Σάββατο, 1 Σεπτεμβρίου 2018

Highlighting Discrepancies in Walking Prediction Accuracy for Patients with Traumatic Spinal Cord Injury: an Evaluation of Validated Prediction Models using a Canadian Multi-centre Spinal Cord Injury Registry

Models for predicting recovery in traumatic spinal cord injury (tSCI) patients have been developed to optimize care. Several models predicting tSCI recovery have been previously validated, yet recent findings question their accuracy, particularly in patients whose prognoses are the least predictable.

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Deficiency of micronutrients in patients affected by chronic atrophic autoimmune gastritis: A single-institution observational study

Chronic atrophic autoimmune gastritis (CAAG) leads to vitamin B12 deficiency, but other micronutrient deficiencies are largely understudied.

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THYROID DYSFUNCTION AND ITS ROLE AS A RISK FACTOR FOR NON-ALCOHOLIC FATTY LIVER DISEASE: WHAT’S NEW



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Deficiency of micronutrients in patients affected by chronic atrophic autoimmune gastritis: A single-institution observational study

Chronic atrophic autoimmune gastritis (CAAG) leads to vitamin B12 deficiency, but other micronutrient deficiencies are largely understudied.

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THYROID DYSFUNCTION AND ITS ROLE AS A RISK FACTOR FOR NON-ALCOHOLIC FATTY LIVER DISEASE: WHAT’S NEW



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When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion

The biological concept of the irreversible cessation of brain function (brain death, BD) occurring while cardiorespiratory function is maintained has been issued already by M. F. Xavier Bichat (1800) and Harvey Cushing (1902), and was systematically developed since the 1950's (Mollaret et al., 1959; Wertheimer et al., 1959; Beecher, 1968, Wijdicks et al., 2010). The primary goal was to establish medico-legal criteria for the termination of mechanical ventilation and intensive medical care in severely brain damaged patients with irreversible coma and fatal outcome.

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Quantification of urinary loss in nulliparous athletes during 1-hour of sports training

urinary incontinence (UI) is a pelvic floor dysfunction that can affect nulliparous female athletes due to the effect of sports modalities on the pelvic floor muscles (PFM).

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Developing, Implementing, and Evaluating Personalized Education for Pediatric Patients Diagnosed With Asthma on an Observation Unit

A quality improvement project was commenced to determine if personalized, patient-specific education can increase parent/guardian knowledge and reduce subsequent emergency department (ED) visits and inpatient admissions secondary to asthma.

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Did Clarification of Medicare Guidelines Change Outpatient Physical Therapy and Occupational Therapy Usage? A retrospective analysis

Publication date: Available online 1 September 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Justine Dee, Benjamin Littenberg

Abstract
Objective

To determine if there was a change in the number of outpatient physical therapy (PT) and occupational therapy (OT) visits for Medicare beneficiaries, and in the number of beneficiaries receiving extended courses of >12 therapy visits, after the "Jimmo v. Sebelius" settlement.

Design

Cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) comparing calendar years 2011 through 2012 to 2014 through 2015.

Setting

Community in-home survey.

Participants

Medicare Part-B recipients who received outpatient PT/OT (N=1183, median age 70.8) during pre (2011-2012) and post-Jimmo settlement (2014-2015) time periods.

Intervention

Not applicable

Main Outcome Measures

Number of therapy visits/patient/year and number of subjects who received > 12 therapy visits/year estimated by linear and logistic regressions controlling for potential confounders (age, body mass index, and geographic region).

Results

The unadjusted median number of therapy visits/year increased from 7 to 8 after the settlement. Linear regression estimated a 1.02 increase in the number of therapy visits after the settlement (95% confidence interval (CI) 0.23,1.80; P=0.01). The odds of having >12 therapy visits/year increased (odds ratio = 1.41; 95% CI 1.02,1.96; P= .04). We observed a significant interaction between race and the effect of the settlement on the odds of having >12 therapy visits (OR 3.64; 95% CI 1.58, 8.39). White subjects saw an increase in utilization while non-white subjects' utilization declined.

Conclusion

Utilization of outpatient PT/OT changed after the 2013 Jimmo settlement. Further research is needed to determine the impact on patient outcomes and cost.



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Quiz: How much do you know about sepsis?

Take our 5-minute quiz to find out how your assessment skills measure up

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Comparing Traditional Versus Retrospective Pre-/Post-assessment in an Interdisciplinary Leadership Training Program

Abstract

Objectives As the U.S. healthcare system shifts toward collaboration, demand for leaders with interdisciplinary skills increases. Leadership competencies guide interdisciplinary training programs; however, identifying cost-effective methods for evaluating leadership competencies is challenging, particularly when interdisciplinary trainees have different areas of expertise and professional goals. Traditional pre-/post-testing, a common method for evaluating leadership competencies, is subject to response-shift bias, which can occur when participants' understanding of a construct changes between pre- and post-test. As a result, participants may rate their knowledge of the construct lower at post-test. Retrospective pre-tests are one method thought to reduce response-shift bias in pre-/post-tests. The current study explores the use of a retrospective pre-test to control for response-shift bias in an interdisciplinary training program. Methods Over three cohort years, thirty-four trainees from an interdisciplinary leadership program completed a self-assessment aligned with MCH leadership competencies. The traditional pre-test self-assessment was completed at the beginning of the training program. The retrospective pre-/post-test self-assessment was completed at the end of the training program. Results Retrospective pre/post-test scores indicate significant self-reported increases in all 24 leadership areas (p ≤ .001). Furthermore, participants' self-ratings were significantly higher on the traditional pre-test for all 24 areas than on the retrospective pre-test (p ≤ .001). Conclusions for Practice Retrospective pre-tests appeared to control for response-shift bias and may be a cost-effective way to evaluate trainee change within an interdisciplinary leadership program. These findings suggest the methodology's usefulness in interdisciplinary training and its potential use in the broader world of community-based MCH training initiatives.



