Response to the Letter to the Editor on “The Effectiveness of Technology-Supported Exercise Therapy for Low Back Pain: A Systematic Review”

No abstract available

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A Risk Scoring System for the Prediction of Functional Deterioration, Institutionalization, and Mortality Among Medicare Beneficiaries

Objective We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes. Design This is a cohort study with 21,257 community-dwelling Medicare beneficiaries 65 yrs and older who participated in the 2001–2008 Medicare Current Beneficiary Survey.  Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated β coefficients, which were used to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality for 2 yrs of follow-up. Results A total of 18 factors were identified for functional deterioration (P

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Rehabilitation for Cancer Survivors: How We Can Reduce the Healthcare Service Inequality in Low- and Middle-Income Countries

Cancer diagnosis often substantially affects patient's physical, psychological, and emotional status. Most patients with cancer experience declining of energy, activity levels, social-cultural participation, and relationships. In addition, cancer progression and adverse effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient's quality of life. Although cancer rehabilitation has been implemented in many high-income countries, it is either not yet or suboptimally delivered in most low- and middle-income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high-quality cancer rehabilitation in the developing countries.

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Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy

Objectives The aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC). Design This was a randomized clinical trial. Volleyball and basketball players (16–31 yrs, n = 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure. Results No significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z = −0.414, P = 0.679) as well as disorganized structure (echo types III + IV) (Z = −0.370, P = 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups. Conclusion Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.

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Efficacy of Bedside Respiratory Muscle Training in Patients With Stroke: A Randomized Controlled Trial

Objective Inspiratory and expiratory muscles are important for effective respiratory function. This study aimed to investigate the efficacy of bedside respiratory muscle training on pulmonary function and stroke-related disabilities in stroke rehabilitation. Design Patients with stroke (N = 40) in a rehabilitation unit were randomly assigned to either the intervention group (n1 = 20) or the control group (n2 = 20). Both groups participated in a conventional stroke rehabilitation program. During the study period, the intervention group received bedside respiratory muscle training twice a day for 3 wks. The respiratory muscle training consisted of (1) a breath stacking exercise, (2) inspiratory muscle training, and (3) expiratory muscle training. The primary outcomes were measures of pulmonary function: forced vital capacity, forced expiratory volume in 1 sec, and peak flow. Secondary outcomes were stroke-related disabilities assessed using the National Institutes of Health Stroke Scale, Modified Barthel Index, Berg Balance Scale, Fugl-Meyer Assessment, the Korean Mini-Mental State Examination, and pneumonia incidence. Results Pulmonary function was significantly improved in the intervention group after 3 wks of respiratory muscle training (P

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Association of Activities of Daily Living With Load During Step Ascent Motion in Nursing Home–Residing Elderly Individuals: An Observational Study

Objective This study aimed to examine the association of independence in activities of daily living with the loads during step ascent motion and other motor functions in 32 nursing home–residing elderly individuals. Design Independence in activities of daily living was assessed by using the Functional Independence Measure. The loads at the upper (i.e., pulling up) and lower (i.e., pushing up) levels during the step ascent task was measured on a step ascent platform. Hip extensor, knee extensor, plantar flexor muscle, and quadriceps setting strengths; lower extremity agility using the stepping test; and hip and knee joint pain severities were measured. One-legged stance and functional reach distance for balance and maximal walking speed, timed up-and-go time, five-chair-stand time, and step ascent time were also measured to assess mobility. Results Stepwise regression analysis revealed that the load at pushing up during step ascent motion and timed up-and-go time were significant and independent determinants of Functional Independence Measure score. Functional Independence Measure score decreased with decreased load at pushing up and increased timed up-and-go time. Conclusions The study results suggest that depending on task specificity, both one step up task's push-up peak load during step ascent motion and timed up-and-go can partially explain activities of daily living's Functional Independence Measure score in nursing home–residing elderly individuals. Lower extremity muscle strength, agility, pain, or balance measures did not add to the prediction.

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Effect of Polydeoxyribonucleotide Injection in a Patient With Carpal Tunnel Syndrome

Ultrasound-guided corticosteroid injection into the carpal tunnel is widely performed for the management of carpal tunnel syndrome. However, this injection may worsen the condition in patients with type 2 diabetes mellitus. Polydeoxyribonucleotide was recently recognized as a substitute for corticosteroid because of its anti-inflammatory effects. A 41-yr-old woman with type 2 diabetes mellitus was admitted to our rehabilitation clinic with a 1-mo history of numbness and tingling in her right hand and first three fingers tips. She declined corticosteroid treatment because of a previous episode of uncontrolled blood glucose levels after corticosteroid injection. Therefore, ultrasound-guided polydeoxyribonucleotide injections into the carpal tunnel were carried out. At the 6-mo follow-up, the patient demonstrated an improvement in the carpal tunnel syndrome symptoms without any complications. Thus, polydeoxyribonucleotide injections into the carpal tunnel can be an alternative to corticosteroid injections for carpal tunnel syndrome if there are limitations because of adverse effects of the latter.

