, patients underwent biliary cannulation and CBDS removal without fluoroscopy followed by DCS to confirm complete CBDS clearance. A final occlusion cholangiogram was performed as the current standard of care to confirm CBDS clearance.
Results
Cannulation success rates were similar between the DCS and cERCP groups (98 vs. 98%). By intention-to-treat analysis, CBDS clearance in the DCS and cERCP groups was not different (90 vs. 98%; p = 0.20, respectively). DCS had successful CBDS removal in 45 cases, whereas 5 (10%) failed for clearance by DCS due to technical limitations. Adverse events were not different between both groups.
Conclusions
In the management of uncomplicated CBDS, our data confirmed the feasibility of DCS for CBDS clearance as it showed efficacy and safety comparable to those of cERCP. Although certain conditions may limit its effectiveness, DCS offers the ability to perform CBDS clearance without the need for fluoroscopy unit and can avoid radiation exposure while ERCP under fluoroscopy remains the current standard of care in patients with CBDS.
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Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes
Abstract
Background
Right posterior sectionectomy is one of the most technically challenging laparoscopic liver resections. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility.
Aim
To report our experience, results and techniques, highlighting a variety of tips and tricks to facilitate this resection. A video is attached for technical demonstration.
Methods
Retrospective review of prospectively maintained databases from June 2006 to June 2016. Three different techniques were used: resection following hilar inflow control, inflow control at Rouviere's sulcus and resection with intra parenchymal control.
Results
29 LRPS were performed over a 10-year period. Median operative time was 240 min (150–480). Pringle's manoeuvre was performed in 19 (65.5%) with a median total duration of 35 (20–75) min. Median perioperative blood loss was 600 (100–2500) ml. Additional liver resections were performed in 16 (55.1%). There were two(6.9%) laparoscopic to open conversions. Median postoperative hospital stay was 5 (2–30) days. The median size of the tumour resected was 25 (10–54) mm with median number of resected lesions were 2 (1–4), median free resection margin was 9.5 (1–45) mm, margins were infiltrated (R1) in two (6.7%) cases. There was one death within 30-days (3.4%).
Conclusion
LRPS is feasible, efficient and safe. However, it is a technically challenging procedure and requires advance skills in liver and laparoscopic surgery. Surgeons should be familiar with a variety of approaches as each offers different advantages depending on the location and nature of the lesion, surgical preference and intraoperative findings.
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Robotic-assisted modified radical neck dissection using a bilateral axillo-breast approach (robotic BABA MRND) for papillary thyroid carcinoma with lateral lymph node metastasis
Abstract
Background
Although safe in patients with papillary thyroid carcinoma (PTC), robotic thyroidectomy using a bilateral axillo-breast approach (BABA) has not been frequently performed in patients with advanced PTC. This study describes surgical outcomes in patients with PTC and lymph node metastasis (LNM) in lateral neck compartment who underwent robotic-assisted modified radical neck dissection with BABA (robotic BABA MRND).
Methods
The medical records of patients with PTC and lateral LNM who underwent robotic BABA MRND from March 2010 to July 2016 were retrospectively reviewed.
Results
Fifteen patients, 14 women and 1 man, of mean age 37.1 ± 9.3 years, were enrolled. Mean operation time was 272.7 ± 33.8 min. A mean 20.7 ± 7.2 lymph nodes were retrieved from the lateral neck compartment, with a mean 5.3 ± 4.4 lymph nodes being metastatic. The rates of transient and permanent hypocalcemia were 46.7 and 0%, respectively, and the rates of transient and permanent vocal cord palsy were 6.7 and 0%, respectively. Fourteen patients (93.3%) had stimulated thyroglobulin concentrations below 2 ng/mL after the first treatment with radioactive iodine.
Conclusions
Robotic BABA MRND could be safely performed and may be a good surgical option in selected patients with PTC and lateral LNM.
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NAAC introduces Certified Ambulance Documentation Specialist (CADS) course
CADS is the nation's first documentation-specific certification course for EMS practitioners and officers HERSHEY, Pa. — Hershey is known for being the sweetest place on earth. But after the five-day abc360 conference at the Hershey Lodge Oct. 21-25, it is also on the map for rolling out the Certified Ambulance Documentation Specialist (CADS) course for the nation's EMS industry. The ...
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Analgesic Drug Prescription After Carpal Tunnel Surgery: A Pharmacoepidemiological Study Investigating Postoperative Pain.
