Immersive virtual reality in orthopaedics-a narrative review.

PURPOSE: This narrative review explores the applications and benefits of immersive virtual reality (VR) in orthopaedics, with a focus on surgical training, patient functional recovery, and pain management. METHODS: The review examines existing literature and research studies on immersive VR in orthopaedics, analyzing both experimental and clinical studies. RESULTS: Immersive VR provides a realistic simulation environment for orthopaedic surgery training, enhancing surgical skills, reducing errors, and improving overall performance. In post-surgical recovery and rehabilitation, immersive VR environments can facilitate motor learning and functional recovery through virtual embodiment, motor imagery during action observation, and virtual training. Additionally VR-based functional recovery programs can improve patient adherence and outcomes. Moreover, VR has the potential to revolutionize pain management, offering a non-invasive, drug-free alternative. Virtual reality analgesia acts by a variety of means including engagement and diverting patients' attention, anxiety reduction, and specific virtual-body transformations. CONCLUSION: Immersive virtual reality holds significant promise in orthopaedics, demonstrating potential for improved surgical training, patient functional recovery, and pain management but further research is needed to fully exploit the benefits of VR technology in these areas.

Ecology of the Atlantic black skipjack Euthynnus alletteratus (Osteichthyes: Scombridae) in the western Mediterranean Sea inferred by parasitological analysis.

Between 2008 and 2011, the head of 150 Euthynnus alletteratus (Osteichthyes: Scombridae) caught inshore off the southeastern Iberian coast (western Mediterranean Sea) were examined for parasites. Two monogeneans, four didymozoid trematodes and four copepods were found. Parasite abundance showed a positive relationship with the annual sea surface temperature, except for Pseudocycnus appendiculatus, but negative with the sea depth (Capsala manteri, Neonematobothrium cf. kawakawa and Caligus bonito). Prevalences and mean abundances differed significantly among sampling areas, except for C. manteri, Oesophagocystis sp. 2 and Ceratocolax euthynni, and sampling years (Melanocystis cf. kawakawa, N.cf. kawakawa, P. appendiculatus and Unicolax collateralis). Results indicate that the parasite abundances of E. alletteratus in the western Mediterranean Sea depend mainly on regional environmental variables, which can show interannual variations. The presence of pelagic parasites, i.e. didymozoids and P. appendiculatus, could indicate that E. alletteratus migrates between inshore and offshore pelagic domains. The different parasite faunas reported in E. alletteratus populations from the western Atlantic Ocean and the Mediterranean Sea appear to point out the geographical host isolation. These results suggest that E. alletteratus inhabiting the western Mediterranean Sea performs inshore-offshore small-scale migrations, and not transoceanic migrations between the western Atlantic Ocean and Mediterranean Sea.

Modern hydroxyethyl starch and acute kidney injury after cardiac surgery: a prospective multicentre cohort.

BACKGROUND: Recent trials have shown hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients. It is uncertain whether these adverse effects also affect surgical patients. We sought to determine the renal safety of modern tetrastarch (6% HES 130/0.4) use in cardiac surgical patients. METHODS: In this multicentre prospective cohort study, 1058 consecutive patients who underwent cardiac surgery from 15th September 2012 to 15th December 2012 were recruited in 23 Spanish hospitals. RESULTS: We identified 350 patients (33%) administered 6% HES 130/0.4 intraoperatively and postoperatively, and 377 (36%) experienced postoperative AKI (AKI Network criteria). In-hospital death occurred in 45 (4.2%) patients. Patients in the non-HES group had higher Euroscore and more comorbidities including unstable angina, preoperative cardiogenic shock, preoperative intra-aortic balloon pump use, peripheral arterial disease, and pulmonary hypertension. The non-HES group received more intraoperative vasopressors and had longer cardiopulmonary bypass times. After multivariable risk-adjustment, 6% HES 130/0.4 use was not associated with significantly increased risks of AKI (adjusted odds ratio 1.01, 95% CI 0.71-1.46, P=0.91). These results were confirmed by propensity score-matched pairs analyses. CONCLUSIONS: The intraoperative and postoperative use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with increased risks of AKI and dialysis after cardiac surgery in our multicentre cohort.

