Identifying behaviors that characterize emergence delirium: An observational study.

BACKGROUND: Diagnostic criteria for emergence agitation are sensitive but not specific; they misclassify patients who are angry or upset as having emergence delirium. AIMS: The aim of this three-phase study was to determine expert agreement on the behaviors that differentiate children with emergence delirium from those without. METHODS: In the first phase of this observational study, pediatric dental patients were video recorded while awakening from anesthesia. In the second phase, salient 10 s segments of the recordings showing patient activity were shown to an expert audience of pediatric dentists, anesthesiologists and Post Anesthetic Care nurses, who scored the recordings as showing or not showing "true emergence delirium." In phase 3, the video segments were assessed by three research assistants using a behavior checklist for features that discriminate between those scored "true emergence delirium" and those scored "NOT true emergence delirium" by the experts. RESULTS: One hundred and fifty-four pediatric dental patients were included. Subsequently, an expert audience consisting of 10 anesthesiologists, 12 anesthesiology residents, 3 pediatric dentists, and 4 experienced Post Anesthesia Care Unit nurses rated each 10-second video segment. This resulted in three groups of patients: a group for whom all experts agreed was "True emergence delirium" (n = 33; CI 21 to 45), a group for whom all agreed was "Not True emergence delirium" (n = 120; CI 107 to 133), and a group where experts disagreed (n = 11; CI 4 to 18). Three research assistants then completed a behavior checklist for each of the 33 "True emergence delirium" video segments and matched "Not True" controls. Twenty-four behaviors were identified as significantly different between videos scored True emergence delirium and those scored Not True emergence delirium. Research assistants reached almost perfect agreement (0.81-1.00) on one behavior, and substantial agreement (0.61-0.80) on seven behaviors that characterized "True emergence delirium." CONCLUSIONS: Eight behaviors that differentiate pediatric dental patients with emergence delirium from those without were found. These discriminators may be used to develop a scale that will lead to better diagnosis and treatment of emergence delirium.

Neurosurgical Consequences of e-Scooter Use: Strategies to Prevent Neurological Injury.

Rideshare electric scooter accidents have led to increasing emergency department (ED) visits and neurosurgical consultations. This study categorizes e-scooter-related injuries requiring neurosurgical consultation at a single level 1 trauma center. Patients who required neurosurgical consultation from June 2019 to June 2021 with a positive finding on computed tomography imaging were selected for review of patient and injury characteristics, resulting in a sample size of 50 cases. Average patient age was 36.9 (15-69) years, and 70% were male. Seventy-four percent of patients were under the influence of alcohol and 12% illicit drugs. None (0%) were helmeted. Seventy-eight percent of accidents occurred between 6:00 pm and 6:00 am. Twenty-two percent of patients required surgical intervention by craniotomy/craniectomy, and 4% required intracranial pressure monitor placement. Average intracranial hemorrhage volume was 17.8 cc (trace to 125). Volume of hemorrhage was associated with the need for an intensive care unit (ICU) stay (odds ratio [OR] = 1.01; p = 0.04), need for surgical intervention (OR = 1.007; p = 0.0001), and mortality (1.816; p < 0.001) and trended toward, but did not reach significance for, overall poor outcome (OR = 1.63; p = 0.06). Sixty-two percent of this patient pool required ICU admission. Average length of ICU stay was 3.5 days (0-35), and average length of hospital stay was 8.3 days (0-82). Mortality in this series was 8%. Lower admission Glasgow Coma Scale (OR = 0.974; p < 0.001) and increased volume of hemorrhage (OR = 1.816; p < 0.001) were associated with increased risk of mortality in the linear regression analysis. Electric scooters have become prevalent in most urban centers, and accidents are a potential source of severe intracranial injury requiring extended ICU and hospital stays, surgical intervention, and sometimes resulting in long-term morbidity and/or mortality. Injuries often occur in the evening hours and are often associated with alcohol/drug use and lack of helmet use. Policy changes to help mitigate the risk of these injuries are recommended.

Assessment of the reliability of virtual preanesthetic airway evaluation compared to traditional in-person airway evaluation: a prospective observational study.

