Min In Phase Research Articles

Learning Curve of Robot-Assisted Thymectomy: Single Surgeon's 7-Year Experience.

BackgroundRobot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs.MethodsA single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time.ResultsIn myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), . In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, ). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p = 0.02).ConclusionsAccording to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC.

Short-term and long-term associations with sleep onset latency in school children in Japan.

This study aims to examine the relationships between sleep onset latency and multiple sleep-related factors of seventh and tenth graders during the transition from childhood to adolescence. Regarding sleep onset latency, we examined the short-term associations in Phase IV (2002) and long-term associations in Phase V (2005) of the Toyama Birth Cohort Study. In total, 4,673 boys and 4,694 girls in Phase IV and 2,969 boys and 3,108 girls in Phase V answered the questionnaire items regarding sleep, physical and mental health, lifestyle, socioeconomic status, and family and school factors. Considering sleep onset latency as the outcome and 13 sleep-related factors as independent variables, we calculated the odds ratio using binary logistic regression. The longitudinal study was conducted with 1,703 boys and 1,919 girls whose sleep onset latency was within 30 min in Phase IV. The following factors were found to be related to longer sleep onset latency in the short term: sleep duration, physical activity, game time, and self-esteem in boys and sleep duration, bedroom environment, game time, abdominal pain, long-standing illness, onset of puberty, mental health difficulties, and school avoidance feelings in girls. Regarding its long-term effects, having a single parent and self-esteem in boys and breakfast, game time, long-standing illness, obesity, onset of puberty, and school avoidance feelings in girls were associated with longer sleep onset latency. Education of adolescent health and sleep hygiene at home and school should include both short-term and long-term associations between sleep and a healthy lifestyle by gender.

Cognitive Aid for Anesthetic Preparation in An Emergency Situation: A Simulation-Based Study.

When anesthesia checklists and preparations are performed urgently, omissions may occur and be deleterious to the patient. The aim of this study was to evaluate in simulation the interest of a cognitive aid to effectively prepare an anesthetic room for an emergency. In a prospective single-center simulation-based study, 32 anesthesia residents had to prepare an anesthetic room in an emergency scenario, without cognitive aid in the first phase. Three months later (phase 2), they were randomly assigned to receive a cognitive aid (aid group) or no additional aid (control) and were involved in the same scenario. The primary outcome was the validation rate of each essential item in the first 5 min in phase 2. Eight items were significantly more frequently completed in the first 5 min in the aid group in phase 2 (vs. phase 1), compared with two only in the control group. However, there were no significant differences in the overall number of completed items between the two groups, as both groups completed significantly more items in phase 2, either in the first 5 min (19 (14–23) vs. 13 (9–15) in phase 1 for all residents, p < 0.001) or without time limit. Preparation times were reduced in phase 2 in both groups. In conclusion, the use of a cognitive aid allowed anesthesia residents to complete some safety items of a simulated urgent anesthesia preparation more frequently. In addition, despite daily clinical experience, a single simulation session improved anesthesia preparation and reduced the preparation time with or without cognitive aid.

Processing Cycle Efficiency to Monitor the Performance of an Intelligent Tube Preparation System for Phlebotomy Services.

Background: The waiting time (WT) for a phlebotomy is directly related to patient satisfaction with a health service. However, the processing time varies widely depending on the type of patients. Monitoring of the WT alone may not enable an effective evaluation of the lean performance of the medical staff for patients with different characteristics. The objective of this study was to use process cycle efficiency (PCE) to assess the performance of an intelligent tube preparation system (ITPS) which automatically labeled test tubes and conducted patient rerouting for phlebotomy services, and to interpret the WT during peak hours. Methods: Three time periods were used. The baseline period was from 1 July to 31 July 2014. Phase 1 was after the establishment of the ITPS, with patients ≥80 years old being rerouted. In phase 2, patients ≥78 years old were rerouted. Those data were recorded with a calling system and ITPS, respectively. Results: PCE was significantly improved from 12.9% at baseline to 51.1% (p < 0.001) in phase 1 and 53.0% (p < 0.001) in phase 2. The WT of 16.9 min at baseline was reduced to 3.8 min in phase 1 (p < 0.001), and 3.6 min in phase 2 (p < 0.001). Moreover, the results showed that a WT < 10 min was consistent with a PCE ≥ 25%. Conclusions: Establishing an ITPS for phlebotomy can significantly increase PCE and shorten the WT. Furthermore, the PCE ≥ 25% could be a good assessment reference for the management of appropriate human resources for phlebotomy services, although it is a complex parameter.

