Esophageal lesions following button-battery ingestion in children: Analysis of causes and proposals for preventive measures

Publication date: Available online 18 October 2017
Source:European Annals of Otorhinolaryngology, Head and Neck Diseases
Author(s): J. Lahmar, C. Célérier, E.N. Garabédian, V. Couloigner, N. Leboulanger, F. Denoyelle
ObjectivesTo study recent cases of esophageal injury due to button-battery ingestion in children presenting in pediatric ENT emergency departments of the Paris area of France (Île-de-France region), in order to propose appropriate preventive measures.Material and methodA retrospective descriptive single-center study included all children under 15 years of age, presenting in pediatric ENT emergency departments between January 2008 and April 2014 for button-battery ingestion with esophageal impaction requiring emergency removal.ResultsTwenty-two boys and 4 girls, with a median age of 25 months, were included. Twenty-five of the 26 batteries had diameters of 20mm or more. Median esophageal impaction time was 7 hours 30 minutes (range, 2 to 72 hours). The complications rate was 23%. Mean hospital stay cost was €38,751 (range, €5130–119,737). The origin of the battery was known in 23 of the 26 cases: remote control without screw-secured compartment (42.3%), open battery pack (15.4%), children's toy (15.3%), camera (7.7%), watch (1 case) and hearing aid without screw-secured compartment (1 case).ConclusionEsophageal lesions due to ingestion of button-batteries in children are almost always due to batteries larger than 20mm in diameter, mostly from devices with a poorly protected compartment, or batteries that are not individually packaged. These lesions cause serious complications in a quarter of cases and their management entails high health costs. Legislation requiring screw-secured compartments and individual blisters for batteries could have prevented 69.2% of the ingestions.



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Gastric cancer: immunohistochemical classification of molecular subtypes and their association with clinicopathological characteristics

Abstract

Gastric cancer is traditionally divided into intestinal and diffuse histological subtypes, but recent molecular analyses have led to novel classification proposals based on genomic alterations. While the intestinal- and diffuse-type tumours are distinguishable from each other at the molecular level, intestinal-type tumours have more diverse molecular profile. The technology required for comprehensive molecular analysis is expensive and not applicable for routine clinical diagnostics. In this study, we have used immunohistochemistry and in situ hybridisation in molecular classification of gastric adenocarcinomas with an emphasis on the intestinal subtype. A tissue microarray consisting of 244 gastric adenocarcinomas was constructed, and the tumours were divided into four subgroups based on the presence of Epstein-Barr virus, TP53 aberrations and microsatellite instability. The intestinal- and diffuse-type tumours were separately examined. The distribution of EGFR and HER2 gene amplifications was studied in the intestinal-type tumours. Epstein-Barr virus positive intestinal-type tumours were more common in male patients (p = 0.035) and most often found in the gastric corpus (p = 0.011). The majority of the intestinal-type tumours with TP53 aberrations were proximally located (p = 0.010). All tumours with microsatellite instability showed intestinal-type histology (p = 0.017) and were associated with increased overall survival both in the univariate (p = 0.040) and multivariate analysis (p = 0.015). In conclusion, this study shows that gastric adenocarcinomas can be classified into biologically and clinically different subgroups by using a simple method also applicable for clinical diagnostics.

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Macroglossia During Awake Craniotomy: A Near Miss.

No abstract available

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Correlation between computed tomography imaging and histopathology in pleomorphic adenoma of parotid gland

The purpose of this study was to correlate the CT imaging features and histopathological findings of pleomorphic adenomas (PA), and also try to identify its clinical significance.

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Baseline asthma burden, comorbidities, and biomarkers in omalizumab-treated patients in PROSPERO

Patients included in clinical trials do not necessarily reflect the real-world population.

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Behavioral Animal Model of the Emotional Response to Tinnitus and Hearing Loss

Abstract

Increased prevalence of emotional distress is associated with tinnitus and hearing loss. The underlying mechanisms of the negative emotional response to tinnitus and hearing loss remain poorly understood, and it is challenging to disentangle the emotional consequences of hearing loss from those specific to tinnitus in listeners experiencing both. We addressed these questions in laboratory rats using three common rodent anxiety screening assays: elevated plus maze, open field test, and social interaction test. Open arm activity in the elevated plus maze decreased substantially after one trial in controls, indicating its limited utility for comparing pre- and post-treatment behavior. Open field exploration and social interaction behavior were consistent across multiple sessions in control animals. Individual sound-exposed and salicylate-treated rats showed a range of phenotypes in the open field, including reduced entries into the center in some subjects and reduced locomotion overall. In rats screened for tinnitus, less locomotion was associated with higher tinnitus scores. In salicylate-treated animals, locomotion was correlated with age. Sound-exposed and salicylate-treated rats also showed reduced social interaction. These results suggest that open field exploratory activity is a selective measure for identifying tinnitus distress in individual animals, whereas social interaction reflects the general effects of hearing loss. This animal model will facilitate future studies of the structural and functional changes in the brain pathways underlying emotional distress associated with hearing dysfunction, as well as development of novel interventions to ameliorate or prevent negative emotional responses.