PURPOSE: Airway evaluation is a fundamental component of the preanesthetic examination. Virtual care has increased during the COVID-19 pandemic. We aimed to assess the reliability of a virtual preanesthetic airway evaluation compared with a traditional in-person airway evaluation. METHODS: This prospective observational study compared the inter-rater agreement of an in-person airway evaluation performed by a consultant anesthesiologist with a virtual airway evaluation (VAE) performed by consultant anesthesiologists and medical students. The airway evaluation was completed using a comprehensive airway evaluation and scoring tool. The primary outcome was the inter-rater agreement of total scores between in-person anesthesiologist airway evaluations and the VAEs of both the anesthesiologists and medical students, assessed using Cohen's Kappa (CK). Secondary outcomes included the inter-rater agreement for each airway evaluation component between the in-person anesthesiologists and both the anesthesiologist and medical student VAEs, assessed using prevalence-adjusted and bias-adjusted Kappa. RESULTS: One hundred out of 111 participants completed all three evaluations. The in-person anesthesiologist airway evaluations had fair and good levels of agreement of total scores with the VAEs of the anesthesiologists (CK, 0.21; 97.5% confidence interval [CI], 0.07 to 0.34) and the medical students (CK, 0.74; 97.5% CI, 0.62 to 0.86), respectively. One participant was reported to have a difficult intubation. CONCLUSION: Virtual airway evaluations performed by anesthesiologists and medical students had fair and good inter-rater agreement, respectively, with in-person anesthesiologist airway evaluations. Further study with a focus on patients with difficult airways is required to define the predictive value of VAEs regarding difficult intubations.

RéSUMé: OBJECTIF: L'évaluation des voies aériennes constitue un élément fondamental de l'examen préanesthésique. Les soins prodigués virtuellement ont augmenté pendant la pandémie de COVID-19. Nous avons tenté d'évaluer la fiabilité d'une évaluation préanesthésique virtuelle des voies aériennes par rapport à une évaluation traditionnelle en personne. MéTHODE: Cette étude observationnelle prospective a comparé la concordance inter-observateurs d'une évaluation des voies aériennes en personne effectuée par un anesthésiologiste avec une évaluation virtuelle des voies aériennes (EVVA) réalisée par des anesthésiologistes et des étudiants en médecine. L'évaluation des voies aériennes a été réalisée à l'aide d'un outil d'évaluation et de notation des voies aériennes. Le critère d'évaluation principal était la concordance inter-observateurs des scores totaux entre les évaluations des voies aériennes réalisées par des anesthésiologistes en personne et les EVVA effectuées par des anesthésiologistes et des étudiants en médecine, évaluée à l'aide du coefficient Kappa de Cohen (CK). Les critères d'évaluation secondaires comprenaient la concordance inter-observateurs pour chaque composante de l'évaluation des voies aériennes entre les anesthésiologistes en personne et les anesthésiologistes et étudiants en médecine ayant réalisé les EVVA, évaluée à l'aide d'un coefficient de Kappa ajusté pour la prévalence et les biais. RéSULTATS: Cent des 111 participants ont complété les trois évaluations. Les évaluations des voies aériennes par des anesthésiologistes en personne présentaient des niveaux de concordance des scores totaux fidèles et bons par rapport aux EVVA réalisées par les anesthésiologistes (CK, 0,21; intervalle de confiance [IC] à 97,5 %, 0,07 à 0,34) et les étudiants en médecine (CK, 0,74; IC 97,5 %, 0,62 à 0,86), respectivement. Une intubation difficile a été rapportée pour un participant. CONCLUSION: Les évaluations virtuelles des voies aériennes réalisées par des anesthésiologistes et des étudiants en médecine avaient une concordance inter-observateurs fidèle et bonne avec les évaluations des voies aériennes réalisées en personne par des anesthésiologistes. Des recherches plus approfondies axées sur les patients présentant une prise en charge difficile des voies aériennes sont nécessaires pour définir la valeur prédictive des EVVA dans un contexte d'intubations difficiles.

Soleus H and Lower Limb Posterior Root Muscle Reflexes During Stepping After Incomplete SCI.

