Delayed Recovery Research Articles

The Downside of Upkeep: Analysing Railway Infrastructure Maintenance Impact on Train Operations in Sweden

Efficient and seamless railway operations depend on the systematic and well-coordinated maintenance of both rolling stock and infrastructure. However, track maintenance, or ‘trackwork’, can cause substantial delays if not properly aligned with train schedules. This study comprehensively investigates how trackwork influences train operations in Sweden. It involves an in-depth analysis of an extensive dataset comprising over 225,000 recorded instances of planned trackwork and approximately 32.5 million train passages throughout the year 2017. Multiple logistic and negative binomial regression models showed that train running time delay occurrence is higher in the sections with scheduled trackwork. Trains passing through trackwork are 1.43 times more likely to experience delays compared to trains that do not pass through scheduled trackwork. The likelihood of an opportunity for the train delay recovery passing the section with scheduled trackwork is reduced by 11%. Additionally, the frequency of train delay increase is 16% higher, and delayed recovery is 4% lower in relation to trackwork. With the number of trackwork set to increase over the coming years, these results bring attention to train scheduling and the performance of trackwork.

Four reasons why we should screen for dissociation in competitive sports

Four reasons why we should screen for dissociation in competitive sports

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02–8.33), BUN ≥9 mmol/L (OR 4.05, 1.37–8.41), infusion of red blood cell suspension (OR 3.93, 1.25–7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24–5.20), age ≥6 (OR 3.01, 1.38–6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.

P1860PERIOPERATIVE CHANGES IN PHYSICAL FUNCTION AND ACCELEROMETER-MEASURED PHYSICAL ACTIVITY IN PRE-EMPTIVE OR POST-DIALYSIS KIDNEY TRANSPLANT RECEIPIENTS

Abstract Background and Aims Pre-emptive kidney transplant (PEKT) is known to have better graft survival, and thereby well established as the optimal treatment for end-stage renal disease patients. On the other hand, the delayed recovery of physical function and physical activity after KT reportedly occurs in approximately 20% of KT recipients, which leads to poor prognosis. However, it is less clear whether PEKT delays recovery of them after KT. We aimed to investigate any differences in perioperative changes in physical function and physical activity for PEKT versus non-PEKT. Method Consecutive 34 recipients who had received a living-donor KT from January 2016 to January 2019 were enrolled in this prospective cohort study. Patient characteristics including age, sex, body mass index, primary cause of kidney disease, smoking habits, and comorbidities were collected at baseline. Six-minute walk distance (6MWD), gait speed, isometric leg strength, accelerometer-measured physical activity (number of steps and moderate to vigorous activity time) and kidney function (eGFR) were assessed at before and 2 months after KT. We divided the recipients into 2 groups: PEKT (n=11) and non-PEKT (n=23), and compared outcomes between the 2 groups using ANCOVA adjusted for baseline patient characteristics. This study was approved by institute ethical committee. Results KT successfully improved eGFR of all the study participants from 6.1±4.6 to 35.4±15.3. PEKT group showed significant shorter dialysis duration as compared with non-PEKT group (mean duration: 0 months in PEKT vs 64.8±95.5 months in non-PEKT, P &amp;lt;0.001). The 6MWD significantly improved after KT in the PEKT group, but not in the non-PEKT group as compared with that of baseline (adjusted mean change [95% confidence interval]: 44.7 [8.2 to 81.2] vs. 8.80 [-32.8 to 15.2], P=0.025). We found a tendency toward improvement of gait speed (0.11 [-0.11 to 0.32] vs. -0.15 [-0.29 to -0.01], P=0.065), and moderate-to-vigorous activity time per day (7.19 [-2.84 to 17.23] vs. -5.60 [-12.97 to 1.77], P=0.057) in the PEKT group. Conclusion PEKT recipients showed higher perioperative changes in physical function and physical activity compared to non-PEKT. Our findings suggest that PEKT may have benefits on early recovery of physical function and physical activity after KT.

