Κυριακή, 3 Δεκεμβρίου 2017

Stem cells: Regenerating the skin of a young patient

Stem cells: Regenerating the skin of a young patient

Stem cells: Regenerating the skin of a young patient, Published online: 04 December 2017; doi:10.1038/nrg.2017.106

Stem cells: Regenerating the skin of a young patient

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Am I ready for CRISPR? A user's guide to genetic screens

Am I ready for CRISPR? A user's guide to genetic screens

Am I ready for CRISPR? A user's guide to genetic screens, Published online: 04 December 2017; doi:10.1038/nrg.2017.97

The rapid development of CRISPR-based gene manipulation has enabled various approaches for high-throughput functional genomics. This Review guides users through the practicalities of CRISPR-based functional genomics screens, including study design options, best-practice approaches, pitfalls to avoid and data analysis strategies.

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Pathogen genomics: Genomics in the time of cholera

Pathogen genomics: Genomics in the time of cholera

Pathogen genomics: Genomics in the time of cholera, Published online: 04 December 2017; doi:10.1038/nrg.2017.105

Pathogen genomics: Genomics in the time of cholera

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Gene expression: SPOTting single RNA molecules transcriptome-wide

Gene expression: SPOTting single RNA molecules transcriptome-wide

Gene expression: SPOTting single RNA molecules transcriptome-wide, Published online: 04 December 2017; doi:10.1038/nrg.2017.107

Gene expression: SPOTting single RNA molecules transcriptome-wide

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Molecular and functional characterization of inwardly rectifying K+ currents in murine proximal colon

Abstract

Membrane potentials of gastrointestinal (GI) muscles are important because voltage dependent Ca2+ channels in smooth muscle cells (SMC) provide the Ca2+ that triggers contraction. Regulation of membrane potential is complicated because SMC are electrically coupled to interstitial cells of Cajal (ICC) and PDGFRα+ cells. Activation of conductances in any of these cells affects the excitability of the syncytium. We explored the role of inward rectifier K+ conductances in colonic ICC that might contribute to regulation of membrane potential. ICC expressed Kcnj2 (Kir2.1), Kcnj4 (Kir2.3), Kcnj14 (Kir2.4) and Kcnj5 (Kir3.4), Kcnj8 (Kir 6.1) and Kcnj11 (Kir6.2). Voltage clamp experiments showed activation of inward current when extracellular K+ ([K+]o) was increased. The current was inwardly rectifying and inhibited by Ba2+ (10 μm) and ML-133 (10 μm). A similar current was not available in SMC. The current activated in ICC by elevated [K+]o was not affect by tertiapinQ, and Gβγ, dialyzed into cells, failed to activate a unique, tertiapinQ-sensitive conductance. Freshly dispersed ICC showed no evidence of functional KATP. Pinacidil failed to activate current and the inward current activated by elevated [K+]o was insensitive to glibenclamide. Under current clamp ML-133 caused depolarization of isolated ICC and of cells impaled with microelectrodes in intact muscle strips. These findings show that ICC, isolated freshly from colonic muscles, expressed a Ba2+-sensitive, inwardly rectifying K+ conductance. This conductance is due, most likely to the expression of multiple Kir2 family paralogues, and the inwardly rectifying conductance contributes to the regulation of resting potentials and excitability of colonic muscles.

This article is protected by copyright. All rights reserved



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Taking intestinal anion secretion to TASK; a role for K2P channels in cyclic AMP-regulated anion secretion

Abstract

Intestinal anion secretion has been the focus of numerous investigations ever since the discovery of its essential role in diarrheal disease.