The goal of this study was to examine and compare the step cycle related modulation of the soleus H and posterior root muscle (PRM) reflexes in subjects with and without spinal cord injury. Ten subjects without neurological injury and fifteen subjects with spinal cord injury (SCI) underwent soleus H reflex and lower limb PRM reflex testing while standing and stepping in a robotic gait orthosis. Reflex amplitudes were evaluated during standing, mid stance and mid swing to determine if speed and/or injury altered step cycle related neuromodulation. H and PRM reflexes in the soleus underwent step cycle related modulation in injured and uninjured subjects though the degree of modulation differed between the two reflexes with the H reflex showing more step cycle related modulation. We found in the SCI group that both the soleus H and soleus PRM reflex amplitudes were higher relative to the non-injured group and modulated less during the step cycle. We also found that modulation of the soleus H reflex, but not soleus PRM reflex, correlated to the lower extremity motor scores in individuals with SCI. Our evidence suggests that the inability to provide appropriate step cycle related reflex modulation may be due to decreased supra-spinal regulation of motoneuron and spinal excitability and could be an indicator of the severity of injury as it relates to clinically measured lower extremity motor scores.

Spinal cord tethering after selective dorsal rhizotomy below the conus medullaris.

BACKGROUND: Two techniques for selective dorsal rhizotomy (SDR) involve stimulating and sectioning nerve rootlets either below the conus medullaris or above the entrances to their respective dural root sleeves. In general, both techniques lead to sustained improvements in lower extremity spasticity with low complication rates. To our knowledge, spinal cord tethering has not been previously reported as a complication of SDR using either technique. METHODS: We review the presentation, treatment, and outcome of two patients who developed symptomatic spinal cord tethering after SDR below the conus. RESULTS: A 4-year-old male and a 6-year-old female each with a history of spastic diparetic cerebral palsy underwent L1-L2 osteoplastic laminectomy and SDR below the conus. Both surgeries went well with no known complications. Both patients initially did well, with marked improvement in their tone and gait. There were no significant immediate postoperative bowel or bladder problems. The male patient presented 10 months after surgery with new-onset urinary incontinence. A urological evaluation was performed but no imaging was performed. He re-presented 8 months later with worsened urinary incontinence, new fecal incontinence, and worsened gait. An MRI showed signs of tethering, including a holocord syrinx. He underwent two untethering surgeries as well syrinx fenestration, and although his gait improved, it remained worse than it had been several months after surgery. The incontinence did not improve. The second patient also developed urinary incontinence a year after SDR. Due to our experience with the first patient, we obtained an MRI immediately and found evidence of tethering. She underwent untethering and her incontinence improved. CONCLUSION: We report two cases of spinal cord tethering after SDR below the conus, a previously unreported complication. It is important to realize that this complication can occur after SDR.

MicroRNA Analysis of Human Stroke Brain Tissue Resected during Decompressive Craniectomy/Stroke-Ectomy Surgery.

BACKGROUND: Signaling pathways mediated by microRNAs (miRNAs) have been identified as one of the mechanisms that regulate stroke progression and recovery. Recent investigations using stroke patient blood and cerebrospinal fluid (CSF) demonstrated disease-specific alterations in miRNA expression. In this study, for the first time, we investigated miRNA expression signatures in freshly removed human stroke brain tissue. METHODS: Human brain samples were obtained during craniectomy and brain tissue resection in severe stroke patients with life-threatening brain swelling. The tissue samples were subjected to histopathological and immunofluorescence microscopy evaluation, next generation miRNA sequencing (NGS), and bioinformatic analysis. RESULTS: miRNA NGS analysis detected 34 miRNAs with significantly aberrant expression in stroke tissue, as compared to non-stroke samples. Of these miRNAs, 19 were previously identified in stroke patient blood and CSF, while dysregulation of 15 miRNAs was newly detected in this study. miRNA direct target gene analysis and bioinformatics approach demonstrated a strong association of the identified miRNAs with stroke-related biological processes and signaling pathways. CONCLUSIONS: Dysregulated miRNAs detected in our study could be regarded as potential candidates for biomarkers and/or targets for therapeutic intervention. The results described herein further our understanding of the molecular basis of stroke and provide valuable information for the future functional studies in the experimental models of stroke.

A performance comparison of the most commonly used minimally invasive monitors of cardiac output.

