Effects of virtual reality on anxiety and pain in adult patients undergoing wound-closure procedures: A pilot randomized controlled trial.

Background: In emergency departments, suturing is a typical procedure for closing lacerated wounds but is invasive and often causes anxiety and pain. Virtual reality (VR) intervention has been reported as a relaxing measure. Objective: The study aims to examine the effects of VR intervention on anxiety, pain, physiological parameters, local anesthesia requirements and satisfaction in Chinese adult patients undergoing wound closure in emergency departments in Hong Kong. Methods: Adult patients who had lacerated wounds and were undergoing wound closure by suturing can communicate in Chinese and were hemodynamically stable were invited for this trial. Eighty patients were randomly assigned to the VR group, which received VR intervention and standard care, or to the control group, which received standard care only. The primary outcome was anxiety, and the secondary outcomes included pain, blood pressure, pulse rate, satisfactory with pain management, service satisfactory, and extra local analgesia requirement. Outcomes were conducted at baseline, during the procedure and 5 min after the procedure. Results: The VR group had a significantly greater reduction in anxiety (p < 0.001), pain (p < 0.001), systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), pulse rate (p = 0.003) and requested less amount of additional local anesthesia (p = 0.025). The satisfactory level with pain management (p = 0.019) and service (p = 0.002) were significantly higher in participants who received VR intervention. In addition, most participants preferred to have VR in the future, and no major adverse events associated with the use of VR were reported. Conclusion: This pilot study provides insight into the use of VR and the direction of future studies. It may effectively improve psychological and physiological outcomes in adult patients during wound-closure procedures in emergency departments.

[Difference of one year death and stroke recurrence in ischemic stroke patients with anterior and posterior circulation intracranial atherosclerosis].

Objective: To explore the differences of one year death and stroke recurrence between ischemic stroke patients with intracranial atherosclerotic stenosis or occlusion of anterior circulation and those of posterior circulation. Methods: All the patients were from the Chinese Intracranial Atherosclerosis Study (CICAS), between October 2007 and June 2009; patients with extracranial stenosis or occlusion, patients without acute infarction by diffusion weighted image, and patients with intracranial atherosclerosis of both anterior and posterior circulation were excluded.All the enrolled patients were divided into three groups: no significant intracranial atherosclerosis group (n=964), anterior circulation intracranial atherosclerosis group (n=440), posterior circulation intracranial atherosclerosis group (n=233). One year outcome was evaluated by any cause of death and stroke recurrence. Results: Of the 1 637 patients, 30 cases were died and 58 cases had stroke recurrence within one year.Compared with : no significant intracranial atherosclerosis group, adjusted hazard ratio (95% confidence interval) of one-year death for anterior and posterior circulation intracranial atherosclerosis group were 1.349 (0.311-5.851), 4.542 (1.227-16.813), respectively.Adjusted hazard ratio (95% confidence interval) of one year stroke recurrence were 1.663 (0.620-4.460) and 2.464 (0.935-6.493), respectively. Conclusions: Ischemic stroke patients with intracranial atherosclerosis of posterior circulation has higher risk of one year death. One year stroke recurrence risk for patients with intracranial atherosclerosis of anterior and posterior circulation needs to be further evaluated.

Intracranial aneurysms in twins: case report and review of the literature.

Intracranial aneurysm in twins is a rare clinical disease entity. Only 15 cases have been described in the literature. We report on a pair of identical twins with intracranial aneurysms. One presented with subarachnoid haemorrhage; digital subtraction angiography showed a left posterior communicating artery aneurysm, which was treated by coiling. The patient's twin sister was called for screening, whereupon digital subtraction angiography revealed a right ophthalmic internal carotid artery aneurysm that was treated conservatively.

Contactless recording of photoplethysmogram on a sleeping bed.

This paper reports a novel contactless monitoring method to record reflective mode photoplethysmogram (PPG) on a sleeping bed for heart rate (HR) estimation. The electrocardiogram (ECG) and pulse transit time (PTT) were also measured in this study. ECG was measured from subjects' limbs whilst PPG was obtained from their right index fingers and their backs with and without direct contact between the PPG sensor and the subjects' skin respectively. Clear PPG waveforms were obtained from the subjects' backs even though the sensor was not directly attached to their skin. Beat-to-beat HRs derived from the back PPGs were closely correlated with those measured from the finger PPGs and ECGs. Thus we found that contactless PPG could be captured from the subjects' backs to determine HR accurately.

