The impact of embryo vitrification on placental histopathology features and perinatal outcome in singleton live births.

STUDY QUESTION: Does embryo vitrification affect placental histopathology pattern and perinatal outcome in singleton live births? SUMMARY ANSWER: Embryo vitrification has a significant effect on the placental histopathology pattern and is associated with a higher prevalence of dysfunctional labor. WHAT IS KNOWN ALREADY: Obstetrical and perinatal outcomes differ between live births resulting from fresh and frozen embryo transfers. The effect of embryo vitrification on the placental histopathology features associated with the development of perinatal complications remains unclear. STUDY DESIGN, SIZE, DURATION: Retrospective cohort study evaluating data of all live births from one academic tertiary hospital resulting from IVF treatment with autologous oocytes during the period from 2009 to 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: All patients had placentas sent for pathological evaluation irrelevant of maternal or fetal complications status. Placental, obstetric and perinatal outcomes of pregnancies resulting from hormone replacement vitrified embryo transfers were compared with those after fresh embryo transfers. A multivariate analysis was conducted to adjust the results for determinants potentially associated with the development of placental histopathology abnormalities. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 1014 singleton live births were included in the final analysis and were allocated to the group of pregnancies resulting from fresh (n = 660) and hormone replacement frozen (n = 354) embryo transfers. After the adjustment for confounding factors the frozen embryo transfers were found to be significantly associated with chorioamnionitis with maternal (odds ratio (OR) 2.0; 95% CI 1.2-3.3) and fetal response (OR 2.6; 95% CI 1.2-5.7), fetal vascular malperfusion (OR 3.9; 95% CI 1.4-9.2), furcate cord insertion (OR 2.3 95% CI 1.2-5.3), villitis of unknown etiology (OR 2.1; 95% CI 1.1-4.2), intervillous thrombi (OR 2.1; 95% CI 1.3-3.7), subchorionic thrombi (OR 3.4; 95% CI 1.6-7.0), as well as with failure of labor progress (OR 2.5; 95% CI 1.5-4.2). LIMITATIONS, REASONS FOR CAUTION: Since the live births resulted from frozen-thawed embryos included treatment cycles with previously failed embryo transfers, the factors over embryo vitrification may affect implantation and placental histopathology. WIDER IMPLICATIONS OF THE FINDINGS: The study results contribute to the understanding of the perinatal future of fresh and vitrified embryos. Our findings may have an implication for the clinical decision to perform fresh or frozen-thawed embryo transfer. STUDY FUNDING/COMPETING INTEREST(S): Authors have not received any funding to support this study. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Tolerance's improvement of flexible bronchoscopy by Ericksonian hypnosis: The BREATH study.

AIM: The aim of this study was to determine whether the use of Ericksonian hypnosis may allow an improvement of the tolerance of flexible bronchoscopy. METHODS: A comparative, two parallel-group, prospective, randomized monocentric clinical trial was conducted. After randomization, patients were divided into two groups: a standard group, in which bronchoscopy was performed according to the official French good practice guidelines and a study group, in which bronchoscopy was performed under hypnosis. RESULTS: Sixty-seven patients were included, 7 patients were excluded and 60 patients were randomized. No significant differences in age, gender, examination indication and duration were observed between both groups. Two patients of the standard group removed the endoscope by themselves, resulting in a premature termination of bronchoscopy and they were excluded from the statistical analysis. In the standard group, the levels of anxiety, cough, dyspnoea and pain increased during the examination and the addition of local anaesthesia was more often required. In the hypnosis group, levels of anxiety, cough, dyspnoea decreased, whereas only the level of pain increased. There was a statistic significative difference in favour of hypnosis for all the other variables. Moreover, the behaviour score was higher in the standard group: 19.5±14.5 versus 7.3±4.7 (P<0.001), indicating a better tolerance in the hypnosis group. In the standard group, 14 patients refused a new examination under the same conditions versus 7 in the hypnosis group, and 12 patients asked for general anaesthesia in case of a new examination versus 7 in the hypnosis group. CONCLUSION: This randomised control trial is the first to test the faisability and the potential usefulness of Ericksonian hypnosis during flexible bronchoscopy. Our results indicates an improvement of tolerance and a positive effect on all studied parameters except pain. This method could be widely offered to all patients undergoing flexible bronchoscopy.

