Δευτέρα 15 Οκτωβρίου 2018

The relationship between seizure in electroconvulsive therapy and pupillary response using an automated pupilometer

Abstract

Objectives

Seizure duration and morphology, postictal suppression, and sympathetic nervous system activation are all recommended as assessments of adequate seizure in electroconvulsive therapy (ECT). However, blood pressure and heart rate are not typically assessed as part of sympathetic nervous system activation because of the administration of anesthetic or cardiovascular agents during ECT. Although the pupils are known to reflect to the activity of autonomic nervous system and the degree of brain damage, previous studies have not examined the relationship between seizure of electroconvulsive therapy and pupillary response.

Methods

We conducted 98 sessions of ECT with 13 patients, divided into two groups according to seizure quality: (1) adequate or (2) inadequate. Pupillary light reflex [% constriction = (maximum resting pupil size {MAX} − minimum pupil size after light stimulation)/MAX × 100] was measured using a portable infrared quantitative pupilometer before anesthesia induction and immediately after electrical stimulation.

Results

The number regarded as adequate was 67 times and as inadequate was 31 times. Maximum pupil size at the control and immediately after electrical stimulation was similar between the adequate and inadequate groups. Pupillary light reflex was similar at the control between both groups, but significantly smaller immediately after stimulation in the adequate group (2.5 ± 3.6%) compared with the inadequate group (10.6 ± 11.5%). Receiver operating characteristic curve analysis revealed that pupillary light reflex (> 5.5%) predicted adequate seizure.

Conclusions

The current findings suggest that pupillary constriction immediately after ECT could provide a helpful method for assessing the efficacy of ECT.



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Do High Levels of Antibodies to the IGF-1 Receptor Ameliorate Orbitopathy in Some Patients with Graves’ Disease?

Clinical Thyroidology, Volume 30, Issue 10, Page 464-467, October 2018.


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Thyroid Cancers with Nodules of Indeterminate Cytology Have a Specific Distribution of Histologic Types

Clinical Thyroidology, Volume 30, Issue 10, Page 480-484, October 2018.


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Persistent Disease is 3.5-Fold More Common Than Recurrent Disease After Initial Therapy for Differentiated Thyroid Cancer

Clinical Thyroidology, Volume 30, Issue 10, Page 447-449, October 2018.


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Integrated Cervical Ultrasound by the Same Specialist Who Performed Parathyroid Scintigraphy Improves Parathyroid Adenoma Detection

Clinical Thyroidology, Volume 30, Issue 10, Page 471-475, October 2018.


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Male Sex Is Associated with Increased Mortality from Papillary Thyroid Cancers with BRAF V600E Mutation

Clinical Thyroidology, Volume 30, Issue 10, Page 450-452, October 2018.


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Radioactive Iodine Therapy Is Associated with Clonal Hematopoiesis, a Precursor for Hematologic Malignancies

Clinical Thyroidology, Volume 30, Issue 10, Page 443-446, October 2018.


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Varying Levothyroxine Doses Within or Near the Reference Range Does Not Affect Energy Expenditure or Body Composition

Clinical Thyroidology, Volume 30, Issue 10, Page 453-455, October 2018.


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Thermal Inkjet Printing of Combination Synthetic LT3+LT4 May Be a Novel Method for Personalizing the Treatment of Hypothyroidism in the Future

Clinical Thyroidology, Volume 30, Issue 10, Page 468-470, October 2018.


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Levothyroxine Replacement for Primary Hypothyroidism Can Be Given Between Meals with Similar Effectiveness at Various Times of the Day

Clinical Thyroidology, Volume 30, Issue 10, Page 456-459, October 2018.


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Benign Nodules Show Little Change in Sonographic Appearance over Time

Clinical Thyroidology, Volume 30, Issue 10, Page 476-479, October 2018.


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Low Maternal Iodine Availability During Pregnancy Is Associated with Poorer Child Language Development

Clinical Thyroidology, Volume 30, Issue 10, Page 460-463, October 2018.


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Paul Walfish—In Memoriam

Clinical Thyroidology, Volume 30, Issue 10, Page 485-485, October 2018.