Background and Objectives: Carpal tunnel syndrome is a frequent cause of neuropathic pain of the upper limb. Surgery is often proposed in second-line treatment, leading to an expected decrease in analgesic drug consumption. The main objective of this study was to investigate the variations in analgesic drug prescriptions, with a special focus on constant or increasing prescription patterns, before and after surgery for carpal tunnel syndrome. Methods: We designed a retrospective cohort study of French beneficiaries from the health insurance system in Midi-Pyrenees area. All patients undergoing carpel tunnel surgery during a specified period were identified and included. Definition of increased or constant prescription of analgesics was based on the comparison of the accumulated defined daily doses received by months and a difference between early preoperative (2 months before) and late postoperative period (2-12 months after surgery) superior to a -3.5 margin. We performed 4 multivariate logistic regression models to identify factors associated with increased or constant analgesic drug prescription patterns (for all analgesics, opioid, antineuropathic, nonopioid drugs). Results: Among the 3665 patients included, 3255 (89%) received at least 1 analgesic drug during the late postoperative period (39% [n = 1426] for opioids and 15% [n = 563] for antineuropathic drugs). Prescription of analgesic, opioid, or antineuropathic drugs was maintained or increased in the late postoperative period in 11%, 5%, and 3% of the population, respectively. High levels of preoperative pain and female sex were associated with an increase in opioid use, whereas inpatient surgery (vs ambulatory surgery), high levels of preoperative pain, and psychiatric disorders were found to be associated with an increase in antineuropathic drug use. Conclusions: This study revealed that approximately 3% to 5% of patients undergoing carpal tunnel surgery had persistent and even increased use of opioid or antineuropathic drugs more than 2 months after surgery, in relation with possible chronic postoperative pain. Considering the incidence of carpal tunnel syndrome, the risks associated with persistent opioid use in this population should be further monitored. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.
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Transversus Abdominis Plane Catheters for Analgesia Following Abdominal Surgery in Adults.
Transversus abdominis plane (TAP) catheters are increasingly being used as an opioid-sparing analgesic technique following abdominal surgery. The aim of this systematic review is to evaluate the efficacy and safety of TAP catheters for postoperative analgesia following abdominal surgery in adults. The authors searched electronic databases and relevant reference lists for randomized controlled trials published between inception and January 2017. Twelve randomized controlled trials were identified, comprising 661 participants, with several trials showing either an equivalence or superiority in analgesia compared with the alternative modality. Because of the extremely heterogeneous nature of the studies, a specific consensus regarding their results, or the ability to construct a meta-analysis, is unviable. Although there are promising indications for the benefit of TAP catheter techniques, extrapolation/comparison of results and application to patient care will be better elucidated when there is more standardization of TAP catheter techniques and the methodology for measuring efficacy. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.
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Effect of pharmacogenetic markers of vitamin D pathway on deferasirox pharmacokinetics in children.
Objectives: Patients with [beta]-thalassemia major have extremely low vitamin D levels, owing to reduced intestinal absorption, subicteric tint, and/or iron-induced higher pigmentation. We investigated whether some polymorphisms within the VDR, CYP24A1, CYP27B1, and GC genes could play a role in deferasirox pharmacokinetics in a cohort of pediatric patients. Patients and methods: Eighteen children with [beta]-thalassemia were enrolled. Drug plasma concentrations at the end of dosing interval (Ctrough) and after 0, 2, 4, 6, and 24 h of drug administration were measured by a HPLC-UV method. Allelic discrimination for VDR (TaqI, FokI, BsmI, Cdx2, and ApaI), CYP24A1 (22776, 3999 and 8620), CYP27B1 (2838 and -1260), and GC (1296) single nucleotide polymorphisms was performed by real-time PCR. Results: CYP24A1 8620 AG/GG group negatively predicted Ctrough in regression analysis (P=0.012). ApaI AA genotype resulted as a negative predictor of Ctrough (P=0.025) and area under the concentration curve (P=0.007); FoKI CC genotype remained as area under the concentration curve positive predictor (P=0.008) and TC/CC group as half-life (t1/2) (P=0.003) and volume of distribution (Vd) (P=0.011) negative one; TaqI TC/CC was retained as a negative predictor of drug maximum concentration (Cmax) (P=0.004). Moreover, GC 1296 TG/GG seemed able to predict lower time to reach drug maximum concentration (Tmax) (P=0.033). Conclusion: Our preliminary experience suggested the potential usefulness of vitamin D pharmacogenetic to better understand deferasirox interindividual variability, also in pediatric patients. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.
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Pertussis Vaccination Among Childcare Center Staff, Administrators, and Parents: Uptake, Policies, and Beliefs
Abstract
Introduction Little is known about childcare staff's and parents' uptake of and attitudes towards pertussis vaccine. Methods Questionnaires were distributed to St. Louis parents and childcare staff in fall, 2014. Parents versus staff and vaccinated versus unvaccinated individuals' beliefs regarding pertussis vaccine were compared using chi square tests. Multivariate logistic regressions were run to develop predictive models for staff's and parents' vaccine uptake. Results Overall, 351 parents and staff from 23 agencies participated (response rate = 32%). Parents were more likely than staff to have received pertussis vaccine (66.5 vs. 45.8%, X 2 = 12.5, p < .001). Predictors for staff vaccination included willingness to get vaccinated even if there was a cost (OR 6.6; CI 1.8–24.6; p < .01), awareness of vaccination recommendations (OR 5.2; CI 1.2–22.8; p < .05), and healthcare provider recommendation (OR 4.2; CI 1.2–15.1; p < .05). Parents' predictors of vaccination included perceived importance of vaccination (OR 9.9; CI 4.1–23.8; p < .001), healthcare provider recommendation (OR 4.6; CI 1.7–12.6; p < .01), believing vaccination is effective (OR 4.4; CI 1.1–18.0; p < .05), and knowing where to get vaccine (OR 3.5; CI 1.5–8.1; p < .01). Among unvaccinated staff (n = 52), 74.5% (n = 38) and 70.0% (n = 35) would receive pertussis vaccine if it were offered free of charge and onsite, respectively. Conclusions for Practice Childcare staff's and parents' pertussis vaccine uptake was higher than overall U.S. rates, though significantly lower than the Global Pertussis Initiative target. Implementing an education campaign and providing free vaccine on-site are likely to result in increased vaccine uptake.