Correction to: The oxygen reserve index (ORI): a new tool to monitor oxygen therapy.

In the original publication of the article, the authors have realized an error in Fig. 1. The corrected version of Fig. 1 is given below.

Valoración cardiorrespiratoria no invasiva y multiparamétrica del paciente hemodinámicamente inestable / Non-invasive multi-parametric cardiorespiratory assessment of the hemodynamically unstable patient

No disponible

The oxygen reserve index (ORI): a new tool to monitor oxygen therapy.

Supplemental oxygen is administered in the vast majority of patients in the perioperative setting and in the intensive care unit to prevent the potentially deleterious effects of hypoxia. On the other hand, the administration of high concentrations of oxygen may induce hyperoxia that may also be associated with significant complications. Oxygen therapy should therefore be precisely titrated and accurately monitored. Although pulse oximetry has become an indispensable monitoring technology to detect hypoxemia, its value in assessing the oxygenation status beyond the range of maximal arterial oxygen saturation (SpO2 ≥97%) is very limited. In this hyperoxic range, we need to rely on blood gas analysis, which is intermittent, invasive and sometimes delayed. The oxygen reserve index (ORI) is a new continuous non-invasive variable that is provided by the new generation of pulse oximeters that use multi-wavelength pulse co-oximetry. The ORI is a dimensionless index that reflects oxygenation in the moderate hyperoxic range (PaO2 100-200 mmHg). The ORI may provide an early alarm when oxygenation deteriorates well before any changes in SpO2 occur, may reflect the response to oxygen administration (e.g., pre-oxygenation), and may facilitate oxygen titration and prevent unintended hyperoxia. In this review we describe this new variable, summarize available data and preliminary experience, and discuss its potential clinical utilities in the perioperative and intensive care settings.

Rapid disease course in African Americans with multiple sclerosis.

OBJECTIVE: To investigate utility of a Multiple Sclerosis Severity Scale (MSSS)-based classification system for comparing African American (AA) and white American (WA) multiple sclerosis (MS) subpopulations in the New York State Multiple Sclerosis Consortium (NYSMSC) database. MSSS is a frequency-rank algorithm relating MS disability to disease duration in a large, untreated reference population. Design/ METHODS: Distributions of patients in 6 MSSS-based severity grades were calculated for AA and WA registrants. RESULTS: There were 419 AA and 5,809 WA patients in the NYSMSC, who had EDSS recorded during years 1-30 since symptom onset. Median EDSS was not different in AA and WA (3.5 vs 3.0, p = 0.60), whereas median MSSS in AA was higher than in WA (6.0 vs 4.8, p = 0.001). AA patients were overrepresented in the 2 most severe grades (41.5% vs 29.3% for WA) and underrepresented in the 2 lowest grades (23.4% vs 35.4%; p < 0.001). In multivariable analysis (ordered logistic and median regression), MSSS for AA remained significantly higher than in WA after adjusting for age, gender, disease duration, disease type distribution, and treatment with disease-modifying therapies. CONCLUSIONS: The 6-tiered MSSS grading system is a powerful tool for comparing rate of disease progression in subpopulations of interest. MSSS-based analysis demonstrates that African ancestry is a risk factor for a more rapidly disabling disease course.

Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial.

OBJECTIVE: To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention. METHODS: This was a randomized, controlled, and blinded study conducted with children 3-8 years of age undergoing general anesthesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mg x kg(-1) oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading. RESULTS: The clown group had a statistically significant lower modified-Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns' effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups. CONCLUSIONS: This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced.

[Minimally invasive cardiopulmonary monitoring with the PiCCO Plus system]. / PiCCO plus: monitorización cardiopulmonar mínimamente invasiva.