http://ift.tt/2gtMqYd

Behavioral Animal Model of the Emotional Response to Tinnitus and Hearing Loss

Abstract

Increased prevalence of emotional distress is associated with tinnitus and hearing loss. The underlying mechanisms of the negative emotional response to tinnitus and hearing loss remain poorly understood, and it is challenging to disentangle the emotional consequences of hearing loss from those specific to tinnitus in listeners experiencing both. We addressed these questions in laboratory rats using three common rodent anxiety screening assays: elevated plus maze, open field test, and social interaction test. Open arm activity in the elevated plus maze decreased substantially after one trial in controls, indicating its limited utility for comparing pre- and post-treatment behavior. Open field exploration and social interaction behavior were consistent across multiple sessions in control animals. Individual sound-exposed and salicylate-treated rats showed a range of phenotypes in the open field, including reduced entries into the center in some subjects and reduced locomotion overall. In rats screened for tinnitus, less locomotion was associated with higher tinnitus scores. In salicylate-treated animals, locomotion was correlated with age. Sound-exposed and salicylate-treated rats also showed reduced social interaction. These results suggest that open field exploratory activity is a selective measure for identifying tinnitus distress in individual animals, whereas social interaction reflects the general effects of hearing loss. This animal model will facilitate future studies of the structural and functional changes in the brain pathways underlying emotional distress associated with hearing dysfunction, as well as development of novel interventions to ameliorate or prevent negative emotional responses.

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Development and evaluation of novel biodegradable chitosan based metformin intrapocket dental film for the management of periodontitis and alveolar bone loss in a rat model

Publication date: January 2018
Source:Archives of Oral Biology, Volume 85
Author(s): Deepak Kumar Khajuria, Omprakash Nandikamba Patil, David Karasik, Rema Razdan
ObjectiveThe aim of this study was to develop a chitosan-metformin based intrapocket dental film (CMIDF) for applications in the treatment of periodontitis and alveolar bone loss in an rat model of periodontitis.DesignCMIDF inserts were fabricated by the solvent casting technique. The fabricated inserts were evaluated for physical characteristics such as folding endurance, surface pH, mucoadhesive strength, metformin content uniformity, and release. X-ray diffraction analysis indicates no crystallinity of metformin in presence of chitosan which confirmed successful entrapment of metformin into the CMIDF. Fourier-transform infrared spectroscopy revealed stability of CMIDF and compatibility between metformin and chitosan. Periodontitis was induced by a combination of Porphyromonas gingivalis- lipopolysaccharide injections in combinations with ligatures around the mandibular first molar. We divided rats into 5 groups (8 rats/group): healthy, untreated periodontitis; periodontitis plus CMIDF-A (1.99±0.09mg metformin; total mass-4.01±0.05mg), periodontitis plus CMIDF-B (2.07±0.06mg metformin; total mass-7.56±0.09mg), and periodontitis plus chitosan film (7.61±0.08mg). After four weeks, mandibles were extracted to evaluate alveolar bone loss by micro-computerized tomography and histological techniques.ResultsAlveolar bone was intact in the healthy group. Local administration of CMIDF resulted in significant improvements in the alveolar bone properties when compared to the untreated periodontitis group. The study reported here demonstrates that novel CMIDF showed good antibacterial activity and effectively reduced alveolar bone destruction in a rat model of experimental periodontitis.ConclusionsNovel CMIDF showed good antibacterial activity and improved alveolar bone properties in a rat model.

Graphical abstract

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Clinical implications of pathologic factors after thyroid lobectomy in patients with papillary thyroid carcinoma

