How Far Are We From Achieving Delabeling of False Penicillin/ß-Lactam Allergy Alerts? A Population Problem.

BACKGROUND: Interest in finding efficient ways to remove penicillin allergy alerts has grown as a result of awareness of the considerable excess of false-negative diagnoses in patients with penicillin allergy labels (90%-95%), the poorer course with non-ß-lactam antibiotics, the increase in bacterial resistance, and the fact that these problems can affect up to 20% of the population in some countries. The strategies proposed have generated many publications in countries where the number of allergists to conduct such studies is low. In many cases where delabeling is performed, the risk of ß-lactam allergy is low, and a single penicillin challenge is sufficient to delabel the alert. However, other less "ultrarapid" strategies can be used to administer a ß-lactam during an admission for infection and thus postpone delabeling until traditional drug allergy consultations. However, the definitive withdrawal of ß-lactam alerts is threatened by nonremoval of alerts in electronic health records and by the reactivation or nonsynchronization of alerts between electronic systems at different levels of care. Allergy departments need to reflect on how to implement practices that enable rapid and efficient delabeling of drug allergy alerts, especially in patients with major comorbidities.

3-T MR-guided focused ultrasound thalamotomy for tremor in patients with a cardiac pacemaker: case series and review of the literature.

MR-guided focused ultrasound (MRgFUS) has proven its efficacy and safety for the treatment of essential tremor (ET) and/or Parkinson's disease (PD). However, having a cardiac pacemaker has been considered an exclusion criterion for the use of MRgFUS. Only 2 patients with a cardiac pacemaker treated with MRgFUS have been previously reported, both treated using 1.5-T MRI. In this paper, the authors present their experience performing 3-T MRgFUS thalamotomy in 4 patients with an implanted cardiac pacemaker. Treatments were uneventful regarding complications or severe side effects. MRgFUS using 3-T MRI was found to be an efficient and safe treatment for ET and/or PD in patients with an MRI-compatible pacemaker.

Clinical utility of intraoperative arterial spin labeling for resection control in brain tumor surgery at 3 T.

Resection control in brain tumor surgery can be achieved in real time with intraoperative MRI (iMRI). Arterial spin labeling (ASL), a technique that measures cerebral blood flow (CBF) non-invasively without the use of intravenous contrast agents, can be performed intraoperatively, providing morpho-physiological information. This study aimed to evaluate the feasibility, image quality and potential to depict residual tumor of a pseudo-continuous ASL (PCASL) sequence at 3 T. Seventeen patients with brain tumors, primary (16) or metastatic (1), undergoing resection surgery with iMRI monitoring, were prospectively recruited (nine men, age 56 ± 16.6 years). A PCASL sequence with long labeling duration (3000 ms) and postlabeling delay (2000 ms) was added to the conventional protocol, which consisted of pre- and postcontrast 3D T1 -weighted (T1w) images, optional 3D-FLAIR, and diffusion. Three observers independently assessed the image quality (four-point scale) of PCASL-derived CBF maps. In those with diagnostic quality (Scores 2-4) they evaluated the presence of residual tumor using the conventional sequences first, and the CBF maps afterwards (three-point scale). Inter-observer agreement for image quality and the presence of residual tumor was assessed using Fleiss kappa statistics. The intraoperative CBF ratio of the surgical margins (i.e., perilesional CBF values normalized to contralateral gray matter CBF) was compared with preoperative CBF ratio within the tumor (Wilcoxon's test). Diagnostic ASL image quality was observed in 94.1% of patients (interobserver Fleiss κ = 0.76). PCASL showed additional foci suggestive of high-grade residual component in three patients, and a hyperperfused area extending outside the enhancing component in one patient. Interobserver agreement was almost perfect in the evaluation of residual tumor with the conventional sequences (Fleiss κ = 0.92) and substantial for PCASL (Fleiss κ = 0.80). No significant differences were found between pre and intraoperative CBF ratios (p = 0.578) in patients with residual tumor (n = 7). iMRI-PCASL perfusion is feasible at 3 T and is useful for the intraoperative assessment of residual tumor, providing in some cases additional information to the conventional sequences.

Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy.

BACKGROUND: Sugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. METHODS: We performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg-1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. RESULTS: Twenty-five patients were included in this study. Compared with baseline, BIS increased at 4-6 min (ß coefficient: 3.63; 95% confidence interval [CI]: 2.22-5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2-4 min (ß coefficient: 0.29; 95% CI: 0.05-0.52; P=0.016) and 4-6 min (ß coefficient: 0.71; 95% CI: 0.47-0.94; P<0.001), and EMG increased at 4-6 min (ß coefficient: 1.91; 95% CI: 1.00-2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2-4 min (ß coefficient: 93; 95% CI: 1-185; P=0.046) and 4-6 min (ß coefficient: 208; 95% CI: 116-300; P<0.001), and decreased delta power was observed at 4-6 min (ß coefficient: -526.72; 95% CI: -778 to -276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. CONCLUSIONS: After neuromuscular block reversal with 2 mg kg-1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.

Effects of dexmedetomidine on subthalamic local field potentials in Parkinson's disease.

BACKGROUND: Dexmedetomidine is frequently used for sedation during deep brain stimulator implantation in patients with Parkinson's disease, but its effect on subthalamic nucleus activity is not well known. The aim of this study was to quantify the effect of increasing doses of dexmedetomidine in this population. METHODS: Controlled clinical trial assessing changes in subthalamic activity with increasing doses of dexmedetomidine (from 0.2 to 0.6 µg kg-1 h-1) in a non-operating theatre setting. We recorded local field potentials in 12 patients with Parkinson's disease with bilateral deep brain stimulators (24 nuclei) and compared basal activity in the nuclei of each patient and activity recorded with different doses. Plasma levels of dexmedetomidine were obtained and correlated with the dose administered. RESULTS: With dexmedetomidine infusion, patients became clinically sedated, and at higher doses (0.5-0.6 µg kg-1 h-1) a significant decrease in the characteristic Parkinsonian subthalamic activity was observed (P<0.05 in beta activity). All subjects awoke to external stimulus over a median of 1 (range: 0-9) min, showing full restoration of subthalamic activity. Dexmedetomidine dose administered and plasma levels showed a positive correlation (repeated measures correlation coefficient=0.504; P<0.001). CONCLUSIONS: Patients needing some degree of sedation throughout subthalamic deep brain stimulator implantation for Parkinson's disease can probably receive dexmedetomidine up to 0.6 µg kg-1 h-1 without significant alteration of their characteristic subthalamic activity. If patients achieve a 'sedated' state, subthalamic activity decreases, but they can be easily awakened with a non-pharmacological external stimulus and recover baseline subthalamic activity patterns in less than 10 min. CLINICAL TRIAL REGISTRATION: EudraCT 2016-002680-34; NCT-02982512.

Silage of the organic fraction of municipal solid waste to improve methane production.

The silage of the organic fraction of municipal solid waste (OFMSW) is a common practice in biogas plants. During silage, fermentation processes take place, affecting the later methanisation stage. There are no studies about how OFMSW silage affects methane production. This work aimed to determine the effects of silage (anaerobic acid fermentation) at different solids concentrations and temperatures on methane production. OFMSW was ensiled at 20, 35, and 55 °C with total solids (TS) concentrations of 10, 20, and 28% for 15 days. The ensiled OFMSW was then tested for methane production at the substrate to inoculum ratios (S/I) of 0.5, 1.0, and 1.5. Independently of the temperature, the production of the metabolites during silage increases with decreasing solids concentration. The highest production was of lactic acid, ethanol, and acetic acid, representing together 95% of the total. Methane production from ensiled OFMSW at 10% solids concentration shows, under every tested condition, better methane production than from fresh OFMSW. Ensiled OFMSW produces more methane than fresh OFMSW, and methane production was highest at 35 °C.

Recovery time after oral and maxillofacial ambulatory surgery with dexmedetomidine: an observational study.

