bluuebunny/crossref_metadata_2025 huggingface dataset:
Not Just Arterial Damage: Increased Incidence of Venous Thromboembolic Events in Cardiovascular Patients With Elevated Plasma Levels of Apolipoprotein CIII
Authors: Olivieri Oliviero , Turcato Gianni , Moruzzi Sara , Castagna Annalisa , Girelli Domenico , Pizzolo Francesca , Friso Simonetta , Sandri Marco , Bassi Antonella , Martinelli Nicola
Published: January 2019

Background

Apolipoprotein
CIII
(apo
CIII
) is a crucial player in triglyceride‐rich lipoprotein metabolism, but may also act pleiotropically, provoking inflammatory responses and stimulating coagulation. Elevated apo
CIII
plasma levels have been associated with increased activity of coagulation factors. Since these features of prothrombotic diathesis are linked with venous thromboembolism (
VTE
), we hypothesized that apo
CIII
plays a role in
VTE
.

Methods and Results

We recorded nonfatal
VTE
events in 1020 patients (age 63.3±11.4 years; 29.1% women) with or without coronary artery disease (79.1% with coronary artery disease and 20.9% without coronary artery disease) during a long follow‐up. Complete plasma lipid and apolipoproteins were available for all patients. Forty‐five patients (4.4%) experienced nonfatal
VTE
events during a median follow‐up period of 144 months. Apo
CIII
plasma concentration at enrollment was higher in patients with VTE compared with patients without
VTE
(12.2 [95% CI, 11.10–13.5] mg/dL vs 10.6 [95% CI, 10.4–10.9] mg/dL, respectively;
P
=0.011). Patients with apo
CIII
levels above the median value (10.6 mg/dL) exhibited an increased risk of
VTE
(incidence rate, 6.0 [95%
CI
, 4.0–8.0] vs 1.8 [95%
CI,
0.7–2.9]
VTE
events/1000 person‐years; unadjusted hazard ratio [
HR
], 3.42 [95%
CI
, 1.73–6.75];
P
<0.001). This association was confirmed after adjustment for sex, age, coronary artery disease diagnosis, body mass index, hypertension, and anticoagulant treatment at enrollment (
HR
, 2.66; 95%
CI
, 1.31–5.37 [
P
=0.007]), with inclusion of lipid parameters in the Cox model (HR, 3.74; 95%
CI
, 1.24–11.33 [
P
=0.019]), and even with exclusion of patients who died at follow‐up (
HR,
3.92; 95%
CI
, 1.68–9.14 [
P
=0.002]) or patients taking anticoagulants (
HR
, 3.39; 95%
CI
, 1.72–6.69 [
P
<0.001]).

Conclusions

Our results suggest that high plasma apo
CIII
concentrations may predict an increased risk of
VTE
in patients with cardiovascular disease.
Thrombotic/Thrombolytic Balance as a Cardiac Treatment Determinant in Patients With Diabetes Mellitus and Coronary Artery Disease
Authors: Tsujimoto Tetsuro , Kajio Hiroshi
Published: January 2019

Background

This study aimed to assess whether the plasminogen activator inhibitor‐1/tissue plasminogen activator (
PAI
‐1/
tPA
) ratio as a prothrombotic state is useful for optimizing cardiac treatment strategy.

Methods and Results

Using BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial data, we used a Cox proportional hazard model to calculate hazard ratios with 95%
CI
s for cardiac events in patients receiving early revascularization (percutaneous coronary intervention or coronary artery bypass grafting) or medical therapy, separately in patients with low (n=1276) and high (n=894)
PAI
‐1/
tPA
ratios. The primary outcome was major cardiac events, which was a composite end point including cardiac death and nonfatal myocardial infarction. The mean±
SD
follow‐up period was 4.1±1.7 years. The risk of major cardiac events in patients with high
PAI
‐1/
tPA
ratio was significantly higher when receiving percutaneous coronary intervention (hazard ratio, 1.84; 95%
CI
, 1.16–2.93;
P
=0.01) than when receiving medical therapy, whereas that in patients with low
PAI
‐1/
tPA
ratio did not differ significantly between the groups (hazard ratio, 0.95; 95%
CI
, 0.66–1.36;
P
=0.77); the interaction between the cardiac treatment strategy and
PAI
‐1/
tPA
ratio was significant (
P
=0.02). However, regardless of the
PAI
‐1/
tPA
ratio, major cardiac event risk seemed to be lower in patients receiving coronary artery bypass grafting than in those receiving medical therapy.

Conclusions

In patients with type 2 diabetes mellitus and coronary artery disease, this study demonstrated that those with high
PAI
‐1/
tPA
ratio were at higher risks of major cardiac events when treated with percutaneous coronary intervention than when treated with intensive medical therapy.
A taxonomic revision of the augochlorine bee genus Ceratalictus Moure (Hymenoptera, Apoidea)
Authors: COELHO BEATRIZ W. T. , GONÇALVES RODRIGO B.
Published: January 2019

The Neotropical halictid bee genus Ceratalictus Moure (Augochlorini) is revised. Five new species are described, Ceratalictus argentinus n. sp., C. camargoi n. sp., C. culminis n. sp., C. nitidus n. sp. and C. orthocarinatus n. sp.; five species are redescribed: Ceratalictus allostictus Moure, C. clonius (Brèthes), C. ischnotes (Vachal), C. psoraspis (Vachal), and C. stigon (Vachal). Ceratalictus lorenzinis (Strand) is synonymized with C. clonius. All catalogued type specimens were examined. Illustrations of all species and an identification key for the 10 presently recognized species are provided.
Aquatic oligochaetes (Annelida: Clitellata) of the Czech Republic: check-list, new records, and ecological remarks
Authors: SCHENKOVÁ JANA , PAŘIL PETR , PETŘIVALSKÁ KARLA , BOJKOVÁ JINDŘIŠKA
Published: January 2019

