Life, Love, Hope, Faith, and Death-Too Complex for Likert.

More research to examine factors contributing to health-care disparities at the end of life is greatly needed. This article outlines a failed attempt to quantify some of the motivators in medical decision-making for African American families faced with a decision to pursue or forego a percutaneous endoscopic gastrostomy in a loved one at the end of life. It explores the complexities of spirituality, history, culture, and death in our patient population in Charleston, South Carolina, where health-care disparities are well-documented, and distrust has deep historical roots. It outlines the need for qualitative research, where the defining role of the researcher is to practice the paramount palliative skill of listening.

Transcranial electrical stimulation motor threshold can estimate individualized tDCS dosage from reverse-calculation electric-field modeling.

BACKGROUND: Unique amongst brain stimulation tools, transcranial direct current stimulation (tDCS) currently lacks an easy or widely implemented method for individualizing dosage. OBJECTIVE: We developed a method of reverse-calculating electric-field (E-field) models based on Magnetic Resonance Imaging (MRI) scans that can estimate individualized tDCS dose. We also evaluated an MRI-free method of individualizing tDCS dose by measuring transcranial magnetic stimulation (TMS) motor threshold (MT) and single pulse, suprathreshold transcranial electrical stimulation (TES) MT and regressing it against E-field modeling. Key assumptions of reverse-calculation E-field modeling, including the size of region of interest (ROI) analysis and the linearity of multiple E-field models were also tested. METHODS: In 29 healthy adults, we acquired TMS MT, TES MT, and anatomical T1-weighted MPRAGE MRI scans with a fiducial marking the motor hotspot. We then computed a "reverse-calculated tDCS dose" of tDCS applied at the scalp needed to cause a 1.00 V/m E-field at the cortex. Finally, we examined whether the predicted E-field values correlated with each participant's measured TMS MT or TES MT. RESULTS: We were able to determine a reverse-calculated tDCS dose for each participant using a 5 × 5 x 5 voxel grid region of interest (ROI) approach (average = 6.03 mA, SD = 1.44 mA, range = 3.75-9.74 mA). The Transcranial Electrical Stimulation MT, but not the Transcranial Magnetic Stimulation MT, significantly correlated with the ROI-based reverse-calculated tDCS dose determined by E-field modeling (R2 = 0.45, p < 0.001). CONCLUSIONS: Reverse-calculation E-field modeling, alone or regressed against TES MT, shows promise as a method to individualize tDCS dose. The large range of the reverse-calculated tDCS doses between subjects underscores the likely need to individualize tDCS dose. Future research should further examine the use of TES MT to individually dose tDCS as an MRI-free method of dosing tDCS.

Is inpatient admission necessary following removal of airway foreign bodies?

OBJECTIVE: To determine the need for postoperative admission following airway foreign body retrieval by examining the preoperative presentation, operative details, and postoperative recovery. INTRODUCTION: Inpatient admission following foreign body removal is common, however little evidence supports this practice. In the era of cost containment and prudent utilization of hospital resources, careful examination of the postoperative course following airway foreign body removal is required. METHODS: A retrospective review of cases over a four year period from a pediatric tertiary care pediatric hospital was performed. All children presenting with concerns for airway foreign bodies were included. Children without identification of an airway foreign body during bronchoscopy were excluded. Microlaryngoscopy and bronchoscopy with airway foreign body extraction was performed. Details concerning demographics, operative findings, and pre and postoperative course including pulse oximetry were collected. All respiratory events, intubations, and persistent oxygen requirements were investigated. RESULTS: Thirty five children underwent successful airway foreign body removal. The mean age was 3.2±2.6 years with a preponderance of males (68.6%). The retrieved items included: nuts (31.4%), popcorn (14.3%), seeds (8.6%), and inorganic materials (34.3%). Mean operative time was 29.7±25.6min. The mean length of stay following surgery was 1.3±1.9 days. Most patients (31/35) (88.6%) were extubated prior to transfer to recovery. 30/35 (85.7%) patients required no supplemental oxygen without desaturations following post anesthesia care unit (PACU) recovery. One patient developed laryngospasm requiring reintubation within 15min of surgery. Two patients were intubated prior to transfer for respiratory distress and remained intubated following surgery. Two patients breathing spontaneously prior to surgery were left intubated following surgery secondary to prolonged pneumonia treatment or multifocal foreign bodies with airway edema. All patients subsequently extubated without complication. In total, 30/31 (96.7%) of patients extubated in the operating room returned to room air oxygenation within 2h of surgery. CONCLUSIONS: PACU observation and discharge is feasible in select children following airway foreign body extraction. Patients carefully monitored in the recovery unit without oxygen requirement are candidates for discharge. Inpatient monitoring is advised in 'children with preoperative respiratory distress or a complicated operative course.