Adiponectin, Leptin, and Insulin-Pathway Receptors as Endometrial Cancer Subtyping Markers

Abstract

Developing a system of molecular subtyping for endometrial tumors might improve insight into disease etiology and clinical prediction of patient outcomes. High body mass index (BMI) has been implicated in development of endometrial cancer through hormonal pathways and might influence tumor expression of biomarkers involved in BMI-sensitive pathways. We evaluated whether endometrial tumor expression of 7 markers from BMI-sensitive pathways of insulin resistance could effectively characterize molecular subtypes: adiponectin receptor 1, adiponectin receptor 2, leptin receptor, insulin receptor (beta subunit), insulin receptor substrate 1, insulin-like growth factor 1 receptor, and insulin-like growth factor 2 receptor. Using endometrial carcinoma tissue specimens from a case-only prospective sample of 360 women from the Nurses' Health Study, we scored categorical immunohistochemical measurements of protein expression for each marker. Logistic regression was used to estimate associations between endometrial cancer risk factors, especially BMI, and tumor marker expression. Proportional hazard modeling was performed to estimate associations between marker expression and time to all-cause mortality as well as time to endometrial cancer-specific mortality. No association was observed between BMI and tumor expression of any marker. No marker was associated with time to either all-cause mortality or endometrial cancer-specific mortality in models with or without standard clinical predictors of patient mortality (tumor stage, grade, and histologic type). It did not appear that any of the markers evaluated here could be used effectively to define molecular subtypes of endometrial cancer.

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Trends in early hospital readmission after kidney transplantation, 2002 to 2014: a population-based multi-center cohort study

ABSTRACTBackgroundEarly hospital readmission (EHR) is associated with morbidity, mortality, and significant health care costs. However, trends over time in EHR events in kidney transplant recipients have not been examined. We conducted a population-based cohort study using linked health care databases from Ontario, Canada to determine whether the EHR incidence has changed from 2002 to 2014 in kidney transplant recipients.MethodsWe defined EHR as an unplanned admission for any reason to an acute care hospital within 30 days of being discharged from the hospital for transplantation; admissions for elective procedures were excluded.ResultsWe included 5437 kidney transplant recipients. More recently transplanted recipients (2011 to 2014 vs. 2002 to 2004) were older and more likely to have coronary artery disease. A total of 1128 (20.7%) kidney transplant recipients experienced an EHR. There was no trend in EHR across eras with a 30-day cumulative incidence of 23.0%, 21.4%, 18.4%, and 21.0% (P for trend =0.197) for the years 2002 to 2004, 2005 to 2007, 2008 to 2010, and 2011 to 2014, respectively. In the multivariable Cox proportional hazards model, we found no association between era of transplant and EHR. When examining variation in EHR across the 6 adult transplant centers we found the 30-day cumulative incidence varied significantly from 15.5% to 27.1% (P

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Can Functional Movement Assessment Predict Football Head Impact Biomechanics?

ABSTRACTPurposeTo determine functional movement assessments' ability to predict head impact biomechanics in college football players, and to determine whether head impact biomechanics could explain preseason to postseason changes in functional movement performance.MethodsParticipants (N = 44, mass = 109.0 ± 20.8 kg, age = 20.0 ± 1.3 years) underwent two preseason and postseason functional movement assessment screenings: 1) Fusionetics Movement Efficiency Test, and 2) Landing Error Scoring System (LESS). Fusionetics is scored 0 to 100, and participants were categorized into the following movement quality groups as previously published: good (≥75); moderate (50 to 75); and poor ( 7 errors). The Head Impact Telemetry (HIT) System measured head impact frequency and magnitude (linear acceleration and rotational acceleration). An encoder with six single-axis accelerometers was inserted between the padding of a commercially available Riddell football helmet. We employed random intercepts general linear mixed models to analyze our data.ResultsThere were no effects of preseason movement assessment group on the two HIT System impact outcomes: linear acceleration and rotational acceleration. Head impact frequency did not significantly predict preseason to postseason score changes obtained from the Fusionetics (F1,36 = 0.22, P = 0.643, R2=0.006) or the LESS (F1,36 7 errors). The Head Impact Telemetry (HIT) System measured head impact frequency and magnitude (linear acceleration and rotational acceleration). An encoder with six single-axis accelerometers was inserted between the padding of a commercially available Riddell football helmet. We employed random intercepts general linear mixed models to analyze our data. Results There were no effects of preseason movement assessment group on the two HIT System impact outcomes: linear acceleration and rotational acceleration. Head impact frequency did not significantly predict preseason to postseason score changes obtained from the Fusionetics (F1,36 = 0.22, P = 0.643, R2=0.006) or the LESS (F1,36

