Σάββατο, 17 Νοεμβρίου 2018

pVAX1-A20 alleviates colitis in mice by promoting regulatory T cells

To investigate whether the intrarectal administration of the ubiquitin E3 ligase A20 (A20) attenuates intestinal inflammation and influences regulatory T cells in experimental colitis.

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Epidemiology of Primary Biliary Cholangitis in Italy: Evidence From a Real-world Database

Primary biliary cholangitis is an autoimmune disease affecting the interlobular bile ducts. Limited information is available on its epidemiology and treatment in Italy.

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FROM INDIVIDUAL TO POPULATION-BASED BENEFIT OF SPLIT LIVER TRANSPLANTATION



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Phase I/II trial of helical IMRT-based stereotactic body radiotherapy for hepatocellular carcinoma

To report the results of a phase I/II study of helical IMRT-based stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC).

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Salivary markers of hepato-metabolic comorbidities in pediatric obesity

The pediatric obesity epidemic calls for the noninvasive detection of individuals at higher risk of complications.

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pVAX1-A20 alleviates colitis in mice by promoting regulatory T cells

To investigate whether the intrarectal administration of the ubiquitin E3 ligase A20 (A20) attenuates intestinal inflammation and influences regulatory T cells in experimental colitis.

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Epidemiology of Primary Biliary Cholangitis in Italy: Evidence From a Real-world Database

Primary biliary cholangitis is an autoimmune disease affecting the interlobular bile ducts. Limited information is available on its epidemiology and treatment in Italy.

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FROM INDIVIDUAL TO POPULATION-BASED BENEFIT OF SPLIT LIVER TRANSPLANTATION



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Phase I/II trial of helical IMRT-based stereotactic body radiotherapy for hepatocellular carcinoma

To report the results of a phase I/II study of helical IMRT-based stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC).

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Salivary markers of hepato-metabolic comorbidities in pediatric obesity

The pediatric obesity epidemic calls for the noninvasive detection of individuals at higher risk of complications.

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The shear complexity of insulin‐stimulated vasodilation



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A Study of the dosage and duration for levobupivacaine infusion by the caudal‐epidural route in infants aged 3‐6 months

Abstract

Aim

To investigate total serum levobupivacaine concentrations after a caudal‐epidural loading dose followed by a maintenance infusion in infants aged 3‐6 months over 48 hours.

Background

The local anaesthetic, levobupivacaine, is the safer enantiomer of racemic bupivacaine. Present protocols for levobupivacaine are based on studies and pharmacokinetic modelling with racemic bupivacaine. This study will inform clinical practice in this age group and validate the pharmacokinetic model for levobupivacaine infusions in infants, aged 3‐6months.

Methods

The clinical trial was conducted in 8 infants aged 3‐6 months, undergoing bladder exstrophy repair. Pharmacokinetic modelling allowed optimisation of clinical sampling to measure total levobupivacaine and α1‐acid glycoprotein and prediction of the effect of α1‐acid glycoprotein on levobupivacaine plasma protein binding.

Results

The observed median total levobupivacaine serum concentration was 0.30 mg.L−1 (range: 0.20‐0.70 mg.L−1) at 1 hour after the loading dose of 2 mg.kg−1. The median total levobupivacaine concentration after 47 hours of infusion, at 0.2 mg.h−1.kg−1, was 1.21 mg.L−1 (0.07‐1.85 mg.L−1). Concentrations of α1‐acid glycoprotein were found to rise throughout the study period. Pharmacokinetic modelling suggested that unbound levobupivacaine quickly reached steady state at a concentration of approximately 0.03 mg.L−1.

Conclusion

This study examines the pharmacokinetics of levobupivacaine after a loading dose (given over 5 minutes) followed by a maintenance infusion in infants 3‐6 months. The study allows the development of a pharmacokinetic model, combining levobupivacaine and α1‐acid glycoprotein data. Modelling indicates that unbound levobupivacaine quickly reaches steady state once the infusion is started. Simulations suggest that it may be possible to continue the infusion beyond 48 hours.

This article is protected by copyright. All rights reserved.



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Predictive Factors for Adverse Outcomes in Pediatric Patients Undergoing Low Risk Skin and Soft Tissue Surgery: A Database Analysis of 6,730 Patients

Abstract

Background

There is a paucity of data regarding risk stratification of pediatric patients presenting for low‐risk skin and soft tissue surgery.

Aim

We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30‐day readmission in a cohort of children undergoing low‐risk skin and soft tissue surgery.

Methods

The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two‐year period. The primary outcome was a 30‐day postoperative complication composite. The secondary outcome was unplanned 30‐day readmission.

Results

The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound‐related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥ 3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30‐day readmission.

Conclusions

Pediatric patients with American Society of Anesthesiologists classification ≥ 3 and nutritional deficiency undergoing low‐risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30‐day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.