This study contributes to the knowledge of central European clitellates by creating a check-list of Oligochaeta (sensu oligochaetous Clitellata; Erséus 2005) of the Czech Republic, exclusive of taxa in the family Enchytraeidae. In total, 95 aquatic oligochaete species representing 43 genera are reported for the Czech Republic. Rare species are highlighted and associated with the categories for threatened species as outlined by the International Union for the Conservation of Nature. The first records of Trichodrilus strandi Hrabě, 1936, Pristina jenkinae (Stephenson, 1931), Pristina osborni (Walton, 1906), Rhyacodrilus subterraneus Hrabě, 1963, Aulodrilus limnobius Bretscher, 1899, and Aulodrilus pigueti Kowalewski, 1914 in the Czech Republic are presented. Their ecology, morphology, and distribution are discussed.
A new species and first record of Gabunillo Schmalfuss & Ferrara, 1983 (Isopoda, Oniscidea, Armadillidae) from the Neotropics
Authors: SOUZA LEILA A. , SENNA ANDRÉ R. , KURY ADRIANO B.
Published: January 2019

A new species of terrestrial isopod, Gabunillo aridicola sp. nov., is described from Ceará and Rio Grande do Norte States, in Karstic formations in the Brazilian semi-arid (caatinga). This genus, hitherto monotypic, was known only from Gabon. This occurrence is remarkable because very few genera of Armadillidae are known from both Afrotropics and Neotropics, and because it offers evidence of a tropical Gondwana biogeographical component.
The tadpole of the hylodid frog Hylodes charadranaetes Heyer and Cocroft, 1986
Authors: COSTA PAULO NOGUEIRA , SIQUEIRA CARLA COSTA , VRCIBRADIC DAVOR , WEBER LUIZ NORBERTO , ROCHA CARLOS FREDERICO D.
Published: January 2019

The genus Hylodes Fitzinger, 1826 is restricted to eastern Brazil, occurring from the states of Espírito Santo to Rio Grande do Sul (Lingnau et al. 2008, Frost 2010). Except for Hylodes otavioi, which inhabits riparian forests in rocky fields (“campos rupestres”) habitats within the Cerrado domain in Minas Gerais State (Sazima & Bokermann 1982), all other species in the genus are endemic to the Atlantic Rainforest domain (Lingnau et al. 2008). The genus currently comprises 24 species (Frost 2010) of small to medium-sized diurnal frogs that live associated to lotic streams in forests (e.g. Lingnau et al. 2008; Silva & Benmaman 2008). Heyer (1982) proposed four species groups for Hylodes, which are still recognized today (but see Haddad et al. 1996; Canedo & Pombal 2007): the glaber (formerly pulcher), lateristrigatus, mertensi, and nasus species groups. The Hylodes lateristrigatus species group is the most specious, being currently composed by 18 species: H. amnicola Pombal, Feio, and Haddad, 2002, H. babax Heyer, 1982, H. charadranaetes Heyer and Cocroft, 1986, H. fredi Canedo and Pombal, 2007, H. heyeri Haddad, Pombal, and Bastos, 1996, H. lateristrigatus (Baumann, 1912), H. magalhaesi (Bokermann, 1964), H. meridionalis (Mertens, 1927), H. ornatus (Bokermann, 1967), H. otavioi Sazima and Bokermann, 1983, H. perere Silva & Benmaman, 2008, H. perplicatus (Miranda-Ribeiro, 1926), H. pipilans Canedo and Pombal, 2007, H. phyllodes Heyer and Cocroft, 1986, H. regius Gouvêa, 1979, H. sazimai Haddad and Pombal, 1995, H. uai Nascimento, Pombal, and Haddad, 2001, and H. vanzolinii Heyer, 1982 (Silva & Benmaman 2008; Frost 2010).
Three new species of Galumnidae (Acari: Oribatida) from Cat Tien National Park, southern Vietnam
Authors: ERMILOV SERGEY G. , ANICHKIN ALEXANDER E.
Published: January 2019

Three new species of oribatid mites of the family Galumnidae, Galumna acutirostrum sp. nov., Galumna levisensilla sp. nov., Neogalumna seniczaki sp. nov., are proposed and described. All three are from sandy soil in a dipterocarp forest of Cat Tien National Park (southern Vietnam). Diagnostic keys to the Vietnamese species of Galumna (Galumna) and known species of Neogalumna are presented.
A new strikingly coloured species of Siphonocryptus, sixth of its order (Diplopoda: Siphonocryptida)
Authors: ENGHOFF HENRIK
Published: January 2019

The small millipede family Siphonocryptidae was revised by Enghoff & Golovatch (1995) who assigned two genera and three species to it: Siphoncryptus compactus Pocock, 1894, from Sumatra, S. latior Enghoff & Golovatch, 1995, from the Malaccan peninsula, and Hirudicryptus canariensis (Loksa, 1967) from the Canary and Madeiran archipelagos in the Atlantic Ocean. This highly disjunct distribution pattern has later become partly filled out by Hirudicryptus taiwanensis Korsós et al., 2008, from Taiwan, and H. quintumelementum Korsós et al., 2009, from Nepal.
A taxonomic study on Chrysotus Meigen (Diptera: Dolichopodidae) from southwest China: descriptions of eleven new species belonging to the redefined C. laesus-group
Authors: WEI LIANMENG , ZHANG LILI
Published: January 2019