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Assessment of the Importance of Tympanic Membrane Mechanoreceptors on Eustachian Tube Function Based on Pressure Chamber Measurements

Introduction: Previously, it was demonstrated how the Eustachian tube (ET) opening function can be influenced by middle ear pressure and movement of the tympanic membrane via neural control. Mechanoreceptors on the tympanic membrane may be part of the afferent arc and could influence the middle ear pressure by activating the musculus veli palatini as part of a reflex. Methods: In a hypo and hyperbaric pressure chamber, 17 participants (34 ears) were twice exposed to a standardized pressure profile of pressure decrease and increase. The ET function reflecting parameters—ET opening pressure (ETOP), ET opening duration (ETOD), and ET opening frequency (ETOF)—were determined before and after local anesthesia of the right tympanic membrane. Results: After pressure exposure by pressure increase (active induced equalization) and pressure decrease (passive equalization) there was no significant difference between the mean value of ETOP, ETOD, and ETOF before and after local anesthesia of the right tympanic membrane on the right (anesthetized) or left side (not anesthetized). Conclusion: These results may lead to the hypothesis that tympanic membrane mechanoreceptors may play a minor role in regulating the ET function in humans. Address correspondence and reprint requests to Moritz F. Meyer, M.D., Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany; E-mail: moritz.meyer@uk-koeln.de All authors of the manuscript "Assessment of the importance of tympanic membrane mechanoreceptors on Eustachian tube function based on pressure chamber measurements" disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. The authors disclose no conflicts of interest. Copyright © 2017 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

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Comparison of DNA Damage and Oxidative Stress in Patients Anesthetized With Desflurane Associated or Not With Nitrous Oxide: A Prospective Randomized Clinical Trial

BACKGROUND: Little is known about the effects of desflurane associated or not with nitrous oxide (N2O) on oxidative stress and patient genetic material. The aim of this study was to compare the effects of anesthesia maintained with desflurane associated or not with N2O on DNA damage (as a primary outcome) and oxidative stress (as a secondary outcome) in patients who underwent an elective minimally invasive surgery. METHODS: This prospective randomized clinical trial analyzed 40 patients of both sexes with an American Society of Anesthesiologists physical status I who were 18–50 years of age and scheduled for septoplasty. The patients were randomly allocated into 2 groups according to anesthesia maintenance as follows: desflurane (n = 20) or desflurane/N2O (n = 20). Blood samples were collected before anesthesia (T1 = baseline), 1.5 hours after anesthesia induction (T2), and on the morning of the postoperative first day (T3). Basal and oxidative DNA damage (determined using formamidopyrimidine DNA glycosylase to detect oxidized purines and endonuclease III to detect oxidized pyrimidines) were evaluated using the comet assay. Oxidative stress markers were evaluated based on lipid peroxidation (by assessing 4-hydroxynonenal and 8-iso-prostaglandin F2α [8-isoprostane] using enzyme linked immunosorbent immunoassay), protein carbonyls (assessed by enzyme linked immunosorbent immunoassay), and antioxidant defense (ferric-reducing antioxidant power by spectrophotometry). The effect size was expressed as the mean differences between groups and the corresponding 95% confidence interval (CI). RESULTS: There was no significant mean difference between groups in relation to DNA damage (−1.7 [95% CI, −7.0 to 3.5]), oxidized DNA pyrimidines (−1.8 [95% CI, −12.5 to 8.9]) and purines (−1.9 [95% CI, −13.9 to 10.1]), 4-hydroxynonenal (−0.2 [95% CI, −2.8 to 2.4]), 8-isoprostane (549 [95% CI, −2378 to 3476]), protein carbonyls (0.2 [95% CI, −2.1 to 2.3]), or ferric-reducing antioxidant power (24 [95% CI, −52.0 to 117.2]). CONCLUSIONS: The coadministration of 60% N2O with desflurane did not seem to impair the effects on DNA or the redox status compared with desflurane anesthesia, suggesting that both studied anesthetic techniques can be suitable options for healthy individuals who undergo minimally invasive surgery lasting at least 1.5 hours. However, due to the low power of the study, more research is necessary to confirm our findings. Accepted for publication November 2, 2017. Funding: Supported by grant 2013/16842-0 from the São Paulo Research Foundation (FAPESP). F.R.N. was granted a scholarship from the National Council for Scientific and Technological Development-CNPq (2014–2015) and from the Coordination of Improvement for Higher Education Personnel-CAPES (2016), and J.R.C.B. received a fellowship from CNPq (303673/2015-0). 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). This report was previously presented in part at Euroanaesthesia 2016, London, United Kingdom, May 28-30, 2016. Clinical trial number: the Brazilian Clinical Trials Registry (RBR-6jg23g; Trial Identification UTN Number: U1111-1150-0903). Registry URL: http://ift.tt/2CG5pp6. Reprints will not be available from the authors. Address correspondence to Mariana G. Braz, PhD, Department of Anesthesiology, Botucatu Medical School, São Paulo State University (UNESP), Professor Mário Rubens G. Montenegro Av, 18618–687, Botucatu, SP, Brazil. Address e-mail to mgbraz@hotmail.com. © 2017 International Anesthesia Research Society

