A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial.

OBJECTIVE: The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU). METHODS: This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate. RESULTS: One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24). CONCLUSIONS: PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

Perception versus reality: elucidating motivation and expectations of current fellowship council minimally invasive surgery fellows.

BACKGROUND: The aim of our study is to determine minimally invasive trainee motivation and expectations for their respective fellowship. Minimally Invasive Surgery (MIS) is one of the largest non-ACGME post-residency training pathways though little is known concerning the process of residents choosing MIS as a fellowship focus. As general surgery evolves, it is important to understand resident motivation in order to better prepare them for a surgical career. METHODS: A survey invitation was sent to current trainees in the Minimally Invasive and related pathways through the Fellowship Council. The participants were asked to complete a web-based questionnaire detailing demographics, experiences preparing for fellowship, motivation in choosing an MIS fellowship, and expectations for surgical practice after fellowship. RESULTS: Sixty-seven MIS trainees responded to the survey out of 151 invitations (44%). The Fellowship Council website, mentors, and other fellows were cited as the most helpful source of information when applying for fellowship. Trainees were active in surgical societies as residents, with 78% having membership in the ACS and 60% in SAGES. When deciding to pursue MIS as a fellowship, the desire to increase laparoscopic training was the most important factor. The least important reasons cited were lack of laparoendoscopic training in residency and desire to learn robotic surgery. The majority of trainees believed their laparoscopic skill set was above that of their residency cohort (81%). The most desired post-fellowship employment model is hospital employee (46%) followed by private practice (27%). Most fellows plan on marketing themselves as MIS surgeons (90%) or General Surgeons (78%) when in practice. CONCLUSIONS: Residents who choose MIS as a fellowship have a strong exposure to laparoscopy and want to become specialists in their field. Mentors and surgical societies including ACS and SAGES play a vital role in preparing residents for fellowship and practice.

Laparoscopic Hill repair: 25-year follow-up.

BACKGROUND: The open Hill repair for gastroesophageal reflux disease and hiatal hernia is remarkably durable, with a median 10-year reoperation rate of only 3% and satisfaction of 93%. No long-term data exist for the laparoscopic Hill repair (LHR). METHODS: Patients who underwent primary LHR at Swedish Medical Center for reflux and/or hiatal hernia at least 5 years earlier (1992-2010) were identified from an IRB-approved database. There were 727 patients who met inclusion criteria, including 648 undergoing repair for reflux and 79 for paraesophageal hernia. Two questionnaires were administered via mail to evaluate long-term quality of life using validated GERD-HRQL, Swallowing score, and global satisfaction score. Outcomes were defined by GERD-HRQL score, Swallowing score, resumption of proton pump inhibitor (PPI) therapy, need for reoperation, and global satisfaction with overall results. RESULTS: Two hundred forty-two patients completed and returned the survey (226 lost to follow-up, 90 deceased, 3 denied undergoing LHR, 166 non-responders), of which 52% were male. The average age at the time of surgery was 49.5 years. Median follow-up was 18.5 years (range 6.2-24.7). The average GERD-HRQL score (7.1) and the average Swallowing score (39.9) both indicated excellent symptomatic outcomes. 30% of patients are using daily PPIs. 24 patients (9.9%) required reoperation for failure during the follow-up period, 21 in the reflux group and 3 in the paraesophageal hernia group. Overall, 85% reported good to excellent results, and 76% would recommend the operation. CONCLUSION: LHR shows excellent long-term durability and quality of life similar to the open Hill repair, with 85% good to excellent results at a median follow-up of 19 years and a reoperation rate under 10%. It is surmised that Hill suture fixation of the gastroesophageal junction to the preaortic fascia may confer unique structural integrity compared to other repairs.

Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke.

BACKGROUND: Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. METHODS: Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. RESULTS: Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. CONCLUSIONS: Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.

Robotic thoracoabdominal hernia repair: a novel approach.

