Resurgent sodium current promotes action potential firing in the avian auditory brainstem

Abstract

Auditory brainstem neurons are functionally primed to fire action potentials (APs) at markedly high-rates in order to rapidly encode acoustic information of sound. This specialization is critical for survival and the comprehension of behaviourally relevant communication functions, including sound localization and understanding speech in noise. Here, we investigated underlying ion channel mechanisms essential for high-rate AP firing in neurons of the chicken nucleus magnocellularis (NM) – the avian analog of bushy cells of the mammalian anteroventral cochlear nucleus. In addition to the established function of high-voltage activated potassium channels, we found that resurgent sodium current (I_NaR) plays a role in regulating rapid firing activity of late-developing (embryonic [E] days 19–21) NM neurons. I_NaR of late-developing NM neurons showed similar properties with mammalian neurons in that its unique mechanism of an "open channel block state" facilitated the recovery and increased the availability of sodium (Na_V) channels after depolarization. Using a computational model of NM neurons, we demonstrated that removal of I_NaR reduced high-rate AP firing. We found weak I_NaR during a prehearing period (E11-12), which transformed to resemble late-developing I_NaR properties around hearing onset (E14-16). Anatomically, we detected strong Na_V1.6 expression near maturation, which became increasingly less distinct at hearing onset and prehearing periods, suggesting that multiple Na_V channel subtypes may contribute to I_NaR during development. We conclude that I_NaR plays an important role in regulating rapid AP firing for NM neurons, a property that may be evolutionarily conserved for functions related to similar avian and mammalian hearing.

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Control networks and hubs

Abstract

Executive control functions are associated with frontal, parietal, cingulate, and insular brain regions that interact through distributed large-scale networks. Here, we discuss how fMRI functional connectivity can shed light on the organization of control networks and how they interact with other parts of the brain. In the first section of our review, we present convergent evidence from fMRI functional connectivity, activation, and lesion studies that there are multiple dissociable control networks in the brain with distinct functional properties. In the second section, we discuss how graph theoretical concepts can help illuminate the mechanisms by which control networks interact with other brain regions to carry out goal-directed functions, focusing on the role of specialized hub regions for mediating cross-network interactions. Again, we use a combination of functional connectivity, lesion, and task activation studies to bolster this claim. We conclude that a large-scale network perspective provides important neurobiological constraints on the neural underpinnings of executive control, which will guide future basic and translational research into executive function and its disruption in disease.

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Molecular adaptations of adipose tissue to 6 weeks of morning fasting vs daily breakfast consumption in lean and obese adults

Abstract

This experiment assessed molecular responses of human subcutaneous abdominal adipose tissue (SCAT) to 6 weeks of morning fasting. Forty-eight, healthy lean (n = 29) and obese (n = 20) adults provided SCAT biopsies before and after six weeks of morning fasting (FAST; 0 kcal until 1200 h) or daily breakfast consumption (BFAST; ≥700 kcal before 1100 h). Biopsies were analysed for mRNA levels of selected genes, and GLUT4 and Akt protein content. Basal and insulin-stimulated Akt activation and tissue glucose uptake rates were also determined. In lean individuals, lipid turnover and insulin signalling genes (ACADM and IRS2) were upregulated with FAST versus BFAST [1.14 (95%CI: 0.97 to 1.30) versus 0.80 (95%CI: 0.64 to 0.96), P = 0.007 and 1.75 (95%CI: 1.33 to 2.16) versus 1.09 (95%CI: 0.67 to 1.51), P = 0.03, respectively). In obese individuals, no differential (FAST versus BFAST) expression was observed in genes involved in lipid turnover (all P > 0.1). GLUT4, Akt protein content and insulin-stimulated Akt phosphorylation were unaffected by FAST versus BFAST in both lean and obese cohorts (all P > 0.1). Lower insulin-stimulated glucose uptake rates in obese versus lean individuals were eradicated when normalised to whole-body fat mass (P = 0.416). We conclude that morning fasting upregulates lipid turnover genes in SCAT of lean individuals. Secondly, altered SCAT insulin sensitivity with morning fasting is unlikely to be explained by signalling proximal to Akt. Finally, lower insulin-stimulated SCAT glucose uptake rates in obese individuals are proportional to whole-body fat mass, suggesting a compensatory downregulation, presumably to prevent excessive de novo lipogenesis in adipose tissue. This trial was registered as ISRCTN31521726.

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Gait performance and foot pressure distribution during wearable robot-assisted gait in elderly adults

A robotic exoskeleton device is an intelligent system designed to improve gait performance and quality of life for the wearer. Robotic technology has developed rapidly in recent years, and several robot-assist...

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Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial

Hemiplegic shoulder pain is a frequent complication after stroke, leading to limited use of the affected arm. Neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) ...

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Anesthetic management of a parturient with hemolysis, elevated liver enzyme levels, and low platelet syndrome complicated by renal insufficiency and coagulopathy

Jinguo Wang, Na Wang, Wei Han, Zhanyang Han

Anesthesia: Essays and Researches 2017 11(4):1126-1128

The objective of this study is to describe the anesthetic management of a parturient with hemolysis, elevated liver enzyme levels, and low platelet (HELLP) syndrome and renal insufficiency. A 28-year-old female patient, gestational age of 35 weeks, with hypertensive crisis (blood pressure 190/110 mmHg), was admitted for an emergency cesarean section after diagnosis of HELLP syndrome and renal insufficiency. We performed total intravenous general anesthesia with rapid sequence induction. During the surgical procedure, reduced urine output and coagulopathy were detected. After the treatments of transfusion, diuresis, and anticoagulation, the surgery finished uneventfully. The patient was taken to the Intensive Care Unit without extubation and discharged on the 6th postoperative day. This case report revealed a successful anesthetic management applied to a pregnant woman with HELLP syndrome complicated by renal insuffciency and coagulopathy. There are several case reports about HELLP syndrome, but the patient in this paper is complicated with renal insuffciency and coagulopathy which made the treatment diffcult to handle.

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Intravenous dexmedetomidine infusion compared with that of fentanyl in patients undergoing arthroscopic shoulder surgery under general anesthesia

Mona Hossam Eldin Abdel Hamid

Anesthesia: Essays and Researches 2017 11(4):1070-1074

Background: Anesthesia for arthroscopic shoulder surgery is challenging due to the need for oligaemic surgical field as well as a good postoperative recovery profile. Aim: The present study was prospective, randomized to evaluate the efficacy of dexmdetomidine infusion compared to that of fentanyl in patients undergoing arthroscopic shoulder surgery under general anesthesia. Patients and Methods: A total of 60 patients aged from thirty to fifty years, American Society of Anesthesiologists Class I/II of either sex for arthroscopic shoulder surgery, were included. The patients were divided into two groups of 30 patients each. Group I received dexmedetomidine loading 1 μg/kg over 10 min followed by maintenance 0.5 μg/kg/h and Group II Fentanyl loading 1 μg/kg followed by maintenance 0.5 μg/kg/h. Measurements: Hemodynamic readings (Heart rate HR, and mean arterial blood pressure MAP) were recorded after the start of the study drug infusion (T1), after intubation (T2), then every 15 minutes till the end of surgery (T15, T30, T45, T60, T75, T90). In the PACU , MAP, and HR were recorded on arrival, after 30 min, 1 hr, and 2 hrs (R0, R30, R1 hr, R2 hr) Postoperative analgesia was assessed by visual analogue scale (VAS), Modified Observers's Assessment of Alertness and Sedation OAA/S was recorded on arrival to PACU. Results: This study showed that in the dexmedatomidine group there was statistically significant decrease of MAP and HR after drug infusion up to two hours in the recovery period, more sedation, better control of pain and surgeon satisfaction. Conclusion: Iv infusion of dexamedatomidine may be an attractive option during arthroscopic shoulder surgery as it provided a better hypotensive anesthesia by lowering MAP and HR which leads to better surgical field and surgeon satisfaction than iv infusion fentanyl along with a better postoperative VAS.

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Application of discharge criteria for home readiness using bispectral and supraglottic airway devices in day-care surgery without using muscle relaxants

Joginder Pal Attri, Manjit Singh, Hemchandra Bhatt, Kamal Jyoti, Harjinder Kaur

Anesthesia: Essays and Researches 2017 11(4):816-820

Introduction: The availability of rapid and short-acting intravenous and volatile anesthetics has facilitated early recovery that is why nowadays ambulatory surgery is becoming more common. If the criteria used to discharge patients from the Postanesthesia Care Unit (PACU) are met in the operating room (OR), it would be appropriate to consider bypassing the PACU and transferring the patient directly to the step-down unit. This process is known as "fast-tracking" after ambulatory surgery. Aims: To compare hemodynamic characteristics and recovery profile as per fast-track criteria (FTC) of recovery and postanesthesia discharge scoring system (PADSS) between sevoflurane and desflurane. Materials and Methods: One hundred American Society of Anesthesiologists Class I–II patients aged 20–50 years were randomly divided into two groups. Following anesthesia induction with injection propofol and injection dexmedetomidine airway was secured with i-gel, Group D (n = 50) received desflurane + dexmedetomidine + O2 + N2O and Group S (n = 50) received sevoflurane in place of desflurane. Emergence time was noted and FTC was evaluated in the OR, Score >12 is considered as shifting criteria for ambulatory surgery unit (ASU). PADSS was noted in ASU at an interval of 15 min for 3 h and Score >9 is considered as ready to discharge home. Results: Response to pain, verbal commands, and spontaneous eye opening in Group D was shorter than that in Group S (P = 0.001). Mean time to achieve FTC score >12 was 15 min in both the groups. Eighty-six percent of patients were ready to go home between 60 and 90 min using PADSS. Conclusion: We concluded that early recovery is faster for desflurane, and there is no difference in ready to go home time between desflurane and sevoflurane.

