Correlation of bupivacaine 0.5% dose and conversion from spinal anesthesia to general anesthesia in cesarean sections.

BACKGROUND: Failed spinal anesthesia for cesarean sections may require conversion to general anesthesia. The aim of this study was to determine whether the administered spinal bupivacaine dose for performing a cesarean section under spinal anesthesia was related to the conversion rate to general anesthesia. METHODS: Retrospective analysis was performed on 1252 electronic data and file of patients who underwent a cesarean section under spinal anesthesia between 2004 and 2011. RESULTS: In 15 patients, spinal anesthesia was converted into general anesthesia due to block failure. Patients in whom a bupivacaine dose of 8 mg or smaller was administered had significantly higher conversion rate (3/61 (4.9%) patients and 12/1191 (1.0%) patients, respectively; p < 0.05.). The relative risk of conversion with a 8 mg dose or lower is 4.88 (95% CI 1.41 - 16.85). CONCLUSION: This retrospective study shows that a low dose administration a bupivacaine 0.5% for spinal anesthesia in cesarean section patients elicits significantly more frequent conversion to general anesthesia.

Ultrasound-guided needle handling using a guidance positioning system in a phantom.

The SonixGPS™ needle guidance positioning system provides navigation assistance to facilitate needle handling during ultrasound-guided procedures. Each of 20 inexperienced nurse anaesthetists performed 12 different ultrasound-guided tasks in a porcine phantom. Using both in-plane and out-of-plane approaches, they inserted a needle and made contact with metal rods at depths of 2, 4 and 6 cm. We compared their performances without and with navigation as paired observations. Using the out-of-plane approach, navigation yielded shorter execution times (26 s vs 14 s, respectively; p = 0.01) and fewer needle repositionings (8 vs 3, respectively; p = 0.001). Using the in-plane approach, the needle was more visible with navigation assistance: 24% vs 52% of execution time, respectively (95% CI: 44%-12%; p = 0.0025). Better needle visibility was associated with shorter execution times and fewer needle repositionings. Combining ultrasound-guided techniques with the needle guidance positioning system may reduce tissue manipulation, thus improving patient comfort and safety.

Patient state index vs bispectral index as measures of the electroencephalographic effects of propofol.

BACKGROUND: The patient state index (PSI) and the bispectral index (BIS) quantify anaesthetic depth based on the EEG using different algorithms. We compared both indices with regard to the prediction of the depth of propofol anaesthesia. METHODS: In 17 patients, propofol was infused until burst suppression occurred and stopped thereafter until BIS recovered to values above 60. This was repeated; afterwards, patients were intubated, for subsequent surgery. Without surgical stimulus, PSI and BIS were measured simultaneously and compared with the estimated effect-site concentrations of propofol. These were derived from simultaneous pharmacokinetic and -dynamic modelling in an individual two-stage and a population-based NONMEM approach. RESULTS: A close sigmoid relationship was observed between the propofol effect-site concentration and both PSI [coefficient of determination rho(2)=0.91 (sd 0.05)] and BIS [rho(2)=0.92 (0.03)], which was significantly steeper for PSI [gamma=2.2 (0.6)] than for BIS [gamma=1.8 (0.4)], and reached significantly lower values for PSI [E(max)=0.3 (1.1)] than for BIS [E(max)=5.3 (6.7)] at maximal propofol concentrations. A significantly smaller k(e0) was obtained for PSI [0.09 (0.03) min(-1)] compared with BIS [0.10 (0.02) min(-1)]. PSI and BIS correlated significantly with each other (rho(2)=0.866) and predicted propofol effect-site concentration with a comparable probability [P(K)=0.87 (0.05) and 0.86 (0.05), respectively]. NONMEM revealed E(0)=89.3 and 92.3, E(max)=1.9 and 8.6, C(e50)=1.38 and 1.92 microg ml(-1), gamma=1.6 and 1.48, and k(e0)=0.103 and 0.131 min(-1) as typical values for PSI and BIS, respectively. CONCLUSIONS: The PSI and the BIS monitors performed equally well in predicting depth of propofol anaesthesia. However, PSI was lower than BIS by approximately 10-15 points at high propofol concentrations.

