Formulation engineering of food systems for 3D-printing applications - A review.

The efficient development of extrusion-based 3D-printing requires flexibility in both formulation- and process design. This task requires a fundamental understanding of the influence of material rheological properties on the extrusion process. Within this review, a qualitative toolbox for food extrusion is presented which provides guidelines for the formulation and engineering of extrusion processes in general and 3D-printing in particular. The toolbox is based on current knowledge of highly viscous food systems and the influence of individual components on the overall rheology. It includes the efficiency of particle packing, microstructure and the influence of shear rate, as well as the formation of self-supporting structures by gelation of the liquid phase and crowding of particles. Physical laws and semi-empirical equations are discussed to describe the rheology and relate relevant theory to the extrusion process. Practical information is presented, including examples of extrusion and 3D-printing of food and non-food systems. The qualitative extrusion toolbox provides a general framework for the emerging field of extrusion-based 3D-printing of food products. It can be used to identify which specific material and process parameters can be changed and how they may be altered to optimize the 3D-printing process. The general framework will assist researchers, as well as industry.

ADAMTS5 is required for normal trabeculated bone development in the mandibular condyle.

OBJECTIVE: Determine the role of the extracellular matrix protease ADAMTS5 in development of the trabeculated bone of the mandibular condyle. METHODS: The mandibular condyles of wild type and mice deficient in the protease ADAMTS5 were examined for histopathology with Safranin O staining. Microcomputed tomography was performed to analyze the developing bone of the mandibular condyle. RNAscope and immunohistochemistry were utilized to investigate cell type and extracellular matrix expression. RESULTS: Mice deficient in Adamts5, (Adamts5tm1Dgen/J) exhibit an increase in trabecular separation (n = 37 wild type; n = 27: P < 0.0001) and reduction of trabecular thickness P = 0.0116 and bone volume fraction P = 0.0869 in the mandibular condylar head compared to wild type littermates. The altered bone parameters were more pronounced in male Adamts5-/- mice compared to female Adamts5-/- mice (TbSp; P = 0.03). Adamts5 was co-expressed with versican and Gli1 in mesenchymal, stem-like cells in the transition zone where the trabeculated bone is adjacent to mature hypertrophic chondrocytes. Loss of Adamts5 caused a reduction of Bglap expressing osteoblasts throughout mandibular condylar development and in young adult mice. The protease Mmp13, that is involved in mineralization and is expressed by hypertrophic chondrocytes and osteoblasts, was reduced in the mandibular condyle of Adamts5 deficient mice. CONCLUSION: This is the first report of a novel and critical role for Adamts5 in bone formation within the mandibular condyle of the temporomandibular joint. These data indicate Adamts5 may be required in the transdifferentiation of hypertrophic chondrocytes to osteoblasts during trabecular bone formation in development of the mandibular condyle.

Comparison of wheelchair securement systems designed for use in large accessible transit vehicles (LATVs).

Design challenges in wheelchair securement for fixed-route, large accessible transit vehicles (LATVs) often create difficulties for passengers who use wheelchairs and operational inefficiencies for public transit agencies. Recent innovations in wheelchair securement technology for LATVs may reduce these challenges. This study explored the usability of three commercially available wheelchair securement systems in a static laboratory environment: a four-point, forward-facing (4P-FF) securement system, a three-point, forward-facing (3P-FF) securement system, and a semi-automated, rear-facing (SA-RF) securement system. Three groups of mobility device users (manual wheelchair users, power wheelchair users, and scooter users) (n = 36) completed wheelchair securement tasks in a full-scale mock-up of an LATV. For the 19 participants who did not use the occupant restraint system (ORS), perceived usability and securement time were compared across the securement systems. Using multiple usability rating scales, most participants reported that each of the systems would be acceptable for regular use. However, the majority indicated an overall preference for the SA-RF, and most rated the SA-RF system as easier, faster, and requiring less assistance to use than the 4P-FF and 3P-FF systems. Alternatives to conventional 4P-FF wheelchair securement in LATVs may thus improve boarding efficiency and transit independence of passengers who use wheelchairs.

Infectious Coryza: Persistence, Genotyping, and Vaccine Testing.