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Femoral Artery Blood Flow and Microcirculatory Perfusion During Acute, Low-Level Functional Electrical Stimulation in Spinal Cord Injury

Objective Functional electrical stimulation (FES) may help to reduce the risk of developing macrovascular and microvascular complications in people with spinal cord injury. Low-intensity FES has significant clinical potential because this can be applied continuously throughout the day. This study examines the acute effects of low-intensity FES using wearable clothing garment on vascular blood flow and oxygen consumption in people with spinal cord injury. Design This was a cross-sectional observation study. Methods Eight participants with a motor complete spinal cord injury received four 3-min unilateral FES to the gluteal and hamstring muscles. Skin and deep femoral artery blood flow and oxygen consumption were measured at baseline and during each bout of stimulation. Results Femoral artery blood flow increased by 18.1% with the application of FES (P = 0.02). Moreover, femoral artery blood flow increased further during each subsequent block of FES (P = 0.004). Skin perfusion did not change during an individual block of stimulation (P = 0.66). Skin perfusion progressively increased with each subsequent bout (P 0.05). Conclusion Low-intensity FES acutely increased blood flow during stimulation, with a progressive increase across subsequent FES bouts. These observations suggest that continuous, low-intensity FES may represent a practical and effective strategy to improve perfusion and reduce the risk of vascular complications.

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The Power of Doppler in the Popliteal Fossa: Sonographic Diagnosis of a Fibular Nerve Neurofibroma in a Patient With Posterior Knee Swelling

No abstract available

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Evidence of the Homeostatic Regulation With the Combination of Transcranial Direct Current Stimulation and Physical Activity

Background Transcranial direct current stimulation (tDCS) can optimize beneficial effects induced by motor practice in patients with neurological disorders. However, possibly because of homeostatic regulation, the conditioning effects of tDCS are often imprecise and variable, limiting its therapeutic application. Objective The aim of the study was to explore the magnitude and direction of the after effects induced by physical activity (PA) on tDCS-preconditioned cortical excitability (CE). Design First, a crossover experiment was performed with 12 subjects to determine whether a single session of low-, moderate-, and high-intensity PA on a treadmill modulates the motor CE measured by transcranial magnetic stimulation. In a second crossover experiment, we investigated long-lasting changes (until 90 mins) of the effects induced by PA (with intensities defined by the first experiment) on motor CE after the subject had been preconditioned by tDCS (using different polarities). Results and Conclusions In experiment 1, we found that high- and moderate-intensity PA modulate the CE. Experiment 2 demonstrated that preconditioning the CE using tDCS homeostatically changes the direction and magnitude of after effects induced by subsequent PA plasticity caused by motor activity. In conclusion, the results suggest that the direction of after effects induced by the combination of physical exercise with tDCS on the CE is regulated within a physiologically defined range.

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Evidence-Based Physiatry: Clinical Practice Guideline Noninvasive Treatments for Low Back Pain

No abstract available

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Two-Year Longitudinal Changes in Lower Limb Strength and Its Relation to Loss in Function in a Large Cohort of Patients With Duchenne Muscular Dystrophy

Objective The main objective of this study was to examine the effect of disease on strength in two functionally important lower limb muscles for a period of 2 yrs in children with Duchene muscular dystrophy. Design Seventy-seven Duchene muscular dystrophy children participated in this study. Plantar flexors, knee extensors, strength, and performance on timed tests (6-min walk, 4-stairs, 10-m walk, supine-up) were assessed yearly for 2 yrs. Multivariate normal regression was used to assess changes in strength over time in the Duchene muscular dystrophy group. Spearman correlations were computed to examine relationship between strength and function. Results Normalized plantar flexor and knee extensor strength showed a significant decrease (P

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Successful First Gait of a Child With Hip-Disarticulation Prosthesis

An infant boy underwent hip disarticulation for infantile fibrosarcoma immediately after birth. His rehabilitation began when he was 4 mos old and involved training with his left (residual) leg. He could stand with support at 12 mos. His initial prosthesis fitting was performed at the age of 13 mos. He could stand and walk with support at 15 mos of age and could walk with no additional support and go up and down stairs at 2 yrs. A single-axis prosthetic knee joint was introduced at the age of 2 yrs 3 mos. His first gait using a hip prosthesis was successful, and his prosthesis was replaced at appropriate intervals with no major problems. The authors believe that the key to achieving a successful prosthetic gait in children is good communication among the medical team, which should comprise an orthopedic doctor, rehabilitation doctor, nurse, physical therapist, prosthetist/orthotist, and the patient's parents.

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Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial

Background Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks. Objective The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy. Methods This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection. Results No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%–99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%–100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy. Conclusions Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.

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Exercise Therapy for Low Back Pain: A Systematic Review

No abstract available

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Cost-Effectiveness Analysis of Routine Venous Doppler Ultrasound for Diagnosis of Deep Venous Thrombosis at Admission to Inpatient Rehabilitation

Objective The aims of the study were to identify whether timing of venous thromboembolism diagnosis is associated with differences in patient outcomes and to perform a cost-effectiveness analysis of routine venous Doppler ultrasound at admission to inpatient rehabilitation, taking into account costs associated with prolonged inpatient rehabilitation length of stay, and development of pulmonary embolism. Design This was a retrospective cohort study of 2312 consecutive patient discharges from a single inpatient rehabilitation facility for an 18-mo period. Cost-effectiveness model was built using TreeAge Healthcare Pro. The base case was constructed using probabilities and inpatient rehabilitation length of stay identified from retrospective analysis. Cost of Doppler ultrasound was obtained through the literature, and daily inpatient rehabilitation cost was obtained from the study institution. Results Venous thromboembolism was diagnosed in 6.6% of patients. Asymptomatic patients diagnosed with venous thromboembolism on screening Doppler ultrasound had shorter inpatient rehabilitation length of stay (P = 0.045) and lower rate of pulmonary embolism (P

