Electroencephalography for predicting antidepressant treatment success: A systematic review and meta-analysis.

BACKGROUND: Patients suffering from major depressive disorder (MDD) regularly experience non-response to treatment for their depressive episode. Personalized clinical decision making could shorten depressive episodes and reduce patient suffering. Although no clinical tools are currently available, machine learning analysis of electroencephalography (EEG) shows promise in treatment response prediction. METHODS: With a systematic review and meta-analysis, we evaluated the accuracy of EEG for individual patient response prediction. Importantly, we included only prediction studies that used cross-validation. We used a bivariate model to calculate prediction success, as expressed by area-under the curve, sensitivity and specificity. Furthermore, we analyzed prediction success for separate antidepressant interventions. RESULTS: 15 studies with 12 individual patient samples and a total of 479 patients were included. Research methods varied considerably between studies. Meta-analysis of results from this heterogeneous set of studies resulted in an area under the curve of 0.91, a sensitivity of 83 % (95 % CI 74-89 %), and a specificity of 86 % (95 % CI 81-90 %). Classification performance did not significantly differ between treatments. Although studies were all internally validated, no externally validated studies have been reported. We found substantial risk of bias caused by methodological shortcomings such as non-independent feature selection, though performance of non-biased studies was comparable. LIMITATIONS: Sample sizes were relatively small and no study used external validation, increasing the risk of overestimation of accuracy. CONCLUSIONS: Electroencephalography can predict the response to antidepressant treatment with high accuracy. However, future studies with more rigorous validation are needed to produce a clinical tool to guide interventions in MDD. PROSPERO REGISTRATION NUMBER: CRD42021268169.

Minimum effective bolus dose of oxytocin during elective Caesarean delivery.

BACKGROUND: The aim of this study was to determine the lowest effective bolus dose of oxytocin to produce adequate uterine tone (UT) during elective Caesarean delivery (CD). METHODS: Seventy-five pregnant patients undergoing elective CD under spinal anaesthesia were randomized to receive oxytocin (0.5, 1, 3, 5 units) or placebo. UT was assessed by a blinded obstetrician as either adequate or inadequate, and using a verbal numerical scale score (0-10; 0, no UT; 10, optimal UT) at 2, 3, 6, and 9 min after oxytocin administration. Minimum effective doses of oxytocin were analysed (ED(50) and ED(95)) using logistic regression. Oxytocin-related side-effects (including hypotension) were recorded. RESULTS: There were no significant differences in the prevalence of adequate UT among the study groups at 2 min (73%, 100%, 93%, 100%, and 93% for 0, 0.5, 1, 3, and 5 units oxytocin, respectively). The high prevalence of adequate UT after placebo and low-dose oxytocin precluded determination of the ED(50) and ED(95). UT scores were significantly lower in patients receiving 0 unit oxytocin at 2 and 3 min compared with 3 and 5 units oxytocin (P<0.05, respectively). The prevalence of hypotension was significantly higher after 5 units oxytocin vs 0 unit at 1 min (47% vs 7%; P=0.04). CONCLUSIONS: The routine use of 5 units oxytocin during elective CD can no longer be recommended, as adequate UT can occur with lower doses of oxytocin (0.5-3 units).

Efficacy and tolerability of vildagliptin vs. pioglitazone when added to metformin: a 24-week, randomized, double-blind study.