PURPOSE: Thoracoabdominal hernias remain a rare and poorly understood entity. Data remain sparse as terminology varies in the literature and case reports demonstrate wide variability in technique. We present a novel approach for repair of thoracoabdominal hernias using the robotic platform. METHODS: Two patients underwent a robotic thoracoabdominal hernia repair in June 2022. They were followed for 1 year with CT scans every 6 months to exclude recurrence. Patient demographics and peri-operative details including defect size, closure technique, mesh size, length of stay, and complications were reported. RESULTS: Both patients successfully underwent a robotic repair of a thoracoabdominal hernia, addressing the intercostal hernia, diaphragmatic disruption, and flank hernia discretely during the operation. One patient had an uneventful recovery and discharged on post-operative day 3; the other developed a small bowel obstruction due to an early port site hernia which required surgical intervention. He eventually discharged on post-operative day 9. At one year, there is no clinical or radiographic evidence of recurrence for either patient. CONCLUSION: Robotic thoracoabdominal hernia repair is feasible and offers a minimally invasive repair option for these extremely complex hernias.

Case report: Scapulohumeral arthrodesis in a reindeer.

This case report describes the anesthetic, surgical, and postoperative management of scapulohumeral arthrodesis in a juvenile reindeer with severe lameness due to a chronic proximal humeral fracture and scapulohumeral luxation. The reindeer was managed with prolonged stall confinement and physical therapy and 9 months postoperatively was walking and bearing weight equally when standing. This case demonstrates that comparative techniques from other veterinary species coupled with considerations for reindeer anesthesia can be successful in restoring functional soundness after scapulohumeral arthrodesis.

Molecular identification and antifungal susceptibility testing of clinical isolates of the Candida rugosa species complex and proposal of the new species Candida neorugosa.

Candida rugosa is a poorly known fungal species occasionally involved in human infections. A molecular analysis of the sequences of the D1/D2 domains and the internal transcribed spacer (ITS) region of the ribosomal genes of 24 clinical isolates phenotypically identified as C. rugosa demonstrated that only 10 (41.6%) isolates belonged to that species. The other isolates were identified as Candida pararugosa (41.6%) and Candida pseudorugosa (8.3%). The remaining two isolates, from human and equine infections, respectively, were clearly different from the others and represent a new species proposed here as Candida neorugosa. The closest species by D1/D2 sequences was the type strain of C. rugosa, with only 92.3% similarity. C. neorugosa can also be differentiated from all other species of the C. rugosa complex by phenotypic features. The eight antifungal drugs tested showed high in vitro activity against the 24 isolates included in the study.

Team Evans and Watkins: Excitatory Amino Acid research at Bristol University 1973-1981.

A series of Special Issues of Neuropharmacology celebrates the 40th anniversary of a seminal review on excitatory amino acid (EAA) receptors by two pioneers of the field - Dick Evans and Jeff Watkins. Brought together in the Department of Pharmacology at the University of Bristol in the 1970s, they forged a partnership that, through the synthetic chemistry prowess of Jeff Watkins, which provided novel agonists and antagonists for EAA receptors for Dick Evans's deft experimental studies, generated enormous insight into the multitude of actions of EAAs in the nervous system. Among many achievements from this time was not just the naming of the N-methyl-d-aspartate (NMDA) receptor, but also the demonstration of its antagonism by magnesium ions. Here, Dick and Jeff reflect upon those early halcyon days of EAA research, which, as these six1 Special Issues of Neuropharmacology demonstrate, is very much alive and kicking. Bruno G. Frenguelli, Editor-in-Chief, Neuropharmacology.

Proximal interphalangeal locking compression plate for pastern arthrodesis in horses.

