Clinical Sciences Building Research Articles

Imaging for Transcatheter Tricuspid Annuloplasty Using the K-Clip Device.

HomeCirculation: Cardiovascular ImagingAhead of PrintImaging for Transcatheter Tricuspid Annuloplasty Using the K-Clip Device Free AccessCase ReportPDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBImaging for Transcatheter Tricuspid Annuloplasty Using the K-Clip Device Alex Pui-Wai Lee, MBChB, MD, Yiming Ni, MD and Yat-yin Lam, MBBS, MD Alex Pui-Wai LeeAlex Pui-Wai Lee Correspondence to: Alex Lee, MBChB, MD, Rm 114037, 9/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, 30-32 Ngan Shing St, Shatin, N.T., Hong Kong. Email E-mail Address: [email protected] https://orcid.org/0000-0002-4120-155X Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, China (A.P.L.). Search for more papers by this author , Yiming NiYiming Ni The First Affiliated Hospital, College of Medicine, Zhejiang University, China (Y.N.). Search for more papers by this author and Yat-yin LamYat-yin Lam Hong Kong Asia Heart Center, Hong Kong, China (Y.-y.L.). Search for more papers by this author Originally published8 Feb 2023https://doi.org/10.1161/CIRCIMAGING.122.015033Circulation: Cardiovascular Imaging. 2023;0:e015033FootnotesFor Sources of Funding and Disclosures, see page xxx.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.122.015033.Correspondence to: Alex Lee, MBChB, MD, Rm 114037, 9/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, 30-32 Ngan Shing St, Shatin, N.T., Hong Kong. Email [email protected]edu.hk Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.122.015033PMID: 36752091 Manuscript receivedOctober 28, 2022Manuscript acceptedDecember 23, 2022Originally publishedFebruary 8, 2023 Keywordswomentricuspid valveatrial remodelingatrial fibrillationdilatationPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)EchocardiographyImaging

Hepatic steatosis provides the terroir that promotes the development of cardiovascular risk factors and disease.

1Leeds Institute for Medical Research, University of Leeds, 6.1 Clinical Sciences Building, St. James’s University Hospital, Leeds, UK 2Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA Correspondence Ian A Rowe, Leeds Institute for Medical Research, University of Leeds, 6.1 Clinical Sciences Building, St. James’s University Hospital, Leeds, UK; Email: [email protected]

CORR Insights®: People Have Mixed Reactions to Both Physiological and Psychological Explanations of Disproportionate Pain.

1Research Associate, The University of Melbourne Department of Surgery, Australia S. Bunzli ✉, The University of Melbourne, Department of Surgery, Level 2, Clinical Sciences Building, 29 Regent Street, Melbourne, Victoria 3065, Australia, Email: [email protected] This CORR Insights® is a commentary on the article “People Have Mixed Reactions to Both Physiological and Psychological Explanations of Disproportionate Pain” by Gonzalez and colleagues available at: DOI: 10.1097/CORR.0000000000002163. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Persistent Dyspnea in a Patient with Altered Immune Status

From the ∗University of Melbourne †Fellow of the Royal Australasian College of Physicians ‡Fellow of the Royal College of Pathologists Australasia §Royal Hobart Hospital, Tasmania, Australia. Correspondence to: Kim Yeoh, MBBS, c/o Microbiology Department, Clinical Sciences Building, Level 2, Royal Melbourne Hospital, Grattan St, Parkville, Victoria 3052, Australia. E-mail: [email protected] or [email protected]. The authors have no funding or conflicts of interest to disclose.

CORR Insights®: What Do Orthopaedists Believe is Needed for Incorporating Patient-reported Outcome Measures into Clinical Care? A Qualitative Study.

1Research Associate, Department of Surgery, The University of Melbourne, St. Vincent's Hospital, Melbourne, Australia S. Bunzli, The University of Melbourne, Department of Surgery, St. Vincent's Hospital, Level 2, Clinical Sciences Building, 29 Regent Street, Melbourne, Victoria 3065, Australia, Email: [email protected] This CORR Insights® is a commentary on the article “What Do Orthopaedists Believe is Needed for Incorporating Patient-reported Outcome Measures into Clinical Care? A Qualitative Study” by Whitebird and colleagues available at: DOI: 10.1097/CORR.0000000000002059. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Cohort profile: ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden).

