Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial).

BACKGROUND: Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy. METHODS: This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects. DISCUSSION: In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy. TRIAL REGISTRATION: Netherlands Trial Registry, NL8037. Registered 19 September 2019.

Improving needle tip identification during ultrasound-guided procedures in anaesthetic practice.

Ultrasound guidance is becoming standard practice for needle-based interventions in anaesthetic practice, such as vascular access and peripheral nerve blocks. However, difficulties in aligning the needle and the transducer can lead to incorrect identification of the needle tip, possibly damaging structures not visible on the ultrasound screen. Additional techniques specifically developed to aid alignment of needle and probe or identification of the needle tip are now available. In this scoping review, advantages and limitations of the following categories of those solutions are presented: needle guides; alterations to needle or needle tip; three- and four-dimensional ultrasound; magnetism, electromagnetic or GPS systems; optical tracking; augmented (virtual) reality; robotic assistance; and automated (computerised) needle detection. Most evidence originates from phantom studies, case reports and series, with few randomised clinical trials. Improved first-pass success and reduced performance time are the most frequently cited benefits, whereas the need for additional and often expensive hardware is the greatest limitation to widespread adoption. Novice ultrasound users seem to benefit most and great potential lies in education. Future research should focus on reporting relevant clinical parameters to learn which technique will benefit patients most in terms of success and safety.

Do medical students copy the drug treatment choices of their teachers or do they think for themselves?

PURPOSE: Although the importance of rational prescribing is generally accepted, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Because clinical teachers are an important role model for medical students, it is of interest to know whether this extends to therapeutic decision-making. The aim of this study was to find out which factors contribute to the drug choices made by medical students and their teachers (general practitioners and clinical specialists). METHODS: Final-year medical students (n = 32), and general practitioners (n = 29), lung specialists (n = 26), orthopaedic surgeons (n = 24), and internists (n = 24) serving as medical teachers from all eight medical schools in the Netherlands participated in the study. They were asked to prescribe treatment (drug or otherwise) for uncomplicated (A) and complicated (B) written patient cases and to indicate which factors influenced their choice of treatment, using a list of factors reported in the literature to influence drug prescribing. RESULTS: Final-year medical students primarily based their drug choice on the factors 'effectiveness of the drugs' and 'examples from medical teachers'. In contrast, clinical teachers primarily based their drug choice on the factors 'clinical experience', 'effectiveness of the drugs', 'side effects of the drugs', 'standard treatment guidelines', and 'scientific literature'. CONCLUSIONS: Medical teachers would appear to base their drug choice mainly on clinical experience and drug-related factors, whereas final-year medical students base their drug choice mainly on examples provided by their medical teachers. It is essential that medical teachers clearly explain to their students how they arrive at a specific choice of medication since medical students tend to copy the therapeutic drug choices from their teachers, mainly because of a lack of experience. Presenting students with clinical therapeutic problems early during undergraduate training will not only give them a chance to gain experience in solving medical problems but will also give meaning to what they are studying as opposed to merely reproducing what they learn or copying what they are told.

Arterial stiffness, endothelial function and microcirculatory reactivity in healthy young males.

Large (C1) and small (C2) arterial stiffness has been suggested to parallel endothelial reactivity and has led researchers to suggest parameters of arterial stiffness may be alternative measures to brachial sonographic assessments of flow-mediated dilatation (FMD). However, past studies comparing these measures can be criticized. In addition to %FMD responses, we recorded concurrent hyperaemic responses of the microcirculation and both were compared with C1 and C2. Twenty-nine subjects 18-30 years of age were investigated. Radial blood pressure was recorded with a tonometer. Pulse waveform analysis was performed to calculate C1 and C2. These were compared with %FMD responses and responses of finger flux measured by laser Doppler fluxmetry (LDF); pulsatile finger volume measured by photoplethysmography (PPG); and palm skin temperature measured by infrared thermography (Tpalm) (i.e. microcirculatory responses). Responses were determined as % changes from control. We only found weak relationships between C1 and %FMD (r=0.4, P=0.04); C2 and %PPG (r=0.38, P=0.07); and C2 and %LDFdorsal (r=-0.38; P=0.04). Responses of %FMD weakly parallel those of C1. Neither C2 nor C1 are viable indicators of endothelial or microcirculatory reactivity (i.e. hyperaemic or venous constriction) in healthy, resting young males. These findings refute the claims that C1 and C2 are substitute measures to sonographic assessments of brachial FMD.

The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.

