Implementation of a new strategy to improve the peri-operative management of neuromuscular blockade and its effects on postoperative pulmonary complications.

Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra-operative documentation of train-of-four measurement before administration of neostigmine. We conducted a pre-specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity-matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre-intervention and 568 (6.3%) of 9088 cases post-intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61-0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93-0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87-0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity-matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra-operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.

The Association of Statin Therapy with Incident Diabetes: Evidence, Mechanisms, and Recommendations.

PURPOSE OF REVIEW: Recent studies have demonstrated a higher risk of incident diabetes associated with statin use, causing concern among patients and clinicians. In this review, we will assess the evidence and proposed mechanisms behind statin therapy and its association with incident diabetes. We will then review the current recommendations for statin use in light of this association and suggest next steps for clinicians managing these patients and researchers exploring this phenomenon. RECENT FINDINGS: The annual risk of developing new-onset diabetes with statin treatment is approximately 0.1%. In comparison, the absolute risk reduction of major coronary events with statin use is approximately 0.42% annually. Statins are associated with the development of incident diabetes, particularly among those with predisposing risk factors for diabetes. However, the benefit of statin use among these patients in preventing major coronary events strongly favors statin use despite its risk of incident diabetes.

Needle Aspiration and Cytology for Suspected Osteoarticular Tuberculosis in Children

@#Introduction: Early diagnosis of osteoarticular tuberculosis (OATB) is essential to prevent significant functional disability. There is no single test for diagnosis. Despite an array of investigations available, definitive diagnosis at early stage before starting antitubercular drugs is still a challenge. Materials and Methods: A cross sectional study was carried out between February 2016 and October 2017. All children less than 18 years of age with suspected osteoarticular tuberculosis were included. The cases were subjected to simple needle aspiration from whichever site was accessible. Multiple sample aspirations were done at site of involvement. Smears were prepared from the aspirated material. Results: Ziehl-Neelsen staining for Acid Fast Bacilli (AFB) showed deep pink red rods under light microscopy. Features suggestive of tuberculosis can be seen by May-GrünwaldGiemsa (MGG) staining. Auramine-O staining method of detecting AFB under fluorescent microscope shows the bacilli as greenish yellow slender curved rods in dark background. Fluorescent microscopy has higher sensitivity and comparable specificity. In our study, microbiological confirmation of OATB could be done in 100% cases where the lesion could be accessed for aspiration. The molecular techniques are relatively more expensive and not available everywhere. Conclusion: Meticulous search for AFB in a well stained smear using three different staining methods provides a direct evidence of infection over costly imaging especially in poor patients seen in resource limited settings.

Updated survival and outcomes for older adults with inoperable stage III non-small-cell lung cancer treated with cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel: analysis of a phase III trial from the Hoosier Oncology Group (HOG) and US Oncology.

BACKGROUND: Concurrent chemoradiation with etoposide and cisplatin (EP/XRT) is standard treatment for inoperable stage III locally advanced non-small-cell lung cancer (LA-NSCLC). Consolidation docetaxel (D; Taxotere) after EP/XRT resulted in increased toxicity but no improvement in survival compared with observation (O). We report updated survival for the entire study population and include an analysis of efficacy and tolerability of EP/XRT with or without D in patients aged ≥ 70 years. PATIENTS AND METHODS: Hoosier Oncology Group LUN 01-24 enrolled 243 patients with LA-NSCLC and randomized 166 after EP/XRT to three cycles of D versus O. the trial was terminated after an analysis of the first 203 patients demonstrated futility of D. RESULTS: Median survival time (MST) for the overall study population was 21.5 months, and 3-, 4-, and 5-year survival rates were 30.7%, 18.0%, and 13.9%, respectively. No differences in MST or 3-year survival were noted between D and O arms. Older patients had similar MST (17.1 versus 22.8 months for younger patients, P = 0.15) but higher rates of grade 3/4 toxicity and hospitalization during induction. CONCLUSIONS: Consolidation docetaxel after EP/XRT does not improve survival in LA-NSCLC. Fit older adults with LA-NSCLC benefit from concurrent chemoradiation similarly as younger patients but experience higher rates of hospitalization and toxicity.

