The role of radiotherapy in immunotherapy strategies in the central nervous system.

The clinical efficacy and relative tolerability of adverse effects of immune checkpoint immunotherapy have led to its increasingly routine use in the management of multiple advanced solid malignancies. Radiation therapy (RT) is well-known to have both local and distant immunomodulatory effects, which has led to extensive investigation into the synergism of these 2 therapies. While the central nervous system (CNS) has historically been thought to be a sanctuary site, well-protected by the blood-brain barrier from the effects of immunotherapy, over the last several years studies have shown the benefits of these drugs, particularly in metastatic disease involving the CNS. This review explores current progress and the future of combination therapy with immune checkpoint inhibitors and RT.

Polymorphous low-grade neuroepithelial tumor of the young with FGFR3-TACC3 fusion mimicking high-grade glioma: case report and series of high-grade correlates.

Background: Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a recently described entity that can mimic high-grade glioma (HGG) in histologic and molecular features; however, factors predicting aggressive behavior in these tumors are unclear. Methods: We present an indolent neuroepithelial neoplasm in a 59-year-old female with imaging initially suggestive of HGG, and a series of adult patients with HGG harboring FGFR3-TACC3 fusions are also presented for comparison. Results: Pathology in the case patient revealed low-grade cytomorphology, microcalcifications, unusual neovascularization, and a low proliferation index. The lesion was diffusely CD34+ and harbored an FGFR3-TACC3 fusion and TERT promoter mutation. A diagnosis of PLNTY was therefore favored and the patient was observed with no progression at 15-month follow-up. In patients with HGG with FGFR3-TACC3 fusions, molecular findings included IDH-wildtype status, absence of 1p19q codeletion, CDKN2A loss, TERT promoter mutations and lack of MGMT promoter methylation. These patients demonstrated a median 15-month overall survival and a 6-month progression-free survival. Conclusion: PLNTY is a rare low-grade entity that can display characteristics of HGG, particularly in adults. Presence of FGFR3-TACC3 fusions and other high-grade features should raise concern for a more malignant precursor lesion when a diagnosis of PLNTY is considered.

Outcomes following upfront radiation versus monitoring in atypical meningiomas: 16-year experience at a tertiary medical center.

BACKGROUND: The role of postoperative upfront radiotherapy (RT) in the management of gross totally resected atypical meningiomas remains unclear. This single-center retrospective review of newly diagnosed histologically confirmed cases of World Health Organization (WHO) Grade II atypical meningioma at Weill Cornell Medicine from 2004 to 2020 aims to compare overall survival (OS) and progression-free survival (PFS) of postoperative upfront RT versus observation, stratified by resection status (gross total resection [GTR] vs subtotal resection [STR]). METHODS: Ninety cases of atypical meningioma were reviewed (56% women; median age 61 years; median follow-up 41 months). RESULTS: In patients with GTR, hazard ratio (HR) of PFS was 0.09 for postoperative upfront RT versus observation alone (95% confidence interval [CI] 0.01-0.68; P = .02), though HR for OS was not significant (HR 0.46; 95% CI 0.05-4.45; P = .5). With RT, PFS was 100% at 12 and 36 months (compared to 84% and 63%, respectively, with observation); OS at 36 months (OS36) was 100% (compared to 94% with observation). In patients with STR, though PFS at 36 months was higher for RT arm versus observation (84% vs 74%), OS36 was 100% in both arms. HR was not significant (HR 0.76; 95% CI 0.16-3.5; P = .73). CONCLUSIONS: This retrospective study suggests postoperative upfront RT following GTR of atypical meningioma is associated with improved PFS compared to observation. Further studies are required to draw conclusions about OS.

Low Incidence of Opioid-Induced Respiratory Depression Observed with Oliceridine Regardless of Age or Body Mass Index: Exploratory Analysis from a Phase 3 Open-Label Trial in Postsurgical Pain.

