Search

Meihui Li,1,2 Haiyan Zheng,3 Jae Chul Koh,4 Ghee Young Choe,5,6 Eun Joo Choi,1,2 Francis Sahngun Nahm,1,2 Pyung Bok Lee1,2 1Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea; 2Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea; 3Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China; 4Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea; 5Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Korea; 6Department of Pathology, Seoul National University College of Medicine, Seoul, KoreaCorrespondence: Pyung Bok Lee, Email painfree@snu.ac.krObjective: To create a deep learning (DL) model that can accurately detect and classify three distinct types of rat dorsal root ganglion neurons: normal, segmental chromatolysis, and central chromatolysis. The DL model has the potential to improve the efficiency and precision of neuron classification in research related to spinal injuries and diseases.Methods: H&E slide images were divided into an internal training set (80%) and a test set (20%). The training dataset was labeled by two pathologists using pre-defined grades. Using this dataset, a two-component DL model was developed with the first component being a convolutional neural network (CNN) that was trained to detect the region of interest (ROI) and the second component being another CNN used for classification.Results: A total of 240 lumbar dorsal root ganglion (DRG) pathology slide images from rats were analyzed. The internal testing results showed an accuracy of 93.13%, and the external dataset testing demonstrated an accuracy of 93.44%.Conclusion: The DL model demonstrated a level of agreement comparable to that of pathologists in detecting and classifying normal and segmental chromatolysis neurons, although its agreement was slightly lower for central chromatolysis neurons. Significance: DL in improving the accuracy and efficiency of pathological analysis suggests that it may have a role in enhancing medical decision-making.Keywords: deep learning, dorsal root ganglion, chromatolysis, automated detection and spinal stenosis

Ji Yeong Kim,1,&ast; Yookyung Jang,2,&ast; Eun Jang Yoon,1 Wootaek Lee,1 Jaewoo Kim,2 Jae Chul Koh2 1Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea&ast;These authors contributed equally to this workCorrespondence: Jae Chul Koh, Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea, Tel +82-2-920-5632, Fax +82-2-928-2275, Email jaykoh@korea.ac.krPurpose: The aim of this prospective study was to develop a virtual reality simulator (VRS) for spinal cord stimulation (SCS) trials and establish its effectiveness.Methods: We developed a VRS for SCS training by integrating patient imaging data analytics, creating artificial X-ray images, and using spatial alignment techniques and virtual reality technologies. The simulator was created by a physician with considerable experience in performing SCS, and can simulate the feeling of the procedure in a virtual environment. The efficacy of the simulator for SCS trials was assessed using a cohort of 20 novice trainees. The primary outcomes were duration of the procedure, checklist score, number of C-arm images captured, and overall trainee satisfaction.Results: The cohort that utilized the VRS had better Zwisch scale scores (P < 0.001), completed the procedure in a shorter time (P < 0.001), took fewer C-arm images (P < 0.001), and reported better overall satisfaction (P = 0.011) than the cohort that did not.Conclusion: We developed a realistic and efficient VRS for educating novice trainees on SCS trials, thereby eliminating the risk of radiation exposure associated with cadaver training. The results of this study indicate that our VRS has potential as an instrumental resource that can be integrated into the educational framework for SCS trials.Keywords: surgical procedure, simulation training, spinal cord stimulator, virtual reality, virtual reality simulator

Eun Kyung Jun,1,&ast; Sunghwan Lim,2,&ast; Joonho Seo,3 Kae Hong Lee,1 Jae Hee Lee,1 Deukhee Lee,2 Jae Chul Koh1 1Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Korea; 2Center for Healthcare Robotics, Artificial Intelligence and Robotics Institute, Korea Institute of Science and Technology, Seoul, Korea; 3Department of Medical Assistant Robot, Korea Institute of Machinery and Materials, Daegu, Korea&ast;These authors contributed equally to this workCorrespondence: Deukhee Lee, Center for Bionics, Korea Institute of Science and Technology, Hwarangno 14-gil 5, Seongbuk-gu, Seoul, 136-791, Republic of Korea, Tel +82-2-958-5633, Fax +82-2-920-2275, Email dkylee@kist.re.kr Jae Chul Koh, Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbukgu, Seoul, 02841, Korea, Tel +82-2-920-5632, Fax +82-2-920-2275, Email jaykoh@korea.ac.krPurpose: Multiple studies have attempted to demonstrate the benefits of augmented reality (AR)-assisted navigation systems in surgery. Lumbosacral transforaminal epidural injection is an effective treatment commonly used in patients with radiculopathy due to spinal degenerative pathologies. However, few studies have applied AR-assisted navigation systems to this procedure. The study aimed to investigate the safety and effectiveness of an AR-assisted navigation system for transforaminal epidural injection.Patients and Methods: Through a real-time tracking system and a wireless network to the head-mounted display, computed tomography images of the spine and the path of a spinal needle to the target were visualized on a torso phantom with respiration movements installed. From L1/L2 to L5/S1, needle insertions were performed using an AR-assisted system on the left side of the phantom, and the conventional method was performed on the right side.Results: The procedure duration was approximately three times shorter, and the number of radiographs required was reduced in the experimental group compared to the control group. The distance from the needle tips to the target areas in the plan showed no significant difference between the two groups. (AR group 1.7 ± 2.3mm, control group 3.2 ± 2.8mm, P value 0.067).Conclusion: An AR-assisted navigation system may be used to reduce the time required for spinal interventions and ensure the safety of patients and physicians in view of radiation exposure. Further studies are essential to apply AR-assisted navigation systems to spine interventions.Keywords: interventional procedure, epidural injection, augmented reality, navigation system, radiation exposure

Jae Chul Koh,1,* Hee Jung Kong,2,* Myoung Hwa Kim,3 Jung Hwa Hong,4 Hyunyoung Seong,1 Na Young Kim,2 Sun Joon Bai2 1Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea; 2Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; 3Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 4Department of Policy Research Affairs, National Health Insurance Service Ilsan Hospital, Goyang, Gyeonggi-do, Republic of Korea*These authors contributed equally to this workCorrespondence: Na Young Kim; Sun Joon BaiDepartment of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of KoreaTel +82 2 2228 4435; +82 2 2228 4432Email knnyyy@yuhs.ac; sjbae@yuhs.acPurpose: Oxycodone has affinities for both kappa- and mu-opioid receptors. Therefore, it has been used for postoperative analgesia of surgeries in which visceral pain is expected to be the main cause of pain. However, there are few studies of the 55:1 potency ratio of oxycodone to fentanyl when using it as intravenous patient-controlled analgesia (IV-PCA). Thus, we compared the analgesic and adverse effects of IV-PCA using the 55:1 potency ratio of oxycodone to fentanyl in patients who underwent robot-assisted laparoscopic gastrectomy.Patients and Methods: This retrospective study included 100 patients using an automatic PCA pump with oxycodone or fentanyl who underwent robot-assisted laparoscopic gastrectomy between January and November 2017. All patients were provided with an IV-PCA consisting of 20 μg/kg of fentanyl or 1.1 mg/kg of oxycodone mixed with 0.9% normal saline solution to a total volume of 250 mL, which was infused basally at a rate of 0.1 mL/h with a bolus dose of 1 mL and lockout time of 6 min. The primary and secondary endpoints were to evaluate the efficacies of IV-PCA using the 55:1 potency ratio of oxycodone to fentanyl on analgesic and adverse effects.Results: Pain intensity on arrival at the post-anesthesia care unit (PACU; 3.6± 1.4 vs 4.4± 2.0, P=0.031) and additional analgesic requirement within an hour after surgery (including the PACU period) (12% vs 37%; P=0.005) were significantly lower in the oxycodone group (n=49) than in the fentanyl group (n=51). Regarding adverse effects, the rate of postoperative nausea within 1 h after surgery (2% vs 16%; P=0.031) was also significantly lower in the oxycodone group than that in the fentanyl group.Conclusion: Oxycodone-based IV-PCA by dose calculations with a 55:1 potency ratio may achieve better analgesia without any significant adverse effects, when using IV-PCA in patients undergoing robot-assisted laparoscopic gastrectomy.Keywords: oxycodone, fentanyl, 55:1 potency ratio, intravenous patient-controlled analgesia, robot-assisted laparoscopic gastrectomy

