Congenital idiopathic megaesophagus in the German shepherd dog is a sex-differentiated trait and is associated with an intronic variable number tandem repeat in Melanin-Concentrating Hormone Receptor 2.

Congenital idiopathic megaesophagus (CIM) is a gastrointestinal (GI) motility disorder of dogs in which reduced peristaltic activity and dilation of the esophagus prevent the normal transport of food into the stomach. Affected puppies regurgitate meals and water, fail to thrive, and experience complications such as aspiration pneumonia that may necessitate euthanasia. The German shepherd dog (GSD) has the highest disease incidence, indicative of a genetic predisposition. Here, we discover that male GSDs are twice as likely to be affected as females and show that the sex bias is independent of body size. We propose that female endogenous factors (e.g., estrogen) are protective via their role in promoting relaxation of the sphincter between the esophagus and stomach, facilitating food passage. A genome-wide association study for CIM revealed an association on canine chromosome 12 (P-val = 3.12x10-13), with the lead SNPs located upstream or within Melanin-Concentrating Hormone Receptor 2 (MCHR2), a compelling positional candidate gene having a role in appetite, weight, and GI motility. Within the first intron of MCHR2, we identified a 33 bp variable number tandem repeat (VNTR) containing a consensus binding sequence for the T-box family of transcription factors. Across dogs and wolves, the major allele includes two copies of the repeat, whereas the predominant alleles in GSDs have one or three copies. The single-copy allele is strongly associated with CIM (P-val = 1.32x10-17), with homozygosity for this allele posing the most significant risk. Our findings suggest that the number of T-box protein binding motifs may correlate with MCHR2 expression and that an imbalance of melanin-concentrating hormone plays a role in CIM. We describe herein the first genetic factors identified in CIM: sex and a major locus on chromosome 12, which together predict disease state in the GSD with greater than 75% accuracy.

The Incidence and Predictors of Failed Spinal Anesthesia After Intrathecal Injection of Local Anesthetic for Cesarean Delivery: A Single-Center, 9-Year Retrospective Review.

BACKGROUND: The incidence of failed spinal anesthesia varies widely in the obstetric literature. Although many risk factors have been suggested, their relative predictive value is unknown. The primary objective of this retrospective cohort study was to determine the incidence of failed spinal anesthesia for cesarean deliveries at a tertiary care obstetric hospital, and its secondary objectives were to identify predictors of failed spinal anesthesia in the obstetrics population and quantify their relative importance in a predictive model for failure. METHODS: With local institutional ethics committee approval, a retrospective review of our hospital database identified the incidence of failed spinal anesthesia for 5361 cesarean deliveries between 2010 and 2019. We performed a multivariable analysis to assess the association of predictors with failure and a dominance analysis to assess the importance of each predictor. RESULTS: The incidence of failed spinal anesthesia requiring an alternative anesthetic was 2.1%, with conversion to general anesthesia occurring in 0.7% of surgeries. Supplemental analgesia or sedation was provided to an additional 2.0% of women. The most important predictors of a failed spinal anesthetic were previous cesarean delivery (odds ratio [OR], 11.33; 95% confidence interval [CI], 7.09-18.20; P < .001), concomitant tubal ligation (OR, 8.23; 95% CI, 3.12-19.20; P < .001), lower body mass index (BMI) (kg·m -2 , OR, 0.94; 95% CI, 0.90-0.98; P = .005), and longer surgery duration (minutes, OR, 1.02; 95% CI, 1.01-1.03; P = .006). Previous cesarean delivery was the most significant risk factor, contributing to 9.6% of the total 17% variance predicted by all predictors examined. CONCLUSIONS: Spinal anesthesia failed to provide a pain-free surgery in 4.1% of our cesarean deliveries. Previous cesarean delivery was the most important predictor of spinal failure. Other important predictors included tubal ligation, lower BMI, and longer surgery duration.

Clinical descriptive and long-term outcome of melanocytic uveal lesions in young dogs: 40 cases (45 eyes) including 13 cases of sector iridectomy.