The reemergence of infectious coryza (IC) caused by Avibacterium paragallinarum (AP) as an acute and occasionally chronic respiratory disease in domestic poultry has caused severe losses in several U.S. states. The disease is also associated with decreased egg production in layers and increased condemnations from air sac infections in broilers. A series of applied experiments were performed to elucidate the persistence of AP in infected broiler flocks, to genotype AP strains isolated from field cases, and to evaluate commercial and autogenous vaccine protection in commercial and specific-pathogen-free (SPF) chickens. Experimental evaluation of environmental persistence suggests that AP did not persist more than 12 hr in a hypothetically contaminated environment. Additionally, other detected potential pathogens such as Gallibacterium anatis and infectious bronchitis virus caused mild respiratory signs in the exposed birds. The HMTp210 and HagA genes of four IC field strains were sequenced and compared with published sequences of HMTp210 and HagA. The HMTp210 phylogeny showed a marginally imperfect clustering of the sequences in genogroups A, B, and C. Although not definitive, this phylogeny provided evidence that the four field strains aligned with previously characterized serovar C strains. Moreover, the base pair homology of the four strains was 100% identical to serovar C reference strains (H-18 and Modesto). HagA phylogeny was unclear, but interestingly, the IC field strains were 100% homologous to C-1 strains reported from Mexico and Ecuador. Finally, vaccine protection studies in commercial hens indicate that clinical signs are induced by a combination of IC and other concomitant pathogens infecting commercial birds. Additionally, vaccine protection experiments performed in SPF hens indicated that protection provided by the two commercial vaccines tested provided a reduction in clinical signs and bacterial shedding after two applications.

Coriza infecciosa: Persistencia, genotipificación y pruebas para vacunas. El resurgimiento de la coriza infecciosa (CI) causada por Avibacterium paragallinarum (AP) como una enfermedad respiratoria aguda y ocasionalmente crónica en aves domésticas ha causado graves pérdidas en varios estados de los Estados Unidos. La enfermedad también se asocia con una disminución en la producción de huevo en gallinas de postura y al incremento de decomisos por infecciones de los sacos aéreos en pollos de engorde. Se realizó una serie de experimentos aplicados para dilucidar la persistencia de A. paragillanarum en parvadas de pollos de engorde infectados, para genotipificar las cepas de A. paragallinarum aisladas de casos de campo y para evaluar la protección de vacunas comerciales y autógenas en pollos comerciales y en aves libres de patógenos específicos (SPF). La evaluación experimental de la persistencia ambiental sugiere que A. paragallinarum no persistió más de doce horas en un ambiente hipotéticamente contaminado. Además, otros patógenos potenciales detectados como Gallibacterium anatis y el virus de la bronquitis infecciosa causaron signos respiratorios leves en las aves expuestas. Los genes HMTp210 y HagA de cuatro cepas de campo de coriza infecciosa se secuenciaron y compararon con las secuencias publicadas de HMTp210 y HagA. La filogenia de HMTp210 mostró una agrupación marginalmente imperfecta de las secuencias en los genogrupos A, B y C. Aunque no es definitiva, esta filogenia proporcionó evidencia de que las cuatro cepas de campo se alinearon con cepas del serovar C previamente caracterizadas. Además, la homología de pares de bases de las cuatro cepas fue 100% idéntica a las cepas de referencia del serovar C (H-18 y Modesto). La filogenia de HagA no fue clara, pero curiosamente, las cepas de campo de coriza infecciosa fueron 100% similares con las cepas C-1 reportadas en México y Ecuador. Finalmente, los estudios de protección de vacunas en gallinas comerciales indican que los signos clínicos son inducidos por una combinación de coriza infecciosa y otros patógenos concomitantes que infectan a las aves comerciales. Además, los experimentos de protección de vacunas realizados en aves libres de patógenos específicos indicaron que la protección proporcionada por las dos vacunas comerciales analizadas proporcionó una reducción en los signos clínicos y en la eliminación bacteriana después de dos aplicaciones.

Systematic alteration of ATAC-seq for profiling open chromatin in cryopreserved nuclei preparations from livestock tissues.