Publication date: December 2017
Source:Oral Oncology, Volume 75
Author(s): Young Min Park, Doh Young Lee, Kyung Ho Oh, Jae-Gu Cho, Seung-Kuk Baek, Soon-Young Kwon, Kwang-Yoon Jung, Jeong-Soo Woo
ObjectiveWe evaluated the clinical and prognostic significance of pathologic factors by analyzing the treatment results of patients who underwent thyroid lobectomy.Materials and methodsWe retrospectively analyzed data from 734 patients diagnosed with papillary thyroid cancer who underwent thyroid lobectomy at Korea University Hospital from January 2004 to December 2016.ResultsA total of 734 patients were included in the study and their mean age was 44.5 years (range, 15–83). On univariate analysis, tumor size and recurrence-free survival were significantly related. The 10-year recurrence-free survival was 98.3% for tumors ≤1cm, 77.8% for >1cm and ≤2cm, and 66.7% for >2cm (p = 0.014). Recurrence-free survival was significantly different between patients with and without microscopic extrathyroidal extension (p=0.002). The 10-year recurrence-free survival rate was 99.2% for patients without extrathyroidal extension and 92.2% for patients with microscopic extrathyroidal extension. Multivariate analysis showed only microscopic extrathyroidal extension was significantly correlated with recurrence-free survival (p=0.029).ConclusionIn patients undergoing thyroid lobectomy for low-risk papillary thyroid cancer, microscopic extrathyroidal extension was an important prognostic factor associated with recurrence-free survival. However, in cases with microscopic extrathyroidal extension findings on postoperative pathologic examination, appropriate ultrasonographic follow-up of the contralateral thyroid lobe and cervical lymph node to facilitate early detection and prompt treatment of recurrence can control the disease without a deterioration of survival rate.



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Verathon launches portable handheld video laryngoscope system

By EMS1 Staff Verathon Inc. announced the launch of its GlideScope Go video laryngoscope system at EMS World Expo 2017. GlideScope Go features a scratch-resistant 3.5-inch color display with anti-glare coating and a wide field of view. It is compatible with GlideScope Spectrum single-use blades, for patients ranging from neonate to large adults. It is designed to provide clear airway views in a wide ...

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Successful treatment of a recurrent granulation polyp in the airways with high-dose-rate brachytherapy: a case report

Benign central airway tumors are very rare diseases. Their unspecific symptoms are responsible for late diagnosis. Endoscopic interventions with different techniques and tools are widely used for their treatme...

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Priming Immunotherapy in Advanced Disease With Radiation

Conditions:   Non-small Cell Lung Cancer;   Squamous Cell Carcinoma of the Head and Neck
Interventions:   Drug: Immune checkpoint inhibitor;   Radiation: Radiation Therapy
Sponsor:   John L. Villano, MD, PhD
Not yet recruiting

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Neoadjuvant Treatment Associated With Maintenance Therapy by Anti-PD1 Immunotherapy in Patients With Resectable Head and Neck Mucosal Melanoma

Condition:   Resectable Head and Neck Mucosal Melanomas
Interventions:   Drug: Pembrolizumab;   Procedure: Surgery;   Radiation: IMRT
Sponsor:   Gustave Roussy, Cancer Campus, Grand Paris
Not yet recruiting

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Recovery from Cogwheel Rigidity and Akinesia and Improvement in Vibration Sense and Olfactory Perception following Removal of an Epoxy-Oleic Acid DNA Adduct

The epoxy fatty acid cis-12,13-epoxy-oleic acid, which acts as a DNA adduct, may be generated during long-term storage of many seed oils, including those used in cooking, with frying oils and fried foods being a major source in the modern human diet. Removal of this epoxy fatty acid from the locus of the N-formyl peptide receptors was associated with recovery from cogwheel rigidity and akinesia as well as with improvement in vibration sense and olfactory perception.

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Overt Lower Gastrointestinal Bleeding and Pseudotumor: A Rare Presentation of Cytomegalovirus Infection

Cytomegalovirus (CMV) is a ubiquitous organism which can infect multiple organs of the body. In an immunocompromised patient, it can have a myriad of gastrointestinal manifestations. We report a case of recurrent hematochezia and concomitant pseudotumor in an AIDS (acquired immunodeficiency syndrome) patient attributable to CMV infection. A 62-year-old man with a history of AIDS, noncompliant with highly active antiretroviral therapy (HAART), presented with bright red blood per rectum. Index colonoscopy showed presence of multiple ulcers, colonic stenosis, and mass-like appearing lesion. Biopsy confirmed CMV infection and ruled out malignancy. Cessation of dual antiplatelet therapy and compliance with HAART lead to clinical cessation of bleeding and endoscopic healing of ulcers with complete resolution of colon mass on follow-up colonoscopy.

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Book Review—Practical Hepatic Pathology: A Diagnostic Approach, 2nd Edition

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Atypical Presentation of Sjögren-Larsson Syndrome

Sjögren-Larsson syndrome is a rare neurocutaneous disorder characterized by ichthyosis, spastic diplegia or tetraplegia, and intellectual disability. Herein, we describe a case of a Greek patient with ichthyosis and spasticity of the legs but with normal intelligence (IQ 95). This syndrome should be suspected when a child presents with ichthyosis and spastic diplegia or tetraplegia, even if intelligence is normal.

