Ketamine for Pediatric Bone Reduction in Emergency Medicine: A Systematic Review and Meta-Analysis of Safety and Efficacy

BackgroundDialysis is a life-sustaining treatment, but many patients suffer symptoms during dialysis and take time to recover. Previous reports have linked recovery time to intra-dialytic hypotension and rapid solute clearances, whereas others have reported an association with psychological factors. As such, we wished to investigate which factors were important in determining symptom self-reporting and delayed recovery times.MethodsWe recorded self-reported patient intra-dialytic symptoms, recovery times along with sessional dialysis prescriptions, blood pressure and urea clearance, and distress thermometer scores to assess psychological factors.FindingsSix hundred twenty-three dialysis patients were studied; 621 treated by haemodiafiltration, 60.8% male, mean age 64.5 ± 16.2 years, and 46.1% diabetic. Almost half (49.6%) reported recovery within 1 h. On multivariate analysis, patient self-reported symptom scores were associated with longer post-dialysis recovery times (odds ratio (OR) 1.61, 95% confidence limits (CL) 1.33–1.95), higher distress thermometer scores (OR 1.3 CL (1.3–1.39), but lower hand grip strength (OR 0.85 CL (0.93–0.94), all p < 0.001, and younger rather than older patients (OR 0.98 CL (0.97–0.99) p = 0.005. We found no association with ultrafiltration rates or weight loss.DiscussionCompared to earlier studies, our patients treated by haemodiafiltration reported fewer symptoms and shorter recovery times. Patients with higher self-reported distress thermometer scores had both longer post-dialysis recovery times and greater dialysis symptom scores. Younger patients reported more dialysis symptoms and longer recovery times than older patients. Future studies investigating patient self-reported recovery times and dialysis-associated symptoms should also consider interventions to reduce patient psychological factors as well as dialysis practices.

Recovery Time, Quality of Life, and Mortality in Hemodialysis Patients: The Dialysis Outcomes and Practice Patterns Study (DOPPS)

Pharmacological agents for procedural sedation and analgesia in patients undergoing gastrointestinal endoscopy: a systematic review and network meta-analysis.

Objective: To verify, through an integrative review, the behavior of lactate in the face of High-Intensity Interval Training (HIIT). Material and method: Specific recommendations for the type of work were followed. Original studies that used HIIT in different populations were used. In order for the discussions to be broader, publication periods were not determined. The studies included in this review were carried out with healthy, trained individuals. Results: Both types of protocol (short and long) result in a significant increase in lactate due to the high metabolic demand. Lactate can provide parameters for the aerobic and anaerobic contribution, as a more significant accumulation of this metabolite can lead to a greater anaerobic contribution. However, in HIIT, recovery time can interfere with lactate accumulation, which predicts the magnitude of the aerobic and/or anaerobic contribution. Shorter recovery times may require greater aerobic contributions, due to insufficient resynthesis of energy (ATP) via the glycolytic pathways. There is a tendency for lactate to accumulate more due to the high anaerobic effect (even with aerobic participation) and the lower removal capacity of this metabolite. On the other hand, a longer recovery time is more conducive to optimizing energy resynthesis via the glycolytic pathway, as there will be more time for this system to re-establish itself (totally or partially) in order to perform a high-intensity stimulus. With regard to lactate, the longer the recovery time, the lower the accumulation, as there is greater removal capacity and less intramuscular imbalance responsible for acidosis. Conclusion: Despite some limitations, this review shows that we can use lactate to determine energy demand. However, it seems that the recovery time between stimuli is a determining factor in energy intake and, consequently, lactate accumulation. In this way, this metabolite can help us understand different HIIT protocols and, therefore, prescribe them for different objectives.

The efficacy of the anaesthetic agents benzocaine, metacaine (MS-222), metomidate, 2-phenoxyethanol, quinaldine and isoeugenol was studied in Atlantic halibut (Hippoglossus hippoglossus). Fish with an average body weight of 33 g were anaesthetized at 8 °C and fish with an average body weight of 1243 g were anaesthetized at 8 and 15 °C. Agents were tested individually and as combination anaesthesia comprising pre-anaesthetic sedation, followed by anaesthesia. Induction and recovery times varied in relation to the body weight and water temperature. Large fish had longer induction times and shorter recovery times, and displayed reduced responsiveness to handling compared with small fish. A higher temperature resulted in shorter induction times, longer recovery times and increased responsiveness to handling. Lower dosages were used for all agents in combination anaesthesia. In small fish, this had no effect on the induction times but resulted in shorter recovery times and reduced responsiveness to handling. In large fish, combination anaesthesia resulted in shorter induction times whereas no uniform trend in recovery times and no differences in responsiveness to handling were observed. Neither individual agents nor combinations blocked all reflex reactions to external stimulation in all fish of any treatment group. MS-222 and benzocaine, used separately or in combination anaesthesia, were the most effective agents in reducing reflex reactions.