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Developing a Research Agenda on the Political Economy of Immigrants’ Oral Health
Abstract
Acculturation has been widely used in health research to explain oral health disparities between immigrants and their native born counterparts. However, immigrants' oral health studies have not clearly defined the acculturation construct. Also, a narrow focus on cultural oral health behaviours is likely to be inadequate for explaining immigrants' oral health inequities, which are also rooted in societal, political and economic factors produced across the globe. In this brief report, we discuss the use of the acculturation framework in the dental public health literature, note gaps in this approach, and argue for the need to incorporate the political economy lens to help better understand the complexities of immigrants' oral health.
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8 more reasons why you should never run to treat patients
By EMS1 Staff If you're not running, then you're not concerned, right" Wrong. In an article about why EMS providers should never run to treat patients, an EMT outlined eight reasons on why not running to patients is not due to a lack of concern. On Facebook, the article received 1,000 Likes and was shared over 1,700 times. What do you think" Should there be any special circumstances for running ...
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Cervical vestibular evoked myogenic potential tuning properties of patients with recurrent peripheral vestibulopathy: Is it Meniere’s disease without hearing loss?
Source:Clinical Neurophysiology, Volume 128, Issue 12
Author(s): Toshihisa Murofushi, Masahito Tsubota, Ryota Suizu, Eriko Yoshimura
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Unexpected Cardiac Computed Tomography Findings in Patients With Postoperative Myocardial Injury
BACKGROUND: Postoperative myocardial injury (PMI) is a strong predictor of mortality after noncardiac surgery. PMI is believed to be attributable to coronary artery disease (CAD), yet its etiology is largely unclear. We aimed to quantify the prevalence of significant CAD in patients with and without PMI using coronary computed tomography angiography (CCTA). METHODS: This prospective cohort study included patients of 60 years or older without a history of cardiac disease and with and without PMI after intermediate- to high-risk noncardiac surgery. PMI was defined as any serum troponin I level ≥60 ng/L on the first 3 postoperative days. Main exclusion criteria were known cardiac disease and postoperative ischemic symptoms or electrocardiography abnormalities. Noninvasive imaging consisted of a postoperative CCTA. Main outcome was CAD defined as >50% coronary stenosis on CCTA. RESULTS: The analysis included 66 patients. Median peak troponin levels in the PMI (n = 46) and control group (n = 20) were 150 (interquartile range, 120–298) vs 15 (interquartile range, 10–31) ng/L (P
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Teacher and Trustee: Examining the Ethics of Experiential Learning in Transesophageal Echocardiography Education
No abstract available
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Artificial Ventilation: A Basic Clinical Guide
No abstract available
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Neuroprotective Effects of Fasudil, a Rho-Kinase Inhibitor, After Spinal Cord Ischemia and Reperfusion in Rats
BACKGROUND: Excessive Rho/Rho-kinase pathway activation occurs subsequent to stroke. We examined the neuroprotective effects of pre- and posttreatment with fasudil (a Rho-kinase inhibitor) in a rat transient spinal cord ischemia-reperfusion model under normothermic conditions. METHODS: After approval by our animal research committee, male Sprague-Dawley rats were assigned to 1 of 6 groups: pre- and postcontrol (C); pre- and postfasudil (F); and pre- and postsham (S). Fasudil (10 mg/kg) or normal saline was administered intravenously over 30 minutes before ischemia in the pre-F or pre-C groups, and over 30 minutes after reperfusion in the post-F or post-C groups. Sham groups were not subjected to ischemia. Ischemia was induced by aortic occlusion using a balloon catheter combined with hypotension for 10 minutes. Neurologic deficit scores (NDS; 0–8 points) were assessed 1, 7, and 14 days after ischemia, and then histopathologic outcomes were assessed. RESULTS: NDS 7 and 14 days after ischemia in the pre-F group (median [range]; 3.5 [2–6] and 2.5 [0–6]) were lower than those in the pre-C group (5.5 [4–7] and 4.5 [4–6]; P = .046 and P = .049), whereas NDS in the post-F group and in the post-C group were not different. The numbers of intact neurons in the gray matter in the pre- and post-F groups (mean ± standard deviation [95% confidence interval]: 25 ± 7 [20–30] and 16 ± 5 [12–19]) were greater than those in the pre- and post-C groups (11 ± 5 [7–14] and 9 ± 3 [7–11]; P
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The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants
Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism–related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk–benefit discussions with patients and facilitate shared decision making. Accepted for publication August 24, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). The Appendix provides the full list of the SOAP VTE Taskforce members, along with their respective affiliations. Reprints will not be available from the authors. Address correspondence to Lisa Leffert, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to lleffert@partners.org. © 2017 International Anesthesia Research Society
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Tricuspid Regurgitation Due to Absent Tricuspid Valve Leaflet: Utility of Three-Dimensional Echocardiography
No abstract available
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Can Lung Ultrasound Be the First-Line Tool for Evaluation of Intraoperative Hypoxemia?
