Medicare Will Likely Face Pushback on Physician Pay Changes

CMS has unveiled a proposed overhaul of evaluation and management billing that may create 'winners and losers' among specialties, while leaving the 2018 MIPS reporting period unchanged.
Medscape Medical News

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Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file

BACKGROUND Residual neuromuscular block (rNMB) after surgery is not difficult to identify if proper neuromuscular monitoring is used, but many clinicians do not use quantitative neuromuscular monitoring. OBJECTIVE The aim of this study was to develop a REsidual neuromuscular block Prediction Score (REPS) to predict postoperative rNMB and compare the predictive accuracy of the prediction score with train-of-four count (TOFC) measurement at the end of a surgical case. DESIGN Retrospective cohort study of data on file. DATA SOURCE Electronic patient data and peri-operative data on vital signs, administered medications, and train-of-four ratio (TOFR) obtained in the postoperative recovery rooms [postanaesthesia care unit (PACU)] at Massachusetts General Hospital in Boston, Massachusetts, USA. PATIENTS Quantitative TOFR measurements obtained on admission to the PACU were available from 2144 adult noncardiac surgical patients. MAIN OUTCOME MEASURE Presence of rNMB at PACU admission, defined as a TOFR of less than 0.9. RESULTS In the score development cohort (n=2144), rNMB occurred in 432 cases (20.2%). Ten independent predictors for residual paralysis were identified and used for the score development. The final model included: hepatic failure, neurological disease, high-neostigmine dose, metastatic tumour, female sex, short time between neuromuscular blocking agent administration and extubation, aminosteroidal neuromuscular blocking agent, BMI more than 35, absence of nurse anaesthetist and having an experienced surgeon. The model discrimination by C statistics was 0.63, 95% confidence interval (0.60 to 0.66), and risk categories derived from the REPS had a higher accuracy than the last documented intra-operative TOFC for predicting rNMB (net reclassification improvement score 0.26, standard error 0.03, P 

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Near-infrared spectroscopy in vegetables and humans: An observational study

BACKGROUND Cerebral near-infrared spectroscopy (NIRS) of tissue oxygen saturation is claimed to be a surrogate marker for global cerebral perfusion. Increasingly, NIRS target-based therapy has been used during cardiac surgery in the hope of decreasing the incidence of adverse neurological outcome. OBJECTIVES We report NIRS values for some common vegetables and faculty at a world-class medical institution. DESIGN Observational nonblinded study. SETTING Single tertiary care institution and local urban vegetable market. PARTICIPANTS Five yams (Dioscorea cayenensis), five courgettes (Cucurbita pepo) and five butternut squashes (Cucurbita moschata) were studied. Five cardiothoracic surgeons and anaesthesiologists were the control group. INTERVENTIONS None. MAIN OUTCOME MEASURES NIRS value of each species. RESULTS Mean NIRS value for the control group was 71% [95% confidence interval (CI) 68 to 74] and was similar to that of the yellow squashes [75% (95% CI 74 to 76)]. These values were significantly greater than the NIRS measurements of both the butternut squash and yam [63% (95% CI 62 to 64) and 64% (95% CI 63 to 65), respectively, P 

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Superior sealing effect of a three-dimensional printed modified supraglottic airway compared with the i-gel in a three-dimensional printed airway model

Abstract

Purpose

The aim of this study was to compare the force exerted by a three-dimensional (3D) printed modified supraglottic airway (mSGA) vs. that exerted by the i-gel on a 3D printed airway model.

Methods

After a preliminary experiment in Thiel embalmed cadavers, we created a 3D printed mSGA and five 3D printed airway models based on computed tomography data from five female Japanese patients. We compared the force exerted by the i-gel and mSGA on the larynx of the 3D printed airway models. In addition, tidal volumes with insertion of the airway devices into the 3D printed airway model and administration of different levels of pressure-controlled ventilation (PCV) were compared.

Results

The values below indicate mean values ± SD (p value, 95% confidence interval) for the mSGA and i-gel, respectively. The forces exerted by the cuff parts were as follows: ventral: 12.5 ± 5.4 vs. 20.7 ± 3.7 N (p = 0.0001, − 10.0 to − 6.5), proximal: 1.9 ± 1.4 vs. 1.7 ± 1.3 N (p = 0.322, − 0.26 to 0.74), and dorsal parts: 6.9 ± 2.2 vs. 12.5 ± 4.8 N (p = 0.0001, − 7.9 to − 3.4), respectively. We also found significantly higher tidal volumes with the mSGA under PCV of 10, 15, and 20 cmH₂O.

Conclusions

The method of creating the mSGA that we proposed in this study can be applied to development of novel SGAs that is anatomically more suitable for pharyngolaryngeal structure.

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Successful Treatment of Methampyrone-Induced Toxic Epidermal Necrolysis with Therapeutic Plasma Exchange

The toxic epidermal necrolysis (TEN) is a severe cutaneous adverse reaction frequently caused by drug exposure. A 58-year-old male was admitted to the hospital after administration of methampyrone. He developed sloughing of the total epidermis which rapidly extended over the trunk and limbs. The presumptive diagnosis was drug-induced TEN. Despite the treatment with pulsed glucocorticoid and cyclosporine, the skin lesions extended over the entire body. Strikingly, the progression of blistering was stopped by therapeutic plasma exchange (TPE). TPE was discontinued after the signs of skin inflammation had been overcome. He recovered in 8 days of hospitalization. We present here a case of a methampyrone-induced TEN which was successfully treated with TPE.

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“Pseudoprogression”: more than semantics

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Contact-independent suppressive activity of regulatory T cells is associated with telomerase inhibition, telomere shortening and target lymphocyte apoptosis

Publication date: September 2018

Source: Molecular Immunology, Volume 101

Author(s): Dmitry D. Zhdanov, Yulia A. Gladilina, Dmitry V. Grishin, Vladimir A. Grachev, Valentina S. Orlova, Marina V. Pokrovskaya, Svetlana S. Alexandrova, Vadim S. Pokrovsky, Nikolai N. Sokolov

Abstract

Regulatory T cells (Tregs) play a fundamental role in the maintenance of immunological tolerance by suppressing effector target T, B and NK lymphocytes. Contact-dependent suppression mechanisms have been well–studied, though contact-independent Treg activity is not fully understood. In the present study, we showed that human native Tregs, as well as induced ex vivo Tregs, can cause in vitro telomere-dependent senescence in target T, B and NK cells in a contact-independent manner. The co-cultivation of target cells with Tregs separated through porous membranes induced alternative splicing of the telomerase catalytic subunit hTERT (human Telomerase Reverse Transcriptase), which suppressed telomerase activity. Induction of the hTERT splicing variant was associated with increased expression of the apoptotic endonuclease EndoG, a splicing regulator. Inhibited telomerase in target cells co-cultivated with Tregs for a long period of time led to a decrease in their telomere lengths, cell cycle arrest, conversion of the target cells to replicative senescence and apoptotic death. Induced Tregs showed the ability to up-regulate EndoG expression, TERT alternative splicing and telomerase inhibition in mouse T, B and NK cells after in vivo administration. The results of the present study describe a novel mechanism of contact-independent Treg cell suppression that induces telomerase inhibition through the EndoG-provoked alternative splicing of hTERT and converts cells to senescence and apoptosis phenotypes.

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