PURPOSE: To describe the clinical features surgical technique, early and long-term outcome with or without surgery, and histopathological findings of melanocytic anterior uveal lesions in young dogs. METHODS: Medical records of dogs at a guide dog facility removed from training due to a pigmented iris lesion were reviewed from 2014 to 2021. Selected dogs had surgical iridectomies performed. RESULTS: Iridal melanocytic lesions were characterized as well-delineated, pigmented, and flat (nevus) or raised (mass) lesions of the iris. Forty dogs (18 Labrador retrievers, 18 German shepherd dogs, 1 Golden retriever, 3 Labrador/Golden mixes) ranging from 0.5 to 3.1 years of age were affected unilaterally (n = 35) or bilaterally (n = 5). Sector iridectomy was performed in 13 dogs with prominent and well-isolated mass lesion and enucleation was carried out in 2 dogs with extensive lesions, while all other cases were monitored without surgical intervention. Postoperative complications included dyscoria (13/13), focal posterior synechia (9/13) and focal nonprogressive cataract (8/13). All eyes remained visual and comfortable up to 6.2 years post-iridectomy with no clinically identifiable local recurrence. Histopathology was consistent with uveal melanocytoma in all samples obtained surgically. All cases that did not undergo surgery remained free of complications up to 4.5 year post diagnosis. CONCLUSION: Melanocytic anterior uveal lesions may be overrepresented in certain lineages of breeds and be present at a young age. While none of the eyes developed complications when monitored without surgery, early surgical excision of the mass by sector iridectomy yields noteworthy functional outcome and retention of a comfortable globe.

New Frontiers in Osteoporosis Therapy.

Current osteoporosis medications reduce fractures significantly but have rare and serious adverse effects (osteonecrosis of the jaw, atypical femoral fractures) that may limit their safety for long-term use. Insights from basic bone biology and genetic disorders have led to recent advances in therapeutics for osteoporosis. New approaches now in clinical use include the antisclerostin monoclonal antibody romosozumab, as well as the parathyroid hormone-related peptide analog abaloparatide. Clinical trial data show significant antifracture benefits with recently approved romosozumab. Studies using abaloparatide build on our longstanding experience with teriparatide and the importance of consolidating the bone mineral density gains achieved from an anabolic agent by following it with an antiresorptive. Combination and sequential treatments using osteoporosis medications with different mechanisms of action have also been tested with promising results. On the horizon is the potential for cell-based therapies (e.g., mesenchymal stem cells) and drugs that target the elimination of senescent cells in the bone microenvironment.

Retinal structural and microvascular abnormalities in retinal dysplasia imaged by OCT and OCT angiography.

OBJECTIVE: To describe the in vivo structural characteristics of multifocal and geographic retinal dysplasia visualized with advanced retinal imaging including confocal scanning laser ophthalmoscopy (cSLO), optical coherence tomography (OCT), en face OCT, and the novel vascular imaging technique OCT angiography (OCTA). DOGS STUDIED AND PROCEDURES: Two dogs were diagnosed with unilateral multifocal or geographic retinal dysplasia and underwent advanced retinal imaging under general anesthesia at the Retinal Disease Studies Facility of the University of Pennsylvania. RESULTS: In both cases, the morphological pattern of the lesions was similar including outer retinal folds that invaginated and formed tubular retinal rosettes, surrounding a central inner retinal thickening (multifocal) or plaque (geographic). The two dogs had multiple vascular anomalies in the lesions such as increased tortuosity, abnormal change of vessel diameter including aneurysms and capillary network disruption. We also identified increased autofluorescence by AF cSLO with short wavelength light source (488 nm and barrier filter at 500 nm), and several areas of photoreceptor loss associated with the lesions. CONCLUSION: The use of OCTA allowed the identification of microvascular abnormalities associated with multifocal and geographic retinal dysplasia in two dogs. To our knowledge, this is the first report where the dye-free OCTA technique is used to study vascular lesions in canine retinas.

Osteoporosis and fractures in rheumatoid arthritis.

PURPOSE OF REVIEW: Rheumatoid arthritis (RA) is associated with increased risk for osteoporotic fracture. We highlight RA-specific risk factors for bone mineral density (BMD) loss and fractures and considerations regarding the diagnosis and treatment of osteoporosis in patients with RA. RECENT FINDINGS: Anticitrullinated protein antibody (ACPA) positivity, although associated with low BMD in early RA, is not associated with accelerated BMD loss over time when compared to ACPA negative individuals. Studies have found reduced BMD in individuals on low doses of glucocorticoids (GCs). Poor functional status and frailty are additional important risk factors for low BMD and fractures. Heightened fracture risk in RA may be mitigated by tight disease control, and biologic therapies are associated with more stable BMD compared to nonbiologic therapies. Evidence-based guidelines specific for treating osteoporosis in patients with RA do not exist. Thus, treatment decisions are based on general osteoporosis guidelines, taking into account additional RA-specific risk factors. SUMMARY: Recent studies have advanced knowledge of RA-specific risk factors for BMD loss and fractures. Future studies applying these findings to modify established fracture risk algorithms as well as evaluating osteoporosis treatments in RA cohorts are needed to reduce the risk of disabling fractures in these patients.

