Πέμπτη, 1 Μαρτίου 2018

Increased Single fiber jitter level is associated with reduction in motor function with aging

ABSTRACTObjectiveAge-associated skeletal muscle weakness is a major contributing factor to an increased late life mortality and morbidity, but its neurobiology is poorly understood. Previously, we provided histological evidence of dying-back axonal degeneration of motor neurons and denervation of neuromuscular junctions (NMJ) in age-associated muscle weakness. Given this, we aim to evaluate the relation between impaired neuromuscular transmission and various aspects of age-associated muscle weakness.DesignWe compared two electrophysiological measures, single fiber jitter and compound motor action potential (CMAP) in mice of different age groups, and correlated them with various physical performance measures, such as grip strength, standing and walking time and treadmill performance.ResultsConsistent with our previous histological data, single fiber jitter, a measure of NMJ transmission, was significantly increased in older animals, while CMAP shows no difference between young and old age groups. Neither jitter nor CMAP correlated with any of physical performance measures, except for jitter and standing activity.ConclusionImpaired neuromuscular transmission – represented as increase in SFEMG jitter level – reflects decline in motor function with aging. Objective Age-associated skeletal muscle weakness is a major contributing factor to an increased late life mortality and morbidity, but its neurobiology is poorly understood. Previously, we provided histological evidence of dying-back axonal degeneration of motor neurons and denervation of neuromuscular junctions (NMJ) in age-associated muscle weakness. Given this, we aim to evaluate the relation between impaired neuromuscular transmission and various aspects of age-associated muscle weakness. Design We compared two electrophysiological measures, single fiber jitter and compound motor action potential (CMAP) in mice of different age groups, and correlated them with various physical performance measures, such as grip strength, standing and walking time and treadmill performance. Results Consistent with our previous histological data, single fiber jitter, a measure of NMJ transmission, was significantly increased in older animals, while CMAP shows no difference between young and old age groups. Neither jitter nor CMAP correlated with any of physical performance measures, except for jitter and standing activity. Conclusion Impaired neuromuscular transmission – represented as increase in SFEMG jitter level – reflects decline in motor function with aging. Acknowledgement This work was supported by RMSTP K12 grant (5K12HD001097-19), the Dr. Miriam and Sheldon G Adelson Medical Research Foundation, the National Institutes on Aging (NIA) (R21-AG025143) and the Johns Hopkins Older Americans Independence Center (P30-AG021334). Correspondence: Tae Chung, MD, Johns Hopkins School of Medicine, Department of Physical Medicine and Rehabilitation, 4940 Eastern Avenue/Asthma Allergy bldg. 1A44, Baltimore MD 21224, Email: tchung7@jhmi.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Cardiac measures of nuclear power plant operator stress during simulated incident and accident scenarios

Abstract

Maintaining optimal performance in demanding situations is challenged by stress-induced alterations in performance. Here, we quantified the stress of nuclear power plant (NPP) operators (N = 20) during a full-scale simulator training for incident and accident scenarios. We compared the ambulatory electrocardiography measurements of heart rate (HR) and heart rate variability (HRV), and self-reported stress during baselines and simulated scenarios. Perceived (scale 0–10) and physiologically measured stress were low during baseline after the scenarios and normal NPP operation (means 1.8–2.2, mean HR 75–80 bpm). During a cognitively challenging scenario simulating a sensor malfunction, the operators' stress was mild to moderate (mean 3.4; HR + 12% from baseline). During simulations of severe accidents of fire and radioactive steam leakage, the experienced stress and cardiac activity were on a moderate to high level (means 4.2 and 4.6; HR + 23% and + 14% from baseline, respectively). Cardiac activity paralleled the self-reported stress: correlation of self-reported stress to HR was 0.61 (p < .001) and to HRV features RMSSD, HF, LF/HF, SD1, and SD1/SD2 were −0.26, −0.28, 0.35, −0.40, and −0.39 (p < .01), respectively. The low shared variance (22%) between HR and physical activity further support the interpretation that the cardiac activity was strongly linked to the experience of stress and not accountable by operators' movement within the simulator. Cardiac measurements in naturalistic settings can thus reveal relevant information on acute stress with the benefit of not interrupting the primary task.



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Loci That Control Nonlinear, Interdependent Responses to Combinations of Drought and Nitrogen Limitation

Crop improvement must accelerate to feed an increasing human population in the face of environmental changes. Including anticipated climatic changes with genetic architecture in breeding programs could better optimize improvement strategies. Combinations of drought and nitrogen limitation already occur world-wide. We therefore analyzed the genetic architecture underlying the response of Zea mays to combinations of water and nitrogen stresses. Recombinant inbreds were subjected to nine combinations of the two stresses using an optimized response surface design, and their growth was measured. Three-dimensional response surfaces were fit globally and to each polymorphic allele to determine which genetic markers were associated with different response surfaces. Three quantitative trait loci that produced nonlinear surfaces were mapped. To better understand the physiology of the response, we developed a model that reproduced the shapes of the surfaces, their most characteristic feature. The model contains two components that each combine the nitrogen and water inputs. The relative weighting of the two components and the inputs is governed by five parameters, and each QTL affects all five parameters. We estimated the model's parameter values for the experimental surfaces using a mesh of points that covered the surfaces' most distinctive regions. Surfaces computed using these values reproduced the experimental surfaces well, as judged by three different criteria at the mesh points. The modeling and shape comparison techniques used here can be extended to other complex, high-dimensional, nonlinear phenotypes. We encourage the application of our findings and methods to experiments that mix crop protection measures, stresses, or both, on elite and landrace germplasm.



