Burst-suppression ratio underestimates absolute duration of electroencephalogram suppression compared with visual analysis of intraoperative electroencephalogram

Background

Machine-generated indices based on quantitative electroencephalography (EEG), such as the patient state index (PSI™) and burst-suppression ratio (BSR), are increasingly being used to monitor intraoperative depth of anaesthesia in the endeavour to improve postoperative neurological outcomes, such as postoperative delirium (POD). However, the accuracy of the BSR compared with direct visualization of the EEG trace with regard to the prediction of POD has not been evaluated previously.

Methods

Forty-one consecutive patients undergoing non-cardiac, non-intracranial surgery with general anaesthesia wore a SedLine ® monitor during surgery and were assessed after surgery for the presence of delirium with the Confusion Assessment Method. The intraoperative EEG was scanned for absolute minutes of EEG suppression and correlated with the incidence of POD. The BSR and PSI™ were compared between patients with and without POD.

Results

Visual analysis of the EEG by neurologists and the SedLine ® -generated BSR provided a significantly different distribution of estimated minutes of EEG suppression ( P =0.037). The Sedline ® system markedly underestimated the amount of EEG suppression. The number of minutes of suppression assessed by visual analysis of the EEG was significantly associated with POD ( P =0.039), whereas the minutes based on the BSR generated by SedLine ® were not associated with POD ( P =0.275).

Conclusions

Our findings suggest that SedLine ® (machine)-generated indices might underestimate the minutes of EEG suppression, thereby reducing the sensitivity for detecting patients at risk for POD. Thus, the monitoring of machine-generated BSR and PSI™ might benefit from the addition of a visual tracing of the EEG to achieve a more accurate and real-time guidance of anaesthesia depth monitoring and the ultimate goal, to reduce the risk of POD.

Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq

BACKGROUND

Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq.

METHODS

This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting.

RESULTS

Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT-ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility.

CONCLUSIONS

BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.

Congenital dermoid inclusion cyst over the anterior fontanelle: report of two cases

Congenital dermoid inclusion cyst over the anterior fontanelle (CDIC) is an uncommon cystic lesion. It is a benign and curative lesion. In these two cases a soft, cystic mass located over the anterior fontanelle. The cyst had no intracranial extension and was easily excised intact. The clinical and image findings of the cysts were described and compared with the usual dermoids. Many different types of lesions over the children's skull exist and some are commonly diagnosed in daily practice. Congenital dermoid inclusion cyst over the anterior fontanelle (CDIC) is a rare and benign lesion.Pulse Vol.7 January-December 2014 p.42-45

A case report on interhemispheric epidermoid tumor

A 30 year old man admitted with the complaints of generalized convulsions, headache and amnesia. The radiological and neuro-pathological findings were interhemispheric epidermoid tumor, which is a rare location. The tumor was removed completely. The diagnosis and management of epidermoid tumors are discussed by reviewing the literature.Pulse Vol.7 January-December 2014 p.46-49

Retrospective comparison of decompressive hemicraniectomy and hematoma evacuation for spontaneous supratentorial intracerebral hematoma

Objectives: The aim of this study was to test the hypothesis that decompressive hemicraniectomy (DHC), compared with craniotomy with evacuation of hematoma, and would improve clinical outcomes of patients with supratentorial intracerebral hemorrhage (SICH).Methods: We compared patients (November 2008–February 2014) with supratentorial ICH treated with DHC without hematoma evacuation and craniotomy with hematoma evacuation. DHC measured at least 150 mm and included opening of the dura. We analyzed clinical, radiological, and surgical characteristics. Outcome at 6 months was divided into good (modified Rankin Scale 0–4) and poor (modified Rankin Scale 5–6).Results: Fifteen patients (mean age 58 years) with ICH were treated by DHC. Median hematoma volume was 61 ml and mean preoperative Glasgow Coma Scale (GCS) was 7. Ten patients had good and five had poor outcomes. In hematoma evacuation group 29 patients were treated. Median hematoma volume was 55 ml and mean preoperative Glasgow Coma Scale (GCS) was 8. Seventeen patients had good and twelve had poor outcomes.Conclusions: DHC is more effective than hematoma evacuation in patients with SICH. Based on this small cohort, DHC may reduce mortality. Larger prospective study is warranted to assess safety and efficacy.Pulse Vol.7 January-December 2014 p.16-21

Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?

AIM

The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test.

METHOD

All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test.

RESULTS

A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%.

CONCLUSIONS

Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.

The role of a multidisciplinary pre-assessment clinic in reducing mortality after complex orthopaedic surgery

INTRODUCTION

This paper describes an audit loop. The aim of this study was to audit the effect of a specialised preoperative anaesthetic assessment clinic after hip and knee arthroplasty and revision arthroplasty.

PATIENTS AND METHODS

We studied patients undergoing hip and knee surgery (arthroplasty and revision arthroplasty). We collected data concerning postoperative admissions to the high dependency unit (HDU), intensive care unit (ICU) and post-anaesthesia care unit (PACU) (planned and unplanned rates of admission, length of stay). We also noted mortality. In the first part of the study (April 2005 to March 2006) we studied 298 patients. All patients were assessed independently by an anaesthetist on the day of surgery. A multidisciplinary preoperative assessment clinic commenced in April 2006. After this date all patients were assessed preoperatively by a multidisciplinary anaesthetic lead team. In the second part of the study (May 2006 to April 2009) a further 1,147 arthroplasty patients were studied. Data were again collected regarding HDU, ICU, PACU and mortality, as noted above.

