Non-Obstetric Safety of Epidurals (NOSE).

Epidurals are a useful perioperative procedure for effective analgesia that allow early mobilisation after major surgery and help to minimise postoperative pulmonary, cardiovascular and thromboembolic complications. However, there are potential rare but life-changing complications such as an epidural haematoma. These require a high standard of post-epidural care for prompt recognition and prevention of permanent paralysis. Following a local critical incident of delayed diagnosis of an epidural haematoma in a patient after epidural catheter removal, a multidisciplinary team undertook a Quality Improvement (QI) project to improve epidural safety. To achieve this aim, it is essential that healthcare staff are aware of the early signs of neurological complications during and after epidurals and of what action to take in the event of a developing complication. The application of robust QI methodology has contributed to a sustained improvement in the healthcare staff competence (as measured using a pulse survey) at managing patients who have received perioperative epidurals. This increased from a baseline mean survey score of 38% on three surgical step down wards (general surgery, vascular and gynaecology) to 68% (averaged over the most recent 3 months of the project time frame). Educational interventions alone rarely lead to meaningful and lasting impact for all healthcare staff, due to high turnover of staff and shift working patterns. However, with multiple plan, do, study, act cycles, and a robust QI approach, there was also sustained improvement in process measures, including the occurrence of written handover from high dependency to the step down wards (baseline 33%-71%), ensuring the application of yellow epidural alert wristbands to make these patients readily identifiable (56%-86%), and early signs in improvement in reliability of motor block checks for 24 hours' post-catheter removal (47%-69%).

Critical care and vitamin D status assessment: what about immunoassays and calculated free 25OH-D?

BACKGROUND: Interpretation of 25OH-D measurement during critical care (CC) may be problematic due to variations of binding protein concentrations (albumin, ALB, and vitamin D binding protein, VDBP). Determination of free 25OH-D concentration may thus be relevant in CC patients. The aim of this observational study was to evaluate effects of an acute hemodilution on vitamin D (VD) status. METHODS: Blood samples were obtained before (T1) and after a crystalloid load (T2) administered at anesthesia induction for minor surgery. 25OH-D was measured with LC-MS/MS and with 3 immunoassays (IA): DiaSorin Liaison, IDS iSYS and bioMérieux Vidas. VDBP was measured with the R&D Elisa and ALB on Cobas. Free 25OH-D was calculated using published formula. Accuracy of each 25OH-D IA was calculated as the percentage of IA values within 20% of their respective LC-MS/MS values. Performances of the three AI were compared with LC-MC/MS using Bland-Altman analysis. RESULTS: Twenty adults were included. Compared to T1 values, VDBP, ALB and LC-MS/MS values decreased in parallel by a mean of 23% at T2. IA values decreased less significantly (12, 14 and 15% for Liaison, iSYS and Vidas, respectively). IA-based calculated free 25OH-D significantly increased after dilution, while LC-MS/MS-based free values remained stable. At T1 and T2, bias were demonstrable for all IA. After hemodilution, bias would lead to overestimation for the three IA. Accuracy of IA decreased after dilution. CONCLUSIONS: Due to matrix effects, compared to LC-MS/MS, IA results were impacted by hemodilution. In CC patients, LC-MS/MS seems to be the best option to measure 25OH-D. Specific LC-MS/MS method should be developed to measure free 25OH-D.

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial.

BACKGROUND: Postoperative pancreatic fistula is the leading cause of death and morbidity after pancreaticoduodenectomy. However, the best reconstruction method to reduce occurrence of fistula is debated. We did a multicentre, randomised superiority trial to compare the outcomes of different reconstructive techniques in patients undergoing pancreaticoduodenectomy for pancreatic or periampullary tumours. METHODS: Patients aged 18-85 years with confirmed or suspected neoplasms of the pancreas, distal bile duct, ampulla vateri, duodenum, or periampullary tumours were eligible for inclusion. An internet-based platform was used to randomly assign patients to either pancreaticojejunostomy or pancreaticogastrostomy as reconstruction after pancreaticoduodenectomy, using permuted blocks with six patients per block. Within each centre the randomisation was stratified on the pancreatic duct diameter (≤3 mm vs >3 mm) measured at the time of surgery. The primary endpoint was the occurrence of clinical postoperative pancreatic fistula (grade B or C) as defined by the International Study Group on Pancreatic Fistula. The study was not masked and analyses were done by intention to treat. Patient follow-up was closed 2 months after discharge from the hospital. This study is registered with ClinicalTrials.gov, number NCT00830778. FINDINGS: Between June, 2009, and August, 2012, we randomly allocated 167 patients to receive pancreaticojejunostomy and 162 to receive pancreaticogastrostomy. 33 (19.8%) patients in the pancreaticojejunostomy group and 13 (8.0%) in the pancreaticogastrostomy group had clinical postoperative pancreatic fistula (OR 2.86, 95% CI 1.38-6.17; p=0.002). The overall incidence of postoperative complications did not differ significantly between the groups (99 in the pancreaticojejunostomy group vs 100 in the pancreaticogastrostomy group), although more events in the pancreaticojejunostomy group were of grade ≥3a than in the pancreaticogastrostomy group (39 vs 35). INTERPRETATION: In patients undergoing pancreaticoduodenectomy for pancreatic head or periampullary tumours, pancreaticogastrostomy is more efficient than pancreaticojejunostomy in reducing the incidence of postoperative pancreatic fistula. FUNDING: Funding Johnson & Johnson Medical Devices, Belgium.

