Intraoperative hemodialysis with supra- and infradiaphragmatic catheters for liver transplantation.

PURPOSE: The benefits of intraoperative dialysis during orthotopic liver transplantation remain controversial. In patients with anuric renal failure and portopulmonary hypertension, maintaining venous return during caval clamping and unclamping along with minimizing fluid overload is critical to avoiding right ventricular strain and failure. CLINICAL FEATURES: We present the case of a 54-yr-old female who underwent orthotopic liver transplantation for alcohol-related liver disease with acute decompensation including severe hepatorenal syndrome (anuric requiring dialysis), probable hepatopulmonary syndrome, moderate pulmonary hypertension (right ventricular systolic pressure, 44 mm Hg), hepatic encephalopathy (grade 2), and esophageal varices. Prior to incision, pulmonary arterial pressures were 48/28 (mean, 35) mm Hg with a central venous pressure of 30 mm Hg, cardiac output of 7.4 L·min-1, and pulmonary vascular resistance of 98 dynes·sec·cm-5. In the context of right ventricular strain and volume overload observed on transthoracic echocardiography, we inserted an additional dialysis catheter into the right femoral vein. We initiated dialysis using the two catheters as a circuit (femoral line to the dialysis machine; blood was reinjected via the subclavian line) acting as a limited venovenous bypass, allowing right ventricular offloading and hemodialysis throughout the case. We removed 4.5 L via hemodialysis during the surgery, while avoiding acidosis, hyperkalemia, and sodium shifts. The patient tolerated reperfusion adequately despite pre-existing right ventricular dilation and dysfunction. CONCLUSION: We report on the use two hemodialysis catheters in a patient undergoing orthotopic liver transplantation as a circuit for simultaneous anuric hepatorenal syndrome and moderate pulmonary hypertension with right ventricular dilation and dysfunction. We believe this technique was instrumental in the patient's successful transplant.

RéSUMé: OBJECTIF: Les avantages de la dialyse peropératoire pendant une transplantation hépatique orthotopique demeurent controversés. Chez la patientèle atteinte d'insuffisance rénale anurique et d'hypertension portopulmonaire, il est essentiel de maintenir le retour veineux pendant le clampage et le déclampage de la veine cave ainsi que de minimiser la surcharge hydrique, afin d'éviter la déformation et l'insuffisance ventriculaires droites. CARACTéRISTIQUES CLINIQUES : Nous présentons le cas d'une femme de 54 ans qui a bénéficié d'une transplantation hépatique orthotopique pour une maladie hépatique liée à l'alcool avec une décompensation aiguë comprenant un syndrome hépatorénal sévère (anurie nécessitant une dialyse), un syndrome hépatopulmonaire probable, une hypertension pulmonaire modérée (pression systolique ventriculaire droite, 44 mm Hg), une encéphalopathie hépatique (grade 2) et des varices œsophagiennes. Avant l'incision, les pressions artérielles pulmonaires étaient de 48/28 (moyenne, 35) mm Hg avec une pression veineuse centrale de 30 mm Hg, un débit cardiaque de 7,4 L·min−1 et une résistance vasculaire pulmonaire de 98 dynes·sec·cm−5. Dans le contexte de la déformation ventriculaire et de la surcharge volémique droites observées à l'échocardiographie transthoracique, nous avons inséré un cathéter de dialyse supplémentaire dans la veine fémorale droite. Nous avons amorcé la dialyse en créant un circuit avec les deux cathéters (ligne fémorale en direction de l'appareil de dialyse; sang réinjecté via la ligne sous-clavière) agissant comme un pontage veino-veineux limité, permettant la décharge du ventricule droit et l'hémodialyse tout au long du cas. Nous avons retiré 4,5 L par hémodialyse pendant la chirurgie, tout en évitant l'acidose, l'hyperkaliémie et les changements en sodium plasmatique. La patiente a toléré la reperfusion de manière adéquate malgré la dilatation et le dysfonctionnement préexistants du ventricule droit. CONCLUSION: Nous rapportons l'utilisation de deux cathéters d'hémodialyse pour créer un circuit chez une patiente bénéficiant d'une transplantation hépatique orthotopique pour le traitement d'un syndrome hépatorénal anurique simultané à une hypertension pulmonaire modérée avec dilatation et dysfonctionnement du ventricule droit. Nous pensons que cette technique a joué un rôle déterminant dans la réussite de la greffe chez la patiente.

