Πέμπτη, 29 Μαρτίου 2018

Pediatric Collagenous Gastritis and Colitis: A Case Series and Review of the Literature

Introduction: Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands. Two phenotypes of the disease have been described: a pediatric-onset and an adult-onset type. The adult-onset form is associated with collagenous colitis and autoimmune disorders. No effective treatment has been identified to date. Objective: We aim to describe the clinical features and outcomes of patients in our cohort and provide a summary of published pediatric cases with collagenous gastritis and colitis reported to date to gather information that will contribute to improved knowledge of this rare condition. Methods: A retrospective chart review of all patients with collagenous gastritis and/or colitis who were treated at the Royal Children's Hospital, Melbourne, was performed. A literature review was also conducted. Results: A total of 12 cases of collagenous gastritis were reviewed. Three of 12 (25%) patients had associated collagenous colitis. The most common clinical presentation was iron deficiency anemia. Nine (75%) patients were followed up, and repeat endoscopies were performed in 8 (67%). Iron deficiency anemia resolved in all patients on oral iron supplementation. Histologic improvement was only identified in one patient with the adult phenotype who had been treated with oral corticosteroids and azathioprine. Conclusions: Collagenous gastritis is a rare condition in children. A small proportion of children develop features of the "'adult" phenotype at a very young age. Patients with collagenous gastritis require long-term follow-up and monitoring of their disease. Further randomized clinical trials are needed to establish an effective therapeutic strategy. Address correspondence and reprint requests to Dr Judy Matta, MD, Department of Gastroenterology and Clinical Nutrition, Saint George Hospital University Medical Center, P.O. Box 166 378, Achrafieh, Beirut 11 00 2807, Lebanon (e-mail: judymatta@gmail.com). Received 21 June, 2017 Accepted 24 February, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). The other authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Multivariate Model for the Prediction of Severity of Acute Pancreatitis in Children

This study aimed to develop a severity prediction system for pediatric patients with acute pancreatitis (AP) based on clinical and laboratory parameters recorded at disease onset. A retrospective cohort study including 130 patients with AP, aged 0 to 18 years, was conducted. Correlations between severe AP (SAP) and clinical and laboratory data were established. Parameters with a significant statistical correlation (P ≤ 0.05) were incorporated in logistic regression models, and receiver operating characteristic curves were generated. The best-performance cutoff points were calculated to propose a severity prediction score, for which sensitivity and specificity were determined. Thirty-eight cases (29.2%) were consistent with SAP. A value of ≥1 point yielded a sensitivity of 81.5% and specificity of 64.1% for SAP prediction, when using a score including blood urea nitrogen ≥12.5 mg/dL (1 point) or hemoglobin

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Gavage Feed Volume Determines the Gastric Emptying Rate in Preterm Infants

Objective: Feeding intolerance, manifesting as increased gastric residual, is a common finding in preterm neonates. Little is known about the regulation of gastric emptying early in life and the extent to which this plays a role in the preterm infants' feeding tolerance. The goal of this study was to evaluate clinically stable 28- to 32-week gestation neonates during the first 4 weeks of life and noninvasively determine their gastric emptying rate. Study design: Ultrasound measurements of gastric milk content volume were obtained from 25 neonates immediately after, 30 and/or 60 minutes following routine gavage feeds. The content emptying rate was calculated from the gastric volume data. Results: Gastric emptying rate was not postnatal age-dependent, was significantly higher at 30 minutes, whenever compared with 60-minute postfeed and directly proportional to the feed volume. At any postnatal age, the gastric emptying rate was at least 6-fold greater, when comparing the lowest and highest average stomach content volumes. Conclusions: The gastric emptying rate of preterm infants is content volume-dependent and unrelated to the postnatal age. Given the present findings, further investigation on the gastric residual of preterm infants receiving larger than currently administered feed volumes at the initiation of enteral nutrition, is warranted. Address correspondence and reprint requests to Jaques Belik, MD, Physiology & Experimental Medicine Program, Department of Paediatrics and Physiology, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, University of Toronto, 686 Bay Street, 9th Floor, Room 09.9713, Toronto, ON M5G 0A4, Canada (e-mail: jaques.belik@sickkids.ca) Received 1 September, 2017 Accepted 6 March, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Funding sources: This study was supported by a grant from the Canadian Institutes of Health Research to J.B. (MOP 133664) and Brazilian Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq; SWE 202940/2015-2) for C.H.F.F. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript. The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Detection of Cytomegalovirus in Colonic Mucosa of Children With Inflammatory Bowel Disease

The aim of this study was to determine the frequency and management of cytomegalovirus (CMV) detection in colonic mucosa of children with inflammatory bowel disease (IBD). Children with moderate-to-severe colitis who had sigmoid biopsy specimens evaluated for CMV by hematoxylin and eosin (H&E) staining, immunohistochemistry (IHC), and polymerase chain reaction (PCR) were included. A total of 90 sigmoid biopsies were collected from 67 patient encounters from 58 patients with colitis including biopsy samples from colectomy specimens of 8 patients who had colectomy during the study period. Four of 61 patient encounters (6.6%) with ulcerative colitis/IBD-unclassified, 2 with corticosteroid refractory disease, had positive biopsies for CMV by PCR but negative H&E and IHC. They responded to escalated medical therapy, without needing anti-viral therapy or colectomy over a median duration of follow-up of 1.1 year. CMV presence is uncommon in colonic mucosa of children with inflammatory bowel disease. Address correspondence and reprint requests to Wael El-Matary, MD, MSc, FRCPCH, FRCPC, Associate Professor and Section Head, Section of Pediatric Gastroenterology, Departments of Pediatrics, Faculty of Medicine, University of Manitoba AE 408, Health Sciences Centre, 840 Sherbrook St., Winnipeg, Manitoba R3A 1S1, Canada (e-mail: welmatary@hsc.mb.ca). Received 3 September, 2017 Accepted 27 February, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Source of funding: W.E.-M. is supported with a grant from the University of Manitoba and the Children's Hospital Research Institute of Manitoba. The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Proton Pump Inhibitors and Infant Pneumonia/Other Lower Respiratory Tract Infections: National Nested Case-control Study

Objective: The possible association between the use of proton pump inhibitors (PPIs) and community-acquired pneumonia (CAP) or any lower respiratory tract infection (LRTI) remains uncertain. We conducted a nested case-control study using routinely collected national health and drug dispensing data in New Zealand to examine the risk of CAP or any LRTI resulting in hospitalization or death in infants dispensed a PPI. Study Design: The cohort included 21,991 patients without a history of CAP or any LRTI who were born between 1 January 2005 and 31 December 2012 and were dispensed omeprazole, lansoprazole, or pantoprazole (the PPIs available in New Zealand during the study period) on at least one occasion during the first year of life. Cases had a first diagnosis after cohort entry (first PPI dispensing) of CAP (n = 65) validated by hospital discharge letter or death record, and chest radiography; or LRTI (including CAP) (n = 566) validated by hospital discharge letter or death record, with or without chest radiography. Up to 10 controls, matched by sex and date of birth, were randomly selected for each case. We conducted complete case analyses for the fully adjusted models. Results: In the adjusted analysis based on CAP cases and their controls, the matched odds ratio for current versus past use of PPIs was 0.88 (95% confidence interval 0.36–2.16). For all LRTI cases and their controls, the matched odds ratio was 1.13 (0.87–1.48). Conclusion: In otherwise healthy community-dwelling infants, current use of a PPI does not appear to increase the risk of CAP or other LRTIs. Address correspondence and reprint requests to Mei-Ling Blank, MPH, Department of Preventive and Social Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand (e-mail: meiling.blank@otago.ac.nz) Received 7 November, 2017 Accepted 6 March, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Contributors' Statement The New Zealand Pharmacovigilance Centre and Medsafe, and a Strategic Research Grant from the Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, New Zealand. None of the funders had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Neurodevelopmental Outcomes in Children With Liver Diseases: a Systematic Review