Jae Chul Koh, Young Song, So Yeon Kim, Sooyeun Park, Seo Hee Ko, Dong Woo Han Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea Abstract: In this retrospective study, data of 2,435 patients who received fentanyl and ropivacaine-based patient-controlled epidural analgesia (PCEA) for pain relief after elective surgery under general or spinal anesthesia were reviewed. Differences in postoperative pain, incidence of patient-controlled analgesia (PCA)-related adverse effects, and risk factors for the need for rescue analgesics for 48 hours postsurgery in young (age 20–39 years) and elderly (age ≥70 years) patients were evaluated. Although there were no significant differences in postoperative pain intensity between the two groups until 6 hours postsurgery, younger patients experienced greater postoperative pain intensity compared with older patients 6–48 hours postsurgery. While younger patients exhibited greater incidence of numbness, motor weakness, and discontinuation of PCA postsurgery, elderly patients exhibited greater incidence of hypotension, nausea/vomiting, rescue analgesia, and antiemetic administration. Upon multivariate analysis, low fentanyl dosage and history of smoking were found to be associated with an increased need for rescue analgesia among younger patients, while physical status classification III/IV and thoracic surgery were associated with a decreased need for rescue analgesia among the elderly. Discontinuation of PCA was more frequent among younger patients than the elderly (18.5% vs 13.5%, P=0.001). Reasons for discontinuation of PCA among young and elderly patients, respectively, were nausea and vomiting (6.8% vs 26.6%), numbness or motor weakness (67.8% vs 11.5%), urinary retention (7.4% vs 8.7%), dizziness (2.2% vs 5.2%), and hypotension (3.1% vs 20.3%). In conclusion, PCEA was more frequently associated with numbness, motor weakness, and discontinuation of PCA in younger patients and with hypotension, nausea/vomiting, and a greater need for rescue analgesics/antiemetics among elderly patients. Therefore, in order to minimize the adverse effects of PCEA and enhance pain relief, different PCEA regimens and administration/prevention strategies should be considered for young and elderly patients. Keywords: adverse effect, age, elderly, epidural analgesia, pain management, patient-controlled analgesia

Li Lim,1– 3,* Elizabeth Wen Ling Lim,4,* Mohamad Rosman,1– 3 Jane Chwee Wah Koh,1 Hla Myint Htoon1,3 1Singapore National Eye Centre, Singapore 168751, Singapore; 2Singapore Eye Research Institute, Singapore 169856, Singapore; 3Duke-NUS Medical School, Singapore 169857, Singapore; 4Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore*These authors contributed equally to this workCorrespondence: Li LimSingapore National Eye Centre, 11 Third Hospital Ave, Singapore 168751, SingaporeTel +65 62277255Fax +65 62277290Email lim.li@singhealth.com.sgPurpose: To determine the long-term visual outcomes of simultaneous femtosecond laser-assisted laser in situ keratomileusis (femto-LASIK) and accelerated cross-linking (CXL) [LASIK Xtra] for the treatment of high myopia.Patients and Methods: All 163 consecutive eyes of 85 patients who underwent LASIK Xtra for the treatment of high myopia and/or myopic astigmatism (spherical equivalent ≥ − 6.00 D) in Singapore National Eye Centre from the years 2013 to 2017 were included in this retrospective case series. Post-operative follow-up was up to 3 years.Results: Of the 163 eyes, 67 were followed up for 1 year (mean 12.9 months), 69 for 2 years (mean 24.0 months) and 43 for 3 years (mean 36.4 months). Overall mean follow-up was 22.8 months (9– 46 months). The mean pre-operative spherical equivalent (SE) was − 8.60 ± 1.47 D [range: − 11.75 to − 4.75] (n = 163) and mean attempted correction SE was − 8.84 ± 1.41 D [range: − 11.88 to − 5.25]. Most eyes (> 95%) maintained an uncorrected distance visual acuity of 6/12 or better over 3 years. Visual outcomes were predictable with ≥ 95% of eyes achieving a SE correction within ± 1D of attempted correction over 3 years. There was a mild regression in SE refraction over 3 years with a mean of − 0.10 ± 0.45 D three years post-operatively (p = 0.03). The safety index was > 1.05 at 3 years follow-up. There were no significant post-operative complications though 24 eyes had mild haze and 2 eyes had grade 1 diffuse lamellar keratitis that resolved within 1 month.Conclusion: Our 3-year LASIK Xtra results show favorable safety, efficacy, predictability and stability outcomes in Asian patients with high myopia.Keywords: LASIK Xtra, refractive surgery, cross-linking

Pump Controlled Retrograde Trial Off (PCRTO) is a relatively new technique in trialing-off Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO). Literature on the use of PCRTO in children remains scarce. We describe our centre's initial experience with PCRTO in a neonate and an older child and review its potential advantages and disadvantages compared to traditional weaning methods. More research and shared best practices are required in children to facilitate wider adoption of this technique., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background : Chest radiography is the standard method for detecting rib fractures. Our study aims to develop an artificial intelligence (AI) model that, with only a relatively small amount of training data, can identify rib fractures on chest radiographs and accurately mark their precise locations, thereby achieving a diagnostic accuracy comparable to that of medical professionals. Methods : For this retrospective study, we developed an AI model using 540 chest radiographs (270 normal and 270 with rib fractures) labeled for use with Detectron2 which incorporates a faster region-based convolutional neural network (R-CNN) enhanced with a feature pyramid network (FPN). The model's ability to classify radiographs and detect rib fractures was assessed. Furthermore, we compared the model's performance to that of 12 physicians, including six board-certified anesthesiologists and six residents, through an observer performance test. Results : Regarding the radiographic classification performance of the AI model, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were 0.87, 0.83, and 0.89, respectively. In terms of rib fracture detection performance, the sensitivity, false-positive rate, and free-response receiver operating characteristic (JAFROC) figure of merit (FOM) were 0.62, 0.3, and 0.76, respectively. The AI model showed no statistically significant difference in the observer performance test compared to 11 of 12 and 10 of 12 physicians, respectively. Conclusions : We developed an AI model trained on a limited dataset that demonstrated a rib fracture classification and detection performance comparable to that of an experienced physician.

Background and Objectives : Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods : This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results : The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions : EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Objectives: Augmented reality (AR) navigation systems are emerging to simplify and enhance the precision of medical procedures. Lumbosacral transforaminal epidural injection is a commonly performed procedure for the treatment and diagnosis of radiculopathy. Accurate needle placement while avoiding critical structures remains a challenge. For this purpose, we conducted a randomized controlled trial for our augmented reality navigation system. Methods: This randomized controlled study involved 28 patients, split between a traditional C-arm guided group (control) and an AR navigation guided group (AR-NAVI), to compare procedure efficiency and radiation exposure. The AR-NAVI group used a real-time tracking system displaying spinal structure and needle position on an AR head-mounted display. The procedural time and C-arm usage (radiation exposure) were measured. Results: All patients underwent successful procedures without complications. The AR-NAVI group demonstrated significantly reduced times and C-arm usage for needle entry to the target point (58.57 ± 33.31 vs. 124.91 ± 41.14, p < 0.001 and 3.79 ± 1.97 vs. 8.86 ± 3.94, p < 0.001). Conclusions: The use of the AR navigation system significantly improved procedure efficiency and safety by reducing time and radiation exposure, suggesting a promising direction for future enhancements and validation.

