Propofol sedation in Drug Induced Sedation Endoscopy without an anaesthesiologist â€" a study of safety and feasibility.

BACKGROUND: Propofol sedation in Drug Induced Sedation Endoscopy (DISE) of the upper airway of patients with obstructive sleep apnea (OSA) without the presence of anesthesiologist has not been done before. Propofol sedation is normally administered by an anesthesiologist. This is the first study of this new method. METHODOLOGY: Based on the positive experience with Nurse-administered Propofol Sedation (NAPS) for endoscopic procedures in the departments of gastroenterology we wanted to test the set-up as method of propofol sedation for DISE procedures in our Otorhinolaryngology (ORL) department. The ORL specialists and staff nurses that carry out DISE procedures all underwent a formalized education in Nurse-administered Propofol Sedation before the study. We included 200 patients with severe snoring and / or obstructive sleep apnea. They were referred for DISE examination prior to possible targeted surgery based on the findings. RESULTS: In our study the aforementioned ORL team successfully cared out propofol sedation without the presence of an anesthesiologist. All examinations were carried out according to plan. There were no adverse events during the procedures or in the following observational period. CONCLUSIONS: The NAPS method of sedation for DISE seems safe and feasible when performed by trained staff in a hospital setting.

First Accurate Normalization of the ß-delayed α Decay of

The ^{12}C(α,γ)^{16}O reaction plays a central role in astrophysics, but its cross section at energies relevant for astrophysical applications is only poorly constrained by laboratory data. The reduced α width, γ_{11}, of the bound 1^{-} level in ^{16}O is particularly important to determine the cross section. The magnitude of γ_{11} is determined via sub-Coulomb α-transfer reactions or the ß-delayed α decay of ^{16}N, but the latter approach is presently hampered by the lack of sufficiently precise data on the ß-decay branching ratios. Here we report improved branching ratios for the bound 1^{-} level [b_{ß,11}=(5.02±0.10)×10^{-2}] and for ß-delayed α emission [b_{ßα}=(1.59±0.06)×10^{-5}]. Our value for b_{ßα} is 33% larger than previously held, leading to a substantial increase in γ_{11}. Our revised value for γ_{11} is in good agreement with the value obtained in α-transfer studies and the weighted average of the two gives a robust and precise determination of γ_{11}, which provides significantly improved constraints on the ^{12}C(α,γ) cross section in the energy range relevant to hydrostatic He burning.

Continuous vital sign monitoring after major abdominal surgery-Quantification of micro events.

INTRODUCTION: Millions of patients undergo major abdominal surgery worldwide each year, and the post-operative phase carries a high risk of respiratory and circulatory complications. Standard ward observation of patients includes vital sign registration at regular intervals. Patients may deteriorate between measurements, and this may be detected by continuous monitoring. The aim of this study was to compare the number of micro events detected by continuous monitoring to those documented by the widely used standardized Early Warning Score (EWS). METHODS: Fifty patients were continuously monitored with peripheral arterial oxygen saturation (SpO2 ), heart rate (HR), and respiratory rate (RR) the first 4 days after major abdominal cancer surgery. EWS was monitored as routine practice. Number and duration of events were analyzed using Fisher's exact test and Wilcoxon rank sum test. RESULTS: Continuous monitoring detected a SpO2 <92% in 98% of patients vs 16% of patients detected by EWS (P < .0001). Micro events of SpO2 <92% lasting longer than 60 minutes were found in 58% of patients by continuous monitoring vs 16% by the EWS (P < .0001). Fifty-two percent of patients had micro events of SpO2 <85% lasting longer than 10 minutes. Continuous monitoring found tachycardia in 60% of patients vs 6% by the EWS. Frequency of events for bradycardia, tachypnea, and bradypnea showed similar patterns. CONCLUSION: Very low SpO2 and tachycardia in post-operative patients are common and under-diagnosed by the EWS. Continuous monitoring can discover these micro events and potentially contribute to earlier detection and, potentially, result in prevention of clinical complications.

Sagittal, vertical and transversal dimensions of the maxillary complex in patients with ectopic maxillary canines.