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An Uncommon Cause of Upper Limb Pain: Cervical Perineural (Tarlov) Cyst Chain

No abstract available

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Delirium Screening and Management in Inpatient Rehabilitation Facilities

Delirium is an acute and fluctuating disturbance in cognition attention and awareness that is often a reflection of abnormal physiological condition of an individual. Delirium is highly prevalent among an older population and is associated with high mortality, poor medical and functional outcomes, and high healthcare cost. Delirium often has iatrogenic triggers, and it has been recognized as a quality indicator of healthcare organizations. Despite its high prevalence and significance, more than 50% of the delirium cases are underrecognized by healthcare professionals and remained untreated. Most patients in inpatient rehabilitation facilities are older adults with multiple risk factors for delirium including operation, intensive care stay, multiple co-morbidities, and impaired mobility. Early detection, intervention, and primary prevention of delirium will allow patients to avoid additional morbidities and reach their maximum functional potential during their rehabilitation stay. After the systematic implementation of delirium screening in our inpatient rehabilitation facility, we found that 10.3% of patients were screened positive for delirium at admission. This review discusses the systematic implementation of screening and intervention for delirium as well as the epidemiology of delirium to increase the awareness and guide clinical practice for clinicians in inpatient rehabilitation facilities.

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Ultrasound-Guided Injection of Botulinum Toxin for Cricopharyngeal Dysphagia

No abstract available

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Whole-Genome Multi-omic Study of Survival in Patients with Glioblastoma Multiforme

Glioblastoma multiforme (GBM) has been recognized as the most lethal type of malignant brain tumor. Despite efforts of the medical and research community, patients' survival remains extremely low. Multi-omic profiles (including DNA sequence, methylation and gene expression) provide rich information about the tumor. These profiles are likely to reveal processes that may be predictive of patient survival. However, the integration of multi-omic profiles, which are high dimensional and heterogeneous in nature, poses great challenges. The goal of this work was to develop models for prediction of survival of GBM patients that can integrate clinical information and multi-omic profiles, using multi-layered Bayesian regressions. We apply the methodology to data from GBM patients from The Cancer Genome Atlas (TCGA, n=501) to evaluate whether integrating multi-omic profiles (SNP-genotypes, methylation and gene expression) with clinical information (demographics as well as treatments) leads to an improved ability to predict patient survival. The proposed Bayesian models were used to estimate the proportion of variance explained by clinical covariates and omics and to evaluate prediction accuracy in cross validation (using the area under the Receiver Operating Characteristic curve, AUC). Among clinical and demographic covariates, age (AUC=0.664) and the use of temozolomide (AUC=0.606) were the most predictive of survival. Among omics, methylation (AUC=0.623) and gene expression (AUC=0.593) were more predictive than either SNP (AUC=0.539) or CNV (AUC=0.547). While there was a clear association between age and methylation, the integration of age, the use of temozolomide, and either gene expression or methylation led to a substantial increase in AUC in cross-validaton (AUC=0.718). Finally, among the genes whose methylation was higher in aging brains, we observed a higher enrichment of these genes being also differentially methylated in cancer.

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Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study

Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby p...

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RETURN TO WORK FOLLOWING SURGERY FOR LUMBAR RADICULOPATHY IS THERE A NEED FOR POSTOPERATIVE REHABILITATION?

We would like to thank Dr. Hai-Qiang Wang and colleagues for their positive comments on our recent systematic review about return to work following surgery for lumbar radiculopathy1. Wang et al. addressed some relevant issues in their letter to the editor, which should be considered in the management of patients with lumbar radiculopathy.

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The Effect of Surgically Implanted Metallic Bullet Fragments on the Intervertebral Disc Using a Canine Model

To characterize the gross, histologic and systemic changes caused by implantation of metal fragments commonly used in commercial bullets into the intervertebral disc.

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New influenza surveillance tool supports communities

LAKEVILLE, Minn. — ImageTrend announces influenza tracking using Continuum® software in preparation for the upcoming flu season1. As each incident report is posted by EMS care providers, Continuum automatically begins to monitor the aggregate data for developing trends or surges in influenza-like symptoms. Sudden spikes or increased concentration of incidents can trigger...

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Research Analysis: Key takeaways from PART and Airways-2 Trials

Comparing endotracheal, laryngeal tube and supraglottic airway device intubation during out of hospital cardiac arrest

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PCR documentation for non-transporting first responders

Including clear, complete documentation in your patient care report is a critical component of patient care

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Defective cortex glia plasma membrane structure underlies light-induced epilepsy in cpes mutants [Genetics]

Seizures induced by visual stimulation (photosensitive epilepsy; PSE) represent a common type of epilepsy in humans, but the molecular mechanisms and genetic drivers underlying PSE remain unknown, and no good genetic animal models have been identified as yet. Here, we show an animal model of PSE, in Drosophila, owing to...

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Cancer-driving H3G34V/R/D mutations block H3K36 methylation and H3K36me3-MutS{alpha} interaction [Genetics]

Somatic mutations on glycine 34 of histone H3 (H3G34) cause pediatric cancers, but the underlying oncogenic mechanism remains unknown. We demonstrate that substituting H3G34 with arginine, valine, or aspartate (H3G34R/V/D), which converts the non-side chain glycine to a large side chain-containing residue, blocks H3 lysine 36 (H3K36) dimethylation and trimethylation...