360 Safety and Depth of Sedation With Ketamine Alone versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. There was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO 2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.

Many studies have identified factors associated with increased symptom burden and prolonged recovery after pediatric and adolescent concussion. Few have systematically examined the effects of prior concussion on these outcomes in patients with concussion due to any mechanism. An improved understanding of the short- and long-term effects of a multiple concussion history will improve counseling and management of this subgroup of patients. A retrospective review of adolescent and young adult acute concussion patients presenting to the multidisciplinary concussion clinic between 2018 and 2019 was conducted at a single center. Patient demographic data, medical history including prior concussion, initial symptom severity score (SSS), injury mechanisms, and recovery times were collected. Univariate and multivariable analyses were conducted to identify associations of history of prior concussion and patient and injury characteristics with symptom score and recovery time. A total of 266 patients with an average age of 15.4 years (age range 13-27 years) were included. Prior concussion was reported in 35% of patients. The number of prior concussions per patient was not significantly associated with presenting symptom severity, recovery time, or recovery within 28 days. Male sex and sports-related concussion (SRC) were associated with lower presenting SSS and shorter recovery time on univariate but not multivariable analysis. However, compared to non-sport concussion mechanisms, SRC was associated with 2.3 times higher odds of recovery within 28 days (p = 0.04). A history of psychiatric disorders was associated with higher SSS in univariate analysis and longer recovery time in univariate and multivariable analyses. Multivariable log-linear regression also demonstrated 5 times lower odds of recovery within 28 days for those with a psychiatric history. The results of this study demonstrated that an increasing number of prior concussions was associated with a trend toward higher presenting SSS after youth acute concussion but did not show a significant association with recovery time or delayed (> 28 days) recovery. Presence of psychiatric history was found to be significantly associated with longer recovery and lower odds of early (≤ 28 days) recovery. Future prospective, long-term, and systematic study is necessary to determine the optimal counseling and management of adolescent and young adult patients with a history of multiple concussions.

A suitable reclosing time is important to guarantee the reliability of the power supply after a temporary failure in dc transmission lines. The design of the reclosing time mainly depends on the recovery time of the insulation strength. Here, an experimental platform was built that can simulate a real situation using a vertical extension arcing horn based on the post arc plasma dissipation. The entire macroperformance process, voltage and after-current characteristics were analyzed. The recovery times were measured under the conditions of the output current from 10 to 200 A and an initial gap length from 1 to 80 mm. The results show that the after-current can better represent the recovery time. The recovery time is a double-exponential function of the gap length and a power function of the initial current. The longest recovery time is 210 ms when the current is 200 A and the initial gap length is 1 mm, while the shortest recovery time is only 60 ms when the current is 10 A at an initial gap length of 40 mm. The entire process of the macroperformance contains three periods: the arc fuse burst, the transient arc extinction, and the post arc plasma dissipation. The maximum gap length for generating a continuous dc arc via the arc fuse is 0.4 mm when the terminal voltage is 560 V and the minimum current for this dc arc's maintenance is 3.5 A under the condition of the maximum gap length. This article is aiming to provide some references for the reset of the reclosing times used in dc transmission grounding lines.

Human activities and climate change cause abiotic factors to fluctuate through time, sometimes passing thresholds for organismal reproduction and survival. Multiple stressors can independently or interactively impact organisms; however, few studies have examined how they interact when they overlap spatially but occur asynchronously. Fluctuations in salinity have been found in freshwater habitats worldwide. Meanwhile, heatwaves have become more frequent and extreme. High salinity pulses and heatwaves are often decoupled in time but can still collectively impact freshwater zooplankton. The time intervals between them, during which population growth and community recovery could happen, can influence combined effects, but no one has examined these effects. We conducted a mesocosm experiment to examine how different recovery times (0-, 3-, 6-week) between salt treatment and heatwave exposure influence their combined effects. We hypothesized that antagonistic effects would appear when having short recovery time, because previous study found that similar species were affected by the two stressors, but effects would become additive with longer recovery time since fully recovered communities would respond to heatwave similar to undisturbed communities. Our findings showed that, when combined, the two-stressor joint impacts changed from antagonistic to additive with increased recovery time between stressors. Surprisingly, full compositional recovery was not achieved despite a recovery period that was long enough for population growth, suggesting legacy effects from earlier treatment. The recovery was mainly driven by small organisms, such as rotifers and small cladocerans. As a result, communities recovering from previous salt exposure responded differently to heatwaves than undisturbed communities, leading to similar zooplankton communities regardless of the recovery time between stressors. Our research bolsters the understanding and management of multiple-stressor issues by revealing that prior exposure to one stressor has long-lasting impacts on community recovery that can lead to unexpected joint effects of multiple stressors.

