Ivabradine preserves dynamic sympathetic control of heart rate despite inducing significant bradycardia in rats

Abstract

Ivabradine is a selective bradycardic agent that inhibits hyperpolarization-activated cyclic nucleotide-gated (HCN) channels. HCN channels play a key role in mediating the positive chronotropic response to sympathetic nerve stimulation (SNS). We examined whether ivabradine would interfere with dynamic sympathetic control of heart rate (HR). The effect of intravenous ivabradine (2 mg/kg, n = 7) or metoprolol (10 mg/kg, n = 6) on the transfer function from SNS to HR was examined in anesthetized rats. Ivabradine preserved the asymptotic dynamic gain of the HR transfer function and nearly doubled the asymptotic dynamic gain of the transfer function from SNS to the R–R interval. In contrast, metoprolol abolished dynamic sympathetic control of HR. Preserved dynamic sympathetic control of HR, with coexisting bradycardia, may contribute to some of the beneficial effects of ivabradine previously reported in clinical application.

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Laparoscopic management of incidental gallbladder cancer

Abstract

Background

The laparoscopic cholecystectomy has allowed the detection of an increasing number of incidental gallbladder cancers (IGBC). Although laparoscopy is employed in the management of a variety of abdominal tumors, its use in gallbladder cancer is reduced and controversial. This study analyzes the role of laparoscopy in gallbladder cancer with the focus in IGBC.

Method

We evaluated our prospective series of 51 patients with an IGBC who were treated by laparoscopy between 2006 and 2016 at the Clinica Alemana in Santiago, Chile.

Results

The series comprised 7 men and 44 women. Age ranged from 43 to 76 years (mean age 60). Regarding wall involvement, 29 patients had a T2 tumor, which was the most common. 8 and 14 patients had T1b and T3 tumors, respectively. Of the patients, 17 underwent only laparoscopic exploration. This was due to the presence tumor dissemination not being observed in the preoperative staging. 10 patients had to be converted to complete the resection, whereas 24 patients were laparoscopically resected. The quality of the resected material was not different between those who were converted and those who were treated by laparoscopy. In the laparoscopic group, the average number of harvested lymph nodes was 7.9, not statistically different from the converted group. The mean of hospital stay in the laparoscopic group (4.3 days) was significantly lower than the converted group.

Conclusions

Laparoscopy has been shown to be a safe and feasible method for the management of IGBC. This method not only allows for a complete exploration, identifying a previously unseen residual tumor, but also makes it possible to accomplish the same oncology objectives as the open procedure. Therefore, laparoscopy should be considered a valid alternative in the management of IGBC.

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Examining the impact of surgical coaching on trainee physiologic response and basic skill acquisition

Abstract

Background

We examined how problem-solving coaching impacts trainee skill acquisition and physiologic stress as well as how trainee sensitivity to feedback, known as self-monitoring ability, impacts coaching effectiveness.

Methods

Medical students completed a pre-training demographics questionnaire, a 12-item self-monitoring ability scale (1 = always false, 5 = always true), and baseline FLS Task 5 with physiologic sensors. After watching a laparoscopic suturing instructional video, students practiced the task for 30 min, either with a surgical coach, or alone, depending on condition. The coach logged frequency of coaching behaviors according to a task-specific coaching script. Trainees then completed FLS Task 5 with physiologic sensors, a post-training questionnaire, and a 12-item coaching quality evaluation (1 = poor, 5 = very good).

Results

Twenty-four students (age 24.5 ± 1.4; 54% men; 58% MS4) participated in the study. All were fairly high self-monitors (3.8 ± 0.76). No differences in baseline suturing skills between the groups emerged. Improvement in the coaching group's suturing (N = 12; 285.0 ± 79.9) was significantly higher than the control group (N = 12; 200.9 ± 110.3). One measure of physiologic stress (rMSSD) was significantly higher in the coaching group. Trainees who received more coaching demonstrated larger improvements (r = 0.7, p < 0.05). Overall ,perceived quality of the coaching relationship was high (4.4 ± 0.6). There was no correlation between trainee self-monitoring ability and skill improvement.

Conclusions

This work suggests that coaching may increase heart rate variability of trainees, indicating coping well with training. Trainee disposition toward feedback did not play a role in this relationship.

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Safety of orogastric tubes in foregut and bariatric surgery

Abstract

Background

Orogastric tubes have traditionally aided foregut procedures with sizing and organ protection. The rise of bariatric surgery has led to the creation of novel medical devices aimed at facilitating the laparoscopic sleeve gastrectomy. While approved by the FDA, the long-term safety profile of these devices in the general population is often unknown. This review looks at complications associated with novel Orogastric Tubes compared to the traditional bougie.

Methods

We performed a review of the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for complications associated with the traditional bougie, Boehringer Labs ViSiGi 3D® and the Medtronic GastriSail™ since 2011. In addition, we looked for reported cases in the literature of complications with these devices.

Results

Overall complication rates reported in the MAUDE database varied in number and severity. The bougie had seven reported complications, one of which was an organ perforation. The ViSiGi 3D® had zero reported complications. The GastriSail™ had 36 total reported complications with 17 perforations. A literature review shows that rates of bougie complications are extremely rare with no case reports or reviews of complications from the novel orogastric tubes.

Conclusions

The complication rates between the traditional bougie and novel devices vary in number and severity, with the GastriSail™ having the highest reported complication rate. Despite rigorous testing for FDA approval, ongoing research into performance of new medical devices in the general population remains important.

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A novel method of intracorporeal end-to-end gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for early gastric cancer, including a unique anastomotic technique: piercing the stomach with a linear stapler

Abstract

Background

Delta-shaped anastomosis is usually applied for an intracorporeal gastrogastrostomy in totally laparoscopic pylorus-preserving gastrectomy (TLPPG). However, the remnant stomach is slightly twisted around the anastomosis because it connects in side-to-side fashion. To realize an intracorporeal end-to-end gastrogastrostomy using an endoscopic linear stapler, we invented a novel method including a unique anastomotic technique.

Materials and methods

In this new approach, we first made small gastrotomies at the greater and lesser curvatures of the transected antrum and then pierced it using an endoscopic linear stapler. After the pierced antrum and the proximal remnant stomach were mechanically connected, the gastrotomies and stapling lines were transected using an endoscopic linear stapler, creating an intracorporeal end-to-end gastrogastrostomy. We have named this technique the "piercing method" because piercing the stomach is essential to its implementation. Between October 2015 and June 2017, 26 patients who had clinically early gastric cancer at the middle third of the stomach without clinical evidence of lymph node metastasis underwent TLPPG involving the novel method.

Results

The 26 patients successfully underwent an intracorporeal mechanical end-to-end gastrogastrostomy by the piercing method. The median operation time of the 26 patients was 272 min (range 209–357 min). With the exception of one gastric stasis, no problems associated with the piercing method were encountered during and after surgery.

Conclusion

The piercing method can safely create an intracorporeal mechanical end-to-end gastrogastrostomy in TLPPG. Piercing the stomach using an endoscopic linear stapler is a new technique for gastrointestinal anastomosis. This method should be considered if the surgical aim is creation of an intracorporeal end-to-end gastrogastrostomy in TLPPG.

