Physical impairment during and between migraine attacks: A daily diary study of patients with chronic migraine.

OBJECTIVE: While a substantial body of research describes the disabling impacts of migraine attacks, less research has described the impacts of migraine on physical functioning between migraine attacks. The objective of this study is to describe physical impairment during and between migraine attacks as a dimension of burden experienced by people living with chronic migraine. METHODS: The physical impairment domain of the Migraine Physical Function Impact Diary was recorded in headache diaries from the Medication Overuse Treatment Strategy trial. Days with moderate to severe headache were used to approximate migraine attacks. Factor analysis and regression analysis were used to describe associations between migraine and physical impairment. RESULTS: 77,662 headache diary entries from 720 participants were analyzed, including 25,414 days with moderate to severe headache, 19,149 days with mild headache, and 33,099 days with no headache. Mean physical impairment score was 41.5 (SD = 26.1) on days with moderate to severe headache, 12.8 (SD = 15.0) on days with mild headache, and 5.2 (SD = 13.1) on days with no headache. Physical impairment on days with mild headache and days with no headache was significantly associated with days since last moderate to severe headache, physical impairment with last moderate to severe headache, mild headache (compared to no headache), depression, hypersensitivities and cranial autonomic symptoms. CONCLUSIONS: Physical impairment occurs on migraine and non-migraine days. Study participants with frequent headaches, symptoms of depression, hypersensitivities and cranial autonomic symptoms experience physical impairment at a higher rate on days with no headache and days with mild headache.Clinical Trial Registration: ClinicalTrials.gov (NCT02764320).

Capnography-An Essential Monitor, Everywhere: A Narrative Review.

Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography's use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography's use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography's safety benefits to all patients, everywhere.

Current status of variations in in-hospital cardiac arrest call numbers in Japan: a nationwide survey.

The use of standardized internal hospital phone numbers for cardiac arrest is advocated in Europe. We evaluated the current status of variations in medical emergency call numbers for in-hospital patients in Japan and whether anesthesiologists would approve a standardized number. From June 2018 to August 2018, a questionnaire survey was mailed to anesthesiologists in 1373 Japanese Society of Anesthesiologists (JSA)-accredited hospitals. The basis for opinions on using a standardized cardiac arrest call number in all Japanese hospitals was evaluated. Of 1373 facilities (response rate, 58%, n = 800), 741/776 (96%) reported a response system for in-hospital cardiac arrest; 638/710 (90%) responded to cardiac arrest through loudspeaker broadcast, audible to both patients and staff; 346/777 (48%) used a number between one and five digits long, four-digit numbers being the most common. Across Japan, 370 different numbers were reported. Only 385/688 (56%) of respondents had the emergency number memorized. Finally, 423/776 (55%) respondents approved standardizing a hospital telephone number for summoning help. Multivariate analysis showed that facilities where the anesthesiologists already memorized the call number were the only reason identified for opposition to the standardization. Although 96% of JSA-accredited hospitals had a response system for in-hospital cardiac arrests, discussions for standardization of a unified number need to be encouraged for improved emergency response.

In Vitro Topical Delivery of Chlorhexidine to the Cornea: Enhancement Using Drug-Loaded Contact Lenses and ß-Cyclodextrin Complexation, and the Importance of Simulating Tear Irrigation.

Microbial keratitis is a severe, sight-threatening condition caused by various pathogens. Eyedrops are the standard delivery modality for treating these disorders; however, blinking reflex, elevated tear production, and nasolacrimal drainage eliminate much of the instilled dose within a few seconds. Therefore, eyedrops must be applied repeatedly for prolonged periods. The present study aimed to probe more effective ocular delivery of chlorhexidine based upon drug-loaded hydrogel contact lenses and ß-cyclodextrin (ß-CD), while also determining the effect of constant irrigation with simulated tear fluid (STF) in in vitro experiments. Chlorhexidine digluconate (as 0.2 and 2% solutions, ß-CD inclusion complexes, and loaded hydrogel contact lenses) were applied to enucleated porcine eyes as single or multiple 10 µL doses, or as drug-loaded contact lenses, with and without ß-CD. The corneas were then excised and drug-extracted quantified by high-performance liquid chromatography (HPLC). The effect of constant irrigation by STF was evaluated to test the effect of increased tear production on corneal delivery. Potential antimicrobial activity of the delivered drug was also assessed. Results showed that drug-loaded contact lenses delivered the greatest amount of chlorhexidine into the cornea over a 24 h period, while the eyedrop solution comparator delivered the least. The ß-CD significantly enhanced chlorhexidine delivery to the cornea from eyedrop solution, although contact lenses loaded with chlorhexidine-ß-CD failed to enhance delivery. ß-CD within the hydrogel matrix impeded drug release. Constant irrigation with STF significantly reduced the amount of drug delivered to the cornea in all cases. Chlorhexidine retained antimicrobial activity in all delivery methods. Hydrogel contact lenses loaded with chlorhexidine delivered significantly higher levels to the cornea compared to eyedrops, either multiple hourly doses or a single dose. They also offer reduced application, in particular, to a nonulcerated corneal infection. Finally, the importance of fully accounting for tear production in in vitro ocular delivery experiments was highlighted.