No abstract available
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Is It Time to Reconsider the Concepts of “Universal Donor” and “ABO Compatible” Transfusions?
No abstract available
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The Anesthesia Records of Harvey Cushing and Ernest Codman
Hundreds of thousands of anesthesia records are created each day. The earliest records were prepared by 2 medical students in late 19th-century Boston. Ernest Codman and Harvey Cushing went on to become prominent surgeons and contributed much to the safety of the surgical patient. Cushing's career is celebrated due to his associations with William Stewart Halsted, Peter Bent Brigham Hospital, Yale University, in New Haven, Connecticut, and his biography of Sir William Osler. Codman is remembered for introducing the morbidity and mortality conference as well as his drive to improve outcomes and patient safety. We analyze every anesthetic record created by Codman and Cushing and provide both a historical context and perspective on many ways in which their doggedness, brilliance, and insight anticipated many advances that enhanced safety for patients undergoing surgical procedures. Accepted for publication September 4, 2017. Funding: This study received intramural support. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Sukumar P. Desai, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to sdesai@partners.org. © 2017 International Anesthesia Research Society
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Type B Aortic Dissection Diagnosed by Left-Sided Transthoracic Ultrasonography in a Woman With Preeclampsia
No abstract available
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Percutaneous Closure of Complex Membranous Ventricular Septal Defect Under Transesophageal Echocardiographic Guidance
No abstract available
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Colloids and the Microcirculation
Colloid solutions have been advocated for use in treating hypovolemia due to their expected effect on improving intravascular retention compared with crystalloid solutions. Because the ultimate desired effect of fluid resuscitation is the improvement of microcirculatory perfusion and tissue oxygenation, it is of interest to study the effects of colloids and crystalloids at the level of microcirculation under conditions of shock and fluid resuscitation, and to explore the potential benefits of using colloids in terms of recruiting the microcirculation under conditions of hypovolemia. This article reviews the physiochemical properties of the various types of colloid solutions (eg, gelatin, dextrans, hydroxyethyl starches, and albumin) and the effects that they have under various conditions of hypovolemia in experimental and clinical scenarios. Accepted for publication September 27, 2017. Funding: H.H. received funding from the China Scholarship Council (No. 201608110082) and the Organization Department of Beijing Municipal Committee (No. 2015000020124G072). C.I. has received honoraria and independent research grants from Fresenius-Kabi, Bad Homburg, Germany, and Baxter HealthCare, Deerfield, IL. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Can Ince, PhD, Department of Intensive Care, Erasmus Medical Center, s-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands. Address e-mail to c.ince@erasmusmc.nl. © 2017 International Anesthesia Research Society
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Comparing Agency Leader and Therapist Perspectives on Evidence-Based Practices: Associations with Individual and Organizational Factors in a Mental Health System-Driven Implementation Effort
Abstract
Agency leaders and therapists are essential stakeholders in implementation of evidence-based practices (EBPs) within publicly-funded mental health services. Little is known about how these stakeholders differ in their perceptions of specific EBPs and which individual and organizational factors differentially influence these perceptions. Within the context of a system-driven implementation of multiple EBPs, survey data from 160 leaders and 720 therapists were examined to assess differences in perceptions of six EBPs. Findings indicated that leaders and therapists have unique perspectives and preferences regarding EBPs that are shaped by distinct sociodemographic and professional characteristics and aspects of organizational functioning.
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EMS Artwork: Responders continue to heal, remain Vegas Strong
There were many first responders who were off duty when the Las Vegas shooting happened, but they came into work and offered to help. They knew their co-workers would be overwhelmed with patients. This event didn't only impact the crews that were on scene, but all first responders in Las Vegas. All sales from this image will go to the Las Vegas First Responder Mental Health Fund that has been set ...
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EMS Artwork: Responders continue to heal, remain Vegas Strong
This AMR crew was working the night a gunman opened fire on 22,000 Las Vegas concert attendees
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Inside EMS Podcast: Tips to pass the NREMT exam
Our co-hosts also discuss how to go from the truck to stepping into an instructor role
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Harnessing the native type I-B CRISPR-Cas for genome editing in a polyploid archaeon
Source:Journal of Genetics and Genomics
Author(s): Feiyue Cheng, Luyao Gong, Dahe Zhao, Haibo Yang, Jian Zhou, Ming Li, Hua Xiang
Research on CRISPR-Cas (clustered regularly interspaced short palindromic repeats-CRISPR associated protein) systems has led to the revolutionary CRISPR/Cas9 genome editing technique. However, for most archaea and half of bacteria, exploitation of their native CRISPR-Cas machineries may be more straightforward and convenient. In this study, we harnessed the native type I-B CRISPR-Cas system for precise genome editing in the polyploid haloarchaeon Haloarcula hispanica. After testing different designs, the editing tool was optimized to be a single plasmid that carries both the self-targeting mini-CRISPR and a 600–800 bp donor. Significantly, chromosomal modifications, such as gene deletion, gene tagging or single nucleotide substitution, were precisely introduced into the vast majority of the transformants. Moreover, we showed that simultaneous editing of two genomic loci could also be readily achieved by one step. In summary, our data demonstrate that the haloarchaeal CRISPR-Cas system can be harnessed for genome editing in this polyploid archaeon, and highlight the convenience and efficiency of the native CRISPR-based genome editing strategy.