Rapid assessment methods of resilience for natural and agricultural systems.

The resilience, ecological function and quality of both agricultural and natural systems were evaluated in the mountainous region of the Atlantic Rain Forest of Rio de Janeiro through Rapid Assessment Methods. For this goal new indicators were proposed, such as eco-volume, eco-height, bio-volume, volume efficiency, and resilience index. The following agricultural and natural systems have been compared according: (i) vegetables (leaf, fruit and mixed); (ii) citrus; (iii) ecological system; (iv) cattle, (v) silvo-pastoral system, (vi) forest fragment and (vii) forest in regeneration stage (1, 2 and 3 years old). An alternative measure (index) of resilience was proposed by considering the actual bio-volume as a function of the potential eco-volume. The objectives and hypotheses were fulfilled; it is shown that there does exist a high positive correlation between resilience index, biomass, energy efficiency and biodiversity. Cattle and vegetable systems have lowest resilience, whilst ecological and silvo-pastoral systems have greatest resilience. This new approach offers a rapid, though valuable assessment tool for ecological studies, agricultural development and landscape planning, particularly in tropical countries.

Rapid assessment methods of resilience for natural and agricultural systems

The resilience, ecological function and quality of both agricultural and natural systems were evaluated in the mountainous region of the Atlantic Rain Forest of Rio de Janeiro through Rapid Assessment Methods. For this goal new indicators were proposed, such as eco-volume, eco-height, bio-volume, volume efficiency, and resilience index. The following agricultural and natural systems have been compared according: (i) vegetables (leaf, fruit and mixed); (ii) citrus; (iii) ecological system; (iv) cattle, (v) silvo-pastoral system, (vi) forest fragment and (vii) forest in regeneration stage (1, 2 and 3 years old). An alternative measure (index) of resilience was proposed by considering the actual bio-volume as a function of the potential eco-volume. The objectives and hypotheses were fulfilled; it is shown that there does exist a high positive correlation between resilience index, biomass, energy efficiency and biodiversity. Cattle and vegetable systems have lowest resilience, whilst ecological and silvo-pastoral systems have greatest resilience. This new approach offers a rapid, though valuable assessment tool for ecological studies, agricultural development and landscape planning, particularly in tropical countries.

Foram avaliadas, em região montanhosa da Mata Atlântica do Rio de Janeiro a resiliência, função ecológica e qualidade tanto do sistema agrícola como natural, através dos métodos de avaliação rápida ("rapid assessment methods"). Para este fim, foram propostos novos indicadores como eco-volume, eco-altura, bio-volume, eficiência volumétrica e índice de resiliência. Os seguintes sistemas agrícolas e naturais foram comparados: (i) hortaliças (folhas, frutos e mistos); (ii) citros; (iii) sistema ecológico; (iv) gado; (v) sistema silvo-pastoral; (vi) fragmento florestal; (vii) floresta em estágio de recuperação (1, 2 e 3 anos de idade). Uma forma alternativa de resiliência foi proposta considerando o bio-volume real como uma função do eco-volume potencial. Os objetivos e hipóteses foram alcançados; demonstrou-se que existe uma correlação altamente positiva entre índice de resiliência, energia da biomassa, eficiência energética e biodiversidade. Pecuária e sistemas de hortaliças apresentaram as mais baixas resiliências enquanto sistemas ecológico e silvo-pastoral tiveram maiores resiliências. Esta nova estratégia oferece uma rápida e valiosa ferramenta de avaliação para estudos ecológicos, desenvolvimento agrícola e planejamento paisagístico, especialmente em países tropicais.

