Molecular Epidemiology of Plasmid-Mediated Fosfomycin Resistance Gene Determinants in Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae Isolates in China

Microbial Drug Resistance, Ahead of Print.


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Multiple Drug Resistance and Virulence Profiling of Salmonella enterica Serovars Typhimurium and Enteritidis from Poultry Farms of Faisalabad, Pakistan

Microbial Drug Resistance, Ahead of Print.


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Overexpression of the nuclear protein gene AtDUF4 increases organ size in Arabidopsis thaliana and Brassica napus

Publication date: Available online 16 August 2018

Source: Journal of Genetics and Genomics

Author(s): Guang-Xia Chen, Xi Cao, Zhao-Xia Ma, Yu Tang, Yue-Juan Zeng, Li-Qun Chen, De Ye, Xue-Qin Zhang

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Genome-wide variants of Eurasian facial shape differentiation and a prospective model of DNA based face prediction

Publication date: Available online 16 August 2018

Source: Journal of Genetics and Genomics

Author(s): Lu Qiao, Yajun Yang, Pengcheng Fu, Sile Hu, Hang Zhou, Shouneng Peng, Jingze Tan, Yan Lu, Haiyi Lou, Dongsheng Lu, Sijie Wu, Jing Guo, Li Jin, Yaqun Guan, Sijia Wang, Shuhua Xu, Kun Tang

ABSTRACT

It is a long-standing question as to which genes define the characteristic facial features among different ethnic groups. In this study, we use Uyghurs, an ancient admixed population to query the genetic bases why Europeans and Han Chinese look different. Facial traits were analyzed based on high-dense 3D facial images; numerous biometric spaces were examined for divergent facial features between European and Han Chinese, ranging from inter-landmark distances to dense shape geometrics. Genome-wide association studies (GWAS) were conducted on a discovery panel of Uyghurs. Six significant loci were identified, four of which, rs1868752, rs118078182, rs60159418 at or near UBASH3B, COL23A1, PCDH7 and rs17868256 were replicated in independent cohorts of Uyghurs or Southern Han Chinese. A prospective model was also developed to predict 3D faces based on top GWAS signals and tested in hypothetic forensic scenarios.

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Microlesion effects, suboptimal lead placement and disease progression are critical determinants for DBS tolerance in essential tremor

Publication date: Available online 16 August 2018

Source: Clinical Neurophysiology

Author(s): Aparna Wagle Shukla, Michael S. Okun

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Virtual Reality for Neurorehabilitation: Insights from Three European Clinics

Virtual reality for the treatment of motor impairment is a burgeoning application of digital technology in neurorehabilitation. Virtual reality systems pose an opportunity for healthcare providers to augment the dose of task orientated exercises delivered both in the clinic, and via telerehabilitation models in the home. The technology is almost exclusively applied as an adjunct to traditional approaches and is typically characterised by the use of gamified exergames which feature task orientated physiotherapy exercises.

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Music meets robotics: a prospective randomized study on motivation during robot aided therapy

Robots have been successfully applied in motor training during neurorehabilitation. As music is known to improve motor function and motivation in neurorehabilitation training, we aimed at integrating music cre...

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Observed Patterns of Cervical Radiculopathy: How Often do They Differ from a Standard, “Netter-diagram” Distribution?

Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a "Netter diagram." To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF.

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Fungal spinal epidural abscess: a case series of nine patients

Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature.

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Diagnostic value of FDG-PET versus magnetic resonance imaging for detecting spondylitis: a systematic review and meta-analysis

Spondylitis is a rare infection in bone requiring multiple diagnostic strategies for verification.

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Microlesion effects, suboptimal lead placement and disease progression are critical determinants for DBS tolerance in essential tremor

Merchant et al. propose a computerized spiral analysis test for differentiation of essential tremor (ET) patients who develop "early tolerance" to deep brain stimulation (DBS) benefits (within two years) from those who exhibit sustained improvements (Merchant et al., 2018). In their study, ET patients were identified to develop "early tolerance" if they had a higher degree of severity score and a greater loop-to-loop width variability index on spiral drawings. The latter characteristic is usually observed in patients with underlying cerebellar dysfunction.

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Management of ulcerative colitis in a real-life setting: an Italian multicenter, prospective, observational AIGO study

No data are available on the variability in the clinical management of ulcerative colitis (UC) patients by Italian gastroenterologists. Therefore, improving the standards of UC care as provided by the National Welfare Clinical Path (PDTA), in accordance with the European Crohn's and Colitis Organization (ECCO) guidelines for UC, is not easy.

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Paramedic - UCHealth

**Paramedic** **responds to calls for emergency medical services and provides patient care as directed and/or determined necessary.** **Requirements** - High School diploma or GED. - National Certification as defined by the unit certification list. - Current State Licensure as an EMT-P. - Valid Driver's License. - Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) Healthcare Provider. BLS ...

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Management of ulcerative colitis in a real-life setting: an Italian multicenter, prospective, observational AIGO study

No data are available on the variability in the clinical management of ulcerative colitis (UC) patients by Italian gastroenterologists. Therefore, improving the standards of UC care as provided by the National Welfare Clinical Path (PDTA), in accordance with the European Crohn's and Colitis Organization (ECCO) guidelines for UC, is not easy.

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Patient-centered EMS leadership

Patient-centered care partnerships with patients and family need to start at the top

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How to keep PTSD out of your EMS agency

Recognize the risk factors and symptoms of PTSD, and how to manage self-talk and meditate to reduce its physical and emotional effects

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Dispersion and removal characteristics of tritium originated from nuclear power plants in the atmosphere

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 192

Author(s): Jung-Seok Chae, Guebuem Kim

Abstract

The activities of tritium in water-vapor (n = 649) and precipitation (n = 2404) samples were measured from 1998 to 2015 around the Wolsong nuclear power plant (NPP) site where four pressurized heavy water reactors and two pressurized water reactors operated. The activity concentrations of tritium in the water-vapor and precipitation samples were in the ranges of 2.2–2200 Bq/L and 0.3–1090 Bq/L, respectively. The concentrations of tritium in the water-vapor in spring were approximately 7 times higher than those in fall and winter, mainly owing to the wind directions at the power plant location. The annual geometric mean activities of tritium in the water-vapor and precipitation samples varied within 56% and 83% from the average, respectively, depending primarily on the annual discharge amount of tritium to the atmosphere. The activities of tritium in the water-vapor and precipitation samples rapidly decreased away from the power plant. Approximately 0.5–30% of tritium discharged from the NPP site was removed by precipitation to the ground within an area with a radius of 30 km from the NPP site, which linearly depended on the precipitation amount. Our results suggest that the wind direction and precipitation, in addition to the amount of discharge, are important factors that control the tritium concentrations in air near the NPP site.

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Colin Groves (1942–2017)

Publication date: Available online 16 August 2018

Source: Journal of Human Evolution

Author(s): Bernard Wood, Peter Andrews

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Sexual dimorphism of body size in an African fossil ape, Nacholapithecus kerioi

Publication date: Available online 16 August 2018

Source: Journal of Human Evolution

Author(s): Yasuhiro Kikuchi, Masato Nakatsukasa, Hiroshi Tsujikawa, Yoshihiko Nakano, Yutaka Kunimatsu, Naomichi Ogihara, Daisuke Shimizu, Tomo Takano, Hideo Nakaya, Yoshihiro Sawada, Hidemi Ishida

Abstract

Sexual size dimorphism in the African fossil ape Proconsul nyanzae (18 million years ago, 18 Ma) has been previously documented. However, additional evidence for sexual dimorphism in Miocene hominoids can provide great insight into the history of extant hominoid mating systems. The present study focused on body mass (BM) sexual dimorphism in Nacholapithecus kerioi from the Middle Miocene (16–15 Ma) in Africa. Bootstrap analysis revealed that P. nyanzae BM sexual dimorphism was lower than that in Pan troglodytes, which exhibits moderate sexual dimorphism, as reported previously. The same simulation revealed that BM sexual dimorphism of N. kerioi was comparable with that in Gorilla spp.; i.e., the males were approximately twice as large as the females. High sexual dimorphism in extant apes is usually indicative of a polygynous social structure (gorilla) or solitary/fission-fusion social system (orangutan). However, because of the high proportion of adult males in this fossil assemblage, the magnitude of dimorphism inferred here cannot be associated with a gorilla-like polygynous or oranguran-like solitary/fission-fusion social structure, and may reflect either taphonomic bias, or some other social structure. Extant hominoids have a long evolutionary history owing to their deep branching, comprising only a few existing members of the original highly successful group. Therefore, it is not surprising that the mating systems of extant hominoids fail to provide fossil apes with a perfect "model". The mating systems of extinct hominoids may have been more diverse than those of extant apes.

