Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery.

BACKGROUND: Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS: This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS: A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS: This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.

A Survey Study of Surgeons and Anesthesiologists Regarding Perioperative Multimodal Analgesia for Opioid-Tolerant Patients.

PURPOSE: Perioperative pain management of opioid-tolerant patients can be challenging. Although regional anesthesia and multimodal analgesics may be beneficial, these modalities are often underused. It is unclear whether practice patterns for perioperative pain management are determined by the knowledge, attitudes, and beliefs of surgeons and anesthesiologists. DESIGN: Descriptive survey. METHODS: Using a Qualtrics survey, we polled a randomly selected group of 25 surgeons and 25 anesthesiologists regarding their knowledge, attitudes, beliefs, and practices for pain management in an opioid-tolerant patient. FINDINGS: Of 25, 23 anesthesiologists and 18/25 surgeons responded to the survey. Demographics were similar between the 2 groups. Most of the participant surgeons and anesthesiologists believed that pain management may be challenging in an opioid-tolerant patient. However, only 56% of surgeons would recommend a preoperative pain consultation. Most surgeons and anesthesiologists believed in the efficacy of regional anesthetics. However, 43% of surgeons would not advocate for a regional block, perhaps due to their perception of the added perioperative time. Multimodal analgesics were widely accepted by both surgeons and anesthesiologists. CONCLUSIONS: There is an urgent need to reinforce the importance of patient-centered care, with a specific focus on addressing knowledge gaps and improving perceptions for all the members of the team, including surgeons, anesthesiologists, and perioperative nursing teams, if optimal outcomes are to be achieved for our patients.

Comparison between the Rotational Thromboelastometry (ROTEM) Delta device against the Cartridge-based Thromboelastography 6s and Quantra in a healthy third trimester pregnant cohort.

Rotational Thromboelastometry (ROTEM) Delta has been described in several postpartum hemorrhage algorithms, but this device requires pipetting and careful mixing of reagents to initiate the clotting reaction. In contrast, thromboelastography (TEG 6s) and the Quantra devices operate utilizing an automated pre-mixed cartridge that only requires a blood sample to start the clot strength analysis. We compared the correlation between 3 point of care viscoelastic testing (POCVT) devices to laboratory Clauss fibrinogen and platelets, their inter-device correlation, and the total running time difference between Quantra and ROTEM. A high correlation was noted between the Clauss fibrinogen and the fibrinogen parameters from ROTEM (r = 0.76-0.84, P < 0.0001), TEG6s (r = 0.71, P < 0.0001) and Quantra (r = 0.72, P = 0.0001). A moderate correlation between laboratory platelets and the ROTEM (r = 0.54;0.45, P < 0.0001; P = 0.0013) and Quantra (r = 0.66, P = 0.0001) parameters was noted. The inter-device correlation showed to be high when comparing the fibrinogen parameters of TEG6s and Quantra to that of ROTEM (r = 0.88 and 0.74, P < 0.0001, respectively). In contrast, a moderate correlation was noted between the platelet parameters of Quantra and ROTEM (r = 0.51, p = 0.0036). The Quantra device resulted 20.9 min (95% CI -0.2 to 4.7, P = 0.07) faster than the ROTEM if the warming and pipetting of reagents of the latter were considered. All the POCVT devices demonstrated a high correlation to laboratory Clauss fibrinogen, making each beneficial for the early recognition and management of hypofibrinogenemia.

Muscular Tissue Oxygen Saturation and Posthysterectomy Nausea and Vomiting: The iMODIPONV Randomized Controlled Trial.