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Fundamental Epidemiology Terminology and Measures: It Really Is All in the Name

Epidemiology is the study of how disease is distributed in populations and the factors that influence or determine this distribution. Clinical epidemiology denotes the application of epidemiologic methods to questions relevant to patient care and provides a highly useful set of principles and methods for the design and conduct of quantitative clinical research. Validly analyzing, correctly reporting, and successfully interpreting the findings of a clinical research study often require an understanding of the epidemiologic terms and measures that describe the patterns of association between the exposure of interest (treatment or intervention) and a health outcome (disease). This statistical tutorial thus discusses selected fundamental epidemiologic concepts and terminology that are applicable to clinical research. Incidence is the occurrence of a health outcome during a specific time period. Prevalence is the existence of a health outcome during a specific time period. The relative risk can be defined as the probability of the outcome of interest (eg, developing the disease) among exposed individuals compared to the probability of the same event in nonexposed individuals. The odds ratio is a measure of risk that compares the frequency of exposure to a putative causal factor in the individuals with the health outcome (cases) versus those individuals without the health outcome (controls). Factors that are associated with both the exposure and the outcome of interest need to be considered to avoid bias in your estimate of risk. Because it takes into consideration the contribution of extraneous variables (confounders), the adjusted odds ratio provides a more valid estimation of the association between the exposure and the health outcome and thus is the preferably reported measure. The odds ratio closely approximates the risk ratio in a cohort study or a randomized controlled trial when the outcome of interest does not occur frequently (

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Intraoperative Esmolol as an Adjunct for Perioperative Opioid and Postoperative Pain Reduction: A Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND: BACKGROUND:Esmolol is an ultrashort β-1 receptor antagonist. Recent studies suggest a role for esmolol in pain response modulation. The authors performed a meta-analysis to determine if the intraoperative use of esmolol reduces opioid consumption or pain scores. METHODS: METHODS:PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, pubget, and Google Scholar were searched. Studies were included if they were randomized, placebo- or opioid-controlled trials written in English, and performed on patients 18 years of age or older. For comparison of opioid use, included studies tracked opioid consumption intraoperatively and/or in the postanesthesia care unit. Pain score comparisons were performed during the first hour after surgery. RESULTS: RESULTS:Seventy-three studies were identified, 23 were included in the systematic review, and 19 were eligible for 1 or more comparisons. In 433 patients from 7 trials, intraoperative esmolol decreased intraoperative opioid consumption (Standard Mean Difference [SMD], −1.60; 95% confidence interval [CI], −2.25 to −0.96; P ≤ .001). In 659 patients from 12 trials, intraoperative esmolol decreased postanesthesia care unit opioid consumption (SMD, −1.21; 95% CI, −1.66 to −0.77; P ≤ .001). In 688 patients from 11 trials, there was insufficient evidence of change in postoperative 1 hour pain scores (SMD, −0.60; 95% CI, −1.44 to 0.24; P = .163). CONCLUSIONS: CONCLUSIONS:This meta-analysis demonstrates that intraoperative esmolol use reduces both intraoperative and postoperative opioid consumption, with no change in postoperative pain scores. Accepted for publication August 3, 2017. Funding: Support was provided solely from institutional and/or departmental sources of the Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA. 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 (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to T. Anthony Anderson, MD, PhD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr, H3590A MC5640, Stanford, CA 94305. Address e-mail to tanders0@stanford.edu. © 2017 International Anesthesia Research Society

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Standardized Care Versus Precision Medicine: Do We Really Need to Wait for Point-of-Care Testing?

No abstract available

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In Response: Subcellular Energetics and Metabolism A Cross-Species Framework

No abstract available

http://ift.tt/2gisdRe

In Response: Standardized Care Versus Precision Medicine; Do We Really Need to Wait for Point-of-Care Testing?

No abstract available

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Subcellular Energetics and Metabolism: A Cross-Species Framework

No abstract available

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Patient Harm in Cataract Surgery: A Series of Adverse Events in Massachusetts

Massachusetts state agencies received reports of 37 adverse events (AEs) involving cataract surgery from 2011 to 2015. Fifteen were anesthesia related, including 5 wrong eye blocks, 3 cases of hemodynamic instability, 2 retrobulbar hematoma/hemorrhages, and 5 globe perforations resulting in permanent loss of vision. While Massachusetts' reported AEs likely underrepresent the true number of AEs that occur during cataract surgery, they do offer useful signal data to indicate the types of patient harm occurring during these procedures. Accepted for publication August 16, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Karen C. Nanji, MD, MPH, Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to knanji@partners.org. © 2017 International Anesthesia Research Society

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Patient Blood Management in Pediatric Cardiac Surgery: A Review