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Customized airway stenting for bronchopleural fistula after pulmonary resection by interventional technique: single-center study of 148 consecutive patients

Abstract

Background

Bronchopleural fistula after pulmonary resection is a serious complication, with major impact on the quality of life and survival. This study aims to evaluate the efficacy and safety of customized airway stenting in the treatment of bronchopleural fistula.

Methods

A series of airway stents for dedicated bronchopleural fistula occlusion were designed after taking into account the anatomical and pathophysiological features of post-pulmonary resection fistulas and the shortcomings of airway stents currently available. The fistulas were occluded with the bullet head or a special part of the covered airway stent. Successful stenting was defined as immediate cessation of air leak from the residual cavity after stenting. The results were retrospectively analyzed.

Results

Airway occlusion stenting was successful on the first attempt in 143/148 (96.6%) patients with bronchopleural fistulas. In the remaining 5 patients, occlusion was successful only on the second try. At follow-up 30 days after stenting, 141 patients reported relief in symptoms. No choking, laryngeal edema, or airway rupture occurred in any patient during stent insertion or removal; 2 patients developed hemorrhage during stent removal.

Conclusions

Airway occlusion stenting appears to be a feasible and effective technique for treatment of bronchopleural fistula.

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Laparoscopic Hill repair: 25-year follow-up

Abstract

Background

The open Hill repair for gastroesophageal reflux disease and hiatal hernia is remarkably durable, with a median 10-year reoperation rate of only 3% and satisfaction of 93%. No long-term data exist for the laparoscopic Hill repair (LHR).

Methods

Patients who underwent primary LHR at Swedish Medical Center for reflux and/or hiatal hernia at least 5 years earlier (1992–2010) were identified from an IRB-approved database. There were 727 patients who met inclusion criteria, including 648 undergoing repair for reflux and 79 for paraesophageal hernia. Two questionnaires were administered via mail to evaluate long-term quality of life using validated GERD-HRQL, Swallowing score, and global satisfaction score. Outcomes were defined by GERD-HRQL score, Swallowing score, resumption of proton pump inhibitor (PPI) therapy, need for reoperation, and global satisfaction with overall results.

Results

Two hundred forty-two patients completed and returned the survey (226 lost to follow-up, 90 deceased, 3 denied undergoing LHR, 166 non-responders), of which 52% were male. The average age at the time of surgery was 49.5 years. Median follow-up was 18.5 years (range 6.2–24.7). The average GERD-HRQL score (7.1) and the average Swallowing score (39.9) both indicated excellent symptomatic outcomes. 30% of patients are using daily PPIs. 24 patients (9.9%) required reoperation for failure during the follow-up period, 21 in the reflux group and 3 in the paraesophageal hernia group. Overall, 85% reported good to excellent results, and 76% would recommend the operation.

Conclusion

LHR shows excellent long-term durability and quality of life similar to the open Hill repair, with 85% good to excellent results at a median follow-up of 19 years and a reoperation rate under 10%. It is surmised that Hill suture fixation of the gastroesophageal junction to the preaortic fascia may confer unique structural integrity compared to other repairs.

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An in vivo analysis of safe laparoscopic grasping thresholds for colorectal surgery

Abstract

Background

Analysis of safe laparoscopic grasping thresholds for the colon has not been performed. This study aimed to analyse tissue damage thresholds when the colon is grasped laparoscopically, correlating histological changes to mechanical compressive forces.

Methods

An instrumented laparoscopic grasper was used to measure the forces applied to porcine colon, with data captured and plotted as a force–time (f–t) curve. Haematoxylin and eosin histochemistry of tissue subjected to 10, 20, 40, 50 and 70 N for 5, 30 and 60 s was performed, and the area of colonic circular and longitudinal muscle was compared in grasped and un-grasped regions. The area under the f–t curve was calculated as a measure of the accumulated force applied, known as the force–time product (FTP).

Results

FTP ranged from 55.7 to 3793 N.s. Significant differences were observed between the muscle area of the grasped and un-grasped regions in both longitudinal and circular muscle at 50 N and above for all grasping times. For the longitudinal muscle, significant differences were observed between grasped and un-grasped areas at 20 N force for 30 s (mean difference = 59 mm², 95% CI 41–77 mm², P = 0.04), 20 N force for 60 s (mean difference = 31 mm², 95% CI 21.5–40.5 mm², P = 0.006) and 40 N force for 30 s (mean difference 37 mm², 95% CI 27–47 mm², P = 0.006). Changes in histology correlated with mechanical forces applied to the longitudinal muscle at a FTP over 300 N s.

Conclusions

This study characterizes the grasping forces that result in histological changes to the colon and correlates these with a mechanical measurement of the applied force. The findings will contribute to the development of smart laparoscopic graspers with active constraints to prevent excessive grasping and tissue injury.

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The effect on surgical skills of expert surgeons using 3D/HD and 2D/4K resolution monitors in laparoscopic phantom tasks

Abstract

Background

Recently, several new imaging technologies, such as three-dimensional (3D)/high-definition (HD) stereovision and high-resolution two-dimensional (2D)/4K monitors, have been introduced in laparoscopic surgery. However, it is still unclear whether these technologies actually improve surgical performance.

Methods

Participants were 11 expert laparoscopic surgeons. We designed three laparoscopic suturing tasks (task 1: simple suturing, task 2: knotting thread in a small box, and task 3: suturing in a narrow space) in training boxes. Performances were recorded by an optical position tracker. All participants first performed each task five times consecutively using a conventional 2D/HD monitor. Then they were randomly divided into two groups: six participants performed the tasks using 3D/HD before using 2D/4K; the other five participants performed the tasks using a 2D/4K monitor before the 3D/HD monitor. After the trials, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and compared performance scores across all monitors.

Results

Surgical performances of participants were ranked in decreasing order: 3D/HD, 2D/4K, and 2D/HD using the total scores for each task. In task 1 (simple suturing), some surgical performances using 3D/HD were significantly better than those using 2D/4K (P = 0.017, P = 0.033, P = 0.492 for operative time, path length, and technical errors, respectively). On the other hand, with operation in narrow spaces such as in tasks 2 and 3, performances using 2D/4K were not inferior to 3D/HD performances. The high-resolution images from the 2D/4K monitor may enhance depth perception in narrow spaces and may complement stereoscopic vision almost as well as using 3D/HD.

Conclusions

Compared to a 2D/HD monitor, a 3D/HD monitor improved the laparoscopic surgical technique of expert surgeons more than a 2D/4K monitor. However, the advantage of 2D/4K high-resolution images may be comparable to a 3D/HD monitor especially in narrow spaces.

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Intraoperative ultrasonography of robot-assisted laparoscopic hepatectomy: initial experiences from 110 consecutive cases

Abstract

Background

To evaluate the safety and efficacy of IOUS in robotic liver surgery and propose a standard protocol of IOUS for safe robot-assisted hepatectomy.

Methods

Between February 2015 and December 2016, liver resection was performed in 110 patients with robotic approach in Tongji Hospital. In these patients, IOUS was routinely performed. All data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed.

Results

A four steps IOUS protocol in robotic liver surgery was proposed, including exploration, verification, guidance, and confirmation. A total of 11 additional lesions in 11 patients were detected and 7 patients accepted strategic surgical modification. No patient suffered from any single or multiple organ dysfunctions, and there were no mortalities observed.

