Ocular torsion responses to electrical vestibular stimulation in Vestibular Schwannoma

Electrical Vestibular Stimulation (EVS) is a simple method for activating the vestibular nerve by directly applying cutaneous currents over the mastoid processes (Fitzpatrick et al., 2004). The resulting change in vestibular afferent firing rate produces a sensation of head roll (Reynolds et al., 2012). This, in turn, evokes a variety of motor outputs including sway (Lund et al., 1983) and orienting responses (Fitzpatrick et al., 2006). EVS also activates the vestibular-ocular reflex. The evoked eye movement is primarily torsional, with minimal lateral or vertical component (Schneider et al., 2002, Jahn et al., 2003a, Jahn et al., 2003b, Severac Cauquil et al., 2003, MacDougall et al., 2005, Mackenzie and Reynolds, 2018b).

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Renal Calculus in Floating–Harbor Syndrome: A Case Study

Floating–Harbor syndrome is a rare condition marked by short stature and delayed bone age, characteristic facial features, and speech impairment. Floating–Harbor syndrome commonly results from a sporadic genetic mutation. Renal abnormalities have rarely been encountered. We report the first patient with Floating–Harbor syndrome who spontaneously passed a renal calculus consisting of calcium oxalate monohydrate and calcium oxalate dihydrate. A renal ultrasound showed echotexture within the renal pyramids, hydronephrosis, and a cyst.

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Immigrant Trauma and Mental Health Outcomes Among Latino Youth

Abstract

While research has demonstrated an association between trauma and mental health, this study examined the association between trauma experienced premigration, during migration, and postmigration, and current mental health status among Latino youth aged 12–17 years old living in the US for < 3 years. Participants reported traumatic events experienced in their home country, during migration, and after settling in the US. Regression models examined trauma experienced at each stage of the migration process predicting current levels of depression, anxiety, and post-traumatic stress disorder. Two-thirds of youth experienced at least one traumatic event, 44% experienced an event once, and 23% experienced two or more traumatic events during migration. Trauma experienced at different migration stages was associated with distinctive mental health outcomes. It is essential that access to culturally sensitive assessment and treatment services be available to ensure transition to a healthy adulthood.

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Erratum to: Changing Places, Changing Plates? A Binational Comparison of Barriers and Facilitators to Healthful Eating Among Central American Communities

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Comparison of Health and Risk Factors of Older, Working-age Australians, Italians and Italian-born Migrants to Australia, with Data from an Italian (PASSI), and an Australian (SAMSS) Risk Factor Surveillance System

Abstract

Italian-born migrants (post-WWII) are the largest non-English-speaking background migrant group in South Australia. A cross-sectional, inter-country comparison using independent samples (40–69 years of age) from two (one in Australia, one in Italy) similar risk factor and chronic disease surveillance systems. None of the three groups (Italians, Australian-born and Italian-born Australians) had definitively worse health although the Italians had high rates for four of the seven risk factors reported (current high blood pressure, current high cholesterol, current smoking, eating less than five fruit and/or vegetables per day) than Australian-born and Italian-born Australians. Italian-born Australians had higher rates for insufficient physical activity, overweight/obese, poor self-reported health and diabetes. Australian respondents were more likely to report having two or more drinks of alcohol per day. Issues facing an ageing population require appropriate health care needs and an assessment of structural or cultural barriers to health services.

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Beriberi Outbreak Among Unauthorised Immigrants in a Detention Camp in Malaysia

Abstract

In February 2012, a district health authority received three inmates with bilateral leg swelling and difficulty in breathing from a detention camp for unauthorized immigrants. A case control study was conducted. Fasting blood samples of case and control groups were collected according to instructions of the laboratory for determining thiamine level, and their 1 week dietary intake was analyzed. 9% (21/226) of inmates had bilateral leg swelling, and 75% (6/8) of them had low thiamine level (< 66 mmol/L). Their diet contained mainly polished rice and other items with low thiamine contents. Bilateral leg swelling was associated with history of no meat consumption during past 3 months (OR 8.4; CI 2.2–32.1). Patients were treated with 100 mg thiamine intravenously and 5 mg orally per day for 6 weeks. All patients responded well. The management was advised to provide vitamin B complex daily, and encouraged to provide thiamine rich foods.

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Obesity and Regional Immigrant Density

Abstract

Canada has an increasingly large immigrant population. Areas of higher immigrant density, may relate to immigrants' health through reduced acculturation to Western foods, greater access to cultural foods, and/or promotion of salubrious values/practices. It is unclear, however, whether an association exists between Canada-wide regional immigrant density and obesity among immigrants. Thus, we examined whether regional immigrant density was related to obesity, among immigrants. Adult immigrant respondents (n = 15,595) to a national population-level health survey were merged with region-level immigrant density data. Multi-level logistic regression was used to model the odds of obesity associated with increased immigrant density. The prevalence of obesity among the analytic sample was 16%. Increasing regional immigrant density was associated with lower odds of obesity among minority immigrants and long-term white immigrants. Immigrant density at the region-level in Canada may be an important contextual factor to consider when examining obesity among immigrants.

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Complexity of Resiliency Framework for Refugee Population: A Letter to the Editor Regarding Wright et al. (2016)

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Somali Older Adults’ and Their Families’ Perceptions of Adult Home Health Services

Abstract

Many studies have identified the vulnerability of ethnic elders, and there is promising evidence indicating home health care (HHC) services can improve the health outcomes of Somali older adults. This study used a community-engaged qualitative descriptive approach with the participation of non-profit organization Refugees Helping Refugees. The purpose of this study was to explore and describe Somali older adults' and their families' perceptions of and experiences with HHC services in order to improve its use and access. Data collection included home visits (n = 15), semi-structured interviews (n = 17) and debriefing sessions (n = 16) with 19 individuals from 14 Somali families. Somali families recognized HHC services were needed and believed having services in the home facilitated learning but HHC agencies should work more with the Somali community. HHC agencies need to work with community organizations to facilitate cultural and health understanding, and better health care for Somali older adults.