Knee osteoarthritis (KOA) is a prevalent common cause of disability and pain among adults. Transcutaneous radiofrequency (RF) diathermy and therapeutic ultrasound (US) are commonly employed treatments for addressing musculoskeletal conditions. This study aims to evaluate and compare the clinical effectiveness of transcutaneous 4.4 MHz RF diathermy and therapeutic US therapy in individuals diagnosed with KOA. A total of 108 patients with KOA were randomly assigned to either the RF or US groups. Each participant underwent a series of 10 treatment sessions over four weeks and was evaluated at different time points. The assessments included physical evaluations, vital sign measurements, the Numeric Rating Scale (NRS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the Lequesne index, gait analysis, the 36-Item Short Form Health Survey (SF-36), and analysis of adverse responses. Both groups showed significant differences in NRS, WOMAC scores, and Lequesne index compared to baseline values at both the 10th treatment session and the one-month follow-up assessment. However, no significant disparities were observed between the two groups at each assessment point. In the gait analysis, following the 10th treatment, the RF group showed significant changes in stride length and stride velocity compared to baseline. Four weeks after the completion of treatment, both groups exhibited significant alterations in stride length and stride velocity when compared to baseline measurements. However, regarding cadence, only the RF group exhibited a significant difference compared to baseline. The findings suggest that transcutaneous 4.4 MHz RF diathermy displays a comparable effectiveness to therapeutic US in reducing pain and enhancing functional capacity among individuals with KOA. Further research endeavors are warranted to advance the efficacy of noninvasive treatments for KOA.

Background: Refractory angina pectoris (RAP) is a chronic, severe chest pain associated with coronary artery disease that cannot be resolved using optimal medical or surgical approaches. Spinal cord stimulation (SCS) is a suitable treatment option. Conventional waveforms of SCS have shown a potent effect on the tempering of RAP. However, SCS is associated with undesired paresthesia. The new burst SCS waveforms have been reported to have fewer adverse effects., Case: We reviewed a case in which RAP was successfully treated with burst SCS in a middle-aged male, with a tonic waveform employed for breakthrough pain as needed., Conclusions: Appropriate use of tonic and burst stimulations according to the symptoms is expected to maximize the effect of relieving chest pain induced by RAP.

Background: Since the onset of the coronavirus disease 2019 pandemic, virtual simulation has emerged as an alternative to traditional teaching methods as it can be employed within the recently established contact-minimizing guidelines. This prospective education study aimed to develop a virtual reality simulator for a lumbar transforaminal epidural block (LTFEB) and demonstrate its efficacy., Methods: We developed a virtual reality simulator using patient image data processing, virtual X-ray generation, spatial registration, and virtual reality technology. For a realistic virtual environment, a procedure room, surgical table, C-arm, and monitor were created. Using the virtual C-arm, the X-ray images of the patient's anatomy, the needle, and indicator were obtained in real-time. After the simulation, the trainees could receive feedback by adjusting the visibility of structures such as skin and bones. The training of LTFEB using the simulator was evaluated using 20 inexperienced trainees. The trainees' procedural time, rating score, number of C-arm taken, and overall satisfaction were recorded as primary outcomes., Results: The group using the simulator showed a higher global rating score (P = 0.014), reduced procedural time (P = 0.025), reduced number of C-arm uses (P = 0.001), and higher overall satisfaction score (P = 0.007)., Conclusions: We created an accessible and effective virtual reality simulator that can be used to teach inexperienced trainees LTFEB without radiation exposure. The results of this study indicate that the proposed simulator will prove to be a useful aid for teaching LTFEB.

Background: In a costoclavicular (CC) approach of an ultrasound (US)-guided infraclavicular brachial plexus block (BPB), a septum between the lateral and the medial/posterior cords can result in an incomplete block. We hypothesized that double injections in each compartment between the septum would result in a higher success rate of BPB than a single injection in the center of the CC space., Objectives: This study was conducted to confirm the superiority of block quality achieved by septum-based double injections (experimental group; group E) over single injection in the center of the CC space (control group; group C)., Study Design: A randomized, controlled trialSETTING: Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital., Methods: Sixty-eight patients who underwent upper extremity surgery randomly received a single (SI group, n = 34) or a septum-based double injection (DI group, n = 34) using the CC approach. Ten milliliters of 2% lidocaine, 10 mL of 0.75% ropivacaine, and 5 mL of normal saline were used for BPB in each group (total 25 mL). Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at 5-minute intervals for 30 minutes immediately after local anesthesia administration. The assessed variables were the success rate, the rate of all 4 nerves blockade, and onset time., Results: Thirty minutes after the block, the success rate was significantly higher in the DI group than in the SI group (64.7% in the SI group vs 91.2% in the DI group, P = 0.009), and the rate of all 4 nerves blockade also significantly increased in the DI group compared to the SI group (44.1% in the SI group vs 91.2% in the DI group, P = 0). The onset time was significantly shortened in the DI group compared with the SI group (26.3 ± 5.6 min in the SI group vs 21.3 ± 6.2 min in the DI group, P = 0.010)., Limitations: We considered that the location of the septum was always between the lateral cord superficially and the medial/posterior cords below it. In some patients in whom the septum was not visible, a superficial lateral cord was injected first, and then deep medial and posterior cords were injected, assuming that the 2 compartments were divided by the septum., Conclusions: Compared with the SI, the septum-based DI of CC approach increased the success rate and the rate of all 4 nerves blockade and shortened the onset time.

Background: Most pain management techniques for challenging procedures are still performed under the guidance of the C-arm fluoroscope although it is sometimes difficult for even experienced clinicians to understand the modified three-dimensional anatomy as a two-dimensional X-ray image. To overcome these difficulties, the development of a virtual simulator may be helpful. Therefore, in this study, the authors developed a virtual simulator and presented its clinical application cases., Methods: We developed a computer program to simulate the actual environment of the procedure. Computed tomography (CT) Digital Imaging and Communications in Medicine (DICOM) data were used for the simulations. Virtual needle placement was simulated at the most appropriate position for a successful block. Using a virtual C-arm, the authors searched for the position of the C-arm at which the needle was visualized as a point. The positional relationships between the anatomy of the patient and the needle were identified., Results: For the simulations, the CT DICOM data of patients who visited the outpatient clinic was used. When the patients revisited the clinic, images similar to the simulated images were obtained by manipulating the C-arm. Transforaminal epidural injection, which was difficult to perform due to severe spinal deformity, and the challenging procedures of the superior hypogastric plexus block and Gasserian ganglion block, were successfully performed with the help of the simulation., Conclusions: We created a pre-procedural virtual simulation and demonstrated its successful application in patients who are expected to undergo challenging procedures.

The objective of this study was to compare facial temperatures and the visual analogue scale (VAS) between the drip method and the topical method of transnasal sphenopalatine ganglion block (SPGB). The transnasal SPGB is administered to patients with facial or head and neck pain. In the transnasal approach, the drip and topical methods are frequently used. We compared facial temperatures and VAS after transnasal SPGB. Medical records of 74 patients who visited the pain clinic and underwent transnasal SPGB were retrospectively reviewed. A total of 156 transnasal SPGB were performed. The patients were divided into the drip-method and topical-method groups. Facial temperatures were measured in six areas of the right and left forehead, maxilla, and mandible before and 30 min after completion of the transnasal SPGB. Temperatures were compared before and 30 min after SPGB in each group and between the two groups. VAS scores were compared at the same times of SPGB in each group and between the two groups. In the drip-method group, there were significant increases at four areas of the face in temperature changes at 30 min after SPGB. In the topical-method group, there was no significant difference in the temperature changes at 30 min after SPGB. There were statistically significant differences in the facial temperature changes between the two groups in the right forehead (p = 0.001), left forehead (p = 0.015), and right maxillary area (p = 0.046). In herpes zoster, there were statistically significant differences in the VAS scores between before and 30 min after SPGB in both groups (p < 0.001, p = 0.008) and between two groups (p < 0.001). In migraine, there were statistically significant differences in VAS scores between before and 30 min after SPGB in both groups (p < 0.001, p = 0.004) and between two groups (p = 0.014). Transnasal SPGB using two methods showed different temperature changes and VAS scores.

