RESUMEN
BACKGROUND: Postoperative delirium is associated with an increased risk of morbidity and mortality, especially in the elderly. Delirium in the postanaesthesia care unit (PACU) could predict adverse clinical outcomes. METHODS: We investigated a potential link between intraoperative EEG patterns and PACU delirium as well as an association of PACU delirium with perioperative outcomes, readmission and length of hospital stay. The risk factors for PACU delirium were also explored. Data were collected from 626 patients receiving general anaesthesia for procedures that would not interfere with frontal EEG recording. RESULTS: Of the 626 subjects enrolled, 125 tested positive for PACU delirium. Whilst age, renal failure, and pre-existing neurological disease were associated with PACU delirium in the univariable analysis, the multivariable analysis revealed the importance of information derived from the EEG, anaesthetic technique, anaesthesia duration, and history of stroke or neurodegenerative disease. The occurrence of EEG burst suppression during maintenance [odds ratio (OR)=1.86 (1.13-3.05)] and the type of EEG emergence trajectory may be predictive of PACU delirium. Specifically, EEG emergence trajectories lacking significant spindle power were strongly associated with PACU delirium, especially in cases that involved ketamine or nitrous oxide [OR=6.51 (3.00-14.12)]. Additionally, subjects with PACU delirium were at an increased risk for readmission [OR=2.17 (1.13-4.17)] and twice as likely to stay >6 days in the hospital. CONCLUSIONS: Specific EEG patterns were associated with PACU delirium. These findings provide valuable information regarding how the brain reacts to surgery and anaesthesia that may lead to strategies to predict PACU delirium and identify key areas of investigation for its prevention.
Asunto(s)
Periodo de Recuperación de la Anestesia , Electroencefalografía/métodos , Delirio del Despertar/diagnóstico , Monitoreo Intraoperatorio/métodos , Adulto , Anciano , Anestesia General/métodos , Diagnóstico Precoz , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Pronóstico , Factores de Riesgo , Procesamiento de Señales Asistido por ComputadorAsunto(s)
Estado de Conciencia , Antebrazo , Anestesia General , Electroencefalografía , Monitoreo FisiológicoRESUMEN
BACKGROUND: The isolated forearm test (IFT) is the gold standard test of connected consciousness (awareness of the environment) during anaesthesia. The frontal alpha-delta EEG pattern (seen in slow wave sleep) is widely held to indicate anaesthetic-induced unconsciousness. A priori we proposed that one responder with the frontal alpha-delta EEG pattern would falsify this concept. METHODS: Frontal EEG was recorded in a subset of patients from three centres participating in an international multicentre study of IFT responsiveness following tracheal intubation. Raw EEG waveforms were analysed for power-frequency spectra, depth-of-anaesthesia indices, permutation entropy, slow wave activity saturation and alpha-delta amplitude-phase coupling. RESULTS: Volitional responses to verbal command occurred in six out of 90 patients. Three responses occurred immediately following intubation in patients (from Sites 1 and 2) exhibiting an alpha-delta dominant (delta power >20 dB, alpha power >10 dB) EEG pattern. The power-frequency spectra obtained during these responses were similar to those of non-responders (P>0.05) at those sites. A further three responses occurred in (Site 3) patients not exhibiting the classic alpha-delta EEG pattern; these responses occurred later relative to intubation, and in patients had been co-administered ketamine and less volatile anaesthetic compared with Site 1 and 2 patients. None of the derived depth-of-anaesthesia indices could robustly discrimate IFT responders and non-responders. CONCLUSIONS: Connected consciousness can occur in the presence of the frontal alpha-delta EEG pattern during anaesthesia. Frontal EEG parameters do not readily discriminate volitional responsiveness (a marker of connected consciousness) and unresponsiveness during anaesthesia. CLINICAL TRIAL REGISTRATION: NCT02248623.