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Genomic Locus Modulating IOP in the BXD RI Mouse Strains

Intraocular pressure (IOP) is the primary risk factor for developing glaucoma, yet little is known about the contribution of genomic background to IOP regulation. The present study leverages an array of systems genetics tools to study genomic factors modulating normal IOP in the mouse. The BXD recombinant inbred (RI) strain set was used to identify genomic loci modulating IOP. We measured the IOP in a total of 506 eyes from 38 different strains. Strain averages were subjected to conventional quantitative trait analysis by means of composite interval mapping. Candidate genes were defined, and immunohistochemistry and quantitative PCR (qPCR) were used for validation. Of the 38 BXD strains examined the mean IOP ranged from a low of 13.2mmHg to a high of 17.1mmHg. The means for each strain were used to calculate a genome wide interval map. One significant quantitative trait locus (QTL) was found on Chr.8 (96 to 103 Mb). Within this 7 Mb region only 4 annotated genes were found: Gm15679, Cdh8, Cdh11 and Gm8730. Only two genes (Cdh8 and Cdh11) were candidates for modulating IOP based on the presence of non-synonymous SNPs. Further examination using SIFT (Sorting Intolerant From Tolerant) analysis revealed that the SNPs in Cdh8 (Cadherin 8) were predicted to not change protein function; while the SNPs in Cdh11 (Cadherin 11) would not be tolerated, affecting protein function. Furthermore, immunohistochemistry demonstrated that CDH11 is expressed in the trabecular meshwork of the mouse. We have examined the genomic regulation of IOP in the BXD RI strain set and found one significant QTL on Chr. 8. Within this QTL, there is one good candidate gene, Cdh11.



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Implementation Science in Perioperative Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Benjamin T. Cobb, Crystal Wiley Cené, Rinad S. Beidas

Teaser

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.


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Copyright

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Contributors

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Contents

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Forthcoming Issues

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1





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Improving Perioperative Care: What Are the Tools That Lead to Sustainable Change?

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Lee A. Fleisher




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Quality Improvement and Implementation Science

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Lee A. Fleisher




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Quality Improvement and Implementation Science: Different Fields with Aligned Goals

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Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Meghan B. Lane-Fall, Lee A. Fleisher




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Human Factors Applied to Perioperative Process Improvement

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Joseph R. Keebler, Elizabeth H. Lazzara, Elizabeth Blickensderfer, Thomas D. Looke

Teaser

This article discusses some of the major theories of the science of human factors/ergonomics (HF/E) in relation to perioperative medicine, with a focus on safety and errors within these systems. The discussion begins with human limitations based in cognition, decision making, stress, and fatigue. Given these limitations, the importance of measuring human performance is discussed. Finally, using the HF/E perspective on safety, high-level recommendations are provided for increasing safety within the perioperative environment.


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Quality Improvement in Anesthesiology — Leveraging Data and Analytics to Optimize Outcomes

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Elizabeth A. Valentine, Scott A. Falk

Teaser

Quality improvement is at the heart of practice of anesthesiology. Objective data are critical for any quality improvement initiative; when possible, a combination of process, outcome, and balancing metrics should be evaluated to gauge the value of an intervention. Quality improvement is an ongoing process; iterative reevaluation of data is required to maintain interventions, ensure continued effectiveness, and continually improve. Dashboards can facilitate rapid analysis of data and drive decision making. Large data sets can be useful to establish benchmarks and compare performance against other providers, practices, or institutions. Audit and feedback strategies are effective in facilitating positive change.


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Emergency Manuals

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Sara N. Goldhaber-Fiebert, Carl Macrae

Teaser

How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care.


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Use of Simulation in Performance Improvement

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Amanda Burden, Erin White Pukenas

Teaser

Human error and system failures continue to play a substantial role in preventable errors that lead to adverse patient outcomes or death. Many of these deaths are not the result of inadequate medical knowledge and skill, but occur because of problems involving communication and team management. Anesthesiologists pioneered the use of simulation for medical education in an effort to improve physician performance and patient safety. This article explores the use of simulation for performance improvement. Educational theories that underlie effective simulation programs are described as driving forces behind the advancement of simulation in performance improvement.


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Developing Multicenter Registries to Advance Quality Science

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Laura E. Schleelein, Kathleen A. Harris, Elizabeth M. Elliott

Teaser

There are several benefits to clinical registries as an information repository tool, ultimately lending itself to the acquisition of new knowledge. Registries have the unique advantage of garnering much data quickly and are, therefore, especially helpful for niche populations or low-prevalence diseases. They can be used to inform on the ideal structure, process, or outcome involving an identified population. The data can be used in many ways, for example, as an observational tool to reveal associations or as a basis for framing future research studies or quality improvement projects.


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Handovers in Perioperative Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Atilio Barbeito, Aalok V. Agarwala, Amanda Lorinc

Teaser

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.


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Rethinking Clinical Workflow

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Joseph J. Schlesinger, Kendall Burdick, Sarah Baum, Melissa Bellomy, Dorothee Mueller, Alistair MacDonald, Alex Chern, Kristin Chrouser, Christie Burger

Teaser

The concept of clinical workflow borrows from management and leadership principles outside of medicine. The only way to rethink clinical workflow is to understand the neuroscience principles that underlie attention and vigilance. With any implementation to improve practice, there are human factors that can promote or impede progress. Modulating the environment and working as a team to take care of patients is paramount. Clinicians must continually rethink clinical workflow, evaluate progress, and understand that other industries have something to offer. Then, novel approaches can be implemented to take the best care of patients.