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Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study

BACKGROUND: Dexmedetomidine provides smooth and hemodynamically stable emergence at the expense of hypotension, delayed recovery, and sedation. We investigated the optimal dose of dexmedetomidine for prevention of cough, agitation, hypertension, tachycardia, and shivering, with minimal side effects. METHODS: In this prospective, randomized, double-blind trial, 216 adult patients were randomly assigned to dexmedetomidine 1 µg/kg (D 1), 0.5 µg/kg (D 0.5), 0.25 µg/kg (D 0.25), or control (C). During emergence, cough, agitation, hemodynamic parameters, shivering, time to extubation, and sedation scores were recorded. RESULTS: A total of 190 patients were analyzed. The respective incidences for the groups D 1, D 0.5, and D 0.25 versus group C were 48%, 64%, and 64% vs 84% for cough—corrected P

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Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different?

BACKGROUND: Routine monitoring of postoperative patients with pulse oximetry–based surveillance monitoring has been shown to reduce adverse events. However, there is some concern that pulse oximetry is limited in its ability to detect deterioration quickly enough to allow for intervention in patients receiving supplemental oxygen. To address such concerns, this study expands on the current limited knowledge of differences in desaturation and respiratory rate characteristics between patients breathing room air and those receiving supplemental oxygen. METHODS: PPulse oximetry–derived data and patient characteristics were used to examine overnight desaturation patterns of 67 postoperative patients who were receiving either supplemental oxygen or breathing room air. The 2 modalities with respect to the speed of desaturation, in addition to magnitude and duration of desaturation events, are compared. Night-time pulse rate, oxygen saturation, respiratory rate, and the transition times from normal oxygen saturation levels to desaturated states are also compared. The behavior of respiratory rate in proximity to desaturation events is described. Statistical methods included multivariable regression and inverse probability of treatment weighted to adjust for any imbalance in patient characteristics between the oxygen and room air patients and linear mixed effect models to account for clustering by patient. RESULTS: The study included 33 patients on room air and 34 receiving supplemental oxygen. The speed of desaturation was not different for room air versus oxygen for 2 types of desaturation (adjusted % difference, 95% confidence interval [CI]: type I; 22.4%, -51.5% to 209%; P = .67, type II; -17.3%, -53.8% to 47.6%; P = .52). Patients receiving supplemental oxygen had a higher mean oxygen saturation (adjusted difference, 95% CI, 2.4 [0.7–4.0]; P = .006). No differences were found for the average overnight respiratory or pulse rate, or proportion of time in desaturation states between the 2 groups. The time to transition from a normal oxygen saturation (92%) to 88% or below was not longer for supplemental oxygen patients (P = .42, adjusted difference 26.1%: 95% CI, -28.1% to 121%). Respiratory rates did not differ between the overall mean and desaturation or recovery phases or between the oxygen and room air group. CONCLUSIONS: In this study, desaturation characteristics did not differ between patients receiving supplemental oxygen and breathing room air with regard to speed, depth, or duration of desaturation. Transition time for desaturations to reach low oxygen saturation alarms was not different, while respiratory rate remained in the normal range during these events. These findings suggest that pulse oximetry–based surveillance monitoring for deterioration detection can be used equally effectively for patients on supplemental oxygen and for those on room air. Accepted for publication November 9, 2017. 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). Funding: This project was supported by Grant Number P30HS024403 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Andreas H. Taenzer, MS, MD, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756. Address e-mail to andreas.h.taenzer@dartmouth.edu. © 2017 International Anesthesia Research Society

