HNF4A-related Fanconi syndrome in a Chinese patient: a case report and review of the literature

The p.R63W mutation in hepatocyte nuclear factor-4 alpha (HNF4A) leads to a heterogeneous group of disorders with various clinical presentations. Recently, patients with congenital hyperinsulinism and Fanconi syn...

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Retrospective definition of reaction risk in Italian children with peanut, hazelnut and walnut allergy through component-resolved diagnosis

Publication date: Available online 14 July 2018

Source: Allergologia et Immunopathologia

Author(s): M. Giovannini, P. Comberiati, M. Piazza, E. Chiesa, G.L. Piacentini, A. Boner, G. Zanoni, D.G. Peroni

Abstract

Background

Serum IgE evaluation of peanut, hazelnut and walnut allergens through the use of component-resolved diagnosis (CRD) can be more accurate than IgE against whole food to associate with severe or mild reactions.

Objectives

The aim of the study was to retrospectively define the level of reaction risk in children with peanut, hazelnut and walnut sensitization through the use of CRD.

Methods

34 patients [n = 22 males, 65%; median age eight years, interquartile range (IQR) 5.0–11.0 years] with a reported history of reactions to peanut and/or hazelnut and/or walnut had their serum analyzed for specific IgE (s-IgE) by ImmunoCAP^® and ISAC^® microarray technique.

Results

In children with previous reactions to peanut, the positivity of Arah1 and Arah2 s-IgE was associated with a history of anaphylaxis to such food, while the positivity of Arah8 s-IgE were associated with mild reactions. Regarding hazelnut, the presence of positive Cora9 and, particularly, Cora14 s-IgE was associated with a history of anaphylaxis, while positive Cora1.0401 s-IgE were associated with mild reactions. Concerning walnut, the presence of positive Jug r 1, Jug r 2, Jug r 3 s-IgE was associated with a history of anaphylaxis to such food. ImmmunoCAP^® proved to be more useful in retrospectively defining the risk of hazelnut anaphylaxis, because of the possibility of measuring Cor a14 s-IgE.

Conclusions

Our data show that the use of CRD in patients with allergy to peanut, hazelnut and walnut could allow for greater accuracy in retrospectively defining the risk of anaphylactic reaction to such foods.

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Comparison of clinical outcomes between butterfly inlay cartilage tympanoplasty and conventional underlay cartilage tympanoplasty

Publication date: Available online 14 July 2018

Source: Auris Nasus Larynx

Author(s): Min Bum Kim, Jin-A. Park, Michelle J. Suh, Chan Il Song

Abstract

Objective

To assess the efficacy of butterfly inlay cartilage tympanoplasty and compare it with conventional underlay cartilage tympanoplasty in terms of success rate and hearing outcomes.

Materials and methods

The study included 35 patients (36 ears) who underwent butterfly inlay cartilage tympanoplasty (inlay group, 23 ears of 22 patients) or conventional underlay cartilage tympanoplasty (underlay group, 13 ears). The anatomical success rate and hearing outcomes were analysed.

Results

Re-perforation occurred in 2 cases (8.7%) in the inlay group and 3 (23.1%) in the underlay group. One patient in the inlay group developed a serious infection, and one in the underlay group developed massive granulation of the tympanic membrane. In the inlay group, the air-bone gap (ABG) decreased from 19.9 (±12.6) dB HL preoperatively to 13.8 (±11.3) dB HL postoperatively (p = 0.047), in the underlay group, it decreased from 23.5 (±15.8) dB HL to 18.3 (±20.6) dB HL. Regarding improvement in ABG, the difference between the group was not statistically significant (p = 0.968).

Conclusion

Butterfly inlay cartilage tympanoplasty is comparable with conventional underlay cartilage tympanoplasty in both anatomic and audiological success rates. Owing to its simplicity, shorter operation time, and rapid patient recovery, butterfly inlay cartilage tympanoplasty could be considered a favourable surgical option.