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Barriers and Facilitators to Breast and Cervical Cancer Screening Among Immigrants in the United States

Abstract

To summarize the literature on barriers and facilitators to breast and cervical cancer screening among immigrants to the US. A literature review was conducted for studies on breast and cervical cancer screening among immigrant populations. A thematic analysis of 180 studies identified a variety of barriers and facilitators to screening at the personal and system levels. Personal barriers included lack of knowledge and insurance coverage, high cost of care, and immigration status. System barriers included poor access to services, lack of interpreter services, and insensitivity to patient needs. Facilitators to screening included knowledge of disease, access to information sources, physician recommendation, and social networks. Cultural norms and resource availability at the individual and system levels influence screening among immigrants. Health insurance coverage was found to be an important predictor of preventative screening use. Future research should seek to identify the best way to address this and other barriers to cancer screening among immigrants groups.

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Genomic Sequencing Assays Characterize the Mutational Landscape of Advanced Thyroid Cancers

Clinical Thyroidology, Volume 30, Issue 8, Page 371-373, August 2018.


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Serum TSH Remains Normal in Those without Significant Risk Factors for Thyroid Dysfunction

Clinical Thyroidology, Volume 30, Issue 8, Page 385-387, August 2018.


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Alemtuzumab, a Monoclonal Antibody to CD52, Frequently Causes Graves’ Disease

Clinical Thyroidology, Volume 30, Issue 8, Page 353-355, August 2018.


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Macro-TSH May Cause a Spurious Diagnosis of Subclinical Hypothyroidism in About 1% of Patients

Clinical Thyroidology, Volume 30, Issue 8, Page 377-380, August 2018.


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Concurrent Differentiated Thyroid Carcinoma (DTC) and Graves’ Disease Has Similar Outcome to DTC Alone

Clinical Thyroidology, Volume 30, Issue 8, Page 356-360, August 2018.


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Hypothyroidism Is Associated with Increased Mortality Risk in Individuals 65 Years of Age or Older

Clinical Thyroidology, Volume 30, Issue 8, Page 350-352, August 2018.


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Patients with Differentiated Thyroid Cancer Who Undergo Reoperation for Recurrence Have Increased Mortality

Clinical Thyroidology, Volume 30, Issue 8, Page 361-363, August 2018.


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There Is No Evidence for Any Effects of TSH on Bone Mineral Density in Humans

Clinical Thyroidology, Volume 30, Issue 8, Page 374-376, August 2018.


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The 2015 ATA Guidelines for the Prediction of Thyroid Cancer Based on Ultrasonography Overestimate the Incidence of Thyroid Cancer

Clinical Thyroidology, Volume 30, Issue 8, Page 364-367, August 2018.


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What Is the Clinical Importance of TSH Staining in Pituitary Tumors?

Clinical Thyroidology, Volume 30, Issue 8, Page 381-384, August 2018.


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Multimodality Therapy Is Needed for Anaplastic Thyroid Cancer

Clinical Thyroidology, Volume 30, Issue 8, Page 368-370, August 2018.


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Gallium-68-PSMA-PET/CT Outperforms Radioiodine Scintigraphy and FDG–PET/CT in a Prospective Series of 10 Patients with Metastasized Differentiated Thyroid Cancer

Clinical Thyroidology, Volume 30, Issue 8, Page 388-390, August 2018.


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The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Abstract

Background

Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.

Objectives

This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.

Methods

Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion. Participants: Elderly individuals (65 + years) who underwent total knee arthroplasty. Interventions: Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

Synthesis methods

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I². A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.

Results

Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I² = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I² = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I² = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I² = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I² = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I² = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I² = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r² = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r² = 0.02; standardised β = 0.13; P = 0.48).

Limitations

A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.

Conclusion

Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

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Intra- and Inter-Muscular Variations in Hamstring Architecture and Mechanics and Their Implications for Injury: A Narrative Review

Abstract

Understanding the architecture, anatomy, and biomechanics of the hamstrings may assist in explaining the mechanisms that affect and improve their function. The aim of this review is to specifically examine intra- and inter-muscular variations in architecture and mechanical properties of the hamstrings. Of the hamstrings, the long head of the biceps femoris shows the shortest and more pennated fibers. The semimembranosus has a similar muscle architecture with a long head of the biceps femoris but it has a different proximal attachment as well as a different moment arm compared with the long head of the biceps femoris. For the same joint motion, the semitendinosus displays less relative strain than the other hamstrings probably owing to a greater length, longer fascicles and, possibly, a longer tendon. Intra-muscular variations in architecture are documented but their implications are currently unclear. Proximally, the long head of the biceps femoris has shorter and more pennated fibers coupled with a narrower aponeurosis than distally, while the semitendinosus is the only muscle that entails a tendinous inscription. In conclusion, some of the identified intra- and inter-muscular variations in architecture may help explain why some muscles sustain injuries more than others. In the same line, exercises designed for the hamstrings may not provide the same stimulus for all components of this muscle group. Future research could examine whether intervention strategies that target specific muscles or specific areas of the hamstrings may offer additional benefits for injury prevention or rehabilitation of their function.

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Genomic data sharing: the Australian context

Abstract

The regulation of genomic data sharing in Australia is a confusing mix of common law, legislation, ethical guidelines, and codes of practice. Beyond privacy laws, which only apply to genomic data that meets the definition of personal information, the key regulatory lever is the National Health and Medical Research Council (NHMRC) National Statement for Ethical Conduct in Human Research ("National Statement") (2007). Compliance with the National Statement is a requirement for institutions to apply to the NHMRC for funding, and includes—among other things—requirements for review of most genomic research by Human Research Ethics Committees. The sections of the National Statement specifying requirements for research with human genomic data are currently under review, including proposed new requirements addressing the return of genetic research findings and oversight of transfer agreements. Ensuring the willingness of Australians to donate their genomic information and participate in medical research will require clarification and harmonisation of the applicable regulatory framework, along with reforms to ensure that these regulations reflect the conditions necessary to promote ongoing public trust in researchers and institutions.

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The effects of dietary supplementation with inulin and inulin-propionate ester on hepatic steatosis in adults with non-alcoholic fatty liver disease

Diabetes, Obesity and Metabolism

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Travelling waves and tonotopicity in the inner ear: a historical and comparative perspective

Abstract

In the 1940s, Georg von Békésy discovered that in the inner ear of cadavers of various vertebrates, structures responded to sound with a displacement wave that travels in a basal-to-apical direction. This historical review examines this concept and sketches its rôle and significance in the development of the research field of cochlear mechanics. It also illustrates that this concept and that of tonotopicity necessarily correlate, in that travelling waves are consequences of the existence of an ordered, longitudinal array of receptor cells tuned to systematically changing frequencies along the auditory organ.

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Germany: a fair balance between scientific freedom and data subjects’ rights?

