Clinical Presentations and Outcomes of Patients Receiving Immune Checkpoint Inhibitors Presenting to the Emergency Department.

Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.

Use of an EHR-Integrated Point-of-Care Mobile Medical Photography Application in a Pediatric Emergency Department.

BACKGROUND: Mobile applications allow health care providers to capture point-of-care medical photographs and transfer them to the electronic health record (EHR). It is unclear how providers use these photographs or how they affect clinical care. OBJECTIVES: We aimed to understand the content, purpose, and outcomes of point-of-care medical photography performed in the pediatric emergency department (ED) at large academic medical center. METHODS: A retrospective chart review was conducted of patients <21 years of age who were seen in the ED and photographed between March 29, 2015 and July 1, 2017 using a secure smartphone application integrated with the EHR. Inter-rater agreement and reliability between the two reviewers was assessed for the first 50 charts, and any discrepancies in interpretation were resolved before proceeding with the remaining data abstraction. The documented rationale for photography, content of photographs, and outcomes were recorded. RESULTS: We identified 619 clinical encounters involving photographs of 605 patients who were eligible for inclusion. Skin was photographed in 499 (81%). The most common finding was rash (N = 177; 29%). Photos were of acceptable quality, with 569 (94%) achieving a score between 4 and 5 out of 5. The primary use of photography was documentation (N = 334; 54%), though teleconsultation was noted in 38 (6%). Nearly one-third (N = 187; 30%) of patients were seen in the ED or outpatient clinic for any reason within 2 weeks, and in 25 (13%), clinical notes explicitly referenced the initial photograph(s). In 53 (9%) cases, patients were photographed at a clinical visit in the subsequent 2 weeks, suggesting that photography was used to track changes over time. CONCLUSION: Documentation of findings using mobile point-of-care photography allows for high-fidelity documentation and facilitates continuity of care.

Measuring achievement goal motivation, mindsets and cognitive load: validation of three instruments' scores.

OBJECTIVE: Measurement of motivation and cognitive load has potential value in health professions education. Our objective was to evaluate the validity of scores from Dweck's Implicit Theories of Intelligence Scale (ITIS), Elliot's Achievement Goal Questionnaire-Revised (AGQ-R) and Leppink's cognitive load index (CLI). METHODS: This was a validity study evaluating internal structure using reliability and factor analysis, and relationships with other variables using the multitrait-multimethod matrix. Two hundred and thirty-two secondary school students participated in a medical simulation-based training activity at an academic medical center. Pre-activity ITIS (implicit theory [mindset] domains: incremental, entity) and AGQ-R (achievement goal domains: mastery-approach, mastery-avoidance, performance-approach, performance-avoidance), post-activity CLI (cognitive load domains: intrinsic, extrinsic, germane) and task persistence (self-directed repetitions on a laparoscopic surgery task) were measured. RESULTS: Internal consistency reliability (Cronbach's alpha) was > 0.70 for all domain scores except AGQ-R performance-avoidance (alpha 0.68) and CLI extrinsic load (alpha 0.64). Confirmatory factor analysis of ITIS and CLI scores demonstrated acceptable model fit. Confirmatory factor analysis of AGQ-R scores demonstrated borderline fit, and exploratory factor analysis suggested a three-domain model for achievement goals (mastery-approach, performance and avoidance). Correlations among scores from conceptually-related domains generally aligned with expectations, as follows: ITIS incremental and entity, r = -0.52; AGQ-R mastery-avoidance and performance-avoidance, r = 0.71; mastery-approach and performance-approach, r = 0.55; performance-approach and performance-avoidance, r = 0.43; mastery-approach and mastery-avoidance, r = 0.36; CLI germane and extrinsic, r = -0.35; ITIS incremental and AGQ-R mastery-approach, r = 0.34; ITIS incremental and CLI germane, r = 0.44; AGQ-R mastery-approach and CLI germane, r = 0.48 (all p < 0.001). We found no correlation between the number of task repetitions (i.e. persistence) and mastery-approach scores, r = -0.01. CONCLUSIONS: ITIS and CLI scores had appropriate internal structures and relationships with other variables. AGQ-R scores fit a three-factor (not four-factor) model that collapsed avoidance into one domain, although relationships of other variables with the original four domain scores generally aligned with expectations. Mastery goals are positively correlated with germane cognitive load.