OBJECTIVES: To analyse the craniofacial maxillary complex in cases with labially and palatally located ectopic canines, subgrouped accordingly: Group I: no deviations in the dentition; Group IIa: deviations in the maxillary incisors only; Group IIb: deviations in the dentition in general. SETTING AND SAMPLE POPULATION: Sixty nine patients (mean age 13 years 6 months) with palatally or labially located ectopic canines. MATERIAL AND METHODS: Profile radiographs and dental casts were analysed. The patients were subgrouped according to a previous registration of dental deviations registered radiographically. Maxillary cross-arch transversal width was analysed on dental casts. Sagittal and vertical dimensions were registered cephalometrically on profile radiographs. RESULTS: In the patient sample the maxillary cross-arch transversal width (from first maxillary molar left to first maxillary molar right), was significantly larger than the normal mean (0.65 mm, 95% Cl: 0.02-1.28, p = 0.043). The sagittal length N-S was significantly shorter (-0.97, 95% Cl:-1.72-(-)0.22, p = 0.002). The vertical length ANS-N length was also significantly shorter (-0.79, 95% Cl:-1.65-(-)0.02, p = 0.047). The remaining variables were non-significant. Tests for interaction between groups (I, IIa and IIb) and palatal/labial ectopic location did not demonstrate significance. CONCLUSION: In patients with ectopic maxillary canines, the maxillary complex is shorter sagittally as well as vertically, while it is wider transversally.

Differences between dentitions with palatally and labially located maxillary canines observed in incisor width, dental morphology and space conditions.

AIM: To analyze the interrelationship between incisor width, deviations in the dentition and available space in the dental arch in palatally and labially located maxillary ectopic canine cases. MATERIALS AND METHODS: Size: On dental casts from 69 patients (mean age 13 years 6 months) the mesiodistal widths of each premolar, canine and incisor were measured and compared with normal standards. Dental deviations: Based on panoramic radiographs from the same patients the dentitions were grouped accordingly: Group I: normal morphology; Group IIa: deviations in the dentition within the maxillary incisors only; Group IIb: deviations in the dentition in general. Descriptive statistics for the tooth sizes and dental deviations were presented by the mean and 95% confidence limits for the mean and the p-value for the T-statistic. Space: Space was expresses by subtracting the total tooth sizes of incisors, canines and premolars from the length of the arch segments. RESULTS: Size of lateral maxillary incisor: The widths of the lateral incisors were significantly different in groups I, IIa and IIb (p=0.016) and in cases with labially located ectopic canines on average 0.65 (95% CI:0.25-1.05, p=0.0019) broader than lateral incisors in cases with palatally located ectopic canines. Space: Least available space was observed in cases with labially located canines. The linear model did show a difference between palatally and labially located ectopic canines (p=0.03). Space related to deviations in the dentition: When space in the dental arch was related to dental deviations (groups I, IIa and IIb), the cases in group IIb with palatally located canines had significantly more space compared with I and IIa. CONCLUSION: Two subgroups of palatally located ectopic maxillary canine cases based on registration of space, incisor width and deviations in the morphology of the dentition were identified.

Technological aided assessment of the acutely ill patient - The case of postoperative complications.

Surgical interventions come with complications and highly reported mortality after major surgery. The mortality may be a result of delayed detection of severe complications due to lower monitoring frequency in the general wards. Several studies have shown that continuous monitoring is superior to the manually intermittent recorded monitoring in terms of detecting abnormal physiological signs. Hopefully improved observations may result in earlier detection and clinical intervention. This narrative review will describe current monitoring possibilities for postoperative patients and how it may prevent complications. Several wireless systems are being developed for monitoring vital parameters, but many of these are not yet validated for critically ill patients. The ultimate goal with patient monitoring and detect of events is to prevent postoperative complications, death and costs in the health care system. A few studies indicate that monitoring systems detect deteriorating patients earlier than the nurses, and this was associated with less clinical instability. An important caveat of future devices is to assess their effect in relevant patient populations and not only in healthy test-subjects. Implementation of novel technologies is expensive although expected to be cost-effective if just few adverse events can be prevented. The future is here with promising devices and the possibility to give an unprecedented precise risk estimation of adverse post-surgical events. Next step is to integrate existing evidence based treatment algorithms to demonstrate the clinical efficacy of implementing the new technology.

