Assessing Full Stomach Prevalence with Ultrasound Following Preoperative Fasting in Diabetic Patients with Dysautonomia: A Comparative Observational Study.

BACKGROUND: Traditionally, diabetics have been considered patients with a high risk of aspiration due to having delayed gastric emptying; However, the evidence concerning residual gastric volume (GV) in fasting diabetic patients is inconsistent. This study aimed to compare the fasting GV of diabetic patients with or without dysautonomia with control patients scheduled for elective surgery using gastric ultrasound. METHODS: This bicentric prospective single-blinded case-control study was conducted at 2 university hospitals in Spain. Patients aged over 18 years, classified as American Society of Anesthesiologists (ASA) physical statuses I to III and having similar fasting statuses, were included in the study. The primary outcome was to compare the prevalence of risk stomach using the Perlas gastric content grading scale evaluated by ultrasound in the 3 groups. Secondary outcomes included the measurement of cross-sectional area (CSA) and GV in the right lateral decubitus (RLD) position, as well as the prevalence of solid gastric residue. RESULTS: A total of 289 patients were recruited for the study, comprising 145 diabetic patients (83 of whom had dysautonomia) and 144 patients in the control group. The percentage of patients classified as Perlas grade 2 was 13.2% in the control group, 16.1% in diabetic patients without dysautonomia, and 22.9% in diabetic patients with dysautonomia (P = .31). Antral CSA was significantly higher in diabetic patients with dysautonomia (6.5 [4.8-8.4]) compared to the control group (5.4 [4.0-7.2]; P = .04). However, no significant differences were observed between groups in residual GV. Among diabetic patients with dysautonomia, 12% exhibited solid gastric residue, which was twice the percentage observed in diabetic patients without dysautonomia (4.8%) and 3 times higher than that in the control group (3.5%; P = .03). The presence of dysautonomia was associated with an increased odds ratio of solid gastric residue (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.28-8.87; P = .01) after adjusting for confounding factors. CONCLUSIONS: This study offers insights into the relationship between dysautonomia in patients with diabetes mellitus and the presence of full stomach, underscoring the significance of preoperative gastric ultrasound evaluation in managing perioperative risks in this population.

[Screening for heart disease in kids and adolescents (Prevencar Program)]. / Screening de cardiopatías en niños y adolescentes (Prevencar Program).

OBJECTIVE: The objective was to develop a screening for heart disease detection in primary care, to identify pathological electrocardiographic changes and underlying heart disease in adolescents. DESIGN: The study was carried out for one year using multistage sampling. SITE: Primary care centers in a health area that had digital ECG equipment (12 centers) were selected. PARTICIPANTS: Initially, 718 (16.6%) 14-year-old adolescents were recruited and those with a previous diagnosis of heart disease were excluded. INTERVENTIONS: Screening consisted of including a health questionnaire in the mandatory 14-year-old check-up. MAIN MEASUREMENTS: Screening included a questionnaire, cardiac auscultation, ECG and echocardiography. Abnormality criteria were established to refer for a second evaluation by a cardiologist. RESULTS: Finally, the sample was made up of 698 adolescents, with a mean age of 13.7±0.5 years, and 354 (50.7%) were boys. A total of 149 (21.3%) were selected for a second review by cardiology: 88 (12.6%) due to a positive questionnaire, 11 (2.2%) due to abnormal cardiac auscultation, and 66 (9.5%) due to ECG findings. Adolescents with evidence of heart disease were 24 (3.4%). Of these, 14 (2.0%) had suggestive alterations and follow-up was recommended, 6 (0.9%) had a definitive diagnosis of heart disease, and 4 (0.6%) had other pathological findings related to the cardiovascular system. CONCLUSIONS: The screening allowed us to identify 1% of adolescents with heart disease and another 2% will remain in follow-up. The ECG detected more pathological cases than the questionnaire.

Enhanced recovery after surgery: comes out to the Sun.

ERAS programs aim to reduce the length of hospital stays and lower costs, and minimize the risk of postoperative complications and readmissions while enhancing the overall patient experience. BMC Anesthesiology has initiated a new collection on ERAS, urging investigators to conduct large-scale, high-quality studies that address the existing knowledge gap.

Wound Infusion of 0.35% Levobupivacaine Reduces Mechanical Secondary Hyperalgesia and Opioid Consumption After Cesarean Delivery: A Prospective, Randomized, Triple-Blind, Placebo-Controlled Trial.