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American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Patient-Reported Outcomes in an Enhanced Recovery Pathway

Patient-reported outcomes (PROs) are measures of health status that come directly from the patient. PROs are an underutilized tool in the perioperative setting. Enhanced recovery pathways (ERPs) have primarily focused on traditional measures of health care quality such as complications and hospital length of stay. These measures do not capture postdischarge outcomes that are meaningful to patients such as function or freedom from disability. PROs can be used to facilitate shared decisions between patients and providers before surgery and establish benchmark recovery goals after surgery. PROs can also be utilized in quality improvement initiatives and clinical research studies. An expert panel, the Perioperative Quality Initiative (POQI) workgroup, conducted an extensive literature review to determine best practices for the incorporation of PROs in an ERP. This international group of experienced clinicians from North America and Europe met at Stony Brook, NY, on December 2–3, 2016, to review the evidence supporting the use of PROs in the context of surgical recovery. A modified Delphi method was used to capture the collective expertise of a diverse group to answer clinical questions. During 3 plenary sessions, the POQI PRO subgroup presented clinical questions based on a literature review, presented evidenced-based answers to those questions, and developed recommendations which represented a consensus opinion regarding the use of PROs in the context of an ERP. The POQI workgroup identified key criteria to evaluate patient-reported outcome measures (PROMs) for their incorporation in an ERP. The POQI workgroup agreed on the following recommendations: (1) PROMs in the perioperative setting should be collected in the framework of physical, mental, and social domains. (2) These data should be collected preoperatively at baseline, during the immediate postoperative time period, and after hospital discharge. (3) In the immediate postoperative setting, we recommend using the Quality of Recovery-15 score. After discharge at 30 and 90 days, we recommend the use of the World Health Organization Disability Assessment Scale 2.0, or a tailored use of the Patient-Reported Outcomes Measurement Information System. (4) Future study that consistently applies PROMs in an ERP will define the role these measures will have evaluating quality and guiding clinical care. Consensus guidelines regarding the incorporation of PRO measures in an ERP were created by the POQI workgroup. The inclusion of PROMs with traditional measures of health care quality after surgery provides an opportunity to improve clinical care. Accepted for publication November 3, 2017. Funding: The Perioperative Quality Initiative meeting received financial assistance from the American Society for Enhanced Recovery. 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. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2017 International Anesthesia Research Society

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Adductor Canal Block With Continuous Infusion Versus Intermittent Boluses and Morphine Consumption: A Randomized, Blinded, Controlled Clinical Trial