The PARADIGHM (physicians advancing disease knowledge in hypoparathyroidism) registry for patients with chronic hypoparathyroidism: study protocol and interim baseline patient characteristics.

BACKGROUND: The PARADIGHM registry of adult and pediatric patients with chronic hypoparathyroidism evaluates the long-term safety and effectiveness of treatment with recombinant human parathyroid hormone, rhPTH(1-84), and describes the clinical disease course under conditions of routine clinical practice. In this first report, we detail the registry protocol and describe the baseline characteristics of two adult patient cohorts from an interim database analysis. One cohort after study entry were prescribed rhPTH(1-84), and the other cohort received conventional therapy of calcium and active vitamin D. METHODS: An observational study of patients with chronic hypoparathyroidism in North America and Europe, collecting data for ≥10 years per patient. Main outcome measures were baseline patient demographics, clinical characteristics, medications, and disease outcome variables of symptoms, biochemical parameters, and health assessments. Baseline is the enrollment assessment for all variables except biochemical measurements in patients treated with rhPTH(1-84); those measurements were the most recent value before the first rhPTH(1-84) dose. Exclusion criteria applied to the analysis of specified outcomes included pediatric patients, patients who initiated rhPTH(1-84) prior to enrollment, and those who received rhPTH(1-34). Clinically implausible biochemical outlier data were excluded. RESULTS: As of 30 June 2019, data of 737 patients were analyzed from 64 centers; 587 (80%) were women, mean ± SD age 49.1±16.45 years. At enrollment, symptoms reported for patients later prescribed rhPTH(1-84) (n=60) and those who received conventional therapy (n=571), respectively, included fatigue (51.7%, 40.1%), paresthesia (51.7%, 29.6%), muscle twitching (48.3%, 21.9%), and muscle cramping (41.7%, 33.8%). Mean serum total calcium, serum phosphate, creatinine, and estimated glomerular filtration rate were similar between cohorts. Health-related quality of life (HRQoL) 36-item Short Form Health Survey questionnaire scores for those later prescribed rhPTH(1-84) were generally lower than those for patients in the conventional therapy cohort. CONCLUSIONS: At enrollment, based on symptoms and HRQoL, a greater percentage of patients subsequently prescribed rhPTH(1-84) appeared to have an increased burden of disease than those who received conventional therapy despite having normal biochemistry measurements. PARADIGHM will provide valuable real-world insights on the clinical course of hypoparathyroidism in patients treated with rhPTH(1-84) or conventional therapy in routine clinical practice. TRIAL REGISTRATION: EUPAS16927, NCT01922440.

Optic nerve colobomas associated with unilateral focal serous retinal detachment in a dog - In-vivo imaging and outcome following laser retinopexy.

PURPOSE: To describe the ophthalmoscopic, in-vivo imaging, fluorescein angiography, and therapeutic photocoagulation outcome in a case of bilateral optic nerve colobomas associated with focal unilateral retinal detachment in a dog. METHODS: Pretraining eye examination of a 1.6-year-old female German shepherd service dog showed a focal juxta-papillary bullous retinal separation in the right eye. In vivo imaging and angiography were performed under general anesthesia using optical coherence tomography. Nonoverlapping diode laser burns were applied through an operating microscope adapter to selected areas along the leading margins of the detachment. RESULTS: The funduscopic examination and in-vivo imaging revealed bilateral optic nerve colobomas associated with a focal bullous detachment in the right eye. Fluorescein angiography showed absence of blood vessel leakage and absence of staining inside of the retinal elevation. Photocoagulation induced immediate changes in retinal layer reflectivity. Three months post-photocoagulation, the retinal detachment had improved and scarring of the burns was visible. One and two years post-procedure, the retinal detachment resolved. CONCLUSIONS: Optical coherence tomography (OCT) imaging provides a detailed analysis of the retinal abnormalities associated with the clinical lesion. Laser retinopexy is a valid therapeutic option to limit the extension of the detachment.