The ESPRESSO study constitutes a novel approach to examine the etiology and prognosis of gastrointestinal disease in which histopathology plays a prominent role. Between 2015 and 2017, all pathology departments (n=28) in Sweden were contacted and asked to procure histopathology record data from the gastrointestinal tract (pharynx to anus), liver, gallbladder, and pancreas. For each individual, local histopathology IT personnel retrieved data on personal identity number, date of histopathology, topography (where the biopsy is taken), morphology (biopsy appearance), and where available free text. In total, between 1965 and 2017, histopathology record data were available in 2.1 million unique individuals, but the number of data entries was 6.1 million because more than one biopsy was performed in many of the study participants. Index individuals with histopathology data were matched with up to five controls from the general population. We also identified all first-degree relatives (parents, children, full siblings), and the index individual’s first spouse. The total study population consisted of 13.0 million individuals. Data from all the study participants have been linked to Swedish National Healthcare Registers allowing research not only on such aspects as fetal and perinatal conditions and the risk of future gastrointestinal disease but also on the risk of comorbidity and complications (including cancer and death). Furthermore, the ESPRESSO database allows researchers and practitioners to identify diagnoses and disease phenotypes not currently indexed in national registers (including disease precursors). The ESPRESSO database increases the sensitivity and specificity of already-recorded diseases in the national health registers. This paper is an overview of the ESPRESSO database.

Using student creativity to promote patient-centredness.

Medical EducationVolume 51, Issue 5 p. 535-535 Really Good Stuff: Lessons learned though innovation in medical education Using student creativity to promote patient-centredness Fiona Kelly, Corresponding Author Fiona Kelly f.kelly@griffith.edu.au Correspondence: Fiona Kelly, School of Pharmacy, Griffith University, Clinical Sciences Building (G16), Gold Coast Campus, Gold Coast, Queensland 4222, Australia. Tel: 00 61 7 5552 9743; E-mails: f.kelly@griffith.edu.au, j.townshend@griffith.edu.auSearch for more papers by this authorJames Townshend, Corresponding Author James Townshend j.townshend@griffith.edu.au Correspondence: Fiona Kelly, School of Pharmacy, Griffith University, Clinical Sciences Building (G16), Gold Coast Campus, Gold Coast, Queensland 4222, Australia. Tel: 00 61 7 5552 9743; E-mails: f.kelly@griffith.edu.au, j.townshend@griffith.edu.auSearch for more papers by this author Fiona Kelly, Corresponding Author Fiona Kelly f.kelly@griffith.edu.au Correspondence: Fiona Kelly, School of Pharmacy, Griffith University, Clinical Sciences Building (G16), Gold Coast Campus, Gold Coast, Queensland 4222, Australia. Tel: 00 61 7 5552 9743; E-mails: f.kelly@griffith.edu.au, j.townshend@griffith.edu.auSearch for more papers by this authorJames Townshend, Corresponding Author James Townshend j.townshend@griffith.edu.au Correspondence: Fiona Kelly, School of Pharmacy, Griffith University, Clinical Sciences Building (G16), Gold Coast Campus, Gold Coast, Queensland 4222, Australia. Tel: 00 61 7 5552 9743; E-mails: f.kelly@griffith.edu.au, j.townshend@griffith.edu.auSearch for more papers by this author First published: 10 April 2017 https://doi.org/10.1111/medu.13287Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume51, Issue5May 2017Pages 535-535 RelatedInformation

Chronic kidney disease and the aging population.

aUniversity of Alberta. Alberta, Canada bCatholic University of Parana, Curitiba, Brazil Correspondence to Dr. Marcello Tonelli, University of Alberta, Edmonton, Canada, Dept. of Medicine, Divison of Nephrology 11-107 Clinical Sciences Building, T6G 2G3 Edmonton, Alberta, Canada. Tel: +780 407 8520; e-mail: [email protected]

Keys to minimizing the risk of spinal cord trauma during a lumbar approach to thoracic epidural

