Evaluation of Quality of Recovery With Quality of Recovery-15 Score After Closed-Loop Anesthesia Delivery System-Guided Propofol Versus Desflurane General Anesthesia in Patients Undergoing Transabdominal Robotic Surgery: A Randomized Controlled Study.

BACKGROUND: Robotic technique of surgery allows surgeons to perform complex procedures in difficult-to-access areas of the abdominal/pelvic cavity (eg, radical prostatectomy and radical hysterectomy) with improved access and precision approach. At the same time, automated techniques efficiently deliver propofol total intravenous anesthesia (TIVA) with lower anesthetic consumption. As both above are likely to bring benefit to the patients, it is imperative to explore their effect on postanesthesia recovery. Quality of Recovery-15 (QoR-15) is a comprehensive patient-reported measure of the quality of postanesthesia recovery and assesses compendious patients' experiences (physical and mental well-being). This randomized study assessed the effect of automated propofol TIVA versus inhaled desflurane anesthesia on postoperative quality of recovery using the QoR-15 questionnaire in patients undergoing elective robotic surgery. METHODS: One hundred twenty patients undergoing robotic abdominal surgery under general anesthesia (GA) were randomly allocated to receive propofol TIVA administered by closed-loop anesthesia delivery system (CLADS) (CLADS group) or desflurane GA (desflurane group). Postoperative QoR-15 score on postoperative day 1 (POD-1) and postoperative day 2 (POD-2) (primary outcome variables), individual QoR-15 item scores (15 nos.), intraoperative hemodynamics (heart rate, mean blood pressure), anesthesia depth consistency, anesthesia delivery system performance, early recovery from anesthesia (time-to-eye-opening, and time to tracheal extubation), and postoperative adverse events (sedation, postoperative nausea and vomiting [PONV], pain, intraoperative awareness recall) (secondary outcome variables) were analyzed. RESULTS: On POD-1, the CLADS group scored significantly higher than the desflurane group in terms of "overall" QoR-15 score (QoR-15 score: 114.5 ± 13 vs 102.1 ± 20.4; P = .001) and 3 individual QoR-15 "items" scores ("feeling rested" 7.5 ± 1.9 vs 6.4 ± 2.2, P = .007; "good sleep" 7.8 ± 1.9 vs 6.6 ± 2.7, P = .027; and "feeling comfortable and in control" 8.1 ± 1.7 vs 6.9 ± 2.4, P = .006). On the POD-2, the CLADS group significantly outscored the desflurane group with respect to the "overall" QoR-15 score (126.0 ± 13.6 vs 116.3 ± 20.3; P = .011) and on "5" individual QoR-15 items ("feeling rested" 8.1 ± 1.4 vs 7.0 ± 2.0, P = .003; "able to return to work or usual home activities" 6.0 ± 2.2 vs 4.6 ± 2.6, P = .008; "feeling comfortable and in control" 8.6 ± 1.2 vs 7.7 ± 1.9, P = .004; "feeling of general well-being" 7.8 ± 1.6 vs 6.9 ± 2.0, P = .042; and "severe pain" 9.0 ± 1.9 vs 8.1 ± 2.5, P = .042). CONCLUSIONS: Automated propofol TIVA administered by CLADS is superior to desflurane inhalation GA with respect to early postoperative recovery as comprehensively assessed on the QoR-15 scoring system. The effect of combined automated precision anesthesia and surgery (robotics) techniques on postoperative recovery may be explored further.

Evaluation of Automated Delivery of Propofol Using a Closed-Loop Anesthesia Delivery System in Patients Undergoing Thoracic Surgery: A Randomized Controlled Study.