Generalization of prior information for rapid Bayesian time estimation.

To enable effective interaction with the environment, the brain combines noisy sensory information with expectations based on prior experience. There is ample evidence showing that humans can learn statistical regularities in sensory input and exploit this knowledge to improve perceptual decisions and actions. However, fundamental questions remain regarding how priors are learned and how they generalize to different sensory and behavioral contexts. In principle, maintaining a large set of highly specific priors may be inefficient and restrict the speed at which expectations can be formed and updated in response to changes in the environment. However, priors formed by generalizing across varying contexts may not be accurate. Here, we exploit rapidly induced contextual biases in duration reproduction to reveal how these competing demands are resolved during the early stages of prior acquisition. We show that observers initially form a single prior by generalizing across duration distributions coupled with distinct sensory signals. In contrast, they form multiple priors if distributions are coupled with distinct motor outputs. Together, our findings suggest that rapid prior acquisition is facilitated by generalization across experiences of different sensory inputs but organized according to how that sensory information is acted on.

European minimum standards for obstetric analgesia and anaesthesia departments: An experts' consensus.

: An important variability of anaesthetic standards of care was discovered in the obstetric departments of many European Union countries. After discussing this issue in various meetings of the European Society of Anaesthesiology (ESA) board and its obstetric subcommittee, European Board of Anaesthesiology of the European Union of Medical Specialists (EBA-UEMS) executive members, ESA obstetric subcommittee members and European experts in obstetric anaesthesiology have participated in the elaboration of this document. This experts' opinion is focused mainly on obstetric patients and safety concerns in terms of minimum standards of practice. An initial bibliographical search was performed in medical databases and general literature, searching for obstetric anaesthesiology standards to select the most important safety issues. After the initial presentation of the project during EBA-UEMS and ESA obstetric subcommittee meetings, participants were asked to review the document; several rounds of revisions were performed by the experts, to reach a common opinion concerning the topics considered central to patient safety in the obstetric setting. After three rounds of revision, a consensus was reached and is presented in this document, which includes the list of topics considered relevant by the involved areas, and the respective recommendations. These recommendations covered some EBA-UEMS strategic key areas, in addition to several clinical aspects of common obstetric practice.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

The role of Peripheral Vision in the Flashed Face Distortion Effect.

The flashed face distortion effect is a phenomenon whereby images of faces, presented at 4-5 Hz in the visual periphery, appear distorted. It has been hypothesized that the effect is driven by cortical, rather than retinal, components. Here, we investigated the role of peripheral viewing on the effect. Normally sighted participants viewed the stimulus peripherally, centrally, and centrally with a blurring lens (to match visual acuity in the peripheral location). Participants rated the level of distortion using a Visual Analogue Scale. Although optical defocus did have a significant effect on distortion ratings, peripheral viewing had a much greater effect, despite matched visual acuity. We suggest three potential mechanisms for this finding: increased positional uncertainty in the periphery, reduced deployment of attention to the visual periphery, or the visual crowding effect.

Improving detection of patient deterioration in the general hospital ward environment.

: Patient monitoring on low acuity general hospital wards is currently based largely on intermittent observations and measurements of simple variables, such as blood pressure and temperature, by nursing staff. Often several hours can pass between such measurements and patient deterioration can go unnoticed. Moreover, the integration and interpretation of the information gleaned through these measurements remains highly dependent on clinical judgement. More intensive monitoring, which is commonly used in peri-operative and intensive care settings, is more likely to lead to the early identification of patients who are developing complications than is intermittent monitoring. Early identification can trigger appropriate management, thereby reducing the need for higher acuity care, reducing hospital lengths of stay and admission costs and even, at times, improving survival. However, this degree of monitoring has thus far been considered largely inappropriate for general hospital ward settings due to device costs and the need for staff expertise in data interpretation. In this review, we discuss some developing options to improve patient monitoring and thus detection of deterioration in low acuity general hospital wards.

