The effect of ultrasound-guided transversus abdominis plane block on pulmonary function in patients undergoing laparoscopic cholecystectomy: a prospective randomized study.

BACKGROUND: Transversus abdominis plane block (TAPB) is commonly used for postoperative pain control after laparoscopic cholecystectomy. However, few studies have analyzed its effect on pulmonary function. The goal of this study was to elucidate the effect of ultrasound-guided bilateral TAPB on pulmonary function preservation and analgesia after laparoscopic cholecystectomy. METHODS: We enrolled 58 patients who underwent laparoscopic cholecystectomy. Among them, 53 were randomized to group T (n = 27) and group C (n = 26). Group T and group C received ultrasound-guided bilateral TAPB with 40 ml of 0.375% ropivacaine and 40 ml of 0.9% normal saline, respectively. Visual analog scale (VAS) scores, patient-controlled analgesia (PCA) consumption, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow rate (PEF), and modified Borg scale scores were measured until 24 h post-surgery. RESULTS: The VAS scores were significantly lower in group T than in group C at 1 and 8 h after the surgery. PCA consumption was significantly lower in group T than in group C at all postoperative time points. FEV1, PEF, and FEV1/FVC were more preserved in group T than in group C at 1 h. Group T had significantly lower modified Borg scale scores than did group C at 1 and 8 h. CONCLUSION: Ultrasound-guided TAPB is effective in pulmonary function preservation and pain control after laparoscopic cholecystectomy. Therefore, it could be a great option for multimodal analgesia, preservation of pulmonary function, prevention of pulmonary complications including atelectasis, and promotion of postoperative recovery after laparoscopic cholecystectomy. CLINICAL REGISTRATION: This study was enrolled in the Clinical Research Information Service (Clinical Research Information Service, KCT0004435, Hwa Yong Shin, 2019-08-19).

Can the Rhomboid Major Muscle Be Used to Identify the Thoracic Spinal Segment on Ultrasonography? A Prospective Observational Study.

OBJECTIVE: We investigated the thoracic segment corresponding to the inferior margin of the rhomboid major muscle (RMM) using ultrasound (US) to evaluate its potential as a reliable anatomic landmark for segment identification. DESIGN: A prospective observational study. SETTING: An operating room. SUBJECTS: Patients who underwent procedures around the thoracic spine. METHODS: Four hundred segments corresponding to the RMM's inferior margin were identified through the use of paravertebral sagittal US and confirmed by fluoroscopy in 100 participants in the prone position with upward and downward shoulder rotation, comprising four datasets (up-right, up-left, down-right, and down-left). The US identification of the RMM's inferior margin was dichotomously scored (clear vs ambiguous). Each dataset was divided into two groups (dominant segment group vs remaining segments group), which were compared. Factors relevant to the dominant segment associated with the RMM's inferior border were determined through univariable analyses. RESULTS: The T6 segment was observed most commonly (59.5%) along the RMM's inferior border on paravertebral sagittal US acquired in the prone position, followed by T5 (25.0%), T7 (12.8%), and T4 (2.7%). The segments corresponding to the RMM remained unchanged by shoulder posture in most participants (n = 74, 74%). The RMM's inferior border was clearly distinguishable in 330 cases (82.5%). When the RMM's inferior border was clearly identified, the corresponding segment was likely to match T6 in all datasets, with odds ratios ranging from 3.24 to 6.2. CONCLUSIONS: The RMM's inferior border over the transverse process corresponded to T6 most frequently on paravertebral sagittal US, and its deep fascia was clearly visible in most cases.

Manual vs pressure-controlled facemask ventilation during the induction of general anesthesia in children: A prospective randomized controlled study.