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Modeling the role of fire and cooking in the competitive exclusion of Neanderthals

Publication date: Available online 1 September 2018

Source: Journal of Human Evolution

Author(s): Anna E. Goldfield, Ross Booton, John M. Marston

Abstract

The Neanderthal body was more robust and energetically costly than the bodies of anatomically modern humans (AMH). Different metabolic budgets between competing populations of Neanderthals and AMH may have been a factor in the varied ranges of behavior and timelines for Neanderthal extinction that we see in the Paleolithic archaeological record. This paper uses an adaptation of the Lotka–Volterra model to determine whether metabolic differences alone could have accounted for Neanderthal extinction. In addition, we use a modeling approach to investigate Neanderthal fire use, evidence for which is much debated and is variable throughout different climatic phases of the Middle Paleolithic. The increased caloric yield from a cooked versus a raw diet may have played an important role in population competition between Neanderthals and AMH. We arrive at two key conclusions. First, given differences in metabolic budget between Neanderthals and AMH and their dependence on similar or overlapping food resources, Neanderthal extinction is likely inevitable over the long term. Second, the rate of Neanderthal extinction increases as the frequency of AMH fire use increases. Results highlight the importance of understanding the variable behaviors at play on a regional scale in order to understand global Neanderthal extinction. We also emphasize the importance of understanding the role of fire use in the Middle to Upper Paleolithic transition.



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Evidence for a humid interval at ∼56–44 ka in the Levant and its potential link to modern humans dispersal out of Africa

Publication date: Available online 1 September 2018

Source: Journal of Human Evolution

Author(s): Dafna Langgut, Ahuva Almogi-Labin, Miryam Bar-Matthews, Nadine Pickarski, Mina Weinstein-Evron

Abstract

This study provides a detailed reconstruction of the paleoenvironmental conditions that prevailed during one of the periods of modern human migration out of Africa and their occupation of the Eastern Mediterranean-Levant during the Late Middle Paleolithic-Early Upper Paleolithic. Tracing the past vegetation and climate within the Eastern Mediterranean-Levant region is largely based on a south-eastern Mediterranean marine pollen record covering the last 90 kyr (core MD-9509). The various palynomorphs were linked to distinct vegetation zones that were correlated to the two climate systems affecting the study area: the low-latitude monsoon system and the North Atlantic-Mediterranean climate system. The bioprovince palynological markers show that during the period between ∼56 and 44 ka, which covers the early part of Marine Isotope Stage 3 (MIS 3), there was an increase in transportation of pollen from Nilotic origin and a rise in dinoflagellate cyst ratios. These changes coincided with maximum insolation values at 65°N, which led to an enhancement in Nile River discharge into the Eastern Mediterranean following the intensification of the African monsoonal system. At the same time, the rise in Mediterranean arboreal pollen values (broadleaved, coniferous and deciduous temperate trees) is most likely driven by increased precipitation related to the intensification of the North Atlantic-Mediterranean climate system. The ∼56–44 ka wet event coincides with Dansgaard-Oeschger interstadials 14 and 12 and with a warming phase in the Levant, as evidenced by the melting of permafrost along the higher elevations of Mount Hermon. We suggest that African modern humans were able to cross the harsher arid areas due to the intensification of the monsoonal system during the first part of MIS 3, and inhabit the Eastern Mediterranean-Levant region where climatic conditions were favorable (wetter and warmer), even in the currently semiarid/steppe regions.



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Words Matter: Charting the Landscape of US and International Health Profession Organizations’ Public Statements About FGM/C

Abstract

Female genital mutilation/cutting (FGM/C) is common across the globe and seen in high income countries that host migrants from high prevalence countries. Management of FGM/C in the host countries can be complicated due its often conflicting social, cultural, ethical, legal, and medical dynamics. Health profession organizations often create policy and position statements that set the tone and direction for the organization and describe desired methods, behaviors and actions applicable to the entire organization and its members. It is unclear whether or what organizational statements exist on FGM/C. We reviewed publicly available statements made by health profession organizations whose members care for women and girls affected by or at risk for, FGM/C, and assessed their content related to medicalization, reinfibulation and vacation cutting. Of a total of 47 organizations, 24 (51%) had any statements. Of 15 physician organizations, only 4 (26%) US-based physician organizations had any statements. 17 had specific statements on clinician involvement, but the tone and instructional nature varied. Re-infibulation was mentioned by 41% organizations with statements. 29% mentioned vacation cutting. Many, but not all, health profession organizations have statements for their members on FGM/C, and those vary in what is covered, and in what recommendations are given. Health profession organizations serve and are the face and voice of their members. As such, they have a responsibility to educate their members, set the tone for the conversation, and make their stand clear to their members and other stakeholders, including patients.



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The effects of Montmorency tart cherry juice supplementation and FATMAX exercise on fat oxidation rates and cardio-metabolic markers in healthy humans

Abstract

Montmorency tart cherries (Prunus cerasus L.) are rich in anthocyanins, compounds capable of augmenting fat oxidation and regulating metabolic dysfunction. The present study examined whether Montmorency tart cherry juice (MTCJ) supplementation could augment fat oxidation rates at rest and during FATMAX exercise, thus improve cardio-metabolic health. Eleven, healthy participants consumed MTCJ or placebo (PLA) twice daily, in a randomised, counterbalanced order for 20 days. Participants cycled at FATMAX for 1-h pre-, mid- (10 days) and post-supplementation whilst substrate oxidation rates were measured. Before exercise anthropometrics and resting metabolic rate were measured. Blood pressure, serum triglycerides, cholesterol, HDL, total antioxidant status (TAS) and glucose were measured immediately before and after exercise. No significant differences between conditions or interactions were observed for any functional and blood-based cardio-metabolic markers or fat oxidation during exercise or rest (P > 0.05). Pre-exercise TAS (P = 0.036) and HDL (P = 0.001) were significantly reduced from mid- to post-supplementation with MTCJ only. Twenty days' MTCJ supplementation had no effect on fat oxidation; therefore, it is unnecessary for individuals in this participant cohort to consume MTCJ with exercise to improve cardio-metabolic biomarkers.