This article is protected by copyright. All rights reserved.



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Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off‐site anesthetizing locations in the Wake‐Up Safe Database

Abstract

Background

Anesthesia services are frequently provided outside of the traditional operating room environment for children. It is unclear if adverse events which occur in off‐site anesthetizing locations result in more severe outcomes compared to events in traditional operating rooms.

Aim

We used a multi‐institutional registry of pediatric patients to compare outcomes of perioperative adverse events between location types.

Methods

De‐identified data from 24 pediatric tertiary care hospitals participating in the Wake Up Safe registry during 2010‐2015 were analyzed. Peri‐procedural adverse events occurring in operating rooms or off‐site locations were included. The primary outcome was whether the adverse event was severe, defined as requiring escalation of care or resulting in temporary or significant harm. Multivariable logistic regression was used to compare location type (operating room vs. off‐site) and the likelihood of a severe outcome among reported events.

Results

There were 1,594 adverse events, of which 362 were associated with off‐site anesthetizing locations. In multivariable logistic regression, off‐site location was associated with greater odds of severe adverse event outcome (adjusted odds ratio, 1.31; 95% confidence interval: 1.01, 1.69; p=0.044). Comparing adverse events in cardiac catheterization suites to events in operating rooms confirmed higher odds of severe outcome in the former group (adjusted odds ratio = 1.48; 95% confidence interval: 1.05, 2.08; p=0.025) while this difference was not found for other off‐site locations.

Conclusion

Multivariable analysis of a large registry revealed a greater likelihood of severe outcome for adverse events occurring in cardiac catheterization suites (but not other out of the OR sites), compared to adverse events occurring in the operating room. Additional prospective studies are needed which better control for patient and environmental characteristics and their effect on severe outcomes after anesthesia.

This article is protected by copyright. All rights reserved.



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Support for Autonomy at School Predicts Immigrant Adolescents’ Psychological Well-being

Abstract

We investigated the relationship between teacher support at school intended to promote students' autonomy and immigrant adolescents' psychological well-being. A structural equation model was tested on 3130 immigrant adolescents who attended a representative sample of 654 Italian high schools. Gender, socioeconomic status, previous school achievement and immigrant generation were included in the analysis as control variables. Results showed that when teachers are perceived as adopting an approach that is supportive of autonomy, immigrant adolescents report significantly higher levels of psychological well-being. Gender appears to be the most relevant background factor, with girls being more at risk than boys as regards mental health. Overall, our findings suggest that interventions of enacted support by teachers at school that aim to foster students' autonomy would be an effective approach for protecting against mental illness in immigrant adolescents.



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Novel method for analyzing transport parameters in through-diffusion tests

Publication date: January 2019

Source: Journal of Environmental Radioactivity, Volume 196

Author(s): Bo-Tsen Wang, Chuan-Pin Lee, Ming-Chee Wu, Tsuey-Lin Tsai, Shih-Chin Tsai, Kuo-Chin Hsu

Abstract

Buffer materials such as bentonite are vital for absorbing radionuclide leakage and retarding migration from radioactive waste canisters. The diffusion coefficient and the retardation factor are the predominant properties controlling the diffusion-reaction process in a buffer material. Diffusion experiments combined with Crank's graphical method are a well-established process for determining asymptotic diffusion coefficients. However, the inaccuracy of the diffusion coefficient that results from the subjective judgement of the late-time linear part of the cumulative concentration data in Crank's graphical method will deteriorate the estimate of the retardation factor. A novel parameter identification process based on an iterative and analytical method (PIPIAM) is proposed here to obtain the diffusion coefficients and porosity of bentonite using concentration data. The results of PIPIAM and the graphical method are compared through an error analysis of concentration. The results show that PIPIAM outperforms the graphical method in terms of the error reduction of the concentration and the uncertainty decrease of the estimated parameters. The proposed method is thus a good alternative for acquiring transport parameters for use in safety assessments of nuclear waste repositories.



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Low and medium frequency auditory steady-state responses decrease during NREM sleep

Publication date: Available online 16 November 2018

Source: International Journal of Psychophysiology

Author(s): Urszula Górska, Marek Binder

Abstract

Previous research on auditory steady-state responses (ASSRs) demonstrated sensitivity of 40 Hz ASSR to changes in the level of arousal, both in sleep and in general anaesthesia. In this study we extended the range of stimulation frequencies, using also low and medium stimulation frequencies (4, 6, 8, 12, 20, 40 Hz) and studied their susceptibility to the loss of consciousness in NREM sleep (N2 and N3 stages).