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Conversations with French Medical Geneticists. A Personal Perspective on the Origins and Early Years of Medical Genetics in France
The history of the beginnings of medical genetics in France is discussed, based on the personal perspective provided by recorded interviews with 16 early French workers in the field. The weakness of French genetics overall up to the beginning of the Second World War meant that post-war medical genetics had to start from new, with its origins largely derived from the medical fields of child health and the prevention of genetic disorders, rather than from basic science. The key people responsible for initiating these developments were Robert Debré and Maurice Lamy at Hôpital Necker in Paris and those interviewed included a number of their colleagues and successors, including Jean Frézal, Pierre Maroteaux, Josué Feingold, André and Joelle Boué, and Jean-Claude Kaplan. A separate group of paediatricians, originally at Hôpital Trousseau under Raymond Turpin, including Jérôme Lejeune, Marthe Gautier and Roland Berger, was responsible for major advances in human cytogenetics. Outside Paris, workers were interviewed from Marseille, Strasbourg and Nancy, though not from Lyon, where Jacques-Michel Robert was an early pioneer, particularly of genetic counselling.
Challenges in the development of medical genetics in France included the advent of prenatal diagnosis with its ethical issues, the emergence of medical genetics as a distinct specialty from paediatrics, and its spread from Paris across France. These and other aspects are described by those interviewed from their own experiences, given in the 'supplementary material', while the full edited transcripts for most interviews are accessible on the Web (http://ift.tt/2gZRksj).
'The early history of medical genetics in France is discussed in the context of recorded interviews with 16 early workers in the field, based principally but not exclusively in Paris. These origins and early years show considerable differences between France and other countries that are of international interest and deserve a more comprehensive study than the personal perspective given here can provide. Further recorded interviews with key workers across France still living will be of particular importance.
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Mexico City updates 911 app to push quake alerts to phones
Users of the free 911 CDMX app can now get sound and vibration alerts for any quake strong enough to threaten damage in the city
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Developing Collaborative Maternal and Child Health Leaders: A Descriptive Study of the National Maternal and Child Health Workforce Development Center
Abstract
Purpose An assessment of the National Maternal and Child Health Workforce Development Center (the Center) was conducted to describe (1) effects of the Center's training on the use of collaborative leadership practices by MCH leaders, and (2) perceived barriers to collaboration for MCH leaders. The Center provides services to strengthen MCH professionals' skills in three core areas: Change Management/Adaptive Leadership, Evidence-Based Decision Making, and Systems Integration. Description This descriptive qualitative study compares eight interview responses from a sample of the Center's participants and findings from a document review of the training curriculum against an existing framework of collaborative leadership themes. Assessment Systems thinking tools and related training were highly referenced, and the interviewees often related process-based leadership practices with their applied learning health transformation projects. Perceived barriers to sustaining collaborative work included: (1) a tendency for state agencies to have siloed priorities, (2) difficulty achieving a consensus to move a project forward without individual partners disengaging, (3) strained organizational partnerships when the individual representative leaves that partnering organization, and (4) difficulty in sustaining project-based partnerships past the short term. Conclusion The findings in this study suggest that investments in leadership development training for MCH professionals, such as the Center, can provide opportunities for participants to utilize collaborative leadership practices.
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Current knowledge and perception of bariatric surgery among Greek doctors living in Thessaly
Abstract
Introduction
The purpose of this study was to assess doctors' knowledge, current conceptions, and clinical practice regarding obesity and bariatric surgery.
Methods
A self-administered survey was administered to 500 doctors with varying medical specialties in public and private practice.
Results
The response rate was 60%. Most participants (77.3%) were in private practice. Although almost half of the participants could define morbid obesity and obesity-related comorbidities, only 8.7% felt educated about bariatric surgery. Participants had little knowledge of various types of bariatric procedures. A minority of doctors (24.7%) knew of the existence of a bariatric center in their area. Only 21.3% of doctors had referred a patient to a bariatric center. Reasons for non-referral included lack of interest in bariatric surgery (37.3%), patient refusal (35.3%), increased operative fees (17.3%), lack of confidence in bariatric surgery (6.3%), and lack of access to a nearby bariatric center (3.7%). The majority of doctors were interested in learning more about bariatric surgery and related guidelines, but they remained reluctant to conduct patients' postoperative follow-ups.
