Education in neuroanesthesia and neurocritical care: trends, challenges and advancements

Purpose of review We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees. Recent findings Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises. Summary High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies. Correspondence to Angela Builes-Aguilar, MD, MSc, MsEpi, Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, 275 Regent Street, London, ON, Canada N6A2H3. Tel: +1 519 671 0313; e-mail: Angelitabuiles@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia for awake craniotomy

Purpose of review The current review reports on current trends in the anesthetic management of awake craniotomy, including preoperative preparation, sedation schemes, pain management, and prevention of intraoperative complications. Recent findings Both approaches for anesthesia for awake craniotomy, asleep–awake–asleep and monitored anesthesia care (MAC), have shown equal efficacy for performing intraoperative brain mapping. Choice of the appropriate scheme is currently based mainly on the preferences of the particular anesthesiologist. Dexmedetomidine has demonstrated high efficacy and safety in MAC for awake craniotomy and has become a rational alternative to propofol. Despite the high efficacy of scalp block and opioids, pain remains a common compliant in awake craniotomy. Appropriate surgical tactics can reduce pain and even prevent postoperative neurological complications. Although the efficacy of prophylaxis of intraoperative seizures with anticonvulsants remains doubtful, levetiracetam can be superior to other drugs for this purpose. Summary Following a great deal of progress in anesthetic management, awake craniotomy, which had been a relatively rare approach, is now a commonly performed procedure for neurosurgical intervention. Modern anesthesia techniques can provide for successful brain mapping in almost any patient. Management of awake craniotomy in high-risk patients is a central task for future research. Correspondence to Alexander Kulikov, MD, PhD, Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia. Tel: +7 903 963 73 64; e-mail: akulikov@nsi.ru Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Opioid-free anesthesia: a different regard to anesthesia practice

Purpose of review In the past two decades, opioids have been prescribed increasingly for the treatment of various chronic pain conditions and during the perioperative period. Perioperative opioid administration is associated with well known adverse effects and recently to long-term use and poor surgical outcomes. In this context, the anesthesiologists have to face their responsibilities. The review discusses the neurophysiological basis of opioid-free anesthesia (OFA), the rational supporting its use in perioperative medicine as well as barriers and future challenges in the field. Recent findings OFA has gained in popularity as a way to enhance early recovery and to spare opioids for the postoperative period. Whether it is possible to deliver safe and stable anesthesia without intraoperative opioids to many patients undergoing various surgical procedures, OFA still raises questions. Accurate monitoring to measure intraoperative nociception and guide the use of adjuvants are not available. There is a need for the development of procedure-specific strategies as well as indications and contraindications to the technique. Finally, objective assessment of OFA use on patient outcomes should be recorded in large multicenter studies. Summary OFA stands as a new paradigm, which questions anesthesiology practice and might help to rationalize perioperative opioids use. Correspondence to Patricia Lavand'homme, MD, PhD, Department of Anesthesiology, Cliniques Universitaires St Luc - University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium. Tel: +32 2 764 18 21; fax: +32 2 764 36 99; e-mail: patricia.lavandhomme@uclouvain.be Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Genetics and genomics in postoperative pain and analgesia

Purpose of review The review describes recent advances in genetics and genomics of postoperative pain, the association between genetic variants and the efficacy of analgesics, and the role of pharmacogenomics in the selection of appropriate analgesic treatments for postoperative pain. Recent findings Recent genetic studies have reported associations of genetic variants in catechol-O-methyltransferase (COMT), brain-derived neurotrophic factor (BDNF), voltage-gated channel alpha subunit 11 (SCN11A) and μ-opioid receptor (OPRM1) genes with postoperative pain. The recent pharmacogenetics studies revealed an association of the organic cation transporter 1 (OCT1) and ATP-binding cassette C3 (ABCC3) polymorphisms with morphine-related adverse effects, an effect of polymorphisms in cytochrome P450 gene CYP2D6 on the analgesic efficacy of tramadol and no effect of CYP2C8 and CYP2C9 variants on efficacy of piroxicam. Summary Genetic variants associate with inter-individual variability in drug responses and they can affect pain sensitivity and intensity of postoperative pain. Despite the recent progress in genetics and genomics of postoperative pain, it is still not possible to precisely predict the patients who are genetically predisposed to have severe postoperative pain or who develop chronic postoperative pain. Correspondence to Eija Kalso, MD, PhD, Pain Clinic, PB 140, 00029 HUS, Finland. Tel: +358 9 47175885; e-mail: eija.kalso@helsinki.fi Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery

Purpose of review Although thoracic epidural analgesia (TEA) is considered often as gold standard in multimodal analgesia with regard to major abdominal surgery, there is an ongoing debate if it is still a viable option for enhanced recovery because of its potential severe complications. Recent findings In addition to the unsurpassed analgesic quality, a TEA offers several advantages. Studies have shown that a TEA does have a positive effect on perioperative morbidity and mortality, bowel function, the occurrence of ileus and patient mobility. Furthermore, TEA can reduce opioid-induced side effects, cardiac arrhythmias and pneumonia. When it is embedded into a multimodal fast-track program, it also shortens intensive care and hospital stay. Summary TEA provides superior pain control with a handful of important advantages if used sensibly and with caution. Because of associated risks for severe neurological complications, clear contraindications should be ruled out. Special attention needs be paid to potential hypotension in the setting of epidural analgesia. If these key points are considered, a TEA still represents a viable option for enhanced recovery after major abdominal surgery. Correspondence to Raphael Weiss, MD, University Hospital Münster, Departement of Anesthesiology and Intensive Care Medicine, Albert-Schweitzer-Campus 1, 48149 Münster, NRW, Germany. Tel: +49 251 83 47266; fax: +49 251 83 47257; e-mail: r_weiss@anit.uni-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine

Purpose of review The purpose of this review is to provide the background and rationale for pursuing accreditation of regional anesthesiology and acute pain medicine (RAAPM) fellowships, explain specific steps and challenges in the process, and forecast the future of fellowship training. Recent findings In 2016, the first fellowship program in RAAPM was able to apply for accreditation from the Accreditation Council for Graduate Medical Education (ACGME). The establishment of this newly accredited subspecialty fellowship and the announcement of the first accredited programs represented a tremendous achievement in anesthesiology training and medical education in general and was the culmination of nearly 4 years of dedicated effort. Summary Programs with initial ACGME accreditation are on a 2-year term and will be reviewed to evaluate adherence to the program requirements and the quality of fellowship training. Deficiencies identified will need to be resolved or face loss of accreditation. However, a program's maintenance of accreditation represents a commitment to its fellows to provide a training experience that can be held as a benchmark for all programs. Correspondence to Edward R. Mariano, MD, MAS, Anesthesiology and Perioperative Care Service; VA Palo Alto Health care System; 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA. Tel: +650 849 0254; fax: +650 852 3423; e-mail: emariano@stanford.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Anesthesia for electroconvulsive therapy

Purpose of review Electroconvulsive therapy (ECT) is a well established and effective therapy in treatment-resistant depression. It is performed under general anesthesia, but no consensus exists regarding the optimal anesthetic drugs. A growing interest in optimizing adjunctive medication regimes in ECT anesthesia has emerged in recent years. Moreover different methods of seizure induction have been evaluated. Recent findings Pretreatment with dexmedetomidine eased the propofol injection pain and reduced the hyperdynamic response to ECT, but prolonged recovery. Remifentanil exhibited no proconvulsive effect and had no effect on seizure quality. Ketamine showed an antidepressive effect but was associated with cardiovascular side effects and an increased recovery time. A bispectral index-guided anesthesia or a time delay between anesthesia and seizure induction resulted in a better seizure quality presumably by avoiding high concentrations of (anticonvulsive) hypnotics. Seizure induction by magnetism seems to be an alternative to ECT, as the former is associated with less cognitive side effects but comparable antidepressive efficacy. Summary The current practice of anesthesia for ECT should not be modified, as the evidence of studies is either too low or the results are inconsistent. Some approaches are promising but require validation in further studies with a higher number of participants. Correspondence to Prof Dr Martin Soehle, Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, D-53127 Bonn, Germany. Tel: +49 228 28714127; e-mail: martin.soehle@ukbonn.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Recent developments in ultrasound imaging for neuraxial blockade