346-P: Predicting True Time to Recovery from Insulin-Induced Hypoglycemia with Dasiglucagon

The efficacy of dasiglucagon 0.6 mg has been investigated in multiple trials in individuals with T1DM. The primary endpoint was time to plasma glucose (PG) recovery from insulin-induced hypoglycemia, defined as first PG increase ≥20 mg/dL after treatment initiation without the need for IV glucose. Different PG sampling schemes were used in phase 2 (5-min intervals) versus phase 3 trials (more frequent sampling). Estimating the true but unmeasured time to recovery for each individual enables for a better comparison between trials when compared to use of observed time only. The true time was calculated using linear interpolation between the 2 time points before and after recovery occurred, assuming a linear PG increase in this limited time interval. The difference between the observed and the estimated true recovery for an individual is illustrated in the figure. The PG sample taken at 10 min is the first sample showing an increase of at least 20 mg/dL from the predose level, leading to an observed time to recovery of 10 min. Linear interpolation estimates the increase of 20 mg/dL to occur at 9 min for this individual. Using interpolated PG values, the median estimated true time to recovery for dasiglucagon was 8.7 min in the phase 2 trial and 9.0 to 9.3 min in phase 3 trials. These data provide further insight into the probable “true time to recovery” and confirm the consistent efficacy of dasiglucagon in the treatment of hypoglycemia. Disclosure T. Battelino: Advisory Panel; Self; Eli Lilly and Company, Medtronic, Sanofi, Research Support; Self; European Union, National Institute of Diabetes and Digestive and Kidney Diseases, Novartis Pharmaceuticals Corporation, Novo Nordisk, Sanofi, Slovenian Research Agency, Zealand Pharma A/S, Speaker’s Bureau; Self; Abbott Diabetes, AstraZeneca, Dexcom, Inc., Eli Lilly and Company, Medtronic, Novo Nordisk, Pfizer Inc., Roche Diabetes Care, Sanofi, Stock/Shareholder; Self; DreaMed Diabetes, Ltd. L. Dimeglio: Advisory Panel; Self; MannKind Corporation. T. Danne: Research Support; Self; Abbott Diabetes, Dexcom, Inc., Eli Lilly and Company, Medtronic, Novo Nordisk, Sanofi, Tandem Diabetes Care, Zealand Pharma A/S, Stock/Shareholder; Self; DreaMed Diabetes, Ltd. A. L. Peters: Advisory Panel; Self; Abbott Diabetes, Eli Lilly and Company, MannKind Corporation, Medscape, Merck & Co., Inc., Novo Nordisk Inc., Zealand Pharma A/S, Other Relationship; Self; Livongo, Research Support; Self; Abbott Diabetes, Dexcom, Inc. T. S. Bailey: Consultant; Self; Abbott Diabetes, LifeScan, Novo Nordisk, Sanofi, Research Support; Self; Abbott, Abbott Diabetes, Biolinq, Capillary Biomedical, Inc., Dexcom, Inc., Eli Lilly and Company, Kowa Research Institute, Inc., Lexicon Pharmaceuticals, Inc., Livongo, Medtronic, Medtrum Technologies, Novo Nordisk, REMD Biotherapeutics, Sanofi, Sanvita, Viacyte, Inc., vTv Therapeutics, Zealand Pharma A/S, Speaker’s Bureau; Self; BD, Medtronic, Sanofi. R. Tehranchi: Employee; Self; Zealand Pharma A/S. L. J. Klaff: Research Support; Self; Abbott Diabetes, Dong-A ST Co. Ltd., Gan & Lee Pharmaceuticals, Lexicon Pharmaceuticals, Inc., Lilly Diabetes, Medtronic, Novo Nordisk, Oramed Pharmaceuticals, Inc., Pfizer Inc., REMD Biotherapeutics. T. Pieber: Advisory Panel; Self; ADOCIA, Arecor, AstraZeneca, Eli Lilly and Company, Novo Nordisk A/S, Sanofi, Research Support; Self; AstraZeneca, Novo Nordisk A/S. U. Hovelmann: None. L. Plum-moerschel: None. A. E. Melgaard: Employee; Self; Zealand Pharma A/S. R. Aronson: None.