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Hair follicles transcriptome profiles in Bashang long-tailed chickens with different plumage colors

Abstract

Despite the rich variety in plumage color found in nature, genetic studies on how hair follicles affect pigmentation are often limited to animals that have black and white pigment. To test how gene expression influences plumage color, transcriptomes of chicken hair follicles with white, black, hemp, reed catkins, silvery grey, and landscape plumage colors were generated using Illumina sequencing. We generated six RNA-Seq libraries with over 25 million paired-end clean reads per library with percentage of paired-end clean reads ranging from 96.73 to 96.98%. 78% of the reads mapped to the chicken genome, and approximately 70% of the reads were mapped to exons and 6% mapped to introns. Transcriptomes of hair follicles producing hemp and land plumage were similar, but these two showed moderate differences compared with gray and reed colored plumage. The black and white follicle transcriptomes were most divergent from the other colors. We identified several candidate genes, including GPNMB, PMEL, TYRP1, GPR143, OCA2, SOX10, SLC45A2, KRT75, and TYR. All of these genes are known to induce pigment formation in mice. White feathers result from the lack of pigment formation, and our results suggest that the white chickens due to the recessive insertion mutation of TYR. The formation of black area size and color depth may be due to the expression levels of GPNMB, PMEL, TYRP1, GPR143, OCA2, SOX10, SLC45A2, KRT75, and TYR. The GO analysis of the differentially expressed genes (DEGs) revealed that DEGs in our transcriptome analysis were enriched in cytoskeleton and cell structure related pathways. The black plumage transcriptome showed significant differences in melanogenesis, tyrosine metabolism, and riboflavin metabolism compared with transcriptomes of other plumage colors. The transcriptome profiles of the different chicken plumage colors provide a valuable resource to understand how gene expression influences plumage color, and will be an important resource for identifying candidate genes in breeding programs.

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What you missed at the 2018 Pinnacle Leadership Forum

Pinnacle program co-chair, Jay Fitch, recounts the highlights from this year's leadership forum

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Drone startup company makes award-winning UAS for responders

DV8 Tech won $50,000 for creating a drone that carried a mini-cell tower to allow responders to communicate in a disaster, such as a forest fire or flood

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Charging for medical records: Patients vs. lawyers

Lawyer requests for medical records are not limited by HIPPA cost-based fees

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Progress and potential in organoid research

Progress and potential in organoid research

Progress and potential in organoid research, Published online: 18 September 2018; doi:10.1038/s41576-018-0051-9

Organoids are 3D structures derived from stem cells that recapitulate some key characteristics of real organs. The authors review recent progress in organoid derivation and applications and outline how advances in other disciplines might lead to more physiologically relevant organoids.

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EMT Hyperbaric Technician/Inside Observer- Westchester - Phelps Memorial Hospital Center

Prepares patients for Hyperbaric Oxygen Therapy (HBO) treatments. Assists clinical staff with patient examination and treatment, documents patient care records. Operates and cleans Hyperbaric Chamber and documents equipment maintenance. 1.Prepares patients for Hyperbaric Oxygen Therapy (HBO) treatments. Documents treatments in patient care record. 2.Participates in patient education as it relates to ...

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Firefighter (AEMT or higher) - James City County Fire Department

**Firefighter I/II/III/IV $41,018-50,993 or higher DOQ.** Progressive fire department offering exciting opportunities for a career in firefighting and emergency medical services! **We are accepting applications beginning September 21 **to fill current vacancies and to create a hiring pool of eligible applicants to fill future vacancies. James City County is located in on The Peninsula in the Tidewater ...

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Spermine and oxacillin stress response on the cell wall synthesis and the global gene expression analysis in Methicillin-resistance Staphylococcus aureus

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) is a rapidly emerging bacteria causing infection, which has developed resistance to most of the beta-lactam antibiotics because of newly acquired low-affinity penicillin-binding protein (PBP2a), which can continue to build the cell wall when beta-lactams block other PBPs. Exogenous spermine exerts a dose-dependent inhibition effect on the growth of Escherichia coli, Salmonella enterica serovar, and S. aureus. Selection of an MRSA Mu50 derivative which harbors mutation on PBP2 gene (named as MuM) showing spermine resistance and which confers a complete abolishment of spermine-beta-lactam synergy was identified. To further investigate the gene expression changes, a transcriptome profiling of MuM against Mu50 (wild-type) without any treatment, MuM and Mu50 in response to high dose spermine and Mu50 in response to spermine-beta-lactam synergy at 15, 30 and 60 min time points was performed. Functional annotation was further performed to delineate the metabolic pathways associated with the significant genes. A significant down-regulation in the iron regulatory system, potassium channel uptake and polyamine transport system with an up-regulation in general stress response sigB dependent operon in MuM strain at 15, 30 and 60 min time points with spermine treatment compared to Mu50 strain was observed. Analysis of spermine-dependent synergy with beta-lactams on cell wall synthesis revealed that it significantly reduces the degree of cross-linkage on cell wall with no change in trypsin digestion pattern of purified PBPs and without affecting PBPs expression or PBPs acylation by Bocillin. A strong relation between PBP2 protein and general stress sigB response, iron, potassium and polyamine transport systems was observed. SigB regulon should be activated on stress, which was not seen in some of our previous studies where it was down-regulated in wild-type Mu50 strain with spermine stress. Here, an intriguing finding is made where there seems to be a correction of this abnormal response of no SigB induction to a significant induction by PBP2 mutation. In MuM strain, a significant down-regulation of KdpABC operon genes at 15, 30 and 60 min time points on spermine stress is seen, which seems to be absent without spermine treatment. Since KCL has been found to protect the cell against spermine stress in wild-type strain by induction of KdpABC operon, it fails to do so in MuM strain underlying the importance of PBP2 protein in spermine stress. Analysis of spermine-dependent synergy with beta-lactams on cell wall synthesis revealed that it significantly reduces the degree of cross-linkage on cell wall with no change in trypsin digestion patterns of purified PBPs and without affecting PBPs expression or PBPs acylation by Bocillin. Furthermore, spermine does not help in enhancing the binding of beta-lactams to PBPs and binding of spermine to PBPs does not cause conformational changes to PBPs, as tested with trypsin digestion patterns. Future studies on the molecular mechanism of spermine interactions with these systems hold great potential for the development of new therapeutics for MRSA infections.