BACKGROUND: Based on the assumption that relatively large volumes of local anesthetic optimize an adductor canal block (ACB), we theorized that an ACB administered as repeated boluses would improve analgesia without compromising mobility, compared with a continuous infusion. METHODS: We performed a randomized, blinded, controlled study, including patients scheduled for total knee arthroplasty with spinal anesthesia. Patients received 0.2% ropivacaine via a catheter in the adductor canal administered as either repeated intermittent boluses (21 mL/3 h) or continuous infusion (7 mL/h). The primary outcome was total (postoperative day [POD], 0–2) opioid consumption (mg), administered as patient-controlled analgesia. Pain, ambulation, and quadriceps muscle strength were secondary outcomes. RESULTS: We randomized 110 patients, of whom 107 were analyzed. Total opioid consumption (POD, 0–2) was a median (range) of 23 mg (0–139) in the bolus group and 26 mg (3–120) in the infusion group (estimated median difference, 4 mg; 95% confidence interval [CI], −13 to 5; P = .29). Linear mixed-model analyses revealed no difference in pain during knee flexion (mean difference, 2.6 mm; 95% CI, −2.9 to 8.0) or at rest (mean difference, 1.7 mm; 95% CI, −1.5 to 4.9). Patients in the bolus group had improved quadriceps sparing on POD 2 (median difference, 7.4%; 95% CI, 0.5%–15.5%). However, this difference was not present on POD 1 or reflected in the ambulation tests (P > .05). CONCLUSIONS: Changing the mode of administration for an ACB from continuous infusion to repeated intermittent boluses did not decrease opioid consumption, pain, nor mobility. Accepted for publication October 24, 2017. Funding: This work was supported by an unrestricted research grant from Smiths Medical (St Paul, MN). In addition, Smiths Medical provided the portable infusion pumps used in this trial. The company had no input or influence into any aspect of study conceptualization, design, data analysis, or reporting of the study. None of the authors have a personal financial interest in this research. Conflicts of Interest: See Disclosures at the end of the article. The abstract has been accepted for presentation at the annual meeting of the American Society of Regional Anesthesia, San Francisco, CA, January 6–8, 2017, and at the IX SIMPAR-ISURA SIMPAR-ISURA (Study In Multidisciplinary Pain Research-International Symposium of Ultrasound for Regional Anesthesia and Pain Medicine) Congress, Florence, Italy, March 29 to April 1, 2017. Clinical trial number: Clinicaltrials.gov Identifier: NCT02539628. Ethics committees approval: H-2-2014-114. Pia Jaeger and Jonas Baggesgaard share first authorship. Reprints will not be available from the authors. Address correspondence to Pia Jaeger, MD, PhD, Department of Anaesthesia 4231, Centre of Head and Orthopaedics, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen E, Denmark. Address e-mail to pia.therese.jaeger@regionh.dk. © 2017 International Anesthesia Research Society

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Airway Management by Laryngeal Mask Airways for Cervical Tracheal Resection and Reconstruction: A Single-Center Retrospective Analysis

BACKGROUND: Supraglottic airway devices (SADs) may have advantages over endotracheal intubation for tracheal resection and reconstruction in cases of severe and proximally located subglottic stenosis. This retrospective case series examines the feasibility of using SADs as a novel approach to airway management in tracheal resections. METHODS: All patients who were managed with SADs for cervical tracheal resection and reconstruction during the study period (2010–2015) in our university hospital were included. To examine the feasibility of airway management with SADs for tracheal resection, medical records were obtained from our institution's electronic database and reviewed. RESULTS: SADs were used in 10 patients who had extensive tracheal stenosis and a high prevalence of severe comorbidities. SAD insertion and subsequent positive pressure ventilation were successful in all patients, although 1 patient with preoperative respiratory failure had persistent hypercarbia. During the phase of resection and reconstruction, high-frequency jet ventilation was used to ensure adequate oxygenation. There were no intraoperative complications related to anesthetic management, apart from transient hypercarbia during and after jet ventilation. Most patients (n = 6; 60%) had an uneventful postoperative course. In this high-risk cohort, postoperative complications (ie, vocal cord edema, postoperative hemorrhage, pneumonia) occurred in 4 patients (40%). CONCLUSIONS: This retrospective case series demonstrates the feasibility of using supraglottic airways alongside high-frequency jet ventilation for airway management in at least some cases of cervical tracheal resection and reconstruction. However, the small number of cases examined limits conclusions regarding indications, contraindications, and periprocedural safety. Accepted for publication November 13, 2017. Funding: None. The authors declare no conflicts of interest. Patient consent: Requirement waived by institutional review board. Ethics approval: Approval by institutional review board of the University Hospital Witten/Herdecke, Medical Center Cologne-Merheim, Board supervisor: Professor Maune. Reprints will not be available from the authors. LMA is a registered trademark of Teleflex Incorporated or its affiliates. Address correspondence to Mark Schieren, MD, Department of Anesthesiology and Intensive Care Medicine, Medical Centre Cologne, University Witten/Herdecke, Ostmerheimer Strasse 200, 51109 Cologne, Germany. Address e-mail to mark.schieren@uni-wh.de. © 2017 International Anesthesia Research Society

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American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period. Accepted for publication October 27, 2017 Funding: The Perioperative Quality Initiative (POQI) meeting received financial assistance from the American Society for Enhanced Recovery (ASER). Conflicts of Interest: See Disclosures at the end of the article. For the Perioperative Quality Initiative (POQI) 2 Workgroup, see Appendix 1. Reprints will not be available from the authors. Address correspondence to Timothy E. Miller, MB, ChB, FRCA, Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to timothy.miller2@duke.edu. © 2017 International Anesthesia Research Society