BACKGROUND: Suboptimal tissue perfusion and oxygenation during surgery may be responsible for postoperative nausea and vomiting in some patients. This trial tested the hypothesis that muscular tissue oxygen saturation-guided intraoperative care reduces postoperative nausea and vomiting. METHODS: This multicenter, pragmatic, patient- and assessor-blinded randomized controlled (1:1 ratio) trial was conducted from September 2018 to June 2019 at six teaching hospitals in four different cities in China. Nonsmoking women, 18 to 65 yr old, and having elective laparoscopic surgery involving hysterectomy (n = 800) were randomly assigned to receive either intraoperative muscular tissue oxygen saturation-guided care or usual care. The goal was to maintain muscular tissue oxygen saturation, measured at flank and on forearm, greater than baseline or 70%, whichever was higher. The primary outcome was 24-h postoperative nausea and vomiting. Secondary outcomes included nausea severity, quality of recovery, and 30-day morbidity and mortality. RESULTS: Of the 800 randomized patients (median age, 50 yr [range, 27 to 65]), 799 were assessed for the primary outcome. The below-goal muscular tissue oxygen saturation area under the curve was significantly smaller in patients receiving muscular tissue oxygen saturation-guided care (n = 400) than in those receiving usual care (n = 399; flank, 50 vs. 140% · min, P < 0.001; forearm, 53 vs. 245% · min, P < 0.001). The incidences of 24-h postoperative nausea and vomiting were 32% (127 of 400) in the muscular tissue oxygen saturation-guided care group and 36% (142 of 399) in the usual care group, which were not significantly different (risk ratio, 0.89; 95% CI, 0.73 to 1.08; P = 0.251). There were no significant between-group differences for secondary outcomes. No harm was observed throughout the study. CONCLUSIONS: In a relatively young and healthy female patient population, personalized, goal-directed, muscular tissue oxygen saturation-guided intraoperative care is effective in treating decreased muscular tissue oxygen saturation but does not reduce the incidence of 24-h posthysterectomy nausea and vomiting.

Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery.

BACKGROUND: Residual neuromuscular block has been associated with postoperative pulmonary complications. We hypothesised that sugammadex reduces postoperative pulmonary complications in patients aged ≥70 yr having surgery ≥3 h, compared with neostigmine. METHODS: Patients were enrolled in an open-label, assessor-blinded, randomised, controlled trial. At surgical closure, subjects were equally randomised to receive sugammadex 2 mg kg-1 or neostigmine 0.07 mg kg-1 (maximum 5 mg) for rocuronium reversal. The primary endpoint was incidence of postoperative pulmonary complications. Secondary endpoints included residual paralysis (train-of-four ratio <0.9 in the PACU) and Phase 1 recovery (time to attain pain control and stable respiratory, haemodynamic, and neurological status). The analysis was by intention-to-treat. RESULTS: Of the 200 subjects randomised, 98 received sugammadex and 99 received neostigmine. There was no significant difference in the primary endpoint of postoperative pulmonary complications despite a signal towards reduced incidence for sugammadex (33% vs 40%; odds ratio [OR]=0.74; 95% confidence interval [CI]=[0.40, 1.37]; P=0.30) compared with neostigmine. Sugammadex decreased residual neuromuscular block (10% vs 49%; OR=0.11, 95% CI=[0.04, 0.25]; P<0.001). Phase 1 recovery time was comparable between sugammadex (97.3 min [standard deviation, sd=54.3]) and neostigmine (110.0 min [sd=62.0]), difference -12.7 min (95% CI, [-29.2, 3.9], P=0.13). In an exploratory analysis, there were fewer 30 day hospital readmissions in the sugammadex group compared with the neostigmine group (5% vs 15%; OR=0.30, 95% CI=[0.08, 0.91]; P=0.03). CONCLUSIONS: In older adults undergoing prolonged surgery, sugammadex was associated with a 40% reduction in residual neuromuscular block, a 10% reduction in 30 day hospital readmission rate, but no difference in the occurrence of postoperative pulmonary complications. Based on this exploratory study, larger studies should determine whether sugammadex may reduce postoperative pulmonary complications and 30 day hospital readmissions. CLINICAL TRIAL REGISTRATION: NCT02861131.

Evaluation of the slurry management strategy and the integration of the composting technology in a pig farm - Agronomical and environmental implications.