Eleven new species of Chrysotus Meigen are described from southwest China: C. adunatus sp. nov., C. agraulus sp. nov., C. anshunus sp. nov., C. apicicaudatus sp. nov., C. biprojicienus sp. nov., C. fanjingshanus sp. nov., C. fuscitibialis sp. nov., C. laxifacialus sp. nov., C. pallidus sp. nov., C. trapezinus sp. nov. and C. xinanus sp. nov. which belong to the redefined Chrysotus laesus species-group. A key to all species of the C. laesus species-group is provided.
Gorditus rotundus, a new genus and species of Pentodontini from Cuba (Coleoptera: Scarabaeidae: Dynastinae)
Authors: RATCLIFFE BRETT C.
Published: January 2019

Gorditus rotundus, a new genus and species of pentodontine, is described from Cuba. A key to the genera of Dynastinae occurring in Cuba is provided.
Three new species and one new record of the subgenus Hispidosperchon Thor, 1901 within the genus Sperchon Kramer, 1877 from China (Acari: Sperchontidae)
Authors: ZHANG XU , JIN DAO-CHAO
Published: January 2019

Three new species of the subgenus Hispidosperchon Thor, 1901, Sperchon (Hispidosperchon) beijingensis sp. nov., Sperchon (Hispidosperchon) heteropoda sp. nov. and Sperchon (Hispidosperchon) huangshanensis sp. nov. are described from China. Sperchon (Hispidosperchon) garhwalensis Kumar, Kumar & Pesic, 2007 is newly recorded with the male described for the first time from China.
Revision of the genus Renda Blackwelder, 1952 (Coleoptera: Staphylinidae: Xantholinini)
Authors: MÁRQUEZ JUAN
Published: January 2019

The genus Renda Blackwelder, 1952 is revised and redescribed. Thirteen previously described species of Renda are redescribed and twenty-one species are described as new. Renda funebris (Sharp, 1876) is proposed as a junior synonym of R. flagellicornis (Nordmann, 1837), R. pubescens (Nordmann, 1837) as a junior synonym of R. formicaria (Laporte, 1835), and R. dalmasi (Fauvel, 1901) as a junior synonym of R. minor Sharp, 1876. A key to the species of Renda is provided and diagnostic characters are illustrated. A generic key for a group of genera consisting of Renda, Agrodes and Plochionocerus is also included. A phylogenetic analysis was performed to analyze the relationships among Renda species, based on the study of 416 specimens belonging to 31 species. The strict consensus tree supports the monophyly of the genus, but species relationships within Renda are poorly resolved, with only two species groups recovered as monophyletic clades.
Parergodrilus heideri Reisinger, 1925 (Annelida: Polychaeta) from a holm oak wood in an extinct volcano of southern Italy
Authors: ROTA EMILIA , DE NICOLA FLAVIA , BARGAGLI ROBERTO
Published: January 2019

A well established population of the soil-dwelling polychaete Parergodrilus heideri Reisinger, 1925 was discovered during a survey of the woodland soil fauna in the Astroni Crater (a State Nature Reserve near Naples, Italy, 50 m a.s.l., 40°50′52″N, 14°08′59″E) (Fig. 1A, B). This is the southernmost capture of this worm in Europe (Fig. 2A), although a lower latitude record (35°22′0.4″N, 127°34′52″E), the sole (so far) outside the continent, has been reported recently from Korea in this same journal (Dózsa-Farkas & Hong 2010). In Italy the species was known only from the Casentino National Park (1,120 m a.s.l.) in Tuscany and the Regional Park of Suviana and Brasimone Lakes (975 m a.s.l.) in Emilia Romagna (Rota 1997; Rota et al. 2001). Also in central Europe the species appears confined to mountain habitats (650-1,200 m a.s.l.), the lowland records being located along the northern coasts of Spain and Germany and in southern Sweden (Fig. 2A, B).
Diagnosis of the Dynamic Efficiency of Latent Heat Release and the Rapid Intensification of Supertyphoon Haiyan (2013)
Authors: Kuo Hung-Chi , Tsujino Satoki , Huang Chien-Chang , Wang Chung-Chieh , Tsuboki Kazuhisa
Published: January 2019

Before landfall in the Philippines, Supertyphoon Haiyan in 2013 experienced a period of rapid intensification (RI) with the maximum wind speed increasing by 31 m s−1 in 24 h. A 2-km horizontal resolution full-physics cloud-resolving model is used to study the RI of Haiyan. To aid in the diagnosis of RI, we employ a dynamic efficiency factor (DEF), which is based on axisymmetric gradient wind vortex theory. The DEF measures the efficacy of convective heating at any point in generating kinetic energy. The DEF is large in the presence of strong baroclinicity near the eyewall. The simulated tropical cyclone (TC) becomes more symmetric and resembles the observations of Haiyan during the RI period. Our results highlight the nonlinear feedback process in which deep convection becomes collocated with the large DEF area near the eyewall. With the intensity increase, the eyewall convection results in significant subsidence warming at the edge of the eye rather than at the center of the eye. The overall eye warming enhances the baroclinicity near the eyewall and the system DEF in the eye-core region is increased by 33% before and after the RI onset. The vortex intensity increase during the RI period also leads to large unbalanced radial inflow in the boundary layer. The large radial inflow causes the deep convection to occur in the region of large inertial stability inside the radius of maximum wind. The deep convection further efficiently intensifies the TC. Our simulation emphasizes the importance of model resolution in simulating the internal nonlinear processes of RI.
A Reduced-Space Ensemble Kalman Filter Approach for Flow-Dependent Integration of Radar Extrapolation Nowcasts and NWP Precipitation Ensembles
Authors: Nerini Daniele , Foresti Loris , Leuenberger Daniel , Robert Sylvain , Germann Urs
Published: January 2019

