Coupling remote sensing and eDNA to monitor environmental impact: A pilot to quantify the environmental benefits of sustainable agriculture in the Brazilian Amazon.

Monitoring is essential to ensure that environmental goals are being achieved, including those of sustainable agriculture. Growing interest in environmental monitoring provides an opportunity to improve monitoring practices. Approaches that directly monitor land cover change and biodiversity annually by coupling the wall-to-wall coverage from remote sensing and the site-specific community composition from environmental DNA (eDNA) can provide timely, relevant results for parties interested in the success of sustainable agricultural practices. To ensure that the measured impacts are due to the environmental projects and not exogenous factors, sites where projects have been implemented should be benchmarked against counterfactuals (no project) and control (natural habitat) sites. Results can then be used to calculate diverse sets of indicators customized to monitor different projects. Here, we report on our experience developing and applying one such approach to assess the impact of shaded cocoa projects implemented by the Instituto de Manejo e Certificação Florestal e Agrícola (IMAFLORA) near São Félix do Xingu, in Pará, Brazil. We used the Continuous Degradation Detection (CODED) and LandTrendr algorithms to create a remote sensing-based assessment of forest disturbance and regeneration, estimate carbon sequestration, and changes in essential habitats. We coupled these remote sensing methods with eDNA analyses using arthropod-targeted primers by collecting soil samples from intervention and counterfactual pasture field sites and a control secondary forest. We used a custom set of indicators from the pilot application of a coupled monitoring framework called TerraBio. Our results suggest that, due to IMAFLORA's shaded cocoa projects, over 400 acres were restored in the intervention area and the community composition of arthropods in shaded cocoa is closer to second-growth forests than that of pastures. In reviewing the coupled approach, we found multiple aspects worked well, and we conclude by presenting multiple lessons learned.

Needle echogenicity in sonographically guided regional anesthesia: blinded comparison of 4 enhanced needles and validation of visual criteria for evaluation.

OBJECTIVES: Needle visualization is important for sonographically guided regional anesthesia procedures. Needle characteristics that improve needle visualization are therefore important to anesthesiologists. This study compared several echogenic needle designs by defining characteristics of needle echogenicity and assessing regional anesthesiologist preferences for these characteristics across various needle angles. METHODS: Twelve blinded regional anesthesiologists graded 5 randomized block needles (1 nonechogenic control and 4 echogenic) on 4 predefined characteristics (overall brightness of the needle, overall clarity of the needle, brightness of the needle tip, and clarity of the needle tip). In-plane needle images in a gel phantom were obtained at 4 needle angles (15°, 30°, 45°, and 60°). Participants rated specific needle characteristics for each needle at each angle and then ranked their overall needle preferences. RESULTS: Significant differences in all 4 needle characteristics were found across needle types (P< .01). Clarity of the needle tip was significantly associated with overall needle rank (P = .009). Other needle visualization characteristics were not significantly correlated with needle rank. The SonoPlex Stim needle (Pajunk Medical Systems, Tucker, GA) was rated highest in all 4 predefined needle characteristics as well as overall needle rank. CONCLUSIONS: This study shows that anesthesiologists prefer certain visual characteristics of needles used in sonographically guided regional anesthesia procedures. Specifically, needle tip clarity most closely predicted clinician needle preferences. These results support the idea that all echogenic needle designs do not uniformly enhance needle visualization. Further studies are needed to determine whether needles with superior tip clarity predict not only clinician preferences but also improved sonographically guided regional anesthetic outcomes.

Role of regional anesthesia in the ambulatory environment.

The use of local anesthetics in ambulatory surgery offers multiple benefits in line with the goals of modern-day outpatient surgery. A variety of regional techniques can be used for a wide spectrum of procedures; all are shown to reduce postprocedural pain; reduce the short-term need for opiate medications; reduce adverse effects, such as nausea and vomiting; and reduce the time to dismissal compared with patients who do not receive regional techniques. Growth in ambulatory procedures will likely continue to rise with future advances in surgical techniques, changes in reimbursement, and the evolution of clinical pathways that include superior, sustained postoperative analgesia. Anticipating these changes in practice, the role of, and demand for, regional anesthesia in outpatient surgery will continue to grow.

Urethral injury during potassium-titanyl-phosphate laser prostatectomy complicated by transurethral resection syndrome.