Conclusion
The penetration of bariatric surgery in the medical community remains limited, despite its proven effectiveness in facilitating sustained weight loss and resolving several obesity-related comorbidities. A great effort should be made to inform health-care providers about the evolution of bariatric procedures, the potential benefits they offer, and the existence of certified bariatric centers. This will allow doctors to provide optimum health care to patients who could benefit from bariatric surgery.
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Intermittent apnea elicits inactivity-induced phrenic motor facilitation via a retinoic acid- and protein synthesis-dependent pathway
Respiratory motoneuron pools must provide rhythmic inspiratory drive that is robust and reliable, yet dynamic enough to respond to respiratory challenges. One form of plasticity that is hypothesized to contribute to motor output stability by sensing and responding to inadequate respiratory neural activity is inactivity-induced phrenic motor facilitation (iPMF), an increase in inspiratory output triggered by a reduction in phrenic synaptic inputs. Evidence suggests that mechanisms giving rise to iPMF differ depending on the pattern of reduced respiratory neural activity (i.e., neural apnea). A prolonged neural apnea elicits iPMF via a spinal TNF-α-induced increase in atypical PKC activity, but little is known regarding mechanisms that elicit iPMF following intermittent neural apnea. We tested the hypothesis that iPMF triggered by intermittent neural apnea requires retinoic acid and protein synthesis. Phrenic nerve activity was recorded in urethane-anesthetized and -ventilated rats treated intrathecally with an inhibitor of retinoic acid synthesis (4-diethlyaminobenzaldehyde, DEAB), a protein synthesis inhibitor (emetine), or vehicle (artificial cerebrospinal fluid) before intermittent (5 episodes, ~1.25 min each) or prolonged (30 min) neural apnea. Both DEAB and emetine abolished iPMF elicited by intermittent neural apnea but had no effect on iPMF elicited by a prolonged neural apnea. Thus different patterns of reduced respiratory neural activity elicit phenotypically similar iPMF via distinct spinal mechanisms. Understanding mechanisms that allow respiratory motoneurons to dynamically tune their output may have important implications in the context of respiratory control disorders that involve varied patterns of reduced respiratory neural activity, such as central sleep apnea and spinal cord injury.
NEW & NOTEWORTHY We identify spinal retinoic acid and protein synthesis as critical components in the cellular cascade whereby repetitive reductions in respiratory neural activity elicit rebound increases in phrenic inspiratory activity.
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Muscle proprioceptors in adult rat: mechanosensory signaling and synapse distribution in spinal cord
The characteristic signaling and intraspinal projections of muscle proprioceptors best described in the cat are often generalized across mammalian species. However, species-dependent adaptations within this system seem necessary to accommodate asymmetric scaling of length, velocity, and force information required by the physics of movement. In the present study we report mechanosensory responses and intraspinal destinations of three classes of muscle proprioceptors. Proprioceptors from triceps surae muscles in adult female Wistar rats anesthetized with isoflurane were physiologically classified as muscle spindle group Ia or II or as tendon organ group Ib afferents, studied for their firing responses to passive-muscle stretch, and in some cases labeled and imaged for axon projections and varicosities in spinal segments. Afferent projections and the laminar distributions of provisional synapses in rats closely resembled those found in the cat. Afferent signaling of muscle kinematics was also similar to reports in the cat, but rat Ib afferents fired robustly during passive-muscle stretch and Ia afferents displayed an exaggerated dynamic response, even after locomotor scaling was accounted for. These differences in mechanosensory signaling by muscle proprioceptors may represent adaptations for movement control in different animal species.
NEW & NOTEWORTHY Muscle sensory neurons signal information necessary for controlling limb movements. The information encoded and transmitted by muscle proprioceptors to networks in the spinal cord is known in detail only for the cat, but differences in size and behavior of other species challenge the presumed generalizability. This report presents the first findings detailing specializations in mechanosensory signaling and intraspinal targets for functionally identified subtypes of muscle proprioceptors in the rat.
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Unbounded evidence accumulation characterizes subjective visual vertical forced-choice perceptual choice and confidence
Humans can subjectively yet quantitatively assess choice confidence based on perceptual precision even when a perceptual decision is made without an immediate reward or feedback. However, surprisingly little is known about choice confidence. Here we investigate the dynamics of choice confidence by merging two parallel conceptual frameworks of decision making, signal detection theory and sequential analyses (i.e., drift-diffusion modeling). Specifically, to capture end-point statistics of binary choice and confidence, we built on a previous study that defined choice confidence in terms of psychophysics derived from signal detection theory. At the same time, we augmented this mathematical model to include accumulator dynamics of a drift-diffusion model to characterize the time dependence of the choice behaviors in a standard forced-choice paradigm in which stimulus duration is controlled by the operator. Human subjects performed a subjective visual vertical task, simultaneously reporting binary orientation choice and probabilistic confidence. Both binary choice and confidence experimental data displayed statistics and dynamics consistent with both signal detection theory and evidence accumulation, respectively. Specifically, the computational simulations showed that the unbounded evidence accumulator model fits the confidence data better than the classical bounded model, while bounded and unbounded models were indistinguishable for binary choice data. These results suggest that the brain can utilize mechanisms consistent with signal detection theory—especially when judging confidence without time pressure.