Abstract

With the German Bundestag's adoption of the Data Protection Adaptation and Implementation Act EU (DSAnpUG-EU) on 30 June 2017, the adaptation of German law to the General Data Protection Regulation (GDPR) has begun (Gesetz zur Anpassung des Datenschutzrechts an die Verordnung (EU) 2016/679 und zur Umsetzung der Richtlinie (EU) 2016/680 (Datenschutz-Anpassungs- und -Umsetzungsgesetz—DSAnpUG-EU) v. 30. Juni 2017, BGBl. 2017 I p. 2097 et seq.). Despite being directly binding on all EU member states, the GDPR does not render national data protection provision obsolete—they are covered by the GDPR's opening clauses which include regulatory mandates and room for derogation. This creates considerable need for national legislative adaptation. Art. 1 DSAnpUG-EU contains the necessary amendments to the Federal Data Protection Law (BDSG(neu)), thus creating the second major building block of future German data protection alongside the GDPR itself. Nevertheless, there are still numerous sector-specific regulations in other federal laws and the data protection laws of the 16 states also need amendments. Adjustment in Germany is well on its way, but implementation in general is still ongoing, with further consequences for data processing and sharing.

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Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration

Abstract

Background

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Severe NAFLD with advanced fibrosis results in substantial morbidity and mortality. Associated with metabolic syndrome, NAFLD is often initially clinically silent, yet intensive lifestyle intervention with 7% or greater weight loss can improve or resolve NAFLD. Using a Veterans Health Administration (VHA) liver biopsy cohort, we evaluated simple noninvasive fibrosis scoring systems to identify NAFLD with advanced fibrosis (or severe disease) to assist providers.

Methods

In our retrospective study of a national VHA sample of patients with biopsy-proven NAFLD or normal liver (2005–2015), we segregated patients by fibrosis stage (0–4). Non-NAFLD liver disease was excluded. We evaluated the diagnostic accuracy of the NAFLD fibrosis score (NFS), fibrosis-4 calculator (FIB-4), aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT ratio), AST-to-platelet ratio index (APRI), and body mass index, AST/ALT ratio, and diabetes (BARD) score by age groups.

Results

We included 329 patients with well-defined liver histology (296 NAFLD and 33 normal controls without fibrosis), in which 92 (28%) had advanced (stage 3–4) fibrosis. Across all age groups, NFS and FIB-4 best predicted advanced fibrosis (NFS with 0.676 threshold: AUROC 0.71–0.76, LR + 2.30–22.05, OR 6.00–39.58; FIB-4 with 2.67 threshold: AUROC of 0.62–0.80, LR + 4.70–27.45, OR 16.34–59.65).

Conclusions

While NFS and FIB-4 scores exhibit good diagnostic accuracy, FIB-4 is optimal in identifying NAFLD advanced fibrosis in the VHA. Easily implemented as a point-of-care clinical test, FIB-4 can be useful in directing patients that are most likely to have advanced fibrosis to GI/hepatology consultation and follow-up.

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Concise Commentary: Remaining Outside the Hospital Is a Golden State in Cirrhosis—Lessons from California

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Tumor Necrosis Factor Ligand-Related Molecule 1A Regulates the Occurrence of Colitis-Associated Colorectal Cancer

Abstract

Background

Tumor necrosis factor ligand-related molecule 1 A (TLlA) is closely related to the occurrence and development of inflammatory bowel disease.

Aims

We aimed to explore whether TLlA was involved in the occurrence of colitis-associated colorectal cancer (CAC).

Methods

Firstly, azoxymethane (AOM) and dextran sulfate sodium (DSS) were used to construct the CAC mice model in wild-type (WT) and TL1A transgenic (Tg) mice with TL1A high expression. The histopathological analysis was used for the evaluation of inflammation level, and the immunohistochemistry staining analysis was used to test the expression and location of proliferating cell nuclear antigen (PCNA) and β-catenin. Secondly, the HCT116 and HT29 cell lines were used for knockdown of TL1A gene for further assay including cell viability, cell clone, cell apoptosis and matrigel invasion. Western blot were used for quantitative protein expression of β-catenin and downstream oncogenes including c-myc and Cyclin D1 after knockdown of TL1A gene.

Results

The evaluation of inflammation level showed that the disease activity index score and tumor formation rate were significantly higher in AOM + DSS/Tg group than that in AOM + DSS/WT group. The expression of PCNA, β-catenin, c-myc, and Cyclin D1 in AOM + DSS/Tg group was significantly higher than that in AOM + DSS/WT group. The cell experiment showed that TL1A knockdown inhibited the cell proliferation, invasion, and migration. Moreover, the expression of c-myc and Cyclin D1 was significantly decreased after TL1A knockdown.

Conclusions

TL1A can induce tumor cell proliferation and promote the occurrence of CAC by activating Wnt/β-catenin pathway.

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G-POEM for Gastroparesis: Is There Pressure to Go with the Flow?

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High Expression of ABL2 Suppresses Apoptosis in Gastric Cancer

Abstract

Background

Diseases associated with Abelson-related gene (also called ABL2) include leukemia; furthermore, previous researches have studied the expressions and functions of ABL2 in different types of malignancies and found that it plays an important role in almost all kinds of cancers.

Aims

Nevertheless, the mechanism of ABL2 in gastric cancer (GC) remains vague.

Methods

In the present study, the level of ABL2 in human GC tissues was detected by immunohistochemistry. Also, the GC cell lines MGC-803 and BGC-823 were selected to stably knock down and overexpress the level of ABL2 by corresponding lentiviral vectors. Puromycin was used to maintain the stable low expression of ABL2 MGC-803 cells compared with control cells; what is more, the high expression of ABL2 BGC-823 cells was also obtained. Based on it, we detected the proteins associated with apoptosis, such as Bcl-2 family and caspase family by western blotting.

Results

The most appropriate concentration of puromycin to kill GC cells is 1 µg/mL; then, we obtained the corresponding stable cell lines. Furthermore, we found that high level of ABL2 in BGC-823 cells increased the expression of Bcl-XL, total PARP, and caspase3, while decreased the level of cleaved caspase3 and cleaved caspase9. Consistent results are received in MGC-803 cells. In addition, ABL2 overexpression led to the protein related with Ras/Erk and PI3K/AKT signaling pathway increased; also, we found that the major proteins play a significant role in it.

Conclusion

All the data showed that high expression of ABL2 suppresses apoptosis through Ras/Erk and PI3K/AKT signaling pathway in GC cell lines.

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Correction to: Antenatal Management for Women with Inflammatory Bowel Disease: Experience from Our ‘IBD MOM’ Clinic

The original version of the article unfortunately contained tagging error in first and family name of authors Ariella Bar-Gil Shitrit and Ami Ben Ya'acov. This has been corrected with this erratum.

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Hospital Cirrhosis Volume and Readmission in Patients with Cirrhosis in California

Abstract

Background

Patients with cirrhosis are at high readmission risk. Using a large statewide database, we evaluated the effect of hospital cirrhosis-related patient volume on 30-day readmissions in patients with cirrhosis.

Methods

We conducted a retrospective study of the Healthcare Cost and Utilization Project State Inpatient Database for adult patients with cirrhosis, as defined by International Classification of Diseases, Ninth Revision (ICD-9) codes, hospitalized in California between 2009 and 2011. Multivariable logistic regression analysis was performed to evaluate the effect of hospital volume on 30-day readmissions.

Results

A total of 69,612 patients with cirrhosis were identified in 405 hospitals; 24,062 patients were discharged from the top 10% of hospitals (N = 41) by cirrhosis volume, and 45,550 patients in the bottom 90% (N = 364). Compared with higher-volume centers, lower-volume hospitals cared for patients with similar average Quan–Charlson–Deyo (QCD) comorbidity scores (6.54 vs. 6.68), similar proportion of hepatitis B and fatty liver disease, lower proportion of hepatitis C (34.8 vs. 41.5%) but greater proportion of alcoholic liver disease (53.1 vs. 47.4%). Multivariable logistic regression analysis demonstrated admission to a lower-volume hospital did not predict 30-day readmission (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.92–1.01) after adjusting for sociodemographics, QCD score, cirrhosis severity, and hospital characteristics. Instead, liver transplant center status significantly decreased the risk of readmission (OR 0.87, 95% CI 0.80–0.94). Ascites, hepatic encephalopathy, hepatocellular carcinoma, higher QCD, and presence of alcoholic liver disease and hepatitis C were also independent predictors.