Long-term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson's disease.

We report the 5 to 6 year follow-up of a multicenter study of bilateral subthalamic nucleus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) in advanced Parkinson's disease (PD) patients. Thirty-five STN patients and 16 GPi patients were assessed at 5 to 6 years after DBS surgery. Primary outcome measure was the stimulation effect on the motor Unified Parkinson's Disease Rating Scale (UPDRS) assessed with a prospective cross-over double-blind assessment without medications (stimulation was randomly switched on or off). Secondary outcomes were motor UPDRS changes with unblinded assessments in off- and on-medication states with and without stimulation, activities of daily living (ADL), anti-PD medications, and dyskinesias. In double-blind assessment, both STN and GPi DBS were significantly effective in improving the motor UPDRS scores (STN, P < 0.0001, 45.4%; GPi, P = 0.008, 20.0%) compared with off-stimulation, regardless of the sequence of stimulation. In open assessment, both STN- and GPi-DBS significantly improved the off-medication motor UPDRS when compared with before surgery (STN, P < 0.001, 50.5%; GPi, P = 0.002, 35.6%). Dyskinesias and ADL were significantly improved in both groups. Anti-PD medications were significantly reduced only in the STN group. Adverse events were more frequent in the STN group. These results confirm the long-term efficacy of STN and GPi DBS in advanced PD. Although the surgical targets were not randomized, there was a trend to a better outcome of motor signs in the STN-DBS patients and fewer adverse events in the GPi-DBS group.

Long-term effects of pallidal or subthalamic deep brain stimulation on quality of life in Parkinson's disease.

We assessed the effects of deep brain stimulation of the subthalamic nucleus (STN-DBS) or internal pallidum (GPi-DBS) on health-related quality of life (HrQoL) in patients with advanced Parkinson's disease participating in a previously reported multicenter trial. Sickness Impact Profile (SIP) questionnaires were available for analysis in a subgroup of n = 20/20 patients with GPi-DBS and n = 45/49 patients with STN-DBS at baseline, 6 and 36 months. The SIP provides a physical dimension and a psychosocial dimension sum score and 12 category scores: Alertness/Intellectual Behavior (AIB), Ambulation (A), Body Care and Movement (BCM), Communication (C), Eating (E), Emotional Behavior (EB), Home Management (HM), Mobility (M), Recreation and Pastimes (RP), Sleep and Rest (SR), Social Interaction (SI), and Work (W). Motor functioning was assessed by means of the Unified Parkinson's Disease Rating Scale and diaries. At 6 months significant improvements in off-period motor symptoms and activities of daily living were paralleled by significant reductions in the total, physical, and psychosocial SIP score in both treatment groups. At 3 years, sustained improvements were observed in the physical dimension score, BCM, E, M, RP after STN-DBS and M, SI after GPi-DBS. All other SIP subscores approached baseline values, but were still the same or better (except C) whereas motor functioning remained stable after 36 months. STN-DBS and GPi-DBS led to significant early improvements in HrQoL. Despite sustained motor improvements many of these initial benefits were lost after 3 years. This may reflect either progression of the disease or adaptive changes in the subjective perception of health-related wellbeing over time.

Sweet potato [Ipomoea batatas (L.) Lam.] cultivated as tuber or leafy vegetable supplier as affected by elevated tropospheric ozone.

Sweet potato cultivars respond differently to elevated tropospheric ozone concentrations of ca. 130 mug m (-3), 8 h a day for 4 weeks, which affects their selection for cultivation. In the first cultivar presented here, an adequate leafy vegetable supplier, the ozone load resulted in a shift of biomass to maintain the canopy at the expense of tuber development. Starch content of leaves was reduced, indicating an impairment of quality, but carotenoid content remained stable. The second cultivar may be grown for tuber production. Although the ratio tuber/plant remained stable under ozone, tuber yield and its starch content were significantly reduced. The lower starch content indicated a worse quality for certain industrial processing, but it is desirable for chip production. Elevated tropospheric ozone concentrations also influenced free amino acids and macronutrient contents of tubers, but these modifications were of minor significance for tuber quality in the second cultivar.

A comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators.

UNLABELLED: In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study. IMPLICATIONS: We compared two different training simulators (computer screen-based versus full-scale) for training anesthesia residents to better document the effectiveness of such devices as training tools. This is an important issue, given the extensive use and the high cost of mannequin-based simulators in anesthesiology.