Objective: The aim of the study was to determine the neurodevelopmental outcomes of children with liver diseases based on a systematical review of the literature. Method: A literature search according to the PRISMA statement was conducted using predefined search terms in PubMed, Cochrane Library, and PsycINFO. The inclusion criterion was studies published from 2000 onwards that reported on the neurodevelopmental outcomes of term-born children with liver diseases. A narrative synthesis was done to appraise the studies. Results: Twenty-five studies were included (1913 children), 19 of which described children after liver transplantation (LTx; 1372 children). Sixty-seven percentage of the studies on children with liver diseases who survived with their native livers showed low-average or abnormal scores on specific subscales of cognitive and behavioral measures. In studies on children after LTx, this was 82%. After LTx, 83% of studies demonstrated impaired outcomes on behavior, whereas 42% of children received special education. Motor development was impaired in 82% of studies in children with native liver and after LTx. Limitations: Studies were heterogenic because of sample sizes, etiology of liver disease and type of assessment tools used. Conclusions: More than two-third of included studies showed neurodevelopmental deficits in children with liver diseases, affecting all neurodevelopmental areas. Knowledge on risk factors for impaired neurodevelopment is limited and lack of long-term follow-up is worrying, especially considering the increasing survival rates, resulting in more at-risk patients. Studying early predictors and risk factors of abnormal developmental trajectories of children with liver diseases is indicated to assess strategies to improve their long-term neurodevelopmental outcomes. Address correspondence and reprint requests to Janneke L.M. Bruggink, MD, PhD, Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands (e-mail: j.l.m.bruggink@umcg.nl). Received 22 November, 2017 Accepted 11 March, 2018 The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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A Celiac Diasease Associated lncRNA Named HCG14 Regulates NOD1 Expression in Intestinal Cells

Objective: To identify additional celiac disease associated loci in the Major Histocompatibility Complex independent from classical HLA risk alleles (HLA-DR3-DQ2) and to characterize their potential functional impact in celiac disease pathogenesis at the intestinal level. Methods: We performed a high resolution SNP genotyping of the MHC region, comparing HLA-DR3 homozygous celiac patients and non-celiac controls carrying a single copy of the B8-DR3-DQ2 conserved extended haplotype. Expression level of potential novel risk genes was determined by RT-PCR in intestinal biopsies and in intestinal and immune cells isolated from control and celiac individuals. Small interfering RNA-driven silencing of selected genes was performed in the intestinal cell line T84. Results: MHC genotyping revealed two associated SNPs, one located in TRIM27 gene and another in the non-coding gene HCG14. After stratification analysis, only HCG14 showed significant association independent from HLA-DR-DQ loci Expression of HCG14 was slightly downregulated in epithelial cells isolated from duodenal biopsies of celiac patients, and eQTL analysis revealed that polymorphisms in HCG14 region were associated with decreased NOD1 expression in duodenal intestinal cells. Conclusions: We have sucessfully employed a conserved extended haplotype-matching strategy and identified a novel additional celiac disease risk variant in the lncRNA HGC14. This lncRNA seems to regulate the expression of NOD1 in an allele-specific manner. Further functional studies are needed to clarify the role of HCG14 in the regulation of gene expression and to determine the molecular mechanisms by which the risk variant in HCG14 contributes to celiac disease pathogenesis. Address correspondence and reprint requests to Dr. Izortze Santin, Endocrinology and Diabetes Research Group, BioCruces Health Research Institute, UPV-EHU, E48903-Barakaldo, Bizkaia, Basque Country, Spain (e-mail: izortze.santingomez@osakidetza.eus). Received 11 December, 2017 Accepted 11 March, 2018 Conflicts of interest: None declared. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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The Membrane-bound O-Acyltransferase7 rs641738 Variant in Pediatric Nonalcoholic Fatty Liver Disease

Background: The rs641738 polymorphism in the membrane-bound O-acyltransferase domain containing protein 7 (MBOAT7) gene has been associated with increased risk of nonalcoholic fatty liver disease (NAFLD). Objectives: To investigate the association between the MBOAT7 rs641738 polymorphism and both hepatic steatosis and biochemical markers of liver damage and to evaluate the potential additive effect of this variant and the I148M patatin-like phospholipase domain-containing 3 (PNPLA3) and the rs58542926 transmembrane 6 superfamily member 2 (TM6SF2) polymorphisms. Methods: One thousand and 2 obese children were genotyped for MBOAT7, PNPLA3, and TM6SF2 polymorphisms and underwent anthropometrical, ultrasonographic, and biochemical evaluation. Indirect measurement of liver fibrosis (Pediatric NAFLD Fibrosis Index [PNFI]) and a genetic risk score from these polymorphisms were calculated. Results: Carriers of the MBOAT7 T allele showed both higher alanine transaminase (ALT) (P = 0.004) and PNFI values (P = 0.04) than noncarriers. These findings were confirmed also for the carriers of the MBOAT7 T allele polymorphism with hepatic steatosis compared with noncarriers. A higher genetic risk score was associated with higher ALT (P = 0.011) and with an odds ratio (OR) to show elevated ALT of 3.4 (95% CI 1.3–5.5, P = 0.003). Patients belonging to genetic risk score 3 group had an OR to present steatosis of 2.6 (95% CI 1.43–4.83, P = 0.0018) compared with those belonging to lower genetic risk score group. Conclusions: We first demonstrated in childhood obesity the role of the MBOAT7 rs641738 variant on serum ALT and the combined effect of the MBOAT7, PNPLA3, and TM6SF2 variants on NAFLD risk. We also provided the first pediatric association of the MBOAT7 polymorphism with indirect markers of liver fibrosis. Address correspondence and reprint requests to Anna Di Sessa, MD, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Via L. De Crecchio n° 2, 80138 Naples, Italy (e-mail: anna.disessa@libero.it) Received 13 December, 2017 Accepted 14 March, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Early Administration of N-acetylcysteine in the Treatment of Clove Oil Ingestion

No abstract available

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Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation

Objectives: Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is doubtful or with a suspicion of organic etiology. The guidelines do not clarify if DRE is mandatory to diagnose impaction. This study aims to determine the frequency of impaction detectable only on DRE among children satisfying Rome III criteria without requiring DRE and also the inter-observer influences on impaction detection by DRE. Methods: Children between 6 months to 13 years of age, presenting with history suggestive of constipation were assessed. After excluding those with suspicion of organic etiology, those who needed DRE for diagnosis of constipation and those who do not satisfy Rome III criteria without DRE, the rest who satisfied Rome III criteria were assessed for impaction by palpable fecoliths or constipation-associated fecal incontinence. Those without such impaction were randomized to 2 examiners for DRE to diagnose impaction, in the absence of contraindications. Results: Two hundred and thirty-three children were assessed. One hundred and sixty-nine satisfied Rome III without needing DRE. Forty-eight (28.4%) had impaction detectable without DRE. Among the rest, 28 (30.1%) had impaction by DRE. There was no difference between the frequency of impaction detected by the 2 examiners. Clinical characteristics were similar (P > 0.05) between those with impaction detectable by DRE and those without. Conclusions: DRE does detect cases of impaction not discernible by other means. Such a finding may be comparable between examiners. These children may be identified by other clinical characteristics. The clinical significance of such a finding needs more understanding from the standpoint of therapeutic choices. Address correspondence and reprint requests to Dr Barath Jagadisan, MD, PDCC, Additional Professor, Pediatric gastroenterology, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry 605006, India (e-mail: barathjag@yahoo.com) Received 17 January, 2018 Accepted 12 March, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Ethical clearance: The study had been approved by the institute ethic committee that complies with international standards and is registered with the government of India (JIP/IEC/2015/23/830). The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Thiopurine Optimization Through Combination With Allopurinol in Children With Inflammatory Bowel Diseases

Objectives: Thiopurines are commonly used in the maintenance of remission for children with inflammatory bowel diseases (IBD). Variation in drug metabolism may impact hepatotoxicity or therapeutic effect. We aimed to describe our center's experience with thiopurine optimization through the use of reduced thiopurine dosing in combination with allopurinol upon hepatotoxicity, drug metabolite levels and clinical outcomes in children with IBD. Methods: Patients aged 2–21 years with IBD treated with the combination of thiopurines/allopurinol between 2008–2015 were retrospectively reviewed. Patients previously treated with anti-tumor necrosis factor (TNF) therapy were excluded. Demographic data, transaminase levels (AST, ALT), drug metabolites levels (6-TG, 6-MMP), physician global assessment (PGA), and corticosteroid use were recorded at baseline, 6 and 12 months. Results: Fifty-two patients (29 female, 56%) met inclusion criteria. Thirty-two of 52 (62%) remained on the combination for 12 months. In those remaining on the thiopurine/allopurinol combination, median ALT and AST levels were reduced (p 

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Microanatomical Nerve Architecture of 6 Mammalian Species: Is Trans-Species Translational Anatomic Extrapolation Valid?

Background and Objectives Various animal models have historically been used to study iatrogenic nerve injury during performance of conduction nerve blocks. Our aims were to compare the microstructures of nerves in commonly used species to those of humans and to explore the validity of the extrapolating these findings to humans. Methods High-resolution, light-microscopic images were obtained from cross sections of sciatic nerves at their bifurcation from fresh rat, rabbit, pig, sheep, dog, and human cadavers. Various microanatomical characteristics were measured and compared between the species. P

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Shourei Prize 2. Utility of TMS for neuroscience of speech

Transcranial magnetic stimulation (TMS) has widely been accepted as a useful method of non-invasive brain stimulation in neuroscience. Compared with neuroimaging and intraoperative mapping, the number of speech experiments using TMS has, however, still been small. Here, an introduction to recent TMS studies that explored speech perception and imitation is presented. Single-pulse TMS of the primary motor cortex (M1) showed a speech specific and topographically specific increase of excitability in the M1 lip area during speech perception.

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O-3-32. Relationship between brain activity and mental state during emotional olfactory stimulation

The aim of this study was to investigate the relationship between mental state and brain activity in response to odors in the environment. The mental state of 20 healthy adults was estimated using the Profile of Mood States (POMS) scale. The subjects were placed in a room, which was individually filled with vanillin, Mainichi-Koh (Japanese incense), skatol, and distilled water (control) odors, and their electroencephalograms (EEGs) were recorded while performing an auditory oddball task in the room.

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O-3-21. Electrophysiological evaluation of peripheral neuropathy in hereditary spinocerebellar ataxia

Peripheral neuropathy often occurs in hereditary spinocerebellar ataxia (hSCA), but the features of nerve involvement have not been fully investigated. We evaluated the prevalence of peripheral neuropathy in hSCAs and classified the underlying pathologies into length-dependent axonopathy and neuronopathy based on sural/radial amplitude ratio (SRAR). SRAR has been reported as a sensitive indicator to differentiate the pathology of peripheral neuropathy. In this study, we defined SRAR less than 0.3 as length-dependent axonopathy, and SRAR more than 0.3 as neuronopathy.

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P3-3-1. Features of the correlation between the sites of EEG based on the difference in duration of epileptiform discharges

To investigate differences in the duration of epileptiform discharges, wavelet-crosscorrelation analysis was performed to identify correlations and time-lags between sites of the brain. Electroencephalography recordings were categorized into two time spans according to the duration of the epileptiform discharge: short run, 2–3 s; and long run, ⩾3 s. Both runs were subcategorized into before, during, and after epileptiform discharge groups. The EEG was divided into 2-s segments. In all patients, wavelet-crosscorrelation coefficients (WCC) and time-lag (LAG) at 6 Hz were calculated between all electrodes, and between all electrodes and the temporal region electrodes for each segment.

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S12-3. Anti-LRP4 autoantibodies in Japanese patients with myasthenia gravis

Low-density lipoprotein receptor-related protein 4 (LRP4) is crucial membrane protein in the development and function of neuromuscular junctions and motor neurons. And, it is currently known myasthenia gravis (MG) is caused by antibodies to the acetylcholine receptor (AChR), muscle-specific kinase (MuSK), and LRP4. MuSK and LRP4 are coreceptors for agrin in the signaling pathway that causes clustering of AChR. We demonstrated anti-LRP4 antibodies played a key role in MG. LRP4 is essential for maintaining the structural and functional integrity of the neuromuscular junction and that loss of muscle LRP4 in adulthood alone is sufficient to cause myasthenic symptoms.

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SP-2. What dose TMS stimulate?

Transcranial magnetic stimulation (TMS) is a technique to stimulate the nervous system non-invasively through the intact scalp and skin. The TMS machine delivers a short pulse of electric current into a TMS coil to generate a quick changing magnetic field surrounding the coil as an example of Ampere's law. TMS stimulates the neuronal circuits with the eddy current induced by the changing magnetic field, not the magnetic field its self, based on Faraday's law. To generate enough power for stimulating human's brain, a TMS machine is generally built to generate a current of around 8000 A for a 2.5–4 Tesla output, although it may vary between machine types and manufacturers.

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P1-2-07. Relationship between Saccadic Eye Movements and Higher Brain Function in the elderly

Saccadic eye movements (SEM) are used as a biomarker for psychiatric disorders. However, the relationship between SEM and higher brain function has not been fully elucidated. Therefore, we examined SEM during the Trail Making Test part A (TMT-A), a neuropsychological test of visual attention and processing speed, and assessed the correlation between the frequency of SEM during TMT-A and neuropsychological test results. The eye movements of 43 elderly subjects (>65 y/o, mean 72.4 y/o), with no history of neuropsychiatric disorders, were measured using eye tracking glasses (SensoMotoric Instruments, Germany).

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Shimazono-Lecture-1. What I have done using TMS techniques

CMCT, CTX-BST CT, BST-Cv CT, CCCT, CECT: Using brainstem and conus medullaris stimulation in combination with the motor cortical and spinal nerve stimulation, we estimated conduction delays at several segments in CSTs.Cerebellar inhibition of the motor cortex (CBI): Purkinje cell activation by TMS induced a transient motor cortical inhibition. Mechanisms underlying ataxia was studied with this method.Shor interval intracortical inhibition (SICI): We showed the dependency of SICI on the motor cortical TMS pulse directions, which gave us a hint about the mechanisms of SICI.

