bluuebunny/crossref_metadata_2025 huggingface dataset:
Zonal analysis in contemporary aesthetic orthognathic surgical planning
Authors: Manisali Mehmet , Naini Farhad B.
Published: February 2023

Background

The purpose of this article is to introduce the concept of zonal analysis in orthognathic surgical planning.

Case presentation

The importance of developing this concept of facial zonal analysis is because grouping together elements of aesthetic importance in a region in a systematic manner allows for accurate diagnosis and logical treatment planning. An orthognathic case presentation is described to demonstrate this concept.

Discussion

The three facial zones described are related in terms of the presenting problem and in relation to the changes envisaged with each planned surgical movement. The importance of developing this concept of facial zonal analysis is because grouping together elements of aesthetic importance in a region in a systematic manner allows for accurate diagnosis and logical treatment planning. Consideration is given to the negative features that require improvement and the positive features that the clinician and patient would prefer not to alter. It also provides an organised tool for postoperative comparison of results. The analysis and synthesis of the information provided from this approach can aid contemporary orthognathic surgical planning.
Value of diffusion‐weighted MRI and lesion‐to‐spinal cord signal intensity ratio in pulmonary lesion characterization
Authors: Kolta Marian Fayek , Abdel-Hamid Hoda Mohamed Mahmoud , Hassan Basma Hussain Tawfik , Tadros Sally Fouad kamal
Published: February 2023

Background

In the scenario of lung lesions, the differential diagnosis is important, since the treatment is determined by the characteristics of the lesion. The goal in the evaluation of pulmonary lesions is to distinguish malignant lesions from benign lesions in a non-invasive manner as possible. Since, CT is not sufficient to accurately distinguish malignant nodules from benign nodules and patients with benign nodules might undergo invasive diagnostic methods, such as lung biopsy or video-assisted thoracoscopic surgery, to rule out a malignancy. Now, MRI performed by using diffusion-weighted (DW) can offer both qualitative and quantitative information that can be helpful for tumour assessment. Moreover, lesion‐to‐spinal cord signal intensity ratio (LSR) has also been shown to be useful for the differentiation of lung lesions. Quantitative tumour assessment is possible by the calculation of ADC.

Results

A total of 30 patients were eligible for inclusion in our final analysis; with male/female case number about 10/20 (33.3%/ 66.7%) and age range from 20 to 74 (46.8 ± 14.9) were subjected to MRI study and MRI diffusion. Sensitivity analysis showed that ADC mean, and ADC min value can significantly predict malignant lung lesions using cutoff point < 1.53 and < 1.34 respectively, with sensitivity 75%, 56.3%, and specificity 92.9%, 100% with p values 0.001, and 0.005 respectively. SI lesion can significantly predict malignant lung lesions using cutoff point > 502.8, with sensitivity 92.9% and specificity 68.7%, AUC 89.3% and p value 0.0001. Lesion-to-spinal cord signal intensity ratio (LSR) can significantly predict malignant lung lesions using cutoff point > 1.3, with sensitivity 85.7% and specificity 75%, AUC 79.7% and p value 0.006.

Conclusions

This study confirmed that the DWI combined with ADC value and LSR is effective and valuable tool in differentiation of pulmonary lesions whether benign or malignant which is considered to be noninvasive alternative tool for the characterization of pulmonary lesions. We recommend before invasive intervention to perform diffusion MRI and LSR as and important aid for proper diagnosis.
A Prediction Model of Gestational Diabetes Mellitus Based on OGTT in Early Pregnancy: A Prospective Cohort Study
Authors: Wu Shan , Li Linghui , Hu Kai-Lun , Wang Siwen , Zhang Runju , Chen Ruixue , Liu Le , Wang Danni , Pan Minge , Zhu Bo , Wang Yue , Yuan Changzheng , Zhang Dan
Published: February 2023

Context

Gestational diabetes mellitus (GDM) is a common obstetric complication. Although early intervention could prevent the development of GDM, there was no consensus on early identification for women at high risk of GDM.

Objective

To develop a reliable prediction model of GDM in early pregnancy.

Methods

In this prospective cohort study, between May 30, 2021, and August 13, 2022, a total of 721 women were included from Women’s Hospital, Zhejiang University School of Medicine. Participants were asked to complete an oral glucose tolerance test (OGTT) during gestational weeks 7 through 14 for early prediction of GDM, and at weeks 24 through 28 for GDM diagnosis. Using OGTT results and baseline characteristics, logistic regression analysis was used to construct the prediction model. Receiver operating characteristic (ROC) curve, Hosmer-Lemeshow test, decision clinical analysis, and a nomogram were used for model performances assessment and visualization. Internal and external validation was performed to testify the stability of this model.

Results

According to the International Association of Diabetes and Pregnancy Study Groups criteria in early OGTT, the mean (SD) age was 30.5 ± 3.7 years in low-risk participants and 31.0 ± 3.9 years in high-risk participants. The area under ROC curve (AUC) of the existing criteria at weeks 7 through 14 varied from 0.705 to 0.724. Based on maternal age, prepregnancy body mass index, and results of early OGTT, the AUC of our prediction model was 0.8720, which was validated by both internal (AUC 0.8541) and external (AUC 0.8241) confirmation.