Conclusions

Readmissions within 30 days were common among patients with cirrhosis hospitalized in California. While hospital cirrhosis volume did not predict 30-day readmissions, liver transplant center status was protective of readmissions. Medically complicated patients with cirrhosis at hospitals without liver transplant centers may benefit from additional support to prevent readmission.

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Combined and Alternating Topical Steroids and Food Elimination Diet for the Treatment of Eosinophilic Esophagitis

Abstract

Background

Few studies have examined combined or alternating treatment algorithms in eosinophilic esophagitis.

Aims

We conducted a retrospective cohort study to ascertain the efficacy and adherence to a combined and alternating treatment approach with topical corticosteroids and 2-food elimination diet for pediatric EoE.

Methods

Patients were prescribed a 2-food elimination diet (milk and soy) and topical corticosteroid (fluticasone or oral viscous budesonide) for 3 months, after which the steroid was discontinued and 2-food elimination diet continued for 3 months. An EGD was performed at baseline, 3 and 6 months. Clinical, endoscopic, and histologic data were extracted from electronic medical records. Nonparametric tests assessed adherence and outcomes.

Results

Twenty-nine eosinophilic esophagitis cases were included (mean age 11.5 years, 61% male). Complete adherence to combined therapy and 2-food elimination diet alone was 75 and 79%, respectively. Median eosinophil counts decreased from 51 to 2 eosinophils/hpf (p < 0.001) after combined treatment and rebounded to 31 (p = 0.07) after 2FED alone. Dysphagia improved after both the combined and 2-food elimination diet alone treatment approaches (52 vs. 11% and 10%; p = 0.001, 0.005). Nonsignificant improvements in endoscopic findings were documented across the length of follow-up.

Conclusions

An initial combined treatment approach resulted in significant improvements in symptoms and histologic findings. While symptomatic improvements continued with 2-food elimination diet alone, the histologic improvement was not maintained. While loss to follow-up may obscure the efficacy of 2-food elimination diet alone, a combined/alternating treatment approach merits assessment in a larger prospective study.

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MiR-27a/b Regulates Liver Regeneration by Posttranscriptional Modification of Tmub1

Abstract

Background

Transmembrane and ubiquitin-like domain-containing 1 protein (Tmub1) negatively regulates liver regeneration. However, whether this regulation involves posttranscriptional modification of Tmub1 expression is unknown.

Aim

The aim of the study was to investigate whether microRNA (miR)-27a/b regulates posttranscriptional modification of Tmub1 and cell proliferation during liver regeneration.

Methods

Tmub1 mRNA 3′-untranslated region (UTR) sequences were analyzed using online software. A luciferase assay was used to verify the relationship between miR-27a/b and the 3′-UTR of Tmub1. Rat partial hepatectomy models were used to investigate miR-27a/b and Tmub1 levels after partial hepatectomy. MiR-27a/b expression was down- and up-regulated with mimics and inhibitors, respectively, to observe the effects of miR-27a/b on Tmub1 expression. Quantitative RT-PCR and Western blot analyses were used to measure miR-27a/b and Tmub1 expression. Hepatocyte proliferation was measured using the CCK8 method for BRL-3A liver cells and proliferating cell nuclear antigen and histone H3 phosphorylation in the regenerating liver.

Results

A potential binding site of miR-27a/b was found in the 3′-UTR sequence of Tmub1. Our luciferase assay confirmed that the Tmub1 mRNA 3′-UTR was the target of miR-27a/b. We observed a temporal correlation between miR-27a/b and Tmub1 expression during liver regeneration. MiR-27a/b down-regulated Tmub1 expression both in vivo and in vitro. MiR-27a/b regulated hepatocyte proliferation during liver regeneration.

Conclusion

MiR-27a/b regulates hepatocyte proliferation by controlling posttranscriptional modification of Tmub1 during liver regeneration.

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Small-Bowel Capsule Endoscopy in Clinical Practice: Has Anything Changed Over 13 Years?

Abstract

Background

In Lombardia, one of the 20 Italian administrative Regions, small-bowel capsule endoscopy (SBCE) was introduced in 2001. In January 2011, the Regional Health Authorities established a reimbursement for outpatient SBCE.

Aim

To prospectively record data on SBCE between 2011–2013 and compare them to similar data retrospectively collected from the same geographical area (covering the period 2001–2008) and published in 2008.

Methods

Consecutive SBCEs performed between January 2011 and December 2013 in Lombardia were prospectively collected.

Results

In 3 years, 3142 SBCEs were collected; the diagnostic yield (DY) and the overall complication rate were 48.4 and 0.9%, respectively. The main indication was suspected small-bowel bleeding (76.6% of patients); complete small-bowel inspection was achieved in 2796 (89.0%) patients. SBCE was performed as an outpatient procedure in 1945 patients (61.9%). A significant increase in the rate of patients undergoing SBCE for suspected small-bowel bleeding was observed from 2001–2008 to 2011–2013 (67.3 vs. 76.1%; p < 0.001). There was an increase in the number of complete small-bowel examinations (81.2 vs. 89.0%; p < 0.001) and of outpatient SBCEs (6.7 vs. 61.9%; p < 0.001). Conversely, both the retention rate (2.1 vs. 0.8%; p < 0.001) and the rate of patients undergoing SBCE for Crohn's disease (11.5 vs. 5.5%; p < 0.001) decreased significantly. The overall DY remained stable (50.6 vs. 48.4%; p = 0.089).

Conclusion

Our study shows that, over 13 years, the SBCE safety profile and completion rate significantly improved over time; a change in the spectrum of clinical indications was also observed.

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Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study

Abstract

Background

There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM.

Methods

A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL.

Results

Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups.

Conclusion

AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time.

Clinical Registration Number

CTRI: REF/2014/06/007146.

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Colorectal Polyps in Childhood Cancer Survivors Treated with Radiation Therapy

Abstract

Background

Cancer survivors treated with abdominal or pelvic radiation therapy (RT) for childhood cancer have an increased risk of colorectal cancer. However, clinical guidelines are inconsistent on recommendations regarding the early initiation of screening in these patients due to the lack of supporting evidence that these patients pass through a pre-invasive phase, in which adenomatous polyps can be detected and removed.

Aims

To determine the prevalence of adenomatous polyps in cancer survivors treated with RT for childhood cancer; the prevalence in average-risk patients aged 17–49; and the prevalence in average-risk patients aged 50–75.

Methods

We conducted a retrospective study comparing the prevalence of adenomatous polyps among three patient groups: childhood cancer survivors aged 17–49 with prior RT who underwent colonoscopy screening from 2006 to 2017; age- and gender-matched patients in the average-risk population; and average-risk patients aged 50–75.

Results

One hundred and forty-five patients were included in the study. The proportion of patients with adenomatous polyps in the cancer survivor group was significantly higher than that in the age- and gender-matched average-risk group (58.6 vs 17.2%, p = 0.00) and higher than the average-risk group aged 50–75 (58.6 vs 27.6%, p = 0.009). The prevalence of adenomas with high-risk features was higher in the survivor group compared to patients aged 50–75 (20.7 vs 3.5%, p = 0.015).

Conclusions

Cancer survivors treated with RT for childhood cancer have a higher prevalence of adenomatous polyps compared to the average-risk population. These findings support the early initiation of colonoscopy screening 10 years after radiation therapy, even in patients who have received RT doses below 30 Gy.

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Topical Steroids and Elimination Diets for EoE: Happier Together?