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Effect of aspirin on disability-free survival in the healthy elderly

New England Journal of Medicine

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Effect of aspirin on cardiovascular events and bleeding in the healthy elderly

New England Journal of Medicine

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Accuracy of the Pediatric End-stage Liver Disease score in estimating pretransplant mortality among pediatric liver transplant candidates

JAMA Pediatrics

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Biliary-enteric drainage vs primary liver transplant as initial treatment for children with biliary atresia

JAMA Surgery

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Long-term outcomes of immunosuppression-naïve steroid responders following hospitalization for ulcerative colitis

Digestive Diseases and Sciences

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Progress and potential in organoid research

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The effect of anesthetic technique on µ-opioid receptor expression and immune cell infiltration in breast cancer

Abstract

Background

Clinical histological studies demonstrate that the distribution of natural killer (NK) cells, other immune cells and μ-opioid receptors (MOR) within cancer tissue can predict cancer prognosis. No clinical study has evaluated whether anesthetic technique influences immune cell and MOR expression within human breast cancer.

Methods

Excised preoperative biopsies and intraoperative breast cancer specimens from 20 patients randomly chosen from patients previously enrolled in an ongoing, prospective, randomized trial (NCT00418457) investigating the effect of anesthetic technique on long-term breast cancer outcome were immunohistochemically stained and microscopically examined by two independent investigators, masked to randomization, to quantify MOR and immune cell infiltration: CD56, CD57 (NK cells), CD4 (T helper cells), CD8 (cytotoxic T cells) and CD68 (macrophages). Patients had been randomized to receive either a propofol–paravertebral anesthetic with continuing analgesia (PPA, n = 10) or balanced general anesthetic with opioid analgesia (GA, n = 10).

Results

There were no differences between the groups in staining intensity in preoperative biopsy specimens. Expression intensity values (median 25–75%) for MOR in intraoperative resected biopsy were higher in GA 8.5 (3–17) versus PPA 1 (0–10), p = 0.04. The numbers of MOR-positive cells were also higher in GA patients. Expression and absolute numbers of CD56, CD57, CD4 and CD68 were similar in resected tumor in both groups.

Conclusion

General anesthesia with opioid analgesia increased resected tumor MOR expression compared with propofol–paravertebral anesthetic technique, but the anesthetic technique did not significantly influence the expression of immune cell markers.

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Kinetics of europium sorption to four different aluminum (hydr)oxides: Corundum, γ-alumina, bayerite, and gibbsite

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 195

Author(s): Teresa Baumer, Amy E. Hixon

Abstract

Kinetic studies can improve our understanding of the environmental mobility of radionuclides by providing insight into sorption mechanisms occurring at the mineral-water interface. While nearly identical equilibrium europium sorption edges are obtained for gibbsite (γ-Al(OH)₃), bayerite (α-Al(OH)₃), corundum (α-Al₂O₃), and γ-Al₂O₃, differences in surface acidity and crystal structure result in distinct reaction rates. Batch kinetic experiments were performed to investigate europium sorption to four aluminum (hydr)oxide minerals as a function of time (10–120 min), mineral concentration (0.5–50 m² L⁻¹), pH (5–7), and europium concentration (10⁻⁸–10⁻⁶ M). Linear and non-linear pseudo-first and pseudo-second order rate equations were used to fit the data. The overall reaction rates and reaction orders with respect to proton concentration, mineral concentration, and europium concentration were determined, leading to a governing rate law for each mineral system. Europium sorption is characterized by a two-step reaction with a fast initial sorption step followed by a slower sorption or aging process. The pseudo-second order equations resulted in better model fits of the data. Using the non-linear pseudo-second order rate constants, it was observed that the reaction orders for each mineral system were similar but resulted in different overall reaction rates following the trend bayerite ∼ γ-Al₂O₃ > corundum > gibbsite. However, the calculated reaction orders are similar to those previously reported for plutonium(IV/V) interactions with iron (oxyhydr)oxide minerals, suggesting that these binary systems share similar elementary reactions.

