The document discusses a presentation on the best medical papers of 2015. It summarizes 5 influential papers, including studies on preoperative sedation with lorazepam, supplemental oxygen therapy for normoxic STEMI patients, and the efficacy of chlorhexidine-alcohol versus iodine-alcohol for preventing catheter-related infections.
My talk in April 2015 Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
My talk in April 2015 Malaysia on Best Practices and Resuscitation Workflow. The new 2015 resuscitation guidelines is expected to be released in Oct 2015.
A presentation by Malin Johnsson Fagerlund at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Aim: The aim of the present study was to perform the set of standard autonomic function
tests in children with a family history of hypertension and compare the results with
children of normotensive parents.
Background: Hypertension is considered one of the highest causes of morbidity
worldwide and it becomes one of the leading causes of death due to cardiovascular and
renal failure. Hypertension can be especially hard to manage when combined with other
disorders, such as diabetes or obesity. Most of the children with a family history of
hypertension forms the risk factor for being hypertensive in future life.
Results: The study included 60 young and healthy children. Out of them, 30 children were
selected based on their family history of hypertension while the remaining were the
children of normotensive parents. Thesubjects were selected based on exclusion-inclusion
criteria. All the children underwent for a set of autonomic function tests which are noninvasive, simple and comfortable. Results showed that children with a family history of
hypertension have abnormal values on autonomicfunction testing, when compared with
children of normotensive parents. The results were obtained using ANOVA and student‘t’
–test, to study the significance of autonomic parameters.
Conclusion: This study stated that the children with family history of hypertension
experienced mild to moderate autonomic fluctuations in early age which may make them
more susceptible to hypertension in their future life
I performed a presentation to the board of directors in Labib Medical Center on the Early Warning Score with a view to introducing this tool which has been standardised across centers in the UK. The evidence states that this tool reduces mortality and morbidity rates and also reduces admissions into Intensive Care Unit.
A presentation by Malin Johnsson Fagerlund at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Aim: The aim of the present study was to perform the set of standard autonomic function
tests in children with a family history of hypertension and compare the results with
children of normotensive parents.
Background: Hypertension is considered one of the highest causes of morbidity
worldwide and it becomes one of the leading causes of death due to cardiovascular and
renal failure. Hypertension can be especially hard to manage when combined with other
disorders, such as diabetes or obesity. Most of the children with a family history of
hypertension forms the risk factor for being hypertensive in future life.
Results: The study included 60 young and healthy children. Out of them, 30 children were
selected based on their family history of hypertension while the remaining were the
children of normotensive parents. Thesubjects were selected based on exclusion-inclusion
criteria. All the children underwent for a set of autonomic function tests which are noninvasive, simple and comfortable. Results showed that children with a family history of
hypertension have abnormal values on autonomicfunction testing, when compared with
children of normotensive parents. The results were obtained using ANOVA and student‘t’
–test, to study the significance of autonomic parameters.
Conclusion: This study stated that the children with family history of hypertension
experienced mild to moderate autonomic fluctuations in early age which may make them
more susceptible to hypertension in their future life
I performed a presentation to the board of directors in Labib Medical Center on the Early Warning Score with a view to introducing this tool which has been standardised across centers in the UK. The evidence states that this tool reduces mortality and morbidity rates and also reduces admissions into Intensive Care Unit.
Caudal Anaesthesia for CTEV with Post-Op Analgesia in Paediatric Patient- A C...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Background: Neck flexion by head elevation using an 8 to 10 cm thick pillow and head extension has been suggested to
align the laryngeal, pharyngeal and oral axis and facilitate tracheal intubation. Presently, the laryngeal view and discomfort
for tracheal intubation were evaluated according to two different degrees of head elevation in adult patients.
Methods: This prospective randomized, controlled study included 50 adult patients aged 18 to 90 years. After induction
of anesthesia, the Cormack Lehane grade was evaluated in 25 patients using a direct laryngoscope while the patient’s head
was elevated with a 4 cm pillow (4 cm group) and then an 8 cm pillow (8 cm group). In the other 25 patients, the grades
were evaluated in the opposite sequence and tracheal intubation was performed. The success rate and anesthesiologist’s
discomfort score for tracheal intubation, and laryngeal, pharyngeal and oral axes were assessed.