Long-term results of trismus release in noma patients.

Noma, also known as cancrum oris, is an infectious disease that results in a loss of orofacial tissue, due to gangrene of soft and bony tissue. It is especially seen in young children in the sub-Saharan region. Among the sequelae of patients who survive noma, trismus is one of the most disabling. This retrospective research studied the long-term results of trismus release in noma patients. Thirty-six patients could be traced in the villages and were included in the study. The mean mouth opening in this group was 10.3mm (95% CI: 7.0; 13.6mm) and the mean period after discharge from hospital was 43 months. Better mouth opening was observed in patients who continued physiotherapy after discharge, were older, and those with a 'soft' (vs. 'hard') inner and outer cheek on palpation. The result of trismus release in noma patients in the long term was extremely poor in this study.

The Entropy Module and Bispectral Index as guidance for propofol-remifentanil anaesthesia in combination with regional anaesthesia compared with a standard clinical practice group.

This study was designed to investigate the impact of the Entropy Module and Bispectral Index (BIS) monitoring on drug consumption and recovery times compared with standard anaesthetic practice in patients undergoing orthopaedic surgery using a combination of regional and general anaesthesia as performed by an experienced anaesthesiologist. We hypothesised that electroencephalogram monitoring would lead to a lower drug consumption as well as shorter recovery times. With institutional review board approval and written informed consent, 90 adult patients undergoing surgery to the upper or lower extremity received regional anaesthesia for post- and intraoperative pain control and were randomised to receive general anaesthesia by propofol/remifentanil infusion controlled either solely by clinical parameters or by targeting Entropy or BIS values of 50. Recovery times and drug consumption were recorded. Data from 79 patients were analysed. Compared with standard practice, patients with Entropy or BIS monitoring showed a similar propofol consumption (standard practice 101 +/- 22 microg/kg/minute, Entropy 106 +/- 24 microg/kg/minute, BIS 104 +/- 20 microg/kg/minute) and showed similar Aldrete scores (10/10) one minute after extubation: 9.1 +/- 0.3, 9.2 +/- 0.6 and 9.3 +/- 0.5, respectively. Time points of extubation were 7.3 +/- 2.9 minutes, 9.2 +/- 3.9 minutes and 6.8 +/- 2.9 minutes, respectively, demonstrating a significant difference between Entropy and BIS (P = 0.023). Compared with standard practice, targeting an Entropy or BIS value of 50 did not result in a reduction of propofol consumption during general anaesthesia combined with regional anaesthesia as performed by an experienced anaesthesiologist in orthopaedic patients.

Forest farming of shiitake mushrooms: aspects of forced fruiting.

Three outdoor shiitake (Lentinula edodes (Berk.) Pegler) cultivation experiments were established during 2002-2004 at the University of Missouri Horticulture and Agroforestry Research Center, in central Missouri. Over three complete years following a year of spawn run, we examined shiitake mushroom production in response to the temperature of forcing water, inoculum strain, substrate host species and physical orientation of the log during fruiting. Forcing compressed the period of most productive fruiting to the two years following spawn run. Further, chilled forcing water, 10-12 degrees C, significantly enhanced yield, particularly when ambient air temperatures were favorable for the selected mushroom strain. The temperature of water available for force-fruiting shiitake logs depends on geographic location (latitude) and source (i.e., farm pond vs. spring or well water). Prospective growers should be aware of this effect when designing their management and business plans.

Forest farming of shiitake mushrooms: an integrated evaluation of management practices.