The fasciola cinereum of the hippocampal tail as an interventional target in epilepsy.

Targeted tissue ablation involving the anterior hippocampus is the standard of care for patients with drug-resistant mesial temporal lobe epilepsy. However, a substantial proportion continues to suffer from seizures even after surgery. We identified the fasciola cinereum (FC) neurons of the posterior hippocampal tail as an important seizure node in both mice and humans with epilepsy. Genetically defined FC neurons were highly active during spontaneous seizures in epileptic mice, and closed-loop optogenetic inhibition of these neurons potently reduced seizure duration. Furthermore, we specifically targeted and found the prominent involvement of FC during seizures in a cohort of six patients with epilepsy. In particular, targeted lesioning of the FC in a patient reduced the seizure burden present after ablation of anterior mesial temporal structures. Thus, the FC may be a promising interventional target in epilepsy.

Touch-screen automatisms in the digital age.

OBJECTIVE: To describe a novel set of gestural automatisms related to the use of digital screens on smartphones and tablets in patients with epilepsy. METHODS: Representative patients were selected from among those admitted to the Epilepsy Monitoring Unit at the Toronto Western Hospital between April 2016 and January 2020, and included if they exhibited automatisms clearly related to or mimicking digital device use. RESULTS: In total 5 patients were included, 4 female. All had temporal lobe epilepsy: 2 had left mesial temporal sclerosis and 3 had normal imaging. Nearly equal numbers of seizures began with right (5/9) and left (4/9) temporal onsets, with most automatisms occurring after seizure propagation to bilateral temporal involvement (6/9). Left-handed automatisms were most common (8/9). The majority of the automatisms (7/9) were perseverative on device usage prior to the seizure. CONCLUSION: Gestural automatisms appear related to the contemporary lived experience, culture, and habitual behaviour of patients with epilepsy. In the modern era, the use of smartphones and tablets are both common and habitual for many, and this case series shows that touch-screen automatisms may be added to the semiological panoply of temporal lobe seizures.

Multisite thalamic recordings to characterize seizure propagation in the human brain.

Neuromodulation of the anterior nuclei of the thalamus (ANT) has shown to be efficacious in a subset of patients with refractory focal epilepsy. One important uncertainty is to what extent thalamic subregions other than the ANT could be recruited more prominently in the propagation of focal onset seizures. We designed the current study to simultaneously monitor the engagement of the ANT, mediodorsal (MD) and pulvinar (PUL) nuclei during seizures in patients who could be candidates for thalamic neuromodulation. We studied 11 patients with clinical manifestations of presumed temporal lobe epilepsy (TLE) undergoing invasive stereo-encephalography (sEEG) monitoring to confirm the source of their seizures. We extended cortical electrodes to reach the ANT, MD and PUL nuclei of the thalamus. More than one thalamic subdivision was simultaneously interrogated in nine patients. We recorded seizures with implanted electrodes across various regions of the brain and documented seizure onset zones (SOZ) in each recorded seizure. We visually identified the first thalamic subregion to be involved in seizure propagation. Additionally, in eight patients, we applied repeated single pulse electrical stimulation in each SOZ and recorded the time and prominence of evoked responses across the implanted thalamic regions. Our approach for multisite thalamic sampling was safe and caused no adverse events. Intracranial EEG recordings confirmed SOZ in medial temporal lobe, insula, orbitofrontal and temporal neocortical sites, highlighting the importance of invasive monitoring for accurate localization of SOZs. In all patients, seizures with the same propagation network and originating from the same SOZ involved the same thalamic subregion, with a stereotyped thalamic EEG signature. Qualitative visual reviews of ictal EEGs were largely consistent with the quantitative analysis of the corticothalamic evoked potentials, and both documented that thalamic nuclei other than ANT could have the earliest participation in seizure propagation. Specifically, pulvinar nuclei were involved earlier and more prominently than ANT in more than half of the patients. However, which specific thalamic subregion first demonstrated ictal activity could not be reliably predicted based on clinical semiology or lobar localization of SOZs. Our findings document the feasibility and safety of bilateral multisite sampling from the human thalamus. This may allow more personalized thalamic targets to be identified for neuromodulation. Future studies are needed to determine if a personalized thalamic neuromodulation leads to greater improvements in clinical outcome.

Attributable Perioperative Cost of Frailty after Major, Elective Noncardiac Surgery: A Population-based Cohort Study.