OBJECTIVE: Automated propofol total intravenous anesthesia (TIVA) administered by a closed-loop anesthesia delivery system (CLADS) exhibits greater efficiency than conventional manual methods, but its use in major thoracic surgery is limited. DESIGN: Prospective, single-blind, randomized controlled study. SETTING: Single-center tertiary care hospital. PARTICIPANTS: Patients undergoing thoracic surgery. INTERVENTIONS: Patients were randomly allocated to receive CLADS-driven (CLADS group) or manually controlled (manual group) propofol TIVA. MEASUREMENTS AND MAIN RESULTS: Anesthesia depth consistency (primary objective) and anesthesia delivery performance, propofol usage, work ergonomics, intraoperative hemodynamics, and recovery profile (secondary objectives) were analyzed. No differences were found for anesthesia depth consistency (percentage of time the bispectral index was within ± 10 of target) (CLADS group: 82.5% [78.5%-87.2%] v manual group: 86.5% [74.2%-92.5%]; p = 0.581) and delivery performance, including median performance error (CLADS group: 3 [-4 to 6] v manual group: 1 [-2.5 to 6]); median absolute performance error (CLADS group: 10 [10-12] v manual group:10 [8-12]); wobble (CLADS group: 10 [8-12] v manual group: 9 [6-10.5]); and global score (CLADS group: 24.2 [21.2-29.3] v manual group: 22.1 [17.3-32.3]) (p > 0.05). However, propofol requirements were significantly lower in the CLADS group for induction (CLADS group: 1.27 ± 0.21] mg/kg v manual group: 1.78 ± 0.51 mg/kg; p = 0.014) and maintenance (CLADS group: 4.02 ± 0.99 mg/kg/h v manual group: 5.11 ± 1.40 mg/kg/h; p = 0.025) of TIVA. Ergonomically, CLADS-driven TIVA was found to be significantly superior to manual control (infusion adjustment frequency/h) (manual infusion: 9.6 [7.8-14.9] v CLADS delivery [none]). CONCLUSIONS: In thoracic surgery patients, CLADS-automated propofol TIVA confers significant ergonomic advantage along with lower propofol usage.

A Review of Complications Due to the Use of Botulinum Toxin A for Cosmetic Indications.

BACKGROUND: Botulinum toxin A (botulinum toxin A) was found to provide a wide variety of therapeutic and aesthetic benefits as one of the most potent toxins in the world. Injectable remedies, including soft tissue fillers and botulinum toxin, have become very common in wrinkling and face rejuvenation management. While these methods of treatment are relatively safe, serious side effects can occur. In this review, the complications of BoNTA are highlighted. METHODS: A literature research considered published journal articles (clinical trials or scientific reviews). Electronic databases (PubMed, Scopus, Science Direct) were searched using key terms, and for identification of additional relevant studies, reference lists have also been examined. Only articles published in English were included in this review with a time restriction from 2000 to 2020. RESULTS: There are various injection-related adverse effects associated (AE) with botulinum toxins such as erythema, oedema, pain, ptosis of eyelid or brow and ecchymosis. The overall majority of adverse events identified are mild and temporary. CONCLUSION: As the use of toxins becomes increasingly more common, adverse events can be expected to increase as well. The practitioners need to be aware of such AEs, and the patients should be informed of these before undertaking such procedures. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Onabotulinumtoxin Type A Dosage for Upper Face Expression Lines in Males: A Systematic Review of Current Recommendations.

BACKGROUND: Botulinum toxin injection is the most commonly performed minimally invasive aesthetic procedure in men. Despite various recommendations by experts on the use of onabotulinumtoxin type A in the literature, distinct guidelines for its use in males and females do not exist. OBJECTIVES: The aim of this study was to delineate safe and effective doses for the use of onabotulinumtoxin type A in males for correction of upper facial expression lines. METHODS: PubMed (MEDLINE), Embase, the Cochrane database, and Google Scholar were searched from 2002 to 2019 inclusive. Three researchers independently assessed trials for inclusion, extracted data, checked for accuracy, and assessed the evidence with AGREE II. RESULTS: Average dosing recommended for the treatment of upper face expression lines was specific to glabellar frown lines, crow's feet, and horizontal forehead lines. Changing trends and gender variation was noted in each of the studies. Six of the 11 recommendations suggest the need to alter dosing in male patients, although do not give separate recommendations. CONCLUSIONS: There is an urgent need for up-to-date recommendations for the use of onabotulinumtoxin type A in upper face expression lines of male patients.