Objective: Technological developments have made it possible to create simulation models to educate clinicians on surgical techniques and patient preparation. In this study, we created an inexpensive lumbar spine phantom using patient data and analyzed its usefulness in clinical education., Methods: This randomized comparative study used computed tomography and magnetic resonance imaging data from a single patient to print a three-dimensional (3D) bone framework and create a mold. The printed bones and structures made from the mold were placed in a simulation model that was used to train residents. The residents were divided into two groups: Group L, which received only an audiovisual lecture, and Group P, which received an additional 1 hour of training using the 3D phantom. The performance of both groups was evaluated using pretest and post-test analyses., Results: Both the checklist and global rating scores increased after training in both groups. However, some variables improved significantly only in Group P. The overall satisfaction score was also higher in Group P than in Group L., Conclusions: We have described a method by which medical doctors can create a spine simulation phantom and have demonstrated its efficiency for procedural education.

Patient-controlled epidural analgesia is widely used to control postoperative pain following major intra-abdominal surgeries. However, determining the optimal infusion dose that can produce effective analgesia while reducing side effects remains a task to be solved. Postoperative pain and adverse effects between variable-rate feedback infusion (VFIM group, n = 36) and conventional fixed-rate basal infusion (CFIM group, n = 36) of fentanyl/ropivacaine-based patient-controlled epidural analgesia were evaluated. In the CFIM group, the basal infusion rate was fixed (5 mL/h), whereas, in the VFIM group, the basal infusion rate was increased by 0.5 mL/h each time a bolus dose was administered and decreased by 0.3 mL/h when a bolus dose was not administered for 2 h. Patients in the VFIM group experienced significantly less pain at one to six hours after surgery than those in the CFIM group. Further, the number of patients who suffered from postoperative nausea was significantly lower in the VFIM group than in the CFIM group until six hours after surgery. The variable-rate feedback infusion mode of patient-controlled epidural analgesia may provide better analgesia accompanied with significantly less nausea in the early postoperative period than the conventional fixed-rate basal infusion mode following open gastrectomy.

Background: The KT Challenge program supports health care professionals to effectively implement evidence-based practices. Unlike other knowledge translation (KT) programs, this program is grounded in capacity building, focuses on health care professionals (HCPs), and uses a multi-component intervention. This study presents the evaluation of the KT Challenge program to assess the impact on uptake, KT capacity, and practice change., Methods: The evaluation used a mixed-methods retrospective pre-post design involving surveys and review of documents such as teams' final reports. Online surveys collecting both quantitative and qualitative data were deployed at four time points (after both workshops, 6 months into implementation, and at the end of the 2-year funded projects) to measure KT capacity (knowledge, skills, and confidence) and impact on practice change. Qualitative data was analyzed using a general inductive approach and quantitative data was analyzed using non-parametric statistics., Results: Participants reported statistically significant increases in knowledge and confidence across both workshops, at the 6-month mark of their projects, and at the end of their projects. In addition, at the 6-month check-in, practitioners reported statistically significant improvements in their ability to implement practice changes. In the first cohort of the program, of the teams who were able to complete their projects, half were able to show demonstrable practice changes., Conclusions: The KT Challenge was successful in improving the capacity of HCPs to implement evidence-based practice changes and has begun to show demonstrable improvements in a number of practice areas. The program is relevant to a variety of HCPs working in diverse practice settings and is relatively inexpensive to implement. Like all practice improvement programs in health care settings, a number of challenges emerged stemming from the high turnover of staff and the limited capacity of some practitioners to take on anything beyond direct patient care. Efforts to address these challenges have been added to subsequent cohorts of the program and ongoing evaluation will examine if they are successful. The KT Challenge program has continued to garner great interest among practitioners, even in the midst of dealing with the COVID-19 pandemic, and shows promise for organizations looking for better ways to mobilize knowledge to improve patient care and empower staff. This study contributes to the implementation science literature by providing a description and evaluation of a new model for embedding KT practice skills in health care settings., (© 2021. The Author(s).)

Background & Aims: The association between nutritional status at pediatric intensive care unit (PICU) admission with clinical outcomes remains unclear. We conducted this systematic review to summarize the overall impact of PICU admission body mass index (BMI) on clinical outcomes., Methods: We searched the following medical databases from inception through May 2020: PubMed, Excerpta Medica database (Embase), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Web of Science. We included studies on patients ≤18 years old admitted to a PICU that investigated the effect of BMI on mortality, PICU or hospital length of stay (LOS), or duration of mechanical ventilation (MV). Classification of underweight, overweight, and obese were based on each study's criteria., Results: There was a total of 21,558 patients from 20 included studies. 12,936 (60.0%), 2965 (13.8%), 2182 (10.1%), 3348 (15.5%) were normal weight, underweight, overweight, and obese patients, respectively. Relative to normal weight patients, underweight (OR 1.32, 95% CI 0.89-1.98; p = 0.171) and overweight/obese patients (OR 1.10, 95% CI 0.86-1.42; p = 0.446) did not have an increase risk in mortality. There was also no difference in duration of MV, PICU and hospital LOS between all three weight categories. Included studies were heterogeneous and lacked standardized nutritional categorization. Sensitivity analysis including only studies that used BMI z-scores as nutritional classification (n = 5) revealed that underweight patients had higher odds of mortality compared to patients with normal weight (OR 1.61, 95% CI 1.35-1.92; p < 0.001); studies that used percentiles as classification did not reveal any differences in mortality. Sensitivity analysis including only studies containing mixed PICU cohorts (i.e., excluding specialized cohorts e.g., congenital heart surgeries, burns) revealed higher mortality odds in underweight patients (OR 1.53, 95% CI 1.25-1.87; p < 0.001) and overweight/obese patients (OR 1.51, 95% CI 1.14-2.01; p = 0.004) relative to normal weight patients., Conclusions: Our systematic review did not reveal any association between PICU admission BMI status and outcomes in critically ill children. Further investigation with standardized nutrition status classification on admission, stratified by patient subgroups, is needed to clarify the association between nutritional status and clinical outcomes of PICU patients., Competing Interests: Conflicts of interest The authors declare no conflict of interest., (Copyright © 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Spinal cord stimulation (SCS) has been used to treat sustained pain that is intractable despite various types of treatment. However, conventional tonic waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or postamputation pain. The pain signal mechanisms of burst waveforms are different to those of conventional tonic waveforms, but few reports have presented the therapeutic potential of burst waveforms for the abovementioned indications. This current case report describes two patients with refractory upper limb pain after SCI and upper limb amputation that were treated with burst waveform SCS. While the patients could not obtain sufficient therapeutic effect with conventional tonic waveforms, the burst waveforms provided better pain reduction with less discomfort. However, further studies are necessary to better clarify the mechanisms and efficacy of burst waveform SCS in patients with intractable pain.

Background: This study aimed to assess the potential efficacy of purified porcine atelocollagen (PAC) for the management of refractory chronic pain due to suspected connective tissue damage., Methods: Patients treated with PAC were retrospectively evaluated. Patients with chronic refractory pain, suspected to have originated from musculoskeletal damage or defects with the evidence of imaging studies were included. Pain intensity, using the 11-point numerical rating scale (NRS), was assessed before the procedure, and 1 month after the last procedure., Results: Eighty-eight patients were finally included for investigation. The mean NRS score was decreased from 5.8 to 4.1 after 1 month of PAC injection ( P < 0.001). No independent factor was reported to be directly related to the decrease in NRS score by more than half., Conclusions: Application of PAC may have potential as a treatment option for refractory chronic musculoskeletal pain. PAC might promote tissue recovery, act as a scaffold for repair, or directly reduce inflammation.

