Patient-embodied virtual reality as a learning tool for therapeutic communication skills among anaesthesiologists: A phenomenological study.

OBJECTIVE: In medicine, especially in a preoperative setting, training of effective communication skills is challenging, since communication is often implicatively copied from professional environment. This phenomenological study describes the development and experience of two patient-embodied virtual reality experiences designed to be used as an educational tool. METHOD: Two patient-embodied VR experiences from a first person patient perspective deployed negative or positive communication styles. The authors investigated the lived learning experiences of these VR tools through semi-structured interviews with ten anaesthesiologists adapting a thematic analysis framework. RESULTS: Interviews revealed acknowledgement of the importance of good communication skills. Overall, participants learned and adapted their style of communication 'on the job'. Patient-embodied VR was effective for a full immersive experience as participants expressed to have felt as if they had been a patient. They were able to distinguish differences in communication styles and analysis of the reflection showed a shift in perception, implying effective immersive experimental learning. CONCLUSIONS: This study elaborated the potency of experimental learning with VR in communication in a preoperative setting. Patient-embodied VR can influence beliefs and values and demonstrated effective as an educative tool. PRACTICAL IMPLICATIONS: The findings of this study can contribute to further research and healthcare education programs avid to use immersive learning with VR.

Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study.

STUDY OBJECTIVE: Quantitative neuromuscular monitoring is traditionally evaluated at the adductor pollicis muscle. By contrast, the TOF-Cuff compressomyograph evaluates neuromuscular block (NMB) at the upper arm. However, compressomyography has not been fully validated against other monitoring entities. This study evaluates the agreement between NMB measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle during various levels of neuromuscular block in patients with and without obesity. INTERVENTIONS: NMB was measured at the upper arm by compressomyography (TOF-Cuff) and by electromyography (GE-NMT) at the adductor pollicis. DESIGN: Prospective, multicenter, observational study. SETTING: Secondary and tertiary care hospitals' operating theatres. PATIENTS: 200 non-obese and 50 obese patients. MEASUREMENTS: During onset and offset of deep (post-tetanic-count 1-15 twitches), moderate (Train-of-Four-count 1-3 twitches) and shallow (Train-of-Four-ratio 0.01-1.0) depths of NMB were measured in obese and non-obese patients. The bias and limits of agreement of both devices were calculated using a Bland-Altman analysis for repeated measurements. Data obtained during spontaneous recovery (i.e. without the use of reversal agents) were used in the primary analyses. MAIN RESULTS: Data from enrolled patients yielded 942 paired post-tetanic-counts, 1175 paired train-of-four-counts and 1574 paired train-of-four ratios during spontaneous recovery. In non-obese patients, mean bias (95% CI) between the two devices was 3.405 (2.294 to 4.517) during deep NMB; -0.023 (-0.205 to 0.160) during moderate NMB and 0.312 (0.287 to 0.338) during shallow NMB. In obese patients, bias was -0.170 (-2.872 to 2.531); 0.178 (-0.202 to 0.558); 0.384 (0.299 to 0.469) for deep, moderate and shallow NMB respectively. CONCLUSIONS: There is variable disagreement between the level of NMB measured at the upper arm by compressomyography and at the adductor pollicis muscle measured by electromyography, throughout the various stages of NMB in obese and non-obese patients. Recovery of NMB on compressomyography preceded recovery on electromyography, which may have consequences for reversal and extubation decisions in clinical practice.

MSI as a predictive factor for treatment outcome of gastroesophageal adenocarcinoma.

Gastroesophageal cancers are a major cause of death worldwide and treatment outcomes remain poor. Adequate predictive biomarkers have not been identified. Microsatellite instability (MSI) as a result of mismatch repair deficiency is present in four to twenty percent of gastroesophageal cancers and has been associated with favorable survival outcomes compared to microsatellite stable tumors. This prognostic advantage may be related to immunosurveillance, which may also explain the favorable response to immune checkpoint inhibition observed in MSI high (MSI-H) tumors. The value of conventional cytotoxic treatment in MSI-H tumors is unclear and results on its efficacy range from detrimental to beneficial effects. Here the recent data on MSI as a predictive factor for outcome of gastroesophageal cancer treatment is reviewed.