INTRODUCTION: Advanced age and obesity are reported to increase the risk of opioid-induced respiratory depression (OIRD). Oliceridine, an intravenous opioid, is a G-protein-biased agonist at the µ-opioid receptor that may provide improved safety. The recent phase 3 ATHENA open-label, multicenter study evaluated postoperative use of oliceridine in patients with moderate-to-severe acute pain. This exploratory analysis of the ATHENA data examined the incidence of OIRD in older (≥ 65 years) and/or obese (BMI ≥ 30 kg/m2) patients and analyzed risk factors of OIRD. METHODS: Patients aged ≥ 18 years with a score ≥ 4 on an 11-point numeric pain rating scale (NPRS) received IV oliceridine as needed via bolus dosing and/or patient-controlled analgesia (PCA). OIRD occurring within 48 h of last dose of oliceridine was defined using two established definitions: (1) naloxone use, (2) respiratory rate < 10 breaths per minute and/or oxygen saturation < 90%. RESULTS: A total of 724 surgical patients with a mean age of 54.5 ± 15.9 years and a mean NRS score of 6.2 ± 2.1 were included in this analysis; 33.3% (241/724) were ≥ 65 years of age and 46.3% (335/724) had BMI (body mass index) ≥ 30 kg/m2. The overall OIRD incidence was 13.7% with no patients requiring naloxone. The OIRD incidence was similar in the elderly and younger adults' cohorts [10.8 vs. 15.1%, OR 0.68 (0.42, 1.1), p = 0.11], and in obese and non-obese groups [14.0 vs. 13.4%, OR 1.06 (0.69, 1.62), p = 0.80]. In patients that were both elderly and obese (n = 120), the incidence was 10.8%. The multivariate analysis identified baseline NRS ≥ 6 [OR 1.6 (1.0, 2.4), p = 0.0499], PCA administration [OR 1.9 (1.2, 3.1), p = 0.005], and concomitant use of benzodiazepines and/or gabapentinoids [OR 1.6 (1.0, 2.6), p = 0.045], as being associated with OIRD. CONCLUSIONS: Postoperative oliceridine use in patients with advanced age and/or increased BMI was not associated with increased risk of OIRD.

Mechanisms of EGFR Resistance in Glioblastoma.

Glioblastoma (GBM) is the most common primary malignant brain tumor in adults. Despite numerous efforts to target epidermal growth factor receptor (EGFR), commonly dysregulated in GBM, approaches directed against EGFR have not achieved the same degree of success as seen in other tumor types, particularly as compared to non-small cell lung cancer (NSCLC). EGFR alterations in glioblastoma lie primarily in the extracellular domain, unlike the kinase domain alterations seen in NSCLC. Small molecule inhibitors are difficult to develop for the extracellular domain. Monoclonal antibodies can be developed to target the extracellular domain but must contend with the blood brain barrier (BBB). We review the role of EGFR in GBM, the history of trialed treatments, and the potential paths forward to target the pathway that may have greater success.

Temporal attention is not affected by working memory load.

Temporal attention refers to the ability to orient attention in time, which serves to enhance performance such as target detection and discrimination and is a fundamental component of cognitive function. Although some research indicates that temporal attention ability is affected by working memory updating, it is unclear whether temporal attention is also affected by the availability of working memory stores. To address this, participants were presented a dual-task paradigm requiring zero, three, or six digits to be held in working memory while engaged in a temporally cued visual discrimination task. Results show that working memory load did not differentially affect the ability to benefit from predictive temporal cues during the visual discrimination task. This indicates that temporal attention is not affected by available working memory stores. Interestingly, posterior beta band (12-30 Hz) activity was differentially modulated by temporal attention and working memory load, such that it decreased prior to expected targets and increased with load. Analysis across participants indicated that those individuals who exhibited greater temporal attention-based modulation of beta activity (i.e., predictive < neutrally cued) displayed improved discrimination performance, but also yielded lowered working memory accuracy. Thus, the ability to benefit from temporal attention processes while multitasking comes at the cost of lowered secondary task performance. Together, these results indicate that available working memory stores do not affect temporal attention ability. Rather, limitations in divided attention ability result in a performance cost that prioritizes one task over another, which may be indexed by beta band activity.

Current usage of tumor treating fields for glioblastoma.

BACKGROUND: Tumor Treating Fields (TTF) have entered clinical practice for newly diagnosed and recurrent glioblastoma (GGM). However, controversies remain unresolved with regard to appropriate usage. We sought to determine TTF usage in major academic neuro-oncology programs in New York City, USA and Heidelberg, Germany and understand current attitudes toward TTF usage among providers. METHODS: We retrospectively determined TTF usage among patients with GGM, before and since the publication of key clinical trial results and regulatory approvals. We also surveyed attendees of an educational session related to TTF during the 2019 American Society of Clinical Oncology annual meeting. RESULTS: TTF usage remains infrequent (3-12% of patients with newly diagnosed GBM, and 0-16% of patients with recurrent disease) in our practices, although it has increased over time. Among 30 survey respondents (77% of whom self-identified as neuro- or medical oncologists), 60% were convinced that TTF prolongs survival for newly diagnosed GGM despite published phase III data and regulatory approval, and only 30% viewed TTF as definitively part of the standard of care treatment. A majority (87%) opposed mandating TTF incorporation into the design of clinical trials. CONCLUSIONS: Providers continue to view TTF with some level of skepticism, with a lack of additional supportive data and logistical concerns representing continued barriers to uptake.