Menstrual Migraine Among Spanish University Students.

PURPOSE: This study sought to determine the prevalence of menstrual migraine among female university students at the Nursing Faculty of Ciudad Real and to determine possible risk factors. DESIGN AND METHODS: A cross-sectional observational study was performed using a self-report questionnaire. Two hundred and ninety-nine female university students participated in the study; all were enrolled in the 2017/2018 academic year at the Faculty of Nursing. Participants were over the age of 18 years and without any diagnosed gynecological pathology. The main measurement tools were menstrual migraine between days -2 and +3 of the menstrual cycle, over the previous six cycles. RESULTS: The prevalence of menstrual migraine was 45.15%, identifying the following possible risk factors: dysmenorrhea (OR 9.19; 1.62-6.28% CI), use of hormonal contraceptive methods (OR 2.60; 95% CI 1.30-5.20), menstrual irritability (OR 2.34; 95% CI 1.25-4.40), menstrual dizziness (OR 2.05; 95% CI % 1.12-3.75) and daily consumption of cola beverages (OR 1.85; 95% CI % 1.04-3.32). CONCLUSIONS: The prevalence of this problem is high among our population and the approach is complex. PRACTICE IMPLICATIONS: It is necessary to continue to research the pharmacological measures and methods of pharmacological pain relief as well as interventions directed at lifestyle modifications considering the potential risk factors involved in menstrual migraine.

The effect of COVID-19 on tourists' intention to resume hotel consumption: The role of resilience.

This study aims to better understand how one particular personal capacity-psychological resilience-may help consumers adapt to the 'new normal' provoked by the COVID-19 pandemic in the hotel context, which is characterized by high uncertainty. We conducted a quantitative empirical study among consumers of hotel services, which showed that their psychological resilience has a negative effect on their perceived health risk and emotional risk. This negative effect on risk helps increase tourist intention to return to consuming hotel services despite the on-going pandemic. The findings are of value to the literature and the professional sector alike, as they demonstrate both relationships jointly for the first time. The work can help hotel firms to design more effective strategies for approaching customers in the 'new normal'.

Efficacy of Intrathecal Fentanyl for Cesarean Delivery: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis.

BACKGROUND: Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS: Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS: Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS: Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

Quadratus lumborum block for postoperative analgesia: a systematic review and meta-analysis.

PURPOSE: The goal of the present systematic review is to determine the efficacy of the quadratus lumborum block (QLB) in providing postoperative analgesia for abdominal wall and hip surgeries when compared with placebo or other analgesic techniques. METHODS: Electronic databases (Medline, Embase, Cochrane Central, and Scopus) were searched for keywords and controlled vocabulary terms related to QLB from their inception to November 2019. The included studies compared ultrasound-guided single-injection QLB to placebo and other analgesic techniques in adult patients. RESULTS: Forty-two randomized-controlled trials provided the data for this systematic review. Eight studies were assessed as high risk of bias in at least one domain. The included studies had significant heterogeneity with regard to the type of surgery, comparator groups, and outcomes measured; therefore, a limited quantitative analysis was undertaken for the comparison of QLB vs no block or placebo in patients undergoing Cesarean delivery only. For Cesarean delivery, the QLB reduced the opioid use by 24.1 (95% confidence interval, 17.3 to 30.9) mg oral morphine equivalents in the first postoperative 24 hr compared with no block or placebo with no difference in pain scores at rest. For other surgical procedures, the pain scores and opioid use were lower in the QLB group when compared with placebo or no regional anesthesia technique. When compared with other regional anesthetic techniques, the analgesic benefit of QLB was marginal. CONCLUSION: Quadratus lumborum block provided analgesic benefits compared with placebo for use in the abdominal wall and hip surgery, with only marginal benefits compared with other regional analgesic techniques. The identified studies used different variants of QLB in many different surgery types. These findings and conclusions, therefore, should be considered preliminary. TRIAL REGISTRATION: PROSPERO (CRD42018095965); registered 6 June 2018.