Prevalence and Predictors of Uncontrolled Asthma in Children Referred for Asthma and Other Atopic Diseases.

BACKGROUND: Uncontrolled asthma in children is still highly prevalent despite the availability of effective asthma treatment. We investigated 1) the prevalence of uncontrolled asthma among children referred for asthma and referred for atopic diseases other than asthma (ie food allergy, allergic rhinitis or atopic dermatitis) to secondary care; and 2) the predictors associated with uncontrolled asthma. METHODS: All children (4 to 18 years) referred for asthma or atopic diseases other than asthma to 8 secondary care centers in The Netherlands were invited to an electronic portal (EP). The EP is a web-based application with several validated questionnaires including the ISAAC questionnaires and the Asthma Control Test (ACT). Children were eligible for inclusion in this study when their parents reported in the EP that their child had asthma diagnosed by a physician. The ACT was used to assess asthma control. Multiple predictors of asthma control (patient, asthma and atopic characteristics) were evaluated by univariable and multivariable logistic regression analyses. RESULTS: We included 408 children: 259 children (63%) with asthma referred for asthma and 149 children (37%) with asthma referred for atopic diseases other than asthma. Thirty-nine percent of all children had uncontrolled asthma: 47% of the children referred for asthma and 26% of the children referred for atopic diseases other than asthma. Predictors associated with uncontrolled asthma were a family history of asthma (odds ratio [OR] 2.08; 95% confidence interval [95% CI] 1.34 to 3.24), and recurrent upper and lower respiratory tract infections in the past year (OR 2.40; 95% CI 1.52 to 3.81 and OR 2.00; 95% CI 1.25 to 3.23, respectively). CONCLUSION: Uncontrolled asthma is highly prevalent in children with asthma referred to secondary care, even if children are primarily referred for atopic diseases other than asthma. Thus, attention should be paid to asthma control in this population.

Safety of sugammadex for reversal of neuromuscular block.

Introduction: Sugammadex is a modified cyclodextrin that is able to reverse neuromuscular block induced by aminosteroidal neuromuscular blocking drugs. Compared to reversal with neostigmine, it reverses neuromuscular block quicker and more predictable and without cholinergic side effects. However, there have been concerns about sugammadex ability to bind other drugs and its effects on QT interval and clotting times. In addition, sugammadex might induce hypersensitivity reactions more frequently than initially anticipated. This review summarizes current evidence with regard to these and other safety aspects of sugammadex. Areas covered: This review provides an overview of the efficacy of sugammadex in various patient populations, evaluates potential interactions with other drugs and discusses adverse effects and reactions that have been reported in the literature. Expert opinion: Sugammadex quickly reverses aminosteroid neuromuscular block with less side effects compared to neostigmine. As such, it has the potential to significantly reduce the incidence of residual neuromuscular block and to improve postoperative pulmonary outcome. Current safety concerns mainly focus on hypersensitivity reactions and cardiac arrhythmias. Although the absolute risk for these events is low, ongoing vigilance and research in this area are needed.

The PFOA substitute GenX detected in the environment near a fluoropolymer manufacturing plant in the Netherlands.

The ban on perfluorooctanoic acid (PFOA) has led to the production and use of alternative fluorinated compounds such as GenX. Limited information is available on the occurrence of this PFOA substitute. In this pilot study, we investigated the presence of GenX in/on grass and leaf samples collected near a fluoropolymer manufacturing plant in the Netherlands and in drinking water produced from surface and surface-water influenced groundwater intake points within 25 km from the plant. GenX was detected in/on all grass and leaf samples collected within 3 km north-east from the plant, with levels ranging from 1 to 27 ng/g wet weight (ww) and 4.3-86 ng/g ww, respectively. The PFOA levels in/on grass and leaves were lower, ranging from 0.7 to 11 ng/g ww and 0.9-28 ng/g ww, respectively. A declining concentration gradient of GenX and PFOA with increasing distance from the plant was observed, which suggests that the plant is a point source of GenX and was a point source for PFOA in the past. In all drinking water samples, GenX and PFOA were detected with levels ranging from 1.4 to 8.0 ng/L and 1.9-7.1 ng/L, respectively. The detection of GenX, which is only used since 2012, in/on grass and leaves and in drinking water indicates that GenX is now distributed through the environment. The presence of GenX and PFOA in/on grass and leaves within 3 km north-east of the plant also suggests that these chemicals could also be present on the locally grown food in gardens around the factory.