Conclusions

The existing diagnostic criteria were unsatisfactory for early prediction of GDM. By combining early OGTT, we provided an effective prediction model of GDM in the first trimester.
Hypoglycemia From Metastatic Meningeal Solitary Fibrous Tumor Occurring Over Two Decades After Initial Diagnosis
Authors: Orrego John J , Chorny Joseph A
Published: February 2023

Despite multiple intracranial and extracranial relapses associated with a widely metastatic meningeal solitary fibrous tumor (formerly classified as hemangiopericytoma), a 66-year-old type 2 diabetic man was first diagnosed with paraneoplastic hypoglycemia 23 years after the original diagnosis and 12 years after the onset of extracranial metastatic disease. An enlarging mass entirely replacing the left kidney measuring 11.6 × 10 × 28 cm, which had not been locally treated before, was considered to be the putative source of IGF-2 excess. The insulin-like effects of IGF-2 not only ameliorated his long-standing type 2 diabetes mellitus, but also caused spontaneous fasting hypoglycemia. The physiopathology, clinical manifestations, diagnostic approach, and treatment of non-islet cell tumor hypoglycemia are briefly discussed here. Palliative tumor debulking improved the hypoglycemia by day 11 after radiation therapy and glucose monitoring with continuous glucose monitoring system (Dexcom G6) facilitated the patient's management and gave him peace of mind.
Pancreatic ACTH Hypersecretion and Pituitary Macroadenoma
Authors: Bettale Chiara M , Allen Jason W , Mahdi Zaid K , Ioachimescu Adriana G
Published: February 2023

A 55-year-old woman admitted for hypertensive emergency and myocardial infarction reported weight gain, muscle weakness, easy bruising, and recent-onset diabetes in the past 3 to 12 months. Urinary and salivary cortisol and adrenocorticotropin hormone (ACTH) levels were elevated. Pituitary imaging detected a macroadenoma. ACTH and cortisol did not increase after corticotropin-releasing hormone administration. Imaging revealed a large pancreatic mass. Pathology indicated a well-differentiated World Health Organization (WHO) grade 2 distal pancreatic neuroendocrine neoplasm which stained for ACTH by immunohistochemistry. Postoperatively, Cushing manifestations resolved, ACTH and cortisol levels became low, and patient required hydrocortisone replacement for 7 months. During the 3.5 years of follow-up, the pituitary macroadenoma size remained stable and pituitary hormone axes other than ACTH remained normal. This extremely rare case of ectopic ACTH-secreting pancreatic neuroendocrine tumor coexisting with a nonfunctioning pituitary macroadenoma illustrates the importance of dynamic endocrine testing in Cushing syndrome.
The Impact of Multicultural Interfacility Video Case Conference: A Novel Education Model After the COVID Pandemic
Authors: Araki Takako , Kameda Hiraku , Yamamoto Masaaki , Tateno Toru , Iwasaki Yasumasa , Yu Run , Chik Constance , Hashmi Hiba , Radulescu Angela , Burmeister Lynn A , Fukuoka Hidenori
Published: February 2023

Context

The COVID-19 pandemic challenged undertaking gradual educational activities for residency and fellowship trainees. However, recent technological advances have enabled broadening active learning opportunities through international online conferences.

Objective

The format of our international online endocrine case conference, launched during the pandemic, is introduced. The objective impact of this program on trainees is described.

Methods

Four academic facilities developed a semiannual international collaborative endocrinology case conference. Experts were invited as commentators to facilitate in-depth discussion. Six conferences were held between 2020 and 2022. After the fourth and sixth conferences, anonymous multiple-choice online surveys were administered to all attendees.

Results

Participants included trainees and faculty. At each conference, 3 to 5 cases of rare endocrine diseases from up to 4 institutions were presented, mainly by trainees. Sixty-two percent of attendees reported 4 facilities as the appropriate size for the collaboration to maintain active learning in case conferences. Eighty-two percent of attendees preferred a semiannual conference. The survey also revealed the positive impact on trainees’ learning regarding diversity of medical practice, academic career development, and confidence in honing of presentation skills.

Conclusion

We present an example of our successful virtual global case conference to enhance learning about rare endocrine cases. For the success of the collaborative case conference, we suggest smaller cross-country institutional collaborations. Preferably, they would be international, semiannually based, and with recognized experts as commentators. Since our conference has engendered multiple positive effects on trainees and faculty, continuation of virtual education should be considered even after the pandemic era.
Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya
Authors: Atandi Bryan Ogoti , Chokwe Thomas Muinga , Sulemanji Demet Sargin
Published: February 2023

BACKGROUND:

Anesthetic monitoring within standards defined by various professional anesthesia organizations has been shown to reduce perioperative mortality. Given the scarce resources for anesthesia and surgery in low- to middle-income countries, we sought to determine the availability of recommended monitoring devices in major referral hospitals in Kenya.

METHODS:

We purposely selected the 16 major referral hospitals in Kenya. A cross-sectional survey was conducted in 103 operating theaters, 96 postanesthesia care unit (PACU) beds, and 16 areas where procedural sedation was routinely administered. A checklist questionnaire based on the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines of 2015 was used to determine the availability of basic and functional monitoring devices.