BACKGROUND: Gastric insufflation frequently occurs during facemask ventilation in children. In the present study, we compared the incidence of gastric insufflation between pressure-controlled facemask ventilation and manual facemask ventilation during general anesthesia induction in children. METHODS: Children in the pressure-controlled ventilation group (n = 76) received pressure-controlled facemask ventilation at an inspiratory pressure of 13 cm H2 O. In the manual ventilation group (n = 75), facemask ventilation was manually performed by anesthesiologists, who tried to maintain an inspiratory pressure of 13 cm H2 O. The adjustable pressure limiting valve was set at 13 cm H2 O. The incidence of gastric insufflation during 90 seconds after the initiation of ventilation was assessed using epigastric auscultation and gastric ultrasonography. RESULTS: The incidence of gastric insufflation was significantly higher in the manual  facemask ventilation group than in the pressure-controlled ventilation group (48% vs 12%, respectively; odds ratio 7.78, 95% confidence interval [CI] 3.38-17.9; P < 0.001). The mean peak airway pressure during ventilation was significantly higher in the manual ventilation group than in the pressure-controlled ventilation group (16.1 [3.0] cm H2 O vs 13.0 [0.1] cm H2 O; 95% CI of differences, 2.36-3.71 cm H2 O; P < 0.001). The manual ventilation group exhibited a wide peak airway pressure  range (11-26 cm H2 O) and a wide variation of tidal volume (0-7.0 mL/kg) compared with those of the pressure-controlled ventilation group (13-14 cm H2 O and 0.6-16.0 mL/kg, respectively). CONCLUSION: At an inspiratory pressure of 13 cm H2 O, pressure-controlled ventilation may be more effective than manual ventilation in preventing gastric insufflation while providing stable ventilation in children.

Optimal inspiratory pressure for face mask ventilation in paralyzed and unparalyzed children to prevent gastric insufflation: a prospective, randomized, non-blinded study.

BACKGROUND: Gastric insufflation is common during face mask ventilation and results in unfavourable respiratory events in children. The purpose of this study was to evaluate the effect of a muscle relaxant on gastric insufflation and determine the optimal inspiratory pressure during face mask ventilation in children. METHODS: Children aged one month to five years were randomly assigned to neuromuscular blocker (NM) or non-neuromuscular blocker (non-NM) groups. After administering intravenous anesthetics, face mask ventilation commenced via pressure-controlled mechanical ventilator. Initial inspiratory pressure was 10 cmH2O and was increased by 2 cmH2O until gastric insufflation was detected via gastric ultrasonography or epigastric auscultation. The primary outcome was the difference in the inspiratory pressure that causes gastric insufflation between the two groups. Diagnostic methods that detect gastric insufflation first were also evaluated. RESULTS: There was no significant difference in the median [interquartile range] inspiratory pressure inducing gastric insufflation between the non-NM (n = 52) and NM groups (n = 60) (18 [16-18] cmH2O vs 18.0 [16-20] cmH2O; median difference, 0 cmH2O; 95% confidence interval [CI], 0 to 2; P = 0.57). The incidence of gastric insufflation increased with increasing inspiratory pressure. Gastric insufflation was detected first by ultrasonography in 44% and by epigastric auscultation in 19% of the non-NM group (difference in percentage, 25%; 95% CI, 6 to 42; P = 0.006) and by ultrasonography in 73% and by epigastric auscultation in 7% of the NM group (difference in percentage, 66%; 95% CI, 50 to 78; P < 0.001). CONCLUSIONS: A neuromuscular blocking agent has minimal effect on the inspiratory pressure that causes gastric insufflation during face mask ventilation in children. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02471521); registered 15 June 2015.