The Effect of Dexmedetomidine on Propofol Requirements During Anesthesia Administered by Bispectral Index-Guided Closed-Loop Anesthesia Delivery System: A Randomized Controlled Study.

BACKGROUND: Dexmedetomidine, a selective α2-adrenergic agonist currently approved for continuous intensive care unit sedation, is being widely evaluated for its role as a potential anesthetic. The closed-loop anesthesia delivery system (CLADS) is a method to automatically administer propofol total intravenous anesthesia using bi-spectral index (BIS) feedback and attain general anesthesia (GA) steady state with greater consistency. This study assessed whether dexmedetomidine is effective in further lowering the propofol requirements for total intravenous anesthesia facilitated by CLADS. METHODS: After ethics committee approval and written informed consent, 80 patients undergoing elective major laparoscopic/robotic surgery were randomly allocated to receive GA with propofol CLADS with or without the addition of dexmedetomidine. Quantitative reduction of propofol and quality of depth-of-anesthesia (primary objectives), intraoperative hemodynamics, incidence of postoperative adverse events (sedation, analgesia, nausea, and vomiting), and intraoperative awareness recall (secondary objectives) were analyzed. RESULTS: There was a statistically significant lowering of propofol requirement (by 15%) in the dexmedetomidine group for induction of anesthesia (dexmedetomidine group: mean ± standard deviation 0.91 ± 0.26 mg/kg; nondexmedetomidine group: 1.07 ± 0.23 mg/kg, mean difference: 0.163, 95% CI, 0.04-0.28; P = .01) and maintenance of GA (dexmedetomidine group: 3.25 ± 0.97 mg/kg/h; nondexmedetomidine group: 4.57 ± 1.21 mg/kg/h, mean difference: 1.32, 95% CI, 0.78-1.85; P < .001). The median performance error of BIS control, a measure of bias, was significantly lower in dexmedetomidine group (1% [-5.8%, 8%]) versus nondexmedetomidine group (8% [2%, 12%]; P = .002). No difference was found for anesthesia depth consistency parameters, including percentage of time BIS within ±10 of target (dexmedetomidine group: 79.5 [72.5, 85.3]; nondexmedetomidine group: 81 [68, 88]; P = .534), median absolute performance error (dexmedetomidine group: 12% [10%, 14%]; nondexmedetomidine group: 12% [10%, 14%]; P = .777), wobble (dexmedetomidine group: 10% [8%, 10%]; nondexmedetomidine group: 8% [6%, 10%]; P = .080), and global score (dexmedetomidine group: 25.2 [23.1, 35.8]; nondexmedetomidine group: 24.7 [20, 38.1]; P = .387). Similarly, there was no difference between the groups for percentage of time intraoperative heart rate and mean arterial pressure remained within 20% of baseline. However, addition of dexmedetomidine to CLADS propofol increased the incidence of significant bradycardia (dexmedetomidine group: 14 [41.1%]; nondexmedetomidine group: 3 [9.1%]; P = .004), hypotension (dexmedetomidine group: 9 [26.5%]; nondexmedetomidine group: 2 [6.1%]; P = .045), and early postoperative sedation. CONCLUSIONS: The addition of dexmedetomidine to propofol administered by CLADS was associated with a consistent depth of anesthesia along with a significant decrease in propofol requirements, albeit with an incidence of hemodynamic depression and early postoperative sedation.

Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.

Various organisations and experts have published numerous statements and recommendations regarding different aspects of sports-related concussion including definition, presentation, treatment, management and return to play guidelines. 1-7 To date, there have been no written consensus statements specific for combat sports regarding management of combatants who have suffered a concussion or for return to competition after a concussion. In combat sports, head contact is an objective of the sport itself. Accordingly, management and treatment of concussion in combat sports should, and must, be more stringent than for non-combat sports counterparts.The Association of Ringside Physicians (an international, non-profit organisation dedicated to the health and safety of the combat sports athlete) sets forth this consensus statement to establish management guidelines that ringside physicians, fighters, referees, trainers, promoters, sanctioning bodies and other healthcare professionals can use in the ringside setting. We also provide guidelines for the return of a combat sports athlete to competition after sustaining a concussion. This consensus statement does not address the management of moderate to severe forms of traumatic brain injury, such as intracranial bleeds, nor does it address the return to competition for combat sports athletes who have suffered such an injury. These more severe forms of brain injuries are beyond the scope of this statement. This consensus statement does not address neuroimaging guidelines in combat sports.