Clinical examination factors that predict delayed recovery in individuals with concussion

BackgroundRisk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis.MethodsThe study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR.Results80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR.ConclusionsThe clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.

Interleukin-33 delays recovery of mucosal inflammation via downregulation of homeostatic ABCG5/8 in the colon

Previous studies have suggested that interleukin-33 (IL-33) is involved in the pathogenesis of ulcerative colitis (UC), though the detailed mechanisms are not fully known. We investigated IL-33-mediated colonic homeostasis using a mechanistic method. Il33−/− mice were more tolerant to dextran sulfate sodium-induced acute colitis than the wild type and also showed delayed recovery from colitis with recombinant IL-33 (rIL-33) administration. Unexpectedly, microarray analysis identified significant downregulation of the Abcg5/8 genes in mouse colons following rIL-33 treatment. ABCG5/8 are known cholesterol transporters in the small intestine and liver, though their colon activities have not been elucidated, thus their role in IL-33-mediated inflammation was investigated. In vitro, toll-like receptor (TLR) stimulation upregulated ABCG5/8 mRNA expression in Caco2 and HCT-15 cells, with subsequent downregulation by rIL-33, while inhibition of ABCG5/8 along with their siRNA increased TLR-stimulated IL-8 production. Together, these results indicated that colonic ABCG5/8 play a regulatory role in TLR-induced inflammation, while histological inflammation in human UC was correlated positively with the level of mucosal IL-33 and inversely with that of colonic ABCG5/8. This is the first report of IL-33-mediated downregulation of colonic ABCG5/8 in a colitis recovery phase, indicating their involvement in UC pathogenesis and potential as a therapeutic target.

Consumption of the Total Western Diet Promotes Colitis and Inflammation-Associated Colorectal Cancer in Mice.

Consumption of a Western type diet is a known risk factor for colorectal cancer. Our group previously developed the total Western diet (TWD) for rodents with energy and nutrient profiles that emulate a typical Western diet. In this study, we tested the hypothesis that consumption of the TWD would enhance colitis, delay recovery from gut injury and promote colon tumorigenesis. In multiple experiments using the azoxymethane + dextran sodium sulfate or ApcMin/+ mouse models of colitis-associated colorectal carcinogenesis (CAC), we determined that mice fed TWD experienced more severe and more prolonged colitis compared to their counterparts fed the standard AIN93G diet, ultimately leading to markedly enhanced colon tumorigenesis. Additionally, this increased tumor response was attributed to the micronutrient fraction of the TWD, and restoration of calcium and vitamin D to standard amounts ameliorated the tumor-promoting effects of TWD. Finally, exposure to the TWD elicited large scale, dynamic changes in mRNA signatures of colon mucosa associated with interferon (IFN) response, inflammation, innate immunity, adaptive immunity, and antigen processing pathways, among others. Taken together, these observations indicate that consumption of the TWD markedly enhanced colitis, delayed recovery from gut injury, and enhanced colon tumorigenesis likely via extensive changes in expression of immune-related genes in the colon mucosa.

Relationships Between Intraoperative Hemodynamic Parameters and Delayed Hemodynamic Recovery After Valve Deployment in Transcatheter Aortic Valve Replacement

To determine the relationships between intraoperative hemodynamic parameters and delayed hemodynamic recovery after valve deployment and identify the predictive factors of delayed hemodynamic recovery by focusing on intraoperative hemodynamics in patients with transcatheter aortic valve replacement (TAVR). A retrospective study. A single university hospital. Sixty-four patients who underwent elective TAVR between 2015 and 2017. No intervention. The 64 patients were divided into the following 2 groups according to the time for recovery: systolic arterial pressure exceeded 90 mmHg and central venous oxygen saturation (ScvO2) exceeded 65%-delayed recovery (DR) (n = 36) group, and early recovery (ER) (n = 28) group. ScvO2 in the DR group was not lower than that in the ER group after induction of anesthesia. However, ScvO2 in the DR group gradually decreased and was lower than that in the ER group before valve deployment, despite improvement in blood pressure through the administration of vasopressor agents. ScvO2 monitoring during TAVR is useful to predict delayed recovery greater than 60 seconds after valve deployment in TAVR.

Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs

After esophagectomy, some patients exceed targeted discharge goal within enhanced recovery after surgery programs. This study reviews the demographics, outcomes, cost, readmission rates, and patient satisfaction for the accelerated recovery (AR) group. Between 2010 and 2013, 137 consecutive esophagectomy patients were compared according to the length of hospital stay: AR 5 to 6 days, targeted recovery (TR) 7 to 8 days, and delayed recovery (DR) 9 days or more. The AR patients increased from 3% to 46% during the study period. The AR patients were younger, but all groups were comparable regarding comorbidities (Charlson, American Society of Anesthesiologists, and Eastern Cooperative Oncology Group score), cancer stage, and treatment approach. The AR patients were more likely to have neoadjuvant therapy, shorter operations, and less blood loss. The DR patients were more likely to have complications (40% AR versus 45% TR versus 90% DR, p < 0.001). Inhospital and 90-day mortality was 1.5%. All AR patients were discharged home (100% AR versus 87% TR versus 63% DR, p < 0.001), and 30-day readmission rates were comparable between groups (14% AR versus 19% TR versus 5% DR, p= 0.122). Overall mean costs ($38,385 AR versus $41,607 TR versus $61,199 DR, p< 0.001) as well as readmission costs ($7,470 AR versus $27,695 TR versus $33,398 DR, p= 0.202) were lower in the AR group. Patient satisfaction scores were comparable between groups. Accelerated recovery is achievable in a significant proportion of patients undergoing esophagectomy. Accelerated recovery is associated with decreased treatment costs but does not lead to increased readmissions or decreased patient satisfaction. Enhanced recovery after surgery programs should be designed to accommodate patients appropriate for AR.

Egg Yolk Protein Delays Recovery while Ovalbumin Is Useful in Recovery from Iron Deficiency Anemia.

Protein is a main nutrient involved in overall iron metabolism in vivo. In order to assess the prevention of iron deficiency anemia (IDA) by diet, it is necessary to confirm the influence of dietary protein, which coexists with iron, on iron bioavailability. We investigated the usefulness of the egg structural protein in recovery from IDA. Thirty-one female Sprague-Dawley rats were divided into a control group (n = 6) fed a casein diet (4.0 mg Fe/100 g) for 42 days and an IDA model group (n = 25) created by feeding a low-iron casein diet (LI, 0.4 mg Fe/100 g) for 21 days and these IDA rats were fed normal iron diet with different proteins from eggs for another 21 days. The IDA rats were further divided into four subgroups depending on the proteins fed during the last 21 days, which were those with an egg white diet (LI-W, 4.0 mg Fe/100 g, n = 6), those with an ovalbumin diet (LI-A, 4.0 mg Fe/100 g, n = 7), those with an egg yolk-supplemented diet (LI-Y, 4.0 mg Fe/100 g, n = 6), and the rest with a casein diet (LI-C, 4.0 mg Fe/100 g, n = 6). In the LI-Y group, recovery of the hematocrit, hemoglobin, transferrin saturation level and the hepatic iron content were delayed compared to the other groups (p < 0.01, 0.01, 0.01, and 0.05, respectively), resulting in no recovery from IDA at the end of the experimental period. There were no significant differences in blood parameters in the LI-W and LI-A groups compared to the control group. The hepatic iron content of the LI-W and LI-A groups was higher than that of the LI-C group (p < 0.05). We found that egg white protein was useful for recovery from IDA and one of the efficacious components was ovalbumin, while egg yolk protein delayed recovery of IDA. This study demonstrates, therefore, that bioavailability of dietary iron varies depending on the source of dietary protein.