Thoracic epidurals provide effective analgesia for thoracic or upper abdominal procedures for both adult and pediatric patients; however, using a thoracic approach to place an epidural catheter is not without risk as it requires needle placement immediately posterior to the spinal cord. Consequently, some clinicians prefer to use a lumbar approach (caudal approach in pediatric cases), or if unsuccessful at a thoracic level, they may thread the epidural catheter cephalad from that point. This issue of the Journal features an interesting study by Gamble et al. in which the authors used a porcine model to address the safety of threading an epidural catheter via a lumbar approach. In their study, the authors show that styletted stimulating thoracic epidural catheters can be advanced in a predictable manner to target thoracic myotomes using a lumbar approach. However, damage to the spinal cord was observed in several animals. It is important to point out that, in humans, such perturbing findings are probably limited to high lumbar approaches (i.e., above L2-L3). This is partly because the human adult spinal cord, unlike the porcine model used in the Gamble et al. study, typically ends at approximately the L1-L2 level. Thus, if needle entry occurs either at or below the L2-L3 level, the risk of direct blunt trauma caused by the initial threading of the catheter from the needle tip is minimized. Nevertheless, the results of Gamble et al.’s study clearly show the risks involved when a catheter is advanced directly towards the spinal cord, as in thoracic and high lumbar approaches. Several key factors influence the risk and potential for spinal cord damage during these approaches, including the angle of catheter insertion, catheter stiffness, and applied force. To address this issue, the relationship between these three factors must be considered. Force must be applied to advance the catheter to its desired target myotome level. This threading force is the total applied force needed to insert the catheter through the Tuohy needle into the epidural space. Threading force itself involves two component forces that must be considered during catheter insertion: a bending force, needed to advance the catheter out of the needle, and a parallel force, needed to thread the catheter cranially past any obstacle within the epidural space (Fig. 1). Assuming there is minimal obstruction along the spinal cord, the initial total threading force is then directly related to the bending force. This is shown in Gamble et al.’s experiment where, in most animals, difficulty was experienced in advancing the catheter beyond the needle tip. The perpendicular angle of insertion used by the authors suggests the need for considerable bending force to advance the catheter out of the needle. Furthermore, the authors speculate that catheter stiffness and the presence of the stylet added to the difficulties in initial catheter advancement. Thus, the bending force required to advance the catheter out of the needle is influenced by two key factors: angulation of the needle and catheter stiffness (i.e., styletted or not). To show this relationship, we used a simple in vitro setup to demonstrate the peak (kilogram) force generated when threading a styletted catheter at various needle angles (Figure). As shown, the peak force increases dramatically as the angulation of the needle approaches 0 (i.e., perpendicular) relative to the surface of the force gauge transducer. With an insertion perpendicular to the plane of the back (i.e., no angulation), these results suggest that the B. C. H. Tsui, MD (&) Department of Anesthesiology and Pain Medicine, University of Alberta, 8-120 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada e-mail: btsui@ualberta.ca

Double-stranded RNA (dsRNA)-induced IP-10/CXCL-10 production is augmented by Fas activation

Event Abstract Back to Event Double-stranded RNA (dsRNA)-induced IP-10/CXCL-10 production is augmented by Fas activation Caitriona Lyons1, Rachael Moran2, Aileen Houston3 and Elizabeth Brint1* 1 University College Cork (UCC), Pathology, Ireland 2 University College Cork, Ireland 3 University College Cork, Medicine, Ireland Viral double-stranded RNA (dsRNA) is recognised by Pathogen Recognition Receptors (PRRs) including RIGI-like Receptors (RLRs) and Toll-Like Receptors (TLRs) and results in cytokine/chemokine production. Fas, a well characterised death receptor, may also mediate inflammation. Our aim was to investigate potential crosstalk between the Fas signalling pathway and anti-viral signalling pathways. THP-1 monocyte-derived macrophages (THP1-Mø’s) were stimulated with poly(I:C) (dsRNA mimetic) +/-agonistic anti-Fas antibody (CH-11). Co-stimulation resulted in a 50% reduction in IL-8, TNFα, IFNβ and IL-10, relative to poly(I:C) alone, as assessed by qRT-PCR. In contrast, IP-10/CXCL-10 production increased by 50% following co-stimulation relative to poly(I:C) alone. Results were confirmed using human monocyte-derived macrophages. Fas-associated death domain (FADD) is recruited to Fas following Fas activation and is required for Fas signalling. Overexpression of FADD inhibited poly(I:C)-induced IP-10 luciferase production, while inhibiting FADD signalling by overexpressing the FADD death-domain augmented poly(I:C)-induced IP-10 luciferase. To further confirm the role of FADD in poly(I:C)-induced IP-10/CXCL-10 production, wild-type and FADD-/-MEFs were treated with increasing doses of poly(I:C). IP-10/CXCL-10 production in FADD-/-MEFs was increased compared to wild-type MEFs. Our results indicate that activation of the Fas signalling pathway, may be necessary for optimal poly(I:C) induced IP-10/CXCL-10 production. As IP-10/CXCL-10 is a potent T-cell chemo-attractant, cross-talk between these pathways may potentially promote the recruitment of T-cells to sites of viral infection. Acknowledgements Science Foundation Ireland (SFI) Dr. Liam Fanning, Molecular Virology, Department of Medicine, Clinical Sciences Building (UCC), Cork University Hospital, Cork, Ireland Keywords: Fas, IP-10, CXCL-10, dsRNA, THP-1 macrophages Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Host-pathogen interactions Citation: Lyons C, Moran R, Houston A and Brint E (2013). Double-stranded RNA (dsRNA)-induced IP-10/CXCL-10 production is augmented by Fas activation. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.00541 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 29 Apr 2013; Published Online: 22 Aug 2013. * Correspondence: Dr. Elizabeth Brint, University College Cork (UCC), Pathology, Cork, Ireland, e.brint@ucc.ie Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Caitriona Lyons Rachael Moran Aileen Houston Elizabeth Brint Google Caitriona Lyons Rachael Moran Aileen Houston Elizabeth Brint Google Scholar Caitriona Lyons Rachael Moran Aileen Houston Elizabeth Brint PubMed Caitriona Lyons Rachael Moran Aileen Houston Elizabeth Brint Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Hepatitis C quasispecies adaptation in the setting of a variable fidelity polymerase

