Regional Cerebral Oxygen Saturation Changes After Decompressive Craniectomy for Malignant Cerebral Venous Thrombosis: A Prospective Cohort Study

Background: Decompressive craniectomy (DC) is a life-saving intervention for malignant cerebral venous thrombosis (CVT). Earlier studies have shown increase in cerebral oxygenation after DC in traumatic brain injury but similar studies are lacking in CVT. We hypothesized that regional cerebral (tissue) oxygen saturation (rSO2) on the side of CVT is lower than the contralateral side and improves after DC. Materials and Methods: In this prospective cohort study, rSO2 was monitored using near-infrared spectroscopy technique, before and after DC on both cerebral hemispheres. Data regarding factors likely to affect rSO2 such as systolic blood pressure, partial pressure of oxygen and carbon dioxide in blood (PaO2 and PaCO2), and hemoglobin were simultaneously collected. The primary outcome measure was pre-post change in rSO2 on the ipsilateral cerebral hemisphere. The secondary outcomes were in-hospital mortality and duration of postoperative hospital stay. Results: Seventeen patients underwent DC during the 6-month study period. Their mean age was 39.2±12.4 years. The pre-post DC change in rSO2 on the hemisphere with CVT was significant (mean difference=3.6%; 95% confidence interval, 1.5-5.7; P=0.002). One patient died in the hospital. There was no difference in the duration of postoperative hospital stay (10 d [range, 6 to 21 d] vs. 14 d [range, 1 to 30 d], P=0.92) between patients with preoperative ipsilateral rSO2 60%. There was no correlation between PaO2, PaCO2, systolic blood pressure, and hemoglobin with rSO2. Conclusions: Patients with malignant CVT had a lower rSO2 on ipsilateral side of the lesion, which improved significantly after DC. Preoperative rSO2 was not correlated with the duration of hospital stay. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Kamath Sriganesh, DM, Department of Neuroanaesthesia and Neurocritical Care, 3rd Floor, Neurosciences Faculty Block, NIMHANS, Hosur Road, Bengaluru 560029, India (e-mail: drsri23@gmail.com). Received November 7, 2017 Accepted January 25, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Stretching the limits: from homeostasis to stem cell plasticity in wound healing and cancer

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Gene expression: Developmental enhancers in action

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Integrative omics for health and disease

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Brainstem catecholaminergic neurones and breathing control during postnatal development in male and female rats

Abstract

The respiratory network undergoes significant development during the postnatal phase, including the maturation of the catecholaminergic (CA) system. However, postnatal development of this network and its effect on the control of pulmonary ventilation (V̇_E), is not fully understood. We investigated the involvement of brainstem CA neurones in respiratory control during postnatal (P) development (P7-8, P14-15 and P20-21), in male and female rats, through chemical injury with conjugated saporin anti-dopamine beta-hydroxylase (DβH-SAP). Thus, DβH-SAP (420 ng μL⁻¹), saporin (SAP) or phosphate buffered solution (PBS) was injected into the 4th ventricle of neonatal Wistar rats of both sexes. V̇_E and oxygen consumption were recorded one week after the injections in unanaesthetized neonatal and juvenile rats during room air and hypercapnia. The resting ventilation was higher in both male and female P7-8 lesioned rats by 33%, and a decrease in respiratory variability was observed in males. The hypercapnic ventilatory response (HCVR) was altered in male and female lesioned rats at all postnatal ages. At P7-8, the HCVR for males and females was increased by 37% and 30%, respectively. For both sexes at P14-15 rats, the increase in V̇_E during hypercapnia was 37% higher for lesioned rats. A sex-specific difference in HCRV was observed at P20-21, with lesioned males showing a 33% decrease, and lesioned females showing an increase of 33%. We conclude that brainstem CA neurones exert a tonic inhibitory effect on V̇_E in the early postnatal days of a rat's life, increase variability in P7-8 males and modulate HCRV during the postnatal phase.