BACKGROUND: Outcomes following proximal interphalangeal joint (PIPJ) arthrodesis by a variety of surgical methods are available. Reports detailing clinical outcomes following PIPJ arthrodesis utilising the proximal interphalangeal joint locking compression plate (PIP-LCP) and abaxial transarticular lag screws technique are limited. OBJECTIVES: To report survival, radiographic and clinical outcomes following PIPJ arthrodesis with PIP-LCP and abaxial transarticular lag screw fixation. STUDY DESIGN: Retrospective case series. METHODS: Medical records of all horses undergoing pastern arthrodesis from 2009 to 2018 were reviewed. Arthrodeses performed using a 3-hole, 4.5 mm narrow LCP, specifically designed for the proximal interphalangeal joint, were included. Patient details, presentation, radiographic findings, intraoperative and post-operative data, and complications were documented. Short- and long-term follow-up was available for 23 horses. RESULTS: Thirty PIPJ arthrodeses were performed in 29 horses meeting the criteria for inclusion. Twenty-eight horses (97%, 95% CI 83-100) survived to discharge. Twenty-three horses (79%, 95% CI 60%-92%) had successful outcomes including 12 of the 15 forelimb cases and 11 of the 13 hindlimb cases with available follow-up. Fifteen of 19 performance horses returned to athletic activity. Soundness in performance horses was recognised at less than 3 months in one case, 3 to 6 months in six cases, 6 to 12 months in five cases, and greater than 12 months in six cases. Complications included three implant infections, support limb laminitis (two horses), and fragmentation of the extensor process of the distal phalanx (one horse). MAIN LIMITATIONS: A retrospectively reviewed, small study population with a variety of breeds and disciplines. CONCLUSIONS: The PIP-LCP construct provides a very good prognosis for performance and an excellent prognosis for pasture soundness.

Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study.

BACKGROUND: Reducing acute care readmissions from inpatient rehabilitation facilities (IRFs) is a healthcare reform goal. Stroke patients have higher acute readmission rates and persistent impairments, warranting second IRF hospitalization consideration. OBJECTIVE: To provide evidence-based information to justify IRF readmission for patients with post-stroke impairments. MAIN OUTCOME MEASURE: Variables that increase the likelihood of a second IRF hospitalization. DESIGN: Retrospective cohort study. SETTING: Seven-center rehabilitation network. PARTICIPANTS: Stroke patients, readmitted to acute care, who returned or did not return to an in-network IRF between 1 October 2014-31 December 2017(n = 380). INTERVENTIONS: Univariable analyses (Returned/Did Not Return to IRF) described demographics, stroke type and risk factors. Between group differences in readmission causes, motor impairments and functional independence measure (FIM) scores were examined. Return to IRF logistic regression model included variables with P < .1. Odds ratio and 95% CI were calculated; Relative risk was calculated for categorical variables. P < .05 equaled statistical significance. RESULTS: One hundred ninety-two stroke patients returned to IRF, 188 did not. Returned to IRF patients were younger (60.6 vs. 66 years; P < .001), sustained hemorrhagic strokes (22.4 vs. 14.2%; P = .01), had lower cardiac disease prevalence (41.7 vs. 55.3%; P = .008) or non-Medicare insurance (59.9 vs. 39.4%; P < .001). Did Not Return to IRF patients had higher admission and discharge motor and total FIM scores. Per point decrease in discharge FIM, second IRF hospitalization odds increased 4% (OR 1.04; 95% CI 1.01-1.07; P = .02). Hemorrhagic stroke patients had 33% increased odds or a 15% higher relative risk of second IRF hospitalization than patients with ischemic stroke [OR 1.33; 95% CI 1.21-1.47; RR 1.15; 95% CI 1.1-1.2; P < .001]. Non-Medicare insurance was associated with 39% increased odds or a 20% higher relative risk of second IRF hospitalization than Medicare [OR 1.39; 95% CI 1.01-1.92; RR 1.2, 95% CI 1.006-1.404; P = .04). CONCLUSIONS: Hemorrhagic stroke, non-Medicare insurance or lower discharge FIM score during the first IRF hospitalization predict a second IRF stay. Further work is needed to establish the validity of within IRF stay readmission measures.

21st century excitatory amino acid research: A Q & A with Jeff Watkins and Dick Evans.