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation. Accepted for publication August 24, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jill M. Cholette, MD, 601 Elmwood Ave, Box 667, Rochester, NY 14642. Address e-mail to Jill_Cholette@urmc.rochester.edu. © 2017 International Anesthesia Research Society

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Photoplethysmography and Heart Rate Variability for the Diagnosis of Preeclampsia

BACKGROUND: BACKGROUND:The goal of this study was to determine a set of timing, shape, and statistical features available through noninvasive monitoring of maternal electrocardiogram and photoplethysmography that identifies preeclamptic patients. METHODS: METHODS:Pregnant women admitted to Labor and Delivery were monitored with pulse oximetry and electrocardiogram for 30 minutes. Photoplethysmogram features and heart rate variability were extracted from each data set and applied to a sequential feature selection algorithm to discriminate women with preeclampsia with severe features, from normotensive and hypertensive controls. The classification boundary was chosen to minimize the expected misclassification cost. The prior probabilities of the misclassification costs were assumed to be equal. RESULTS: RESULTS:Thirty-seven patients with clinically diagnosed preeclampsia with severe features were compared with 43 normotensive controls; all were in early labor or beginning induction. Six variables were used in the final model. The area under the receiver operating characteristic curve was 0.907 (standard error [SE] = 0.004) (sensitivity 78.2% [SE = 0.3%], specificity 89.9% [SE = 0.1%]) with a positive predictive value of 0.883 (SE = 0.001). Twenty-eight subjects with chronic or gestational hypertension were compared with the same preeclampsia group, generating a model with 5 features with an area under the curve of 0.795 (SE = 0.007; sensitivity 79.0% [SE = 0.2%], specificity 68.7% [SE = 0.4%]), and a positive predictive value of 0.799 (SE = 0.002). CONCLUSIONS: CONCLUSIONS:Vascular parameters, as assessed noninvasively by photoplethysmography and heart rate variability, may have a role in screening women suspected of having preeclampsia, particularly in areas with limited resources. Accepted for publication August 24, 2017. Funding: This material is based on study supported by the National Institutes of Health (Grant No. 1R41HD075550-1). 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 (http://ift.tt/KegmMq). Reprints will not be available from the authors. Clinical trial identification number: UF IRB: 189–2011; URL of the registration site: http://irb.ufl.edu. Address correspondence to Tammy Y. Euliano, MD, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, P.O. Box 100254, Gainesville, FL 32610. Address e-mail to teuliano@anest.ufl.edu. © 2017 International Anesthesia Research Society

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An Intraplantar Hypertonic Saline Assay in Mice for Rapid Screening of Analgesics

BACKGROUND: BACKGROUND:Development of new analgesics is limited by shortcomings of existing preclinical screening assays such as wide variations in response, suitability for a narrow range of analgesics, and propensity to induce tissue damage. Our aim was to determine the feasibility of a new in vivo animal assay as an analgesic screen based on nociceptive responses (licking and biting) after intraplantar (i.pl.) injection of hypertonic saline (HS) in mice. METHODS: METHODS:With approval from the Institutional Animal Care Committee, we conducted a randomized, investigator-blinded in vivo study in adult CD-1 mice. We first studied the concentration–response relationship, time course, and sex difference of animals' nociceptive responses to HS. Subsequently, we assessed the screening ability of the HS assay to detect a range of established analgesics belonging to different classes. Finally, we performed histopathologic studies to assess potential tissue damage. RESULTS: RESULTS:The response produced by i.pl. HS was greater and longer in female than in male mice. The responses to HS were concentration dependent with minimal variance. Ten percent HS evoked a maximal response within the first 5 minutes. Morphine dose-dependently attenuated animals' nociceptive responses (1–10 mg/kg intraperitoneally [i.p.]). The peripherally restricted µ-opioid receptor agonist, loperamide, reduced nociceptive responses when injected locally (30–100 µg/paw, i.pl.) but not systemically (1–10 mg/kg, i.p.). Acetylsalicylic acid (300 mg/kg, i.p.), naproxen (150 mg/kg, i.p), and acetaminophen (300 mg/kg, i.p.) all decreased nociceptive responses, as did i.pl. coinjections of lidocaine (0.003%–1%) with 10% HS. Histopathologic assessment revealed no tissue damage due to HS. CONCLUSIONS: CONCLUSIONS:The i.pl. HS assay is easily performed, rapidly detects standard analgesics, and produces minimal animal suffering without tissue damage. We propose this assay as a useful addition to the armamentarium of existing preclinical analgesic screens. Accepted for publication August 24, 2017. Funding: This work was funded in part by the Dr Jean Templeton Hugill Endowment for Anesthesia Memorial Fund and The University of British Columbia Faculty of Medicine. S.K.W.S. holds the Dr Jean Templeton Hugill Chair in Anesthesia. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Bernard A. MacLeod, MD, FRCPC, Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC, Canada V6T 1Z3. Address e-mail to bernard.macleod@gmail.com. © 2017 International Anesthesia Research Society