The use of Assay for Transposase-Accessible Chromatin (ATAC-seq) to profile chromatin accessibility has surged over the past years, but its applicability to tissues has been very limited. With the intent of preserving nuclear architecture during long-term storage, cryopreserved nuclei preparations from chicken lung were used to optimize ATAC-seq. Sequencing data were compared with existing DNase-seq, ChIP-seq, and RNA-seq data to evaluate library quality, ultimately resulting in a modified ATAC-seq method capable of generating high quality chromatin accessibility data from cryopreserved nuclei preparations. Using this method, nucleosome-free regions (NFR) identified in chicken lung overlapped half of DNase-I hypersensitive sites, coincided with active histone modifications, and specifically marked actively expressed genes. Notably, sequencing only the subnucleosomal fraction dramatically improved signal, while separation of subnucleosomal reads post-sequencing did not improve signal or peak calling. The broader applicability of this modified ATAC-seq technique was tested using cryopreserved nuclei preparations from pig tissues, resulting in NFR that were highly consistent among biological replicates. Furthermore, tissue-specific NFR were enriched for binding motifs of transcription factors related to tissue-specific functions, and marked genes functionally enriched for tissue-specific processes. Overall, these results provide insights into the optimization of ATAC-seq and a platform for profiling open chromatin in animal tissues.

Comparing refractive outcomes of a standard industry toric IOL calculator using anterior corneal astigmatism and total corneal refractive power.

PURPOSE: To evaluate refractive outcomes for a standard industry calculator using anterior corneal astigmatism or total corneal refractive power. METHODS: This prospective interventional study evaluated the refractive outcomes of 56 eyes using a standard industry calculator (Zeiss ZCalc) and a digital IOL alignment software. After A-constant optimisation the ZCalc was recalculated with two different keratometry values using appropriate refractive indices: anterior corneal astigmatism (ACA) by IOLMaster 700 and total corneal refractive power (TCRP) by Pentacam. The Barrett toric calculator was used as a reference. RESULTS: Undercorrection of 0.04 ± 0.42 D after 1 week and 0.13 ± 0.48 D after 3 months was achieved for the spherical equivalent by using a standard industry calculator. IOL misalignment was 2.8° ± 3.4° using a digital alignment system. For the ZCalc, the mean absolute error could be reduced from 0.19 ± 0.40 D using ACA to 0.04 ± 0.48 D when considering total corneal refractive power (p = 0.06). The Barrett calculator delivered better refractive outcomes than using a standard industry calculator with ACA measurements only (- 0.06 ± 0.43 D; p < 0.01). CONCLUSION: Reliable and accurate refractive outcomes in toric IOL calculation were achieved by using the ZCalc calculator. The prediction error for a widely used standard industry toric IOL calculator could be reduced by using measured total corneal refractive power.

The 2017-19 activity at Mount Agung in Bali (Indonesia): Intense unrest, monitoring, crisis response, evacuation, and eruption.

After 53 years of quiescence, Mount Agung awoke in August 2017, with intense seismicity, measurable ground deformation, and thermal anomalies in the summit crater. Although the seismic unrest peaked in late September and early October, the volcano did not start erupting until 21 November. The most intense explosive eruptions with accompanying rapid lava effusion occurred between 25 and 29 November. Smaller infrequent explosions and extrusions continue through the present (June 2019). The delay between intense unrest and eruption caused considerable challenges to emergency responders, local and national governmental agencies, and the population of Bali near the volcano, including over 140,000 evacuees. This paper provides an overview of the volcanic activity at Mount Agung from the viewpoint of the volcano observatory and other scientists responding to the volcanic crisis. We discuss the volcanic activity as well as key data streams used to track it. We provide evidence that magma intruded into the mid-crust in early 2017, and again in August of that year, prior to intrusion of an inferred dike between Mount Agung and Batur Caldera that initiated an earthquake swarm in late September. We summarize efforts to forecast the behavior of the volcano, to quantify exclusion zones for evacuations, and to work with emergency responders and other government agencies to make decisions during a complex and tense volcanic crisis.

Genotypic Characterization of Emerging Avian Reovirus Genetic Variants in California.