In 1981 Jeff Watkins and Dick Evans wrote what was to become a seminal review on excitatory amino acids (EAAs) and their receptors (Watkins and Evans, 1981). Bringing together various lines of evidence dating back over several decades on: the distribution in the nervous system of putative amino acid neurotransmitters; enzymes involved in their production and metabolism; the uptake and release of amino acids; binding of EAAs to membranes; the pharmacological action of endogenous excitatory amino acids and their synthetic analogues, and notably the actions of antagonists for the excitations caused by both nerve stimulation and exogenous agonists, often using pharmacological tools developed by Jeff and his colleagues, they provided a compelling account for EAAs, especially l-glutamate, as a bona fide neurotransmitter in the nervous system. The rest, as they say, is history, but far from being consigned to history, EAA research is in rude health well into the 21st Century as this series of Special Issues of Neuropharmacology exemplifies. With EAAs and their receptors flourishing across a wide range of disciplines and clinical conditions, we enter into a dialogue with two of the most prominent and influential figures in the early days of EAA research: Jeff Watkins and Dick Evans.

The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair.

While the majority of the literature written concerning minimally invasive hiatal hernia repair involves laparoscopy, little has been written concerning the transition to a robotic technique. We present our experience, with a transparent analysis of data, with regard to the introduction of robotic paraesophageal hernia (PEH) repair by an experienced laparoscopic surgeon. We reviewed our first 30 consecutive patients who underwent robotic PEH over a 2-year period after the introduction of robotic surgery at our institution. Patients were divided into two groups: the early experience group (procedures performed within the first year of introduction of robotic technique, n = 13) and a late experience group (procedures performed in the second year, n = 17). All procedures were performed by a single experienced foregut surgeon. The mean operative time for the early group was significantly greater than for the late group, 184 min versus 142 min, respectively (p < 0.01). Four patients in the early group required conversion to open, while zero patients in the late group required conversion (p = 0.03). Patient demographics and complications did not differ significantly between the two patient populations. The early robotic hiatal hernia repair experience can be more difficult than expected, even in the hands of an experienced laparoscopic team. We identify several areas of improvement including patient positioning, operating room team training, and technical experience. This data can help other surgeons prepare for the transition to robotic foregut surgery.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy.

BACKGROUND AND OBJECTIVES: As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE). METHODS: Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon. RESULTS: Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention. CONCLUSIONS: Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.

Rehab MATRIX: Content Validity of a Nursing-Led Patient Assignment Algorithm.

PURPOSE: The provision of conscientious nursing care is at the forefront of health quality. Unfortunately, a lack of standardization in the assignment of patients to nurses can lead to care inequities. Rehab MATRIX is a nursing-led tool that equitably assigns patients using select acuity variables. DESIGN AND METHODS: In this initial study, we asked focus groups of 19 registered nurses and 8 patient care assistants to identify medical interventions that increase the effort of nursing care at a 24-bed inpatient rehabilitation facility (IRF). This IRF is affiliated with a comprehensive heart and vascular institute, a level I trauma center, and a The Joint Commission (TJC) Comprehensive Stroke Center. FINDINGS: Thirteen acuity variables were included in the Rehab MATRIX patient assignment grid. High-acuity patients with greater than 6 variables were color-coded "red," medium-acuity patients with 3 to 5 variables were color-coded "yellow," and low-acuity patients with less than 3 variables were color-coded "green." Each registered nurse and patient care assistant were assigned an equitable number of red-, yellow-, and green-coded patients per shift. New admissions were Rehab MATRIX color-coded during nursing report and assigned objectively. CONCLUSIONS: Nursing staff at a wide-ranging IRF created Rehab MATRIX, an equitable patient assignment tool, representative of nursing effort needed to provide quality care. CLINICAL RELEVANCE: Nursing-led patient assignment tools increase autonomy and provide the opportunity for all nursing staff to influence healthcare practice. These factors may lead to increased nursing satisfaction and decreased burnout.

Endoluminal Therapies for Esophageal Perforations and Leaks.

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Biologic Keyhole Mesh in Hiatal Hernia Repair.