This article is protected by copyright. All rights reserved



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Pathogen genomics: Genomics in the time of cholera



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Stem cells: Regenerating the skin of a young patient



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Am I ready for CRISPR? A user's guide to genetic screens



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Gene expression: SPOTting single RNA molecules transcriptome-wide



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Three-dimensional morphology and volume of the free Achilles tendon at rest and under load in people with unilateral mid-portion Achilles tendinopathy

Abstract

Mid-portion Achilles tendinopathy (MAT) adversely affects free Achilles tendon (AT) structure and composition. However, it is not known how these pathological alterations associated with MAT change the normal three-dimensional (3D) morphology of free AT at rest and under load throughout the entire free tendon length. Here, we used 3D ultrasound to examine the effect of unilateral MAT on free tendon 3D morphology [length, cross-sectional area (CSA), antero-posterior (AP) diameter, and medio-lateral (ML) diameter] and volume at rest and during a sub-maximal (50%) voluntary isometric plantarflexion contraction bilaterally in individuals with unilateral MAT (= 10) compared to a matched healthy control group (= 10). The tendinopathic free AT had a greater CSA relative to the control tendons along the entire tendon length which was mainly driven by a greater tendon AP diameter. Under load, the tendinopathic tendon experienced greater longitudinal and transverse strains than the control tendons. In contrast to the control tendons, which experienced a reduction in tendon CSA and ML diameter and bulged along the AP axis and behaved iso-volumetrically under load, the tendinopathic tendon experienced a reduction in tendon CSA, AP diameter, ML diameter, and an overall volume reduction. Overall, these findings suggest that the magnitude of longitudinal strain and volume change and the corresponding magnitude and direction of transverse strain under load are altered in MAT compared to normal tendon. These findings are indicative of a fundamental reorganization of the tendon matrix and alterations in tendon fluid content and distribution under load in tendinopathic tendon.

This article is protected by copyright. All rights reserved



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Spontaneous Synaptic Activity in Projection Neurons of Lamina I of the Isolated Rat Lumbar Spinal Cord: Effect of Peripheral Inflammation

Spino-cerebral (projection) neurons localized in lamina I of the spinal gray substance play an important role in the transmission of pain-related information to the brain. We examined spontaneous excitatory postsynaptic currents (sEPSC) recorded from lamina I spino-pontine neurons in isolated preparations of the rat lumbar spinal cord; the respective neurons were retrogradely labeled by a fluorescent dye. We tried to find out how experimentally induced peripheral inflammation affects the amplitude/time characteristics of these currents. It was found that, in preparations obtained from animals with inflammation of hind limb tissues, the frequency and (to a lesser extent) amplitude of sEPSC in projection neurons are, on average, higher than those measured in neurons of the control animals. It is belived that such changes result mostly from plastic modifications of neuron-to-neuron interactions in neuronal networks of lamina II, which form main synaptic inputs to neurons of lamina I. Increased frequency and amplitude of sEPSC in lamina I neurons should lead to some facilitation of transmission of nociceptive information to the cerebral structures. Such hyperexcitability of lamina 1 projection neurons can provide a notable contribution to the development of hyperalgesia in chronic inflammatory states and to facilitation of generation of pain-related emotions.



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Correction to: Somatosensory and Motor Functions in Smartphone Systematic Users and Non-Users

In the article metadata on SpringerLink, the email icon should appear after S. Y. Kang.



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Neuroprotective Effect of Curcumin on LPS-activated Astrocytes Is Related to the Prevention of GFAP and NF-κB Upregulation

We examined the effects of 2.0 μM curcumin, a known antioxidant, on the cultures of normal rat astrocytes and of those subjected to the action of 0.01 μM lipopolysaccharide, LPS. As was found, 24-h-long exposure of astrocytes to LPS resulted in a relatively mild decrease in the cell viability of astrocytes (a decrement of 22%). The action of curcumin significantly ameliorated this decrease. LPS induced significant upregulation of GFAP, NF-κB, and poly(ADP-ribose)polymerase (PARP) in activated astrocytes. Curcumin significantly decreased these effects (to 60, 71, and 89% as compared to those in astrocytes subjected to isolated action of LPS). Thus, curcumin significantly prevents the decrease in cell viability and moderates the cytoskeleton rearrangements and disorders in NF-κBdependent regulation in astrocytes activated by LPS.



