Observational Assessment Research Articles

The neoclassical and Keynesian standpoint and policy implications regarding the Greek Financial Crisis

PurposeThe purpose of this paper is to discover the contradistinctions between the neoclassical and Keynesian paradigms of economics regarding the Greek Financial Crisis.Design/methodology/approachThe answers to the questions and policies regarding the Greek Financial Crisis cannot be derived by using economic analysis alone; they also depend on the perception of social reality and ethical issues. Based on the assumptions about economic behavior, the answers and policies inevitably reflect the observer's assessment of each economic and non-economic performance dimension, as well as the significance assigned to those performance dimensions. Different views on “social reality” and “what is a good society?” are associated with distinct paradigms and a particular set of social values, which have implications for economic policy formulae. These give rise to alternative answers and policies to the Greek Financial Crisis, based on different assumptions, different methods of analysis and different goals.FindingsOverall, in contradistinction, the two paradigms recommend quite distinct policies tackling the Greek Financial Crisis, and at the end, both paradigms have different perspectives on ethics and moral fundamentals regarding debt.Originality/valueStudents of the global financial crisis will benefit from this unique approach in testing the two alternative paradigms, between the neoclassical and Keynesian, concerning the Greek Financial Crisis.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia.

To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery. Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients' movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient. 123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement - mostly voluntary - occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score. Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial.

ObjectiveThe optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy.MethodsA total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events.ResultsThe procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups.ConclusionRT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.

P12‐5: Correlation between bispectral index (BIS) and modified observer's assessment of alertness/sedation (MOAA/S) score in flexible bronchoscopy

P12‐5: Correlation between bispectral index (BIS) and modified observer's assessment of alertness/sedation (MOAA/S) score in flexible bronchoscopy

Observer's Assessment of Alertness/Sedation-based titration reduces propofol consumption and incidence of hypotension during general anesthesia induction: A randomized controlled trial.

Administration of a single propofol bolus dose for anesthesia induction causes hypotension. We included 160 patients (74 males and 86 females; mean age, 42.4 ± 10.7 [range: 18-60] years) with the American Society of Anesthesiologists status I-II undergoing elective surgery under general anesthesia. Using simple randomization, the patients were divided into a conventional group (n = 80; received 2 mg/kg propofol at a rate of 250 mg/min) and titrated group (n = 80; received propofol at a rate of 1 mg/kg/min until the Observer's Assessment of Alertness/Sedation scale score reached 1 point). Fentanyl (4 µg/kg) and cisatracurium (0.2 mg/kg) were administered, as appropriate. Systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate were recorded at different time points. Propofol consumption, hypotension, and other adverse events were recorded. All the patients were intubated without awareness. Compared with the conventional group, the titrated group showed more stable blood pressure (p < 0.05), as well as a lower decrease in systolic blood pressure, mean blood pressure at 1 and 3 min, and diastolic blood pressure at 1 min after propofol administration (p < 0.01). Moreover, compared with the conventional group, the titrated group showed a lower post-intubation hypotension incidence (9 vs. 19 cases; p = 0.04), as well as lower total propofol dosage and propofol dose per kilogram of body weight (93.57 ± 14.40 mg vs. 116.80 ± 22.37 mg and 1.73 ± 0.27 mg/kg vs. 2.02 ± 0.08 mg/kg, respectively, p < 0.01). Compared with conventional propofol usage, titrated propofol administration can reduce the incidence of hypotension and propofol consumption during anesthesia induction.

Efficacy of a Single Dose of Pregabalin on Signs of Anxiety in Cats During Transportation-A Pilot Study.