This study focuses on virus isolation of avian reoviruses from a tenosynovitis outbreak between September 2015 and June 2018, the molecular characterization of selected isolates based on partial S1 gene sequences, and the full genome characterization of seven isolates. A total of 265 reoviruses were detected and isolated, 83.3% from tendons and joints, 12.3% from the heart and 3.7% from intestines. Eighty five out of the 150 (56.6%) selected viruses for sequencing and characterization were successfully detected, amplified and sequenced. The characterized reoviruses grouped in six distinct genotypic clusters (GC1 to GC6). The most represented clusters were GC1 (51.8%) and GC6 (24.7%), followed by GC2 (12.9%) and GC4 (7.2%), and less frequent GC5 (2.4%) and GC3 (1.2%). A shift on cluster representation throughout time occurred. A reduction of GC1 and an increase of GC6 classified strains was noticed. The highest homologies to S1133 reovirus strain were detected in GC1 (~77%) while GC2 to GC6 homologies ranged between 58.5 and 54.1%. Over time these homologies have been maintained. Seven selected isolates were full genome sequenced. Results indicated that the L3, S1 and M2 genes, coding for proteins located in the virus capsid accounted for most of the variability of these viruses. The information generated in the present study helps the understanding of the epidemiology of reoviruses in California. In addition, provides insights on how other genes that are not commonly studied add variability to the reovirus genome.

The 2018 rift eruption and summit collapse of Kilauea Volcano.

In 2018, Kilauea Volcano experienced its largest lower East Rift Zone (LERZ) eruption and caldera collapse in at least 200 years. After collapse of the Pu'u 'O'o vent on 30 April, magma propagated downrift. Eruptive fissures opened in the LERZ on 3 May, eventually extending ~6.8 kilometers. A 4 May earthquake [moment magnitude (M w) 6.9] produced ~5 meters of fault slip. Lava erupted at rates exceeding 100 cubic meters per second, eventually covering 35.5 square kilometers. The summit magma system partially drained, producing minor explosions and near-daily collapses releasing energy equivalent to M w 4.7 to 5.4 earthquakes. Activity declined rapidly on 4 August. Summit collapse and lava flow volume estimates are roughly equivalent-about 0.8 cubic kilometers. Careful historical observation and monitoring of Kilauea enabled successful forecasting of hazardous events.

Risk factors for post-dural puncture headache following injury of the dural membrane: a root-cause analysis and nested case-control study.

BACKGROUND: Post-dural puncture headache following trauma to the dural membrane during neuraxial anaesthesia occurs in 0.13-6.5% of pregnant patients. Identifying factors beyond individual performance that contribute to this adverse event is crucial to developing improvement strategies. METHODS: We used a root cause analysis framework, in a nested case-control study, to identify associated factors. Cases were all patients who had a post-dural puncture headache requiring an epidural blood patch. These patients were matched to a random group of control patients without post-dural puncture headache or known dural injury. Mixed logistic modelling was used. RESULTS: Within a dataset of 35 763 patients, we selected all 154 patients with post-dural puncture headache and compared them with 616 controls. Migraine (odds ratio [OR] 10.60, 95% CI 2.74 to 41.05), obstetric and perinatal pathology (OR 10.85, 95% CI 4.29 to 21.42), and multiple insertion attempts (OR 11.48, 95% CI 6.29 to 20.94), increased the risk of post-dural puncture headache. In contrast, training >3 years (OR 0.20, 95% CI 0.55 to 0.76) and a nurse anaesthetist present during the procedure (OR 0.05, 95% CI 0.01 to 0.29) decreased the risk. The anaesthetist's identity, the size of the labour room, the timing of the procedure or workload did not modify the risk. CONCLUSION: Post-dural puncture headache in this setting is not the result of the individual anaesthetist's characteristics alone. Additional factors including team composition, the presence of obstetrical perinatal pathology, and associated patient's conditions, are also associated with this event. Improvement strategies should consider all these factors.

Modern Corneal Eye-Banking Using a Software-Based IT Management Solution.

BACKGROUND: Increasing government legislation and regulations in manufacturing have led to additional documentation regarding the pharmaceutical product requirements of corneal grafts in the European Union. The aim of this project was to develop a software within a hospital information system (HIS) to support the documentation process, to improve the management of the patient waiting list and to increase informational flow between the clinic and eye bank. MATERIALS AND METHODS: After an analysis of the current documentation process, a new workflow and software were implemented in our electronic health record (EHR) system. RESULTS: The software takes over most of the documentation and reduces the time required for record keeping. It guarantees real-time tracing of all steps during human corneal tissue processing from the start of production until allocation during surgery and includes follow-up within the HIS. Moreover, listing of the patient for surgery as well as waiting list management takes place in the same system. CONCLUSION: The new software for corneal eye banking supports the whole process chain by taking over both most of the required documentation and the management of the transplant waiting list. It may provide a standardized IT-based solution for German eye banks working within the same HIS.