BACKGROUND: Patients with frailty consistently experience higher rates of perioperative morbidity and mortality; however, costs attributable to frailty remain poorly defined. This study sought to identify older patients with and without frailty using a validated, multidimensional frailty index and estimated the attributable costs in the year after major, elective noncardiac surgery. METHODS: The authors conducted a retrospective population-based cohort study of all patients 66 yr or older having major, elective noncardiac surgery between April 1, 2012, and March 31, 2018, using linked health data obtained from an independent research institute (ICES) in Ontario, Canada. All data were collected using standard methods from the date of surgery to the end of 1-yr follow-up. The presence or absence of preoperative frailty was determined using a multidimensional frailty index. The primary outcome was total health system costs in the year after surgery using a validated patient-level costing method capturing direct and indirect costs. Secondary outcomes included costs to postoperative days 30 and 90 along with sensitivity analyses and evaluation of effect modifiers. RESULTS: Of 171,576 patients, 23,219 (13.5%) were identified with preoperative frailty. Unadjusted costs were higher among patients with frailty (ratio of means 1.79, 95% CI 1.76 to 1.83). After adjusting for confounders, an absolute cost increase of $11,828 Canadian dollar (ratio of means 1.53; 95% CI, 1.51 to 1.56) was attributable to frailty. This association was attenuated with additional control for comorbidities (ratio of means 1.24, 95% CI, 1.22 to 1.26). Among contributors to total costs, frailty was most strongly associated with increased postacute care costs. CONCLUSIONS: For patients with preoperative frailty having elective surgery, the authors estimate that attributable costs are increased 1.5-fold in the year after major, elective noncardiac surgery. These data inform resource allocation for patients with frailty.

Transcranial direct current stimulation for focal status epilepticus or lateralized periodic discharges in four patients in a critical care setting.

OBJECTIVE: Transcranial direct current stimulation (tDCS) has been advocated for various neurological conditions, including epilepsy. A 1-4-mA cathodal current applied to the scalp over a seizure focus can reduce spikes and seizures. This series of four patients with focal status epilepticus is among the first case series to demonstrate benefit of tDCS in the critical care setting. METHODS: Patients in the intensive care unit were referred for tDCS treatment when focal status epilepticus or clinically relevant lateralized periodic discharges did not resolve with conventional antiseizure medications and anesthetics. Battery-powered direct cathodal current at 2 mA was delivered by an ActivaDose (Caputron) tDCS device via a saline-soaked sponge on the scalp over the seizure focus. Anode was on the contralateral forehead or shoulder. Treatment was for 30 min, repeated twice in a day, then again 1-4 times more over the next few days. RESULTS: Three females and one male, aged 34-68 years, were treated. Etiologies of status epilepticus were posterior reversible encephalopathy syndrome in association with immunosuppressants for a liver transplant, perinatal hypoxic-ischemic injury, a prior cardioembolic parietal stroke, and central nervous system lupus. tDCS led to significant reduction of interictal spikes (.78 to .38/s, p < .0001) in three cases and electrographic seizures (3.83/h to 0/h, p < .001) in two cases. Medication reductions were enabled in all cases subsequent to tDCS. The only side effect of tDCS was transient erythema under the sponge in one case. Two patients died of causes unrelated to tDCS, one was discharged to a nursing home, and one became fully responsive as seizures were controlled with tDCS. SIGNIFICANCE: Spikes and electrographic seizure frequency significantly improved within 1 day of tDCS. Results are potentially confounded by multiple ongoing changes in medications and treatments. These results might encourage further investigation of tDCS in the critical care setting, but verification by controlled studies will be required.

Precision medicine in epilepsy.

Epilepsy is a common neurological disorder affecting over 50 million people worldwide. Although more than 20 new anti-seizure medications have been developed in the past three decades, about one-third of patients still experience recurrent seizures. The heterogeneity of epilepsy types and the highly variable inter-individual response to the therapies makes disease management challenging. A precision medicine approach of treatment for epilepsy patients that considers individual patient characteristics has long been advocated. With advances in DNA sequencing technology, it has been estimated than >30% of all epilepsy syndromes have genetic components. Here we summarize recent approaches in genetic testing and current personalized treatments that are already applicable in genetic epilepsy syndromes. We also discuss current precision therapy utilized in personalized pharmacogenomics, as well as tailored treatment with neuromodulation for epilepsy patients. In the near future, we envision precision medicine in epilepsy will be applicable on a large scale involving not only targeted therapies, but also diagnosis, prognosis, and comorbidity management.