The green light potassium-titanyl-phosphate laser photoselective vaporization of the prostate is the latest modality for treatment of benign prostatic obstruction. Because of effective superficial tissue coagulation, intravascular absorption of fluid is minimal; therefore, development of transurethral resection syndrome is unlikely. To our knowledge, this is the first report of a patient undergoing photoselective vaporization of the prostate who developed full-blown transurethral resection syndrome because of intravascular absorption of sterile water. Absorption of hypotonic irrigant presumably occurred through the injury induced during insertion of the laser cystoscope.

Status epilepticus and intrathecal fluorescein: anesthesia providers beware.

Fluorescein is a fluorochrome dye occasionally administered by intrathecal injection to identify and localize cerebrospinal fluid leaks. Although generally considered to be a benign intervention, intrathecal administration of fluorescein has resulted in adverse events. We report a case of status epilepticus after intrathecal administration of fluorescein. Anesthesia providers should be aware of complications associated with intrathecal fluorescein use and be prepared to manage neurologic complications during the perioperative period.

Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training.

Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.

A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery.

BACKGROUND AND OBJECTIVES: Patients undergoing major orthopedic surgery experience significant postoperative pain. Failure to provide adequate analgesia may impede early physical therapy and rehabilitation, which are important factors for maintaining joint range of motion and facilitating hospital dismissal. We examined the effect of a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block in patients undergoing total hip (THA) and total knee (TKA) arthroplasty. Perioperative outcomes and major postoperative complications were evaluated. METHODS: One hundred consecutive patients undergoing primary or revision THA or TKA using the Mayo Clinic Total Joint Regional Anesthesia (TJRA) protocol were retrospectively reviewed. The TJRA protocol is a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block that was jointly developed by the Departments of Anesthesiology and Orthopedic Surgery. Identified patients were matched 1:1 with historical controls undergoing identical surgical procedures with traditional anesthetic techniques. Matching criteria included patient age, gender, surgeon, date of surgery, and American Society of Anesthesiologists physical status. Patient demographics, preoperative joint range of motion, and anesthetic management were recorded for each patient. The primary study outcome was hospital length of stay. Secondary outcome variables included time to ambulation, joint range of motion, and discharge eligibility. Postoperative verbal analog pain scores (VAS), opioid requirements, side effects, and perioperative complications were also documented. RESULTS: One hundred patients underwent THA or TKA using the newly implemented Mayo Clinic TJRA protocol. Matched controls (n = 100) received intravenous patient-controlled analgesia with subsequent conversion to oral analgesics for postoperative pain management. TJRA patients had significantly shorter hospital lengths of stay (3.8 days v 5.0 days; P < .001), achieved discharge eligibility significantly sooner (1.7 +/- 1.9 days earlier; P < .0001), and had improved joint range of motion (90 degrees v 85 degrees ; P = .008) when compared with matched controls. TJRA patients had significantly improved postoperative analgesia, including lower VAS pain scores (postoperative day 0 through postoperative day 3; P < .001), and lower opioid requirements (postoperative day 0 to postoperative day 2; P = .04). Adverse outcomes such as postoperative urinary retention (50% v 31%; P < .001), and ileus formation (7% v 1%; P = .01) occurred more frequently among control patients. CONCLUSIONS: Patients undergoing THA or TKA using a comprehensive, pre-emptive, multimodal analgesic regimen emphasizing peripheral nerve block may have significantly improved perioperative outcomes, and fewer adverse events, when compared with patients receiving traditional intravenous opioids during the initial postoperative period. Improved perioperative outcomes include a shortened hospital length of stay, and a significant reduction in postoperative urinary retention and ileus formation.

Epidural analgesia improves early rehabilitation after total knee replacement.

STUDY OBJECTIVE: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement. DESIGN: Randomized prospective study. SETTING: Tertiary care, academic medical center. PATIENTS: Thirty-eight patients scheduled for total knee replacement. INTERVENTIONS: Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200,000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis. MEASUREMENTS: Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05. MAIN RESULTS: All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention. CONCLUSION: By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.

The use of peripheral nerve blocks at the elbow for carpal tunnel release.

This case report illustrates that median, radial, and ulnar nerve blocks at the elbow provides anesthesia for ambulatory carpal tunnel release surgery. This report discusses 3 patients with medical conditions, including vascular access problems and morbid obesity, which made nerve blocks at the elbow advantageous compared with other anesthetic techniques. Peripheral nerve blocks at the elbow were done before surgery in a block room, so the patients spent less time in the operating room. Nerve blocks at the elbow are effective anesthesia for hand procedures with no patient requiring further local anesthetic injection and opioids for pain or expressing any discomfort during surgery. The blocks are easy to perform and set up quickly, and using long-acting local anesthetics, elbow blocks provide postoperative pain control for approximately 10 hours. The nerve blocks at the elbow facilitate the perioperative process by being done out of the operating room and providing prolonged pain control without the need for opioids, so nausea may be avoided.