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Developing Capacity to Do Improvement Science Work

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Irene McGhee, Yehoshua Gleicher

Teaser

Developing capacity to do improvement science starts with prioritizing quality improvement training in all health professions curricula so that a common knowledge base and understanding are created. Educational programs should include opportunities for colearning with patients, health professionals, and leaders. In this way, knowledge translation (also called implementation) is more effective and better coordinated when applied across organizations. Key factors that enable and drive behavior change are reviewed, as is the importance of influence and leadership. A comprehensive approach that accounts for these factors hardwires quality improvement into the health care systems and creates a culture that enables its ongoing development.


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Diffusing Innovation and Best Practice in Health Care

Publication date: March 2018
Source:Anesthesiology Clinics, Volume 36, Issue 1
Author(s): Philip E. Greilich, Mary Eleanor Phelps, William Daniel

Teaser

Diffusing innovation and best practices in healthcare are among the most challenging aspects of advancing patient safety and quality improvement. Recommendations from the Baldrige Foundation, Institute for Healthcare Improvement, and The Joint Commission provide guidance on the principles for successful diffusion. Perioperative leaders are encouraged to applying these principles to high priority areas such as handovers, enhanced recovery and patient blood management. Completing a successful pilot project can be exciting, however, effective diffusion is essential to achieving meaningful and lasting impact on the service line and health system.


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Optimal Gestational Weight Gain for Women with Gestational Diabetes and Morbid Obesity

Abstract

Objectives

Our aim was to investigate the greatest gestational weight gain (GWG) without adverse pregnancy complications in women with gestational diabetes mellitus (GDM) and morbid obesity.

Methods

An observational retrospective study including 3284 patients with single pregnancies and GDM was completed. Of the patients, 131 (4.0%) were classified as having pre-pregnancy morbid obesity (BMI ≥ 35 kg/m2). Perinatal complications were compared among BMI groups. In the group with morbid obesity, GWG threshold values to predict outcomes were examined based on sensitivity and specificity values under the receiver operating characteristic curve.

Results

GWG was higher in mothers with morbid obesity and macrosomic neonates: 11.3 (4.4–15.7) versus 4.8 (1.5–8.2) kg (p = 0.033). The GWG and neonatal ponderal index were positively correlated (r = 0.305, p = 0.001). The GWG was 7.0 (2.9–11.6) kg in women with hypertensive disorder versus 4.5 (1.0–7.5) kg in normotensive women (p = 0.017). A GWG above 5 kg was a risk factor for macrosomia (87.8% sensitivity, 54.7% specificity) and hypertensive disorder (70.0% sensitivity, 48.4% specificity). GWG associations were maintained after controlling for glycemic control, maternal and gestational age, parity, smoking and neonatal sex.

Conclusions for practice

A GWG below 5 kg is recommended for women with GDM and morbid obesity. In these women, adequate GWG may prevent macrosomia, fetal overgrowth and hypertensive disorder.



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Sexual Migration and HIV Risk in a Sample of Brazilian, Colombian and Dominican Immigrant MSM Living in New York City

Abstract

We examined motivations for migration to the United States (US) among 482 Brazilian, Colombian, and Dominican men who have sex with men (MSM). Participants' most common reason for migration was to improve their financial situation (49%), followed by sexual migration in order to affirm their sexual orientation (40%). Fewer endorsed sexual migration motivated by avoiding persecution due to being gay (13%). We conducted further analyses among 276 participants who migrated after age 15 and were HIV-negative at the time of migration. We hypothesized that sexual migration would be associated with greater likelihood of HIV acquisition post-migration. Hierarchical logistic regression analysis indicated that sexual migration motivated by avoiding persecution due to being gay was associated with increased odds of contracting HIV after arrival in the US whereas sexual migration to lead a gay life was not. Our findings highlight the importance of addressing the negative impact of anti-gay discrimination in countries of origin.



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The central venous pressure, and ‘a plea for some common-sense’

imageNo abstract available

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Obstructive sleep apnoea in adults: peri-operative considerationsA narrative review

imageObstructive sleep apnoea (OSA) is a common breathing disorder of sleep with a prevalence increasing in parallel with the worldwide rise in obesity. Alterations in sleep duration and architecture, hypersomnolence, abnormal gas exchange and also associated comorbidities may all feature in affected patients. The peri-operative period poses a special challenge for surgical patients with OSA who are often undiagnosed, and are at an increased risk for complications including pulmonary and cardiovascular, during that time. In order to ensure the best peri-operative management, anaesthetists caring for these patients should have a thorough understanding of the disorder, and be aware of the individual's peri-operative risk constellation, which depends on the severity and phenotype of OSA, the invasiveness of the surgical procedure, anaesthesia and also the requirement for postoperative opioids. The objective of this review is to educate clinicians in the epidemiology, pathogenesis and diagnosis of OSA in adults and also to highlight specific tasks in the preoperative assessment, namely to select a suitable intra-operative anaesthesia regimen, and manage the extent and duration of postoperative care to facilitate the best peri-operative outcome.

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Is the dose and mode of administration of dipyrone associated with acute kidney injury?

