Contact with psychiatric care prior to suicide: are there differences between migrants and the majority population in Sweden? A cohort study of 12 474 persons who died by suicide between 2006 and 2016.

AIMS: The aim of this study was to determine possible differences in psychiatric care contact and the type of contact in the year prior to suicide by migrant status and region of origin compared to Swedish persons. METHODS: A population-based open cohort design, using linked national registers, to study all individuals aged 20-64 years who died by suicide between 1 January 2006 and 31 December 2016 in Sweden (N = 12 474). The primary exposure was migrant status compared to the Swedish majority population in the following categories: non-refugee migrants, refugee migrants and children of migrants. The secondary exposure was region of origin in seven regions: Sweden, other Nordic countries, Europe, Sub-Saharan Africa, the Middle East and North Africa, Asia, the Americas and Oceania. The four outcomes were psychiatric in- and outpatient care, prescribed and purchased psychotropic medication and a variable composing the other variables, all measured the year before death. Logistic regression models adjusted for age, sex, income and marital status estimated the likelihood of psychiatric care utilisation by type of care within the year prior to death by migrant status and region of origin (individually and combined). RESULTS: Out of all who had died by suicide, 81% had had psychiatric care of any type in the year before death by suicide. Among refugees the prevalence of psychiatric care before death by suicide was 88%. Compared with the Swedish reference group, non-refugees and persons from Asia and Sub-Saharan Africa had a lower likelihood of utilising psychiatric care prior to suicide driven by a lower use of prescribed psychotropic medication. Persons from the Middle East and North Africa had a higher likelihood, driven by higher use of psychiatric outpatient care and prescribed psychotropic medication. Non-refugees' likelihood of utilising care before death by suicide was lower within the first 5 years of living in Sweden. CONCLUSION: A large share of those who die by suicide use psychiatric care the year before they die. Non-refugee migrants and persons from Asia and Sub-Saharan Africa have a lower likelihood of utilising psychiatric care prior to suicide compared to Swedish, whereas persons from the Middle East and North Africa have a higher likelihood. Health care and policy makers should consider both migrant status, region of origin and time in the new country for further suicide prevention efforts.

Migrant status and risk of compulsory admission at first diagnosis of psychotic disorder: a population-based cohort study in Sweden.

BACKGROUND: Minority ethnic and migrant groups face an elevated risk of compulsory admission for mental illness. There are overlapping cultural, socio-demographic, and structural explanations for this risk that require further investigation. METHODS: By linking Swedish national register data, we established a cohort of persons first diagnosed with a psychotic disorder between 2001 and 2016. We used multilevel mixed-effects logistic modelling to investigate variation in compulsory admission at first diagnosis of psychosis across migrant and Swedish-born groups with individual and neighbourhood-level covariates. RESULTS: Our cohort included 12 000 individuals, with 1298 (10.8%) admitted compulsorily. In an unadjusted model, being a migrant [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.26-1.73] or child of a migrant (OR 1.27; 95% CI 1.10-1.47) increased risk of compulsory admission. However after multivariable modelling, region-of-origin provided a better fit to the data than migrant status; excess risk of compulsory admission was elevated for individuals from sub-Saharan African (OR 1.94; 95% CI 1.51-2.49), Middle Eastern and North African (OR 1.46; 95% CI 1.17-1.81), non-Nordic European (OR 1.27; 95% CI 1.01-1.61), and mixed Swedish-Nordic backgrounds (OR 1.33; 95% CI 1.03-1.72). Risk of compulsory admission was greater in more densely populated neighbourhoods [OR per standard deviation (s.d.) increase in the exposure: 1.12, 95% CI 1.06-1.18], an effect that appeared to be driven by own-region migrant density (OR per s.d. increase in exposure: 1.12; 95% CI 1.02-1.24). CONCLUSIONS: Inequalities in the risk of compulsory admission by migrant status, region-of-origin, urban living and own-region migrant density highlight discernible factors which raise barriers to equitable care and provide potential targets for intervention.

Genotype-phenotype correlations of low-frequency variants in the complement system in renal disease and age-related macular degeneration.