Syntheses and catalytic oxotransfer activities of oxo molybdenum(vi) complexes of a new aminoalcohol phenolate ligand.

The new aminoalcohol phenol 2,4-di-tert-butyl-6-(((2-hydroxy-2-phenylethyl)amino)methyl)phenol (H2L) was prepared by a facile solvent-free synthesis and used as a tridentate ligand for new cis-dioxomolybdenum(vi)(L) complexes. In the presence of a coordinating solvent (DMSO, MeOH, pyridine), the complexes crystallise as monomeric solvent adducts while in the absence of such molecules, a trimer with asymmetric Mo[double bond, length as m-dash]O→Mo bridges crystallises. The complexes can catalyse epoxidation of cis-cyclooctene and sulfoxidation of methyl-p-tolylsulfide, using tert-butyl hydroperoxide as oxidant.

High frequency spinal cord stimulation-New method to restore cough.

Spinal cord stimulation (SCS, 50Hz) is a useful method to restore an effective cough in persons with spinal cord injury (SCI). However, high stimulus amplitudes and potential activation of pain fibers, significantly limits this application. It is our hypothesis that high frequency SCS (HF-SCS), with low stimulus amplitudes may provide the same level of expiratory muscle activation. In 6 dogs, the effects of SCS, with varying stimulus parameters on positive pressure (P) generation was evaluated. At any given level of stimulus current, mean P was largest at 500Hz, compared to all other stimulus frequencies. For example, with stimulation at 1mA and frequencies of 200, 500 and 600Hz, P were 25±3, 58±4, 51±6cmH2O, respectively. By comparison, P achieved with conventional SCS parameters was 61±5cmH2O. HF-SCS results in a comparable P compared to that achieved with conventional stimulus parameters but with much lower stimulus amplitudes. This method may be useful to restore cough even in subjects with intact sensation.

The function and evolution of male and female genitalia in Phyllophaga Harris scarab beetles (Coleoptera: Scarabaeidae).

Genitalia diversity in insects continues to fuel investigation of the function and evolution of these dynamic structures. Whereas most studies have focused on variation in male genitalia, an increasing number of studies on female genitalia have uncovered comparable diversity among females, but often at a much finer morphological scale. In this study, we analysed the function and evolution of male and female genitalia in Phyllophaga scarab beetles, a group in which both sexes exhibit genitalic diversity. To document the interaction between male and female structures during mating, we dissected flash-frozen mating pairs from three Phyllophaga species and investigated fine-scale morphology using SEM. We then reconstructed ancestral character states using a species tree inferred from mitochondrial and nuclear loci to elucidate and compare the evolutionary history of male and female genitalia. Our dissections revealed an interlocking mechanism of the female pubic process and male parameres that appears to improve the mechanical fit of the copulatory position. The comparative analyses, however, did not support coevolution of male and female structures and showed more erratic evolution of the female genitalia relative to males. By studying a group that exhibits obvious female genitalic diversity, we were able to demonstrate the relevance of female reproductive morphology in studies of male genital diversity.

Isomerization of the osmium-tellurium cluster Os3(µ-TeR)2(CO)10: a kinetic and computational study.

The kinetics for the isomerization of the 50e cluster Os3(µ-TeTol-p)2(CO)10 (), where the tellurides bridge two different Os-Os edges, to one in which the tellurides bridge the same open OsOs edge () have been measured experimentally by (1)H NMR spectroscopy. The determined activation parameters are ΔH(‡) = 77 ± 9 kJ mol(-1) and ΔS(‡) = -12 ± 28 J mol(-1) K. The conversion of to has been computationally investigated by electronic structure calculations using the model compound Os3(µ-TeMe)2(CO)10. The computed isomerization pathway is consistent with the kinetic data and the thermodynamic preference for the product stereoisomer that possesses a slipped, eclipsed conformation for the two p-tolyl groups.

Radiation of the Drosophila nannoptera species group in Mexico.