A novel method for the contactless and continuous measurement of arterial blood pressure on a sleeping bed.

Nighttime blood pressure (BP) is found to best predict the 5-year risk of cardiovascular death in comparison to daytime BP, BP measured over a 24-hour period and clinical BP. In view of this, a novel contactless system has been developed on a sleeping bed for the cuffless and continuous estimation of BP at night. Experiments were conducted on 11 subjects to evaluate the contactless system, particularly its performance compared to a contact system. The results of this study showed that the accuracy of the contactless system to estimate BP by a cuffless approach is comparable to that of the contact system when measured at the same posture. More studies have to be conducted in order to understand the difference of the cuffless BP estimation approach when measuring at supine and sitting postures.

Vitamin B12 deficiency--need for a new guideline.

OBJECTIVES: Many patients with vitamin B12 deficiency do not have anemia or macrocytosis, but the prevalence of B12 deficiency in patients without macrocytosis is not known. METHODS: We investigated the prevalence of B12 deficiency among patients with normocytosis and microcytosis and recommended a screening strategy. All patients (n = 3714) with serum B12 measured at the Prince of Wales Hospital in 1996 were reviewed. The prevalence of serum B12 less than 140 pmol/L was determined for the following patient subgroups: younger than 70 y, older than 70 y, anemic, non-anemic, macrocytic, normocytic, microcytic, documented iron deficiency, and documented thalassemia. RESULTS: The prevalence of B12 deficiency (<140 pmol/L) ranged from 4.8% to 9.8% among the different subgroups. CONCLUSIONS: Whatever screening criteria were used, a significant number of B12-deficient patients will be missed. Therefore, there may be a case for universal vitamin B12 screening.

Intravenous pretreatment of hypertonic saline can prevent systemic hypotension induced by spinal anesthesia.

BACKGROUND: Hypertonic saline improves organ perfusion and patient survival during hemorrhagic shock because it expands plasma volume and increases tissue oxygenation. Its beneficial results have been reported in patients suffering from hypotension during spinal anesthesia. The purpose of this study was to compare the influence between prehydration with 3% hypertonic saline and with isotonic lactated Ringer's solution on the hemodynamic changes and serum electrolyte concentrations in patients undergoing spinal anesthesia. METHODS: Sixty ASA class I patients scheduled for herniorrhapy under spinal anesthesia were assigned randomly into two groups. Group 1 = patients were prehydrated with isotonic lactated Ringer's solution at 7 mg/kg (n = 30); Group 2 = patients were given prehydration with 3% hypertonic saline at 7 ml/kg (n = 30). Following prehydration, arterial blood pressure and heart rate were recorded and serum electrolyte concentrations were measured. RESULTS: The incidence of hypotension was 17/30 (57%) in the isotonic lactated Ringer's solution group as against 7/30 (23%) in the hypertonic saline group (p < 0.05). There was no significant difference between two groups in relation to the level of anesthesia or maximal heart rate, and electrolyte imbalance did not occur in either group. CONCLUSIONS: Prior to spinal anesthesia, hydration with small amount of hypertonic saline is effective to minimize hypotension associated with spinal anesthesia. If so administered it would not increase bodily sodium load and unlike isotonic crystalloid solution it dose not cause accumulation of water in the body on equipollent basis.

Lidocaine-induced CNS toxicity--a case report.

Lidocaine is the first local anesthetic of the amide type to be introduced to clinical practice. It is a versatile drug and in anesthesia, is the most commonly used local anesthetic because of its aptness of potency, rapid onset, moderate duration of action and topical activity. It is relatively safe and useful in many other clinical settings. Unfortunately, systemic intoxication and psychotic reaction associated with its use often occur because of its popularity and wider safety margin, for which guide in use is often ignored and overdose becomes commonplace. Moreover, due to its universality in use seldom reports have recently dealt with lidocaine, particularly regarding its toxic reaction. Here, we present a case of lidocaine intoxication occurring during circumcision for a reviewal of the problem. A healthy young male, weighing 65 kg, underwent circumcision for phimosis under penile block with 2% lidocaine which totaled 600 mg. Twenty minutes after injection the patient developed headache, tinnitus, visual and auditory disturbances. Muscle twitching over the mouth angles, trismus and rigidity of extremities were also noted. Later in the course he became restless, agitative, hallucinative, talkative, and verbose with repetitious words. The whole course of the disorder lasted about 5 h. It was believed that lidocaine-induced CNS intoxication, manifested by psychotic reaction broke out. Treatment with thiopental was not very impressive. Also, we took this opportunity to discuss and review the toxic reaction associated with the use of lidocaine, its risk factors, mechanism, treatment and prevention. The complicated associations of lidocaine-induced CNS toxic reaction with central control of behavior and the neurotransmitter systems (adrenergic, dopaminergic and serotonin) were also touched.