Infragranular layers lead information flow during slow oscillations according to information directionality indicators.

The recurrent circuitry of the cerebral cortex generates an emergent pattern of activity that is organized into rhythmic periods of firing and silence referred to as slow oscillations (ca 1 Hz). Slow oscillations not only are dominant during slow wave sleep and deep anesthesia, but also can be generated by the isolated cortical network in vitro, being a sort of default activity of the cortical network. The cortex is densely and reciprocally connected with subcortical structures and, as a result, the slow oscillations in situ are the result of an interplay between cortex and thalamus. Due to this reciprocal connectivity and interplay, the mechanism responsible for the initiation of waves in the corticothalamocortical loop during slow oscillations is still a matter of debate. It was our objective to determine the directionality of the information flow between different layers of the cortex and the connected thalamus during spontaneous activity. With that purpose we obtained multilayer local field potentials from the rat visual cortex and from its connected thalamus, the lateral geniculate nucleus, during deep anaesthesia. We analyzed directionality of information flow between thalamus, cortical infragranular layers (5 and 6) and supragranular layers (2/3) by means of three information theoretical indicators: transfer entropy, symbolic transfer entropy and transcript mutual information. These three indicators coincided in finding that infragranular layers lead the information flow during slow oscillations both towards supragranular layers and towards the thalamus.

Metazoan parasites in the head region of the bullet tuna Auxis rochei (Osteichthyes: Scombridae) from the western Mediterranean Sea.

The head region of 72 bullet tuna Auxis rochei from the western Mediterranean Sea (south-east Spain and the Strait of Gibraltar) was examined for parasites. Seven metazoan species were found in the fish from south-east Spain: three monogeneans, two trematodes and two copepods, whereas only three species were isolated in the fish from the Strait of Gibraltar. A comparison of the levels of infection of the parasites according to fish size in south-east Spain showed that the prevalence of Didymozoon auxis and the mean abundance of Allopseudaxine macrova were higher in the larger hosts (range of fork length = 38-44 cm) than in the smaller ones (33-37 cm). A comparison of the parasite infections according to geographical region showed that the mean abundances of Nematobothriinae gen. sp. and Caligus bonito were higher in fish from south-east Spain than in those from the Strait of Gibraltar. A comparison of the parasite fauna of A. rochei from the Mediterranean Sea with the published data on Auxis spp. from the Atlantic, Indian and Pacific Oceans revealed the closest similarity between the Mediterranean A. rochei and the Atlantic A. thazard.

Slow wave activity as the default mode of the cerebral cortex.

The function of sleep remained one of largest enigmas of neuroscience for most of the 20th century. However in recent years different evidence has accumulated in support of a critical role of sleep on functions such as replay and memory consolidation. In particular slow wave sleep, and its underlying corticothalamocortical activity, slow oscillations, could be critical not only for memory but also for the maintenance of the brain's structural and func- tional connectivity. In this article we ask: why slow oscillations? To answer this question we put forward the idea that slow oscillations are the default activity of the cortical network based on both experimental and theoretical evidence. We go on to discuss why slow oscillations emerge from the cortical circuits and what are the dynamic advantages of this activity pattern, such as the resilience to perturbances and the facilitation of transitions between a disconnected (e.g. deep sleep) brain and a connected, awake brain.

Chronic full-band recordings with graphene microtransistors as neural interfaces for discrimination of brain states.