A Bayesian precipitation nowcasting system based on the ensemble Kalman filter is formulated. Starting from the last available radar observations, the prediction step of the filter consists of a stochastic radar extrapolation technique, while the correction step updates the radar extrapolation nowcast using information from the most recent forecast by the numerical weather prediction model (NWP). The result is a flow-dependent and seamless blending scheme that is based on the spread of the nowcast and NWP ensembles, used as the definition of the forecast error. To simplify the matrix operations, the Bayesian update is performed in the subspace spanned by the principal components, hence the term reduced space. Synthetic data experiments demonstrated that the Bayesian nowcast correctly captures the flow dependency in both the NWP forecast and the radar extrapolation skills. Four experiments with real precipitation data and a relatively small ensemble size (21 members) represented a first test under realistic conditions, such as stratiform wintertime precipitation and localized summertime convection. The skill was quantified in terms of fractions skill score at 32-km scale and 2.0 mm h−1 intensity. The results indicate that the system is able to produce blended forecasts that are at least as skillful as the nowcast-only or the NWP-only forecasts at any lead time.
Exploring the Relationship Between Lifestyle Behaviors and Health-Related Quality of Life Among Older Adults With Diabetes
Authors: Qin Weidi , Blanchette Julia E. , Murrock Carolyn
Published: January 2019

Purpose

The purpose of the study was to examine the association between 3 lifestyle behaviors (smoking, physical activity, and fruit and vegetable consumption) and health-related quality of life (HRQOL) among older adults diagnosed with diabetes.

Methods

A sample of the US population 65 years and older who were diagnosed with diabetes from the 2015 Behavioral Risk factor Surveillance System (N = 11 503) was analyzed. The 4 HRQOL measures were self-rated health, physically unhealthy days, mentally unhealthy days, and impaired activity days in the past month. Multiple logistic regression analysis was conducted to predict HRQOL.

Results

The multiple logistic regression results showed that smoking and lack of physical activity were significant predictors for higher odds of fair or poor self-rated health, more physically unhealthy days, more mentally unhealthy days, and more impaired activity days during past 30 days. No significant relationship was found between fruit and vegetable consumption and any HRQOL measure.

Conclusions

Findings imply that diabetes education could continue and enhance efforts in smoking cessation and increase physical activity to promote the HRQOL among older adults diagnosed with diabetes. In addition, the measure of fruit and vegetable consumption should be further studied to reflect the needs of older adults with diabetes.
Nontraumatic rupture of the costal margin: a single-center experience
Authors: Mary Parks Ruth , Jadoon Mehmood , Duffy John
Published: January 2019

Background

Rupture of the costal margin is uncommon. Whilst most often seen after major trauma, we describe its occurrence in patients with no direct chest trauma.

Methods

A search was performed in our thoracic surgery database for all patients with rupture of the costal margin. Patients were excluded if the injury was a result of trauma. Data were collected on sex, age, body mass index, profession, past medical history, smoking status, presenting complaint, mechanism of injury, and management.

Results

There were 9 patients with rupture of the costal margin that was caused in all cases by a severe coughing fit. All patients were male and the mean age was 62.5 years (range 47–76 years). Chronic obstructive pulmonary disease was present in 6 cases. Presentations included a palpable defect (5 cases), cough (9 cases), and chest pain (6 cases). On radiological examination, all patients had widening of the rib space, 4 had associated rib fractures, and 5 had lung herniation. Time from injury to presentation was 12 months (range 1–24 months). All patients underwent surgery and were followed-up for 59 months (range 8–129 months). Two patients suffered major complications in the immediate postoperative period.

Conclusions

Rupture of the costal margin, in the absence of direct trauma, is characterized by pain, a palpable defect, and lung herniation. It is associated with widening of the rib space and rib fractures, and can be treated surgically with success but not without significant risks.
Tuberous Sclerosis Presenting for Laparotomy
Authors: Ong E. L. , Koay C. K.
Published: January 2019

A 30-year-old female patient with tuberous sclerosis presented for anaesthesia and surgery for haemorrhagic renal angiomyolipoma. The anaesthetic management of this case was tailored to the prevention of seizures. Diagnostic features and possible complications of the disease are also described.
The Effect of Haemodilution on Antithrombin Concentration during Cardiac Surgery
Authors: Linden M. D. , Gibbs N. M. , Bremner M. , Schneider M. , Erber W. N.
Published: January 2019

The effect of haemodilution on antithrombin concentration was investigated in 73 patients undergoing elective cardiac surgery with and without cardiopulmonary bypass. In patients who required cardiopulmonary bypass (n=45), the antithrombin concentration fell to 52% of baseline during surgery (24.2 mg.dl−1 to 12.6 mg.dl−1), and the haemoglobin level fell to 55% (136 g.l−1 to 75 g.l−1). In patients who did not require cardiopulmonary bypass (n=28), the antithrombin concentration fell to 82% of baseline (23.7 mg.dl−1 to 19.5mg.dl−1), and the haemoglobin concentration fell to 78% (141 g.l−1 to 109 g.l−1). The overall correlation coefficient (r) for changes in antithrombin and haemoglobin concentrations was 0.76. The results indicate that most of the decrease in concentration of antithrombin during cardiac surgery is a consequence of cardiopulmonary bypass and is due to haemodilution. This data demonstrates that the percentage decrease in haemoglobin concentration can be used to estimate the percentage decrease in antithrombin concentration that occurs during cardiac surgery, if blood products that might effect the results are not administered between measurements.
Oral Ketamine or Midazolam or Low Dose Combination for Premedication in Children
Authors: Darlong V. , Shende D. , Subramanyam M. S. , Sunder R. , Naik A.
Published: January 2019

This randomized controlled trial was designed to evaluate whether the combination of low dose oral midazolam (0.25 mg/kg) and low dose oral ketamine (3 mg/kg) provides better premedication than oral midazolam (0.5 mg/kg) or oral ketamine (6 mg/kg). Seventy-eight children of ASA physical status I or II scheduled for elective ophthalmic surgery were randomly divided into three groups and given premedication in the holding area 30 minutes before surgery. Two subjects from each group vomited the medication and were excluded, leaving 72 subjects for further analysis.