RESULTS:

We determined that only 1 of 16 (6.25%) hospitals had all the monitoring devices recommended by the AAGBI. Automated noninvasive blood pressure (NIBP) monitoring and pulse oximetry were present in all operating theaters. Continuous electrocardiography (ECG) was available in 102 of 103 (99%) operating theaters, skin temperature monitoring probes in 73 of 103 (70.9%), and capnography in 49 (47.6%). A nerve stimulator was accessible in 5 of 16 (31.25%) hospitals. There were functional patient monitors in all operating theaters (100%). One of the regional referral hospitals did not have a PACU. We encountered 9 of 96 (9.4%) PACU beds without any monitoring devices. Pulse oximetry was the most common device (84.4%) in the PACU beds equipped with monitoring. In 5 of 16 (31.25%) procedural sedation areas, pulse oximetry was the only monitoring device, whereas there were no devices in 2 of 16 (12.5%) areas. Portable multiparameter devices used for patient transport were present in 5 of 16 (31.25%) hospitals.

CONCLUSIONS:

The availability of recommended monitoring devices in major referral hospitals in Kenya is inadequate. Thus, there are challenges to anesthetic monitoring in these hospitals, and perioperative patient safety is jeopardized. We recommend the universal provision of basic monitoring devices and suggest the use of the data collected in this study to affect policy change and safe anesthesia practice in our country.
Activated 4-Factor Prothrombin Complex Concentrate as a Hemostatic Adjunct for Neonatal Cardiac Surgery: A Propensity Score-Matched Cohort Study
Authors: Navaratnam Manchula , Mendoza Julianne M. , Zhang Shiqi , Boothroyd Derek , Maeda Katsuhide , Kamra Komal , Williams Glyn D.
Published: February 2023

BACKGROUND:

Prothrombin complex concentrates are an emerging “off-label” therapy to augment hemostasis after cardiopulmonary bypass (CPB), but data supporting their use for neonatal cardiac surgery are limited.

METHODS:

We retrospectively reviewed neonates undergoing open heart surgery with first-time sternotomy between May 2014 and December 2018 from a hospital electronic health record database. Neonates who received activated 4-factor prothrombin complex concentrate (a4FPCC) after CPB were propensity score matched (PSM) to neonates who did not receive a4FPCC (control group). The primary efficacy outcome was total volume (mL/kg) of blood products transfused after CPB, including the first 24 hours on the cardiovascular intensive care unit (CVICU). The primary safety outcome was the incidence of 7- and 30-day postoperative thromboembolism. Secondary outcomes included 24 hours postoperative chest tube output, time to extubation, duration of CVICU stay, duration of hospital stay, 30-day mortality, and incidence of acute kidney injury on postoperative day 3. We used linear regression modeling on PSM data for the primary efficacy outcome. For the primary safety outcome, we tested for differences using McNemar test on PSM data. For secondary outcomes, we used linear regression, Fisher exact test, or survival analyses as appropriate, with false discovery rate-adjusted P values.

RESULTS:

A total of 165 neonates were included in the final data analysis: 86 in the control group and 79 in the a4FPCC group. After PSM, there were 43 patients in the control group and 43 in the a4FPCC group. We found a statistically significant difference in mean total blood products transfused for the a4FPCC group (47.5 mL/kg) compared with the control group (63.7 mL/kg) for PSM patients (adjusted difference, 15.3; 95% CI, 29.4–1.3; P = .032). We did not find a statistically significant difference in 7- or 30-day thromboembolic rate, postoperative chest tube output, time to extubation, incidence of postoperative acute kidney injury (AKI), or 30-day mortality between the groups. The a4FPCC group had a significantly longer length of intensive care unit stay (32.9 vs 13.3 days; adjusted P = .049) and hospital stay (44.6 vs 24.1 days; adjusted P = .049) compared with the control group.

CONCLUSIONS:

We found that the use of a4FPCC as a hemostatic adjunct for post-CPB bleeding in neonatal cardiac surgery was associated with a decrease in mean total blood products transfused after CPB without an increased rate of 7- or 30-day postoperative thromboembolism. Our findings suggest that a4FPCCs can be considered as part of a hemostasis pathway for refractory bleeding in neonatal cardiac surgery.
Understanding the Intricacies of Delivering Compassionate Care in the Intensive Care Unit and What Hinders It: A Qualitative Study of Members of 2 Critical Care Societies
Authors: Siddiqui Shahla , Mohamed Enas , Johansson Anna , Rock Laura , Hartog Christiane , Subramaniam Balachundhar
Published: February 2023

BACKGROUND:

Patient-centered care is increasing in importance especially in the post-coronavirus disease 2019 (COVID-19) pandemic era. We sought to understand factors affecting compassionate care faced by intensivists in the intensive care unit (ICU).

METHODS:

Using survey methodology incorporating 3 real-life case vignettes, responses were elicited to difficult ethical and moral dilemmas in the ICU setting. Members of 2 critical care societies in the United States and Europe were included in the survey.