Prospective, Randomized Comparisons of Induction of Anesthesia with Ketamine, Propofol and Sevoflurane for Quality of Recovery from Short Sevoflurane Anesthesia in Pediatric Patients

Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children. When rapid intravenous induction of general anesthesia is indicated in a brief procedure, the induction agent can reduce the incidence of EA after sevoflurane anesthesia. The aim of this study was to compare the efficacy of intravenous induction with ketamine and propofol for reducing EA in children after short sevoflurane anesthesia. Methods: Children aged 2 to 6 years who were scheduled to undergo inguinal hernia repair were randomly divided into 3 groups to receive 2 mg/kg ketamine iv, 3 mg/kg propofol iv, or inspired concentration of 8% sevoflurane for induction of anesthesia. After a laryngeal mask airway (LMA) insertion, a caudal block was performed in all children. Anesthesia was maintained with 1.5% sevoflurane and 65% nitrous oxide in oxygen with spontaneous ventilation. The recovery characteristics were recorded and EA were evaluated by using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Results: One hundred and twenty children were enrolled and randomized to treatment. Children who received ketamine induction had higher incidence of EA than those who received propofol (42% vs 16%, P < 0.05) and showed delayed recovery (32 ± 9 min) as compared with those who received propofol or sevoflurane (22 ± 8 min and 20 ± 7 min, respectively, P < 0.05). The mean peak PAED score was significantly lower in children who received propofol induction (6.8 ± 4.0, P < 0.05) than ketamine (11.8 ± 4.1) or sevoflurane (11.6 ± 3.8). Conclusions: Intravenous induction with ketamine does not prevent the incidence of EA and delays recovery. Induction with propofol improves the quality of recovery by reducing the incidence of EA and provides a safe and early recovery.

Intracellular Zn2+ accumulation enhances suppression of synaptic activity following spreading depolarization

Spreading depolarization (SD) is a feed-forward wave that propagates slowly throughout brain tissue and recovery from SD involves substantial metabolic demand. Presynaptic Zn(2+) release and intracellular accumulation occurs with SD, and elevated intracellular Zn(2+) ([Zn(2+) ]i ) can impair cellular metabolism through multiple pathways. We tested here whether increased [Zn(2+) ]i could exacerbate the metabolic challenge of SD, induced by KCl, and delay recovery in acute murine hippocampal slices. [Zn(2+) ]i loading prior to SD, by transient ZnCl2 application with the Zn(2+) ionophore pyrithione (Zn/Pyr), delayed recovery of field excitatory post-synaptic potentials (fEPSPs) in a concentration-dependent manner, prolonged DC shifts, and significantly increased extracellular adenosine accumulation. These effects could be due to metabolic inhibition, occurring downstream of pyruvate utilization. Prolonged [Zn(2+) ]i accumulation prior to SD was required for effects on fEPSP recovery and consistent with this, endogenous synaptic Zn(2+) release during SD propagation did not delay recovery from SD. The effects of exogenous [Zn(2+) ]i loading were also lost in slices preconditioned with repetitive SDs, implying a rapid adaptation. Together, these results suggest that [Zn(2+) ]i loading prior to SD can provide significant additional challenge to brain tissue, and could contribute to deleterious effects of [Zn(2+) ]i accumulation in a range of brain injury models.

Medical errors: The performance gap in hypoplastic left heart syndrome and physiologic equivalents?