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Post-mortem analysis of suicide victims shows ABCB1 haplotype 1236T–2677T–3435T as a candidate predisposing factor behind adverse drug reactions in females

Background Genetic variation in efflux transporter, permeability glycoprotein (P-gp), has recently been associated with completed violent suicides and also violent suicide attempts. As depression is known to be a risk factor for suicide and many antidepressants are P-gp substrates, it has been speculated that inadequate antidepressant treatment response or adverse side effects could be involved. Objectives The aim of this study was to investigate whether there is an association between the P-gp coding ABCB1 gene and completed suicides in citalopram users. Also, the effect of sex and suicide method used (violent vs. non-violent) was evaluated. Materials and methods All cases included in the study population, 349 completed suicide victims and 284 controls, were shown to be positive for antidepressant citalopram in a post-mortem toxicological drug screen. ABCB1 1236C>T, 2677G/A>T, and 3435C>T polymorphisms were determined by TaqMan genotyping assays. Haplotypes were constructed from genotype data using the PHASE software. The association between the manner of death and the ABCB1 haplotype was tested with logistic regression analysis. Results No statistically significant differences were observed in the ABCB1 allele or genotype frequencies between the suicide and control groups. However, the ABCB1 1236T–2677T–3435T haplotype was associated with completed suicides of female citalopram users (odds ratio: 2.23; 95% confidence interval: 1.22–4.07; P=0.009). After stratification by the method used for suicide, the association emerged in fatal intoxications (odds ratio: 2.51; 95% confidence interval: 1.29–4.87; P=0.007). In other groups, no statistically significant associations were observed. Conclusion Our results suggest that female citalopram users with ABCB1 1236T–2677T–3435T are more vulnerable to adverse effects of the drugs as this haplotype was enriched in non-violent suicides of female citalopram users. Even though the biological mechanism behind this observation is unknown, the results provide another example of the importance of sex-based segregation in pharmacogenetics studies. Correspondence to Anna-Liina Rahikainen, MSc, Department of Forensic Medicine, PO Box 40 (Kytösuontie 11) University of Helsinki, Helsinki FI-00014, Finland Tel: +358 504 151 573; e-mail: anna-liina.rahikainen@helsinki.fi Received November 10, 2017 Accepted January 27, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Spinal Cord Stimulation 50 Years Later: Clinical Outcomes of Spinal Cord Stimulation Based on Randomized Clinical Trials—A Systematic Review

To assess the efficacy of spinal cord stimulation (SCS) for each indication, one must critically assess each specific clinical outcome to identify outcomes that benefit from SCS therapy. To date, a comprehensive review of clinically relevant outcome-specific evidence regarding SCS has not been published. We aimed to assess all randomized controlled trials from the world literature for the purpose of evaluating the clinical outcome-specific efficacy of SCS for the following outcomes: perceived pain relief or change pain score, quality of life, functional status, psychological impact, analgesic medication utilization, patient satisfaction, and health care cost and utilization. Interventions were SCS, without limitation to the type of controls or the type of SCS in the active arms. For each study analyzed, a quality assessment was performed using a validated scale that assesses reporting, external validity, bias, confounding, and power. Each outcome was assessed specific to its indication, and the primary measure of each abovementioned outcome was a summary of the level of evidence. Twenty-one randomized controlled trials were analyzed (7 for trunk and limb pain, inclusive of failed back surgery syndrome; 8 for refractory angina pectoris; 1 for cardiac X syndrome; 3 for critical limb ischemia; 2 for complex regional pain syndrome; and 2 for painful diabetic neuropathy). Evidence assessments for each outcome for each indication were depicted in tabular format. Outcome-specific evidence scores were established for each of the abovementioned indications, providing both physicians and patients with a summary of evidence to assist in choosing the optimal evidence-based intervention. The evidence presented herein has broad applicability as it encompasses a breadth of patient populations, variations of SCS therapy, and comparable controls that, together, reflect comprehensive clinical decision making. Accepted for publication October 22, 2017. Address correspondence to: Nagy Mekhail, MD, PhD, Cleveland Clinic, C25, 9500 Euclid Ave, Cleveland, OH 44195 (e-mail: mekhain@ccf.org). The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Corrigendum

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Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis

BACKGROUND: General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA). METHODS: We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models. RESULTS: Of 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m2 (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P

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Point-of-Care Fibrinogen Testing in Pregnancy