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P3-6-03. Visualization of nerve impulse traveling along the brachial plexus after ulnar nerve stimulation using 132ch SQUID magnetoneurography system

Using 132ch superconducting quantum interference device (SQUID) magnetoneurography sensor system, we succeeded in visualizing nerve impulse traveling along the brachial plexus (BP) after median nerve stimulation and propagating into the C5–C8 intervertebral foramen with participant's X-ray imaging. Here we analyzed the nerve impulse traveling along BP following ulnar nerve stimulation at the wrist.Magnetoneurogram following wrist stimulation were measured over BP from 5 healthy volunteers. Somatosensory evoked potential (SEP) was simultaneously measured at Erb's point for making sure to deliver supramaximal stimulation.

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P2-3-8. Change of cross frequency coupling by symptom provocation in Obsessive Compulsive Disorder (OCD) based on sLORETA

We investigated the changes in directional cross frequency interactions between theta and alpha oscillations, across six cortical regions, induced by a symptom provocation procedure, in patients with OCD, and in normal controls. Nine OCD outpatients and nine controls participated in this study. Eyes closed EEG was recorded before and under the instruction to imagine that the towel placed on their hands is contaminated (symptom provocation, SP). Cortical electric neuronal activity were calculated with sLORETA at medial-prefrontal, precuneus, inferior-parietal, and dorsolateral-prefrontal cortices.

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A-19. Visual evoked potentials: Basic technology and clinical applications

Visual information is processed simultaneously via multiple parallel channels and each channel constitutes a set of sequential processes. The visual evoked potentials (VEPs) are the evoked electrophysiological potential that can be extracted, using signal averaging, from the electroencephalographic activity recorded at the scalp. VEPs can provide important diagnostic information regarding the functional integrity of the visual pathways and the visual cortex. Commonly used visual stimuli are flashing lights or pattern reversal (checkerboards or gratings) on the TV monitor or video screen.

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S11-3. Three points to remember when you conduct research using event-related potentials

Event-related potentials (ERP) are a part of the electroencephalogram (EEG) that is time-locked to a certain event, such as stimulus presentation or movement onset. As recent advances in electronics bring inexpensive and easy-to-use EEG amplifiers to the market, more and more people are interested in also recording ERPs. However, easy-to-use does not mean easy-to-succeed. In this talk, I will make three practical recommendations for conducting ERP research. First, make sure that the timings of events are precisely registered with the EEG data.

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B-2. Clinical application of patterned DC stimulation

In addition to conventional surgical and pharmacological methods, electromagnetic interventions to the human brain have been developed for testing and treating neuropsychiatric disorders. Considering that the central principle of brain coding is based on neural firings and cell membrane potentials, that is electrical phenomena, electromagnetic intervention to the brain can be useful and effective for modulating brain functions.Among various electromagnetic methods, the most advanced one is the transcranial magnetic stimulation (TMS) which was put into practical use in 1985.

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S14-2. F wave and spinal excitability; masseteric contraction or motor imagery enhances ulnar nerve F wave

We tested the validity of instructing patients to clench the teeth to facilitate F-waves recorded from a limb muscle in clinical practice. We explored to study effect of motor imagery and voluntary contraction of the masseter muscles on F waves recorded from the first dorsal interosseous muscle in healthy subjects. F waves were recorded at rest, during motor imagery and during voluntary contraction monitored by a force transducer to maintain the level at 10% of maximal effort. F-wave persistence increased from at rest to during motor imagery, and during voluntary contraction.

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B-3. Electroencephalography and seizures learned from ictal recording

Experience on ictal video electroencephalography (EEG) recording enriches knowledge on EEG and seizures. Following five fundamentals are important for correct interpretation of EEG during focal epileptic seizures.Epileptic seizures never happen without EEG changes.Epileptic seizure propagates.EEG changes are not necessarily visible.EEG changes occur as a remote effect.EEG seizure explains clinical symptoms.Focal epileptic seizure starts with several patterns such as low voltage fast activity or repetitive spikes, followed by ictal rhythm that evolves spatially from focal to diffuse area, and temporally from low amplitude fast to high amplitude slow waves.

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P3-4-8. Utility of diaphragm ultrasound and phrenic nerve conduction in myopathy

Respiratory dysfunction in myopathy such as muscular dystrophy is extremely important because it is directly related to life prognosis, and appropriate evaluation and management is necessary. For objective assessment of respiratory muscle strength in myopathy, we study the usefulness of diaphragm ultrasonography and phrenic nerve study. Nineteen myopathy patients who were confirmed by genetic testing or muscle biopsy during our hospital visit were included. In both cases, respiratory function test, phrenic nerve conduction test, diaphragm ultrasonic examination were performed.

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B-4. Neurophysiology of sleep in humans

Studies on EEG slowing in the progression of sleep since the discovery of electroencephalogram (EEG) in the 1920s, and identification of rapid eye movement (REM) sleep in the 1950s lead to the current principle that human sleep consists of REM and non-REM (NREM) sleep cycles. In this lecture, I will review sleep-wake homeostasis. Quantitative analysis of sleep EEG has revealed that delta EEG activity is enhanced according to the length of prior wakefulness, and achieved the recovery of the brain.

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P3-1-2. Assessment of the atypical cortico-cortical evoked potentials

Cortico-cortical evoked potential (CCEP) has been widely used to probe brain network.Typically CCEP waveform consists of two negative potentials, N1 (peak: 10–50 ms) and N2 (peak: 100–500 ms). We, however, occasionally encounter atypical responses, such as those with prolonged N1 peak latency. We attempt to classify these atypical patterns and clarify their anatomical distribution. We retrospectively reviewed CCEP responses in two patients with intractable focal epilepsy, in whom CCEPs were obtained bystimulating all the implanted subdural electrodes (IRB#443).

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B-7. Electrodiagnostic criteria for ALD: Current state and perspectives

The diagnosis of amyotrophic lateral sclerosis (ALS) requires (1) evidence for extensive upper and lower motor neuron dysfunction, (2) progressive course, and (3) exclusion of other causes of motor neuronal loss. So far, a number of diagnostic criteria for ALS have been proposed, such as El Escorial (1990), revised El Escorial (1998), Awaji (2008), and updated Awaji (2015). According to the frequent revision/proposal criteria, electrodiagnostic criteria for ALS are somewhat confusing. In these criteria, the body motor system are divided into 4 regions; cranial, cervical, thoracic, and lumbosacral, and evidence for upper and lower motor neuron signs in the two or more regions are required for the diagnosis of "probable" ALS.

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P1-5-02. Evaluation of facial muscle elasticity with real-time tissue elastography – Examination in cases with synkinesis following peripheral facial nerve paresis

The study was performed to clarify the relationship between facial muscle elasticity measured by real-time tissue elastography (RTE) and the clinical phenotypes of peripheral facial nerve paresis (PFP). We examined the orbicularis oculi muscles of nine PFP patients with synkinesis by RTE. The strain ratio (SR) of the muscle to an acoustic coupler was calculated as an index of muscle elasticity. We also recorded and integrated electromyograms of left and right orbicularis oculi muscles, respectively.