BACKGROUND: Some patients still report moderate-to-severe postoperative pain after cesarean delivery. Local anesthetic wound infusion improves acute pain and might act on peripheral and central sensitization mechanisms; however, no studies have proved this hypothesis. We evaluated the potential benefits of continuous wound infusion of levobupivacaine after cesarean delivery on secondary hyperalgesia (primary end point) and primary hyperalgesia, pain relief, persistent pain, and inflammatory and metabolic stress response. METHODS: Healthy women scheduled for elective cesarean delivery participated in this prospective, randomized, triple-blind, placebo-controlled trial (NCT01458431). All patients received spinal anesthesia with 0.5% hyperbaric bupivacaine with fentanyl and a multiholed wound catheter placed under the fascia. Women were randomized to receive continuous wound infusion (0.35% levobupivacaine 7 mL/h for 48 hours; group L) or an equal volume of saline (group S). Secondary hyperalgesia to punctate mechanical stimuli was evaluated using dynamic tests, and primary hyperalgesia was evaluated using an electronic von Frey anesthesiometer; both were assessed at 24, 48, and 72 hours. The following variables were collected: intensity of postoperative parietal and visceral pain at rest and on movement rated on a visual analog scale >72 hours, time to first bolus of patient-controlled analgesia (PCA), cumulative dose of rescue morphine (PCA) and acetaminophen, ability to sleep and sleep quality, and patient satisfaction. Persistent postoperative pain was evaluated during a telephone interview at 1, 3, 6, and 12 months after surgery. C-reactive protein, acid glycoprotein, preprandial glucose, insulin, cortisol, prolactin, growth hormone, and interleukin-6 were measured before cesarean delivery and at 8, 24, and 48 hours. Adverse events and patient outcomes were recorded. RESULTS: Seventy women were included. In group L, the area of secondary hyperalgesia was significantly reduced (43.4 [18.5-80] vs 68.4 [39.0-136] cm2 and 45.1 [0.9-89.8] vs 67.3 [31.3-175] cm2 at 24 and 48 hours, respectively; group:time interaction P value < .001), the mechanical pain threshold was significantly higher at 24 hours (633 [441-802] vs 417 [300-572] g.mm-2; P = .001), and morphine consumption was significantly lower at 24 hours (4 [2-11] vs 11[6-23]; P = .003) compared with group S. Levobupivacaine had no effect on persistent postoperative pain at 1, 3, 6, and 12 months. Plasma insulin levels in the immediate postoperative period and at 8, 24, and 48 hours were significantly lower in group L (P < .001). There were no significant differences in other biochemical parameters of inflammatory and endocrine-metabolic response. CONCLUSIONS: Levobupivacaine wound infusion provides adequate analgesia and might be an effective antihyperalgesic adjunct.

Biomechanical Analysis of Cervical Motion With a Pediatric Immobilization and Extrication Device.

OBJECTIVE: To determine the motions produced during pediatric extrication when using a system of motion estriction and extrication. METHODS: Simulation-based biomechanical analysis study conducted with inertial sensors to measure motion produced in the cervical spine of a pediatric simulator during extrication from a vehicle. RESULTS: The mean of the movements was 3.5° (SD ±1.35°). The mean time was 4 minutes 1 second (SD, ±45.09 seconds). The mean rotation toward the right was 3.34° (SD ±3.52°) and toward the left 2.62° (SD ±2.26°). The mean for lateralization was 6.24° (SD ±3.20°) toward the right and 2.50° (DE ±2.76°) toward the left. The mean for flexion was 2.36° (SD ±2.10°) and for extension 4.21° (SD ±2.15°). CONCLUSIONS: The device analyzed allows for the extrication of the pediatric patient with high levels of motion restriction of the spinal column with the Pediatric Immobilization and Extrication System.

"Dispatcher, Can You Help Me? A Woman Is Giving Birth". A Pilot Study of Remote Video Assistance with Smart Glasses.

Smart glasses (SG) could be a breakthrough in emergency situations, so the aim of this work was to assess the potential benefits of teleassistance with smart glasses (SG) from a midwife to a lifeguard in a simulated, unplanned, out-of-hospital birth (OHB). Thirty-eight lifeguards were randomized into SG and control (CG) groups. All participants were required to act in a simulated imminent childbirth with a maternal−fetal simulator (PROMPT Flex, Laerdal, Norway). The CG acted autonomously, while the SG group was video-assisted by a midwife through SG (Vuzix Blade, New York, NY, USA). The video assistance was based on the OHB protocol, speaking and receiving images on the SG. The performance time, compliance with the protocol steps, and perceived performance with the SG were evaluated. The midwife's video assistance with SG allowed 35% of the SG participants to perform the complete OHB protocol. No CG participant was able to perform it (p = 0.005). All OHB protocol variables were significantly better in the SG group than in the CG (p < 0.05). Telemedicine through video assistance with SG is feasible so that a lifeguard with no knowledge of childbirth care can act according to the recommendations in a simulated, unplanned, uncomplicated OHB. Communication with the midwife by speaking and sending images to the SG is perceived as an important benefit to the performance.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

Aim: This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background: NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods: Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results: Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion: Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article: Karim HMR, Sarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

Impact of simulation-based learning on family caregivers during the rehabilitation period of individuals with spinal cord injury.