The Zonal Architecture of the Mandibular Condyle Requires ADAMTS5.

Temporomandibular joint (TMJ) osteoarthritis (TMJOA) disrupts extracellular matrix (ECM) homeostasis, leading to cartilage degradation. Upregulated a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-5 leads to cleavage of its substrate aggrecan (Acan) and is considered a hallmark of TMJOA. However, most research on ADAMTS5-Acan turnover has focused on hyaline cartilage, not fibrocartilage, which comprises the TMJ. The mandibular condylar cartilage (MCC) of the TMJ is organized in zones, and chondrocytes are arranged in axial rows, yet the molecular mechanisms required to generate the MCC zonal architecture have not been elucidated. Here, we test the hypothesis that ADAMTS5 is required for development of the TMJ MCC. Adamts5+/+ and Adamts5-/- murine TMJs were harvested at postnatal day 7 (P7), P21, 2 mo, and 6 mo of age; histomorphometrics indicated increased ECM. Immunohistochemistry and Western blots demonstrated the expanded ECM correlated with increased Acan localization in Adamts5-/- compared to Adamts5+/+. Cell volume was also decreased in the MCC of Adamts5-/- due to both a reduction in cell size and less mature hypertrophic chondrocytes. Analysis of chondrogenic maturation markers by quantitative real-time polymerase chain reaction indicated Col2a1, Col10a1, and Sox9 were significantly reduced in Adamts5-/- MCC compared to that of Adamts5+/+. The older (6 mo) Adamts5-/- MCC exhibited changes in chondrogenic cell arrangements, including clustering and chondrogenic atrophy, that correlated with early stages of TMJOA using modified Mankin scoring. These data indicate a potentially novel and critical role of ADAMTS5 for maturation of hypertrophic chondrocytes and establishment of the zonal architecture that, when disrupted, may lead to early onset of TMJOA.

Comparison of Two Toric IOL Calculation Methods.

PURPOSE: To compare two calculators for toric intraocular lens (IOL) calculation and to evaluate the prediction of refractive outcome. METHODS: Sixty-four eyes of forty-five patients underwent cataract surgery followed by implantation of a toric intraocular lens (Zeiss Torbi 709 M) calculated by a standard industry calculator using front keratometry values. Prediction error, median absolute error, and refractive astigmatism error were evaluated for the standard calculator. The predicted postoperative refraction and toric lens power values were evaluated and compared after postoperative recalculation using the Barrett calculator. RESULTS: We observed a significant undercorrection in the spherical equivalent (0.19 D) by using a standard calculator (p ≤ 0.05). According to the Baylor nomogram and the refractive influence of posterior corneal astigmatism (PCA), undercorrection of the cylinder was lower for patients with WTR astigmatism, because of the tendency of overcorrection. An advantage of less residual postoperative SE, sphere, and cylinder for the Barrett calculator was observed when retrospectively comparing the calculated predicted postoperative refraction between calculators (p ≤ 0.01). CONCLUSION: Consideration of only corneal front keratometric values for toric lens calculation may lead to postoperative undercorrection of astigmatism. The prediction of postoperative refractive outcome can be improved by using appropriate methods of adjustment in order to take PCA into account.

Proteomic Alterations Associated with Biomechanical Dysfunction are Early Processes in the Emilin1 Deficient Mouse Model of Aortic Valve Disease.

Aortic valve (AV) disease involves stiffening of the AV cusp with progression characterized by inflammation, fibrosis, and calcification. Here, we examine the relationship between biomechanical valve function and proteomic changes before and after the development of AV pathology in the Emilin1-/- mouse model of latent AV disease. Biomechanical studies were performed to quantify tissue stiffness at the macro (micropipette) and micro (atomic force microscopy (AFM)) levels. Micropipette studies showed that the Emilin1-/- AV annulus and cusp regions demonstrated increased stiffness only after the onset of AV disease. AFM studies showed that the Emilin1-/- cusp stiffens before the onset of AV disease and worsens with the onset of disease. Proteomes from AV cusps were investigated to identify protein functions, pathways, and interaction network alterations that occur with age- and genotype-related valve stiffening. Protein alterations due to Emilin1 deficiency, including changes in pathways and functions, preceded biomechanical aberrations, resulting in marked depletion of extracellular matrix (ECM) proteins interacting with TGFB1, including latent transforming growth factor beta 3 (LTBP3), fibulin 5 (FBLN5), and cartilage intermediate layer protein 1 (CILP1). This study identifies proteomic dysregulation is associated with biomechanical dysfunction as early pathogenic processes in the Emilin1-/- model of AV disease.

Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: a prospective cohort study.

BACKGROUND: Post-traumatic stress disorder (PTSD) occurs in 1-7% of women following childbirth. While having a caesarean section (C-section) is known to be a significant risk factor for postpartum PTSD, it is currently unknown whether coexisting anaesthesia-related factors are also associated to the disorder. The aim of this study was to assess anaesthesia-linked factors in the development of acute postpartum PTSD. METHODS: We performed a prospective cohort study on women having a C-section in a tertiary hospital in Switzerland. Patients were followed up six weeks postpartum. Patient and procedure characteristics, past morbidity or traumatic events, psychosocial status and stressful perinatal events were measured. Outcome was divided into two categories: full PTSD disease and PTSD profile. This was based on the number of DSM-IV criteria of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) present. The PTSD Checklist Scale and the Clinician Administered PTSD Scale were used for measurement. RESULTS: Of the 280 patients included, 217 (77.5%) answered the questionnaires and 175 (62.5%) answered to an additional phone interview. Twenty (9.2%) had a PTSD profile and six (2.7%) a PTSD. When a full predictive model of risk factors for PTSD profile was built using logistic regression, maternal prepartum and intrapartum complications, anaesthetic complications and dissociative experiences during C-section were found to be the significant predictors for PTSD profile. CONCLUSION: This is the first study to show in parturients having a C-section that an anaesthesia complication is an independent risk factor for postpartum PTSD and PTSD profile development, in addition to known perinatal and maternal risk factors.

[Smart eye data : Development of a foundation for medical research using Smart Data applications]. / "Smart eye data" : Entwicklung eines Fundaments für medizinische Forschung mittels Smart-Data-Applikationen.

BACKGROUND: Smart Data means intelligent data accumulation and the evaluation of large data sets. This is particularly important in ophthalmology as more and more data are being created. Increasing knowledge and personalized therapies are expected by combining clinical data from electronic health records (EHR) with measurement data. OBJECTIVE: In this study we investigated the possibilities to consolidate data from measurement devices and clinical data in a data warehouse (DW). MATERIAL AND METHODS: An EHR was adjusted to the needs of ophthalmology and the contents of referral letters were extracted. The data were imported into a DW overnight. Measuring devices were connected to the EHR by an HL7 standard interface and the use of a picture archiving and communications system (PACS). Data were exported from the review software using a self-developed software. For data analysis the software was modified to the specific requirements of ophthalmology. RESULTS: In the EHR 12 graphical user interfaces were created and the data from 32,234 referral letters were extracted. A total of 23 diagnostic devices could be linked to the PACS and 85,114 optical coherence tomography (OCT) scans, 19,098 measurements from IOLMaster as well as 5,425 pentacam examinations were imported into the DW including over 300,000 patients. Data discovery software was modified providing filtering methods. CONCLUSION: By building a DW a foundation for clinical and epidemiological studies could be implemented. In the future, decision support systems and strategies for personalized therapies can be based on such a database.

Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial.

BACKGROUND: Hemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We tested the hypothesis that an injection lateral to the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with a conventional intrafascial injection, while providing similar analgesia. METHODS: Forty ASA I-III patients undergoing elective shoulder and clavicle surgery under general anaesthesia were randomized to receive an ultrasound-guided interscalene brachial plexus block for analgesia, using 20 ml bupivacaine 0.5% with epinephrine 1:200 000 injected either between C5 and C6 within the interscalene groove (conventional intrafascial injection), or 4 mm lateral to the brachial plexus sheath (extrafascial injection). The primary outcome was incidence of hemidiaphragmatic paresis (diaphragmatic excursion reduction >75%), measured by M-mode ultrasonography, before and 30 min after the procedure. Secondary outcomes were forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow. Additional outcomes included time to first opioid request and pain scores at 24 h postoperatively (numeric rating scale, 0-10). RESULTS: The incidences of hemidiaphragmatic paresis were 90% (95% CI: 68-99%) and 21% (95% CI: 6-46%) in the conventional and extrafascial injection groups, respectively (P<0.0001). Other respiratory outcomes were significantly better preserved in the extrafascial injection group. The mean time to first opioid request was similar between groups (conventional: 802 min [95% CI: 620-984 min]; extrafascial: 973 min [95% CI: 791-1155 min]; P=0.19) as were pain scores at 24 h postoperatively (conventional: 1.6 [95% CI: 0.9-2.2]; extrafascial: 1.6 [95% CI: 0.8-2.4]; P=0.97). CONCLUSIONS: Ultrasound-guided interscalene brachial plexus block with an extrafascial injection reduces the incidence of hemidiaphragmatic paresis and impact on respiratory function while providing similar analgesia, when compared with a conventional injection. CLINICAL TRIAL REGISTRATION: NCT02074397.