The Drosophila nannoptera species group, a taxon of Mexican cactophilic flies, is an excellent model system to study the influence of abiotic and biotic factors on speciation, the genetic causes of ecological specialization and the evolution of unusual reproductive characters. However, the phylogenetic relationships in the nannoptera species group and its position within the virilis-repleta phylogeny have not been thoroughly investigated. Using a multilocus data set of gene coding regions of eight nuclear and three mitochondrial genes, we found that the four described nannoptera group species diverged rapidly, with very short internodes between divergence events. Phylogenetic analysis of repleta group lineages revealed that D. inca and D. canalinea are sister to all other repleta group species, whereas the annulimana species D. aracataca and D. pseudotalamancana are sister to the nannoptera and bromeliae species groups. Our divergence time estimates suggest that the nannoptera species group radiated following important geological events in Central America. Our results indicate that a single evolutionary transition to asymmetric genitalia and to unusual sperm storage may have occurred during evolution of the nannoptera group.

The use of oral sildenafil for management of right ventricular dysfunction after pediatric heart transplantation.

High pulmonary vascular resistance index (PVRI) can lead to right ventricular dysfunction and failure of the donor heart early after pediatric heart transplantation. Oral pulmonary vasodilators such as sildenafil have been shown to be effective modifiers of pulmonary vascular tone. We performed a retrospective, observational study comparing patients treated with sildenafil ("sildenafil group") to those not treated with sildenafil ("nonsildenafil group") after heart transplantation from 2007 to 2012. Pre- and posttransplant data were obtained, including hemodynamic data from right heart catheterizations. Twenty-four of 97 (25%) transplant recipients were transitioned to sildenafil from other systemic vasodilators. Pretransplant PVRI was higher in the sildenafil group (6.8 ± 3.9 indexed Woods units [WU]) as compared to the nonsildenafil group (2.5 ± 1.7 WU, p=0.002). In the sildenafil group posttransplant, there were significant decreases in systolic pulmonary artery pressure, mean pulmonary artery pressure, transpulmonary gradient and PVRI (4.7 ± 2.9 WU before sildenafil initiation to 2.7 ± 1 WU on sildenafil, p=0.0007). While intubation time, length of inotrope use and time to hospital discharge were longer in the sildenafil group, survival was similar between both groups. Oral sildenafil was associated with a significant improvement in right ventricular dysfunction and invasive hemodynamic measurements in pediatric heart transplant recipients with high PVRI early after transplant.

Pediatric cardiac transplantation using hearts previously refused for quality: a single center experience.

Pediatric donor hearts are regularly refused for donor quality with limited evidence as to which donor parameters are predictive of poor outcomes. We compare outcomes of recipients receiving hearts previously refused by other institutions for quality with the outcomes of recipients of primarily offered hearts. Data for recipients aged ≤18 and their donors were obtained. Specific UNOS refusal codes were used to place recipients into refusal and nonrefusal groups; demographics, morbidity and mortality were compared. Kaplan-Meier analysis with log-rank test was used to determine differences in graft survival. A multivariable Cox proportional hazards model was constructed to determine independent risk factors for postoperative mortality. From July 1, 2000 to April 30, 2011, 182 recipients were transplanted and included for analysis. One hundred thirty received a primarily offered heart; 52 received a refused heart. No difference in postoperative complications or graft survival between the two groups (p = 0.190) was found. Prior refusal was not an independent risk factor for recipient mortality. Analysis of this large pediatric cohort examining outcomes with quality-refused hearts shows that in-hospital morbidity and long-term mortality for recipients of quality-refused hearts are no different than recipients of primarily offered hearts, suggesting that donor hearts previously refused for quality are not necessarily unsuitable for transplant and often show excellent outcomes.

SU-E-I-11: A Novel High Resolution CT Imager for a Breast SPECT-CT System.