Aprotinin attenuates platelet accumulation in ischaemia-reperfusion-injured porcine skeletal muscle.

This purpose of this study was to evaluate the effect of aprotinin, a serine protease inhibitor, in ischaemia- and reperfusion-injured myocutaneous flaps and skin flaps. Flap survival, microcirculatory platelet accumulation, and regional blood flow were investigated in seventeen pigs which had been subjected to 8 h of ischaemia and 18 h of reperfusion. The pigs were randomly assigned to aprotinin treatment (n = 9) or saline (n = 8). In-vitro studies were performed to investigate the influence of aprotinin on the activated partial thromboplastin time. The survival of skeletal muscle correlated positively with the concentration of aprotinin (P = 0.02) and could not be explained by regional changes in blood flow. Platelet accumulation was decreased in aprotinin-treated muscle (P = 0.04). In-vitro (n = 10), 100 kallikrein inactivator units/ml aprotinin prolonged the activated partial thromboplastin time both in plasma (P = 0.001) and in blood (P = 0.002), suggesting an anticoagulant rather than a procoagulant effect. In conclusion, aprotinin at high concentrations may be beneficial for the survival of skeletal muscle and provides protection from platelet accumulation in the microcirculation of skeletal muscle exposed to ischaemia and reperfusion injury.

Complications by translumbar aortography.

The complications resulting from different methods of translumbar aortography were evaluated by checking 1192 examinations performed with 1) a cannula, 2) a straight catheter, and 3) a curved catheter. The latter method was found to be far more safe than the other two. According to the complication rates found in the literature the curved catheter translumbar method is also safer than the transaxillar and comparable to transfemoral aortography by the Seldinger method.

Rapid eye movement sleep behavior disorder as an outlier detection problem.

OBJECTIVE: Idiopathic rapid eye movement (REM) sleep behavior disorder is a strong early marker of Parkinson's disease and is characterized by REM sleep without atonia and/or dream enactment. Because these measures are subject to individual interpretation, there is consequently need for quantitative methods to establish objective criteria. This study proposes a semiautomatic algorithm for the early detection of Parkinson's disease. This is achieved by distinguishing between normal REM sleep and REM sleep without atonia by considering muscle activity as an outlier detection problem. METHODS: Sixteen healthy control subjects, 16 subjects with idiopathic REM sleep behavior disorder, and 16 subjects with periodic limb movement disorder were enrolled. Different combinations of five surface electromyographic channels, including the EOG, were tested. A muscle activity score was automatically computed from manual scored REM sleep. This was accomplished by the use of subject-specific features combined with an outlier detector (one-class support vector machine classifier). RESULTS: It was possible to correctly separate idiopathic REM sleep behavior disorder subjects from healthy control subjects and periodic limb movement subjects with an average validation area under the receiver operating characteristic curve of 0.993 when combining the anterior tibialis with submentalis. Additionally, it was possible to separate all subjects correctly when the final algorithm was tested on 12 unseen subjects. CONCLUSIONS: Detection of idiopathic REM sleep behavior disorder can be regarded as an outlier problem. Additionally, the EOG channels can be used to detect REM sleep without atonia and is discriminative better than the traditional submentalis. Furthermore, based on data and methodology, arousals and periodic limb movements did only have a minor influence on the quantification of the muscle activity. Analysis of muscle activity during nonrapid eye movement sleep may improve the separation even further.

Automatic REM sleep detection associated with idiopathic rem sleep Behavior Disorder.