The Need for Structured Strategies to Improve Stroke Care in a Rural Telestroke Network in Northern New South Wales, Australia: An Observational Study.

Introduction: A telestroke network in Northern New South Wales, Australia has been developed since 2017. We theorized that the telestroke network development would drive a progressive improvement in stroke care metrics over time.Aim: This study aimed to describe changes in acute stroke workflow metrics over time to determine whether they improved with network experience.Methods: We prospectively collected data of patients assessed by telestroke who received multimodal computed tomography (mCT) and were diagnosed with ischemic stroke or transient ischemic attack from January 2017 to July 2019. The period was divided into two phases (phase 1: January 2017 – October 2018 and phase 2: November 2018 – July 2019). We compared median door-to-call, door-to-image, and door-to-decision time between the two phases.Results: We included 433 patients (243 in phase 1 and 190 in phase 2). Each spoke site treated 1.5–5.2 patients per month. There were Door-to-call time (median 39 in phase 1, 35 min in phase 2, p = 0.18), and door-to-decision time (median 81.5 vs. 83 min, p = 0.31) were not improved significantly. Similarly, in the reperfusion therapy subgroup, door-to-call time (median 29 vs. 24.5 min, p = 0.12) and door-to-decision time (median 70.5 vs. 67.5 min, p = 0.75) remained substantially unchanged. Regression analysis showed no association between time in the network and door-to-decision time (coefficient 1.5, p = 0.32).Conclusion: In our telestroke network, acute stroke timing metrics did not improve over time. There is the need for targeted education and training focusing on both stroke reperfusion competencies and the technical aspects of telestroke in areas with limited workforce and high turnover.

Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality

BackgroundThe feasibility of performing MRI first for patients with suspected hyperacute stroke in real-world practice has not been fully examined. Moreover, most past studies of reducing door-to-reperfusion time (DRT) in...

Timed synchronization of muscle contraction to heartbeat enhances muscle hyperemia.

Blood flow (BF) to exercising muscles is susceptible to variations of intensity, and duration of skeletal muscle contractions, cardiac cycle, blood velocity, and vessel dilation. During cyclic muscle activity, these elements may change proportionally with or without direct optimal temporal alignment, likely influencing BF to active muscle. Ideally, the pulsed delivery of blood to active muscle timed with the inactive phase of muscle duty-cycle would enhance the peak and average BF. To investigate the phenomenon of muscle contraction and pulse synchronicity, electrically evoked muscle contractions (trains of 20 Hz, 200-ms duration) were synchronized with each systolic phase of the anterograde blood velocity spectrum (aBVS). Specifically, unilateral quadriceps contractions matched in-phase (IP) with the aBVS were compared with contractions matched out-of-phase (OP) with the aBVS in 10 healthy participants (26 ± 3 yr). During each trial, femoral BF of the contracting limb and central hemodynamics were recorded for 5 min with an ultrasound Doppler, a plethysmograph, and a cardioimpedance device. At steady state (5th min) IP BF (454 ± 30 mL/min) and vascular conductance (4.3 ± 0.2 mL·min-1·mmHg-1), and OP MAP (108 ± 2 mmHg) were significantly lower (P < 0.001) in comparison to OP BF (784 ± 25 mL/min) and vascular conductance (6.7 ± 0.2 mL·min-1·mmHg-1), and IP MAP (113 ± 3 mmHg). On the contrary, no significant difference (all, P > 0.05) was observed between IP and OP central hemodynamics (HR: 79 ± 10 vs. 76 ± 11 bpm, CO: 8.0 ± 1.6 vs. 7.3 ± 1.6 L/min), and ventilatory patterns (V̇e:14 ± 2 vs. 14 ± 1 L/min, V̇o2:421 ± 70 vs. 397 ± 34 mL/min). The results suggest that muscle contractions occurring during OP that do not interfere with aBVS elicit a maximization of muscle functional hyperemia.NEW & NOTEWORTHY When muscle contraction is synchronized with the pulsed delivery of blood flow to active muscle, muscle functional hyperemia can be either maximized or minimized. This suggests a possibility to couple different strategies to enhance the acute and chronic effects of exercise on the cardiovascular system.