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Association of Tinnitus and Other Cochlear Disorders With a History of Migraines.

Related Articles

Association of Tinnitus and Other Cochlear Disorders With a History of Migraines.

JAMA Otolaryngol Head Neck Surg. 2018 Jul 12;:

Authors: Hwang JH, Tsai SJ, Liu TC, Chen YC, Lai JT

Abstract
Importance: A headache is a symptom of a migraine, but not all patients with migraine have headaches. It is still unclear whether a migraine might increase the risk of cochlear disorders, even though a migraine does not occur concurrently with cochlear disorders.
Objective: To investigate the risk of cochlear disorders for patients with a history of migraines.
Design, Setting, and Participants: This study used claims data from the Taiwan Longitudinal Health Insurance Database 2005 to identify 1056 patients with migraines diagnosed between January 1, 1996, and December 31, 2012. A total of 4224 controls were also identified from the same database based on propensity score matching. Statistical analysis was performed from January 23, 1996, to December 28, 2012.
Main Outcomes and Measures: The incidence rate of cochlear disorders (tinnitus, sensorineural hearing impairment, and/or sudden deafness) was compared between the cohorts by use of the Kaplan-Meier method. The Cox proportional hazards regression model was also used to examine the association of cochlear disorders with migraines.
Results: Of the 1056 patients with migraines, 672 were women and 384 were men, and the mean (SD) age was 36.7 (15.3) years. Compared with the nonmigraine cohort, the crude hazard ratio for cochlear disorders in the migraine cohort was 2.83 (95% CI, 2.01-3.99), and the adjusted hazard ratio was 2.71 (95% CI, 1.86-3.93). The incidence rates of cochlear disorders were 81.4 (95% CI, 81.1-81.8) per 1 million person-years for the migraine cohort and 29.4 (95% CI, 29.2-29.7) per 1 million person-years for the nonmigraine cohort. The cumulative incidence of cochlear disorders in the migraine cohort (12.2%) was significantly higher than that in the matched nonmigraine cohort (5.5%). Subgroup analysis showed that, compared with the nonmigraine cohort, the adjusted hazard ratios in the migraine cohort were 3.30 (95% CI, 2.17-5.00) for tinnitus, 1.03 (95% CI, 0.17-6.41) for sensorineural hearing impairment, and 1.22 (95% CI, 0.53-2.83) for sudden deafness.
Conclusions and Relevance: In this population-based study, the risk of cochlear disorders, especially for tinnitus, was found to be significantly higher among patients with a history of migraines. This finding may support the presence and/or concept of "cochlear migraine."

PMID: 30003226 [PubMed - as supplied by publisher]

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The Role of Migraine in Hearing and Balance Symptoms.

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The Role of Migraine in Hearing and Balance Symptoms.

JAMA Otolaryngol Head Neck Surg. 2018 Jul 12;:

Authors: Lin HW, Djalilian HR

PMID: 30003218 [PubMed - as supplied by publisher]

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Sociodemographic Characteristics and Treatment Response Among Aging Adults With Voice Disorders in the United States.

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Sociodemographic Characteristics and Treatment Response Among Aging Adults With Voice Disorders in the United States.

JAMA Otolaryngol Head Neck Surg. 2018 Jul 12;:

Authors: Bertelsen C, Zhou S, Hapner ER, Johns MM

Abstract
Importance: Aging adults face unique barriers to care and have unique health care needs with a high prevalence of chronic conditions. A high proportion of individuals in this group have voice disorders, in part due to age-related changes in laryngeal anatomy and physiologic features. These disorders contribute significantly to health care costs and remain poorly understood.
Objective: To describe sociodemographic characteristics and response to treatment among aging adults with voice disorders.
Design, Setting, and Participants: A cross-sectional study using the 2012 National Health Interview Survey was used to evaluate adults who reported voice disorders in the past 12 months. Self-reported demographics and data regarding health care visits for voice disorders were analyzed. Statistical analysis was conducted from March 1, 2017, to February 1, 2018.
Main Outcomes and Measures: Self-reported voice disorders, whether or not treatment was sought, which types of professionals were seen for treatment, and whether or not the voice disorder improved after treatment.
Results: Among 41.7 million adults in the United States 65 years or older, 4.20 million (10.1%; 2 683 199 women and 1 514 909 men; mean [SE] age, 74.5 [0.3] years) reported having voice disorders. Of those with voice disorders, 10.0% (95% CI, 8.3%-11.7%) sought treatment. Of individuals seeking treatment, 22.1% (95% CI, 7.9%-36.3%) saw an otolaryngologist and 24.3% (95% CI, 10.6%-38.0%) saw a speech language pathologist. By controlling for race/ethnicity, income, sex, and geography, it was found that men were less likely than women to report voice disorders (36.1% [95% CI, 31.7%-40.5%] vs 63.9% [95% CI, 59.5%-68.3%]; odds ratio, 0.70; 95% CI, 0.57-0.86). Race/ethnicity, income, and geography were not significantly associated with the likelihood that an individual 65 years or older reported voice disorders. A greater percentage of elderly adults seeking treatment than not seeking treatment reported improvement in symptoms (32.4%; 95% CI, 17.9%-47.0% vs 15.6%; 95% CI, 10.4%-20.8%). Among adults treated for a voice disorder, a lower proportion of adults 65 years or older reported improvement in symptoms with treatment compared with adults younger than 65 years (32.4%; 95% CI, 17.9%-47.0% vs 56.0%; 95% CI, 42.5%-69.6%).
Conclusions and Relevance: A small percentage of older adults with voice disorders seek treatment; even fewer are treated by an otolaryngologist or a speech language pathologist. A greater percentage of those who undergo treatment experienced symptomatic improvement compared with those who did not undergo treatment. These trends highlight the need for greater access to and awareness of services available to older adults with voice disorders.

PMID: 30003217 [PubMed - as supplied by publisher]

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Association of Symptoms and Clinical Findings With Anticipated Outcomes in Patients With Recurrent Head and Neck Cancer.

Related Articles

Association of Symptoms and Clinical Findings With Anticipated Outcomes in Patients With Recurrent Head and Neck Cancer.

JAMA Otolaryngol Head Neck Surg. 2018 Jul 12;:

Authors: Pipkorn P, Licata J, Kallogjeri D, Piccirillo JF

Abstract
Importance: Despite advances in treatment over the last decades, recurrent head and neck cancer continues to have a poor prognosis. Prognostic accuracy may help in patient counseling.
Objective: To explore whether symptoms and clinical variables can predict prognosis in the setting of recurrent head and neck cancer.
Design, Setting, and Participants: In this retrospective cohort study, patients treated for head and neck cancer with curative intent at Siteman Cancer Center in St Louis, Missouri (a tertiary cancer center) between January 1, 2007, and December 31, 2014, were reviewed. The dates of data analysis were October 2016 to June 2017. Patients who developed a recurrent cancer were included, with 196 patients meeting inclusion criteria.
Main Outcomes and Measures: Symptoms and clinical findings at presentation of recurrence were recorded. Sequential sequestration and conjunctive consolidation (2 multivariable techniques) were used to create a composite staging system to predict 1-year overall survival (OS).
Results: Among 196 patients (mean [SD] age, 61 [11] years; 166 [84.7%] of white race/ethnicity; 76.5% male), 1-year OS was 58.2% (114 of 196 patients). Time to recurrence, symptom severity stage, and rTNM stage were consolidated into a 3-category Clinical Severity Staging System, with 1-year OS rates of 90.2% (95% CI, 82.7%-97.6%) for the 61 patients classified as A, 58.1% (95% CI, 47.7%-68.6%) for the 86 patients classified as B, and 18.4% (95% CI, 7.5%-29.2%) for the 49 patients classified as C. The discriminative power of the new composite staging was better than that of the American Joint Committee on Cancer classification (C = 0.79 vs C = 0.66).
Conclusions and Relevance: These findings suggest that clinical variables are associated with anticipated outcomes in patients with recurrent head and neck cancer.