BACKGROUND: Shock is common in critically ill and injured patients. Survival during shock is highly dependent on rapid restoration of tissue oxygenation with therapeutic goals based on cardiac output (CO) optimization. Despite the clinical availability of numerous minimally invasive monitors of CO, limited supporting performance data are available. METHODS: Following approval of the University of Saskatchewan Animal Research Ethics Board, we assessed the performance and trending ability of PiCCOplus™, FloTrac™, and CardioQ-ODM™ across a range of CO states in pigs. In addition, we assessed the ability of invasive mean arterial blood pressure (iMAP) to follow changes in CO using a periaortic transit-time flow probe as the reference method. Statistical analysis was performed with function-fail, bias and precision, percent error, and linear regression at all flow, low-flow (> 1 standard deviation [SD] below the mean), and high-flow (> 1 SD above the mean) CO conditions. RESULTS: We made a total of 116,957 paired CO measurements. The non-invasive CO monitors often failed to provide a CO value (CardioQ-ODM: 40.6% failed measurements; 99% confidence interval [CI], 38.5 to 42.6; FloTrac: 9.6% failed measurements; 99% CI, 8.7 to 10.5; PiCCOplus: 4.7% failed measurements; 99% CI, 4.5 to 4.9; all comparisons, P < 0.001). The invasive mean arterial pressure provided zero failures, failing less often than any of the tested CO monitors (all comparisons, P < 0.001). The PiCCOplus was most interchangeable with the flow probe at all flow states: PiCCOplus (20% error; 99% CI, 19 to 22), CardioQ-ODM (25% error; 99% CI, 23 to 27), FloTrac (34% error; 99% CI, 32 to 38) (all comparisons, P < 0.001). At low-flow states, CardioQ-ODM (43% error; 99% CI, 32 to 63) and Flotrac (45% error; 99% CI, 33 to 70) had similar interchangeability (P = 0.07), both superior to PiCCOplus (48% error; 99% CI, 42 to 60) (P < 0.001). Regarding CO trending, the CardioQ-ODM (correlation coefficient, 0.82; 99% CI, 0.81 to 0.83) was statistically superior to other monitors including iMAP, but at low flows iMAP (correlation coefficient, 0.58; 99% CI, 0.58 to 0.60) was superior to all minimally invasive CO monitors (all comparisons P < 0.001). CONCLUSIONS: None of the minimally invasive monitors of CO performed well at all tested flows. Invasive mean arterial blood pressure most closely tracked CO change at critical flow states.

RéSUMé: CONTEXTE: L'état de choc est fréquent chez les patients blessés et en urgence absolue. La survie pendant le choc dépend fortement de la restauration rapide de l'oxygénation tissulaire avec des objectifs thérapeutiques basés sur l'optimisation du débit cardiaque (DC). Malgré la disponibilité clinique de nombreux moniteurs minimalement invasifs du DC, il n'existe que des données limitées sur leur performance pour appuyer leur utilisation. MéTHODE: À la suite de l'approbation du comité d'éthique de la recherche animale de l'Université de la Saskatchewan, nous avons évalué la performance et la capacité de suivi des tendances des appareils PiCCOplus™, FloTrac™ et CardioQ-ODM™ sur une vaste gamme d'état de DC chez des cochons. Nous avons également évalué la capacité de la tension artérielle moyenne invasive (iMAP) à suivre les changements de DC en utilisant une sonde périaortique de débit basée sur le temps de transit comme méthode de référence. L'analyse statistique a été réalisée avec fonction-échec, biais et précision, pourcentage d'erreur et régression linéaire à des conditions de DC de tous les débits, de faible débit (> 1 écart-type [ET] au-dessous de la moyenne) et de débit élevé (> 1 ET au-dessus de la moyenne). RéSULTATS: Nous avons effectué un total de 116 957 mesures de DC appariées. Les moniteurs non invasifs de la DC n'ont souvent pas réussi à fournir une valeur de DC (CardioQ-ODM : 40,6% de mesures échouées; intervalle de confiance [IC] de 99 %, 38,5 à 42,6; FloTrac : 9,6 % de mesures échouées; IC 99 %, 8,7 à 10,5; PiCCOplus : 4,7 % de mesures échouées; IC 99 %, 4,5 à 4,9; toutes les comparaisons, P < 0,001). La tension artérielle moyenne invasive n'a fourni aucun échec plus souvent que n'importe lequel des moniteurs de DC testés (toutes les comparaisons, P < 0,001). Le PiCCOplus était le plus interchangeable avec la sonde de débit à tous les états de débit : PiCCOplus (erreur de 20 %; IC 99 %, 19 à 22), CardioQ-ODM (erreur de 25 %; IC 99 %, 23 à 27), FloTrac (erreur de 34 %; IC 99 %, 32 à 38) (toutes les comparaisons, P < 0,001). Aux états de débit faible, les moniteurs CardioQ-ODM (erreur de 43 %; IC 99 %, 32 à 63) et FloTrac (erreur de 45 %; IC 99 %, 33 à 70) présentaient une interchangeabilité similaire (P = 0,07), tous deux supérieurs au PiCCOplus (erreur de 48 %; IC 99 %, 42 à 60) (P < 0,001). En ce qui concerne le suivi des tendances de DC, le CardioQ-ODM (coefficient de corrélation, 0,82; IC 99 %, 0,81 à 0,83) était statistiquement supérieur aux autres moniteurs, y compris au iMAP, mais à faibles débits, l'iMAP (coefficient de corrélation, 0,58; IC 99 %, 0,58 à 0,60) était supérieure à tous les moniteurs de DC minimalement invasifs (toutes les comparaisons, P < 0,001). CONCLUSION: Aucun des moniteurs de DC minimalement invasif n'a donné de bons résultats à tous les débits testés. La tension artérielle moyenne invasive était le moniteur qui a suivi de plus près les changements de DC dans des états critiques de débit.