Conclusion

IOUS is indispensable to understand lesions and vessels in robotic liver surgery. A four-step standard protocol of IOUS is essential for safe robot-assisted hepatectomy.

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Evolution in the management of acute cholecystitis in the elderly: population-based cohort study

Abstract

Background

Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.

Methods

Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.

Results

47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10–0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.

Conclusion

Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

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Laparoscopic surgery for large left lateral liver tumors: safety and oncologic outcomes

Abstract

Background

Although laparoscopic hepatectomy has been proven to be safe and reliable, the influence of tumor size on the feasibility of laparoscopic left lateral segmentectomy (LLLS) is unclear. We retrospectively reviewed our surgical results focusing on hepatic tumor located in the left lateral segment.

Methods

From January 2003 to June 2016, patients who underwent left lateral segmentectomy were retrospectively reviewed, and data were collected on patient characteristics, peri-operative outcomes, and pathologic results. Patients with intrahepatic stone, cystic lesion, or unmeasurable tumor size were excluded. The continuous variables were compared using the Mann–Whitney U test and categorical variables using the Chi square or Fisher's exact test. The overall and disease-free survival rates were computed using the Kaplan–Meier method and compared using the log-rank test.

Results

A total of 103 patients were enrolled for analysis. Among the patients with tumors larger than 5 cm in the left lateral segment, those who underwent laparoscopic surgery had significantly shorter hospital stay and larger resection margin than those who underwent open surgery. The surgical results of the patients who underwent LLLS were not significantly different from those of the patients with tumors larger than 5 cm. Specifically, the 5-year overall survival and disease-free survival rates of the patients with hepatocellular carcinoma (HCC) larger than 5 cm who underwent LLLS were comparable to those of the patients who underwent open left lateral segmentectomy.

Conclusions

LLLS is safe and also feasible for hepatic tumors larger than 5 cm. For HCCs larger than 5 cm, the laparoscopic approach yields satisfying oncologic outcomes as the open approach.

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SAGES climate survey: results and strategic planning for our future

Abstract

Background

While SAGES prides itself on diversity and inclusivity, we also recognize that as an organization we are not impervious to blind spots impacting equity within the membership. To address this, the We R Sages task force was formed to identify the barriers and facilitators to creating a diverse organization and develop a strategic plan for the implementation of programing and opportunities that promote diversity and inclusivity within our membership. As the first step in the process, a survey was administered to gauge the current organizational climate.

Methods

In September of 2017, a validated climate survey was administered to 704 SAGES committee members via SurveyMonkey®. Climate was assessed on: overall SAGES experience, consideration of leaving the organization, mentorship within the organization, resources and opportunities within the organization, and attitudes and experiences within the organization. Additional free text responses were encouraged to generate qualitative themes.

Results

The survey response rate was 52.1% (n = 367). Respondent self-identified demographics were: male (73%), white (63%), heterosexual (95.5%), and non-disabled (98%). Average overall satisfaction was 8.1/10. 12.5% of respondents had considered leaving the organization and 74.4% had not identified a formal mentor within the organization. Average agreement with equitable distribution of resources and opportunities was 5.8/10. 93.6% of respondents had not experienced bias within the organization.

Conclusion

Overall SAGES has a very positive climate; however, several key issues were identified from the quantitative survey as well as the free text responses. Strategic planning to address issues of membership recruitment, committee engagement, advancement transparency, diversity awareness, leadership development, and formal mentorship are being implemented.

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The change in groin pain perception after transabdominal preperitoneal inguinal hernia repair with glue fixation: a prospective trial of a single surgeon’s experience

Abstract

Background

Although inguinal hernia is one of the most common conditions requiring surgical treatment, no reliable information is available on the quality of life of patients with inguinal hernias before surgery. Additionally, patients with intense inguinal pain prior to surgery are more susceptible to postoperative chronic pain. In such cases, less invasive laparoscopic techniques can be used, allowing atraumatic mesh fixation to reduce postoperative pain. The aim of the study was to determine, whether these treatments for patients with preoperative pain would minimize upsetting experiences after surgery.

Materials and methods

Data were gathered prospectively from the National Hernia Repair Register for 146 patients who underwent TAPP repairs in the general surgery department (2013–2016). The demographic data were recorded, the pain intensity was determined and patients described the occurrence of pain during ten everyday activities.

Results

The average surgery time was 56.4 min. The follow-up was 23.4 months. The pain before surgery was 4.28 and 12 months after surgery 0.38 (p < 0.001). Pain intensity before surgery was scored as 4.1, 4.3, and 4.9 among patients who had a hernia < 12 months, > 1 year, and > 5 years, respectively (p = 0.028). Twelve months after surgery, the pain was 0.26, 0.34, and 0.40 (p = 0.037), respectively. Patients < 40 years experienced pain before the surgery more often. The intensity of pre-/postoperative pain was significantly higher < 40 years (4.9/0.63) than > 60 years (3.8/0.29).

Conclusions

TAPP inguinal hernia repair with glue fixation significantly decreased the frequency and intensity of the pain compared to that experienced preoperatively. After TAPP repair, the influence of pain on basic everyday activities is substantially lower. Patients under 40 years of age experience frequent and intense pre- and postoperative pain. A longer hernia duration prior to surgery causes increased pre- and postoperative pain.

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Computer tomographic analysis of organ motion caused by respiration and intraoperative pneumoperitoneum in a porcine model for navigated minimally invasive esophagectomy

Abstract

Background

Navigation systems have the potential to facilitate intraoperative orientation and recognition of anatomical structures. Intraoperative accuracy of navigation in thoracoabdominal surgery depends on soft tissue deformation. We evaluated esophageal motion caused by respiration and pneumoperitoneum in a porcine model for minimally invasive esophagectomy.

Methods

In ten pigs (20–34 kg) under general anesthesia, gastroscopic hemoclips were applied to the cervical (CE), high (T1), middle (T2), and lower thoracic (T3) level, and to the gastroesophageal junction (GEJ) of the esophagus. Furthermore, skin markers were applied. Three-dimensional (3D) and four-dimensional (4D) computed tomography (CT) scans were acquired before and after creation of pneumoperitoneum. Marker positions and lung volumes were analyzed with open source image segmentation software.

Results

Respiratory motion of the esophagus was higher at T3 (7.0 ± 3.3 mm, mean ± SD) and GEJ (6.9 ± 2.8 mm) than on T2 (4.5 ± 1.8 mm), T1 (3.1 ± 1.8 mm), and CE (1.3 ± 1.1 mm). There was significant motion correlation in between the esophageal levels. T1 motion correlated with all other esophagus levels (r = 0.51, p = 0.003). Esophageal motion correlated with ventilation volume (419 ± 148 ml) on T1 (r = 0.29), T2 (r = 0.44), T3 (r = 0.54), and GEJ (r = 0.58) but not on CE (r = − 0.04). Motion correlation of the esophagus with skin markers was moderate to high for T1, T2, T3, GEJ, but not evident for CE. Pneumoperitoneum led to considerable displacement of the esophagus (8.2 ± 3.4 mm) and had a level-specific influence on respiratory motion.

Conclusions

The position and motion of the esophagus was considerably influenced by respiration and creation of pneumoperitoneum. Esophageal motion correlated with respiration and skin motion. Possible compensation mechanisms for soft tissue deformation were successfully identified. The porcine model is similar to humans for respiratory esophageal motion and can thus help to develop navigation systems with compensation for soft tissue deformation.