PURPOSE: To evaluate the intrinsic characteristics of a new high resolution, large area, small bezel, digital imager developed for a dedicated SPECT-CT system for fully-3D mammotomographic imaging applications. METHODS: A new flat panel digital imager was developed having 127µm pixels (identical to those in the Paxscan 2520) with an active 40×30cm area and 3200×2304 total pixels, which is well suited for pendant breast imaging close to the chest wall. The readout and driver ASIC TAB bonding pads were arranged on only two sides of the imager plate, to eliminate dead edge spacing. A special housing was developed to accommodate this imaging plate providing very narrow 8mm edges (bezels) on two orthogonal sides The TFT array imager was coated with 600µm thick micro-columnar CsI, which provides >90% absorption in the breast CT (60-80kVp) x-ray energy range. It provides better than 70% absorption for RQA5 (70kVp 21mm Al filter) x- ray radiation. The readout ASICs are connected to 14 bit A/D converters, and special readout ASICs with gain switching feature, which provide an additional 4bit virtual (2-3 effective) dynamic range. RESULTS: The MTF is ∼7.5% at the 3.9 lp/mm Nyquist frequency. The NPS curves continuously decrease with increasing spatial frequencies, characteristic of scintillator based imagers. The excellent DQE (0) measured at RQA5 is ∼75% in the 0.1-1mR dose range and ∼10% at the Nyquist frequency. The imager has excellent linearity over the full dynamic range, and high contrast images are readily acquired. CONCLUSIONS: The new 4030 flat panel imager is a high resolution, state of the art detector, ideal for breast imaging and other applications. This detector is included in the SPECT-CT device in development.

Migration depths of adult steelhead Oncorhynchus mykiss in relation to dissolved gas supersaturation in a regulated river system.

Adult steelhead Oncorhynchus mykiss tagged with archival transmitters primarily migrated through a large river corridor at depths >2 m interspersed with frequent but short (<5 min) periods closer to the surface. The recorded swimming depths and behaviours probably provided adequate hydrostatic compensation for the supersaturated dissolved gas conditions encountered and probably limited development of gas bubble disease (GBD). Results parallel those from a concurrent adult Chinook salmon Oncorhynchus tshawytscha study, except O. mykiss experienced greater seasonal variability and were more likely to have depth uncompensated supersaturation exposure in some dam tailraces, perhaps explaining the higher incidence of GBD in this species.

Utility of lipid biomarkers in support of bioremediation efforts at army sites.

Lipid biomarker analysis has proven valuable in testing the hypothesis that attributes of the extant microbiota can directly reflect the occurrence of contaminant biodegradation. Two past research efforts have demonstrated this utility and are described here. A 4.5 m vertical core was obtained from a diesel fuel oil contamination plume. Core material was assayed for total petroleum hydrocarbons (TPH) and bacterial membrane phospholipids (PLFA) via a single solvent extraction. Microbial viable biomass and the relative abundance of Gram-negative bacterial PLFA biomarkers were found to be significantly correlated with TPH concentration. The core TPH profile also revealed two distinct areas where the average TPH level of 3,000 microg g(-1) fell to near detection limits. Both areas were characterized by a three-fold decrease in the hexadecane/pristane ratio, indicating alkane biodegradation, and a distinct PLFA profile that showed a close similarity to the uncontaminated surface soil. Low-order, incomplete detonations can deposit hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) into training range surface soils. Since surface soils are exposed to temporal and diurnal moisture cycles, we investigated the effect two very different soil moisture tensions had on the in situ microbiota and RDX biodegradation. Saturated soils were characterized by rapid RDX biodegradation, 4 day half-life, a decrease in number of species detected and increase in PLFA biomarkers for Gram-negative proteobacteria (n16:1omega7c, n18:1omega9c, and n18:1omega7c) and Gram-positive firmicutes (i15:0 and a15:0). Terminal restriction fragment length polymorphism (T-RFLP) profiles of endpoint microbial communities indicated a shift from 18 to 36% firmicutes, the loss of gamma-proteobacteria and the emergence of alpha-proteobacteria. These two past research efforts demonstrated the utility of the lipid biomarker analysis in identifying microbial community characteristics that were associated with two very different soil contaminants. Lipid biomarkers defined areas of TPH biodegradation and identified community shifts as a result of soil conditions that affected explosives fate. Information like this can be used to enhance the predictive power of ecological models such as the Army Training and Testing Area Carrying Capacity for munitions model [ATTACC].

The malignant course of acute rheumatic Fever in the modern era: implications for early surgical intervention in cases of bivalvular insufficiency with impaired ventricular function.