PMID: 30003215 [PubMed - as supplied by publisher]

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Impact of balloon laryngoplasty on management of acute subglottic stenosis

Abstract

Purpose

To assess the impact of balloon laryngoplasty on clinical and surgical outcomes in pediatric patients with acute subglottic stenosis.

Methods

Two case series were included and compared. The first group included patients treated initially either with tracheostomy (if severe symptoms) or with close follow-up (if mild symptoms). Those children underwent re-evaluation and specific treatment of their stenosis with laser incisions or open surgeries some weeks later. The other group included children treated initially with balloon laryngoplasty, reflecting a shift in surgical practice after 2009. Data as success of the procedure, mean hospital stay, mean pediatric intensive care unit (PICU) stay, post-procedure fever, need of antibiotics, procedure-related complications, and deaths were assessed and compared between both cohorts.

Results

The sample comprised 38 pediatric patients aged 0–5 years. Fifteen children were treated before 2009, of who 10 (66.7%) required tracheostomy soon after the diagnosis. Ultimately, 13 (86.6%) underwent laryngotracheal reconstruction. Twenty-three children were treated after 2009 and the success rate in these patients treated primarily with balloon laryngoplasty was 82.6%. Of these, only 3 (13%) required tracheostomy and 1 (4.3%) required further open laryngotracheal reconstruction. Patients treated by balloon laryngoplasty underwent fewer procedures under general anesthesia and had a lower burden of treatment-related morbidity, as denoted by shorter PICU stay, less antibiotic use, earlier postoperative resumption of oral feeding, and a lower incidence of postoperative complications and fever.

Conclusion

When used for management of acute laryngeal stenosis, balloon laryngoplasty is associated with a high success rate, presenting lower morbidity than open surgery.

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Comparison between Slow Components of HR and V˙O2 Kinetics: Functional Significance

Purpose Aerobic exercise prescription is often based on a linear relationship between pulmonary oxygen consumption (V˙O2) and heart rate (HR). The aim of the present study was to test the hypothesis that during constant work rate (CWR) exercises at different intensities, the slow component of HR kinetics occurs at lower work rate and is more pronounced that the slow component of V˙O2 kinetics. Methods Seventeen male (age, 27 ± 4 yr) subjects performed on a cycle ergometer an incremental exercise to voluntary exhaustion and several CWR exercises: 1) moderate CWR exercises, below gas exchange threshold (GET); 2) heavy CWR exercise, at 45% of the difference between GET and V˙O2 peak (Δ); 3) severe CWR exercise, at 95% of Δ; 4) "HRCLAMPED" exercise in which work rate was continuously adjusted to maintain a constant HR, slightly higher than that determined at GET. Breath-by-breath V˙O2, HR, and other variables were determined. Results In moderate CWR exercises, no slow component of V˙O2 kinetics was observed, whereas a slow component with a relative amplitude (with respect to the total response) of 24.8 ± 11.0% was observed for HR kinetics. During heavy CWR exercise, the relative amplitude of the HR slow component was more pronounced than that for V˙O2 (31.6 ± 11.2% and 23.3 ± 9.0%, respectively). During HRCLAMPED, the decrease in work rate (~14%) needed to maintain a constant HR was associated with a decreased V˙O2 (~10%). Conclusions The HR slow component occurred at a lower work rate and was more pronounced than the V˙O2 slow component. Exercise prescriptions at specific HR values, when carried out for periods longer than a few minutes, could lead to premature fatigue.