The frequency and impact of medical errors during staged palliation are unknown. All patients with hypoplastic left heart syndrome and physiologic equivalents (N=191) who underwent staged palliation (2001-2011) were studied. Stage 1, interstage, and stage 2 were reviewed to identify diagnostic, technical, judgment, and management errors. The impact of errors on transplant-free survival was examined by parametric competing risks and risk-adjusted regressions using bootstrapping. Stage 1 (N=191) errors (n=111, 58%) were common and predominantly intraoperative (n=84, 44%) or postoperative (n=43, 23%). Postoperative errors were determinants of death/transplant (hazard ratio, 1.7; P=.01), whereas technical errors (n=65, 34%) were not, but they delayed recovery and discharge (extra 24 days approximately, P=.0024). Postoperative stage 1 errors led to decrements in total strategy success of approximately 30% (78% vs 48%, P=.004). Stage 2 (N=134) errors (n=66, 49%) were common. Intraoperative errors were the most prevalent (n=61, 46%) but did not compromise survival. Postoperative errors (n=11, 8%) were determinants of death/transplant (hazard ratio, 2.4; P<.0001). Interstage errors (n=21, 16%) led to twice the intensive care unit stay (16 vs 7 days, P<.0001) and hospital stay (30 vs 17 days, P<.02) after stage 2. Overall, a child presenting with ideal morphology and managed with no postoperative errors at stage 1 or 2 would have a predicted late survival in excess of 80%. Technical errors are common and delay recovery. Their effects on survival are mitigated. Intraoperative judgment errors are associated with strategy failure in a univariate model and lead to increased postoperative errors in a multivariate model. Postoperative errors are independently associated with a decrease in univentricular strategy survival.

Role of Disease and Macronutrient Dose in the Randomized Controlled EPaNIC Trial

Early parenteral nutrition to supplement insufficient enteral feeding during intensive care (early PN) delays recovery as compared with withholding parenteral nutrition for 1 week (late PN). To assess whether deleterious effects of early PN relate to severity of illness or to the dose or type of macronutrients. Secondary analyses of a randomized controlled trial (EPaNIC; n = 4,640) performed in seven intensive care units from three departments in two Belgian hospitals. In part 1, all patients were included to assess the effect of the randomized allocation to early PN or late PN in subgroups of patients with increasing-on-admission severity of illness. In part 2, observationally, the association of the amount and type of macronutrients with recovery was documented in those patient cohorts still present in intensive care on Days 3, 5, 7, 10, and 14. The primary end point was time to live discharge from the intensive care unit. For part 1, a secondary end point, acquisition of new infections, was also analyzed. All statistical analyses were performed by univariable and adjusted multivariable methods. In none of the subgroups defined by type or severity of illness was a beneficial effect of early PN observed. The lowest dose of macronutrients was associated with the fastest recovery and any higher dose, administered parenterally or enterally, was associated with progressively more delayed recovery. The amount of proteins/amino acids rather than of glucose appeared to explain delayed recovery with early feeding. Early combined parenteral/enteral nutrition delayed recovery irrespective of severity of critical illness. No dose or type of macronutrient was found to be associated with improved outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 00512122).

Use of cerebral state index to predict long-term unconsciousness in patients after elective craniotomy with delay recovery

BackgroundThe major difficulty in postoperative care in patients after craniotomy is to distinguish the intracranial deficits from the residual effect of general anesthesia. In present study, we used cerebral state index (CSI) monitoring in patients after craniotomy with delayed recovery, and evaluated the prediction probability of CSI for long-term postoperative unconsciousness.MethodsWe enrolled 57 consecutive adult patients admitted to neurosurgical intensive care unit (NICU) after elective craniotomy with delayed recovery. CSI was continuously monitored for 6 hours after admission. Patient's level of consciousness was followed up for 24 hours. According to whether obeyed verbal command, patients were divided into awaken group and non-awaken group. CSI values were compared between the two groups. Prediction probability (PK) was calculated to determine the probability of CSI in predicting unconsciousness 24 hours after operation.ResultsIn awaken group (n = 51), CSI increased significantly after the 2nd NICU admitted hour (P < 0.05). At each time point, CSI values in awaken group were significantly higher than those in non-awaken group (n = 6) (P < 0.05). The values of PK (SE) for CSI in the first 6 admitted hours ranged from 0.94 (0.06) to 0.99 (0.02).ConclusionsIn patients after craniotomy with delayed recovery, CSI monitoring in early postoperative hours had high prediction probability for long-term unconsciousness. CSI monitoring may be a reliable objective method to predict level of consciousness after elective craniotomy.