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Knowledge About Cervical Cancer Risk Factors and Practices of Pap Testing Among Turkish Immigrant Women in the United States

Abstract

The objective of this study was to examine knowledge about cervical cancer risk factors and practices of Pap testing among female Turkish immigrants in the state of Florida in the United States of America (USA). This descriptive study was conducted between April and September 2012. The study sampling was consist of 156 Turkish women living in the state of Florida. A questionnaire-based survey was conducted among the population of Turkish immigrant women. On the survey form comprised of a total of 37 questions and three sections there are questions pertaining to the socio-demographic characteristics of the individuals, their knowledge on the cervical cancer risk factors and their approach to getting Pap smear tests. Statistical Package for Social Sciences (version 16.0) was used to compute frequency and descriptive statistics related to demographic data. The average age of the women is 35.67 ± 10.0. More than half of women (66%) women reported cervical cancer screening at least one. Over two-thirds knew that having abnormal vaginal bleeding (85.8%) and vaginal infections (78.2%), having sexual activity with a man who has had multiple sexual partners (61.5%), and having multiple sexual partners (61.5%) increase the risk of cervical cancer. The result of the multivariate regression analysis have determined that the age of immigrant women (OR 11.3, 95 % CI 5.1–25.2, p:0.000) and the number of children ( OR 3.4, 95 % CI 1.7–6.9, p:0.000) are factors that impact pap smear testing behavior. Our study findings confirm low levels of Pap testing and show important knowledge deficits about cervical cancer risk factors and the importance of Pap testing among Turkish immigrant women. It is recommended that the immigrant women be educated about cervical cancer by means of organizing conferences in their own language and preparing informative materials.

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An Innovative Mobile Health System to Improve and Standardize Antenatal Care Among Underserved Communities: A Feasibility Study in an Italian Hosting Center for Asylum Seekers

Abstract

Innovative migrant-friendly tools are needed to assist health personnel manage the high number of pregnancies within reception centers. This study tests functionality and acceptability of a new mHealth system in providing antenatal care amongst migrants. The study, carried out between 2014 and 2016, involved 150 pregnant women residing in the largest European migrant reception center in Sicily. A ticket tracking system assessed the system's functionality and a questionnaire assessed women's acceptability. The system facilitated the collection of clinical data, enabling the creation of electronic patient records and identifying 10% of pregnancies as high-risk. The application's digital format increased health providers' adherence to antenatal-care recommendations, while the graphic interface facilitated women's engagement and retention of the health education modules. The study recorded a 91.9% patient satisfaction rate. The system was efficient in providing comprehensive and high-quality antenatal care amongst migrants, facilitating the continuity of care for a population undergoing frequent relocations.

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Update on Chinese American Childhood Obesity Prevalence in New York City

Abstract

Prevalence of overweight and obesity was measured in 12,275 Chinese American children and adolescents, ages 2–19, who were patients at a large federally qualified health center in 2015. Demographic characteristics sex, age, and birthplace were further stratified to explore disaggregated prevalence. Comparison of this 2015 cohort to an ethnically similar study cohort from the same health center in 2004 showed that the overall prevalence in overweight and obesity dropped to 21% from previously recorded 24%. US Born school-aged males continue to have the highest prevalence of overweight and obesity at 36%. School-aged children have higher odds of being overweight or obese (OR 1.61, P < 0.001; OR 1.99, P < 0.001) compared to adolescents. Although the foreign-born females had the lowest prevalence of overweight and obesity (12%), they were the only group in 2015 to have increased prevalence in overweight and obesity since 2004 (by 5.8%).

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3-Aminobenzamide Prevents Concanavalin A-Induced Acute Hepatitis by an Anti-inflammatory and Anti-oxidative Mechanism

Abstract

Background and Aims

Concanavalin A is known to activate T cells and to cause liver injury and hepatitis, mediated in part by secretion of TNFα from macrophages. Poly(ADP-ribose) polymerase-1 (PARP-1) inhibitors have been shown to prevent tissue damage in various animal models of inflammation. The objectives of this study were to evaluate the efficacy and mechanism of the PARP-1 inhibitor 3-aminobenzamide (3-AB) in preventing concanavalin A-induced liver damage.

Methods

We tested the in vivo effects of 3-AB on concanavalin A-treated mice, its effects on lipopolysaccharide (LPS)-stimulated macrophages in culture, and its ability to act as a scavenger in in vitro assays.

Results

3-AB markedly reduced inflammation, oxidative stress, and liver tissue damage in concanavalin A-treated mice. In LPS-stimulated RAW264.7 macrophages, 3-AB inhibited NFκB transcriptional activity and subsequent expression of TNFα and iNOS and blocked NO production. In vitro, 3-AB acted as a hydrogen peroxide scavenger. The ROS scavenger N-acetylcysteine (NAC) and the ROS formation inhibitor diphenyleneiodonium (DPI) also inhibited TNFα expression in stimulated macrophages, but unlike 3-AB, NAC and DPI were unable to abolish NFκB activity. PARP-1 knockout failed to affect NFκB and TNFα suppression by 3-AB in stimulated macrophages.

Conclusions

Our results suggest that 3-AB has a therapeutic effect on concanavalin A-induced liver injury by inhibiting expression of the key pro-inflammatory cytokine TNFα, via PARP-1-independent NFκB suppression and via an NFκB-independent anti-oxidative mechanism.