Two outdoor shiitake (Lentinula edodes) cultivation experiments, established in Missouri USA in 1999 and 2000, produced mushrooms in 2000-2005. We examined shiitake production in response to substrate species, inoculum form, inoculum strain, and inoculation timing, using total mushroom weight per log as the primary response variable with log characteristics as covariates. The significantly greater mushroom weight produced by sugar maple logs compared with white or northern red oak was attributable to the higher proportion of undiscolored wood volume in the maple logs, rather than to bark thickness or log diameter. The "wide temperature range" shiitake strain produced significantly greater yield compared with the "warm" or "cold" weather strains. Both the wide-range and warm-weather strains were stimulated to fruit by significant rain events, while the cold-weather strain was responsive to temperature. Inoculation with sawdust spawn gave significantly greater yield than colonized wooden dowels or pre-packaged "thimble" plug inoculum. The second and third full years following inoculation were the most productive.

[Target-controlled infusion. Clinical relevance and special features when using pharmacokinetic models]. / "Target-controlled infusion". Klinische Relevanz und Besonderheiten im Umgang mit pharmakokinetischen Modellen.

Since its commercial introduction in 1996, target-controlled infusion (TCI) has become an established technique for administration of intravenous anaesthetics. Modern TCI systems, however, are characterized by an increasing number of additional options and features, such as the choice between different pharmacokinetic models and modes of application, which may confuse the less experienced user. This review describes the differences between pharmacokinetic models, modes of application and the effect of covariates as well as the consequences for dosing. The aim is to explicate for the user of modern TCI systems the underlying scientific concepts and the relevance for clinical practice.

Soft tissue landmark for ultrasound identification of the sciatic nerve in the infragluteal region: the tendon of the long head of the biceps femoris muscle.

BACKGROUND AND OBJECTIVES: The sciatic nerve block represents one of the more difficult ultrasound-guided nerve blocks. Easy and reliable internal ultrasound landmarks would be helpful for localization of the sciatic nerve. Earlier, during ultrasound-guided posterior approaches to the infragluteal sciatic nerve, the authors recognized a hyperechoic structure at the medial border of the long head of biceps femoris muscle (BFL). The present study was performed to determine whether this is a potential internal landmark to identify the infragluteal sciatic nerve. METHODS: The depth and the thickness of this hyperechoic structure, its relationship with the sciatic nerve and the ultrasound visibility of both were recorded in the proximal upper leg of 21 adult volunteers using a linear ultrasound probe in the range of 7-13 MHz. The findings were verified by an anatomical study in two cadavers. RESULTS: The hyperechoic structure at the medial border of the BFL extended in a dorsoventral direction between 1.4+/-0.6 cm (mean+/-SD) and 2.8+/-0.8 cm deep from the surface, with a width of 2.2+/-0.9 mm. Between 2.6+/-0.9 and 10.0+/-1.5 cm distal to the subgluteal fold, the sciatic nerve was consistently identified directly at the ventral end of the hyperechoic structure in all volunteers. The anatomical study revealed that this hyperechoic structure corresponds to tendinous fibres inside and at the medial border of the BFL. CONCLUSION: The hyperechoic BFL tendon might be a reliable soft tissue landmark for ultrasound localization of the infragluteal sciatic nerve.

Real-time PCR detection and quantification of fish probiotic Phaeobacter strain 27-4 and fish pathogenic Vibrio in microalgae, rotifer, Artemia and first feeding turbot (Psetta maxima) larvae.

AIMS: To develop a SYBR Green quantitative real-time PCR protocol enabling detection and quantification of a fish probiotic and two turbot pathogenic Vibrio spp. in microcosms. METHODS AND RESULTS: Phaeobacter 27-4, Vibrio anguillarum 90-11-287 and Vibrio splendidus DMC-1 were quantified as pure and mixed cultures and in presence of microalgae (Isochrysis galbana), rotifers (Brachionus plicatilis), Artemia nauplii or turbot (Psetta maxima) larvae by real-time PCR based on primers directed at genetic loci coding for antagonistic and virulence-related functions respectively. The optimized protocol was used to study bioencapsulation and maintenance of the probiont and pathogens in rotifers and for the detection and quantification of Phaeobacter and V. anguillarum in turbot larvae fed rotifers loaded with the different bacteria in a challenge trial. CONCLUSIONS: Our real-time PCR protocol is reproducible and specific. The method requires separate standard curve for each host organism and can be used to detect and quantify probiotic Phaeobacter and pathogenic Vibrio bioencapsulated in rotifers and in turbot larvae. SIGNIFICANCE AND IMPACT OF THE STUDY: Our method allows monitoring and quantification of a turbot larvae probiotic bacteria and turbot pathogenic vibrios in in vivo trials and will be useful tools for detecting the bacteria in industrial rearing units.

Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography.

BACKGROUND: The sciatic nerve block by the posterior approaches represents one of the more difficult ultrasound-guided nerve blocks. Our clinical experiences with these blocks indicated a point slightly distal to the subgluteal fold as an advantageous position to allow good ultrasonic visibility. In this study, we systematically scanned the sciatic nerve from the subgluteal fold to the popliteal crease, to determine an optimal point for ultrasonographic visualization. METHODS: After institutional approval and written informed consent, we recruited 15 volunteers to visualize the sciatic nerve from the subgluteal fold to the popliteal crease using a linear ultrasound probe in the range of 7-13 MHz. The ultrasonographic visibility of the sciatic nerve, nerve diameter (width and thickness), and skin-to-nerve distance at 20 equidistant points between the subgluteal fold and the popliteal crease were recorded. RESULTS: The sciatic nerve could be successfully visualized in cross-section as a hyperechoic structure on ultrasound in all volunteers. In the course from subgluteal to the popliteal area, the shape of the sciatic nerve changed from flat to round, while the skin-nerve distance varied with the smallest skin-nerve distances at the popliteal crease and at 5.4 cm (on average) distal to the subgluteal fold. The best ultrasonographic visibility scores were found between 7.2 and 10.8 cm (on average) distal to the gluteal fold. CONCLUSION: Between 5.4 and 10.8 cm from the subgluteal fold seems to be the best area to scan the sciatic nerve in terms of superficial nerve position and good ultrasonic visibility.

A needle guidance device compared to free hand technique in an ultrasound-guided interventional task using a phantom.

In this in vitro study, a needle guidance device and a 'free hand' technique for ultrasound guided needle insertion were compared in a simulated ultrasound-guided interventional task using a porcine phantom. Residents inexperienced in using ultrasonography were asked to insert a needle, using an in-plane techniques, and to make contact with metal rods at a depth of 2 and 4 cm in the phantom. The transducer made angles of 90 degrees, 60 degrees and 45 degrees with the surface of the phantom. The times to perform the procedures were significantly shorter and the needle visualisation was significantly better when using the needle guidance device. The residents ranked their satisfaction with the needle-guidance device significantly better than the 'free-hand' technique. This device may be beneficial when performing ultrasound guided peripheral nerve blocks, especially by inexperienced operators.

[Target-controlled infusion (TCI) - a concept with a future?: state-of-the-art, treatment recommendations and a look into the future]. / "Target controlled infusion" (TCI) - ein Konzept mit Zukunft?: Standortbestimmung, Handlungsempfehlungen und Blick in die Zukunft.

Over the last 10 years the technique of target-controlled infusion (TCI) has substantially influenced the development and practice of intravenous anaesthesia. It opened the possibility of many new and exciting applications of perioperative anaesthetic care. More recent and current developments, such as open TCI (target-controlled infusion) and the availability of generic anaesthetic agents combined with modern infusion pumps, means that TCI can become a standard procedure in anaesthesia and is no longer just a research tool for specialists and enthusiasts. This review explains the fundamentals and applications of intravenous drug delivery by TCI and gives practice guidelines to successfully implement the technique into clinical practice. The aim is to provide a comprehensive reference based on clinically proven evidence.

Inferences on the phylogeography of the fungal pathogen Heterobasidion annosum, including evidence of interspecific horizontal genetic transfer and of human-mediated, long-range dispersal.