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Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe

BACKGROUND: Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. METHODS: In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. RESULTS: The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were

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Prophylactic Platelet Transfusions for Critically Ill Patients With Thrombocytopenia: A Single-Institution Propensity-Matched Cohort Study

BACKGROUND: Thrombocytopenia is frequently encountered in critically ill patients, often resulting in prophylactic transfusion of platelets for the prevention of bleeding complications. However, the efficacy of this practice remains unclear. The objective of this study was to determine the relationship between prophylactic platelet transfusion and bleeding complications in critically ill patients. METHODS: This is a retrospective cohort study of adults admitted to surgical, medical, or combined medical-surgical intensive care units (ICUs) at a single academic institution between January 1, 2009, and December 31, 2013. Inclusion criteria included age ≥18 years and a platelet count measured during ICU admission. Propensity-matched analyses were used to evaluate associations between prophylactic platelet transfusions and the outcomes of interest with a primary outcome of red blood cell transfusion in the ensuing 24 hours and secondary outcomes of ICU and hospital-free days and changes in sequential organ failure assessment scores. RESULTS: A total of 40,693 patients were included in the investigation with 3227 (7.9%) receiving a platelet transfusion and 1065 (33.0%) for which platelet transfusion was prophylactic in nature. In propensity-matched analyses, 994 patients with prophylactic platelet transfusion were matched to those without a transfusion. Patients receiving prophylactic platelets had significantly higher red blood cell transfusion rates (odds ratio 7.5 [5.9–9.5]; P

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Heating and Cooling Rates With an Esophageal Heat Exchange System

BACKGROUND: The Esophageal Cooling Device circulates warm or cool water through an esophageal heat exchanger, but warming and cooling efficacy in patients remains unknown. We therefore determined heat exchange rates during warming and cooling. METHODS: Nineteen patients completed the trial. All had general endotracheal anesthesia for nonthoracic surgery. Intraoperative heat transfer was measured during cooling (exchanger fluid at 7°C) and warming (fluid at 42°C). Each was evaluated for 30 minutes, with the initial condition determined randomly, starting at least 40 minutes after induction of anesthesia. Heat transfer rate was estimated from fluid flow through the esophageal heat exchanger and inflow and outflow temperatures. Core temperature was estimated from a zero-heat-flux thermometer positioned on the forehead. RESULTS: Mean heat transfer rate during warming was 18 (95% confidence interval, 16–20) W, which increased core temperature at a rate of 0.5°C/h ± 0.6°C/h (mean ± standard deviation). During cooling, mean heat transfer rate was −53 (−59 to −48) W, which decreased core temperature at a rate of 0.9°C/h ± 0.9°C/h. CONCLUSIONS: Esophageal warming transferred 18 W which is considerably less than the 80 W reported with lower or upper body forced-air covers. However, esophageal warming can be used to supplement surface warming or provide warming in cases not amenable to surface warming. Esophageal cooling transferred more than twice as much heat as warming, consequent to the much larger difference between core and circulating fluid temperature with cooling (29°C) than warming (6°C). Esophageal cooling extracts less heat than endovascular catheters but can be used to supplement catheter-based cooling or possibly replace them in appropriate patients. Accepted for publication October 20, 2017. Funding: This work was supported by Advanced Cooling Therapy (Chicago, IL). Conflicts of Interest: See Disclosures at the end of the article. Institutional review board: Cleveland Clinic Institutional Review Board, 9500 Euclid Ave, Desk OS01, Cleveland, OH 44195. E-mail: IRBCOI@ccf.org. This study was registered at ClinicalTrials.gov. Reprints will not be available from the authors., Address correspondence to Daniel I. Sessler, MD, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave—P77, Cleveland, OH 44195. Address e-mail to DS@OR.org. © 2017 International Anesthesia Research Society

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Axillary Temperature, as Recorded by the iThermonitor WT701, Well Represents Core Temperature in Adults Having Noncardiac Surgery