NEW & NOTEWORTHY We found that choice confidence data show dynamics consistent with evidence accumulation for a forced-choice subjective visual vertical task. We also found that the evidence accumulation appeared unbounded when judging confidence, which suggests that the brain utilizes mechanisms consistent with signal detection theory to determine choice confidence.
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Parkinsonism and vigilance: alteration in neural oscillatory activity and phase-amplitude coupling in the basal ganglia and motor cortex
Oscillatory neural activity in different frequency bands and phase-amplitude coupling (PAC) are hypothesized to be biomarkers of Parkinson's disease (PD) that could explain dysfunction in the motor circuit and be used for closed-loop deep brain stimulation (DBS). How these putative biomarkers change from the normal to the parkinsonian state across nodes in the motor circuit and within the same subject, however, remains unknown. In this study, we characterized how parkinsonism and vigilance altered oscillatory activity and PAC within the primary motor cortex (M1), subthalamic nucleus (STN), and globus pallidus (GP) in two nonhuman primates. Static and dynamic analyses of local field potential (LFP) recordings indicate that 1) after induction of parkinsonism using the neurotoxin MPTP, low-frequency power (8–30 Hz) increased in the STN and GP in both subjects, but increased in M1 in only one subject; 2) high-frequency power (~330 Hz) was present in the STN in both normal subjects but absent in the parkinsonian condition; 3) elevated PAC measurements emerged in the parkinsonian condition in both animals, but in different sites in each animal (M1 in one subject and GPe in the other); and 4) the state of vigilance significantly impacted how oscillatory activity and PAC were expressed in the motor circuit. These results support the hypothesis that changes in low- and high-frequency oscillatory activity and PAC are features of parkinsonian pathophysiology and provide evidence that closed-loop DBS systems based on these biomarkers may require subject-specific configurations as well as adaptation to changes in vigilance.
NEW & NOTEWORTHY Chronically implanted electrodes were used to record neural activity across multiple nodes in the basal ganglia-thalamocortical circuit simultaneously in a nonhuman primate model of Parkinson's disease, enabling within-subject comparisons of electrophysiological biomarkers between normal and parkinsonian conditions and different vigilance states. This study improves our understanding of the role of oscillatory activity and phase-amplitude coupling in the pathophysiology of Parkinson's disease and supports the development of more effective DBS therapies based on pathophysiological biomarkers.
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Intermittent cortical involvement in the preservation of tremor in essential tremor
Cortical involvement in essential tremor, an involuntary action tremor supposedly of subcortical origin, is uncertain. Conflicting results of corticomuscular coherence studies in essential tremor suggest an intermittent corticomuscular coupling. On the basis of the literature, we hypothesized that corticomuscular coupling is influenced by bilateral motor synchronization and "cognitive states" such as awareness of tremor. In the present study, we investigated 1) the existence of intermittent corticomuscular coherence (CMC) in essential tremor and 2) factors that influence CMC strength. In 18 essential tremor patients and 18 healthy controls, who mimicked tremor, we simultaneously recorded 64-channel EEG and 6-channel bipolar surface EMG from right and left wrist extensors and flexors. Right-sided (mimicked) hand tremor was recorded with and without a cognitive arithmetic task and with left-sided (mimicked) hand tremor. CMC values per task were compared within and between groups. Changes in CMC strength during tasks were calculated. Our main findings are 1) significant CMC around the (mimicked) tremor frequency across all tasks in both groups; 2) significant differences in CMC between unilateral tasks, with the highest values during the cognitive task only in the essential tremor group; and 3) significant fluctuations of CMC strength over time, independent of the tremor intensity, only in the essential tremor group. Our results suggest a limited role, and certainly not a continuous steering role, of sensorimotor cortical neurons in the generation of tremor. In clinical practice, these findings might help to standardize tremor registration and the interpretation of the analysis.
NEW & NOTEWORTHY The part of the motor cortex involved in essential tremor is uncertain. The current electrophysiological study is the first to assess corticomuscular coherence systematically. The study shows a dynamic nature of corticomuscular coherence and a possible influence of cognitive states. The results elucidate the involvement of the motor cortex in tremor and help interpret the varying results in the literature. In clinical practice, the findings may guide in standardizing tremor registration and its interpretation.
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Distinct coordinate systems for adaptations of movement direction and extent
Learned compensations for perturbed visual feedback of movement extent and direction generalize differently to unpracticed movement directions, which suggests different underlying neural mechanisms. Here we investigated whether gain and rotation adaptations are consistent with representation in different coordinate systems. Subjects performed a force-aiming task with the wrist and learned different gains or rotations for different force directions. Generalization was tested without visual feedback for the same extrinsic directions but with the forearm in a different pronation-supination orientation. When the change in forearm orientation caused the adapted visuomotor map to conflict in extrinsic and joint-based coordinates, rotation generalization occurred in extrinsic coordinates but with reduced magnitude. In contrast, gain generalization appeared reduced and phase shifted. When the forearm was rotated further, such that all imposed perturbations aligned in both joint-based and extrinsic coordinates in both postures, rotation generalization was further reduced, whereas there was neither reduction nor phase shift in the pattern of extent generalization. These results show that rotation generalization was expressed in extrinsic coordinates, and that generalization magnitude was modulated by posture. In contrast, gain generalization appeared to depend on target direction defined by an integrated combination of extrinsic and joint-based coordinates and was not reduced substantially by posture changes alone. Although the quality of the model fit underlying our interpretation prevents us from making strong conclusions, the data suggest that adaptations of movement direction and extent are represented according to distinct coordinate systems.