Results: There were no differences in the laryngeal view and success rate for tracheal intubation between the two groups.
The discomfort score during tracheal intubation was higher in the 8 cm group when the patient’s head was elevated 4 cm
first and then 8 cm. The alignment of laryngeal, pharyngeal and oral axes were not different between the two degrees of
head elevation.
Conclusions: A pillow of 8 cm height did not improve laryngeal view and alignment of airway axes but increased the anesthesiologist
discomfort, compared to a pillow of 4 cm height, during tracheal intubation in adult patients.
Key Words: Airway management, Intratracheal intubation, Laryngoscope, Vocal cords.
Marketing Excellence Case Study - ElectroluxAakash Goyal
This is a presentation on the basis of a case study against a Internship Program of Management by IIM Lucknow.
Here we have to thoroughly study about the company read about it and explain the case study by telling like a story "The Managers of the Futures will be Storytellers"
Transitions of Care (OR-PACU) - Aalap Shah , MDAalap Shah
An update regarding our initiative to improve the post-operative transtion of care for patients after surgery at Harborview Medical Center in Seattle, WA
STROBE (Strengthening The Reporting of OBservational Studies in Ep.docxsusanschei
STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Checklist
Direction: The following is a checklist of items that should be included in reports of observational studies. Use this checklist to evaluate the article by Olotu et al. Give an explanation of whether or not a particular criterion is missing in the article and the page number where a criterion is reported in the article. Do NOT write your name anywhere on the document.
Section and Item
Recommendation
Present?
Explanation
Reported on article
Page #
TITLE AND ABSTRACT
Indicated the study’s design with a commonly used term in the title or the abstract?
☐yes
☐ no
☐n/a
Provided in the abstract an informative and balanced summary of what was done and what was found?
☐yes
☐ no
☐n/a
INTRODUCTION
Background/rationale
Explained the scientific background and rationale for the investigation being reported?
☐yes
☐ no
☐n/a
Objectives
Stated specific objectives, including any pre-specified hypotheses?
☐yes
☐ no
☐n/a
METHODS
Study design
Presented key elements of study design early in the paper?
☐yes
☐ no
☐n/a
ORIGINAL RESEARCH ARTICLE
Use of Statins and the Risk of Incident Diabetes: A Retrospective
Cohort Study
Busuyi S. Olotu1,2,3 • Marvin D. Shepherd2 • Suzanne Novak2,3 • Kenneth A. Lawson2 •
James P. Wilson2 • Kristin M. Richards2 • Rafia S. Rasu1
� Springer International Publishing Switzerland 2016
Abstract
Introduction Even though several landmark statin trials
have demonstrated the beneficial effects of statin therapy
in both primary and secondary prevention of cardiovas-
cular disease, several studies have suggested that statins
are associated with a moderate increase in risk of new-
onset diabetes. These observations prompted the US
FDA to revise statin labels to include a warning of an
increased risk of incident diabetes mellitus as a result of
increases in glycosylated hemoglobin (HbA1c) and fast-
ing plasma glucose. However, few studies have used US-
based data to investigate this statin-associated increased
risk of diabetes.
Objective The primary objective of our study was to
examine whether the use of statins increases the risk of
incident diabetes mellitus using data from the Thomson
Reuters MarketScan
�
Commercial Claims and Encounters
Database.
Method This study was a retrospective cohort analysis
utilizing data for the period 2003–2004. The study popu-
lation included new statin users aged 20–63 years at index
who did not have a history of diabetes.
Results The proportion (3.4 %) of statin users
(N = 53,212) who had incident diabetes was higher
than the proportion (1.2 %) of non-statin users
(N = 53,212) who had incident diabetes. Compared
with no statin use and controlling for demographic and
clinical covariates, statin use was significantly associ-
ated with increased risk of incident diabetes (hazard
ratio 2.01; 99 % confidence interval 1.74–2.33;
p \ 0.0001). In addition, risk of diabetes was highest
amo.
GOLD Reports 2018
2018 GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD
Evidence-based strategy document for COPD diagnosis, management, and prevention, with citations from the scientific literature.