The European Board of Anaesthesiology recommendations for safe medication practice: First update.

These European Board of Anaesthesiology (EBA) recommendations for safe medication practice replace the first edition of the EBA recommendations published in 2011. They were updated because evidence from critical incident reporting systems continues to show that medication errors remain a major safety issue in anaesthesia, intensive care, emergency medicine and pain medicine, and there is an ongoing need for relevant up-to-date clinical guidance for practising anaesthesiologists. The recommendations are based on evidence wherever possible, with a focus on patient safety, and are primarily aimed at anaesthesiologists practising in Europe, although many will be applicable elsewhere. They emphasise the importance of correct labelling practice and the value of incident reporting so that lessons can be learned, risks reduced and a safety culture developed.

Object size determines the spatial spread of visual time.

A key question for temporal processing research is how the nervous system extracts event duration, despite a notable lack of neural structures dedicated to duration encoding. This is in stark contrast with the orderly arrangement of neurons tasked with spatial processing. In this study, we examine the linkage between the spatial and temporal domains. We use sensory adaptation techniques to generate after-effects where perceived duration is either compressed or expanded in the opposite direction to the adapting stimulus' duration. Our results indicate that these after-effects are broadly tuned, extending over an area approximately five times the size of the stimulus. This region is directly related to the size of the adapting stimulus-the larger the adapting stimulus the greater the spatial spread of the after-effect. We construct a simple model to test predictions based on overlapping adapted versus non-adapted neuronal populations and show that our effects cannot be explained by any single, fixed-scale neural filtering. Rather, our effects are best explained by a self-scaled mechanism underpinned by duration selective neurons that also pool spatial information across earlier stages of visual processing.

A Comparison of Spectacles Purchased Online and in UK Optometry Practice.

PURPOSE: To compare spectacles bought online with spectacles from optometry practices. METHODS: Thirty-three participants consisting of single vision spectacle wearers with either a low (N = 12, mean age 34 ± 14 years) or high prescription (N = 11, mean age 28 ± 9 years) and 10 presbyopic participants (mean age 59 ± 4 years) wearing progressive addition lenses (PALs) purchased 154 pairs of spectacles online and 154 from UK optometry practices. The spectacles were compared via participant-reported preference, acceptability, and safety; the assessment of lens, frame, and fit quality; and the accuracy of the lens prescriptions to international standard ISO 21987:2009. RESULTS: Participants preferred the practice spectacles (median ranking 4th, IQR 1-6) more than online (6th, IQR 4-8; Mann-Whitney U = 7345, p < 0.001) and practice PALs (median ranking 2nd, IQR 1-4) were particularly preferred (online 6.5th, IQR 4-9, Mann-Whitney U = 455, p < 0.001). Of those deemed unacceptable and unsafe, significantly more were bought online (unacceptable: online 43/154 vs. practice 15/154, Fisher's exact p = 0.0001; unsafe: online 14/154 vs. practice 5/154, Fisher's exact p = 0.03). CONCLUSIONS: Participants preferred spectacles from optometry practice rather than those bought online, despite lens quality and prescription accuracy being similar. A greater number of online spectacles were deemed unsafe or unacceptable because of poor spectacle frame fit, poor cosmetic appearance, and inaccurate optical centration. This seems particularly pertinent to PAL lenses, which are known to increase falls risk. Recommendations are made to improve both forms of spectacle provision.

Google Glass Glare: disability glare produced by a head-mounted visual display.