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MiR-19b non-canonical binding is directed by HuR and confers chemosensitivity through regulation of P-glycoprotein in breast cancer

Publication date: Available online 31 August 2018

Source: Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms

Author(s): James L. Thorne, Sebastiano Battaglia, Diana E. Baxter, Josie L. Hayes, Samantha A. Hutchinson, Samir Jana, Rebecca A. Millican-Slater, Laura Smith, Melina C. Teske, Laura M. Wastall, Thomas A. Hughes

Abstract

MicroRNAs and RNA-binding proteins exert regulation on >60% of coding genes, yet interplay between them is little studied. Canonical microRNA binding occurs by base-pairing of microRNA 3′-ends to complementary "seed regions" in mRNA 3′UTRs, resulting in translational repression. Similarly, regulatory RNA-binding proteins bind to mRNAs, modifying stability or translation. We investigated post-transcriptional regulation acting on the xenobiotic pump ABCB1/P-glycoprotein, which is implicated in cancer therapy resistance. We characterised the ABCB1 UTRs in primary breast cancer cells and identified UTR sequences that responded to miR-19b despite lacking a canonical binding site. Sequences did, however, contain consensus sites for the RNA-binding protein HuR. We demonstrated that a tripartite complex of HuR, miR-19b and UTR directs repression of ABCB1/P-glycoprotein expression, with HuR essential for non-canonical miR-19b binding thereby controlling chemosensitivity of breast cancer cells. This exemplifies a new cooperative model between RNA-binding proteins and microRNAs to expand the repertoire of mRNAs that can be regulated. This study suggests a novel therapeutic target to impair P-glycoprotein mediated drug efflux, and also indicates that current microRNA binding predictions that rely on seed regions alone may be too conservative.



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Nerve ultrasound findings differentiate Charcot-Marie-Tooth disease (CMT) 1A from other demyelinating CMTs

Publication date: Available online 1 September 2018

Source: Clinical Neurophysiology

Author(s): Giampietro Zanette, Gian Maria Fabrizi, Federica Taioli, Matteo Francesco Lauriola, Andrea Badari, Moreno Ferrarini, Tiziana Cavallaro, Stefano Tamburin

Abstract
Objective

Ulnar/median motor nerve conduction velocity (MNCV) is ≤38 m/s in demyelinating Charcot-Marie-Tooth disease (CMT). Previous nerve high resolution ultrasound (HRUS) studies explored demyelinating CMT assuming it as a homogeneous genetic/pathological entity or focused on CMT1A.

Methods

To explore the spectrum of nerve HRUS findings in demyelinating CMTs, we recruited patients with CMT1A (N = 44), CMT1B (N = 9), CMTX (N = 8) and CMT4C (N = 4). They underwent nerve conduction study (NCS) and HRUS of the median, ulnar, peroneal nerve, and the brachial plexus.

Results

Median, ulnar and peroneal MNCV significantly differed across CMT subtypes. Cross sectional area (CSA) was markedly and diffusely enlarged at all sites, except entrapment ones, in CMT1A, while it was slightly enlarged or within normal range in the other CMTs. No significant right-to-left difference was found. Age had limited effect on CSA. CSAs of some CMT1A patients largely overlapped with those of other demyelinating CMTs. A combination of three median CSA measures could separate CMT1A from other demyelinating CMTs.

Conclusions

Nerve HRUS findings are heterogeneous in demyelinating CMTs.

Significance

Nerve HRUS may separate CMT1A from other demyelinating CMTs. The large demyelinating CMTs HRUS spectrum may be related to its pathophysiological variability.



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Evidence for a differential visual M300 brain response in gamblers

Publication date: Available online 1 September 2018

Source: Clinical Neurophysiology

Author(s): Noam Zilberman, Yair Dor Ziderman, Maor Zeev-Wolf, Abraham Goldstein, Gal Yadid, Yehuda Neumark, Yuri Rassovsky

Abstract
Objective

Gambling disorder is the first behavioral addiction recognized in the DSM-5. This marks the growing realization that both behavioral and substance-related addictions are manifestations of an 'addicted brain', displaying similar altered neurophysiological mechanisms. A decreased electrophysiological visual P300 is considered a hallmark effect of substance-related addictions, but has not yet been shown in behavioral addictions.

Methods

Magnetoencephalographic recordings of 15 gamblers and 17 controls were taken as they performed a cue-reactivity paradigm in which they passively viewed addiction- and non-addiction-related cues.

Results

The main finding of the study is a reduction in the magnetic counterpart of P300 (M300) for gamblers beyond cue condition over frontal regions. Additionally, we found a significant group by cue-type interaction. Gamblers exhibited heightened sensitivity to addiction-related cues in regions corresponding to the frontoparietal attentional network, whereas controls exhibited an opposite effect localized to the right insula.

Conclusions

The results suggest that a reduced P300 characterizes addictions in general, not just substance-related addictions, thus providing important neurophysiological support for the inclusion of behavioral addictions in the DSM-5 and in the incentive-sensitization theory.

Significance

The study offers important insights into neural mechanisms underlying behavioral addictions, and may assist in developing better prevention and intervention strategies.