RESULTS:

Responses from 323 intensivists (32% out of 1000 members who opened the initial email invitation) around the world were analyzed thematically. Conflicts between patient choices and suggested medical care, institutional/work constraints restricting compassionate care and leading to burnout, and personal variables influencing compassionate care were the themes that emerged from our investigation. The results demonstrate that intensivists have compassion for their patients and want to provide patient-centered care, but also experience stress due to their limited ability to improve their patients’ conditions.

CONCLUSIONS:

Compassionate attitudes can be hindered by an underlying worry about the decision made by the patient and their family, a lack of confidence in making hard moral decisions, and the burdens of burnout.
Burnout Among Chinese Anesthesiologists After the COVID-19 Pandemic Peak: A National Survey
Authors: Che Lu , Ma Shuang , Zhang Yue Lun , Huang Yuguang
Published: February 2023

BACKGROUND:

Evidence has shown that large-scale pandemics can have prolonged psychological impacts on health care professionals. The current study aimed to evaluate the prevalence of burnout after the coronavirus disease 2019 (COVID-19) epidemic peak and to explore the prolonged impact of COVID-19 on burnout among Chinese anesthesiologists.

METHODS:

From August 2021 to October 2021, a nationwide cross-sectional survey was conducted. Burnout was measured using the Maslach Burnout Inventory-Human Service Survey. Basic demographic information, exposure to COVID-19, and perceived institutional support were documented. Validated tools measuring mental health status, including anxiety, depression, post-traumatic stress disorder (PTSD) and resilience, were also used to provide additional information on psychological distress.

RESULTS:

Of the 8850 anesthesiologists from the 218 institutions who were invited to participate, 6331 (74.93%) completed the surveys and were included in the analysis. A total of 52.7% (95% confidence interval [CI], 51.5–53.9) met the criteria for burnout. Depression, anxiety, and PTSD were positively associated with burnout. After pooled multivariate analysis adjusting for potential confounding factors, among the COVID-19 exposure parameters, redeployment outside normal professional boundaries remained associated with an increased risk of burnout (odds ratio, 0.84; 95% CI, 0.72–0.92; P = .039). Higher perceived institutional support and resilience could act as protective factors against burnout.

CONCLUSIONS:

The impact of the COVID-19 epidemic on the psychological well-being of anesthesiologists still exists more than 1 year after the outbreak. Building better institutional support and cultivating stronger resilience may be helpful future intervention measures.
Evolution of Accredited Pediatric Cardiac Anesthesiology Fellowship Training in the United States: A Step in the Right Direction
Authors: Nasr Viviane G. , Ambardekar Aditee , Grant Stephanie , Edgar Laura , Gross Cheryl , McLoughlin Thomas M. , Stafford-Smith Mark , Suresh Santhanam , Deutsch Nina
Published: February 2023

Pediatric cardiac anesthesiology has developed as a subsubspecialty of anesthesiology over the past 70 years. The evolution of this specialty has led to the establishment in 2005 of a dedicated professional society, the Congenital Cardiac Anesthesia Society (CCAS). By 2010, multiple training pathways for pediatric cardiac anesthesia emerged. Eight programs in the United States offered advanced pediatric cardiac anesthesia with variable duration, ranging from 3 to 12 months. Other programs offered a combined fellow/staff position for 1 year. The need for a standardized training pathway was recognized by the Pediatric Anesthesia Leadership Council (PALC) and CCAS in 2014. Specifically, it was recommended that pediatric cardiac anesthesiology be a second, 12-month advanced fellowship following pediatric anesthesia to acquire skills unique from those acquired during a pediatric anesthesia fellowship. This was reiterated in 2018, when specific pediatric cardiac anesthesia training milestones were developed through consensus by the CCAS leadership. However, given the continuous increasing demand for well-trained pediatric cardiac anesthesiologists, it is essential that a supply of comprehensively trained physicians exists. High-quality training programs are therefore necessary to ensure excellent clinical care and enhanced patient safety. Currently, there are 23 programs offering one or more positions for 1-year pediatric cardiac anesthesia fellowship. Due to the diverse curriculum and evaluation process, formalization of the training with accreditation through the Accreditation Council for Graduate Medical Education (ACGME) was the obvious next step. Initial inquiry started in April 2020. The ACGME recognized pediatric cardiac anesthesia as a subsubspecialty in February 2021. The program requirements and milestones for the 1-year fellowship training were developed in 2021 and 2022. This special article reviews the history of pediatric cardiac anesthesia training, the ACGME application process, the development of program requirements and milestones, and implementation.
Maternal Cardiovascular Morbidity Events Following Preeclampsia: A Retrospective Cohort Study
Authors: Meng Marie-Louise , Frere Zachary , Fuller Matthew , Li Yi-Ju , Habib Ashraf S. , Federspiel Jerome J. , Wheeler Sarahn M. , Gilner Jennifer B. , Shah Svati H. , Ohnuma Tetsu , Raghunathan Karthik , Krishnamoorthy Vijay
Published: February 2023

BACKGROUND:

Patients with preeclampsia are at high risk for long-term cardiovascular events, yet the short-term, acute cardiovascular complications that follow preeclampsia are understudied. The objective of this study was to compare the short-term, acute maternal cardiovascular morbidity events after delivery among patients with a diagnosis of preeclampsia versus those without this diagnosis.