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Emergence delirium in children is related to epileptiform discharges during anaesthesia induction: An observational study

BACKGROUND Epileptiform discharges frequently occur in children during induction of anaesthesia. However, studies analysing the impact of epileptiform discharges on postoperative emergence delirium in children are still scarce. The aim of this study is to correlate the incidence of epileptiform activity during anaesthesia induction with the occurrence of emergence delirium during stay in the recovery room. OBJECTIVES Prospective, observational cohort study in children 0.5 to 8 years old undergoing planned surgery. Bifrontal electroencephalogram electrodes were placed before induction of anaesthesia. Visual electroencephalogram analysis was performed from start of anaesthetic agent administration until intubation with regard to epileptiform patterns: rhythmic polyspikes; periodic epileptiform discharges; delta with spikes; and suppression with spikes. Emergence delirium was assessed during stay in the recovery room using the Pediatric Assessment of Emergence Delirium Score. DESIGN Prospective, observational cohort study. SETTING University hospital – Germany/Berlin. Children were included between September 2015 and February 2017. PATIENTS A total of 62 Children, aged 0.5 to 8 years old undergoing planned surgery were included. MAIN OUTCOME MEASURES Primary outcome was emergence delirium. Secondary outcomes, peri-operative Electroencephalography (EEG) data analysis. The presented study analysed an association between emergence delirium and the occurrence of epileptiform discharges during anaesthesia induction. RESULTS A total of 43.5% of the children developed emergence delirium and 56.5% did not. Epileptiform discharges were observed more often in children developing emergence delirium (63%) compared with children not developing emergence delirium (43%). But only the occurrence of interictal spike events – such as rhythmic polyspikes; periodic epileptiform discharges and delta with spikes – were significantly related to emergence delirium (emergence delirium-group 48% vs. nonemergence delirium-group 14%, OR = 5.6 [95% CI: 1.7 to 18.7]; P = 0.004). CONCLUSION Emergence delirium in children is significantly related to interictal spike events occurring during induction of anaesthesia. CLINICAL TRIAL NCT02481999. Correspondence to Susanne Koch, Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany Tel: +49 30 450 651 078; fax: +49 30 450551019; e-mail: susanne.koch@charite.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Low-dose ketamine infusion reduces postoperative hydromorphone requirements in opioid-tolerant patients following spinal fusion: A randomised controlled trial

BACKGROUND The current opioid epidemic highlights the urgent need for effective adjuvant therapies to complement postoperative opioid analgesia. Intra-operative ketamine infusion has been shown to reduce postoperative opioid consumption and improve pain control in opioid-tolerant patients after spinal fusion surgery. Its efficacy for opioid-naïve patients, however, remains controversial. OBJECTIVE We hypothesised that low-dose ketamine infusion after major spinal surgery reduces opioid requirements in opioid-tolerant patients, but not in opioid-naïve patients. DESIGN Randomised placebo-controlled prospective study. SETTING Single-centre, tertiary care hospital, November 2012 until November 2014. PATIENTS A total of 129 patients were classified as either opioid-tolerant (daily use of opioid medications during 2 weeks preceding the surgery) or opioid-naïve group, then randomised to receive either ketamine or placebo; there were thus four groups of patients. All patients received intravenous hydromorphone patient-controlled analgesia postoperatively. INTERVENTION Patients in the ketamine groups received a ketamine infusion (bolus 0.2 mg kg−1 over 30 min followed by 0.12 mg kg−1 h−1 for 24 h). Patients in the placebo groups received 0.9% saline. MAIN OUTCOME MEASURES The primary outcome was opioid consumption during the first 24 h postoperatively. The secondary outcome was numerical pain scores during the first 24 h and central nervous system side effects. RESULTS Postoperative hydromorphone consumption was significantly reduced in the opioid-tolerant ketamine group, compared with the opioid-tolerant placebo group [0.007 (95% CI 0.006 to 0.008) versus 0.011 (95% CI 0.010 to 0.011) mg kg−1 h−1, Bonferroni corrected P 

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Frailty Phenotypes and Relations With Surgical Outcomes: A Latent Class Analysis

BACKGROUND: Frailty is an important concept in the care of older adults although controversy remains regarding its defining features and clinical utility. Both the Fried phenotype and the Rockwood deficit accumulation approaches cast frailty as a "burden" without exploring the relative salience of its cardinal markers and their relevance to the patient. New multifactorial perspectives require a reliable assessment of frailty that can validly predict postoperative health outcomes. METHODS: In a retrospective study of 2828 unselected surgical patients, we used item response theory to examine the ability of 32 heterogeneous markers capturing limitations in physical, functional, emotional, and social activity domains to indicate severity of frailty as a latent continuum. Eighteen markers efficiently indicated frailty severity and were then subject to latent class analysis to derive discrete phenotypes. Next, we validated the obtained frailty phenotypes against patient-reported 30-day postoperative outcomes using multivariable logistic regression. Models were adjusted for demographics, comorbidity, type and duration of surgery, and cigarette and alcohol consumption. RESULTS: The 18 markers provided psychometric evidence of a single reliable continuum of frailty severity. Latent class analyses produced 3 distinct subtypes, based on patients' endorsement probabilities of the frailty indicators: not frail (49.7%), moderately frail (33.5%), and severely frail (16.7%). Unlike the moderate class, severely frail endorsed emotional health problems in addition to physical burdens and functional limitations. Models adjusting for age, sex, type of anesthesia, and intraoperative factors indicated that severely frail (odds ratio, 1.89; 95% confidence interval, 1.42–2.50) and moderately frail patients (odds ratio, 1.31; 95% confidence interval, 1.03–1.67) both had higher odds of experiencing postoperative complications compared to not frail patients. In a 3-way comparison, a higher proportion of severely frail patients (10.7%) reported poorer quality of life after surgery compared to moderately frail (9.2%) and not frail (8.3%) patients (P

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Midazolam Premedication Facilitates Mask Ventilation During Induction of General Anesthesia: A Randomized Clinical Trial

BACKGROUND: During induction of general anesthesia, proper mask ventilation is crucial for supplying sufficient oxygen to unconscious patients. Midazolam has a relaxing effect on airway muscles. We hypothesized that sedative premedication with midazolam would facilitate mask ventilation during anesthetic induction. METHODS: Patients undergoing elective surgery under general anesthesia were randomized into 2 groups. The midazolam group received midazolam premedication at the reception area, 3 minutes before transfer to the operating room. Patients in the control group were treated with normal saline as a placebo. The primary outcome was difficulty of mask ventilation during induction, as evaluated using the Warters scales. RESULTS: A total of 97 patients completed the analysis: 49 in the control group and 48 in the midazolam group. The patients in the midazolam group showed a significantly lower mask ventilation difficulty score on the Warters scale than that of the control group (mean [standard deviation], 0.92 [1.13] vs 0.19 [0.57]; estimated difference [95% confidence interval], 0.73 [0.37−1.09]; P

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Comparison of Intermittent Intravenous Boluses of Phenylephrine and Norepinephrine to Prevent and Treat Spinal-Induced Hypotension in Cesarean Deliveries: Randomized Controlled Trial

BACKGROUND: Phenylephrine (PE) is currently the vasopressor of choice to prevent and treat spinal-induced hypotension at cesarean delivery (CD). However, its use is often associated with reflex bradycardia. Norepinephrine (NE) has been put forward as an alternative vasopressor during CD due to its ability to treat hypotension while maintaining heart rate (HR). Recent studies have focused on the role of NE used as an infusion with favorable results compared to PE. No studies have compared equipotent bolus doses of PE and NE at CD. We hypothesized that when used in equipotent doses as an intermittent bolus regimen to prevent and treat spinal-induced hypotension, NE would result in a reduction in the incidence of bradycardia compared to PE. METHODS: This was a double-blind, randomized clinical trial of women undergoing elective CD under spinal anesthesia. Women were randomized to receive either PE 100 µg or NE 6 µg when the systolic blood pressure (SBP) was below baseline. In addition to the randomized treatment, ephedrine was given intravenously to both groups if the SBP was below baseline and the HR 120% of baseline), tachycardia (HR >120% of baseline), ≥2 episodes of bradycardia, nausea, vomiting, umbilical artery and vein blood gases, and Apgar scores. RESULTS: One hundred twelve patients were randomized. The incidence of bradycardia was lower in the NE group compared to the PE group (10.9% vs 37.5%; P