AIM: The aim of this study was to compare the efficacy and tolerability of vildagliptin vs. pioglitazone as add-on therapy in patients with type 2 diabetes inadequately controlled with metformin monotherapy. METHODS: This 24-week, multicentre, double-blind, randomized, active-controlled study compared vildagliptin (100 mg daily, given as equally divided doses, n = 295) and pioglitazone (30 mg daily, given as a single q.d. dose, n = 281) in patients with inadequate glycaemic control (A1C 7.5-11%) while receiving a stable metformin dose (> or =1500 mg daily). The adjusted mean changes from baseline to study endpoint (AMDelta) in A1C, fasting plasma glucose (FPG), fasting lipids and body weight were compared by analysis of covariance. RESULTS: When added to a stable dose of metformin (mean dose at baseline >2000 mg/day), both vildagliptin and pioglitazone decreased A1C (AMDelta = -0.9 +/- 0.1% and -1.0 +/- 0.1%, respectively) from identical baseline values (8.4 +/- 0.1%). The between-group difference in AMDelta A1C was 0.1 +/- 0.1%, and non-inferiority of vildagliptin to pioglitazone was established at both 0.4 and 0.3% margins for upper limit of the 95% confidence intervals. Pioglitazone decreased FPG (AMDelta = -2.1 +/- 0.1 mmol/l) to a greater extent than vildagliptin (AMDelta = -1.4 +/- 0.1 mmol/l), but only pioglitazone increased body weight (AMDelta = +1.9 +/- 0.2 kg: between-group difference = -1.6 +/- 0.3 kg, p < 0.001). Adverse events (AEs) were reported by 60% of vildagliptin-treated patients and by 56.4% of pioglitazone-treated patients; serious AEs were reported by 2.0 and 4.6% of patients receiving vildagliptin and pioglitazone respectively. Mild hypoglycaemia was reported by one patient (0.3%) in the vildagliptin group and by no patients receiving pioglitazone. CONCLUSIONS: When added to metformin, the efficacy of vildagliptin is non-inferior to that of pioglitazone. The treatments were similarly well tolerated, but only pioglitazone increased body weight.

Local infiltration of epinephrine-containing lidocaine with bicarbonate reduces superficial bleeding and pain during labor epidural catheter insertion: a randomized trial.

BACKGROUND: Superficial bleeding after labor epidural catheter placement is a common phenomenon. In addition to delaying securing the epidural catheter, it may loosen the adhesive catheter dressing. The primary aim of this study was to determine whether skin infiltration with epinephrine-containing rather than plain lidocaine reduces superficial bleeding after catheter placement. Secondary objectives were to determine whether adding epinephrine and/or sodium bicarbonate affected infiltration pain. METHODS: After institutional review board approval and informed consent, 80 healthy women receiving epidural analgesia during labor were randomly assigned in a double-blind manner to four local anesthetic mixtures (n=20 in each group): group L: lidocaine 1.5%, group LB: lidocaine 1.5% with 8.4% sodium bicarbonate, group LE: lidocaine 1.5% with epinephrine 1:200000, and group LEB: lidocaine 1.5% with epinephrine 1:200000 and 8.4% sodium bicarbonate. Clinical endpoints included the amount of superficial bleeding at the catheter site, pain during local anesthetic infiltration and epidural catheter movement during labor. RESULTS: Demographic data were similar among the groups. The addition of epinephrine to lidocaine significantly reduced superficial bleeding. Solutions containing epinephrine were well tolerated and caused no cardiovascular disturbances. The addition of epinephrine did not increase pain, while bicarbonate reduced it [verbal score (scale 0-10) 3.6+/-2.2 vs. 2.6+/-1.8; P=0.04]. There were no differences in epidural catheter movement among the groups; no catheters became displaced during labor. CONCLUSION: Local infiltration of epinephrine-containing lidocaine before epidural catheter insertion reduces superficial bleeding and the addition of bicarbonate decreases pain during skin infiltration.

A survey of labor patient-controlled epidural anesthesia practice in California hospitals.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for labor analgesia including fewer physician interventions, improved analgesia and satisfaction, and reduced local anesthetic doses. However, anesthesiologists have been slow to adopt this technique, first described in 1988. No previous studies have evaluated specific labor patient-controlled epidural analgesia practices in the United States. The aim of this study was to determine labor epidural and patient-controlled epidural analgesia practices among California hospitals. METHODS: Following institutional review board exemption approval, an online survey was created using freeonlinesurveys.com. An anonymous survey was sent via e-mail to 230 California Society of Anesthesiologists' members chosen at random to represent their hospitals' labor analgesia practices. RESULTS: We received 133 replies from the 230 survey requests sent, a 58% response rate. The median labor epidural rate among the hospitals involved was 65% (range 0-95%). Overall, only 25% of California hospitals use patient-controlled epidural analgesia for analgesia in labor, with greater use among hospitals with dedicated obstetric anesthesia coverage and larger numbers of deliveries. Reasons given for not using patient-controlled epidural analgesia include cost, clinician preference, safety concerns and the inconvenience of change. CONCLUSIONS: Despite the potential advantages of patient-controlled epidural analgesia over continuous epidural infusions for labor analgesia, patient-controlled epidural analgesia has not been widely adopted in California hospitals. Education regarding this technique is needed to encourage its increased use.