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Muscle Ergoreflex Activity and Autonomic Balance Assessed in the Vertical and Horizontal Body Positions in Young Healthy Men

We investigated whether indices of the reflex regulation of the cardiovascular system, i.e., muscle ergoreflex activity (ERGO) and characteristics of the autonomic balance, differ from each other while measured in the vertical vs. horizontal positions in healthy humans. Ten young healthy men (mean age 28 ± 1 years; BMI 23.6 ± 0.8 kg/m2) were examined. In each subject, the ERGO (ventilatory response to a control handgrip exercise, with repetitive isometric contractions at 50% of the maximal strength), baroreflex sensitivity (BRS, the sequence method), heart rate variability (HRV), and a few hemodynamic parameters were measured in two positions, horizontal and vertical. In the latter position, the heart rate, and diastolic and mean blood pressures (BP) were higher, while the stroke volume was smaller (all P < 0.05) with no differences in the systolic BP, cardiac output, and systemic vascular resistance (all P > 0.2). The HRV time domains, as well as BRS, decreased, whereas HRV-LF increased (all P < 0.05) in the vertical position as compared to the horizontal one. There were no differences between other HRV parameters (all P > 0.2) in the two examined positions. Minute ventilation during the exercise increased, while ERGO was reduced in the vertical position (all P < 0.05). Thus, the body position noticeably affects both reflex regulation of the cardiovascular system and autonomic balance. This observation has to be taken into account during physiological testing.



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Postvaccination Accumulation of the Influenza Virus Antigen in the Rat Choroid Plexus

We examined the accessibility of influenza virus and diphtheria-tetanus toxin (DiTe) antigens to the choroid plexus (CP) within the postvaccination period and the expression of CD11b molecules (by immunohistochemistry). Eighteen Dark Agouti (DA) rats were divided into three groups: (i) animals administered with influenza vaccine (Flu), (ii) animals administered with DiTe vaccine (DiTe), and (iii) nontreated (Contr) animals. The serum antibody titers following influenza and diphtheria-tetanus vaccination were detected by the ELISA test. Immunohistochemical staining revealed a great number of viral antigen-positive and CD11b-positive brain cells in Flu rats compared to a very small number of the respective cells in DiTe animals and no staining in the Contr group. DiTe- and Flu-rats showed significant increases in the serum anti-tetanus toxoid and anti-influenza virus antibody levels compared to those in the Contr group. The results obtained attract attention towards the dynamic role of the CP in the immunosurveillance of the CNS. Based on the viral antigen deposits accumulated in the CP, it has been proposed that the latter can play an active role in modulation of the immune response after influenza vaccine immunization.



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Changing Default Ventilator Settings on Anesthesia Machines Improves Adherence to Lung-Protective Ventilation Measures

Perioperative lung-protective ventilation (LPV) can reduce perioperative pulmonary morbidity. We hypothesized that modifying default anesthesia machine ventilator settings would increase the use of intraoperative LPV. Default tidal volume settings on our anesthesia machines were decreased from 600 to 400 mL, and default positive end-expiratory pressure was increased from 0 to 5 cm H2O. This modification increased mean positive end-expiratory pressure from 3.1 to 5.0 cm H2O and decreased mean tidal volume from 8.2 to 6.7 mL/kg predicted body weight. Notably, increased adherence to LPV from 1.6% to 23.0% occurred quickly with the rate of increase more than doubling from 1.8% to 3.9% per year. Accepted for publication September 12, 2017. Funding: This work was supported by Institutional and Departmental Sources. 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 Katherine T. Forkin, MD, Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908. Address e-mail to ket2a@hscmail.mcc.virginia.edu. © 2017 International Anesthesia Research Society

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Respiratory Gas Analysis—Technical Aspects

A technology-focused review of respiratory gas analysis, with an emphasis on carbon dioxide analysis, is presented. The measurement technologies deployed commercially are highlighted, and the basic principles and technical concerns of infrared spectroscopy and mainstream versus sidestream gas sampling are discussed. The specifications of particular interest to the clinician, accuracy and response time, and the related standard, with typical values for a capnometer, are presented. Representative time and volumetric capnograms are shown with the clinically relevant parameters described. Aspects of the terminology in present-day use and the need for clarity in defining what is a breath and an end-tidal value are reviewed. The applications of capnography of particular interest to the anesthesiologist are noted, and key references are provided. Ongoing developments with respect to respiratory gas analysis, and those that will impact it, are noted. Accepted for publication June 28, 2017. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Michael B. Jaffe, PhD, Cardiorespiratory Consulting, LLC, 410 Mountain Rd, Cheshire, CT 06410. Address e-mail to mbjengineering@cox.net. © 2017 International Anesthesia Research Society

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Is Compliance With Surgical Care Improvement Project Cardiac (SCIP-Card-2) Measures for Perioperative β-Blockers Associated With Reduced Incidence of Mortality and Cardiovascular-Related Critical Quality Indicators After Noncardiac Surgery?