Background: Radiofrequency ablation (RFA) of the articular branches innervating the anterior knee capsule has been studied as a possible alternative to surgery for degenerative arthritis. However, the neurovascular topography of the anterior knee capsule remains unclear., Methods: One leg from each of the 20 formalin-embalmed cadaveric specimens was investigated. Modified ablation points (MAPs) were evaluated for a possible alternative for conventional target points (CAPs)., Results: For the nerve to vastus medialis (NVM), the probability of identifying the nerve was higher at MAP compared with CAP (62.5% vs. 25%). The mean shortest distance from the nerve was shorter at MAP compared with CAP (18.0 mm vs. 29.9 mm). The probabilities and distances for other nerves were not significantly different between the points. However, the probability of identifying the artery was significantly lower at MAPs compared with CAPs for arteries (0%, 5.3%, and 0% vs. 84.2%, 84.2%, and 73.3% for superior medial genicular, superior lateral genicular, and inferior medial genicular artery, respectively). For the recurrent peroneal nerve (RPN), a new target point was set in MAPs., Conclusions: The current landmark for genicular nerve procedures may not accurately target the correct nerve position, or reduce the risk for vessel damage. A more proximal target may reduce complications and increase the probability of successful procedures, although clinical correlation is needed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: This study aimed to identify alterations in pharmacokinetics in children on extracorporeal membrane oxygenation (ECMO), identify knowledge gaps, and inform future pharmacology studies. Data Sources: We systematically searched the databases MEDLINE, CINAHL, and Embase from earliest publication until November 2018 using a controlled vocabulary and keywords related to "ECMO" and "pharmacokinetics," "pharmacology," "drug disposition," "dosing," and "pediatrics." Study Selection: Inclusion criteria were as follows: study population aged <18 years, supported on ECMO for any indications, received any medications while on ECMO, and reported pharmacokinetic data. Data Extraction: Clearance and/or volume of distribution values were extracted from included studies. Data Synthesis: Forty-one studies (total patients = 574) evaluating 23 drugs met the inclusion criteria. The most common drugs studied were antimicrobials ( n = 13) and anticonvulsants ( n = 3). Twenty-eight studies (68%) were conducted in children <1 year of age. Thirty-three studies (80%) were conducted without intra-study comparisons to non-ECMO controls. Increase in volume of distribution attributable to ECMO was demonstrated for nine (56%) drugs: cefotaxime, gentamicin, piperacillin/tazobactam, fluconazole, micafungin, levetiracetam, clonidine, midazolam, and sildenafil (range: 23-345% increase relative to non-ECMO controls), which may suggest the need for higher initial dosing. Decreased volume of distribution was reported for two drugs: acyclovir and ribavirin (50 and 69%, respectively). Decreased clearance was reported for gentamicin, ticarcillin/clavulanate, bumetanide, and ranitidine (range: 26-95% decrease relative to non-ECMO controls). Increased clearance was reported for caspofungin, micafungin, clonidine, midazolam, morphine, and sildenafil (range: 25-455% increase relative to non-ECMO controls). Conclusions: There were substantial pharmacokinetic alterations in 70% of drugs studied in children on ECMO. However, studies evaluating pharmacokinetic changes of many drug classes and those that allow direct comparisons between ECMO and non-ECMO patients are still lacking. Systematic evaluations of pharmacokinetic alterations of drugs on ECMO that incorporate multidrug opportunistic trials, physiologically based pharmacokinetic modeling, and other methods are necessary for definitive dose recommendations. Trial Registration Prospero Identifier : CRD42019114881., (Copyright © 2020 Sutiman, Koh, Watt, Hornik, Murphy, Chan and Lee.)

Study Objective: To evaluate the influence of reversal of neuromuscular blockade with sugammadex or neostigmine on postoperative quality of recovery following a single bolus dose of rocuronium after pars plana vitrectomy (PPV) under general anesthesia., Design: Prospective, double-blind, randomized controlled trial., Setting: This study was conducted in a University Teaching Hospital from February to July 2017., Patients: A total of 84 patients with an American Society of Anesthesiologists physical status of I or II who were scheduled to undergo PPV under general anesthesia., Interventions: The patients were randomly assigned to the neostigmine (Group N, n = 44) or sugammadex (Group S, n = 40) groups; 3 ml of study drug was prepared for the patients. For patients in Group N, a solution of neostigmine methylsulfate (1 mg) and glycopyrrolate (0.2 mg) was prepared, while a solution of sugammadex sodium (2 mg/kg) and normal saline was prepared for patients in Group S., Measurements: The primary endpoint was the effect of sugammadex, compared with neostigmine, on the recovery rate in the physiological domain in patients who underwent PPV with general anesthesia. The quality of recovery was assessed using the Postoperative Quality Recovery Scale at 15 min and 40 min after surgery, and on postoperative day 1., Main Results: The recovery rate in the physiological domain was higher in Group S at 15 min after surgery (P = 0.020). Though there were no significant differences in the overall cognitive recovery domain, patients in Group S could recall more numbers in reverse order. However, there were no significant differences between the groups in the other domains of the scale., Conclusions: The use of sugammadex may increase the quality of physiological recovery at early postoperative periods, compared with that of neostigmine, following a single bolus dose of rocuronium in patients undergoing PPV with general anesthesia., Trial Registration: Registered at ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03108989). Registration number: NCT03108989., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Outcome in severe acute necrotizing encephalopathy of childhood is poor, with high mortality (30%) and moderate to severe disability in survivors despite the use of intravenous corticosteroids or immunoglobulins. Increased blood interleukin 6 level correlates with poor outcome., Methods: We report the early use of tocilizumab, a monoclonal antibody against the interleukin 6 receptor, in three patients (aged five, eight, and 10 years) with severe acute necrotizing encephalopathy., Results: All three patients experienced a rapid neurological deterioration associated with febrile viral illnesses and met criteria for severe acute necrotizing encephalopathy with a high risk for death or severe disability. Intravenous methylprednisolone and tocilizumab were administered at 18 to 32 hours of encephalopathy in addition to supportive medical therapy. No side effects were observed with this therapeutic strategy. The two patients with influenza A(H1N1)pdm09 virus-related acute necrotizing encephalopathy had a short illness with excellent clinical and radiological recovery. The patient with influenza B virus-related acute necrotizing encephalopathy and florid hemorrhagic brain lesions had a slow recovery with eventual mild disability despite focal encephalomalacia on follow-up neuroimaging., Conclusions: The early use of interleukin 6 blockade in acute necrotizing encephalopathy is safe and may have a role in improving outcomes and preventing disability., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Osteoarthritis (OA) is considered to be one of the most disabling diseases. The intra-articular opioid injection has been widely studied for its simplicity, safety, and efficacy in OA. In this study, however, we suggest a novel method of buprenorphine transdermal patch (BTDP) to painful knee joints of OA patients, instead of intra-articular opioid injection, and subsequently compared the knee application with conventional chest application. We retrospectively enrolled 213 patients with knee OA who did not respond to conventional therapy. The Numeric Rating Scale (NRS), adverse effects, and compliance were recorded before and after the application of the BTDP. All parameters were compared between the knee applied group and the chest applied group. After the BTDP application, the NRS score in the knee applied group was lower than that of the chest applied group ( p = 0.007). NRS scores after buprenorphine patch decreased to 2.21 ± 0.77, and 2.55 ± 0.71 in the chest applied group and the knee applied group, respectively. The adverse effects were 19.32% in the knee applied group, and 64.00% in the chest applied group. The compliances were 82.95% and 37.60% in the knee applied group and chest applied group, respectively. This novel application of BTDP directly to the painful knee joint of knee OA patients led to a decrease in the NRS score, adverse effects, and an increase in compliance compared with the chest application method.

Objective: Pneumoperitoneum and the head-up position reportedly stimulate the sympathetic nervous system, potentially increasing the risk of cardiac arrhythmia. We evaluated the effects of a long duration of pneumoperitoneum in the head-up position on the heart rate-corrected QT (QTc) interval during robotic gastrectomy., Methods: This prospective observational study involved 28 patients undergoing robotic gastrectomy. The QTc interval was recorded at the following time points: before anaesthetic induction (baseline); 10 minutes after tracheal intubation; 1, 5, 30, 60, and 90 minutes after pneumoperitoneum induction in the head-up position; after pneumoperitoneum desufflation in the supine position; and at the end of surgery. The primary outcome was the QTc interval, which was measured 90 minutes after pneumoperitoneum combined with the head-up position., Results: Compared with baseline, the QTc interval was significantly prolonged at 1 and 60 minutes after pneumoperitoneum, peaked at 90 minutes, and was sustained and notably prolonged until the end of surgery. However, no considerable haemodynamic changes developed., Conclusion: A long period of carbon dioxide pneumoperitoneum application in a head-up position significantly prolonged the QTc interval during robotic gastrectomy. Therefore, diligent care and close monitoring are required for patients who are susceptible to developing ventricular arrhythmia. Trial Registration: Registered at ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT02604979 ; Registration number NCT02604979.