Performance evaluation and model analysis of BTEX contaminated air in corn-cob biofilter system

Biofiltration of BTEX with corn-cob packing material have been performed for a period of 68days in five distinct phases. The overall performance of a biofilter has been evaluated in terms of its elimination capacity by using 3-D mesh techniques. Maximum removal efficiency was found more than 99.85% of all four compounds at an EBRT of 3.06min in phase I for an inlet BTEX concentration of 0.0970, 0.0978, 0.0971 and 0.0968gm−3, respectively. Nearly 100% removal achieved at average BTEX loadings of 20.257gm−3h−1 to biofilter. A maximum elimination capacity (EC) of 20.239gm−3h−1 of the biofilter was obtained at inlet BTEX load of 20.391gm−3h−1. Moreover, using convection–diffusion reaction (CDR) model for biofilter depth shows good agreement with the experimental values for benzene, toluene and ethyl benzene, but for o-xylene the model results deviated from the experimental.

Successive phase transitions in [C(NH2)3]4Cl2SO4 crystal—dielectric, pyroelectric and optical evidences

Studies of the dielectric and pyroelectric properties of a [C(NH2)3]4Cl2SO4 crystal along the ferroelectric c-axis and the optical observation along the b-axis in the temperature range 330–380K covering the phase transitions region were performed with various heating/cooling rates. At faster heating, a diffused dielectric anomaly in the range of phase transitions was observed. Slow heating (0.01K/min) shows two successive phase transitions: III→II at T2h=354.5K and II→I at T1h=357.5K. Pyroelectric studies showed polar properties of phases III and II. The disappearance of polarization is diffused at the first heating run. The sample kept for 400min in phase II undergoes a direct sharp II→I transition during heating. Optical observations on the heating run at a 0.01K/min rate confirmed successive phase transitions with symmetry changes according to a scheme: orthorhombic (III)→orthorhombic (II)→tetragonal (I). The dielectric, pyroelectric and optical studies revealed a slow III→II transition. On the cooling run, we deal with one transition at T1c equal to 355K between the tetragonal phase (I) and the orthorhombic phase (II).

Effects of daily levels of fatigue and acutely induced fatigue on the visual evoked magnetic response

Fatigue is a common complaint in modern society. As photosensitivity is associated with fatigue, this study aimed to clarify the relationship between neural response to visual stimuli and fatigue using a 160-channel whole-head-type magnetoencephalographic system. Twelve healthy male volunteers were enrolled. Participants were randomly assigned to two groups in a single-blinded, crossover fashion to perform acute fatigue-inducing mental task sessions, i.e., 0-back or 2-back test for 30min. Visual evoked magnetic field (VEF) intensities were evaluated by standardized low-resolution brain electromagnetic tomography modified for a quantifiable method. VEF consisted of two phases, and although acute fatigue did not alter the VEF intensities and the intensities before the acute fatigue-inducing mental task sessions were not correlated with the Chalder's Fatigue Scale scores in either of the two phases, the intensities after the 0-back test trials for 30min in Phase 1 and those after the 2-back test trials in Phase 2 were significantly correlated with the fatigue scale scores. The daily level of fatigue was related to VEF intensity after the acute mental fatigue loads. Our findings provide new perspectives to evaluate our daily level of fatigue as well as to clarify the neural mechanisms underlying it.