Purpose of review Recent research has shed further light on the place of ultrasound imaging in neuraxial blockade in routine clinical practice, its use in thoracic epidurals, and real-time ultrasound-guided techniques. Recent findings Compared with the conventional technique of surface landmark palpation, preprocedural ultrasound imaging minimizes technical difficulty associated with lumbar neuraxial blockade in patients with poor-quality surface landmarks. Novice practitioners are able to learn to employ the technique effectively. Safety benefits include a reduction in postprocedural back pain associated with fewer needle passes and a lower risk of procedure-associated bleeding. The advantage of ultrasound is minimal however in patients with easily discernible surface landmarks, especially if the practitioner is highly experienced. Recent trials show that preprocedural ultrasound scanning for thoracic epidural insertion reduces needle punctures and increases early analgesic efficacy compared with the palpation technique. Real-time ultrasound-guided techniques, while feasible, remain challenging and may not offer significant benefit over preprocedural imaging in lumbar neuraxial blockade. Their role in thoracic epidural insertion requires further investigation. Summary Ultrasound imaging of the spine is a valuable technique that, while not indicated for routine use, should be part of the skillset of any practitioner that regularly performs lumbar and thoracic neuraxial blockade. Correspondence to Ki Jinn Chin, MBBS, MMed, FRCPC, Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St, McL 2–405, Toronto, Ontario M5T 2S8, Canada. Tel: +1 416 603 5118; fax: +1 416 603 6494; e-mail: gasgenie@gmail.com Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Relation between memory impairment and the fornix injury in patients with mild traumatic brain injury; a diffusion tensor tractography study

Objective We investigated the relation between memory impairment and the fornix injury in patients with mild traumatic brain injury(TBI), using diffusion tensor tractography(DTT). Design Eighty six chronic patients with mild TBI and 50 normal control subjects were recruited. Fractional anisotropy(FA) and fiber volume were measured for each reconstructed fornix. The patients were classified according to three types; type A(47 patients) - intact integrity of both fornical crura, type B(27 patients) - showed a discontinuation in either fornical crus, and type C(12 patients) - discontinuations in both fornical crura.The Memory Assessment Scale(MAS) was used for evaluation of memory function. Results FA and fiber volume showed weak positive correlations with global memory of MAS, respectively(r=0.303, P=0.006, r=0.271, P=0.014). Significant difference in the global memory of MAS was observed between type A and B, and between type A and C without difference between type B and C(p

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Mechanical In-Exsufflation–Expiratory Flows as Indication for Tracheostomy Tube Decannulation: Case Studies

Mechanical insufflation exsufflation–expiratory flows (MIE-EF) correlate with upper airway patency. Patients dependent on continuous noninvasive ventilatory support (CNVS) with severe spinal muscular atrophy type 1, now over 20 years old, have used MIE sufficiently effectively along with CNVS to avoid tracheotomy indefinitely. While MIE-EF can apparently decrease in amyotrophic lateral sclerosis to necessitate tracheotomy, they can increase over time and remain effective in all spinal muscular atrophy types. Two cases demonstrate an association between increasing MIE-EF and ultimately successful decannulation of a continuous tracheostomy mechanical ventilation dependent patient with spinal muscular atrophy type 2 and a patient with obesity hypoventilation syndrome. Only when MIE-EF increased to exceed 200 L/m did the decannulations succeed. Definitive noninvasive management (CNVS) of these patients may only be possible when MIE is effective and the greater the MIE-EF, the greater its effectiveness. Thus, increasing MIE-EF can signal resolution of upper airway obstruction sufficiently to permit decannulation whether a patient is ventilator dependent or not. Correspondence: John R. Bach, MD, Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen Street, Newark, NJ 07103, Phone: 1-973-9722085, Fax: 1-973-9725725, E-mail: bachjr@njms.rutgers.edu Author Disclosures: Financial disclosure statements have been obtained and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Comment on: Efficacy of Armeo® Robotic Therapy Versus Conventional Therapy on Upper Limb Function in Children with Hemiplegic Cerebral Palsy

No abstract available

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Efficacy of Compression Gloves in the Rehabilitation of Distal Radius Fractures: Randomized Controlled Study

Objective To examine the outcomes of wearing made-to-measure compression gloves following distal radius fracture. Design In a randomized controlled trial, adults who were about six weeks post-distal radius fracture were recruited and divided into a comparison control group (N=15), who received standard rehabilitation twice a week for half an hour, and an intervention group (N=17), who additionally used compression gloves. All treatments were conducted at a single rehabilitation clinic. Outcomes assessed were wrist and fingers range of motion; grip strength; swelling, pain, and activities of daily living (using the Patient Rating Wrist Evaluation). The intervention group underwent additional objective dynamic assessments of range of motion with and without the gloves. Results The intervention group demonstrated reduced swelling, pain, and analgesic use; increased wrist range of motion; better scores for specific hand functions, and greater participation in activities of daily living compared with the comparison group. Conclusion This randomized controlled trial shows that using compression gloves during the rehabilitation phase following distal radius fracture improves daily functioning and reduces adverse symptoms. These improvements, which are important in their own right, are also expected to aid in preventing the development of chronic conditions and disability. Evidence Level II: un-blinded prospective comparative study. Correspondence: Dr. Naomi Schreuer, Dept. of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa, 31905 Israel, Phone: +972 5252 11119, Fax +972 4 8249753, Email nchreuer@univ.haifa.ac.il Disclosures: This research was partially supported by the donation of made-to-measure compression gloves by Uriel Meditex Ltd and by the provision of the MediTouch HandTutorTM system for use during the study. However, neither manufacturer employed or otherwise remunerated any of the authors. Researchers declare no competing interests. The paper is based on a thesis submitted as part of the requirements for the MSc. degree in Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel (In Hebrew). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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EMS and grief: Understanding your emotions

For EMTs, grief is often a surprising reaction to every day interactions with patients and their loved ones

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Disruption of INOS, a Gene Encoding myo-Inositol Phosphate Synthase, Causes Male Sterility in Drosophila melanogaster

Inositol is a precursor for the phospholipid membrane component phosphatidylinositol (PI), involved in signal transduction pathways, endoplasmic reticulum stress, and osmoregulation. Alterations of inositol metabolism have been implicated in human reproductive issues, the therapeutic effects of drugs used to treat epilepsy and bipolar disorder, spinal cord defects, and diseases including diabetes and Alzheimer's. The sole known inositol synthetic enzyme is myo-inositol synthase (MIPS), and the homologue in D. melanogaster is encoded by the Inos gene. Three identical deletion strains (inos^DF/CyO) were constructed, confirmed by PCR and sequencing, and homozygotes (inos^DF/ inos^DF) were shown to lack the transcript encoding the MIPS enzyme. Without inositol, homozygous inos^DF deletion fertilized eggs develop only to the first-instar larval stage. When transferred as pupae to food without inositol, however, inos^DF homozygotes die significantly sooner than wild-type flies. Even with dietary inositol the homozygous inos^DF males are sterile. An inos allele, with a P-element inserted into the first intron, fails to complement this male sterile phenotype. An additional copy of the Inos gene inserted into another chromosome rescues all the phenotypes. These genetic and phenotypic analyses establish Drosophila melanogaster as an excellent model organism in which to examine the role of inositol synthesis in development and reproduction.

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The Sleep Inbred Panel, a Collection of Inbred Drosophila melanogaster with Extreme Long and Short Sleep Duration

Understanding how genomic variation causes differences in observable phenotypes remains a major challenge in biology. Specifically, tracing the sequence of events originating from genomic variants of interest, from changes in transcriptional responses to protein modifications, is difficult. Ideally, one would conduct experiments with individuals that are at either extreme of the trait of interest, but such resources are often not available. Additionally, advances in genome editing will enable testing of candidate polymorphisms individually and in combination. Here we have created a resource for the study of sleep with 39 inbred lines of Drosophila-the Sleep Inbred Panel (SIP). SIP lines have stable long- and short-sleeping phenotypes developed from naturally occurring polymorphisms. These lines are fully sequenced, enabling more accurate targeting for genome editing and transgenic constructs. This panel facilitates the study of intermediate transcriptional and proteomic correlates of sleep, and supports genome editing studies to verify polymorphisms associated with sleep duration.

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Surveillance of Pediatric Hypertension Using Smartphone Technology

Elevated blood pressure is becoming increasingly common in the pediatric population. Hypertension costs nearly $51 billion/year, and cardiovascular disease is responsible for 17% of the nation's health care expenditures. Traditionally, time-consuming and complicated interpretation standards result in infrequent pediatric blood pressure screenings. This may lead to the under-diagnosis of pediatric hypertension. Early detection of elevated blood pressure is important in order to prevent hypertension related conditions such as, target organ damage, left ventricular hypertrophy, and cerebrovascular disease.

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P23. Does visual attentional performance determine working memory capacity?

In everyday life, working memory plays an important role. In the case of cognitive deficits, especially in old age, a diminishing working memory frequently causes increasing uncertainty and self-sufficiency among those affected. However, it is difficult to train the working memory to counter the effects of degeneration. Studies, in particular from the group around E.K. Vogel, suggest a link between individual working memory capacity (WMC) and selective attention. Subjects who are able to blend out irrelevant information had a higher individual WMC.

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P24. Psychology of Monosynaptic T (tendon) and H (Hoffmann) Reflexes (MSR) – History, results and relevance

Soon after monosynaptic reflexes were discovered (Erb 1875, Westphal 1875) studies concerning supraspinal influences including psychophysiological effects were carried out. A survey of methods with some historical illustrations and results of experiments from nearly a century of research is given.Lombard (1887, AmJPsychol, vol. one) was the first to show tonic variations of the 'knee jerk' due to psychophysiological influences, whereas Bowditch and Warren (1890) showed phasic activation with sophisticated techniques, allowing short time registration within the range of 0 to about 2000 ms after different kinds of stimuli.

