Informing Federal Policy on Firearm Restrictions for Veterans with Fiduciaries: Risk Indicators in the Post-Deployment Mental Health Study

Abstract

This article examines the public safety rationale for a federal policy of prohibiting gun sales to veterans with psychiatric disabilities who are assigned a fiduciary to manage their benefits from the Department of Veterans Affairs. The policy was evaluated using data on 3200 post-deployment veterans from the Iraq and Afghanistan war era. Three proxy measures of fiduciary need—based on intellectual disability, drug abuse, or acute psychopathology—were associated in bivariate analysis with interpersonal violence and suicidality. In multivariate analysis, statistical significance remained only for the measure based on acute psychopathology. Implications for reforms to the fiduciary firearm restriction policy are discussed.

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Erector Spinae Plane Block Versus Retrolaminar Block: A Magnetic Resonance Imaging and Anatomical Study

Background and Objectives The erector spinae plane (ESP) and retrolaminar blocks are ultrasound-guided techniques for thoracoabdominal wall analgesia involving injection into the musculofascial plane between the paraspinal back muscles and underlying thoracic vertebrae. The ESP block targets the tips of the transverse processes, whereas the retrolaminar block targets the laminae. We investigated if there were differences in injectate spread between the 2 techniques that would have implications for their clinical effect. Methods The blocks were performed in 3 fresh cadavers. The ESP and retrolaminar blocks were performed on opposite sides of each cadaver at the T5 vertebral level. Twenty milliliters of a radiocontrast dye mixture was injected in each block, and injectate spread was assessed by magnetic resonance imaging and anatomical dissection. Results Both blocks exhibited spread to the epidural and neural foraminal spaces over 2 to 5 levels. The ESP block produced additional spread to intercostal spaces over 5 to 9 levels and was associated with a greater extent of craniocaudal spread along the paraspinal muscles. Conclusions The clinical effect of ESP and retrolaminar blocks can be explained by epidural and neural foraminal spread of local anesthetic. The ESP block produces additional intercostal spread, which may contribute to more extensive analgesia. The implications of these cadaveric observations require confirmation in clinical studies. Accepted for publication January 28, 2018. Address correspondence to: Ki Jinn Chin, FRCPC, Department of Anesthesia, Toronto Western Hospital, McL 2-405, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8 (e-mail: gasgenie@gmail.com). The authors have no sources of funding to declare for this article. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Use of Serratus Plane Block for Repair of Coarctation of Aorta: A Report of 3 Cases

Objectives The practice of regional anesthesia techniques (thoracic, epidural, paravertebral) in pediatric cardiac surgery enhances perioperative outcomes such as improved perioperative analgesia, decreased stress response, early extubation, and shortened hospital stay. However, these blocks can be technically challenging and can be associated with unacceptable failure rate and complications in infants. For these reasons, regional anesthesia is sometimes avoided in pediatric cardiac surgery. We describe the simple and effective serratus plane block for thoracotomy analgesia in 2 neonates and a child. Case Report We present 3 pediatric patients, each of whom was having coarctation repair and received an ultrasound-guided serratus plane block for thoracotomy analgesia. The patients were 3 days, 14 days, and 4 years old, weighing from 1.9 to 16 kg. The serratus plane block was performed prior to surgical incision. The block was technically simple compared with thoracic epidural or paravertebral block. All patients were extubated immediately after completion of surgery. Apart from the induction dose of fentanyl (2 μg/kg), no further opioids were required intraoperatively. Postoperative opioid requirements as well as duration of intensive care and hospital stay were lower than recent averages (for the same demographic and procedure) in our hospital. Conclusions We propose that the serratus plane block is a simple procedure that provides good perioperative analgesia for infant thoracotomy, potentially facilitating early extubation and a shorter hospital stay. Accepted for publication January 15, 2018. Address correspondence to: Abhijit Biswas, MBBS, MSc, FCARCSI, EDRA, Department of Anesthesia and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, Ontario, Canada N6A 5A5 (e-mail: avijitbsws@yahoo.com). This work is attributed to the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada. Funding was provided by the Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada. The authors declare no conflict 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 Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Major Laparoscopic Intraperitoneal Surgery Performed With Combined Bilateral Subcostal Transversus Abdominal Plane Block and Celiac Plexus Block, Intravenous Sedation Without Tracheal Intubation: A Feasibility Study of 3 Cases