The onset of sedation was earlier in the combination group than the other two groups. At 10 minutes after premedication 12.5% in the combination group had an acceptable sedation score compared with none in the other two groups. After 20 minutes 54% in the combination group had an acceptable sedation score, 21% in the midazolam group and 16% in the ketamine group (P<0.05). There were no significant differences in the parental separation score, response to induction and emergence score. The mean time for best parental separation score was significantly less in the combination group (19±8 min) than either the midazolam (28±7) or ketamine (29±7 min) groups (P<0.05). Recovery was earlier in the combination group, as the time required to reach a modified Aldrete score of 10 was significantly less in the combination group (22±5 min) than in the oral midazolam (36±11 min) or ketamine (38±8 min) groups. The incidence of excessive salivation was significantly higher in the ketamine alone group (P<0.05). In conclusion, the combination of oral ketamine (3 mg/kg) and midazolam (0.25 mg/kg) has minimal side effects and gives a faster onset and more rapid recovery than ketamine 6 mg/kg or midazolam 0.5 mg/kg for premedication in children.
Muscle Weakness after Muscle Relaxants: An Audit of Clinical Practice
Authors: Alkhazrajy W. , Khorasanee A. D. , Russell W. J.
Published: January 2019

Residual muscle weakness after general anaesthesia, assessed using handgrip strength, was audited in a teaching hospital. The relationships between residual weakness, the use of muscle relaxants and patient characteristics were examined.

Handgrip strength was measured preoperatively, one hour postoperatively and one day postoperatively using a hand dynamometer in 151 patients having general anaesthesia. Forty-nine patients received no muscle relaxant, 34 patients received vecuronium and 68 received rocuronium. Patients were managed by their anaesthetist according to that anaesthetist's clinical choice. All patients who received muscle relaxants received neostigmine.

One hour postoperatively, there was a decline in handgrip strength of 16% for the no relaxant group, 24% for vecuronium and 29% for rocuronium. The degree of weakness for the relaxant groups was unrelated to age (P=0.89) but was strongly influenced by the patient's sex. Almost all of the increased weakness with relaxants was found in the female patients. The mean decline in handgrip strength in the male patients who received either vecuronium or rocuronium was similar to that seen when relaxants had not been used (P=0.40). One hour postoperatively, female patients showed a marked decrease in handgrip strength after both vecuronium and rocuronium (32% and 34% respectively, combined P=0.01).

These results suggest that in usual clinical practice at our institution, female patients are more likely to have residual weakness after muscle relaxants.
Fatal Systemic Air Embolism during Endoscopic Retrograde Cholangio-pancreatography
Authors: Nayagam J. , Ho K. M. , Liang J.
Published: January 2019

Air embolism is a rare complication of gastrointestinal endoscopy. We present a 56-year-old male who developed both venous and systemic arterial air embolism during an endoscopic retrograde cholangiopancreatogram. Despite early treatment based on clinical diagnosis and confirmation by transthoracic echocardiography, the patient died as a result of severe cerebral ischaemia. Risk factors associated with air embolism in gastrointestinal endoscopic procedures include situations where the mucosa is not intact or where high pressures are generated in the lumen of the gastrointestinal tract. Clinical diagnosis of air embolism during endoscopy is difficult and urgent echocardiography is the investigation of choice. Treatment is largely supportive but hyperbaric oxygen therapy should be considered in any severe cases, especially if neurological injury is present.
Assessment of Outcome over a 10-year Period of Patients Admitted to a Multidisciplinary Adult Intensive Care Unit with Haematological and Solid Tumours
Authors: Moran J. L. , Solomon P. J. , Williams P. J.
Published: January 2019

The risk factors for time to mortality, censored at 30 days, of patients admitted to an adult teaching hospital ICU with haematological and solid malignancies were assessed in a retrospective cohort study.

Patients, demographics and daily ICU patient data, from admission to day 8, were identified from a prospective computerized database and casenote review in consecutive admissions to ICU with haematological and solid tumours over a 10-year period (1989–99). The cohort, 108 ICU admissions in 89 patients was of mean age (±SD) 55±14 years; 43% were female. Patient diagnoses were leukaemia (35%), lymphoma (38%) and solid tumours (27%). Median time from hospital to ICU admission was five days (range 0–67). On ICU admission, 50% had septic shock and first day APACHE II score was 28±9. Forty-six per cent of patients were ventilated. ICU and 30-day mortality were 39% and 54% respectively. Multivariate Cox model predictors (P<0.05), using only ICU admission day data were: Charlson comorbidity index (CCI), time to ICU admission (days) and mechanical ventilation. For daily data (admission through day 8), predictors were: cohort effect (2nd vs 1st five-year period); CCI; time to ICU admission (days); APACHE II score and mechanical ventilation.