RéSUMé: OBJECTIF: L'objectif de cette revue systématique était de déterminer l'efficacité d'un bloc du muscle du carré des lombes pour l'analgésie postopératoire après une chirurgie impliquant la paroi abdominale ou les hanches, comparativement à un placebo ou à d'autres techniques analgésiques. MéTHODE: Nous avons réalisé des recherches dans les bases de données électroniques (Medline, Embase, Cochrane Central, et Scopus) pour trouver les mots-clés et les termes de vocabulaire contrôlé liés au bloc du carré des lombes depuis la création des bases de données jusqu'au mois de novembre 2019. Les études incluses comparaient une injection échoguidée unique pour réaliser un bloc du carré des lombes à un placebo et à d'autres techniques analgésiques chez des patients adultes. RéSULTATS: Quarante-deux études randomisées contrôlées ont fourni des données pour cette revue systématique. Huit études démontraient un risque élevé de biais dans au moins un domaine. Les études incluses présentaient une hétérogénéité importante en matière de type de chirurgie, de groupes comparés, et de résultats mesurés; une analyse quantitative limitée a par conséquent été entreprise pour comparer l'utilisation d'un bloc du muscle carré des lombes vs aucun bloc ou un placebo chez des patientes subissant un accouchement par césarienne. Lors d'un accouchement par césarienne, le bloc du carré des lombes a réduit la consommation d'opioïdes de 24,1 (intervalle de confiance 95 %, 17,3 à 30,9) mg en équivalent de morphine orale au cours des premières 24 h postopératoires par rapport à un accouchement par césarienne sans bloc ou avec placebo, et aucune différence n'a été observée dans les scores de douleur au repos. En ce qui a trait aux autres interventions chirurgicales, les scores de douleur et la consommation d'opioïdes étaient plus bas dans le groupe bloc du carré des lombes par rapport aux groupes placebo / aucune technique d'anesthésie régionale. Comparativement à d'autres techniques d'anesthésie régionale, les bienfaits analgésiques d'un bloc du carré des lombes étaient marginaux. CONCLUSION: Le bloc du carré des lombes a procuré des bienfaits analgésiques par rapport à un placebo lorsqu'il était utilisé en cas de chirurgie impliquant la paroi abdominale ou la hanche, mais ses bienfaits étaient marginaux comparativement aux autres techniques d'analgésie régionale. Les études identifiées utilisaient différentes variantes du bloc du carré des lombes dans de nombreux types différents de chirurgie. Il convient donc de considérer comme préliminaires ces observations et conclusions. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42018095965); enregistrée le 6 juin 2018.

Top ten priorities for anesthesia and perioperative research: a report from the Canadian Anesthesia Research Priority Setting Partnership.

PURPOSE: The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada. METHODS: We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop. RESULTS: A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities. CONCLUSION: The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.

RéSUMé: OBJECTIF: L'objectif du Partenariat canadien pour l'établissement des priorités de la recherche en anesthésie (CAR-PSP) était d'établir une liste des dix principales priorités pour la recherche sur les soins anesthésiques et périopératoires au Canada. MéTHODES: Nous avons utilisé la méthodologie de la James Lind Alliance pour impliquer des patients, des aidants, des professionnels de la santé et des chercheurs afin de déterminer quelles étaient les priorités en matière de recherche au Canada. Dans une première enquête, les participants ont envoyé des questions sur les soins anesthésiques et périopératoires auxquelles ils voulaient que la recherche réponde. Nous avons résumé ces envois par une liste exhaustive de questions. Nous avons passé en revue les publications pour voir s'il existait déjà des réponses à ces questions. Dans une deuxième étude, les participants ont choisi dans la liste jusqu'à dix questions qui leur semblaient les plus importantes et pour lesquelles la recherche devrait fournir des réponses. À partir de cette liste, les questions les mieux classées ont été discutées et un classement définitif leur a été attribué au cours d'un atelier où tous les participants étaient présents en personne. RéSULTATS: Au total, 254 participants ont envoyé 574 suggestions de recherche qui ont été résumées en 49 questions. La littérature a été examinée pour s'assurer que ces questions n'avaient pas déjà reçu des réponses adéquates, et dans une seconde étude, les participants ont choisi jusqu'à 10 questions qu'ils jugeaient les plus importantes parmi ces 49 questions. Au total, 233 participants ont communiqué leurs priorités qui ont alors servi à choisir 24 questions ouvertes pour la discussion dans un atelier final. Dans cet atelier, 22 participants se sont mis d'accord sur une liste des dix principales priorités. CONCLUSION: Les dix principales priorités du CAR-PSP sont le reflet d'un grand éventail de priorités venant de Canadiens de tous horizons qui reçoivent ou fournissent des soins d'anesthésie. Ces priorités sont un outil permettant d'entamer et de guider une recherche axée sur le patient dans le domaine des soins anesthésiques et périopératoires.