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Postoperative ultrasound guided continuous femoral nerve blockade for unilateral total knee arthroplasty: A comparison of 0.125% bupivacaine and 0.2% ropivacaine

Sruthi C Babu, Gokuldas Menon, Bindu K Vasu, Mathew George, Jai Thilak, Sundaram Iyer

Anesthesia: Essays and Researches 2017 11(4):1026-1029

Context: Total knee arthroplasty (TKA) is associated with severe postoperative pain which increases morbidity and mortality. Aims: The aim of the study was to compare the analgesic efficacy and motor blockade of continuous infusion of 0.125% bupivacaine and 0.2% ropivacaine in femoral nerve block following unilateral TKA and to assess the effectiveness of femoral nerve block. Settings and Design: One hundred and fifty patients undergoing unilateral total knee replacement surgery were included in this prospective observational comparative study. Subjects and Methods: Patients are divided into two groups of 75 each. Femoral nerve catheter was placed at the end of surgery using ultrasound. Postoperative analgesia and motor blockade were compared for the next 24 h using visual analog scale (VAS) score, additional analgesic requirement, and Bromage scale. Statistical Analysis: Student's t-test and Chi-square test were applied. Results: There was no statistically significant difference in pain between the two groups though VAS score (during rest and movement) and opioid consumption were lower in bupivacaine group. Nearly 28.6% patients experienced pain and required additional analgesics. Seventy-two percent among them complained of pain in the popliteal region supplied by sciatic nerve. Eight patients excluded from the study also had pain in the popliteal fossa. There was a statistically significant difference in motor blockade between the two groups at 12, 18, and 24 h after starting infusion. Bupivacaine group had a higher percentage of type three blocks compared to ropivacaine group. Conclusion: Continuous femoral nerve block (CFNB) with 0.125% bupivacaine infusion provided better analgesia with denser motor blockade compared to 0.2% ropivacaine infusion. CFNB alone is not sufficient to provide adequate analgesia following unilateral TKA.

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Preemptive epidural analgesia for postoperative pain relief revisited: Comparison of combination of buprenorphine and neostigmine with combination of buprenorphine and ketamine in lower abdominal surgeries, a double-blind randomized trial

Sanjay Choubey, Raj Bahadur Singh

Anesthesia: Essays and Researches 2017 11(4):821-827

Context: Postoperative pain relief provides subjective comfort to patient in addition to blunting of autonomic and somatic reflex responses to pain, subsequently enhancing restoration of function by allowing the patient to breathe, cough, and move easily. Aims: The aim is to evaluate and compare the effects of neostigmine + buprenorphine and ketamine + buprenorphine for preemptive epidural analgesia for postoperative pain relief in patients undergoing abdominal surgeries under general anesthesia (GA). Settings and Design: A double-blind randomized trial. Subjects and Methods: A total of 60 American Society of Anesthesiologists physical status Classes I and II patients undergoing abdominal surgeries under GA were taken up for the study. They were randomly allocated into two groups, Group A and Group B of thirty patients each. Preemptive epidural analgesia for postoperative pain relief was provided by a combination of neostigmine 1 μg/kg + buprenorphine 2 μg/kg in Group A patients and ketamine 1 mg/kg + buprenorphine 2 μg/kg in Group B patients after induction of GA but before surgical incision. Postoperatively, vital parameters, pain score, requirement of top up doses, and side effects in the two groups were observed and recorded at 2, 4, 6, 10, 18, and 22 h. Statistical Analysis Used: Mean values within each of the Group A and Group B were compared using one-way analysis of variance (one-way ANOVA). Mean values between Group A and Group B were compared using double analysis of variance (two-way ANOVA). Results: Group A patients had a significant analgesia (visual analog scale [VAS] pain scores reduced significantly from 54.6 ± 6.3 at 2 h to 8.1 ± 8.9 at 22 h postoperatively). Group B patients had significant analgesia too (VAS pain scores reduced significantly from 36 ± 12.5 at 2 h to 5.3 ± 10.9 at 22 h postoperatively). There was however no significant difference between the two groups with respect to the degree of postoperative analgesia on comparison of VAS scores, effect on vital parameters, and incidence of side effects. Conclusions: Either of the two combinations, neostigmine 1 μg/kg + buprenorphine μg/kg or ketamine 1 mg/kg + buprenorphine 2 μg/kg can be safely used for preemptive epidural analgesia for postoperative pain relief in patients undergoing abdominal surgeries under GA.

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Anesthetic management for prolonged incidental surgery in advanced liver disease

Riddhi Kundu, Rajeshwari Subramaniam, Arijit Sardar

Anesthesia: Essays and Researches 2017 11(4):1101-1104

In spite of advances in perioperative management, operative procedures in patients with chronic liver disease pose a significant challenge for the anesthesiologist due to multisystem involvement, high risk of postoperative hepatic decompensation, and mortality. We describe the anesthetic management of an elderly patient with advanced liver disease (model for end-stage liver disease 16) for prolonged abdominal surgery. The use of invasive hemodynamic monitoring, point-of-care biochemical, and hematological surveillance coupled with prompt correction of all abnormalities was responsible for good outcome. The patient's inguinal swellings turned out to be extensions of a large peritoneal mesothelioma, necessitating a large abdominal incision and blood loss. Analgesia was provided by bilateral transversus abdominis plane blocks, which helped to reduce opioid use and rapid extubation.

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Comparison of dexmedetomidine and midazolam for sedation in mechanically ventilated patients guided by bispectral index and sedation-agitation scale

Manoj Tripathi, Virendra Kumar, Mahendra B Kalashetty, Deepak Malviya, Prateek Singh Bais, Om Prakash Sanjeev

Anesthesia: Essays and Researches 2017 11(4):828-833

Background: Mechanical ventilation and sedation are inextricably linked components of critical care that represent, what we do for the patients during their vulnerable course in Intensive Care Unit (ICU). Aims: The aim of this study is to compare the efficacy and safety of midazolam and dexmedetomidine in patients on mechanical ventilator with the help of Bispectral Index (BIS) monitoring and correlation of BIS with Sedation-Agitation Scale (SAS). Settings and Design: Prospective, observational, and comparative study. Materials and Methods: In this study, recruited patients were allocated into two groups of 14 patients each. Group A and Group B patients received injection dexmedetomidine and injection Midazolam, respectively. Hemodynamic parameters, time of extubation, duration of mechanical ventilation, and mortality were compared between two groups. Statistical Analysis: Mean and the standard deviation were calculated. Test of analysis between two groups was performed using unpaired t-test. We applied correlation technique, that is, Pearson product-moment correlation coefficient (r) to assess the correlation between BIS and SAS. It varies from + 1–0 to −1. Results: Heart rate and blood pressure were more stable and less in Group A than Group B. Duration of mechanical ventilation was found extremely significant between Group A (77.86 ± 5.71 h) and Group B (95.64 ± 17.00 h) (P = 0.001). There was significant difference found in the time of extubation between Group A (21 ± 6.44 h) and Group B (30.4 ± 10.62 h) P = 0.008. Conclusion: It is concluded in this study that sedation with dexmedetomidine resulted in quick extubation and decreased the duration of mechanical ventilation in comparison to midazolam in ICU patients. There was found moderate to high correlation between BIS index and SAS.

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Comparison of analgesic efficacy of caudal dexamethasone with intravenous dexamethasone as an adjuvant to caudal block in pediatric patients undergoing urogenital surgeries

Dhanashree H Dongare, Seema S Karhade

Anesthesia: Essays and Researches 2017 11(4):1009-1012

Context: Caudal block is one of the most common regional anesthetic techniques employed in pediatric urogenital surgeries. Adjuvants play an important role to improve postoperative analgesia. Aims: The aim of this study was to evaluate the analgesic effect of dexamethasone when given systemically as against caudally as an adjuvant to caudal block. Subjects and Methods: In this randomized controlled study, sixty American Society of Anesthesiologists Physical Status I and II patients aged 3–6 years were randomly allocated into two groups of thirty each. Group D received caudal block with local anesthetic solution and 0.1 mg/kg injection dexamethasone. Group I received a caudal block with local anesthetic solution. They received intravenous injection dexamethasone 0.1 mg/kg after the block. Both the groups were compared for the duration of postoperative analgesia and analgesic requirement. Statistical Analysis Used: Statistical analysis was done with unpaired t-test and Chi-square test as was appropriate. Results: Group D showed a significant prolongation of postoperative analgesia (626.33 ± 59.39 min) as compared to Group I (194.67 ± 27.76 min). Similarly, requirement of analgesic was reduced on 1st postoperative day in group receiving caudal dexamethasone. Conclusions: Dexamethasone significantly prolongs the duration of postoperative analgesia of a caudal block when given caudally than when given intravenously.

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To evaluate the efficacy of intravenous infusion of dexmedetomidine as premedication in attenuating the rise of intraocular pressure caused by succinylcholine in patients undergoing rapid sequence induction for general anesthesia: A randomized study

Raj Bahadur Singh, Sanjay Choubey, Saurabh Mishra

Anesthesia: Essays and Researches 2017 11(4):834-841

Context: Laryngoscopy and intubation performed during RSI lead to choroidal blood volume increase and an eventual rise in intraocular pressure (IOP). Use of succinylcholine (SCh) causes an undesirable rise in IOP which is further aggravated by laryngoscopy and endotracheal intubation. Dexmedetomidine is a highly selective centrally acting α2adrenergic agonist that has IOP lowering properties. Aims: This study aims to evaluate the efficacy of intravenous (i.v.) infusion of dexmedetomidine (0.5 μg/kg) as premedication in attenuating the rise of IOP and adverse effect if any caused by SCh in patients undergoing RSI for general anesthesia. Settings and Design: This was a double-blind, randomized trial. Subjects and Methods: Sixty adult patients in the age group of 20–50 years scheduled for elective surgeries under general anesthesia. Group I (dexmedetomidine group) (n = 30) received i.v. infusion of dexmedetomidine (0.5 μg/kg) and Group II (control group) (n = 30) received i.v. infusion of 50 ml normal saline as premedication Statistical Analysis Used: The analysis was done using Statistical Package for Social Sciences Version 15.0 statistical Analysis Software. Results: It was observed that Group I (dexmedetomidine group) had a better attenuating effect over the increases in IOP in patients undergoing RSI for general anesthesia using SCh. An increase in IOP was seen in Group II (control group) patients with RSI. Conclusions: The findings in the present study indicate that i.v. dexmedetomidine effectively attenuates the increases in IOP with an additional advantage of control on hemodynamic responses following RSI.