Insertion of a central venous catheter and an arterial catheter would be indicated in hemodynamically unstable or severely hypoxic patients in critical care units. In this setting, cardiorespiratory monitoring by transpulmonary thermodilution (TPTD) can be considered minimally invasive given that only a single arterial thermodilution catheter and a single central venous catheter are required to be connected to a specific monitor (the PiCCO Plus, Pulsion Medical Systems, Munich, Germany). TDTP simultaneously measures cardiac output, preloading, and cardiac function in hemodynamically unstable patients and predicts the response to volume. The technique can be managed by any health care professional. In hypoxic patients, TDTP identifies cases of pulmonary edema that might benefit from a negative fluid balance, evaluates pulmonary vascular permeability, facilitates our understanding of pathophysiologic mechanisms of hypoxemia, and predicts the likelihood of deleterious hemodynamic effects of positive end-expiratory pressures.

PiCCO plus: monitorización cardiopulmonar mínimamente invasiva / Minimally invasive cardiopulmonary monitoring with the PiCCO Plus system

En los pacientes hemodinámicamente inestables oseveramente hipoxémicos ingresados en una unidad decríticos, estaría indicada la inserción de un catéter venosocentral y un catéter arterial. En este contexto, lamonitorización cardiorrespiratoria por termodilucióntranspulmonar (TDTP) puede considerarse mínimamenteinvasiva, ya que sólo requiere de un catéter arterial determodilución, de un catéter venoso central y de unmonitor específico (PiCCO plus, Pulsion Medical Systems®, Munich, Alemania).En pacientes con inestabilidad hemodinámica, laTDTP permite la evaluación simultánea y en pocosminutos del gasto cardiaco, precarga, función cardiaca yla predicción de la respuesta al volumen. Además es unatécnica que puede ser realizada por cualquier profesionalsanitario.En pacientes hipoxémicos, la TDTP identifica el edemapulmonar que podría beneficiarse de balances hídricosnegativos, evalúa la permeabilidad vascular pulmonar,facilita la comprensión de los mecanismosfisiopatológicos de la hipoxemia y predice los posiblesefectos hemodinámicos deletéreos de la PEEP (AU)

Insertion of a central venous catheter and an arterialcatheter would be indicated in hemodynamicallyunstable or severely hypoxic patients in critical careunits. In this setting, cardiorespiratory monitoring bytranspulmonary thermodilution (TPTD) can beconsidered minimally invasive given that only a singlearterial thermodilution catheter and a single centralvenous catheter are required to be connected to a specificmonitor (the PiCCO Plus, Pulsion Medical Systems,Munich, Germany). TDTP simultaneously measurescardiac output, preloading, and cardiac function inhemodynamically unstable patients and predicts theresponse to volume. The technique can be managed byany health care professional. In hypoxic patients, TDTPidentifies cases of pulmonary edema that might benefitfrom a negative fluid balance, evaluates pulmonaryvascular permeability, facilitates our understanding ofpathophysiologic mechanisms of hypoxemia, and predictsthe likelihood of deleterious hemodynamic effects ofpositive end-expiratory pressures (AU)

Comparison of stroke volume (SV) and stroke volume respiratory variation (SVV) measured by the axillary artery pulse-contour method and by aortic Doppler echocardiography in patients undergoing aortic surgery.

BACKGROUND: The goal of the study was to compare stroke volume (SV) and respiratory stroke volume variation (SVV) measured by pulse-contour analysis and aortic Doppler. METHODS: These were measured by pulse-contour analysis and thermodilution (PiCCO) and by aortic pulsed wave Doppler with transoesophageal echocardiography in patients undergoing abdominal aortic surgery. Simultaneous measurements were done at different times of surgery. All data were recorded on PiCCOwin software and videotape and analysed off-line by a blinded investigator. RESULTS: A total of 114 measurements were achieved in 20 patients. There was a good correlation and small bias between the PiCCO and the echo-Doppler values of the mean SV [r=0.885; bias=0.2 (8) ml], and between the minimum [r=0.842; bias=1 (9) ml] and maximum SV [r=0.840; bias=2 (10) ml] values. CONCLUSIONS: There is a fair correlation between pulse-contour analysis and aortic Doppler for beat-by-beat measurement of SV but not for calculation of SV respiratory ventilation.