Genetic alterations in the complement system have been linked to a variety of diseases, including atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathy (C3G), and age-related macular degeneration (AMD). We performed sequence analysis of the complement genes complement factor H (CFH), complement factor I (CFI), and complement C3 (C3) in 866 aHUS/C3G and 697 AMD patients. In total, we identified 505 low-frequency alleles, representing 121 unique variants, of which 51 are novel. CFH contained the largest number of unique low-frequency variants (n = 64; 53%), followed by C3 (n = 32; 26%) and CFI (n = 25; 21%). A substantial number of variants were found in both patients groups (n = 48; 40%), while 41 (34%) variants were found only in aHUS/C3G and 32 (26%) variants were AMD specific. Genotype-phenotype correlations between the disease groups identified a higher frequency of protein altering alleles in short consensus repeat 20 (SCR20) of factor H (FH), and in the serine protease domain of factor I (FI) in aHUS/C3G patients. In AMD, a higher frequency of protein-altering alleles was observed in SCR3, SCR5, and SCR7 of FH, the SRCR domain of FI, and in the MG3 domain of C3. In conclusion, we observed a substantial overlap of variants between aHUS/C3G and AMD; however, there is a distinct clustering of variants within specific domains.

Extramacular drusen are highly associated with age-related macular degeneration, but not with CFH and ARMS2 genotypes.

BACKGROUND: To evaluate the association of extramacular drusen (EMD) with age-related macular degeneration (AMD) and with complement factor H (CFH rs1061170) and age-related maculopathy susceptibility 2 (ARMS2 rs10490924) polymorphisms in individuals with and without AMD. METHODS: In this case-control study, AMD staging was performed in 622 individuals. EMD were defined as ≥10 drusen (including ≥1 intermediate drusen) outside the Early Treatment of Diabetic Retinopathy Study Grid within field 2. Genotype associations for CFH and ARMS2 variants were assessed using logistic regression analysis. RESULTS: EMD (n=213) showed a strong association with AMD (OR=3.85; p=1.66×10(-13)). AMD (n=316) was strongly associated with CFH (p=1.78×10(-7)) and ARMS2 genotypes (p=1.67×10(-8)). After adjustment for AMD, age and gender, EMD were neither associated with CFH (p=0.11) nor with ARMS2 (p=0.45) genotypes. In individuals without AMD, the groups with and without EMD showed no differences regarding both genetic variants. CONCLUSIONS: The strong association between drusen within and outside of the macula suggests a common pathogenesis. However, EMD were not AMD-independently associated with CFH or ARMS2 genotypes. Our results indicate that patients without AMD but with EMD can serve as controls in studies evaluating AMD risk factors. Further studies are required to elucidate the aetiology and clinical relevance of EMD.

Development and evaluation of a standardized method and atlas for contouring primary and permanent dentition.

OBJECTIVES: Radiation toxicity of the dentition may present significant treatment-related morbidity in the paediatric head and neck cancer population. However, clear dose-effect relationships remain undetermined and must be predicated upon accurate structure delineation and dosimetry at the individual tooth level. Radiation oncologists generally have limited familiarity or experience with relevant dental anatomy. METHODS: We therefore developed a detailed CT atlas of permanent and primary dentition. After studying this atlas, five radiation oncology clinicians delineated all teeth for each of eight different cases (selected for breadth of dental maturity and anatomical variability). They were asked to record confidence in their contours on a per-tooth basis as well as the duration of time required per case. Contour accuracy and interclinician variability were assessed by Hausdorff distance and Dice similarity coefficient. All analyses were performed using R v. 3.1.1 and the RadOnc v. 1.0.9 package. RESULTS: Participating clinicians delineated teeth with varying degrees of completeness and accuracy, stratified primarily by the age of the subject. On a per-tooth basis, delineation of permanent dentition was feasible for incisors, canines, premolars and first molars among all subjects, even at the youngest ages. However, delineation of second and third molars was less consistent, commensurate with approximate timing of tooth development. Within each tooth contour, uncertainty was the greatest at the level of the dental roots. CONCLUSIONS: Delineation of individual teeth is feasible and serves as a necessary precursor for dental dose assessment and avoidance. Among the paediatric radiation oncology community in particular, this atlas may serve as a useful tool and reference.

A new process-centered description tool to initiate meta-reporting methodology in healthcare - 7CARECAT™. Feasibility study in a post-anesthesia care unit.