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Teleost Fish-Specific Preferential Retention of Pigmentation Gene-Containing Families After Whole Genome Duplications in Vertebrates

Vertebrate pigmentation is a highly diverse trait mainly determined by neural crest cell derivatives. It has been suggested that two rounds (1R/2R) of whole-genome duplications (WGDs) at the basis of vertebrates allowed changes in gene regulation associated with neural crest evolution. Subsequently, the teleost fish lineage experienced other WGDs, including the teleost-specific Ts3R before teleost radiation and the more recent Ss4R at the basis of salmonids. As the teleost lineage harbors the highest number of pigment cell types and pigmentation diversity in vertebrates, WGDs might have contributed to the evolution and diversification of the pigmentation gene repertoire in teleosts. We have compared the impact of the basal vertebrate 1R/2R duplications with that of the teleost-specific Ts3R and salmonid-specific Ss4R WGDs on 181 gene families containing genes involved in pigmentation. We show that pigmentation genes (PGs) have been globally more frequently retained as duplicates than other genes after Ts3R and Ss4R but not after the early 1R/2R. This is also true for non-pigmentary paralogs of PGs, suggesting that the function in pigmentation is not the sole key driver of gene retention after WGDs. On the long-term, specific categories of PGs have been repeatedly preferentially retained after ancient 1R/2R and Ts3R WGDs, possibly linked to the molecular nature of their proteins (e.g. DNA binding transcriptional regulators) and their central position in protein-protein interaction networks. Taken together, our results support a major role of WGDs in the diversification of the pigmentation gene repertoire in the teleost lineage, with a possible link with the diversity of pigment cell lineages observed in these animals compared to other vertebrates.

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H3K4 Methylation Dependent and Independent Chromatin Regulation by JHD2 and SET1 in Budding Yeast

Set1 and Jhd2 regulate the methylation state of histone H3 lysine-4 (H3K4me) through their opposing methyltransferase and demethylase activities in the budding yeast Saccharomyces cerevisiae. H3K4me associates with actively transcribed genes and, like both SET1 and JHD2 themselves, is known to regulate gene expression diversely. It remains unclear, however, if Set1 and Jhd2 act solely through H3K4me. Relevantly, Set1 methylates lysine residues in the kinetochore protein Dam1 while genetic studies of the S. pombe SET1 ortholog suggest the existence of non-H3K4 Set1 targets relevant to gene regulation. We interrogated genetic interactions of JHD2 and SET1 with essential genes involved in varied aspects of the transcription cycle. Our findings implicate JHD2 in genetic inhibition of the histone chaperone complexes Spt16-Pob3 (FACT) and Spt6-Spn1. This targeted screen also revealed that JHD2 inhibits the Nrd1-Nab3-Sen1 (NNS) transcription termination complex. We find that while Jhd2's impact on these transcription regulatory complexes likely acts via H3K4me, Set1 governs the roles of FACT and NNS through opposing H3K4-dependent and -independent functions. We also identify diametrically opposing consequences for mutation of H3K4 to alanine or arginine, illuminating that caution must be taken in interpreting histone mutation studies. Unlike FACT and NNS, detailed genetic studies suggest an H3K4me-centric mode of Spt6-Spn1 regulation by JHD2 and SET1. Chromatin immunoprecipitation and transcript quantification experiments show that Jhd2 opposes the positioning of a Spt6-deposited nucleosome near the transcription start site of SER3, a Spt6-Spn1 regulated gene, leading to hyper-induction of SER3. In addition to confirming and extending an emerging role for Jhd2 in the control of nucleosome occupancy near transcription start sites, our findings suggest some of the chromatin regulatory functions of Set1 are independent of H3K4 methylation.

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Influence of fascicle length on twitch potentiation of the medial gastrocnemius across three ankle angles



Length dependence of post-activation potentiation (PAP) is a well-established phenomenon in animal models but less certain in intact whole human muscles. Recent advances in B-mode ultrasonography provide real-time imaging and evaluation of human muscle fascicles in vivo, thus removing the assumption that joint positioning alters fascicle length and influences the extent of PAP. The purpose of this study was to determine whether a conditioning maximal voluntary contraction (MVC) would influence the return of medial gastrocnemius (MG) fascicles to baseline length and alter the extent of twitch potentiation between three ankle positions.


Ultrasonography was used to measure MG fascicle length for baseline and potentiated twitches at angles of 10° dorsiflexion (DF), 0° neutral (NEU—tibia perpendicular to the sole of the foot), and 20° plantar flexion (PF). A MVC was used as a conditioning contraction and PAP determined for each ankle angle.


PAP of the plantar flexors was greater in PF (28.8 ± 2.6%) compared to NEU (19.8 ± 1.8%; p < 0.05) and DF (9.3 ± 2.8%; p < 0.0001). In PF, fascicle lengths (4.64 ± 0.17 cm) were shorter than both NEU (5.78 ± 0.15 cm; p < 0.0001) and DF (6.09 ± 0.15 cm; p < 0.0001). Fascicle lengths for the baseline twitches were longer (5.92 ± 0.11 cm) than the potentiated twitches (5.83 ± 0.10 cm; p < 0.01) at all joint angles.


Although PAP is greatest in PF compared to NEU and DF, the higher PAP in the PF joint angle cannot be attributed to fascicles remaining shortened following the MVC because across all joint positions, fascicles are similarly shortened following the MVC.

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Occurrence and Characterization of Carbapenemase-Producing Enterobacteriaceae in a Tunisian Hospital

Microbial Drug Resistance, Ahead of Print.

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Oscillatory local field potentials of the nucleus accumbens and the anterior limb of the internal capsule in heroin addicts

The nucleus accumbens (NAc), a crucial structure of the cortical-striatal-thalamic-cortical (CSTC) loop, is an important region in brain networks responsible for the motivational control of behavior (Robbins et al., 1996; Salamone et al., 2007; Nicola, 2010). Similar to the dorsal striatum, the NAc is characterized by the predominant expression of GABAergic medium spiny neurons (MSNs) and acts as the main structure of the ventral striatum (Mancall et al., 2014). Centrally situated in the CSTC loop, the NAc also receives numerous inputs from limbic regions, including the prefrontal cortex, the hippocampal formation, and the amygdala as well as the ventral tegmental area (VTA), which contains rich dopaminergic neurons (Everitt et al., 1999; Groenewegen et al., 1999; Yager et al., 2015).

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Advanced dynamic statistical parametric mapping with MEG in localizing epileptogenicity of the bottom of sulcus dysplasia

Focal cortical dysplasia at bottom of sulcus (FCDB) is defined as a focal cortical dyplasia (FCD) type II located at the bottom of a sulcus. FCDB is intrinsically epileptogenic and provokes early onset focal seizures, with a high frequency of seizures during active periods, and occasionally with hospitalization for severe exacerbation (Harvey et al., 2015). Complete resection of FCDB, however, results in seizure freedom in up to 90% of selected cases (Chassoux et al., 2010).