BACKGROUND AND OBJECTIVES: Laparoscopic paraesophageal hernia repair (LPEHR) is the new standard, but the use of mesh is still debated. Biologic mesh has shown great promise, but only the U-shaped onlay has been extensively studied. Postoperative dysphagia has historically been a concern with the use of synthetic keyhole mesh and subsequently slowed its adoption. The purpose of our study was to identify the incidence of postoperative dysphagia in a series of patients who underwent laparoscopic paraesophageal hernia repair with novel placement of keyhole biologic mesh. METHODS: Thirty consecutive patients who underwent hernia repair with primary suture cruroplasty and human acellular dermal matrix keyhole mesh reinforcement were reviewed over a 2-year period. All procedures were performed at a single institution. Postoperative symptoms were retrospectively identified. Any postoperative hernia on imaging was defined as radiographic recurrence. RESULTS: Of the 30 consecutive patients who underwent hernia repair, 3 (10%) had mild preoperative dysphagia. The number remained unchanged after LPEHR with keyhole mesh. Return of mild reflux symptoms occurred in 6 (20%) patients. Repeat imaging was performed in 11 patients (37%) at an average of 8 months with 2 slight recurrences. All hernias were classified on preoperative imaging as large hiatal hernias. There were no postoperative complications. CONCLUSION: Laparoscopic paraesophageal hernia repair with biologic keyhole mesh reinforcement has a low recurrence rate and no increase in postoperative dysphagia. The traditional belief that keyhole mesh has a higher incidence of dysphagia was not evident in this series.

Acute outcomes after coronary orbital atherectomy at a single center without on-site surgical backup: An experience in diabetics versus non-diabetics.

BACKGROUND: Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with a high risk of angiographic complication, incomplete stent expansion, and restenosis. The prevalence of calcification is increased in diabetics (DM) and the PCI outcome in this population is often suboptimal. Treatment with orbital atherectomy (OA) in severely calcified lesions has been shown to result in favorable procedural outcomes and low reintervention rates; in DM and non-DM. We sought to determine the acute safety of OA in a center without on-site surgical backup in DM and non-DM. METHODS: All comers treated with OA at Sanford Bemidji Heart and Vascular Center (Bemidji, MN) from 8/30/16 to 4/14/17 were included in this retrospective analysis. Baseline, procedure, and acute outcome data were compared in DM and non-DM patients. RESULTS: Of the 70 patients treated with OA, 40% were DM. History of hypertension and chronic renal disease were more prevalent in the DM group. Successful stent delivery occurred in 96.4% of DM and 100% in non-DM, respectively. None of the patients treated with OA died or experienced abrupt closure, severe dissection, embolization, or no reflow. The overall perforation and slow flow rates were 1.4%. One non-DM patient had a non-target vessel MI due to side branch closure. CONCLUSIONS: Our study demonstrates the safety of OA in a center without on-site surgical backup. In this study, OA treatment resulted in a high rate of successful stent delivery and low rates of angiographic complications and acute MACE, in DM and non-DM patients. SUMMARY: In this retrospective study we sought to determine the acute safety of coronary orbital atherectomy treatment in a center without on-site surgical backup in diabetic and non-diabetic patients. None of the patients treated with orbital atherectomy died or experienced abrupt closure, severe dissection, embolization, or no reflow; the overall perforation and slow flow rates were 1.4% and one non-diabetic patient had a non-target vessel myocardial infarction due to side branch closure. Our study demonstrates the safety of orbital atherectomy in a center without on-site surgical backup; orbital atherectomy treatment resulted in a high rate of successful stent delivery and low rates of angiographic complications and acute major adverse cardiac events in diabetic and non-diabetic patients.

The glutamate story.