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The Influence of Age on Sensitivity to Dexmedetomidine Sedation During Spinal Anesthesia in Lower Limb Orthopedic Surgery

To investigate the influence of age on sensitivity to dexmedetomidine sedation in adult patients, we selected 79 patients scheduled for lower limb orthopedic surgery under spinal anesthesia to identify the dexmedetomidine ED50 for adequate sedation among different age groups. After a spinal anesthetic was placed, a dose of dexmedetomidine determined by the Dixon up–and–down method was administered over 15 minutes. The ED50 in the elderly group was lower than in the other 2 groups (elderly: 0.88 ± 0.07; middle aged: 1.16 ± 0.08; young: 1.21 ± 0.06 µg/kg; both P

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Pearls of Wisdom for High-Risk Laser Lead Extractions: A Focused Review

Due to new indications and improved technology, the incidence of laser lead extraction (LLE) has significantly increased over the past years. While LLE has been well studied and proven to be safe and effective, only few studies are geared toward the anesthesiologist's role during high-risk LLEs. This article utilized both a focused review and authors' experience to investigate anesthetic protocols during LLEs. Through this review, we recommend best practices for the anesthesiologist including appropriate procedure location, onsite availability of a cardiac surgeon, availability of a cardiopulmonary bypass machine, and intraoperative use of echocardiography to detect and address potential complications during high-risk LLEs. Accepted for publication August 31, 2017. 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 (http://ift.tt/KegmMq). Portions of this submitted manuscript were presented at the Society of Cardiovascular Anesthesiologists Annual Meeting PBLD section in San Diego, CA, April 2016. Reprints will not be available from the authors. Address correspondence to Lilibeth Fermin, MD, MBA, 2950 Cleveland Clinic Blvd, Weston, FL 33331. Address e-mail to ferminl@ccf.org. © 2017 International Anesthesia Research Society

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A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists

BACKGROUND: BACKGROUND:Burnout affects all medical specialists, and concern about it has become common in today's health care environment. The gold standard of burnout measurement in health care professionals is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures emotional exhaustion, depersonalization (DP), and personal accomplishment. Besides affecting work quality, burnout is thought to affect health problems, mental health issues, and substance use negatively, although confirmatory data are lacking. This study evaluates some of these effects. METHODS: METHODS:In 2011, the American Society of Anesthesiologists and the journal Anesthesiology cosponsored a webinar on burnout. As part of the webinar experience, we included access to a survey using MBI-HSS, 12-item Short Form Health Survey (SF-12), Social Support and Personal Coping (SSPC-14) survey, and substance use questions. Results were summarized using sample statistics, including mean, standard deviation, count, proportion, and 95% confidence intervals. Adjusted linear regression methods examined associations between burnout and substance use, SF-12, SSPC-14, and respondent demographics. RESULTS: RESULTS:Two hundred twenty-one respondents began the survey, and 170 (76.9%) completed all questions. There were 266 registrants total (31 registrants for the live webinar and 235 for the archive event), yielding an 83% response rate. Among respondents providing job titles, 206 (98.6%) were physicians and 2 (0.96%) were registered nurses. The frequency of high-risk responses ranged from 26% to 59% across the 3 MBI-HSS categories, but only about 15% had unfavorable scores in all 3. Mean mental composite score of the SF-12 was 1 standard deviation below normative values and was significantly associated with all MBI-HSS components. With SSPC-14, respondents scored better in work satisfaction and professional support than in personal support and workload. Males scored worse on DP and personal accomplishment and, relative to attending physicians, residents scored worse on DP. There was no significant association between MBI-HSS and substance use. CONCLUSIONS CONCLUSIONSMany anesthesiologists exhibit some high-risk burnout characteristics, and these are associated with lower mental health scores. Personal and professional support were associated with less emotional exhaustion, but overall burnout scores were associated with work satisfaction and professional support. Respondents were generally economically satisfied but also felt less in control at work and that their job kept them from friends and family. The association between burnout and substance use may not be as strong as previously believed. Additional work, perhaps with other survey instruments, is needed to confirm our results. Accepted for publication May 9, 2017. Funding: Vanderbilt Institute for Clinical and Translational Research (VICTR, #VR8248). 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 (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Steve Alan Hyman, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37205. Address e-mail to steve.hyman@vanderbilt.edu. © 2017 International Anesthesia Research Society

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Preventing Adverse Events in Cataract Surgery: Recommendations From a Massachusetts Expert Panel