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Muscle transcriptome resource for growth, lipid metabolism and immune system in Hilsa shad, Tenualosa ilisha

Abstract

The information on the genes involved in muscle growth, lipid metabolism and immune systems would help to understand the mechanisms during the spawning migration in Hilsa shad, which in turn would be useful in its future domestication process. The primary objective of this study was to generate the transcriptome profile of its muscle through RNA seq. The total RNA was isolated and library was prepared from muscle tissue of Tenualosa ilisha, which was collected from Padma River at Farakka, India. The prepared library was then sequenced by Illumina HiSeq platform, HiSeq 2000, using paired-end strategy. A total of 8.68 GB of pair-end reads of muscle transcriptome was generated, and 43,384,267 pair-end reads were assembled into 3,04,233 contigs, of which 23.99% of assembled contigs has length ≥ 150 bp. The total GO terms were categorised into cellular component, molecular function and biological process through PANTHER database. Fifty-three genes related to muscle growth were identified and genes in different pathways were: 75 in PI3/AKT, 46 in mTOR, 76 in MAPK signalling, 24 in Janus kinase–signal transducer and activator of transcription, 45 in AMPK and 27 in cGMP pathways. This study also mined the genes involved in lipid metabolism, in which glycerophospholipid metabolism contained highest number of genes (32) and four were found to be involved in fatty acid biosynthesis. There were 58 immune related genes found, in which 31 were under innate and 27 under adaptive immunity. The present study included a large genomic resource of T. ilisha muscle generated through RNAseq, which revealed the essential dataset for our understanding of regulatory processes, specifically during the seasonal spawning migration. As Hilsa is a slow growing fish, the genes identified for muscle growth provided the basic information to study myogenesis. In addition, genes identified for lipid metabolism and immune system would provide resources for lipid synthesis and understanding of Hilsa defense mechanisms, respectively.

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Exploring the effect of exercise training on testicular function

Abstract

Purpose

The impact of exercise training on testicular function is relatively ill-defined. To gain new insights into this important topic, published data, deriving from both humans and animal studies, were critically analyzed.

Results and conclusions

The effects of exercise on the hypothalamus–pituitary–gonadal axis, influenced by the type, intensity and duration of the exercise program, can be evaluated in terms of total and free testosterone and/or luteinizing hormone and follicle-stimulating hormone serum levels and sperm parameters. High-intensity exercise promotes a common decrease in these parameters, and therefore, negatively impacts upon testicular function. However, published data for moderate-intensity exercise training are inconsistent. Conversely, there is consistent evidence to support the benefits of exercise training to prevent and/or counteract the impairment of testis function caused by aging, obesity and doxorubicin treatment. This positive effect is likely the consequence of decreased oxidative stress and inflammatory status. In the future, it will be important to clarify the molecular mechanisms which explain these reported discrepancies and to establish guidelines for an active lifestyle to promote healthy testicular function.

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Intrinsic Network Reactivity Differentiates Levels of Consciousness in Comatose Patients

Publication date: Available online 7 September 2018

Source: Clinical Neurophysiology

Author(s): Sina Khanmohammadi, Osvaldo Laurido-Soto, Lawrence N. Eisenman, Terrance T. Kummer, ShiNung Ching

Abstract

Objective

We devise a data-driven framework to assess the level of consciousness in etiologically heterogeneous comatose patients using intrinsic dynamical changes of resting-state Electroencephalogram (EEG) signals.

Methods

EEG signals were collected from 54 comatose patients (GCS⩽8) and 20 control patients (GCS>8). We analyzed the EEG signals using a new technique, termed Intrinsic Network Reactivity Index (INRI), that aims to assess the overall lability of brain dynamics without the use of extrinsic stimulation. The proposed technique uses three sigma EEG events as a trigger for ensuing changes to the directional derivative of signals across the EEG montage.

Results

The INRI had a positive relationship with GCS and was significantly different between various levels of consciousness. In comparison, classical band-limited power analysis did not show any specific patterns correlated to GCS.

Conclusions

These findings suggest that reaching low variance EEG activation patterns becomes progressively harder as the level of consciousness of patients deteriorate, and provide a quantitative index based on passive measurements that characterize this change.

Significance

Our results emphasize the role of intrinsic brain dynamics in assessing the level of consciousness in coma patients and the possibility of employing simple electrophysiological measures to recognize the severity of disorders of consciousness (DOC).

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The bony labyrinth in the Aroeira 3 Middle Pleistocene cranium

Publication date: Available online 7 September 2018

Source: Journal of Human Evolution

Author(s): Mercedes Conde-Valverde, Rolf Quam, Ignacio Martínez, Juan-Luis Arsuaga, Joan Daura, Montserrat Sanz, João Zilhão

Abstract

The discovery of a partial cranium at the site of Aroeira (Portugal) dating to 389–436 ka augments the current sample of Middle Pleistocene European crania and makes this specimen penecontemporaneous with the fossils from the geographically close Atapuerca Sima de los Huesos (SH) and Arago sites. A recent study of the cranium documented a unique combination of primitive and derived features. The Aroeira 3 cranium preserves the right temporal bone, including the petrosal portion. Virtual reconstruction of the bony labyrinth from μCT scans provides an opportunity to examine its morphology. A series of standard linear and angular measures of the semicircular canals and cochlea in Aroeira 3 were compared with other fossil hominins and recent humans. Our analysis has revealed the absence of derived Neandertal features in Aroeira 3. In particular, the specimen lacks both the derived canal proportions and the low position of the posterior canal, two of the most diagnostic features of the Neandertal bony labyrinth, and Aroeira 3 is more primitive in these features than the Atapuerca (SH) sample. One potentially derived feature (low shape index of the cochlear basal turn) is shared between Aroeira 3 and the Atapuerca (SH) hominins, but is absent in Neandertals. The results of our study provide new insights into Middle Pleistocene population dynamics close to the origin of the Neandertal clade. In particular, the contrasting inner ear morphology between Aroeira 3 and the Atapuerca (SH) hominins suggests a degree of demographic isolation, despite the close geographic proximity and similar age of these two sites.