Sensor calibration and compensation using artificial neural network.

Artificial neural network (ANN) based inverse modeling technique is used for sensor response linearization. The choice of the order of the model and the number of the calibration points are important design parameters in this technique. An intensive study of the effect of the order of the model and number of calibration points on the lowest asymptotic root-mean-square (RMS) error has been reported in this paper. Starting from the initial value of the nonlinearity in the characteristics of a sensor and required RMS error, it is possible to quickly fix the order of the model and the number of calibration points required using results of this paper. The number of epochs needed to calibrate the sensor, and thereafter the epochs needed to recalibrate in event of sensitivity or offset drifts, are also presented to bring out the convergence time of the technique. More importantly, the advantages of the ANN technique over traditional regression based modeling are also discussed from the point of view of its advantage in hardware simplicity in microcontroller based implementation. Results presented in this paper would be of interest to instrumentation design engineers.

Dna fragmentation factor 45 mutant mice exhibit resistance to kainic acid-induced neuronal cell death.

Excitotoxicity is a process where glutamate or other excitatory amino acids induce neuronal cell death. Emerging evidence suggests that apoptosis plays a key part in excitotoxic neurodegeneration. The DNA fragmentation factor 45 (DFF45 or ICAD) is a subunit of a heterodimeric DNase complex crucial for DNA fragmentation during apoptosis. Using a DFF45 mutant mouse model, we previously found that DFF45 deficient cells are more resistant to apoptosis than normal control cells. To investigate whether the lack of DFF45 may attenuate neuronal cell death induced by excitotoxicity, we compared kainic acid-induced seizure behavior and neuronal cell death in DFF45 mutant and wild-type control mice. We found that the mutant mice exhibit similar kainic acid-induced seizure severity compared to control mice. However, DFF45 mutant mice are more resistant than control mice to kainic acid-induced CA3 neuronal cell death. Interestingly, residual DNA degradation can be detected in the hippocampus of DFF45 mutant mice that exhibit KA-induced lesions. Our results suggest that a lack of DFF45 can lead to neuronal resistance to excessive activity-induced toxicity.

Exercise conditioning and heart rate variability: evidence of a threshold effect.

BACKGROUND: A protective effect of exercise in preventing sudden cardiac death is supported by studies in healthy populations as well as in patients with cardiac disease. The mechanisms involved in this protective effect are unknown. HYPOTHESIS: We hypothesized that exercise conditioning would beneficially alter autonomic nervous system tone, measured by heart rate variability. METHODS: We prospectively studied 20 cardiac patients enrolled in a Phase 2 12-week cardiac rehabilitation program following a recent cardiac event. The patients underwent 24 h Holter monitoring at program entry and 12 weeks later. Heart rate variability analysis was assessed for both time domain and spectral analysis. RESULTS: The group demonstrated a modest mean conditioning effect, indicated by an average reduction in resting heart rate from 81 +/- 16 to 75 +/- 12 beats/min (p = 0.03), and an increase in training METS from 2.1 +/- 0.4 to 3.3 +/- 1.1 (p < 0.0001). Overall, 15 of 20 (75%) patients demonstrated increased total and high-frequency power, and mean high-frequency power was significantly increased (3.9 +/- 1.4 vs. 4.4 +/- 1.0 ln, p = 0.05). When stratified according to the magnitude of exercise conditioning, patients achieving an increase of > 1.5 training METS demonstrated significant increases in SDNN, SDANN index, SDNN index, pNN50, total power, and high-frequency power (all p < 0.05) (see text for explanation of abbreviations). CONCLUSIONS: Exercise conditioning improves heart rate variability in cardiac patients, particularly in patients who achieve a threshold of > 1.5 training METS increase over a 12-week period. These study results are supportive of the concept that exercise training lowers the risk of sudden cardiac death via increased vagal tone, which likely beneficially alters ventricular fibrillatory and ischemic thresholds.