A Validation Study of Freezing of Gait (FoG) Detection and Machine-Learning-Based FoG Prediction Using Estimated Gait Characteristics with a Wearable Accelerometer.

One of the most common symptoms observed among most of the Parkinson's disease patients that affects movement pattern and is also related to the risk of fall, is usually termed as "freezing of gait (FoG)". To allow systematic assessment of FoG, objective quantification of gait parameters and automatic detection of FoG are needed. This will help in personalizing the treatment. In this paper, the objectives of the study are (1) quantification of gait parameters in an objective manner by using the data collected from wearable accelerometers; (2) comparison of five estimated gait parameters from the proposed algorithm with their counterparts obtained from the 3D motion capture system in terms of mean error rate and Pearson's correlation coefficient (PCC); (3) automatic discrimination of FoG patients from no FoG patients using machine learning techniques. It was found that the five gait parameters have a high level of agreement with PCC ranging from 0.961 to 0.984. The mean error rate between the estimated gait parameters from accelerometer-based approach and 3D motion capture system was found to be less than 10%. The performances of the classifiers are compared on the basis of accuracy. The best result was accomplished with the SVM classifier with an accuracy of approximately 88%. The proposed approach shows enough evidence that makes it applicable in a real-life scenario where the wearable accelerometer-based system would be recommended to assess and monitor the FoG.

Development of Ocular Delivery System for Glaucoma Therapy Using Natural Hydrogel as Film Forming Agent and Release Modifier.

BACKGROUND: Glaucoma is characterized by increased intraocular pressure, which results in damage to the optic nerve. The existing therapy with conventional eye drops is inefficient due to nasolachrymal drainage, resulting in a reduced corneal residence of the drug. OBJECTIVES: The objective was to develop controlled-release ocular films of timolol maleate using natural hydrogel from Tamarindus indica seeds as a sustaining and film-forming agent, to overcome the problems associated with eye drops. MATERIAL AND METHODS: The hydrogel was isolated using hot aqueous extraction followed by precipitation with ethanol. Six batches of ocular films were prepared and evaluated for drug content, weight variation, thickness, diameter and in vitro release profile. The ideal batch of the films was subjected to stability, pharmacodynamic and ocular safety studies. RESULTS: The yield of the hydrogel was 58.29%. The thickness of the ocular films was in the range of 0.17 to 0.25 mm and the weight of the films was found to increase with the increase in polymer content. The drug release from the films was found to be controlled over a period of 8 h. The films were found to be stable and were able to reduce the intraocular pressure for 24 h in a more efficient manner than the eye drops. The films were found to be practically non-irritating to the eye. CONCLUSIONS: It can be concluded that the hydrogel from tamarind seeds can be used as a film-forming and release-controlling agent for the development of an ocular drug delivery system for the effective therapy of glaucoma.

Care of The Older Fighter: Position Statement of the Association of Ringside Physicians.

Older Fighters are defined as combat sports athletes older than 35 years, based on heightened medical risks and historical classification. Age-related changes to the neurological, cardiopulmonary, endocrinological, thermoregulatory, osmoregulatory, and musculoskeletal systems increase these athletes' risks for injury and may prolong their recovery. These age-related risks warrant special considerations for competition, licensure, prefight medical clearance, in-fight supervision, post-fight examination, and counseling regarding training practices and retirement from combat sports. Neurological considerations include increased risk of intracranial lesions, intracranial hemorrhage, and sequelae from traumatic brain injury (TBI), warranting more comprehensive neurological evaluation and neuroimaging. Increased risk of myocardial ischemia and infarction warrant careful assessment of cardiac risk factors and scrutiny of cardiovascular fitness. Older fighters may take longer time to recover from musculoskeletal injury; post-injury clearance should be individualized.