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When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion

Publication date: Available online 1 September 2018

Source: Clinical Neurophysiology

Author(s): Uwe Walter, José Luis Fernández-Torre, Timo Kirschstein, Steven Laureys

Abstract

The widely accepted concept of brain death (BD) comprises the demonstration of irreversible coma in combination with the loss of brainstem reflexes and irreversible apnea. In some countries the combined clinical finding of coma, apnea, and loss of all tested brainstem reflexes ("brainstem death") is sufficient for diagnosing BD irrespective of the primary location of brain lesion. The present article aims to substantiate the need for ancillary testing in patients with primary infratentorial brain lesions. Anatomically, the "brainstem-death" syndrome can theoretically occur without relevant lesion of the mesopontine tegmental reticular formation (MPT-RF). Thus, a brainstem lesion may cause an apneic total locked-in syndrome, a rare syndrome with preserved capability for consciousness, mimicking "brainstem death". Findings in animals and humans have shown that alpha- or alpha/theta- EEG patterns in case of isolated brainstem lesion indicate intactness of relevant parts of the MPT-RF. In such patients the presence of irreversible coma has to be doubted, and the potential capacity for some degree of consciousness cannot be excluded as long as the EEG activity persists. Consequently the demonstration of either ancillary finding, electro-cortical inactivity or, preferably, cerebral circulatory arrest, is mandatory for diagnosing BD in patients with a primary infratentorial brain lesion.



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Effect of Epileptiform Abnormality Burden on Neurologic Outcome and Antiepileptic Drug Management After Subarachnoid Hemorrhage

Publication date: Available online 1 September 2018

Source: Clinical Neurophysiology

Author(s): Sahar F. Zafar, Eva N. Postma, Siddharth Biswal, Emily J. Boyle, Sophia Bechek, Kathryn O'Connor, Apeksha Shenoy, Jennifer Kim, Mouhsin S. Shafi, Aman B. Patel, Eric S. Rosenthal, M. Brandon Westover

Abstract
Objective

To quantify the burden of epileptiform abnormalities (EAs) including seizures, periodic and rhythmic activity, and sporadic discharges in patients with aneurysmal subarachnoid hemorrhage (aSAH), and assess the effect of EA burden and treatment on outcomes.

Methods

Retrospective analysis of 136 high-grade aSAH patients. EAs were defined using the American Clinical Neurophysiology Society nomenclature. Burden was defined as prevalence of <1%, 1-9%, 10-49%, 50-89%, and >90% for each 18-24 hour epoch. Our outcome measure was 3-month Glasgow Outcome Score.

Results

47.8% patients had EAs. After adjusting for clinical covariates EA burden on first day of recording and maximum daily burden were associated with worse outcomes. Patients with higher EA burden were more likely to be treated with anti-epileptic drugs (AEDs) beyond the standard prophylactic protocol. There was no difference in outcomes between patients continued on AEDs beyond standard prophylaxis compared to those who were not.

Conclusions

Higher burden of EAs in aSAH independently predicts worse outcome. Although nearly half of these patients received treatment, our data suggest current AED management practices may not influence outcome.

Significance

EA burden predicts worse outcomes and may serve as a target for prospective interventional controlled studies to directly assess the impact of AEDs, and create evidence-based treatment protocols.



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The Median to Ulnar Cross-Sectional Surface Area Ratio in Carpal Tunnel Syndrome

Publication date: Available online 31 August 2018

Source: Clinical Neurophysiology

Author(s): Nadim Jiwa, Alon Abraham, Vera Bril, Hans D Katzberg, Leif E. Lovblom, Carolina Barnett, Ari Breiner

Abstract
Objective

To investigate the use of a sonographic median-to-ulnar cross-sectional area ratio (MUR) in diagnosis of carpal tunnel syndrome (CTS); and to compare the MUR with currently used sonographic parameters, and electrophysiology.

Methods

Subjects with CTS and healthy volunteers underwent ultrasound studies of the median and ulnar nerves in the wrist and forearm. Various sonographic parameters and ratios were calculated, and compared between CTS patients and controls. The sensitivity and specificity of the different parameters were compared by plotting receiver operator characteristic curves. Correlations of sonographic results with electrophysiologic studies were calculated.

Results

The MUR was increased in patients with CTS, in comparison with controls. A cut-point of >2.09 yielded a sensitivity of 86% and specificity of 84%. This was comparable to the currently used ultrasound metrics for CTS. The MUR also correlated with electrophysiologic severity.

Conclusions

The MUR is an effective means of diagnosing CTS and correlates with electrophysiologic severity.

Significance

This report provides support for the use of the MUR in the sonographic diagnosis of CTS.



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Towards closed-loop deep brain stimulation for freezing of gait in Parkinson’s disease

Publication date: Available online 31 August 2018

Source: Clinical Neurophysiology

Author(s): Moran Gilat



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Sudomotor dysfunction is frequent and correlates with disability in Friedreich ataxia

Publication date: Available online 31 August 2018

Source: Clinical Neurophysiology

Author(s): Karen A.G. Takazaki, Thiago Junqueira R. Rezende, Alberto R.M. Martinez, Carelis González, Anamarli Nucci, Iscia Lopes-Cendes, Marcondes C. França

Abstract
Objectives

To evaluate autonomic symptoms and function in Friedreich's Ataxia (FRDA).

Methods

Twenty-eight FRDA patients and 24 controls underwent clinical/electrophysiological testing. We employed the Friedreich's Ataxia Rating Scale (FARS) and the Scales for Outcomes in Parkinson's Disease: Autonomic Questionnaire-SCOPA-AUT to estimate the intensity of ataxia and autonomic complaints, respectively. Cardiovagal tests and the quantitative sudomotor axonal reflex, Q-SART were then assessed in both groups. Results

In the patient group, there were 11 men with mean age of 31.5±11.1 years. Mean SCOPA-AUT score was 15.1±8.1. Minimum RR interval at rest was shorter in the FRDA group (Median 831.3 x 724.0ms, p<0.001). The 30:15 ratio, Valsalva index, E:I ratio, low and high frequency power presented no differences between patients and controls (p>0.05). Sweat responses were significantly reduced in patients for all sites tested (forearm 0.389 x1.309 µL; proximal leg 0.406 x1.107 µL; distal leg 0.491 x 1.232 µL; foot 0.265 x 0.708µL; p value<0.05). Sweat volumes correlated with FARS scores. Conclusions

We found abnormal sudomotor but normal heart rate variability in FRDA. Small cholinergic post-ganglionic fibers are affected in the disease.