METHODS:

In this retrospective cohort study, the Premier inpatient database was used to examine a cohort of obstetric patients older than 18 years, who delivered from January 1, 2016, to September 30, 2020. A diagnosis of preeclampsia and preeclampsia with severe features during delivery hospitalization were the exposures of interest. The primary outcome was a composite of maternal cardiovascular morbidity events during delivery hospital admission. The secondary outcome was the occurrence of maternal cardiovascular morbidity events during a readmission within 90 days of delivery hospitalization.

RESULTS:

In total, 4,488,759 patients met inclusion criteria, of which 158,114 (3.5%) were diagnosed with preeclampsia without severe features, and 117,940 (2.6%) with preeclampsia with severe features. Adjusted odds of maternal cardiovascular morbidity events were higher in patients with preeclampsia and in those with preeclampsia with severe features compared with those without preeclampsia during delivery hospitalization (adjusted odds ratio [OR] [95% confidence interval {CI}] 1.87 [1.78–1.97] and 4.74 [4.44–5.05], respectively) and within 90 days (adjusted OR [95% CI] 2.01 [1.83–2.21] and 2.32 [2.10–2.57], respectively).

CONCLUSIONS:

Patients with both preeclampsia and preeclampsia with severe features have higher rates of maternal cardiovascular morbidity events than those without preeclampsia. Future studies are necessary to examine which patients with preeclampsia are at highest risk for cardiovascular complications.
Benefit of Flow-Controlled Over Pressure-Regulated Volume Control Mode During One-Lung Ventilation: A Randomized Experimental Crossover Study
Authors: Schranc Álmos , Diaper John , Südy Roberta , Fodor Gergely H. , Habre Walid , Albu Gergely
Published: February 2023

BACKGROUND:

Application of a ventilation modality that ensures adequate gas exchange during one-lung ventilation (OLV) without inducing lung injury is of paramount importance. Due to its beneficial effects on respiratory mechanics and gas exchange, flow-controlled ventilation (FCV) may be considered as a protective alternative mode of traditional pressure- or volume-controlled ventilation during OLV. We investigated whether this new modality provides benefits compared with conventional ventilation modality for OLV.

METHODS:

Ten pigs were anaesthetized and randomly assigned in a crossover design to be ventilated with FCV or pressure-regulated volume control (PRVC) ventilation. Arterial partial pressure of oxygen (Pao
2), carbon dioxide (Paco
2), ventilation and hemodynamical parameters, and lung aeration measured by electrical impedance tomography were assessed at baseline and 1 hour after the application of each modality during OLV using an endobronchial blocker.

RESULTS:

Compared to PRVC, FCV resulted in increased Pao
2 (153.7 ± 12.7 vs 169.9 ± 15.0 mm Hg; P = .002) and decreased Paco
2 (53.0 ± 11.0 vs 43.2 ± 6.0 mm Hg; P < .001) during OLV, with lower respiratory elastance (103.7 ± 9.5 vs 77.2 ± 10.5 cm H2O/L; P < .001) and peak inspiratory pressure values (27.4 ± 1.9 vs 22.0 ± 2.3 cm H2O; P < .001). No differences in lung aeration or hemodynamics could be detected between the 2 ventilation modalities.

CONCLUSIONS:

The application of FCV in OLV led to improvement in gas exchange and respiratory elastance with lower ventilatory pressures. Our findings suggest that FCV may offer an optimal, protective ventilation modality for OLV.
Minimizing Lung Injury During Laparoscopy in Head-Down Tilt: A Physiological Cohort Study
Authors: De Meyer Gregory R. A. , Morrison Stuart G. , Saldien Vera , Jorens Philippe G. , Schepens Tom
Published: February 2023

BACKGROUND:

Increased intra-abdominal pressure during laparoscopy induces atelectasis. Positive end-expiratory pressure (PEEP) can alleviate atelectasis but may cause hyperinflation. Cyclic opening of collapsed alveoli and hyperinflation can lead to ventilator-induced lung injury and postoperative pulmonary complications. We aimed to study the effect of PEEP on atelectasis, lung stress, and hyperinflation during laparoscopy in the head-down (Trendelenburg) position.

METHODS:

An open-label, repeated-measures, interventional, physiological cohort trial was designed. All participants were recruited from a single tertiary Belgian university hospital. Twenty-three nonobese patients scheduled for laparoscopy in the Trendelenburg position were recruited.

We applied a decremental PEEP protocol: 15 (high), 10 and 5 (low) cm H2O. Atelectasis was studied with the lung ultrasound score, the end-expiratory transpulmonary pressure, the arterial oxygen partial pressure to fraction of inspired oxygen concentration (Pa
o
2/Fio
2) ratio, and the dynamic respiratory system compliance. Global hyperinflation was evaluated by dead space volume, and regional ventilation was evaluated by lung ultrasound. Lung stress was estimated using the transpulmonary driving pressure and dynamic compliance. Data are reported as medians (25th–75th percentile).