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study.

BACKGROUND: Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS: After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS: Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS: Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Frame-based versus frameless stereotactic brain biopsies: A systematic review and meta-analysis.

BACKGROUND: Stereotactic brain biopsy techniques have been a focus of rapid technological innovation. The recent advent of frameless stereotaxy has invited the question of whether it can provide the same diagnostic yield as frame-based techniques, without increasing risk of harm to patients. The goal of this meta-analysis was to compare each of these techniques in terms of yield and safety. METHODS: We independently searched four databases for English studies comparing frameless and frame-based stereotactic brain biopsies. Our primary outcome was biopsy diagnostic yield. Our secondary outcomes included mortality, morbidity (e.g., symptomatic postbiopsy intracranial hemorrhage, asymptomatic postbiopsy intracranial hemorrhage, new postbiopsy neurological deficit, and postbiopsy seizure), and frequency of repeat biopsy. We calculated pooled estimates and relative risks for dichotomous outcomes using Review Manager 5.3, with corresponding 95% confidence intervals. RESULTS: A total of 3256 stereotactic brain biopsies (2050 frame based and 1206 frameless), from 20 studies, were included in our final analysis. The results did not demonstrate any significant difference between the two stereotactic systems in terms of diagnostic yield (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.99-1.02, P = 0.64, I2 = 0%). The only significant difference was the increased frequency of asymptomatic hemorrhages in the frameless group (RR 1.37, 95% CI 1.06-1.75, P = 0.01, I2 = 0%). Application of Grading of Recommendations Assessment, Development, and Evaluation to the results yielded very low quality of all outcomes. CONCLUSION: Based on very low-quality evidence, both frame-based and frameless stereotaxy are safe and effective for biopsy of intracranial tumors. Further study of patient preference and cost comparing analysis is required to identify if either modality should be preferred.

Surrogate Humane Endpoints in Small Animal Models of Acute Lung Injury: A Modified Delphi Consensus Study of Researchers and Laboratory Animal Veterinarians.

OBJECTIVES: In many jurisdictions, ethical concerns require surrogate humane endpoints to replace death in small animal models of acute lung injury. Heterogenous selection and reporting of surrogate endpoints render interpretation and generalizability of findings between studies difficult. We aimed to establish expert-guided consensus among preclinical scientists and laboratory animal veterinarians on selection and reporting of surrogate endpoints, monitoring of these models, and the use of analgesia. DESIGN: A three-round consensus process, using modified Delphi methodology, with researchers who use small animal models of acute lung injury and laboratory animal veterinarians who provide care for these animals. Statements on the selection and reporting of surrogate endpoints, monitoring, and analgesia were generated through a systematic search of MEDLINE and Embase. Participants were asked to suggest any additional potential statements for evaluation. SETTING: A web-based survey of participants representing the two stakeholder groups (researchers, laboratory animal veterinarians). Statements were rated on level of evidence and strength of support by participants. A final face-to-face meeting was then held to discuss results. SUBJECTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-two statements were evaluated, and 29 were rated as important, with varying strength of evidence. The majority of evidence was based on rodent models of acute lung injury. Endpoints with strong support and evidence included temperature changes and body weight loss. Behavioral signs and respiratory distress also received support but were associated with lower levels of evidence. Participants strongly agreed that analgesia affects outcomes in these models and that none may be necessary following nonsurgical induction of acute lung injury. Finally, participants strongly supported transparent reporting of surrogate endpoints. A prototype composite score was also developed based on participant feedback. CONCLUSIONS: We provide a preliminary framework that researchers and animal welfare committees may adapt for their needs. We have identified knowledge gaps that future research should address.

Physiological factors characterizing heat-vulnerable older adults: A narrative review.