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Regulation of Root Angle and Gravitropism

Regulation of plant root angle is critical for obtaining nutrients and water and is an important trait for plant breeding. A plant's final, long-term root angle is the net result of a complex series of decisions made by a root tip in response to changes in nutrient availability, impediments, the gravity vector and other stimuli. When a root tip is displaced from the gravity vector, the short-term process of gravitropism results in rapid reorientation of the root toward the vertical. Here, we explore both short- and long-term regulation of root growth angle, using natural variation in tomato to identify shared and separate genetic features of the two responses. Mapping of expression quantitative trait loci mapping and leveraging natural variation between and within species including Arabidopsis suggest a role for PURPLE ACID PHOSPHATASE 27 and CELL DIVISION CYCLE 73 in determining root angle.



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P160 Nutritional status and gastrointestinal disorders in pediatric patients with Rett syndrome



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P109 Are symptoms really relevant in ESPGHAN 2012 criteria for Celiac disease diagnosis?



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P101 Dietary therapy for pediatric eosinophilic esophagitis: a retrospective chart review



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P168 Iatrogenic protein malnutrition: acrodermatitis, hypoalbuminemia, pancytopenia in a child with newly diagnosed propionic acidemia



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P152 Therapeutic efficacy of ginger on vomiting in children with acute gastroenteritis



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P105 The growth in children with Celiac disease after the gluten free diet: a comparison between Italian and American children



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P172 Third generation lipid emulsions with fish oil in intestinal failure patients on long term parenteral nutrition: do they help doing better?



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P164 A personalized and non-automated mobile-based intervention in the management of paediatric obesity: preliminary results of a pilot study (PediaFit)



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P156 Gastrointestinal disorders in children with spinal muscular atrophy type 1 after percutaneous endoscopic gastrostomy placement: comparison between homemade and commercial formula



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P099 Screening of Celiac disease: adherence to the ESPGHAN guidelines



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P103 Longitudinal analysis of intestinal biopsies from children with potential Coeliac disease: immunohistochemical markers predicting evolution to villous atrophy



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P107 Proteomics in the age of precautionary labeling: a translational approach to food allergy



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P174 Cognitive survey on food habits in pre-school age: some general considerations



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P170 Ketogenic diet: new applications beyond epilepsy



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P166 Gastro-esophageal reflux in infants: a cross-over evaluation of effectiveness of magnesium alginate vs anti-regurgitation formula



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P162 The colon as an energy salvage organ for children with short bowel syndrome



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P158 Mediterranean diet: let's give the scores! A pilot study



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P154 Analysis of the pediatric home enteral nutrition in Campania region: implementation rates and observed trends during the past 10 years



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P150 Nutrition and gastroenterological pediatric outpatient clinic for children with rare disease and disability: report of 20 months of activity



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DUODENAL TUMOR RISK IN LYNCH SYNDROME

Lynch syndrome (LS) is associated with an increased risk of small bowel tumors but routine screening is not recommended in international guidelines. The aim of our study was to determinate the prevalence of duodenal tumors in a French cohort of LS patients.

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Why all EMS providers should be pre-planning hospital evacuations

Pre-plan, build an equipment stock and consider future ambulance and specialty vehicle design to serve as an evacuation function in your community

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Why all EMS providers should be pre-planning hospital evacuations

Pre-plan, build an equipment stock and consider future ambulance and specialty vehicle design to serve as an evacuation function in your community

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Base editing: precision chemistry on the genome and transcriptome of living cells

Base editing: precision chemistry on the genome and transcriptome of living cells

Base editing: precision chemistry on the genome and transcriptome of living cells, Published online: 15 October 2018; doi:10.1038/s41576-018-0059-1

Genome editing through direct editing of bases holds promise for achieving precise genomic changes at single-nucleotide resolution while minimizing the occurrence of potentially mutagenic double-strand DNA breaks. In this Review, Rees and Liu provide a comprehensive account of the state of the art of base editing of DNA and RNA, including the progressive improvements to methodologies, understanding and avoiding unintended edits, cellular and organismal delivery of editing reagents and diverse applications in research and therapeutic settings.

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Base editing: precision chemistry on the genome and transcriptome of living cells



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Tracheal Intubation: The Proof is in the Bevel.