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A composite position independent monitor of reactor fuel irradiation using Pu, Cs, and Ba isotope ratios

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 195

Author(s): Martin Robel, Brett Isselhardt, Erick Ramon, Anna Hayes, Amy Gaffney, Lars Borg, Rachel Lindvall, Anna Erickson, Kevin Carney, Terry Battisti, Andrew Conant, Brian Ade, Holly Trellue, Charles Weber

Abstract

When post-irradiation materials from the nuclear fuel cycle are released to the environment, certain isotopes of actinides and fission products carry signatures of irradiation history that can potentially aid a nuclear forensic investigation into the material's provenance. In this study, combinations of Pu, Cs, and Ba isotope ratios that produce position (in the reactor core) independent monitors of irradiation history in spent light water reactor fuel are identified and explored. These position independent monitors (PIMs) are modeled for various irradiation scenarios using automated depletion codes as well as ordinary differential equation solutions to approximate nuclear physics models. Experimental validation was performed using irradiated low enriched uranium oxide fuel from a light water reactor, which was sampled at 8 axial positions from a single rod. Plutonium, barium and cesium were chemically separated and isotope ratio measurements of the separated solutions were made by quadrupole and multi-collector inductively coupled mass spectrometry (Cs and Pu, respectively) and thermal ionization mass spectrometry (Ba). The effect of axial variations in neutron fluence and energy spectrum are evident in the measured isotope ratios. Two versions of a combined Pu and Cs based PIM are developed. A linear PIM model, which can be used to solve for irradiation time is found to work well for natural U fuel with <10% ²⁴⁰Pu and known or short cooling times. A non-linear PIM model, which cannot be solved explicitly for irradiation time without additional information, can nonetheless still group samples by irradiation history, including high burnup LEU fuel with unknown cooling time. ¹³⁷Ba/¹³⁸Ba is also observed to act as a position independent monitor; it is nearly single valued across the sampled fuel rod, indicating that samples sharing an irradiation history (same irradiation time and cooling time) in a reactor despite experiencing different neutron fluxes will have a common ¹³⁷Ba/¹³⁸Ba ratio. Modeling of this Ba PIM shows it increases monotonically with irradiation and cooling time, and a confirmatory first order analytical solution is also presented.

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Antioxidant response of Arabidopsis thaliana seedlings to oxidative stress induced by carbon ion beams irradiation

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 195

Author(s): Lin Wang, Ruonan Ma, Yue Yin, Zhen Jiao

Abstract

Due to the fact that carbon ion beams irradiation as an important type of ionizing radiation can potentially cause oxidative stress in plants, it is significant to evaluate the antioxidant response of plants to carbon ion beams radiation. Therefore, the objective of this study is to investigate the effects of carbon ion beams irradiation on oxidative stress induced by reactive oxygen species (ROS) and antioxidant response in Arabidopsis thaliana seedlings by irradiating the dry seeds at various doses of carbon ion beams (0, 50, 100, 150 and 200 Gy) and measuring the plant growth parameters, ROS and malondialdehyde (MDA) levels, activities of antioxidant systems and antioxidant-related gene expression. The results showed that 50-Gy carbon ion beam irradiation exhibited stimulatory effects on germination index, root length and fresh weight in Arabidopsis seedlings, while high-dose irradiation (100–200 Gy) inhibited plant growth. Moreover, the production rate of superoxide anion radical, hydroxyl radical generation activity, hydrogen peroxide and MDA contents in Arabidopsis seedlings were obviously increased with the irradiation dose. Additionally, the antioxidant enzyme activities (superoxide dismutase, catalase and peroxidase) and non-enzymatic antioxidant contents (ascorbate and glutathione) in 50-Gy irradiated seedlings were apparently higher than control. Notably, transcriptional analysis displayed that 50-Gy carbon ion beams irradiation could enhance the expression of antioxidant-related genes in Arabidopsis seedlings. These results suggest that the improved activities of antioxidant systems induced by moderate ROS levels play important roles in growth promotion of Arabidopsis seedlings caused by low-dose carbon ion beams irradiation.

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Six-year monitoring study of radiocesium transfer in forest environments following the Fukushima nuclear power plant accident

Publication date: Available online 18 September 2018

Source: Journal of Environmental Radioactivity

Author(s): Hiroaki Kato, Yuichi Onda, Zul Hilmi Saidin, Wataru Sakashita, Keigo Hisadome, Nicolas Loffredo

Abstract

The study investigated temporal changes in the ¹³⁷Cs concentrations in vegetal and hydrological samples collected from various forests in Yamakiya District, Kawamata Town of Fukushima prefecture over six years following the Fukushima Dai-ichi nuclear power plant accident. Cesium-137 was detected in all forest environmental samples. However, the concentration in most samples decreased exponentially with time. The ¹³⁷Cs concentrations in throughfall samples exhibited a double-exponential decreasing trend with time. Temporal changes in the ¹³⁷Cs concentration in vegetal samples and stemflow were approximated by using a single-exponential equation. A comparison of the decline coefficient for the latter observation period (>2 y since the accident) revealed that the declining trend of ¹³⁷Cs concentrations varied between foliage and the outer barks of the Japanese cedar and Japanese konara oak trees. The ¹³⁷Cs concentration in cedar needles decreased exponentially while that in konara oak leaves was constant over the last six years. Conversely, the declining trend of ¹³⁷Cs concentration in the outer bark of konara oak exceeded that of cedar. The results suggested that self-decontamination processes and internal recycling of ¹³⁷Cs varied among tree species and different tree parts. The results indicated that the leaching of ¹³⁷Cs in the throughfall in Japanese cedar was dependent on the ¹³⁷Cs concentration in needles. However, a comparison of ¹³⁷Cs concentrations in vegetal and hydrological samples from each sampling year showed that the leaching rate decreased with time. Conversely, the ¹³⁷Cs concentrations in the stemflow were independent of the concentrations in the outer bark. The declining trend of ¹³⁷Cs concentrations in litterfall (λ: 0.31–0.33 y⁻¹) was similar to that of the mean of new/old needles (λ: 0.26–0.33 y⁻¹) for cedar stands. With respect to the hydrological components, the ¹³⁷Cs concentration in the stemflow (λ: 0.32–0.33 y⁻¹) decreased at a slightly slower rate than that in the throughfall (λ: 0.36–0.54 y⁻¹) for the cedar forest. The decline coefficients of ¹³⁷Cs concentration in the aforementioned types of hydrological components slightly exceeded that for the vegetal samples. The results suggest that monitoring of ¹³⁷Cs concentrations in hydrological components and vegetal samples can aid in further understanding the leaching mechanisms of ¹³⁷Cs from trees to rainwater.