Hepatitis C quasispecies adaptation in the setting of a variable fidelity polymerase Daniel Schmidt-Martin,1 Orla Crosbie,2 Elizabeth Kenny-Walsh,2 Liam J Fanning11Molecular Virology Diagnostic and Research Laboratory, Department of Medicine, University College Cork, Clinical Sciences Building, Cork University Hospital, 2Department of Gastroenterology and Hepatology, Cork, IrelandAbstract: Hepatitis C (HCV) is a virus characterized by an RNA-dependent RNA polymerase that lacks a proofreading mechanism and, as a result, generates a quasispecies. There is emerging evidence that this RNA-dependent RNA polymerase may in fact have variable fidelity. Here, we review the relevant concepts, including fitness landscapes, clonal interference, robustness, selection, adaptation, mutation rates, and their optimization, and provide a unique interpretation of a number of relevant theoretical models, evolving the theory of replicative homeostasis in light of their findings. We suggest that a variable fidelity polymerase can find its own optimal mutation rate, which is governed by the sequence itself and certain population dynamics. We propose that this concept can explain features of viral kinetics and clearance, both spontaneously and following treatment of chronic HCV. We point to evidence that supports this theory and explain how it refines replicative homeostasis and conclude by discussing particular areas of potential research that might augment our understanding of viral host interactions at an individual cellular level.Keywords: fitness landscapes, adaptation, evolution, quasispecies, hepatitis C, replicative homeostasis

Clinical evaluation of a fully implantable hearing device in six patients with mixed and sensorineural hearing loss: Our experience

Clinical OtolaryngologyVolume 37, Issue 3 p. 240-244 CORRESPONDENCE: OUR EXPERIENCE Clinical evaluation of a fully implantable hearing device in six patients with mixed and sensorineural hearing loss: Our experience A.C.S. Kam, A.C.S. Kam Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorJ.K.K. Sung, J.K.K. Sung Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorJ.K.Y. Yu, J.K.Y. Yu Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorM.C.F. Tong, M.C.F. Tong Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this author A.C.S. Kam, A.C.S. Kam Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorJ.K.K. Sung, J.K.K. Sung Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorJ.K.Y. Yu, J.K.Y. Yu Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this authorM.C.F. Tong, M.C.F. Tong Department of Otorhinolaryngology, Head & Neck Surgery, Chinese University of Hong Kong Institute of Human Communicative Research, Chinese University of Hong Kong, Hong Kong, ChinaSearch for more papers by this author First published: 19 June 2012 https://doi.org/10.1111/j.1749-4486.2012.02492.xCitations: 14 M.C.F. Tong, Department of Otorhinolaryngology, Head & Neck Surgery, The Chinese University of Hong Kong, 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China. Tel.: (852) 2632 2633; Fax: (852) 2632 4678; e-mail: mtong@ent.cuhk.edu.hk This paper was presented at the XXXth International Congress of Audiology, Sao Paulo, Brazil, held from 28 March to 1 April 2010 and organised by the International Society of Audiology and the Brazilian Academy of Audiology. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume37, Issue3June 2012Pages 240-244 RelatedInformation