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Optimal dose of dexmedetomidine retrobulbar anesthesia during phacoemulsification cataract surgery

Ahmed Ahmed Nagy, Saber Hamed El-Sayd, Ahmed Abdelaziz Ahmed, Ghada Zin-Eldin Rajab

Anesthesia: Essays and Researches 2017 11(4):1046-1050

Background: The cataract surgery anesthesia should be to make the procedure as safe and as satisfactory as possible for all concerned. The recent progress in anesthesia and surgery now allow cataract extraction to be done with minimal physiological changes to the patient. We aimed in the study to compare between two different doses of dexmedetomidine combined with lidocaine and bupivacaine during retrobulbar anesthesia for cataract extraction by phacoemulsification. Materials and Methods: This study was done on forty patients with cataract. The patients were enrolled in two groups: Group (A):Twenty patients were received 1.5 ml 2% lidocaine + 1.5 ml 0.5% bupivacaine + 0.25 μg/kg of dexmedetomidine and Group (B): Twenty patients were received 1.5 ml 2% lidocaine + 1.5 ml 0.5% bupivacaine + 0.5 μg/kg of dexmedetomidine. Results: The globe anesthesia duration, globe, and lid akinesia were significantly longer in the Group B than in the Group A (P < 0.05). Intraocular pressure decreased through the first 15 min after anesthesia in the two groups, and the changes were not significant between the two groups but highly significant in every group when compared to its baseline reading. As regards the conscious level in the two groups, there was a significant difference (P < 0.001). Group A is higher regarding score 2 and 3, and Group B higher in score 4. Conclusions: We concluded that dexmedetomidine 0.25 μg/kg, when added to retrobulbar block for cataract surgery, will significantly increase the duration of retrobulbar block and improve both the surgeon and the patient satisfaction.

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Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention in young doctors joining postgraduation program

Vidhu Bhatnagar, Urvashi Tandon, Kavitha Jinjil, Deepak Dwivedi, S Kiran, Rohit Verma

Anesthesia: Essays and Researches 2017 11(4):842-846

Background: High-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation the cornerstone for resuscitation from cardiac arrest and increase the incidence of return of spontaneous circulation. Regular CPR training imparted to health-care personnel increases knowledge and helps in skill enhancing. Aims: The aim of this study is to evaluate background knowledge, percentage improvement in the skills, and residual knowledge after a period of 6 months of postgraduate (PG) students as well as the efficacy of the designed teaching program for CPR. Design: The study type was interventional, nonrandomized with end point classification as efficacy study. Study Interventional model was single group assignment. Methods: A questionnaire-based study was conducted on 41 first year PG students. Their educational qualification was Bachelor of Medicine and Bachelor of Surgery. The study was conducted; 3 months after, these PG students joined hospital for their PG studies. The questionnaire designed by the Department of Anesthesiology and Critical Care was given as the pretest (before the CPR training program was initiated), posttest (immediately after the CPR training program was concluded), and residual knowledge test (conducted after 6 months of the CPR training program). After collection of data, a descriptive analysis was performed to evaluate results. Statistical Analysis: Statistical analysis was conducted for determining the test of significance using two-tailed, paired t-test. Results: The average overall score was 25.58 (±5.605) marks out of a maximum of 40 marks in the pretest, i.e., 63.97%. It improved to 33.88 (±3.38) marks in posttest, i.e., 84.74%. After 6 months in the residual knowledge test, the score declined to 26.96 (±6.09) marks, i.e., 67.4%. Conclusion: The CPR training program being conducted was adequately efficacious, but a refresher course after 6 months could help taking the knowledge and skills acquired by our PG students a long way.

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Postoperative chylothorax of unclear etiology in a patient with right-sided subclavian central venous catheter placement

Samie Asghar, Faisal Shamim

Anesthesia: Essays and Researches 2017 11(4):1088-1090

A young male underwent decompressive craniotomy for an intracerebral bleed. A right-sided subclavian central venous catheter was placed in the operating room after induction of anesthesia. Postoperatively, he was shifted to Intensive Care Unit (ICU) for mechanical ventilation due to low Glasgow coma scale. He had an episode of severe agitation and straining on the tracheal tube in the evening same day. On the 2nd postoperative day in ICU, his airway pressures were high, and chest X-ray revealed massive pleural effusion on right side. Under ultrasound guidance, 1400 milky white fluid was aspirated. It was sent for analysis (triglycerides) that confirmed chyle and hence, chylothorax was made as diagnosis. A duplex scan was done which ruled out thrombosis in subclavian vein. The catheter had normal pressure tracing with free aspiration of blood from all ports. Enteral feeding was continued as it is a controversial matter in the literature and he was monitored clinically and radiologically.

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To Compare the effects of different doses of dexmedetomidine on intrathecal bupivacaine in infraumbilical surgeries: A prospective, randomized, double-blind clinical study

Shashikala Thuraganur Kapinegowda, Tejesh Channasandra Anandswamy, Vijaya Hanumanthappa Narayanappa, Sachin Kumar, Prashant Hatti

Anesthesia: Essays and Researches 2017 11(4):847-853

Introduction: Spinal anesthesia is preferred technique of choice in infraumbalical surgeries. Limitation of this technique is shorter duration of analgesia, so various adjuvants have been used with intrathecal bupivacaine such as fentanyl, clonidine, and dexmedetomidine. Dexmedetomidine is a highly selective alpha 2 adrenergic agonist. The aim of our study was to know the effect of different doses of dexmedetomidine on intrathecal bupivacaine. Materials and Methods: The prospective, randomized, double-blind study was conducted in tertiary health care center, on ninety patients of the American Society of Anesthesiology Class I and II, of age group 18–60 years of either sex. They were randomly allocated into three groups. Group BD5 (n = 30): intrathecal bupivacaine 12.5 mg (2.5 ml) + dexmedetomidine 5 μg (0.5 ml), Group BD10 (n = 30): intrathecal bupivacaine 12.5 mg (2.5 ml) + dexmedetomidine 10 μg (0.5 ml), Group BD15 (n = 30): intrathecal bupivacaine 12.5 mg (2.5 ml) + dexmedetomidine 15 μg (0.5 ml) administered intarthecally. The onset and maximum level of sensory block, time to reach maximum level of sensory block, time of two-segment sensory regression, the total duration analgesia, time of rescue analgesia, onset and duration of motor block and heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, respiratory rate, and oxygen saturation were recorded at various intervals. Moreover, any adverse effects such as bradycardia, hypotension, nausea, vomiting, and sedation were recorded. Results: The onset time of sensory block in Group D5-2.76 ± 1.32, Group D10-2.45 ± 1.50, and Group D15-1.86±0.93, which is statistically significant (P = 0.025). The time taken for two-segment sensory regression Group D5-96.66 ± 33.67, Group D10-116.80 ± 36.27, and Group D15 120.96 ± 30.24, (P = 0.014). The time taken for complete sensory recovery in Group D5-319.83 ± 61.41, Group D10-336.13 ± 61.38, and Group D15-415.20 ± 96.6, which is statistically highly significant (P = 0.000). Time for rescue analgesia in Group D5-377.46 ± 60.05, in Group D10-401.60 ± 61.11, and in Group D15-517.96 ± 97.30, which is statistically highly significant (P < 0.000). Conclusion: We concluded that there was decrease in onset of sensory and motor blockade with the prolongation of duration of anesthesia and analgesia in a dose-dependent manner.

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Anaesthetic implications of severe hyperthyroidism secondary to molar pregnancy: A case report and review of literature

Srinivasan Swaminathan, Roshin Ann James, Rashmi Chandran, Reesha Joshi

Anesthesia: Essays and Researches 2017 11(4):1115-1117

Pregnant women with gestational trophoblastic disease have an increased likelihood to develop hyperthyroidism secondary to increased secretion of human chorionic gonadotropin. Most of these cases of hyperthyroidism remain undiagnosed and may present as a thyrotoxic crisis during the perioperative period. Pregnant patients with gestational trophoblastic disease should be always evaluated for hyperthyroidism, and in cases of severe hyperthyroidism, antithyroid treatment should be initiated before evacuation of the mole. Anesthetic management of these cases is challenging in view of the emergency nature of the surgery and potential for thyroid crisis. Spinal anesthesia can be safely administered and has a protective role in preventing thyroid crisis.

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Efficacy of oral transmucosal fentanyl citrate for premedication in patients for surgery under general anesthesia

Raj Bahadur Singh, Sanjay Choubey, Ria Mehra

Anesthesia: Essays and Researches 2017 11(4):854-858

Background: Oral transmucosal fentanyl citrate (OTFC), a water soluble salt when mixed in saliva is 80% nonionized; making it the only opioid suitable for transmucosal absorption. OTFC has rapid onset of action (3–5 min) with peak effect at 20–40 min and total duration of activity is 2–3 h. Aims: This study aims to determine the efficacy of OTFC as premedicant in patients scheduled for surgery under general anesthesia (GA) and to assess the effects of OTFC on anxiety, sedation. Settings and Design: A prospective randomized study. Subjects and Methods: Patients between 21 and 60 years of age in American Society of Anesthesiologists physical status Classes I and II scheduled for elective surgery under GA were randomly assigned to three groups of 30 each: OTFC, placebo, and control. Mean arterial blood pressure (MAP), heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2) along with anxiety and sedation scores were recorded as baseline and upon entering the operation theater. Adverse effects were also recorded. Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences Version 15.0 Statistical Analysis Software. Results: No significant differences were found in MAP, HR, RR, or SpO2among the groups. OTFC group demonstrated significantly higher levels of anxiolysis than the control group (P < 0.05). No significant difference in sedation score was found. No remarkable adverse effects were observed. Conclusions: OTFC is an effective anxiolytic in adult with minimal risks and side effects. It is readily acceptable by the patients in its given form.