Brain states such as sleep, anesthesia, wakefulness, or coma are characterized by specific patterns of cortical activity dynamics, from local circuits to full-brain emergent properties. We previously demonstrated that full-spectrum signals, including the infraslow component (DC, direct current-coupled), can be recorded acutely in multiple sites using flexible arrays of graphene solution-gated field-effect transistors (gSGFETs). Here, we performed chronic implantation of 16-channel gSGFET arrays over the rat cerebral cortex and recorded full-band neuronal activity with two objectives: (1) to test the long-term stability of implanted devices; and (2) to investigate full-band activity during the transition across different levels of anesthesia. First, we demonstrate it is possible to record full-band signals with stability, fidelity, and spatiotemporal resolution for up to 5.5 months using chronic epicortical gSGFET implants. Second, brain states generated by progressive variation of levels of anesthesia could be identified as traditionally using the high-pass filtered (AC, alternating current-coupled) spectrogram: from synchronous slow oscillations in deep anesthesia through to asynchronous activity in the awake state. However, the DC signal introduced a highly significant improvement for brain-state discrimination: the DC band provided an almost linear information prediction of the depth of anesthesia, with about 85% precision, using a trained algorithm. This prediction rose to about 95% precision when the full-band (AC + DC) spectrogram was taken into account. We conclude that recording infraslow activity using gSGFET interfaces is superior for the identification of brain states, and further supports the preclinical and clinical use of graphene neural interfaces for long-term recordings of cortical activity.

Uric acid and acute kidney injury in high-risk patients for developing acute kidney injury undergoing cardiac surgery: A prospective multicenter study.

PURPOSE: It is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI. DESIGN: Multicenter prospective international cohort study. SETTING: Fourteen university hospitals in Spain and the United Kingdom. PARTICIPANTS: We studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥ 4 points, from July to December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: AKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (≥7 mg/dL) and AKI. Elevated preoperative AUS (≥7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81-3; P = .17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95%CI 0.93-1.19, P = .37). CONCLUSIONS: Hyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

Variability and information content in auditory cortex spike trains during an interval-discrimination task.

Processing of temporal information is key in auditory processing. In this study, we recorded single-unit activity from rat auditory cortex while they performed an interval-discrimination task. The animals had to decide whether two auditory stimuli were separated by either 150 or 300 ms and nose-poke to the left or to the right accordingly. The spike firing of single neurons in the auditory cortex was then compared in engaged vs. idle brain states. We found that spike firing variability measured with the Fano factor was markedly reduced, not only during stimulation, but also in between stimuli in engaged trials. We next explored if this decrease in variability was associated with an increased information encoding. Our information theory analysis revealed increased information content in auditory responses during engagement compared with idle states, in particular in the responses to task-relevant stimuli. Altogether, we demonstrate that task-engagement significantly modulates coding properties of auditory cortical neurons during an interval-discrimination task.

Distribution and prognosis of molecular breast cancer subtypes defined by immunohistochemical biomarkers in a Spanish population-based study.

BACKGROUND: The objective of this study is to analyze the distribution, clinicopathological features, relative survival rate and excess risk of death among females diagnosed with invasive breast cancer and classified by molecular subtype from ten Spanish cancer registries. METHOD: Three thousand four hundred and eighty incident cases of women - mostly diagnosed in 2005 - were classified into five molecular subtypes according to immunohistochemical status of hormonal receptors and HER2 (human epidermal growth factor receptor 2): estrogen receptor (ER) and/or progesterone receptor (PR)+ and HER2-, ER+ and/or PR+ and HER2+, HER2-overexpressed (ER-, PR- and HER2+), triple negative (ER, PR and HER2-) and unclassified (hormonal receptor or/and HER2 unknown). Relative survival rates at 1, 3 and 5years and relative excess risks (RER) of death adjusting for molecular subtype, age, stage and histological grade were estimated. RESULTS: Marked differences in clinicopathological characteristics and relative survival rate were observed between molecular subtypes. Compared with women with ER+ and/or PR+ and HER2-, ER+ and/or PR+ and HER2+ cases had an RER of 1.00 (95% CI: 0.66 to 1.52) after adjusting for age, stage and histological grade, whereas HER2-overexpressed, triple negative and women with unclassified subtypes presented an RER of 1.72 (95% CI: 1.15 to 2.57), 3.16 (95% CI: 2.26 to 4.41) and 2.55 (95% CI: 1.96 to 3.32), respectively. CONCLUSION: The prognostic value of molecular subtype persists when adjusting for age, stage and histological grade. Hormone receptor-positive tumors were associated with a better prognosis when compared with HER2-overexpressed and triple negative subtypes. Further research is required to improve triple negative prognosis.