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A prospective, single-arm study on the use of the da Vinci® Table Motion with the Trumpf TS7000dV operating table

Abstract

Background

The da Vinci® Table Motion (dVTM) comprises a combination of a unique operating table (Trumpf Medical™ TruSystem® 7000dV) capable of isocenter motion connected wirelessly with the da Vinci Xi® robotic platform, thereby enabling patients to be repositioned without removal of instruments and or undocking the robot.

Materials and methods

Between May 2015 to October 2015, the first human use of dVTM was carried out in this prospective, single-arm, post-market study in the EU, for which 40 patients from general surgery (GS), urology (U), or gynecology (G) were enrolled prospectively. Primary endpoints of the study were dVTM feasibility, efficacy, and safety.

Results

Surgeons from the three specialties obtained targeting success and the required table positioning in all cases. Table movement/repositioning was necessary to gain exposure of the operating field in 106/116 table moves (91.3%), change target in 2/116 table moves (1.7%), achieve hemodynamic relief in 4/116 table moves (3.5%), and improve external access for tumor removal in 4/116 table moves (3.5%). There was a significantly higher use of tilt and tilt plus Trendelenburg in GS group (GS vs. U p = 0.055 and GS vs. G p = 0.054). There were no dVTM safety-related or adverse events.

Conclusions

The dVTM with TruSystem 7000dV operating table in wireless communication with the da Vinci Xi is a perfectly safe and effective synergistic combination, which allows repositioning of the patient whenever needed without imposing any delay in the execution of the operation. Moreover, it is helpful in avoiding extreme positions and enables the anesthesiologist to provide immediate and effective hemodynamic relief to the patient when needed.

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Transferability of laparoscopic skills using the virtual reality simulator

Abstract

Background

Skill transfer represents an important issue in surgical education, and is not well understood. The aim of this randomized study is to assess the transferability of surgical skills between two laparoscopic abdominal procedures using the virtual reality simulator in surgical novices.

Methods

From September 2016 to July 2017, 44 surgical novices were randomized into two groups and underwent a proficiency-based basic training consisting of five selected simulated laparoscopic tasks. In group 1, participants performed an appendectomy training on the virtual reality simulator until they reached a defined proficiency. They moved on to the tutorial procedural tasks of laparoscopic cholecystectomy. Participants in group 2 started with the tutorial procedural tasks of laparoscopic cholecystectomy directly. Finishing the training, participants of both groups were required to perform a complete cholecystectomy on the simulator. Time, safety and economy parameters were analysed.

Results

Significant differences in the demographic characteristics and previous computer games experience between the two groups were not noted. Both groups took similar time to complete the proficiency-based basic training. Participants in group 1 needed significantly less movements (388.6 ± 98.6 vs. 446.4 ± 81.6; P < 0.05) as well as shorter path length (810.2 ± 159.5 vs. 945.5 ± 187.8 cm; P < 0.05) to complete the cholecystectomy compared to group 2. Time and safety parameters did not differ significantly between both groups.

Conclusion

The data demonstrate a positive transfer of motor skills between laparoscopic appendectomy and cholecystectomy on the virtual reality simulator; however, the transfer of cognitive skills is limited. Separate training curricula seem to be necessary for each procedure for trainees to practise task-specific cognitive skills effectively. Mentoring could help trainees to get a deeper understanding of the procedures, thereby increasing the chance for the transfer of acquired skills.

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Updated panel report: best practices for the surgical treatment of obesity

Abstract

Background

During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce.

Methods

An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery.

Results

On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel.

Conclusion

Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

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Learning curve for performing choledochotomy bile duct exploration with primary closure after laparoscopic cholecystectomy

Abstract

Background

Primary closure after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) is a safe and effective approach for treating cholecystolithiasis with choledocholithiasis. The aim of this study was to evaluate the learning curve of performing primary closure after LC+LCBDE.

Methods

We retrospectively identified all patients who underwent primary closure after LC+LCBDE performed by a single surgeon from January 2009 to April 2015 in our institution, and analyzed preoperative, intraoperative, and postoperative data using the cumulative sum (CUSUM) analysis to evaluate the learning curve for this procedure.

Results

Overall, there were 390 patients. The total postoperative complications rate was 7.2%, including bile leakage in 9 (2.3%) patients and retained common bile duct stone in 3 (0.8%) patients. The CUSUM operating time (OT) learning curve was best modeled by the equation: CUSUM_OT = 312.209 × procedure^0.599 × e^{(−0.011×procedure)} + 122.608 (R² = 0.96). The learning curve was composed of two phases, phase 1 (the initial 54 patients) and phase 2 (the remaining 336 patients). A significant decrease in the OT (116.8 ± 22.4 vs. 93.8 ± 17.8 min; p < 0.001) and complication rate (16.7 vs. 5.7%; p < 0.01) including the rate of bile leakage (7.4 vs. 1.5%; p < 0.01) and retained stone (3.7 vs. 0.3%; p < 0.01) was observed between the two phases. In addition, 20 patients had conversion to open surgery. Impacted stones were independently associated with conversion, as indicated by a multivariable analysis.

Conclusion

The data suggest that the learning curve of this procedure was achieved in approximately 54 cases. An impacted stone was the only risk factor that affected the conversion rate.

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Thoracoscopic resection of a cystic seminoma of the mediastinum

Asian Journal of Endoscopic Surgery, EarlyView.


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Type 1 Muscle Fiber Hypertrophy after Blood Flow–restricted Training in Powerlifters

PURPOSE To investigate the effects of blood flow restricted resistance exercise (BFRRE) on myofiber areas (MFA), number of myonuclei and satellite cells (SC), muscle size and strength in powerlifters. METHODS Seventeen national level powerlifters (25±6 yrs [mean±SD], 15 men) were randomly assigned to either a BFRRE group (n=9) performing two blocks (week 1 and 3) of five BFRRE front squat sessions within a 6.5-week training period, or a conventional training group (Con; n=8) performing front squats at ~70% of one-repetition maximum (1RM). The BFRRE consisted of four sets (first and last set to voluntary failure) at ~30% of 1RM. Muscle biopsies were obtained from m. vastus lateralis (VL) and analyzed for MFA, myonuclei, SC and capillaries. Cross sectional areas (CSA) of VL and m. rectus femoris (RF) were measured by ultrasonography. Strength was evaluated by maximal voluntary isokinetic torque (MVIT) in knee extension and 1RM in front squat. RESULTS BFRRE induced selective type I fiber increases in MFA (BFRRE: 12% vs. Con: 0%, p

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Effects of EPO on Blood Parameters and Running Performance in Kenyan Athletes