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Editorial Board

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 192

Author(s):

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Uptake, depuration, dose estimation and effects in zebrafish exposed to Am-241 via dietary route

Publication date: October 2018

Source: Journal of Environmental Radioactivity, Volumes 193–194

Author(s): O. Simon, I. Barjhoux, V. Camilleri, B. Gagnaire, I. Cavalié, D. Orjollet, F. Darriau, S. Pereira, K. Beaugelin-Seillers, C. Adam-Guillermin

Abstract

Zebrafish were chronically exposed to Am-241, an alpha-emitting radionuclide via daily consumption of an enriched artificial diet. Am-241 uptake was quantified in Danio rerio after 5 and 21 days of exposure via daily Am-spiked food ingestion and after 21 days of exposure followed by 5 days of depuration. Americium accumulates mostly in digestive tract, muscle, rest of the body but the accumulation levels and trophic transfer rate (0.033–0.013%) were low. Corresponding cumulative doses were calculated for the whole body (9 mGy) and for the digestive tract (42 mGy) with internal alpha radiation contributing to more than 99% of the total dose. Genotoxic effects (gamma-H2AX assay) and differential gene expressions of main biological functions were examined. Although fish were exposed to a low dose rate of 13 μGy h⁻¹, DNA integrity and gene expression linked to oxidative stress, hormonal signaling and spermatogenesis were altered after 21 days of Am-241 exposure. These results underline the higher toxicity of alpha emitter Am-241, as compared to other studies on gamma radiation exposure.

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Families’ and health care professionals’ attitudes towards Li‐Fraumeni Syndrome testing in children: a systematic review

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


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Clinical, radiographic, and genetic characteristics of hypohidrotic ectodermal dysplasia: A cross‐sectional study

Clinical Genetics, EarlyView.


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Androgen receptor mRNA analysis from whole blood: a low‐cost strategy for detection of androgen receptor gene splicing defects

Clinical Genetics, EarlyView.


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The influence of alkalosis on repeated high-intensity exercise performance and acid–base balance recovery in acute moderate hypoxic conditions

Abstract

Purpose

Exacerbated hydrogen cation (H⁺) production is suggested to be a key determinant of fatigue in acute hypoxic conditions. This study, therefore, investigated the effects of NaHCO₃ ingestion on repeated 4 km TT cycling performance and post-exercise acid–base balance recovery in acute moderate hypoxic conditions.

Methods

Ten male trained cyclists completed four repeats of 2 × 4 km cycling time trials (TT₁ and TT₂) with 40 min passive recovery, each on different days. Each TT series was preceded by supplementation of one of the 0.2 g kg⁻¹ BM NaHCO₃ (SBC2), 0.3 g kg⁻¹ BM NaHCO₃ (SBC3), or a taste-matched placebo (0.07 g kg⁻¹ BM sodium chloride; PLA), administered in a randomized order. Supplements were administered at a pre-determined individual time to peak capillary blood bicarbonate concentration ([HCO₃⁻]). Each TT series was also completed in a normobaric hypoxic chamber set at 14.5% FiO₂ (~ 3000 m).

Results

Performance was improved following SBC3 in both TT₁ (400.2 ± 24.1 vs. 405.9 ± 26.0 s; p = 0.03) and TT₂ (407.2 ± 29.2 vs. 413.2 ± 30.8 s; p = 0.01) compared to PLA, displaying a very likely benefit in each bout. Compared to SBC2, a likely and possible benefit was also observed following SBC3 in TT₁ (402.3 ± 26.5 s; p = 0.15) and TT₂ (410.3 ± 30.8 s; p = 0.44), respectively. One participant displayed an ergolytic effect following SBC3, likely because of severe gastrointestinal discomfort, as SBC2 still provided ergogenic effects.

Conclusion

NaHCO₃ ingestion improves repeated exercise performance in acute hypoxic conditions, although the optimal dose is likely to be 0.3 g kg⁻¹ BM.

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Postnatal deficiency of ADAMTS1 ameliorates thoracic aortic aneurysm and dissection in mice

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


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Acute and chronic exercise in patients with HFrEF: Evidence of structural and functional plasticity and intact angiogenic signaling in skeletal muscle

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


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Effects of lorazepam and baclofen on short‐ and long‐latency afferent inhibition

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


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Ultrasound-Guided Botulinum Toxin Injections in Cervical Dystonia Needs Prompt Muscle Selection, Appropriate Dosage and Precise Guidance

No abstract available

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THE EFFECT OF STATIC STRETCHING OF PERONEAL AND TIBIAL MUSCLES ON THE REACTION TIME: A RANDOMIZED CONTROLLED STUDY

Objective The aim of this study is to investigate the acute and chronic effects of static stretching on peroneal and tibialis anterior reaction characteristics. Design All 23 participants who volunteered for this study were randomly divided into static (n=12) and control (n=11) groups. The subjects in the static stretching group performed stretching exercises for the ankle evertor and dorsiflexor muscles 5 days a week for 6 weeks. Peroneal and tibial muscle reaction characteristics were evaluated at the beginning (2 times for acute effect) and end of this period. Electromyographic activity parameters of the muscles were measured using an ankle inversion tilting platform that simulated a sudden ankle inversion. There were four different ankle inversion conditions: (a) ankle-neutral, 15° inversion; (b) ankle-neutral, 30° inversion; (c) ankle-20° plantarflexion, 15° inversion; and (d) ankle-20° plantarflexion, 30° inversion. Results Either in terms of acute or chronic effects, no significant differences were found following static stretching exercises for peroneal and tibial muscle reaction time, reaction duration and muscle activity evaluated in 4 positions on the ankle inversion simulation platform (p>0.05). Conclusion In light of these results, it is possible to state that short duration of static stretching exercises can still be applied before sports activities. CORRESPONDING AUTHOR: Ufuk SEKIR, Department of Sports Medicine, Medical Faculty of Uludag University, 16059 Gorukle, Bursa – TURKEY, +90 (224) 295 35 00, ufuksek@gmail.com Conflict of interest No potential conflict of interest was reported by the authors. Furthermore, there is no financial disclosure and no funding was received. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Intraoperative Mortality in Malawi