OBJECTIVES: To evaluate the relationship between pharmacokinetic descriptors of dexmedetomidine (predicted area under the curve during the procedure, predicted plasma level at the end of the procedure, and duration of procedure) and sedation depth (proportion of time with bispectral index < 85 during the procedure) with recovery time after ambulatory procedures. MATERIALS AND METHODS: Clinical observational study of patients undergoing oral and maxillofacial ambulatory surgery with dexmedetomidine as sole sedative agent. Patients received a loading dose of dexmedetomidine (0.25-1 µg kg-1) followed by a maintenance infusion (0.2-1.4 µg kg-1 h-1) to keep a bispectral index < 85 until 5 min before the end of the procedure, and were transferred to a post-anesthesia care unit until criteria for discharge were met. RESULTS: Data from 75 patients was analyzed. Sedation depth was directly associated with recovery time (Pearson correlation coefficient [r] = 0.26; p = 0.024). Around 7% of the variation in recovery time was explained by the proportion of time with bispectral index < 85. No association with procedure duration (r = 0.01; p = 0.9), predicted area under the curve (r = 0.1; p = 0.4), or predicted plasma level of dexmedetomidine at the end of the procedure (r = 0.12; p = 0.3) with recovery time was observed. CONCLUSIONS: Sedation depth with dexmedetomidine could play a role in increasing recovery time after oral and maxillofacial ambulatory surgery. In our study, the pharmacokinetic descriptors of dexmedetomidine did not seem to influence recovery time. CLINICAL RELEVANCE: Sedation depth with dexmedetomidine could play a role in increasing recovery time after ambulatory procedures.

Effect of Dexmedetomidine and Propofol on Basal Ganglia Activity in Parkinson Disease: A Controlled Clinical Trial.

BACKGROUND: Deep brain stimulation electrodes can record oscillatory activity from deep brain structures, known as local field potentials. The authors' objective was to evaluate and quantify the effects of dexmedetomidine (0.2 µg·kg·h) on local field potentials in patients with Parkinson disease undergoing deep brain stimulation surgery compared with control recording (primary outcome), as well as the effect of propofol at different estimated peak effect site concentrations (0.5, 1.0, 1.5, 2.0, and 2.5 µg/ml) from control recording. METHODS: A nonrandomized, nonblinded controlled clinical trial was carried out to assess the change in local field potentials activity over time in 10 patients with Parkinson disease who underwent deep brain stimulation placement surgery (18 subthalamic nuclei). The relationship was assessed between the activity in nuclei in the same patient at a given time and repeated measures from the same nucleus over time. RESULTS: No significant difference was observed between the relative beta power of local field potentials in dexmedetomidine and control recordings (-7.7; 95% CI, -18.9 to 7.6). By contrast, there was a significant decline of 12.7% (95% CI, -21.3 to -4.7) in the relative beta power of the local field potentials for each increment in the estimated peak propofol concentrations at the effect site relative to the control recordings. CONCLUSIONS: Dexmedetomidine (0.2 µg·kg·h) did not show effect on local field potentials compared with control recording. A significant deep brain activity decline from control recording was observed with incremental doses of propofol.

First identification of Francisella noatunensis subsp. orientalis causing mortality in Mexican tilapia Oreochromis spp.

Francisellosis, an emerging disease in tilapia Oreochromis spp., is caused by the facultative, intracellular bacterium Francisella noatunensis subsp. orientalis, which is present in various countries where tilapia farming is commercially important. We confirmed the presence of francisellosis in Mexican tilapia cultures in association with an outbreak during the second semester of 2012. Broodstock fish presented a mortality rate of approximately 40%, and disease was characterized by histologically classified granulomas, or whitish nodules, in different organs, mainly the spleen and kidney. Through DNA obtained from infected tissue and pure cultures in a cysteine heart medium supplemented with hemoglobin, F. noatunensis subsp. orientalis was initially confirmed through the amplification and analysis of the 16S rRNA gene and the internal transcribed spacer region. Phylogenetic analysis of these genes demonstrated close similarity with previously reported F. noatunensis subsp. orientalis sequences obtained from infected tilapia from various countries. The identification of this subspecies as the causative agent of the outbreak was confirmed using the iglC gene as a target sequence, which showed 99.5% identity to 2 F. noatunensis subsp. orientalis strains (Ethime-1 and Toba04). These findings represent the first documented occurrence of francisellosis in Mexican tilapia cultures, which highlights the importance of establishing preventative measures to minimize the spread of this disease within the Mexican aquaculture industry.