Comparison of preoperative and postoperative iliohypogastric ilioinguinal nerve block for pediatric herniorrhaphy patients.

The purpose of this study was to compare the effects of preoperative and postoperative iliohypogastric ilioinguinal nerve block (IINB) performed on 30 pediatric patients having elective unilateral herniorrhaphy for postoperative pain control and to discuss the theory of post-injury hypersensitivity of the nerves system. The patients were assigned into two groups (A = 15, B = 15) randomly. Both groups were given GA during the surgical procedure except that group A received IINB 15 minutes prior to skin incision and group B immediately after skin closure. The local anesthetic used was 0.25% bupivacaine and the dosage was 1 mg/Kg. The heart rate, BP, and anesthetic concentration (halothane) were recorded during the procedure and postoperative pain was assessed by using the modification of the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) behavior pain score which were taken at 1 hr, 3 hr (POR), 6 hr, and 24 hr (ward) postoperatively. Group A had less pain at 1 hr and 3 hr than group B postoperatively and is statistically significant. There was no statistically significant in pain score at 6 hr and 24 hr between the two groups.

[Incidence of venous air embolism in parturients during cesarean section with regional anesthesia].

The purpose of the study is to probe the situation of venous air embolism (VAE) and the accompanying complications occurring in Chinese parturients in Taiwan during Cesarean section. Sixty ASA physical status class I-II parturients who were subjected to cesarean section under regional anesthesia were evaluated. The sensor of the Doppler device was placed on the anterior chest to detect the rumbles of air when it came to pass, and simultaneously the signs and symptoms following VAE were observed. Our results demonstrated that the usual or normal Doppler heart sound changed in 38 parturients out of 60 (63.3%), and the alteration occurred very often when the uterus was being incised (81.6%), or sutured (97.4%), and concurred strong correlation with such signs and symptoms such as chest tightness or precordial pain (78.9%), shortness of breath (60.5%), and change of heart rate or blood pressure (86.8%). The method of anesthesia (spinal or epidural block) did not have effect on the occurrence of VAE, but different surgical approaches and different positions in which the patients were posed during operation did apparently bring about VAE of variable degree. Besides, supplying of oxygen could mitigate the symptoms produced by VAE. Consequently, the application of Doppler monitor during Cesarean section can detect VAE earlier and more efficiently and thus provides information timely treatment.

Effects of pH and Water Activity on Microbiological Stability of Salad Dressing.

The water activity and pH of an experimental starch-based salad dressing were varied to evaluate inhibitory effects on microorganisms selected from groups known to be principal dressing spoilage agents. Dressing samples were inoculated with Lactobacillus fructivorans , Zygosaccharomyces bailii , or a yeast isolated from a spoiled commercial salad dressing. Both yeast and L. fructivorans displayed a minimum growth pH of approximately 3.55 to 3.60. The minimum aw observed was 0.89 for yeast growth and 0.91 for L. fructivorans . Combinations of aw and pH which imparted microbial stability without use of preservatives are described.

Assignment of selected hyperfine proton NMR resonances in the met forms of Glycera dibranchiata monomer hemoglobins and comparisons with sperm whale metmyoglobin.

This work indicates a high degree of purity for our preparations of all three of the primary Glycera dibranchiata monomer hemoglobins and details assignments of the heme methyl and vinyl protons in the hyperfine shift region of the ferric (aquo?) protein forms. The assignments were carried out by reconstituting the apoproteins of each component with selectively deuteriated hemes. The results indicate that even though the individual component preparations consist of essentially a single protein, the proton NMR spectra indicate spectroscopic heterogeneity. Evidence is presented for identification and classification of major and minor protein forms that are present in solutions of each component. Finally, in contrast to previous results, a detailed analysis of the proton hyperfine shift patterns of the major and minor forms of each component, in comparison to the major and minor forms of metmyoglobin, leads to the conclusion that the corresponding forms of the proteins from each species have strikingly similar heme-globin contacts and display nearly identical heme electronic structures and coordination numbers.

