Delta sleep-inducing peptide alters bispectral index, the electroencephalogram and heart rate variability when used as an adjunct to isoflurane anaesthesia.

BACKGROUND AND OBJECTIVE: Delta sleep-inducing peptide (DSIP) is an endogenous peptide that crosses the blood-brain barrier, named after its association with natural sleep and enhanced electroencephalogram (EEG) delta rhythm. The objective of this study was to determine whether DSIP could be used as an adjunct to volatile anaesthesia in humans, our hypothesis being that DSIP is a natural hypnotic that would increase anaesthetic depth. The aims were to assess depth of anaesthesia using bispectral index (BIS), the EEG and heart rate variability (HRV), and to determine whether DSIP altered the symmetry of EEG between the left and right cerebral hemispheres. METHODS: Twenty-four female ASA I or II patients gave written, informed consent to a protocol approved by our local research ethics committee. Twelve were randomly assigned as controls to receive saline. The other 12 were randomly allocated to receive one of three intravenous bolus doses of DSIP (Clinalfa) at 25, 50 or 100 nmol kg(-1). The first administration of DSIP was while awake and the second after induction of anaesthesia with propofol and maintenance with isoflurane. BIS and EEG parameters were measured continuously using a bilateral electrode montage. RESULTS: DSIP significantly increased heart rate, decreased HRV and, paradoxically, significantly reduced delta rhythm along with reducing burst suppression and increasing BIS at 25 nmol kg(-1) during isoflurane anaesthesia. DSIP also significantly altered bilateral symmetry of EEG. CONCLUSION: DSIP probably reduced parasympathetic tone and decreased (lightened) the depth of anaesthesia measured using BIS.

The vagus nerve as a conduit for neuroinvasion, a diagnostic tool, and a therapeutic pathway for transmissible spongiform encephalopathies, including variant Creutzfeld Jacob disease.

It is hypothesised that the vagus nerve (cranial nerve X) is an important conduit for infective neuroinvasion during the incubation of certain transmissible spongiform encephalopathies (TSEs) including scrapie in sheep, variant Creutzfeld Jacob disease in humans, chronic wasting disease in deer, and bovine spongiform encephalopathy in cattle. Presence of infection in the brainstem will disrupt normal function of this important region responsible for autonomic control of visceral function via the vagus nerve. It is proposed that physiological study of disrupted vagal function using techniques such as heart rate variability will indicate early, and ongoing, functional signs of infection even before levels of abnormal prion protein reach the thresholds currently used in tests for the presence of TSEs. It is further suggested that repeated measures of vagal function during treatment with experimental therapies will give a non-invasive, repeated measures index of drug efficacy. In addition, pharmaceutical interventions directed via the vagus nerve will bypass the blood brain barrier and take an anatomical route appropriate to the treatment of TSEs.

Management of proximal interphalangeal joint injuries.

Injuries about the PIP joint of the finger are commonly encountered by primary care physicians and are associated with significant morbidity, including pain, stiffness, instability, premature degenerative arthritis, and residual deformities. An accurate understanding of the regional anatomy and appreciation of the mechanism of injury allows for classification so that a treatment protocol can be formulated for each injury pattern. Emphasis on careful consideration of the implications of open reduction, rational splinting, and early, active, protected motion provides for the most favorable outcome.

The impact of increasing oximetry usage in India: A pilot study.

The overall goal of the global oximetry (GO) project was to increase patient safety during anaesthesia and surgery in low and middle income countries by decreasing oximetry costs and increasing oximetry utilisation. Results from the overall project have been previously published. This paper reports specifically on pilot work undertaken in four hospitals in one Indian State. The aim of this work was to assess the impact of increasing oximetry provision in terms of benefits to anaesthetists and in the identification of patient problems during anaesthesia, to identify training needs and to explore perceptions regarding barriers to more comprehensive oximetry coverage. Data collection was by interview with hospital staff, use of a log-book to capture data on desaturation episodes and a follow-up questionnaire at 10 months after the introduction of additional oximeters. Increasing oximetry utilisation in the four hospitals was viewed positively by the anaesthetic staff and enabled improvement in monitoring patients. Of the 939 monitored patients studied, 214 patients (23%) experienced a total of 397 desaturation episodes. For nearly half of the patients undergoing caesarean section under regional anaesthesia following a desaturation event supplementary oxygen was required. In 53 of the 379 female sterilisations (14%) desaturation episodes occurred and in eight patients, there were 17 episodes of desaturation due to obstruction. In the recovery room, 91 of the 939 patients were monitored using the oximeters with 12 patients (13%) requiring oxygen. This study has highlighted that pulse oximetry must be used even in patients having surgical procedures or caesarean section under regional or local anaesthesia as these procedures are associated with hypoxic episodes. Anaesthetists must ensure they are complying with the Indian Society of Anaesthesiologists monitoring standards for anaesthesia and ensure patients are monitored by pulse oximetry.

New model for learning ultrasound-guided needle to target localization.

BACKGROUND AND OBJECTIVES: The acquisition of technical skills for the novice learner presents challenges for students and teachers alike. With the introduction of ultrasound techniques in regional anesthesia, there has been interest from residents, fellows, and staff to acquire the skills necessary to incorporate this technology into their everyday practice. However, as both ultrasound machines and commercial target models are inherently costly, there are often issues of accessibility that may affect the opportunity to learn the desired skills. METHODS: Readily available extra-firm tofu, wood dowel, and electrical wire are easily composed to create models for learning ultrasound-guided needle manipulation. RESULTS: Wood and wire targets embedded in tofu present hypo- and hyper-echoic targets that allow the learner to appreciate the relationship between the two-dimensional ultrasound screen image and three-dimensional target planes. CONCLUSIONS: This report presents an inexpensive, variable complexity model for learning ultrasound-guided needle-to-target localization.

Research audit and publication.

The ethics of research, audit and publication have developed mainly within the last fifty years. The Declaration of Helsinki is the universally accepted code of conduct for researchers worldwide. All research has to be approved by an ethics committee, all of which are governed by a centralised structure which is the Central Office for Research Ethics Committees (COREC) in the UK. This standardised system has been developed to oversee all research activity across the whole of Europe and every European county will have an equivalent organisation. The committees concern themselves with research but the differences between audit and research are difficult to discern in many places. If there is any doubt then the advice of the local research ethics committee should be sought. Only the individual him/herself can give consent. This may produce difficulties in cases of certain groups especially unconscious patients and children. The outcome of every study should be published whatever the results and the ongoing development of centralised (national) research trial databases will promote this philosophy. Publication of results thought to be of lesser importance may prove difficult, however, and so there is a temptation to falsify or modify data to make it more attractive. This, together with other activities such as the fabrication of data, plagiarism, dual publication, salami publication, conflicts of interest and irregularities in authorship, have given Editors of journals a number of problems. Many of these issues around publication ethics may prove difficult to detect but the fear of sanctions from employers and professional organisations is a useful deterrent.