BACKGROUND: In the healthcare domain, different analytic tools focused on accidents appeared to be poorly adapted to sub-accidental issues. Improving local management and intra-institutional communication with simpler methods, allowing rapid and uncomplicated meta-reporting, could be an attractive alternative. METHODS: A process-centered structure derived from the industrial domain - DEPOSE(E) - was selected and modified for its use in the healthcare domain. The seven exclusive meta-categories defined - Patient, Equipment, Process, Actor, Supplies, work Room and Organization- constitute 7CARECAT™. A collection of 536 "improvement" reports from a tertiary hospital Post anesthesia care unit (PACU) was used and four meta-categorization rules edited prior to the analysis. Both the relevance of the metacategories and of the rules were tested to build a meta-reporting methodology. The distribution of these categories was analyzed with a χ 2 test. RESULTS: Five hundred and ninety independent facts were collected out of the 536 reports. The frequencies of the categories are: Organization 44%, Actor 37%, Patient 11%, Process 3%, work Room 3%, Equipment 1% and Supplies 1%, with a p-value <0.005 (χ 2). During the analysis, three more rules were edited. The reproducibility, tested randomly on 200 reports, showed a <2% error rate. CONCLUSION: This meta-reporting methodology, developed with the 7CARECAT™ structure and using a reduced number of operational rules, has successfully produced a stable and consistent classification of sub-accidental events voluntarily reported. This model represents a relevant tool to exchange meta-informations important for local and transversal communication in healthcare institutions. It could be used as a promising tool to improve quality and risk management.

The intensity of chair-assisted exercises in cognitively healthy older adults.

INTRODUCTION: The American College of Sports Medicine prescribes regular performance of at least moderate-intensity physical activity for healthy aging. This study examined whether 1 session of 30 min of chair-assisted exercises for the elderly meets this intensity criterion. METHOD: This cross-sectional study included 47 cognitively healthy volunteers (mean age 84 years). During the performance of 30 min of chair-assisted exercises the authors determined oxygen uptake (VO2), carbon dioxide production, heart rate (HR), and rating of perceived exertion (RPE). These measures were expressed as a percentage of the estimated maximal VO2 (VO2max) and the estimated maximal HR (HRmax) and estimated as metabolic equivalent units (METs). RESULTS: Participants performed chair-assisted exercises at 61.0% ± 14.7% of VO2max, 67.6% ± 11.3% HRmax, 3.9 ± 0.9 METs, and 13.1 ± 2.1 RPE. CONCLUSIONS: The intensity of these chair-assisted exercises is at least moderate for older adults, which is necessary for healthy aging.

Influence of in vitro maturation of engineered cartilage on the outcome of osteochondral repair in a goat model.

This study was designed to determine if the maturation stage of engineered cartilage implanted in a goat model of cartilage injury influences the repair outcome. Goat engineered cartilage was generated from autologous chondrocytes cultured in hyaluronic acid scaffolds using 2 d, 2 weeks or 6 weeks of pre-culture and implanted above hydroxyapatite/hyaluronic acid sponges into osteochondral defects. Control defects were left untreated or treated with cell-free scaffolds. The quality of repair tissues was assessed 8 weeks or 8 months post implantation by histological staining, modified O'Driscoll scoring and biochemical analyses. Increasing pre-culture time resulted in progressive maturation of the grafts in vitro. After 8 weeks in vivo, the quality of the repair was not improved by any treatment. After 8 months, O'Driscoll histology scores indicated poor cartilage architecture for untreated (29.7 ± 1.6) and cell-free treated groups (24.3 ± 5.8). The histology score was improved when cellular grafts were implanted, with best scores observed for grafts pre-cultured for 2 weeks (16.3 ± 5.8). As compared to shorter pre-culture times, grafts cultured for 6 weeks (histology score: 22.3 ± 6.4) displayed highest type II/I collagen ratios but also inferior architecture of the surface and within the defect, as well as lower integration with native cartilage. Thus, pre-culture of engineered cartilage for 2 weeks achieved a suitable compromise between tissue maturity and structural/integrative properties of the repair tissue. The data demonstrate that the stage of development of engineered cartilage is an important parameter to be considered in designing cartilage repair strategies.