PURPOSE: Head mounted displays are a type of wearable technology - a market that is projected to expand rapidly over the coming years. Probably the most well known example is the device Google Glass (or 'Glass'). Here we investigate the extent to which the device display can interfere with normal visual function by producing monocular disability glare. METHODS: Contrast sensitivity was measured in two normally sighted participants, 32 and 52 years of age. Data were recorded for the right eye, the left eye and then again in a binocular condition. Measurements were taken both with and without the Glass in place, across a range of stimulus luminance levels using a two-alternative forced-choice methodology. RESULTS: The device produced a significant reduction in contrast sensitivity in the right eye (>0.5 log units). The level of disability glare increased as stimulus luminance was reduced in a manner consistent with intraocular light scatter, resulting in a veiling retinal illuminance. Sensitivity in the left eye was unaffected. A significant reduction in binocular contrast sensitivity occurred at lower luminance levels due to a loss of binocular summation, although binocular sensitivity was not found to fall below the sensitivity of the better monocular level (binocular inhibition). CONCLUSIONS: Head mounted displays such as Google Glass have the potential to cause significant disability glare in the eye exposed to the visual display, particularly under conditions of low luminance. They can also cause a more modest binocular reduction in sensitivity by eliminating the benefits of binocular summation.

The addition of stripes (a version of the 'horizontal-vertical illusion') increases foot clearance when crossing low-height obstacles.

Trips over obstacles are one of the main causes of falling in older adults, with vision playing an important role in successful obstacle negotiation. We determined whether a horizontal-vertical illusion, superimposed onto low-height obstacles to create a perceived increase in obstacle height, increased foot clearances during obstacle negotiation thus reducing the likelihood of tripping. Eleven adults (mean ± 1 SD: age 27.3 ± 5.1 years) negotiated obstacles of varying heights (3, 5, 7 cm) with four different appearance conditions; two were obstacles with a horizontal-vertical illusion (vertical stripes of different thickness) superimposed on the front, one was a plain obstacle and the fourth a plain obstacle with a horizontal black line painted on the top edge. Foot clearance parameters were compared across conditions. Both illusions led to a significant increase in foot clearance when crossing the obstacle, compared to the plain condition, irrespective of obstacle height. Superimposing a horizontal-vertical illusion onto low-height obstacles can increase foot clearance, and its use on the floor section of a double-glazing door frame for example may reduce the incidence of tripping in the home. Practitioner Summary: Low-height obstacles such as the floor section of a double-glazing door frame are potential tripping hazards. In a gait lab-based study we found that a horizontal-vertical illusion superimposed onto low-height obstacles led to significantly higher foot clearances; indicating their potential as a useful safety measure.

Capnography standards for outside the operating room.

PURPOSE OF REVIEW: Standards for capnography inside operating theatres in high and middle-income countries are well recognized and implemented. This review examines recent standards and recommendations for the use of capnography outside the operating room and their rationale and development. RECENT FINDINGS: The landmark publication of the Royal College of Anaesthetists and Difficult Airway Society's National Audit Project 4 report provided compelling evidence of airway deaths and a significant patient harm occurring outside the operating room, particularly in ICUs and to a lesser extent in emergency departments. Up to 74% of these ICU deaths could have been prevented by capnography. This provided a serious wake up call for relevant clinicians. As a result, there have recently been new standards published for the use of capnography in these and other areas of the hospital. Waveform capnography can also reflect cardiac output, as the 2015 resuscitation guidelines emphasized. Work still needs to be done on implementing all of these new standards. SUMMARY: Established standards for using capnography within the operating theatre have significantly improved patient safety and it is hoped that the recent publication of new but similar capnography standards for application outside the operating theatre will do the same there. The reasons for the current low levels of implementation of some of these standards outside the operating room are worthy of further research.

A neural hierarchy for illusions of time: duration adaptation precedes multisensory integration.

Perceived time is inherently malleable. For example, adaptation to relatively long or short sensory events leads to a repulsive aftereffect such that subsequent events appear to be contracted or expanded (duration adaptation). Perceived visual duration can also be distorted via concurrent presentation of discrepant auditory durations (multisensory integration). The neural loci of both distortions remain unknown. In the current study we use a psychophysical approach to establish their relative positioning within the sensory processing hierarchy. We show that audiovisual integration induces marked distortions of perceived visual duration. We proceed to use these distorted durations as visual adapting stimuli yet find subsequent visual duration aftereffects to be consistent with physical rather than perceived visual duration. Conversely, the concurrent presentation of adapted auditory durations with nonadapted visual durations results in multisensory integration patterns consistent with perceived, rather than physical, auditory duration. These results demonstrate that recent sensory history modifies human duration perception prior to the combination of temporal information across sensory modalities and provides support for adaptation mechanisms mediated by duration selective neurons situated in early areas of the visual and auditory nervous system (Aubie, Sayegh, & Faure, 2012; Duysens, Schaafsma, & Orban, 1996; Leary, Edwards, & Rose, 2008).