Background: Propofol is a rapid, efficient hypnotic agent with antiemetic effects. However, a high dosage is related to hemodynamic abnormalities such as hypotension and bradycardia. Pretreatment with remifentanil can decrease injection pain and stabilize hemodynamics during the induction period. Remifentanil or midazolam in combination with propofol can provide synergistic or additive effects during anesthesia induction. However, the hypnotic doses of propofol required in patients who receive pretreatment with remifentanil or midazolam remain unclear., Methods: Patients aged 20 to 50 years who were scheduled to undergo surgery under general anesthesia were enrolled in this study. The patients were randomized into 3 groups using a computer-generated randomization table. Patients in Group P (Propofol) received only propofol for loss of consciousness, those in Group PR (Propofol-Remifentanil) received remifentanil prior to propofol, and those in Group PMR (Propofol-Midazolam-Remifentanil) received remifentanil and midazolam prior to propofol. After propofol administration, loss of both the eyelash reflex and verbal response represented success. The 95% effective dose of propofol for loss of consciousness in each group, which was the primary outcome, was determined using a modified biased coin up-and-down method., Results: A total of 124 patients were initially enrolled. Of these, 4 were excluded, and the remaining 120 patients were randomized to each (n = 40) of the 3 groups. The 95% effective dose of propofol for loss of consciousness was 1.74 , 1.38, and 0.92 mg/kg in Groups P, PR, and PMR, respectively. Blood pressure decreased at 2 minutes after propofol administration in all the groups. However, compared with Group P, Groups PR and PMR exhibited a significant decrease in blood pressure., Conclusions: The effective dose of propofol for loss of consciousness could be decreased by 21% and 47% when remifentanil pretreatment was used without and with midazolam, respectively. However, the decrease in blood pressure was greater with pretreatment than sole propofol use. These findings suggest that the combination of remifentanil with or without midazolam may have no benefit on hemodynamic stability during induction using propofol., Trial Registration: NCT02536690 (clinicaltrials.gov).

Background: To achieve a prolonged therapeutic effect in patients with lumbar facet joint syndrome, radiofrequency medial branch neurotomy (RF-MB) is commonly performed. The purpose of this study was to evaluate the prognostic value of paravertebral muscle twitching when performing RF-MB in patients with lumbar facet joint syndrome., Methods: We collected and analyzed data from 68 patients with confirmed facet joint syndrome. Sensory stimulation was performed at 50 Hz with a 0.5 V cut-off value. Patients were divided into 3 groups according to the twitching of the paravertebral muscle during 2 Hz motor stimulation: 'Complete', when twitching was observed at all needles; 'Partial', when twitching was present at 1 or 2 needles; and 'None', when no twitching was observed. The relationship between the long-term effects of RF-MB and paravertebral muscle twitching was analyzed., Results: The mean effect duration of RF-MB was 4.6, 5.8, and 7.0 months in the None, Partial, and Complete groups, respectively ( P = 0.47). Although the mean effect duration of RF-MB did not increase significantly in proportion to the paravertebral muscle twitching, the Complete group had prolonged effect duration (> 6 months) than the None group in subgroup analysis. ( P = 0.03)., Conclusions: Paravertebral muscle twitching while performing lumbar RF-MB may be a reliable predictor of long-term efficacy when sensory provocation under 0.5 V is achieved. However, further investigation may be necessary for clarifying its clinical significance.

Background: The Spurling test, although a highly specific provocative test of the cervical spine in cervical radiculopathy (CR), has low to moderate sensitivity. Thus, we introduced the neck tornado test (NTT) to examine the neck and the cervical spine in CR., Objectives: The aim of this study was to introduce a new provocative test, the NTT, and compare the diagnostic accuracy with a widely accepted provocative test, the Spurling test., Design: Retrospective study., Methods: Medical records of 135 subjects with neck pain (CR, n = 67; without CR, n = 68) who had undergone cervical spine magnetic resonance imaging and been referred to the pain clinic between September 2014 and August 2015 were reviewed. Both the Spurling test and NTT were performed in all patients by expert examiners. Sensitivity, specificity, and accuracy were compared for both the Spurling test and the NTT., Results: The sensitivity of the Spurling test and the NTT was 55.22% and 85.07% ( P < 0.0001); specificity, 98.53% and 86.76% ( P = 0.0026); accuracy, 77.04% and 85.93% ( P = 0.0423), respectively., Conclusions: The NTT is more sensitive with superior diagnostic accuracy for CR diagnosed by magnetic resonance imaging than the Spurling test., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Background: The aim of this study was to investigate the optimal exhaled sevoflurane concentration that produces adequate endotracheal intubation conditions when sevoflurane is combined with the different bolus doses of remifentanil used in clinical practice., Methods: The patients were randomized to 3 groups (groups 1.0, 1.5, and 2.0), receiving remifentanil bolus doses of 1.0, 1.5, and 2.0 μg/kg, respectively. For each group, the concentration of sevoflurane used for each consecutive patient was increased or decreased using the "up-and-down" method based on the success or failure to achieve adequate conditions for intubation in the previous patient. The remifentanil bolus dose was administered 90 s before intubation and after the target sevoflurane concentration was achieved., Results: In groups 1.0, 1.5, and 2.0, the effective concentration in 50% (EC50) of the sevoflurane concentration required to perform successful intubation was 3.0, 2.0, and 1.29 vol% and the effective concentration in 95% was 3.45, 2.91, and 1.89 vol%, respectively. When sevoflurane was administered for the induction, the increase in heart rate (HR) of group 1.0 was the highest among the groups. The highest number of adverse events occurred in group 2.0, including vocal cord rigidity, hypotension, and bradycardia., Discussion: The EC50 of the sevoflurane concentration was 3.0, 2.0, and 1.29 vol% when it was combined with a bolus dose of remifentanil of 1.0, 1.5, and 2.0 μg/kg, respectively. Of the 3 different bolus doses of remifentanil, the dose of 1.5 μg/kg was least associated with changes in the HR/mean blood pressure during intubation without increasing adverse effects.

The incidence of obesity is increasing in Asia, with implications on gastrointestinal (GI) and liver diseases. The Gut and Obesity in Asia Workgroup comprises regional experts with the aim of studying relationship between obesity and the GI and liver diseases in Asia. Through literature review and the modified Delphi process, consensus statements examining the impact of obesity on esophageal, gastric, pancreatic, colorectal, and liver diseases, exploring relationship between gut microbiome and obesity, and assessing obesity therapies have been produced by the Gut and Obesity in Asia Workgroup. Sixteen experts participated with 9/15 statements having strong consensus (>80% agreement). The prevalence of obesity in Asia is increasing (100% percentage agreement in brackets), and this increased prevalence of obesity will result in a greater burden of obesity-related GI and liver diseases (93.8%). There was consensus that obesity increases the risk of gastric cancer (75%) and colorectal neoplasia (87.5%). Obesity was also associated with Barrett's esophagus and esophageal adenocarcinoma (66.7%) and pancreatic cancer (66.7%) in Asia. The prevalence of non-alcoholic fatty liver disease (NAFLD) in Asia is on the rise (100%), and the risk of NAFLD in Asia (100%) is increased by obesity. Obesity is a risk factor for the development of hepatocellular carcinoma (93.8%). Regarding therapy, it was agreed that bariatric surgery was an effective treatment modality for obesity (93.8%) but there was less agreement on its benefit for NAFLD (62.5%). These experts' consensus on obesity and GI diseases in Asia forms the basis for further research, and its translation into addressing this emerging issue., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Two stilbenes, resveratrol and pterostilbene, exhibit antifungal activity against Leptosphaeria maculans, the fungal pathogen responsible for blackleg (stem canker) in canola (Brassica napus). In vitro studies on the effect of these stilbenes on L. maculans mycelial growth and conidia germination showed that pterostilbene is a potent fungicide and sporicide, but resveratrol only exerted minor inhibition on L. maculans. Cell viability of hyphae cultures was markedly reduced by pterostilbene and SYTOX green staining showed that cell membrane integrity was compromised. We demonstrate that pterostilbene exerts fungicidal activity across 10 different L. maculans isolates and the compound confers protection to the blackleg-susceptible canola cv. Westar seedlings. The potential of pterostilbene as a control agent against blackleg in canola is discussed.