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The role of EEG localized activation and central nervous system arousal in executive function performance in children with Attention-Deficit/Hyperactivity Disorder

Resting-state electroencephalogram (RS-EEG) provides a window to understand spontaneous brain activity in children with Attention-Deficit/Hyperactivity Disorder (AD/HD) (Barry et al., 2003). Its measures (e.g. the theta to beta ratio) have been considered as candidate biomarkers to diagnose AD/HD (Thome et al., 2012; Faraone et al., 2014); however, the diagnostic reliability of RS-EEG measures is controversial (Arns et al., 2013; Faraone et al., 2014). Instead, it has also been proposed that RS-EEG measures have prognostic value in AD/HD (Arns et al., 2013; Arns and Gordon, 2014; Olbrich et al., 2015), based on evidence that RS-EEG profiles are heterogeneous (Clarke et al., 2001, 2011) and different RS-EEG profiles are associated with different responses to medication-based treatment (Clarke et al., 2002; Arns et al., 2008, 2013; Arns, 2012).

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Database Quality and Access Issues Relevant to Research Using Anesthesia Information Management System Data

For this special article, we reviewed the computer code, used to extract the data, and the text of all 47 studies published between January 2006 and August 2017 using anesthesia information management system (AIMS) data from Thomas Jefferson University Hospital (TJUH). Data from this institution were used in the largest number (P = .0007) of papers describing the use of AIMS published in this time frame. The AIMS was replaced in April 2017, making this finite sample finite. The objective of the current article was to identify factors that made TJUH successful in publishing anesthesia informatics studies. We examined the structured query language used for each study to examine the extent to which databases outside of the AIMS were used. We examined data quality from the perspectives of completeness, correctness, concordance, plausibility, and currency. Our results were that most could not have been completed without external database sources (36/47, 76.6%; P = .0003 compared with 50%). The operating room management system was linked to the AIMS and was used significantly more frequently (26/36, 72%) than other external sources. Access to these external data sources was provided, allowing exploration of data quality. The TJUH AIMS used high-resolution timestamps (to the nearest 3 milliseconds) and created audit tables to track changes to clinical documentation. Automatic data were recorded at 1-minute intervals and were not editable; data cleaning occurred during analysis. Few paired events with an expected order were out of sequence. Although most data elements were of high quality, there were notable exceptions, such as frequent missing values for estimated blood loss, height, and weight. Some values were duplicated with different units, and others were stored in varying locations. Our conclusions are that linking the TJUH AIMS to the operating room management system was a critical step in enabling publication of multiple studies using AIMS data. Access to this and other external databases by analysts with a high degree of anesthesia domain knowledge was necessary to be able to assess the quality of the AIMS data and ensure that the data pulled for studies were appropriate. For anesthesia departments seeking to increase their academic productivity using their AIMS as a data source, our experiences may provide helpful guidance. Accepted for publication January 29, 2018. 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 (https://ift.tt/KegmMq). Data from this study were presented, in part, at the 2017 Annual Meeting of the American Society of Anesthesiologists, October 21–25, 2017, Boston, MA. Reprints will not be available from the authors. Address correspondence to Richard H. Epstein, MD, Department of Anesthesiology, Perioperative Medicine & Pain Management, University of Miami, Miller School of Medicine, 1400 NW 12th Ave, Suite 3075, Miami, FL 33136. Address e-mail to repstein@med.miami.edu. © 2018 International Anesthesia Research Society

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The Impact of Postreperfusion Syndrome on Acute Kidney Injury in Living Donor Liver Transplantation: A Propensity Score Analysis

BACKGROUND: Postreperfusion syndrome (PRS) has been shown to be related to postoperative morbidity and graft failure in orthotopic liver transplantation. To date, little is known about the impact of PRS on the prevalence of postoperative acute kidney injury (AKI) and the postoperative outcomes after living donor liver transplantation (LDLT). The purpose of our study was to determine the impact of PRS on AKI and postoperative outcomes after LDLT surgery. METHODS: Between January 2008 and October 2015, we retrospectively collected and evaluated the records of 1865 patients who underwent LDLT surgery. We divided the patients into 2 groups according to the development of PRS: PRS group (n = 715) versus no PRS group (n = 1150). Risk factors for AKI and mortality were investigated by multivariable logistic and Cox proportional hazards regression model analysis. Propensity score (PS) analysis (PS matching and inverse probability of treatment weighting analysis) was designed to compare the outcomes between the 2 groups. RESULTS: The prevalence of PRS and the mortality rate were 38% and 7%, respectively. In unadjusted analyses, the PRS group showed more frequent development of AKI (P

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Anesthetics Influence Mortality in a Drosophila Model of Blunt Trauma With Traumatic Brain Injury

Background: Exposure to anesthetics is common in the majority of early survivors of life-threatening injuries. Whether and to what degree general anesthetics influence outcomes from major trauma is unknown. Potential confounding effects of general anesthetics on outcome measures are usually disregarded. We hypothesized that exposure to isoflurane or sevoflurane modulates the outcome from blunt trauma with traumatic brain injury (bTBI). Methods: We tested the hypothesis in a novel model of bTBI implemented in Drosophila melanogaster. Fruit flies of the standard laboratory strain w1118 were cultured under standard conditions. We titrated the severity of bTBI to a mortality index at 24 hours (MI24) of approximately 20% under control conditions. We administered standard doses of isoflurane and sevoflurane before, before and during, or after bTBI and measured the resulting MI24. We report the MI24 as mean ± standard deviation. Results: Isoflurane or sevoflurane administered for 2 hours before bTBI reduced the MI24 from 22.3 ± 2.6 to 10.4 ± 1.8 (P

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Dexamethasone as an Adjuvant for Caudal Blockade in Pediatric Surgical Patients: A Systematic Review and Meta-analysis

BACKGROUND: Caudal block is commonly used to provide postoperative analgesia after pediatric surgery in the lower abdomen. Typically administered as a single-shot technique, 1 limitation of this block is the short duration of analgesia. To overcome this, dexamethasone has been used as an adjuvant to prolong block duration. However, there are concerns about steroid-related morbidity and the optimal route of dexamethasone administration (eg, caudal or intravenous) is unknown. METHODS: We conducted a systematic review and random-effects meta-analysis of randomized controlled trials recruiting pediatric surgical patients receiving a caudal block for surgical anesthesia or postoperative analgesia. Included studies compared dexamethasone (caudal, intravenous, or both) to control. Duration of analgesia was the primary outcome. Database sources were Medline, Embase, the Cochrane Library, and Google Scholar searched up to August 18, 2017, without language restriction. Screening of studies, data extraction, and risk of bias assessment were performed independently and in duplicate by 2 authors. Risk of bias was assessed using Cochrane methodology and the strength of evidence was scored using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS: The initial search retrieved 93 articles. Fourteen randomized controlled trials that comprised 1315 pediatric patients met the inclusion criteria. All but 1 study involved lower abdominal operations (orchidopexy, inguinal hernia repair, and hypospadias repair). The caudal and intravenous dose of dexamethasone ranged from 0.1 to 0.2 mg/kg and 0.5 to 1.5 mg/kg, respectively, and all studies were pooled in the main analysis. Dexamethasone prolonged the duration of analgesia by both the caudal route (5.43 hours, 95% confidence interval [CI], 3.52–7.35; P

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Time for a Fresh Approach to Examining Factors Associated With Red Blood Cell Transfusion Outcome

No abstract available

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Repeated Morphine Prolongs Postoperative Pain in Male Rats