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Acute Effect of Noradrenergic Modulation on Motor Output Adjustment in Men

Purpose To determine the role of noradrenergic modulation in the control of motor output, we compared the acute effect of reboxetine (REB), a noradrenaline reuptake inhibitor, to a placebo (PLA) on knee extensors motor performance and cortical and spinal excitability. Methods Eleven young men took part in two randomized experiments during which they received either 8 mg of REB or a PLA. The torque produced during a maximal voluntary contraction (MVC) and its variability (i.e., coefficient of variation) during submaximal contractions ranging from 5% to 50% MVC were measured. Paired electrical (PES) and transcranial magnetic stimulation (TMS) were used to assess changes in voluntary activation during MVC, and corticospinal (motor-evoked potential (MEP)) and spinal excitability (Hoffmann (H) reflex) during contraction at 20% MVC. Results MVC torque and torque steadiness increased respectively by 9.5% and 24% on average in REB compared with PLA condition (P

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Caffeine, CYP1A2 Genotype, and Endurance Performance in Athletes

Purpose Many studies have examined the effect of caffeine on exercise performance, but findings have not always been consistent. The objective of this study was to determine whether variation in the CYP1A2 gene, which affects caffeine metabolism, modifies the ergogenic effects of caffeine in a 10-km cycling time trial. Methods Competitive male athletes (n = 101; age = 25 ± 4 yr) completed the time trial under three conditions: 0, 2, or 4 mg of caffeine per kilogram body mass, using a split-plot randomized, double-blinded, placebo-controlled design. DNA was isolated from saliva and genotyped for the −163A > C polymorphism in the CYP1A2 gene (rs762551). Results Overall, 4 mg·kg−1 caffeine decreased cycling time by 3% (mean ± SEM) versus placebo (17.6 ± 0.1 vs 18.1 ± 0.1 min, P = 0.01). However, a significant (P

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Functional Endoscopic Sinus Surgery of Nasal Polyposis: The Vexing Question of Whether to Resect or Preserve Middle Turbinate

Abstract

Functional endoscopic sinus surgery is the mainstay of surgical management of nasal polyposis since 1975. The decision between the partial resection and preservation of the middle turbinate (MT) has stirred up considerable debate. Partial MTR permits easy access to the affected paranasal sinuses intraoperatively and postoperatively. However, there may be alteration of nasal function, frontal sinusitis and anosmia. Preservation of middle turbinate is precludes these complications, and allows the MT to serve as a vital anatomical landmark for revision surgery. Therefore, our study compared the outcomes of the two approaches to aid surgeons in deciding the best possible approach. Randomized control trial. 31 patients (60 sides of nasal cavity) with nasal polyposis were divided into two groups. Group I consisted of 30 sides of nasal cavity with middle turbinate resection, while group II consisted of 30 sides of nasal cavity without middle turbinate resection. Both the groups were compared postoperatively for 6 months. In group I and group II, 5 sides (16.6%) and 11 sides (36.6%) showed polypoidal changes respectively. 3 sides (10%) in group I and 8 sides (26.6%) in group II showed blockage of maxillary sinus ostia. All the sides in group I had patency of frontal sinus. In group II, 5 sides (16.6%) showed blockage of frontal sinus ostia. The maxillary antrostomy patency in group I and group II were 90% (27) and 73.33% (22) respectively. Assessment of symptomatic improvements for nasal obstruction, hyposmia, headache and rhinorrhoea was done using questionnaires. Symptomatic improvement was higher in group I compared to group II with statistical significance (p = 0.001). Our study demonstrated that partial resection of middle turbinate decreased the chances of recurrence of disease and post-operative complications and resulted in significantly better symptomatic improvements.