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Factors Associated With Recovery Room Intravenous Opiate Requirement After Pediatric Outpatient Operations

BACKGROUND: Many children recovering from anesthesia experience pain that is severe enough to warrant intravenous (IV) opioid treatment within moments of admission to the postanesthesia care unit (PACU). Postoperative pain has several negative consequences; therefore, preventing significant PACU pain in children is both a major clinical goal and a moral/ethical imperative. This requires identifying patient-level and perioperative factors that may be used to predict PACU IV opioid requirement. This should allow for the development of personalized care protocols to prevent clinically significant PACU pain in children. Our objective was to develop prediction models enabling practitioners to identify children at risk for PACU IV opioid requirement after various painful ambulatory surgical procedures. METHODS: After Institutional Review Board approval, clinical, demographic, and anthropometric data were prospectively collected on 1256 children 4–17 years of age scheduled for painful ambulatory surgery (defined as intraoperative administration of analgesia or local anesthetic infiltration). Three multivariable logistic regression models to determine possible predictors of PACU IV opioid requirement were constructed based on (1) preoperative history; (2) history + intraoperative variables; and (3) history + intraoperative variables + PACU variables. Candidate predictors were chosen from readily obtainable parameters routinely collected during the surgical visit. Predictive performance of each model was assessed by calculating the area under the respective receiver operating characteristic curves. RESULTS: Overall, 29.5% of patients required a PACU IV opioid, while total PACU analgesia requirement (oral or IV) was 41.1%. Independent predictors using history alone were female sex, decreasing age, surgical history, and non-Caucasian ethnicity (model area under the receiver operating characteristic curve [AUROC], 0.59 [95% confidence interval {CI}, 0.55–0.63]). Adding a few intraoperative variables improved the discriminant ability of the model (AUROC for the history + intraoperative variables model, 0.71 [95% CI, 0.67–0.74]). Addition of first-documented PACU pain score produced a substantially improved model (AUROC, 0.85 [95% CI, 0.82–0.87]). CONCLUSIONS: Postoperative pain requiring PACU IV opioid in children may be determined using a small set of easily obtainable perioperative variables. Our models require validation in other settings to determine their clinical usefulness. Accepted for publication July 3, 2018. Funding: National Institute of General Medical Sciences grant number K23 GM104354 supported O.O.N.'s work. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Olubukola O. Nafiu, MD, FRCA, MS, Department of Anesthesiology, Section of Pediatric Anesthesiology, University of Michigan Health System, 1500 E Medical Centre Dr, Room UH 1H247, Ann Arbor, MI 48109. Address e-mail to onafiu@med.umich.edu. © 2018 International Anesthesia Research Society

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The GCs-SGK1-ATP Signaling Pathway in Spinal Astrocytes Underlied Presurgical Anxiety-Induced Postsurgical Hyperalgesia

BACKGROUND: Patients undergoing surgery often feel anxious. Accumulating evidence indicated that presurgical anxiety was related to the more severe postsurgical pain. An animal model was established that exposed Sprague-Dawley rats to a single-prolonged stress (SPS) procedure to induce presurgical anxiety-like behaviors. The experiment revealed that presurgical anxiety not only aggravated but also prolonged postsurgical pain. However, the underlying mechanisms were unknown. METHODS: The rats in group C + Cort, group I + Cort, group A + Cort, and group AI + Cort were injected with corticosterone. The rats in group C + RU486, group I + RU486, group A + RU486, and group AI + RU486 were injected with mifepristone (RU486). The rats in group C + GSK650394 and group AI + GSK650394 were injected with GSK650394. The rats in group C + FC1 and group AI + FC1 were injected with fluorocitrate (FC) 30 minutes before SPS, 30 minutes before incision, and on postoperative days 1, 2, 3, 4, and 5. The rats in group C + FC2 and group AI + FC2 were injected with FC on postoperative days 7, 8, 9, 10, 11, 12, and 13. The paw withdrawal mechanical threshold was assessed 24 hours before SPS and from postoperative days 1 to 28. The level of corticosterone was determined by enzyme-linked immunosorbent assay. The expression of serum/glucocorticoid regulated kinase 1 (SGK1), interleukin-1β, and tumor necrosis factor-α was visualized by Western blot. The concentrations of adenosine triphosphate (ATP) were measured by ATP assay kit. RESULTS: This study showed SPS elevated plasma glucocorticoids and ATP release from astrocytes, which meant the mechanical pain hypersensitivity in presurgical anxiety-induced postsurgical hyperalgesia was dependent on GCs-SGK1-ATP signaling pathway. SGK1 protein level in astrocytes was increased in response to the glucocorticoid stimuli and enhanced the extracellular release of ATP. Furthermore, spinal astrocytes played a key role in the maintenance. Targeting spinal astrocytes in maintenance phase prevented the pathological progression. CONCLUSIONS: These data suggested an important signaling pathway that affected the pain sensitivity after operation caused by presurgical anxiety. Accepted for publication June 12, 2018. Funding: Supported by National Natural Science Foundation of China 81471129, 81171048, and a grant from the Department of Health of Jiangsu Province of China XK201140. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Z. Zhang and H. Wu contributed equally to this work. Reprints will not be available from the authors. Address correspondence to ZhengLiang Ma, PhD, Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China. Address e-mail to mazhengliang1964@163.com. © 2018 International Anesthesia Research Society

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Comparative Regimens of Lipid Rescue From Bupivacaine-Induced Asystole in a Rat Model

BACKGROUND: It is currently unknown whether bupivacaine-induced asystole is better resuscitated with lipid emulsion (LE) administered peripherally or centrally, and whether different LE regimens administered peripherally demonstrated similar effects. In this study, we compared the effects of various regimens of lipid administration in a rat model of bupivacaine-induced asystole. METHODS: Forty-five adult male Sprague-Dawley rats were subjected to bupivacaine-induced asystole and randomly divided into 3 lipid regimens groups: (1) 20% LE was administered continuously via the internal jugular vein (CV-infusion group); (2) 20% LE was administered continuously via the tail vein (PV-infusion group); and (3) 20% LE was administered as divided boluses via the tail vein (PV-bolus group). The maximum dose of LE did not exceed 10 mL·kg−1. External chest compressions were administered until the return of spontaneous circulation (ROSC) or the end of a 40-minute resuscitation period. RESULTS: The survival rate, rate of ROSC, systolic blood pressure, heart rate, heart rate–blood pressure product, and coronary perfusion pressure during 2–40 minutes in the CV-infusion and PV-bolus groups were significantly higher than those in the PV-infusion group (P

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Postoperative Corneal Injuries: Incidence and Risk Factors

BACKGROUND: Previous studies of postoperative corneal injury rates relied on provider-initiated incident reports, which may underestimate the true incidence. Postoperative administration of proparacaine eye drops is used almost exclusively to diagnose corneal injury; therefore, identifying instances of administration may provide a better estimate of corneal injuries. We compared proparacaine administration versus provider-initiated reports to determine rates of corneal injury. In addition, potential associations between clinical variables and injury were assessed with a matched case–control study. METHODS: The health records of 132,511 sequential adult postanesthesia recovery room admissions (January 1, 2011 to June 30, 2017) were reviewed to identify postoperative proparacaine administration and incident reports of corneal injury. Patients with corneal injury were matched with control patients at a 1:2 ratio to assess factors associated with injury. RESULTS: Proparacaine drops were administered to 442 patients (425 patients received proparacaine for diagnosis and 17 patients received proparacaine for unrelated reasons). Incident reports identified 320 injuries, and the aggregate corneal injury count was 436 (incidence, 3.3 injuries [95% confidence interval {CI}, 3.0–3.6] per 1000 cases of general anesthesia). Proparacaine administration had a greater case ascertainment percentage than incident reporting (97.5% vs 73.4%; P