Focal/multifocal and geographic retinal dysplasia in the dog-In vivo retinal microanatomy analyses.

PURPOSE: To examine the in vivo microanatomy of retinal folds and geographic lesions in dogs with acquired or inherited retinal dysplasia. MATERIAL AND METHODS: Thirteen dogs had retinal microanatomy evaluation under general anesthesia using cSLO/sdOCT; two eyes had noninherited multifocal retinal folds, five had inherited multifocal retinal folds (drd1 or drd2), and 10 geographic retinal dysplasia. Retinas from two drd2 carrier dogs were examined by histology and immunohistochemistry (IHC) after in vivo imaging. RESULTS: Retinal folds are the common feature of acquired focal/multifocal or geographic retinal dysplasia, are indistinguishable structurally from those associated with syndromic oculoskeletal dysplasia, and represent outer nuclear layer invaginations and rosettes visible by sdOCT. In dogs heterozygous for oculoskeletal dysplasia, the folds form clusters in a perivascular distribution along superior central vessels. IHC confirmed photoreceptor identity in the retinal folds. The geographic dysplasia plaques are not focally detached, but have inner retinal disorganization and intense autofluorescence in cSLO autofluorescence mode that is mainly limited to the geographic lesion, but is not uniform and in some extends beyond the plaques. CONCLUSION: We propose that the autofluorescent characteristic of the geographic lesions is associated with an inner retinal disruption associated with perivascular or infiltrating macrophages and phagocytosis of cellular debris. As well, we suggest restructuring the examination forms to distinguish the folds that are sporadically distributed from those that have a perivascular distribution as the latter likely represent carriers for drd. In this latter group, DNA testing would be a helpful tool to provide specific breeding advice.

Heart rate variability parameters as markers of the adaptation to a sealed environment (a hypoxic normobaric chamber) in the horse.

Simulated hypoxic normobaric devices have been used in human beings in order to enhance endurance capacity. These devices are sealed chambers where the athletes are supposed to stay for at least 6-8 hr daily. The current research assesses the changes in time-domain, spectral and non-geometrical heart rate variability (HRV) parameters in 6 horses subjected to progressive duration periods inside of a hermetically sealed chamber. It was pursued, firstly to evaluate the intensity of the stress experienced by the animals and secondly to elucidate whether the horses might require an acclimation period before implementation of hypoxic conditions. HRV parameters were monitored for 6 days: day 0 (6-hr duration; in paddocks; basal conditions), and days 1, 2, 3, 4 and 5 (1, 2, 3, 4 and 6 hr inside the chamber every day respectively). During day 1 and during the first hours of days 2 and 3, compared to day 0, horses presented increased HR and SDHR values and decreased RR interval duration. SD1 values decreased on some hours of days 2 and 3, but differences with day 0 were not found on day 1. Increased SDNN, RMSSD, SD1 and SD2 values were observed on days 4 and 5. These results showed an activation of the sympathetic activity together with an attenuation of the parasympathetic activity during the days 1 to 3. Increased parasympathetic activity was found only during the first hours of days 4 and 5. Spectral parameters experienced minor variations, with increased LFpeak and LF% during some hours of days 4 and 5. In conclusion, at least 3 days are needed to adapt the horse to a sealed environment before starting to subject the animals to hypoxic conditions. When the horses were acclimatized, however, a minor stress was detected with they spent more than 4 hr inside of the chamber.

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women.

PURPOSE: Hypotension is common after spinal anesthesia for Cesarean delivery. It is associated with nausea, vomiting, and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion vs those who received bolus dosing for the treatment of spinal-induced hypotension. METHODS: In this multicentre, double-blinded randomized controlled trial, 160 obese women undergoing elective Cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 µg·min-1 (and titrated according to a predefined algorithm) or 100 µg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV. RESULTS: Intraoperative nausea and vomiting were significantly reduced in the infusion group compared to the bolus group (46% vs 75%, respectively; relative risk [RR], 0.61; 95% confidence interval [CI], 0.47 to 0.80; P < 0.001). This was associated with significantly reduced need for intraoperative rescue antiemetics (26% vs 42%, respectively; RR, 0.62; 95% CI, 0.40 to 0.97; P = 0.04), but no difference in the incidence of vomiting. Postoperative vomiting at two hours was reduced in the infusion group (11% vs 25%; RR, 0.44; 95% CI, 0.21 to 0.90; P = 0.02);however, there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at two hours and 24 hr, or the incidence of postoperative vomiting at 24 hr. CONCLUSION: In obese women undergoing Cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics, and reduced early postoperative vomiting. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT01481740). Registered 22 July 2011.