Interventions to reduce unplanned hospital admission, a study from NHS Bristo...Emergency Live
This review represents one of the most comprehensive sources of evidence on interventions for unplanned hospital admissions. There was evidence that education/self-management, exercise/rehabilitation and telemedicine in selected patient populations, and specialist heart failure interventions can help reduce unplanned admissions. However, the evidence to date suggests that majority of the remaining interventions included in these reviews do not help reduce unplanned admissions in a wide range of patients.
Effect of tobacco control policies on perinatal and child health: What's the ...Health Evidence™
Health Evidence™ hosted a 60 minute webinar examining the effect of tobacco control policies on perinatal and child health. Click here for access to the audio recording for this webinar: https://youtu.be/pPXVfmJuLX0
Dr. Jasper Been, Consultant Neonatologist at the Erasmus University MC-Sophia Children’s Hospital and Honorary Research Fellow in the Centre for Medical Informatics at the University of Edinburgh led the session and presented findings from their recent systematic review and meta-analysis:
Faber T, Kumar A, Mackenbach J, Millett C, Basu S, Sheikh A, & Been JV. (2017). Effect of tobacco control policies on perinatal and child health: A systematic review and meta-analysis. The Lancet Public Health, 2(9), e420-e437.
Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. This review examines the effect of tobacco control policies on perinatal and child health. Forty-one studies were included in the review. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth, rates of hospital attendance for asthma exacerbations and rates of hospital attendance for all respiratory tract infections and for lower respiratory tract infections. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. These findings provide strong support for implementation of such policies comprehensively across the world.
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
ACLS 2015 Updates - The Malaysian PerspectiveChew Keng Sheng
This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. WAS
February
27,
2016
Best Papers of 2015
Alana M. Flexman, MD FRCPC
Clinical Assistant Professor
Department of Anesthesiology and Perioperative Care
Vancouver General Hospital
University of British Columbia
Whistler Anesthesiology Summit
February 27, 2016
2. WAS
February
27,
2016
Disclosures
• Research
grants:
² Canadian
Anesthesiologists’
Society
² Hospira,
Inc
² Masimo,
Inc
• Honoraria
² Hospira,
Inc
3. WAS
February
27,
2016
Paper
selecGon
• Clinical
Focus
• General
Appeal
• Past
12
months
• 5
papers
selected
Objec&ve:
To
review
influen&al
publica&ons
from
the
past
year
4. WAS
February
27,
2016
Survey says…
Premedication with lorazepam results in
which of the following:
A. Improved patient satisfaction
B. Similar time to extubation
C. Reduced intraoperative hypotension
D. Slower recovery of early cognition
5. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
6. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
To assess the efficacy of preoperative
sedation in influencing a patient’s
perioperative experience
7. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
N=1062 randomized
Elective surgery, GA
N=354
Lorazepam
2.5 mg
N=354
No Premed
N=354
Placebo
Primary Outcome: Patient Satisfaction (EVAN-G)
Secondary Outcomes: PQRS, cooperation, anxiety, pain,
well-being, quality of sleep & recover, time to extubation
8. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
Lorazepam No
premed
Placebo P-
Value
Overall
satisfaction
72 73 71 0.38
Time to
extubation
17 min 12 min 13 min <0.001
Amnesia 24% 6% 6% <0.001
Anxiety in
OR (VAS)
35 38 44 0.001*
Pain
satisfaction
68 66 53 0.01
9. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
10. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
• Sedation with lorazepam did NOT improve
self-reported patient experience the day of
surgery
• But reduced anxiety on arrival to OR
• Sedation was associated with 4 min
prolongation of extubation time and lower
rate of early cognitive recovery
11. WAS
February
27,
2016
Szamburski
et
al
Szamburski
et
al,
JAMA
2015;
313:
916-‐925.
Rou&ne
premedica&on
with
lorazepam
12. WAS
February
27,
2016
Survey says…
In the management of acute STEMI,
providing supplemental oxygen to normoxic
patients results in:
A. Worse patient outcomes
B. No effect on patient outcomes
C. Improved patient outcomes
13. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
14. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
• AMA: : no clear recommendation
• 90% receive supplemental oxygen
Beasley
et
al,
J
R
Soc
Med
2007;100:130-‐133.
15. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
Compare supplemental oxygen therapy with
no oxygen therapy in normoxic patients with
STEMI to determine its effect on myocardial
infarct size
16. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
Primary
Outcome:
Myocardial
injury
(peak
cTnI
&
CK)
Secondary
Outcomes:
ST-‐segment
resoluGon,
mortality,
major
adverse
cardiac
events,
infarct
size
at
6
months
N=470 enrolled, 441 completed
STEMI, SpO2 >94%
Supplemental O2
8 L/min
N=218
No O2 unless SpO2
<94%
N=223
17. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
• 7% of No Oxygen group required O2
• SpO2 higher in Supplemental O2 group
• Baseline characteristics, hemodynamics
and procedures similar
18. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
Outcome Oxygen No Oxygen P-value
Mean peak TnI 57.4 48.0 0.18
Mean peak CK 1948 1543 0.01
Mean infarct size 14.6 10.2 0.06
ST resolution 62% 70% 0.10
Recurrent MI 5.5% 0.9% 0.006
Death 1.8% 4.5% 0.11
Major arrhythmias 40% 31% 0.05
19. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
20. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
• Routine oxygen therapy not
associated with reduction in
symptoms or infarct size
• Routine high-flow oxygen
may be accompanied by
harm
21. WAS
February
27,
2016
Stub et al
Stub
et
al,
CirculaGon
2015;131:2143-‐2150.
Supplemental
O2
in
normoxia
for
STEMI?
(cardiac
ischemia?)
22. WAS
February
27,
2016
Survey says…
Jorgenson
et
al,
JAMA
2014;312(3):269-‐277.
Which of the following is most
effective in reducing intravascular
catheter-associated infections?
A. Chlorhexidine-alcohol
B. Iodine
C. Iodine-alcohol
D. Skin scrubbing before insertion
23. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
24. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
1) To compare the efficacy of chlorhexidine-
alcohol vs providone iodine-alcohol to
prevent short-term catheter-related
infections
2) To determine the effect of skin scrubbing
with antiseptic detergent on catheter
colonisation
25. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
N=2349 enrolled
ICU requiring CVL or arterial line >48h
Iodine-
alcohol &
scrubbing
N=1286
catheters
Iodine-
alcohol & no
scrubbing
N=1326
catheters
Chlorhex-
alcohol &
scrubbing
N=1270
catheters
Chlorhex-
alcohol & no
scrubbing
N=1277
catheters
Primary
Outcome:
Incidence
of
catheter-‐related
infecGons
Secondary
Outcomes:
Incidence
of
catheter
colonisaGon
26. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
• Groups similar with respect to:
• Demographics
• History of immune deficiency/disease
• Metastatic cancer
• Indication for admission
• Type of line inserted
• Operator experience
28. WAS
February
27,
2016
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
NNT 78 catheters in place for a
mean of 8 days to prevent 1
infection
29. WAS
February
27,
2016
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
Less catheter-related blood
infections with chlorhexidine
30. WAS
February
27,
2016
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
No benefit to scrubbing
31. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
• No difference in ICU length of stay or
mortality between the preps
• No difference in incidence of colonisation
with scrubbing
• Higher rate of severe skin reactions with
chlorhexidine-alcohol (3% vs 1%, p=0.0017)
32. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
1 infection=€19583($39346.89)
Chlorhexidine for 78catheters=€227($456.14)
33. WAS
February
27,
2016
Mimoz et al
Mimoz
et
al,
Lancet
2015;386:2069-‐2077.
• Chlorhexidine-alcohol combination should
now be standard of skin preparation
before major intravascular catheter
insertion
• Scrubbing of the skin with detergent
should not be standard
34. WAS
February
27,
2016
Pollack
et
al
Pollack
et
al,
NEJM
2015;
373:
511-‐20.