ATHENA: A Phase 3, Open-Label Study Of The Safety And Effectiveness Of Oliceridine (TRV130), A G-Protein Selective Agonist At The µ-Opioid Receptor, In Patients With Moderate To Severe Acute Pain Requiring Parenteral Opioid Therapy.

BACKGROUND: Pain management with conventional opioids can be challenging due to dose-limiting adverse events (AEs), some of which may be related to the simultaneous activation of ß-arrestin (a signaling pathway associated with opioid-related AEs) and G-protein pathways. The investigational analgesic oliceridine is a G-protein-selective agonist at the µ-opioid receptor with less recruitment of ß-arrestin. The objective of this phase 3, open-label, multi-center study was to evaluate the safety and tolerability, of IV oliceridine for moderate to severe acute pain in a broad, real-world patient population, including postoperative surgical patients and non-surgical patients with painful medical conditions. METHODS: Adult patients with a score ≥4 on 11-point NRS for pain intensity received IV oliceridine either by bolus or PCA; multimodal analgesia was permitted. Safety was assessed using AE reports, study discontinuations, clinical laboratory and vital sign measures. RESULTS: A total of 768 patients received oliceridine. The mean age (SD) was 54.1 (16.1) years, with 32% ≥65 years of age. Most patients were female (65%) and Caucasian (78%). Surgical patients comprised the majority of the study population (94%), most common being orthopedic (30%), colorectal (15%) or gynecologic (15%) procedures. Multimodal analgesia was administered to 84% of patients. Oliceridine provided a rapid reduction in NRS pain score by 2.2 ± 2.3 at 30 mins from a score of 6.3 ± 2.1 (at baseline) which was maintained to the end of treatment. No deaths or significant cardiorespiratory events were reported. The incidence of AEs leading to early discontinuation and serious AEs were 2% and 3%, respectively. Nausea (31%), constipation (11%), and vomiting (10%) were the most common AEs. AEs were mostly of mild (37%) or moderate (25%) severity and considered possibly or probably related to oliceridine in 33% of patients. CONCLUSION: Oliceridine IV for the management of moderate to severe acute pain was generally safe and well tolerated in the patients studied. CLINICALTRIALSGOV IDENTIFIER: NCT02656875.

Neurologic Immune-Related Adverse Events Associated with Immune Checkpoint Inhibition.

PURPOSE OF REVIEW: This review highlights the spectrum of neurologic adverse events seen with use of immune checkpoint inhibitors (ICIs), their potential mechanisms, the treatments undertaken, and the clinical outcomes. RECENT FINDINGS: The advent of ICIs has revolutionized cancer therapy. Neurologic adverse events (NAEs) are rare but clinically significant complication of ICIs. They can involve both the central and peripheral nervous system. Examples include myositis, neuropathy, encephalopathy, and myasthenia gravis. Treatment consists of holding the ICI, administration of corticosteroids, and other immunomodulatory agents as needed. The outcomes are generally favorable; however, rarely severe events can lead to significant morbidity and even mortality. Identifying and treating the range of neurologic adverse events that may potentially arise with ICIs is very important as the oncologic indications for their use continues to expand.

Recovery of physical activity after cesarean delivery and its relationship with pain.

Pain and physical activity are tightly intertwined. Although their relationship has been explored in chronic pain conditions, we know little about the pattern of recovery in activity and its short- and long-term relationship with pain after surgery. We recruited 103 women undergoing elective cesarean delivery and acquired daily pain assessments and hourly steps in 98 of them for 2 months after surgery. Compliance was good, with 78% of subjects missing less than 7 days of activity. Study personnel required daily checking for compliance and 20 minutes per subject per week in study. Activity increased over the first 2 postoperative months in a log(time) manner. The slope of each modeled individual curve for activity was inversely correlated (r = -0.54; P < 0.0001) with worst daily pain. After removing these 2-month trends, pain and activity within an individual day were negatively associated with each point increase in pain being inversely associated with -119 steps (95% confidence interval [CI] = -214 to -25; P = 0.013). A patient's previous experience of pain was not associated with current activity as well as current activity was not associated with future pain scores. These data, although limited by the study of a single operation in a unique social circumstance with low risk of chronic postsurgical pain, demonstrate feasibility of measuring hourly activity for 2 months after surgery. Recovery from pain and inactivity are tightly correlated, and the negative relationship between within-day pain and activity without interday carryover relationships is in stark contrast to findings in chronic pain conditions.