Therapeutic hypothermia after recanalization in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Therapeutic hypothermia improves outcomes in experimental stroke models, especially after ischemia-reperfusion injury. We investigated the clinical and radiological effects of therapeutic hypothermia in acute ischemic stroke patients after recanalization. METHODS: A prospective cohort study at 2 stroke centers was performed. We enrolled patients with acute ischemic stroke in the anterior circulation with an initial National Institutes of Health Stroke Scale≥10 who had successful recanalization (≥thrombolysis in cerebral ischemia, 2b). Patients at center A underwent a mild hypothermia (34.5°C) protocol, which included mechanical ventilation, and 48-hour hypothermia and 48-hour rewarming. Patients at center B were treated according to the guidelines without hypothermia. Cerebral edema, hemorrhagic transformation, good outcome (3-month modified Rankin Scale, ≤2), mortality, and safety profiles were compared. Potential variables at baseline and during the therapy were analyzed to evaluate for independent predictors of good outcome. RESULTS: The hypothermia group (n=39) had less cerebral edema (P=0.001), hemorrhagic transformation (P=0.016), and better outcome (P=0.017) compared with the normothermia group (n=36). Mortality, hemicraniectomy rate, and medical complications were not statistically different. After adjustment for potential confounders, therapeutic hypothermia (odds ratio, 3.0; 95% confidence interval, 1.0-8.9; P=0.047) and distal occlusion (odds ratio, 7.3; 95% confidence interval; 1.3-40.3; P=0.022) were the independent predictors for good outcome. Absence of cerebral edema (odds ratio, 5.4; 95% confidence interval, 1.6-18.2; P=0.006) and no medical complications (odds ratio, 9.3; 95% confidence interval, 2.2-39.9; P=0.003) were also independent predictors for good outcome during the therapy. CONCLUSIONS: In patients with ischemic stroke, after successful recanalization, therapeutic hypothermia may reduce risk of cerebral edema and hemorrhagic transformation, and lead to improved clinical outcomes.

Ultrasound diagnosis and treatment of intractable anterior chest pain from golf - A case report.

BACKGROUND: Pleurisy is an inflammation of the parietal pleura and is characterized by pleuritic pain. The most common cause of pleurisy is infection; other causes include rheumatoidarthritis, malignancy, rib fractures, or trauma. Possible causes of chest pain associated withgolf include costochondritis, stress fractures of the ribs, intercostal muscle strain, or, rarely,Tietze's syndrome and slipping rib syndrome. CASE: A 64-year-old female presented with intractable chest pain that began 4 months priorwhile playing golf. No specific cause was found after various examinations. There was persistent pain despite medical treatment. Ultrasonography (US) was performed over the painful areas, which revealed focal pleural effusions. A mixture of ropivacaine and triamcinolonewas injected into the focal pleural effusions using US guidance, which dramatically relievedher pain. CONCLUSIONS: This case demonstrates that US can be used as a diagnostic and therapeuticmodality for intractable chest pain with an undetected pathology.

Disaster Healthcare Workers' Experience of Using the Psychological First Aid Mobile App During Disaster Simulation Training.

OBJECTIVE: The study aimed to examine the experience of disaster healthcare workers with simulation training using the Psychological First Aid (PFA) mobile app. METHODS: This study was designed using qualitative research methodology with focus group interviews. The participants were 19 disaster healthcare workers from community mental health service centers who attended disaster simulation training in flood, fire, or leakage of hazardous chemicals. Before the simulation, participants were provided the PFA mobile app and allowed to practice the PFA techniques to apply them during the simulation. Data were collected through focus group interviews and qualitatively analyzed using the content analysis method. RESULTS: The findings were divided into 6 categories: experience in realistic disaster situations, satisfaction with education methods using a mobile app, effectiveness of the PFA app in disaster relief, confidence in disaster relief by integrating experience and knowledge of the PFA app, self-reflection as a disaster healthcare worker, and identifying limitations and making developmental suggestions. CONCLUSIONS: Based on the participants' developmental proposals in this study, the disaster simulation training, incorporating improvements in the disaster simulation training and the PFA app features, will serve as a new framework for disaster support education and systematic mental health services to survivors by disaster healthcare workers.

Effectiveness of virtual reality immersion on procedure-related pain and anxiety in outpatient pain clinic: an exploratory randomized controlled trial.