Progression of microalbuminuria to proteinuria in type 1 diabetes: nonlinear relationship with hyperglycemia.

While small clinical trials have shown that improved glycemic control reduces the risk of progression of microalbuminuria to proteinuria, two recent clinical trials did not confirm this finding. We sought to reconcile the contradictory evidence by examining the dose-response relationship between hyperglycemia and progression of microalbuminuria to proteinuria in individuals with type 1 diabetes and microalbuminuria (n = 312) who were followed for 4 years with repeated assessments of urinary albumin excretion. Since 33 patients did not participate in follow-up (10.6%), data for 279 patients were analyzed. Urinary albumin excretion level worsened to proteinuria in 40 (4.1 per 100 person-years). To examine the dose-response relationship, baseline HbA1c was divided into four roughly equal groups using the cut points 8, 9, and 10%. The incidence rate varied significantly among the four groups (P = 0.008). Among those with HbA1c <8.0%, the incidence rate of progression was only 1.3 per 100 person-years, while it was 5.1, 4.2, and 6.7 per 100 person-years in the three other groups. We used generalized additive models to examine the dose-response curve using HbA1c as a continuous variable and found that the risk of progression rises steeply between an HbA1c of 7.5-8.5% and then remains approximately constant across higher levels. In conclusion, the results of this study suggest that, in patients with microalbuminuria, the risk of progression to overt proteinuria can be reduced by improved glycemic control only if the HbA1c is maintained below 8.5%. Moreover, below that value, the risk declines as the level of HbA1c decreases.

"Ultra-light" patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload.

BACKGROUND: Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for maintenance of labor analgesia. Some of these benefits may depend on the PCEA settings. This study evaluated several regimens for "ultra-light" (0.125%) PCEA with basal continuous infusion (CI) in labor with goals of minimizing physician interventions while providing good analgesia. METHODS: Two hundred and twenty ASA I-II women receiving epidural analgesia during active labor (cervical dilation <5 cm) were randomly assigned in a double-blind manner to four treatment groups (n=30 in each). Analgesia was maintained with a PCEA/CI pump using bupivacaine 0.0625% + sufentanil 0.35 microg/mL. PCEA settings were: group A: CI 10 mL/h, PCEA bolus 6 mL, 8-min lockout; group B: CI 10 mL/h, PCEA bolus 12 mL, 16-min lockout; group C: CI 15 mL/h, PCEA bolus 6 mL, 8-min lockout; group D: CI 15 mL/h, PCEA bolus 12 mL, 16-min lockout. RESULTS: In groups A, B, C and D, 76, 77, 75 and 85% of parturients respectively, required no physician rescue boluses. Pain scores were low and maternal satisfaction was high in all groups, with minimal differences among them. Spontaneous vaginal delivery occurred in 78% of patients overall, instrumental (forceps or vacuum) delivery in 10% and cesarean section in 12%. CONCLUSIONS: These ultra-light PCEA regimens provided excellent analgesia with minimal physician workload and a high spontaneous delivery rate. Use of moderate to high-volume, ultra-light PCEA/CI techniques should facilitate provision of labor analgesia in busy obstetric units.

Receptive language development in preterm children as related to caregiver-child interaction.

Fifty preterm children who had experienced a range of biological hazards were divided into two competence groups on the basis of their receptive language development at 24 months. The groups were then compared in terms of the kinds of caregiver-child interactions the children and their primary caregivers engaged in three months earlier in a laboratory assessment. The two language skill groups did not differ on perinatal factors such as birth weight and gestational age, or on length of hospitalization, but did differ in social transactions. The more competent group as compared to the less competent group had caregivers who were more stimulating, the children themselves emitted more vocalization, and the caregivers and children engaged in more reciprocal social transactions.

Neuropsychological functioning in human immunodeficiency virus type 1 seropositive children infected through neonatal blood transfusion.