Massachusetts health care facilities reported a series of cataract surgery–related adverse events (AEs) to the state in recent years, including 5 globe perforations during eye blocks performed by 1 anesthesiologist in a single day. The Betsy Lehman Center for Patient Safety, a nonregulatory Massachusetts state agency, responded by convening an expert panel of frontline providers, patient safety experts, and patients to recommend strategies for mitigating patient harm during cataract surgery. The purpose of this article is to identify contributing factors to the cataract surgery AEs reported in Massachusetts and present the panel's recommended strategies to prevent them. Data from state-mandated serious reportable event reports were supplemented by online surveys of Massachusetts cataract surgery providers and semistructured interviews with key stakeholders and frontline staff. The panel identified 2 principal categories of contributing factors to the state's cataract surgery–related AEs: systems failures and choice of anesthesia technique. Systems failures included inadequate safety protocols (48.7% of contributing factors), communication challenges (18.4%), insufficient provider training (17.1%), and lack of standardization (15.8%). Choice of anesthesia technique involved the increased relative risk of needle-based eye blocks. The panel's surveys of Massachusetts cataract surgery providers show wide variation in anesthesia practices. While 45.5% of surgeons and 69.6% of facilities reported increased use of topical anesthesia compared to 10 years earlier, needle-based blocks were still used in 47.0% of cataract surgeries performed by surgeon respondents and 40.9% of those performed at respondent facilities. Using a modified Delphi approach, the panel recommended several strategies to prevent AEs during cataract surgery, including performing a distinct time-out with at least 2 care-team members before block administration; implementing standardized, facility-wide safety protocols, including a uniform site-marking policy; strengthening the credentialing and orientation of new, contracted and locum tenens anesthesia staff; ensuring adequate and documented training in block administration for any provider who is new to a facility, including at least 10 supervised blocks before practicing independently; using the least invasive form of anesthesia appropriate to the patient; and finally, adjusting anesthesia practices, including preferred techniques, as evidence-based best practices evolve. Future research should focus on evaluating the impact of these recommendations on patient outcomes. Accepted for publication August 21, 2017. Funding: This work was supported, in part, by the Agency for Health care Research and Quality Grant #1K08HS024764-01. 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 (http://ift.tt/KegmMq). The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Karen C. Nanji, MD, MPH, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston MA 02114. Address e-mail to knanji@partners.org. © 2017 International Anesthesia Research Society

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Incidence and Operative Factors Associated With Discretional Postoperative Mechanical Ventilation After General Surgery

BACKGROUND: BACKGROUND:Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors. METHODS: METHODS:At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ2 test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05. RESULTS: RESULTS:Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P

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Thermal A-δ Nociceptors, Identified by Transcriptomics, Express Higher Levels of Anesthesia-Sensitive Receptors Than Thermal C-Fibers and Are More Suppressible by Low-Dose Isoflurane

We investigated the effect of isoflurane on 2 main types of thermal nociceptors: A-δ and C-fibers. Surprisingly, 1% inhaled isoflurane led to a hyperalgesic response to C-fiber thermal stimulation, whereas responses to A-δ thermal stimulation were blunted. We explored the hypothesis that differences in withdrawal behavior are mediated by differential expression of isoflurane-sensitive proteins between these types of thermal nociceptors. Multiple transcriptomic databases of peripheral neurons were integrated to reveal that isoflurane-susceptible proteins Htr3a, Kcna2, and Scn8a were enriched in thermosensitive A-δ neurons. This exploratory analysis highlights the differing role that volatile anesthetics might have on nociceptors in the peripheral nervous system. Accepted for publication August 24, 2017. Funding: This study was supported by the intramural research program of the National Institutes of Health (NIH), Clinical Center. S.J.R. was supported by the NIH Medical Research Scholars Program, a public–private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from the Doris Duke Charitable Foundation, The American Association for Dental Research, the Colgate-Palmolive Company, Genentech, alumni of student research programs, and other individual supporters. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Michael J. Iadarola, PhD, Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bldg 10, Room 2C401, 10 Center Dr, MSC 1510, Bethesda, MD 20892. Address e-mail to miadarol@cc.nih.gov. © 2017 International Anesthesia Research Society

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Truncated μ-Opioid Receptors With 6 Transmembrane Domains Are Essential for Opioid Analgesia