Objectives: The aim of this clinical pilot study was to evaluate the dosage, efficacy, and clinical safety of a single oral dose of pregabalin in cats that experience fear and anxiety when placed into a carrier and transported by car.Methods: Thirteen client-owned cats were enrolled in a blinded, randomized, crossover study with three treatment days approximately 1 week apart. The cats were assigned to receive pregabalin oral solution at dosages of 5 and 10 mg/kg and placebo in a randomized order, one treatment per week. Treatment was administered ~90 min before placing the cat into a carrier and starting transportation. Efficacy was assessed by the owners using a categorical scale and, based on video recordings, by an external observer, both blinded to the treatment.Results: Owners assessed that cats given pregabalin displayed less vocalization, restlessness, and panting during transportation than did cats given placebo. Correlation between owners' and external observer's assessment of the overall treatment effect was good (0.63, p < 0.01), which confirms the owners' ability to observe reliably their own cat's behavior. Transient mild ataxia was the most common adverse event reported. The human commercial formulation used in this study was found difficult or very difficult to administer by 79% of the owners.Conclusions and Relevance: Based on results of this pilot study, a single oral dose of pregabalin was well tolerated and decreased signs of anxiety and fear associated with car transportation in cats, as evaluated by blinded owners and external observer. The use of pregabalin prior to traveling may improve cat welfare and compliance for transportation. Further studies are needed to investigate the use of oral pregabalin in cats to alleviate signs of anxiety and fear associated with transportation and sequelae, like veterinary visits, and to develop a more user-friendly formulation.

PEMBELAJARAN MENULIS TEKS NEGOSIASI DENGAN MENGGUNAKAN METODE DISCOVERY LEARNING SETTING DECISION MAKING

This study aims to describe the implementation of learning to write negotiation text using discovery learning method of decision making setting, and to describe the students' ability in writing negotiation text. The research was conducted using a qualitative descriptive method. The subjects in this study were 22 high school class X students. Based on the results of the observer's assessment that 94.64% of teachers were able to carry out learning activities well. Based on the results of the observer's assessment that 96.42% of students were able to follow the learning process of writing negotiating texts well. The results of the research conducted showed that students had difficulty understanding aspects of spelling. The results of the test of the ability to write negotiation text for class X MIPA I high school students got an average final score of 81.79.

Correlation of Vital Signs and Depth of Sedation by Modified Observer's Assessment of Alertness and Sedation (MOAA/S) Scale in Bronchoscopy.

With complex, lengthy bronchoscopies, there is a need for safe, effective sedation. Most bronchoscopists strive for moderate sedation, though often difficult without compromising vital signs. The Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scale is a validated 6-point scale assessing responsiveness of patients coinciding with the American Society of Anesthesiologists (ASA) continuum of sedation. It is commonly used in studying bronchoscopic sedation, but depth of sedation by MOAA/S and correlation with vital signs and adverse events has not been determined. This study was a post hoc analysis of a prospective, double-blind, randomized trial evaluating the safety and efficacy of remimazolam. MOAA/S and corresponding vital signs were used to assess the effect of the level of sedation on vital signs and adverse events. A total of 23,341 MOAA/S scores from 431 patients were recorded. Older and higher ASA class patients spent more time in deeper sedation (MOAA/S 0 to 1) (6% vs. 2%, P=0.01). Oxygen saturation was equal in deep sedation (MOAA/S 0 to 1) (97±3%) compared with moderate sedation (96±3%) (P=0.11). Mean systolic and diastolic blood pressures were significantly lower when comparing MOAA/S 0 to 1 to MOAA/S 5 (systolic blood pressure: 126±19 vs. 147±24 mm Hg, P<0.01; diastolic blood pressure: 68±14 vs. 84±15 mm Hg, P<0.01). There was a nonsignificant trend towards lower heart rate at deep versus moderate sedation (84±15 vs. 94±18 beats/min, P=0.07). Respiratory rate was also comparable with moderate and deep sedation (17±5 vs. 18±6 beats/min, P=0.94). There was no clinically meaningful correlation between vital signs and depth of sedation assessed by MOAA/S. Older and higher ASA class patients spend more time in deeper sedation. However, when in deep sedation, there was no difference in vital signs other than a slightly increased incidence of clinically insignificant hypotension.