Epidural Neostigmine versus Fentanyl to Decrease Bupivacaine Use in Patient-controlled Epidural Analgesia during Labor: A Randomized, Double-blind, Controlled Study.

BACKGROUND: The addition of opioids to epidural local anesthetic reduces local anesthetic consumption by 20% but at the expense of side effects and time spent for regulatory compliance paperwork. Epidural neostigmine also reduces local anesthetic use. The authors hypothesized that epidural bupivacaine with neostigmine would decrease total hourly bupivacaine use compared with epidural bupivacaine with fentanyl for patient-controlled epidural analgesia. METHODS: A total of 215 American Society of Anesthesiologists physical status II, laboring parturients requesting labor epidural analgesia consented to the study and were randomized to receive 0.125% bupivacaine with the addition of either fentanyl (2 µg/ml) or neostigmine (2, 4, or 8 µg/ml). The primary outcome was total hourly local anesthetic consumption, defined as total patient-controlled epidural analgesia use and top-ups (expressed as milliliters of 0.125% bupivacaine) divided by the infusion duration. A priori analysis determined a group size of 35 was needed to have 80% power at α = 0.05 to detect a 20% difference in the primary outcome. RESULTS: Of 215 subjects consented, 151 patients were evaluable. Demographics, maternal and fetal outcomes, and labor characteristics were similar among groups. Total hourly local anesthetic consumption did not differ among groups (P = 0.55). The total median hourly bupivacaine consumption in the fentanyl group was 16.0 ml/h compared with 15.3, 14.6, and 16.2 ml/h in the 2, 4, and 8 µg/ml neostigmine groups, respectively (P = 0.55). CONCLUSIONS: The data do not support any difference in bupivacaine requirements for labor patient-controlled epidural analgesia whether patients receive epidural bupivacaine with 2 to 8 µg/ml neostigmine or epidural bupivacaine with 2 µg/ml fentanyl.

MCQ-construction improves Quality of Essay Assessment among undergraduate dental students.

A well-constructed essay is indicative of deep strategic understanding and is considered a valid assessment tool in many dental schools. It has been suggested that constructing MCQs could be an effective learning tool for students while at the same time contribute towards a pool of well-constructed MCQs that could stand up to scrutiny at high-stakes examinations. This study aimed to compare the quality of essays written by students trained and untrained in MCQ construction. The null hypothesis was that construction of MCQs did not result in higher grades achieved in "closed-book" time-limited assessment conditions. A Test cohort (n=48) of undergraduate dental students were taught and constructed MCQs during their preclinical prosthodontics course. The Control cohort (n=48) consisted of students who underwent the same course 1 year prior. The same question was administered to both cohorts without the students׳ knowledge. Answers were de-identified and randomized for grading by a blinded expert prosthodontic examiner not involved in the teaching of the students. Based on a passing grade of 50 and a maximum grade of 100, the Test cohort exhibited significantly improved essay quality, scoring a mean grade of 73.0±8.0, compared to a mean grade of 63.6±11.8 achieved by the control cohort (p<0.001). The null hypothesis was rejected. Under the conditions of this double-blind study, MCQ-construction resulted in better essays written by students under examination conditions.

Combined Spinal Epidural Technique for Labor Analgesia Does Not Delay Recognition of Epidural Catheter Failures: A Single-center Retrospective Cohort Survival Analysis.