The changes in livestock production systems towards intensification frequently lead to an excess of manure generation with respect to the agricultural land available for its soil application. However, treatment technologies can help in the management of manures, especially in N-surplus areas. An integrated slurry treatment system based on solid-liquid separation, aerobic treatment of the liquid and composting the solid fraction was evaluated in a pig farm (sows and piglets) in the South of Spain. Solid fraction separation using a filter band connected to a screw press had low efficiency (38%), which was greatly improved incorporating a rotatory sieve (61%). The depuration system was very efficient for the liquid, with total removal of 84% total solids, 87% volatile solids, and 98% phosphorus. Two composting systems were tested through mechanical turning of: 1- a mixture of solid fraction stored for 1 month after solid-liquid separation and cereal straw; 2- recently-separated solid fraction mixed with cotton gin waste. System 2 was recommended for the farm, as it exhibited a fast temperature rise and a long thermophilic phase to ensure compost sanitisation, and high recovery of nutrients (TN 77%, P and K > 85%) and organic matter (45%). The composts obtained were mature, stable and showed a high degree of humification of their organic matter, absence of phytotoxicity and concentrations of nutrients similar to other composts from pig manure or separated slurry solids. However, the introduction of slurry from piglets into the solid-liquid separation system should be avoided in order to reduce the content of Zn in the compost, which lowers its quality. The slurry separation followed by composting of the solid fraction using a passive windrow system, and aeration of the liquid phase, was the most recommendable procedure for the reduction of GHG emissions on the farm.

Relationship of pain relief with catastrophizing following interventional pain procedures for low back pain.

INTRODUCTION: Catastrophizing is associated with worse pain outcomes after various procedures suggesting its utility in predicting response. However, the stability of pain catastrophizing as a static predictor has been challenged. We assess, among patients undergoing steroid injections for chronic low back pain (cLBP), whether catastrophizing changes with the clinical response to pain interventions. METHODS: This prospective study enrolled patients undergoing fluoroscopic-guided injections for cLBP. Patients filled out Brief Pain Inventory (BPI) and Pain Catastrophizing Scale (PCS) at baseline and 1-month follow-up. We assessed the change in PCS scores from pre-injection to post-injection and examined its predictors. We also examined the correlation of various domains of BPI, such as pain severity and effect on Relationships, Enjoyment, and Mood (REM), with PCS scores at baseline and follow-up. RESULTS: 128 patients were enrolled. Mean (SD) PCS and pain severity scores at baseline were 22.38 (±13.58) and 5.56 (±1.82), respectively. Follow-up PCS and pain severity scores were 19.76 (±15.25) and 4.42 (±2.38), respectively. The change in PCS pre-injection to post-injection was not significant (p=0.12). Multiple regression models revealed baseline PCS and REM domain of BPI as the most important predictors of change in PCS after injection. Pain severity, activity-related pain, age, sex, insurance status, depression, prior surgery, opioid use, or prior interventions did not predict change in PCS score. In correlation analysis, change in PCS was moderately correlated with change in pain (r=0.38), but weakly correlated with baseline pain in all pain domains. CONCLUSIONS: PCS showed non-significant improvement following steroid injections; the study was not powered for this outcome. Follow-up PCS scores were predicted by the REM domain of BPI, rather than pain severity. Larger studies are needed to evaluate a statistically significant and clinically meaningful change in catastrophizing scores following pain interventions.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. BACKGROUND: There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. METHODS: The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. RESULTS: Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes. CONCLUSIONS: Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Weight loss after diagnosis with gestational diabetes and birth weight among overweight and obese women.