BACKGROUND: Core temperature can be accurately measured from the esophagus or nasopharynx during general anesthesia, but neither site is suitable for neuraxial anesthesia. We therefore determined the precision and accuracy of a novel wireless axillary thermometer, the iThermonitor, to determine its suitability for use during neuraxial anesthesia and in other patients who are not intubated. METHODS: We enrolled 80 adults having upper abdominal surgery with endotracheal intubation. Intraoperative core temperature was measured in distal esophagus and was estimated at the axilla with a wireless iThermonitor WT701 (Raiing Medical, Boston MA) at 5-minute intervals. Pairs of axillary and reference distal esophageal temperatures were compared and summarized using linear regression and repeated-measured Bland–Altman methods. We a priori determined that the iThermonitor would have clinically acceptable accuracy if most estimates were within ±0.5°C of the esophageal reference, and suitable precision if the limits of agreement were within ±0.5°C. RESULTS: There were 3339 sets of paired temperatures. Axillary and esophageal temperatures were similar, with a mean difference (esophageal minus axillary) of only 0.14°C ± 0.26°C (standard deviation). The Bland–Altman 95% limits of agreement were reasonably narrow, with the estimated upper limit at 0.66°C and the lower limit at −0.38°C, thus ±0.52°C, indicating good agreement across the range of mean temperatures from 34.9°C to 38.1°C. The absolute difference was within 0.5°C in 91% of the measurements (95% confidence interval, 88%–93%). CONCLUSIONS: Axillary temperature, as recorded by the iThermonitor WT701, well represents core temperature in adults having noncardiac surgery and thus appears suitable for clinical use. Accepted for publication September 29, 2017. Funding: This work was supported by the Raiing Medical, Boston, MA. None of the authors has a personal financial interest in this research. The sponsor was not involved in data analysis or interpretation. 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 Yuguang Huang, MD, Department of Anesthesiology, Peking Union Medical College Hospital (PUMCH), 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China. Address e-mail to garybeijing@163.com (www.OR.org). © 2017 International Anesthesia Research Society

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Severe macroglossia after posterior fossa and craniofacial surgery in children

Publication date: Available online 1 January 2018
Source:International Journal of Oral and Maxillofacial Surgery
Author(s): J. Bouaoud, A. Joly, A. Picard, B. Thierry, E. Arnaud, S. James, I. Hennessy, B. McGarvey, P. Cairet, A. Vecchione, E. Vergnaud, C. Duracher, R.H. Khonsari
Massive swelling of the tongue can occur after posterior fossa and craniofacial surgery. Several hypotheses have been proposed to explain the occurrence of such severe postoperative macroglossia, but this phenomenon is still poorly understood. Severe postoperative macroglossia can be a life-threatening condition due to upper airway obstruction. Three cases of severe postoperative macroglossia that occurred after cervical spine, craniofacial, and posterior fossa surgical procedures are reported here. These cases required specialized maxillofacial management and a prolonged stay in the intensive care unit. Causal factors involved in this condition are reported, in order to highlight appropriate prevention and treatment options adapted to the management of paediatric patients. An overview of the current literature on severe postoperative macroglossia in paediatric populations is also provided.



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Assessment of the Importance of Tympanic Membrane Mechanoreceptors on Eustachian Tube Function Based on Pressure Chamber Measurements

Introduction: Previously, it was demonstrated how the Eustachian tube (ET) opening function can be influenced by middle ear pressure and movement of the tympanic membrane via neural control. Mechanoreceptors on the tympanic membrane may be part of the afferent arc and could influence the middle ear pressure by activating the musculus veli palatini as part of a reflex. Methods: In a hypo and hyperbaric pressure chamber, 17 participants (34 ears) were twice exposed to a standardized pressure profile of pressure decrease and increase. The ET function reflecting parameters—ET opening pressure (ETOP), ET opening duration (ETOD), and ET opening frequency (ETOF)—were determined before and after local anesthesia of the right tympanic membrane. Results: After pressure exposure by pressure increase (active induced equalization) and pressure decrease (passive equalization) there was no significant difference between the mean value of ETOP, ETOD, and ETOF before and after local anesthesia of the right tympanic membrane on the right (anesthetized) or left side (not anesthetized). Conclusion: These results may lead to the hypothesis that tympanic membrane mechanoreceptors may play a minor role in regulating the ET function in humans. Address correspondence and reprint requests to Moritz F. Meyer, M.D., Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany; E-mail: moritz.meyer@uk-koeln.de All authors of the manuscript "Assessment of the importance of tympanic membrane mechanoreceptors on Eustachian tube function based on pressure chamber measurements" disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. The authors disclose no conflicts of interest. Copyright © 2017 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