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P21. Neural correlates of cognitive control in motor processes

The fronto-striato-subthalamic-pallidal network is involved in different aspects of motor and cognitive control (Jahanshahi et al., 2015), seeking as inhibition and conflict-induced slowing. Thus, in an automatic controlled mode of action. It has been proposed that this network 'communicates' in beta frequency oscillations (13–35 Hz) (Aron et al., 2016), which might reflect the cognitive control of motor processes.

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P27. The fasting hormone FGF21-an alternative therapy for Alzheimer’s disease?

Lipolysis is regulated by PPAR and its target genes apoE and ABCA1, which not only control the transport of cholesterol but also the proteolytic degradation of A-peptide (A plaques, which are found to be deposited in increased number in Alzheimer's disease (AD). Accordingly, it was shown that PPAR-activation stimulates A-degradation, in an ABCA1- and apoE-dependent manner. Thus, it is reasonable to assume that increased lipolysis may be neuroprotective and could in part minimize the risk of developing dementia.

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P28. The functional role of the anterior intraparietal sulcus for recovery of hand function in chronic stroke patients – A combined fMRI-TMS study

After stroke, neuroimaging studies frequently show increased activation of contralesional regions such as the primary motor cortex (M1) and the anterior intraparietal sulcus (aIPS) during movements of the impaired hand (Rehme et al., 2012). There is evidence that these areas may adopt either supportive or disturbing implications for motor control, depending on multiple factors, such as age, stroke severity, and lesion location (Di Pino et al., 2014). Importantly, previous research has mainly focused on investigating this question in the contralesional M1, while other areas involved in motor control, such as the aIPS have often been neglected despite considerable changes in post-stroke activity.

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Severe endoscopic lesions are not associated with more infliximab fecal loss in acute severe ulcerative colitis

It has been observed that early infliximab (IFX) fecal excretion in patients with acute severe ulcerative colitis (ASUC) was associated with low treatment response.

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Severe endoscopic lesions are not associated with more infliximab fecal loss in acute severe ulcerative colitis

It has been observed that early infliximab (IFX) fecal excretion in patients with acute severe ulcerative colitis (ASUC) was associated with low treatment response.

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EMS Poem: ‘The Physicians Choice’

A volunteer firefighter/AEMT relates who is chosen to be guardian angels on Earth

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Evolutionary genomic dynamics of Peruvians before, during, and after the Inca Empire [Genetics]

Native Americans from the Amazon, Andes, and coastal geographic regions of South America have a rich cultural heritage but are genetically understudied, therefore leading to gaps in our knowledge of their genomic architecture and demographic history. In this study, we sequence 150 genomes to high coverage combined with an additional...

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Gentamicin induces LAMB3 nonsense mutation readthrough and restores functional laminin 332 in junctional epidermolysis bullosa [Genetics]

Herlitz junctional epidermolysis bullosa (H-JEB) is an incurable, devastating, and mostly fatal inherited skin disease for which there is only supportive care. H-JEB is caused by loss-of-function mutations in LAMA3, LAMB3, or LAMC2, leading to complete loss of laminin 332, the major component of anchoring filaments, which mediate epidermal-dermal adherence....

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Real-time dynamics of mutagenesis reveal the chronology of DNA repair and damage tolerance responses in single cells [Genetics]

Evolutionary processes are driven by diverse molecular mechanisms that act in the creation and prevention of mutations. It remains unclear how these mechanisms are regulated because limitations of existing mutation assays have precluded measuring how mutation rates vary over time in single cells. Toward this goal, I detected nascent DNA...

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Sex-chromosome dosage effects on gene expression in humans [Genetics]

A fundamental question in the biology of sex differences has eluded direct study in humans: How does sex-chromosome dosage (SCD) shape genome function? To address this, we developed a systematic map of SCD effects on gene function by analyzing genome-wide expression data in humans with diverse sex-chromosome aneuploidies (XO, XXX,...

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miR-34a directly targets tRNAiMet precursors and affects cellular proliferation, cell cycle, and apoptosis [Genetics]

It remains unknown whether microRNA (miRNA/miR) can target transfer RNA (tRNA) molecules. Here we provide evidence that miR-34a physically interacts with and functionally targets tRNAiMet precursors in both in vitro pulldown and Argonaute 2 (AGO2) cleavage assays. We find that miR-34a suppresses breast carcinogenesis, at least in part by lowering...

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Single-cell mutagenic responses and cell death revealed in real time [Genetics]

When musing about evolution, the physician and scientific essayist Lewis Thomas wrote, "The capacity to blunder slightly is the real marvel of DNA. Without this special attribute, we would still be anaerobic bacteria and there would be no music" (1). Understanding how DNA mutations arise in cells, either spontaneously or...

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Long Noncoding RNA SNHG7 Promotes the Tumor Growth and Epithelial-to-Mesenchymal Transition via Regulation of miR-34a Signals in Osteosarcoma

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Salvage Radioimmunotherapy of Advanced Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen: Efficacy and Safety in Routine Practice

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Long Noncoding RNA SNHG7 Promotes the Tumor Growth and Epithelial-to-Mesenchymal Transition via Regulation of miR-34a Signals in Osteosarcoma

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Salvage Radioimmunotherapy of Advanced Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen: Efficacy and Safety in Routine Practice

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Teen couple urges public to learn CPR after lightning strike incident

Isaiah Cormier said he is "very grateful" that his girlfriend, Juliette Moore, saved him by performing CPR after he was struck by lightning

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EMS Stories: Provo Fire & Rescue - Provo, UT

In the second installment of our EMS Stories series we spoke with Provo Fire & Rescue, in Provo, Utah. Hear about the care they administer in the back of their ambulance on a day-to-day basis. Brought to you by Stryker

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EMS Stories: Provo Fire & Rescue - Provo, UT

In the second installment of our EMS Stories series we spoke with Provo Fire & Rescue, in Provo, Utah. Hear about the care they administer in the back of their ambulance on a day-to-day basis. Brought to you by Stryker

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EMS Stories: Provo Fire & Rescue - Provo, UT

In the second installment of our EMS Stories series we spoke with Provo Fire & Rescue, in Provo, Utah. Hear about the care they administer in the back of their ambulance on a day-to-day basis. Brought to you by Stryker

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EMS Stories: Provo Fire & Rescue - Provo, UT

In the second installment of our EMS Stories series we spoke with Provo Fire & Rescue, in Provo, Utah. Hear about the care they administer in the back of their ambulance on a day-to-day basis. Brought to you by Stryker

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Addressing leadership and caregiver bias in EMS

The EMS leader's task is to recognize and reduce negative impacts of bias as much as possible

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EMS From a Distance: Upgrading EMS

Changing a fragmented industry from the bottom up

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Endoloop versus endostapler: what is the best option for appendiceal stump closure in children with complicated appendicitis? Results of a multicentric international survey

Abstract

Background

There is a limited and conflicting evidence about the most appropriate method for appendiceal stump closure during laparoscopic appendectomy (LA). We aimed to compare endoloop (EL) versus endostapler (ES) for stump closure during LA for complicated perforated appendicitis in children.

Methods

We retrospectively reviewed the records of 708 patients (463 boys and 245 girls with an average age of 9.8 years) who underwent LA for complicated appendicitis in 5 international centers of Pediatric Surgery over a 5-years period (January 2011–December 2016). The appendix was perforated with localized peritonitis in 470 cases and diffuse peritonitis in 238 patients. EL was used in 374 cases (G1), whereas ES was adopted in 334 cases (G2).

Results

No intra-operative complication occurred in both groups but 5 conversions to open surgery were reported in G1 (1.3%) and 4 in G2 (1.1%) (OR 1.1; 95% CI 0.30–4.19). Use of EL was significantly associated with higher incidence of intra-abdominal abscess (OR 1.36; 95% CI 0.84–2.18), postoperative ileus (OR 3.61; 95% CI 0.76–17.11), and re-operations/readmissions (OR 6.46; 95% CI 1.46–28.62) compared to ES. The average cost of supplies for LA was significantly higher in G2 (€ 915.60) compared to G1 (€ 578.36) (p = 0.0001). The average cost of re-operations/readmissions was significantly higher in G1 (€ 4.091,39) compared to G2 (€ 2.127,88) (p = 0.0001) (OR 1.72; 95% CI 1.47–2.01).

Conclusions

Our study is the first in the pediatric population to demonstrate that the method used for appendiceal stump closure may influence the outcome of LA in complicated appendicitis. Although ES is more expensive compared to EL, our results demonstrated that appendix stump closure should be performed using ES rather than EL in complicated perforated appendicitis since its use was associated with a lower incidence of postoperative intra-abdominal abscess and postoperative ileus and lower re-operations and readmissions rates and costs.