More frequent and intense periods of extreme heat (heatwaves) represent the most direct challenge to human health posed by climate change. Older adults are particularly vulnerable, especially those with common age-associated chronic health conditions (e.g., cardiovascular disease, hypertension, obesity, type 2 diabetes, chronic kidney disease). In parallel, the global population is aging and age-associated disease rates are on the rise. Impairments in the physiological responses tasked with maintaining homeostasis during heat exposure have long been thought to contribute to increased risk of health disorders in older adults during heatwaves. As such, a comprehensive overview of the provisional links between age-related physiological dysfunction and elevated risk of heat-related injury in older adults would be of great value to healthcare officials and policy makers concerned with protecting heat-vulnerable sectors of the population from the adverse health impacts of heatwaves. In this narrative review, we therefore summarize our current understanding of the physiological mechanisms by which aging impairs the regulation of body temperature, hemodynamic stability and hydration status. We then examine how these impairments may contribute to acute pathophysiological events common during heatwaves (e.g., heatstroke, major adverse cardiovascular events, acute kidney injury) and discuss how age-associated chronic health conditions may exacerbate those impairments. Finally, we briefly consider the importance of physiological research in the development of climate-health programs aimed at protecting heat-vulnerable individuals.

Logging in: a comparative analysis of electronic health records versus anesthesia resident-driven logbooks.

PURPOSE: Resident logbooks (RLBs) documenting clinical case exposure are widespread in medical education despite evidence of poor accuracy. Electronic health records (e.g., anesthesia information management systems [AIMS]) may provide advantages for auditing longitudinal case exposure. We evaluated the agreement between AIMS and RLBs for tracking case exposure during anesthesiology residency. METHODS: We performed a historical cohort study with anesthesiology residents (2011-2018, all of whom used a RLB contemporaneously with AIMS) working in a multisite academic health sciences network. The primary outcome was total case-load logging; secondary outcomes were volumes for seven surgical specialties (general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery). Correlation of case numbers tracked by AIMS vs RLB was assessed using Pearson correlation; agreement was determined using Bland-Altman plots and intraclass correlation coefficients (ICC). RESULTS: Data from 27 anesthesiology residents were collected. Overall, mean (standard deviation) case numbers were generally greater with AIMS vs RLB [649 (103) vs 583 (191); P = 0.049). Total case volumes between systems had moderate correlation (r = 0.50) and agreement (intraclass correlation coefficient [ICC], 0.42; 95% CI, 0.34 to 0.59). Bland-Altman plots showed variable agreement between AIMS and RLB data [mean (SD) bias = 66 (166) cases]. For general, gynecology, neuro, orthopedic, thoracic, urology, and vascular surgery, there was a range of poor to moderate agreement (ICC, 0.23-0.57) between AIMS and RLB. CONCLUSION: For anesthesiology resident case-logging, the number of cases logged in an AIMS was higher with lower variance compared with RLBs. Anesthesia information management systems vs RLB data showed low-moderate correlation and agreement. Given the additional time and resources required for RLBs, AIMS may be a superior method for tracking cases where available.

RéSUMé: OBJECTIF: Les logbooks des résidents documentant leur exposition à des cas cliniques sont répandus dans la formation médicale et ce, malgré des données probantes déplorant leur manque de précision. Les dossiers médicaux informatisés (par ex., les systèmes de gestion de l'information en anesthésie [SGIA]) pourraient présenter des avantages pour le contrôle de l'exposition longitudinale des résidents aux cas. Notre étude a évalué la concordance entre les SGIA et les logbooks pour l'exposition aux cas pendant la résidence en anesthésiologie. MéTHODE: Nous avons réalisé une étude de cohorte historique auprès de résidents en anesthésiologie (2011­2018, tous les résidents ayant utilisé un logbook simultanément aux SGIA) travaillant dans un réseau universitaire de sciences de la santé multisite. Le critère d'évaluation principal était l'enregistrement du nombre de cas total; les critères d'évaluation secondaires comprenaient les volumes pour sept spécialités chirurgicales (soit la chirurgie générale, gynécologique, orthopédique, thoracique, urologique, vasculaire et la neurochirurgie). La corrélation entre le nombre de cas enregistrés dans les SGIA vs les logbooks a été évaluée à l'aide d'une corrélation de Pearson; l'agrément a été déterminé à l'aide d'un graphique de Bland­Altman et de coefficients de corrélation intraclasse (CCI). RéSULTATS: Les données de 27 résidents en anesthésiologie ont été colligées. Globalement, les nombres de cas moyens (écart type) étaient en général plus élevés dans les SGIA que dans les logbooks [649 (103) vs 583 (191); P = 0,049). Les volumes de cas totaux entre les systèmes présentaient une corrélation (r = 0,50) et un agrément (coefficient de corrélation intraclasse [CCI], 0,42; IC 95 %, 0,34 à 0,59) modérés. Les graphiques de Bland­Altman ont démontré un agrément variable entre les données des SGIA et celles des logbooks [biais moyen (ÉT) = 66 (166) cas]. Pour les chirurgies générales, gynécologiques, orthopédiques, thoraciques, urologique, vasculaires et neurochirurgies, l'agrément allait de faible à modéré (CCI, 0,23-0,57) entre les SGIA et les logbooks. CONCLUSION: En ce qui a trait à l'enregistrement des cas des résidents en anesthésiologie, le nombre de cas enregistrés dans un SGIA était plus élevé et présentait une variance moindre que dans les logbooks. Les données des systèmes de gestion de l'information en anesthésie vs des logbooks ont affiché une corrélation et un agrément faible à modéré. Étant donné le temps et les ressources supplémentaires nécessaires pour compléter les logbooks, les SGIA pourraient constituer une méthode supérieure pour le suivi des cas, lorsqu'un tel système est disponible.