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Evaluation of effectiveness of dexmedetomidine and fentanyl-midazolam combination on sedation and safety during awake fiberoptic intubation: A randomized comparative study

Abida Yousuf, Basharat Ahad, Aabid Hussain Mir, Abdul Waheed Mir, Juvera Gul Wani, Sheikh Quyoom Hussain

Anesthesia: Essays and Researches 2017 11(4):998-1003

Background: Awake fiberoptic intubation (AFOI) is a recommended technique for anticipated difficult airway. An ideal regime should provide patient comfort, cooperation, amnesia, hemodynamic stability, and blunt airway reflexes and maintain a patent airway with spontaneous ventilation. The aim of our study was to compare intubation conditions between dexmedetomidine and fentanyl–midazolam combination during AFOI. Methods: This prospective, randomized study was conducted on a total of sixty patients of the American Society of Anesthesiologists physical status I and II of either sex, in the age group of 18–60 years having predicted difficult intubation undergoing elective surgeries and the patients were allocated to two groups of thirty patients each. After premedication and topicalization of airways, dexmedetomidine group (Group I, n = 30) received dexmedetomidine 1 μg/kg over 10 min and midazolam–fentanyl group (Group II, n = 30) received fentanyl 2 μg/kg plus midazolam 0.02 mg/kg over 10 min. Adequacy of intubation condition was evaluated by cough score and postintubation score. Incidence of desaturation, hemodynamic changes, and sedation using Ramsay sedation scale were noted and compared between two groups. Results: The demographic characteristics were comparable in the two groups (P > 0.05). The mean Ramsay sedation score in Group I was 3.13 ± 0.937 and Group II was 3.16 ± 0.949, and the comparison between two groups was statistically insignificant (P = 0.891). Cough scores and postintubation scores were favorable in dexmedetomidine group than midazolam–fentanyl group and were statistically significant with P < 0.001 and 0.0001, respectively. Group I also showed better hemodynamics and less episodes of desaturation than Group II. Conclusions: Dexmedetomidine is more effective than midazolam–fentanyl during AFOI, as it provides better intubation condition, hemodynamic stability, and preservation of airway and spontaneous ventilation.

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“Comparison of nalbuphine hydrochloride and fentanyl as an adjuvant to bupivacaine for spinal anesthesia in lower abdominal surgeries:” A randomized, double-blind study

Umesh N Prabhakaraiah, Archana B Narayanappa, Shivakumar Gurulingaswamy, Krishna Kempegowda, Kiran A Vijaynagar, Nagarajaiah B Hanumantharayappa, Diwakar S Ramegowda

Anesthesia: Essays and Researches 2017 11(4):859-863

Background and Aims: Opioids have been favored as adjuvants to local anesthetics during spinal anesthesia. Nalbuphine, a μ-receptor antagonist and ĸ-receptor agonist, seems to be a suitable adjuvant to local anesthetics. The aim of this study was to compare postoperative analgesia and adverse effects of nalbuphine and fentanyl when used as an adjuvant to hyperbaric bupivacaine during spinal anesthesia. Materials and Methods: Sixty patients belonging to the American Society of Anesthesiologists Physical Status I and II were randomly allocated into two groups of thirty each. Patients in bupivacaine nalbuphine group (Group BN) received 0.8 mg (0.3 ml) of nalbuphine with 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine diluted to 3 ml and bupivacaine-fentanyl group (Group BF) received 25 μg (0.5 ml) of fentanyl with 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine. Patients were assessed for hemodynamic changes, sensory and motor block, early postoperative analgesia, and adverse effects. Results: Onset, duration of sensory and motor block, and duration of effective analgesia were comparable between both groups. Postoperative visual analog scale score was 4.8 ± 1.12 in Group BN, and in Group BF, it was 3.86 ± 1.04 which was statistically highly significant (P = 0.0007). The number of patients demanding rescue analgesia in early postoperative period was 18 (60.0%) in Group BN and 7 (23.33%) in Group BF which was statistically significant (P = 0.004). Conclusion: Fentanyl was more efficient than nalbuphine in providing early postoperative analgesia when used as an adjuvant to hyperbaric bupivacaine.

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Short-term outcome of patients with infective endocarditis: A single-center prospective study

Kianoush Saberi, Mehrdad Salehi, Ali Reza Bakhshandeh, Shahnaz Sharifi, Mehrzad Rahmanian, Roya Sattarzadeh, Anahita Tavoosi

Anesthesia: Essays and Researches 2017 11(4):1018-1021

Objectives: To investigate the short-term outcome of patients with infective endocarditis (IE). Patients and Methods: We analyzed data from 42 patients with active endocarditis which underwent different cardiac surgeries. An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue and/or blood culture and acute inflammation Gram stains of sample tissue. Design: Collecting data of 42 patients prospectively. Setting: University hospital single center. Participants: Patients with IE from July 2014 to June 2016. Interventions: None. Measurement and Main Results: We collected data of 42 patients in Imam Hospital which is a university-based 1700-bed center. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 mitral valve repair, and only one patient had experienced a subaortic web resection. Seven cases were addict; in which, 5 of them were intravenous abusers. There was 1 porphyric patient which suffered from pethidine reliability. Most of our cases underwent Bentall or tricuspid valve repair operation, and multivalve operation was more scarce. Conclusions: We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.

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Effect of clonidine as adjuvant in thoracic paravertebral block for patients undergoing breast cancer surgery: A prospective, randomized, placebo-controlled, double-blind study

Nairita Mayur, Anjan Das, Hirak Biswas, Subinay Chhaule, Surajit Chattopadhyay, Tapobrata Mitra, Sandip Roybasunia, Subrata Kumar Mandal

Anesthesia: Essays and Researches 2017 11(4):864-870

Background and Aims: Postoperative pain after breast cancer surgery is unavoidable. Thoracic paravertebral block (TPVB), a locoregional anesthetic technique, has been proven successful for postoperative pain management in different thoracic surgical procedures, such as thoracotomy, breast cancer surgeries. Clonidine, an adjuvant, in TPVB may enhance the quality and prolong the duration of analgesia. This prospective study was to evaluate the effectiveness of clonidine; administered with TPVB; in addition to conventional local anesthetic solution. Materials and Methods: Fifty-two patients (25–55 years) scheduled for breast cancer surgery under general anesthesia were randomly divided into Group A (n = 26) receiving preoperative TPVB at T3with clonidine added to local anesthesia solution and Group B (n = 26) receiving identical TPVB with local anesthesia but without any adjuvant. This was followed by balanced general anesthesia. A visual analog scale was used to assess pain postoperatively up to 48 h. Meantime to administration of the first dose of rescue analgesic was noted. Total dose of fentanyl consumption, hemodynamic parameters, and side effects were all recorded for each patient. Results: The dosage of fentanyl required in the intraoperative period was significantly lower in Group A. Mean time to administration of rescue analgesic was found to be significantly longer in clonidine group. Hemodynamics and side effects were quite comparable among two groups. Conclusion: Clonidine as adjuvant in TPVB provided profound analgesia for up to 48 h postoperatively for patients undergoing breast cancer surgery without any appreciable side effects.

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Comparative study of clonidine with ropivacaine versus ropivacaine alone in epidural anesthesia for lower limb orthopedic surgery

Mahendra Singh, Amitesh Pathak, Aamir laique Khan, Amit Srivastava, Devendra Negi

Anesthesia: Essays and Researches 2017 11(4):1035-1039

Background: Epidural anesthesia has been well established as a safe and effective technique not only for perioperative anesthesia but also for postoperative analgesia. Various adjuvants have been added to local anesthetic agent in an effort to prolong this duration. Aims: The aim of this study was to compare and evaluate the anesthesia and analgesic property of ropivacaine to its combination with clonidine for lower limb orthopedic surgery under epidural. Materials and Methods: In a prospective, randomized, double-blind study, eighty adult patients undergoing lower limb surgeries received either 0.75% ropivacaine or 75 μg clonidine with 0.75% ropivacaine through epidural route. Patients were compared for hemodynamic variability, quality of motor and sensory block, intra- and post-operative analgesia, and the side effects associated. Statistical Analysis: Data analysis was done by Student's paired t-test, Chi-square test, and Mann–Whitney test. P < 0.05 was considered statistically significant. Results: The time taken for onset of the motor as well as the sensory block was significantly shorter in ropivacaine with clonidine group as compared to ropivacaine alone group. Mean duration of analgesia was significantly higher in patients who received clonidine as an adjunct (P < 0.001). There was no significant difference observed in the incidence of hemodynamic changes or side effects. Conclusion: The study demonstrated that use of clonidine as an adjuvant to ropivacaine through epidural route provides a hemodynamically stable, faster, and prolonged epidural block and a longer analgesic effect as compared to ropivacaine alone.

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Evaluation of sediment and 137Cs redistribution in the Oginosawa River catchment near the Fukushima Dai-ichi Nuclear Power Plant using integrated watershed modeling

Publication date: February 2018
Source:Journal of Environmental Radioactivity, Volume 182
Author(s): Kazuyuki Sakuma, Alex Malins, Hironori Funaki, Hiroshi Kurikami, Tadafumi Niizato, Takahiro Nakanishi, Koji Mori, Kazuhiro Tada, Takamaru Kobayashi, Akihiro Kitamura, Masaaki Hosomi
The Oginosawa River catchment lies 15 km south-west of the Fukushima Dai-ichi nuclear plant and covers 7.7 km². Parts of the catchment were decontaminated between fall 2012 and March 2014 in preparation for the return of the evacuated population. The General-purpose Terrestrial Fluid-flow Simulator (GETFLOWS) code was used to study sediment and ¹³⁷Cs redistribution within the catchment, including the effect of decontamination on redistribution. Fine resolution grid cells were used to model local features of the catchment, such as paddy fields adjacent to the Oginosawa River. The simulation was verified using monitoring data for river water discharge rates (r = 0.92), suspended sediment concentrations, and particulate ¹³⁷Cs concentrations (r = 0.40). Cesium-137 input to watercourses came predominantly from land adjacent to river channels and forest gullies, e.g. the paddy fields in the Ogi and Kainosaka districts, as the ground in these areas saturates during heavy rain and is easily eroded. A discrepancy between the simulation and monitoring results on the sediment discharge rate following decontamination may be explained by fast erosion occurring after decontamination. Forested areas far from the channels only made a minor contribution to ¹³⁷Cs input to watercourses, total erosion of between 0.001 and 0.1 mm from May 2011 to December 2015, as ground saturation is infrequent in these areas. The 2.3–6.9% y⁻¹ decrease in the amount of ¹³⁷Cs in forest topsoil over the study period can be explained by radioactive decay (approximately 2.3% y⁻¹), along with a migration downwards into subsoil and a small amount of export. The amount of ¹³⁷Cs available for release from land adjacent to rivers is expected to be lower in future than compared to this study period, as the simulations indicate a high depletion of inventory from these areas by the end of 2015. However continued monitoring of ¹³⁷Cs concentrations in river water over future years is advised, as recultivation of paddy fields by returnees may again lead to fast erosion rates and release of the remaining inventory.