Agreement between estimated fibrinogen concentration via thromboelastography and traditional assays is not established in the parturient. We therefore recruited 56 parturients and performed Clauss and functional fibrinogen level (FLEV) tests. Mean difference of measurements was 36.8 mg/dL (95% CI, 21.8–51.9) with a standard deviation of 52.8 mg/dL. Calculated limits of agreement were 140.2 mg/dL (95% CI, 166.3–114.6) and −66.6 mg/dL (95% CI, −40.8 to −92.5), within the maximum allowable difference of 165 mg/dL. We therefore conclude that while most measurements fell within the limits of agreement, more work is needed to clearly define the role of this test in the obstetric population. Accepted for publication December 29, 2017. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Summary Statement: In this study, the relationship between formal laboratory Clauss and thromboelastography-derived fibrinogen counts is examined. Reprints will not be available from the authors. Address correspondence to Daniel Katz, MD, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1010 KCC 8th Floor, New York, NY 10029. Address e-mail to Daniel.Katz@mountsinai.org. © 2018 International Anesthesia Research Society

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Pupillary Dilation Reflex Measurement: Ideal Time—Pre- or Postsurgery?

No abstract available

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Treatment of Chronic Pain Conditions: A Comprehensive Handbook

No abstract available

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Analgesic Effects of Oxycodone Relative to Those of Sufentanil, in the Presence of Midazolam, During Endoscopic Injection Sclerotherapy for Patients With Cirrhosis and Esophageal Varices

BACKGROUND: We evaluated the efficacy and gastroenterologist/patient satisfaction of midazolam combined with oxycodone, relative to that of midazolam combined with sufentanil, for anesthesia during endoscopic injection sclerotherapy (EIS) in patients with cirrhosis and esophageal varices. METHODS: Patients with cirrhosis (20–69 years of age), body mass index, 18–25 kg/m2, American Society of Anesthesiology patient classification physical status I–II who underwent elective EIS were randomly assigned to 1 of 2 groups. In this prospective, double-blinded, randomized controlled trial, 1 group received midazolam and oxycodone (n = 64), and the other group received midazolam and sufentanil (n = 63). Primary and secondary outcome measures were compared between groups. The primary outcome measure was the incidence of hypoxia. Secondary outcome measures included perioperative limb movement, need for rescue analgesics, need for additional sedative propofol, specified adverse reactions (postoperative myoclonus, nausea, vomiting, dizziness, and drowsiness), gastroenterologist satisfaction, and patient satisfaction with postoperative analgesia. RESULTS: Patients in the midazolam–oxycodone group had 32% fewer episodes of hypoxia than did those in the midazolam–sufentanil group (95% confidence interval [CI], –45% to –18%; P

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Perioperative Temperature Management

No abstract available

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Inflammation Triggered by the Use of Blood Products

No abstract available

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In Response

No abstract available

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Does A Low 6-Minute Walk Distance Predict Elevated Postoperative Troponin?

Our study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98–0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57–0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting. Accepted for publication January 16, 2018. Funding: None. The authors declare no conflicts of interest. Institutional review board contact information: 310-825-5344; webIRBHelp@research.ucla.edu. Reprints will not be available from the authors. Address correspondence to Dana L. Russell, MPH, Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, 757 Westwood Pl, Los Angeles, CA 90095. Address e-mail to danarussell@mednet.ucla.edu. © 2018 International Anesthesia Research Society

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The Migration of Caudally Threaded Thoracic Epidural Catheters in Neonates and Infants

BACKGROUND: The migration of pediatric thoracic epidural catheters via a thoracic insertion site has been described. We assessed the migration of caudally threaded thoracic epidural catheters in neonates and infants at our institution. METHODS: The anesthesia records and diagnostic imaging studies of neonates and infants who had caudal epidural catheters placed during a 26-month period at our hospital were analyzed. Imaging studies were reviewed for changes in epidural catheter tip position. RESULTS: Eighty-five patients 1–325 days of age (median, 51 days; interquartile range, 39–78 days) and weights of 2.5–9.5 kg (median, 5 kg; interquartile range, 4.3–5.8 kg) met the study criteria. Fifty-four (64%) of the patients (95% CI, 52%–73%) experienced catheter migration of 1 or more vertebral levels (range, 3 levels caudad [outward] to 3 levels cephalad [inward]), and 23 (27%) of the patients (95% CI, 18%–38%) experienced catheter migration to the T4 level or higher. Migration of 2 or more vertebral levels occurred only in children who weighed