The implementation of an anesthesia information management system.

BACKGROUND AND OBJECTIVE: Anaesthesia information management systems, though still not used widely, will inevitably replace handwritten records and may eventually serve as a core for the development of computerized decision support. We investigated staff expectations and the accuracy of data entry in a recently implemented commercially available anaesthesia information management system. METHODS: A structured questionnaire was administered to the staff before and 1 week and 3 months after implementation in order to assess their opinion. The quality of manual data entry, and of automatic data record was evaluated by looking for missing data and the prevalence of artefacts. RESULTS: Despite initial fears the users quickly accepted the system. Both automatic and manual data entry were found to be accurate and reliable while the prevalence of artefacts was relatively low. CONCLUSIONS: A commercially available anaesthesia information management system can be easily implemented and used instead of paper charts.

A novel point-of-care information system reduces anaesthesiologists' errors while managing case scenarios.

BACKGROUND AND OBJECTIVES: The On-Line Electronic Help (OLEH) is a point-of-care information system for anaesthesia providers prepared by the European Society of Anaesthesiologists. In this preliminary study the effect of the OLEH availability on the incidence of knowledge-based errors during the management of case scenarios and participants' subjective evaluation of the OLEH were evaluated. METHODS: After a short training session, 48 anaesthesiologists (24 junior residents, 12 senior residents and 12 board-certified) were presented randomly with six computer screen-based case scenarios with, and six without, the option of using the OLEH. Two reviewers evaluated the answers independently according to preconfigured guidelines. RESULTS: The availability of the OLEH was associated with higher scores in 11 of the 12 scenarios, and with a decrease in the incidence of critical errors in 10 scenarios. Time to task completion was increased in one scenario only when the OLEH was used. The degree of professional experience was associated with better scores in five of the scenarios and with a reduced occurrence of critical errors in three scenarios. Forty-two out of 48 participants stated that finding information in the OLEH software was easy and that the system was helpful in managing the scenarios. CONCLUSIONS: This preliminary study demonstrates the potential value of the OLEH in decreasing the number of knowledge-based errors made by anaesthesiologists. According to the encouraging results, the OLEH system is currently under evaluation using full-scale simulation scenarios in an operating room environment.

Predicting fluid responsiveness in patients undergoing cardiac surgery: functional haemodynamic parameters including the Respiratory Systolic Variation Test and static preload indicators.

BACKGROUND: Prediction of the response of the left ventricular stroke volume to fluid administration remains an unsolved clinical problem. We compared the predictive performance of various haemodynamic parameters in the perioperative period in patients undergoing coronary artery bypass surgery. These parameters included static indicators of cardiac preload and functional parameters, derived from the arterial pressure waveform analysis. These included the systolic pressure variation (SPV) and its delta down component (dDown), pulse pressure variation (PPV), stroke volume variation (SVV), and a new parameter, termed the respiratory systolic variation test (RSVT), which is a measure of the slope of the lowest systolic pressure values during a standardized manoeuvre consisting of three successive incremental pressure-controlled breaths. METHODS: Eighteen patients were included into this prospective observational study. Seventy volume loading steps (VLS), each consisting of 250 ml of colloid administration were performed before surgery and after the closure of the chest. The response to each VLS was considered as a positive (increase in stroke volume more than 15%) or non-response. Receiver operating characteristic curves were plotted for each parameter to evaluate its predictive value. RESULTS: All functional parameters predicted fluid responsiveness better than the intrathoracic blood volume and the left ventricular end-diastolic area. Parameters with the best predictive ability were the RSVT and PPV. CONCLUSIONS: Functional haemodynamic parameters are superior to static indicators of cardiac preload in predicting the response to fluid administration. The RSVT and PPV were the most accurate predictors of fluid responsiveness, although only the RSVT is independent of the settings of mechanical ventilation.