Whiplash: Nothing to Lose Sleep Over

To the Editor: Although Radanov, et al 1 have recently suggested that sleep disturbance may be an important problem in chronic whiplash, we would argue that the etiology of chronic whiplash is nothing to lose sleep over, since we are coming to understand the individual factors that determine who develops chronic pain and who does not2. Radanov, et al have confirmed what has long been known: that the symptoms and/or pattern of symptoms of chronic whiplash are in fact not distinct. Indeed, it was shown as much as a decade ago that there is no distinct symptom pattern for chronic whiplash as assessed by the Symptom Checklist-90-R3, and this tool does not even distinguish between minor head injury and whiplash injury, … Address correspondence to Dr. R. Ferrari, University of Alberta Hospital, Department of Medicine, 13-103 Clinical Sciences Building 11350 — 83 Avenue, Edmonton, Alberta T6G 2P4, Canada. E-mail: rferrari{at}shaw.ca

The importance of angiographic and venographic cranial imaging in intracerebral hemorrhage occurring during pregnancy and the puerperium

European Journal of NeurologyVolume 18, Issue 9 p. e112-e113 LETTER TO THE EDITOR The importance of angiographic and venographic cranial imaging in intracerebral hemorrhage occurring during pregnancy and the puerperium M. A. Kirkman, M. A. Kirkman Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorP. J. Tyrrell, P. J. Tyrrell Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Stroke Medicine, The University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorA. T. King, A. T. King Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this authorH. C. Patel, H. C. Patel Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this author M. A. Kirkman, M. A. Kirkman Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorP. J. Tyrrell, P. J. Tyrrell Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Stroke Medicine, The University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorA. T. King, A. T. King Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this authorH. C. Patel, H. C. Patel Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this author First published: 11 August 2011 https://doi.org/10.1111/j.1468-1331.2011.03463.xCitations: 1 Matthew A. Kirkman, Brain Injury Research Group, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK (tel.: +44 (0) 7886608978; fax: +44 (0) 161 7076534; e-mail: [email protected]). Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume18, Issue9September 2011Pages e112-e113 RelatedInformation

Ultrasound beyond regional anesthesia: formal training?

In this issue of the Journal, Dugani et al. present a case concerning a patient undergoing a caudal block for chronic pain treatment wherein a bowel hernia, inferoposterior to the coccygeal ligament, was found incidentally using fluoroscopy and confirmed with ultrasound. The initial procedure was abandoned, and subsequently, the patient underwent coccygeal hernia repair. In this case, Dugani et al. raise two important issues in both chronic pain management and ultrasound-guided regional anesthesia, namely, ‘‘incidental detection’’ and ‘‘the capability of ultrasound to identify nonneural pathology’’, that are more notable than the authors’ ability to define the pathological condition and modify patient management using ultrasound and fluoroscopy. Undoubtedly, the continuing popularity of ultrasound techniques in regional anesthesia will result in the exposure of anesthesiologists to these issues; in fact, an increasing number of such cases are reported in many journals. However, when it comes to diagnosing pathology using ultrasound, most anesthesiologists lack training and experience. Collaboration with radiologists and formal training in ultrasound are considerations for equipping anesthesiologists to take advantage of the possibilities offered by imaging technologies. In chronic pain management, pain syndromes can be complex and difficult to diagnose. Coccydynia is no exception, presenting with symptoms from discomfort to acute and severe pain, varying between patients, and changing over time. It can occur after falls, childbirth, repetitive strain, or prior surgery. In many cases, the origin of the pain is unclear and the cause unknown. Although a diagnosis of coccydynia often is based solely on the symptoms, other organic causes (e.g., local rashes from shingles) and bone and tissue disorders (fracture) must be ruled out by performing a physical examination, diagnostic imaging, and other appropriate tests. In many cases, this ‘‘incidental detection’’ can be avoided from the outset; however, in this case, could investigations have been performed prior to the caudal injection to prevent the ‘‘on-table’’ incidental finding? Recently, the American College of Physicians and the American Pain Society proposed a joint clinical practice guideline suggesting a focused history and examination is important to identify the nature of the pain and the warning signs for underlying pathologies. Appropriate diagnostic imaging should be considered and reserved for patients with severe or progressive neurologic deficits or in cases where serious underlying conditions are suspected. In the case of Dugani et al., bowel herniation post-coccygectomy is extremely rare, and the symptoms persisting after surgery would not necessarily prompt further investigations prior to intervention, barring a change of symptoms. This case reminds clinicians to conduct appropriate investigations in patients with nonspecific pain prior to committing to an invasive intervention, especially after a surgical procedure. Nevertheless, despite the most thorough history and examination, diagnoses will occasionally be missed, thus opening the window for ‘‘incidental detection’’ in cases where extensive investigations are not indicated. Ultrasound is a challenging imaging modality because it is highly operator-dependent in terms of both acquisition and interpretation of the image. The inherent user-dependent sensitivity and specificity of ultrasound could result in either a false negative (missed diagnosis) or a false positive (misinterpretation of an insignificant lesion). Either of B. C. H. Tsui, MD (&) V. H. Y. Ip, MBChB Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, 8-120 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada e-mail: btsui@ualberta.ca