Significance

Quantification of sudomotor function might be a biomarker for FRDA.



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Early warning scores in the perioperative period: applications and clinical operating characteristics

Purpose of review Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. Recent findings Early warning scores can be used to screen for postoperative deterioration and surgical complications. We describe a framework to evaluate the balance between missed events and warning signals that are not followed by an adverse event (nonevents). In large surgical cohort studies, the missed event rates ranged between 19 and 69% and the nonevent rates ranged between 72 and 99% for 'optimal' threshold early warning sores. Recent investigations have shown that there may be a substantial discrepancy between the theoretical benefits shown in validation studies and the practical clinical implementation of early warning scores, which may partly explain the absence of measurable benefit from these systems. Summary Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness. Correspondence to Harm-Jan de Grooth, MD, Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. Tel: +31 6 46 37 15 07; e-mail: h.degrooth@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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What we can learn from Big Data about factors influencing perioperative outcome

Purpose of review This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. Recent findings The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. Summary Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising. Correspondence to Jurgen C. de Graaff, MD, Department of Anesthesiology, Medical Center, SB-3646, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 10 704 34964; e-mail: j.degraaff@erasmusmc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Perioperative cognitive evaluation

Purpose of review This article reviews the recent clinical evidence published between January 2017 and June 2018 – related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. Recent findings Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. Summary Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care. Correspondence to Federico Bilotta, MD, PhD, Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University, Rome, Italy. Tel: +39 6 8608273; fax: +39 6 8608273; e-mail: bilotta@tiscali.it Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Pediatric Endoscopic Procedure Complications

Abstract

Purpose of Review

This review summarizes the current body of research, define high-risk patients and endoscopic processes, and outline evidence-based countermeasures aimed at minimizing the incidence of complications during endoscopy in children.

Recent Findings

Significant complications of endoscopy requiring emergency department or inpatient admission in otherwise healthy children are unusual, but more common with therapeutic procedures; risk from procedures increases incrementally with preoperative coexisting conditions. Duodenal hematoma is predominantly a pediatric endoscopic complication and is more likely in hematology-oncology patients. Air embolism is a well-defined endoscopic retrograde cholangiopancreatography (ERCP) complication in adults and is likely to increase in children with increased performance of pediatric ERCP.

Summary

Increased physician expertise is the most often proposed countermeasure, especially in the context of endoscopy complications in the higher-risk patient and procedure. Endoscopy in children remains a very safe group of procedures, although a more detailed understanding of risk factors and ideal training and practice organization is lacking.



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A Prospective Observational Cohort Study of Calls for Help in a Tertiary Care Academic Operating Room Suite

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1–1.8), corresponding to a rate of 5.0 (3.8–6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR. Accepted for publication June 11, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Cameron J. Ricks, MD, Department of Anesthesiology and Perioperative Care, University of California, Irvine School of Medicine, 333 The City Blvd W, Suite 2150, Orange, CA 92868. Address e-mail to cricks@uci.edu. © 2018 International Anesthesia Research Society

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Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents

BACKGROUND: Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Secondgeneration drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS: The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS: A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0.90, 91–180, 181–365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0–90 days and 3.4 (0.8 to 15.3) at 91–180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS: The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT. Accepted for publication March 9, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Gregory A. Nuttall, MD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Address e-mail to Gnuttall@mayo.edu. © 2018 International Anesthesia Research Society

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Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial

BACKGROUND: Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. METHODS: This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 and 10 μg/kg or an equal volume of saline. RESULTS: Visual analog scale scores were significantly better (P2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P

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Caution in Using Gadolinium-Based Contrast Agents in Interventional Pain Procedures

No abstract available

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Reversal of Deep Pipecuronium-Induced Neuromuscular Block With Moderate Versus Standard Dose of Sugammadex: A Randomized, Double-Blind, Noninferiority Trial

BACKGROUND: Certain surgical interventions may require a deep neuromuscular block (NMB). Reversal of such a block before tracheal extubation is challenging. Because anticholinesterases are ineffective in deep block, sugammadex 4 mg/kg has been recommended for the reversal of rocuronium- or vecuronium-induced deep NMB. However, this recommendation requires opening 2 vials of 200 mg sugammadex, which results in an increase in drug costs. Therefore, we sought a less expensive solution for the induction and reversal of deep NMB. Although the optimal dose of sugammadex for antagonism of deep block from pipecuronium has not been established, data pertaining to moderate block are available. Accordingly, we hypothesized that sugammadex 2 mg/kg would be a proper dose to reverse deep pipecuronium block, enabling us to avoid cost increases. In the present study, we compared sugammadex 2 mg/kg with the standard dose of 4 mg/kg for reversal of deep block from pipecuronium. METHODS: This single-center, randomized, double-blind, 2 parallel-arms, noninferiority study comprised 50 patients undergoing general anesthesia with propofol, sevoflurane, fentanyl, and pipecuronium. Neuromuscular monitoring was performed with acceleromyography (TOF-Watch SX). Noninferiority margin was specified beforehand as an increase in reversal time of no

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Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case–Control Study