BACKGROUND: The study investigated virtual reality (VR) immersion in alleviating procedure-related pain in patients with chronic pain undergoing fluoroscopy-guided minimally-invasive intervention in a prone position at an outpatient clinic. METHODS: In this prospective randomized controlled study, 38 patients undergoing lumbar sympathetic ganglion block were randomized into either the VR or the control group. In the VR group, procedure-related pain was controlled via infiltration of local anesthetics while watching a 30-minute VR hypnotic program. In the control group, the skin infiltration alone was used, with the VR device switched off. The primary endpoint was an 11-point score on the numerical rating scale, indicating procedure-related pain. Patients' satisfaction with pain control, anxiety levels, the need for additional local anesthetics during the procedure, hemodynamic stability, and any adverse events were assessed. RESULTS: Procedure-related pain was significantly lower in the VR group (3.7 ± 1.4) than in the control group (5.5 ± 1.7; P = 0.002). Post-procedural anxiety was lower in the VR group than in the control group (P = 0.025), with a significant reduction from pre-procedural anxiety (P < 0.001). Although patients' satisfaction did not differ significantly (P = 0.158) between the groups, a higher number of patients required additional local anesthetics in the control group (n = 13) than in the VR group (n = 4; P = 0.001). No severe adverse events occurred in either group during the study. CONCLUSIONS: VR immersion can be safely used as a novel adjunct to reduce procedural pain and anxiety during fluoroscopic pain intervention.

Analysis of judicial precedent cases regarding epidural injection in chronic pain management in Republic of Korea.

BACKGROUND: Although there is a low incidence of complications associated with epidural injections, pain physicians should still remain vigilant for potentially serious adverse outcomes. This study aimed to identify and describe the major complications of epidural injections. METHODS: This retrospective, observational, medicolegal study analyzed closed cases of precedents involving complications of epidural injections from January 1997 to August 2019 using the database of the Supreme Court of Korea's judgement system. Clinical characteristics and judgement statuses were analyzed. RESULTS: Of the 73 potential cases assessed for eligibility, a total of 49 malpractice cases were included in the final analysis. Thirty-three claims resulted in payments to the plaintiffs, with a median payment of US$103 828 (IQR: US$45 291-US$265 341). The most common complication was infection (n=13, 26.5%), followed by worsening pain (n=8, 16.3%). Physician malpractice before, during, and after the procedure was claimed by plaintiffs in 18 (36.7%), 44 (89.8%), and 31 (63.3%) cases, respectively. Of these cases, 6 (33.3%), 19 (43.2%), and 15 (48.4%), respectively, were adjudicated in favor of the plaintiffs by the courts. In cases involving postprocedural physician errors, the majority (13/15) of the plaintiff verdicts were related to delayed management. Violation of the physician's duty of informed consent was claimed by plaintiffs in 31 (63.3%) cases, and 14 (45.2%) of these cases were judged medical malpractice. CONCLUSIONS: Our data will allow pain physicians to become acquainted with the major epidural injection-associated complications that underlie malpractice cases.

Effect of Fentanyl-Based Intravenous Patient-Controlled Analgesia with and without Basal Infusion on Postoperative Opioid Consumption and Opioid-Related Side Effects: A Retrospective Cohort Study.