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Norwegian monitoring (1990–2015) of the marine environment around the sunken nuclear submarine Komsomolets

Publication date: February 2018
Source:Journal of Environmental Radioactivity, Volume 182
Author(s): Justin P. Gwynn, Hilde Elise Heldal, Janita K. Flo, Ingrid Sværen, Torbjörn Gäfvert, Hallvard Haanes, Lars Føyn, Anne Liv Rudjord
Norway has monitored the marine environment around the sunken Russian nuclear submarine Komsomolets since 1990. This study presents an overview of 25 years of Norwegian monitoring data (1990–2015). Komsomolets sank in 1989 at a depth of 1680 m in the Norwegian Sea while carrying two nuclear torpedoes in its armament. Subsequent Soviet and Russian expeditions to Komsomolets have shown that releases from the reactor have occurred and that the submarine has suffered considerable damage to its hulls. Norwegian monitoring detected ¹³⁴Cs in surface sediments around Komsomolets in 1993 and 1994 and elevated activity concentrations of ¹³⁷Cs in bottom seawater between 1991 and 1993. Since then and up to 2015, no increased activity concentrations of radionuclides above values typical for the Norwegian Sea have been observed in any environmental sample collected by Norwegian monitoring. In 2013 and 2015, Norwegian monitoring was carried out using an acoustic transponder on the sampling gear that allowed samples to be collected at precise locations, ∼20 m from the hull of Komsomolets. The observed ²³⁸Pu/^239,240Pu activity ratios and ²⁴⁰Pu/²³⁹Pu atom ratios in surface sediments sampled close to Komsomolets in 2013 did not indicate any releases of Pu isotopes from reactor or the torpedo warheads. Rather, these values probably reflect the overprinting of global fallout ratios with fluxes of these Pu isotopes from long-range transport of authorised discharges from nuclear reprocessing facilities in Northern Europe. However, due to the depth at which Komsomolets lies, the collection of seawater and sediment samples in the immediate area around the submarine using traditional sampling techniques from surface vessels is not possible, even with the use of acoustic transponders. Further monitoring is required in order to have a clear understanding of the current status of Komsomolets as a potential source of radioactive contamination to the Norwegian marine environment. Such monitoring should involve the use of ROVs or submersibles in order to obtain samples next to and within the different compartments of the submarine.



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Ultrasound examination of the antrum to predict gastric content volume in the third trimester of pregnancy as assessed by MRI: A prospective cohort study

BACKGROUND Ultrasound examination of the gastric antrum allows reliable pre-operative assessment of gastric contents and volume in adult patients. However, during pregnancy, the change in the anatomical position of the stomach due to the gravid uterus leads to a change in the measured value of the antral area. Therefore, current mathematical models predicting gastric content volume (GCV) in the adult may not apply in term pregnant women. OBJECTIVE To propose a mathematical model which is predictive of GCV in pregnant women and to assess the performance of an ultrasound qualitative grading scale (0 to 2) for the diagnosis of clear fluid volumes more than 0.8 and 1.5 ml kg−1. DESIGN Prospective cohort study. SETTING Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon and Assistance Publique – Hôpitaux de Marseille, Hôpital Nord, Marseille, France. PATIENTS Pregnant women in the third trimester of pregnancy. MAIN OUTCOME MEASURES Comparison of the GCV as measured by MRI and the ultrasound measured antral cross-sectional area, and an assessment of gastric contents according to a 0 to 2 qualitative grading scale. RESULTS Data from 34 women were analysed. A linear model predictive of GCV was constructed with a 95% agreement band of ±95 ml, with a mean polar angle of −8.7°. Performance of the qualitative grading scale to detect fluid volumes >0.8 and >1.5 ml kg−1 was improved when used in a composite scale including a 505 mm2 antral area cut-off value in the semirecumbent supine position. CONCLUSION We report a new mathematical model predictive of GCV in women in the third trimester of pregnancy. Furthermore, the combination of the qualitative and the quantitative ultrasound examination of the gastric antrum might be useful to assess gastric fluid volume in pregnant women. TRIAL REGISTRATION ANSM Register N°2015-A00800-49 Correspondence to Lionel Bouvet, MD, PhD, Department of Anaesthesiology and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, Boulevard Pinel, Bron, 69500 Lyon, France Tel: +33 4 72 12 97 63; e-mail: lionel.bouvet@chu-lyon.fr © 2017 European Society of Anaesthesiology

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Does a hypnosis session reduce the required propofol dose during closed-loop anaesthesia induction?: A randomised controlled trial

BACKGROUND Hypnosis has a positive effect on peri-operative anxiety and pain. OBJECTIVE The objective of this study was to assess the impact of a formal deep hypnosis session on the consumption of propofol for anaesthetic induction using automated administration of propofol guided by the bispectral index (BIS) in a closed loop. DESIGN A 1 : 1 randomised, usual-care-controlled, single-centre trial. SETTING Tertiary care centre in France from April 2014 to December 2015. PATIENTS Female adult patients scheduled for outpatient gynaecological surgery under general anaesthesia. INTERVENTION Before surgery, patients were randomised to receive either a deep hypnosis session or routine care. Anaesthetic induction was performed automatically by propofol without opioids and was assisted by the BIS in a closed loop. MAIN OUTCOME MEASURES The primary endpoint was the propofol dose required for anaesthesia induction, defined as a BIS less than 60 for at least 30 s. RESULTS Data for 31 patients in the hypnosis group and 35 in the control group were analysed. There was no evidence of a difference in the mean required propofol dose for anaesthetic induction between the hypnosis and the control groups (2.06 mg kg−1 (95% confidence interval [1.68 to 2.43]) versus 1.79 mg kg−1 (95% CI [1.54 to 2.03]), P = 0.25, respectively). CONCLUSION The current study, which was designed to determine the effect of a deep hypnosis session on anaesthesia induction using an automated tool for propofol administration, failed to detect a difference in the required dose of propofol. TRIAL REGISTRATION ClinicalTrials.gov, NCT02249364. Correspondence to: Prof Marc Fischler, Department of Anaesthesiology, Hôpital Foch, 40, rue Worth, 92151 Suresnes, France E-mail: m.fischler@hopital-foch.org © 2017 European Society of Anaesthesiology

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Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery: An observational study

BACKGROUND Perioperative acute kidney injury (AKI) is common and increases the risk of morbidity and mortality. OBJECTIVES To determine the association between intraoperative hypotension, defined as an individual decrease from baseline and the risk of perioperative AKI. DESIGN Observational cohort study. SETTING Karolinska University Hospital, Stockholm, Sweden, from October 2012 to May 2013 and October 2015 and April 2016. PATIENTS All adult patients undergoing major elective noncardiac surgery who were scheduled for an overnight admission in the postoperative unit were included. Patients undergoing phaeochromocytoma surgery were excluded. DATA COLLECTION Preoperative risk factors (comorbidities), intraoperative events (hypotension defined as a more than 40 or 50% decrease in SBP relative to each patient's baseline and lasting more than 5 min) and postoperative data were collected from medical records. MAIN OUTCOME MEASURES AKI within the first two postoperative days. RESULTS Of the final cohort of 470 patients, 127 (27%) developed AKI in the perioperative period. AKI was associated with male sex [(66 vs. 48%) P 40%, 70 vs. 57%, P = 0.013; >50%, 20 vs. 12%, P = 0.024) and greater blood loss (800 vs. 400 ml, P 

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Selective Serotonin Reuptake Inhibitors and Serotonin–Norepinephrine Reuptake Inhibitors Are Not Associated With Bleeding or Transfusion in Cardiac Surgical Patients

BACKGROUND: Selective serotonin reuptake inhibitor (SSRI) and serotonin–norepinephrine reuptake inhibitor (SNRI) use is known to alter platelet activation and aggregation leading to impairment in hemostasis. Previous studies are ambiguous with regard to bleeding, transfusion, and perioperative complications in patients undergoing cardiac surgery. The purpose of this study was to evaluate the risk of perioperative bleeding, transfusion, morbidity, and mortality in cardiac surgical patients taking SSRI/SNRIs compared with propensity-matched controls. METHODS: Adult patients undergoing cardiac surgery with cardiopulmonary bypass at our institution between January 1, 2004, and December 31, 2014, were eligible for study inclusion. Patients taking SSRI/SNRI medications at the time of surgery were identified and compared against all other patients not taking SSRI/SNRI medications to produce well-matched groups via propensity score analysis. Patients taking SSRI/SNRI medications were matched in a 1:1 ratio to control patients not taking these medications based on an internally estimated propensity score. Primary outcomes included perioperative blood transfusion, chest tube output, and reoperation for bleeding. Secondary outcomes included postoperative complications (renal failure, stroke or transient ischemic accident, prolonged mechanical ventilation, and perioperative myocardial infarction), intensive care unit (ICU) and hospital length of stay (LOS), and 30-day mortality. RESULTS: A total of 1417 pairs of SSRI/SNRI patients and matched controls were retained for analysis. Between SSRI/SNRI patients and matched controls, there was no significant difference in postoperative chest tube output (median, 750.0 vs 750.0 mL; P = .860) or reoperation for bleeding (2.8% vs 2.5%; P = .892). Perioperative transfusion rates across all time points and blood product type were not significantly different between groups, with the overall perioperative transfusion rate for SSRI/SNRI patients 66.5% vs 64.9% for matched controls (P = .697). Patients in the SSRI/SNRI group had a higher rate of prolonged mechanical ventilation (13.1% vs 8.6%; P = .002), longer ICU LOS (median, 25.5 vs 23.8 hours; P

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Nonhuman Primates in Anesthesia Research: Have We Reached the End of the Road?