Effects of NREM sleep were examined in power domain with relative power (RP), and in phase domain using inter-trial phase coherence (PC) parameter. The activity in power domain was also compared to no-stimulation data. Regions displaying significant waking-NREM sleep differences were selected using non-parametric suprathreshold cluster test. For 4, 6, 20 and 40 Hz stimulation relative power of ASSRs was lower in NREM sleep, with maximal change for 40 Hz stimulation. This decrease was not seen in no-stimulation condition. For all stimulation frequencies (except 12 Hz) we observed decrease of phase coherence of ASSR during NREM sleep.

Our results demonstrate that low and medium frequency ASSRs are state-sensitive, thus susceptible to loss of consciousness during NREM sleep. Diminishing of power and phase coherence may result from cortical down states and/or thalamic inhibition. Our results support possible use of low- and medium-frequency ASSRs for discrimination between states of altered consciousness and emphasize the role of the auditory system in determining these variations.



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Detecting Abnormal Electroencephalograms Using Deep Convolutional Networks

Publication date: Available online 17 November 2018

Source: Clinical Neurophysiology

Author(s): K.G. van Leeuwen, H. Sun, M. Tabaeizadeh, A.F. Struck, M.J.A.M van Putten, M.B. Westover

Abstract
Objectives

Electroencephalography (EEG) is a central part of the medical evaluation for patients with neurological disorders. Training an algorithm to label the EEG normal vs abnormal seems challenging, because of EEG heterogeneity and dependence of contextual factors, including age and sleep stage. Our objectives were to validate prior work on an independent data set suggesting that deep learning methods can discriminate between normal vs abnormal EEGs, to understand whether age and sleep stage information can improve discrimination, and to understand what factors lead to errors.

Methods

We train a deep convolutional neural network on a heterogeneous set of 8,522 routine EEGs from the Massachusetts General Hospital. We explore several strategies for optimizing model performance, including accounting for age and sleep stage.

Results

The area under the receiver operating characteristic curve (AUC) on an independent test set (n = 851) is 0.917 marginally improved by including age (AUC=0.924), and both age and sleep stages (AUC= 0.925), though not statistically significant.

Conclusions

The model architecture generalizes well to an independent dataset. Adding age and sleep stage to the model does not significantly improve performance.

Significance

Insights learned from misclassified examples, and minimal improvement by adding sleep stage and age suggest fruitful directions for further research.



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Electroencephalogram Dynamics during General Anesthesia Predict the Later Incidence and Duration of Burst-suppression During Cardiopulmonary Bypass

Publication date: Available online 16 November 2018

Source: Clinical Neurophysiology

Author(s): George S. Plummer, Reine Ibala, Eunice Hahm, Jingzhi An, Jacob Gitlin, Hao Deng, Kenneth T Shelton, Ken Solt, Jason Z. Qu, Oluwaseun Akeju

Abstract
Objective

Electroencephalogram burst-suppression during general anesthesia is associated with post-operative delirium (POD). Whether burst-suppression causes POD or merely reflects susceptibility to POD is unclear. We hypothesized decreased intraoperative alpha (8-12 Hz) and beta (13-33 Hz) power prior to the occurrence of burst-suppression in susceptible patients.

Methods

We analyzed intraoperative electroencephalogram data of cardiac surgical patients undergoing cardiopulmonary bypass (CPB). We detected the incidence and duration of CPB burst-suppression with an automated burst-suppression detection algorithm. We analyzed EEG data with multi-taper spectral estimation methods. We assessed associations between patient characteristics and burst-suppression using Binomial and Zero-inflated Poisson Regression Models.

Results

We found significantly decreased alpha and beta power (7.8-22.95 Hz) in the CPB burst-suppression cohort. The odds ratio for the association between point estimates for alpha and beta power (7.8-22.95 Hz) and the incidence of burst-suppression was 0.88 (95% CI: 0.79 to 0.98). The incidence rate ratio for the association between point estimates for power between the alpha and beta range and the duration of burst-suppression was 0.89 (95% CI: 0.84 to 0.93).

Conclusion

Decreased intra-operative power within the alpha and beta range was associated with susceptibility to burst-suppression during CPB.

Significance

This dynamic may be used to develop principled neurophysiological-based approaches to aid the preemptive identification and targeted care of POD vulnerable patients.



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Predicting prognosis in patients with first-episode psychosis using auditory P300: A 1-year follow-up study

Publication date: Available online 16 November 2018

Source: Clinical Neurophysiology

Author(s): Silvia Kyungjin Lho, Minah Kim, Tak Hyung Lee, Yoo Bin Kwak, Jun Soo Kwon

Abstract
Objective

To clarify the role of auditory P300 in predicting prognosis in patients with first-episode psychosis (FEP) during a 1-year follow-up.

Methods

Auditory P300 of 24 patients with FEP and 24 matched healthy control (HC) participants were measured at baseline. The clinical status of the FEP patients was assessed at baseline and reassessed after 1 year. P300 amplitudes and latencies among the groups were analyzed using repeated measures analysis of variance. Multiple regression analysis was conducted to assess the predictive value of P300 in patients with FEP during the 1-year follow-up.