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Simulation study of the effects of buildings, trees and paved surfaces on ambient dose equivalent rates outdoors at three suburban sites near Fukushima Dai-ichi

Publication date: Available online 17 September 2018

Source: Journal of Environmental Radioactivity

Author(s): Minsik Kim, Alex Malins, Kazuya Yoshimura, Kazuyuki Sakuma, Hiroshi Kurikami, Akihiro Kitamura, Masahiko Machida, Yukihiro Hasegawa, Hideaki Yanagi

Abstract

The influence of buildings, trees and paved surfaces on outdoor ambient dose equivalent rates (H˙∗(10)) in suburban areas near to the Fukushima Dai-ichi Nuclear Power Plant (FDNPP) was investigated with Monte Carlo simulations. Simulation models of three un-decontaminated sites in Okuma and Tomioka were created with representations of individual buildings, trees and roads created using geographic information system (GIS) data. The ¹³⁴Cs and ¹³⁷Cs radioactivity distribution within each model was set using in-situ gamma spectroscopy measurements from December 2014 and literature values for the relative radioactive cesium concentration on paved surfaces, unpaved land, building outer surfaces, forest litter and soil layers, and different tree compartments. Reasonable correlation was obtained between the simulations and measurements for H˙∗(10) across the sites taken in January 2015. The effect of buildings and trees on H˙∗(10) was investigated by performing simulations removing these objects, and their associated ¹³⁴Cs and ¹³⁷Cs inventory, from the models. H˙∗(10) were on average 5.0% higher in the simulations without buildings and trees, even though the total ¹³⁴Cs and ¹³⁷Cs inventory within each model was slightly lower. The simulations without buildings and trees were then modified to include ¹³⁴Cs and ¹³⁷Cs in the ground beneath locations where buildings exist in reality, and the inventory of paved surfaces modelled as if they had high retention of ¹³⁴Cs and ¹³⁷Cs fallout like soil areas. H˙∗(10) increased more markedly in these cases than when considering the shielding effect of buildings and trees alone. These results help clarify the magnitude of the effect of buildings, trees and paved surfaces on H˙∗(10) at the un-decontaminated sites within Fukushima Prefecture.

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Contents

Publication date: October 2018

Source: Clinical Neurophysiology, Volume 129, Issue 10

Author(s):

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Editorial Board

Publication date: October 2018

Source: Clinical Neurophysiology, Volume 129, Issue 10

Author(s):

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Revisiting Panda 100, the first archaeological chimpanzee nut-cracking site

Publication date: Available online 18 September 2018

Source: Journal of Human Evolution

Author(s): T. Proffitt, M. Haslam, J.F. Mercader, C. Boesch, L.V. Luncz

Abstract

Archaeological recovery of chimpanzee Panda oleosa nut cracking tools at the Panda 100 (P100) and Noulo sites in the Taï Forest, Côte d'Ivoire, showed that this behavior is over 4000 years old, making it the oldest known evidence of non-human tool use. In 2002, the first report on the lithic material from P100 was directly compared to early hominin stone tools, highlighting their similarities and proposing the name 'Pandan' for the chimpanzee material. Here we present an expanded and comprehensive technological, microscopic, and refit analysis of the late twentieth century lithic assemblage from P100. Our re-analysis provides new data and perspectives on the applicability of chimpanzee nut cracking tools to our understanding of the percussive behaviors of early hominins. We identify several new refit sets, including the longest (>17 m) hammerstone transport seen in the chimpanzee archaeological record. We provide detailed evidence of the fragmentation sequences of Panda nut hammerstones, and characterize the percussive damage on fragmented material from P100. Finally, we emphasize that the chimpanzee lithic archaeological record is dynamic, with the preservation of actual hammerstones being rare, and the preservation of small broken pieces more common. P100 – the first archaeological chimpanzee nut cracking lithic assemblage – provides a valuable comparative sample by which to identify past chimpanzee behavior elsewhere, as well as similar hominin percussive behavior in the Early Stone Age.

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Understanding Conflict Management Styles in Anesthesiology Residents

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios. METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%–99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores. RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1–Q3 = 27–87) and accommodating (69th, Q1–Q3 = 30–94) styles, and the lowest scores for competing (32nd, Q1–Q3 = 10–57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1–Q3 = 14–16; counterpart: 16, Q1–Q3 = 15–16) and problem solving (self: 17, Q1–Q3 = 16–18; counterpart: 16, Q1–Q3 = 16–17), and lower scores for forcing (self: 13, Q1–Q3 = 10–15; counterpart: 13, Q1–Q3 = 13–15) and avoiding (self: 14, Q1–Q3 = 10–16; counterpart: 14.5, Q1–Q3 = 11–16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05). CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one's dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations.

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Preventing Adverse Events in Cataract Surgery

No abstract available

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Maternal Hemorrhage—Regional Versus General Anesthesia: Does It Really Matter?