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy. Accepted for publication July 3, 2018. Funding: This work was supported by the University of Michigan Health System Department of Anesthesiology. Support for REDCap (Research Electronic Data Capture) reported in this publication was provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000433. E.A.S.C. is supported by a grant from the Burroughs Wellcome Foundation. P.T. was supported by a grant from the Robert Wood Johnson Foundation (Princeton, NJ), Harold Amos Medical Faculty Development Program (award 69779). B.T.B. is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Bethesda, MD) under Award Number K08HD075831. No source of funding had a role in any stage of the study, analysis, or writing of this manuscript. Conflicts of Interest: See Disclosures at the end of the article. This work was presented, in part, at the 48th Society for Obstetric Anesthesia and Perinatology Annual Meeting, Boston, MA, May 18–22, 2016. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Sydney Behrmann, BS, is currently affiliated with the University of Michigan Medical School, Ann Arbor, Michigan; Anthony Chau, MD, MMSc, is currently affiliated with the Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia; Caitlin Clancy, BA, BSN, RN, is currently affiliated with the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York; Stephanie Lin, MD, is currently affiliated with the Department of Perinatal Medicine, Marian Regional Medical Center, Santa Maria, California; Kristina Priessnitz, BS, is currently affiliated with the Michigan State College of Human Medicine, East Lansing, Michigan; Anuj Shah, MD, is currently affiliated with the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan. Reprints will not be available from the authors. Address correspondence to Melissa E. Bauer, DO, Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to mbalun@med.umich.edu. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Preoperative Salivary Cortisol AM/PM Ratio Predicts Early Postoperative Cognitive Dysfunction After Noncardiac Surgery in Elderly Patients

BACKGROUND: The diagnosis of postoperative cognitive dysfunction (POCD) requires complicated neuropsychological testing and is often delayed. Possible biomarkers for early detection or prediction are essential for the prevention and treatment of POCD. Preoperative screening of salivary cortisol levels may help to identify patients at elevated risk for POCD. METHODS: One hundred twenty patients >60 years of age and undergoing major noncardiac surgery underwent neuropsychological testing 1 day before and 1 week after surgery. Saliva samples were collected in the morning and the evening 1 day before surgery. POCD was defined as a Z-score of ≤−1.96 on at least 2 different tests. The primary outcome was the presence of POCD. The primary objective of this study was to assess the relationship between the ratio of AM (morning) to PM (evening) salivary cortisol levels and the presence of POCD. The secondary objective was to assess the relationship between POCD and salivary cortisol absolute values in the morning or in the evening. RESULTS: POCD was observed in 17.02% (16 of 94; 95% confidence interval [CI], 9.28%–24.76%) of patients 1 week after the operation. A higher preoperative AM/PM salivary cortisol ratio predicted early POCD onset (odds ratio [OR], 1.56; 95% CI, 1.20–2.02; P = .001), even after adjusting for the Mini-Mental Sate Examination score (odds ratio, 1.55; 95% CI, 1.19–2.02; P = .001). The area under the receiver operating characteristic curve for the salivary cortisol AM/PM ratio in individuals with POCD was 0.72 (95% CI, 0.56–0.88; P = .006). The optimal cutoff value was 5.69, with a sensitivity of 50% and specificity of 91%. CONCLUSIONS: The preoperative salivary cortisol AM/PM ratio was significantly associated with the presence of early POCD. This biomarker may have potential utility for screening patients for an increased risk and also for further elucidating the etiology of POCD. Accepted for publication July 18, 2018. Funding: Supported by the National Natural Science Foundation of China (81720108013, 81571059); Jiangsu Provincial Special Program of Medical Science (BL2014029); Scientific Research Innovation Project for Graduate Students of Jiangsu Universities, Jiangsu, China (SJZZ16_0290); and China Postdoctoral Science Foundation Funded Project (Project No: 2015M580473). 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). Y. Han, L. Han, and M.-M. Dong contributed equally to this work and share first authorship. Reprints will not be available from the authors. Address correspondence to Jun-Li Cao, MD, PhD, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai Rd, Quanshan District, Xuzhou City 221002, Jiangsu Province, China. Address e-mail to caojl0310@aliyun.com. © 2018 International Anesthesia Research Society

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Anticipated Rates and Costs of Guideline-Concordant Preoperative Stress Testing

BACKGROUND: Current guidelines recommend that patients have preoperative assessment of cardiac risk and functional status, and that patients at "elevated" cardiac risk with poor or unknown functional status be referred for preoperative stress testing. Little is known about current rates of testing or resultant medical costs. We set out to estimate the expected rates of preoperative stress testing and resultant costs if physicians in the United States were to follow current guidelines and to investigate differences that would arise from 2 risk prediction methods included in current guidelines. METHODS: We applied 2 risk prediction tools (Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest) included in current American College of Cardiology/American Heart Association guidelines to a multicenter prospective registry of patients undergoing surgery in the United States in 2009. We then calculated expected rates of preoperative cardiac stress testing if physicians were to follow American College of Cardiology/American Heart Association guidelines, expected nationwide direct medical expenditures that would result (in 2017 US dollars), and agreement beyond chance between the 2 risk prediction tools. RESULTS: Current guidelines recommend considerable spending on preoperative stress testing. Guideline-recommended spending would differ substantially depending on the risk prediction tool used and the reliability of the functional status assessment. Rates of testing and resultant spending are likely much greater among patients at "elevated" risk, compared with patients at "low" risk. Two guideline-recommended risk assessment tools, Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest, have poor agreement beyond chance across the currently recommended risk threshold. CONCLUSIONS: Preoperative stress testing is likely a considerable source of medical spending, despite unproven benefit. Which perioperative risk assessment tool clinicians should use, what risk thresholds are appropriate for patient selection, and the reliability of the functional status assessment all warrant further attention. Accepted for publication July 23, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Matthew A. Pappas, MD, MPH, Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Stop G-10, Cleveland, OH 44195. Address e-mail to pappasm@ccf.org. © 2018 International Anesthesia Research Society

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Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields. Accepted for publication July 3, 2018. M. M. Longacre, MD, MM, and A. M. Bader, MD, MPH, are currently affiliated with the Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, Boston, Massachusetts. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Mckenna M. Longacre, MD, MM, Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to mmlongacre@partners.org. © 2018 International Anesthesia Research Society