Variability and Reproducibility of the SYNTAX Score for Triple-Vessel Disease

BackgroundThe SYNTAX score (SX) is an angiographic grading system to determine the burden and complexity of coronary artery disease (CAD) and to guide operators as to the appropriateness of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG). However, variability of the SX may exist since the assessment relies on individual clinicians to visually interpret lesion severity and characteristics. We therefore aimed to assess SX variability and reproducibility among interpreting physicians. MethodsFifty patient angiograms were randomly selected from a registry of patients with multi-vessel CAD (treated with PCI or CABG) completed at our institution during the years 2011–2018. Each angiogram was evaluated by 6 clinicians on 2 separate occasions (minimum 8 weeks between occasions) for a total of 600 SX. Our goal was to evaluate both inter- and intra- observer reliability of SX scores. Variation in both raw score as well as risk classification (low, intermediate or high SX) was observed. Inter- and intra-observer reliability were assessed using the intra-class correlation coefficient (ICC), Cohen's weighted Kappa, and Fleiss' Kappa. ResultsSYNTAX scores on both assessments and across all 6 cardiologists had a mean score of 25.3. On the first assessment, the ICC for the inter-observer reliability of SX scores was 0.61 (95% CI: 0.50, 0.73). Across the 6 observers, only 16% of angiograms were classified in the same risk classification by all observers. 34% of angiograms had less than a majority agreement (3 or less observers) on risk classification. The weighted Kappa for intra-observer reliability of risk classification scores ranged from 0.30 to 0.81. Across the 6 observers, the proportion of angiograms classified as the same risk classification between each observer's 1st and 2nd assessment ranged from 46% to 84%. ConclusionThis study shows a wide inter- and intra- user variability in calculating SX. Our data indicates a significant limitation in using the SX to guide revascularization strategies. Further studies are needed to determine more reliable ways to quantitate burden of CAD.

Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study

BACKGROUND CONTEXTPostoperative experience plays a vital role in patient recovery and does not depend on the type and quality of the surgical procedure alone. Non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Most recently evolved among these are the regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae (ESP) block. PURPOSETo assess the efficacy of ultrasound-guided (US) ESP block for postoperative analgesia after a single level lumbar spine fusion surgery compared with conventional (opioid-based) multimodal postoperative analgesia. STUDY DESIGNA prospective, randomized, controlled, and double-blinded clinical trial. PATIENT SAMPLEA 100 consecutive patients requiring single-level lumbar spinal fusion procedure were randomized into two groups- block (multimodal analgesia with US-ESP) and control (only multimodal analgesia) groups. OUTCOME MEASURESDemographic and surgical data, intra-operative blood loss, duration of surgery, total opioid consumption (TOC) and amount of muscle relaxants used were assessed. Postoperatively, the Numeric pain Rating Scale(NRS), Modified Observer's assessment of Alertness and/or Sedation Scale (MOASS) and Patient satisfaction scores were recorded every 2 hours for the first 6 hours followed by every 6 hours for 24 hours. Continuous variables were analyzed using Student's t-test, and categorical variables were analyzed using either the Chi-square test or Fisher's exact test. p-value < .05 was considered statistically significant. METHODSPatients in both groups underwent the identical protocol for pre-emptive analgesia and induction of anesthesia. Patients in the block group received the US-ESP block after induction and positioning, followed by the multimodal analgesia, while the control group received only the multimodal analgesia. RESULTSBoth groups had identical demographic backgrounds and surgical profile. TOC for 24 hours following induction was significantly lower in the block group than the control group (105.0 ± 15.15 vs 158.00 ± 23.38mcg; p < .001). The total muscle relaxant consumption during surgery was also significantly less in the block group than the control group (51.90 ± 3.17 vs 57.70 ± 5.90; p < .001). The intra-operative blood loss was significantly less (p < .001) in the block group (303.00 ± 86.55 ml) than the control group (437.00 ± 116.85 ml). Compared to the block group, the control group's pain score (NRS) was significantly higher in the first 48 hours following surgery. The MOASS score was significantly lower in the control group (4.46 ± 0.50 vs 3.82 ± 0.82; p < .001) in the immediate postoperative period. The satisfaction score was significantly higher in the block group than the control group (9.52 ± 0.65 vs 8.22 ± 0.79; p < .001). CONCLUSIONThe employed US-ESP block for single-level lumbar fusion surgery is an effective component of multimodal analgesia for reducing blood loss, total opioid consumption, and related side effects with a significant reduction of postoperative pain and higher patient satisfaction.

Effect of continuous infusion of a subhypnotic dose of propofol on nausea and vomiting after carboprost administration at cesarean delivery: A randomized, double-blind, placebo-controlled trial.