Results

Auditory P300 amplitudes were significantly smaller in FEP patients than HCs. Higher baseline P300 amplitudes at CPz significantly predicted better improvements in the Positive and Negative Syndrome Scale total, positive, and general scores, as well as in the Global Assessment of Functioning and Brief Psychiatric Rating Scale.

Conclusions

P300 may predict improvements in symptoms, functional status, and overall psychiatric status in patients with FEP.

Significance

We first show that P300 amplitude at baseline predicts symptomatic and functional improvements after 1 year of treatment in patients with FEP. This finding may aid in effective interventions from the beginning of a psychotic episode to improve subsequent outcomes in clinical practice.



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Do ratings of swallowing function differ by videofluoroscopic rate? An exploratory analysis in patients after acute stroke

Publication date: Available online 16 November 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Rachel Mulheren, Alba Azola, Marlís González-Fernández

Objective

To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke.

Design

Blinded comparison.

Setting

Acute hospital.

Participants

20 patients after ischemic stroke.

Interventions

Not applicable.

Main outcome measures

Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests.

Results

Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores.

Conclusion

Continuous VFSS recorded at 30fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.



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Effect of Transcutaneous Electrical Nerve Stimulation (TENS) on spasticity in adults with stroke: A systematic review and meta-analysis

Publication date: Available online 16 November 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Amreen Mahmood, Sundar Kumar Veluswamy, Aditi Hombali, Aditi Mullick, Manikandan N, John M. Solomon

Abstract
Objectives

1. To determine the effect of transcutaneous electrical nerve stimulation (TENS) on post-stroke spasticity. 2a. To determine the effect of different parameters (intensity, frequency, and duration) of TENS on spasticity reduction in adults with stroke; 2b. To determine the influence of time since stroke on the effectiveness of TENS on spasticity.

Data sources

PubMed, PEDro, CINAHL, Web of Science, CENTRAL and EMBASE databases were searched from inception to March 2017.

Study Selection

Randomized controlled trial (RCT), quasi RCT and non-RCT were included if: (a) they evaluated the effects of TENS for the management of spasticity in participants with acute/sub-acute/chronic stroke using clinical and neurophysiological tools; and (b) TENS was delivered either alone or as an adjunct to other treatments.

Data extraction

Two authors independently screened and extracted data from 15 of the 829 studies retrieved through the search using a pilot tested pro-forma. Disagreements were resolved through discussion with other authors. Quality of studies was assessed using Cochrane risk of bias criteria.

Data synthesis

Meta-analysis was performed using a random-effects model which showed (a) TENS along with other physical therapy treatments was more effective in reducing spasticity in the lower limbs compared to placebo TENS (SMD -0.64, 95% CI -0.98 to -0.31; p = 0.0001; I2 =17%); and (b) TENS, when administered along with other physical therapy treatments, was effective in reducing spasticity when compared to other physical therapy interventions alone (SMD -0.83, 95% CI -1.51 to -0.15; p =0.02; I2 = 27%). There were limited studies to evaluate the effectiveness of TENS for upper limb spasticity.

Conclusion

There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors. (Review protocol registered at PROSPERO: CRD42015020151).



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New estimates of blood flow rates in the vertebral artery of euarchontans and their implications for encephalic blood flow scaling: A response to Seymour and Snelling (2018)

Publication date: Available online 17 November 2018

Source: Journal of Human Evolution

Author(s): Doug M. Boyer, Arianna R. Harrington



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Chronological change in oropharyngeal leak pressure of pediatric i‐gel™

Abstract

Sir‐The i‐gel (Intersurgical, Wokingham, UK) is a single‐use supraglottic airway device with a noninflatable cuff made of a soft, gel‐like thermoplastic elastomer. It was previously reported that oropharyngeal leak pressure (OLP) of i‐gel improved over time after insertion in adults.1 However, there is limited evidence regarding the change in sealing ability of pediatric i‐gel.

This article is protected by copyright. All rights reserved.



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Sasa quelpaertensis leaf extract mitigates fatigue and regulates the transcriptome profile in mice

Abstract

Introduction

It has been reported that various plant species may enhance the elimination of fatigue-related metabolites. However, relatively few studies have directly addressed the potential anti-fatigue effects.

Objective

The objective of this study was to investigate the anti-fatigue potential of a hot water extract of Sasa quelpaertensis Nakai leaf (SQH) in male ICR mice.

Methods

The animals were divided into three groups. The normal control (NC) group was administered saline without exercise every day for 7 days. The exercise control (EC) and exercise with SQH (ES) groups were administered saline and SQH (50 mg/kg of body weight), respectively, every day for 7 days and underwent swimming exercise. RNA sequencing technology was used to analyze the transcriptome profiles of muscle.