A comparison of methods used to secure pediatric endotracheal tubes using a live human dermal model.

BACKGROUND: Endotracheal intubation is a common lifesaving procedure. An in situ endotracheal tube (ETT) must be secured in position to avoid displacement and potentially life-threatening complications. Adhesive tapes form the most common intraoperative ETT stabilization methods. Limited published data are available to guide the clinical decision regarding ETT taping method. We performed an interventional study aiming to establish which of many commonly employed ETT tape/supplementary adhesive methods provides the most resistance to ETT distraction. METHODS: An experiment was undertaken to measure the force required to distract an ETT secured to a live dermal model with 24 different ETT securing methods comprising six types of tape alone and in combination with one of three supplementary adhesives. The primary measurement was the peak force (Newtons) required to distract a secured ETT 3 cm. RESULTS: A total of 1,164 measurements were made. The mean force required to distract the ETT ranged from 7.8 to 21.8 Newtons. The combination of Cloth Adhesive™ + Mastisol® had the greatest observed mean distraction force, as well as the greatest estimated lower and upper confidence limits. CONCLUSIONS: There are significant differences in force required to distract an ETT based on taping methods.

RéSUMé: CONTEXTE: L'intubation endotrachéale est une intervention critique courante. Le tube endotrachéal (TET) in situ doit être fixé en position adéquate pour éviter qu'il ne se déplace et provoque des complications potentiellement fatales. Les bandes adhésives sont la méthode de stabilisation peropératoire de TET la plus fréquemment utilisée. Il n'existe que peu de données publiées pour guider la décision clinique quant à la méthode de fixation du TET. Nous avons réalisé une étude interventionnelle visant à établir laquelle des nombreuses méthodes couramment employées de bandes adhésives ou de méthodes adhésives supplémentaires du TET procurait la meilleure protection contre un déplacement du TET. MéTHODE: Une expérience a été menée pour mesurer la force nécessaire à déplacer/déloger un TET fixée à un modèle de derme vivant avec 24 méthodes différentes de sécurisation du TET, comprenant six types de ruban adhésif seuls et en combinaison avec l'un de trois adhésifs supplémentaires. La mesure principale était la force maximale (en newton) nécessaire pour déplacer un TET sécurisée de 3 cm. RéSULTATS: Au total, 1164 mesures ont été effectuées. La force moyenne requise pour déplacer le TET allait de 7,8 à 21,8 newtons. La combinaison du ruban Cloth Adhesive™ + Mastisol® a entraîné la plus grande force de déplacement moyenne observée, ainsi que les plus grandes limites inférieure et supérieure estimées des intervalles de confiance. CONCLUSION: Il existe des différences significatives dans la force nécessaire pour déplacer un TET en fonction des méthodes de fixation utilisées.

Transfusion Use and Hemoglobin Levels by Blood Conservation Method After Cardiopulmonary Bypass.