Outcomes were considered appropriate for severity of illness and demonstrated improvement over time. Ventilation was an independent outcome determinant. Controlling for other factors, mortality has improved over time (1st vs 2nd five year period). Analysis restricted to admission data alone may be insensitive to particular covariate effects.
The Linearity of the Visual Analogue Scale in Patients with Severe Acute Pain
Authors: Myles P. S. , Urquhart N.
Published: January 2019

The visual analogue scale (VAS) is a standard measurement tool in pain research and clinical practice, and has been shown to have linear scale properties for mild to moderate pain. Our aim was to evaluate the scaling properties of the VAS in subjects with severe acute pain. After Ethics Committee approval we studied 22 patients and asked them to rate the severity of their pain on a 100 mm VAS at the initial assessment (VAS1), and again after administration of analgesic medication. The subject was asked to nominate when they considered their pain intensity had halved, and at this time they were asked to rate this on a second VAS (VAS0.5). When the subject had received satisfactory relief of their pain, they were asked to describe how much their pain had been relieved and were then asked to rate their final pain state using a third VAS (VASfinal). The mean (SD) scores were VAS1 84 (14) (range 56–100), VAS0.5 42 (13) and VASfinal 21 (16). The mean (95% CI) for VASratio was 0.51 (0.45–0.57). The mean (SD) patients’ estimate of pain relief was 77 (21)% from that of baseline, with a mean (SD) VASfinal 0.26 (0.20), 95% CI 0.17–0.38. The correlation of the patients’ estimate of pain relief with the VASfinal was r=0.89, rho=0.87, both P<0.001. The VAS is a linear scale in subjects with severe acute pain. Changes in the VAS score represent a relative change in the magnitude of pain sensation.
Diagnosis and Outcome from Suspected Mesenteric Ischaemia following Cardiac Surgery
Authors: Edwards M. , Sidebotham D. , Smith M. , Leemput J. V. , Anderson B.
Published: January 2019

A three-year retrospective chart review was undertaken of all post-cardiothoracic ICU patients who underwent laparotomy for suspected mesenteric ischaemia, or who had the diagnosis confirmed at post mortem. The aim was to compare the clinical and diagnostic characteristics of cardiothoracic patients with suspected mesenteric ischaemia with patients who had a confirmed diagnosis.

There were 3024 admissions to the cardiothoracic ICU over the three-year period. Twenty-six laparotomies were performed for suspected mesenteric ischaemia and 15 were positive for mesenteric ischaemia. The overall incidence of mesenteric ischaemia was 17/3024 (0.6%). Mortality for patients with mesenteric ischaemia was 13/17 (76%). Ischaemia was limited to a single segment of bowel in the four survivors. Mortality in patients who had a negative laparotomy for suspected mesenteric ischaemia was 7/11 (64%), attributable to cardiovascular failure (2/11) and multi-organ dysfunction syndrome (5/11). No clinical, biochemical or haematological test was discriminatory for mesenteric ischaemia. In patients with proven ischaemia, 7/13 plain abdominal radiographs were positive for ischaemia and 7/7 radiographs were negative for ischaemia in patients with no ischaemia (P=0.05, PPV 1.0, NPV 0.5, sensitivity 54%, specificity 100%).

Neither routine clinical investigations nor plain abdominal radiography reliably diagnose mesenteric ischaemia when the diagnosis is suspected clinically. Early laparotomy is recommended in these patients and further investigation may delay this procedure unnecessarily. The presence of mesenteric ischaemia identifies a cohort of patients with high mortality.
A Teenager with Severe Asthma Exacerbation following Ibuprofen
Authors: Palmer G. M.
Published: January 2019

Aspirin-sensitive asthma, aspirin-intolerant asthma, aspirin- (or non-steroidal anti-inflammatory drug [NSAID]) exacerbated respiratory disease are terms for a disorder commonly described as affecting adults aged >30y. With this perception, ibuprofen was administered for postoperative pain management to a 17-year-old boy with allergic rhinitis and previous severe asthma (at a time when well controlled), who then had a severe asthma exacerbation. Analysis of the literature in response to this case highlights four points:

1) NSAID-exacerbated asthma is not only a disorder of adults; it occurs in up to of 2% in asthmatic children, approaching probably 30% in older children with severe asthma and nasal disease.

2) The asthmatic reaction is dose-dependent and can occur with sub-therapeutic doses. Oral NSAID/aspirin challenge should be conducted in an environment where a severe asthma exacerbation can be appropriately managed.

3) The therapeutic use of non-selective [COX-1 preferential] NSAIDs should be avoided when sensitivity is known or suspected in adults and teenagers with severe asthma and chronic rhinosinusitis or nasal polyps. Use of these agents in younger children with mild episodic wheeze is probably safe.

4) Paracetamol use is probably safe, but aspirin-exacerbated respiratory disease may occur with clinical doses in a subgroup of aspirin-exacerbated respiratory disease patients. COX-2 selective inhibitors are probably safe, although this is controversial. Opioids and tramadol are suitable analgesic alternatives for patients with known or suspected susceptibility.
Outcome-based Clinical Indicators for Intensive Care Medicine
Authors: Duke G. , Santamaria J. , Shann F. , Stow P.
Published: January 2019

The clinical indicator is a tool used to monitor the quality of health care. Its use in the Intensive Care Unit (ICU) is desirable for many reasons: the maintenance of minimum standards, the development of best practice and the delivery of cost-effective health care. The utility of clinical indicators in ICU is limited by the lack of universal, robust, transparent, evidence-based and risk-adjusted measures of quality, and the difficulties in defining “quality care” and “good outcome”. Monitoring of adverse events, system descriptors, and resource indicators is valuable but they have a limited relationship to the quality of care. ICU mortality prediction models provide a global measure of quality and, despite their inherent deficiencies, remain one of the most robust and useful clinical indicators.
Anaesthesia for a Patient with Congenital Methaemoglobinaemia and Temporomandibular Joint Ankylosis
Authors: Trikha A. , Venkataraju A. J. , Sadera G. S.
Published: January 2019