Results

Swimming times were prolonged in the ES group compared with the EC group. The ES group had higher blood glucose and lower blood lactate levels, and higher muscular glycogen and lower muscular lactate levels, compared with the EC group. The groups did not differ in histopathological parameters of the muscle and liver, but muscle cell sizes were smaller in the EC group than in the ES and NC groups. RNA sequencing analysis revealed that SQH administration regulated genes associated with energy-generating metabolic pathways in skeletal muscle.

Conclusion

These results suggest that SQH exerts anti-fatigue properties by balancing various biological systems and helping maintain the basic harmonious pattern of the body.



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Clinical Safety and Utility of Pediatric Balloon Assisted Enteroscopy; A Multicenter Prospective Study in Japan

Objectives: The benefit of balloon-assisted enteroscopy (BAE) had been recently documented in pediatric patients, but previous reports are based on single institution experiences. We evaluated the feasibility of pediatric BAE in 8 tertiary referral hospitals throughout Japan. Methods: This was a prospective, multi-institutional study. Patients under 18 years were enrolled between April 2014 and March 2017 to undergo double-balloon or single-balloon enteroscopy. Data were collected prospectively using a standardized questionnaire. Results: We enrolled 79 pediatric patients (96 procedures, 70 boys, 26 girls; median age 12.7 years, range 1–17 years). Antegrade (oral-route) BAE was performed in 20 procedures (lowest body weight 12.9 kg, youngest age 3.7 years), and retrograde (anal-route) BAE in 76 (lowest body weight 10.8 kg, youngest age 1.6 years). Severe adverse events were associated with BAE in two patients: one with hemorrhage due to polypectomy, and one with pancreatitis after double balloon endoscopic retrograde cholangioscopy. No intestinal perforation was reported. Procedure duration of oral-route BAE for diagnosis was significantly longer than anal-route for diagnosis (p 

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Association Between Obesity/Overweight and Functional Gastrointestinal Disorders in Children

Objective: Although emerging data indicate that obese/overweight children are more likely to develop functional gastrointestinal disorders (FGIDs) than normal-weight peers, contrasting results have been reported. The present observational, case-control study aimed at estimating the prevalence of FGIDs in obese/overweight children compared to normal-weight peers. Methods: Consecutive obese and overweight children aged 4–18 years attending the obesity outpatient clinic were enrolled as study cases. Normal-weight children were enrolled as comparison group. All the enrolled patients received a thorough health examination from both a pediatric endocrinologist and gastroenterologist. Moreover, they were asked to fill out the Rome III questionnaire for the diagnosis of FGIDs. Data were analyzed to compare the prevalence of FGIDs between cases and controls. Results: Throughout the study period we enrolled 103 cases and 115 controls. No significant age and gender differences were found between the 2 groups. FGIDs were significantly more prevalent in obese/overweight compared to normal-weight children (47.57% vs 17.39%; p 

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Neurostimulation-Guided Anal Intrasphincteric Botulinum Toxin Injection in Children with Hirschsprung's Disease

Objectives: In Hirschsprung's disease (HD), despite successful surgical treatment, 50% of children experience long-term functional gastrointestinal problems, particularly chronic functional obstructive symptoms. We report our experience regarding clinical effects of neurostimulation-guided anal intrasphincteric botulinum toxin (BT) injections on postoperative obstructive symptoms attributed to a non-relaxing anal sphincter complex in HD patients. Methods: In this monocenter cohort study, 15 HD patients with postoperative functional intestinal obstructive symptoms received neurostimulation-guided anal intrasphincteric BT injections. Short, medium and long-term effects were evaluated. The Bristol stool form scale was used to assess stool consistency, and the Jorge-Wexner (JW) score to assess fecal continence. Results: The median age at first injection was 4 years. In the short-term, a significant improvement in stool consistency was noted in 12/14 patients (p = 0.0001) and JW score decreased for 14/15 patients (p = 0.001). In the medium-term, JW score significantly decreased for all patients (p = 0.0001), with an improvement of 50% or more for 10 patients (66.7%). In the long-term, 83.3% of patients had normal stool consistency and JW score was less than 3 for all. Recurrent enterocolitis decreased from 86.7% to 8.3%. A complete resolution of all symptoms without further medication was observed in 66.7% of patients in the long-term. Conclusions: Intrasphincteric BT injection was a safe, effective and durable option for the management of postoperative functional intestinal obstructive symptoms in HD. The use of neurostimulator guidance for specific delivery of BT to muscular fibers of non-relaxing anal sphincter complex takes into consideration the variability of patient's anatomy secondary to curative surgery. Address correspondence and reprint requests to Claude Louis-Borrione, MD, Pediatric Surgery Department, Hôpital La Timone-Enfants, 264 rue Saint Pierre, 13385 Marseille, France (E-mail: claude.louis@ap-hm.fr); Anne Dariel, MD, Pediatric Surgery Department, Hôpital La Timone-Enfants, 264 rue Saint Pierre, 13385 Marseille, France (e-mail: anne_dariel@yahoo.fr). Received 22 April, 2018 Accepted 30 August, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Conflicts of interest and source of funding: none declared. Author Contributions: Claude Louis-Borrione is a pediatric surgeon with an expertise in colorectal surgery in children with Hirschsprung's disease. She designed and conducted the entire study: patient's inclusion, botulinum toxin injections, patient's follow-up and acquisition of data. She supervised the study. Anne Dariel analyzed and interpreted the data, then wrote the paper. Sarah Garnier did the bibliographic research. Julien Labreuche performed the statistical analysis. Claude Borrione, Géraldine Héry, Alice Faure, Jean-Michel Guys and Thierry Merrot were the pediatric surgeons in charge of the primary surgical management of the included patients. They also participated in the critical reading of the manuscript for important intellectual contents. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Brain Protection Beyond the OR: Consensus Statement on Perioperative Neurocognitive Disorders (PND)