Asunto(s)
Anestesia General/métodos , Estado de Conciencia/efectos de los fármacos , Electroencefalografía/efectos de los fármacos , Monitoreo Intraoperatorio/métodos , Adulto , Estudios de Cohortes , Electroencefalografía/métodos , Femenino , Antebrazo , Humanos , Masculino , Estudios Prospectivos , Adulto JovenRESUMEN
Methoxyflurane, an agent formerly used as a volatile anaesthetic but that has strong analgesic properties, will soon become available again in the UK and Europe in the form of a small hand-held inhaler. We describe our experience in the use of inhaled methoxyflurane for procedural analgesia within a large tertiary hospital. In a small pilot crossover study of patients undergoing burns-dressing procedures, self-administered methoxyflurane inhalation was preferred to ketamine-midazolam patient-controlled analgesia by five of eight patients. Patient and proceduralist outcomes and satisfaction were recorded from a subsequent case series of 173 minor surgical and radiological procedures in 123 patients performed using inhaled methoxyflurane. The procedures included change of dressing, minor debridement, colonoscopy and incision-and-drainage of abscess. There was a 97% success rate of methoxyflurane analgesia to facilitate these procedures. Limitations of methoxyflurane include maximal daily and weekly doses, and uncertainty regarding its safety in patients with pre-existing renal disease.
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Analgesia Controlada por el Paciente/métodos , Anestésicos por Inhalación/administración & dosificación , Metoxiflurano/administración & dosificación , Dolor/tratamiento farmacológico , Centros de Atención Terciaria , Administración por Inhalación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Australasia , Quemaduras/complicaciones , Estudios Cruzados , Desbridamiento , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Resultado del Tratamiento , Adulto JovenAsunto(s)
Inhibidores de la Angiogénesis/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Coriorretinitis/complicaciones , Neovascularización Coroidal/tratamiento farmacológico , Toxocariasis/complicaciones , Adolescente , Anticuerpos Monoclonales Humanizados , Coriorretinitis/tratamiento farmacológico , Coriorretinitis/etiología , Neovascularización Coroidal/etiología , Humanos , Inyecciones Intravítreas , Masculino , Ranibizumab , Hemorragia Retiniana/tratamiento farmacológico , Hemorragia Retiniana/etiología , Resultado del Tratamiento , Agudeza VisualRESUMEN
BACKGROUND AND OBJECTIVES: Rh-associated glycoprotein (RhAG) is closely associated with the Rh proteins in the red cell membrane. Two high frequency antigens (Duclos and DSLK) and one low frequency antigen (Ol(a)) have serological characteristics suggestive of expression on RhAG. MATERIALS AND METHODS: RHAG was sequenced from the DNA of one Duclos-negative, one DSLK-negative, and two Ol(a+) individuals. Recombinant protein was expressed in HEK 293 cells. Protein models with RhAG subunits were constructed. RESULTS: The original Duclos-negative patient was homozygous for RHAG 316C>G, encoding Gln106Glu. HEK 293 cells expressing Gln106Glu mutant RhAG did not react with anti-Duclos. An individual with DSLK-negative red cells was homozygous for 490A>C, encoding Lys164Gln. Two Ol(a+) members of the original Norwegian family were heterozygous for 680C>T, encoding Ser227Leu. A Japanese donor with Rh(mod) phenotype had Ol(a+) red cells and was homozygous for 680C>T. CONCLUSION: The three red cell antigens encoded by RHAG form the RHAG blood group system: Duclos is RHAG1 (030001); Ol(a) is RHAG2 (030002); and DSLK is provisionally RHAG3 (030003).
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Proteínas Sanguíneas/genética , Glicoproteínas de Membrana/genética , Sistema del Grupo Sanguíneo Rh-Hr/genética , Secuencia de Aminoácidos , Sustitución de Aminoácidos , Proteínas Sanguíneas/inmunología , Citometría de Flujo , Humanos , Glicoproteínas de Membrana/inmunología , Modelos Moleculares , Datos de Secuencia Molecular , Proteínas Recombinantes/genética , Proteínas Recombinantes/inmunología , Sistema del Grupo Sanguíneo Rh-Hr/inmunologíaRESUMEN
OBJECTIVE: To evaluate audiotape-recorded consultations at which a new diagnosis of oesophageal or gastric cancer was given to patients with reference to information retention, psychological outcome and socio-economic deprivation. METHODS: Fifty-eight patients were randomised to receive audiotaped consultations or not. Thirty-one patients received tapes (12 oesophageal and 19 gastric cancers) and were compared with 27 control patients (12 oesophageal and 15 gastric cancers). All patients were re-interviewed and completed a hospital anxiety and depression (HAD) questionnaire. Socio-economic deprivation scores were calculated using National Indices of Multiple Deprivation. RESULTS: Patients randomised to receive tapes were more likely to retain information (31 patients) than control patients (18 patients, p=0.001). Median (range) HAD scores were similar in both groups of patients [HAD A tape 6 (0-21) vs. no tape 5 (2-14), HAD D tape 3 (0-23) vs. 4 (0-10), respectively]. Deprivation correlated significantly with higher HAD A scores in control patients (p=0.039) but was not associated with information retention (p=0.667). CONCLUSION: Taped consultations were associated with significantly better information retention without adverse psychological outcomes. Providing an audiotape may reduce the effect of socio-economic deprivation on patient anxiety. PRACTICE IMPLICATIONS: Audiotaping, or its equivalent, would be a valuable tool in the multidisciplinary approach to cancers of the upper gastrointestinal tract.