Factors Associated with Tremor Changes during Sedation with Dexmedetomidine in Parkinson's Disease Surgery.

INTRODUCTION: Dexmedetomidine is an α2-agonist recently proposed as a potentially ideal drug for sedation during the surgical treatment of Parkinson's disease (PD). This report documents the incidence of changes in motor symptoms (especially tremor) in PD patients sedated with dexmedetomidine for deep brain stimulation or ablation procedures. METHODS: We reviewed a retrospective cohort of 22 patients who underwent surgery for PD with dexmedetomidine sedation at a single institution from 2010 to 2014. A logistic regression analysis was performed to analyze possible confounding factors. RESULTS: 14 cases of tremor reduction or suppression were recorded (cumulative incidence: 63.6%; 95% CI: 40.7-82.8). No association could be identified between loading dose, ß-blocker use and preoperative total Unified Parkinson's Disease Rating Scale III, with tremor changes. The maintenance dose of dexmedetomidine was higher in patients who did not experience changes [median and range for patients with and without tremor alteration 0.75 (0.2-1.0) and 1.0 µg × kg(-1) × h(-1) (0.7-1.4), respectively; p = 0.021]. CONCLUSION: Dexmedetomidine provides adequate sedation during surgery for PD, but it might affect motor signs making intraoperative testing difficult or even impossible. Dosage appears not to be the determining factor in motor changes, whose cause remains unclear.

Pure menstrual tension-type headache: demonstration of its existence.

INTRODUCTION AND OBJECTIVE: Menstrual migraine (MM) is widely recognized among the scientific community, with diagnostic criteria included in the appendix of the third edition of the International Headache Classification. However, this classification does not include other primary headaches that may occur during menstruation. Previous retrospective studies suggest the existence of menstrual tension-type headache. Our objective is to prospectively determine the existence of this type of headache and to determine its frequency relative to that of MM. METHODS: This is a descriptive, cross-sectional (case series), prospective, observational study, conducted in a hospital neurology department, using a previously validated ad hoc questionnaire. Participants were recruited by consecutive sampling, applying inclusion and exclusion criteria among women accompanying neurology outpatients, and classified into five groups: pure menstrual tension-type headache, menstrual-related tension-type headache, pure menstrual migraine, menstrual-related migraine and unclassifiable. RESULTS: Ninety-five women (median age of 38.50 years, IQR: 13) were included, with the following group distribution: 13 (13.6%) pure menstrual tension-type headache, 14 (14.7%) menstruation-related tension-type headache, 23 (24.2%) pure menstrual migraine, 44 (46.3%) menstrual-related migraine and 1 unclassifiable. Of these patients, 23% did not treat menstrual headache, but this figure rose to 30.8% in the case of pure menstrual tension-type headache. CONCLUSION: The results confirm the existence of pure menstrual tension-type headache among women who do not seek medical care for this condition. The frequency of this headache is lower than that of MM. This reduced incidence, together with its generally mild nature, may explain the lack of prior recognition.

Neuropsychological deficits associated with destruction of the right nigrostriatal pathway.

Hemiparkinsonism secondary to a vascular mesencephalic lesion is infrequent; these patients offer an exceptional opportunity to study neuropsychological alterations attributable to unilateral dopaminergic denervation, shedding light on the pathophysiology of cognitive disorders in early-stage idiopathic Parkinson's disease (PD). From the investigation of our case, we conclude that destruction of the right nigrostriatal pathway is accompanied by deficits in executive functioning and verbal/visual memory similar to those observed in many patients with early-stage idiopathic PD. The more complex neuropsychological dysfunction developed by other PD patients must therefore be related to the additional involvement of other brain structures.

Influence of air flow rate and backwashing on the hydraulic behaviour of a submerged filter.