imageNo abstract available

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Mild Perioperative Hypothermia and Myocardial Injury: A Retrospective Cohort Analysis

imageBACKGROUND: We tested the primary hypothesis that final intraoperative esophageal temperature is associated with increased odds of a composite of in-hospital all-cause mortality and myocardial injury within 7 days after noncardiac surgery. Secondary exposures were time-weighted average intraoperative temperature and area

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Going With the Flow: Cerebrovascular Disease and Autoregulation

imageNo abstract available

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Cerebral Small Vessel, But Not Large Vessel Disease, Is Associated With Impaired Cerebral Autoregulation During Cardiopulmonary Bypass: A Retrospective Cohort Study

imageBACKGROUND: Impaired cerebral blood flow (CBF) autoregulation during cardiopulmonary bypass (CPB) is associated with stroke and other adverse outcomes. Large and small arterial stenosis is prevalent in patients undergoing cardiac surgery. We hypothesize that large and/or small vessel cerebral arterial disease is associated with impaired cerebral autoregulation during CPB. METHODS: A retrospective cohort analysis of data from 346 patients undergoing cardiac surgery with CPB enrolled in an ongoing prospectively randomized clinical trial of autoregulation monitoring were evaluated. The study protocol included preoperative transcranial Doppler (TCD) evaluation of major cerebral artery flow velocity by a trained vascular technician and brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. Brain MRI images were evaluated for chronic white matter hyperintensities (WMHI) by a vascular neurologist blinded to autoregulation data. "Large vessel" cerebral vascular disease was defined by the presence of characteristic TCD changes associated with stenosis of the major cerebral arteries. "Small vessel" cerebral vascular disease was defined based on accepted scoring methods of WMHI. All patients had continuous TCD-based autoregulation monitoring during surgery. RESULTS: Impaired autoregulation occurred in 32.4% (112/346) of patients. Preoperative TCD demonstrated moderate-severe large vessel stenosis in 67 (25.2%) of 266 patients with complete data. In adjusted analysis, female sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25–0.86; P = .014) and higher average temperature during CPB (OR, 1.23; 95% CI, 1.02–1.475; P = .029), but not moderate-severe large cerebral arterial stenosis (P = .406), were associated with impaired autoregulation during CPB. Of the 119 patients with available brain MRI data, 42 (35.3%) demonstrated WMHI. The presence of small vessel cerebral vascular disease was associated with impaired CBF autoregulation (OR, 3.25; 95% CI, 1.21–8.71; P = .019) after adjustment for age, history of peripheral vascular disease, preoperative hemoglobin level, and preoperative treatment with calcium channel blocking drugs. CONCLUSIONS: These data confirm that impaired CBF autoregulation is prevalent during CPB predisposing affected patients to brain hypoperfusion or hyperperfusion with low or high blood pressure, respectively. Small vessel, but not large vessel, cerebral vascular disease, male sex, and higher average body temperature during CPB appear to be associated with impaired autoregulation.

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Chromosome 18 gene dosage map 2.0

Abstract

In 2009, we described the first generation of the chromosome 18 gene dosage maps. This tool included the annotation of each gene as well as each phenotype associated region. The goal of these annotated genetic maps is to provide clinicians with a tool to appreciate the potential clinical impact of a chromosome 18 deletion or duplication. These maps are continually updated with the most recent and relevant data regarding chromosome 18. Over the course of the past decade, there have also been advances in our understanding of the molecular mechanisms underpinning genetic disease. Therefore, we have updated the maps to more accurately reflect this knowledge. Our Gene Dosage Map 2.0 has expanded from the gene and phenotype maps to also include a pair of maps specific to hemizygosity and suprazygosity. Moreover, we have revamped our classification from mechanistic definitions (e.g., haplosufficient, haploinsufficient) to clinically oriented classifications (e.g., risk factor, conditional, low penetrance, causal). This creates a map with gradient of classifications that more accurately represents the spectrum between the two poles of pathogenic and benign. While the data included in this manuscript are specific to chromosome 18, they may serve as a clinically relevant model that can be applied to the rest of the genome.