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Neoplasias Esofágicas/psicología , Educación del Paciente como Asunto/métodos , Derivación y Consulta , Neoplasias Gástricas/psicología , Grabación en Cinta/métodos , Anciano , Anciano de 80 o más Años , Ansiedad/psicología , Distribución de Chi-Cuadrado , Comunicación , Depresión/psicología , Evaluación Educacional , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/terapia , Estudios de Factibilidad , Femenino , Humanos , Masculino , Recuerdo Mental , Persona de Mediana Edad , Satisfacción del Paciente , Relaciones Médico-Paciente , Estudios Prospectivos , Derivación y Consulta/organización & administración , Factores Socioeconómicos , Estadísticas no Paramétricas , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/terapia , Encuestas y Cuestionarios , GalesRESUMEN
OBJECTIVES: To determine the feasibility of a) direct optometrist referral of patients with cataract, and b) combined assessment with same day cataract surgery ('one stop' cataract surgery). METHODS: Evaluation of 169 patients referred directly by optometrists into a pilot 'one stop' cataract surgery facility. RESULTS: Of 169 referrals, 160 patients (94.7%) were given confirmed appointments for the 'one stop' cataract service and 9 patients (5.3%) were appointed conventionally. Of 160 patients attending the 'one stop' cataract service, 154 patients (96.3%) underwent cataract surgery at the same visit, in 4 patients (2.5%) cataract surgery was indicated but deferred and in 2 patients (1.3%) cataract surgery was not indicated. The referral was supplemented with information regarding the patient's medical history forwarded by the general practitioner for 3 patients (1.8%). There were no systemic or sight-threatening complications. 151 patients (98.1%) achieved a visual acuity of 6/12 or better at a mean of 31 days post-operatively. CONCLUSION: Optometrists can accurately predict the need for cataract surgery and refer directly into a pilot 'one stop' cataract surgery facility, without the need for general practitioner involvement. 'One stop' cataract surgery is feasible; benefits to the patient include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment.
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Procedimientos Quirúrgicos Ambulatorios , Extracción de Catarata , Optometría , Derivación y Consulta , Catarata/diagnóstico , Humanos , Proyectos Piloto , Factores de Tiempo , Reino UnidoRESUMEN
Signing is a commonly used intervention technique for children with cognitive impairments who have expressive language delays. Novel word learning in three conditions (signed only, spoken only, signed and spoken combined) was compared for children with Down syndrome (2;1 to 5;2) and mental-age matched control children (1;4 to 2;6). Spontaneous imitations and responses to production and comprehension probes were examined after 5, 10, and 15 word exposures. No group differences in frequency of imitations or productions were obtained. The frequency of imitations was highest in the combined condition. Probed productions were infrequent, although novel words were produced most often in spoken and combined conditions. For both imitated and probed productions in the combined condition, the spoken portion was almost exclusively produced. Across conditions, children with Down syndrome comprehended fewer words than did control children. The evidence for and explanations of the facilitative effect of signs and the advantage of dual-method presentation are discussed.
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Síndrome de Down , Aprendizaje Verbal , Vocabulario , Niño , Preescolar , Trastornos del Conocimiento/diagnóstico , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Índice de Severidad de la EnfermedadRESUMEN
The protein hRPABC14.4 is an essential subunit of human RNA polymerases I, II, and III and is required for the transcription of all human nuclear genes. The structure of hRPABC14.4 was determined by nuclear magnetic resonance spectroscopy. The protein fold comprises a highly conserved central domain forming two antiparallel alpha-helices flanked by the less conserved N- and C-terminal regions forming a five-stranded beta-sandwich. Amino acids from the two helices participate in the generation of a hydrophobic surface area which is conserved in all eukaryotic and archaeal homologous subunits, and likely constitutes a critical macromolecular interaction interface. The hRPABC14.4 structure accounts for mutagenesis results in Saccharomyces cerevisiae and provides a structural working model for elucidating the role of this subunit in the molecular architecture and function of the human nuclear RNA polymerases.