RESULTS

We found statistically significant (p = 0.001) reductions in the admissions to PACU (22% down to 10%) and in mortality (6.1% down to 1.2%) after the introduction of the pre-assessment clinic. There was also a statistically significant (p = 0.01) reduction in the HDU length of stay (2.1 days to 1.6 days), ICU unplanned admissions (1.3% to 0.4%) and the ICU length of stay (2.3 to 1.9 days). We estimated cost savings of nearly £50,000 in the second part of the study. This is based on the average decrease in HDU and ICU length of stay.

CONCLUSIONS

We recommend the use of a multidisciplinary pre-assessment clinic for complex orthopaedic surgery.

The role of recombinant activated Factor VII in major obstetric haemorrhage: the Farnborough experience

Major obstetric haemorrhage is one of the commonest causes of maternal mortality and morbidity worldwide. It may result in coagulopathy and diffuse pelvic or vaginal bleeding. Correction of coagulopathy when administering Factor VII may be crucial to the management of selected cases. We report the use of recombinant activated factor in three cases of massive obstetric haemorrhage. Prolonged international normalised ratio, activated partial thromboplastin time, and reduced fibrinogen were the trigger to use rFVIIa. It was effective to halt the process of coagulopathy, secure haemostasis and improve laboratory parameters in all three patients. We review the relevant literature and discuss its indications, the potential benefits and possible complications. Recombinant activated Factor VII is a potential haemostatic agent in massive obstetric haemorrhage. Its successful use has been reported in post-surgical bleeding and consumptive coagulopathy. It may abolish the need for hysterectomy, which has a devastating effect on the patient future fertility and psychological well-being.

Maternal nutritional history predicts obesity in adult offspring independent of postnatal diet

Significant alterations in maternal nutrition may induce long-term metabolic consequences in offspring, in particular obesity and leptin and insulin resistance. Although maternal nutrient deprivation has been well characterized in this context, there is a relative paucity of data on how high fat (HF) nutrition impacts on the subsequent generation. The present study investigated the effects of maternal HF nutrition either throughout the mother's life up to and including pregnancy and lactation or HF nutrition restricted to pregnancy and lactation, on growth and metabolic parameters in male and female offspring. Virgin Wistar rats were assigned to one of three experimental groups: (1) controls (Cont): dams fed a standard chow diet throughout their life and throughout pregnancy and lactation; (2) maternal high fat (MHF) group: dams fed a HF diet from weaning up to and throughout pregnancy and lactation; and (3) pregnancy and lactation high fat (PLHF): dams fed a chow diet through their life until conception and then fed a HF diet throughout pregnancy and lactation. At weaning, all offspring were fed either a chow or HF diet for the remainder of the study (160 days). Litter size and sex ratios were not significantly different between the groups. MHF and PLHF offspring had significantly lower body weights and were hypoleptinaemic and hypoinsulinaemic at birth compared to Cont offspring. As adults however, chow-fed MHF and PLHF offspring were significantly more obese than Cont offspring (DEXA scanning at day 150, P < 0.001 for maternal HF diet). As expected a postweaning HF diet resulted in increased adiposity in all groups; MHF and PLHF offspring, however, always remained significantly more obese than Cont offspring. Increased adiposity in MHF and PLHF offspring was paralleled by hyperinsulinaemia and hyperleptinaemia (P < 0.001; MHF and PLHF versus Cont). It is of interest that a lifetime of HF nutrition produced a similar offspring phenotype to HF nutrition restricted to pregnancy and lactation alone, thus suggesting that the postnatal sequelae of maternal HF nutrition occurs independent of preconceptional diet. These data further reinforce the importance of maternal nutrition during these critical windows of development and show that maternal HF feeding can induce a markedly obese phenotype in male and female offspring completely independent of postnatal nutrition.

Improved detection of medullary thyroid cancer with radiolabeled antibodies to carcinoembryonic antigen

PURPOSE

This investigation was undertaken to assess the targeting of established and occult medullary thyroid cancer (MTC) with radiolabeled monoclonal antibodies (MAbs) reactive with carcinoembryonic antigen (CEA).

PATIENTS AND METHODS

Twenty-six assessable patients with known (n = 17) or occult (n = 9) MTC were studied with radiolabeled anti-CEA MAbs. Scintigraphic images were collected to determine targeting of tumor lesions.

RESULTS

The targeting results of technetium 99m (99mTc)-,iodine 123 (123I)-, and iodine 131 (131I)-labeled anti-CEA antibodies (all directed against the same epitope of CEA) indicated that all these reagents were capable of detecting established and occult MTC. The sensitivity for detection of known sites of disease ranged from 76% to 100% for the various anti-CEA MAbs used, when compared with computed tomography (CT), magnetic resonance imaging (MRI), bone scan, or other imaging modalities. Moreover, the antibody scan was positive in seven of nine patients with occult disease (patients with negative conventional imaging studies, but who had elevated calcitonin and/or CEA levels). Three of seven patients underwent surgery and the disease was confirmed by histopathology in all three.

CONCLUSION

Anti-CEA MAbs are excellent agents for imaging recurrent, residual, or metastatic MTC. The high lesion sensitivity in patients with known lesions, combined with the ability to detect disease, may make these agents ideal for staging patients, monitoring disease pretherapy or posttherapy, and especially for evaluating patients with recurrent or persistent hypercalcitonemia or CEA elevations after primary surgery. Analogous to radioiodine in the evaluation of patients with differentiated thyroid cancer, radiolabeled anti-CEA MAbs may achieve a similar role in diagnosing and monitoring patients with MTC.