Introduction Recombinant human erythropoietin (rHuEpo) administration enhances oxygen carrying capacity and performance at sea level. It remains unknown whether similar effects would be observed in chronic altitude-adapted endurance runners. The aim of this study was to assess the effects of rHuEpo on haematological and performance parameters in chronic altitude-adapted endurance runners as compared to sea level athletes. Methods Twenty well-trained Kenyan endurance runners (KEN) living and training at ~2,150 m received rHuEpo injections of 50 IU[BULLET OPERATOR]kg-1 body mass every 2 days for 4 weeks and responses compared to another cohort (SCO) that underwent an identical protocol at sea level. Blood samples were obtained at baseline, during rHuEpo administration and 4 weeks after the final injection. A maximal oxygen uptake ( O2max) test and 3,000 m time trial was performed before, immediately after and 4 weeks after the final rHuEpo injection. Results Haematocrit (HCT) and haemoglobin concentration (HGB) were higher in KEN compared to SCO prior to rHuEpo but similar at the end of administration. Prior to rHuEpo administration, KEN had higher V˙O2max and faster time trial performance compared to SCO. Following rHuEpo administration, there was a similar increase in V˙O2max and time trial performance in both cohorts; most effects of rHuEpo were maintained 4 weeks after the final rHuEpo injection in both cohorts. Conclusion Four weeks of rHuEpo increased the HGB and HCT of Kenyan endurance runners to a lesser extent than in SCO (~17% vs ~10%, respectively) and these alterations were associated with similar improvements in running performance immediately after the rHuEpo administration (~5%) and 4 weeks after rHuEpo (~3%). Corresponding Author Professor Yannis P Pitsiladis, Collaborating Centre of Sports Medicine, University of Brighton, Brighton, United Kingdom, University of Brighton, Hillbrow, Denton Road, Eastbourne, BN20 7SR, United Kingdom, email: Y.Pitsiladis@brighton.ac.uk, Mobile: +44 (0) 7733226682 This study was part of a larger research project supported by grant from the World Anti-doping Agency (08C19YP). A partial grant was also provided by MEPI and the postgraduate office of Addis Ababa University, Ethiopia. The results of the present study does not constitute endorsement by ACSM. Results of this study are presented clearly, honestly, and without fabrication, falsification or inappropriate data manipulation. Conflict of interest: All authors declare no conflict of interest. © 2018 American College of Sports Medicine

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Estimating Asian Contribution to the Brazilian Population: A New Application of a Validated Set of 61 Ancestry Informative Markers

Estimates of different ancestral proportions in admixed populations are very important in population genetics studies, especially for the detection of population substructure effects in studies of case-control associations. Brazil is one of the most heterogeneous countries in the world, both from a socio-cultural and a genetic point of view. In this work, we investigated a previously developed set of 61 ancestry informative markers (AIM), aiming to estimate the proportions of four different ancestral groups (African, European, Native American and Asian) in Brazilian populations. To the best of our knowledge, this is the first study to use a set of AIM to investigate the genetic contribution of all four main parental populations to the Brazilian population, including Asian contribution. All selected markers were genotyped through multiplex PCR and capillary electrophoresis. The set was able to successfully differentiate the four ancestral populations (represented by 939 individuals) and identify their genetic contributions to the Brazilian population. In addition, it was used to estimate individual interethnic admixture of 1050 individuals from the Southeast region of Brazil and it showed that these individuals present a higher European ancestry contribution, followed by African, Asian and Native American ancestry contributions. Therefore, the 61 AIM set has proved to be a valuable tool to estimate individual and global ancestry proportions in populations mainly formed by these four groups. Our findings highlight the importance of using sets of AIM to evaluate population substructure in studies carried in admixed populations, in order to avoid misinterpretation of results.

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Awake Craniotomy During Pregnancy

No abstract available

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Macroglossia During Awake Craniotomy: A Near Miss

No abstract available

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Ketamine and Electroconvulsive Therapy for Depression

No abstract available

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An Unusual Presentation of Tapia Syndrome Mimicking a Partial Wallenberg Syndrome Following Anterior Cervical Spine Surgery

No abstract available

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Perioperative Care for Pediatric Patients With Penetrating Brain Injury: A Review

Traumatic brain injury (TBI) continues to be the leading cause of death and acquired disability in young children and adolescents, due to blunt or penetrating trauma, the latter being less common but more lethal. Penetrating brain injury (PBI) has not been studied extensively, mainly reported as case reports or case series, due to the assumption that both types of brain injury have common pathophysiology and consequently common management. However, recommendations and guidelines for the management of PBI differ from those of blunt TBI in regards to neuroimaging, intracranial pressure (ICP) monitoring, and surgical management including those pertaining to vascular injury. PBI was one of the exclusion criteria in the second edition of guidelines for the acute medical management of severe TBI in infants, children, and adolescents that was published in 2012 (it is referred to as "pediatric guidelines" in this review). Many reviews of TBI do not differentiate between the mechanisms of injury. We present an overview of PBI, its presenting features, epidemiology, and causes as well as an analysis of case series and the conclusions that may be drawn from those and other studies. More clinical trials specific to penetrating head injuries in children, focusing mainly on pathophysiology and management, are needed. The term PBI is specific to penetrating injury only, whereas TBI, a more inclusive term, describes mainly, but not only, blunt injury.

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Journal Club

No abstract available

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Anesthesia for Same Day Discharge After Craniotomy: Review of a Single Center Experience

Same day discharge or outpatient surgery for intracranial procedures has become possible with the advent of image-guided minimally invasive approaches to surgery and availability of short-acting anesthetic agents. In addition, patient satisfaction and the benefits of avoiding hospital stay have resulted in the evolution of neurosurgical day surgery. We reviewed our experience and the available literature to determine the perioperative factors involved which have promoted and will improve this concept in the future. Craniotomy and biopsy for supratentorial brain tumors and surgical clipping of intact cerebral aneurysms have been successfully performed as day surgeries. Patient perceptions and satisfaction surveys have helped in better understanding and delivery of care and successful outcomes. There are major differences in health care across the globe along with socioeconomic, medicolegal, and ethical disparities, which must be considered before widespread application of this approach. Nevertheless, collaborative effort by surgeons, anesthesiologists, and nurses can help in same day discharge of patients after cranial neurosurgery.

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Toxic Epidermal Necrolysis in a Neurosurgical Patient

No abstract available

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Ketamine Anesthesia Does Not Improve Depression Scores in Electroconvulsive Therapy: A Randomized Clinical Trial

Background: Although interest in ketamine use during electroconvulsive therapy (ECT) has increased, studies have been equivocal with regard to its efficacy. The aims of this clinical trial were to evaluate ketamine's antidepressive effects in ECT as a primary anesthetic, determine ketamine's tolerability when compared with standard anesthesia, and determine if plasma brain-derived neurotrophic factor (BDNF) is necessary for treatment response. Materials and Methods: Adults meeting criteria for treatment-resistant depression undergoing index course ECT received either methohexital (1 to 2 mg/kg) or ketamine (1 to 2 mg/kg) anesthesia in this dual-arm double-blinded randomized clinical trial (NCT02752724). The primary outcome of this study is change in depression questionnaire scores before and after ECT. Seizure data, depression severity using self-reported and clinician-assessed questionnaires, cognitive scoring, and plasma BDNF concentrations were obtained before and after completion of ECT. Results: There were no differences in seizure lengths, hemodynamics, or seizure stimuli between the ketamine (n=23;138 ECTs) and methohexital (n=27;159 ECTs) groups. Depression scores improved similarly after ECT in both groups. In the methohexital group, 15% of patients failed to achieve adequate seizures and were switched to ketamine and 26% were converted to bilateral ECT stimulus, whereas all ketamine patients achieved adequate seizures and only 4% required bilateral stimulus. Plasma BDNF increased after ECT only in the ketamine group. Conclusions: Our data show that ketamine does not significantly improve depression when compared with methohexital as a single induction agent for ECT, increases serum BDNF and does not increase rates of post-ECT agitation. Ketamine use in ECT may have some benefits for some patients that are not captured through standard depression assessment questionnaires alone.