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ARN Polimerasas Dirigidas por ADN/química , ARN Polimerasas Dirigidas por ADN/metabolismo , Secuencia de Aminoácidos , Animales , Sitios de Unión , Secuencia Conservada , ARN Polimerasas Dirigidas por ADN/genética , Humanos , Modelos Moleculares , Datos de Secuencia Molecular , Mutación , Resonancia Magnética Nuclear Biomolecular , Estructura Secundaria de Proteína , Estructura Terciaria de Proteína , Subunidades de Proteína , Proteínas de Saccharomyces cerevisiae/química , Proteínas de Saccharomyces cerevisiae/genética , Proteínas de Saccharomyces cerevisiae/metabolismo , Alineación de Secuencia , Soluciones , Electricidad Estática , Relación Estructura-ActividadRESUMEN
Recently, there have been several reports describing the cloning and characterization of the novel family of protein tyrosine phosphatase-like receptor molecules (known as IA-2 and PTP-NP/PTP-IAR/IA-2beta/phogrin), which may act as autoantigens in diabetes. Here, we report the molecular characterization and chromosomal localization of a new isoform of this family in brain termed PTP-NP-2 (for PTP-NP tyrosine phosphatase isoform), and its function in rat primary hippocampal neurons. PTP-NP-2 has 48% identity to IA-2. The principal difference between PTP-NP-2 and PTP-NP is a 17-amino-acid insert near the N-terminus of PTP-NP that is absent in PTP-NP-2. Genomic DNA analysis indicates that the 17-amino-acid insert is coded by a separate exon, suggesting that both IA-2beta and PTP-NP-2 are isoforms arising by alternate splicing of the same gene. Reverse transcriptase-PCR revealed that both isoforms are present in human SH-SY5Y neuroblastoma cells. PTP-NP-2 mRNA expression is highly restricted, with a 5.5-kb specific transcript in human fetal and adult brain and 5.5 and 3. 8 kb in human adult pancreas. SH-SY5Y neuroblastoma and U87-MG glioblastoma cells showed specific transcripts of 5.5 and 3.8
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Encéfalo/metabolismo , Cromosomas Humanos Par 7 , Glicoproteínas de Membrana/genética , Proteínas de la Membrana , Neuronas/metabolismo , Proteínas Tirosina Fosfatasas/genética , Sinapsis/metabolismo , Adulto , Secuencia de Aminoácidos , Animales , Secuencia de Bases , Sitios de Unión , Encéfalo/embriología , Mapeo Cromosómico , Femenino , Feto , Regulación del Desarrollo de la Expresión Génica , Glioblastoma , Hipocampo/metabolismo , Humanos , Masculino , Glicoproteínas de Membrana/biosíntesis , Glicoproteínas de Membrana/química , Modelos Moleculares , Datos de Secuencia Molecular , Neuroblastoma , Conformación Proteica , Proteínas Tirosina Fosfatasas/biosíntesis , Proteínas Tirosina Fosfatasas/química , Ratas , Proteínas Tirosina Fosfatasas Clase 8 Similares a Receptores , Transcripción Genética , Células Tumorales CultivadasRESUMEN
PURPOSE: To assess the role postoperative mydriatics play after extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (IOL) implantation in causing iris modifications and in controlling inflammation. SETTING: Outpatients Department, Ninewells Hospital, Dundee, Scotland. METHODS: The prospective study comprised 136 patients who had standardized ECCE. Half the patients used a mydriatic for 2 weeks postoperatively. Anterior chamber activity, pain, and eye redness were evaluated at 2 weeks postoperatively; pupil shape, peripheral anterior synechias, IOL position, and iris adhesions, at 6 weeks. RESULTS: Iris-lens adhesions were significantly more common in the group using a mydriatic. There was no difference between the two groups in postoperative inflammation. CONCLUSION: Mydriatics should not be used routinely after ECCE with posterior chamber IOL implantation.