Effect of Low Concentration Isoflurane with Thiopental Sodium for Craniotomies of Intracranial Space Occupying Lesion

The primary objective of anaesthesia is to facilitate surgery at minimal risk to the patient and to ensure safe optimal recovery following the procedure. The minimal risk to the neurosurgical patient can be achieved with meticulous attention to the detail of intraoperative systemic and brain homeostasis. Safe early recovery from craniotomy necessitates an anaesthetic technique pharmacology adequate to permit early awakening. The present study was designed to observe the effect of different anaesthetic technique that permits early recovery and hemodynamic stability. A total number of thirty patients both male and female age range 18 to 60 yrs having ASA grade-I &amp; II and were randomly selected. They were equally divided into two groups. Group A received TPS infusion and group B received isoflurane inhalation with low dose of TPS infusion. Other drugs remained same for both group. Group A Received induction dose of TPS 4 - 5 mg/kg, maintained by TPS (4 - 5 mg/kg/h infusion), fentanyl (3 mgm/kg bolus, 1 - 2 mgm/ kg/h infusion), oxygen/N2O mixture FiO2 being 0.3. Group B- Received induction dose of TPS 4 - 5 mg/kg and maintained by isoflurane 0.5%, oxygen/ N2O mixture FiO2 being 0.3, fentanyl (3 mgm/kg bolus, 1 - 2 mgm/kg/h infusion), and low dose TPS (1 - 2 mg/kg/h) infusion. In all patients induction was done with TPS 4 - 5 mg/kg and vecuronium (0.1 mg/kg) was used for tracheal intubation, muscle relaxation was maintained by vecuronium 0.01 mg/kg intermittently. Both groups received midazolam (0.1 mg/kg), lignocaine 1.5 mg/kg 2 minutes before induction. Both groups received frusemide 1 mg/ kg just after induction and mannitol 1 gm/kg when scalp incision was given. Anaesthetic procedure was performed with monitoring of hemodynamic variable pulse, blood pressure, SPO2, ETCO2, temperature, urine output. Hemodynamic variable pulse, blood pressure were measure before induction, at intubation, every 15 min. interval and before extubation. Data were analyzed by paired and unpaired student's t-test as appropriate using SPSS software. Hemodynamic response to intubation does not differ significantly between the two groups. But it was observed that at intubation in both groups the pulse and mean arterial blood pressure was raised in compare to baseline, which gradually came down as anaesthetic depth increased and then remained stable all through the procedure. Recovery was evaluated using Aldrete score. Total score significantly differ between two groups up to 30 min after extubation. Group A showed delay recovery up to 30 min in compare to group B. But after 30 min there was no significant difference in scoring between two groups. Total cost of main anaesthetic agent used significantly lower in group A. This study showed that the total infusion of TPS technique was as equally effective as using low concentration of isoflurane with conjunction of low dose TPS regarding perioperative hemodynamic stability. But the cost was minimal in thiopental sodium infusion group with the expense of a little bit delayed recovery. Journal of BSA, Vol. 21, No. 1, January 2008 21-28

Evaluating Malingering in Contested Injury or Illness

An interdisciplinary task force of physicians and neuropsychologists with advanced training in impairment and disability assessment provided a review of the literature on malingering in chronic pain, medical disorders, and mental/cognitive disorders. Our review suggests that treating health care providers often do not consider malingering, even in cases of delayed recovery involving work injuries or other personal injuries, where there may be a significant incentive to feign or embellish symptoms or delay recovery. This report discusses the implications of this issue and offers recommendations to evaluating physicians and other health care professionals.