Gender Differences in Motility of the Large and Small Intestine in Patients With IBS

Background: Visceral hypersensitivity, and altered gastrointestinal motility and secretion, are considered to be key pathophysiological factors in irritable bowel syndrome (IBS), and of great importance for symptom generation. The symptom pattern differs between female and male IBS patients , with more severe abdominal pain, bloating and constipation in females (Khatai et al. DDW 2010). Whether this can be explained by gender differences in pathophysiological alterations is incompletely understood. Aim: To evaluate potential gender differences in small intestinal motility and secretion, colonic motility and rectal sensorimotor function in patients with IBS. Methods: We included 36 male and 36 female IBS patients, matched for age (mean age 39 (20-64) years), who fulfilled the ROME II criteria. All patients underwent investigations to assess colonic motility (colonic transit time using radiopaque markers), small intestinal motility and secretion (antroduodenojejunal manometry with jejunal transmural potential difference (PD) measurement in the fasting state (3h) and after meal intake (1h)) and rectal sensorimotor function (rectal balloon distensions before and after meal intake; 800kcal; 60% fat). Results: Colonic transit time differed between female and male IBS patients, with slower transit in females (2.1±1.3 (mean±SD) vs. 1.2±0.8 days; p<0.0001). Differences were also found in the small intestinal motility with slower propagation velocity of phase III in females (8.7±4.5 vs. 15±9.4 cm/min; p<0.01), and a tendency towards shorter duration of phase III in females (p<0.1). The motility indices in the jejunum also tended to be lower in female versus male IBS patients, but this only reached statistical significance in the fasting state (last 30 min of phase II) (3310±1040 vs. 4510±2730 mmHg x sec; p<0.05). No gender differences were seen in PD measurements in the small intestine, reflecting chloride secretion, or in rectal compliance, tone or sensitivity. Conclusion: We have demonstrated gender differences in small and large intestinal motility in IBS patients, but not in small intestinal secretion or rectal sensorimotor function. These findings are of potential importance for observed differences in the symptom pattern between male and female IBS patients.

Efficacy of a tool combining guide-wire and stylet for the left ventricular lead positioning

The left ventricular (LV) lead for cardiac resynchronization therapy (CRT) is usually positioned in the coronary sinus via a stylet-guided or an 'over-the-wire' approach. Recently, a new tool has been developed, the Medtronic Attain Hybrid, that combines guide-wire and stylet features. We assessed its safety and efficacy in comparison with standard tools currently used in clinical practice. Patients undergoing standard CRT device implantation were enrolled in seven Italian centres. In the preliminary phase of the study (Phase I), data were collected during implantation procedures performed with standard tools (three patients per centre). Subsequently, the Attain Hybrid was made available in the centres and data were collected for all consecutive patients undergoing implantation during the following year. A learning phase was considered (Phase II), and the last three patients per centre (Phase III) were used for comparison with Phase I. One hundred and seventeen patients were enrolled: 21 patients in Phase I, 75 in Phase II, and 21 in Phase III. Rates of successful implantation were similar in Phases I and III (95 vs. 100%, P=1.000). The pre-defined target vein was reached in 15 (71%) patients in Phase I and in 21 (100%) patients in Phase III (P=0.021). In 10 (48%) procedures during Phase I, LV lead positioning necessitated switching from guide-wire to stylet; this proportion decreased during Phase III (14%, P=0.043). Mean LV positioning time was 16±7 min in Phase I and 11±6 min in Phase III (P=0.040). No adverse events or lead-related complications were detected on implantation or during a follow-up of 6±4 months. The Attain Hybrid is safe and effective. It significantly improves target vein accessibility and reduces procedural time in comparison with conventional tools.