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Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery

Abstract

Background

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery.

Methods

A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded.

Results

A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4–17.8)]. The organ–space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1–11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028).

Conclusions

The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ–space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

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Robotic versus laparoscopic distal pancreatectomy: a French prospective single-center experience and cost-effectiveness analysis

Abstract

Background

Benefits and cost-effectiveness of robotic approach for distal pancreatectomy (DP) remain debated. In this prospective study, we aim to compare the short-term results and real costs of robotic (RDP) and laparoscopic distal pancreatectomy (LDP).

Methods

From 2011 until 2016, all consecutive patients underwent minimally invasive DP were included and data were prospectively collected. Patients were assigned in two groups, RDP and LDP, according to the availability of the Da Vinci® Surgical System for our Surgical Unit.

Results

A minimally invasive DP was performed in 38 patients with a median age of 61 years old (44–83 years old) and a BMI of 26 kg/m² (20–31 kg/m²). RDP group (n = 15) and LDP group (n = 23) were comparable concerning demographic data, BMI, ASA score, comorbidities, malignant lesions, lesion size, and indication of spleen preservation. Median operative time was longer in RDP (207 min) compared to LDP (187 min) (p = 0.047). Conversion rate, spleen preservation failure, and perioperative transfusion rates were nil in both groups. Pancreatic fistula was diagnosed in 40 and 43% (p = 0.832) of patients and was grade A in 83 and 80% (p = 1.000) in RDP and LDP groups, respectively. Median postoperative hospital stay was similar in both groups (RDP: 8 days vs. LDP: 9 days, p = 0.310). Major complication occurred in 7% in RDP group and 13% in LDP group (p = 1.000). Ninety-days mortality was nil in both groups. No difference was found concerning R0 resection rate and median number of retrieved lymph nodes. Total cost of RDP was higher than LDP (13611 vs. 12509 €, p < 0.001). The difference between mean hospital incomes and costs was negative in RDP group contrary to LDP group (− 1269 vs. 1395 €, p = 0.040).

Conclusion

Short-term results of RDP seem to be similar to LDP but the high cost of RDP makes this approach not cost-effective actually.

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Logistical considerations for establishing reliable surgical telementoring programs: a report of the SAGES Project 6 Logistics Working Group

Abstract

Surgical telementoring programs (STMPs) as educational tools have consistently demonstrated success in the training of surgeons in a variety of surgical disciplines. The goal of an STMP is to train and educate practicing surgeons by improving or remediating surgical skills or assisting in the safe adoption of new procedures. STMPs may even have a role in assisting with recertification. In 2015, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched the SAGES Telementoring Initiative at the Project 6 Summit. Herein, we provide a report on the SAGES Project 6 Logistics working group and lay out a plan for the recommended logistical framework to carry out an STMP.

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Comparison of long-term clinical outcomes between endoscopic and surgical resection for early-stage adenocarcinoma of the esophagogastric junction

Abstract

Background

The aim of this study was to analyze long-term clinical and oncologic outcomes in patients with early-stage adenocarcinoma of the esophagogastric junction (AEG) managed with either endoscopic resection (ER) or surgery.

Methods

The inclusion criteria were AEG, meeting classic or expanded indications for ER of early gastric cancer, and complete resection. A total of 66 patients with Siewert type II AEG were included (ER group, n = 38; vs. surgery group, n = 28).

Results

The mean age of the ER group was greater than that of the surgery group (mean ± SD, 66.9 ± 9.7 vs. 58.5 ± 10.4 years, respectively; p = 0.001). Compared to the ER group, macroscopically flat or depressed-type lesions were more common (47.4 vs. 89.3%; p = 0.001), and mean lesion size was larger in the surgery group (13.3 ± 8.4 vs. 18.6 ± 11.0 mm; p = 0.039). One intensive care unit admission and subsequent surgery-related death occurred in the surgery group (1/28 vs. 0/38 in the ER group; p = 0.424). During follow-up, recurrence was detected in both groups (4/38 vs. 1/28; p = 0.385). Overall survival and 5-year disease-free survival did not differ between the groups (93.3 vs. 92.9%; p  = 0.282 and 88.0 vs. 100.0%; p = 0.066).

Conclusions

Once complete resection is achieved in patients with AEG who met the expanded criteria for endoscopic submucosal dissection of gastric cancer, there was no significant difference in clinical outcomes between ER and surgery.

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Effect of premedication on lesion detection rate and visualization of the mucosa during upper gastrointestinal endoscopy: a multicenter large sample randomized controlled double-blind study

Abstract

Background

Premedication in upper gastrointestinal endoscopy for higher lesions detection rate has not been well studied so far. This study aimed to confirm whether premedication could improve the detection rate of early cancer or precancerous lesions and mucosal visibility.

Method

From July 2015 to December 2015, 7200 participants from 6 centers were screened by endoscopy with one of the 4 following premedications randomly: (1) water (group D); (2) pronase (group A); (3) simethicone (group B); (4) pronase and simethicone (group C). Early cancer and precancerous lesions detection rates were taken as the primary endpoints, and mucosal visibility was taken as the secondary endpoint. They were compared among four groups to determine different premedication effects in terms of different anatomical sites. Trial was registered at Chinese Clinical Trial Registry; the registration number is ChiCTR-IOR-17010985.

Results

The upper gastrointestinal overall precancerous lesion detection rates among four groups were 8.7, 8.4, 10.0, and 10.3%, the overall early cancer detection rates were 1.3, 1.4%, 1.5, and 1.6%, both without significant difference (p = 0.138 and 0.878). However, the visibility score distributions between control group (D) and premedication groups (A, B, and C) were all statistically significant, with all anatomical sites p values < 0.001. Subgroup analyses, from 2 centers without screening before, also showed significant difference in esophageal (3.9, 3.3, 4.5, and 8.4% with p = 0.004) and overall (7.0, 5.5, 7.3, and 12.0% with p = 0.004) precancerous lesion detection rate.

Conclusions

Premedication with pronase and simethicone may not increase lesion detection rates but could significantly increase the upper gastrointestinal mucosal visibility.

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FUSE certification enhances performance on a virtual computer based simulator for dispersive electrode placement

Abstract

Background

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed the fundamental use of surgical energy (FUSE) didactic curriculum in order to further understanding of the safe use of surgical energy. The virtual electrosurgical skill trainer (VEST) is being developed as a complementary simulation-based curriculum, with several modules already existing. Subsequently, a new VEST module has been developed about dispersive electrode placement. The purpose of this study is to assess knowledge about dispersive electrode placement in surgeons and surgical trainees in addition to describing a new VEST module.

Methods

Forty-six subjects (n = 46) were recruited for participation at the 2016 SAGES conference Learning Center. Subjects were asked to complete demographic surveys, a five-question pre-test, and a five-question post-test after completing the VEST dispersive electrode module. Subjects were then asked to rate different aspects of the module using a five-point Likert scale questionnaire.

Results

Mean pre-simulator and post-simulator assessment scores were 1.5 and 3.4, respectively, with Wilcoxon signed rank analysis showing a significant difference in the means (p < 0.05). Subjects were grouped by the presence (n = 12) or absence (n = 31) of prior FUSE experience and by training level. Mann–Whitney U testing showed no significant difference in pre-simulator assessment scores between attending surgeons and trainees (p > 0.05). In those with and without FUSE exposure, a significant difference (p < 0.05) was seen in pre-simulator assessment scores, and no significant difference in Likert scale assessment scores was seen.

Conclusions

This study demonstrated a new VEST educational module. Consistently high Likert assessment scores showed that users felt that the VEST module helped their understanding of dispersive electrode placement. Additionally, the study reflected a potential knowledge deficit in the safe use of dispersive electrodes in the surgical community, also demonstrating that even some exposure to the FUSE curriculum developed by SAGES provides increased awareness about dispersive electrode use.

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Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach

Abstract

Background

Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation.

Methods

Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips.

Results

Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86 min (range 40–135). There were no perioperative or postoperative complications.

Conclusions

Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.

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A single surgeon’s experience transitioning to robotic-assisted right colectomy with intracorporeal anastomosis

Abstract

Background

Despite substantial evidence demonstrating benefits of minimally invasive surgery, a large percentage of right colectomies are still performed via an open technique. Most laparoscopic right colectomies are completed as a hybrid procedure with extracorporeal anastomosis. As part of a pure minimally invasive procedure, intracorporeal anastomosis (ICA) may confer additional benefits for patients. The robotic platform may shorten the learning curve for minimally invasive right colectomy with ICA.

Methods

From January 2014 to May 2016, 49 patients underwent robotic-assisted right colectomy by a board-certified colorectal surgeon (S.R). Extracorporeal anastomosis (ECA) was used in the first 20 procedures, whereas ICA was used in all subsequent procedures. Outcomes recorded in a database for retrospective review included operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, complications, readmissions, and mortality rate.