Identification of the altered pyrrole in the isomeric sulfmyoglobins: hyperfine shift patterns as indicators of ring saturation in ferric chlorins.

Analysis of the 1H NMR hyperfine shift patterns of isomeric sulfmyoglobins is carried out in the met-aquo and met-cyano states to determine the site of saturation in each protein. The utility of the patterns for structure elucidation is established by specific deuterium labeling of the heme methyls of the terminal base product. On the basis of the known saturation of ring B in this isomer [Chatfield, M.J., La Mar, G.N., Lecomte, J.T.J., Balch, A.L., Smith, K.M., & Langry, K.C. (1986) J. Am. Chem. Soc. 108, 7108-7110], the methyl resonance of the saturated ring is found to have strongly attenuated contact shift. Thus, the heme methyl contact shift pattern is diagnostic for the saturated pyrrole in the high-spin state. This rationale is then applied to analyze the assigned NMR spectra of the initial and terminal acid sulfmyoglobin products, revealing that the same ring B is saturated in each isomer. In contrast, the heme methyl contact shift pattern in low-spin ferric complexes reveals that the methyls both on the affected pyrrole and on the trans pyrrole are influenced similarly on sulfmyoglobin formation, precluding the use of this methyl shift pattern as a unique indicator of the site of saturation. Identification of exchangeable proximal histidine resonances for met-aquo sulfmyoglobin complexes with shifts similar to that in native myoglobin dictates inconsequential axial alterations in the sulfmyoglobins, while location of downfield meso proton resonances analogous to those of the native protein demonstrates the retention of the coordinate water in the active site of met-sulfmyoglobin.

1H-NMR heme resonance assignments by selective deuteration in low-spin complexes of ferric hemoglobin A.

The heme methyl and vinyl alpha-proton signals have been assigned in low-spin ferric cyanide and azide ligated derivatives of the intact tetramer of hemoglobin A, as well as the isolated chains, by reconstituting the proteins with selectively deuterated hemins. For the hemoglobin cyanide tetramer, assignment to individual subunits was effected by forming hybrid hemoglobins possessing isotope-labeled hemins in only one type of subunit. The heme methyl contact shift pattern has 1-methyl and 5-methyl shifts furthest downfield in both chains and the individual subunits of the intact hemoglobin in both the cyanide- and azide-ligated species, which is consistent with a dominant rhombic perturbation due to the proximal His-F8 imidazole pi bonding in the known structure for human adult hemoglobin. The individual chain and subunit assignments confirm that the detailed electronic/magnetic properties of the heme pocket are essentially unaltered upon assembling the R-state tetramer from the isolated subunits.

Structural and electronic properties of the liver fluke hemoglobin heme cavity by nuclear magnetic resonance: hemin isotope labeling.

Reconstitution of liver fluke (Dicrocoelium dendriticum) apo-hemoglobin with hemins selectively deuterated at specific positions has permitted the assignment of several heme resonances in the proton nuclear magnetic resonance spectrum of the Met-aquo and Met-cyano forms of the holoprotein. It was established that in the Met-aquo form the meso protons resonate at positions characteristic of a six-co-ordinated in-plane iron. From this, we deduced that the Met-aquo species retains a bound water molecule at pH values as low as 4.5. The orientation of the proximal histidine imidazole ring with respect to the heme group in the cavity was determined through the identification of the heme methyl signals and the analysis of the hyperfine shift pattern in the Met-cyano hemoglobin proton nuclear magnetic resonance spectrum. Compared to sperm whale myoglobin, the heme appears to be rotated by 180 degrees about the alpha, gamma meso-axis. Protein isomers with the heme group in a reversed orientation were not detected, even shortly after reconstitution. In the Met-cyano form, the resonances most affected by the Bohr transition were shown to arise from the heme propionates.

Thermal Resistance of Microorganisms and Polyphenol Oxidase as Related to Solar Pasteurization of Concord Grape Juice 1.

Pasteurization conditions for grape juice were examined and the concept of pasteurizing grape juice utilizing solar energy was explored in this study. The z-values of four selected micro-organisms in grape juice were approximately 5-8 C, whereas polyphenol oxidase in fresh grapes had a z-value of 8.0 C at pH 3 .4. Using a 0.5 m2 solar collector test module constructed for this study, 2.5 h were required to heat the grape juice from 10 to 85 C. The solar pasteurized juice and commercially pasteurized juice were different in flavor and color but not in pH, titratable acidity or soluble solids.