BACKGROUND: A variety of diagnostic imaging techniques is available for excluding or confirming chronic osteomyelitis. Until now, an evidence-based algorithmic model for choosing the most suitable imaging technique has been lacking. The objective of this study was to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis. METHODS: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of the MEDLINE, EMBASE, and Current Contents databases to identify clinical studies on chronic osteomyelitis that evaluated diagnostic imaging modalities. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months. RESULTS: A total of twenty-three clinical studies in which the accuracy was described for radiography (two studies), magnetic resonance imaging (five), computed tomography (one), bone scintigraphy (seven), leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone and leukocyte scintigraphy (six), combined bone and gallium scintigraphy (three), and fluorodeoxyglucose positron emission tomography (four) were included in the review. No meta-analysis was performed with respect to computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity demonstrated that fluorodeoxyglucose positron emission tomography was the most sensitive technique, with a sensitivity of 96% (95% confidence interval, 88% to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for magnetic resonance imaging. Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% confidence interval, 16% to 36%) compared with 60% (95% confidence interval, 38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63% to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%) for combined bone and leukocyte scintigraphy, and 91% (95% confidence interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared with 21% (95% confidence interval, 11% to 38%) for its detection of chronic osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared with 80% (95% confidence interval, 61% to 91%) for the peripheral skeleton. CONCLUSIONS: Fluorodeoxyglucose positron emission tomography has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission tomography is superior for detecting chronic osteomyelitis in the axial skeleton.

Agar as a gelling agent: chemical and physical analysis.

Agars with different performance in bioassays were analysed for physical and chemical properties. Agars with the highest gel strength had the best performance. Good performance was also related to a low pH of a suspension of agars and to a low sulphur content. The diffusion rate of ions in gels differed between agars, but could not explain differences in agar performance. The time of autoclaving had a marked effect on the gel strength, however, without affecting the performance. Chemical analysis revealed large differences between agars. The best agars had a relatively low salt content. One of the best agars had an extremely high content of trace elements. Agar impurities, especially of the trace elements were tightly bound to the agars. Up to 30% of the Murashige and Skoog (MS) salts were also immobilized in the gel. At pH 4.2, less nitrogen and phosphate were available from the MS medium than at pH 5.7. Chlorine could be washed out completely and appeared to be a good marker for agar quality and purity. With AgNO3, chlorine contamination could easily be visualized.

The benefits of the application of geographical information systems in public and environmental health.

One of the most important issues in public and environmental health today concerns the type of instruments that can be used to devise quick, reliable and scientifically valid methods of rapid assessment which, in turn, can be utilized in health research and in the planning, monitoring and evaluation of health programmes. As the applications of geographical information systems (GIS) relate to the collection, storage, integration, management, retrieval, analysis and display of spatial data, it is not surprising that the potential usefulness of this new technology in the fields of health research and policy is beginning to be realized. This article seeks to demonstrate the opportunities which the use of geographical information systems can offer to research and policy on health issues. The article first describes the principles and objectives of GIS before going on to discuss hardware and software developments as well as the variety of application fields, organizations and users. Some examples of current applications are provided to illustrate the type of work being undertaken. The final sections address issues specifically related to the application of GIS in health research and policies in the European context.

Nitrate reductase deficient cell lines from diploid cell cultures and lethal mutant M2 plants of Arabidopsis thaliana.

Cell suspensions of diploid Arabidopsis thaliana were screened for resistance to chlorate on a medium with ammonium nitrate as the nitrogen source, and after plating on filters to increase the plating efficiency. Thirty-nine lines were selected, four of which were still resistant after two years of subculturing on non-selective medium. Of the latter lines three were nitrate reductase deficient but exhibited some residual nitrate reductase activity; the fourth line showed a high level of enzyme activity. Screening M2-seeds for callus production on selective medium with amino acids as the nitrogen source and chlorate revealed resistant calli in 17 out of 483 M2-groups. Nine well-growing lines, all but one (G3) exhibiting no detectable in vivo nitrate reductase activity, were classified as defective in the cofactor. Two lines (G1 and G3) could be analysed genetically at the plant level. Chlorate resistance was monogenic and recessive. Sucrose gradient fractionation of callus extracts of G1 revealed that a complete enzyme molecule can be assembled. Nitrate reductase activity in G1 could partly be restored by excess molybdenum. It is suggested that G1 is disturbed in the catalytic properties of the cofactor. It appeared that G1 is neither allelic with another molybdenum repairable mutant (B73) nor with another cofactor mutant (B25). Wilting of intact G1 plants could be ascribed to non-closing stomata.

Escherichia coli mutant strain with altered expression of the tryptophan operon: isolation and preliminary characterization.

From a strain of Escherichia coli with two copies of the tryptophan (trp) operon and one copy of the lactose (lac) operon, under control of one of the trp regulatory elements, we have isolated a mutant which does not grow in a medium containing 19 amino acids, unless tryptophan is added, and which cannot ferment lactose. The apparent pleiotropic nature of the mutation(s) is indicated by the very slow growth of mutant bacteria on minimal-medium agar supplemented with glucose and tryptophan. The amount of the trp enzymes (anthranilate synthetase and tryptophan synthetase) and trp messenger ribonucleic acid is reduced several-fold in the mutant compared to the isogenic wild-type strain, whereas the enzymes tryptophanyl-transfer ribonucleic acid synthetase and glucose 6-phosphate dehydrogenase remain the same. The incorporation of radioactive label into pulse-labeled but not into stable ribonucleic acid is significantly lower. Our results suggest that in the mutant organism the control of transcription of some operons, including the trp operon, is modified. An alternative explanation is that mutant bacteria contain a ribonuclease with increased activity for some messenger ribonucleic acid species.