Fungi in the basidiomycete species complex Heterobasidion annosum are significant root-rot pathogens of conifers throughout the northern hemisphere. We utilize a multilocus phylogenetic approach to examine hypotheses regarding the evolution and divergence of two Heterobasidion taxa associated with pines: the Eurasian H. annosum sensu stricto and the North American H. annosum P intersterility group (ISG). Using DNA sequence information from portions of two nuclear and two mitochondrial loci, we infer phylogenetic relationships via parsimony, Bayesian and median-joining network analysis. Analysis of isolates representative of the entire known geographic range of the two taxa results in monophyletic sister Eurasian and North American lineages, with North America further subdivided into eastern and western clades. Genetically anomalous isolates from the Italian presidential estate of Castelporziano are always part of a North American clade and group with eastern North America, upholding the hypothesis of recent, anthropogenically mediated dispersal. P ISG isolates from Mexico have phylogenetic affinity with both eastern and western North America. Results for an insertion in the mitochondrial rDNA suggest this molecule was obtained from the Heterobasidion S ISG, a taxon sympatric with the P ISG in western North America. These data are compatible with an eastern Eurasian origin of the species, followed by dispersal of two sister taxa into western Eurasia and into eastern North America over a Beringean land bridge, a pattern echoed in the phylogeography of other conifer-associated basidiomycetes.

[Pharmacokinetic-pharmacodynamic models for inhaled anaesthetics]. / Pharmakokinetische/pharmakodynamische Modelle für Inhalationsanästhetika.

Pharmacokinetic models can be differentiated into two groups: physiological-based models and empirical models. Traditionally the pharmacokinetics of volatile anaesthetics are described using physiological-based models together with the respective tissue-blood distribution coefficients. The compartments of the empirical model have no anatomical equivalents and are merely the product of the mathematical procedure for parameter estimation. The end expiratory concentration of volatile anaesthetics is approximately equal to the arterial concentration and, therefore, the description of the transition between plasma and effect site for volatile anaesthetics plays a central role. The most important parameter here is the k(e0) value which is a time constant and describes the time delay for the transition from the central compartment to the calculated effect compartment. The k(e0) values for sevoflurane and isoflurane are the same but the concentration balance between the end-tidal concentration and the effect compartment occurs twice as quickly with desflurane. In clinical practice volatile anaesthetics are normally combined with N(2)O and/or opioids. This results in an additive interaction between volatile anaesthetics and N(2)O but a synergistic interaction of volatile anaesthetics with opioids. However, there are relatively few investigations on the interactions between the clinically widely used combination of volatile anaesthetics, N(2)O and opioids.

Profiling acylated homoserine lactones in Yersinia ruckeri and influence of exogenous acyl homoserine lactones and known quorum-sensing inhibitors on protease production.

AIMS: To profile the quorum-sensing (QS) signals in Yersinia ruckeri and to examine the possible regulatory link between QS signals and a typical QS-regulated virulence phenotype, a protease. METHODS AND RESULTS: Liquid chromatography-high resolution mass spectrometry (HPLC-HRMS) showed that Y. ruckeri produced at least eight different acylated homoserine lactones (AHLs) with N-(3-oxooctanoyl)-L-homoserine lactone (3-oxo-C8-HSL) being the dominant molecule. Also, some uncommon AHL, N-(3-oxoheptanoyl)-L-homoserine lactone (3-oxo-C7-HSL) and N-(3-oxononanoyl)-L-homoserine lactone (3-oxo-C9-HSL), were produced. 3-oxo-C8-HSL was detected in organs from fish infected with Y. ruckeri. Protease production was significantly lower at temperatures above 23 degrees C than below although growth was faster at the higher temperatures. Neither addition of sterile filtered high-density Y. ruckeri culture supernatant nor the addition of pure exogenous AHLs induced protease production. Furthermore, three QS inhibitors (QSIs), sulfur-containing AHL analogues, did not inhibit protease production in Y. ruckeri. CONCLUSIONS: Exogenous AHL or sulfur-containing AHL analogues did not influence the protease production indicating that protease production may not be QS regulated in Y. ruckeri. SIGNIFICANCE AND IMPACT OF THE STUDY: The array of different AHLs produced indicates that the QS system of Y. ruckeri is complex and could involve several regulatory systems. In this case, neither AHLs nor QSI would be likely to directly affect a QS-regulated phenotype.