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Gait Mechanics and T1ρ MRI of Tibiofemoral Cartilage 6 Months Post ACL Reconstruction

Purpose Aberrant walking biomechanics following anterior cruciate ligament reconstruction (ACLR) are hypothesized to associate with deleterious changes in knee cartilage. T1ρ magnetic resonance imaging (MRI) is sensitive to decreased proteoglycan density of cartilage. Our purpose was to determine associations between T1ρ MRI inter-limb ratios (ILR) and walking biomechanics 6-months post-ACLR. Methods Walking biomechanics (peak vertical ground reaction force [vGRF], vGRF loading rate [vGRF-LR], knee extension moment [KEM], knee abduction moment [KAM]) were extracted from the first 50% of stance phase in 29 individuals with unilateral ACLR. T1ρ MRI ILR (ACLR limb/uninjured limb) were calculated for regions of interest in both medial and lateral femoral (MFC and LFC) and tibial (MTC & LTC) condyles. Separate, stepwise linear regressions were used to determine associations between biomechanical outcomes and T1ρ MRI ILR after accounting for walking speed and meniscal/chondral injury (P≤0.05). Results Lesser peak vGRF in the ACLR limb associated with greater T1ρ MRI ILR for the LFC (Posterior ΔR2=0.14 P=0.05; Central ΔR2=0.15, P=0.05) and MFC (Central ΔR2=0.24, P=0.01). Lesser peak vGRF-LR in the ACLR limb (ΔR2=0.21, P=0.02) and the uninjured limb (ΔR2=0.27, P=0.01) associated with greater T1ρ MRI ILR for the Anterior LFC. Lesser KAM for the injured limb associated with greater T1ρ MRI ILR for the Anterior LFC (ΔR2=0.16, P=0.04) as well as the Posterior MTC (ΔR2=0.13, P=0.04). Conclusion Associations between outcomes related to lesser mechanical loading during walking and greater T1ρ MRI ILR were found 6-months post-ACLR. While preliminary, our results suggest under-loading of the ACLR limb at 6 months post-ACLR may be associated with lesser proteoglycan density in the ACLR limb compared to the uninjured limb. Corresponding Author: Steven Pfeiffer, MS, University of North Carolina at Chapel Hill, CB# 8700, 209 Fetzer Hall, Chapel Hill, NC 27599. Phone: 919-962-7187. Fax: 919-962-0489. Email: stevenpf@email.unc.edu Research reported in this original manuscript was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (1R03AR066840-01A1), North Carolina Translational and Clinical Sciences (TRaCS) Institute, and National Athletic Trainers Association Research and Education Foundation (#14NewInv001). The results of the current study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Conflicts of Interest. No conflicts of interests are reported. The results of the present study do not constitute endorsement by the American College of Sports Medicine. Accepted for publication October 2018. © 2018 American College of Sports Medicine

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Mechanical Ventilation in the Critically Ill Obese Patient

No abstract available

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Brain Protection Beyond the OR: Consensus Statement on Perioperative Neurocognitive Disorders (PND)

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Going With the Flow: Cerebrovascular Disease and Autoregulation

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The World Health Organization Surgical Safety Checklist: Happy 10th Birthday!

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Should We Always Continue β-Blocking Agents Preoperatively?

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The Hidden Value of Ultrasound?

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

No abstract available

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Prevention of Thrombophlebitis in Peripheral Intravenous Catheters: The Butterfly Effect

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In Response

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Pediatric Anesthesia Informed Consent: “That’s the Signpost Up Ahead – Your Next Stop, The Twilight Zone!”

No abstract available

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Lack of Bias Evaluation and Inadequate Study Selection May Produce Misleading Results

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Clarifying Misconceptions About US Food and Drug Administration Unapproved Drugs Program

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Starving Patients Before Cataract Surgery Under Regional Anesthesia: Needed or Not?

No abstract available

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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Education in Anesthesia: How to Deliver the Best Learning Experience

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The Perioperative Management of Ascending Aortic Dissection

imageAcute aortic syndromes are a distinct group of pathologies involving the wall of the aorta that present acutely and can be potentially fatal unless treated in a timely fashion. The syndrome is dominated by aortic dissections, which comprise ≥95% of all such presentations. Those involving the ascending aorta are particularly lethal and require specific and early surgical treatment compared to dissections involving other parts of the aorta. The surgical repair of an ascending aortic dissection presents multiple challenges to the anesthesiologist. Thoughtful management throughout the perioperative period is critical for minimizing the significant morbidity and mortality associated with this condition. In this narrative review, we provide an overview of the perioperative management of patients presenting for the surgical repair of an ascending aortic dissection. Preoperative discussion focuses on assessment, hemodynamic management, and risk stratification. The intraoperative section includes an overview of anesthetic management, transesophageal echocardiographic assessment, and coagulopathy, as well as surgical considerations that may influence anesthetic management.