Results

Comparison of average OT, EBL, and LOS between extracorporeal and intracorporeal groups demonstrated no significant differences. For all patients, average OT was 141.6 ± 25.8 (range 86–192) min, average EBL was 59.5 ± 83.3 (range 0–500) mL, and average LOS was 3.4 ± 1.19 (range 1.5–8) days. Four patients required conversion, all of which occurred in the extracorporeal group. There were no conversions after the 18th procedure. The 60-day mortality rate was 0%. There were no anastomotic leaks, ostomies created, or readmissions. As the surgeon gained experience, a statistically significant increase in lymph node sampling was observed in oncologic cases (p = .02).

Conclusions

The robotic platform may help more surgeons safely and efficiently transition to a purely minimally invasive procedure, enabling more patients to reap the benefits of less invasive surgery. Transitioning from ECA to ICA during robotic right colectomy resulted in no significant change in OT or LOS. A lower rate of conversion to open surgery was noted with increased experience.

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Immersive virtual reality-based training improves response in a simulated operating room fire scenario

Abstract

Background

SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics.

Methods

The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment.

Results

A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014).

Conclusions

Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

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Does prolonged operative time impact postoperative morbidity in patients undergoing robotic-assisted rectal resection for cancer?

Abstract

Background

Several studies have shown a correlation between longer operative times and higher rates of postoperative morbidity for open and laparoscopic surgery for rectal cancer. The aim of the study was to determine the impact of prolonged operative time on early postoperative morbidity in patients undergoing robotic-assisted rectal cancer resection.

Methods

The study was a retrospective review of a prospectively maintained database conducted in two centers of the same institution. A total of 260 consecutive patients undergoing with robotic-assisted resection for rectal cancer between 2007 and 2016 were included. Patients were divided into two groups regarding median operative time: > 300 min (prolonged operative time; n = 133) and ≤ 300 min (control; n = 127). Patient characteristics, operative and postoperative data were compared between groups. Univariate and multivariate analyses were performed to determine whether prolonged operative time was a predictive factor of 30-day postoperative morbidity.

Results

Prolonged operative time was noted more frequently in males (p = 0.02), patients with higher BMI (p < 0.01), more severe comorbidities (p < 0.01), in tumors of the mid-rectum, and in surgery performed after neoadjuvant chemoradiation or upon surgeons' learning curve. The two groups had similar overall postoperative morbidity (32 vs. 41%; p = 0.16) and severe morbidity (6 vs. 6%; p = 0.92) rates. Prolonged operative time was associated with longer hospital stay (3.8 ± 2.5 vs. 5.0 ± 3.7 days; p = 0.004) in univariate analysis. Prolonged operative time was not independently associated with postoperative morbidity or with increased hospital stay on multivariate analysis.

Conclusion

In our study, prolonged operative time was not associated with an over-risk of morbidity in patients undergoing robotic resection for rectal cancer. These results suggest that more difficult robotic procedures do not lead to increased postoperative morbidity.

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Clinical versus patient-reported measures of depression in bariatric surgery

Abstract

Background

Bariatric surgery patients with mental illness may experience worse surgical outcomes compared to those without. Depression is the most prevalent mental health diagnosis amongst Americans with obesity. Accurate diagnosis and treatment is of paramount importance to mitigate perioperative risk. Unfortunately, there is no standard method to screen patients for depression prior to surgery. Our goal was to understand the relationship between traditional clinical screening tools and a novel patient-reported depression screening survey, Patient Health Questionnaire 8 (PHQ-8), in the setting of the bariatric surgery preoperative assessment.

Methods

The study included all adult bariatric surgery patients from January 2014 through June 2016. Patients who were not assessed using both the PHQ-8 and a traditional clinical depression screening were excluded from the study. There were a total of 4486 patients who met the eligibility criteria and were included in analysis. We used comparative statistics to examine the association between these screening tools and to test for contributing demographic, surgical, and socioeconomic factors.

Results

The overall rate of clinically diagnosed depression in the study cohort was 45.6%. In comparison, 14.8% of all patients screened positive for depression using the PHQ-8. Of the patients without a traditional clinical diagnosis of depression, 10.2% screened positive for depression using the PHQ-8. This subset of undiagnosed patients was more likely to be non-white, employed, and had a higher BMI than their clinically diagnosed counterparts.

Conclusions and Relevance

We found a higher rate of clinically diagnosed depression in our cohort compared to the general population. However, when using the validated PHQ-8 survey, the rate of depression more closely approximated the national incidence. Further, a significant proportion of patients were undiagnosed and/or misdiagnosed by current clinical assessments. Standardizing preoperative depression screening using validated patient-centered tools may prevent the consequences of untreated depression.

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Treatment of benign perforations and leaks of the esophagus: factors associated with success after stent placement

Abstract

Background

Self-expanding metal stent (SEMS) is effective and safe for the treatment of benign esophageal perforations or leaks. The purpose of this study was to identify factors associated with clinical success after SEMS placement.

Methods

Patients who received SEMS placement for treatment of benign esophageal perforations or leaks were retrospectively identified. These patients were analyzed for factors associated with clinical success and complications.

Results

A total of 31 patients underwent stent insertion for benign esophageal perforations (n = 11) or anastomotic leaks (n = 20). Clinical success was achieved in twenty-three patients (74.2%) after initial stent insertion. In multivariate analysis, early stent insertion within 1 day was identified as a significant independent predictor of successful sealing (Odds ratio = 3.14, 95% CI 1.36–7.24; p = 0.013). The anastomotic leak group needed a longer stent dwelling time (≥ 4 weeks) compared to the perforation group (75.0% vs. 27.3%, p = 0.022).

Conclusions

Clinical success was significantly associated with early stent insertion. The dwelling time of stent was shorter for benign perforations compared to anastomotic leaks.

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3D vision and maintenance of stable pneumoperitoneum: a new step in the development of laparoscopic right hepatectomy

Abstract

Background

Although laparoscopic liver resection is widely performed, many technical difficulties remain, such as accurate isolation/division of hepatic vessels in laparoscopic right hepatectomy (LRH). Innovative surgical devices, such as three-dimensional (3D) laparoscopy and optimized carbon dioxide (CO₂) insufflation system, may help to overcome technical difficulties in LRH. The purpose of this study was to analyze the efficacy of 3D vision associated with active pneumoperitoneum maintenance in LRH.

Methods

In our prospectively maintained database from 2006, 75 consecutive LRH from May 2011 to June 2017 were included in this study. All LRH were performed with 2D vision and standard CO₂ insufflator (2D-LRH group, 45 cases) or 3D vision with optimized CO₂ insufflator (3D-LRH group, 30 cases). Preoperative clinical characteristics, surgical data including operation time of separate steps within the procedure, and postoperative complications were compared between the two groups.

Results

Clinical and pathological factors were comparable between two groups. Total operative time was significantly shorter in 3D-LRH group than in 2D-LRH (360 vs 390 min, P = 0.029). Right hepatic pedicle dissection time was significantly shorter in 3D-LRH group (101 vs 123 min, P = 0.003). Liver parenchyma transection time was also shorter in 3D-LRH group (138 vs 151 min, P = 0.089), although not significant. There was no significant difference in liver mobilization time, intraoperative bleeding/transfusion, and postoperative complications.

Conclusions

3D vision with maintenance of pneumoperitoneum facilitates hepatic vascular isolation/division, and may contribute to the development of LRH.

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Reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection for gastric cancer: a modified technique using Single-Site ® and two additional ports

Abstract

Background

Reduced-port laparoscopic gastrectomy further minimizes the invasiveness of laparoscopic gastrectomy, thereby improving patient quality of life. However, suboptimal ergonomics and visualization are challenges to performing reduced-port laparoscopy. As the application of a robotic surgical system may help overcome these challenges, the present study was performed to evaluate the short-term outcomes of reduced-port totally robotic distal subtotal gastrectomy.

Method

An initial 40 consecutive gastric cancer patients treated with reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection from February 2016 to February 2017 were retrospectively reviewed. An overturned infraumbilical Single-Site^® port and two additional abdominal ports were utilized. Clinicopathological characteristics and short-term surgical outcomes were analyzed to evaluate the safety and feasibility of the procedure.

Result

Patients comprised 23 (57.5%) males and 17 females. Mean age and body mass index were 54 years and 23.7 kg/m², respectively. Preoperative clinical T stage was early in 22 patients and advanced (T2 or more) in 18 (45%) patients. No conversions to laparoscopic or open surgery and no additional port insertions were required. Eighteen patients (45%) underwent D2 lymph node dissection. All reconstructions after gastrectomy were made intracorporeally, including 34 (85%) Billroth I anastomoses. Mean operative time and blood loss were acceptable (210 min and 49.9 ml, respectively). The mean number of retrieved lymph nodes was 58.8. Postoperative clinical courses were acceptable for all patients, with no grade III or higher complications recorded.