A rapid admission protocol to reduce emergency department boarding times

IntroductionProlonged emergency department boarding times (EDBT) are associated with adverse clinical outcomes and longer hospital stays. A rapid admission protocol was designed at our institution to reduce both EDBT and...

Acute changes in cardiovascular function during the onset period of daytime sleep: comparison to lying awake and standing

The siesta habit is associated with a 37% reduction in coronary mortality, possibly because of reduced cardiovascular stress associated with daytime sleep. Whether the most important behavior is the daytime nap itself, a supine posture, or the expectancy of a nap is unknown. We present the first detailed description on healthy individuals of the acute changes in cardiovascular function during defined phases of the daytime sleep-onset period. These responses were compared with lying awake and standing. Following a night of restricted (4 h) sleep, nine healthy participants (aged 34 +/- 5 yr) were allowed to sleep at 1400 for up to 1 h. Polysomnography was used to calculate three phases of daytime sleep onset: phase 1, a baseline period of relaxed wakefulness before lights out; phase 2, the period between lights out and onset of stage 1 sleep; and phase 3, the period between onsets of stages 1 and 2 sleep. Differences (means +/- SD) in blood pressure, heart rate, and forearm cutaneous vascular conductance (CVC) between phases were analyzed. During the 9.7 +/- 13.8 min of phase 2, systolic and diastolic blood pressure was 4.7 +/- 4.5 and 3.6 +/- 2.8 mmHg lower than baseline, whereas CVC was 9.5 +/- 4.3% higher than baseline (P < 0.05). Subsequent changes in cardiovascular function during the sleep itself were trivial (P > 0.05). The above changes were not observed when subjects stood or laid supine in relaxed wakefulness for 1 h (P > 0.05). Our findings suggest that the period between lights out and sleep onset is associated with the largest acute reduction in blood pressure during one afternoon siesta.

Duodenal Acid Clearance in Humans: Observations Made with Intraluminal Impedance Recording

Duodenal acid clearance appears to be involved not only in the pathogenesis of duodenal ulcer disease but also in functional dyspepsia. Duodenal contractile activity can help to maintain neutral pH in the duodenum by mixing acid with bicarbonate or by aborally transporting the acid load. Intraluminal impedance recording, allowing the detection of nonacid liquid boluses, can be carried out concomitantly with antroduodenal manometry and pH recording and may thus provide useful information about the mechanisms involved in duodenal clearance of endogenous acid and volume boluses. Eight H. pylori-negative healthy volunteers were studied with two catheters positioned across the pylorus, allowing the recording of five impedance signals (one antral, one pyloric, and three duodenal) simultaneously with six pressure signals (two antral, one pyloric, and three duodenal) as well as distal antral and proximal duodenal pH. During phase II of the migrating motor complex, which is known to be associated with the highest duodenal acid exposure, each duodenal acidification event (defined as a pH drop >2 pH units) was characterized by its maximal amplitude, duration, temporal relationship with antroduodenal manometric events, and relation to impedance variations. Acid was considered to have been cleared from the duodenum when the preacidification pH was restored (+/-0.2 unit). A total of 164 duodenal pH drops were recorded during the 323 min of phase II recordings. Eleven percent of the duodenal acidification events were short-lived (<10 sec). All of these events were temporally associated with a propagated antroduodenal contraction and a short-lived drop in impedance, suggesting rapid aboral passage of the acid bolus. The long-lived duodenal acidification events lasted a mean of 32 sec (range, 25-66 sec). In 90% of these events an antroduodenal propagated contraction was recorded at the time of onset. Repetitive duodenal contractions followed the onset of the long-lived acidification events in 34% of the cases. These remained present until complete clearance of the acid. In 81% of the long-lived acidification events, recovery of the associated impedance drop occurred simultaneously with the pH recovery, suggesting a complete clearance of the bolus. Less frequently (19%), the duodenal pH recovered while the impedance remained low, suggesting that the bolus was not cleared but neutralized. Interdigestive duodenal acidification events usually last about 30 sec. They evoke duodenal contractions in only one-third of cases. Combined pH and impedance recording makes it possible to distinguish between neutralization of acid boluses and their complete total clearance.