Intraperitoneal insufflation of carbon dioxide may affect the sympathetic activity that leads to changes in ventricular repolarization. This in turn can result in changes of heart rate-corrected QT (QTc) interval and Tpeak-Tend (Tp-e) interval. Dexmedetomidine is a highly selective α2-receptor agonist and has potential antiarrhythmic properties. This prospective, randomized, double-blinded, controlled study evaluated the effects of dexmedetomidine administration on QTc and Tp-e intervals during robot-assisted laparoscopic prostatectomy with steep Trendelenburg position.Fifty patients scheduled for robot-assisted laparoscopic prostatectomy randomly received either a continuous infusion of dexmedetomidine at a rate of 0.3 μg/kg/hour, from anesthetic induction until the end of the Trendelenburg position (dexmedetomidine group; n = 25), or the same volume of normal saline (control group; n = 25). Anesthesia was maintained with sevoflurane and remifentanil. The primary and secondary goals were to evaluate the effect of dexmedetomidine on the QTc and Tp-e interval changes. Mean arterial pressure, heart rate, end-tidal CO2, and end-tidal sevoflurane concentrations were assessed as well.Forty-seven patients (94%) completed the study. Dexmedetomidine significantly attenuated QTc interval prolongation and reduced the Tp-e interval, even though the baseline values of the QTc and Tp-e intervals were similar between the 2 groups (PGroup × Time = 0.001 and 0.014, respectively). Twenty-two patients (96%) in the control group and 13 (54%) in the dexmedetomidine group had QTc interval prolongation of >20 ms from the baseline value during surgery (P = 0.001). The maximum QTc interval prolongation from the baseline value during surgery was 46 ± 21 ms in the control group and 24 ± 21 ms in the dexmedetomidine group (mean ± SD, P = 0.001). Mean arterial pressure and heart rate were comparable between the groups.Continuous infusion of dexmedetomidine at a rate of 0.3 μg/kg/hour significantly attenuated the QTc interval prolongation induced by CO2 pneumoperitoneum with steep Trendelenburg position. Furthermore, dexmedetomidine reduced the Tp-e interval. Thus, dexmedetomidine administration may be effective for patients who are susceptible to the development of ventricular arrhythmia during robot-assisted laparoscopic prostatectomy.

Background: The location and the number of lumbar sympathetic ganglia (LSG) vary between individuals. The aim of this study was to determine the appropriate level for a lumbar sympathetic ganglion block (LSGB), corresponding to the level at which the LSG principally aggregate., Methods: Seventy-four consecutive subjects, including 31 women and 31 men, underwent LSGB either on the left (n = 31) or the right side (n = 43). The primary site of needle entry was randomly selected at the L3 or L4 vertebra. A total of less than 1 ml of radio opaque dye with 4% lidocaine was injected, taking caution not to traverse beyond the level of one vertebral body. The procedure was considered responsive when the skin temperature increased by more than 1℃ within 5 minutes., Results: The median responsive level was significantly different between the left (lower third of the L4 body) and right (lower margin of the L3 body) sides (P = 0.021). However, there was no significant difference in the values between men and women. The overall median responsive level was the upper third of the L4 body. The mean responsive level did not correlate with height or BMI. There were no complications on short-term follow-up., Conclusions: Selection of the primary target in the left lower third of the L4 vertebral body and the right lower margin of the L3 vertebral body may reduce the number of needle insertions and the volume of agents used in conventional or neurolytic LSGB and radiofrequency thermocoagulation.

Barriers to dietitians' participation in research include lack of time, self-perceived competence, confidence, administrative support, and funding. Providence Health Care, a multi-site health care organization in Vancouver, British Columbia implemented the Practice-based Research Challenge (RC), a 1-year research program, to support interdisciplinary teams of nurses and allied health professionals to conduct practice-relevant research projects. Funding, mentoring, and research education were provided to research teams. From 2011 to 2015, 37% of all dietitians in the organization were involved in the RC in 4 cohorts of the 1-year program. An online survey was conducted to understand these dietitians' interest and experience in the RC. The survey results indicated that the major reasons for participating in the program were to increase knowledge, improve patient care, and to work on a project of interest. Respondents thought they gained knowledge, enhanced professional development, and improved patient care. A majority stated they would likely conduct future research. The RC enabled and supported dietitians' participation in research; infrastructure supports for research and enabling a culture of research participation are key contributors to promoting dietitians involvement in research.

Background and Aims. Endoscopic submucosal dissection (ESD) outcomes have traditionally been reported from high volume centers in East Asia. Data from low volume centers in other parts of Asia remain sparse. Methods. A retrospective survey with a structured questionnaire of 5 tertiary centers in 3 countries in South East Asia was conducted. Details of training and clinical outcomes of ESD cases, with follow-up data from these centers, were analyzed. Results. Seven endoscopists from the 5 centers performed a total of 35 cases of ESD in the upper gastrointestinal tract (UGIT) over a 6-year duration. Details of the lesions excised were as follows: median size was 20 mm, morphologically 20 (68.6%) were flat/depressed and 6 (17.1%) were submucosal, and histologically 27 (77.1%) were neoplastic. The median duration of ESD procedures was 105 minutes, with an en-bloc resection rate of 91.4%. There was 1 (2.9%) case of delayed bleeding, but no perforation nor mortality in any of the cases. The recurrence rate after ESD was 5.7%. A prolonged ESD duration was influenced by a larger size of lesion (25 mm, p = 0.02) but not by factors related to the training experience of endoscopists. Conclusions. ESD in the UGIT is feasible and safe in low volume centers in Asia., Competing Interests: The authors declare that there is no conflict of interests regarding the publication of this paper.

The Professional Development Network (PDN) program was implemented to enhance mentoring and learning opportunities for dietitians at a multisite health care organization. Program development, implementation, and evaluation were carried out by a Professional Practice Council composed of dietitians in the organization. An exploratory evaluation was conducted after the first year of PDN implementation. Evaluation data were collected from an online survey containing open- and closed-ended questions and PDN documents submitted by dietitians. Data were analyzed with descriptive statistics and thematic analysis. Survey results indicate the PDN provided a mechanism for dietitians to learn from each other, apply learning to their career development, reflect on their strengths, and connect with others in the department. Analysis of PDN documents showed that dietitians pursued learning related to clinical practice, technology, private practice, and research. Mentoring interactions were also described by participants within PDN documents. Findings from this study demonstrate how multiple frameworks from academic literature can be integrated to create a professional development program in a dietetics practice environment. Evaluation results from this study may provide useful insights for others interested in implementing professional development programming.