No abstract available

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ECMO in the Adult Patient: Core Critical Care

No abstract available

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Predicting Severity of Acute Pain After Cesarean Delivery: A Narrative Review

Cesarean delivery is one of the most common surgical procedures in the United States, with over 1.3 million performed annually. One-fifth of women who undergo cesarean delivery will experience severe pain in the acute postoperative period, increasing their risk of developing chronic pain and postpartum depression, and negatively impacting breastfeeding and newborn care. A growing body of research has investigated tools to predict which patients will experience more severe pain and have increased analgesic consumption after cesarean delivery. These include quantitative sensory testing, assessment of wound hyperalgesia, response to local anesthetic infiltration, and preoperative psychometric evaluations such as validated psychological questionnaires and simple screening tools. For this review, we searched MEDLINE, the Cochrane database, and Google Scholar to identify articles that evaluated the utility of various tools to predict severe pain and/or opioid consumption in the first 48 hours after cesarean delivery. Thirteen articles were included in the final review: 5 utilizing quantitative sensory testing, including patient responses to pressure, electrical, and thermal stimuli; 1 utilizing hyperalgesia testing; 1 using response to local anesthetic wound infiltration; 4 utilizing preoperative psychometric evaluations including the State-Trait Anxiety Inventory, the Pain Catastrophizing Scale, the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, and simple questionnaires; and 2 utilizing a combination of quantitative sensory tests and psychometric evaluations. A number of modalities demonstrated statistically significant correlations with pain outcomes after cesarean delivery, but most correlations were weak to modest, and many modalities might not be clinically feasible. Response to local anesthetic infiltration and a tool using 3 simple questions enquiring about anxiety and anticipated pain and analgesic needs show potential for clinical use, but further studies are needed to evaluate the utility of these predictive tests in clinical practice. Accepted for publication October 9, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to ashraf.habib@dm.duke.edu. © 2017 International Anesthesia Research Society

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Management of 1-Lung Ventilation—Variation and Trends in Clinical Practice: A Report From the Multicenter Perioperative Outcomes Group

BACKGROUND: Lung-protective ventilation (LPV) has been demonstrated to improve clinical outcomes in surgical patients. There are very limited data on the current use of LPV for patients undergoing 1-lung ventilation (1LV) despite evidence that 1LV may be a particularly important setting for its use. In this multicenter study, we report trends in ventilation practice for patients undergoing 1LV. METHODS: The Multicenter Perioperative Outcomes Group database was used to identify patients undergoing 1LV. We retrieved and calculated median initial and overall tidal volume (VT) for the cohort and for high-risk subgroups (female sex, obesity [body mass index >30 kg/m2], and short stature), percentage of patients receiving positive end-expiratory pressure (PEEP) ≥5 cm H2O, LPV during 1LV (VT ≤ 6 mL/kg predicted body weight [PBW] and PEEP ≥5 cm H2O), and ventilator driving pressure (ΔP; plateau airway pressure − PEEP). RESULTS: Data from 5609 patients across 4 institutions were included in the analysis. Median VT was calculated for each case and since the data were normally distributed, the mean is reported for the entire cohort and subgroups. Mean of median VT during 1LV for the cohort was 6.49 ± 1.82 mL/kg PBW. VT (mL/kg PBW) for high-risk subgroups was significantly higher; 6.86 ± 1.97 for body mass index ≥30 kg/m2, 7.05 ± 1.92 for female patients, and 7.33 ± 2.01 for short stature patients. Mean of the median VT declined significantly over the study period (from 6.88 to 5.72; P

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Design and Evaluation of a Closed-Loop Anesthesia System With Robust Control and Safety System

BACKGROUND: Closed-loop control of anesthesia involves continual adjustment of drug infusion rates according to measured clinical effect. The NeuroSENSE monitor provides an electroencephalographic measure of depth of hypnosis (wavelet-based anesthetic value for central nervous system monitoring [WAVCNS]). It has previously been used as feedback for closed-loop control of propofol, in a system designed using robust control engineering principles, which implements features specifically designed to ensure patient safety. Closed-loop control of a second drug, remifentanil, may be added to improve WAVCNS stability in the presence of variable surgical stimulation. The objective of this study was to design and evaluate the feasibility of a closed-loop system for robust control of propofol and remifentanil infusions using WAVCNS feedback, with an infusion safety system based on the known pharmacological characteristics of these 2 drugs. METHODS: With Health Canada authorization, research ethics board approval, and informed consent, American Society of Anesthesiologists I–III adults, requiring general anesthesia for elective surgery, were enrolled in a 2-phase study. In both phases, infusion of propofol was controlled in closed loop during induction and maintenance of anesthesia, using WAVCNS feedback, but bounded by upper- and lower-estimated effect-site concentration limits. In phase I, remifentanil was administered using an adjustable target-controlled infusion and a controller was designed based on the collected data. In phase II, remifentanil was automatically titrated to counteract rapid increases in WAVCNS. RESULTS: Data were analyzed for 127 patients, of median (range) age 64 (22–86) years, undergoing surgical procedures lasting 105 (9–348) minutes, with 52 participating in phase I and 75 in phase II. The overall control performance indicator, global score, was a median (interquartile range) 18.3 (14.2–27.7) in phase I and 14.6 (11.6–20.7) in phase II (median difference, −3.25; 95% confidence interval, −6.35 to −0.52). The WAVCNS was within ±10 of the setpoint for 84.3% (76.6–90.6) of the maintenance of anesthesia in phase I and 88.2% (83.1–93.4) in phase II (median difference, 3.7; 95% confidence interval, 0.1–6.9). The lower propofol safety bound was activated during 30 of 52 (58%) cases in phase I and 51 of 75 (68%) cases in phase II. CONCLUSIONS: Adding closed-loop control of remifentanil improved overall controller performance. This controller design offers a robust method to optimize the control of 2 drugs using a single sensor. The infusion safety system is an important component of a robust automated anesthesia system, but further research is required to determine the optimal constraints for these safe conditions. Accepted for publication September 27, 2017. Funding: This work was supported by funds received from the Collaborative Health Research Projects (CHRP 446511–13) (Principal Investigator: G.A.D.), a joint initiative between the Natural Sciences and Engineering Research Council of Canada and the Canadian Institutes of Health Research. NeuroWave Systems Inc provided loan equipment for use in this study. Conflicts of Interest: See Disclosures at the end of the article. Trial Registration: clinicaltrials.gov (NCT01771263). Reprints will not be available from the authors. Address correspondence to Nicholas West, MSc, Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, V3-350, Clinical Support Bldg, 950 W 28th Ave, Vancouver, BC V5Z 4H4, Canada. Address e-mail to nicholas.west@cw.bc.ca. © 2017 International Anesthesia Research Society

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Technical Solutions and the Safety Big Picture

No abstract available

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Failure of the Oxygen Gauge to Accurately Reflect the Pressure in the Oxygen Tank

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Effect of Remote Ischemic Preconditioning on Outcomes in Adult Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies

BACKGROUND: Remote ischemic preconditioning (RIPC) has been demonstrated to prevent organ dysfunction in cardiac surgery patients. However, recent large, prospective, multicenter, randomized controlled trials (RCTs) had controversial results. Thus, a meta-analysis of RCTs was performed to investigate whether RIPC can reduce the incidence of acute myocardial infarction (AMI), acute kidney injury (AKI), and mortality in adult cardiac surgery patients. METHODS: Study data were collected from Medline, Elsevier, Cochrane Central Register of Controlled Trials and Web of Science databases. RCTs involving the effect of RIPC on organ protection in cardiac surgery patients, which reported the concentration or total release of creatine kinase-myocardial band, troponin I/troponin T (TNI/TNT) after operation, or the incidence of AMI, AKI, or mortality, were selected. Two reviewers independently extracted data using a standardized data extraction protocol where TNI or TNT concentrations; total TNI released after cardiac surgery; and the incidence of AKI, AMI, and mortality were recorded. Review Manager 5.3 software was used to analyze the data. RESULTS: Thirty trials, including 7036 patients were included in the analyses. RIPC significantly decreased the concentration of TNI/TNT (standard mean difference [SMD], −0.25 ng/mL; 95% confidence interval [CI], 0.12 to −0.04 ng/mL; P = .004), creatine kinase-myocardial band (SMD, −0.22; 95% CI, 0.07–0.35 ng/mL; P = .46), and the total TNI/TNT release (SMD, −0.49 ng/mL; 95% CI, 0.93 to −0.55 ng/mL; P = .03) in cardiac surgery patients after a procedure. However, RIPC could not reduce the incidence of AMI (relative risk, 0.89; 95% CI, 0.77–1.03; P = .12) and AKI (relative risk, 0.88; 95% CI, 0.72–1.06; P = .18), and there was also no effect of RIPC on mortality in adult cardiac surgery patients. Interestingly, subgroup analysis showed that RIPC reduced mortality of cardiac surgery patients who received volatile agent anesthesia. CONCLUSIONS : Our meta-analysis demonstrated that RIPC reduced TNI/TNT release after cardiac surgery. RIPC did not significantly reduce the incidence of AKI, AMI, and mortality. However, RIPC could reduce mortality in patients receiving volatile inhalational agent anesthesia. Accepted for publication October 10, 2017. Funding: Supported by Clinical Medicine Science and Technology program of Jiangsu Province (BL2013030). 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 Haibo Qiu, MD, PhD, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China. Address e-mail to haiboq2000@163.com. © 2017 International Anesthesia Research Society

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Total Intravenous Anesthesia and Target Controlled Infusions: A Comprehensive Global Anthology

No abstract available

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Perioperative Steroid Use for Tonsillectomy and Its Association With Reoperation for Posttonsillectomy Hemorrhage: A Retrospective Cohort Study

BACKGROUND: Steroids reduce postoperative complications after tonsillectomy such as nausea and vomiting, pain, and delayed recovery. However, steroids may also increase the risk of severe posttonsillectomy bleeding requiring reoperation. METHODS: To evaluate the risk of postoperative bleeding requiring reoperation related to perioperative steroid use, we conducted a retrospective cohort study of 6149 patients treated at 68 hospitals using a hospital-based claims database. The primary outcome was reoperation for bleeding within 14 postoperative days. We estimated odds ratios (ORs) between perioperative steroid use and reoperation by multivariable logistic regression analysis adjusted for confounders. We also estimated differences in the adjusted risk. Subgroup analyses after dividing patients into adults and children were also performed. RESULTS: The incidence of reoperation did not differ significantly between patients who received steroids on the day of tonsillectomy and those who did not (1.8%, n = 15 vs 1.5%, n = 79; adjusted OR 0.81, 95% confidence interval [CI], 0.45–1.43; P = .46). We also found nonsignificant associations in both adults (OR, 0.73; 95% CI, 0.38–1.38; P = .33) and children (OR, 1.18; 95% CI, 0.34–4.11; P = .80). The adjusted risk differences estimated by the logistic regression model were −0.30% (95% CI, −1.05 to 0.45) in all patients, −0.64% (95% CI, −1.82 to 0.54) in adults, and 0.13% (95% CI, −0.93 to 1.19) in children. CONCLUSIONS: Steroid use on the day of tonsillectomy was not associated with an increased risk of reoperation for bleeding. Although the wide range of CIs for the ORs could not eliminate the possibility of increased risk, especially in children, the incremental risks of reoperation for steroid use were within an acceptable range for both adults and children. Our results support the safety of perioperative steroid use for tonsillectomy, considering the magnitude of risk of reoperation because of bleeding. Accepted for publication October 20, 2017. Funding: Support was provided solely from institutional and/or departmental sources. Conflicts of Interest: See Disclosures at the end of the article. 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). Yoshihisa Miyamoto, MD, MPH, is currently affiliated with the Department of Anesthesia, Kanagawa Children's Medical Center, Yokohama, Japan. Maki Shinzawa, MD, PhD, is currently affiliated with the Department of Nephrology, Graduate School of Medicine, Osaka University, Suita, Japan. Shiro Tanaka, PhD, is currently affiliated with the Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan. Sachiko Tanaka-Mizuno, PhD, is currently affiliated with the Department of Medical Statistics, Shiga University of Medical Science, Otsu, Japan. Reprints will not be available from the authors. Address correspondence to Koji Kawakami, MD,hD, Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto 606–8501, Japan. Address e-mail to kawakami.koji.4e@kyoto-u.ac.jp. © 2017 International Anesthesia Research Society