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Use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator During Preoperative Risk Discussion: The Patient Perspective

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk. METHODS: Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions. RESULTS: Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P

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Traumatic Brain Injury in Flies

No abstract available

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Observation of Complement Protein Gene Expression Before and After Surgery in Opioid-Consuming and Opioid-Naive Patients

Opioids may influence inflammation. We compared genes associated with pain and inflammation in patients who consumed opioids (3–120 mg of oral morphine equivalents per day) with those who did not for differential expression. White blood cells were assayed in 20 patients presenting for total lower extremity joint replacement. We focused on messenger ribonucleic acid expression of complement proteins. We report that the expression of a complement inhibitor, complement 4 binding protein A, was reduced, and the expression of a complement activator, complement factor D, was increased in opioid-consuming patients. We conclude that opioid consumption may influence expression of complement activators and inhibitors. Accepted for publication July 12, 2018. Funding: Supported in part by the Department of Anesthesiology at the University of Utah. 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). Clinical trial number and registry URL: This study is not subject to ClinicalTrials.gov review because the study is not a clinical trial and does not involve an intervention or investigational use of a device or drug. Reprints will not be available from the authors. Address correspondence to Ken B. Johnson, MD, Department of Anesthesiology, University of Utah, 30 N 1900 E RM 3C444, Salt Lake City, UT 84112. Address e-mail to ken.b.johnson@hsc.utah.edu. © 2018 International Anesthesia Research Society

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Intravenous Lidocaine for the Prevention of Cough: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: It remains unclear to what extent intravenous lidocaine prevents cough and whether there is dose-responsiveness and risk of harm. METHODS: We searched electronic databases to January 1, 2017 for randomized trials comparing intravenous lidocaine with placebo for the prevention of cough in surgical patients. Primary outcome was the incidence of cough. Data were analyzed using a random-effects model and were expressed as risk ratio (RR) and number needed to treat (NNT) with 95% confidence interval. RESULTS: In 20 trials in adults (n = 3062) and 5 trials in children (n = 445), intravenous lidocaine 0.5–2 mg·kg−1 was tested for the prevention of intubation-, extubation-, or opioid-induced cough. Twenty-two trials included only American Society of Anesthesiologists I or II patients; 3 trials (n = 99) also included American Society of Anesthesiologists III patients. Lidocaine was associated with a lower incidence of cough compared to placebo in adults and children, irrespective of dosage and cough etiology. Data from adults suggested dose-responsiveness; with 0.5 mg·kg−1, RR was 0.66 (0.50–0.88) and NNT was 8 (5.4–14.3); with 1 mg·kg−1, RR was 0.58 (0.49–0.69) and NNT was 7 (4.6–8.9); with 1.5 mg·kg−1, RR was 0.44 (0.33–0.58) and NNT was 5 (3.3–5.2); and with 2 mg·kg−1, RR was 0.39 (0.24–0.62) and NNT was 3 (2.0–3.4). Adverse effect reporting was sparse. CONCLUSIONS: Within a range of 0.5–2 mg·kg−1, intravenous lidocaine dose dependently prevents intubation-, extubation-, and opioid-induced cough in adults and children with NNTs ranging from 8 to 3. The risk of harm in high-risk patients remains unknown. Accepted for publication April 12, 2018. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Sara Clivio, MD, Department of Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland. Address e-mail to sara.clivio@cardiocentro.org. © 2018 International Anesthesia Research Society

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Global Anesthesia

No abstract available

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Incentive-Based Game for Allaying Preoperative Anxiety in Children: A Prospective, Randomized Trial

BACKGROUND: Induction of anesthesia can be distressing both for children and their parents. Nonpharmacological behavioral interventions can reduce the anxiety of children without significant adverse effects as seen with sedative medications. We hypothesized that the use of incentive-based game therapy in conjunction with parental involvement would be a simple and cost-effective intervention in reducing the preoperative anxiety in children. METHODS: Eighty children between the age group of 4 and 8 years scheduled to undergo surgery were randomly assigned to a control group (n = 40) and intervention group (n = 40). Children in the intervention group participated in an incentive-based game in the preoperative room. Anesthesia was induced with parental presence in both the groups. The modified Yale Preoperative Anxiety Scale (mYPAS) score to measure the anxiety of the children during induction was taken as the primary outcome. Induction Compliance Checklist score and parental satisfaction were assessed as secondary outcomes. RESULTS: The mYPAS score of children in the intervention group was significantly less than the control group during anesthesia induction. The mean difference (95% confidence interval [CI]) of the mYPAS at induction between the 2 groups was 20 (95% CI, 16–24; P

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Positive Work Contribution Shifts from Distal to Proximal Joints during a Prolonged Run

Purpose To investigate the joint-specific contributions to the total lower extremity joint work during a prolonged fatiguing run. Methods Recreational long-distance runners (RR; n = 13) and competitive long-distance runners (CR; n = 12) performed a 10-km treadmill run with near-maximal effort. A three-dimensional motion capture system synchronized with a force-instrumented treadmill was used to calculate joint kinetics and kinematics of the lower extremity in the sagittal plane during the stance phase at 13 distance points over the 10-km run. Results A significant (P

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Use of Biosimilars in Paediatric Inflammatory Bowel Disease: An Updated Position Statement of the Paediatric IBD Porto Group of ESPGHAN