The use of botanicals to replace as anaesthetics in fish is gaining momentum in recent years. This study was carried out to determine the efficacy of Nutmeg (Myristica fragrans) as anaesthetics in three life stages of African catfish (Clarias gariepinus). A total of 180 specimens of C. gariepinus were procured from Production Ponds in African Regional Aquaculture Centre, (ARAC), Aluu, and Rivers State of Nigeria. They were exposed to nut Meg extracts at different concentrations of 4.00, 6.00, 8.00, 10.00 and 12.00mg/L. The results obtained indicated a size related responses to nut Meg extracts. The induction time decreased significantly (P&lt;0.05) as the concentrations of the nut Meg extracts increased. The highest induction time (15.08±0.04 min) was recorded in adult fish at 12.00mlL-1. While the lowest (3.18±0.06 min) was recorded in fingerlings at 4.00mlL However, the longest recovery time (11.59±0.06 min) was observed in the adult fish at 12.00 mg/l and the shortest (1.13±0.02) in fingerlings at 4.00mg/l of the nut Meg extracts. The recovery time for all the life stages generally increased as the concentrations of the anaesthetics increased. Also, the recovery times in adult fish were higher at all concentrations; this was closely followed by juvenile fish, while the shortest recovery time was observed in fingerlings in all concentrations of exposure. This trend followed the pattern of typical fish anaesthetics in terms of induction time and recovery time.

Quantifying human muscle strength, endurance and fatigue.

The peak-to-end of the T wave in the limb ECG leads reflects total spatial rather than transmural dispersion of ventricular repolarization in an anthopleurin-A model of prolonged QT interval

Introduction Soft palate muscles are crucial in the maintenance of UA patency. Different contraction tasks have been used to investigate tongue mechanical properties, but not to soft palate muscles. This study aimed to investigate the mechanical consequences of tongue and soft palate muscles fatigue in moderate-severe OSA patients. Methods 12 moderate and 8 severe patients with OSA were enrolled. Measurements include strength, endurance, and fatigue indices. During the soft palate fatiguing protocol, subjects were asked to develop repetitive intra-oral positive pressure during cheek-bulging maneuvers while wearing a mouth piece to keep the jaw opened. Tongue mechanical properties were also assessed using protrusion tasks with similar protocol. Subjects were encouraged to develop sustained maximal bulging pressure or tongue protrusion force for 5 sec every 10 sec until the peak pressure did not reach 85% of baseline maximal pressure for 2 consecutive times. The influence of age and BMI were also investigated. Results The sex, age were not significantly different between the 2 OSA groups. BMI was significantly higher in severe OSA patients (p&amp;lt;0.05). Overall, the tongue maximal voluntary contraction force (MVC), endurance time and total muscle work were respectively positively associated with the ones obtained from the soft palate fatiguing task (rs=0.51, 0.43, 0.66, respectively). The MVC of both tongue and soft palate muscles were positively correlated with BMI in all subjects (rs=0.43, 0.5 respectively). The recovery time from soft palate fatigue was significantly longer in moderate than severe OSA patients (270s ± 192.3s and 120s ± 0, p =0.02). Interestingly, the recovery time was positively correlated with AHI in tongue fatiguing task, while negatively correlated with supine AHI and age in soft palate fatiguing task (p&amp;lt;0.05). In both tasks, MVC was negatively correlated with the endurance time (p&amp;lt;0.05). Conclusion Moderate patients are less likely to recover from soft palate muscle fatigue. A more severe apneic disease is associated with longer recovery time from tongue fatigue, but with shorter recovery time from soft palate fatigue. Our results suggest that alteration in tongue and velopharyngeal muscles function may differ according to the severity of disease. Support SBD from IUCPQ Foundation.

Identifying the ‘Miserable Minority’ Among Pediatric Patients Following Concussion