STUDY DESIGN: Mixed-methods study. OBJECTIVE: Evaluate the knowledge that family caregivers of individuals with spinal cord injuries acquired through the use of a high-fidelity simulation-based learning (SBL) program. SETTING: The study was comprised of three phases: a previous qualitative research study detecting training needs, one in which clinical simulation scenarios were designed, and a final quasi-experimental phase in which ten caregivers of individuals with spinal cord injuries were trained in their care using simulations at the Toledo National Hospital for Paraplegics (Spain). METHODS: The competences acquired by the family were evaluated before and after the simulation training. A researcher-validated tool for each scenario was utilized for this evaluation. RESULTS: Four learning scenarios were designed based on the needs identified through the caregiver interviews. Following the training of the caregivers with SBL, an increase in their knowledge and skills was identified. For all the scenarios, the caregivers obtained a higher average score on the post test than on the pre test, and these differences were significant (p < 0.001). CONCLUSIONS: Simulation training is a useful and efficient learning tool for caregivers of individuals with a spinal cord injury.

Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D, Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial.

BACKGROUND: The use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario. OBJECTIVE: We compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin. METHODS: Thirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation. RESULTS: All participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42 s, 56 s, and 56 s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29 s and 40 s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation. CONCLUSIONS: In an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.

Developing and Implementing Low-Cost Remote Laboratories for Undergraduate Biology and Neuroscience Courses.

The global pandemic caused by the novel coronavirus (SARS-COV-2) has forced many universities to abruptly change the delivery of courses from in-person to online. This change to remote learning requires creating new ways to deliver lectures, exams, and discussion groups through online meeting platforms. An often-overlooked challenge is performing lab courses that require access to specialized equipment and resources typically found in the undergraduate laboratory classrooms. Here we discuss some strategies for developing and implementing a full semester neuroscience laboratory course that allows students to fully participate in laboratory exercises at home or in their dorm rooms. Performing lab exercises remotely and independently was shown to significantly improve participant's self-efficacy and confidence that they can learn complex neuroscience material, when compared to participants who passively watch experiments online. We review best practices to ensure that lessons can be successfully demonstrated by the instructor and carried out by all students. Finally, we discuss the need to provide a level playing field such that all students may succeed, regardless of their current technology resources at home.

Relatives of people with spinal cord injury: a qualitative study of caregivers' metamorphosis.

STUDY DESIGN: Qualitative study. OBJECTIVE: To detect the major challenges and needs reported by family member caregivers of people with spinal cord injury (SCI). SETTING: Family member caregivers of people with SCI and expert professionals were evaluated. This study was conducted in Spain, and most of the participants attended the National Paraplegics Hospital of Toledo. METHODS: We performed 25 semi-structured interviews. The data were analyzed from a phenomenological perspective using the Colaizzi method. RESULTS: The metamorphosis of the caregiver is a complex personal and family-related process. Analysis of the adjustment phase of the caregiving role allowed us to describe three stages, patterns, and trends. Five basic needs were identified. CONCLUSIONS: People with SCI and their primary caregivers experienced changes in every sphere of their lives. Their most important needs were psychological support, social support, economic resources, information, training throughout the process of suffering, and the creation of informal groups of mutual aid.

Effect of Hydrolyzed Infant Formula vs Conventional Formula on Risk of Type 1 Diabetes: The TRIGR Randomized Clinical Trial.