BACKGROUND: Guidelines recommend modified ultrafiltration (MUF) and cell washing for blood conservation after cardiopulmonary bypass (CPB), although information on outcomes is lacking. This research compared online MUF (ultrafiltration of the patient's entire circulating volume) with off-line MUF (ultrafiltration of the residual CPB volume) and centrifugation (cell washing of the residual CPB volume). METHODS: This prospective cohort study enrolled 99 consecutive patients, grouped by method (group I, online MUF, n = 35; group II, off-line MUF, n = 30; group III, centrifugation, n = 34). Primary outcome was transfusion by 18 hours. Secondary outcomes were 18-hour hemoglobin levels, fluid balance (weight change), and biomarker levels indicating coagulation and organ function. RESULTS: By 18 hours, 22.9%, 6.7%, and 14.7% of group I, II, and III patients, respectively, had undergone transfusion (P = .19). Percentage weight gain differed by group (group I, 5.7%; group II, 1.3%; group III, 4.5%; P < .0001). Baseline to 18-hour hemoglobin change also differed by group, with the group I increase significantly exceeding that of group II (P = .002) but not differing from group III (P = .36). After adjustment for European System for Cardiac Operative Risk Evaluation II (EuroSCORE), weight gain, and transfusion, only the group II to III difference remained significant (P = .002). CONCLUSIONS: Online MUF does not appear to offer a reduction in blood transfusion over other methods. Although patients undergoing online MUF had greater improvement in baseline to 18-hour hemoglobin compared with patients undergoing off-line MUF, this benefit appeared attributable to fluid shifting. Off-line MUF was associated with the least frequent transfusions. Although online MUF does not appear to reduce blood transfusion, larger prospective randomized controlled studies are required for confirmation.

Comparative Efficacy of Commonly Available Human Bone Graft Substitutes as Tested for Posterolateral Fusion in an Athymic Rat Model.

BACKGROUND: Insufficient data exist on bone graft substitute materials efficacy; two thirds lack any clinical data.1,2 This prospective animal study identified efficacy differences among commercially available materials of several classes. METHODS: Historically validated muscle pouch osteoinduction study (OIS) and posterolateral fusion (PLF) were performed in an athymic rat model. Grafting material products implanted were demineralized bone matrix (DBM)-based allografts (Accell EVO3, DBX Mix, DBX Strip, Grafton Crunch, Grafton Flex, Grafton Matrix, Grafton Putty, Magnifuse, and Progenix Plus), allografts (OsteoSponge, MinerOss), cellular allograft (Osteocel Plus), ceramics (Mozaik Strip), or activated ceramics (Actifuse ABX Putty, Vitoss BA). After 4 weeks, OIS specimens were evaluated ex vivo by histologic osteoinductivity. After 8 weeks, PLF ex vivo specimens were evaluated for fusion by manual palpation (FMP), radiography (FXR), and histology (FHISTO). RESULTS: OIS: No materials exhibited a rejection reaction on histology. All DBM-based materials exhibited osteoinductive potential as new bone formation at > 88% of implanted sites. One plain allograft (OsteoSponge) formed bone at 25% of sites. No bone formed for one ceramic (Mozaik Strip), three activated ceramics (Actifuse ABX Putty), or one cellular allograft, regardless of human bone marrow aspirate (hBMA) when added. PLF: Among the 10 DBMs, 6 had FMP of 100% (Accell EVO3, DBX Mix, DBX Strip, Grafton Flex, Grafton Putty, Magnifuse), 2 had FMP of 94% (Grafton Crunch, Grafton Matrix), and 2 conditions had FMP of 0% (Progenix Plus, Progenix Plus + athymic rat iliac crest bone graft [arICBG]). Ceramics (Mozaik Strip), activated ceramics (Actifuse ABX Putty, Vitoss BA), plain allograft (OsteoSponge, MinerOss (PLF study), and cellular allograft (Osteocel Plus) demonstrated 0% FMP. ArICBG demonstrated 13% FMP. CONCLUSIONS: Eight DBM-based materials (Accell EVO3, DBX Mix, DBX Strip, Grafton Crunch, Grafton Flex, Grafton Matrix, Grafton Putty, Magnifuse) demonstrated excellent (> 90% FMP) efficacy in promoting fusion via bone healing. Two DBM conditions (Progenix Plus, Progenix Plus + arICBG) showed no manual palpation fusion (FMP). Systematically, over the 2 studies (OIS and PLF), cellular (Osteocel Plus), plain allografts (OsteoSponge, MinerOss; PLF study), ceramic (Mozaik Strip), and activated ceramics (Actifuse ABX Putty, Vitoss BA) demonstrated poor FMP efficacy (< 10%). CLINICAL RELEVANCE: When selecting DBMs, clinicians must be cognizant of variability in DBM efficacy by product and lot. While theoretically osteoinductive, cellular allograft and activated ceramics yielded poor in vivo efficacy. Whole allograft and ceramics may provide osteoconductive scaffolding for mixed-material grafting; however, surgeons should be cautious in using them alone. Direct clinical data are needed to establish efficacy for any bone graft substitute.