[Blood transfusion during heart surgery. A retrospective nested case-control study]. / Transfusión intraoperatoria en cirugía cardiaca. Estudio retrospectivo anidado de casos y controles.

OBJECTIVE: To assess the correlation between intraoperative packed red blood cells transfusion and adverse outcome in a Spanish cohort of cardiac surgery patients. METHODS: Retrospective observational multicentre study. An analysis was performed on the data from 927 cardiac surgery patients treated in 24 Spanish hospitals in 2007. Patients who received intraoperative transfusions were compared with non-transfused patients. Multivariate analyses were performed (including, among others, several items from the Euroscore, surgery type, basal renal status and haemoglobin levels, and Thakar score). RESULTS: Every transfusion of packed red cells was associated with increased postoperative risk of acute kidney damage at 72 hours after surgery, prolonged mechanical ventilation, and need for haemodynamic support. Moreover, transfused patients showed an increased in-hospital mortality rates (Adjusted OR: 1.30; 95% CI: 1.19-1.42), as well as longer hospital stays (almost 4 days). CONCLUSIONS: In this cohort of patients, intraoperative transfusion might independently predict higher risk of early acute kidney damage, prolonged postoperative mechanical ventilation, and a need for haemodynamic support, and reduced short term survival (adjusted OR for mortality: 1.30; 95% CI: 1.19-1.42), and longer hospital stays (4 days longer).

Cortical auditory adaptation in the awake rat and the role of potassium currents.

Responses to sound in the auditory cortex are influenced by the preceding history of firing. We studied the time course of auditory adaptation in primary auditory cortex (A1) from awake, freely moving rats. Two identical stimuli were delivered with different intervals ranging from 50 ms to 8 s. Single neuron recordings in the awake animal revealed that the response to a sound is influenced by sounds delivered even several seconds earlier, the second one usually yielding a weaker response. To understand the role of neuronal intrinsic properties in this phenomenon, we obtained intracellular recordings from rat A1 neurons in vitro and mimicked the same protocols of adaptation carried out in awake animals by means of depolarizing pulses of identical duration and intervals. The intensity of the pulses was adjusted such that the first pulse would evoke a similar number of spikes as its equivalent in vivo. A1 neurons in vitro adapted with a similar time course but less than in awake animals. At least two potassium currents participated in the in vitro adaptation: a Na(+)-dependent K(+) current and an apamin-sensitive K(+) current. Our results suggest that potassium currents underlie at least part of cortical auditory adaptation during the awake state.

A simple algorithm for differential diagnosis in hemodynamic shock based on left ventricle outflow tract velocity-time integral measurement: a case series.

Echocardiography has gained wide acceptance among intensive care physicians during the last 15 years. The lack of accredited formation, the long learning curve required and the excessive structural orientation of the present algorithms to evaluate hemodynamically unstable patients hampers its daily use in the intensive care unit. The aim of this article is to show 4 cases where the use of our simple algorithm based on VTI, was crucial. Subsequently, to explain the benefit of using the proposed algorithm with a more functional perspective, as a means for clinical decision-making. A simple algorithm based on left ventricle outflow tract velocity-time integral measurement for a functional hemodynamic monitoring on patients suffering hemodynamic shock or instability is proposed by Spanish Critical Care Ultrasound Network Group. This algorithm considers perfusion and congestion variables. Its simplicity might be useful for guiding physicians in their daily decision-making managing critically ill patients in hemodynamic shock.

Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES).

Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine-part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Medical comorbidity in recurrent versus first-episode depressive patients.