BACKGROUND: It is unclear whether recognition of epidural catheter failures is delayed with combined spinal epidural technique (CSE) compared to traditional epidural technique (EPID) when used for labor analgesia. The authors hypothesized that recognition of failed catheters is not delayed by CSE. METHODS: Anesthetic, obstetric, and quality assurance records from 2,395 labor neuraxial procedures (1,440 CSE and 955 EPID) performed at Forsyth Medical Center (Winston-Salem, North Carolina) between June 30 and December 31, 2012, were retrospectively analyzed. The primary outcome was catheter survival (failure-free) time during labor analgesia. A proportional hazards model with the counting method was used to assess relationships between the techniques and survival (failure-free) time of catheters, while controlling for subjects' body mass index and providers' level of training in the final best-fit multivariable regression model. RESULTS: Cumulative incidence of epidural catheter failures was 6.6% for CSE and 11.6% for EPID (P = 0.001). In the multivariable regression model, catheters placed with CSE versus epidural were less likely to fail (hazard ratio, 0.58; 95% CI, 0.43 to 0.79; P = 0.0002) for labor analgesia. Among the catheters that failed, there was no overall difference in failure time course between the techniques (hazard ratio, 1.17; 95% CI, 0.89 to 1.54; P = 0.26) even though more failed catheters with CSE (48.4%) than with EPID (30.6%) were recognized within the first 30 min of placement (P = 0.009). CONCLUSIONS: In this cohort, CSE has a significantly lower risk of overall epidural catheter failures than EPID and does not delay recognition of epidural catheter failures. Choice of CSE versus EPID should be based on overall risk of failure, efficacy, and side effects.

Qualitative Study of a Solution-Focused Training Program for Taiwanese Military Instructors.

This study explored Taiwanese military instructors' perceptions of a training program using a solution-focused approach and its initial application to students with behavior problems. A total of 25 military instructors (16 men, 9 women; M age = 38.6 years, SD = 5.8) and 10 students (three men, seven women; M age = 17.5 years, SD = 0.9) participated in the study through convenience sampling. Grounded theory method was adopted for data analysis. Six prominent categories emerged from the focus group interview, weekly training notes, and the researcher's field notes, including reactions to learning solution-focused approach, strengths and weaknesses of using the solution-focused approach, identification of military instructors role function, initial responses to the techniques of the solution-focused approach, a positive attitude to deal with students' problems, and from assimilation to transformation. In addition, feedback collected from students was grouped into a seventh category. Finally, a modified pattern was developed for military instructors to use when working with students.

A Randomized Controlled Trial Comparing Two Multimodal Analgesic Techniques in Patients Predicted to Have Severe Pain After Cesarean Delivery.

BACKGROUND: Improved pain control after cesarean delivery remains a challenging objective. Poorly treated acute pain following delivery is associated with an increased risk of chronic pain and depression. This study was conducted to determine whether the addition of systemic acetaminophen and an increased dose of intrathecal morphine would further reduce acute pain. The primary outcome was pain intensity with movement at 24 hours postoperatively. Secondary measures included persistent pain and depression at 8 weeks. METHODS: Seventy-four parturients scheduled for elective cesarean delivery under spinal anesthesia that were predicted to be above the 80th percentile for evoked pain intensity based on a 3-item preoperative screening questionnaire were enrolled. Patients in the intervention group received 300 mcg spinal morphine and 1 gram acetaminophen every 6 hours for 24 hours postoperatively. Patients in the control group received 150 mcg spinal morphine and placebo tablets. All patients received scheduled ibuprofen by mouth and IV morphine patient-controlled analgesia. At 24 hours, patients rated their pain intensity with movement, at rest, on average, and worst score using a visual analog scale for pain (100-mm unmarked line). The presence of persistent pain and depression was assessed at 8 weeks using the Edinburgh postpartum depression survey. RESULTS: Providing a higher dose of spinal morphine combined with systemic acetaminophen to patients predicted to be at high risk for severe post-cesarean delivery pain significantly reduced evoked pain scores with movement at 24 hours (mean ± SD: 46 ± 25 mm in control group versus 31 ±17 mm in intervention group, P = 0.009; 95% confidence interval for the difference between means: 4 mm, 26 mm). There was no difference in the incidence of persistent pain (13% (4/30) in control group versus 10% (3/30) in intervention group, P > 0.99), or depression at 8 weeks postoperatively (10% (3/30) in control group versus 13% (4/30) in intervention group, P > 0.99). CONCLUSIONS: Adding a higher dose of intrathecal morphine and oral acetaminophen to a multimodal pain regimen in patients predicted to be at risk for high acute postpartum pain after cesarean delivery results in a significant reduction of acute postoperative pain scores at 24 hours.

Perspectives of Taiwanese pastoral counselors on the use of scripture and prayer in the counseling process.

