Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks.

BACKGROUND: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle/catheter tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. Epidural waveform analysis can be carried out through the tip of the needle (EWA-N) or the catheter (EWA-C). In this randomized trial, we compared the two methods. We hypothesized that, compared with EWA-C, EWA-N would result in a shorter performance time. METHODS: One hundred and twenty patients undergoing thoracic epidural blocks for thoracic or abdominal surgery were randomized to EWA-N or EWA-C. In the EWA-N group, LOR was confirmed by connecting the epidural needle to a pressure transducer. After obtaining a satisfactory waveform, the epidural catheter was advanced 5 cm beyond the needle tip. In the EWA-C group, the epidural catheter was first advanced 5 cm beyond the needle tip after the occurrence of LOR. Subsequently, the catheter was connected to the pressure transducer to detect the presence of waveforms. In both study groups, the block procedure was repeated at different intervertebral levels until positive waveforms could be obtained (through the needle or catheter as per the allocation) or until a predefined maximum of three intervertebral levels had been reached. Subsequently, the operator administered a 4 mL test dose of lidocaine 2% with epinephrine 5 µg/mL through the catheter. An investigator present during the performance of the block recorded the performance time (defined as the temporal interval between skin infiltration and local anesthetic administration through the epidural catheter). Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Success was defined as a bilateral block in at least two dermatomes. Furthermore, postoperative pain scores, local anesthetic consumption, and breakthrough analgesic consumption were recorded. RESULTS: No intergroup differences were found in terms of performance time, success rate, postoperative pain, local anesthetic requirement, and breakthrough analgesic consumption. CONCLUSION: EWA can be carried out through the needle or through the catheter with similar efficiency (performance time) and efficacy (success rate, postoperative analgesia). TRIAL REGISTRATION NUMBER: NCT03603574.

A basic anesthesia training program for nurses in Chad: first steps for a south-south academic cooperation program.

PURPOSE: Safe perioperative care remains a large public healthcare problem in low- and middle-income countries. Anesthesia care provided by trained professionals is one of the essential determinants to address this situation. This article reports the design and implementation of a focused anesthesia educational program for nurses in Chad. METHOD: This program consisted of four full-time courses of one month each, taught in a local hospital. The program included supervised practice in the operating room and post-anesthesia recovery room, skills lab simulation training, high fidelity crisis simulation, theoretical classes, integration sessions, evaluations, and structured feedback sessions. RESULTS: Seven male nurses, aged 28-40 yr, were accepted and successfully completed the program. The median [interquartile range] students' global satisfaction with the program was high (86 [85-93]%). Cognitive and skills assessment improved significantly after the program. Students subsequently worked in city and district hospitals performing essential and emergency surgical interventions. CONCLUSIONS: This is a novel south-south academic cooperation program for nurses in Chad. The program evaluation indicated a high level of satisfaction, effective cognitive and skills learning, and changes in clinical behaviour. Addressing the lack of adequate provision of anesthesia care is a task still to be faced, and this program depicts a bridge alternative until formal educational programs are implemented in the country.

RéSUMé: OBJECTIF: Des soins périopératoires sécuritaires demeurent un important problème de santé publique dans les pays à faible et à moyen revenu. Les soins anesthésiques offerts par des professionnels formés constituent l'un des éléments déterminants essentiels pour régler le problème. Cet article rapporte la conception et la mise en œuvre d'un programme spécialisé de formation en anesthésie s'adressant au personnel infirmier au Tchad. MéTHODE: Ce programme était composé de quatre cours intensifs d'une durée d'un mois chacun, donnés dans un hôpital local. Le programme comportait une pratique supervisée en salle d'opération et en salle de réveil, des séances pratiques en laboratoire de simulation, une simulation de crise haute fidélité, des classes théoriques, des séances d'intégration, des évaluations et des séances de rétroaction structurées. RéSULTATS: Sept infirmiers âgés de 28 à 40 ans ont été acceptés dans le programme et l'ont terminé avec succès. La satisfaction globale moyenne [écart interquartile] des étudiants était élevée (86 [85­93] %). L'évaluation cognitive et des connaissances s'est considérablement améliorée après avoir suivi le programme. Les étudiants ont par la suite travaillé dans des hôpitaux de ville et de district réalisant des interventions chirurgicales essentielles et urgentes. CONCLUSION: Il s'agit d'un programme de coopération universitaire sud-sud innovant au Tchad. L'évaluation du programme a indiqué un niveau élevé de satisfaction, un apprentissage efficace au niveau cognitif et des compétences, ainsi que des changements au niveau du comportement clinique. Il reste encore beaucoup de travail pour régler le problème suscité par l'absence d'une offre adéquate de soins anesthésiques, et ce programme décrit une alternative temporaire intéressante jusqu'à ce que des programmes de formation formels soient mis en œuvre dans ce pays.

Pharmacogenetics of osteoporosis: towards novel theranostics for personalized medicine?

Osteoporosis is a complex multifactorial bone disorder with a strong genetic basis. It is the most common, severe, progressive skeletal illness that has been increasing, particularly in developed countries. Osteoporosis will no doubt constitute a serious clinical burden in healthcare management in the coming decades. The genetics of osteoporosis should be analyzed from both the disease susceptibility and the pharmacogenetic treatment perspectives. The former has been widely studied and discussed, while the latter still requires much more information and research. This article provides a synthesis of the literature on the genetics of osteoporosis and an update on progress made in pharmacogenetics of osteoporosis in recent years, specifically regarding the new molecular targets for antiresorptive drugs. In-depth translation of osteoporosis pharmacogenetics approaches to clinical practice demands a new vision grounded on the concept of "theranostics," that is, the integration of diagnostics for both disease susceptibility testing, as well as for prediction of health intervention outcomes. In essence, theranostics signals a broadening in the scope of inquiry in diagnostics medicine. The upcoming wave of theranostics medicine also suggests more distributed forms of science and knowledge production, both by experts and end-users of scientific products. Both the diagnosis and personalized treatment of osteoporosis could conceivably benefit from the emerging postgenomics field of theranostics.

Pharmacogenetics of osteoporosis-related bone fractures: moving towards the harmonization and validation of polymorphism diagnostic tools.

Osteoporosis is one of the most common skeletal chronic conditions in developed countries, hip fracture being one of its major healthcare outcomes. There is considerable variation in the implementation of current pharmacological treatment and prevention, despite consistent recommendations and guidelines. Many studies have reported conflicting findings of genetic associations with bone density and turnover that might predict fracture risk. Moreover, it is not clear whether genetic differences exist in relation to the morbidity and efficiency of the pharmacotherapy treatments. Clinical response, including beneficial and adverse events associated with osteoporosis treatments, is highly variable among individuals. In this context, the present article intends to summarize putative candidate genes and genome-wide association studies that have been related with BMD and fracture risk, and to draw the attention to the need for pharmacogenetic methodology that could be applicable in clinical translational research after an adequate validation process. This article mainly compiles analysis of important polymorphisms in osteoporosis documented previously, and it describes the simple molecular biology tools for routine genotype acquisition. Validation of methods for the easy, fast and accessible identification of SNPs is necessary for evolving pharmacogenetic diagnostic tools in order to contribute to the discovery of clinically relevant genetic variation with an impact on osteoporosis and its personalized treatment.