OBJECTIVE: This study compares the comorbidity of affective disorders and medical diseases in primary care patients with either a first or recurrent depressive episode. METHOD: A cross-sectional epidemiological study in primary care centres in Spain was designed. A total of 10,257 primary care patients suffering a DSM-IV major depressive episode (MDD) were analysed. Depression was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS), and World Health Organization (WHO) medical diagnoses were provided by the patient's general practitioner according to medical records revised on the basis of radiology or laboratory test data. RESULTS: A total of 88.6% of recurrent patients and 71.1% of first-episode depressive patients reported a medical condition (aOR = 2.61, CI = 2.31-2.93). All medical conditions were more prevalent in the recurrent group than in first-episode group, and with the exception of myocardial infarction, psoriasis and migraine, all other crude ORs showed statistically significant differences between first- and recurrent episodes patients after adjusting for gender, age, education, socioeconomic status and body mass index (BMI). CONCLUSION: Recurrent depression is associated with a decrement in health that is significantly greater than in first-episode depression. Special attention needs to be paid to the physical health in the middle- and long-term management of patients with affective disorders.

Mutual information and redundancy in spontaneous communication between cortical neurons.

An important question in neural information processing is how neurons cooperate to transmit information. To study this question, we resort to the concept of redundancy in the information transmitted by a group of neurons and, at the same time, we introduce a novel concept for measuring cooperation between pairs of neurons called relative mutual information (RMI). Specifically, we studied these two parameters for spike trains generated by neighboring neurons from the primary visual cortex in the awake, freely moving rat. The spike trains studied here were spontaneously generated in the cortical network, in the absence of visual stimulation. Under these conditions, our analysis revealed that while the value of RMI oscillated slightly around an average value, the redundancy exhibited a behavior characterized by a higher variability. We conjecture that this combination of approximately constant RMI and greater variable redundancy makes information transmission more resistant to noise disturbances. Furthermore, the redundancy values suggest that neurons can cooperate in a flexible way during information transmission. This mostly occurs via a leading neuron with higher transmission rate or, less frequently, through the information rate of the whole group being higher than the sum of the individual information rates-in other words in a synergetic manner. The proposed method applies not only to the stationary, but also to locally stationary neural signals.

[Acute kidney injury]. / Insuficiencia renal aguda.

Acute kidney injury (AKI) is defined as an abrupt decline in the glomerular filtration rate with accumulation of nitrogenous waste products and the inability to maintain fluid and electrolyte homeostasis. Occurring in 7% of all hospitalized patients and 28% to 35% of those in intensive care units, AKI increases hospital mortality. Early evaluation should include differentiating prerenal and postrenal components from intrinsic renal disease. Biological markers can give early warning of AKI and assist with differential diagnosis and assessment of prognosis. The most effective preventive measure is to maintain adequate circulation and cardiac output, avoiding ischemia- or nephrotoxin-induced injury. To that end, patients and situations of risk must be identified, hemodynamics and diuresis monitored, hypovolemia reversed, and nephrotoxins avoided. Protective agents such as sodium bicarbonate, mannitol, prostagiandins, calcium channel blockers, N-acetyl-L-cysteine, sodium deoxycholate, allopurinol, and pentoxifylline should be used. Treatment includes the elimination of prerenal and postrenal causes of AKI; adjustment of doses according to renal function; avoidance of both overhydration and low arterial pressure; maintenance of electrolytic balance, avoiding hyperkalemia and correcting hyperglycemia; and nutritional support, assuring adequate protein intake. For severe AKI, several modalities of renal replacement therapy, differentiated by mechanism and duration, are available. Timing--neither the best moment to start dialysis nor the optimal duration--has been not established. Early detection of AKI is necessary for preventing progression and starting renal replacement therapy at adjusted doses that reflect metabolic requirements.

Diploma on Ultrasound training and competency for Intensive Care and Emergency Medicine: Consensus document of the Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES). / Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la definición de competencias mínimas de ecografía en Cuidados Intensivos y Urgencias y la obtención del Diploma acreditativo.

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.