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Virtual Reality Analgesia in Labor: The VRAIL Pilot Study—A Preliminary Randomized Controlled Trial Suggesting Benefit of Immersive Virtual Reality Analgesia in Unmedicated Laboring Women

This pilot study investigated the use of virtual reality (VR) in laboring women. Twenty-seven women were observed for equivalent time during unmedicated contractions in the first stage of labor both with and without VR (order balanced and randomized). Numeric rating scale scores were collected after both study conditions. Significant decreases in sensory pain −1.5 (95% CI, −0.8 to −2.2), affective pain −2.5 (95% CI, −1.6 to −3.3), cognitive pain −3.1 (95% CI, −2.4 to −3.8), and anxiety −1.5 (95% CI, −0.8 to −2.3) were observed during VR. Results suggest that VR is a potentially effective technique for improving pain and anxiety during labor. Accepted for publication June 6, 2018. D. P. Frey is currently affiliated with the Oregon Anesthesiology Group, Obstetric Anesthesiology, Providence Portland Medical Center, Portland, Funding: Funding for this study was provided by the Department of Anesthesiology, University of Michigan as well as in part by the National Institutes of Health (AR054115 and GM042725). 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). Clinical trial: NCT02926469 at https://ift.tt/2zCUsXv. Reprints will not be available from the authors. Address correspondence to David P. Frey, DO, Oregon Anesthesiology Group, Obstetric Anesthesiology, Providence Portland Medical Center, 707 SW Washington St, Suite 700, Portland, OR 97205. Address e-mail to VRAILQuestions@gmail.com. © 2018 International Anesthesia Research Society

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In Response

No abstract available

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Frequency of Operative Anesthesia Care After Traumatic Injury

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I–V), using data from a comprehensive, regional database—the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III–V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P

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A Systematic Review Evaluating Neuraxial Morphine and Diamorphine-Associated Respiratory Depression After Cesarean Delivery

The prevalence of neuraxial opioid–induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20–15.16) and 5.96 per 10,000 (95% CI, 2.23–11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62–8.77) and 1.08 per 10,000 (95% CI, 0.24–7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51–74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low. 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). Accepted for publication May 31, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Nadir Sharawi, MBBS, FRCA, MSc, Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 515, Little Rock, AR 72205. Address e-mail to nelsharawi@uams.edu. © 2018 International Anesthesia Research Society

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Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery

BACKGROUND: Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS: We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32–36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS: Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60–0.84] vs 0.68 [0.54–0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54–0.92) and a specificity of 74% (95% CI, 0.55–0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42–0.88) and a specificity of 74% (95% CI, 0.48–0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP= 0.818 [P = .0001]; PPVPC= 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP= 0.645 [P = .19]; PPVPC= 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: −2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66–77). CONCLUSIONS: In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness. Accepted for publication June 7, 2018. A. Joosten and C. Boudart contributed equally and share first authorship. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Registration: Clinicaltrials.gov (NCT02692222). Reprints will not be available from the authors. Address correspondence to Alexandre Joosten, MD, Department of Anesthesiology, Hopital Erasme, 808 Rt de Lennik, 1070 Bruxelles, Brussels, Belgium. Address e-mail to Alexandre.Joosten@erasme.ulb.ac.be. © 2018 International Anesthesia Research Society

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Did ultrasound fulfill the promise of safety in regional anesthesia?

Purpose of review Ultrasound guidance has become the accepted standard of practice for peripheral regional anesthesia. Despite evidence supporting the efficacy of ultrasound-guided regional anesthesia, its impact on patient safety has been less clear. Recent findings Evidence has been consistent that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax and phrenic nerve block. Within the limited global scope of the epidemiology and etiologic complexity of perioperative (including block-related) peripheral nerve injury, there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. However, a recently published retrospective cohort study has demonstrated that the incidence of short-term nerve injury was decreased with ultrasound guidance compared with nerve stimulation. Ultrasound has led to development of novel blocks, approaches and refinement of existing ones, which may contribute to patient safety. Summary Ultrasound has revolutionized the way we approach regional anesthesia and contributed to patient safety. It is important to note that patient safety does not hinge on one single technology. Patient safety in regional anesthesia relies on a well trained practitioner to pay meticulous attention to indication, block and patient selection, anatomy, pharmacology, equipment and technique. Correspondence to Michael J. Barrington, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia. Tel: +61 3 9288 2211; e-mail: Michael.BARRINGTON@svha.org.au Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Traumatic brain injured patients: primum non nocere