Early and late parameters describing the offset of neuromuscular blockade are highly intercorrelated.

BACKGROUND: Neuromuscular blocking agents have always shown wide inter-individual variability when it comes to their duration of action. This prevents clinicians from anticipating the evolution of the neuromuscular block for any given patient. With this study, we aimed to assess the nature of the relationships existing between different time course parameters used to describe paralysis onset and offset. METHODS: Sixty American Society of Anesthesiologists (ASA) score III-IV anaesthetised patients were randomised to receive a single equipotent dose (2ED95) of either rocuronium, mivacurium or atracurium. We used acceleromyography to monitor neuromuscular transmission. We described the relationships between the time-interval measurements of: onset, the first response (T1) reappearance, T1 25% of control, train-of-four ratio 0.25 and 0.75. Pearson correlation coefficients were calculated. RESULTS: We found no significant relationships between onset and any of the four parameters used to describe the offset. On the other hand, we showed strong and highly significant linear relationships between all the parameters describing the offset for each of the muscle relaxants studied (correlation coefficients ranging from 0.850 to 0.992). CONCLUSIONS: We evidenced strong linear correlations between the four offset time course parameters of spontaneous recovery after a single neuromuscular blocking agents (NMBAs) bolus. Such relationships open up new clinical perspectives concerning quantitative neuromuscular transmission monitoring: the scope of individual valuable anticipation of the patient's recovery.

Interleukin-1ß enhances cartilage-to-cartilage integration.

The failure of cartilages to fuse, particularly in the case of articular cartilage under conditions of repair is due to morphological and structural constraints of the tissue. Factors that impede integration include, non-vascularisation, low cellularity, and proteoglycan in the surrounding extracellular matrix acting as a natural barrier to cellular migration. We hypothesised that brief activation of a catabolic cascade by cytokines followed by culture under anabolic conditions would promote tissue fusion in a ring-disk model of cartilage integration. Our results show that transient exposure to 10 ng mL(-1) interleukin-1ß, followed by two weeks post-culture under anabolic conditions, enhanced cartilage-cartilage integration compared to untreated explants. Quantitative PCR analysis of catabolism-related genes ADAMTS4 and MMP13 showed both were transiently upregulated and these findings correlated with evidence of extracellular matrix remodelling. At the level of histology, we observed chondrocytes readily populated the interfacial matrix between fused explants in interleukin-1ß treated explants, whereas in control explants this region was relatively acellular in comparison. Catabolic cytokine treated explants exhibited 29-fold greater adhesive strength (0.859 MPa versus 0.028 MPa, P 〈 0.05) than untreated counterparts. Collectively, our results demonstrate that a single short catabolic pulse followed by an anabolic response is sufficient to generate mechanically robust, integrative cartilage repair.

[Reporting of muscle relaxant effects in anaesthesia files concerning visceral surgery - a observational and multicenter study]. / Traçabilité de la gestion de l'utilisation des curares dans le dossier d'anesthésie en chirurgie viscérale : une étude observationnelle et multicentrique.

OBJECTIVES: To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes. TYPE OF STUDY: Prospective, observational and multicenter. PATIENTS AND METHODS: A single operator analysed 1453 files proposed by nine anaesthetists' teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied. RESULTS: Items related to laryngoscopy and intubation conditions were observed in 43% (0-95) [general average (intercentres min-max)] and in 11% (0-97) of the files, respectively. At least one level of paralysis was reported in 23% (0-96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4-96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12-89) of the notes. Adductor pollicis was concerned for 30% (1-89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3-19) of the documents. Pharmacological reversal was noted for 25% (4-67) of the patients; the assessment of the effects so produced was reported in 8% (0-58). CONCLUSION: In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline - defining the criteria for producing a good documentation of the muscle relaxant use - becomes necessary to secure these practices for all physicians using muscle relaxants.

Regulation of osteoarthritis by omega-3 (n-3) polyunsaturated fatty acids in a naturally occurring model of disease.