Demographic differences in Canadian medical students' motivation and confidence to promote physical activity.

BACKGROUND: Physical activity (PA) remains under prescribed by physicians. Motivation and confidence are clear drivers of frequency of promoting PA. Research shows demographic differences in physicians' preventive practices, yet none have included medical students who form habits during training. OBJECTIVES: Study objectives were to (i) examine how Canadian medical students' motivation to recommend PA to future patients differs according to six demographic variables (i.e. gender, ethnicity, year of study, university, proposed specialty and academic background) and (ii) examine how Canadian medical students' confidence to recommend PA to future patients differs according to these same demographic variables. METHODS: A cross-sectional design was used. First to fourth year medical students from three medical schools responded to an online survey (N = 221). RESULTS: Female participants were more motivated to counsel patients on PA and refer to an exercise specialist compared to males (P < 0.01). Second year students were more motivated to assess a patients' level of PA compared to third and fourth year students (P < 0.01). Students pursuing family medicine were more confident to assess and counsel compared to students pursuing paediatrics (P < 0.01). CONCLUSION: Given that motivation and confidence have a positive influence on frequency-promoting PA, these results suggest where future efforts should focus, to improve PA promotion in medical practice. Physical inactivity continues to be a major issue worldwide, and medical students as future physicians have a unique opportunity to enhance PA amongst the population.

From the Lab to Patients: a Systematic Review and Meta-Analysis of Mesenchymal Stem Cell Therapy for Stroke.

There may be the potential to improve stroke recovery with mesenchymal stem cells (MSCs); however, questions about the efficacy and safety of this treatment remain. To address these issues and inform future studies, we performed a preclinical and clinical systematic review of MSC therapy for subacute and chronic ischemic stroke. MEDLINE, Embase, the Cochrane Register of Controlled Trials, and PubMed were searched. For the clinical review, interventional and observational studies of MSC therapy in ischemic stroke patients were included. For the preclinical review, interventional studies of MSC therapy using in vivo animal models of subacute or chronic stroke were included. Measures of safety and efficacy were assessed. Eleven clinical and 76 preclinical studies were included. Preclinically, MSC therapy was associated with significant benefits for multiple measures of motor and neurological function. Clinically, MSC therapy appeared to be safe, with no increase in adverse events reported (with the exception of self-limited fever immediately following injection). However, the efficacy of treatment was less apparent, with significant heterogeneity in both study design and effect size being observed. Additionally, in the only randomized phase II study to date, efficacy of MSC therapy was not observed. Preclinically, MSC therapy demonstrated considerable efficacy. Although MSC therapy demonstrated safety in the clinical setting, efficacy has yet to be determined. Future studies will need to address the discordance in the continuity of evidence as MSC therapy has been translated from "bench-to-bedside".

Canadian medical students' perceived motivation, confidence and frequency recommending physical activity.