BACKGROUND: Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality. METHODS: This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004–2006 (early cohort) and 2015–2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality. RESULTS: There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26–108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56–286), with 76 per 100,000 surgeries (95% CI, 44–124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9–2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5–12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5–23.6; P

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Radiation Safety Perceptions and Practices Among Pediatric Anesthesiologists: A Survey of the Physician Membership of the Society for Pediatric Anesthesia

BACKGROUND: Pediatric anesthesiologists are exposed to ionizing radiation from x-rays on an almost daily basis. Our goal was to determine the culture of safety in which they work and how they adhere to preventative strategies that minimize exposure risk in their daily practice. METHODS: After Institutional Review Board waiver and approval of the Society for Pediatric Anesthesia's research and quality and safety committees, an electronic e-mail questionnaire was sent to the Society's physician, nontrainee members and consisted of questions specific to provider use of protective lead shielding, the routine use of dosimeters, and demographic information. Univariate analyses were performed using the Wilcoxon rank sum test for ordinal variables, the Fisher exact test for categorical variables, and the Spearman test to analyze correlation between 2 ordinal variables, while a proportional odds logistic regression was used for a multivariable ordinal outcome analysis. P values of <.05 were considered statistically significant. results: twenty-one percent of the surveyed anesthesiologists completed online questionnaire. radiation exposure is ubiquitous and regardless sex most respondents either concerned or very about however women significantly more than men odds ratio confidence interval p=".002)." despite this independent level concern was not associated with use a dosimeter .85 lead glasses thyroid shield .12 dosimeters rarely never used mandated in only institutions. virtually none had ever taken safety course received personal dose report notification their knew how many millirem safe. half female while pregnant tried to avoid by requesting be assigned cases requiring x-rays. these requests honored time. discussion: universal ionizing from x-rays pediatric do routinely adhere strategies designed limit intensity work institutions which culture exists. our study highlights need improve education change within operating rooms imaging suites fully investigate utility shielding eye measures anesthesia practice. accepted for publication july funding: none. authors declare no conflicts interest. supplemental digital content available article. direct url citations appear printed text are provided html pdf versions article on journal website g. m. whitney j. thomas contributed equally share first authorship. brief summary statement: routine safety. reprints will authors. address correspondence james md children hospital colorado e ave b090 aurora co e-mail james.j.thomas international research society>

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Obstructive Sleep Apnea and Risk of Postcardiac Surgery Atrial Fibrillation

No abstract available

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In Response

No abstract available

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Perioperative Considerations for Evolving Artificial Pancreas Devices

Type 1 diabetes mellitus is a lifelong condition. It requires intensive patient involvement including frequent glucose measurements and subcutaneous insulin dosing to provide optimal glycemic control to decrease short- and long-term complications of diabetes mellitus without causing hypoglycemia. Variations in insulin pharmacokinetics and responsiveness over time in addition to illness, stress, and a myriad of other factors make ideal glucose control a challenge. Control-to-range and control-to-target artificial pancreas devices (closed-loop artificial pancreas devices [C-APDs]) consist of a continuous glucose monitor, response algorithm, and insulin delivery device that work together to automate much of the glycemic management for an individual while continually adjusting insulin dosing toward a glycemic target. In this way, a C-APD can improve glycemic control and decrease the rate of hypoglycemia. The MiniMed 670G (Medtronic, Fridley, MN) system is currently the only Food and Drug Administration–cleared C-APD in the United States. In this system, insulin delivery is continually adjusted to a glucose concentration, and the patient inputs meal-time information to modify insulin delivery as needed. Data thus far suggest improved glycemic control and decreased hypoglycemic events using the system, with decreased need for patient self-management. Thus, the anticipated use of these devices is likely to increase dramatically over time. There are limited case reports of safe intraoperative use of C-APDs, but the Food and Drug Administration has not cleared any device for such use. Nonetheless, C-APDs may offer an opportunity to improve patient safety and outcomes through enhanced intraoperative glycemic control. Anesthesiologists should become familiar with C-APD technology to help develop safe and effective protocols for their intraoperative use. We provide an overview of C-APDs and propose an introductory strategy for intraoperative study of these devices. Accepted for publication August 8, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Micah T. Long, MD, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 UW CSC, 600 Highland Ave, Madison, WI 53792. Address e-mail to mtlong@wisc.edu. © 2018 International Anesthesia Research Society

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Evaluation of the Determinants of Satisfaction With Postoperative Pain Control After Thoracoscopic Surgery: A Single-Center, Survey-Based Study

BACKGROUND: The need to measure, compare, and improve the quality of pain management is important to patients, payers, and health care providers. Pain after thoracic surgery can be severe, and thoracoscopic approaches have not had the favorable impact on pain as anticipated. The aim of this study was to evaluate the determinants of patient satisfaction with acute pain management and the effectiveness of pain control after video-assisted thoracoscopic surgery using a modified version of the Revised American Pain Society Patient Outcome Questionnaire. METHODS: We performed a single-center, prospective, survey-based study of 300 patients who had undergone elective video-assisted thoracoscopic surgery. Patients were enrolled and completed the survey on postoperative day 1 or 2. The primary outcome variable was patient-reported satisfaction with acute postoperative pain treatment measured on a 1–4 scale. The relationship between the items on the survey and patient satisfaction was analyzed to determine the factors significantly associated with satisfaction. RESULTS: Fifty-one percent of the patients had the highest satisfaction level with pain treatment, and 4% of the patients had the lowest satisfaction level. The mean reported acceptable pain level was 3.8 ± 1.9 (numeric rating scale [NRS], 0–10). The average pain intensity score at the time of the survey was 2.8 ± 2.1 (NRS, 0–10). The median for the most pain in the prior 24 hours was 7 (NRS, 0–10; interquartile range, 5–9). Five items from the survey were significantly associated with the satisfaction level. The predictor with the highest associated odds ratio (OR) with satisfaction was the ability to participate in pain management decisions (OR, 1.45; P