To determine if, among overweight or obese women with gestational diabetes (GDM), weight loss after GDM diagnosis is associated with lower infant birth weight within levels of overweight or obesity class. Overweight and obese women with singleton pregnancies managed for GDM at a large diabetes and pregnancy program located in Charlotte, NC between November 2000 and April 2010, were eligible for this retrospective cohort study. All were managed using a rigorous standardized clinical protocol. Clinical information including maternal pre-pregnancy body mass index, gestational weight gain, treatment, and medical and obstetric history was abstracted from medical records. The association of weight loss after GDM diagnosis and birth weight was analyzed using linear regression stratified by maternal pre-pregnancy overweight or obesity class (I, II/III). Of the 322 women in this study 19 % lost weight between diagnosis of GDM and delivery. After adjustment for maternal age, parity, race/ethnicity, gestational week at first hemoglobin A1c (A1C), A1C at diagnosis, weight gain prior to GDM, treatment with insulin or oral hypoglycemic agents, gestational age at delivery, and infant sex, weight loss was associated with 238.3 g lower mean infant birth weight among overweight women (95 % CI -393.72, -82.95 g), but was not associated with lower mean infant birth weight among obese class II/III women (95 % CI -275.61, 315.38 g). Weight loss, after diagnosis of GDM, is associated with lower infant birth weight among overweight women, but not among obese class II/III women.

Risk of spontaneous preterm birth in relation to maternal exposure to intimate partner violence during pregnancy in Peru.

Intimate partner violence (IPV) is increasingly recognized as an important cause of maternal and perinatal morbidity. We assessed the relation between IPV and risk of spontaneous preterm birth (PTB) among Peruvian women. The study was conducted among 479 pregnant women who delivered a preterm singleton infant (<37 weeks gestation) and 480 controls (≥37 weeks gestation). Participants' exposure to physical and emotional violence during pregnancy was collected during in-person interviews conducted after delivery and while patients were in hospital. Odds ratios (aOR) and 95 % confidence intervals (CI) were estimated from logistic regression models. The prevalence of any IPV during pregnancy was 52.2 % among cases and 34.6 % among controls. Compared with those reporting no exposure to IPV during pregnancy, women reporting any exposure had a 2.1-fold increased risk of PTB (95 % CI 1.59-2.68). The association was attenuated slightly after adjusting for maternal age, pre-pregnancy weight, and other covariates (OR = 1.99; 95 % CI 1.52-2.61). Emotional abuse in the absence of physical violence was associated with a 1.6-fold (95 % CI 1.21-2.15) increased risk of PTB. Emotional and physical abuse during pregnancy was associated with a 4.7-fold increased risk of PTB (95 % CI 2.74-7.92). Associations of similar directions and magnitudes were observed when PTB were sub-categorized according to clinical presentation or severity. IPV among pregnant women is common and is associated with an increased risk of PTB. Our findings and those of others support recent calls for coordinated global health efforts to prevent violence against women.

Risk of spontaneous preterm birth in relation to maternal depressive, anxiety, and stress symptoms.

OBJECTIVE: To examine the risk of preterm birth (PTB) in relation to maternal psychiatric symptoms during pregnancy in Peruvian women. STUDY DESIGN: This case-control study included 479 PTB cases and 480 term controls. In-person interviews were conducted to assess women's depressive, anxiety, and stress symptoms using the Patient Health Questionnaire (PHQ-9) and the Depression Anxiety Stress Scales (DASS-21). Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Compared with women reporting no or minimal depressive symptoms, the aOR (95% CI) for PTB associated with consecutive severity of depressive symptoms based on the PHQ-9 assessment method were as follows: mild, 2.22 (95% CI 1.64-3.00) and moderate-severe, 3.67 (95% CI 2.09-6.46). The corresponding aORs for normal, mild, and moderate-severe depressive symptoms based on the DASS-21 assessment were 1.00 (reference), 3.82 (95% CI 1.90-7.66), and 2.90 (95% CI 1.66-5.04), respectively. A positive gradient was observed for the odds of PTB with severity of anxiety (Ptrend < 0.001) and stress symptoms (Ptrend < 0.001). CONCLUSION: The odds of PTB increased in pregnant Peruvian women with psychiatric symptoms. Efforts to screen and treat affected women may modify risks of PTB and possibly other associated disorders.

Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities.

Background: Point-of-care testing provides a representation of the patient's coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods: The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results: A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions: Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.

Antenatal haemoglobin A1c and risk of large-for-gestational-age infants in a multi-ethnic cohort of women with gestational diabetes.

Gestational diabetes mellitus (GDM) is a risk factor for delivering a large-for-gestational-age (LGA) infant. Haemoglobin A1c (A1C) is an indicator of glycaemic control. The objective of this study was to test whether higher A1C quartile at the time of diagnosis of GDM is associated with increased risk of delivering a LGA or macrosomic infant. Women with singleton pregnancies treated for GDM at a large diabetes and pregnancy programme located in Charlotte, North Carolina, were eligible for inclusion in this retrospective cohort study. Clinical information, including A1C at diagnosis, treatment, prior medical and obstetric history, and birth data were abstracted from medical records. LGA was defined as birthweight >90th percentile for gestational age and sex and macrosomia as birthweight >4000 g. Logistic regression was used to analyse the association of A1C at GDM diagnosis with risk of delivering LGA or macrosomic infants. This study included 502 women. Prevalences of LGA and macrosomia were 4% and 6% respectively. After adjustment there was no detectable trend of increased risk for LGA (P for trend = 0.12) or macrosomia (P for trend = 0.20) across increasing quartiles of A1C at GDM diagnosis. A1C at GDM diagnosis may not be linearly associated with LGA or macrosomia, possibly because of the mediating effect of strict glycaemic control in this clinical setting.

Demonstration and Performance Evaluation of Two Novel Algorithms for Removing Artifacts From Automated Intraoperative Temperature Data Sets: Multicenter, Observational, Retrospective Study.

BACKGROUND: The automated acquisition of intraoperative patient temperature data via temperature probes leads to the possibility of producing a number of artifacts related to probe positioning that may impact these probes' utility for observational research. OBJECTIVE: We sought to compare the performance of two de novo algorithms for filtering such artifacts. METHODS: In this observational retrospective study, the intraoperative temperature data of adults who received general anesthesia for noncardiac surgery were extracted from the Multicenter Perioperative Outcomes Group registry. Two algorithms were developed and then compared to the reference standard-anesthesiologists' manual artifact detection process. Algorithm 1 (a slope-based algorithm) was based on the linear curve fit of 3 adjacent temperature data points. Algorithm 2 (an interval-based algorithm) assessed for time gaps between contiguous temperature recordings. Sensitivity and specificity values for artifact detection were calculated for each algorithm, as were mean temperatures and areas under the curve for hypothermia (temperatures below 36 C) for each patient, after artifact removal via each methodology. RESULTS: A total of 27,683 temperature readings from 200 anesthetic records were analyzed. The overall agreement among the anesthesiologists was 92.1%. Both algorithms had high specificity but moderate sensitivity (specificity: 99.02% for algorithm 1 vs 99.54% for algorithm 2; sensitivity: 49.13% for algorithm 1 vs 37.72% for algorithm 2; F-score: 0.65 for algorithm 1 vs 0.55 for algorithm 2). The areas under the curve for time × hypothermic temperature and the mean temperatures recorded for each case after artifact removal were similar between the algorithms and the anesthesiologists. CONCLUSIONS: The tested algorithms provide an automated way to filter intraoperative temperature artifacts that closely approximates manual sorting by anesthesiologists. Our study provides evidence demonstrating the efficacy of highly generalizable artifact reduction algorithms that can be readily used by observational studies that rely on automated intraoperative data acquisition.

Patterns of Use of Opioid Sparing Adjuncts for Perioperative Pain Management of Patients on Chronic Opioids.