Glutamatergic synaptic transmission in the mammalian central nervous system was slowly established over a period of some 20 years, dating from the 1950s. Realisation that glutamate and like amino acids (collectively known as excitatory amino acids (EAA)) mediated their excitatory actions via multiple receptors preceded establishment of these receptors as synaptic transmitter receptors. EAA receptors were initially classified as N-methyl-D-aspartate (NMDA) and non-NMDA receptors, the latter subdivided into quisqualate (later AMPA) and kainate receptors after agonists that appeared to activate these receptors preferentially, and by their sensitivity to a range of differentially acting antagonists developed progressively during the 1970s. NMDA receptors were definitively shown to be synaptic receptors on spinal neurones by the sensitivity of certain excitatory pathways in the spinal cord to a range of specific NMDA receptor antagonists. Importantly, specific NMDA receptor antagonists appeared to be less effective at synapses in higher centres. In contrast, antagonists that also blocked non-NMDA as well as NMDA receptors were almost universally effective at blocking synaptic excitation within the brain and spinal cord, establishing both the existence and ubiquity of non-NMDA synaptic receptor systems throughout the CNS. In the early 1980s, NMDA receptors were shown to be involved in several central synaptic pathways, acting in concert with non-NMDA receptors under conditions where a protracted excitatory postsynaptic potential was effected in response to intense stimulation of presynaptic fibres. Such activation of NMDA receptors together with non-NMDA receptors led to the phenomenon of long-term potentiation (LTP), associated with lasting changes in synaptic efficacy (synaptic plasticity) and considered to be an important process in memory and learning. During the 1980s, it was shown that certain glutamate receptors in the brain mediated biochemical changes that were not susceptible to NMDA or non-NMDA receptor antagonists. This dichotomy was resolved in the early 1990s by the techniques of molecular biology, which identified two families of glutamate-binding receptor proteins (ionotropic (iGlu) and metabotropic (mGlu) receptors). Development of antagonists binding to specific protein subunits is currently enabling precise identification of discrete iGlu or mGlu receptor subtypes that participate in a range of central synaptic processes, including synaptic plasticity.

Genetic Influence on Slope Variability in a Childhood Reflexive Attention Task.

Individuals are not perfectly consistent, and interindividual variability is a common feature in all varieties of human behavior. Some individuals respond more variably than others, however, and this difference may be important to understanding how the brain works. In this paper, we explore genetic contributions to response time (RT) slope variability on a reflexive attention task. We are interested in such variability because we believe it is an important part of the overall picture of attention that, if understood, has the potential to improve intervention for those with attentional deficits. Genetic association studies are valuable in discovering biological pathways of variability and several studies have found such associations with a sustained attention task. Here, we expand our knowledge to include a reflexive attention task. We ask whether specific candidate genes are associated with interindividual variability on a childhood reflexive attention task in 9-16 year olds. The genetic makers considered are on 11 genes: APOE, BDNF, CHRNA4, COMT, DRD4, HTR4, IGF2, MAOA, SLC5A7, SLC6A3, and SNAP25. We find significant associations with variability with markers on nine and we discuss the results in terms of neurotransmitters associated with each gene and the characteristics of the associated measures from the reflexive attention task.

The found down patient: A Western Trauma Association multicenter study.

BACKGROUND: Unconscious patients who present after being "found down" represent a unique triage challenge. These patients are selected for either trauma or medical evaluation based on limited information and have been shown in a single-center study to have significant occult injuries and/or missed medical diagnoses. We sought to further characterize this population in a multicenter study and to identify predictors of mistriage. METHODS: The Western Trauma Association Multicenter Trials Committee conducted a retrospective study of patients categorized as found down by emergency department triage diagnosis at seven major trauma centers. Demographic, clinical, and outcome data were collected. Mistriage was defined as patients being admitted to a non-triage-activated service. Logistic regression was used to assess predictors of specified outcomes. RESULTS: Of 661 patients, 33% were triaged to trauma evaluations, and 67% were triaged to medical evaluations; 56% of all patients had traumatic injuries. Trauma-triaged patients had significantly higher rates of combined injury and a medical diagnosis and underwent more computed tomographic imaging; they had lower rates of intoxication and homelessness. Among the 432 admitted patients, 17% of them were initially mistriaged. Even among properly triaged patients, 23% required cross-consultation from the non-triage-activated service after admission. Age was an independent predictor of mistriage, with a doubling of the rate for groups older than 70 years. Combined medical diagnosis and injury was also predictive of mistriage. Mistriaged patients had a trend toward increased late-identified injuries, but mistriage was not associated with increased length of stay or mortality. CONCLUSION: Patients who are found down experience significant rates of mistriage and triage discordance requiring cross-consultation. Although the majority of found down patients are triaged to nontrauma evaluation, more than half have traumatic injuries. Characteristics associated with increased rates of mistriage, including advanced age, may be used to improve resource use and minimize missed injury in this vulnerable patient population. LEVEL OF EVIDENCE: Epidemiologic study, level III.