Magnetization transfer ratio for the assessment of perianal fistula activity in Crohn's disease.

OBJECTIVES: Assessment of perianal fistulas is important to guide management of Crohn's disease (CD). Our objectives were to analyze the feasibility of magnetization transfer (MT) imaging to assess fistulas and to evaluate its contribution in assessing disease activity. METHODS: During 15 months, all patients referred for perianal fistulas in CD underwent 3T-MRI including diffusion, T2/T1-weighted gadolinium-enhanced sequences and MT sequences (one with an off-resonance saturation pulse of 800 and one with 1200 Hz). We collected Van Assche score, fistula activity signs by analyzing T2, diffusion and contrast enhancement. We calculated MT ratio (MTR) with a ROI in the largest fistula. RESULTS: Twenty-nine patients (mean 34.9 years, range 17-53) were included. Van Assche score was 11.7, range 4-21. In 22 patients, the fistula presented with a bright T2 and diffusion signal with contrast enhancement, and was characterized as active. Mean MTR was respectively 47.2 (range 12-68) and 34.3 (range 11-57) at 800 and 1200 Hz. MTR at 800 Hz was significantly lower in non-active (34, range 12-55) than in active fistulas (51, range 24-68) (p < 0.02). CONCLUSIONS: MTR is feasible for the assessment of fistulas in CD and in the future could be used to help identify active and non-active fistulas. KEY POINTS: • MTR is feasible for the assessment of perianal fistulas in CD. • MT allows quantitative imaging of perianal fistula activity in CD. • MTR could be used to help identify active and non-active fistulas in CD.

Hyperbaric Versus Isobaric Bupivacaine for Spinal Anesthesia: Systematic Review and Meta-analysis for Adult Patients Undergoing Noncesarean Delivery Surgery.

BACKGROUND: It is widely believed that the choice between isobaric bupivacaine and hyperbaric bupivacaine formulations alters the block characteristics for the conduct of surgery under spinal anesthesia. The aim of this study was to systematically review the comparative evidence regarding the effectiveness and safety of the 2 formulations when used for spinal anesthesia for adult noncesarean delivery surgery. METHODS: Key electronic databases were searched for randomized controlled trials, excluding cesarean delivery surgeries under spinal anesthesia, without any language or date restrictions. The primary outcome measure for this review was the failure of spinal anesthesia. Two independent reviewers selected the studies and extracted the data. Results were expressed as relative risk (RR) or mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Seven hundred fifty-one studies were identified between 1946 and 2016. After screening, there were 16 randomized controlled clinical trials, including 724 participants, that provided data for the meta-analysis. The methodological reporting of most studies was poor, and appropriate judgment of their individual risk of bias elements was not possible. There was no difference between the 2 drugs regarding the need for conversion to general anesthesia (RR, 0.60; 95% CI, 0.08-4.41; P = .62; I = 0%), incidence of hypotension (RR, 1.15; 95% CI, 0.69-1.92; P = .58; I = 0%), nausea/vomiting (RR, 0.29; 95% CI, 0.06-1.32; P = .11; I = 7%), or onset of sensory block (MD = 1.7 minutes; 95% CI, -3.5 to 0.1; P = .07; I = 0%). The onset of motor block (MD = 4.6 minutes; 95% CI, 7.5-1.7; P = .002; I = 78%) was significantly faster with hyperbaric bupivacaine. Conversely, the duration of motor (MD = 45.2 minutes; 95% CI, 66.3-24.2; P < .001; I = 87%) and sensory (MD = 29.4 minutes; 95% CI, 15.5-43.3; P < .001; I = 73%) block was longer with isobaric bupivacaine. CONCLUSIONS: Both hyperbaric bupivacaine and isobaric bupivacaine provided effective anesthesia with no difference in the failure rate or adverse effects. The hyperbaric formulation allows for a relatively rapid motor block onset, with shorter duration of motor and sensory block. The isobaric formulation has a slower onset and provides a longer duration of both sensory and motor block. Nevertheless, the small sample size and high heterogeneity involving these outcomes suggest that all the results should be treated with caution.