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Elevated Presepsin Is Associated With Perioperative Major Adverse Cardiovascular and Cerebrovascular Complications in Elevated-Risk Patients Undergoing Noncardiac Surgery: The Leukocytes and Cardiovascular Perioperative Events Study

BACKGROUND: Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs) are incompletely understood, and risk prediction is imprecise. Atherogenic leukocytes are crucial in cardiovascular events. However, it is unclear if surgical interventions affect leukocyte counts or activation status. Therefore, we investigated whether noncardiac surgery in patients with elevated cardiovascular risk is associated with changes in atherogenic leukocyte subsets and if these changes are related to perioperative MACCEs. METHODS: We enrolled 40 patients in this single-center prospective observational cohort study. Total leukocytes and subpopulations, including classical, intermediate, and nonclassical monocytes and natural killer and regulatory T cells, were quantified before surgery, at 2 and 6 hours after skin incision, and at postoperative days 1 and 2 (POD1+2). The monocyte activation marker presepsin (sCD14-ST) was measured post hoc to determine differentiation of classical to nonclassical monocytes. We evaluated presepsin for prediction of the composite primary end point MACCE (cardiovascular death, myocardial infarction, myocardial ischemia, and stroke) at 30 days. Its additive value to risk assessment based on high-sensitive cardiac troponin T and N-terminal probrain natriuretic peptide (NT-proBNP) was analyzed. RESULTS: We evaluated 38 patients, of whom 5 (13%) reached MACCE. In the entire cohort, classical monocytes continuously increased and peaked at POD1 (0.35 [0.23–0.43] cells per nanoliter blood [nL−1] vs 0.45 [0.31–0.66] cells·nL−1, preoperative [pre-OP] vs POD1, P = .002). Intermediate monocytes doubled by POD1 (0.017 [0.013–0.021] vs 0.036 [0.022–0.043] cells·nL−1, pre-OP versus POD1, P = .0003). Nonclassical monocytes decreased (0.022 [0.012–0.032] vs 0.012 [0.005–0.023] cells·nL−1, pre-OP vs 6 hours, P = .003). In our patient population, we did not detect changes in any of the other predefined leukocyte subsets investigated. In patients experiencing a MACCE, classical monocyte expansion was reduced (0.081 [−0.16 to 0.081] cells·nL−1 vs 0.179 [0.081 to 0.292] cells·nL−1, MACCE versus non-MACCE, P = .016). Patients in the event group presented with elevated pre-OP presepsin (1528 [406–1897] pg·mL−1 vs 123 [82.2–174] pg·mL−1, MACCE versus non-MACCE, P = .0001). Presepsin was associated with MACCE (area under the curve = 0.964, [0.846–0.998], P = .001). Presepsin above the calculated threshold >184 pg·mL−1 was superior to high-sensitive cardiac troponin T for improvement of NT-proBNP-based risk prediction (28 [74%] vs 22 [58%] correctly classified patients, P = .014). CONCLUSIONS: Noncardiac surgery was associated with an increase in atherogenic leukocyte subsets. In a post hoc analysis, elevated pre-OP presepsin was associated with MACCE and improved NT-proBNP-based risk assessment. After validation in an independent data set, a presepsin cutoff of 184 pg·mL−1 might qualify to complement NT-proBNP-based risk prediction, thereby increasing the proportion of correctly identified high-risk patients. Accepted for publication July 10, 2018. Funding: Internal. 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 Jan Larmann, MD, PhD, Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. Address e-mail to Jan.Larmann@med.uni-heidelberg.de. © 2018 International Anesthesia Research Society

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Advanced Procedures for Pain Management: A Step-by-Step Atlas

No abstract available

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National Trends and Factors Associated With Inpatient Mortality in Adult Patients With Opioid Overdose

BACKGROUND: The prevalence of opioid misuse and opioid-related mortality has increased dramatically over the past decade. There is limited evidence on factors associated with mortality from opioid overdose in the inpatient setting. The primary objective was to report national trends in opioid overdose and mortality. The secondary objectives were to explore factors associated with inpatient mortality and report differences in prescription opioid overdose (POD) versus illicit opioid overdose (IOD) cohorts. METHODS: Using the 2010–2014 Nationwide Inpatient Sample, we performed a cross-sectional analysis and identified a weighted estimate of 570,987 adult patients with an International Classification of Disease, Ninth Revision, or External Cause of Injury code of POD or IOD. We performed multivariable logistic regression to identify predictors of inpatient mortality. The odds ratio (OR) and their associated 95% confidence interval (CI) are reported. RESULTS: Of the 570,987 patients with opioid overdose, 13.8% had an admissions diagnosis of IOD, and the remaining had POD. Among all opioid overdose admissions, the adjusted odds of IOD admissions increased by 31% per year (OR, 1.31; 95% CI, 1.29–1.31; P

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Nighttime Extubation Does Not Increase Risk of Reintubation, Length of Stay, or Mortality: Experience of a Large, Urban, Teaching Hospital