We report a 10-year-old child with congenital methaemoglobinaemia and temporomandibular joint ankylosis who presented for ophthalmic surgery. He had had two previous anaesthetics in another institution. The first was short and uneventful, and no abnormality was noted. During the second anaesthetic, low haemoglobin oxygen saturation on pulse oximetry was noted after an inhalational induction. The diagnosis was not apparent and the management of the apparent hypoxaemia markedly complicated the clinical course. The patient required prolonged intensive care and tracheostomy. The tracheostomy was ultimately decannulated. Before his third anaesthetic (after referral to the authors’ institution) preoperative investigation revealed that the patient, his father and brother all had methaemoglobinaemia.
Anaesthetic Considerations during Endoscopic Retrograde Cholangiopancreatography
Authors: Martindale S. J.
Published: January 2019

Endoscopic retrograde cholangiopancreatography has evolved from being a simple diagnostic procedure, performed under proceduralist-administered sedation, to a therapeutic one involving increasingly complex techniques that require a high degree of patient cooperation. The anaesthetist has become a vital member of the team. Many of the patients are medically unfit for surgery. Sedation or general anaesthesia is generally indicated for the increasingly complex, long and painful procedures being performed. Although there is very little published evidence of specific anaesthetic techniques in this area, knowledge of these problems allows the anaesthetist to select an appropriate technique to provide safe and effective anaesthesia.
Variation in Preoperative Assessment of Cardiac Output Reserve and Likelihood of Transfusion among Anaesthetists: A Pilot Study
Authors: Harrison M. J.
Published: January 2019

The aim of this pilot study was to investigate anaesthetists’ assessment of the ability of patients to increase cardiac output over a range of clinical scenarios and of their perceived ‘likelihood of transfusion’ in these scenarios. Specialist anaesthetists were given a questionnaire with clinical cues in the form of diagnoses about theoretical patients. They were asked to use 100 mm visual analogue scales (VAS) for their assessments of each patient's cardiac reserve and their ‘likelihood of transfusion’ of these patients; the endpoints of the VAS being ‘Very low’ (0 mm) to ‘High’ (100 mm), and ‘Do not transfuse’ (0 mm) to ‘Transfuse’ (100 mm) respectively.

The assessment of patients’ cardiac output reserve by anaesthetists (n=54) showed great variation; for example, a patient with severe aortic stenosis was perceived overall to have a limited ability to increase cardiac output (mean VAS 16 mm) but there was considerable variation between anaesthetists (25–75 percentiles 10 mm to 21 mm). Assessment of ‘likelihood of transfusion’ (n=42) also had great variation; as an example a patient with ‘angina’ with a haemoglobin of 95 gt-1 was perceived overall to have an average likelihood of transfusion of 50 mm, but the 25–75 percentiles ranged from 33 mm to 71 mm.

This study suggests that inter-anaesthetist variability in the assessment of a patient's ‘cardiac output reserve’ and his ‘likelihood of transfusion’ is large.
Massive Intraoperative Pulmonary Embolism: It may not be as Bad as it Looks …
Authors: Forrest A. P. , Sutton B.
Published: January 2019

An elderly patient suffered a cardiac arrest while undergoing repair of a pathological femoral fracture. Intraoperative transoesophageal echocardiography demonstrated massive pulmonary embolism. Pulmonary embolectomy was considered inappropriate in view of her underlying terminal disease, so a decision was made to withdraw all further supportive measures. Despite this, the patient's haemodynamics improved spontaneously.

The embolic material was presumed to be bone marrow fat. Fat may traverse the pulmonary circulation; hence the clinical consequences (and management implications) of massive intraoperative pulmonary embolism may vary, depending on the composition of the embolic material. As there are no reliable means of determining the composition of embolic material intraoperatively, the clinical suspicion of fat embolism poses a management dilemma. Should these cases be managed surgically or conservatively?
Risks of Regional Anaesthesia for Caesarean Section: Women's Recall and Information Sources
Authors: Cheng W. Y. C. , Cyna A. M. , Osborn K. D.
Published: January 2019

Recall and information sources regarding the risks of regional anaesthesia in women having lower segment caesarean section have not been adequately assessed previously. We aimed to survey women's recall of their pre-anaesthesia risk discussion and determine where women, presenting for lower segment caesarean section under regional anaesthesia, obtain risk information. Following a small pilot survey, women's responses were recorded for “spontaneous” or “prompted” recalled risks, the information source and its reliability. One-hundred and fifty women were surveyed following caesarean section. Seventy women (46.7%) had an elective procedure and 80 (53.3%) had an emergency procedure. Overall, 142 women (94.6%) recalled at least four risks (44.6% spontaneously; 66% prompted). Of those women giving at least four spontaneous responses, 41 (58.6%) had elective and 26 (32.5%) had emergency lower segment caesarean section (P=0.001). The majority of women stated that anaesthetists were the main, and most reliable, source of their information regarding risks of regional anaesthesia for caesarean section. This report identifies the risks associated with regional anaesthesia for caesarean section that women most frequently recall, namely headache, paralysis, nerve damage and inadequate block.
Talc-induced Interstitial Pneumonitis with Respiratory Failure
Authors: Griffo S. , Musumeci A. , De Luca G. , Saccenti A. , Grande L. M. , Stassano P.
Published: January 2019

Talc is the most frequently used chemical agent to induce pleurodesis and complications after this procedure, usually benign and self-limiting, are resolved easily. Pneumonitis with acute respiratory distress after talc pleurodesis is a rare complication, it requires intensive treatment and may be fatal.