In this retrospective analysis of 10,575 patients who used fentanyl-based intravenous patient-controlled analgesia (IV-PCA) after surgery, we evaluated difference between young and elderly patients on their characteristic of adverse effects.We reviewed the data collected from the patients who were provided IV-PCA for pain control following elective surgery under either general or spinal anesthesia between September 2010 and March 2014. Postoperative pain, incidence of PCA-related adverse effects, and risk factors for the need of rescue analgesics and antiemetics for postoperative 48 hours were analyzed.Pain intensity (numerical rating scale [NRS]) at postoperative 6 to 12 hours (4.68 vs 4.58, P < 0.01) and incidence of nausea or vomiting (23.8% vs 20.6%, P < 0.001) were higher in young patients, while incidence of PCA discontinuation (9.9% vs 11.5%, P < 0.01) and sedation (0.1% vs 0.7%, P < 0.001) was higher in elderly patients. Despite larger fentanyl dose used, a greater proportion of young patients required rescue analgesics (53.8% vs 47.9%, P < 0.001) while addition of ketorolac was effective in reducing postoperative pain. Despite lower incidence of postoperative nausea and vomiting (PONV), a larger proportion of elderly patients required rescue antiemetics (10.1% vs 12.2%, P < 0.001) while addition of ramosetron was effective in reducing PONV.In conclusion, when fentanyl-based IV-PCA is used for postoperative pain control, a larger proportion of young patients may require rescue analgesics while elderly patients may require more rescue antiemetics. The addition of ketorolac or ramosetron to the PCA of young and elderly patients can be effective to prevent rescue analgesics or antiemetics use.

Purpose: To describe the transition and outcomes of 3 refractive lenticule extraction (ReLEx) techniques: femtosecond lenticule extraction (FLEx), small-incision lenticule extraction (SMILE), and pseudo small-incision lenticule extraction., Setting: Singapore National Eye Center, Singapore., Design: Prospective comparative case series., Methods: Refractive lenticule extraction was performed between March 1, 2010, and November 1, 2012, using the Visumax 500 kHz femtosecond laser system. The main outcome measures were the refractive efficacy, predictability, and safety over 12 months., Results: The study enrolled 88 eyes. All 3 refractive lenticule extraction techniques yielded good refractive outcomes and stability over 12 months. Three months postoperatively, the mean overall efficacy index of refractive lenticule extraction was 0.89±0.22 (SD), with 95.5% of eyes attaining an uncorrected distance visual acuity (UDVA) of better than 20/40 and 60.2% of better than 20/20. Of all eyes, 95.5% were within ±1.00 diopter (D) and 78.4% within ±0.50 D of the attempted correction. The mean overall safety index was 1.06±0.17. At 3 months, all small-incision lenticule extraction eyes and 96.7% of pseudo small-incision lenticule extraction eyes had a UDVA of 20/40 or better, while femtosecond lenticule extraction eyes had a lower efficacy index (87.0%). However, efficacy was comparable in all 3 groups by 12 months (mean 0.87±0.04 [standard error of the mean]; P=1.00)., Conclusion: The efficacy, safety, and predictability profiles of the 3 refractive lenticule extraction techniques were good over a 12-month follow-up., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the efficacy, predictability, and safety outcomes of 2 femtosecond laser platforms for flap creation during laser in situ keratomileusis (LASIK) for myopia and myopic astigmatism., Setting: Singapore National Eye Centre, Singapore., Design: Retrospective case review., Methods: In this single-center multisurgeon study, patients had LASIK with flaps created using a Visumax 500 kHz or Intralase 60 kHz femtosecond laser system. Ablation was performed with the Wavelight Allegretto Eye-Q 400 Hz excimer laser in all patients. Preoperative and 3-month postoperative manifest refraction, attempted treatment spherical equivalent (SE), visual acuity, and complications were compared., Results: The 500 kHz femtosecond laser group comprised 381 patients (381 eyes) and the 60 kHz femtosecond laser group, 362 patients (362 eyes). Three months postoperatively, the uncorrected distance visual acuity was 20/40 or better in 99.1% of eyes in the 60 kHz laser group and 99.4% of eyes in the 500 kHz laser group (P=.678). Regarding predictability, 98.6% of eyes and 97.4% of eyes, respectively, were within ± 1.0 diopter of the attempted SE correction postoperatively (P=.228). The safety index was similar in the 60 kHz laser group and the 500 kHz laser group (mean 1.06 ± 0.16 [SD] versus 1.05 ± 0.14) (P=.321)., Conclusion: The safety, predictability, and efficacy profiles of the 500 kHz femtosecond platform for LASIK were excellent and comparable to those of the 60 kHz platform., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Study Design: Prospective study on intraoperative blood loss during lumbar spine surgery., Objective: To evaluate the relationship between airway pressure change due to the patient's prone position and intraoperative blood loss during lumbar spine surgery., Summary of Background Data: A prone position may increase abdominal pressure. Changes in abdominal pressure may influence airway pressure and cause intraoperative blood loss as a result of epidural venous congestion., Methods: Patients undergoing lumbar spine surgery were placed in a prone position after the administration of general anesthesia. Peak airway pressure, plateau pressure, mean blood pressure, and heart rate were measured 5 minutes after anesthesia induction and 15 minutes after being placed in a prone position. Intraoperative blood loss was measured at the end of surgery., Results: Mean peak airway pressure was 13.7 ± 1.8 mm Hg while in a supine position and increased to 15.1 ± 2.5 mm Hg after placement in the prone position (P = 0.002). Plateau pressure was 12.6 ± 2.5 mm Hg while in a supine position and increased to 14.1 ± 1.9 mm Hg after placement in a prone position (P = 0.0002). Intraoperative blood loss was correlated with peak (R2 = 0.405) and plateau (R2 = 0.489) airway pressure changes., Conclusion: Increase in airway pressure resulting from placement into a prone position may predict intraoperative surgical blood loss.

The American Dietetic Association Nutrition Care Process (NCP) is designed to improve patient care and interdisciplinary communication through the consistent use of standardized nutrition language. Supported by Dietitians of Canada, the NCP has been gaining prominence across Canada. In spring 2009, registered dietitians at Providence Health Care, an academic, multisite health care organization in Vancouver, British Columbia, began using the NCP with a focus on nutrition diagnosis. The success of nutrition diagnosis at Providence Health Care has depended on support from the Clinical Nutrition Department leadership, commitment from the NCP champions, regularly scheduled lunch-and-learn sessions, revised nutrition assessment forms with a section for nutrition diagnosis statements, and the Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Audit results from June through August 2010 showed a 92% nutrition diagnosis completion rate for acute-care and long-term care sites within Providence Health Care. Ongoing audits will be used to evaluate the accuracy and quality of nutrition diagnosis statements. This evaluation will allow Providence Health Care dietitians to move forward with nutrition intervention.

Background: For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar., Methods: Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation., Results: The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 ± 20%) than in Group L (6 ± 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups., Conclusions: The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injury.

This randomised, double-blinded, controlled trial was designed to identify the optimal dose of remifentanil for cough suppression without adverse effects during emergence from sevoflurane-remifentanil anaesthesia for thyroidectomy. One hundred and four patients were randomly assigned to maintain target effect-site concentrations of remifentanil at 0 (control group), 1.0 (remifentail 1 group), or 1.5 ng.ml(-1) (remifentanil 1.5 group) during emergence. The incidence of coughing was lower in the remifentanil 1.5 group (31%) than in the control group (74%) or remifentanil 1 group (63%) (p = 0.0004). In addition, the severity of coughing during extubation was lower in the remifentanil 1.5 group (median (IQR [range]) 0 (0-1 [0-1]) than in the control group (1 (0-2 [0-3])) and remifentanil 1 group (1 (0-2 [0-3])) (p = 0.004). Haemodynamic changes were reduced, but emergence time and stay in the post-anaesthesia care unit was prolonged in the remifentanil 1.5 group. Maintaining the remifentanil effect-site concentration at 1.5 ng.ml(-1) during emergence from sevoflurane-remifentanil anaesthesia reduces the incidence and severity of coughing without serious adverse events and may provide haemodynamic stability in patients undergoing thyroidectomy. However, awakening may be delayed., (© 2010 The Authors. Journal compilation © 2010 The Association of Anaesthetists of Great Britain and Ireland.)

Nutrition resources in Chinese have been developed for the patients in St. Paul's Hospital's Renal Program. The goal was to support this patient subgroup to understand and practice the complicated diet guidelines within their own language and cultural contexts.