The Comparison of Reasons for not Receiving Reperfusion Therapy on Acute Myocardial Infarction for the Recent 10 Years

Background and Objectives:This study was performed to evaluate the changing aspects of the reasons why patients with an acute myocardial infarction were not given the adequate reperfusion therapy over the last 10 years. Subjects and Methods:All patients were divided into a reperfusion group (phase I=55, phase II=289) who received reperfusion therapy such as a thrombolytic trial or direct PCI, and a conservative group who had not received reperfusion therapy (phase I=83, phase II=81). We analyzed the clinical characteristics and the various time delays from chest pain onset, the first hospital arrival time, the transfer time, the ER arrival time, and the door to reperfusion time in 138 patients with acute myocardial infarction admitted to Wonju Christian Hospital from Jan. 1991 to Oct. 1993 and 370 patients from Jan. 1997 to Jun. 2002. Results:55 cases (39.9%) received an adequate reperfusion therapy during phase I and 289 cases (78.1%) received an adequate reperfusion therapy on phase II. 213 cases (78.1%) received direct PTCA on phase II and 12 cases on phase I. The patient time delay was 305.0±346.8 min and 253.7±233.4 min, the first hospital time delay, 237.2±320.7 min and 183.0±243.6 min in phase I and phase II. Only 4.8% of patients was were transferred from the first hospital after reperfusion therapy in phase I, but 43.1% of patients were transferred in phase II. The Patient time delay was the most common reason for not receiving reperfusion therapy in phase I , and II, and the time delay and lack of adequate reperfusion therapy at the first hospital despite the early arrival were the second most common reason. Other reasons included a contraindication to lytic therapy, a subsidence of pain or a ST segment elevation, no initial change in the ST segment on EKG and a delay in therapy. Conclusion:The most common reason of not receiving reperfusion therapy was patient delay and the time delay at the first hospital. In addition, reperfusion therapy in the first hospital has increased over the last 10 years. To maximize the effectiveness of reperfusion therapy, it is important to shorten the hospital 논문접수일:2002년 9월 6일 심사완료일:2002년 10월 14일 교신저자:유병수, 220-701 강원도 원주시 일산동 162번지 연세대학교 의과대학 원주기독병원 내과학교실 전화:(033) 741-0917·전송:(033) 741-0502·E-mail:yubs@wonju.yonsei.ac.kr

Effects of electroacupuncture on gastric migrating myoelectrical complex in dogs.

The aim-of this study was to investigate the characteristics of the gastric slow wave during different phases of the migrating myoelectrical complex (MMC) and the effect of electroacupuncture on the MMC. The experiment was performed in eight hound dogs implanted with one pair of bipolar serosal electrodes 2 cm proximal to the pylorus. Gastric myoelectrical activity was recorded for three complete cycles of the MMC in two sessions, one with electroacupuncture at points ST36 and PC6 and the other at sham points. The acupuncture was performed for 30 min in phase I of the second cycle of the MMC. Spectral analysis was performed to compute the frequency and power (amplitude) of the gastric slow wave, whereas blind visual analysis was applied to compute the appearance of spike potentials and the length of each phase of the MMC. It was found that there was a significant difference in the frequency and power of the gastric slow wave during different phases of the MMC (P < 0.05). Phase I was characterized with the highest frequency and lowest power of the gastric slow wave, whereas phase III exhibited the highest power in the slow wave. It was also found that in comparison with the sham points, electroacupuncture at the acupoints increased the number of spike bursts. This increase was not significant during the MMC cycle with electroacupuncture (34.4+/-4.1 vs 27.5+/-2.5%, P > 0.05) but became significant during the cycle after electroacupuncture (39.8+/-3.3% vs 27.5+/-2.5%, P < 0.0005). Similarly, during the MMC cycle after electroacupuncture at the acupoints, there was a significant decrease in the length of phase I (14.8+/-2.2 vs 46.9+/-6.1 min, P < 0.003) and a significant increase in the length of phase II (75.6+/-9.9 vs 30.6+/-4.1 min, P < 0.003) and phase III (25.8+/-0.6 vs 22.1+/-0.7 min, P < 0.003). A similar increase was observed during the MMC cycle with electroacupuncture but was not statistically significant. In conclusion, the gastric slow wave has the highest power during phase III of the MMC, indicating that the antral contraction is characterized not only by the appearance of spikes, but also by the increased power of the slow wave. Electroacupuncture at acupoints of ST36 and PC6 enhances the gastric MMC by reducing the length of phase I and increasing the length of phases II and III.