Differential role of nitric oxide in the psychedelic symptoms induced by racemic ketamine and esketamine in human volunteers.

BACKGROUND: Animal studies suggest that N-methyl-d-aspartate receptor (NMDAR) hypofunction and subsequent decline in intracellular nitric oxide (NO) are responsible for development of ketamine-induced psychedelic symptoms. To examine this mechanism in humans, we administered the NO donor sodium nitroprusside during infusion of racemic ketamine (RS-ketamine), containing equal amounts of S(+)- and R(-)-ketamine isomers, or esketamine, containing just the S(+)-isomer. METHODS: In this randomised, double blind, placebo-controlled crossover study, healthy volunteers were treated with sodium nitroprusside 0.5 µg kg-1 min-1 or placebo during administration of escalating doses of RS-ketamine (total dose 140 mg) or esketamine (70 mg). Drug high, internal and external perception, obtained using the Bowdle questionnaire, were scored over time on a visual analogue scale. The area-under-the-time-effect-curve (AUC) was calculated for each end-point. RESULTS: Sodium nitroprusside significantly reduced drug high AUC [mean (standard deviation); placebo 9070 (4630) vs sodium nitroprusside 7100 (3320), P=0.02], internal perception AUC [placebo 1310 (1250) vs nitroprusside 748 (786), P<0.01] and external perception AUC [placebo 4110 (2840) vs nitroprusside 2890 (2120), P=0.02] during RS-ketamine infusion, but was without effect on any of these measures during esketamine infusion. CONCLUSIONS: These data suggest that NO depletion plays a role in RS-ketamine-induced psychedelic symptoms in humans. The sodium nitroprusside effect was observed for R(-)- but not S(+)-isomer-induced psychedelic symptoms. Further studies are needed to corroborate our findings and assess whether higher sodium nitroprusside doses will reduce esketamine-induced psychedelic symptoms. CLINICAL TRIAL REGISTRATION: NTR 5359.

Esketamine counters opioid-induced respiratory depression.

BACKGROUND: Opioids can produce life-threatening respiratory depression. This study tested whether subanaesthetic doses of esketamine stimulate breathing in an established human model of opioid-induced respiratory depression. METHODS: In a study with a randomised, double blind, placebo controlled, crossover design, 12 healthy, young volunteers of either sex received a dose escalating infusion of esketamine (cumulative dose 40 mg infused in 1 h) on top of remifentanil-induced respiratory depression. A population pharmacokinetic-pharmacodynamic analysis was performed with sites of drug action at baseline ventilation, ventilatory CO2-chemosensitivity, or both. RESULTS: Remifentanil reduced isohypercapnic ventilation (end-tidal PCO2 6.5 kPa) by approximately 40% (from 20 to 12 litre min-1) in esketamine and placebo arms of the study, through an effect on baseline ventilation and ventilatory CO2 sensitivity. The reduction in ventilation was related to a remifentanil effect on ventilatory CO2 sensitivity (~39%) and on baseline ventilation (~61%). Esketamine increased breathing through an exclusive stimulatory effect on ventilatory CO2 sensitivity. The remifentanil concentration that reduced ventilatory CO2 sensitivity by 50% (C50) was doubled at an esketamine concentration of 127 (84-191) ng ml-1 [median (interquartile range)]; the esketamine effect was rapid and driven by plasma pharmacokinetics. Placebo had no systematic effect on opioid-induced respiratory depression. CONCLUSIONS: Esketamine effectively countered remifentanil-induced respiratory depression, an effect that was attributed to an increase in remifentanil-reduced ventilatory CO2 chemosensitivity.