BACKGROUND: While continuation of β-blockers (BBs) perioperatively has become a national quality improvement measure, the relationship between BB withdrawal and mortality and cardiovascular-related critical quality indicators has not been studied in a contemporary cohort of patients undergoing noncardiac surgery. METHODS: For this retrospective study, the quality assurance database of a large community-based anesthesiology group practice was used to identify 410,288 surgical cases, 18 years of age or older, who underwent elective or emergent noncardiac surgical procedures between January 1, 2009, and December 31, 2014. Each surgical case that was withdrawn from BBs perioperatively was propensity matched by clinical and surgical characteristics to 4 cases that continued BBs perioperatively. Subsequently, multivariable conditional logistic regression analyses were performed in the matched cohort to determine the extent to which withdrawal of perioperative BBs was independently associated with mortality as the primary outcome and cardiovascular-related critical quality indicators as the secondary outcome (need for vasopressor, electrocardiographic changes requiring treatment, unplanned admission to intensive care unit, postanesthesia care unit stay >2 hours, and a combination of cardiac arrest and myocardial infarction) within 48 hours postoperatively. RESULTS: Of the 66,755 (16%) cases in the cohort admitted on BB therapy, BBs were withdrawn in 3829 (6%) and continued in 62,926 (94%). Propensity score matching resulted in an analysis cohort of 19,145 cases. Withdrawal of perioperative BBs in the multivariable conditional logistic regression analysis was significantly associated with an increased risk for mortality (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.75–7.35; P = .0003), but a significantly decreased risk for need of blood pressure support requiring vasopressor initiation (OR, 0.84; 95% CI, 0.76–0.92; P = .0003) and extended postanesthesia care unit stay (OR, 0.69; 95% CI, 0.54–0.88; P = .004) within 48 hours after noncardiac surgery. CONCLUSIONS: Perioperative withdrawal of BBs was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in the postanesthesia care unit. Accepted for publication September 12, 2017. M. D. Kertai is currently affiliated with the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Miklos D. Kertai, MD, PhD, Department of Anesthesiology, Vanderbilt University Medical Center, 1215 21st Ave S, Suite 5160, Nashville, TN 37232. Address e-mail to miklos.kertai@vanderbilt.edu. © 2017 International Anesthesia Research Society

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In Response

No abstract available

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Informed Consent and Cognitive Dysfunction After Noncardiac Surgery in the Elderly

Cognitive dysfunction 3 months after noncardiac surgery in the elderly satisfies informed consent thresholds of foreseeability in 10%–15% of patients, and materiality with new deficits observed in memory and executive function in patients with normal test performance beforehand. At present, the only safety step to avoid cognitive dysfunction after surgery is to forego surgery, thereby precluding the benefits of surgery with removal of pain and inflammation, and resumption of normal nutrition, physical activity, and sleep. To assure that consent for surgery is properly informed, risks of both cognitive dysfunction and alternative management strategies must be discussed with patients by the surgery team before a procedure is scheduled. Accepted for publication October 23, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Kirk J. Hogan, MD, JD, Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, B6/319 Clinical Science Center, 600 Highland Ave, Madison, WI 53792. Address e-mail to khogan@wisc.edu. © 2017 International Anesthesia Research Society

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Cardiac Arrest in the Operating Room: Part 2—Special Situations in the Perioperative Period