Related Articles

Tracheal Intubation: The Proof is in the Bevel.

J Emerg Med. 2018 Oct 10;:

Authors: Ho AM, Ho AK, Mizubuti GB

Abstract
BACKGROUND: Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management.
DISCUSSION: The ETT bevel orientation is the main determinant of which mainstem bronchus the ETT enters when advanced too distally, despite a common belief that attributes a higher incidence of right mainstem bronchial intubation to the straighter angle sustained by the right mainstem bronchus. Likewise, a bougie- or fiberscope-assisted tracheal intubation can be impeded by the ETT tip hooking onto laryngeal structures; a 90-degree counterclockwise turn of the ETT (such that the bevel is facing posteriorly) prior to advancing it toward the larynx produces a first-pass success rate of 100%. Similarly, a posterior-facing bevel is believed to improve the ease of passage through the back of the nasal cavity when performing nasotracheal intubation. If resistance is met after the ETT tip has reached the laryngeal vicinity, further counterclockwise rotation may change the plane and incident angle of the ETT tip, facilitating passage through the vocal cords. Clockwise twisting of the ETT reduces the incident angle in the sagittal plane, thereby facilitating videolaryngoscopy-assisted tracheal intubation. Finally, a posterior-facing ETT bevel is the least likely to intubate a tracheoesophageal fistula.
CONCLUSIONS: Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.

PMID: 30316622 [PubMed - as supplied by publisher]



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Diet-quality scores and the risk of symptomatic gallstone disease: A prospective cohort study of male US health professionals

International Journal of Epidemiology

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Determination of the thoron emanation coefficient using a powder sandwich technique

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 195

Author(s): K. Danyłec, J. Mazur, K. Kozak, D. Grządziel

Abstract

Thoron (220 Rn) is a natural radioactive gas, tasteless, odourless, colourless, undetectable without proper equipment. This gas is carcinogenic, just like radon (222 Rn) but due to the short half-life (55.6s) and a small amount in the environment, its share in the absorbed radiation dose is often neglected. However, in areas rich in thorium (232Th), the radiation dose from the thoron can be much larger and quite significant. The problem is to measure the concentration of the thoron due to its short decay time as well as the fact that it is alpha-emitting as radon. An even greater challenge is to determine the emanation coefficient for the thoron.

The method used in this experiment was developed by S.D. Kanse based on the work of D.J Greeman and adapted to the equipment used in Laboratory of Radiometric Expertise IFJ PAN. In the technique used to determine the thoron emanation coefficient, a closed loop system is used in which thoron is pushed out by means of a flow system from the sample and measured by a AlphaGuad DF2000 detector that is adapted to determine concentration of this gas. A sample of the material is placed between 2 filters in the geometry of the sandwich. This arrangement ensures that the thickness of the powder sample is significantly less than the length of the thoron diffusion, thus avoiding significant loss of the thoron due to intergranular absorption and facilitates the complete removal of this gas escaping from the powder. Using this technique, it is important to determine the concentration of 226Ra and the 232Th, since for the AlphaGuard detector, the ratio between thoron and radon should not exceed 5:1 for proper determination of the thoron concentration. Measurements of 226Ra and 232Th activity were carried out using gamma spectroscopy (HPGe detector). It was examined how the type of filter and grain size of sample affects the obtained results.



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Electrophysiological properties of Ia excitation and recurrent inhibition in cat abdominal motoneurons

Abstract

Ia excitation and recurrent inhibition are basic neuronal circuits in motor control in hind limb. Renshaw cells receive synaptic inputs from axon collaterals of motoneurons and inhibit motoneurons and Ia inhibitory interneurons. It is important to know properties of Ia excitation and recurrent inhibition of trunk muscle such as abdominal muscles. The abdominal muscles have many roles and change those roles for different kind of functions. Intracellular recordings were obtained from the abdominal motoneurons of the upper lumbar segments in cats anesthetized. First, dorsal roots were left intact, and sensory and motor axons were electrically stimulated. Ia excitatory post-synaptic potentials were elicited in five of eight motoneurons at same segment stimulated. Second, dorsal roots were sectioned, and motor axons were electrically stimulated. Recurrent inhibitory post-synaptic potentials were elicited in one of 11 abdominal motoneurons. Renshaw cells extracellularly fired high-frequency bursts at short latency and at same segment stimulated.