Chlorhexidine-‐
alcohol
✔
35. WAS
February
27,
2016
Survey says…
Which of the following is NOT associated with
increased perioperative mortality:
A. Age > 65 years
B. Case start after 4:00pm
C. ASA physical status > 3
D. Male gender
E. Age <1 year
36. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
37. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
• Predictors of postoperative mortality
across broad surgical populations unclear
• National Anesthesia Clinical Outcomes
Registry (NACOR)
38. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
To identify factors associated with
perioperative mortality using the
NACOR dataset
39. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
Entire NACOR Dataset
18 487 093
Outcome eligible
2 948 842 cases
Missing data
17383 cases
Obstetric
65318 cases
Final Dataset
2 866 141
cases
No outcome
15 538 251 cases
40. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
Predictor
variables:
PracGce/facility
type
PaGent
factors
(age,
sex,
ASA)
Emergency/elecGve
Procedure
factors
(type)
Anesthesia
factors
(type)
Case
start
Gme
and
duraGon
Primary
Outcome:
Death
within
48
hours
of
inducGon
41. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
Predictor
variables:
PracGce/facility
type
PaGent
factors
(age,
sex,
ASA)
Emergency/elecGve
Procedure
factors
(type)
Anesthesia
factors
(type)
Case
start
Gme
and
duraGon
Primary
Outcome:
Death
within
48
hours
of
inducGon
Multivariate regression
42. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
Predictor
variables:
PracGce/facility
type
PaGent
factors
(age,
sex,
ASA)
Emergency/elecGve
Procedure
factors
(type)
Anesthesia
factors
(type)
Case
start
Gme
and
duraGon
Primary
Outcome:
Death
within
48
hours
of
inducGon
Sensitivity analysesMultivariate regression
43. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
Variables independently associated with mortality
Increasing ASA
Emergency case
Age < 1 year
Age > 65 years
Cases beginning between 4:00pm and 6:59am
44. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
45. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
46. WAS
February
27,
2016
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
• Confirmed association with known
predictors of outcome (e.g. ASA
class, age)
• Increased mortality in cases starting
after 4pm
• Potentially modifiable risk factor NEW
47. WAS
February
27,
2016
Minimize
surgery
aIer
4:00pm?
✔
Whitlock et al
Whitlock
et
al,
Anesthesiology
2015;123:1312-‐1321.
48. WAS
February
27,
2016
Survey says…
In patients with atrial fibrillation, bridging
warfarin with LMW heparin around surgery:
A. Reduces the risk of stroke
B. Increases the risk of bleeding
C. Reduces the risk of DVT/PE
D. Reduces the risk of death
49. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
50. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
51. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
N=1884 randomized
Afib on Warfarin
Bridging
(Dalteparin)
No bridging
(Placebo)
Primary Efficacy Outcome: Arterial thromboembolism
Primary Safety Outcome: Major bleeding
52. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
Patients:
• Mean CHADS2 score: 2.3
• 34% on ASA
• 3.7% on Clopidogrel
• 31% CHF or LV dysfunction
53. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
Outcome
No
Bridging
Bridging
P-‐value
Arterial
thromboembolism
0.4%
0.3%
0.73
(0.01
Non-‐Inf)
Major
Bleeding
1.3%
3.2%
0.005
Death
0.5%
0.4%
0.88
Myocardial
Infarc&on
0.8%
1.6%
0.10
DVT/PE
0%
0.1%
0.25
Minor
Bleeding
12%
20.9%
<0.001
54. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
• Discontinuing warfarin without bridging was
non-inferior to bridging in preventing arterial
thromboembolism
• Bridging led to increased major and minor
bleeding
• No difference in MI, VTE, death
• Net benefit in avoiding bridging
55. WAS
February
27,
2016
DoukeGs
et
al
DoukeGs
et
al,
NEJM
2015;373:823-‐33.
Rou&ne
bridging
for
atrial
fibrilla&on
56. WAS
February
27,
2016
References
1. Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart
J, et al. Effect of sedative premedication on patient experience after
general anesthesia: a randomized clinical trial. JAMA. 2015 Mar 3;313(9):
916-25.
2. Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al. Air
Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation.
2015 Jun 16;131(24):2143-50.
3. Mimoz O, Lucet JC, Kerforne T, Pascal J, Souweine B, Goudet V, et al. Skin
antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol,
with and without skin scrubbing, for prevention of intravascular-catheter-
related infection (CLEAN): an open-label, multicentre, randomised,
controlled, two-by-two factorial trial. Lancet. 2015 Nov 21;386(10008):
2069-77.
4. Whitlock EL, Feiner JR, Chen LL. Perioperative Mortality, 2010 to 2014: A
Retrospective Cohort Study Using the National Anesthesia Clinical
Outcomes Registry. Anesthesiology. 2015 Dec;123(6):1312-21.
5. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al.
Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.
N Engl J Med. 2015 Aug 27;373(9):823-33.