Lessons of Pandemic Influenza From Sub-Saharan Africa

School of Public Health and Epidemiology University of Nottingham, Nottingham, United Kingdom Correspondence: School of Public Health and Epidemiology, Room A40d Division of Epidemiology and Public Health, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK ([email protected]).

Practical Concepts in Nerve Stimulation

University of Alberta Edmonton, Alberta, Canada Dr Tsui is supported in part by a Clinical Scholar award from the Alberta Heritage Foundation for Medical Research, Edmonton, Alberta, Canada and a CAS–Abbott Laboratories Ltd Career Scientist Award in Anesthesia from Canadian Anesthesiologists' Society. The authors have no conflicts of interest to disclose. Reprints: Ban C. H. Tsui, MSc, MD, FRCPC, Department of Anesthesiology and Pain Medicine, 8-120 Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G3. e-mail: [email protected]

Innover sans toxicité: à la recherche d’un anesthésique local plus sécuritaire

The search for an ‘‘ideal’’ local anesthetic for perioperative anesthesia and analgesia has continued for more than a century. The ideal local anesthetic is an agent with a rapid onset and desirable duration of action that is capable of producing reversible and selective blockade of sensory nerve conduction without risks of local (neurotoxic and myotoxic) or systemic (neurological and cardiovascular) toxicity. Since Koller’s introduction of cocaine as a surgical anesthetic in 1884, several hundred compounds have been tested and found to produce local anesthetic effects. The chemical structures of these agents are diverse and include amino esters (procaine analogues), aminoamides (lidocaine analogues), alcohols (benzyl alcohol), and phenol. However, only a handful of these agents are of clinical value, and the search for the ‘‘ideal’’ local anesthetic continues. For decades, systemic local anesthetic toxicity has received much attention due to the relatively large quantity of local anesthetic administered when performing regional anesthesia. Given the advent of ultrasound-guided regional anesthesia, it is now possible to deposit local anesthetic in close proximity to the desired neurological structure with great precision. Therefore, most regional anesthesia experts are capable of producing successful and desirable effects using substantially reduced quantities of local anesthetic. Furthermore, the ability to visualize the anatomic surroundings in a dynamic manner allows the spread of local anesthetic to take place with a greatly reduced risk of accidental intravascular injection. Although the evidence is still pending, it is likely that this advance in technology holds great promise for reducing the incidence of systemic toxicity. Barrington et al. reported an incidence of systemic anesthetic toxicity to be 0.98 per 1,000 blocks. Our anxiety about the risk of systemic toxicity to local anesthetics has been reduced in recent years by the introduction of the ‘‘lipid sink’’ idea. Prior to this innovation, serious systemic toxic reaction to long-acting local anesthetic drugs was associated with a very poor patient outcome. With the advent of ultrasound-guided regional anesthesia, experts in regional anesthesia have become aware and concerned about the emerging evidence that intraneural injection is a common occurrence during performance of regional anesthesia. In addition, studies have demonstrated that commonly used local anesthetics can cause injury to Schwann cells, disrupt the blood-nerve barrier, decrease neural blood flow with associated ischemia, and disrupt cell membrane integrity. Fortunately, the longterm clinical significance of neurotoxicity without direct needle trauma remains rare. Nevertheless, any drug deposited in the perineural region must be clearly evaluated for its local neurotoxicity. Dextromethorphan has been used as a cough suppressant for decades. Both the parent drug and its metabolite are voltage-dependent sodium channel antagonists, equating them in most ways with local anesthetics. Their local anesthetic properties have been demonstrated in various regional anesthesia techniques, including cutaneous infiltration, peripheral nerve blockade, and intrathecal anesthesia. In this issue of the Journal, Chen et al. undertook an intriguing step to determine and evaluate the systemic toxicity in rodents of dextromethorphan and its metabolite, dextrorphan. After demonstrating the local anesthetic properties of these two agents in their animal models, they administered equipotent doses of these new V. H. Y. Ip, MB B. C. H. Tsui, MD (&) Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, 8-120 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada e-mail: btsui@ualberta.ca