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Heated humidified high-flow nasal oxygen prevents intraoperative body temperature decrease in non-intubated thoracoscopy

Abstract

Purpose

In patients receiving non-intubated video-assisted thoracic surgery (NIVATS), transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has been applied instead of oxygen mask for better oxygenation. However, the THRIVE effects on intraoperative temperature decrease have not been investigated.

Methods

Pre- and postoperative temperatures, measured by an infrared tympanic ear thermometer, taken before sending patients to the operation room and immediately upon their arrival in the postoperative anesthesia unit, were collected from medical records of patients who received NIVATS either with oxygen mask or THRIVE. Intraoperative temperature decrease, calculated by preoperative temperature minus postoperative temperature, was compared between different groups. Multiple linear regression analysis was performed to determine factors associated with intraoperative temperature decrease.

Results

Records of 256 adult patients with forced-air warming were retrospectively analyzed. 172 patients of them received THRIVE and 84 patients received oxygen mask. Preoperative temperatures were comparable between groups (THRIVE: 36.25 ± 0.46 °C; mask: 36.30 ± 0.39 °C, p = 0.43). Postoperative temperatures were significantly higher in patients using THRIVE than those using oxygen masks (36.05 ± 0.59 vs 35.87 ± 0.62 °C, p = 0.025). Significantly less intraoperative temperature decrease was shown in THRIVE group (THRIVE: 0.20 ± 0.69 °C; mask: 0.43 ± 0.69 °C, p = 0.04). According to the multiple linear regression analysis, significant temperature decrease was associated with the advanced age (βage = 0.01) but not the anesthetic duration. Using THRIVE was correlated with significantly less body temperature decrease (βTRIVE = − 0.24).

Conclusions

THRIVE effectively prevents intraoperative temperature decrease during NIVATS, especially in old patients.



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Electronic Audit and Feedback With Positive Rewards Improve Anesthesia Provider Compliance With a Barcode-Based Drug Safety System

BACKGROUND: We implemented a previously described barcode-based drug safety system in all of our anesthetizing locations. Providers were instructed to scan the barcode on syringes using our Anesthesia Information Management System before drug administration, but the rate of provider adherence was low. We studied an implementation intervention intended to increase the rate of scanning. METHODS: Using our Anesthesia Information Management System and Smart Anesthesia Manager software, we quantified syringe drug administrations by anesthesia providers with and without barcode scanning. We use an anesthesia team model in which an attending anesthesiologist is paired with a certified registered nurse anesthetist (CRNA) or a resident. Our system identified the pair of providers associated with a particular drug administration, but did not distinguish which providers actually administered the drug. Therefore, the rate of barcode scanning for a particular case was assigned to both providers equally. A baseline rate of scanning was established over a period of 17 months. An audit and feedback intervention was then performed that consisted of monthly performance reports sent by email to individual providers along with coffee gift card awards for top performers. The coffee gift cards were awarded in only the first 2 months of the intervention, while the email performance reports continued on a monthly basis. The coffee card awards were made public. The monthly emails reported the individual provider's rank order of performance relative to other providers, but was otherwise anonymous. The baseline rate of scanning was compared to the rate of scanning after the intervention for a period of 7 months. RESULTS: From November 2014 to March 2017, we accumulated 60,197 cases performed by 88 attending anesthesiologists, 65 CRNAs, and 148 residents. The total number of syringe drug administrations was 653,355. Average scanning performance improved from 8.7% of syringe barcodes scanned during the baseline period from November 2014 to February 2016 to 64.4% scanned during the period September 2016 to March 2017 (P

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Concepts for the Development of Anesthesia-Related Patient Decision Aids