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Beyond the “E” in OSCE

No abstract available

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Correlation Coefficients: Appropriate Use and Interpretation

Correlation in the broadest sense is a measure of an association between variables. In correlated data, the change in the magnitude of 1 variable is associated with a change in the magnitude of another variable, either in the same (positive correlation) or in the opposite (negative correlation) direction. Most often, the term correlation is used in the context of a linear relationship between 2 continuous variables and expressed as Pearson product-moment correlation. The Pearson correlation coefficient is typically used for jointly normally distributed data (data that follow a bivariate normal distribution). For nonnormally distributed continuous data, for ordinal data, or for data with relevant outliers, a Spearman rank correlation can be used as a measure of a monotonic association. Both correlation coefficients are scaled such that they range from –1 to +1, where 0 indicates that there is no linear or monotonic association, and the relationship gets stronger and ultimately approaches a straight line (Pearson correlation) or a constantly increasing or decreasing curve (Spearman correlation) as the coefficient approaches an absolute value of 1. Hypothesis tests and confidence intervals can be used to address the statistical significance of the results and to estimate the strength of the relationship in the population from which the data were sampled. The aim of this tutorial is to guide researchers and clinicians in the appropriate use and interpretation of correlation coefficients. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication January 11, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Patrick Schober, MD, PhD, MMedStat, Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081HV Amsterdam, the Netherlands. Address e-mail to p.schober@vumc.nl. © 2018 International Anesthesia Research Society

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Treatment Patterns and Clinical Outcomes in Neonates Diagnosed With Respiratory Distress Syndrome in a Low-Income Country: A Report From Bangladesh

Respiratory distress syndrome remains a leading cause of neonatal mortality worldwide. This retrospective study describes practice patterns for respiratory distress syndrome in a resource-limited setting and seeks to identify both risk factors for mortality and beneficial treatment modalities. Health, demographic, and treatment data were collected. Potential associations were analyzed using univariable and multivariable logistic regression. Of 104 children included for analysis, 38 died. Although most children were initially treated with noninvasive respiratory support, 59 progressed to invasive ventilation. Requirement for invasive ventilation was associated with death. A clear trend toward improved survival in mechanically ventilated patients was seen with surfactant administration. Accepted for publication January 11, 2018. Funding: This study was supported in part by the National Institutes of Heath (NIH) Building Interdisciplinary Research Careers in Women's Health (BIRCWH) NIH K12HD043441 scholar funds to G.L. The project described was supported by NIH through grant number UL1TR001857. Support for data collection on-site in Bangladesh ($650 total) was provided via the crowd-funding website https://experiment.com/. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Richard M. Hubbard, MD, 710 Beaver St, Sewickley, PA 15143. Address e-mail to rhubbardmd@gmail.com. © 2018 International Anesthesia Research Society

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Research Needs Assessment for Children With Obstructive Sleep Apnea Undergoing Diagnostic or Surgical Procedures

Recent concerns have been raised about the quality and safety of adenotonsillectomy, a common surgery performed to treat obstructive sleep apnea (OSA) in children. OSA is a risk factor for opioid-related perioperative respiratory complications including those associated with anoxic brain injury or death. Our objective was to identify controversial issues related to the care of children with OSA. A standardized Delphi consensus technique involving an interdisciplinary group of 24 pediatric OSA experts identified 3 key issues: "postoperative disposition, preoperative screening, and pain management." These topics are prime candidates for future systematic reviews and will guide Society of Anesthesia and Sleep Medicine–related research endeavors. Accepted for publication December 19, 2017. Funding: This study was supported solely by institutional and/or 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 Kimmo T. Murto, MD, FRCPC, Department of Anesthesiology and Pain Medicine, Children's Hospital of Eastern Ontario-Ottawa Children's Treatment Center, University of Ottawa, 401 Smyth Rd, Ottawa, ON K1H 8L1, Canada. Address e-mail to kmurto@cheo.on.ca. © 2018 International Anesthesia Research Society

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Opioid Omission Is Not Opioid Sparing. Response to “Surgery-Induced Opioid Dependence: Adding Fuel to the Fire?”