In recent years, the incidence of acute rheumatic fever (ARF) has drastically decreased in the United States while remaining common in developing nations. However, immigration to the United States from developing nations has resulted in the continued prevalence of ARF. Patients with ARF face the potential development of significant valvular insufficiency and rheumatic carditis, which are associated with significant morbidity and mortality. Potentially adverse outcomes may be avoided with advanced interventions such as aortic and/or mitral valve replacement or repair, the use of inotropic agents, and ventricular assist devices for mechanical circulatory support. This report describes a series of three ARF carditis cases. This series serves not only to emphasize proper ARF prevention, but also to demonstrate the need for timely surgical intervention once medical therapy has failed.

Jaw complications associated with bisphosphonate use in patients with plasma cell dyscrasias.

Osteonecrosis of the jaw has been linked with bisphosphonate use in breast cancer and multiple myeloma patients. We report 17 cases of patients with plasma cell dyscrasia being treated with bisphosphonate who developed osteonecrosis/osteomyelitis of the jaw. Seventeen patients evaluated at our institution between 1998 and 2005 are reported. All were being treated with bisphosphonates for a median of 5 mo prior to the onset of jaw symptoms. Sixteen of the 17 patients are 51 yr or older. None of the patients had been irradiated in the jaw nor had obvious osseous manifestation of multiple myeloma in the jaw. Thirteen patients were receiving zoledronic acid and four patients were receiving pamidronate at the onset of jaw symptoms. Six of the 17 did receive both agents at some time and all of these individuals were receiving zoledronic acid at diagnosis. Microorganisms were isolated in 7/17 patients with the most common organism being actinomycosis. We have initiated the following guidelines in an effort to ameliorate the incidence of this complication. Patients should have a full dental examination at the time of diagnosis of the plasma cell dyscrasia especially if bisphosphonates are to be considered as part of the therapy. In addition, bisphosphonates are held for a period of 3 mo prior to invasive dental procedures to allow for the osteoclastic recovery, therefore enhanced debris removal and lessening the chance of creating a fertile bacterial medium. Following the dental procedure we would re-introduce bisphosphonates only after the healing process is complete. Finally, multiple myeloma patients diagnosed with jaw osteonecrosis probably have a concurrent infection and should be aggressively treated with antibiotics.

Underwater, low-frequency noise in a coastal sea turtle habitat.

Underwater sound was recorded in one of the major coastal foraging areas for juvenile sea turtles in the Peconic Bay Estuary system in Long Island, New York. The recording season of the underwater environment coincided with the sea turtle activity season in an inshore area where there is considerable boating and recreational activity, especially during the summer between Independence Day and Labor Day. Within the range of sea turtle hearing, average noise pressure reached 110 dB during periods of high human activity and diminished proportionally, down to 80 dB, with decreasing human presence. Therefore, during much of the season when sea turtles are actively foraging in New York waters, their coastal habitats are flooded with underwater noise. During the period of highest human activity, average noise pressures within the range of frequencies heard by sea turtles were greater by over two orders of magnitude (26 dB) than during the lowest period of human activity. Sea turtles undoubtedly are exposed to high levels of noise, most of which is anthropogenic. Results suggest that continued exposure to existing high levels of pervasive anthropogenic noise in vital sea turtle habitats and any increase in noise could affect sea turtle behavior and ecology.

An X-ray outburst from the rapidly accreting young star that illuminates McNeil's nebula.

Young, low-mass stars are luminous X-ray sources whose powerful X-ray flares may exert a profound influence over the process of planet formation. The origin of the X-ray emission is uncertain. Although many (or perhaps most) recently formed, low-mass stars emit X-rays as a consequence of solar-like coronal activity, it has also been suggested that X-ray emission may be a direct result of mass accretion onto the forming star. Here we report X-ray imaging spectroscopy observations which reveal a factor approximately 50 increase in the X-ray flux from a young star that is at present undergoing a spectacular optical/infrared outburst (this star illuminates McNeil's nebula). The outburst seems to be due to the sudden onset of a phase of rapid accretion. The coincidence of a surge in X-ray brightness with the optical/infrared eruption demonstrates that strongly enhanced high-energy emission from young stars can occur as a consequence of high accretion rates. We suggest that such accretion-enhanced X-ray emission from erupting young stars may be short-lived, because intense star-disk magnetospheric interactions are quenched rapidly by the subsequent flood of new material onto the star.