Preoperative oral methadone for postoperative pain in patients undergoing cardiac surgery: A randomized double-blind placebo-controlled pilot.

Background: Inadequately controlled sternotomy pain after cardiac surgery can lead to delayed recovery and patient suffering. Preoperative intravenous methadone is effective for reducing both postoperative pain and opioid consumption. Despite ease of administration, the effects of preoperative oral methadone are not well described in the literature. Aims: This pilot study investigated the effect of preoperative oral methadone on pain scores, analgesia requirements, and opioid-induced side effects. Methods: A randomized double-blind placebo-controlled model was used with sampling of patients undergoing sternotomy for isolated coronary artery bypass graft (CABG) surgery (ClinicalTrials.gov registration no. NCT02774499). Participants were randomized to receive oral methadone (0.3 mg/kg) or oral placebo prior to entering the operating room. The primary outcome was pain scores on a 0-10 Verbal Rating Scale. Secondary outcomes included morphine requirements using patient-controlled analgesia (PCA), time to extubation, level of sedation, and side effects such as nausea, vomiting, pruritus, hypoventilation, and hypoxia over a 72-h monitoring time. Results: Twenty-one patients completed the study. Oral methadone did not reduce pain scores in the methadone group (P = 0.08). However, postoperative morphine requirement during the first 24 h was reduced by a mean of 23 mg in the methadone group (mean difference, -23; 99% confidence interval [CI], 37-13 mg; P < 0.005). No reduction in pain scores or PCA morphine was observed beyond 24 h postoperatively. There was no difference in incidence of opioid-related side effects between groups throughout the postoperative period. Conclusions: Though preoperative oral methadone did not reduce pain scores, morphine requirements were reduced in the first 24 h post-CABG.

Surveys of post-operative pain management in a teaching hospital in Rwanda - 2013 and 2017.

Background: Postoperative pain management (POPM) appeared to be weak in Rwanda. Aims: The aim of this study was to compare POPM measures in a teaching hospital between 2013 and 2017. Methods: A two-phase observational study in 2013 and 2017. was conducted. Participants were recruited prior to major surgery and followed for two postoperative days. A numerical rating scale (0-10) was administered to all participants in both years, and the International Pain Outcomes questionnaire was administered in 2017. Recruitment, consent, and data collection were performed in participants' preferred language. Results: One hundred adult participants undergoing major general, gynecologic, orthopedic, or urologic surgery were recruited in 2013 and 83 were recruited in 2017. Fourteen percent of participants in 2013 and 46% in 2017 scored their worst pain as severe (>6; P < 0.001). This was despite improved preoperative recognition of patients at high risk for severe postoperative pain (those with chronic pain or preoperative pain); 27% and 0% of these patients were not documented in 2013 and 2017, respectively (P = 0.006). Other measures of improved planning included "any preoperative discussion of POPM" (P < 0.001) and "discussion of POPM options" (P = 0.002). Preemptive analgesia use increased (3% of participants in 2013 and 54% in 2017; P < 0.001). Incidence of participants having no postoperative analgesic at all decreased from 25% in 2013 to 5% in 2017 (P < 0.001). Conclusions: Though severe postoperative pain incidence did not improve from 2013 to 2017, POPM improved by a number of measures. These changes may be attributed to pain research conducted there having raised awareness.