No abstract available

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Effect of various durations of smoking cessation on postoperative outcomes: A retrospective cohort analysis

imageBACKGROUND Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. OBJECTIVE We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. DESIGN Retrospective cohort analysis. SETTING Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. PATIENTS A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis. MAIN OUTCOME MEASURES The relationship between smoking cessation and in-hospital morbidity/mortality. RESULTS The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years. CONCLUSION Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.

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About anaesthetists and artists

No abstract available

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Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: A 6-year observational study from a tertiary care university hospital

imageBACKGROUND In recent decades, the incidences of anaesthesia-related perioperative mortality and adverse outcomes have decreased drastically. However, to date, data on perioperative cardiac arrest and risk factors of perioperative cardiac arrest from European countries are scarce. OBJECTIVES To determine the incidences of perioperative cardiac arrest and rates of anaesthesia-related and anaesthesia-contributory cardiac arrest. Identification of pre-existing risk factors leading to perioperative cardiac arrest. DESIGN Retrospective cohort study. SETTING Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany. INTERVENTIONS Perioperative critical incident reports between 2007 and 2012 were screened, and reports on cardiac arrest within 24 h postoperatively were identified. Cardiac arrests were classified as 'anaesthesia-related', 'anaesthesia-contributory' or 'anaesthesia-unrelated' by two reviewers independently. Univariate and multi-variate logistic regression analysis was used to identify risk factors associated with perioperative cardiac arrest. RESULTS Analysis of 318 critical incidents from 169 500 anaesthetics revealed 99 perioperative cardiac arrests. This is an overall incidence of perioperative cardiac arrest of 5.8/10 000 anaesthetics [95% confidence interval (CI), 4.7 to 7.0]. The rate of anaesthesia-related cardiac arrest was 0.7/10 000 (95% CI, 0.3 to 1.1), and the rate of anaesthesia-contributory cardiac arrest was 1.7/10 000 (95% CI, 1.1 to 2.3). Most cardiac arrests related to anaesthesia were due to respiratory events. From the multi-variate analysis, American Society of Anesthesiologists physical status grade at least 3 [P = 0.007, odds ratio (OR) 2.59 (95% CI, 1.29 to 5.19)], emergency surgery [P 

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Does the technique of two-hand mask ventilation matter?

No abstract available

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

imageBACKGROUND 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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Is the Arné risk index a valid predictor for difficult intubation with indirect laryngoscopy?

No abstract available

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Comparing peri-operative complications of paediatric and adult anaesthesia: A retrospective cohort study of 81 267 cases

imageBACKGROUND Comparisons of peri-operative complications associated with paediatric (≤16 years) and adult anaesthesia are poorly available, especially in which cardiac surgery, organ transplantation and neurosurgery are involved. OBJECTIVE The aim of this study was to evaluate the nature and incidence of peri-operative complications that might be due to anaesthesia and to identify independent risk factors for complications in children and adults, including those undergoing cardiac surgery, organ transplantation and neurosurgery. DESIGN Retrospective cohort study. SETTING The study was performed at the University Medical Centre Groningen in the 4 years between 1 January 2010 and the 31 December 2013. MAIN OUTCOME MEASURES Complications and their severity were graded according to the standard complication score (20 items) of the Dutch Society of Anaesthesia. Univariate and multivariate regression analysis was used to identify independent risk factors for the reported complications. RESULTS A total of 81 267 anaesthetic cases were included. In the paediatric cohort, there were 410 (2.9%) complications and 1675 (2.5%) in the adults. In both cohorts age, American Society of Anaesthesiologists classification and emergency treatment were independent risk factors for complications. With respect to age, infants less than 1 year were at the highest risk, whereas in the adult cohort, increased age was related to a greater number of complications. The incidences of the specific complications were different between both cohorts. Upper airway obstruction was more frequently observed in paediatric patients (26%), whereas in the adults, complications with the highest incidence concerned conversion of regional-to-general anaesthesia (25%) and hypotension (17%). CONCLUSION Risk factors for all peri-operative complications were similar for paediatric and adult anaesthesia. However, the incidence of specific complications differed between both age categories.

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Reply to: maternal anaemia - the story behind the number

No abstract available

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The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study

imageBACKGROUND Pre-operative anaemia and transfusion are common among patients undergoing elective orthopaedic surgery. Application of 'patient blood management' might be the most effective way to reduce both anaemia and transfusion. Pre-operative administration of iron and/or erythropoietin (EPO) is one of the cornerstones of the first pillar of patient blood management, but in a daily clinical setting, efficacy and long-term safety of this measure have not been analysed thoroughly to date. OBJECTIVE To investigate the influence of pre-operative preparation (PREP) of patients with iron and/or EPO on peri-operative transfusion needs and long-term survival. DESIGN Single-centre, retrospective study. SETTING Anaesthesia department, University hospital. INTERVENTIONS Pre-operative preparation with iron and/or EPO versus no preparation. METHODS After approval of our local ethics committee, data of 5518 patients who received total hip or total knee replacement between 2008 and 2014 were included. Patients receiving iron and/or EPO were included in the PREP group, whereas patients without iron and/or EPO were included in the no preparation group. From the full data set, a bias-reduced subset of 662 patients was obtained by means of propensity score-matching to compare peri-operative red blood cell utilisation and long-term survival of patients between groups. RESULTS Patients in the PREP group needed a lower number of units of red blood cells than patients in the no preparation group (0.2 ± 0.8 vs. 0.5 ± 1.3, P 

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Reply to: is the dose and mode of administration of dipyrone associated with acute kidney injury?