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High Flow Nasal Cannula, A Novel Approach to Airway Management in Awake Craniotomies

No abstract available

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Cerebral Oxygen Saturation During Electroconvulsive Therapy: A Secondary Analysis of a Randomized Crossover Trial

Background: Electroconvulsive therapy (ECT) causes acute changes in cerebral perfusion and oxygenation. Near-infrared spectroscopy is a novel, noninvasive technique to assess cerebral oxygen saturation (cSO2). We hypothesized that cSO2 increases during ECT and more so with atropine premedication and decreases when systemic desaturation (peripheral oxygen saturation 60% at any measured time point, even in those with systemic desaturation. Conclusions: ECT increased cSO2 irrespective of atropine premedication. cSO2 was lower when systemic desaturation occurred. Future studies should explore the effect of cerebral oxygenation changes during ECT on outcome of psychiatric conditions.

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The Old and the New: An Enhanced Vision for JNA

No abstract available

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Red Cell Distribution Width After Subarachnoid Hemorrhage

Background: High red cell distribution width (RDW) values have been associated with increased hospital mortality in critically ill patients, but few data are available for subarachnoid hemorrhage (SAH). Methods: We analyzed an institutional database of adult (>18 y) patients admitted to the Department of Intensive Care after nontraumatic SAH between January 2011 and May 2016. RDW (normal value, 10.9% to 13.4%) was obtained daily from admission for a maximum of 7 days, from routine blood analysis. We recorded the occurrence of delayed cerebral ischemia (DCI), and neurological outcome (assessed using the Glasgow Outcome Scale [GOS]) at 3 months. Results: A total of 270 patients were included (median age 54 y—121/270 male [45%]), of whom 96 (36%) developed DCI and 109 (40%) had an unfavorable neurological outcome (GOS, 1 to 3). The median RDW on admission was 13.8 [13.3 to 14.5]% and the highest value during the intensive care unit (ICU) stay 14.2 [13.6 to 14.8]%. The RDW was high (>13.4%) in 177 patients (66%) on admission and in 217 (80%) at any time during the ICU stay. Patients with a high RDW on admission were more likely to have an unfavorable neurological outcome. In multivariable regression analysis, older age, a high WFNS grade on admission, presence of DCI or intracranial hypertension, previous neurological disease, vasopressor therapy and a high RDW (OR, 1.1618 [95% CI, 1.213-2.158]; P=0.001) during the ICU stay were independent predictors of unfavorable neurological outcome. Conclusions: High RDW values were more likely to result in an unfavorable outcome after SAH. This information could help in the stratification of SAH patients already on ICU admission.

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Journal Club

No abstract available

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Safety Outcomes Following Spine and Cranial Neurosurgery: Evidence From the National Surgical Quality Improvement Program

Background: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to establish predictors for 30-day postoperative complications following spine and cranial neurosurgery. Materials and Methods: The ACS-NSQIP participant use files were queried for neurosurgical cases between 2005 and 2015. Prevalence of postoperative complications following neurosurgery was determined. Nested multivariable logistic regression analysis was used to identify demographic, comorbidity, and perioperative characteristics associated with any complication and mortality for spine and cranial surgery. Results: There were 175,313 neurosurgical cases (137,029 spine, 38,284 cranial) identified. A total of 23,723 (13.5%) patients developed a complication and 2588 (1.5%) patients died. Compared with spine surgery, cranial surgery had higher likelihood of any complication (22.2% vs. 11.1%; P

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MRI Sedation for Patient With Spinal Myoclonus

No abstract available

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Effects of Transcutaneous Electrical Acupoint Stimulation on the Stress Response During Extubation After General Anesthesia in Elderly Patients Undergoing Elective Supratentorial Craniotomy: A Prospective Randomized Controlled Trial

Background: Elderly patients have an increased risk of a stress response during extubation after general anesthesia. In this study, we aimed to investigate whether transcutaneous electrical acupoint stimulation (TEAS) might decrease the stress response and improve the quality of recovery in elderly patients after elective supratentorial craniotomy. Materials and Methods: In this prospective randomized controlled study, patients were randomly assigned to either a TEAS group (n=37) or a control group (n=38). The primary outcomes were the hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol. The secondary outcome included the consumption of remifentanil and propofol, time to extubation and reorientation, extubation quality score, postoperative quality of recovery, and postoperative complications. Results: Compared with the control group, hemodynamic parameters and plasma concentrations of epinephrine, norepinephrine, and cortisol during extubation were decreased in the TEAS group. TEAS reduced the consumption of remifentanil (P

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Simultaneous Surgical Decompression of Bilateral Subdural Hematoma and an Administration of Epidural Blood Patch for Spontaneous Intracranial Hypotension

No abstract available

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Hemodynamic Instability and Cardiovascular Events After Traumatic Brain Injury Predict Outcome After Artifact Removal With Deep Belief Network Analysis

Background: Hemodynamic instability and cardiovascular events heavily affect the prognosis of traumatic brain injury. Physiological signals are monitored to detect these events. However, the signals are often riddled with faulty readings, which jeopardize the reliability of the clinical parameters obtained from the signals. A machine-learning model for the elimination of artifactual events shows promising results for improving signal quality. However, the actual impact of the improvements on the performance of the clinical parameters after the elimination of the artifacts is not well studied. Materials and Methods: The arterial blood pressure of 99 subjects with traumatic brain injury was continuously measured for 5 consecutive days, beginning on the day of admission. The machine-learning deep belief network was constructed to automatically identify and remove false incidences of hypotension, hypertension, bradycardia, tachycardia, and alterations in cerebral perfusion pressure (CPP). Results: The prevalences of hypotension and tachycardia were significantly reduced by 47.5% and 13.1%, respectively, after suppressing false incidents (P=0.01). Hypotension was particularly effective at predicting outcome favorability and mortality after artifact elimination (P=0.015 and 0.027, respectively). In addition, increased CPP was also statistically significant in predicting outcomes (P=0.02). Conclusions: The prevalence of false incidents due to signal artifacts can be significantly reduced using machine-learning. Some clinical events, such as hypotension and alterations in CPP, gain particularly high predictive capacity for patient outcomes after artifacts are eliminated from physiological signals.

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Scalp Block: Tool for Diagnosis in Postoperative Headache of Unknown Origin

No abstract available

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The risk of major cardiovascular events for adults with transfemoral amputation

It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we exa...

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Advancements in prosthetics and orthotics: overview of the Journal of NeuroEngineering & Rehabilitation’s special topic edition

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Economic value of orthotic and prosthetic services among medicare beneficiaries: a claims-based retrospective cohort study, 2011–2014

There are few studies of the economic value of orthotic and prosthetic services. A prior cohort study of orthotic and prosthetic Medicare beneficiaries based on Medicare Parts A and B claims from 2007 to 2010 ...

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Energy storing and return prosthetic feet improve step length symmetry while preserving margins of stability in persons with transtibial amputation

Energy storing and return (ESAR) feet are generally preferred over solid ankle cushioned heel (SACH) feet by people with a lower limb amputation. While ESAR feet have been shown to have only limited effect on ...