An experimental study comparing the respiratory effects of tapentadol and oxycodone in healthy volunteers.

Background: There is a clinical need for potent opioids that produce little or no respiratory depression. In the current study we compared the respiratory effects of tapentadol, a mu-opioid receptor agonist and noradrenaline reuptake inhibitor, and oxycodone, a selective mu-opioid receptor agonist. We hypothesize that tapentadol 100 mg has a lesser effect on the control of breathing than oxycodone 20 mg. Methods: Fifteen healthy volunteers were randomized to receive oral tapentadol (100 and 150 mg), oxycodone 20 mg or placebo immediate release tablets in a crossover double-blind randomized design. The main end-point of the study was the effect of treatment on the ventilatory response to hypercapnia and ventilation at an extrapolated end-tidal PCO2 of 7.3 kPa (55 mmHg, VE55); VE55 was assessed prior and for 6-h following drug intake. Results: All three treatments had typical opioid effects on the hypercapnic ventilatory response: a shift to the right coupled to a decrease of the response slope. Oxycodone 20 mg had a significantly larger respiratory depressant effect than tapentadol 100 mg (mean difference -5.0 L min-1, 95% confidence interval: -7.1 to -2.9 L min-1, P<0.01), but not larger than tapentadol 150 mg (oxycodone vs. tapentadol 150 mg: P>0.05). Conclusions: In this exploratory study we observed that both tapentadol and oxycodone produce respiratory depression. Tapentadol 100 mg but not 150 mg had a modest respiratory advantage over oxycodone 20 mg. Further studies are needed to explore how these results translate to the clinical setting.

Waterijs na een operatie vermindert opiaatbehoefte.

OBJECTIVE To evaluate the effect of an ice-lolly on acute postoperative pain. DESIGN Randomised prospective intervention study. METHOD A total of 100 patients scheduled for an elective laparoscopic cholecystectomy were recruited to participate in the study. Patients were randomised to receive either an ice-lolly or no treatment after arrival at the post-anaesthesia care unit. The analgesic requirements (opioid and non-opioid), pain scores, and the presence of nausea and vomiting were registered on the post- anaesthesia care unit and ward during the first 24 hours after surgery. This study is registered in the Nederlands Trial Register under number NTR5335. RESULTS In the post-anaesthesia care unit, pain scores did not differ between patients who received an ice-lolly and those who did not. The opioid requirements of patients who had consumed an ice-lolly were significantly lower than those of the patients who had not (cumulative piritramide dose: 4.9 (SD 4.2) with ice-lolly vs. 6.6 (SD 4.0) without ice-lolly mg; P = 0.04). Furthermore, patients who did not receive an ice-lolly required more additional pain relief with non-opioid analgesics than patients who had been given an ice- lolly (31% vs. 10%; P = 0.01). Combining all administered opioid and non-opioid analgesics into one analgesic composite score showed that patients who received an ice-lolly required significantly fewer analgesics in the post-anaesthesia care unit than patients who had not been given an ice-lolly (2.2 (SD 1.7) vs. 2.9 (SD 1.8); P = 0.03). No differences between the groups in pain scores or use of analgesics were observed on the ward in the first 24 hours postoperatively. CONCLUSION The postoperative consumption of an ice-lolly reduces postoperative opioid and non-opioid analgesic requirements in the post- anaesthesia care unit. Conflict of interest and financial support: none declared.

Microplastics en route: Field measurements in the Dutch river delta and Amsterdam canals, wastewater treatment plants, North Sea sediments and biota.