No abstract available

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Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive end-expiratory pressure: A randomised animal study

imageBACKGROUND Harmful effects of spontaneous breathing have been shown in experimental severe acute respiratory distress syndrome (ARDS). However, in the clinical setting, spontaneous respiration has been indicated only in mild ARDS. To date, no study has compared the effects of spontaneous assisted breathing with those of fully controlled mechanical ventilation at different levels of positive end-expiratory pressure (PEEP) on lung injury in ARDS. OBJECTIVE To compare the effects of assisted pressure support ventilation (PSV) with pressure-controlled ventilation (PCV) on lung function, histology and biological markers at two different PEEP levels in mild ARDS in rats. DESIGN Randomised controlled experimental study. SETTING Basic science laboratory. PARTICIPANTS Thirty-five Wistar rats (weight ± SD, 310 ± 19) g received Escherichia coli lipopolysaccharide (LPS) intratracheally. After 24 h, the animals were anaesthetised and randomly allocated to either PCV (n=14) or PSV (n=14) groups. Each group was further assigned to PEEP = 2 cmH2O or PEEP = 5 cmH2O. Tidal volume was kept constant (≈6 ml kg−1). Additional nonventilated animals (n=7) were used as a control for postmortem analysis. MAIN OUTCOME MEASURES Ventilatory and mechanical parameters, arterial blood gases, diffuse alveolar damage score, epithelial integrity measured by E-cadherin tissue expression, and biological markers associated with inflammation (IL-6 and cytokine-induced neutrophil chemoattractant, CINC-1) and type II epithelial cell damage (surfactant protein-B) were evaluated. RESULTS In both PCV and PSV, peak transpulmonary pressure was lower, whereas E-cadherin tissue expression, which is related to epithelial integrity, was higher at PEEP = 5 cmH2O than at PEEP = 2 cmH2O. In PSV, PEEP = 5 cmH2O compared with PEEP = 2 cmH2O was associated with significantly reduced diffuse alveolar damage score [median (interquartile range), 11 (8.5 to 13.5) vs. 23 (19 to 26), P = 0.005] and expressions of IL-6 and CINC-1 (P = 0.02 for both), whereas surfactant protein-B mRNA expression increased (P = 0.03). These changes suggested less type II epithelial cell damage at a PEEP of 5 cmH2O. Peak transpulmonary pressure correlated positively with IL-6 [Spearman's rho (ρ) = 0.62, P = 0.0007] and CINC-1 expressions (ρ = 0.50, P = 0.01) and negatively with E-cadherin expression (ρ = −0.67, P = 0.0002). CONCLUSION During PSV, PEEP of 5 cmH2O, but not a PEEP of 2 cmH2O, reduced lung damage and inflammatory markers while maintaining epithelial cell integrity.

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Reply to: does the technique of two-hand mask ventilation matter?

No abstract available

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Effect of pressure-controlled inverse ratio ventilation on dead space during robot-assisted laparoscopic radical prostatectomy: A randomised crossover study of three different ventilator modes

imageBACKGROUND Pressure-controlled inverse inspiratory to expiratory ratio ventilation (PC-IRV) is thought to be beneficial for reducing the dead space volume. OBJECTIVE To investigate the effects of PC-IRV on the components of dead space during robot-assisted laparoscopic radical prostatectomy (RLRP). DESIGN A randomised crossover study of three different ventilator modes. SETTING A single university hospital from September 2014 to April 2015. PATIENTS Twenty consecutive study participants undergoing RLRP. INTERVENTIONS Patients were ventilated sequentially with three different modes in random order for 30 min: volume control ventilation (VCV; inspiratory to expiratory ratio 0.5), pressure control ventilation (PCV; inspiratory to expiratory ratio 0.5) and PC-IRV. Inverse inspiratory to expiratory ratio was adjusted individually by observing the expiratory flow-time wave to prevent the risk of dynamic pulmonary hyperinflation. MAIN OUTCOME MEASURES The primary outcome included physiological dead space (VDphys), airway dead space (VDaw), alveolar dead space (VDalv) and shunt dead space (VDshunt). VDphys was calculated by Enghoff's method. We also analysed respiratory dead space (VDresp) and VDaw using a novel analytical method. Then, VDalv and VDshunt were calculated by VDalv = VDresp − VDaw and VDshunt = VDphys − VDresp, respectively. RESULTS The VDphys/expired tidal volume (VTE) ratio in PC-IRV (29.2 ± 4.7%) was significantly reduced compared with that in VCV (43 ± 8.5%) and in PCV (35.9 ± 3.9%). The VDshunt/VTE in PC-IRV was significantly smaller than that in VCV and PCV. VDaw/VTE in PC-IRV was also significantly smaller than that in VCV but not that in PCV. There was no significant change in VDalv/VTE. CONCLUSION PC-IRV with the inspiratory to expiratory ratio individually adjusted by the expiratory flow-time wave decreased VDphys/VTE in patients undergoing RLRP. TRIAL REGISTRATION University Hospital Medical Information Network in Japan 000014004.

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Reply to: the central venous pressure, and ‘a plea for some common-sense’

No abstract available

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Maternal anaemia - the story behind the number

No abstract available

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Reply to: is the Arné risk index a valid predictor for difficult intubation with indirect laryngoscopy?