Biologic therapies have changed the outcome of both adult and paediatric patients with Inflammatory Bowel Disease (IBD). In September 2013, the first biosimilar of infliximab was introduced into the pharmaceutical market. In 2015, a first position paper on the use of biosimilars in paediatric IBD was published by the ESPGHAN IBD Porto group. Since then, more data have accumulated for both adults and children demonstrating biosimilars are an effective and safe alternative to the originator. In this updated position statement we summarize current evidence and provide joint consensus statements regarding the recommended practice of biosimilar use in children with IBD. Address correspondence and reprint requests to Lissy de Ridder, MD, PhD, Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands (e-mail: l.deridder@erasmusmc.nl). Received 7 June, 2018 Accepted 15 August, 2018 Conflicts of interests Ridder, L de – Last 3 years received consultation fee, research grant, or honorarium from ZonMw (national health institute), Janssen, Pfizer, Mundipharma, Shire and Abbvie. Assa, A- Last 3 years received consultation fee, research grant, or honorarium from Abbvie, Janssen and Rafa pharmaceuticals. Bronsky J - Last 3 years received consultation fee and honoraria from AbbVie and MSD. Russell, RK - Has received speaker's fees, travel support, and participated in medical board meetings with Abbvie, Janssen, Shire, Celltrion, NAPP and Nestle. Hauer AC - Last 3 years received consultation fee and honoraria from AbbVie, MSD, Janssen and Nutricia. Lionetti, P - Last 3 years received consultation fee and honoraria from Abbvie, Pfizer and Nutricia. Veres G - Last 3 years received consultation fee from AbbVie, Nutricia, and Nestle. Sladek M - has received consultant fee, speakers fee, travel support, and honoraria from AbbVie, Astellas, Egis, Ferring, Mundipharma, Nestle, Nutricia. Winter H - Last 3 years received consultant fee, royalties, speakers fee, travel support, honoraria and participated in advisory boards for Janssen Pharma, Nutricia, Nestle Nutrition, Abbvie, Shire, Pediatric IBD Foundation, Women's Wellness, QOL, Autism Research Foundation, UpToDate. Vulto, A – Has received consultation fees, speakers fees, and participated in advisory boards for AbbVie, Biogen Idec Ltd, Pfizer / Hospira Inc, Novartis / Sandoz Ltd., Samsung Bioepis, Amgen Inc; Bristol Meyers Squibb, F. Hoffmann-La Roche Ltd, Eli Lilly, Febelgen, Medicines for Europe AISBL, Mundipharma, Hexal / Sandoz Ltd., Biogen Idec Ltd, Boehringer-Ingelheim. Dias, J – Has received speakers' fee from Abbvie, Danone, Nestlé. Partcipated at Advisory board of Celgene, Danone and Falk. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Enteric Virome and Bacterial Microbiota in Children with Ulcerative Colitis and Crohn's Disease

Objectives: We examined the fecal enteric virome and bacterial community composition of children with Crohn's disease (CD), ulcerative colitis (UC), and healthy controls to test the hypothesis that unique patterns of viral organisms and/or presence of bacterial pathogens may be identified that could contribute to the pathogenesis of pediatric inflammatory bowel disease (IBD). Methods: Fecal samples from 24 children (mean 12.2 years) with CD (n = 7) or UC (n = 5) and similar aged controls (n = 12) were processed to determine individual viromes. Viral sequences were identified through translated protein sequence similarity search. Bacterial microbiota were determined by sequencing of the V4 region of the 16S rRNA gene. Results: Only a few human viruses were detected, so virome analyses focused on bacterial viruses. The relative abundance of Caudovirales was greater than that of Microviridae phages in both IBD and healthy controls. Caudovirales phages were more abundant in CD (mean 80.8%) than UC (48.8%) (p = 0.05) but not controls. The richness of viral strains in Microviridae but not Caudovirales was higher in controls than CD (p = 0.05) but not UC cases. No other measure of phage abundance, richness, or Shannon diversity showed significant difference between the two IBD and control groups. Bacterial microbiota analysis revealed that IBD diagnosis, albumin, hemoglobin, erythrocyte sedimentation rate, and probiotic supplementation correlated to the composition of gut bacterial microbiota. Conclusions: Minor patterns in gut virome and bacterial community composition distinguish pediatric IBD patients from healthy controls. Probiotics are associated with bacterial microbiota composition. These exploratory results need confirmation in larger studies. Correspondence: Melvin B. Heyman, MD, 550 16th St, 5th floor, Mailstop 0136, Pediatric Gastroenterology/Nutrition, University of California, San Francisco CA 94143 (e-mail: mel.heyman@ucsf.edu). Received 27 April, 2018 Accepted 14 August, 2018 Sources of support that require acknowledgment: Blood Systems Research Institute for support to TGP, XD, ED. Funded in part by NIH Grant T32DK007762 (MAF, SGV) and by generous support from donors to the UCSF Pediatric IBD Research and Education Fund. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Anxiety and Salivary Cortisol Levels in Children Undergoing Esophago-Gastro-Duodenoscopy Under Sedation

Objectives: Esophagogastroduodenoscopy (EGD) can cause fear and anxiety in children. Cortisol, which is the most important glucocorticoid hormone in humans, can increase under physiological stress. The purpose of this study was to measure the salivary cortisol level (SCL) and anxiety level in patients undergoing EGD and evaluate their effects on the procedure. Methods: Children undergoing EGD under sedoanalgesia with propofol for various reasons were included. Their basal SCLs were compared with those of healthy age- and sex-matched controls. Moreover, SCL of the patient group at 30 min before EGD and 2 h after the procedure were measured. Their anxiety scores were calculated using the modified Yale Preoperative Anxiety Scale before EGD. Duration of endoscopy, sedation, and recovery and total propofol doses were recorded. Results: Demographic properties of the patient group (n = 119; 10.9 ± 3.2 years; 43.7% male) and control group (n = 85; 11.8 ± 2.8 years; 45.1% male) were not significantly different. Basal SCLs of both groups were similar (16.9 ± 0.7 ng/mL vs 19.7 ± 1.8 ng/mL, p = 0.16). SCL before EGD in the patient group was significantly higher than basal and post-EGD values (p 

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