Conclusion

Reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection was successfully applied and provided acceptable short-term postoperative results.

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Extreme clustering of type-1 NF1 deletion breakpoints co-locating with G-quadruplex forming sequences

Abstract

The breakpoints of type-1 NF1 deletions encompassing 1.4-Mb are located within NF1-REPa and NF1-REPc, which exhibit a complex structure comprising different segmental duplications in direct and inverted orientation. Here, we systematically assessed the proportion of type-1 NF1 deletions caused by nonallelic homologous recombination (NAHR) and those mediated by other mutational mechanisms. To this end, we analyzed 236 unselected type-1 deletions and observed that 179 of them (75.8%) had breakpoints located within the NAHR hotspot PRS2, whereas 39 deletions (16.5%) had breakpoints located within PRS1. Sixteen deletions exhibited breakpoints located outside of these NAHR hotspots but were also mediated by NAHR. Taken together, the breakpoints of 234 (99.2%) of the 236 type-1 NF1 deletions were mediated by NAHR. Thus, NF1-REPa and NF1-REPc are strongly predisposed to recurrent NAHR, the main mechanism underlying type-1 NF1 deletions. We also observed a non-random overlap between type-1 NF1-deletion breakpoints and G-quadruplex forming sequences (GQs) as well as regions flanking PRDM9_A binding-sites. These findings imply that GQs and PRDM9_A binding-sites contribute to the clustering of type-1 deletion breakpoints. The co-location of both types of sequence was at its highest within PRS2, indicative of their synergistic contribution to the greatly increased NAHR activity within this hotspot.

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Deferred treatment with sofosbuvir–velpatasvir–voxilaprevir for patients with chronic hepatitis C virus who were previously treated with an NS5A inhibitor: an open-label substudy of POLARIS-

The Lancet: Gastroenterology & Hepatology

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Reference values of liver volume in caucasian population and factors influencing liver size

European Journal of Radiology

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Real‐time optical manipulation of cardiac conduction in intact hearts

The Journal of Physiology, Volume 0, Issue ja, -Not available-.


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Report of second case and clinical and molecular characterization of Eiken syndrome

Clinical Genetics, Volume 0, Issue ja, -Not available-.


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[Vagus and hypoglossus palsy after nasotracheal intubation and throat packing].

[Vagus and hypoglossus palsy after nasotracheal intubation and throat packing].

Ugeskr Laeger. 2018 Jul 02;180(27):

Authors: Schmidt T, Philipsen BB, Manhoobi Y, Bruun Christiansen EL

Abstract
Ipsilateral extracranial palsy of the hypoglossus and vagus nerve is a rare complication of intubation. This is a case report of a 50-year-old male with unilateral palsy of the hypoglossus and vagus nerve after reoperation for a mandibular fracture. The patient underwent logopaedic treatment, and ten months after the operation there was significant but not complete remission of symptoms. Videostroboscopy revealed near-normalisation of vocal cord movement.

PMID: 29984697 [PubMed - in process]

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Airway management in a displaced comminuted fracture of the mandible and atlas with a vertebral artery injury: A case report.

Related Articles

Airway management in a displaced comminuted fracture of the mandible and atlas with a vertebral artery injury: A case report.

J Dent Anesth Pain Med. 2018 Jun;18(3):183-187

Authors: Paramaswamy R

Abstract
Complex cervical spine fractures are a serious complications of maxillofacial trauma and associated with high mortality and neurological morbidity. Strict vigilance in preventing further insult to the cervical spine is a crucial step in managing patients who are at risk for neurologic compromise. We report a rare case of a right transverse process of atlas fracture with right-sided vertebral artery injury that was associated with a comminuted fracture of the body and angle of the mandible, which restricted mouth opening. Airway management was performed by an awake fiber-optic nasotracheal intubation, where neck movement was avoided with a cervical collar. Vertebral artery injuries may have disastrous consequences, such as basilar territory infarction and death, and should be suspected in patients with head and neck trauma. After mandibular plating, the patient was on cervical collar immobilization for 12 weeks and anti-coagulant therapy.

PMID: 29984323 [PubMed]

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fGWAS: an R package for genome-wide association analysis with longitudinal phenotypes

Publication date: Available online 10 July 2018

Source: Journal of Genetics and Genomics

Author(s): Zhong Wang, Nating Wang, Rongling Wu, Zuoheng Wang

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Critical Care Transport Paramedic – Vitalink - New Hanover Regional Medical Center

**Critical Care Transport Paramedic – Vitalink** Essential Responsibilities: · Provides high quality patient care and safe medical transport to sick and injured patients in all age groups · Uses an interdisciplinary model to work with the Airlink/Vitalink Staff Nurse and other appropriate medical personnel to establish and prioritize a plan of care consistent with approved treatment protocols, policies ...

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Advanced EMT - New Hanover Regional Medical Center

**Advanced EMT** Full-Time New Hanover Regional EMS Wilmington, NC The Advanced EMT provides **high quality patient care and safe medical transport to sick and injured patients in all age groups, primarily in a non-emergent setting**. · Patient care will be consistent with approved treatment protocols · Communicates and coordinates the patient's care in an interdisciplinary model

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Staff Nurse – Vitalink - New Hanover Regional Medical Center

**Staff Nurse – Vitalink** The Staff RN **provides high quality patient care and safe medical transport to sick and injured patients in all age groups**. _Essential Responsibilities:_ · Collaborates with team and initiates care plan based on patient assessment and significant other input/data. · Continuously reviews and revises plan as needed per patient's condition. · Maintains thorough patient care ...

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Paramedic - EMS - New Hanover Regional Medical Center

**Paramedic - EMS** Full-Time The Staff Paramedic provides **high quality patient care and safe medical transport to sick and injured patients in all age groups**. · Develops a plan of care for each patient that is consistent with approved treatment protocols, policies and procedures. · Responsible for the operation of emergency vehicles

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First Aid Services Team (FAST) Responder - American Red Cross

**Job Summary: ** To provide immediate and temporary first aid services for victims of injury and sudden illness at events that are contracted between organizations and the American Red Cross. Due to the high degree of risk associated with the provision of this service, this position requires judgment and decision-making abilities that help provide life-saving response and balance the risks to the organization ...

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Paramedic 24/hr - Carle Foundation Hospital

$2,500 sign-on bonus for Paramedics with 1 or more years experience - External Applicants Only Position Summary: The Paramedic responds to emergency and non-emergency ambulance requests. Has assigned daily and weekly duties, such as cleaning of ambulances and medi-vans, to complete during work hours. Provides directions and leadership to EMT on calls that require Advanced Life Support. EDUCATIONAL REQUIREMENTS ...

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Paramedic or EMT CC - Northern Ambulance Corps, LLC

Seeking immediately, NY State certified EMT Critical Care or Paramedic for well established 24 hour ambulance service in Malone, NY. Candidate will be expected to provide emergency medical care to individuals during both urgent 911 calls and inter-facility transfers. Company willing to consider 8, 12 or 24 hour shift. Competitive wage, commensurate with experience.

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EMS Clinical Coordinator - Chattahoochee Technical College

- Coordinates and evaluates clinical education for the EMT and Paramedic Program - Coordinates, presents and evaluates lab instruction for EMT and Paramedic Programs - Utilizes Meti Man technology in lab instruction for the EMT and Paramedic Programs - Prepares and presents classroom didactic instruction for the EMT and Paramedic Programs - Prepares and maintains all required documentation - Ensures ...

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Team Captain (Paramedic) - Galveston County Health District

Make a Difference in your community and join our Emergency Medical Service Team! Galveston County Health District is seeking a new Team Captain (Paramedic)! The right candidate will be for performing responsible and technical medical work dealing with emergency or non-emergency and/or lifesaving treatment of patients who are transported via Mobile Intensive Care Unit or Basic Life Support ambulance ...

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Director of EMS - Galveston County Health District

Make a difference in our community and lead our EMS team! Are you ready for the challenge" Galveston County Health District is seeking a new Director of EMS! The right candidate will be responsible for successfully managing all operational aspects of emergency medical and transport services provided by the Galveston County Health District's Galveston Area Ambulance Authority (GAAA). We can offer you: ...

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Training Day: Video laryngoscopes for increased intubation success

Ensure your EMS providers understand when to use video laryngoscopes and airway anatomy, and practice their intubation skills

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BVM: 3 tips to avoid over-ventilating your patient

The bag-valve-mask can save your patient's life; ensure you're using it properly with these tools

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Johnson and Johnson Innovation opens JLABS @ NYC in collaboration with New York state and the New York Genome Center

NEW YORK CITY — Johnson & Johnson Innovation LLC today announced the opening of JLABS @ NYC. The 30,000-square foot facility, located at the New York Genome Center in the heart of SoHo, is a collaboration between Johnson & Johnson Innovation, New York State and the New York Genome Center. JLABS @ NYC can accommodate up to 30 biotech, pharmaceutical, medical device, consumer and health ...