As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes. Accepted for publication September 8, 2017. Funding: This review was developed from previous iterations on behalf of the American Society of Anesthesiologists and the Society of Critical Care Anesthesiologists. Portions of those documents appear verbatim and are used with the permission of the ASA. Conflicts of Interest: See Disclosures at the end of the article. Implication statement: The spectrum of causes of periprocedural cardiac arrest warrants specific adaptations of the advanced circulatory life support algorithms. A number of rare, life-threatening etiologies of profound hemodynamic and respiratory disturbance leading to cardiac arrest are reviewed. Good patient outcomes in these special situations can be achieved by vigilance, timely formulation of a differential diagnosis for the crisis, and adherence to best practices. Reprints will not be available from the authors. Address correspondence to Matthew D. McEvoy, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Dr, TVC 4648, Nashville, TN 37232. Address e-mail to matthew.d.mcevoy@vanderbilt.edu. © 2017 International Anesthesia Research Society

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Reduced Left Ventricular Global Longitudinal Strain Predicts Prolonged Hospitalization: A Cohort Analysis of Patients Having Aortic Valve Replacement Surgery

BACKGROUND: Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS: In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS: Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01–1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01–2.79] per 0.1 second−1 decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS: Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement. Accepted for publication October 10, 2017. Funding: This investigation was supported by National Institutes of Health K23 HL093065 (A.E.D.) and the Departments of Cardiothoracic Anesthesia and Outcomes Research at the Cleveland Clinic. None of the investigators has a personal financial interest in this research. 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). Abraham Sonny, MD, is currently affiliated with the Harvard Medical School, Boston, Massachusetts; and Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Clinical Trial Registry: Clinical Trials.gov #NCT01187329. Reprints will not be available from the authors. Address correspondence to Andra E. Duncan, MD, MS, FASE, Departments of Cardiothoracic Anesthesia and Outcomes Research, Cleveland Clinic, 9500 Euclid Ave/J4, Cleveland, OH 44195. Address e-mail to duncana@ccf.org. © 2017 International Anesthesia Research Society

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Randomized Clinical Trial of Preoperative High-Dose Methylprednisolone on Postoperative Pain at Rest After Laparoscopic Appendectomy

BACKGROUND: Methylprednisolone administered intravenously preoperatively has been shown to reduce pain, nausea, and fatigue after elective surgery. We aimed to show that 125 mg of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for suspected appendicitis would reduce pain at rest during the first 3 postoperative days. METHODS: A multicenter, parallel-group, double-blind, placebo-controlled study was conducted including patients 18 years of age and older with an American Society of Anesthesiologist class of I–III undergoing laparoscopic surgery for suspected appendicitis. The primary outcome was pain at rest measured on the 11-point numerical rating scale 5 times during the first 3 days after surgery. The effect of 125 mg of methylprednisolone on postoperative pain at rest during the first 3 days was assessed using a mixed-effects model with time and intervention as main effects. RESULTS: From April 2016 to August 2016, 78 patients were included, and all were eligible for analysis of the primary outcome. The estimated effect of 125 mg of methylprednisolone on pain at rest during the first 3 days after surgery was a nonsignificant increase of 0.2 (95% confidence interval, −0.5 to 0.9; P = .571) on the 11-point numerical rating scale. There was no difference between the 2 groups regarding the need for opioid agonists during hospital stay on the first postoperative day (P = .381). CONCLUSIONS: A 125-mg dose of methylprednisolone given intravenously 30 minutes before laparoscopic surgery for appendicitis seemed no better than placebo at providing a clinical meaningful reduction in postoperative pain at rest. Accepted for publication October 24, 2017. Funding: This work was supported by the A.P. Møller Foundation for the Advancement of Medical Science, Grosserer L.F. Foghts Fond, and the Augustinus Foundation. The primary author received a research grant from Nordsjællands Hospital and financial support from the Department of Surgery, Nordsjællands Hospital, Copenhagen University Hospital. 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). Trial Registration: Registered at http://ift.tt/PmpYKN (NCT02711449) and EudraCT (2015-004800-46). All authors agree to be accountable for all aspects of the work presented. Reprints will not be available from the authors. Address correspondence to Jakob Kleif, MD, Department of Surgery, Nordsjællands Hospital, Copenhagen University Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark. Address e-mail to kleifen@dadlnet.dk. © 2017 International Anesthesia Research Society

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Distracted Doctoring: Returning to Patient-Centered Care in the Digital Age. Do We Have Time for This?