Proximity of a Lower Third Molar to the Inferior Alveolar Canal as a Predictor of Delayed Recovery

This study was designed to test the hypothesis that removal of lower third molars below the occlusal plane and in close proximity to the inferior alveolar canal (IAC) delays recovery after surgery as compared with lower third molars below the occlusal plane yet not close to the IAC. Recovery data were available for 579 patients enrolled in an institutional review board-approved clinical trial. After surgery a questionnaire designed to assess health-related quality of life (HRQOL) recovery was given to the patient to be completed each day for 14 days. At each postsurgery visit, clinical data were collected detailing healing and treatment. Based on radiographic findings, patients with at least 1 mandibular third molar below the occlusal plane were identified. Outcomes for patients with at least 1 radiographic sign indicating proximity of a lower third molar to the IAC were compared with those with none. Clinical and HRQOL outcomes were compared with Cochran-Mantel-Haensel statistics (P < .05). No significant differences were found between groups for delayed clinical recovery. If radiographic signs for a patient at presurgery evaluation indicated close proximity of a lower third molar to the IAC, odds were significantly increased for delayed HRQOL recovery for worst pain, lifestyle, and oral function. Our findings support the hypothesis that a presurgery finding of a lower third molar below the occlusal plane and in close proximity to the IAC is associated with patients' prolonged HRQOL recovery, but not a significant delay in clinical recovery.

Premedication with Midazolam Delays Recovery After Ambulatory Sevoflurane Anesthesia in Children

We studied the effect of oral premedication with midazolam on the recovery characteristics of sevoflurane anesthesia in small children.In a randomized, double-blinded study, 60 children (1-3 yr, ASA physical status I or II) undergoing ambulatory adenoidectomy received either midazolam 0.5 mg/kg (Group M) or placebo (Group P) PO approximately 30 min before the induction of anesthesia. All children received atropine 0.01 mg/kg IV and alfentanil 10 [micro sign]g/kg IV before the induction of anesthesia with sevoflurane up to 8 vol% inspired concentration in N2 O 67% in O2. Tracheal intubation was facilitated with mivacurium 0.2 mg/kg. Anesthesia was continued with sevoflurane adjusted to maintain hemodynamic stability. In the postanesthesia care unit, predetermined recovery end points (emergence, recovery, discharge) were recorded. A pain/discomfort scale was used to determine the quality of recovery. A postoperative questionnaire was used to evaluate the well-being of the patient at home 24 h after surgery. Emergence (spontaneous eye opening), recovery (full points on the modified Aldrete scale), and discharge were achieved later in Group M than in Group P (15 +/- 6 vs 11 +/- 3 min [P = 0.002], 25 +/- 17 vs 16 +/- 6 min [P = 0.01], and 80 +/- 23 vs 70 +/- 23 min [P = 0.03]). Side effects, postanesthetic excitement, and analgesic treatment did not differ significantly between groups. At home, more children in Group P (30%) experienced disturbed sleep during the night compared with those in Group M (4%) (P = 0.007). Implications: In this randomized, double-blinded, placebo-controlled study, premedication with midazolam 0.5 mg/kg PO delayed recovery in children 1-3 yr of age after brief (<30 min) sevoflurane anesthesia. Except for more peaceful sleep at home, premedication did not affect the quality of recovery. (Anesth Analg 1999;89:75-9)

Agonists for metabotropic glutamate receptors in the rat delay recovery from halothane anesthesia

Intraventricular injection of (2 S,1′ R,2′ R,3′ R)-2-(2,3-dicarboxycyclopropyl)glycine (DCG-IV), a potent agonist for metabotropic glutamate receptors, to rats retarded dose-dependently the recovery from halothane anesthesia at a dose range from 30 to 300 pmol/rat. At a dose of 300 pmol/rat, recovery was prolonged up to about 630% of the control. (2 S,1′ S,2′ S)-2-(carboxycycloprophyl)glycine (L-CCG-I) and (1 S,3 R)-1-aminocyclopentane-1,3-dicarboxylic acid ((1 S,3 R)-ACPD) also delayed recovery, but doses much higher than those of DCG-IV were required (about 300 and 1000 times, respectively). These results suggest that some agonists for a certain kind of metabotropic glutamate receptors have a central depressant action in the rat.