The aim of this study was to evaluate backwashing effects on the apparent porosity of the filter media and on the hydraulic behaviour of a pilot scale submerged filter, prior to biofilm colonization, under different hydraulic retention times, and different air flow rates. Tracer curves were analysed with two mathematical models for ideal and non-ideal flow (axial dispersion and Wolf and Resnick models). The filter media was lava stones sieved to 4.5 mm. Backwashing causes attrition of media particles, decreasing the void volume of the filter media and, consequently, the tracer flow is more uniform. The eroded media presented lower dead volumes (79% for the filter with aeration and 8% for the filter without aeration) compared with the new media (83% for the filter with aeration and 22% for the filter without aeration). The flow patterns of eroded and new media were different because the more regular shape of the particles decreases the void volume of the filter media. The dead volume is attributed, in the case of the filter with aeration, to the turbulence caused by the air bubbles that generate preferential channelling of the bulk liquid along the filter media, creating large zones of stagnant liquid and, for the filter without aeration, to the channels formed due to the irregular shaped media.

Characteristics of the digestates from OFMSW methane production at psychrophilic, mesophilic, and thermophilic conditions under different organic loading rates.

The anaerobic digestion of the organic fraction of municipal solid waste (OFMSW) has shown to be a viable alternative since it allows energy recovery in the form of methane and generates a residue (digestate) that can be applied effectively as a soil improver or fertiliser. The potential for methane production and the digestates' characteristics depend on the substrate characteristics and the process variables such as temperature, solids retention time, and organic load. This study dealt with OFMSW anaerobic digestion under different organic loading rates and temperatures and the characteristics of the resulting digestates. Three semi-continuous reactors were operated at 20, 35, and 55°C and fed daily with ground, fresh OFMSW from Mexico City. The inoculum was temperature-adapted UASB granular sludge. The main results indicate that the anaerobic digestion was adequate, as the pH values were slightly alkaline, which is sufficient for methanization, and the alkalinity was not a limiting factor. Potassium and PO4-P increased with the organic load, and Kjeldahl nitrogen decreased. At 20°C, total organic carbon (TOC) increased substantially with the organic load; at 35°C, it remained without significant changes; and at 55°C, TOC slightly decreased with the organic load. The C/N ratio changed accordingly to TOC variations. At 20°C, the residual biogas potential increased with the organic load; at 35 and 55°C, it decreased with increasing organic load; the residual biogas potential increased with residual fatty acids concentrations. To comply with international standards for agricultural use, the digestates need only dewatering and supplementing with PO4-P.

Bilateral subgaleal hematoma after a robot-assisted radical prostatectomy: an uncommon complication.

Robot-assisted radical prostatectomy is a relatively recent technique. Its advantages include less invasiveness and better pain management, but has specific anesthesia requirements, such as steep Trendelenburg position and pneumoperitoneum. Mild complications are common, e.g., transient hypotension or soft tissue edema. We present a case of a 62-year old male who developed subgaleal hematoma associated with transient neurologic impairment after surgery. Jugular vein insufficiency was suspected as the most likely cause. The patient recovered fully. Robot-assisted radical prostatectomy can be a challenging procedure due to the anesthesia requirements, but most complications are mild and transient. However, patients should be carefully assessed before surgery. We identified potential factors that may have led to this complication: the abnormal prolonged surgical time, the steep Trendelenburg, a non-assessed jugular vein insufficiency, and/or patient`s obesity.

Effectiveness of antithrombotic prophylaxis in hospitalised patients with SARS-CoV-2 infection.