No abstract available

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Impact of Maternal Infant Weight Perception on Infant Feeding and Dietary Intake

Abstract

Introduction Obesity is a global problem that is challenging to prevent and expensive to treat. Early childhood interventions show promise in establishing lifelong healthy eating patterns, however a better understanding of how parental feeding practices develop is needed. The study aimed to investigate maternal perception of infant weight and its relationship to feeding practices and infant dietary intake. Methods A questionnaire was completed by 263 Queensland mothers of infants aged between 5 and 13 months. Logistic regression was used to describe the association between maternal feeding practices (restriction, pressure-to-eat, monitoring), parenting style (warmth, hostility), infant weight concern and infant dietary intake. Correlation and linear regression were used to identify relationships between maternal feeding practices, parenting style, infant weight concern and infant weight. Results Mothers were found to be more concerned about underweight than overweight, misjudge infants as being underweight and failed to recognise overweight infants. Underweight concern was associated with infant weight (r = −0.27, p < 0.01), early introduction of solids (OR 0.24, CI 0.11–0.51) and pressure-to-eat (r = 0.19, p < 0.01). Pressure-to-eat was associated to maternal perception of infant weight (r = − 0.21, p < 0.01), infant weight (r = − 0.17, p < 0.05) and lower fruit and vegetable intake (OR 0.50, CI 0.27–0.92). Restrictive feeding practices were correlated to overweight concern (r = 0.08, p < 0.05). Discussion Maternal infant weight perception and concerns are related to control feeding practices which can be detrimental to infant dietary intake. Inability to recognise healthy weight may ignite these concerns or fail to address infant feeding risk factors. Discussing healthy growth should be a fundamental component of strategies to support healthy infant feeding and eating.



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Authors’ Reply to Buckner et al.: ‘Comment on: “The General Adaptation Syndrome: A Foundation for the Concept of Periodization”



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Comment on: “The General Adaptation Syndrome: A Foundation for the Concept of Periodization”



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Trading Health Risks for Glory: A Reformulation of the Goldman Dilemma

Abstract

Background

The Goldman dilemma presented athletes with a Faustian bargain that guaranteed winning an Olympic gold medal in their sport but resulted in certain death 5 years later. Athletes' responses to Goldman's bargain were reported from 1982 to 1995. Several studies subsequently evaluated people's willingness to accept the bargain proposed in the Goldman question. Our study updates Goldman's question using contingent-behavior questions, a preference-elicitation method widely applied in economics, marketing and psychology to understand people's choice behavior. Contingent-behavior questions ask people to evaluate hypothetical tradeoffs between outcomes when real-world decisions are unobservable, nonexistent, or unreliable.

Methods

A web-enabled survey was conducted with athletes in 50 sports between June, 2012 and April, 2013. Athletes were invited by their sport governing bodies in the United States to complete the online survey. Responses from 2888 athletes were collected. Our reformulation elicited athletes' willingness to accept a performance-enhancing drug (PED) associated with the risk of a realistic fatal event, not certain death. A double-bounded dichotomous-choice question format was used to elicit athletes' maximum acceptable mortality risk (MAMR) for winning an Olympic gold medal. Data were analyzed using an interval regression model to estimate the implicit probability of accepting a continuous risk level. MAMR was defined as the mortality risk level with a 0.50 probability of acceptance.

Results

Estimated mean MAMRs varied between 7 and 14% across athletes in different ranks and sports. Elite athletes were generally the most willing to accept a fatal cardiovascular risk to win a gold medal in the Olympics. This range was similar to the levels of risk that patients accept for life-changing interventions.

Conclusions

Results suggest that very few athletes would be expected to accept a PED in the bargain postulated by the Goldman dilemma. Risk tolerance among elite athletes suggest they may be more aware of the potential financial and nonfinancial benefits of such a win, and/or less optimistic about their potential to move up in the level of competition without the use of PEDs.



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Locomotor training using an overground robotic exoskeleton in long-term manual wheelchair users with a chronic spinal cord injury living in the community: Lessons learned from a feasibility study in terms of recruitment, attendance, learnability, performance and safety

For individuals who sustain a complete motor spinal cord injury (SCI) and rely on a wheelchair as their primary mode of locomotion, overground robotic exoskeletons represent a promising solution to stand and w...

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ZNF687 mutations are frequently found in pagetic patients from South Italy: implication in the pathogenesis of Paget's disease of bone.

Paget's disease of bone (PDB) is a skeletal disorder whose molecular basis are not fully elucidated. However, 10% of patients show a familial PDB and 35% of them carry mutations in the SQSTM1 gene. We recently reported a founder mutation (p.Pro937Arg) in the ZNF687 gene, underlying PDB complicated by Giant Cell Tumor (GCT/PDB) and rarely occurring in PDB patients without neoplastic degeneration. Since 80% of Italian GCT/PDB patients derive from Avellino, we hypothesized that ZNF687 mutation rate was higher in this region than elsewhere. Interestingly, our molecular analysis on 30 PDB patients showed that 33% hosted ZNF687 mutations, with the p.Pro937Arg identified in 8 familial cases. Two novel ZNF687 mutations (p.Pro665Leu and p.Gln784Glu) were detected in 2 sporadic patients. Only 2 subjects were positive for the p.Pro392Leu mutation in SQSTM1.