No abstract available

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Development and Initial Evaluation of a Novel, Ultraportable, Virtual Reality Bronchoscopy Simulator: The Computer Airway Simulation System

BACKGROUND: Virtual reality (VR) simulation is an effective and safe method of teaching bronchoscopic skills. Few VR bronchoscopy simulators exist; all are expensive. The present study aimed to describe the design, development, and evaluation of a new, affordable, VR bronchoscopy simulator. METHODS: Anesthesiologists and engineers collaborated to design and develop the Computer Airway Simulation System (CASS), an iPad-based, high-fidelity, VR bronchoscopy simulator. We describe hardware and software development, as well as the technical and teaching features of the CASS. Twenty-two senior anesthesiologists evaluated various aspects of the simulator (using a 5-point Likert scale) to assess its face validity. RESULTS: Anesthesiologists performed a simulated bronchoscopy (mouth to carina) with a median (range) procedural time of 66 seconds (30–96). The simulator's ease of use was rated 4.3 ± 0.8 and the bronchoscope proxy's handling 4.0 ± 0.7. Criticisms included that excessive system reactivity created handling difficulties. Anatomical accuracy, 3-dimensional bronchial segmentation, and mucosal texture were judged to be very realistic. The simulator's usefulness for teaching and its educational value were highly rated (4.9 ± 0.3 and 4.8 ± 0.4, respectively). CONCLUSIONS: We describe the design, development, and initial evaluation of the CASS—a new, ultraportable, affordable, VR bronchoscopy simulator. The simulator's face validity was supported by excellent assessments from senior anesthesiologists with regard to anatomical realism, quality of graphics, and handling performance, even though some future refinements are required. All the practitioners agreed on the significant educational potential of the CASS. Accepted for publication December 29, 2017. Funding: Cardiocentro Ticino's Department of Cardiac Anesthesia and Intensive Care in Lugano, Switzerland, employs Gabriele Casso and Tiziano Cassina. This institution received financial support for the CASS research and development project from the Foundation for Cardiological Research and Education and the FLAVA Foundation (Fondation Latine des Voies Aériennes), both charitable (not-for-profit) organizations. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Gabriele Casso, MD, Department of Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland. Address e-mail to gabriele.casso@cardiocentro.org. © 2018 International Anesthesia Research Society

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Interoception sensitivity in the parental brain during the first months of parenting modulates children's somatic symptoms six years later: The role of oxytocin

Publication date: Available online 24 February 2018
Source:International Journal of Psychophysiology
Author(s): Eyal Abraham, Talma Hendler, Orna Zagoory-Sharon, Ruth Feldman
Interoception, the perception and interpretation of one's own bodily signals, is a key aspect of human caregiving that impacts infant health and well-being across life. Interoception relies on limbic structures, mainly the amygdala, and the agranular visceromotor cortex, particularly the anterior insula (AI), that integrate with the oxytocin (OT) system to support interoceptive sensitivity. Here, we used functional magnetic resonance imaging (fMRI) to examine whether interoception sensitivity in the parent's brain during the first months of parenting combines with sensitive parenting and OT-system functionality to predict children's somatic symptoms six years later. We followed 45 primary-caregiving first-time mothers and fathers and their infants across the first six years of parenting. In infancy (Time 1), parents' brain response to infant stimuli was imaged, salivary OT measured, and parent-infant interactions coded for parent sensitivity. In preschool (Time 2), parent and child's OT and parent sensitivity were measured again. At six years (Time 3), parents reported on children's somatic symptoms. Greater activation of the parent's AI bilaterally when his/her child was an infant predicted lower child somatic problems at six years. Parent sensitivity partially mediated the links between parental AI activation and child somatic symptoms. In addition, greater parental bilateral amygdala activity predicted higher child OT levels at 3 years and parental OT moderated the relations between preschoolers' OT and later somatic symptoms. Our findings chart two independent cross-generational pathways from interoception sensitivity in the parent's brain and child somatization. The first defines an evolutionary-ancient path including the amygdala and the OT system that support mammalian attention to arousal modulations in response to social cues; the second, via the AI, implicates higher-order interoceptive representations of bodily responses and affective states that underpins human embodiment.



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