No abstract available

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Visualization Improves Supraclavicular Access to the Subclavian Vein in a Mixed Reality Simulator

BACKGROUND: We investigated whether visual augmentation (3D, real-time, color visualization) of a procedural simulator improved performance during training in the supraclavicular approach to the subclavian vein, not as widely known or used as its infraclavicular counterpart. METHODS: To train anesthesiology residents to access a central vein, a mixed reality simulator with emulated ultrasound imaging was created using an anatomically authentic, 3D-printed, physical mannequin based on a computed tomographic scan of an actual human. The simulator has a corresponding 3D virtual model of the neck and upper chest anatomy. Hand-held instruments such as a needle, an ultrasound probe, and a virtual camera controller are directly manipulated by the trainee and tracked and recorded with submillimeter resolution via miniature, 6 degrees of freedom magnetic sensors. After Institutional Review Board approval, 69 anesthesiology residents and faculty were enrolled and received scripted instructions on how to perform subclavian venous access using the supraclavicular approach based on anatomic landmarks. The volunteers were randomized into 2 cohorts. The first used real-time 3D visualization concurrently with trial 1, but not during trial 2. The second did not use real-time 3D visualization concurrently with trial 1 or 2. However, after trial 2, they observed a 3D visualization playback of trial 2 before performing trial 3 without visualization. An automated scoring system based on time, success, and errors/complications generated objective performance scores. Nonparametric statistical methods were used to compare the scores between subsequent trials, differences between groups (real-time visualization versus no visualization versus delayed visualization), and improvement in scores between trials within groups. RESULTS: Although the real-time visualization group demonstrated significantly better performance than the delayed visualization group on trial 1 (P = .01), there was no difference in gain scores, between performance on the first trial and performance on the final trial, that were dependent on group (P = .13). In the delayed visualization group, the difference in performance between trial 1 and trial 2 was not significant (P = .09); reviewing performance on trial 2 before trial 3 resulted in improved performance when compared to trial 1 (P

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Perioperative Management of the Patient With a Left Ventricular Assist Device for Noncardiac Surgery

The pandemic of heart failure and the limited options for treatment of end-stage disease have resulted in an increase in the utilization of left ventricular assist devices (LVADs). Improvements in device technology and patient survival have led to an expanding population of patients requiring noncardiac surgery while on LVAD therapy, thus leading to a growing need for familiarity with the physiology of these patients. This review describes the functional mechanics of the most prevalent continuous-flow LVAD, the HeartMate II, and focuses on perioperative anesthetic concerns. Accepted for publication October 16, 2017. Funding: None. The author declares no conflicts of interest. Reprints will not be available from the author. Address correspondence to Mabel Chung, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to mchung8@mgh.harvard.edu. © 2017 International Anesthesia Research Society

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Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III Local Instillation Analgesia—A Systematic Review and Meta-Analysis

BACKGROUND: Local infiltration analgesia offers effective postoperative analgesia after knee arthroplasty, but the role of its counterpart, local instillation analgesia (LIA), in anterior cruciate ligament reconstruction (ACLR) is unclear. This systematic review and meta-analysis evaluates the analgesic benefits of LIA for outpatient ACLR. METHODS: We sought randomized controlled trials investigating the analgesic effects of LIA versus control in adults having outpatient ACLR and receiving multimodal analgesia (excluding nerve blocks, which are examined in parts I and II of this project). Cumulative postoperative analgesic consumption at 24 hours was designated as a primary outcome. Analgesic consumption during postanesthesia care unit stay, proportion of patients requiring analgesic supplementation, time-to-first analgesic request, rest pain scores during the first 48 hours, hospital length of stay, and incidence of opioid-related side effects were analyzed as secondary outcomes and pooled using random effects modeling. RESULTS: Eleven randomized controlled trials (515 patients) were included. Analgesic consumption was selected as the primary outcome in 4 trials (36%). Compared to control, LIA reduced the 24-hour morphine consumption by a weighted mean difference (95% confidence interval) of −18.0 mg (−33.4 to −2.6) (P = .02). LIA reduced postanesthesia care unit morphine consumption by −55.9 mg (−88.4 to −23.4) (P

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Tailored Holder for Continuous Echocardiographic Monitoring