BACKGROUND: Opioids are effective postoperative analgesics. Disturbingly, we have previously reported that opioids such as morphine can worsen inflammatory pain and peripheral and central neuropathic pain. These deleterious effects are mediated by immune mediators that promote neuronal hyperexcitability in the spinal dorsal horn. Herein, we tested whether perioperative morphine could similarly prolong postoperative pain in male rats. METHODS: Rats were treated with morphine for 7 days, beginning immediately after laparotomy, while the morphine was tapered in a second group. Expression of genes for inflammatory mediators was quantified in the spinal dorsal horn. In the final experiment, morphine was administered before laparotomy for 7 days. RESULTS: We found that morphine treatment after laparotomy extended postoperative pain by more than 3 weeks (time × treatment: P

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A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before-after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0–3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0–6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0–3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6–106.3 mg MEQs) versus 144.0 mg MEQs (68.9–238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1– 124.0; P 50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients. 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 February 2, 2018. E. T. Said and J. F. Sztain contributed equally to this manuscript. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. This work has been presented, in part, as an oral presentation at the Enhanced Recovery After Surgery US Conference, November 10, 2017, Dallas, TX. Reprints will not be available from the authors. Address correspondence to Engy T. Said, MD, Department of Anesthesiology, University of California, 200 W Arbor Dr, MC 8770, San Diego, CA 92103. Address e-mail to esaid@ucsd.edu. © 2018 International Anesthesia Research Society

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Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part I—Femoral Nerve Block

The optimal management of pain after ambulatory anterior cruciate ligament reconstruction (ACLR) is unclear. Femoral nerve block (FNB) is purported to enhance postoperative analgesia, but its effectiveness in the setting of modern multimodal analgesia is unclear. This systematic review examines the effect of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, whether or not the analgesic regimen used included local instillation analgesia (LIA). We retrieved randomized controlled trials evaluating the effects of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, compared to multimodal analgesia alone (control). We designated postoperative opioid consumption at 24 hours as our primary outcome. Secondary outcomes included postoperative opioid consumption at 24–48 hours, rest, and dynamic pain severity between 0 and 48 hours, time to analgesic request, postanesthesia care unit and hospital stay durations, patient satisfaction, postoperative nausea and vomiting, functional outcomes, and long-term (>1 month) quadriceps strength. Eight randomized controlled trials (716 patients) were identified. Five trials compared FNB administration to control, and another 3 compared the combination of FNB and LIA to LIA alone. Compared to control, adding FNB resulted in modest reductions in 24-hour opioid consumption in 2 of 3 trials, and improvements in rest pain at 1 hour in 1 trial and up to 24 hours in another. In contrast, the combination of FNB and LIA, compared to LIA alone, did not reduce opioid consumption in any of the trials, but it did improve pain scores at 20 minutes only in 1 trial. The effect of FNB on long-term quadriceps strength or function after ACLR was not evaluated in the reviewed trials. Contemporary evidence suggests that the benefits of adding FNB to multimodal analgesia for ACLR are modest and conflicting, but there is no incremental analgesic benefit if the multimodal analgesic regimen included LIA. Our findings do not support the routine use of FNB for analgesia in patients having ACLR. Accepted for publication January 10, 2018. Funding: Departmental. Both F. W. Abdallah and R. Brull are supported by the Merit Award Program, Department of Anesthesia, University of Toronto. R. Brull receives research support from the Evelyn Bateman Cara Operations Endowed Chair in Ambulatory Anesthesia and Women's Health, Women's College Hospital, Toronto. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Faraj W. Abdallah, MD, Department of Anesthesia, St Michael's Hospital, 30 Bond St, Toronto, ON M5B 1W8, Canada. Address e-mail to abdallahf@smh.ca. © 2018 International Anesthesia Research Society

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Determination of Geolocations for Anesthesia Specialty Coverage and Standby Call Allowing Return to the Hospital Within a Specified Amount of Time

BACKGROUND: For emergent procedures, in-house teams are required for immediate patient care. However, for many procedures, there is time to bring in a call team from home without increasing patient morbidity. Anesthesia providers taking subspecialty or backup call from home are required to return to the hospital within a designated number of minutes. Driving times to the hospital during the hours of call need to be considered when deciding where to live or to visit during such calls. Distance alone is an insufficient criterion because of variable traffic congestion and differences in highway access. We desired to develop a simple, inexpensive method to determine postal codes surrounding hospitals allowing a timely return during the hours of standby call. METHODS: Pessimistic travel times and driving distances were calculated using the Google distance matrix application programming interface for all N= 136 postal codes within 60 great circle ("straight line") miles of the University of Miami Hospital (Miami, FL) during all 108 weekly standby call hours. A postal code was acceptable if the estimated longest driving time to return to the hospital was ≤60 minutes (the anesthesia department's service commitment to start an urgent case during standby call). Linear regression (with intercept = 0) minimizing the mean absolute percentage difference between the distances (great circle and driving) and the pessimistic driving times to return to the hospital was performed among all 136 postal codes. Implementation software written in Python is provided. RESULTS: Postal codes allowing return to the studied hospital within the specified interval were identified. The linear regression showed that driving distances correlated poorly with the longest driving time to return to the hospital among the 108 weekly call hours (mean absolute percentage error = 25.1% ± 1.7% standard error [SE]; N = 136 postal codes). Great circle distances also correlated poorly (mean absolute percentage error = 28.3% ± 1.9% SE; N = 136). Generalizability of the method was determined by successful application to a different hospital in a rural state (University of Iowa Hospital). CONCLUSIONS: The described method allows identification of postal codes surrounding a hospital in which personnel taking standby call could be located and be able to return to the hospital during call hours on every day of the week within any specified amount of time. For areas at the perimeter of the acceptability, online distance mapping applications can be used to check driving times during the hours of standby call. Accepted for publication January 9, 2018. 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 (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Richard H. Epstein, MD, Department of Anesthesiology, Perioperative Medicine & Pain Management, University of Miami, Miller School of Medicine, 1400 NW 12th Ave, Suite 3075, Miami, FL 33136. Address e-mail to repstein@med.miami.edu. © 2018 International Anesthesia Research Society

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Intravenous Acetaminophen Does Not Reduce Inpatient Opioid Prescription or Opioid-Related Adverse Events Among Patients Undergoing Spine Surgery

BACKGROUND: Having entered the US market relatively recently, the perioperative role of intravenous acetaminophen (ivAPAP) remains to be established for several surgeries. Using national data, we therefore assessed current utilization and whether it reduces inpatient opioid prescription and opioid-related side effects in a procedure with relatively high opioid utilization. METHODS: Patients undergoing a lumbar/lumbosacral spinal fusion (n = 117,269; 2011–2014) were retrospectively identified in a nationwide database and categorized by the amount and timing of ivAPAP administration (1 or >1 dose on postoperative day [POD] 0, 1, or 1+). Multivariable models measured associations between ivAPAP utilization categories and opioid prescription and perioperative complications; odds ratios (or % change) and 95% confidence intervals are reported. RESULTS: Overall, ivAPAP was used in 18.9% (n = 22,208) of cases of which 1 dose on POD 0 was the most common (73.6%; n = 16,335). After covariate adjustment, use of ivAPAP on POD 0 and 1 was associated with minimal changes in opioid prescription, length and cost of hospitalization particularly favoring >1 ivAPAP dose with a modestly (-5.2%, confidence interval, -7.2% to -3.1%; P

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Clonidine Effect on Pain After Cesarean Delivery: A Randomized Controlled Trial of Different Routes of Administration