RESULTS:

At 15, 10, and 5 cm H2O PEEP, the respective measurements were: lung ultrasound scores (%) 11 (0–22), 27 (11–39), and 53 (42–61) (P < .001); end-expiratory transpulmonary pressures (cm H2O) 0.9 (–0.6 to 1.7), –0.3 (–2.0 to 0.7), and −1.9 (–4.6 to −0.9) (P < .001); Pa
o
2/Fio
2 ratios (mm Hg) 471 (435–538), 458 (410–537), and 431 (358–492) (P < .001); dynamic respiratory system compliances (mL/cm H2O) 32 (26–36), 30 (25–34), and 27 (22–30) (P < .001); driving pressures (cm H2O) 8.2 (7.5–9.5), 9.3 (8.5–11.1), and 11.0 (10.3–12.2) (P < .001); and alveolar dead space ventilation fractions (%) 10 (9–12), 10 (9–12), and 9 (8–12) (P = .23). The lung ultrasound score was similar between apical and basal lung regions at each PEEP level (P = .76, .37, and .76, respectively).

CONCLUSIONS:

Higher PEEP levels during laparoscopy in the head-down position facilitate lung-protective ventilation. Atelectasis and lung stress are reduced in the absence of global alveolar hyperinflation.
Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study
Authors: Östlund Åsa , Fläring Urban , Norberg Åke , Kaiser Sylvie , Frisk Tony , Larsson Peter , Andersson Andreas
Published: February 2023

BACKGROUND:

Midline catheters are peripheral intravenous (IV) catheters in which the tip of the catheter does not reach the central circulation. In children, the use of midline catheters could lead to decreased complications from central venous catheters. To validate the safety of midline catheter use in children, we aimed to describe the complications and dwell time of pediatric midline catheters. The primary outcome was the incidence of catheter-related venous thromboembolism (VTE).

METHODS:

We conducted an observational, prospective study including consecutive patients at a tertiary multidisciplinary pediatric hospital. One hundred pediatric midline catheters were followed for thrombotic, infectious, and mechanical complications. After catheter removal, Doppler ultrasonography was performed to detect asymptomatic VTE.

RESULTS:

The mean age was 6.0 years (standard deviation [SD], 4.7), and median catheter dwell time was 6 (4–8) days. Most midline catheters were inserted in arm veins, most commonly in the basilic vein (56%). Catheter-related VTE was diagnosed in 30 (30%; 95% confidence interval [CI], 21%–40%) cases, corresponding to an incidence rate of 39 (95% CI, 26–55) cases per 1000 catheter days. Eight of 14 saphenous vein catheters were complicated by VTE compared to 22 of 86 arm vein catheters, suggesting an imbalance in favor of arm vein insertion site. Two patients needed anticoagulation therapy due to catheter-related VTE. Thirty (30%) catheters were removed unintentionally or due to complications, 22 of these needed additional IV access to complete the intended therapy. No catheter-related bloodstream infection (95% CI, 0%–4%) occurred. Mechanical complications occurred in 33 (33%; 95% CI, 24%–43%) midline catheters.

CONCLUSIONS:

In children, thrombotic and mechanical complications of midline catheters are common, but only few VTEs are severe enough to warrant anticoagulation therapy. Systemic infectious complications are rare. Seventy-eight percent of patients did not need additional venous access to complete short-term IV therapy. Considering the rate of clinically relevant complications and the catheter dwell time, pediatric midline catheters could be an alternative to central venous access for short-term (5–10 days) IV therapy.
Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study
Authors: Yagani Seshagiribabu , Jain Kajal , Bhatia Nidhi , Singla Karan , Bagga Rashmi , Bahl Ajay
Published: February 2023

BACKGROUND:

Lung interstitial edema is a clinically silent pathology that develops before overt pulmonary edema among pre-eclamptic women with severe features. Point-of-care lung ultrasonography (LUS) has been suggested as an accessible bedside tool that may identify lung interstitial edema before developing clinical signs and symptoms. Thus, we planned to use bedside LUS as a diagnostic tool in admitted pre-eclamptic women with severe features, with the aim of identifying alveolar-interstitial fluid, seen as B-lines. Our primary objective was to assess the incidence of interstitial alveolar syndrome on lung ultrasonography.

METHODS:

We conducted a prospective, single-center, observational study on parturients with pre-eclampsia with severe features over a period of 15 months. LUS in 4 intercostal spaces (ICS) was performed on all eligible patients. The number of single or confluent B-lines in each space was recorded by an independent observer. A scoring system was used to grade the lung fluid content based on the number of single and confluent B-lines per ICS, with scores ranging from 0 to 32 (low, 0–10; moderate, 11–20; and high, 21+). The incidence of B-lines at admission and before and after delivery was calculated. In addition, bedside 2D echocardiography was performed to assess left ventricular systolic and diastolic function. Any correlation between presence of B-lines on LUS and blood pressure, clinical symptoms, or echocardiography findings was assessed.