BACKGROUND: In the intensive care unit (ICU), extubation failure has been associated with greater resource utilization and worsened clinical outcomes. Most recently, nighttime extubation (NTE) has been reported as a risk factor for increased ICU and hospital mortality. We hypothesized that, in a large, urban, university-affiliated hospital with multidisciplinary assessment for extubation, rigorously protocolized extubation algorithms, and expert airway managers available at all times of day for assessment of high-risk extubations, NTE would not confer additional risk of adverse clinical outcomes. METHODS: This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital. NTE was defined as occurring between 7:00 PM and 6:59 AM the following day. All data were extracted from the institution's electronic medical record. Multi­vari­able regression analyses were used to assess associations between NTE and reintubation, ICU and hospital length of stay (LOS), and mortality with adjustments for demographic and clinical covariates defined a priori. Palliative, unplanned, and routine postoperative extubations were excluded in sensitivity analyses. RESULTS: Of 2241 patients, 204 of 2241 (9.1%) underwent NTE. The rates of reintubation (NTE 6.9% versus daytime extubation [DTE] 12.4%; adjusted odds ratio [95% confidence interval {CI}], 0.78 [0.43–1.41]; P = .41) and in-hospital mortality (NTE 3.4% versus DTE 5.9%; adjusted odds ratio [95% CI], 0.72 [0.28–1.84]; P = .49) were not found to differ. NTE, compared to DTE, was associated with shorter duration of mechanical ventilation (median [interquartile range], 1 [0–1] days vs 2 [1–4] days; adjusted ratio of geometric means [RGMs] [95% CI], 0.64 [0.54–0.70]; P

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A Study of Practice Behavior for Endotracheal Intubation Site for Children With Congenital Heart Disease Undergoing Surgery: Impact of Endotracheal Intubation Site on Perioperative Outcomes—An Analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database

BACKGROUND: In adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children, nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of a nasal route against an oral one. METHODS: Patients 100 cases/y) examining how infection risk may change with age at the time of surgery. RESULTS: Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in school-aged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59–1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947–1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869–0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6–12 months of age (P = .003). CONCLUSIONS: While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations. Accepted for publication May 21, 2018. Funding: This study was funded jointly by the Society of Thoracic Surgeons and the Congenital Cardiac Anesthesia Society. 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 Nathaniel H. Greene, MD, MHS, Department of Anesthesiology, Duke ­University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to Nathaniel.Greene@duke.edu. © 2018 International Anesthesia Research Society

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Pharmacokinetics of Dexmedetomidine in Infants and Children After Orthotopic Liver Transplantation

BACKGROUND: Dexmedetomidine (DEX) is a sedative and analgesic medication that is frequently used postoperatively in children after liver transplantation. Hepatic dysfunction, including alterations in drug clearance, is common immediately after liver transplantation. However, the pharmacokinetics (PK) of DEX in this population is unknown. The objective of this study was to determine the PK profile of DEX in children after liver transplantation. METHODS: This was a single-center, open-label PK study of DEX administered as an intravenous loading dose of 0.5 μg/kg followed by a continuous infusion of 0.5 μg/kg/h. Twenty subjects, 1 month to 18 years of age, who were admitted to the pediatric intensive care unit after liver transplantation were enrolled. Whole blood was collected and analyzed for DEX concentration using a dried blood spot method. Nonlinear mixed-effects modeling was used to characterize the population PK of DEX. RESULTS: DEX PK was best described by a 2-compartment model with first-order elimination. A typical child after liver transplantation with an international normalized ratio (INR) of 1.8 was found to have a whole blood DEX clearance of 52 L/h (95% confidence interval [CI], 31–73 L/h). In addition, intercompartmental clearance was 246 L/h (95% CI, 139–391 L/h), central volume of distribution was 186 L/70 kg (95% CI, 140–301 L/70 kg), and peripheral volume of distribution was 203 L (95% CI, 123–338 L). Interindividual variability ranged from 11% to 111% for all parameters. Clearance was not found to be associated with weight but was found to be inversely proportional to INR. An increase in INR to 3.2 resulted in a 50% decrease in DEX clearance. Weight was linearly correlated with central volume of distribution. All other covariates, including age, ischemic time, total bilirubin, and alanine aminotransferase, were not found to be significant predictors of DEX disposition. CONCLUSIONS: Children who received DEX after liver transplantation have large variability in clearance, which was not found to be associated with weight but is influenced by underlying liver function, as reflected by INR. In this population, titration of DEX dosing to clinical effect may be important because weight-based dosing is poorly associated with blood concentrations. More attention to quality of DEX sedation may be warranted when INR values are changing. Accepted for publication July 26, 2018. Funding: Supported by Child Health Research Institute, Ernest and Amelia Gallo Endowed Postdoctoral Fellow, National Institutes of Health, Clinical and Transitional Science Award (NIH CTSA) UL1 RR025744. 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 Mihaela A. Damian, MD, MPH, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Rd, Suite 435, Palo Alto, CA 94304. Address e-mail to mdamian@stanford.edu. © 2018 International Anesthesia Research Society

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An In Vitro Model for Identifying Cardiac Side Effects of Anesthetics

The understanding of anesthetic side effects on the heart has been hindered by the lack of sophisticated clinical models. Using micropatterned human-induced pluripotent stem cell–derived cardiomyocytes, we obtained cardiac muscle depressant profiles for propofol, etomidate, and our newly identified anesthetic compound KSEB01-S2. Propofol was the strongest depressant among the 3 compounds tested, exhibiting the largest decrease in contraction velocity, depression rate, and beating frequency. Interestingly, KSEB01-S2 behaved similarly to etomidate, suggesting a better cardiac safety profile. Our results provide a proof-of-concept for using human-induced pluripotent stem cell–derived cardiomyocytes as an in vitro platform for future drug design. Accepted for publication July 26, 2018. 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). Funding: This research was supported by the Canadian Institutes of Health Research Fellowship (201411MFE-338745-169197 to A.C.Y.C.); the Baxter Foundation and National Institutes of Health (AG044815 and AR063963 to H.M.B.); and Stanford University Department of Anesthesia Field of anesthesia Investigator Departmental benefit Leverage for external research dollars (FIDL) Grant, Stanford University SPARK Drug Discovery Program, and Stanford University Children's Health Research Initiative to M.F.D. and E.J.B. Reprints will not be available from the authors. Address correspondence to Alex C. Y. Chang, PhD, Stanford University, 269 Campus Dr, CCSR Building, Room 3200, Stanford, CA 94305-5175. Address e-mail to acychang@stanford.edu; and Edward J. Bertaccini, MD, Department of Anesthesia, 112A Palo Alto Veterans Affairs Health Care System, Palo Alto Division, 3801 Miranda Ave, Palo Alto, CA 94304. Address e-mail to edward.Bertaccini@va.gov. © 2018 International Anesthesia Research Society