BACKGROUND: Intrathecal clonidine prolongs spinal anesthesia. We evaluated the effects of the addition of intrathecal or intravenous clonidine (75 µg) to standard cesarean delivery spinal anesthesia on postoperative pain and neonatal outcomes. METHODS: In a randomized, placebo-controlled, double-blind trial, 64 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated and compared among 3 groups: intrathecal clonidine 75 µg, intravenous clonidine 75 µg, and placebo. The primary outcome was acute postoperative pain. A sample size of 26 individuals per group (N = 78) was planned. RESULTS: From April 2015 to April 2016, 64 women were analyzed (14 excluded). No differences in postoperative pain scores were found (Numerical Verbal Scale for pain at movement at 24 hours of postcesarean delivery: 4.53 ± 3.0 vs 4.45 ± 2.73 vs 3.93 ± 3.07 for control, intrathecal, and intravenous, respectively, P = .771). Intrathecal and intravenous clonidine led to more sedation, in comparison to the control group, during the intraoperative period (Richmond Agitation and Sedation Scale: −0.3 ± 0.47 vs −1 ± 0.53 vs −0.73 ± 0.45 for control, intrathecal, and intravenous, respectively, overall P

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Changes in International Normalized Ratios After Plasma Transfusion of Varying Doses in Unique Clinical Environments

BACKGROUND: Plasma transfusion is commonly performed for the correction of abnormal coagulation screening tests. The goal of this investigation was to assess the relationship between the dose of plasma administered and changes in coagulation test results in a large and diverse cohort of patients with varying levels of coagulation abnormalities and comorbid disease and in a variety of clinical settings. METHODS: In this single-center historical cohort study, all plasma transfusion episodes in adult patients with abnormal coagulation screening tests were extracted between 2011 and 2015. The primary outcome was the proportion of patients attaining normal posttransfusion international normalized ratio (INR ≤1.1) with secondary outcomes including the proportion of patients attaining partial normalization of INR (INR ≤1.5) or at least 50% normalization in pretransfusion values with respect to an INR of 1.1. RESULTS: In total, 6779 unique patients received plasma with a median (quartiles) pretransfusion INR of 1.9 (1.6–2.5) and a median transfusion volume of 2 (2–3) units. The majority (85%) of transfusions occurred perioperatively, with 20% of transfusions administered prophylactically before a procedure. The median decrease in INR was 0.4 (0.2–0.8). Complete INR normalization was obtained in 12%. Reductions in INR were modest with pretransfusion INR values

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Ethical Responsibilities of the Authors

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EEG Indices in Children with Primary Headache Disorders

Both episodic migraine and tension-type headache (TTH) are characterized by attacks of strong headache. There is growing evidence that the brain functions are abnormal even within between-attack periods. We tried to evaluate interictal brain functions in children with primary headache using quantitative EEG. Sixty patients were recruited, 25 children with migraine and 35 with TTH. Patients were classified according to the ICHD. Migraine patients had significantly higher relative spectral powers of slow-wave bands (theta and delta) and decreased alpha relative powers in most of the regions examined than those in TTH patients. Apart from the above-mentioned specificities and negative correlation of age with the powers of delta and theta bands in both groups, we could not find other clinical variables that appeared to significantly affect EEG indices. Our results support that interictal brain dysfunction is, in general, more typical of migraine patients. These results shall help to contribute to better management and brain protection in children with headache.

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The N6-adenine methylation in yeast genome profiled by single-molecule technology


Publication date: Available online 28 March 2018
Source:Journal of Genetics and Genomics
Author(s): Zhe Liang, Guoliang Yu, Jingrong Liu, Yuke Geng, Jinghui Mao, Depeng Wang, Jiapeng Zhou, Xiaofeng Gu

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Which safety standards should your ambulance remount meet?

With more safety data available, ambulance remounts may be the next to receive significant upgrades to minimum quality standards

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Piercing the dark matter: bioinformatics of long-range sequencing and mapping

Piercing the dark matter: bioinformatics of long-range sequencing and mapping

Piercing the dark matter: bioinformatics of long-range sequencing and mapping, Published online: 29 March 2018; doi:10.1038/s41576-018-0003-4

Various genomics-related fields are increasingly taking advantage of long-read sequencing and long-range mapping technologies, but making sense of the data requires new analysis strategies. This Review discusses bioinformatics tools that have been devised to handle the numerous characteristic features of these long-range data types, with applications in genome assembly, genetic variant detection, haplotype phasing, transcriptomics and epigenomics.

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How to train for 3 common patient lifting scenarios

Prepare mentally and physically to avoid injury when lifting patients from awkward positions

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Gastric cancer prevention and Helicobacter pylori

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Reply to the letter to the editor: H . pylori test-and-treat should not be put off for gastric cancer prevention in East Asia any longer

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Piercing the dark matter: bioinformatics of long-range sequencing and mapping

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Isoflurane anesthesia does not affect spinal cord neurovascular coupling: evidence from decerebrated rats


Neurological examination remains the primary clinical investigation in patients with spinal cord injury. However, neuroimaging methods such as functional magnetic resonance imaging (fMRI) are promising tools for following functional changes in the course of injury, disease and rehabilitation. However, the relationship between neuronal activity and blood flow in the spinal cord on which fMRI relies has been largely overlooked. The objective of this study was to examine neurovascular coupling in the spinal cord of decerebrated rats during electrical stimulation of the sciatic nerve with and without isoflurane anesthesia (1.2%). Local field potentials (LFP) and spinal cord blood flow (SCBF) were recorded simultaneously in the lumbosacral enlargement. Isoflurane did not significantly alter LFP (p = 0.53) and SCBF (p = 0.57) amplitude. Accordingly, neurovascular coupling remained comparable with or without isoflurane anesthesia (p = 0.39). These results support the use of isoflurane in rodents to investigate nociceptive functions of the spinal cord using fMRI.

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Nasotracheal intubation in ICU: an unfairly forgotten procedure.

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Nasotracheal intubation in ICU: an unfairly forgotten procedure.

Minerva Anestesiol. 2018 Mar 27;:

Authors: Hariri G, Baudel JL, Dubée V, Dumas G, Joffre J, Bourcier S, Bigé N, Ait Oufella H, Maury E

PMID: 29589421 [PubMed - as supplied by publisher]

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Dissolution of studtite [UO2(O2)(H2O)4] in various geochemical conditions

Publication date: September 2018
Source:Journal of Environmental Radioactivity, Volume 189
Author(s): Jungjin Kim, HyunJu Kim, Won-Seok Kim, Wooyong Um
This study determined the dissolution rate of studtite, (UO2)O2(H2O)4, which can be formed by reaction between H2O2 and UO22+ that leaks from spent nuclear fuel (SNF) in deep geological repositories. The batch dissolution experiments were conducted using synthesized studtite under different solution conditions with varying pHs and concentrations of HCO3 and [H2O2] in synthetic groundwater. The experimental results suggested that carbonate ligand and H2O2 in groundwater accelerated the dissolution of studtite and uranium (U) release. Above 10−5 M of H2O2 initial concentration, the released uranium concentration in solution decreased, possibly as a result of reprecipitation of studtite due to reaction between uranium and H2O2. The results will be useful to assess the comprehensive transport of uranium from both nuclear waste and SNF stored in deep geological repositories.

Graphical abstract


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