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CATI’s CQB Armor will do more than just stop bullets

If you are law enforcement, security, or a first responder of any kind, you deserve two things: To be safe. And to be comfortable. CATI Armor has what you deserve, all packaged up and ready to ship. You're out there pounding the streets day after day. Endless hours in the vehicle. Endless hours on your feet. Head constantly on a swivel, reporting and observing everything in sight, ready to respond ...

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Time is running short in California Casualty’s “Better Safe than Sorry” Safe Giveaway

SAN MATEO, Calif. — California Casualty, provider of auto and home insurance for first responders across the country, is reminding law enforcement officers, firefighters and EMTs that they can win a Liberty Safe filled with 5.11 Tactical gear from the company's Work Hard/Play Hard "Better Safe Than Sorry" Sweepstakes. Three lucky winners will each receive $2,250 to purchase the ...

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Aortoenteric fistula: a rare cause of upper gastrointestinal bleed captured on endoscopy with exceptional clarity

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Improving Rates of Early Entry Prenatal Care in an Underserved Population

Abstract

Introduction Early prenatal care can improve pregnancy outcomes, reduce complications, and ensure a healthier pregnancy. Unfortunately, many pregnant women do not seek early care. This research provides a framework for improving prenatal care in a low income community-based obstetrics clinic. Methods A multi-disciplinary quality improvement initiative was implemented at a large federally qualified health clinic in Houston, Texas to improve the rate of early entry into prenatal care by identifying barriers through patient surveys, focus groups, stakeholder feedback, and improving processes to reduce these barriers. Results A significant increase in early prenatal care was achieved by redesigning operational and clinical processes to improve access to care, expand patient education and outreach, increase resources, extend hours of operation, and increase presumptive insurance eligibility. Three months post implementation, an increase of 44.5% (p < 0.001) occurred in patients who had a prenatal visit in the first trimester. Patients with early prenatal care had better obstetrical and neonatal outcomes; however, the results were not statistically significant likely due to the small sample size. Discussion This quality improvement project provides various strategies and resources for other community-based clinics to consider when seeking improvement in their rates of early prenatal care.

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How Do the Mechanical Demands of Cycling Affect the Information Content of the EMG?

Purpose The persistence of phase-related information in EMG signals can be quantified by its entropic half-life, EnHL. It has been proposed that the EnHL would increase with the demands of a movement task, and thus increase as the pedalling power increased during cycling. However, simulation work on the properties of EMG signals suggests that the EnHL depends on burst duration and duty cycle in the EMG that may not be related to task demands. This study aimed to distinguish between these alternate hypotheses. Methods The EnHL was characterized for 10 muscles from nine cyclists cycling at a range of powers (35 to 260 W) and cadences (60 to 140 r.p.m.) for the raw EMG, phase-randomized surrogate EMG, EMG intensity and the principal components describing the muscle coordination patterns. Results There was phase-related information in the raw EMG signals and EMG intensities that was related to the EMG burst duration, duty cycle pedalling cadence and power. The EnHLs for the EMG intensities of the individual muscles (excluding quadriceps) and for the coordination patterns decreased as cycling power and cadence increased. Conclusions The EnHLs provide information on the structure of the motor control signals and their constituent motor unit action potentials, both within and between muscles, rather than on the mechanical demands of the cycling task per se. Corresponding Author: James M. Wakeling, Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada. phone 1-778-7828444. fax 1-778 7823040. wakeling@sfu.ca Conflicts of Interest and Source of Funding: There are no professional relationships with companies or manufacturers to disclose for all authors. This research was supported by the Natural Sciences and Engineering Research Council of Canada. The results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Submitted for publication November 2017. Accepted for publication June 2018. © 2018 American College of Sports Medicine

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Sport and Triad Risk Factors Influence Bone Mineral Density in Collegiate Athletes

Purpose Athletes in weight bearing sports may benefit from higher bone mineral density (BMD). However, some athletes are at risk for impaired BMD with Female Athlete Triad (Triad). The purpose of this study is to understand the influence of sports participation and Triad on BMD. We hypothesize that athletes in high-impact and multi-directional loading sports will have highest BMD, whereas non-impact and low-impact sports will have lowest BMD. Triad risk factors are expected to reduce BMD values independent of sports participation. Methods 239 female athletes participating in 16 collegiate sports completed dual energy x-ray absorptiometry (DXA) scans to measure BMD Z-scores of the lumbar spine(LS) and total body(TB). Height and weight were measured to calculate body mass index (BMI). Triad risk assessment variables were obtained from preparticipation examination. Mean BMD Z-scores were compared between sports and by sport category (high-impact, multi-directional, low-impact, and non-impact). Multivariable regression analyses were performed to identify differences of BMD Z-scores accounting for Triad and body size/composition. Results Athlete populations with lowest average BMD Z-scores included synchronized swimming (LS:-0.34,TB:0.21) swimming/diving (LS:0.34,TB:-0.06), crew/rowing (LS:0.27,TB:0.62), and cross-country (LS:0.29,TB:0.91). Highest values were in gymnastics (LS:1.96,TB:1.37), volleyball (LS:1.90,TB:1.74), basketball (LS:1.73,TB:1.99), and softball (LS:1.68,TB:1.78). All Triad risk factors were associated with lower BMD Z-scores in univariable analyses; only low BMI and oligomenorrhea/amenorrhea were associated in multivariable analyses (all P

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Reducing Impact Loading in Runners: A One-Year Follow-up

Increased vertical impact loading during running has been associated with a variety of running related injuries including stress fractures, patellofemoral pain and plantar fasciitis. Purpose The purpose of this study was to examine the acute and long-term effect of a gait retraining program aimed at teaching runners with high impact loading to run softer. Methods 19 runners with high tibial shock first underwent a control period of 8 sessions of treadmill running over 2 weeks, progressing from 15 to 30 minutes. This was followed by 8 sessions of gait retraining over two weeks using the identical treadmill protocol. Real-time feedback of tibial shock was provided as the participant ran. Feedback was gradually removed during the last 4 sessions. Variables of interest included peak tibial shock (TS), vertical impact peak (VIP) and vertical average (VALR) and instantaneous loading rates (VILR). These variables were assessed at intervals following the retraining and at a one-year follow-up. Results All variables of interest were significantly reduced post-retraining (p

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Differences within Elite Female Tennis Players during an Incremental Field Test

Purpose To compare technical and physiological responses between junior and professional female players during an incremental field test to exhaustion specific to tennis (TEST). Methods Twenty-seven female players (n=14 and 13 for juniors and professionals, respectively) completed an incremental field test to exhaustion specific to tennis, which consisted of hitting alternatively forehand and backhand strokes at increasing ball frequency (ball machine) every minute. Ball accuracy and ball velocity were determined by radar and video analysis for each stroke, in addition to cardiorespiratory responses (portable gas analyzer). Results The stage corresponding to the second ventilatory threshold (+ 20.0%, P = 0.027), time to exhaustion (+ 18.9%, P = 0.002) and V[Combining Dot Above]O2max (+ 12.4%, P = 0.007) were higher in professionals than in juniors. The relative percentage of maximal heart rate was lower at both the first (– 4.7%, P = 0.014) and the second (– 1.3%, P = 0.018) ventilatory thresholds in professionals. Backhand ball velocity was the only technical parameter that displayed larger (+ 7.1%, P = 0.016) values in professionals. Conclusion Compared to juniors, female professional tennis players possess higher exercise capacity, maximal and submaximal aerobic attributes along with faster backhand stroke velocities during an incremental field test specific to tennis. Address for correspondence: Cyril Brechbuhl, French Tennis Federation, National Tennis Center, 4 Place de la Porte Molitor, 75016 Paris, France. Tel: +33 675 00 16 46. e-mail: cyril.brechbuhl@fft.fr The authors have no conflicts of interest, source of funding, or financial ties to disclose and no current or past relationship with companies or manufacturers who could benefit from the results of the present study. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and statement that results of the present study do not constitute endorsement by ACSM. Submitted for publication April 2018. Accepted for publication June 2018. © 2018 American College of Sports Medicine

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EARLY MOTOR UNIT CONDUCTION VELOCITY CHANGES TO HIIT VERSUS CONTINOUS TRAINING

Purpose Moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT) are associated with different adjustments in motor output. Changes in motor unit (MU) peripheral properties may contribute to these adjustments, but this is yet to be elucidated. This study evaluated early changes in MU conduction velocity (MUCV) and MU action potential (MUAP) amplitude following two weeks of either HIIT or MICT. Methods Sixteen men were assigned to either an MICT or HIIT group (n=8 each), and participated in six training sessions over 14 days. HIIT: 8-12×60-s intervals at 100% peak power output. MICT: 90-120min continuous cycling at ~65% VO2peak. Pre and post intervention, participants performed maximal voluntary contractions (MVC) and submaximal (10, 30, 50 and 70% of MVC) isometric knee extensions while high-density electromyography (HDEMG) was recorded from the vastus medialis (VM) and vastus lateralis (VL) muscles. The HDEMG was decomposed into individual MUs by convolutive blind-source separation and tracked pre-and post-intervention. Results Both training interventions induced changes in MUCV, but these changes depended on the type of training (p

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The Respiratory Compensation Point/Deoxy-BP are not Valid Surrogates for Critical Power/Maximum Lactate Steady State

No abstract available

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Is Ischemic Preconditioning Feasible to Improve Performance at Moderate Altitude?