Contexte : La prise en charge de la douleur postopératoire (POPM) semblait faible au Rwanda.Objectifs : Comparer les mesures de prise en charge de la douleur postopératoire dans un hôpital d'enseignement entre 2013 et 2017.Méthodes : Étude observationnelle en deux phases réalisée en 2013 et 2017; les participants ont été recrutés avant de subir une chirurgie majeure et ont été suivis pendant deux jours après l'opération. Une échelle de notation numérique (0 à 10) a été administrée à tous les participants les deux années, tandis que le questionnaire International Pain Outcomes a été administré en 2017. Le recrutement, le consentement et toutes les collectes de données se sont déroulés dans la langue préférée par les participants.Résultats : Cent participants adultes ayant subi une chirurgie générale, gynécologique, orthopédique ou urologique majeure ont été recrutés en 2013; 83 en 2017. Quatorze pour cent des participants ont qualifié leur pire douleur de sévère (> 6) en 2013, et 46 % en 2017 (p = 0,001). Cela est survenu malgré l'amélioration de la reconnaissance préopératoire des patients à haut risque de douleur postopératoire sévère (ceux atteints de douleur chronique ou de douleur préopératoire); 27 % de ces patients n'ont pas été documentés en 2013 ; 0 % en 2017, p < 0,006. Parmi les autres mesures de planification améliorée, mentionnons « toute discussion préopératoire de la prise en charge de la douleur postopératoire ¼ (p < 0,001) et « la discussion des options de prise en charge de la douleur postopératoire ¼ (p < 0,002). L'utilisation préventive de l'analgésie a augmenté (3 % des participants en 2013; 54 % en 2017; p < 0,001). L'incidence des participants n'ayant reçu aucun analgésique postopératoire est passée de 25 % en 2013 à 5 % en 2017 (p < 0,001).Conclusions : Bien que l'incidence de la douleur postopératoire sévère ne se soit pas améliorée de 2013 à 2017, la prise en charge de la douleur postopératoire a été améliorée par un certain nombre de mesures. Ces changements peuvent être attribués au fait que la recherche sur la douleur menée là-bas a permis une plus grande sensibilisation.

Respiratory muscle activation patterns during maximum airway pressure efforts are different in women and men.

Maximum inspiratory and expiratory pressure values (PImax and PEmax) are indirect measures of respiratory muscle strength that, in healthy adults, are known to be significantly lower in women compared to men. In part, sex differences in breathing kinematics, lung size, body composition, muscle mass, and muscle fiber composition are thought to be responsible for these effects. However, it is not known whether respiratory muscle activation during maximum respiratory efforts is also sex-specific. In this study, we addressed whether respiratory multi-muscle activation patterns during PImax and PEmax efforts are different between healthy women and men. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), PImax, PEmax, and surface electromyographic (sEMG) activity recorded from respiratory muscles during these maximum airway pressure efforts were obtained in 13 women and 11 men. Percent predicted values of FVC and FEV1 were not significantly different in these two groups (women vs. men: 112 ± 14 vs. 105 ± 15%, p = 0.29; and 92 ± 12 vs. 93 ± 13, p = 0.82, Mean ± SD, respectively), while PImax and PEmax measures were significantly lower in women compared to men (68 ± 16 vs. 88 ± 19 cmH2O, p = 0.011; and 69 ± 13 vs. 94 ± 17, p = 0.0004, respectively). Using vector-based methodology, by calculating the Similarity Index (SI) as measure of the resemblance between two sEMG patterns and the Magnitude (Mag) representing the overall amount sEMG during motor task, we have found that although the Mag values for both PImax and PEmax tasks were not significantly different in two groups, the SIs revealed significant sex-dependent differences in muscle activation patterns (0.89 ± 0.08 vs. 0.97 ± 0.02, p = 0.016; and 0.77 ± 0.11 vs. 0.92 ± 0.04, p = 0.0006, respectively). During the PImax effort, presented as the percentage of total sEMG amplitude, activity of upper trapezius muscle was significantly larger (p = 0.001) while activation of rectus abdominus, oblique, and lower paraspinal muscles were significantly smaller (p = 0.002, p = 0.040, p = 0.005, respectively) in women when compared to the men (50 ± 21 vs. 22 ± 11%; 2 ± 2 vs. 8 ± 7; 4 ± 3 vs. 9 ± 7, 2 ± 3 vs. 7 ± 6, respectively). During PEmax effort, the percentage of sEMG activity were significantly larger in upper and lower trapezius, and intercostal muscles (p = 0.038, p = 0.049, p = 0.037, respectively) and were significantly smaller in pectoralis, rectus abdominus, and oblique muscles (p = 0.021, p < 0.0001, p = 0.048, respectively) in women compared to men (16 ± 10 vs. 9 ± 4%; 16 ± 9 vs. 8 ± 5; 36 ± 12 vs. 25 ± 9; 6 ± 3 vs. 15 ± 5; 14 ± 5 vs. 20 ± 7, respectively). These findings indicate that respiratory muscle activation patterns during maximum airway pressure efforts in healthy individuals are sex-specific. This information should be considered during respiratory motor control evaluation and treatment planning for people with compromised respiratory motor function.

Author Correction: The experience of spasticity after spinal cord injury: perceived characteristics and impact on daily life.

There is an author correction associated with this article.