Disability Payments for Persons With Severe Mental Illness in Alberta, Canada

Disability Payments for Persons With Severe Mental Illness in Alberta, Canada

What about the other two-thirds of the cardiac cycle?

Diastolic dysfunction is a relatively new clinical diagnosis being made in patients where the observed echocardiographic findings are deemed to be consistent with abnormalities of left ventricular (LV) filling. Left ventricular filling is dependent on the complex interaction of three processes: LV relaxation, LV compliance, and left atrial (LA) contraction. Left ventricular relaxation is an active process involving the uptake of Ca into the sarcoplasmic reticulum by the sarcoendoplasmic reticulum Ca ATPase pump and removal of Ca from the cell by way of the sodium-calcium exchanger. Sarcoendoplasmic reticulum Ca ATPase pump expression and activity is reduced in the cardiomyocyte (and diastolic function is altered) with the onset of senescence, hypertrophy, and heart failure. Left ventricular compliance is a measure of the relationship between LV volume and LV pressure development during LV filling (dV/dp). Left ventricular compliance is influenced by: 1) the presence of ventricular hypertrophy; 2) the functional state of the right ventricle (direct diastolic ventricular interaction), since both ventricles share the septum as a common wall; and 3) the properties of the pericardium. Abnormal LV compliance is a feature of longstanding poorly-controlled hypertension, right ventricular dysfunction, and pericardial disease. In the presence of abnormal LV relaxation and/or compliance, LA contraction assumes a key role in maintaining LV filling. Under physiological conditions in youthful individuals, atrial contraction contributes approximately 20% of the total filling volume of the LV; whereas, in patients with LV diastolic dysfunction, LA contraction may account for over 50% of LV volume at enddiastole. Absence of LA contraction, as occurs with the development of atrial fibrillation, is a harbinger of heart failure and is a marker of an increased risk of premature death. The occurrence of abnormal LV relaxation and compliance, as a consequence of hypertensive heart disease, is one of the most common determinants of LA enlargement, poor LA contractile function, and LA dysrhythmia development. It is difficult, if not impossible, to individually assess the components of LV filling in humans; however, relatively precise global estimates of diastolic function can be performed following cardiac catheterization. This approach is invasive, time consuming, and not without risk. In reality, both our knowledge of diastolic function in the broader clinical environment and our interest in the topic did not materialize until the introduction of pulse wave Doppler echocardiography. Pulse wave Doppler echocardiography allows the timing and amplitude of the blood flow and tissue velocity profiles within the heart to be ascertained and graphically displayed. Extensive research has determined which blood flow/tissue velocity profile patterns are considered normal and which appear to be characteristic of diastolic dysfunction. The mitral inflow velocity profile, one of the earliest patterns studied, offers a relatively simple example of the deductive reasoning underlying the evolution of Doppler derived diastolic function assessment. Under ‘‘normal’’ circumstances, flow velocity across the mitral valve is biphasic, i.e., greater during early diastole (E wave) than during subsequent atrial contraction (A wave). In the presence of mild diastolic dysfunction associated with impaired ventricular relaxation, the early diastolic passive flow velocity is reduced while the flow velocity associated with atrial contraction is enhanced (reversed E/A ratio). It is clear, however, that many factors B. A. Finegan, MB (&) Department of Anesthesiology and Pain Medicine, University of Alberta, 8-120 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada e-mail: chassist@ualberta.ca