A systematic review of ultrasound-guided methods for brachial plexus blockade.

We systematically reviewed 25 randomised controlled trials of ultrasound-guided brachial plexus blockade that recruited 1948 participants: either one approach vs another (axillary, infraclavicular or supraclavicular); or one injection vs multiple injections. There were no differences in the rates of successful blockade with approach, relative risk (95% CI): axillary vs infraclavicular, 1.0 (1.0-1.1), p = 0.97; axillary vs supraclavicular, 1.0 (1.0-1.1), p = 0.68; and infraclavicular vs supraclavicular, 1.0 (1.0-1.1), p = 0.32. There was no difference in the rate of successful blockade with the number of injections, relative risk (95% CI) 1.0 (1.0-1.0), p = 0.69, for one vs multiple injections. The rate of procedural paraesthesia was less with one injection than multiple injections, relative risk (95% CI) 0.6 (0.4-0.9), p = 0.004.

A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks.

We systematically reviewed the safety and efficacy of perineural dexamethasone as an adjunct for peripheral nerve blockade in 29 controlled trials of 1695 participants. We grouped trials by the duration of local anaesthetic action (short- or medium- vs long-term). Dexamethasone increased the mean (95% CI) duration of analgesia by 233 (172-295) min when injected with short- or medium-term action local anaesthetics and by 488 (419-557) min when injected with long-term action local anaesthetics, p < 0.00001 for both. However, these results should be interpreted with caution due to the extreme heterogeneity of results, with I2 exceeding 90% for both analyses. Meta-regression did not show an interaction between dose of perineural dexamethasone (4-10 mg) and duration of analgesia (r2 = 0.02, p = 0.54). There were no differences between 4 and 8 mg dexamethasone on subgroup analysis.

EUS-Guided Bile Duct Drainage (EUBD) in 95 Patients.

PURPOSE: Bile duct stenting during ERCP has long been established as the gold standard for the treatment of biliary obstruction. However, when the ampulla cannot be reached or bile duct cannulation fails, percutaneous or surgical drainage is performed. The study aimed to investigate the feasibility and long-term outcome of a potential alternative intervention, EUS-guided transluminal biliary drainage (EUBD), in a representative number of patients. MATERIALS AND METHODS: All patients undergoing EUBD were included in a prospectively collected single-center database over a 10-year period. Feasibility was characterized by technical and clinical success, including long-term follow-up data. RESULTS: From IV/2002 - XI/2012, 10 832 EUS and 8756 ERCP procedures were performed. Simultaneously, 223 PTCD and 95 EUBD were performed. Cholangiography was achieved in 93/95 patients (97.9 %). However, in one patient stone extraction was executed by means of the rendezvous technique. Therefore, drainage was not necessary. Intention to treat with EUS-guided drainage was given in 80/94 patients (86.9 %) using different techniques depending on anatomical variations and requirements. The cause of bile duct obstruction could not be cured in 77 patients (malignancy). In 18 patients, a benign (n = 15) or unknown etiology (n = 3) of bile duct stenosis was found. The complication rate was 15.7 % (mortality, 1.1 %; n = 1/95). The follow-up ranged from 3 - 60 months with reintervention in 3 patients. CONCLUSION: EUBD is a promising therapy for bile duct obstruction in patients predominantly with malignant diseases. Using EUBD, an excellent interventional approach is available for long-term internal drainage to prevent percutaneous drainage (PTCD). EUS-guided drainage is challenging and needs extraordinary interventional expertise, preferentially in tertiary gastroenterological and endoscopic centers.