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The Hoffmann reflex is different in men and women

To compare the maximum Hoffmann reflex (H-reflex) and the maximum M-wave (H : M) ratio of the H-reflex in men and women when all participants showed similar saliva levels of estradiol and progesterone. This is a cohort design study involving healthy men and women with a mean age of 22.4±3.4 years. The H : M ratio of the H-reflex was assessed in women and men at a point in time when naturally occurring levels of estradiol and progesterone were similar. The female participants had a significantly higher H : M ratio compared with the male participants, whereas no differences in the saliva levels of progesterone and estradiol were detected. This is the first study to report differences between women and men in the H : M ratio of the H-reflex. An additional novel aspect of this study is that the assessments were performed when the levels of neuroactive sex hormones (estradiol and progesterone) were similar in all participants. Correspondence to Mark Hoffman, PhD, College of Public Health and Human Sciences, 226 Langton Hall, Oregon State University, Corvallis, OR 97333, USA Tel: +1 541 737 6787; fax: +1 541 737 6914; e-mail: mark.hoffman@oregonstate.edu Received October 16, 2017 Accepted December 11, 2017 © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Exploring the role of subcortical structures in developmental reading impairments: evidence for subgroups differentiated by caudate activity

Although the role of cortical structures in skilled and impaired reading has been the topic of considerable investigation, the contribution of subcortical structures to reading performance is less well understood. Here, we assess the role of the caudate, putamen, and thalamus in adults with and without reading impairment. Thirty-three individuals (19 skilled readers and 14 reading impaired individuals) participated in two functional MRI tasks: (a) silent reading of real words and (b) silent reading of nonwords. Percent signal change was calculated for each of the three structures by evaluating the signal change relative to the baseline (i.e. no task or fixation crosses), and response time was measured for each reading condition. We found that for skilled readers, activity in the putamen predicted behavioral performance for both real words and nonwords. In contrast, we found evidence for two subgroups of impaired readers: a positive caudate activity group and a negative caudate activity group. Interestingly, brain activity differentially predicted reading performance depending on whether individuals had positive or negative caudate activity. We discuss our findings in the context of developmental reading impairments, print-to-speech networks, and language processing in general. Correspondence to Jacqueline Cummine, PhD, Department of Rehabilitation Medicine, Faculty of Rehabilitation Medicine, University of Alberta, 3-58, 8205 114 St Corbett Hall, Edmonton, AB, Canada T6G 2G4 Tel: +1 780 492 3965; fax: +1 780 492 9333; e-mail: jcummine@ualberta.ca Received August 20, 2017 Accepted August 24, 2017 © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Expression of pannexin-1 in the trigeminal ganglion after chronic constriction injury of the infraorbital nerve in a rat model

Pannexin-1 (Panx 1) is a large-pore membrane channel that is expressed widely in the nervous system and is involved in the physiological and pathological processes of some neurological diseases. Here, we investigate the expression of Panx 1 in a rat model of trigeminal neuralgia (TN). After chronic constriction injury (CCI) of the infraorbital nerve (ION), rats showed mechanical hypersensitivity responses to mechanical stimuli by von Frey hairs in contrast to sham rats. In comparison with sham rats, quantitative RT-PCR and western blot showed that Panx 1 expression was upregulated in the trigeminal ganglion (TG) of ION-CCI rats. Immunohistochemical staining indicated an endoneurial abundance of Panx 1 in neurons of TN after CCI, which was higher than that in sham rats. Our finding indicates that ION-CCI leads to a regulation of Panx 1 in the TG, which might contribute toward the development of TN. Correspondence to Yuanyin Wang, PhD, College and Hospital of Stomatology, Key Lab. of Oral Diseases Research of Anhui Province, Anhui Medical University, No. 81 Meishan Road, Hefei 230032, Anhui Province, China Tel: +86 516 7736; fax: +86 55 165 161 132; e-mail: wyy1970548@sohu.com Received November 19, 2017 Accepted December 7, 2017 © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins

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