RESULTS:

Seventy patients were enrolled in the study. On LUS, B-lines were seen in 64.3% patients at admission (45/70 vs 25/70 without B-lines; P = .02), 65.7% patients before delivery (46/70 vs 24/70 without B-lines; P = .01), and 58.6% patients 24 hours postpartum (41/70 versus 29/70 without B-lines; P = .15). Nearly all patients (94.3%) exhibited low to moderate severity of pulmonary fluid burden at admission. Echocardiography revealed diastolic dysfunction in 47.1% (n = 33/70) patients with associated B-lines in the majority (n = 32/33). The total B-line score and E/e’ ratio among patients with diastolic dysfunction was found to be strongly correlated (r = 0.848; P < .001). All pre-eclamptic women with presence of breathlessness (11/11; 100%) and facial puffiness (16/16; 100%) on admission had B-lines on LUS.

CONCLUSIONS:

We conclude that ultrasonographic pulmonary interstitial syndrome is present in more than half of the women with pre-eclampsia with severe features and correlates with diastolic dysfunction, high blood pressure records, and acute-onset breathlessness.
Performance of the SEDLine Monitor: Age Dependency and Time Delay
Authors: Obert David P. , Schneider Frederick , Schneider Gerhard , von Dincklage Falk , Sepulveda Pablo , García Paul S. , Kratzer Stephan , Kreuzer Matthias
Published: February 2023

BACKGROUND:

Devices monitoring the hypnotic component of general anesthesia can help to guide anesthetic management. The main purposes of these devices are the titration of anesthesia dose. While anesthesia at low doses can result in awareness with intraoperative memory formation, excessive administration of anesthetics may be associated with an increased risk of postoperative neurocognitive disorder. We have previously shown for various indices that they are significantly influenced by the patient’s age and that the monitors have a significant time delay. Here, we evaluated the influence of patient’s age and time delay on the patient state index (PSI) of the SEDLine monitor.

METHODS:

To analyze the influence of the patient’s age, we replayed 2 minutes of electroencephalography (EEG) of 141 patients (19–88 years, ASA I–IV) undergoing general anesthesia maintained with desflurane, sevoflurane, or propofol to the SEDLine monitor. We extracted the PSI as well as the spectral edge frequency (SEF) and performed a linear regression analysis. For evaluation of the time delay, we replayed 5 minutes of EEG of stable episodes of adequate anesthesia (PSI between 25 and 50) or light sedation/wake (PSI >70) in different orders to the SEDLine to simulate sudden changes between the states. Time delays were defined as the required time span of the monitor to reach the stable target index.

RESULTS:

PSI and SEF increased significantly with the patient’s age. These findings did not depend on the administered anesthetic. The evaluation of the correlation between SEF and PSI showed a strong correlation with Spearman’s correlation coefficient of ρ = 0.86 (0.82; 0.89). The time delays depended on the type of transition. We found a median time delay of 54 (Min: 46; Max: 61) seconds for the important transition between adequate anesthesia and awake and 55 (Min: 50; Max: 67) seconds in the other direction.

CONCLUSIONS:

With our analyses, we show that the indices presented on the SEDLine display, the PSI and the SEF, increase with age for patients under general anesthesia. Additionally, a delay of the PSI to react to sudden neurophysiologic changes due to dose of the maintenance anesthetic is of a time course that is clinically significant. These factors should be considered when navigating anesthesia relying on only the proprietary index for the SEDLine monitor.
Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study
Authors: Mohamed Shuweikha Salim , Temu Rogers , Komba Leticia F. , Kaino Mwemezi M. , Olotu Frank I. , Ndebea Ansbert S. , Vaughan Brian N.
Published: February 2023

BACKGROUND:

Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania.

METHODS:

Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively.

RESULTS:

A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87–95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4–8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93–98) patients and 145 of 170 (95% CI, 80–90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed.

CONCLUSIONS:

Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.
Metastatic Breast Cancer to the Spine: Incidence of Somatic Gene Alterations and Association of Targeted Therapies With Overall Survival
Authors: Rabah Nicholas M. , Jarmula Jakub , Hamza Omar , Khan Hammad A. , Chakravarthy Vikram , Habboub Ghaith , Wright James M. , Steinmetz Michael P. , Wright Christina H. , Krishnaney Ajit A.
Published: February 2023

BACKGROUND:

The increase in use of targeted systemic therapies in cancer treatments has catalyzed the importance of identifying patient- and tumor-specific somatic mutations, especially regarding metastatic disease. Mutations found to be most prevalent in patients with metastatic breast cancer include TP53, PI3K, and CDH1.

OBJECTIVE:

To determine the incidence of somatic mutations in patients with metastatic breast cancer to the spine (MBCS). To determine if a difference exists in overall survival (OS), progression-free survival, and progression of motor symptoms between patients who do or do not undergo targeted systemic therapy after treatment for MBCS.

METHODS:

This is a retrospective study of patients with MBCS. Review of gene sequencing reports was conducted to calculate the prevalence of various somatic gene mutations within this population. Those patients who then underwent treatment (surgery/radiation) for their diagnosis of MBCS between 2010 and 2020 were subcategorized. The use of targeted systemic therapy in the post-treatment period was identified, and post-treatment OS, progression-free survival, and progression of motor deficits were calculated for this subpopulation.

RESULTS:

A total of 131 patients were included in the final analysis with 56% of patients found to have a PI3K mutation. Patients who received targeted systemic therapies were found to have a significantly longer OS compared with those who did not receive targeted systemic therapies.