Pulse pressure and stroke volume variations during severe haemorrhage in ventilated dogs.

BACKGROUND: Similarly to systolic pressure variation (SPV), pulse pressure variation (PPV) and stroke volume variation (SVV) derived from arterial pulse contour analysis have been shown to reflect fluid responsiveness in ventilated patients. However, unlike the SPV, both PPV and SVV have not been validated during extreme hypovolaemia. The aim of the present study was to examine whether these newly introduced variables respond to gradual hypovolaemia like the SPV by increasing gradually with each step of the haemorrhage even during extreme hypovolaemia. METHODS: SPV, SVV and PPV were measured in 8 dogs following initial volume loading (10% of the estimated blood volume administered as colloid solution), 5 steps of graded haemorrhage, each consisting of 10% of the estimated blood volume, followed by retransfusion of the shed blood. RESULTS: The correlations of the SVV, SPV and PPV to the stroke volume (SV) throughout the study were -0.89, -0.91 and -0.91, respectively. Correlations of the CVP and the global end-diastolic volume (GEDV) of the heart chambers to the SV were 0.79 and 0.95, respectively. The SPV correlated significantly with both the PPV and the SVV (r=0.97 and 0.93 respectively). However, the PPV increased by more than 400% at 50% haemorrhage compared with increases of 200% and 120% for the SVV and %SPV, respectively. CONCLUSION: This study demonstrates that the present algorithm used for the calculation of the SVV and the formula used to calculate the PPV, perform well over a wide range of preload states including severe hypovolaemia. However, the PPV changes more than the SPV and SVV. This may be due to the changing relation of the SV to the pulse pressure when the filling of the aorta is greatly decreased.

Anaesthesiologists' views on the need for point-of-care information system in the operating room: a survey of the European Society of Anaesthesiologists.

BACKGROUND AND OBJECTIVE: In this preliminary study we wanted to explore the attitudes of anaesthesiologists to a point-of-care information system in the operating room. The study was conducted as a preliminary step in the process of developing such a system by the European Society of Anaesthesiologists (ESA). METHODS: A questionnaire was distributed to all 2240 attendees of the ESA's annual meeting in Gothenburg, Sweden, which took place in April 2001. RESULTS: Of the 329 responders (response rate of 14.6%), 79% were qualified specialists with more than 10 yr of experience (68%), mostly from Western Europe. Most responders admitted to regularly experiencing lack of medical knowledge relating to real-time patient care at least once a month (74%) or at least once a week (46%), and 39% admitted to having made errors during anaesthesia due to lack of medical information that can be otherwise found in a handbook. The choice ofa less optimal but more familiar approach to patient management due to lack of knowledge was reported by 37%. Eighty-eight percent of responders believe that having a point-of-care information system for the anaesthesiologists in the operating room is either important or very important. CONCLUSIONS: This preliminary survey demonstrates that lack of knowledge of anaesthesiologists may be a significant source of medical errors in the operating room, and suggests that a point-of-care information system for the anaesthesiologist may be of value.

Multiple sclerosis characteristics in African American patients in the New York State Multiple Sclerosis Consortium.

The objective of this study was to determine the clinical characteristics of multiple sclerosis (MS) in African American (AA) patients in the New York State Multiple Sclerosis Consortium (NYSMSC) patient registry. The NYSMSC is a group of 18 MS centers throughout New York State organized to prospectively assess clinical characteristics of MS patients. AAs comprise 6% (329) of the total NYSMSC registrants (5602). Demographics, disease course, therapy, and socioeconomic status were compared in AA registrants versus nonAfrican Americans (NAA). There was an increased female preponderance and a significantly younger age at diagnosis in the AA group. AA patients were more likely to have greater disability with increased disease duration. No differences were seen in types of MS and use of disease modifying therapies. Our findings suggest a racial influence in MS. Further genetic studies that consider race differences are warranted to elucidate mechanisms of disease susceptibility.