Objectives Major abdominal surgery usually requires general anesthesia with tracheal intubation and may be supplemented with neuraxial anesthesia to provide intraoperative and postoperative pain relief. Attempts at using only neuraxial anesthesia for major abdominal surgery have often been shown to be poorly effective. This report demonstrates that laparoscopic colonic surgical procedures can be performed with ultrasound-guided blocks (bilateral transversus abdominal plane block and celiac plexus block) and intravenous sedation, while avoiding general or neuraxial anesthesia. Case Report We report our preliminary experience in 3 patients (all American Society of Anesthesiologists physical status III) who underwent laparoscopic colonic surgery without general anesthesia. Intraoperative visceral analgesia was provided by single-injection ultrasound anterior celiac plexus block to which was added a bilateral subcostal transversus abdominal plane block to obtain parietal analgesia. Light intravenous sedation was added. Surgical exposure was satisfactory, and no patient complained of any symptom during the procedure. No adverse effect was recorded. Postoperative pain was minimal, and recovery was enhanced with mobilization and walking within hours after surgery. Patient satisfaction was excellent. Conclusions To date, celiac plexus block has been used almost exclusively to relieve pancreatic cancer pain. This is the first report in which it is shown that major intra-abdominal surgery can be performed almost exclusively with regional anesthesia while avoiding adverse effects and problems associated with either general or neuraxial anesthesia. In addition, prolonged postoperative pain relief facilitated early recovery. Accepted for publication January 15, 2018. Address correspondence to: Dan Benhamou, MD, Département d'Anesthésie Réanimation, Hôpital Bicêtre Université Paris-Sud, 78 Rue du Général Leclerc, 94275 Le Kremlin-Bicêtre Cedex, France (e-mail: dan.benhamou@aphp.fr). The work should be attributed to Private Hospital Eure et Loir, Mainvilliers, France. The work was managed with hospital funds only. The authors declare no conflict of interest. Authors Contributions: A.T. provided anesthesia to the patients, collected data, and wrote the first draft. M.B. performed the surgical procedure and participated in writing the manuscript. P.J.Z. participated in writing the manuscript. D.B. participated in writing the manuscript and coordinated manuscript preparation and submission. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Inter-ray variation in metatarsal strength properties in humans and African apes: Implications for inferring bipedal biomechanics in the Olduvai Hominid 8 foot

Publication date: Available online 24 May 2018
Source:Journal of Human Evolution
Author(s): Biren A. Patel, Tea Jashashvili, Stephanie H. Bui, Kristian J. Carlson, Nicole L. Griffin, Ian J. Wallace, Caley M. Orr, Randall L. Susman
When measured as a ratio of mean midshaft diameter to bone length, the OH 8 fossil hominin foot exhibits a metatarsal (Mt) robusticity pattern of 1 > 5 > 3 > 4 > 2, which differs from the widely perceived "common" modern human pattern (1 > 5 > 4 > 3 > 2); African apes generally exhibit a third pattern (1 > 2 > 3 > 4 > 5). Largely because of the relative ranking of Mt2 and Mt5, OH 8 metatarsals structurally resemble the pattern exhibited by bipedal humans more than the pattern of quadrupedal and climbing African apes. Considering only these three phenotypes, however, discounts the potentially important functional implications of variation in modern human (and African ape) metatarsal robusticity patterns, suggesting that they are not useful for interpreting the specific biomechanics of a bipedal gait in fossils (i.e., whether it was modern human-like or not). Using computed tomography scans to quantify metatarsal midshaft cross-sectional geometry in a large sample of Homo (n=130), Gorilla (n=44) and Pan (n=80), we documented greater variation in metatarsal robusticity patterns than previously recognized in all three groups. While apes consistently show a 1 > 2 > 3 > 4 > 5 pattern in our larger sample, there does not appear to be a similarly precise single "common" human pattern. Rather, human metatarsals converge towards a 1 > 4/5 > 2/3 pattern, where metatarsals 4 and 5, and metatarsals 2 and 3, often "flip" positions relative to each other depending on the variable examined. After reassessing what a "common" human pattern could be based on a larger sample, the previously described OH 8 pattern of 1 > 5 > 3 > 4 > 2 is only observed in some humans (<6%) and almost never in apes (<0.5%). Although this suggests an overall greater similarity to (some) humans than to any ape in loading of the foot, the relatively rare frequency of these humans in our sample underscores potential differences in loading experienced by the medial and lateral columns of the OH 8 foot compared to modern humans.



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The Child and Adolescent Services Assessment: Interrater Reliability and Predictors of Rater Disagreement

Abstract

The current study evaluated the interrater reliability of the Child and Adolescent Services Assessment (CASA), a widely used structured interview measuring pediatric mental health service use. Interviews (N = 72) were randomly selected from a pediatric effectiveness trial, and audio was coded by an independent rater. Regressions were employed to identify predictors of rater disagreement. Interrater reliability was high for items (> 94%) and summary metrics (ICC > .79) across service sectors. Predictors of disagreement varied by domain; significant predictors indexed higher clinical severity or social disadvantage. Results support the CASA as a reliable and robust assessment of pediatric service use, but administrators should be alert when assessing vulnerable populations.

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Piepkorn type of osteochondrodysplasia: Defining the severe end of FLNB‐related skeletal disorders in three fetuses and a 106‐year‐old exhibit

American Journal of Medical Genetics Part A, EarlyView.


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