Environmental contamination by plastic particles, also known as 'microplastics', brings synthetic materials that are non-degradable and biologically incompatible into contact with ecosystems. In this paper we present concentration data for this emerging contaminant in wastewater treatment plants (WWTPs) and freshwater and marine systems, reflecting the routes via which these particles can travel and the ecosystems they potentially impact along their path. Raw sewage influents, effluents and sewage sludge from seven municipal WWTPs in the Netherlands contained mean particle concentrations of 68-910L-1, 51-81L-1 and 510-760kg-1 wet weight (ww), respectively (particle sizes between 10 and 5000µm). Even after treatment, wastewater constitutes a source of microplastic pollution of surface waters, and via biosolids applications in farming and forestry, plastic retained in sewage sludge can be transferred to terrestrial environments. The WWTPs investigated here had a mean microplastics retention efficiency of 72% (s.d. 61%) in the sewage sludge. In the receiving waters of treated and untreated wastewaters, we detected high microplastic levels in riverine suspended particulate matter (1400-4900kg-1 dry weight (dw)) from the Rhine and Meuse rivers. Amsterdam canal water sampled at different urban locations contained microplastic concentrations (48-187L-1), similar to those observed in wastewater that is emitted from sewage treatment facilities in the area. At least partial settling of the particles occurs in freshwater as well, as indicated by microplastics in urban canal sediments (<68 to 10,500particleskg-1dw). Microplastics in suspension in the water column have the potential to be discharged into the sea with other riverine suspended particulates. We report microplastic concentrations from 100 up to 3600particleskg-1 dry sediment collected at 15 locations along the Dutch North Sea coast. The high microplastic enrichment in marine sediments compared to most literature data for seawater at the surface supports the hypothesis of a seabed sink for these materials. Marine species are heavily exposed to plastic particles. Body residues between 10 and 100particlesg-1dw were measured in benthic macroinvertebrate species inhabiting the Dutch North Sea coast: filter-feeding mussels and oysters (species for human consumption) as well as other consumers in the marine food chain.

Exposure to organophosphate and polybrominated diphenyl ether flame retardants via indoor dust and childhood asthma.

Although the ubiquitous detection of polybrominated diphenyl ether (PBDE) and organophosphate flame retardants (PFRs) in indoor dust has raised health concerns, only very few epidemiological studies have assessed their impact on human health. Inhalation of dust is one of the exposure routes of FRs, especially in children and can be hazardous for the respiratory health. Moreover, PFRs are structurally similar to organophosphate pesticides, which have been associated with allergic asthma. Thus, we investigated whether the concentrations of PFRs and PBDEs in indoor dust are associated with the development of childhood asthma. We selected 110 children who developed asthma at 4 or at 8 years old and 110 matched controls from a large prospective birth cohort (BAMSE - Barn, Allergy, Milieu Stockholm Epidemiology). We analyzed the concentrations of 7 PFRs and 21 PBDEs in dust collected around 2 months after birth from the mother's mattress. The abundance rank in dust was as follows: TBOEP⪢TPHP>mmp-TMPP>EHDPHP~TDCIPP>TCEP~TCIPP~BDE-209⪢BDE-99>BDE-47>BDE-153>BDE-183>BDE-100. There was no positive association between the FRs in mattress dust and the development of childhood asthma. In contrast, dust collected from mattresses of the mothers of children who would develop asthma contained significant lower levels of TPHP and mmp-TMPP. This study provides data on a wide range of PFRs and PBDEs in dust samples and development of asthma in children.

A randomized controlled trial and novel mathematical analysis of the analgesic effect of oxycodone versus paracetamol orodispersible tablets.