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Transversus Abdominal Plane Block in Children: Efficacy and Safety A Randomized Clinical Study and Pharmacokinetic Profile

BACKGROUND: The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. METHODS: This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg−1 levobupivacaine as either HVLC (0.2 mL·kg−1 of 0.2% levobupivacaine) or LVHC (0.1 mL·kg−1 of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. RESULTS: Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29–1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference −0.60 (95% CI, −1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL−1, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL−1, remained far below theoretical toxic thresholds. CONCLUSIONS: In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg−1 administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity. Accepted for publication July 16, 2018. Funding: Support was provided solely from institutional and departmental sources of Lapeyronie University Hospital, Montpellier, France. The authors declare no conflicts of interest. Clinical registration: Clinical-Trials.gov (NCT02064088), Principal Investigator Chrystelle Sola, Registration Date February 4, 2014. Reprints will not be available from the authors. Address correspondence to Chrystelle Sola, MD, MSc, Pediatric Anesthesia Unit, Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France. Address e-mail to c-sola@chu-montpellier.fr. © 2018 International Anesthesia Research Society

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Perioperative Two-Dimensional Transesophageal Echocardiography: A Practical Handbook, 2nd ed

No abstract available

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The Resuscitation Crisis Manual: For the Briefcase, the Breakroom, and Beyond, 1st ed

No abstract available

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Role of Endocannabinoid System in the Peripheral Antinociceptive Action of Aripiprazole

BACKGROUND: Recently, we demonstrated that the antipsychotic dopaminergic and serotoninergic agonist aripiprazole induced peripheral antinociception. However, the mechanism underlying this effect has not been fully established. Here, our aim was to identify possible relationships between this action of aripiprazole and the endocannabinoid system. METHODS: All drugs were given locally into the right hind paw of male Swiss mice weighing 30–35 g in a volume of 20 µL. The hyperalgesia was induced by intraplantar injection of prostaglandin E2 (2 μg). Aripiprazole was injected 10 minutes before the measurement, and an irreversible inhibitor of anandamide hydrolase (MAFP), an inhibitor for monoacylglycerol lipase (JZL184), and an anandamide reuptake inhibitor (VDM11) were given 10 minutes before the aripiprazole. Nociceptive thresholds were measured using an algesimetric apparatus in the third hour after prostaglandin E2 injection. Data were analyzed by ANOVA and Bonferroni tests. RESULTS: The antinociceptive effect induced by aripiprazole (100 μg) was blocked by cannabinoid 1 or 2 receptor antagonists AM251 (40 μg [P

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What Is New in Obstetric Anesthesia: The 2017 Gerard W. Ostheimer Lecture

The Gerard W. Ostheimer lecture is given each year at the Society for Obstetric Anesthesia and Perinatology annual meeting and is intended to summarize important new scientific literature relevant to practicing obstetric anesthesiologists. This review highlights some of the most consequential papers covered in this lecture. It discusses landmark clinical trials that are likely to change the practice of obstetrics and obstetric anesthesia. It summarizes several articles that focus on how to optimize the provision of neuraxial anesthesia and postoperative pain control. Finally, it reviews studies aimed at identifying systems-based interventions that can improve obstetrical outcomes. A proposed "to-do" list focused on quality improvement initiatives that can be implemented on labor and delivery units is provided. Accepted for publication July 26, 2018. Funding: None. The author declares 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 Brian T. Bateman, MD, MSc, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA 02120. Address e-mail to bbateman@bwh.harvard.edu. © 2018 International Anesthesia Research Society

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Critical Care Sedation

No abstract available

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Pupillary Pain Index Changes After a Standardized Bolus of Alfentanil Under Sevoflurane Anesthesia: First Evaluation of a New Pupillometric Index to Assess the Level of Analgesia During General Anesthesia

BACKGROUND: The pupillary pain index (PPI) is a novel pupillometric index, designed to assess intraoperative analgesia. It is based on the evaluation of the pupillary response to electrical stimuli of increasing intensity. It ranges from 1 (low level of pupillary reactivity, high level of analgesia) to 10 (high level of pupillary reactivity, low level of analgesia). In this first evaluation of the PPI, our objective was to investigate the PPI changes after a bolus of 10 µg·kg−1 of alfentanil in children under sevoflurane general anesthesia. METHODS: After ethics committee approval and informed consent, 20 healthy children (9 ± 5 years) undergoing elective surgery under general anesthesia were included in this prospective, open, registered pilot study (NCT02646592). Anesthetic induction was standardized with sevoflurane 6% and propofol 1 mg·kg−1. After tracheal intubation, sevoflurane concentration was maintained at 2% for 10 minutes. A first PPI measurement was performed (PPI-1), and a bolus of 10 µg·kg−1 was administered. Two minutes after this bolus, a second PPI measurement was performed (PPI-2). Heart rate, blood pressure, and bispectral index were recorded before and after each PPI measurement. Resting pupillary diameter was recorded before each PPI measurement. PPI scores before and after the bolus of alfentanil were compared using a Wilcoxon signed rank test. RESULTS: PPI scores decreased after administration of a bolus of alfentanil (median difference: −3 [95% confidence interval, −4 to −2]). The median (quartiles) of PPI-1 (baseline, before alfentanil) was 6 (4, 7), and the median (quartiles) of PPI-2 (after alfentanil) was 2 (2, 3) (P

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