Factors affecting discharge time in adult outpatients.

Discharge time (total recovery time) is one determinant of the overall cost of outpatient surgery. We performed this study to determine what factors affect discharge time. Details regarding patients, anesthesia, surgery, and recovery were recorded prospectively for 1088 adult patients undergoing ambulatory surgery over an 8-mo period. The contribution of factors to variability in the discharge time was assessed by using multivariate linear regression analysis. In the last 4 mo of the study, nurses indicated the causes of discharge delays > or =50 min in Phase 1 or > or =70 min in Phase 2 recovery. When all anesthetic techniques were included, anesthetic technique was the most important determinant of discharge time (R2 = 0.10-0.15; P = 0.001), followed by the Phase 2 nurse. After general anesthesia, the Phase 2 nurse was the most important factor (R2 = 0.13; P = 0.01-0.001). In women, the choice of general anesthetic drugs was significant (R2 = 0.04; P = 0.002). The three most common medical causes of delay were pain, drowsiness, and nausea/vomiting. System factors were the foremost cause of Phase 2 delays (41%), with lack of immediate availability of an escort accounting for 53% of system-related delays. We conclude that efforts to shorten discharge time would best be directed at improving nursing efficiency; ensuring availability of an escort for the patient; and preventing postoperative pain, drowsiness, and emetic symptoms. The selection of anesthetic technique and anesthetic drug seems to be of selective importance in determining discharge time depending on patient gender and type of surgery. The relative importance of anesthetic and nonanesthetic factors were evaluated as determinants of discharge time after ambulatory surgery. Postoperative nursing care was the single most important factor after general anesthesia; anesthetic drugs, anesthetic technique, and prevention of pain and emetic symptoms were of selective importance depending on patient gender and type of surgery.

Human duodenogastric reflux, retroperistalsis, and MMC.

The aim of this study was to determine to what extent human migrating motor complex (MMC)-related secretory phenomena are influenced by a recently discovered period of duodenal retroperistalsis during late phase III. A constant-flow perfusion technique was used to measure gastric appearance of acid, bicarbonate, pepsin, bilirubin, IgA, and duodenally infused [14C]polyethylene glycol (PEG) 4000 in 12 healthy volunteers. Interdigestive gastroduodenal motility was recorded by digital manometry. During late antral phase II and III, the gastric lumen was acidified (P < 0.005 phase III vs. phase I) together with a marked increase in luminal pepsin output (3.1 +/- 1.2 during phase III vs. 0.25 +/- 0.08 kU/5 min in phase I, P < 0.01), followed by a realkalinization due to a simultaneous reduction of acid secretion and a duodenogastric reflux, aided by retrograde peristalsis, of bicarbonate and IgA but not of bilirubin, at the end of antral phase III (P < 0.05 phase III vs. phase I values). This physiological duodenoantral reflux phenomenon may play an important role in the chemical and immunological restitution of the antral mucosal barrier function after the exposure to high acid and pepsin concentrations during antral phase III activity.