BACKGROUND: Perioperative pain management of patients on chronic opioids is challenging. Although experts recommend regional anesthesia and multimodal analgesics for their opioid sparing effects, their use and predictors of use are unknown. OBJECTIVES: To examine the patterns and predictors of use of regional anesthesia and multimodal analgesics for perioperative pain control of patients on chronic opioids. A secondary objective was to examine the association of patient and surgical factors with 24-hour postoperative opioid use. STUDY DESIGN: Retrospective cross sectional. SETTING: Single center tertiary care academic hospital. METHODS: We studied patients with chronic opioid use undergoing painful operations such as abdominal, gynecologic, breast, orthopedic, spine, amputation, and laparoscopic surgeries. Chronic opioid use was identified using the narcotic score - a score generated from the state prescription drug monitoring database via the NarxCare platform. A narcotic score >= 320 corresponding to a preoperative home dose of approximately 40 milligram morphine equivalents (MMEs) daily, was chosen as a cutoff since the risk of overdose death increases above 40 MMEs. We reported the use of regional anesthesia and >= 3 multimodal analgesics in this cohort (n = 155) and examined the association of this use with patient and surgical factors such as preoperative narcotic score, age, race, comorbidity index, operative timetime, and intraoperative opioid use. In addition, we examined the association of patient and surgical factors with 24-hour postoperative opioid use. RESULTS: Out of 2470 patients undergoing painful surgeries between July 2017and- December 2018, 155 patients had a narcotic score >= 320. The median narcotic score was 411 (interquartile range (IQR) 351-520), the median preoperative home MME dose was 67.5 (IQR 32-180) mg daily. Regional anesthesia was used in only 9.7% of cases and was associated with intraoperative opioid used, but not the preoperative narcotic score. Patients receiving 1 SD more MMEs intraoperatively had a higher odds of receiving regional anesthesia (OR = 1.57, 95% CI [1.06, 2.32]). Three or more multimodals were used in 83% of cases. Every 10-point increase in narcotic score and every additional hour of operative time was associated with higher odds of receiving >= 3 multimodals (OR = 1.05, 95% CI [1.00, 1.11] and OR = 1.49, 95% CI [1.11, 1.99] respectively). Total 24 hour post-operative opioid dose was associated with narcotic score, with an 8.6 higher mean MME for every 10-point increase in narcotic score (mean difference = 8.6, 95% CI [4.1, 13.1]). It was also moderately associated with age, where patients an year older received 4.7 MMEs less (mean difference = - 4.7, 95% CI [-9.3, -0.5]). LIMITATIONS: This was a single center retrospective observational study. We could not adjust for inter-physician or inter-surgery effect on use of regional anesthesia or multimodal analgesics. Since this was one of the first studies to use narcotic scores to identify patients on chronic opioids, comparing the outcomes of interest to a control group was beyond the scope of the current study. Narcotic scores need to be validated to identify chronic opioid use. CONCLUSIONS: Despite consensus guidelines, regional anesthesia remains underutilized. Multimodals are used frequently and are modestly associated with preoperative narcotic scores.

Variation in propofol induction doses administered to surgical patients over age 65.

BACKGROUND/OBJECTIVES: Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery. DESIGN: Retrospective observational study using the Multicenter Perioperative Outcomes Group data set. SETTING: Thirty-six institutions across the United States. PARTICIPANTS: A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018. INTERVENTION: None. MEASUREMENTS: Total induction bolus dose of propofol administered. RESULTS: The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older. CONCLUSION: The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.

Diffuse white matter loss in a transgenic rat model of cerebral amyloid angiopathy.

Diffuse white matter (WM) disease is highly prevalent in elderly with cerebral small vessel disease (cSVD). In humans, cSVD such as cerebral amyloid angiopathy (CAA) often coexists with Alzheimer's disease imposing a significant impediment for characterizing their distinct effects on WM. Here we studied the burden of age-related CAA pathology on WM disease in a novel transgenic rat model of CAA type 1 (rTg-DI). A cohort of rTg-DI and wild-type rats was scanned longitudinally using MRI for characterization of morphometry, cerebral microbleeds (CMB) and WM integrity. In rTg-DI rats, a distinct pattern of WM loss was observed at 9 M and 11 M. MRI also revealed manifestation of small CMB in thalamus at 6 M, which preceded WM loss and progressively enlarged until the moribund disease stage. Histology revealed myelin loss in the corpus callosum and thalamic CMB in all rTg-DI rats, the latter of which manifested in close proximity to occluded and calcified microvessels. The quantitation of CAA load in rTg-DI rats revealed that the most extensive microvascular Aß deposition occurred in the thalamus. For the first time using in vivo MRI, we show that CAA type 1 pathology alone is associated with a distinct pattern of WM loss.