The neuropsychological development of 15 human immunodeficiency virus type 1 (HIV-1) seropositive children infected through neonatal blood transfusion was compared with that of a control group of 33 HIV-1 seronegative children who had also received blood transfusions as neonates. Human immunodeficiency virus type 1 infection was identified on the basis of a callback blood testing. Two thirds of the HIV-1-infected children were asymptomatic at time of enrollment in the study of development. The children were administered two psychological batteries approximately 8 months apart. The results indicated that the two serostatus groups did not differ in overall intelligence, even as long as 8 years after HIV-1 infection. Significant group differences, though slight, were found on school achievement and on tasks that require motor speed, visual scanning, and cognitive flexibility. Continued longitudinal study of this cohort will be important in characterizing the evolution of neuropsychological deficits.

Randomized comparison of intravenous nitroglycerin and magnesium sulfate for treatment of preterm labor.

OBJECTIVE: To compare the safety and efficacy of high-dose intravenous (IV) nitroglycerin with those of IV magnesium sulfate for acute tocolysis of preterm labor. METHODS: Thirty-one women with preterm labor before 35 weeks' gestation were assigned randomly to IV magnesium sulfate or IV nitroglycerin for tocolysis. Preterm labor was defined as the occurrence of at least two contractions in 10 minutes, with cervical change or ruptured membranes. Acute tocolysis was defined as tocolysis for up to 48 hours. Magnesium sulfate was administered as a 4-g bolus, then at a rate of 2-4 g/h. Nitroglycerin was administered as a 100-microg bolus, then at a rate of 1- to 10-microg/kg/min. The primary outcome measure was achievement of at least 12 hours of successful tocolysis. RESULTS: Thirty patients were available for analysis. There were no significant differences in gestational age, cervical dilation, or incidence of ruptured membranes between groups at the initiation of tocolysis. Successful tocolysis was achieved in six of 16 patients receiving nitroglycerin, compared with 11 of 14 receiving magnesium sulfate (37.5 versus 78.6%, P = .033). Tocolytic failures (nitroglycerin versus magnesium sulfate) were due to persistent contractions with cervical change or rupture of previously intact membranes (five of 16 versus two of 14), persistent hypotension (four of 16 versus none of 14), and other severe side effects (one of 16 versus one of 14). Maternal hemodynamic alterations were more pronounced in patients who received nitroglycerin, and 25% of patients assigned to nitroglycerin treatment had hypotension requiring discontinuation of therapy. CONCLUSION: Tocolytic failures were more common with nitroglycerin than with magnesium sulfate. The hemodynamic alterations noted in patients receiving nitroglycerin, including a 25% incidence of persistent hypotension, might limit the usefulness of IV nitroglycerin for the acute tocolysis of preterm labor.

Experimental evaluation of primary repair of colonic injuries.

To evaluate the management of colonic injuries, experimental models simulating acute injuries of the colon were studied utilizing New Zealand white rabbits. Seventy-nine rabbits underwent primary repair of colonic injuries in the presence of massive contamination and none showed any evidence of anastomotic leakage or breakdown. The fact that primary colonic repairs do heal even in the presence of infection suggests that breakdown of colonic anastomosis results from factors other than infection. Despite the absence of anastomotic leaks in this series, morbidity and mortality were high in those animals not given antibiotics. The high morbidity and mortality were due to peritonitis, intra-abdominal abscess, and wound infection, and were directly proportional to the length of time from colonic injury to repair. On the basis of this study, it is concluded that most isolated injuries of the colon can be closed primarily, if antibiotic therapy is begun immediately after injury and continued throughout the operative and postoperative periods.

Antiperistaltic ileal segment in the prevention of ileostomy diarrhea.

Diarrhea, often profuse, accompanied by skin excoriation and nutritional and electrolyte depletion is a major complication of ileostomy. In an attempt to improve the course of these patients, an experimental study using dogs was undertaken to investigate an antiperistaltic ileal segment for the prevention of ileostomy diarrhea. Ileostomies were created in dogs. All the dogs with ileostomies died within nine days of weight loss and massive electrolyte and water depletion. A second group of animals underwent creation of an ileostomy simultaneously, with an antiperistaltic ileal segment placed 30.5 cm proximal to the ileostomy. These dogs maintained their weight and electrolyte and water balance. The stools in the group with the reversed ileal segment became semisolid to solid, compared to the watery diarrhea of dogs with ileostomies only.

Direct right atrial catheter insertion with video-assisted thoracic surgery.