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Acute Stroke Management in the First 24 Hours: A Practical Guide for Clinicians

No abstract available

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Cerebral Small Vessel, But Not Large Vessel Disease, Is Associated With Impaired Cerebral Autoregulation During Cardiopulmonary Bypass: A Retrospective Cohort Study

imageBACKGROUND: Impaired cerebral blood flow (CBF) autoregulation during cardiopulmonary bypass (CPB) is associated with stroke and other adverse outcomes. Large and small arterial stenosis is prevalent in patients undergoing cardiac surgery. We hypothesize that large and/or small vessel cerebral arterial disease is associated with impaired cerebral autoregulation during CPB. METHODS: A retrospective cohort analysis of data from 346 patients undergoing cardiac surgery with CPB enrolled in an ongoing prospectively randomized clinical trial of autoregulation monitoring were evaluated. The study protocol included preoperative transcranial Doppler (TCD) evaluation of major cerebral artery flow velocity by a trained vascular technician and brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. Brain MRI images were evaluated for chronic white matter hyperintensities (WMHI) by a vascular neurologist blinded to autoregulation data. "Large vessel" cerebral vascular disease was defined by the presence of characteristic TCD changes associated with stenosis of the major cerebral arteries. "Small vessel" cerebral vascular disease was defined based on accepted scoring methods of WMHI. All patients had continuous TCD-based autoregulation monitoring during surgery. RESULTS: Impaired autoregulation occurred in 32.4% (112/346) of patients. Preoperative TCD demonstrated moderate-severe large vessel stenosis in 67 (25.2%) of 266 patients with complete data. In adjusted analysis, female sex (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25–0.86; P = .014) and higher average temperature during CPB (OR, 1.23; 95% CI, 1.02–1.475; P = .029), but not moderate-severe large cerebral arterial stenosis (P = .406), were associated with impaired autoregulation during CPB. Of the 119 patients with available brain MRI data, 42 (35.3%) demonstrated WMHI. The presence of small vessel cerebral vascular disease was associated with impaired CBF autoregulation (OR, 3.25; 95% CI, 1.21–8.71; P = .019) after adjustment for age, history of peripheral vascular disease, preoperative hemoglobin level, and preoperative treatment with calcium channel blocking drugs. CONCLUSIONS: These data confirm that impaired CBF autoregulation is prevalent during CPB predisposing affected patients to brain hypoperfusion or hyperperfusion with low or high blood pressure, respectively. Small vessel, but not large vessel, cerebral vascular disease, male sex, and higher average body temperature during CPB appear to be associated with impaired autoregulation.

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In Response

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Tranexamic Acid Dosing for Cardiac Surgical Patients With Chronic Renal Dysfunction: A New Dosing Regimen

imageBACKGROUND: Tranexamic acid (TXA) is a common antifibrinolytic agent used to minimize bleeding in cardiac surgery. Up to 50% cardiac surgical patients have chronic renal dysfunction (CRD). Optimal dosing of TXA in CRD remains poorly investigated. This is important as TXA is renally eliminated with accumulation in CRD. High TXA doses are associated with postoperative seizures. This study measures plasma TXA concentrations in CRD cardiac surgical patients for pharmacokinetic modeling and dose adjustment recommendations. METHODS: This prospective cohort study enrolled 48 patients with stages 1–5 CRD, classified by Kidney Disease Outcome Quality Initiative. Patients were separated into 2 treatment groups. A "low-risk" group underwent simple aortocoronary bypass or single-valve repair/replacement and received a 50 mg/kg TXA bolus. A "high-risk" group underwent redo, aortic, multiple valve or combination surgery and received the Blood Conservation Using Anti-fibrinolytics Trial dosing regimen (loading dose 30 mg/kg, infusion 16 mg/kg/h with 2 mg/kg in pump prime). Primary outcome identified changes in TXA clearance and distribution volume, which provided the rationale for dose adjustment. Descriptive clinical outcomes assessed postoperative seizures, blood loss, ischemic-thrombotic complications, in-hospital mortality, and length of hospital stay. RESULTS: TXA concentrations were elevated and sustained above the therapeutic threshold for approximately 12 hours in high-risk stages 3–5 groups, in accordance to CRD severity. CONCLUSIONS: Using a pharmacokinetic model, we propose a simple new TXA dosing regimen that optimizes maximal antifibrinolysis and avoids excessive drug dosing.

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