Hemodynamic monitoring is essential for prompt and effective interventions in intensive care unit patients. We developed a custom-made transthoracic echocardiography transducer holder consisting of transducer holder and skin patch attachment. This holder allowed continuous transthoracic echocardiography monitoring in 5 adult patients with circulatory failure due to shock, and 6 pediatric patients after successful percutaneous closure of a ventricular septal defect. One case of an unexpected hemopericardium was promptly diagnosed and pericardiocentesis was performed, and 1 patient required extracorporeal membrane oxygenation support. Accepted for publication October 16, 2017. Funding: This study was supported by research grants from the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (Zy2016101) and Taipei Cheng Hsin General Hospital (CHGH105-1). The authors declare no conflicts of interest. H. Song and S. K. Tsai contributed equally to this work. Reprints will not be available from the authors. Address correspondence to Jin Liu, MD, PhD, Department of Anesthesiology, West China Hospital, Sichuan University, Wainan Guoxuexiang St #37, Chengdu, Sichuan 610041, China. Address e-mail to scujinliu@foxmail.com. © 2017 International Anesthesia Research Society

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Decreased Parasympathetic Activity of Heart Rate Variability During Anticipation of Night Duty in Anesthesiology Residents

BACKGROUND: In residency programs, it is well known that autonomic regulation is influenced by night duty due to workload stress and sleep deprivation. A less investigated question is the impact on the autonomic nervous system of residents before or when anticipating a night duty shift. In this study, heart rate variability (HRV) was evaluated as a measure of autonomic nervous system regulation. METHODS: Eight residents in the Department of Anesthesiology were recruited, and 5 minutes of electrocardiography were recorded under 3 different conditions: (1) the morning of a regular work day (baseline); (2) the morning before a night duty shift (anticipating the night duty); and (3) the morning after a night duty shift. HRV parameters in the time and frequency domains were calculated. Repeated measures analysis of variance was performed to compare the HRV parameters among the 3 conditions. RESULTS: There was a significant decrease of parasympathetic-related HRV measurements (high-frequency power and root mean square of the standard deviation of R–R intervals) in the morning before night duty compared with the regular work day. The mean difference of high-frequency power between the 2 groups was 80.2 ms2 (95% confidence interval, 14.5–146) and that of root mean square of the standard deviation of R–R intervals was 26 milliseconds (95% confidence interval, 7.2–44.8), with P = .016 and .007, respectively. These results suggest that the decrease of parasympathetic activity is associated with stress related to the condition of anticipating the night duty work. On the other hand, the HRV parameters in the morning after duty were not different from the regular workday. CONCLUSIONS: The stress of anticipating the night duty work may affect regulation of the autonomic nervous system, mainly manifested as a decrease in parasympathetic activity. The effect of this change on the health of medical personnel deserves our concern. Accepted for publication July 25, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Hui-Hsun Huang, MD, PhD, Department of Anesthesiology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd, Taipei 10051, Taiwan. Address e-mail to hhhuangq@gmail.com. © 2017 International Anesthesia Research Society

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Survival of Staphylococcus epidermidis in Propofol and Intralipid in the Dead Space of Intravenous Injection Ports

We tested whether propofol or Intralipid inoculated with Staphylococcus epidermidis would promote bacterial growth within an intravenous (IV) injection hub, a site prone to bacterial contamination. In tubes incubated under optimal conditions, S epidermidis exhibited growth in Intralipid, but not in propofol. In contrast, within the IV hub incubated with either propofol or intralipid at room temperature, S epidermidis bacterial numbers declined with time, and virtually no contamination remained after 12 hours. These data suggest that certain IV lines are inhospitable for S epidermidis. Accepted for publication October 9, 2017. The authors Noble, Salim, Gragasin, and Bourque contributed equally to this study. Funding: This study was supported by funds from the Canadian Institutes of Health Research (MOP142396 to S.L.B. and MOP142446 to F.S.G.), and the Department of Anesthesiology & Pain Medicine at the University of Alberta. The authors declare no conflicts of interest. S. L. Bourque and F. S. Gragasin contributed equally to this work. Reprints will not be available from the authors. Address correspondence to Stephane L. Bourque, PhD, Department of Anesthesiology & Pain Medicine, 3-020H Katz Group Centre for Pharmacy and Health Research, University of Alberta, Edmonton, AB T6G 2E1, Canada. Address e-mail to sbourque@ualberta.ca. © 2017 International Anesthesia Research Society

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A World of Need

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Some Cautionary Tales About Ideal Body Weight Dosing of Anesthetic Medications: It Is Not All that Ideal!