BACKGROUND: For effective treatment of acute pain, a rapid onset of action is important. Here we quantify the antinociceptive profile of an orodispersible oxycodone tablet (OOT) in a randomized, double-blind, active comparator (paracetamol orodispersible tablet, POT), crossover study design in a population of healthy volunteers. METHODS: Twelve female volunteers were randomized to receive 20 mg OOT and 500 mg POT sublingually on two occasions. The electrical pain threshold (EPTh), electrical pain tolerance (EPTol) and pressure pain threshold (PPT) were obtained at regular intervals for 5 h. Time-response data were analysed with a longitudinal pharmacodynamic model characterized by rate constants for analgesia onset (kON ), offset (kOFF ), potency parameter (EFF) and validated with a bootstrap analysis. Values are the median (95% CI) as derived from the bootstrap analysis. RESULTS: OOT produced a rapid increase in response values. For electrical pain analgesia onset, t½kON , 44 (25-67) versus analgesia offset, t½kOFF , 156 (63-552) min, p < 0.01. For pressure pain, t½kON equalled t½kOFF : 30 (16-48) min. OOT was most potent on EPTol: EFF 0.95 (0.39-1.71), p < 0.01, with similar potencies on EPTh, 0.43 (0.19-0.87) and PPT, 0.40 (0.21-0.67). Paracetamol displayed 14% of the analgesic efficacy of oxycodone. CONCLUSIONS: The analgesic effect of orodispersible oxycodone was successfully quantified using a mathematical model of analgesia evolution. This method allows quantification of a variety of responses times from sparse data sets. Response times as defined by a 30% increase in response thresholds varied significantly among end points: EPTol 15 min, PPTh 18 min and EPTh 41 min.

Integrated chemical and biological analysis to explain estrogenic potency in bile extracts of red mullet (Mullus barbatus).

A biological screening was performed to establish the total exposure to estrogenic compounds of red mullet (Mullus barbatus) collected at several sites along the Spanish Mediterranean coast by testing male fish bile extracts using the in vitro ER-LUC reporter gene assay. In addition, major metabolites were identified and measurements of OH-PAHs (1-naphthol, 9-phenantrol, 9-fluorenol, 1-pyrenol, 1OH-BaP and 3OH-BaP) and alkylphenols (4-n-nonylphenol (4-n-NP) and 4-tertoctylphenol (4-tert-OP)) in the same fish bile extracts were taken by gas chromatography-mass spectrometry in electron ionization mode (GC-EI-MS). Relative in vitro estrogenic potencies of the chemically quantified compounds were also tested. The highest biliary concentrations of 1-pyrenol, 9-fluorenol and 4-n-NP were found in fish from Barcelona and from the Mar Menor coastal lagoon. However, these concentrations can be considered relatively low compared to values reported in red mullet from other polluted waters in the Mediterranean Sea. The contribution of 1-pyrenol, 4-n-NP and 4-tert-OP to the total estrogenic potency measured in male fish bile was found to be negligible, indicating the presence of other estrogenic compounds in red mullet bile. Estrogenic potency in bile from male fish was markedly elevated in Mar Menor lagoon (234.8±5.7 pg E2EQ/µl), and further research will be necessary to explain whether the presence of natural and synthetic-hormones in the lagoon contributed to this finding. Values of approximately 15-16E2EQ pg/mg bile can be regarded as preliminary baseline levels of bile estrogenicity in male red mullet from the western Mediterranean Sea.

Positive urinary antigen tests for Streptococcus pneumoniae in community-acquired pneumonia: a 7-year retrospective evaluation of health care cost and treatment consequences.

A positive pneumococcal urinary antigen test (PUAT) for Streptococcus pneumoniae allows an early switch from empiric to targeted treatment in hospitalised community-acquired pneumonia (CAP) patients. The economic and treatment consequences of this widespread implemented test are, however, unknown. We retrospectively evaluated all tests performed since its introduction in two teaching hospitals. Data on patient characteristics, treatment, admission and outcome were retrieved from the electronic patient files. Test benefits were expressed as the number of days that targeted therapy (i.e. penicillin) was administered to hospitalised CAP patients due to a positive PUAT. This calculation was based on the timing of the PUAT and the initiation of targeted therapy. Subsequently, we performed two direct cost analyses from a hospital perspective, first including tests performed for CAP only, and second including costs of all (excessive) tests. Between 2005 and 2012, 3,479 PUATs were performed, of which 1,907 (55 %) were for CAP. A total of 1,638 PUATs (86 %) were negative and 269 (14 %) were positive. Fifty-two (19 %) positive tests were excluded. In 75 (35 %) of the 217 remaining positive tests, a positive PUAT led to targeted treatment during 293 cumulative admission days. Testing costs for CAP only were €131 per targeted treatment day. These costs were €257 if local protocol dictated PUAT use for all CAP cases, as opposed to €72 if the test was reserved for severe cases only. When including all tests, PUAT costs were €254 per targeted treatment day. Therefore, improving the selective use of the PUAT in hospitalised CAP patients may lead to increased (cost-)efficiency.