Patient decision aids are educational tools used by health care providers to assist patients in choosing their treatment and care. The use of anesthesia-related patient decision aids can help practitioners provide patient-centered care by facilitating shared decision-making. The benefits of these aids have been well documented, yet a structured approach for developing patient decision aids in anesthesia has not been well established. Educating patients on various anesthesia-related options is paramount in their decision-making, yet accessible and validated resources are limited. In addition, many limitations exist with current patient decision aids that must be addressed. We have reviewed multiple processes for developing decision aids and have suggested a structured approach to their creation. We address the common limitations of current patient decision aids and provide improvements to the developmental process. Improvements include increasing patient input during development, thoroughly evaluating data included in the aids, and integrating a cyclic review of the aids before and after their use. Using the provided developmental process and checklist, anesthesia providers can create evidence-based patient decision aids in a standardized manner. It is important to evaluate decision aids and measure their decision quality, or patient-centeredness, to further improve them and maximize their effectiveness. Moving forward, development of proper metrics for patient participation and decision quality are required. Accepted for publication July 30, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis St CWN L1, Boston, MA 02115. Address e-mail to rurman@bwh.harvard.edu. © 2018 International Anesthesia Research Society

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Attenuation of Unevoked Mechanical and Cold Pain Hypersensitivities Associated With Experimental Neuropathy in Mice by Angiotensin II Type-2 Receptor Antagonism

Recent findings from a phase II clinical trial showed analgesic effects of an angiotensin II type-2 receptor (AT2R) antagonist in postherpetic neuralgia patients. This study aimed to investigate whether AT2R antagonism could provide effective analgesia in voluntary measures of unevoked/ongoing pain-like behaviors in mice with experimental neuropathy. Mice were subjected to spared nerve injury to induce neuropathy and tested in 2 operant behavioral tests to measure ongoing mechanical and cold pain hypersensitivities. Systemic administration of an AT2R antagonist provided effective analgesia in these behavioral measures of mechanical and cold pain in spared nerve injury mice, suggesting its effectiveness in neuropathic pain. Accepted for publication September 6, 2018. Funding: This study was supported by a pilot and feasibility grant from the Washington University Nutrition Obesity Research Center National Institutes of Health grant P30DK056341 (to A.J.S.) and by start-up funds from the Department of Anesthesiology, Washington University Pain Center and Washington University School of Medicine (to D.P.M.). 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 Andrew J. Shepherd, PhD, Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine in St Louis, St Louis, MO 63110. Address e-mail to a.shepherd@wustl.edu; and Durga P. Mohapatra, PhD, Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine in St Louis, St Louis, MO 63110. Address e-mail to d.p.mohapatra@wustl.edu. © 2018 International Anesthesia Research Society

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Hepatic Critical Care

No abstract available

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Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children

BACKGROUND: Because nausea is difficult to evaluate in children, vomiting is used as the objective clinical end point in managing pediatric postoperative nausea and vomiting and postdischarge nausea and vomiting (PDNV). The recently developed pictorial Baxter Retching Faces (BARF) scale has content, construct, and convergent validity in quantifying pediatric nausea intensity. We determined its clinical usefulness in assessing pediatric postoperative nausea and vomiting and PDNV, establishing the lowest age associated with consistently reliable use, the score at which patients identify a need for therapy, and the minimum clinically relevant change in scores, and examined its test–retest reliability. METHODS: We obtained subject ratings of the severity of their nausea using the BARF and visual analog scales in the preoperative, postanesthesia care unit and postdischarge phases. Changes in nausea were rated on a 5-point Likert scale, along with responses to queries of a need for rescue antiemetics at these time points. RESULTS: Children ≥6 years of age had a consistently reliable ability to use the BARF scale (132/132 [100%] vs 59/76 [77.6%] for children ≥6 and 6) in 13 (6.7%). Emesis occurred in 8 (4.1%). Rescue antiemetics were administered to 16 (8.3%), including 2 with severe emesis (≥3 episodes) but in only 2 of 11 (18.2%) with severe nausea without vomiting. PDNV was reported in 39 of the 99 who returned diaries (39.4%), with nausea in 34 (34.3%), severe nausea in 15 (15.2 %), and emesis in 16 (16.2%). CONCLUSIONS: The pictorial BARF scale is easy to use in the clinical setting by children ≥6 years of age, has a minimum clinically relevant difference of 1.47, with scores of 4 or higher associated with a patient-identified need for rescue antiemetics. Assessment of postoperative nausea by the BARF scale has shown that clinically significant nausea occurs frequently in children but is not always treated unless accompanied by vomiting. Accepted for publication September 5, 2018. Funding: This work was supported by internal funding from the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, TX, and Baylor College of Medicine, Houston, TX. The authors declare no conflicts of interest. Clinical trials registration: The trial was registered before patient enrollment at clinicaltrials.gov (NCT 02421952, principal investigator: S.A.B.; date of registration: April 21, 2015). Reprints will not be available from the authors. Address correspondence to Mehernoor F. Watcha, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin St, Suite A 3300, Houston, TX 77030. Address e-mail to mwatcha@gmail.com. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Prospective, Randomized Comparison of the i-gel and the Self-Pressurized air-Q Intubating Laryngeal Airway in Elderly Anesthetized Patients