Counter-responses as organizers in adolescent analysis and therapy.

The author introduces Counter-response as a phenomological term to replace theory-burdened terms like counter-transference, counter-identification, and counter-resistance. He discusses the analyst's use of self (drawing on the comparison with Winnicott's use of the object) in processing the expectable destabilizing counter-reactions that occur in working therapeutically with disturbed adolescents and their parents. Further; he discusses the counter-reaction to the patient's narrative, acting-out, and how re-enactments can serve as an organizer for understanding the patient's inner life when the analyst formulates his/her counter-response. Emphasis is placed on the therapist forming his or her own narrative with the adolescent that takes into account the evoked counter-reaction. For this purpose, the author recommends the use of a combined counter-response and metaphor-orienting perspective to acknowledge and work with the denial, illusions, reversal of perspective, and catastrophic anxieties experienced with these adolescents. The counter-response perspective permits the emergence of the disturbed adolescent's novel narrative; however, since these experiences can be destabilizing or disruptive, the author also recommends the use of a personal metaphor to anticipate the reluctance to examining, processing, and formulating the analyst's dysphoric counter-reaction. With the use of the counter-response, the analyst's therapeutic ideal is to achieve a more optimal balance between using accepted narrative theories and exploring novel enactment experiences. His swimming metaphor stratagem is designed to keep the analyst in these difficult encounters.

Comparative effects of GnRH and porcine zona pellucida (PZP) immunocontraceptive vaccines for controlling reproduction in white-tailed deer (Odocoileus virginianus).

Fawning rates and mating behaviour were compared between white-tailed deer (Odocoileus virginianus) treated with GnRH and porcine zona pellucida (PZP) immunocontraceptive vaccines from 1997 to 2000. Female deer from a herd of 102 deer at Seneca Army Depot, near Romulus, New York, were treated with prime and booster injections of PZP (n = 22) or GnRH vaccine (n = 32), or remained untreated as controls (n = 34). During the summers after booster treatment, observed fawning rates for adult female deer were similar for both PZP-treated (0.10-0.11 fawns per female) and GnRH-treated (0.13-0.22 fawns per female) female deer, and were significantly lower (t = -8.93 and t = -9.73; P < or = 0.0005, respectively) than those observed for control female deer (1.22-1.38 fawns per female). During the second (0.36 fawns per female) and third summers (0.61 fawns per female) after the last booster injection, GnRH-treated female deer still produced significantly fewer fawns than did the controls (1.38 and 1.31 fawns per female, respectively). In one breeding season after treatment, five of 18 (28%) females vaccinated with PZP produced fawns, similar to the rate for GnRH-treated females (29%). In addition, females treated with GnRH had fewer oestrous cycles per female (0.06, P < or = 0.05) than did either control (0.22 cycles per female) or PZP-treated deer (0.36 cycles per female). Initial PZP treatment followed by a booster dose 5-7 months later reduced fawn production and prolonged the breeding season as females repeatedly returned to oestrus, similar to results reported in other studies.

Assessment of diaphragm function after stellate ganglion block using magnetic stimulation.

Stellate ganglion block is a procedure frequently used for the management of patients with chronic sympathetically mediated pain affecting the arm, neck or head. We studied the effect of stellate ganglion block on ipsilateral phrenic nerve function, and hence diaphragmatic strength, in 11 adult patients with chronic sympathetically mediated pain. Pre- and post-block forced vital capacity (FVC) measurements were recorded using a pneumotachograph and a Magstim nerve stimulator was used to generate pre- and post-block twitch mouth pressures (P(TWM)). This device can be used to stimulate the phrenic nerves and hence the diaphragm. The resulting change in airway pressure was measured at the mouth and has previously been shown to reflect diaphragm strength. There was no statistically significant difference in FVC or P(TWM) pre- or post stellate ganglion block. In conclusion, a stellate ganglion block has no adverse effect on ipsilateral phrenic nerve function or diaphragm strength in healthy adult patients.