Pulse transit time as a quick predictor of a successful axillary brachial plexus block.

BACKGROUND: It can take up to 30 min to determine whether or not axillary block has been successful. Pulse transit time (PTT) is the time between the R-wave on electrocardiography (ECG) and the arrival of the resulting pressure pulse wave in the fingertip measured with photoplethysmography. It provides information about arterial resistance. Axillary block affects vasomotor tone causing loss of sympathetic vasoconstriction resulting in an increased PTT. Early objective assessment of a block can improve efficacy of operating room time and minimize patient's fear of possible conversion to general anesthesia. This study explores whether PTT can objectively, reliably and quickly predict a successful axillary block. METHODS: Forty patients undergoing hand surgery under axillary block were included. A three-lead ECG and photoplethysmographic sensors were placed on both index fingers. Measurements were made from 2 min before until 30 min after induction of the block or less if the patient was transferred for operation. Afterwards, PTT was calculated as the time between the R-wave on ECG and a reference point on the photoplethysmogram. To assess the change in PTT caused by the block, the PTT difference between the control and blocked arm was calculated. Sensitivity and specificity of PTT difference were calculated using receiver operating characteristic analysis. RESULTS: In a successful block, the mean PTT difference significantly increased after 3 min by 12 (standard error of the mean 3.9) ms, sensitivity 87% and specificity 71% (area under the curve 0.87, P = 0.004). CONCLUSIONS: PTT is a reliable, quick and objective method to assess whether axillary block is going to be successful or not.

Halogenated contaminants in farmed salmon, trout, tilapia, pangasius, and shrimp.

Polychlorinated biphenyls (PCBs), polychlorinated dibenzo-p-dioxins and dibenzo-p-furans (PCDD/Fs), organochlorine pesticides (OCPs), polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane diastereomers (HBCDs), and perfluorinated compounds (PFCs) were analyzed in popular farmed fish such as salmon, trout, tilapia, and pangasius and in farmed shrimp. The samples originated from southeast Asia, Europe, and South America. Results show the following: (i) Carnivorous species contained higher contaminant concentrations than omnivorous species. (ii) Contaminant concentrations generally decreased per species in the following order of salmon > trout >> tilapia approximately equal to pangasius approximately equal to shrimp. (iii) Most contaminant concentrations decreased in the following order of PCBs approximately equal to dichloro-diphenyl-trichloroethanes (DDTs) >> hexachlorobenzene approximately equal to pentachlorobenzene approximately equal to dieldrin approximately equal to PBDEs approximately equal to alpha-HBCD approximately equal to perfluorooctane sulfonate (PFOS) >> World Health Organization toxic equivalents (WHO-TEQ) [PCDD/Fs and dioxin-like (dl)-PCBs]. (iv) Contaminant concentrations were very low (mostly <1 ng/g wet weight) and far below the European and Dutch legislative limits. (v) Contaminant concentrations in farmed shrimp, pangasius, and tilapia were lower than those in wild fish, whereas contaminant concentrations in farmed salmon and trout were higher than those in lean wild marine fish. From the five species investigated, salmon is predominantly responsible (97%) for human exposure to the sum of the investigated contaminants. The contribution of trout, tilapia, pangasius, and shrimp is small (3%) because contaminant concentrations and consumption volumes were much lower.

Improved glucuronide hydrolysis in the determination of urinary 1-hydroxypyrene.

The efficiency of the glucuronide hydrolysis in the determination of urinary 1-hydroxypyrene was investigated as a function of the reaction conditions. A significant improvement could be obtained by increasing the enzyme concentration described in the literature.