Real-World Study of Definisse Threads for Facial Reshaping in Indian Patients: REDEFINE FACE Study.

INTRODUCTION: In recent years, thread lifting has gained popularity as a less invasive cosmetic surgery. It helps raise and realign sagging tissue. The newest thread type for thread lifting procedure is poly-lactic acid-polycaprolactone (PLCL) Definisse threads (RELIFE S.r.l., Florence, Italy). These are fourth-generation absorbable suspended barbed threads. Their double action involves an immediate elevating impact through mechanical action and, over time, the promotion of histological rejuvenating activity through inducing fibroblasts and the synthesis of elastin, hyaluronic acid, and collagen. OBJECTIVES: The REDEFINE FACE study assessed the effectiveness and tolerance of Definisse threads in a real-world setting for facial reshaping in patients in India. METHODS: This multicenter, retrospective observational research included patients treated with Definisse threads for face contouring. RESULTS: Three hundred seventeen patients with a mean follow-up of 4.9 months and an average age of 48.6 years participated in the study. All patients underwent thread lifts using either a single or a combination of Definisse thread reshaping techniques. The Global Aesthetic Improvement Scale for Physicians and Subjects (PGAIS and SGAIS) reported improvement instantly following the treatment (mean score- 3.23 and 3.18, respectively). Improvements continued to enhance during the follow-up visits (mean score- 4.09 and 4.03, respectively). Following the procedure, 96% of patients on the PGAIS and SGAIS exhibited enhancement. Most procedure-related side effects were minor and went away on their own in a few days without the need for proactive care. CONCLUSION: The results of this real-world analysis showed that the latest Definisse threads effectively achieve facial reshaping on patients in India and have both immediate and long-term effects. Treatment was generally well tolerated, and no patient experienced serious adverse events.

Asymptomatic elevation of liver enzymes due to levetiracetam: a case report.

Levetiracetam is a commonly used broad-spectrum anticonvulsant efficacious in both partial and generalized seizures. It has an extremely favorable side effect profile with few drug-drug interactions, low potential for hematological and hepatic toxicity, and thus has rapidly become the preferred drug in patients with traumatic brain injuries who need seizure prophylaxis. We report, here, a patient who was started on levetiracetam for seizure prophylaxis after developing large bifrontal-parietal traumatic subdural hematomas (SDH) following a fall from a horse necessitating bifrontal craniotomies for evacuation. The patient developed an asymptomatic elevation of the liver enzymes. The liver enzymes trended back to normal after levetiracetam was stopped, and topiramate was initiated in its place.

Curriculum Innovations: Developing an EEG Workshop for Hands-on Training in Electroencephalography During Resident Rotation in Clinical Neurophysiology.

A 3-hour hands-on EEG workshop was conducted as a part of resident rotation in clinical neurophysiology to determine its feasibility and educational value for neurology residents, medical students, and EEG technologists, with the learning objectives of motivating interest in clinical electroencephalography, enhancing ability to recognize a normal EEG and identify physiological and non-physiological artifacts, and enhancing teaching, organizational and communication skills of EEG technologists. The workshop included a demonstration of EEG electrode placement according to the 10-20 System on a resident volunteer by the EEG technologist. Activation procedures (photic stimulation and hyperventilation) were demonstrated to the residents during the 25-minute recording. A board-certified epileptologist later reviewed the record with the residents. Resident and EEG technologist feedback on the workshop was obtained via non-formal e-mail request. All residents rated the workshop highly and found it more engaging and motivating than the didactic EEG lecture in which basics of EEG recording are reviewed. The residents gained improved awareness and appreciation of the role of the technologist and the skill and time involved in obtaining an EEG record. The EEG technologist appreciated the face-to-face interaction with the residents and felt part of the patient care team. A hands-on EEG workshop as a part of resident clinical neurophysiology rotation is feasible, effective, and motivating in teaching residents and medical students the basis of EEG recording and recognition of common physiological and non-physiological artifacts in a normal record.