No abstract available

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Beyond the “E” in OSCE

No abstract available

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Optimal Organization of Acute Pain Services: At the Confluence of Semantics, Logistics, and Economics

No abstract available

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Natural Born Survivors?

No abstract available

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Sevoflurane Protects Hepatocytes From Ischemic Injury by Reducing Reactive Oxygen Species Signaling of Hepatic Stellate Cells: Translational Findings Based on a Clinical Trial

BACKGROUND: Randomized controlled trials (RCTs) data demonstrate that sevoflurane postconditioning improves clinical outcomes of liver resection with inflow occlusion, presumably due to hepatocyte protection from ischemic injury. However, mechanisms remain unclear. This study examines liver biopsy samples obtained in an RCT of sevoflurane postconditioning to test the hypothesis that sevoflurane attenuates hepatocyte apoptosis. METHODS: Messenger ribonucleic acid (mRNA) of pro- and antiapoptotic regulators Bax and B-cell lymphoma 2 (Bcl2) was examined in hepatic biopsies obtained during the RCT. Hepatic stellate cells (HSCs) and hepatocytes were exposed to hypoxia/reoxygenation (H/R) in vitro to evaluate the effect of sevoflurane postconditioning on apoptosis. The role of HSC as a potential apoptosis trigger in hepatocytes through the production of reactive oxygen species induced by H/R was explored by transferring supernatants from H/R-exposed HSC to hepatocytes as target cells. RESULTS: In patients of the RCT, the Bax/Bcl2 mRNA ratio in liver tissue was markedly decreased in the sevoflurane arm (25% ± 21% reduction; P = .001). In vitro, H/R increased reactive oxygen species production in HSC by 33% ± 16% (P = .025), while it was abolished in the presence of sevoflurane (P

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Target-Controlled Infusion: Not a One-Sized-Fits-All Answer to Drug Administration

No abstract available

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I Contain Multitudes: The Microbes Within Us and a Grander View of Life

No abstract available

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Subspecialization … and Clinical Guidelines

No abstract available

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Special Cardiac Arrest Situations in the Perioperative Period

No abstract available

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An Intellectual Framework for Drug Administration Methods in Anesthesia: Three Practice Domains

No abstract available

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Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0–0.0009952).

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Identifying the Best Cut-Point for a Biomarker, or Not

No abstract available

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A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before–after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0–3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0–6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0–3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6–106.3 mg MEQs) versus 144.0 mg MEQs (68.9–238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1–124.0; P 50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

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To Thine Own Self Be True: A First Step Toward Learning How Anesthesiologists Deal With Adversity in the Operating Room

No abstract available

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Propensity Score Methods: Theory and Practice for Anesthesia Research

Observational data are often readily available or less costly to obtain than conducting a randomized controlled trial. With observational data, investigators may statistically evaluate the relationship between a treatment or therapy and outcomes. However, inherent in observational data is the potential for confounding arising from the nonrandom assignment of treatment. In this statistical grand rounds, we describe the use of propensity score methods (ie, using the probability of receiving treatment given covariates) to reduce bias due to measured confounders in anesthesia and perioperative medicine research. We provide a description of the theory and background appropriate for the anesthesia researcher and describe statistical assumptions that should be assessed in the course of a research study using the propensity score. We further describe 2 propensity score methods for evaluating the association of treatment or therapy with outcomes, propensity score matching and inverse probability of treatment weighting, and compare to covariate-adjusted regression analysis. We distinguish several estimators of treatment effect available with propensity score methods, including the average treatment effect, the average treatment effect for the treated, and average treatment effect for the controls or untreated, and compare to the conditional treatment effect in covariate-adjusted regression. We highlight the relative advantages of the various methods and estimators, describe analysis assumptions and how to critically evaluate them, and demonstrate methods in an analysis of thoracic epidural analgesia and new-onset atrial arrhythmias after pulmonary resection.

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Poor Sleep, Worse Outcomes: Obstructive Sleep Apnea and Perioperative Care

No abstract available

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Opioids for Acute Pain Management in Patients With Obstructive Sleep Apnea: A Systematic Review

The intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with obstructive sleep apnea (OSA). The association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population. The aims of this systematic review were to summarize current evidence with respect to perioperative OIRD, changes in sleep-disordered breathing, and alterations in pain and opioid sensitivity in patients with OSA. A systematic literature search of studies published between 1946 and October 2017 was performed utilizing the following databases: Medline, ePub Ahead of Print/Medline In-process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed—NOT-Medline and ClinicalTrials.Gov. Of 4321 initial studies, 40 met the inclusion criteria. The Oxford level of evidence was assessed. Overall, high-quality evidence on the comparative impact of acute opioid analgesia in OSA versus non-OSA patients is lacking. The current body of evidence is burdened by significant limitations including risk of bias and large heterogeneity among studies with regard to OSA severity, perioperative settings, outcome definitions, and the presence or absence of various perioperative drivers. These factors complicate an accurate interpretation and robust analysis of the true complication risk. Nevertheless, there is some consistency among studies with regard to a detrimental effect of opioids in the presence of OSA. Notably, the initial 24 hours after opioid administration appear to be most critical with regard to life-threatening OIRD. Further, OSA-related increased pain perception and enhanced opioid sensitivity could predispose patients with OSA to a higher risk for OIRD without overdosing. While high-quality evidence is needed, retrospective analyses indicate that critical, life-threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.

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Society Guidelines Infographic: SASM Guideline on Intraoperative Management of OSA

No abstract available

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Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

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