The use of dynamic external fixation to obtain tibiocalcaneal fusion after Boyd's amputation.

Two patients sustained severe injuries of the foot and ankle, which were managed with Boyd's amputation. A large-pin dynamic external fixator was used to obtain fusion between the calcaneus and distal tibia. Boyd's amputation preserves limb length and prevents posterior migration of the heel pad (both are disadvantages of Syme's amputation). Use of a dynamic external fixator may result in reliable and rapid consolidation of the fusion (thus overcoming the disadvantage associated with Boyd's amputation).

The effects of subconjunctival verapamil on filtering blebs in rabbits.

BACKGROUND AND OBJECTIVE: Verapamil is a calcium antagonist that has been shown to modulate wound healing through multiple mechanisms. The wound modulating effects of verapamil were studied in a rabbit model of filtering surgery. MATERIALS AND METHODS: Twenty New Zealand albino rabbits underwent a fistulizing procedure, with either verapamil or saline injected subconjunctivally daily for 6 days following surgery. The animals were sacrificed at 20 days after the fistulizing procedure. The effectiveness of verapamil in modulating wound healing was evaluated by bleb patency testing, histology, measurement of scar thickness, and counts of bromodeoxyuridine (BrdU)-labeled cells at the sclerostomy site. RESULTS: The group treated with verapamil had a 44 percent patency rate compared with 10 percent in the control group (P < .05), a mean scar thickness of 195.96 +/- 68 mu m compared with 313.55 +/- 110.4 mu m in the control group (P < .02), and a mean BrdU-labeled cell count of 15.5 +/- 14.7 compared with 26.3 +/- 17.0 in the control group (P < .002). CONCLUSION: Verapamil was effective in reducing scar formation at the sclerostomy site. At the doses administered, verapamil appeared to modulate wound healing in filtering blebs in the rabbit model. Further studies are needed to determine the dose-response and the efficacy of the drug in nonhuman primates.

Quantitative CW Nd:YAG pars plana transscleral photocoagulation in postmortem eyes.

The effect of different types of burns and numbers of lesions on, and the role of initial pressure head in, the rate of aqueous outflow was studied in enucleated human and porcine eyes. Noncontact and contact CW Nd:YAG laser applied to human eyes 3 mm posterior to the limbus produced a 34% and 51% increase, respectively, in outflow as compared with controls (P = .01). In porcine eyes, outflow increased directly with the number of noncontact burns as well as with the amount of perfusion pressure. Our results suggest that intraocular pressure and outflow are functions of both the intensity of irradiation and the surface area treated, and that each individual pressure head may require an optimal pars plana area of treatment of therapeutic degree to lower pressure and yet prevent overfiltration and phthisis. Our results also suggest that there may be a passive transneuroepithelial and transscleral outflow component in clinical laser cycloablation and, therefore, a need to grade laser treatments in order to prevent visual loss through unnecessary injury.

Changes in aqueous outflow after in vitro neodymium: yttrium aluminum garnet laser cyclophotocoagulation.

To examine the possible role of transscleral outflow routes, enucleated human and porcine eyes underwent noncontact neodymium:yttrium aluminum garnet (Nd:YAG) laser cyclophotocoagulation 3 mm posterior to the limbus. Pars plana lesions were verified histologically. The eyes were perfused with saline solution at 50 mm Hg perfusion pressure, placing the tip of the needle into the hyaloid orbicular space. The outflow facility was 0.072 microliter/min/mm Hg in paired controls and 0.105 microliter/min/mm Hg in human lasered eyes, a difference of 31%. In porcine eyes the difference was 43%. Since concepts of aqueous production, impaired circulation, and inflammation do not apply to enucleated eyes, the increase may be related to pars plana transscleral flow facilitated by disruption of the neuroepithelial barrier.