We describe a patient who developed pneumonitis with bilateral interstitial infiltrates and respiratory distress after talc pleurodesis. This complication required the transfer of the patient into the intensive care unit and an aggressive treatment management. After an uneventful talc pleurodesis, close surweillance of the patient and a high index of suspicion are mandatory.
Central Pontine Myelinolysis despite Slow Sodium Rise in a Case of Severe Community-acquired Hyponatraemia
Authors: Schuster M. , Diekmann S. , Klingebiel R. , Volk T.
Published: January 2019

The management of severe hyponatraemia is a challenging task for intensivists. It should be based on underlying pathophysiology, especially the duration of hyponatraemia (acute vs. chronic) and the presence or absence of severe neurologic symptoms. We describe a case of severe community-acquired hyponatraemia in which central pontine myelinolysis developed several days after discharge from the intensive care unit, despite a gradual increase of plasma sodium levels during the intensive care unit stay.
The Effects of Dexmedetomidine and Fentanyl on Emergence Characteristics after Adenoidectomy in Children
Authors: Erdil F. , Demirbilek S. , Begec Z. , Ozturk E. , Ulger M. H. , Ersoy M. O.
Published: January 2019

This randomised controlled study evaluated the effects of fentanyl and dexmedetomidine on emergence characteristics of children having adenoidectomy and anaesthetised with sevoflurane.

Ninety children, two to seven years of age and ASA physical status I, were studied. Children were randomly assigned to one of three groups of 30 children, with the study intervention injection given intravenously after intubation. Children in Group F received fentanyl 2.5 μg.kg−1 children in Group D received dexmedetomidine 0.5 μg.kg−1 and children in Group C received saline solution. Anaesthesia was induced with 50% N2O and 8% sevoflurane in O2 by mask and atracurium 0.6 mg.kg−1 was administered for tracheal intubation. All children received paracetamol 40 mg/kg rectally one hour preoperatively and dexamethasone 0.5 mg.kg−1 intravenously.

The time to extubation was shorter in Group D than Group F. The eye-opening time was longer in Group F (16.1∓5.3 minutes) than in Groups C (12.0∓4.2 minutes) and D (12.7∓3.2 minutes). The proportion of pain-free children in early recovery was significantly higher in Groups D (47%) and F (43%) than Group C (13%) (P <0.05). The proportion of children with agitation scores >3 was lower in Groups D 17% (5/30) and F 13% (4130) than in Group C 47% (14/30) (P <0.05). Fentanyl 2.5 μg.kg−1 and dexmedetomidine 0.5 μg.kg−1 had similar haemodynamic effects and emergence characteristics. Fentanyl has been safely used in children for many years. Further studies of dexmedetomidine safety and its interaction with other anaesthetic agents are required before recommending its routine use during general anaesthesia in children.
Web-Based Formative Assessment Case Studies: Role in a Final Year Medicine Two-Week Anaesthesia Course
Authors: Critchley L. A. H. , Kumta S. M. , Ware J. , Wong J. W.
Published: January 2019

Formative Assessment Case Studies (FACS) are an e-learning resource consisting of a case scenario punctuated with decision-making steps (multiple-choice questions) and feedback for wrong answers. FACS was developed to enhance clinical decision-making skills.

We wrote six FACS scenarios covering preoperative assessment topics and made them accessible to 149 final year medical students as part of their two-week anaesthesia module. A data management system recorded usage and performance by each student.

Eighty-one percent of students attempted FACS (six cases 53%, five cases 17%, one to four cases 9%) and 61 to 70% completed all steps. On average FACS was attempted 1.5 times. Students required 44 to 95% more steps than the minimum to complete each case. There were two patterns of use: some students completed the cases within five to seven minutes (first quartile) focusing on the questions, while others spent over 22 to 35 minutes (fourth quartile) exploring the FACS and feedback. FACS usage correlated (r2=0.32: P <0.01) with written case report marks. The students’ evaluation of FACS was high.

FACS is an e-learning resource that is interactive and facilitates higher learning. It can be applied successfully to disciplines less well represented in the medical curriculum, such as anaesthesia. FACS facilitated our teaching of preoperative assessment to a group of final year medical students. It was well received and shown to facilitate the learning of decision-making skills. The students’ usage of FACS could have been enhanced by making FACS compulsory and using summative FACS for assessment.
A Comparison of Transcutaneous Doppler Corrected Flow Time, B-Type Natriuretic Peptide and Central venous Pressure as Predictors of Fluid Responsiveness in Septic Shock: A Preliminary Evaluation.
Authors: Sturgess D. J. , Pascoe R. L. S. , Scalia G. , Venkatesh B.
Published: January 2019

Aortic corrected flow time (FTc) is easily measured by Doppler techniques. Recent data using transoesophageal Doppler suggest that it may predict fluid responsiveness in critical care. This use of FTc has not previously been evaluated in septic shock, nor have any studies incorporated transcutaneously measured FTc. Furthermore, no comparison has been made between FTc, plasma B-type natriuretic peptide concentration (BNP) or central venous pressure. The aim of this preliminary study was to compare FTc, BNP and central venous pressure as predictors of fluid responsiveness in septic shock patients without cardiac dysrhythmia.

This was a prospective study of 10 consecutive adult septic shock patients (in sinus rhythm; 60% mechanically ventilated) treated with intravenous fluid challenge (4% albumin 250 ml over 15 minutes) in a mixed medical/surgical tertiary intensive care unit.

Mean ± SD Acute Physiological and Chronic Health Evaluation II score was 21.8±12.7. Haemodynamic assessment incorporating transcutaneous aortic Doppler (USCOM®) occurred before and five minutes after fluid challenge. Concurrent with initial assessment, blood samples were collected for BNP assay (ADIVA Centaur®). Four patients demonstrated an increase in stroke volume ≥15% (responders). Percent change in stroke volume strongly correlated with baseline FTc (r=-0.81, P=0.004) but not BNP (r=-0.3, P=0.4) or central venous pressure (r=-0.4, P=0.2). Baseline FTc <350 ms discriminated responders from non-responders (P=0.047).

Our data support FTc as a better predictor of fluid responsiveness than either BNP or central venous pressure in septic shock. Transcutaneous aortic Doppler FTc offers promise as a simple, completely non-invasive predictor of fluid responsiveness and should be evaluated further.