OBJECTIVE: To examine effects of high omega-3 (n-3) polyunsaturated fatty acid (PUFA) diets on development of osteoarthritis (OA) in a spontaneous guinea pig model, and to further characterise pathogenesis in this model. Modern diets low in n-3 PUFAs have been linked with increases in inflammatory disorders, possibly including OA. However, n-3 is also thought to increases bone density, which is a possible contributing factor in OA. Therefore we aim to determine the net influence of n-3 in disease development. METHOD: OA-prone Dunkin-Hartley (DH) Guinea pigs were compared with OA-resistant Bristol Strain-2s (BS2) each fed a standard or an n-3 diet from 10 to 30 weeks (10/group). We examined cartilage and subchondral bone pathology by histology, and biochemistry, including collagen cross-links, matrix metalloproteinases (MMPs), alkaline phosphatase, glycosaminoglycan (GAG), and denatured type II collagen. RESULTS: Dietary n-3 reduced disease in OA-prone animals. Most cartilage parameters were modified by n-3 diet towards those seen in the non-pathological BS2 strain - significantly active MMP-2, lysyl-pyridinoline and total collagen cross-links - the only exception being pro MMP-9 which was lower in the BS2, yet increased with n-3. GAG content was higher and denatured type II lower in the n-3 group. Subchondral bone parameters in the DH n-3 group also changed towards those seen in the non-pathological strain, significantly calcium:phosphate ratios and epiphyseal bone density. CONCLUSION: Dietary n-3 PUFA reduced OA in the prone strain, and most disease markers were modified towards those of the non-OA strain, though not all significantly so. Omega-3 did not increase markers of pathology in either strain.

Gravity is an important determinant of oxygenation during one-lung ventilation.

BACKGROUND: The role of gravity in the redistribution of pulmonary blood flow during one-lung ventilation (OLV) has been questioned recently. To address this controversial but clinically important issue, we used an experimental approach that allowed us to differentiate the effects of gravity from the effects of hypoxic pulmonary vasoconstriction (HPV) on arterial oxygenation during OLV in patients scheduled for thoracic surgery. METHODS: Forty patients with chronic obstructive pulmonary disease scheduled for right lung tumour resection were randomized to undergo dependent (left) one-lung ventilation (D-OLV; n=20) or non-dependent (right) one-lung ventilation (ND-OLV; n=20) in the supine and left lateral positions. Partial pressure of arterial oxygen (PaO2) was measured as a surrogate for ventilation/perfusion matching. Patients were studied before surgery under closed chest conditions. RESULTS: When compared with bilateral lung ventilation, both D-OLV and ND-OLV caused a significant and equal decrease in PaO(2) in the supine position. However, D-OLV in the lateral position was associated with a higher PaO2 as compared with the supine position [274.2 (77.6) vs. 181.9 (68.3) mmHg, P<0.01, analysis of variance (ANOVA)]. In contrast, in patients undergoing ND-OLV, PaO2 was always lower in the lateral as compared with the supine position [105.3 (63.2) vs. 187 (63.1) mmHg, P<0.01, ANOVA]. CONCLUSION: The relative position of the ventilated vs. the non-ventilated lung markedly affects arterial oxygenation during OLV. These data suggest that gravity affects ventilation-perfusion matching independent of HPV.

Type II and VI collagen in nasal and articular cartilage and the effect of IL-1alpha on the distribution of these collagens.

The distribution of type II and VI collagen was immunocytochemically investigated in bovine articular and nasal cartilage. Cartilage explants were used either fresh or cultured for up to 4 weeks with or without interleukin 1alpha (IL-1alpha). Sections of the explants were incubated with antibodies for both types of collagen. Microscopic analyses revealed that type II collagen was preferentially localized in the interchondron matrix whereas type VI collagen was primarily found in the direct vicinity of the chondrocytes. Treatment of the sections with hyaluronidase greatly enhanced the signal for both types of collagen. Also in sections of explants cultured with IL-1alpha a higher level of labeling of the collagens was found. This was apparent without any pre-treatment with hyaluronidase. Under the influence of IL-1alpha the area positive for type VI collagen that surrounded the chondrocytes broadened. Although the two collagens in both types of cartilage were distributed similarly, a remarkable difference was the higher degree of staining of type VI collagen in articular cartilage. Concomitantly we noted that digestion of this type of cartilage hardly occurred in the presence of IL-1alpha whereas nasal cartilage was almost completely degraded within 18 days of culture. Since type VI collagen is known to be relatively resistant to proteolysis we speculate that the higher level of type VI collagen in articular cartilage is important in protecting cartilage from digestion.