Chronic gastrointestinal disorders may require support with long-term total parenteral nutrition via a central venous catheter. Central venous access may be problematic because of infection or thrombosis of previous catheters. We report a case where video-assisted thoracic surgical catheter insertion directly into the right atrium provided a successful and safe method of long-term central venous access for parenteral nutrition.

Emergent applications of cardiopulmonary support: a multiinstitutional experience.

The use of emergent portable bypass systems is increasing. Because of limited patient use in any one institution, a combined experience can better determine the applicability of these systems. A total of 187 patients from 17 centers were analyzed. Causes leading to bypass initiation were cardiac arrest (125 patients), cardiogenic shock (44), profound hypothermia (7), pulmonary insufficiency (9), and miscellaneous (2). Weaning from bypass was successful in 30.5% (57 patients). Sixty-four patients (34.2%) were transferred to standard bypass or other modes of circulatory assist. Of the total population, 40 patients (21.4%) were alive greater than 30 days. There were no survivors of unwitnessed arrests. Major diagnostic or therapeutic interventions were carried out on bypass in 74.9% of all patients. In survivors, 77.1% (37/48) had major therapeutic interventions as compared with 50.0% (67/135) of nonsurvivors. Emergency portable bypass systems can successfully resuscitate and support cardiac hemodynamics, although the underlying causes necessitating bypass remain difficult to correct. When corrective intervention can be performed, there is an increased chance of survival. Unwitnessed arrest, prolonged cardiopulmonary resuscitation, and lack of treatment options are relative contraindications. Appropriate patient selection and early application of these systems should lead to improved survival.

Meckel's diverticulum: should it be excised incidentally at operation?

Meckel's diverticulum is the most common congenital abnormality of the small intestine, occurring in about 2 per cent of the population. Complications of a Meckel's diverticulum, including hemorrhage, inflammation, bowel obstruction, and neoplasms, occur in 15 to 33 per cent of cases and invariably demand operative treatment. When signs or symptoms arise from a Meckel's diverticulum, morbidity and mortality are high. Incidental Meckel's diverticulectomy should be performed at any age when the morbidity and mortality of the primary procedure will not be increased substantially.

Maternal sensitivity during infancy and subsequent life events relate to attachment representation at early adulthood.

A prospective longitudinal research study of 86 prematurely born children from birth to age 18 years provided empirical evidence for continuity from infancy experience to representations of attachment at age 18 years. Young adults whose representation of attachment was dismissing had been objectively observed during infancy, 16-17 years earlier, to receive less sensitive maternal care than those infants who were later judged at early adulthood to have secure or preoccupied representations. Infancy experience alone did not differentiate young adults with secure representations from those with preoccupied representations. Rather, adverse life events through age 12, particularly parental divorce, reduced the likelihood of secure representations and increased the likelihood of preoccupied representations. The absence of adverse life events did not increase the likelihood of security for those who had not experienced early sensitive caregiving.

Effects of antibiotics on prevention of infection in contaminated abdominal operations.

A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.

Traumatic duodenal injuries: an analysis of 32 cases.

Thirty-two patients were treated for duodenal and associated injuries during the past five years. Fifty-nine per cent resulted from penetrating trauma, while 41 per cent were secondary to blunt injury. The incidence of blunt trauma represents a fourfold increase from previously published series. The morbidity rate still remains high at 47 per cent, with fistulas and infections being the most common complications. The mortality rate was 9.3 per cent, with death resulting from major intra-abdominal vascular injuries. Awareness of the potential injury to the duodenum, aggressive resuscitative measures, early operative management and improved postoperative care can lead to further reduction of these figures.

A patient with hypoparathyroidism, dysmorphic features and mental retardation.

There have been various reports in the medical literature concerning children with syndromes of congenital hypoparathyroidism, seizures, dysmorphic features and mental retardation. We describe a patient with hypoparathyroidism, mental retardation, micrognathia, deep-set eyes and pes cavus in a 31-year-old man. This combination of abnormalities in an adult is unique.

Conservative therapy in an ERCP-induced abdominal abscess.

We describe a 30 year-old man who presented with an abdominal abscess as an unusual complication of endoscopic retrograde cholangiopancreatography with papillotomy. His presenting symptom was recurrent vomiting, while fever, abdominal pain, and leukocytosis were not significant. The abscess was observed with repeated computerized tomographic scans and completely regressed with intravenous antibiotic treatment over a three week period, leading to complete remission.