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Developing Reflective Practice: A Guide for Medical Students, Doctors, and Teachers

No abstract available

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In Response: Investigation of 2 Prototypes of Novel Noncontact Technologies for Automated Real-Time Capture of Incremental Drug Administration Data From Syringes

No abstract available

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Large Variability in the Diversity of Physiologically Complex Surgical Procedures Exists Nationwide Among All Hospitals Including Among Large Teaching Hospitals

BACKGROUND: Multiple previous studies have shown that having a large diversity of procedures has a substantial impact on quality management of hospital surgical suites. At hospitals with substantial diversity, unless sophisticated statistical methods suitable for rare events are used, anesthesiologists working in surgical suites will have inaccurate predictions of surgical blood usage, case durations, cost accounting and price transparency, times remaining in late running cases, and use of intraoperative equipment. What is unknown is whether large diversity is a feature of only a few very unique set of hospitals nationwide (eg, the largest hospitals in each state or province). METHODS: The 2013 United States Nationwide Readmissions Database was used to study heterogeneity among 1981 hospitals in their diversities of physiologically complex surgical procedures (ie, the procedure codes). The diversity of surgical procedures performed at each hospital was quantified using a summary measure, the number of different physiologically complex surgical procedures commonly performed at the hospital (ie, 1/Herfindahl). RESULTS: A total of 53.9% of all hospitals commonly performed 3-fold larger diversity (ie, >30 commonly performed physiologically complex procedures). Larger hospitals had greater diversity than the small- and medium-sized hospitals (P 30 procedures (lower 99% CL, 71.9% of hospitals). However, there was considerable variability among the large teaching hospitals in their diversity (interquartile range of the numbers of commonly performed physiologically complex procedures = 19.3; lower 99% CL, 12.8 procedures). CONCLUSIONS: The diversity of procedures represents a substantive differentiator among hospitals. Thus, the usefulness of statistical methods for operating room management should be expected to be heterogeneous among hospitals. Our results also show that "large teaching hospital" alone is an insufficient description for accurate prediction of the extent to which a hospital sustains the operational and financial consequences of performing a wide diversity of surgical procedures. Future research can evaluate the extent to which hospitals with very large diversity are indispensable in their catchment area. Accepted for publication October 3, 2017. Funding: Departmental funding. 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 Division of Management Consulting, Department of Anesthesia, University of Iowa, performs the calculations described in the Introduction and Discussion of this article. F.D. receives no funds personally other than his salary and allowable expense reimbursements from the University of Iowa and has tenure with no incentive program. He and his family have no financial holdings in any company related to his work, other than indirectly through mutual funds for retirement. Income from the Division's consulting work is used to fund Division research. Reprints will not be available from the authors. Address correspondence to Franklin Dexter, MD, PhD, Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6 JCP, Iowa City, IA 52242. Address e-mail to Franklin-Dexter@UIowa.edu. © 2017 International Anesthesia Research Society

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Sequential induction of Fur-regulated genes in response to iron limitation in Bacillus subtilis [Genetics]

Bacterial cells modulate transcription in response to changes in iron availability. The ferric uptake regulator (Fur) senses intracellular iron availability and plays a central role in maintaining iron homeostasis in Bacillus subtilis. Here we utilized FrvA, a high-affinity Fe2+ efflux transporter from Listeria monocytogenes, as an inducible genetic tool to...

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Paleoecology of the Serengeti during the Oldowan-Acheulean transition at Olduvai Gorge, Tanzania: The mammal and fish evidence

Publication date: Available online 27 November 2017
Source:Journal of Human Evolution
Author(s): Faysal Bibi, Michael Pante, Antoine Souron, Kathlyn Stewart, Sara Varela, Lars Werdelin, Jean-Renaud Boisserie, Mikael Fortelius, Leslea Hlusko, Jackson Njau, Ignacio de la Torre
Eight years of excavation work by the Olduvai Geochronology and Archaeology Project (OGAP) has produced a rich vertebrate fauna from several sites within Bed II, Olduvai Gorge, Tanzania. Study of these as well as recently re-organized collections from Mary Leakey's 1972 HWK EE excavations here provides a synthetic view of the faunal community of Olduvai during Middle Bed II at ∼1.7–1.4 Ma, an interval that captures the local transition from Oldowan to Acheulean technology. We expand the faunal list for this interval, name a new bovid species, clarify the evolution of several mammalian lineages, and record new local first and last appearances. Compositions of the fish and large mammal assemblages support previous indications for the dominance of open and seasonal grassland habitats at the margins of an alkaline lake. Fish diversity is low and dominated by cichlids, which indicates strongly saline conditions. The taphonomy of the fish assemblages supports reconstructions of fluctuating lake levels with mass die-offs in evaporating pools. The mammals are dominated by grazing bovids and equids. Habitats remained consistently dry and open throughout the entire Bed II sequence, with no major turnover or paleoecological changes taking place. Rather, wooded and wet habitats had already given way to drier and more open habitats by the top of Bed I, at 1.85–1.80 Ma. This ecological change is close to the age of the Oldowan-Acheulean transition in Kenya and Ethiopia, but precedes the local transition in Middle Bed II.The Middle Bed II large mammal community is much richer in species and includes a much larger number of large-bodied species (>300 kg) than the modern Serengeti. This reflects the severity of Pleistocene extinctions on African large mammals, with the loss of large species fitting a pattern typical of defaunation or 'downsizing' by human disturbance. However, trophic network (food web) analyses show that the Middle Bed II community was robust, and comparisons with the Serengeti community indicate that the fundamental structure of food webs remained intact despite Pleistocene extinctions. The presence of a generalized meat-eating hominin in the Middle Bed II community would have increased competition among carnivores and vulnerability among herbivores, but the high generality and interconnectedness of the Middle Bed II food web suggests this community was buffered against extinctions caused by trophic interactions.



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Clinical and molecular characterization of an emerging chromosome 22q13.31 microdeletion syndrome

Microdeletion of chromosome 22q13.31 is a very rare condition. Fourteen patients have been annotated in public databases but, to date, a clinical comparison has not been done and, consequently, a specific phenotype has not been delineated yet. We describe a patient showing neurodevelopmental disorders, dysmorphic features, and multiple congenital anomalies in which SNP array analysis revealed an interstitial 3.15 Mb de novo microdeletion in the 22q13.31 region encompassing 21 RefSeq genes and seven non-coding microRNAs. To perform an accurate phenotype characterization, clinical features observed in previously reported cases of 22q13.31 microdeletions were reviewed and compared to those observed in our patient. To the best of our knowledge, this is the first time that a comparison between patients carrying overlapping 22q13.31 deletions has been done. This comparison allowed us to identify a distinct spectrum of clinical manifestations suggesting that patients with a de novo interstitial microdeletion involving 22q13.31 have an emerging syndrome characterized by developmental delay/intellectual disability, speech delay/language disorders, behavioral problems, hypotonia, urogenital, and hands/feet anomalies. The microdeletion identified in our patient is the smallest reported so far and, for this reason, useful to perform a detailed genotype-phenotype correlation. In particular, we propose the CELSR1, ATXN10, FBLN1, and UPK3A as candidate genes in the onset of the main clinical features of this contiguous gene syndrome. Thus, the patient reported here broadens our knowledge of the phenotypic consequences of 22q13.31 microdeletions facilitating genotype-phenotype correlations. Additional cases are needed to corroborate our hypothesis and confirm genotype–phenotype correlations of this emerging syndrome.

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Clinical and genetic characterization of AP4B1-associated SPG47

The hereditary spastic paraplegias (HSPs) are a heterogeneous group of disorders characterized by degeneration of the corticospinal and spinocerebellar tracts leading to progressive spasticity. One subtype, spastic paraplegia type 47 (SPG47 or HSP-AP4B1), is due to bi-allelic loss-of-function mutations in the AP4B1 gene. AP4B1 is a subunit of the adapter protein complex 4 (AP-4), a heterotetrameric protein complex that regulates the transport of membrane proteins. Since 2011, 11 individuals from six families with AP4B1 mutations have been reported, nine of whom had homozygous mutations and were from consanguineous families. Here we report eight patients with AP4B1-associated SPG47, the majority born to non-consanguineous parents and carrying compound heterozygous mutations. Core clinical features in this cohort and previously published patients include neonatal hypotonia that progresses to spasticity, early onset developmental delay with prominent motor delay and severely impaired or absent speech development, episodes of stereotypic laughter, seizures including frequent febrile seizures, thinning of the corpus callosum, and delayed myelination/white matter loss. Given that some of the features of AP-4 deficiency overlap with those of cerebral palsy, and the discovery of the disorder in non-consanguineous populations, we believe that AP-4 deficiency may be more common than previously appreciated.