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Control within a virtual environment is correlated to functional outcomes when using a physical prosthesis

Advances such as targeted muscle reinnervation and pattern recognition control may provide improved control of upper limb myoelectric prostheses, but evaluating user function remains challenging. Virtual envir...

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COST SAVINGS USING A TEST-BASED DE-ESCALATION STRATEGY FOR PATIENTS WITH CROHN’S DISEASE IN REMISSION ON OPTIMIZED INFLIXIMAB: A DISCRETE EVENT MODEL STUDY

Drug de-escalation is considered in Crohn's disease patients in sustained remission on optimized infliximab treatment.

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Obstructive jaundice caused by myeloid sarcoma in duodenal ampulla

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COST SAVINGS USING A TEST-BASED DE-ESCALATION STRATEGY FOR PATIENTS WITH CROHN’S DISEASE IN REMISSION ON OPTIMIZED INFLIXIMAB: A DISCRETE EVENT MODEL STUDY

Drug de-escalation is considered in Crohn's disease patients in sustained remission on optimized infliximab treatment.

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Obstructive jaundice caused by myeloid sarcoma in duodenal ampulla

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The cerebellum seems not a ‘little brain’ for the autonomic nervous system

Neurogenic postural hypotension is a debilitating condition in patients with Parkinson's disease, multiple system atrophy (MSA), autoimmune autonomic ganglionopathy, and advanced diabetic neuropathy (Palma and Kaufmann, 2017). Pathology for this condition are mostly peripheral (periarterial nerves innervating alpha 1B receptors on the vessel wall), and in MSA, spinal intermediolateral nucleus and medullary A1,2/C1,2 neurons are the responsible sites. In pure autonomic failure (lesion overlaps that of Parkinson's disease), cingulate and medial frontal pathology is contributing to postural hypotension (Hirano et al, 2009).

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Cerebellar impairment during an orthostatic challenge in patients with neurogenic orthostatic hypotension

Neurogenic Orthostatic Hypotension (NOH) is a cardinal feature of autonomic dysfunction. NOH is clinically defined as a sustained reduction in systolic blood pressure (SBP) ≥30mmHg or diastolic blood pressure of ≥15mmHg within 3 minutes of standing or head-up tilt performed at 60°(Freeman et al. 2011). NOH is unique in that the orthostatic component relates to an excessive BP drop associated with an upright/standing position and the neurogenic component highlights a failure of the autonomic nervous system to reflexively increase sympathetic outflow to counteract the BP drop.

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Deep vs. moderate neuromuscular blockade during laparoscopic surgery: A systematic review and meta-analysis

BACKGROUND Previous studies have reported that deep neuromuscular block (posttetanic-count 1 to 2 twitches) improves surgical conditions during laparoscopy compared with moderate block (train-of-four count: 1 to 2 twitches). However, comparisons of surgical conditions were made using different scales and assessment intervals with variable results. OBJECTIVE To explore the heterogeneity of previous comparisons between deep and moderate neuromuscular block. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to October 2017. ELIGIBILITY CRITERIA Our meta-analysis included RCTs comparing the effects of deep with moderate neuromuscular block on surgical field conditions during laparoscopic surgery. The frequency of excellent or good operating conditions on a surgical rating scale was compared. Heterogeneity was assessed by subgroup analyses. RESULTS Eleven RCTs involving 844 patients were included. On the surgical rating scale, the frequency of excellent or good operating conditions was higher with deep block compared with a moderate block (odds ratio 2.83, 95% confidence interval 1.34 to 5.99, P = 0.007, I2 = 59%). We analysed surgical rating according to the number of assessments made. There was a significant difference in surgical rating with multiple assessments, but no difference when the assessment was made on only one occasion. A significant difference in rating was noted with variable abdominal pressures; there was no significant difference with the same fixed abdominal pressure. Trial sequential analysis demonstrated that the cumulative z-curve crossed the O′Brien–Fleming significance boundary. However, required information size was not achieved. CONCLUSION Deep block was associated with excellent or good surgical rating more frequently than moderate block. However, this finding was not consistent on subgroup analyses based on frequencies of assessment of surgical conditions and abdominal pressure. Further studies are required to address the heterogeneity and power shortage demonstrated by the trial sequential analysis. Correspondence to Won Ho Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Institute of the Research of the Perioperative Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea Tel: +82 2 2072 2462; fax: +82 2 747 5639; e-mail: wonhokim.ane@gmail.com 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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Sequence-based 5-mers highly correlated to epigenetic modifications in genes interactions

Abstract

One of the main concerns in biology is extracting sophisticated features from DNA sequence for gene interaction determination, receiving a great deal of researchers' attention. The epigenetic modifications along with their patterns have been intensely recognized as dominant features affecting on gene expression. However, studying sequenced-based features highly correlated to this key element has remained limited. The main objective in this research was to propose a new feature highly correlated to epigenetic modifications capable of classification of genes. In this paper, classification of 34 genes in PPAR signaling pathway associated with muscle fat tissue in human was performed. Using different statistical outlier detection methods, we proposed that 5-mers highly correlated to epigenetic modifications can correctly categorize the genes involved in the same biological pathway or process. Thirty-four genes in PPAR signaling pathway were classified via applying a proposed feature, 5-mers strongly associated to 17 different epigenetic modifications. For this, diverse statistical outlier detection methods were applied to specify the group of thoroughly correlated genes. The results indicated that these 5-mers can appropriately identify correlated genes. In addition, our results corresponded to GeneMania interaction information, leading to support the suggested method. The appealing findings imply that not only epigenetic modifications but also their highly correlated 5-mers can be applied for reconstructing gene regulatory networks as supplementary data as well as other applications like physical interaction, genes prioritization, indicating some sort of data fusion in this analysis.

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Genetic landscape of isolated pediatric cataracts: extreme heterogeneity and variable inheritance patterns within genes

Abstract

Pediatric cataract represents an important cause of pediatric visual impairment. While both genetic and environmental causes for pediatric cataract are known, a large proportion remains idiopathic. The purpose of this review is to discuss genes involved in isolated pediatric cataract, with a focus on variable inheritance patterns within genes. Mutations in over 52 genes are known to cause isolated pediatric cataract, with a major contribution from genes encoding for crystallins, transcription factors, membrane proteins, and cytoskeletal proteins. Interestingly, both dominant and recessive inheritance patterns have been reported for mutations in 13 different cataract genes. For some genes, dominant and recessive alleles represent distinct types of mutations, but for many, especially missense variants, there are no clear patterns to distinguish between dominant and recessive alleles. Further research into the functional effects of these mutations, as well as additional data on the frequency of the identified variants, is needed to clarify variant pathogenicity. Exome sequencing continues to be successful in identifying novel genes associated with congenital cataract but is hindered by the extreme genetic heterogeneity of this condition. The large number of idiopathic cases suggests that more genes and potentially novel mechanisms of gene disruption remain to be identified.

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Examining motor tasks of differing complexity after concussion in adolescents

Publication date: Available online 5 September 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): David R. Howell, Gregory D. Myer, Dustin Grooms, Jed Diekfuss, Weihong Yuan, William P. Meehan

Abstract

Objectives

(1) to determine effects of concussion related motor impairments at different task complexities in isolation and with a cognitive dual-task and (2) to determine if self-reported balance deficits after concussion are associated with gait, quiet stance, or cognitive dual-task impairments.