Purpose of review Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI. Recent findings Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired. Summary Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population. Correspondence to Dr Dhuleep S. Wijayatilake, Department of Anaesthesia and Intensive Care Medicine, Queens Hospital, Rom Valley Way, Romford RM7 0AG, UK. Tel: +44 1708503727; e-mail: sanjay.wijayatilake@nhs.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Stratification of neuropathic pain patients: the road to mechanism-based therapy?

Purpose of review It has been demonstrated that within one pain entity, patients may report highly heterogenic sensory signs and symptoms. Although mechanism might differ fundamentally between those patients, yet the treatment recommendations are uniform throughout all phenotypes. Therefore, the introduction of new stratification tools could pave the way to an individualized pain treatment. Recent findings In the past, retrospective stratifications of patients successfully identified responders to certain pharmacological treatments. This indicated predictive validity and reliability of this classification tool in those patient subgroups. Further on, these observations have been confirmed in prospective studies. Summary This review focusses on recent achievements in neuropathic pain and suggests a promising implementation of an individualized pharmacological therapy in the future. Correspondence to Dr Ralf Baron, MD, Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany. Tel: +49 431 500 23911; fax: +49 431 500 23914; e-mail: r.baron@neurologie.uni-kiel.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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New blocks for the same old joints

Purpose of review New block techniques are being constantly developed or old techniques modified to improve outcomes after surgery. This review discusses the reasons why new block techniques need to be developed to match the needs of contemporary anesthetic practice. Recent findings New block techniques have been developed for joint surgeries of both upper and lower extremities. New upper extremity blocks focus on decreasing the risk of complications like diaphragmatic paresis and improving the quality of blocks. Techniques for lower extremity surgeries are being performed distally, closer to the joints, to minimize weakness of the extremity. A review of the available evidence for these techniques is undertaken to get an understanding of the indications and limitations of these techniques. Summary Future studies need to be undertaken to further refine these techniques and produce evidence of support for analgesic efficacy, safety, and reliability. Correspondence to Sanjay K. Sinha, MBBS, Department of Anesthesiology, St. Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105, USA. E-mail: sanjaysinha@comcast.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Regional anesthesia by nonanesthesiologists

Purpose of review As the evidence supporting the notion that regional anesthesia improves patient outcomes grows, utilization of regional anesthesia techniques has similarly increased. Best care should not be restricted by the background of care providers, however, the evidence replicating benefits of regional anesthesia when it is delivered by nonanesthesiologists is unclear. In this review, the provision of regional anesthesia by nonanesthesiologists is discussed so that readers can come to their own conclusions. Recent findings Regional anesthesia procedures are performed by nonanesthesiology physicians such as emergency physicians, critical care specialists, and surgeons. Patients benefit from the provision of regional anesthesia by these groups, but inconsistencies exist in training, service provision, and collaboration between these specialties and anesthesiologists. Nonphysician anesthesia providers also provide regional anesthesia. There are limited data on outcomes or benefits of this nonphysician-provided service, but consideration of team-based care and alternative models of care based upon geographical need is worthwhile. Summary The provision of regional anesthesia requires the accumulation of a suitable knowledge, skills, and behaviors that can be taught. Whilst it may not be appropriate for all techniques to be performed by all individuals, the possession of these competencies with the appropriate training and quality assurance means that more patients may ultimately benefit from the provision of regional anesthesia services. Correspondence to Amit Pawa, BSc(Hons), MBBS(Hons), FRCA, EDRA, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, SE1 9RT London, UK. Tel: +44 207 188 0644; fax: +44 207 188 0642; e-mail: amit.pawa@gstt.nhs.uk. Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Neuroanesthesiology: building the path to superior clinical care through research and education

No abstract available

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