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Informed Consent in Pediatric Anesthesia: A Narrative Review

Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia. Accepted for publication July 3, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Max M. Feinstein, MA, Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH, 44106. Address e-mail to mmf76@case.edu. © 2018 International Anesthesia Research Society

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Questions Raised by “Profound Intraoperative Hypotension Associated With Transfusion via the Belmont Fluid Management System”

No abstract available

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Feasibility of a Perioperative Text Messaging Smoking Cessation Program for Surgical Patients

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1–3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message–based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted. Accepted for publication July 3, 2018. Funding: This study was funded internally by Mayo Clinic. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Margaret B. Nolan, MD, Department of Anesthesiology, Mayo Clinic, 200 1st St SW, Joseph Bldg 4–184, Rochester, MN 55906. Address e-mail to Nolan.margaret@mayo.edu. © 2018 International Anesthesia Research Society

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Smoothing Effect in Vital Sign Recordings: Fact or Fiction? A Retrospective Cohort Analysis of Manual and Continuous Vital Sign Measurements to Assess Data Smoothing in Postoperative Care

BACKGROUND: Data smoothing of vital signs has been reported in the anesthesia literature, suggesting that clinical staff are biased toward measurements of normal physiology. However, these findings may be partially explained by clinicians interpolating spurious values from noisy signals and by the undersampling of physiological changes by infrequent manual observations. We explored the phenomenon of data smoothing using a method robust to these effects in a large postoperative dataset including respiratory rate, heart rate, and oxygen saturation (SpO2). We also assessed whether the presence of the vital sign taker creates an arousal effect. METHODS: Study data came from a UK upper gastrointestinal postoperative ward (May 2009 to December 2013). We compared manually recorded vital sign data with contemporaneous continuous data recorded from monitoring equipment. We proposed that data smoothing increases differences between vital sign sources as vital sign abnormality increases. The primary assessment method was a mixed-effects model relating continuous-manual differences to vital sign values, adjusting for repeated measurements. We tested the regression slope significance and predicted the continuous-manual difference at clinically important vital sign values. We calculated limits of agreement (LoA) between vital sign sources using the Bland–Altman method, adjusting for repeated measures. Similarly, we assessed whether the vital sign taker affected vital signs, comparing continuous data before and during manual recording. RESULTS: From 407 study patients, 271 had contemporaneous continuous and manual recordings, allowing 3740 respiratory rate, 3844 heart rate, and 3896 SpO2 paired measurements for analysis. For the model relating continuous-manual differences to continuous-manual average vital sign values, the regression slope (95% confidence interval) was 0.04 (−0.01 to 0.10; P = .11) for respiratory rate, 0.04 (−0.01 to 0.09; P = .11) for heart rate, and 0.10 (0.07–0.14; P

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Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery

Enhanced recovery after surgery protocols for bariatric surgery are increasingly being implemented, and reports suggest that they may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after bariatric surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, opioid minimization and multimodal analgesia, protective ventilation strategy, fluid minimization), and postoperative (multimodal analgesia with opioid minimization) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for enhanced recovery after surgery for bariatric surgery. There is evidence in the literature, and from society guidelines, to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for bariatric surgery. Accepted for publication July 2, 2018. Funding: This project was funded under contract number HHSP233201500020I from the Agency for Healthcare Research and Quality and US Department of Health and Human Services. Conflicts of Interest: See Disclosures at the end of the article. The opinions expressed in this document are those of the authors and do not reflect the official position of Agency for Healthcare Research and Quality or the US Department of Health and Human Services. Reprints will not be available from the authors. Address correspondence to Christopher L. Wu, MD, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. Address e-mail to wuch@hss.edu. © 2018 International Anesthesia Research Society

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Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles

Introduction Weakness of foot muscles may contribute to a variety of loading related injuries. Supportive footwear may contribute to intrinsic foot muscle weakness by reducing the muscles' role in locomotion (e.g. absorbing forces and controlling motion). Increased stimulus to the foot muscles can be provided through a variety of mechanisms, including minimalist footwear and directed exercise. Purpose To determine the effect of walking in minimalist footwear or performing foot strengthening exercises on foot muscle size and strength. Results In study 1, genotype frequencies for ESR1 rs2234693 were significantly different between the injured and non-injured groups in a C-allele dominant (CC+CT vs. TT: odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.43–0.91) and additive (CC vs. CT vs. TT: OR = 0.70, 95% CI = 0.53–0.91) model in all athletes. In study 2, hamstring muscle stiffness was lower in subjects with the CC+CT genotype than in those with the TT genotype; a significant linear trend was found (r = 0.135, P = 0.029). In contrast, no associations were observed between ESR1 rs9340799 G/A and muscle injury or stiffness. Methods Fifty-seven runners were randomly assigned to one of three groups – minimalist shoe walking (MSW), foot strengthening exercise (FS), or control (C). All groups maintained their pre-study running mileage throughout the study. The MSW group walked in provided footwear, increasing weekly the number of steps/day taken in the shoes. The FS group performed a set of progressive resistance exercises at least 5 days/week. Foot muscle strength (via custom dynamometers) and size (via ultrasound) were measured at the beginning (week 0), middle (week 4), and end (week 8) of the study. Mixed model ANOVAs were run to determine if the interventions had differing effects on the groups. Key Terms Single nucleotide polymorphism; estrogen receptor; muscle stiffness; injury prediction; athletes Results There were significant group by time interactions for all muscle size and strength measurements. All muscle sizes and strength increased significantly from weeks 0-8 in the FS and MSW groups, while there were no changes in the C group. Some muscles increased in size by week 4 in the FS and MSW groups. Key Terms Single nucleotide polymorphism; estrogen receptor; muscle stiffness; injury prediction; athletes Conclusion Minimalist shoe walking is as effective as foot strengthening exercises in increasing in foot muscle size and strength. The convenience of changing footwear rather than performing specific exercises may result in greater compliance. Corresponding author: Sarah T. Ridge, 116B RB, Brigham Young University, Provo, UT 84602, (801) 422-1365, sarah_ridge@byu.edu The results of the present study do not constitute endorsement by the American College of Sports Medicine and are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Conflicts of Interest and Source of Funding: None Submitted for publication April 2018. Accepted for publication July 2018. © 2018 American College of Sports Medicine

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Equivalent Hypertrophy and Strength Gains in HMB- or Leucine-supplemented Men

Ingestion of proteins with high leucine content during resistance training (RT) can augment hypertrophy. Some data suggest that a leucine metabolite, β-hydroxy, β-methylbutyrate (HMB), is substantially more anabolically efficacious than leucine. Purpose We aimed to test whether supplementation with HMB versus leucine, added to whey protein, would result in differential muscle hypertrophy and strength gains in young men performing resistance training. Methods Twenty-six resistance-trained men (23 ± 2 y) performed 12 wk of RT with 3 phases. Phase 1: 8 wk of periodized RT (3 training sessions/wk). Phase 2: 2 wk overreaching period (5 sessions/wk). Phase 3: 2 wk taper (3 sessions/wk). Participants were randomly assigned to twice daily ingestion of: whey protein (25 g) plus HMB (1.5 g) (Whey+HMB; n=13) or whey protein (25 g) plus leucine (1.5 g) (Whey+Leu; n=13). Skeletal muscle biopsies were performed before and after RT. Measures of fat and bone-free mass (FBFM), vastus lateralis (VL) muscle thickness and muscle cross-sectional area (CSA – both by ultrasound), muscle fiber CSA, and 1-repetition maximum (1-RM) strength tests were determined. Results We observed increases in FBFM, VL muscle thickness, muscle CSA and fiber type CSA and 1-RM strength with no differences between groups at any phase. We observed no differences between groups or time-by-group interactions in hormone concentrations at any phase of the RT program. Conclusion HMB added to whey did not result in greater increases in any measure of muscle mass, strength, or hormonal concentration compared to leucine added to whey. Our results show that HMB is no more effective in stimulating RT-induced hypertrophy and strength gains than leucine. Author for correspondence: Prof. Stuart Phillips, Ph.D. Department of Kinesiology, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada, T: +1-905-525-9140 x24465, E: phillis@mcmaster.ca Submitted for publication May 2018. Accepted for publication July 2018. © 2018 American College of Sports Medicine