BACKGROUND: Age-related changes in upper airway anatomy may affect the overall performance of supraglottic airways significantly. The clinical performance of the i-gel and the self-pressurized air-Q intubating laryngeal airways with noninflatable cuffs for elderly populations remains unknown, unlike in children. Thus, we performed a prospective, randomized comparison of these 2 supraglottic airways in elderly patients undergoing general anesthesia. METHODS: We recruited 100 patients, 65–90 years of age, who were scheduled for elective surgery under general anesthesia with muscle relaxation. The enrolled patients were allocated to the i-gel or self-pressurized air-Q group. We assessed oropharyngeal leak pressure as the primary outcome and fiberoptic view after placement and fixation of the airway and at 10 minutes after the initial assessment. The fiberoptic view was scored using a 5-point scale as follows: vocal cords not visible; vocal cords and anterior epiglottis visible, >50% visual obstruction of epiglottis to vocal cords; vocal cords and anterior epiglottis visible,

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Prohemostatic Activity of Factor X in Combination With Activated Factor VII in Dilutional Coagulopathy

BACKGROUND: Recombinant activated factor VII (rFVIIa) concentrate reduces allogeneic blood transfusions, but it may increase thromboembolic complications in complex cardiac surgery. The mixture of activated factor VII (FVIIa) and factor X (FX) (FVIIa/FX) (FVIIa:FX = 1:10) is a novel bypassing agent for hemophilia patients. We hypothesized that the combination of FX and FVIIa could improve thrombin generation (TG) in acquired multifactorial coagulation defects such as seen in cardiac surgery and conducted in vitro evaluation of FVIIa/FX in parallel with other coagulation factor concentrates using in vitro and in vivo diluted plasma samples. METHODS: Plasma samples were collected from 9 healthy volunteers and 12 cardiac surgical patients. We measured TG (Thrombinoscope) using in vitro 50% dilution plasma and in vivo dilution plasma after cardiopulmonary bypass, in parallel with thromboelastometry (ROTEM) and standard coagulation assays. In vitro additions of FVIIa/FX (0.35, 0.7, and 1.4 μg/mL, based on the FVIIa level), rFVIIa (1.4, 2.8, and 6.4 μg/mL), prothrombin complex concentrate (0.3 international unit), and 20% plasma replacement were evaluated. RESULTS: In diluted plasma, the addition of either FVIIa/FX or rFVIIa shortened the lag time and increased the peak TG, but the effect in lag time of FVIIa/FX at 0.35 μg/mL was more extensive than rFVIIa at 6.4 μg/mL. Prothrombin complex concentrate increased peak TG by increasing the prothrombin level but failed to shorten the lag time. No improvement in any of the TG variables was observed after 20% volume replacement with plasma. The addition of factor concentrates normalized prothrombin time/international normalized ratio but not with plasma replacement. In cardiac patients, similar patterns were observed on TG in post–cardiopulmonary bypass samples. FVIIa/FX shortened clotting time (CT) in a concentration-dependent manner on CT on thromboelastometry. Plasma replacement did not improve CT, but a combination of plasma and FVIIa/FX (0.35 μg/mL) more effectively shortened CT than FVIIa/FX alone. CONCLUSIONS: The combination of FVIIa and FX improved TG more efficiently than rFVIIa alone or plasma in dilutional coagulopathy models. The required FVIIa dose in FVIIa/FX was considerably lower than those reported during bypassing therapy in hemophilia patients (1.4–2.8 μg/mL). The combination of plasma could restore coagulation more efficiently compared to FVIIa/FX alone. Lesser FVIIa requirement to exert procoagulant activity may be favorable in terms of reducing systemic thromboembolic complications. Accepted for publication September 6, 2018. Funding: This work was supported by a grant-in-aid from the Japanese Society of Cardiothoracic Vascular Anesthesia. 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 Satoru Ogawa, MD, PhD, Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 8566, Japan. Address e-mail to s-ogawa@koto.kpu-m.ac.jp. © 2018 International Anesthesia Research Society

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Anesthesia in Enhanced Recovery Pathways for Hip and Knee Arthroplasty: Where Is the Evidence?