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Consensus Statement on Perioperative Use of Neuromuscular Monitoring

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A panel of clinician scientists with expertise in neuromuscular blockade (NMB) monitoring was convened with a charge to prepare a consensus statement on indications for and proper use of such monitors. The aims of this article are to: (a) provide the rationale and scientific basis for the use of quantitative NMB monitoring; (b) offer a set of recommendations for quantitative NMB monitoring standards; (c) specify educational goals; and (d) propose training recommendations to ensure proper neuromuscular monitoring and management. The panel believes that whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation. Ideally, this should be done at the hand muscles (not the facial muscles) with a quantitative (objective) monitor. Objective monitoring (documentation of train-of-four ratio ≥0.90) is the only method of assuring that satisfactory recovery of neuromuscular function has taken place. The panel also recommends that subjective evaluation of the responses to train-of-four stimulation (when using a peripheral nerve stimulator) or clinical tests of recovery from NMB (such as the 5-second head lift) should be abandoned in favor of objective monitoring. During an interim period for establishing these recommendations, if only a peripheral nerve stimulator is available, its use should be mandatory in any patient receiving a neuromuscular blocking drug. The panel acknowledges that publishing this statement per se will not result in its spontaneous acceptance, adherence to its recommendations, or change in routine practice. Implementation of objective monitoring will likely require professional societies and anesthesia department leadership to champion its use to change anesthesia practitioner behavior. Accepted for publication October 10, 2017. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Mohamed Naguib, MB BCh, MSc, FCARCSI, MD, Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, NB3-78, Cleveland, OH 44195. Address e-mail to naguibm@ccf.org. © 2017 International Anesthesia Research Society

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Sugammadex and Oral Contraceptives: Is It Time for a Revision of the Anesthesia Informed Consent?

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Biallelic mutations in LARS2 can cause Perrault syndrome type 2 with neurologic symptoms

Perrault syndrome represents a genetically heterogeneous disorder characterized by sensorineural hearing loss in males and females and ovarian dysfunction in females. Causative genes include HARS2, HSD17B4, CLPP, C10orf2, and LARS2. Some patients with Perrault syndrome exhibit neurologic features including learning disability, cerebellar ataxia, and peripheral neuropathy and are classified as type 2 and are clinically separate from those without neurological symptoms other than a hearing loss (type 1). To date, all reported patients with LARS2 mutations (15 patients in 8 families) have been classified as type 1. Here, we report female siblings with biallelic mutations in LARS2, p.Glu294Lys, and p.Thr519Met, who were classified as type 2. The proposita developed progressive sensorineural hearing loss at 18 months and pervasive developmental disorder at 8 years, with repetitive behavior, insistence on sameness, attention deficit, tic, irritability, and an ataxic gait. At age 15 years, she was diagnosed as having primary amenorrhea with elevated FSH and LH and a decreased estradiol; ultrasound and magnetic resonance imaging examinations revealed a small uterus and no detectable ovaries. The proposita's younger sister presented with neonatal sensorineural hearing loss and a mild delay in motor and speech development. She was diagnosed as having primary amenorrhea with endocrinologic and radiographic findings that were comparable to those of her sister. She had difficulty with reading comprehension, and had trouble with open-ended test questions at 12 years of age. We concluded that Perrault syndrome patients with LARS2 mutations are at risk for neurologic problems, despite previous notions otherwise.



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Teenager has 'singular focus:' Care of the sick and injured

By Cathy Dyson The Free Lance-Star via AP SPOTSYLVANIA, Va. — Patrick Jett had been waiting most of his young life for the moment he could climb into the front of an ambulance and respond to whatever emergency awaited. For two years, he'd been running calls with the Spotsylvania Volunteer Rescue Squad, responding to vehicle accidents or drug overdoses, general illnesses or diabetic reactions ...

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