Importance: Early exposure to complex dietary proteins may increase the risk of type 1 diabetes in children with genetic disease susceptibility. There are no intact proteins in extensively hydrolyzed formulas. Objective: To test the hypothesis that weaning to an extensively hydrolyzed formula decreases the cumulative incidence of type 1 diabetes in young children. Design, Setting, and Participants: An international double-blind randomized clinical trial of 2159 infants with human leukocyte antigen-conferred disease susceptibility and a first-degree relative with type 1 diabetes recruited from May 2002 to January 2007 in 78 study centers in 15 countries; 1081 were randomized to be weaned to the extensively hydrolyzed casein formula and 1078 to a conventional formula. The follow-up of the participants ended on February 28, 2017. Interventions: The participants received either a casein hydrolysate or a conventional adapted cow's milk formula supplemented with 20% of the casein hydrolysate. The minimum duration of study formula exposure was 60 days by 6 to 8 months of age. Main Outcomes and Measures: Primary outcome was type 1 diabetes diagnosed according to World Health Organization criteria. Secondary outcomes included age at diabetes diagnosis and safety (adverse events). Results: Among 2159 newborn infants (1021 female [47.3%]) who were randomized, 1744 (80.8%) completed the trial. The participants were observed for a median of 11.5 years (quartile [Q] 1-Q3, 10.2-12.8). The absolute risk of type 1 diabetes was 8.4% among those randomized to the casein hydrolysate (n = 91) vs 7.6% among those randomized to the conventional formula (n = 82) (difference, 0.8% [95% CI, -1.6% to 3.2%]). The hazard ratio for type 1 diabetes adjusted for human leukocyte antigen risk group, duration of breastfeeding, duration of study formula consumption, sex, and region while treating study center as a random effect was 1.1 (95% CI, 0.8 to 1.5; P = .46). The median age at diagnosis of type 1 diabetes was similar in the 2 groups (6.0 years [Q1-Q3, 3.1-8.9] vs 5.8 years [Q1-Q3, 2.6-9.1]; difference, 0.2 years [95% CI, -0.9 to 1.2]). Upper respiratory infections were the most common adverse event reported (frequency, 0.48 events/year in the hydrolysate group and 0.50 events/year in the control group). Conclusions and Relevance: Among infants at risk for type 1 diabetes, weaning to a hydrolyzed formula compared with a conventional formula did not reduce the cumulative incidence of type 1 diabetes after median follow-up for 11.5 years. These findings do not support a need to revise the dietary recommendations for infants at risk for type 1 diabetes. Trial Registration: clinicaltrials.gov Identifier: NCT00179777.

Exploring APOE genotype effects on Alzheimer's disease risk and amyloid ß burden in individuals with subjective cognitive decline: The FundacioACE Healthy Brain Initiative (FACEHBI) study baseline results.

INTRODUCTION: Subjective cognitive decline (SCD) has been proposed as a potential preclinical stage of Alzheimer's disease (AD). Nevertheless, the genetic and biomarker profiles of SCD individuals remain mostly unexplored. METHODS: We evaluated apolipoprotein E (APOE) ε4's effect in the risk of presenting SCD, using the Fundacio ACE Healthy Brain Initiative (FACEHBI) SCD cohort and Spanish controls, and performed a meta-analysis addressing the same question. We assessed the relationship between APOE dosage and brain amyloid burden in the FACEHBI SCD and Alzheimer's Disease Neuroimaging Initiative cohorts. RESULTS: Analysis of the FACEHBI cohort and the meta-analysis demonstrated SCD individuals presented higher allelic frequencies of APOE ε4 with respect to controls. APOE dosage explained 9% (FACEHBI cohort) and 11% (FACEHBI and Alzheimer's Disease Neuroimaging Initiative cohorts) of the variance of cerebral amyloid levels. DISCUSSION: The FACEHBI sample presents APOE ε4 enrichment, suggesting that a pool of AD patients is nested in our sample. Cerebral amyloid levels are partially explained by the APOE allele dosage, suggesting that other genetic or epigenetic factors are involved in this AD endophenotype.

Randomised clinical simulation designed to evaluate the effect of telemedicine using Google Glass on cardiopulmonary resuscitation (CPR).

AIM: Through a clinical simulation, this study aims to assess the effect of telematics support through Google Glass (GG) from an expert physician on performance of cardiopulmonary resuscitation (CPR) performed by a group of nurses, as compared with a control group of nurses receiving no assistance. METHODS: This was a randomised study carried out at the Catholic University of Murcia (November 2014-February 2015). Nursing professionals from the Emergency Medical Services in Murcia (Spain) were asked to perform in a clinical simulation of cardiac arrest. Half of the nurses were randomly chosen to receive coaching from physicians through GG, while the other half did not receive any coaching (controls). The main outcome of the study expected was successful defibrillation, which restores sinus rhythm. RESULTS: Thirty-six nurses were enrolled in each study group. Statistically significant differences were found in the percentages of successful defibrillation (100% GG vs 78% control; p=0005) and CPR completion times: 213.91 s for GG and 250.31 s for control (average difference=36.39 s (95% CI 12.03 to 60.75), p=0.004). CONCLUSIONS: Telematics support by an expert through GG improves success rates and completion times while performing CPR in simulated clinical situations for nurses in simulated scenarios.