Design

Cross-sectional

Setting

Sports medicine clinic

Participants

Adolescent athletes clinically diagnosed with a sport-related concussion and healthy controls.

Interventions

Athletes with concussion completed a single/dual-task standing and walking protocol within 14 days of injury and were compared to healthy controls.

Main outcome measures

Outcome measures included gait speed, quiet stance (root mean square [RMS] coronal/sagittal plane sway), and cognitive performance (accuracy). Dual-task costs were calculated as the percentage change between single-task and dual-task conditions. Participants with concussion were then stratified by those who did and did not report subjective balance problems at the time of testing and compared using objective balance and gait metrics.

Results

Forty-nine concussion (mean age=14.9±1.9 years; 51% female; tested 7.0±3.0 days post-injury) and 65 control participants (mean age=14.9±1.6 years; 52% female) completed the study. The concussion group walked slower during dual-task gait than controls (0.83±0.17 m/s vs. 0.92±0.15 m/s; Cohen's d=0.53). Dual-task quiet stance RMS sway values were similar for concussion and control groups in coronal (1.20±0.52 m/s^-2 vs. 1.26±0.65 m/s^-2; d=0.09) and sagittal (0.56±0.24 m/s^-2 vs. 0.73±0.44 m/s^-2; d=0.20) movement planes. The concussion participants with subjectively-reported balance problems had significantly greater walking speed dual-task costs than concussion participants without self-reported balance problems (-25±10% vs. -19±9%; p=0.02).

Conclusion

Following concussion, adolescents demonstrate slower gait speeds, but similar quiet stance values relative to healthy controls. The study results indicate that tasks requiring greater motor coordination may elicit greater alterations following a concussion.

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The effects of the surface texture and weight of a pinch apparatus on the reliability and validity of a hand sensorimotor control assessment in carpal tunnel syndrome

Publication date: Available online 5 September 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Hsiu-Yun Hsu, Ta-Shen Kuan, Hsiu-Ching Yang, Ching-Liang Tsai, Chien-Hsien Yeh, Chih-Chun Lin, Li-Chieh Kuo

Abstract

Objective

To investigate the reliability and validity of a modified pinch apparatus devised with three surface textures and two different weights for clinical application.

Design

Case-controlled study.

Setting

A university hospital.

Participants

The participants included 16 carpal tunnel syndrome (CTS) patients with 20 sensory neuropathy hands, and an equal number of age-gender matched healthy volunteers, as well as twenty healthy young volunteers used to analyze both the testing validity and reliability of the modified device.

Main Outcome Measures

The Semmes-Weinstein monofilament (SWM) and two-point discrimination (2PD) tests were conducted, and the force ratio between the FP_peak (peak pinch force during lifting phase) and FL_max (maximum load force at maximum upward acceleration onset) detected from a pinch-holding-up activity (PHUA) under various testing conditions was obtained.

Results

The range of the intra-class correlation coefficient of this pinch device was 0.369-0.952. The CTS patients exhibited poorer force modulation ability according to the inertial change in a dynamic lifting task when compared to the controls under all testing conditions (p<.001). The area under the receiver operating characteristic force ratio curve was 0.841, revealing high accuracy of the test for diagnosing CTS neuropathic hands under the testing condition in which the 125g coarse texture device was used. In addition, the weight factor was shown to have significant impacts on the sensitivity and accuracy of the PHUA assessment.

Conclusions

This study showed that the PHUA test via the modified pinch apparatus is a sensitive tool that can be used in clinical practice for detecting neuropathic CTS hands. In addition, changing the weight of the pinch device has a significant impact on the sensitivity and accuracy of the PHUA assessment.

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Proton pump inhibitors and risk of hepatocellular carcinoma in patients with chronic hepatitis B or C

Hepatology

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Advancing age and comorbidity in a United States insured population-based cohort of patients with chronic hepatitis B

Hepatology

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Alcohol consumption and the risk of gastroesophageal reflux disease: A systematic review and meta-analysis

Alcohol and Alcoholism

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Blue laser imaging-bright improves real-time detection rate of early gastric cancer: A randomized controlled study

Gastrointestinal Endoscopy

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Distal duplication of chromosome 16q22.1q23.1 in a Vietnamese patient with midface hypoplasia and intellectual disability

American Journal of Medical Genetics Part A, EarlyView.


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Sustained vasomotor control of skin microcirculation in Sherpas versus altitude‐naïve Lowlanders–experimental evidence from Xtreme Everest 2

Experimental Physiology, Volume 0, Issue ja, -Not available-.


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Non-coding RNAs in retinal development and function

Abstract

Accumulating evidence on the role of non-protein-coding RNA sequences in the regulation of gene expression is greatly expanding our understanding of the flow of genetic information within biological systems. The interplay between protein-coding and non-coding RNAs (ncRNAs) is essential for tissue development, homeostasis, and function. NcRNAs can be divided in short ncRNAs, whose main subtype is represented by microRNAs, and long ncRNAs, which constitute a more heterogeneous class. The retina is a light-sensitive tissue consisting of highly interconnected cell types and is the primary target of many genetic diseases. Among these, the genetically heterogeneous group of inherited retinal diseases (IRDs) represents the most frequent monogenic cause of visual impairment that can ultimately lead to blindness. Here, we provide an overview on the role of ncRNAs in retinal development and function with an emphasis on microRNAs and on different types of long ncRNAs. We also review how sequence variations in ncRNAs can play a pathogenic role in IRDs as well as in multifactorial ocular disorders. These data indicate that a comprehensive study of the contribution of ncRNAs to the mutation repertoire associated with retinal disease can shed light on previously unknown pathophysiological mechanisms and open new therapeutic avenues. We conclude that a more comprehensive dissection of the pathogenic role of non-coding RNAs in retinal function and disease will not only improve our diagnostic ability, but will allow the development of novel targeted therapies for ocular disease.

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Energy expenditure associated with walking speed and angle of turn in children

Abstract

Purpose

Recent studies have suggested that turning is power intensive. Given the sporadic and irregular movement patterns of children, such findings have important implications for the assessment of true energy expenditure associated with habitual physical activity. The purpose of this study was to investigate the influence of walking speed and angle, and their interaction, on the energy expenditure of healthy children.

Methods

20 children (10.1 ± 0.5 years; 10 boys) participated in the study. On two separate days, participants completed a turning protocol involving 3-min bouts of walking at one of the 16 speed (2.5, 3.5, 4.5, and 5.5 km h^− 1) and angle (0°, 45°, 90°, and 180°) combinations, interspersed by 3 min seated rest. The movement involved 5 m straight walking interspaced with prescribed turns with speed dictated by a digital, auditory metronome. Breath-by-breath gas exchange was measured, in addition to tri-axial acceleration and magnetic field intensity recorded at 100 Hz.

Results

Mixed models revealed a significant main effect for speed (p < 0.006) and angle (p < 0.006), with no significant interaction between speed and angle (p > 0.006). Significant differences to straight-line walking energy expenditure within speed were established for 3.5 and 5.5 km h^− 1 for 180° turns (~ 13% and ~ 30% increase, respectively).

Conclusion

These findings highlight the importance of accounting for the magnitude and frequency of turns completed when estimating children's habitual physical activity and have significant implications for the assessment of daily energy expenditure.

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