CONCLUSION:

The results of this study demonstrate that there is an increased prevalence of PI3K mutations in patients with MBCS and there are a significant survival benefit and delay in progression of motor symptoms associated with using targeted systemic therapies for adjuvant treatment.
Trends in Online Patient Perspectives of Neurosurgeons: A Sentiment Analysis
Authors: Quinones Addison , Tang Justin E. , Vasan Vikram , Li Troy , Schupper Alexander J. , Ali Muhammad , White Christopher A. , Hannah Theodore C. , Asfaw Zerubabbel , Li Adam Y. , Durbin John , Arvind Varun , Kim Jun S. , Choudhri Tanvir F.
Published: February 2023

BACKGROUND:

Patients increasingly rely on readily available physician reviews to inform their provider choices. Sentiment analysis and machine learning techniques quantitatively analyze written prose to understand patient desires from physician encounters. Patient perspectives on their medical care have been understudied in neurosurgery.

OBJECTIVE:

To analyze patient reviews of neurosurgeons to uncover trends between patient ratings of their encounters and content in their reviews.

METHODS:

Identification of neurosurgeons and demographic data were collected from 115 Accreditation Council for Graduate Medical Education–accredited programs using public data. Healthgrades.com was used to obtain online written and star rating reviews which were analyzed using a machine learning sentiment analysis package to generate a sentiment score. Student t tests compared differences between demographics and outcomes from the sentiment analysis. Multivariate regression was performed to examine associations between sentiment rating and word/word pair frequency.

RESULTS:

One thousand two hundred eighty-four neurosurgeons were found to have review profiles which consisted of 6815 reviews. Analysis revealed a direct correlation between sentiment score and star rating (r2 = 0.554, P < .0001). There were no differences in the sentiment score based on neurosurgeons' sex; however, younger surgeons had more positive reviews (P = .022). Word frequency analysis showed that reviews were less likely to be positive if they included “pain” (odds ratio [OR]: 0.28, CI: 0.24-0.32, P < .0001) or “rude” (OR: 0.03, CI: 0.01-0.06, P < .0001). Reviews were more likely to be positive when they included “kind” (OR: 3.7, CI: 2.6-5.3, P < .0001) or “pain-free” (OR: 3.1, CI: 2.1-4.7, P < .0001).

CONCLUSION:

Top-rated reviews demonstrate the importance of compassion in patient satisfaction. The word “pain” arose for both negative and positive reviews. Pain management seems to be a salient component of patients' evaluation of their neurosurgical care, thereby underscoring the importance of guiding patient pain expectations.
Foraging habitat and site selection do not affect feeding rates in European shags
Authors: Watanuki Yutaka , Sato Katsufumi , Shiomi Kozue , Wanless Sarah , Daunt Francis
Published: February 2023

During feeding trips, central-place foragers make decisions on whether to feed at a single site or move to other sites and/or exploit different habitats. However, for many marine species the lack of fine resolution data on foraging behaviour and success has hampered our ability to test whether individuals follow predictions of the optimal foraging hypothesis. Here we tested how benthic foraging habitat usage, time spent at feeding sites and probability of change of feeding sites affected feeding rates in European shags Gulosus aristotelis, using time-depth-acceleration data loggers in 24 chick-rearing males. Foraging habitat (rocky or sandy) was identified from characteristic differences in dive patterns and body angle. Increase in body mass was estimated from changes in wing stroke frequency during flights. Bout feeding rate (increase in body mass per unit time of dive bout), did not differ between rocky and sandy habitats or in relation to the order of dive bouts during trips. Bout feeding rates did not affect the duration of flight to the next feeding site or whether the bird switched habitat. However, the likelihood of a change in habitat increased with the number of dive bouts within a trip. Our findings that shags did not actively move further or switch habitats after they fed at sites of lower quality are in contrast to the predictions of optimal foraging theory. Instead, it would appear that birds feed probabilistically in habitats of varying capture rate affected by prey density and conspecific competition or facilitation.
Weanling gut microbiota composition of a mouse model selectively bred for high voluntary wheel-running behavior
Authors: McNamara Monica P. , Venable Emily M. , Cadney Marcell D. , Castro Alberto A. , Schmill Margaret P. , Kazzazi Lawrence , Carmody Rachel N. , Garland, Jr Theodore
Published: February 2023

We compared the fecal microbial community composition and diversity of four replicate lines of mice selectively bred for high wheel-running activity over 81 generations (HR lines) and four non-selected control lines. We performed 16S rRNA gene sequencing on fecal samples taken 24 h after weaning, identifying a total of 2074 bacterial operational taxonomic units. HR and control mice did not significantly differ for measures of alpha diversity, but HR mice had a higher relative abundance of the family Clostridiaceae. These results differ from a study of rats, where a line bred for high forced-treadmill endurance and that also ran more on wheels had lower relative abundance of Clostridiaceae, as compared with a line bred for low endurance that ran less on wheels. Within the HR and control groups, replicate lines had unique microbiomes based on unweighted UniFrac beta diversity, indicating random genetic drift and/or multiple adaptive responses to selection.