Acute Q fever related in-hospital mortality in the Netherlands.

INTRODUCTION: A large outbreak of acute Q fever has been reported in the Netherlands with over 3500 cases from 2007 to 2009, during which 749 patients were hospitalised. In foreign cohorts, reported mortality rates in patients hospitalised with acute Q fever, ranged from 0.9 to 2.4%. We analysed mortality among hospitalised patients with acute Q fever in the Netherlands. METHODS: Physicians from hospitals in the afflicted region were asked to provide details about patients who died with a diagnosis of acute Q fever between 2007 and 2009. RESULTS: Nine patients (seven males, median age 72 years) from six hospitals were reported, who died within approximately one month following hospitalisation for acute Q fever. Six definite acute Q fever cases and three probable cases were identified. Six patients presented with infiltrates on the chest X-ray and a median CURB-65 score of 3. Median time of hospitalisation was 13 days (range 1-33). All patients had serious, often coinciding, underlying conditions including chronic cardiovascular disease, chronic lung disease, diabetes mellitus and malignancy. CONCLUSION: The mortality rate of patients hospitalised because of acute Q fever was estimated at approximately 1%. Patients who died with acute Q fever were often male, of older age, and had chronic coinciding underlying conditions, which gives an a priori higher risk of death.

A homozygous p.Glu150Lys mutation in the opsin gene of two Pakistani families with autosomal recessive retinitis pigmentosa.

PURPOSE: To identify the gene mutations responsible for autosomal recessive retinitis pigmentosa (arRP) in Pakistani families. METHODS: A cohort of consanguineous families with typical RP phenotype in patients was screened by homozygosity mapping using microsatellite markers that mapped close to 21 known arRP genes and five arRP loci. Mutation analysis was performed by direct sequencing of the candidate gene. RESULTS: In two families, RP21 and RP53, homozygosity mapping suggested RHO, the gene encoding rhodopsin, as a candidate disease gene on chromosome 3q21. In six out of seven affected members from the two families, direct sequencing of RHO identified a homozygous c.448G>A mutation resulting in the p.Glu150Lys amino acid change. This variant was first reported in PMK197, an Indian arRP family. Single nucleotide polymorphism analysis in RP21, RP53, and PMK197 showed a common disease-associated haplotype in the three families. CONCLUSIONS: In two consanguineous Pakistani families with typical arRP phenotype in the patients, we identified a disease-causing mutation (p.Glu150Lys) in the RHO gene. Single nucleotide polymorphism analysis suggests that the previously reported Indian family (PMK197) and the two Pakistani families studied here share the RHO p.Glu150Lys mutation due to a common ancestry.

[Residual curarization and pharyngeal muscles: remain vigilant!]. / Curarisation résiduelle et musculature pharyngée: restons vigilants!

The different concepts treating of "residual curarization" were presented according to two directions: the analysis of their contents--epidemiologic, clinical, instrumental--and the description of the pharyngeal striated muscles functions in these contexts. It appears that certain, too marked, "residual curarization" levels remain a well-evidenced factor increasing some morbidities in numerous clinical situations. All the methods of instrumental monitoring of the level of curarization--mecanography, electromyography, accelerometry--appeared useful to document the levels of "residual curarization" before patient's extubation or awakening. Today, for our speciality, it became particularly clear that: neither the selected muscle-- adductor pollicis--, neither the test currently privileged--train-of-four 2Hz--, nor the thresholds currently selected--0.90 or 1.00--did not constitute the unavoidable proof of a "residual curarization" complete absence. For the healthy volunteer receiving a curare, a train of four of the adductor pollicis greater than 0.90 can exist in presence of spirometric alterations evidencing the lack of adequate pharyngeal dilatation. In daily routine, the pharyngeal control is already disturbed by numerous molecules including: benzodiazepines, halogenated vapours, propofol, i.e. even under non-hypnotic concentrations. Faced to such evidences, our medical speciality will, undoubtedly, have to acquire new knowledge to develop muscle relaxant management control processes eliminating the surmorbidities related to "residual curarization". These tests must be validated also to exclude morbidity-prone dysfunctions of the pharyngeal striated muscles. Considering this new paradigm would be a major safety evolution for our speciality.