No abstract available

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Response

No abstract available

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Small-sided Soccer in School Reduces Postprandial Lipaemia in Adolescent Boys

Purpose While laboratory based moderate- to high-intensity exercise reduces postprandial lipaemia in adolescents this exercise differs to the free-living physical activities in which young people typically engage. This study compared the effect of free-living afterschool soccer activity and treadmill exercise on in-school postprandial lipaemia in adolescent boys. Methods Fifteen boys (12.6 (0.5) years) completed three, 2-day experimental trials. On Day 1, participants either: rested (CON); exercised for 48 min on a treadmill at 60% peak V[Combining Dot Above]O2 (TM); played 48 min of 5-a-side soccer (SOC). On Day 2, participants attended school where a capillary blood sample determined fasting triacylglycerol ([TAG]) and glucose ([glucose]) concentrations. Participants then consumed a standardised breakfast (0 h) and lunch (4.5 h) and blood samples were taken postprandially at 2.5, 5.0 and 7.0 h. Results Reductions in fasting [TAG] were small-moderate after TM (-16%, 95% CI = -27 to -2%, ES = 0.46), but large after SOC (-30%, 95% CI = -40 to -20%, ES = 1.00) compared with CON; the concentration was also lower in SOC compared with TM (-18%, 95% CI = -29 to -5%, ES = 0.53). Based on ratios of geometric means, the area under the TAG versus time curve was 18% lower after TM (95% CI = -29 to -5%, ES = 0.51) and 25% lower after SOC (95% CI = -35 to -13%, ES = 0.76,) compared with CON. In contrast, SOC and TM were not significantly different (-9%, 95% CI = -21 to 5%, ES = 0.25). Conclusion Compared with duration-matched inactivity (CON), after-school small sided soccer (SOC) and treadmill exercise (TM) resulted in a similar, moderate reduction of postprandial lipaemia in adolescent boys. Corresponding author: Dr Keith Tolfrey, Loughborough University, School of Sport Exercise and Health Sciences, Epinal Way, Loughborough, LE11 3TU. k.tolfrey@lboro.ac.uk, +44 (0)1509 226355 The authors acknowledge the support of the North American Society for Pediatric Exercise Medicine (NASPEM) and their awarding of the Marco Cabrera Student Research Award to support this research. This research was supported by the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The authors declare no conflict of interest. The results of the present study do not constitute endorsement by ACSM. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for Publication: 16 June 2018 © 2018 American College of Sports Medicine

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RESISTANCE EXERCISE SELECTIVELY MOBILIZES MONOCYTE SUBSETS: ROLE OF POLYPHENOLS

Purpose To examine the impact of polyphenol supplementation on the recruitment, mobilization and activation of monocyte subsets following resistance exercise. Methods Thirty-eight recreationally active males (22.1 ± 3.1 yrs; 173.9 ± 7.9 cm; 77.8 ± 14.5 kg) were assigned to 28-days of polyphenol supplementation (PPB), placebo (PL) or control (CON). Blood samples were obtained before (PRE), immediately-(IP), one-(1H), five-(5H), 24-(24H) and 48-(48H) hours post-resistance exercise (PPB/PL) or rest (CON). Fine-needle biopsies were obtained from the vastus lateralis at PRE, 1H, 5H and 48H. Circulating concentrations of macrophage chemoattractant protein-1 (MCP-1) and fractalkine, as well as intramuscular MCP-1 were analyzed via multiplex assay. Changes in the proportions and expression of CD11b on monocyte subsets were assessed via flow cytometry. Results Circulating MCP-1 increased in PPB and PL at IP with further increases at 5H. Intramuscular MCP-1 was increased at 1H, 5H and 48H in all groups. Classical monocyte proportions were reduced in PPB and PL at IP, and increased at 1H. Nonclassical monocytes were increased in PPB and PL at IP, while intermediate monocytes were increased at IP, and reduced at 1H. Intermediate monocytes were increased in PPB at 24H and 48H. CD11b expression was reduced on PPB compared to PL and CON at PRE on intermediate and nonclassical monocytes. Conclusions Resistance exercise may elicit selective mobilization of intermediate monocytes at 24H and 48H, which may be mediated by tissue damage. Additionally, polyphenol supplementation may suppress CD11b expression on monocyte subsets at rest. Author Contributions:Conception and design of research: ARJ, JRH, JRT, KSB, DDC, KAH, JRS; Acquisition of data: ARJ, JRT, KSB, ANV, DDC, LPO; Data analysis and interpretation: ARJ, JRH, DDC, DHF; Manuscript draft and revision: ARJ, JRH, KAH SRA, DHF, JRS; Approval of final version: ARJ, JRH, JRT, KSB, ANV, DDC, LPO, KAH, SRA, DHF, JRS. Clinical Trial Registration: NCT02442245 Corresponding Author: Adam R. Jajtner, PhD. Department of Exercise Physiology; Kent State University, 350 Midway Dr.; Kent, OH 44242, Phone: 330-672-0212; Fax: 330-672-2250. ajajtner@kent.edu Funding: Kemin Foods, L.C. Conflict of Interest: KAH is employed by Kemin Foods, LC. All other authors report no actual or potential conflicts of interest. Accepted for Publication: 18 June 2018 © 2018 American College of Sports Medicine

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Intermittent Running and Cognitive Performance after Ketone Ester Ingestion

Purpose Ingestion of exogenous ketones alters the metabolic response to exercise and may improve exercise performance, but has not been explored in variable intensity team sport activity, or for effects on cognitive function. Methods On two occasions in a double-blind, randomised crossover design, eleven male team sport athletes performed the Loughborough Intermittent Shuttle Test (Part A, 5x15 min intermittent running; Part B, shuttle run to exhaustion), with a cognitive test battery before and after. A 6.4% carbohydrate-electrolyte solution was consumed before and during exercise either alone (PLA), or with 750 mg⋅kg−1 of a ketone ester supplement (KE). Heart rate (HR), rating of perceived exertion (RPE), and 15 m sprint times were recorded throughout, and serial venous blood samples were assayed for plasma glucose, lactate and β-hydroxybutyrate (βHB). Results KE resulted in plasma βHB concentrations of ~1.5 to 2.6 mM during exercise (P

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Physical Activity, Cardiorespiratory Fitness, and Incident Glaucoma

Purpose To examine the associations of physical activity and cardiorespiratory fitness (hereafter fitness) with incident glaucoma in a prospective observational study. Methods Physical activity was measured by self-reported leisure-time activities and fitness was measured by maximal treadmill test. Incident glaucoma was defined based on physician-diagnosis. Participants were 9519 men and women between the ages of 40 and 81 years old (mean age 50) who were enrolled in the Aerobics Center Longitudinal Study. Hazard ratios were estimated using Cox proportional hazard regression after adjusting for age, sex, race, examination year, smoking status, heavy alcohol drinking, hypertension, hypercholesterolemia, abnormal electrocardiogram, diabetes, cardiovascular disease, and cancer. Results Total 128 cases of incident glaucoma were reported during a mean follow-up of 5.7 years. A significantly lower risk of incident glaucoma (hazard ratio [HR] 0.53, 95% confidence interval [95% CI] 0.35-0.79), was found in individuals who met the physical activity guidelines of ≥500 metabolic equivalent-minutes (MET-min) per week compared to inactive individuals (0 MET-min/week). Compared with low fitness (lower third), individuals with high fitness (upper third) also had a significantly lower risk of incident glaucoma (HR 0.60, 95% CI 0.38-0.95). A joint analysis of physical activity and fitness showed that meeting physical activity guidelines and being in the high fitness category was associated with the lowest risk for developing glaucoma (HR 0.49, 95% CI 0.31-0.79). Conclusion These data provide epidemiological evidence that meeting physical activity guidelines or being fit reduces the risk of developing glaucoma. Correspondence: Dr. Duck-chul Lee, Iowa State University, 103H Forker Building, Ames, IA 50011, Phone: (515) 294-8042, Fax: (515) 294-8740, email: dclee@iastate.edu This study was supported by the National Institutes of Health grants (AG06945, HL62508, DK088195, and HL133069). Steven N. Blair has received unrestricted research grants from The Coca-Cola Company, but the grants were not used to support this manuscript. Other authors declare no conflicts of interest. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The authors have no conflicts of interest. The results of the present study do not constitute endorsement by the American College of Sports Medicine. Accepted for Publication: 12 June 2018 © 2018 American College of Sports Medicine

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