UNLABELLED: Rapid eye movement sleep Behavior Disorder (RBD) is a strong early marker of later development of Parkinsonism. Currently there are no objective methods to identify and discriminate abnormal from normal motor activity during REM sleep. Therefore, a REM sleep detection without the use of chin electromyography (EMG) is useful. This is addressed by analyzing the classification performance when implementing two automatic REM sleep detectors. The first detector uses the electroencephalography (EEG), electrooculography (EOG) and EMG to detect REM sleep, while the second detector only uses the EEG and EOG. METHOD: Ten normal controls and ten age matched patients diagnosed with RBD were enrolled. All subjects underwent one polysomnographic (PSG) recording, which was manual scored according to the new sleep-scoring standard from the American Academy of Sleep Medicine. Based on the manual scoring, an automatic computerized REM detection algorithm has been implemented, using wavelet packet combined with artificial neural network. RESULTS: When using the EEG, EOG and EMG modalities, it was possible to correctly classify REM sleep with an average Area Under Curve (AUC) equal to 0.90 ± 0.03 for normal subjects and AUC = 0.81 ± 0.05 for RBD subjects. The performance difference between the two groups was significant (p < 0.01). No significant drop (p > 0.05) in performance was observed when only using the EEG and EOG in neither of the groups. CONCLUSION: The overall result indicates that the EMG does not play an important role when classifying REM sleep.

Qualitative importance of the microbial loop and plankton community structure in a eutrophic lake during a bloom of cyanobacteria.

Plankton community structure and major pools and fluxes of carbon were observed before and after culmination of a bloom of cyanobacteria in eutrophic Frederiksborg Slotssø, Denmark. Biomass changes of heterotrophic nanoflagellates, ciliates, microzooplankton (50 to 140 µm), and macrozooplankton (larger than 140 µm) were compared to phytoplankton and bacterial production as well as micro- and macrozooplankton ingestion rates of phytoplankton and bacteria. The carbon budget was used as a means to examine causal relationships in the plankton community. Phytoplankton biomass decreased and algae smaller than 20 µm replacedAphanizomenon after the culmination of cyanobacteria. Bacterial net production peaked shortly after the culmination of the bloom (510 µg C liter(-1) d(-1) and decreased thereafter to a level of approximately 124 µg C liter(-1) d(-1). Phytoplankton extracellular release of organic carbon accounted for only 4-9% of bacterial carbon demand. Cyclopoid copepods and small-sized cladocerans started to grow after the culmination, but food limitation probably controlled the biomass after the collapse of the bloom. Grazing of micro- and macrozooplankton were estimated from in situ experiments using labeled bacteria and algae. Macrozooplankton grazed 22% of bacterial net production during the bloom and 86% after the bloom, while microzooplankton (nauplii, rotifers and ciliates larger than 50 µm) ingested low amounts of bacteria and removed 10-16% of bacterial carbon. Both macro-and microzooplankton grazed algae smaller than 20 µm, although they did not control algal biomass. From calculated clearance rates it was found that heterotrophic nanoflagellates (40-440 ml(-1)) grazed 3-4% of the bacterial production, while ciliates smaller than 50 µm removed 19-39% of bacterial production, supporting the idea that ciliates are an important link between bacteria and higher trophic levels. During and after the bloom ofAphanizomenon, major fluxes of carbon between bacteria, ciliates and crustaceans were observed, and heterotrophic nanoflagellates played a minor role in the pelagic food web.

Local application of FFR-rFVIIa reduces thrombus formation at arterial anastomosis in rats.

Thrombosis is still a significant problem in microvascular surgery. The aim of this study was to evaluate the antithrombotic effect of topically applied active site-inhibited recombinant human factor VIIa (FFR-rFVIIa) in a rat model with microvascular thrombosis. Forty-five male rats were allocated to one of three groups: local treatment with vehicle only, local treatment with 0.035 mg of FFR-rFVIIa, or local treatment with 0.35 mg of FFR-rFVIIa. An arteriotomy was made in the right femoral artery. Ten minutes following topical application, a thrombogenic anastomosis was performed. Using a transilluminator, thrombus formation and anastomotic bleeding episodes were observed and registered for 40 min. Local application of FFR-rFVIIa resulted in a 85-90% reduction of thrombus formation in both treated groups compared to the control group, but the reduction was only statistically significant in the group treated with 0.035 mg of FFR-rFVIIa. An increased occurrence and duration of anastomotic bleeding episodes were observed in both FFR-rFVIIa-treated groups.