PURPOSE: We aimed to investigate the effect of a basal opioid infusion in fentanyl-based intravenous patient-controlled analgesia (IV-PCA) on postoperative opioid consumption, pain intensity, and occurrence of opioid-related side effects. PATIENTS AND METHODS: We retrospectively reviewed 2097 consecutive patients who received IV-PCA after elective general, thoracic, urologic, and plastic surgery under general anesthesia between June 2019 and October 2019. The patients were divided into two groups: IV-PCA with basal infusion (basal group) and IV-PCA without basal infusion (no basal group). We performed a propensity score matching (PSM) analysis to adjust for baseline differences between both groups. We compared the fentanyl PCA consumption (mcg), pain intensity, rescue analgesic administration, and occurrence of opioid-related side effects (nausea, vomiting, somnolence or dizziness, and overall side effects) during the first 48 hours postoperatively between the two groups before and after PSM. RESULTS: We analyzed 1317 eligible patients. Of these, 757 (57.5%) patients received IV-PCA without basal infusion. The PSM of the total cohort yielded 539 pairs of cases. After PSM, the fentanyl PCA consumption was significantly lower in the no basal group at 48 hours postoperatively as compared to the basal group (at 24 hours, the median difference: -80 mcg, P<0.001, 95% CI=-112 - -45 mcg; at 48 hours, the median difference: -286 mcg, P<0.001, 95% CI=-380 - -190 mcg), without significantly increasing pain intensity and administration of rescue analgesia. The occurrence of overall opioid-related side effects was also significantly lower in the no basal group (at 24 hours: 31.0% vs 23.0%, OR=0.67, P=0.003, 95% CI=0.51 - 0.87; at 48 hours: 18.9% vs 11.0%, OR=0.48, P<0.001, 95% CI=0.31 - 0.75). CONCLUSION: Basal infusion of fentanyl-based IV-PCA was significantly associated with an increase in fentanyl consumption and the occurrence of opioid-related side effects in postsurgical patients.

Flexible carbon nanotube Schottky diode and its integrated circuit applications.

Carbon nanotubes (CNTs), a low-dimensional material currently popular in industry and academia, are promising candidates for addressing the limits of existing semiconductors. In particular, CNTs are attractive candidates for flexible electronic materials due to their excellent flexibility and potential applications. In this work, we demonstrate a flexible CNT Schottky diode based on highly purified, preseparated, solution-processed 99% semiconducting CNTs and an integrated circuit application using the CNT Schottky diodes. Notably, the fabricated flexible CNT diode can greatly modulate the properties of the contact formed between the semiconducting CNT and the anode electrode via the control gate bias, exhibiting a high rectification ratio of up to 2.5 × 105. In addition, we confirm that the electrical performance of the CNT Schottky diodes does not significantly change after a few thousand bending/releasing cycles of the flexible substrate. Finally, integrated circuit (IC) applications of logic circuits (OR and AND gates) and an analog circuit (a half-wave rectifier) were presented through the use of flexible CNT Schottky diode combinations. The correct output responses are successfully achieved from the circuit applications; hence, we expect that our findings will provide a promising basis for electronic circuit applications based on CNTs.

Associations among Elder Abuse, Depression and PTSD in South Korean Older Adults.

Increasing attention is being placed on the prevalence of elder abuse and its impact on mental health. This study conducted a survey of 172 elderly people in South Korea to determine the prevalence of elder abuse and the relationships involving elder abuse, depression and posttraumatic stress disorder (PTSD). Participants completed a battery of self-report questionnaires, which included the Korean Geriatric Depression Screening Scale (KGDS) and Impact of Event Scale-Revised Korean version (IES-R-K). Descriptive analyses were conducted to examine the frequency of specific forms of abuse. Logistic regression models were estimated to identify the factors that contributed to risk of abuse exposure and the relationship between exposure and PTSD or depression. The results indicated around 22% of the participants reported abuse exposure, which most commonly included being refused physical contact, verbal threats, and/or being excluded from decision-making about personal issues. Low education and being unmarried, separated or divorced was associated with an increased risk of abuse exposure. There were strong associations between elder abuse and PTSD symptoms, while comparable relationships with depression were weaker and were not robust to the inclusion of control variables. The findings provided empirical support for the relationship between abuse experiences of the elderly and poor mental health and raise important issues for the mental health care of the elderly.

A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection.

OBJECTIVE Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects. METHODS A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration. RESULTS The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only. CONCLUSIONS The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ).

Retrospective analysis of vocal cord-to-suprasternal notch distance: Implications for preventing endotracheal tube cuff-induced vocal cord injury.