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Augmented Anabolic Responses following 8-weeks Cycling with Blood Flow Restriction

Introduction Low-intensity endurance training performed with blood flow restriction (ET-BFR) can improve muscle strength, cross-sectional area (CSA) and cardiorespiratory capacity. Whether muscle strength and CSA as well as cardiorespiratory capacity (i.e.:V˙O2max) and underlying molecular processes regulating such respective muscle adaptations are comparable to resistance and endurance training is unknown. Purpose To determine the respective chronic (i.e.: 8 weeks) functional, morphological and molecular responses of ET-BFR training compared to conventional, unrestricted resistance training (RT) and endurance training (ET). Methods Thirty healthy young men were randomly assigned to one of three experimental groups: ET-BFR (n=10, 4 days/wk, 30 min cycling at 40% of V˙O2max), RT (n=10, 4 days/wk, 4 sets of 10 reps leg-press at 70% of 1-RM with 60 s rest) or ET (n=10, 4 days/wk, 30 min cycling at 70% of V˙O2max) for 8 weeks. Measures of quadriceps CSA, leg press 1-RM, and V˙O2max as well as muscle biopsies were obtained prior to and post intervention. Results Both RT and ET-BFR increased muscle strength and hypertrophy responses. ET-BFR also increased V˙O2max, total COXIV abundance and VEGF mRNA abundance despite the lower work load compared to ET. Conclusion Eight weeks of ET-BFR can increase muscle strength and induce similar muscle hypertrophy responses to RT while V˙O2max responses also increased post-intervention even with a significantly lower work load compared to ET. Our findings provide new insight to some of the molecular mechanisms mediating adaptation responses with ET-BFR and the potential for this training protocol to improve muscle and cardiorespiratory capacity. Author for correspondence: Miguel S. Conceição, Faculty of Physical Education, University of Campinas, Av. Érico Veríssimo, 701, Cidade Universitária "Zeferino Vaz" Barão Geraldo, Campinas, São Paulo, Brazil. CEP: 13083-851, Email: conceicao.miguel0106@gmail.com, Phone: + 55 19 35216625 The authors would like to express gratitude for the São Paulo Research Foundation (FAPESP), grant #2014/00985-0 #2015/19756-3. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The authors declare no conflicts of interest. The results of the present study do not constitute endorsement by ACSM. Submitted for publication November 2017. Accepted for publication July 2018. © 2018 American College of Sports Medicine

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Predictors of Dropout in Exercise Trials in Older Adults

Purpose Dropout from exercise programs, both in the real world and in research, is a challenge, and more information on dropout-predictors is needed for establishing strategies to increase the likelihood of maintaining participants in a prescribed exercise program. The aim of the present study was to determine the dropout rate and its predictors during a 3-year exercise program in older adults. Methods In total, 1514 men and women (age 72.4±1.9 years) were included in the present study. Participants were randomized to either a supervised exercise intervention or to follow national guidelines for physical activity (PA). Self-reported demographics (e.g. education), general health, morbidity (e.g. heart disease, memory loss, psychological distress), smoking and PA were examined at baseline. Cardiorespiratory fitness (CRF) and grip strength were directly measured at baseline. Dropout rate was evaluated after 1- and 3-years. Multivariate logistic regression analysis was used to identify dropout-predictors. Results The total dropout rate was 11.0% (n=166) after 1-year and 14.9% (n=225) after 3-years. Significant predictors of dropout after 1-year were low education, low grip strength, lower CRF, low PA level and randomization to supervised exercise. The same predictors of dropout were significant after 3-years, with reduced memory status as an additional predictor. Conclusion This is the largest study to identify dropout-predictors in a long-term exercise program in older adults. Our findings provide new and important knowledge about potential risk factors of dropout in long-term exercise programs in older adults. Corresponding author: Hallgeir Viken, Ph.D., Norwegian University of Science and Technology, Department of Circulation and Medical Imaging, PO Box 8905, 7491 Trondheim, Norway. Telephone: 0047 72574393. Fax: 0047 72828372. E-mail: hallgeir.viken@ntnu.no This study was supported by the K. G. Jebsen Foundation for medical research, Norway; the Liaison Committee for education, research and innovation in Central Norway and the Research Council of Norway. There are no conflicts of interest to disclose. The results of the present study do not constitute endorsement by ACSM. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. © 2018 American College of Sports Medicine

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Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization

Introduction Knee injuries are common in sports, and post-injury immobilization is often required to protect healing tissues and alleviate pain, but both the injury and the immobilization can lead to a knee contracture. Knee flexion contractures limit performance. Previous research has identified posterior knee capsule fibrosis as a contributor to immobility-induced knee flexion contractures. This study aims to measure posterior knee capsule length at various durations of remobilization after knee immobilization and to correlate with the recovery of knee range of motion. Methods 259 male Sprague-Dawley rats had one knee extra-articularly immobilized in flexion with a Delrin® plate at a 45° angle for one of six durations: 1, 2, 4, 8, 16, or 32 weeks, followed by spontaneous remobilization after plate removal, which lasted zero, one, two, and four times the duration of immobilization. The contralateral knees served as controls. The posterior knee capsule length was measured by histomorphometry. These measures were correlated with previously published range of motion data from the same cohort of specimens. Results Knees immobilized for 1 and 2 weeks partially recovered posterior capsule length (P>0.05). Knees immobilized beyond 2 weeks failed to recover posterior capsule length irrespective of the duration of remobilization (P

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ESR1 rs2234693 Polymorphism Is Associated with Muscle Injury and Muscle Stiffness

Purpose Muscle injury is the most common sports injury. Muscle stiffness, a risk factor for muscle injury, is lower in females than in males, implying that sex-related genetic polymorphisms influence muscle injury associated with muscle stiffness. The present study aimed to clarify the associations between two genetic polymorphisms (rs2234693 and rs9340799) in the estrogen receptor 1 gene (ESR1) and muscle injury or muscle stiffness. Methods In study 1, a questionnaire was used to assess the muscle injury history of 1,311 Japanese top-level athletes. In study 2, stiffness of the hamstring muscles was assessed using ultrasound shear wave elastography in 261 physically active young adults. In both studies, rs2234693 C/T and rs9340799 G/A polymorphisms in the ESR1 were analysed using the TaqMan SNP Genotyping Assay. Results In study 1, genotype frequencies for ESR1 rs2234693 were significantly different between the injured and non-injured groups in a C-allele dominant (CC+CT vs. TT: odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.43–0.91) and additive (CC vs. CT vs. TT: OR = 0.70, 95% CI = 0.53–0.91) model in all athletes. In study 2, hamstring muscle stiffness was lower in subjects with the CC+CT genotype than in those with the TT genotype; a significant linear trend was found (r = 0.135, P = 0.029). In contrast, no associations were observed between ESR1 rs9340799 G/A and muscle injury or stiffness. Conclusion Our results suggest that the ESR1 rs2234693 C allele, in contrast to the T allele, provides protection against muscle injury by lowering muscle stiffness. Key Terms Single nucleotide polymorphism; estrogen receptor; muscle stiffness; injury prediction; athletes Correspondence: Noriyuki Fuku, Ph.D. Graduate School of Health and Sports Science, Juntendo University, 1-1 Hiraka-gakuendai, Inzai-city, Chiba 270-1695, Japan. Tel: +81 476-98-1001 (ext. 9303), Fax: +81 476-98-1011, E-mail: noriyuki.fuku@nifty.com No conflicts of interest, financial or otherwise, are declared by the authors. The results of the present study do not constitute endorsement by ACSM. All authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Submitted for publication March 2018. Accepted for publication July 2018. © 2018 American College of Sports Medicine

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