Remifentanil provides better analgesia than alfentanil during breast biopsy surgery under monitored anesthesia care.

PURPOSE: To compare the analgesic effects of remifentanil and alfentanil during breast biopsy under monitored anesthesia care (MAC). METHODS: Sixty patients received sedation with propofol (50 microg.kg(-1).min(-1)). After receiving a loading dose of opioid (either remifentanil 0.5 microg.kg(-1), or alfentanil 2.5 microg.kg(-1)), an infusion was initiated (remifentanil 0.05 microg.kg(-1).min(-1) or alfentanil 0.25 microg.kg(-1).min(-1)), and this was supplemented with local anesthetic infiltration. The pain was evaluated with a ten-point visual analogue scale (VAS) during local anesthetic infiltration and deep tissue dissection. Inadequate analgesia, defined as VAS scores > or = 5, was treated first with boluses of opioid (remifentanil group 10 microg or alfentanil group 50 microg) and if inadequate after two treatments with additional local anesthetic. Postoperative times were recorded including the times until discharge criteria were achieved and patient's actual discharge. RESULTS: The pain scores were similar between the two groups during the initial injections of local anesthetic in the breast, however, patients in the remifentanil group had lower mean pain scores during deep tissue dissection (2.3 vs 4.3, P < 0.01). Patients in the remifentanil group required fewer rescue doses of opioid (1.9 vs 3.6, P < 0.03) and local anesthetic (5 vs 15, P < 0.006). The two study groups had comparable speed of recovery. CONCLUSION: Remifentanil was a better opioid choice than alfentanil for breast biopsy under MAC at the doses studied, but it did not increase the rapidity in which patients recovered postoperatively.

Octreotide-induced bradycardia and heart block during surgical resection of a carcinoid tumor.

UNLABELLED: Octreotide may be a life-saving treatment in the case of an acute carcinoid crisis, but when given as an i.v. bolus in larger doses, it may cause significant effects on the cardiac conduction system. We describe cardiac conduction impairment observed during octreotide administration in a patient undergoing carcinoid tumor surgery. In this patient, i.v. boluses of 100 microg of octreotide resulted in symptomatic bradycardia, Mobitz type II atrioventricular block, and complete heart block. Perioperative physicians especially need to be aware of these potential effects because they may be more likely to occur during surgery because of the larger doses and boluses that are used to treat acute symptoms secondary to tumor manipulation. IMPLICATIONS: In some susceptible patients, i.v. bolus administration of octreotide may cause significant bradycardia and cardiac conduction defects. Therefore, when octreotide is administered as a bolus, it may be advisable to give it slowly while monitoring the electrocardiogram.

Use of WuScope for exchange of endotracheal tube in a patient with difficult airway.

OBJECTIVE: To describe a method for the exchange of a defective endotracheal tube using the WuScope in patients with difficult airways who cannot tolerate interrupted ventilation. STUDY DESIGN: Case report. METHODS: Detailed description of proposed modality for the endotracheal tube exchange. RESULTS: Exchanging a defective endotracheal tube in patients with a "difficult airway" and compromised oxygenation can be a challenging task. Performing fiberoptic visualization with the WuScope and using a "double intubation" technique may be an acceptable method for endotracheal tube exchange in some clinical situations. CONCLUSION: By using our technique the exchange of an endotracheal tube in a patient with a difficult airway may be achieved without interrupting the ventilation.

Thin films of block copolymer blends for enhanced performance of acoustic wave-based chemical sensors.

The performance of quartz crystal oscillator-based volatile organic compound (VOC) sensors has been enhanced by using coatings made from poly(styrene-block-ethylene-co-butylene-block-styrene) block copolymers blended with resins and homopolymers. Enhanced performance is characterized by a wider operational temperature range (-10 to +50 degrees C) over which the sensors displayed, concurrently, an analyte sensitivity of >0.2 Hz/ppm toluene, minimal energy loss (resistance <120 ohms), and response times of <20 min (time required to reach 90% of full response). Atomic force microscopy images are consistent with a process in which the additive associates with the polystyrene portions of the microphase-separated block copolymer. This association reinforces the rigidity of the polystyrene network while allowing the rapid uptake of VOCs by the softer polyethylene/butylene phase.