Endotracheal tube (ETT) positioning using the cuff ballottement test, which confirms that the inflated cuff is positioned at the suprasternal notch with squeezing or inflating a pilot balloon, has been reported to be a simple and reliable method of preventing endobronchial intubation. However, in patients with a short vocal cord-to-suprasternal notch, ETT placement using the cuff ballottement test can cause vocal cord injury. In the present study, we assessed the distance from a point 15 mm below the vocal cord to the suprasternal notch (VSD-15), the safe position for ETT cuff placement above the suprasternal notch, and investigated variables for predicting VSD-15.We retrospectively examined neck computed tomography in 427 adult patients and measured VSD-15 and the distance from the thyroid notch to the suprasternal notch (TSD). Patient height, weight, sex, and age were also recorded.In total, 47 patients (11.0%) showed a VSD-15 shorter than 45 mm. VSD-15 significantly correlated with TSD (r = 0.778, P < 0.001) and height (r = 0.312, P < 0.001), and inversely correlated with age (r = -0.321, P < 0.001). In multiple linear regression models, a formula was obtained for VSD-15 (VSD-15 [mm] = -6.220 + 0.744 × TSD [mm] + 0.092 × height [cm] - 0.065 × age [years], R = 0.621).The cuff ballottement test should be used cautiously in patients with a predicted short VSD-15. VSD-15 can be predicted from TSD, height, and age.

Expression of open reading frame 5 protein of porcine reproductive and respiratory syndrome virus using semliki forest virus expression system.

The ORF5 gene encodes a major envelope glycoprotein (GP5), which is one of the three major proteins of porcine reproductive and respiratory syndrome virus (PRRSV). The GP5 protein has been known to be a 24.5-26 kDa N-glycosylated envelope protein. The GP5 is involved in inducing neutralizing antibodies. For this reason, the GP5 is primary candidate for the PRRSV subunit vaccine. To produce the native form of GP5 in mammalian cells, we have cloned the ORF5 gene from PRRSV CNV-1 into the Semliki Forest virus (SFV)-based expression vector, resulting in recombinant pSFV-ORF5. By the infection with recombinant pSFV-ORF5 to BHK-21 cells, the GP5 expression was confirmed by immunocytochemistry and immunoblotting assay. The recombinant virus particle harboring ORF5 gene was infectious to BHK-21 and MARC-145. The RNA synthesis and expression of GP5 in the infected cell was also confirmed by RT-PCR.

Reinfection rate and endoscopic changes after successful eradication of Helicobacter pylori.

AIM: To determine the long-term outcomes regarding reinfection with Helicobacter pylori (H. pylori) and endoscopic changes after successful H. pylori eradication. METHODS: From June 1994 to January 2007, 186 patients (M:F = 98:88; mean age 50.0 +/- 11.4 years), in whom H. pylori had been successfully eradicated, were enrolled. The mean duration of follow up was 41.2 +/- 24.0 mo. RESULTS: H. pylori reinfection occurred in 58 patients (31.2%). The average annual reinfection rate was 9.1% per patient year. No recurrence of peptic ulcer was detected at the follow up endoscopy. There were no significant differences between the H. pylori eradication regimens for the reinfection rate and no significant differences in endoscopic findings between the H. pylori-recurred group and the H. pylori-cured group. CONCLUSION: The reinfection rate in Korea is 9.1% which represents a decreasing trend. There was no relationship between H. pylori infection status and changes in endoscopic findings. There was also no recurrence or aggravation of ulcers.

Left valsalva sinus aneurysm rupture into left atrium and aortic valve prolapse confirmed with transesophageal echocardiography.

We report a very rare case of left Valsalva sinus aneurysm rupture into left atrium in a 55-year-old man with severe aortic regurgitation caused by aortic valve prolapse. The Valsalva sinus aneurysm rupture was clearly visualized with transesophageal echocardiography performed to further delineate the aortic valve pathology. The 3-dimensional reconstruction of multislice computed tomography images nicely visualized the left Valsalva sinus aneurysm.