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Oligonephronia and Wolf-Hirschhorn syndrome: A further observation

Wolf-Hirschhorn syndrome (WHS) is a rare chromosomal disorder caused by a partial deletion of chromosome 4 (4p16.3p16.2). We describe a case of a male 9 years old children with WHS proteinuria and hypertension. Laboratory data showed creatinine 1.05 mg/dl, GFR 65.9 ml/min/1.73 m², cholesterol 280 mg/dl, triglyceride 125 mg/dl with electrolytes in the normal range. Urine collection showed protein 2.72 g/L with a urine protein/creatinine ratio (U_P/U_Cr ratio) of 4.2 and diuresis of 1,100 ml. Renal ultrasound showed reduced kidney dimensions with diffusely hyperechogenic cortex and poorly visualized pyramids. Renal biopsy showed oligonephronia with focal segmental glomerulosclerosis associated with initial tubulointerstitial sclerotic atrophy. The child began therapy with Angiotensin-converting enzyme inhibitors (ACE-inhibitors) to reduce proteinuria and progression of chronic kidney disease. In the literature the anomalies of number of glomeruli oligonephronia and oligomeganephronia (OMN) are described in two forms, one without any associated anomalies, sporadic, and solitary and the other with one or more anomalies. Our review of the literature shows that the pathogenesis of this anomaly is unknown but the role of chromosome 4 is very relevant. Many cases of OMN are associated with anomalies on this chromosome, in the literature cases series we observed this association in 14/48 cases (29.2%) and in 7 of these 14 cases with WHS. Our case and the review of literature demonstrate how periodic urinalysis and renal ultrasound monitoring is recommended in patients affected by WHS and the renal biopsy must be performed when there is the onset of proteinuria.

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Cognitive and behavioral phenotype of children with pseudohypoparathyroidism type 1A

Pseudohypoparathyroidism 1A (PHP1A) is a rare, genetic disorder. Most patients with PHP1A have cognitive impairment but this has not been systematically studied. We hypothesized that children with PHP1A would have lower intelligent quotient (IQ) scores than controls. To evaluate cognition and behavior, we prospectively enrolled children with PHP1A, one unaffected sibling (when available) and controls matched on BMI/age/gender/race. Evaluations included cognitive and executive function testing. Parents completed questionnaires on behavior and executive function. We enrolled 16 patients with PHP1A, 8 unaffected siblings, and 15 controls. Results are presented as mean (SD). The PHP1A group had a composite IQ of 85.9 (17.2); 25% had a composite IQ < −2 SD. The PHP1A group had significantly lower IQs than matched controls (composite IQ −17.3, 95%CI −28.1 to −6.5, p < 0.01) and unaffected siblings (composite IQ −21.5, 95%CI −33.9 to −9.1, p < 0.01). Special education services were utilized for 93% of the patients with PHP1A. Deficits were observed in executive function and parents reported delayed adaptive behavior skills and increased rates of attention deficit hyperactivity disorder. In conclusion, children with PHP1A have lower intelligence quotient scores, poorer executive function, delayed adaptive behavior skills, and increased behavior problems.

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Gap junctional communication between β- and δ-cells: another player for suppression of glucagon release

Abstract

Islets of Langerhans are characterized by precisely sensing changes in blood glucose concentration and transferring this signal to adequate secretion of pancreatic hormones.

This article is protected by copyright. All rights reserved

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Hypermanganesemia with dystonia, polycythemia and cirrhosis in 10 patients: Six novel SLC30A10 mutations and further phenotype delineation

Abstract

Biallelic mutations in the SLC30A10 gene cause an inborn error of Mn metabolism characterized by hypermanganesemia, polycythemia, early-onset dystonia, and liver cirrhosis (HMDPC). To-date only 14 families from various ethnic groups have been reported. Here, we describe 10 patients from 7 unrelated Egyptian families with HMDPC. Markedly elevated blood Mn levels, the characteristic basal ganglia hyperintensity on T1W images, and variable degrees of extrapyramidal manifestations with or without liver disease were cardinal features in all patients. Eight patients presented with striking early diseased onset (<2 years). Unexpectedly, early hepatic involvement before the neurological regression was noted in 3 patients. Mutational analysis of SLC30A10 gene revealed six novel homozygous mutations [c.77T>C (p.Leu26Pro), c.90C>G (p.Tyr30*), c.119A>C (p.Asp40Ala), c.122_124delCCT (p.Ser41del), c.780_782delCAT (p.Iso260del) and c.957+1G>C]. Treatment using 2,3 dimercaptosuccinic acid as a manganese chelating agent showed satisfactory results with improvement of biochemical markers, hepatic manifestations and relative amelioration of the neurological symptoms. Our findings present a large cohort of patients with HMDPC from same ethnic group. The majority of our patients showed severe and early presentation with clear phenotypic variability among sibship. Moreover, we extend the phenotypic and mutational spectrum and emphasize the importance of early diagnosis and treatment of this potentially fatal disorder.

We describe 10 patients with hypermanganesemia. polycythemia, early-onset dystonia. and liver cirrhosis syndrome carrying six novel homozygous SLC30A10 mutations. Our patients had a striking early onset of symptoms (<2 years) with unexpected early hepatic involvement before the neurological regression in some patients.

Treatment with DMSA showed satisfactory results and improvement of biochemical markers. hepatic manifestations and relative amelioration of the neurological symptoms.

Thus. we believe that we expanded the mutational spectrum and further delineate the phenotypic spectrum of this very rare inborn error of Mn metabolism.

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Rehabilitation Outcomes in Spinal Abscess Patients With and Without a History of Intravenous Substance Abuse

Objective To compare functional outcomes of acute inpatient rehabilitation for spinal epidural abscess (SEA) patients with and without history of intravenous substance abuse (IVSA). Design Retrospective case series study in freestanding rehabilitation hospital. Methods Charts of 28 SEA patients admitted from 01/2012 to 9/2015: 13 with IVSA and 15 without IVSA were reviewed. Both groups received standard-of-care rehabilitation. Statistical analyses of Functional Independence Measure (FIM) scores were conducted using individual 2 (substance use) X 2 (rehabilitation status) repeated measures analysis of variance (ANOVA). Functional outcomes were defined by total FIM scores as well as motor and cognitive subsets. Length of stay (LOS) and morphine equivalents were also compared. Results There were no significant differences between the 2 groups. There was a significant main effect of treatment on total FIM scores (P<.001 fim motor scores and cognitive from admission to discharge. subsequent student t-tests revealed that the of both groups significantly improved on all components. there were no group differences los morphine equivalents at conclusions acute inpatient rehabilitation can effectively improve functional outcomes in sea patients with or without ivsa even though these patient vary clinical factors. corresponding author information: sara s salles do department physical medicine university kentucky lexington ky usa phone number: address: versailles road e-mail sara.salles disclosures: funding was received for this research. is financial benefit authors. copyright wolters kluwer health inc. rights reserved.>

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Does a rehabilitation program of aerobic and progressive resisted exercises influence HIV-induced distal neuropathic pain?

ABSTRACT Objective Distal symmetrical polyneuropathy (DSPN) is a common neurological sequela following HIV which leads to neuropathic pain and functional limitations. Rehabilitation programs with exercises are used to augment pharmacological therapy to relieve pain but appropriate and effective exercises are unknown. This study explored the safety and effect of moderate intensity aerobic exercises (AE) and progressive resisted exercises (PRE) for HIV-induced DSPN neuropathic pain. Design A randomized pre-test, post-test of 12 weeks of AE or PRE compared to a control. Outcome measures were assessed using the Subjective Periphery Neuropathy, Brief Peripheral Neuropathy Screening and Numeric Pain Rating Scale. Pain was assessed at baseline, 6 and 12weeks. Data between groups were compared using Kruskal Wallis, Mann Whitney U test and within groups Friedman and Wilcoxon Signed Rank tests. Results There were 136 participants (mean age 36.79±8.23years) and the exercise groups completed the protocols without any adverse effects. Pain scores within and between AE and PRE groups showed significant improvement (p0.05). Conclusion This study supports a rehabilitation program of moderate intensity AE and PRE being safe and effective for reducing neuropathic pain and is beneficial with analgesics for HIV-induced DSPN. The authors declare no conflict of interest and no funding was received for this study Corresponding author: Dr Sonill S. Maharaj, B.Paed Sc (UDW); BEd(Unisa); B. Physio (UDW); M.Med Sc. Sports Medicine(Natal); PhD(UKZN), maharajss@ukzn.ac.za, Senior Lecturer: Department of Physiotherapy, School of Health Sciences, University of KwaZulu-Natal, Durban, Republic of South Africa Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Lumbar Transforaminal Epidural Steroid Injection in Patients with Chronic Unilateral Radicular Pain

No abstract available

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Lactotripeptides supplementations alleviate the decrease in maximal isometric force following high-intensity eccentric exercise: a randomized, placebo-controlled, double-blinded clinical trial

Objective To investigate whether lactotripeptides (LTP) supplementations alleviate the decrease in the maximal isometric force (MIF), an indirect marker of muscle damage, following eccentric exercise (ECC). Design Twenty-two young men performed 50-ECC of the elbow flexors using an isokinetic dynamometer. The subjects were randomly assigned to either the placebo or LTP group, and were each given a 4.5 mg/day placebo or LTP three-time on the exercise day and the day after. MIF and brachial arterial diameter were assessed before and two days after the ECC. Results The interaction of time and group on MIF was significant (p

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Lumbar Transforaminal Epidural Steroid Injection in Patients with Chronic Unilateral Radicular Pain

No abstract available

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The Emergence of the Rehabilitative Strategy: The driving forces in the United States of America

Abstract The aim of this essay is to show the impact that driving forces have had on the emergence of rehabilitation as a health strategy in the USA. Specifically, this essay 1) identifies the driving forces that have addressed the development of rehabilitation, 2) examines how the rehabilitative strategy has been driven by the driving forces through turning points and facilitators, and 3) identifies the barriers of each force against the development of rehabilitation. Critical and scoping review of the literature was conducted from the late 1910s until the end of the century. War, economy, the power of the state, and science were identified as the driving forces that led rehabilitation to become a health strategy complementing prevention, promotion, cure and palliation. WWI and WWII played as a stimulus for rehabilitation, federal funding facilitated its development, acts, amendments, and governmental programs enabled its implementation, and the acknowledgment of PM&R as medical field contributed to its international recognition as health strategy. WHO's ICF is also identified as an emerging facilitator of rehabilitation. Based on the example of USA, this paper closes with recommendations toward the implementation of rehabilitation as a health strategy in countries where so far this has not occurred. Correspondence: All correspondence and requests for reprints should be addressed to: Gerold Stucki, Swiss Paraplegic Research, Guido A. Zäch Strasse 4, 6207 Nottwil, Phone +41 41 939 65 70, Fax +41 41 939 65 77, E-Mail gerold.stucki@paraplegie.ch Author disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. No funding was received for this study. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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