NEW & NOTEWORTHY Visuomotor gain and rotation adaptations generalize differently to novel movement directions, which suggests different neural mechanisms. When extrinsic and joint-based coordinates are effectively dissociated in an isometric aiming task, we find that they also generalize in different coordinate systems. Specifically, rotation generalized in extrinsic coordinates and decayed as posture departed from that adopted during adaptation. In contrast, gain generalization was expressed according to mixed extrinsic/joint-based coordinates and was not substantially reduced by postural changes.
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Rapid visuomotor feedback gains are tuned to the task dynamics
Adaptation to novel dynamics requires learning a motor memory, or a new pattern of predictive feedforward motor commands. Recently, we demonstrated the upregulation of rapid visuomotor feedback gains early in curl force field learning, which decrease once a predictive motor memory is learned. However, even after learning is complete, these feedback gains are higher than those observed in the null field trials. Interestingly, these upregulated feedback gains in the curl field were not observed in a constant force field. Therefore, we suggest that adaptation also involves selectively tuning the feedback sensitivity of the sensorimotor control system to the environment. Here, we test this hypothesis by measuring the rapid visuomotor feedback gains after subjects adapt to a variety of novel dynamics generated by a robotic manipulandum in three experiments. To probe the feedback gains, we measured the magnitude of the motor response to rapid shifts in the visual location of the hand during reaching. While the feedback gain magnitude remained similar over a larger than a fourfold increase in constant background load, the feedback gains scaled with increasing lateral resistance and increasing instability. The third experiment demonstrated that the feedback gains could also be independently tuned to perturbations to the left and right, depending on the lateral resistance, demonstrating the fractionation of feedback gains to environmental dynamics. Our results show that the sensorimotor control system regulates the gain of the feedback system as part of the adaptation process to novel dynamics, appropriately tuning them to the environment.
NEW & NOTEWORTHY Here, we test whether rapid visuomotor feedback responses are selectively tuned to the task dynamics. The responses do not exhibit gain scaling, but they do vary with the level and stability of task dynamics. Moreover, these feedback gains are independently tuned to perturbations to the left and right, depending on these dynamics. Our results demonstrate that the sensorimotor control system regulates the feedback gain as part of the adaptation process, tuning them appropriately to the environment.
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A functional strategy to characterize expression Quantitative Trait Loci
Abstract
The study of genetic variation has been revolutionized by the advent of high-throughput technologies able to determine the complete genomic sequence of thousands of individuals. Understanding the functional relevance of variants is, however, still a difficult task, especially when focusing on non-coding variants. Most of the variants associated with disease by Genome-Wide Association Studies (GWAS) are indeed non-coding, and presumably exert their effects by altering gene regulation. Expression Quantitative Trait Loci (eQTL) studies represent an important step in understanding the functional relevance of regulatory variants. We propose a new strategy to detect and characterize eQTLs, based on the effect of variants on the Total Binding Affinity (TBA) profiles of regulatory regions. Using a large dataset of coupled genome and expression data, we show that TBA-based inference allows the identification of eQTLs not revealed by traditional methods and helps in their interpretation in terms of altered transcription factor binding.
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Striatal neurons get a kick out of dopamine
Abstract
Dopamine (DA) is critically involved in reinforcement learning and malfunction in dopamine signalling is associated with numerable brain disorders, including ADHD, Parkinson's disease, drug abuse and schizophrenia.
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Intrauterine growth restriction results in persistent vascular mismatch in adulthood
Abstract
Maternal nutrient reduction induces intrauterine growth restriction (IUGR), increasing risks of chronic diseases later in life, including cardiovascular dysfunction. Using ultrasound, we determined regional blood flow, blood vessels sizes, and distensibility in IUGR baboons (8M/8F, 8.8 years, similar to 35 human years) and controls (12M/12F, 9.5 years). The measured blood vessels were larger in size in the males compared to females before but not after normalization to body surface area. Smaller IUGR normalized blood vessel sizes were observed in the femoral and external iliac arteries but not the brachial or common carotid arteries and not correlated significantly with birth weight. Mild decrease in distensibility in the IUGR group was seen in the iliac but not the carotid arteries without between-sex differences. In IUGR baboons there was increased carotid arterial blood flow velocity during late systole and diastole. Overall, our findings support the conclusion that region specific vascular and hemodynamic changes occur with IUGR, which may contribute to the occurrence of later life cardiac dysfunction. The pattern of alteration observed suggests vascular redistribution efforts in response to challenges in the perinatal period may persist into adulthood. Further studies are needed to determine the life course progression of these changes.
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