BACKGROUND: BACKGROUND:Most clinical opioids act through μ-opioid receptors. They effectively relieve pain but are limited by side effects, such as constipation, respiratory depression, dependence, and addiction. Many efforts have been made toward developing potent analgesics that lack side effects. Three-iodobenzoyl-6β-naltrexamide (IBNtxA) is a novel class of opioid active against thermal, inflammatory, and neuropathic pain, without respiratory depression, physical dependence, and reward behavior. The μ-opioid receptor (OPRM1) gene undergoes extensive alternative precursor messenger ribonucleic acid splicing, generating multiple splice variants that are conserved from rodents to humans. One type of variant is the exon 11 (E11)–associated truncated variant containing 6 transmembrane domains (6TM variant). There are 5 6TM variants in the mouse OPRM1 gene, including mMOR-1G, mMOR-1M, mMOR-1N, mMOR-1K, and mMOR-1L. Gene-targeting mouse models selectively removing 6TM variants in E11 knockout (KO) mice eliminated IBNtxA analgesia without affecting morphine analgesia. Conversely, morphine analgesia is lost in an exon 1 (E1) KO mouse that lacks all 7 transmembrane (7TM) variants but retains 6TM variant expression, while IBNtxA analgesia remains intact. Elimination of both E1 and E11 in an E1/E11 double KO mice abolishes both morphine and IBNtxA analgesia. Reconstituting expression of the 6TM variant mMOR-1G in E1/E11 KO mice through lentiviral expression rescued IBNtxA but not morphine analgesia. The aim of this study was to investigate the effect of lentiviral expression of the other 6TM variants in E1/E11 KO mice on IBNtxA analgesia. METHODS: METHODS:Lentiviruses expressing 6TM variants were packaged in HEK293T cells, concentrated by ultracentrifugation, and intrathecally administered 3 times. Opioid analgesia was determined using a radiant-heat tail-flick assay. Expression of lentiviral 6TM variant messenger ribonucleic acids was examined by polymerase chain reaction (PCR) or quantitative PCR. RESULTS: RESULTS:All the 6TM variants restored IBNtxA analgesia in the E1/E11 KO mouse, while morphine remained inactive. Expression of lentiviral 6TM variants was confirmed by PCR or quantitative PCR. IBNtxA median effective dose values determined from cumulative dose–response studies in the rescued mice were indistinguishable from wild-type animals. IBNtxA analgesia was maintained for up to 33 weeks in the rescue mice and was readily antagonized by the opioid antagonist levallorphan. CONCLUSIONS: CONCLUSIONS:Our study demonstrated the pharmacological relevance of mouse 6TM variants in IBNtxA analgesia and established that a common functional core of the receptors corresponding to the transmembrane domains encoded by exons 2 and 3 is sufficient for activity. Thus, 6TM variants offer potential therapeutic targets for a distinct class of analgesics that are effective against broad-spectrum pain models without many side effects associated with traditional opioids. Funding: This work was supported, in part, by grants from a National Natural Science Foundation of China grant (81673412) to Z.L., the Peter F. McManus Charitable Trust, Mr William H. Goodwin and Mrs Alice Goodwin and the Commonwealth Foundation for Cancer Research, the Experimental Therapeutics Center of Memorial Sloan-Kettering Cancer Center, and the National Institute on Drug Abuse of the National Institutes of Health (DA06241 and DA07242 to G.W.P., and DA029244, DA013997, and DA04585 to Y.-X.P.), a core grant from the National Cancer Institute of the National Institutes of Health (CA08748) to the Memorial Sloan-Kettering Cancer Center. Accepted for publication August 24, 2017. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Ying-Xian Pan, MD, PhD, Department of Neurology and the Molecular Pharmacology Program, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065. Address e-mail to pany@mskcc.org. © 2017 International Anesthesia Research Society

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Higher Operating Table for Optimal Needle-Entry Angle and Less Discomfort During Spinal Anesthesia

The aim of this study was to find the optimal table height to facilitate insertion of the spinal needle at a 90° angle and to reduce the anesthesiologist's discomfort. Sixty patients were randomly allocated according to landmarks on the anesthesiologist's body: umbilicus (group U), lowest rib margin (R), xiphoid process (X), and nipple (N). The coronal insertion angle between the patient's skin and the spinal needle was obtuse in groups U and R, and 90° in group X. We demonstrated that high operating tables at the xiphoid and nipple level facilitate more optimal needle entry angles while reducing the discomfort and joint flexion of anesthesiologists during spinal anesthesia. Funding: None. Accepted for publication August 4, 2017. 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 (http://ift.tt/KegmMq). Clinical trial number: This trial was registered at the Clinical Research Information Service http://ift.tt/1JTfppE. Identifier: KCT0001437. Reprints will not be available from the authors. Address correspondence to Jinhee Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea. Address e-mail to Anesing1@snu.ac.kr. © 2017 International Anesthesia Research Society

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“Difficult Airway” Bibliometrics: Importance of Capturing the Correct Literature

No abstract available

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Comparative Effectiveness Research in Health Services

No abstract available

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