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Rapid Titration of Intravenous Treprostinil to Treat Severe Pulmonary Arterial Hypertension Postpartum: A Retrospective Observational Case Series Study

BACKGROUND: Pulmonary hypertension during pregnancy carries high mortality rate. The relatively long-acting, specific pulmonary vasodilator treprostinil has been used to improve survival in these parturients. Slow uptitration is performed in most cases, and rapid titration has not been reported in the postpartum period. METHODS: We retrospectively reviewed 17 pregnant patients with severe pulmonary arterial hypertension who were treated with intravenous treprostinil in our institution between 2014 and 2016. Patients' demographic characteristics, etiology, functional status, mode of delivery, anesthetic administration, medical therapy, echocardiographic and hemodynamic measurements, subsequent clinical course, and maternal–fetal outcomes were assessed. The a priori primary outcome is maternal mortality in this study. RESULTS: Rapid titration of intravenous treprostinil was initiated at 1.25 ng/kg/min and increased to effective dose of 10 ng/kg/min by 1.25–2.5 ng/kg/min every 3 hours. In the next 24 hours, we adjusted the dosage to a median maximum dose of 15 ng/kg/min (interquartile range, 15–20 ng/kg/min) over a median uptitration period of 34 hours (interquartile range, 24–41 hours) for 17 parturients with severe pulmonary hypertension. Treprostinil was weaned off by 0.50–1.25 ng/kg/min every 3 hours in 94.3 ± 42.4 hours. Fifteen patients survived to discharge, and only 2 patients died of pulmonary hypertensive crisis (maternal mortality rate, 11.7%). No treprostinil infusion-related postpartum complication was observed. CONCLUSIONS: Our experience suggested that rapid uptitration of intravenous treprostinil combined with oral sildenafil in the postpartum period may be a safe and effective approach for these very sick parturients with severe pulmonary hypertension. Accepted for publication August 23, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). T. Wang and J. Lu contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to Jiapeng Huang, MD, PhD, Department of Anesthesiology and Perioperative Medicine, University of Louisville, 200 Abraham Flexner Way, Louisville, KY 40202. Address e-mail to jiapenghuang@yahoo.com; and Jinglan Zhang, MD, Department of Surgical Intensive Care Medicine, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing AnZhen Hospital, Capital Medical University, No. 2 AnZhen Rd, Chaoyang District, Beijing 100029, People's Republic of China. Address e-mail to jinglanzhang2006@163.com. © 2018 International Anesthesia Research Society

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In Response

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Factor XI Deficiency: The Key Is Individualization

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Improving outcomes in ambulatory anesthesia by identifying high risk patients

Purpose of review Currently, outcome data in ambulatory anesthesia are somewhat limited though results are quite good with low reported rates of mortality and major morbidity. As patient comorbidities and surgical invasiveness increase, identifying those patients at higher risk will help to focus quality improvement energy and research where most effective. Better data collection and analysis will refine patient and procedure selection and improve outcomes going forward. Recent findings Complications after ambulatory surgery are associated with age, higher American Society of Anesthesiologists physical status, obstructive sleep apnea, and obesity. Frailty has recently been linked to increased complications in ambulatory surgery as well. Newer ambulatory procedures such as spine and total joint arthroplasty require careful patient selection. Summary Identifying high-risk ambulatory patients can help facilitate development of a strategy to triage these patients, optimize their conditions prior to surgery, and manage their care and disposition postoperatively. Inpatient surgery or admission should be considered for higher risk patients having high invasive surgery. Correspondence to Michael T. Walsh, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +507 284 9700; fax: +507 284 0120; e-mail: walsh.michael1@mayo.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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