ZNF687 mutated patients showed a severe PDB, with a remarkable number of affected sites. In vitro studies revealed that the ZNF687 mutant osteoclasts appeared as giant-sized with up to 150 nuclei, never described in PDB.

Finally, we also confirmed the causality of the p.Pro937Arg mutation in 4 additional GCT/PDB cases deriving from the same geographic area, indicating that PDB and GCT/PDB represent two sides of the same coin.

Thumbnail image of graphical abstract

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Caring for Children with Special Health Care Needs: Profiling Pediatricians and Their Health Care Resources

Abstract

Background and Objectives Pediatricians face numerous challenges in providing care for children with special health care needs (CSHCN). Few studies have described health care resources available to support pediatricians to care for CSHCN. This study investigated available resources to care for CSHCN and factors associated with having a greater proportion of CSHCN in practice. Methods We conducted a statewide survey of active members of the American Academy of Pediatrics in California to study pediatric subspecialty care access, community and office resources and practice barriers. We performed a logistic regression model on having an "above average proportion" of CSHCN in practice, adjusting for demographics, practice type (rural vs. suburban/urban) and medical resources, care satisfaction, and ease of subspecialty access. Results Our response rate was 50.2% (n = 1290); 75% of respondents reported providing some primary care services, with many primary care pediatricians caring for a high proportion of CSHCN. Pediatricians reported an average of 28% CSHCN in their practices. Rural pediatricians lacked subspecialty access (10–59% reporting no access to the various subspecialties). Factors relating to higher CSHCN in practice included being in academic medical centers and satisfaction in caring for CSHCN. Conclusions Pediatricians report lack of access to mental health services, care coordination and case management. Academic medical centers and higher physician satisfaction in care delivery for CSHCN are associated with more CSHCN in practice. Promoting ways to support pediatricians, such as practice collaboration with behavioral specialists, may be necessary to encourage primary care pediatricians to provide medical homes for CSHCN.



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A Comparison of Regional Versus General Anesthesia for Lumbar Spine Surgery: An Untouched Aspect of the Meta-Analysis

No abstract available

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Inflammatory Markers in Serum and Cerebrospinal Fluid for Early Detection of External Ventricular Drain–associated Ventriculitis in Patients With Subarachnoid Hemorrhage

Background: External ventricular drain (EVD)-associated ventriculitis is a serious complication. Early diagnosis can be difficult particularly in critically ill patients with aneurysmal subarachnoid hemorrhage (aSAH). We examined the diagnostic potential of standard serum and cerebrospinal fluid (CSF) biomarkers to differentiate between EVD-associated infections and aseptic courses in patients with aSAH. Materials and Methods: We retrospectively evaluated the levels of inflammatory markers in serum (white blood cell count, percentage of neutrophils [sN%], and procalcitonin) and CSF (total leukocyte count [CSFTLC], CSFglucose, CSF/serumglucose ratio, CSF total protein [CSFTP]) of 63 consecutive patients with aSAH. Receiver operating characteristic curves and the area-under-the-curve (AUC) were calculated to detect the diagnostic potential, optimized threshold, sensitivity (SE), specificity (SP), + likelihood ratio (LR), and −LR of each biomarker. Results: Of all patients, 17 (27%) developed an EVD-associated ventriculitis within a mean of 7.8±2.3 days after implantation. sN% had a very good diagnostic potential (AUC=0.900, SE=70.0%, SP=100%), followed by the CSFTLC with good diagnostic potential (AUC=0.841, SE=75.0%, SP=88.5%), and the CSFTP with moderate diagnostic potential (AUC=0.772, SE=73.3%, SP=76.0%). sN% higher than 70% and a CSFTLC higher than 635/µL were highly associated with the diagnosis of ventriculitis (+LR=∞ and 6.5), sN%

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The Effectiveness of Standing on a Balance Board for Increasing Energy Expenditure

ABSTRACTPURPOSETo investigate differences in energy expenditure (EE), heart rate (HR), productivity, fatigue, and pain while performing desk work while sitting (SIT), standing (STAND), and standing on a balance board (BOARD).METHODSThirty healthy adults (60% female; age 39.7 ± 11.8 y; BMI 26.7 ± 5.0 kg·m−2) employed in sedentary-based jobs volunteered for this randomized crossover trial. Participants performed typing work in three different positions: SIT, STAND, and BOARD; each condition lasting 30 min. Oxygen consumption (VO2) was measured via indirect calorimetry and EE was calculated using respiratory quotient and corresponding caloric equivalent values. Productivity was quantified by measuring words typed per min, accuracy, and typing mistakes. Overall feelings of fatigue and pain were self-reported three times during each position using validated 10-cm visual analog scales. Repeated measures ANOVA were used to assess differences in outcome variables across conditions.RESULTSVO2 was significantly different among all conditions regardless of current standing desk use (SIT 3.35 ± 0.53; STAND 3.77 ± 0.48; BOARD 3.92 ± 0.54 mL·kg−1·min−1, p0.05). Fatigue progressively increased over each 30 min condition whereas pain in SIT and BOARD increased from min 10 to 20, then leveled off between min 20 to 30. For STAND, pain continued to increase over time.CONCLUSIONCompared with sitting, a balance board may be effective for increasing EE without interfering with productivity in an occupational setting. PURPOSE To investigate differences in energy expenditure (EE), heart rate (HR), productivity, fatigue, and pain while performing desk work while sitting (SIT), standing (STAND), and standing on a balance board (BOARD). METHODS Thirty healthy adults (60% female; age 39.7 ± 11.8 y; BMI 26.7 ± 5.0 kg·m−2) employed in sedentary-based jobs volunteered for this randomized crossover trial. Participants performed typing work in three different positions: SIT, STAND, and BOARD; each condition lasting 30 min. Oxygen consumption (VO2) was measured via indirect calorimetry and EE was calculated using respiratory quotient and corresponding caloric equivalent values. Productivity was quantified by measuring words typed per min, accuracy, and typing mistakes. Overall feelings of fatigue and pain were self-reported three times during each position using validated 10-cm visual analog scales. Repeated measures ANOVA were used to assess differences in outcome variables across conditions. RESULTS VO2 was significantly different among all conditions regardless of current standing desk use (SIT 3.35 ± 0.53; STAND 3.77 ± 0.48; BOARD 3.92 ± 0.54 mL·kg−1·min−1, p0.05). Fatigue progressively increased over each 30 min condition whereas pain in SIT and BOARD increased from min 10 to 20, then leveled off between min 20 to 30. For STAND, pain continued to increase over time. CONCLUSION Compared with sitting, a balance board may be effective for increasing EE without interfering with productivity in an occupational setting. Corresponding author: Chantal A. Vella, PhD, Address: 875 Perimeter Drive MS 2401, Moscow, ID 83844–2401. Phone: 208-885-2189. Email: cvella@uidaho.edu There was no financial support in relation to the current project. The results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare that there are no conflicts of interest and that the results of the present study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. © 2018 American College of Sports Medicine