Despite the evidence supporting the benefits of physical activity in the prevention and treatment of most medical conditions, physical activity remains under-prescribed by physicians. Medical students will form habits during training that they are likely to maintain as future physicians. The overall purpose of this study was to investigate the underlying mechanism(s) contributing to frequency in recommending physical activity, to provide insight into how we can increase physical activity recommendations in future practice as physicians. First to fourth year medical students at three Canadian universities responded to an online survey (N = 221; 12% response rate) between November 2017 and January 2018. Results revealed that engaging in strenuous physical activity was a strong predictor for frequency in recommending physical activity to patients (p < .001). Confidence in recommending physical activity mediated the relationship between strenuous physical activity and frequency recommending physical activity (p = .005); motivation did not mediate this relationship. Students were more motivated, than they were confident, to assess, advise, counsel, prescribe and refer patients regarding physical activity (p < .05). While 70% of students stated they are aware of the Canadian physical activity guidelines, only 52% accurately recalled them. Findings suggest that increased training related to physical activity should be included in the medical school curriculum to increase students' confidence to recommend physical activity. Another way to increase confidence and frequency in recommending physical activity is to help students engage in more strenuous physical activity themselves, which will ultimately benefit both medical students and their future patients.

Reporting preclinical anesthesia study (REPEAT): Evaluating the quality of reporting in the preclinical anesthesiology literature.

Poor reporting quality may contribute to irreproducibility of results and failed 'bench-to-bedside' translation. Consequently, guidelines have been developed to improve the complete and transparent reporting of in vivo preclinical studies. To examine the impact of such guidelines on core methodological and analytical reporting items in the preclinical anesthesiology literature, we sampled a cohort of studies. Preclinical in vivo studies published in Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and the British Journal of Anaesthesia (2008-2009, 2014-2016) were identified. Data was extracted independently and in duplicate. Reporting completeness was assessed using the National Institutes of Health Principles and Guidelines for Reporting Preclinical Research. Risk ratios were used for comparative analyses. Of 7615 screened articles, 604 met our inclusion criteria and included experiments reporting on 52 490 animals. The most common topic of investigation was pain and analgesia (30%), rodents were most frequently used (77%), and studies were most commonly conducted in the United States (36%). Use of preclinical reporting guidelines was listed in 10% of applicable articles. A minority of studies fully reported on replicates (0.3%), randomization (10%), blinding (12%), sample-size estimation (3%), and inclusion/exclusion criteria (5%). Statistics were well reported (81%). Comparative analysis demonstrated few differences in reporting rigor between journals, including those that endorsed reporting guidelines. Principal items of study design were infrequently reported, with few differences between journals. Methods to improve implementation and adherence to community-based reporting guidelines may be necessary to increase transparent and consistent reporting in the preclinical anesthesiology literature.

Screening criteria for increased susceptibility to heat stress during work or leisure in hot environments in healthy individuals aged 31-70 years.

Population aging and global warming generate important public health risks, as older adults have increased susceptibility to heat stress (SHS). We defined and validated sex-specific screening criteria for SHS during work and leisure activities in hot environments in individuals aged 31-70 years using age, anthropometry, and cardiorespiratory fitness. A total of 123 males and 44 females [44 ± 14 years; 22.9 ± 7.4% body fat; 40.3 ± 8.6 peak oxygen uptake (mlO2/kg/min)] participated, separated into the Analysis (n = 111) and Validation (n = 56) groups. Within these groups, participants were categorized into YOUNG (19-30 years; n = 47) and OLDER (31-70 years; n = 120). All participants performed exercise in the heat inside a direct calorimeter. Screening criteria for OLDER participants were defined from the Analysis group and were cross-validated in the Validation group. Results showed that 30% of OLDER individuals in the Analysis group were screened as SHS positive. A total of 274 statistically valid (p < 0.05) criteria were identified suggesting that OLDER participants were at risk for SHS when demonstrating two or more of the following (males/females): age ≥ 53.0/55.8 years; body mass index ≥29.5/25.7 kg/m2; body fat percentage ≥ 28.8/34.9; body surface area ≤2.0/1.7 m2; peak oxygen uptake ≤48.3/41.4 mlO2/kg fat free mass/min. In the Validation group, McNemar χ2 comparisons confirmed acceptable validity for the developed criteria. We conclude that the developed criteria can effectively screen individuals 31-70 years who are at risk for SHS during work and leisure activities in hot environments and can provide simple and effective means to mitigate the public health risks caused by heat exposure.

Increasing age is a major risk factor for susceptibility to heat stress during physical activity.

We evaluated the extent to which age, cardiorespiratory fitness, and body fat can independently determine whole-body heat loss (WBHL) in 87 otherwise healthy adults. We show that increasing age is a major predictor for decreasing WBHL in otherwise healthy adults (aged 20-70 years), accounting for 40% of the variation in the largest study to date. While greater body fat also had a minor detrimental impact on WBHL, there was no significant role for cardiorespiratory fitness.