BACKGROUND: Antithrombotic prophylaxis in hospitalised patients with SARS-CoV-2 acute infection has increased. Currently, most of the evidence relates to patients in intensive care units; however, there is little information on patients admitted to hospital wards and there is no consensus protocol on thromboprophylaxis during admission and after discharge. OBJECTIVE: To assess the effectiveness of antithrombotic prophylaxis in patients admitted with COVID-19 and 30 days after discharge. METHOD: A prospective observational study was conducted of patients admitted with COVID-19 in which the hospital thromboprophylaxis protocol was applied, classifying the patients as having a standard or high risk of thrombosis. Pharmacists performed a daily follow-up and actively intervened during admission and at discharge. The main outcome measure was the global incidence of symptomatic venous thromboembolism (VTE) related to hospitalisation. RESULTS: A total of 113 patients were included, 98.23% of whom were admitted to a hospital ward. The incidence of hospital-acquired VTE was 1.77%. In 75.22% of the subjects, thromboprophylaxis was adjusted to the protocol during admission. A total of 23 pharmaceutical interventions were conducted, with an adherence of 52.17%. At discharge, 94.28% of the patients who had no haemorrhage and ≥4 points on the Padua Prediction Score required thromboprophylaxis, aligning with the protocol. The global incidence of haemorrhagic events during the follow-up period was 0.88%. CONCLUSION: The incidence of hospital-acquired VTE was lower than that described in the literature. Although it cannot be certain that it is directly related to the instituted protocol, the data can show that the management of prevention of VTE is being optimally performed at the hospital. Long-term studies are needed to evaluate the incidence after discharge, as well as to agree on a specific protocol in the COVID-19 population for the prevention of these events during hospitalisation and post-discharge.

Development and Performance Evaluation of a Clinical Predictive Model to Estimate the Risk of Red Blood Cell Requirements in Brain Tumor Surgery.

BACKGROUND: The identification of factors associated with perioperative red blood cell (RBC) transfusion provides an opportunity to optimize the patient and surgical plan, and to guide perioperative crossmatch and RBC orders. We examined the association among potential bleeding risk factors and RBC requirements to develop a novel predictive model for RBC transfusion in patients undergoing brain tumor surgery. METHODS: This retrospective study included 696 adults who underwent brain tumor surgery between 2008 and 2018. Multivariable logistic regression with backward stepwise selection for predictor selection was used during modeling. Model performance was evaluated using area under the receiver operating characteristic curve, and calibration was evaluated with Hosmer-Lemeshow goodness-of-fit χ 2 -estimate. RESULTS: Preoperative hemoglobin level was inversely associated with the probability of RBC transfusion (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.39-0.63; P <0.001). The need for RBC transfusion was also greater in patients who had a previous craniotomy (OR: 2.71; 95% CI: 1.32-5.57; P =0.007) and in those with larger brain tumor volume (OR: 1.01; 95% CI: 1.00-1.02; P =0.009). The relationship between number of planned craniotomy sites and RBC transfusion was not statistically significant (OR: 2.11; 95% CI: 0.61-7.32; P =0.238). A predictive model for RBC requirements was built using these 4 variables. The area under the receiver operating characteristic curve was 0.79 (95% CI: 0.70-0.87; P <0.001) showing acceptable calibration for predicting RBC transfusion requirements. CONCLUSIONS: RBC requirements in patients undergoing brain tumor surgery can be estimated with acceptable accuracy using a predictive model based on readily available preoperative clinical variables. This predictive model could help to optimize both individual patients and surgical plans, and to guide perioperative crossmatch orders.

Immunosuppression of HLA identical living-donor kidney transplant recipients: A systematic review.

BACKGROUND: Kidney transplant (KT) recipients of HLA identical siblings (HLAid) have lower immunological risk, but there are no specific recommendations for immunosuppression. Our aim was to analyze evidence about results from HLAid living-donor recipients under different immunosuppression in the current era of immunological risk assessment. METHODS: Systematic review of studies describing associations between outcomes of HLAid living-donor KT recipients according to their immunological risk and applied immunosuppression. RESULTS: From 1351 studies, 16 (5636 KT recipients) were included in the analysis. All studies were retrospective, ten comparing immunosuppression strategies, and six immunological risk strata. Of those ten, six studies were published in 1990 or earlier and only three included tacrolimus. The evidence is poor, and the inclusion of calcineurin inhibitors does not demonstrate better results. Furthermore, only few studies describe different immunosuppression regimens according to the patient immunological risk and, in general, they do not include the assessment with new solid phase assays. CONCLUSIONS: There are no studies analyzing the association of outcomes of HLAid KT recipients with current immunological risk tools. In the absence of evidence, no decision or proposal of immunosuppression adapted to modern immunological risk assessment can be made currently by the Descartes Working Group.