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Correction to: Development of 21 polymorphic microsatellite markers for the black-banded sea krait, Laticauda semifasciata (Elapidae: Laticaudinae), and cross-species amplification for two other congeneric species

Unfortunately, one of the co-author's family name has been incorrectly published in the original online publication. The correct family name should be Tsai.



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Comparison of propofol and desflurane for postanaesthetic morbidity in patients undergoing surgery for aneurysmal SAH: a randomized clinical trial

Abstract

Purpose

Surgery for aneurysmal clipping after subarachnoid haemorrhage (SAH) poses a unique anaesthetic challenge. However, data on the influence of anaesthetic agents in these patients are lacking. The study aims to evaluate the superiority of propofol over desflurane for postanaesthetic morbidity in patients undergoing surgery following aneurysmal SAH.

Methods

Seventy World Federation of Neurosurgeons Grade I and II patients were randomized into propofol (n = 35) and desflurane groups (n = 35). Anaesthesia was maintained with propofol/fentanyl in propofol group and desflurane/fentanyl in the desflurane group. Jugular venous oxygen saturation (SjVO2) and brain relaxation were assessed intraoperatively. Time to eye opening, response to verbal commands, and extubation were noted from the time of discontinuing the anaesthetic agent. Duration of postoperative hospital stay and modified Rankin score (MRS) at discharge were subsequently compared.

Results

Median postoperative hospital stay was 9 (6, 14) days with use of propofol and 9 (7, 12) days in desflurane group (P = 0.671). 18 patients in the propofol group and 14 patients in the desflurane group had good outcome (modified Rankin score 0–1; P = 0.453). Both the anaesthetics were similar in terms of intraoperative haemodynamics, brain relaxation, time to eye opening, response to verbal commands, and extubation time (P > 0.05). Emergence hypertension was more in the desflurane group (P = 0.007). The intraoperative SjVO2 values were significantly higher in the desflurane group (P < 0.05).

Conclusion

Propofol and desflurane are comparable in terms of postoperative morbidity in patients undergoing aneurysm neck clipping following SAH.



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The influence of the carotid baroreflex on dynamic regulation of cerebral blood flow and cerebral tissue oxygenation in humans at rest and during exercise

Abstract

Purpose

This preliminary study tested the hypothesis that the carotid baroreflex (CBR) mediated sympathoexcitation regulates cerebral blood flow (CBF) at rest and during dynamic exercise.

Methods

In seven healthy subjects (26 ± 1 years), oscillatory neck pressure (NP) stimuli of + 40 mmHg were applied to the carotid baroreceptors at a pre-determined frequency of 0.1 Hz at rest, low (10 ± 1W), and heavy (30 ± 3W) exercise workloads (WLs) without (control) and with α − 1 adrenoreceptor blockade (prazosin). Spectral power analysis of the mean arterial blood pressure (MAP), mean middle cerebral artery blood velocity (MCAV), and cerebral tissue oxygenation index (ScO2) in the low-frequency range (0.07–0.20 Hz) was estimated to examine NP stimuli responses.

Results

From rest to heavy exercise, WLs resulted in a greater than three-fold increase in MCAV power (42 ± 23.8–145.2 ± 78, p < 0.01) and an almost three-fold increase in ScO2 power (0.51 ± 0.3–1.53 ± 0.8, p = 0.01), even though there were no changes in MAP power (from 24.5 ± 21 to 22.9 ± 11.9) with NP stimuli. With prazosin, the overall MAP (p = 0.0017), MCAV (p = 0.019), and ScO2 (p = 0.049) power was blunted regardless of the exercise conditions. Prazosin blockade resulted in increases in the Tf gain index between MAP and MCAV compared to the control (p = 0.03).

Conclusion

CBR-mediated changes in sympathetic activity contribute to dynamic regulation of the cerebral vasculature and CBF at rest and during dynamic exercise in humans.



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