Interviews were carried out with 10 Christian pastoral counselors to explore their perspectives on the use of Scripture and prayer in the counseling process. Grounded Theory was utilized. Five main categories including a theological framework of pastoral counseling, counselors' considerations of using Scripture and prayer, preparation for Christian spiritual intervention, implications of spiritual resources, and ethical issues in the pastoral counseling process were generated. The results suggest the theological framework of pastoral counseling is crucial to the use of Scripture and prayer, and the issue of a neutral response should first be clarified for clients. Basic guidelines for ethically using Scripture and prayer for working with Christian clients are proposed for further pastoral counselor training, practice, and research.

Using Kollar's solution-focused pastoral counseling for bereaved clients: the process of empowerment from clients' perception.

The purpose of this study was to investigate how bereaved clients recovered from grief and loss after receiving Kollar's solution-focused pastoral counseling (KSFPC) from a perspective of empowerment. Ten Taiwanese Christian clients (3 men, 7 women; M age = 42.5 yr., SD = 8.5), who had experienced a significant loss of a loved one within the past two years, were recruited from churches in northern Taiwan, forming a convenience sample. The clients, based on their time availability, were randomly assigned to one of the two pastoral counselors and had four KSFPC sessions. The grounded theory procedure was adopted for qualitative data analysis. Four prominent categories emerged from the open-ended questions, in-depth interviews, and interactive counseling notes, including First Encounter with Solution-focused Pastoral Counseling (SFPC), Transitional Life Re-Decision-Making Process, Reflections and Changes, and New Participatory Competencies, within which 12 axial categories and 42 meaning units were identified. The results support the use of KSFPC to empower clients' competence in recovery from grief and loss. Implications for future research and KSFPC practice are suggested.

Effectiveness of an enhancement program on Taiwanese university students' self-concept'.

This study examined the effectiveness of a Self-Concept Enhancement Program (SCEP) on Taiwanese university students. Participants were randomly assigned to an experimental group (n = 30) and a waiting-list control group (n = 30). The experimental group received SCEP psycho-educational treatment for 8 weeks, whereas the control group did not. Results indicated significant improvements on physical, personal, self-identity, and total self-concept in the experimental group, but not in the control group. Participants evaluated the SCEP as useful, beneficial, and powerful in promoting their self-concept. Cultural issues were highlighted and discussed. Implications for research and counseling practice are suggested.

A randomized controlled comparison between combined spinal-epidural and single-shot spinal techniques in morbidly obese parturients undergoing cesarean delivery: time for initiation of anesthesia.

BACKGROUND: There is no current consensus on the optimal technique for subarachnoid anesthesia in morbidly obese parturients even though some providers prefer the combined spinal-epidural (CSE) over single-shot spinal (SSS) technique. In this randomized controlled study, we compared the time required for initiation of subarachnoid anesthesia between SSS and CSE techniques in morbidly obese parturients undergoing elective cesarean delivery. METHODS: Morbidly obese parturients presenting for elective cesarean delivery were randomized to receive subarachnoid anesthesia performed either with a SSS or a CSE technique. The spinal procedure in the sitting position was attempted by an experienced resident for up to 10 minutes, and if unsuccessful, the attending obstetric anesthesiologist assumed control of the procedure. The primary outcome was the time it took from the insertion of the introducer needle (SSS group) or insertion of the epidural needle (CSE group) to the end of intrathecal injection of drugs (procedure time). RESULTS: Forty-four patients were enrolled and completed the study. Three were excluded due to protocol violations. Of the remaining, 21 patients were in the SSS group and 20 in the CSE group. Demographic variables and mean (SD) body mass index (48.7 ± 7.6 kg/m for SSS; 49.9 ± 8.6 kg/m for CSE) were not different between groups. The median [interquartile range] for procedure time was 210 [116-692] seconds and 180 [75-450] seconds for SSS and CSE groups, respectively (P = 0.36), while the 95% confidence interval (CI) of the difference was -80 to +180 seconds. The first operator completed the procedure in <10 minutes in 71% of subjects in the SSS group and 95% of those in the CSE group (P = 0.09) and the 95% CI of the difference was -2% to +45%. There were more attempts to successful completion of the procedure in the SSS group (P = 0.007) with its 95% CI of the difference being +1 to +6. CONCLUSION: Our results suggest that the CSE technique is noninferior to the SS technique in morbidly obese parturients for time of initiation of subarachnoid anesthesia and may be accomplished with fewer attempts than the SSS technique with experienced residents.