Individual progression of carotid intima media thickness as a surrogate for vascular risk (PROG-IMT): Rationale and design of a meta-analysis project.

Carotid intima media thickness (IMT) progression is increasingly used as a surrogate for vascular risk. This use is supported by data from a few clinical trials investigating statins, but established criteria of surrogacy are only partially fulfilled. To provide a valid basis for the use of IMT progression as a study end point, we are performing a 3-step meta-analysis project based on individual participant data. Objectives of the 3 successive stages are to investigate (1) whether IMT progression prospectively predicts myocardial infarction, stroke, or death in population-based samples; (2) whether it does so in prevalent disease cohorts; and (3) whether interventions affecting IMT progression predict a therapeutic effect on clinical end points. Recruitment strategies, inclusion criteria, and estimates of the expected numbers of eligible studies are presented along with a detailed analysis plan.

Retrospective chart review and survey to identify adverse safety events in the emergency medical services care of children with out-of-hospital cardiac arrest in the USA: a study protocol.

INTRODUCTION: Efforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA. METHODS AND ANALYSIS: This is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression. ETHICS AND DISSEMINATION: This study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.

A new giant Pristimantis (Anura, Craugastoridae) from the paramos of the Podocarpus National Park, southern Ecuador.

A new species of frog of the genus Pristimantis is described from the paramos of the Nudo de Cajanuma, Podocarpus National Park, on the border between the provinces of Loja and Zamora-Chinchipe, Ecuador. The new species is readily distinguished from all other species of Pristimantis by its large body size (snout-vent length: 50.0-50.5 mm in adult females, 34.7-42.5 mm in adult males), thick glandular skin, large warts on flanks, prominent glandular patches on head and legs, and dark brown dorsum. This new species is among the largest and stoutest Pristimantis frogs of the high Andes. It is only known from its type locality, where it occurs in paramo bambusoid meadows at elevations between 3300 and 3400 m. It is morphologically similar to Pristimantiserythros, P.farisorum, P.obmutescens, P.orcesi, P.racemus, P.simoterus, P.simoteriscus, and P.thymelensis. Notorious morphological characters present in this new species are thick glandular patches covering dorsum and limbs and porous skin texture, which are shared with P.erythros.

ResumenDescribimos una nueva especie de rana del género Pristimantis de los páramos del Nudo de Cajanuma, Parque Nacional Podocarpus, en el límite entre las provincias de Loja y Zamora-Chinchipe. La nueva especie se diferencia de otras especies de Pristimantis por su gran tamaño corporal (longitud rostro-cloacal: 50,0­50,5 mm en hembras adultas, 34,7­42,5 mm en machos adultos), piel glandular y gruesa, verrugas grandes en los flancos del cuerpo, prominentes parches glandulares en la cabeza y patas, y dorso café oscuro. Esta nueva especie está entre las ranas Pristimantis más grandes y fornidas de los altos Andes. Solo se conoce de su localidad tipo, donde habita en herbazales bambusoides de páramo a elevaciones entre 3300 y 3400 m. Es morfológicamente similar a Pristimantiserythros, P.farisorum, P.obmutescens, P.orcesi, P.racemus, P.simoterus, P.simoteriscus, y P.thymelensis. Características morfológicas notorias en esta nueva especie son los parches glandulares gruesos que cubren el dorso y las patas y la textura de la piel porosa, las cuales son compartidas con P.erythros.