To investigate whether continuous infusion of propofol at a subhypnotic dose prevents nausea and vomiting following carboprost administration at cesarean delivery. A prospective, randomized, double-blind, placebo-controlled trial conducted at West China Second University Hospital, from June 28, 2017 to January 30, 2018. Pregnant women were randomly allocated to propofol or saline infusion immediately before receiving carboprost at cesarean delivery under combined spinal-epidural (CSE) anesthesia. Propofol was given at an infusion rate of 1.0mg/kg/h following a loading dose of 0.3mg/kg. Primary outcome was incidence of intraoperative nausea and vomiting (IONV). Potential sedative effect of propofol infusion was assessed using Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scoring and continuous Bispectral Index (BIS) monitoring. The incidence of IONV was lower in patients who received propofol compared with saline (46.7% vs 76.7%, OR 0.27; 95% CI, 0.092-0.78, P=0.016 for nausea; 26.7% vs 53.3%, OR 0.50; 95% CI, 0.25-0.95, P=0.032 for retching; 10.0% vs 50.0%, OR 0.11; 95% CI, 0.03-0.44, P<0.001 for vomiting). There were no differences in MOAA/S scoring or BIS between the two groups. A subhypnotic dose of propofol reduces the incidence of nausea and vomiting following carboprost administration at cesarean delivery under CSE anesthesia, without measurable effect on patients' consciousness or alertness. ClincalTrials.gov: NCT03185156.

Comparison of the Effects of Sufentanil and Fentanyl on Postoperative Sleep Quality of Children Undergoing Tonsillectomy and Adenotomy: A Randomized Controlled Trial.

ObjectiveThe primary purpose was to compare the effects of sufentanil and fentanyl on the postoperative sleep quality. And the secondary purposes were to evaluate perioperative hemodynamics, postoperative pain and complications of children undergoing tonsillectomy and adenotomy.MethodsSeventy-six patients were randomly assigned to the sufentanil or fentanyl group. The subjective sleep quality was assessed by the Athens Insomnia Scale (AIS) on the night before surgery (Sleep preop 1), the first night after surgery (Sleep POD 1), and the third night after surgery (Sleep POD 3). The Faces Pain Scale-Revised (FPS-R) was used to evaluate the postoperative pain level 24 hours after surgery. The Observer’s Assessment of Alertness and Sedation (OAA/S) scale was used to assess the level of sedation in children. Perioperative hemodynamics and adverse effects were also evaluated.ResultsThe AIS score in the sufentanil group was significantly lower at Sleep POD 1 and Sleep POD 3 (P < 0.001, respectively). Children in the sufentanil group had significantly lower FPS-R scores at 2, 4, and 6 hours after surgery (P = 0.004, P = 0.004, and P = 0.001, respectively). The intraoperative hemodynamic parameters were more stable (P < 0.05, respectively) and the OAA/S scores at 2 hours after surgery were lower in the sufentanil group (P < 0.05). There was no significant difference in the incidence of postoperative nausea and vomiting between the two groups (P = 0.435).ConclusionChildren undergoing tonsillectomy and adenotomy after general anesthesia who received sufentanil had better postoperative sleep quality and less postoperative pain at 2, 4, and 6 hours post operation. Moreover, children who received sufentanil showed better hemodynamic stability during surgery. Therefore, sufentanil should be considered as a better choice to facilitate rapid recovery in children following tonsillectomy and adenotomy.

A population pharmacodynamic Markov mixed-effects model for determining remimazolam-induced sedation when co-administered with fentanyl in procedural sedation.

ABSTRACTThe clinical effects of remimazolam (an investigational, ultra‐short acting benzodiazepine being studied in procedural sedation) were measured using the Modified Observer’s Assessment of Awareness/Sedation Scale (MOAA/S). The objective of this analysis was to develop a population pharmacokinetic/pharmacodynamic model to describe remimazolam‐induced sedation with fentanyl over time in procedural sedation. MOAA/S from 10 clinical phase I–III trials were pooled for analysis, where data were collected after administration of placebo or remimazolam with or without concomitant fentanyl. A Markov model described transition states for 35,356 MOAA/S‐time observations from 1071 subjects. Effect‐compartment models of remimazolam and fentanyl linked plasma concentrations to the Markov model, and drug effects were described using a synergistic maximum effect (Emax) model. Simulations were performed to identify the optimal remimazolam‐fentanyl combination doses in procedural sedation. Fentanyl showed synergistic effects with remimazolam in sedation. Increasing age was related to longer recovery from sedation. Patients with body mass index greater than 25 kg/m2 had ~30% higher rates of distribution from plasma to the effect site (keo), indicating a slightly faster onset of sedation. Simulations showed that remimazolam 5 mg was more appropriate than 4 or 6 mg when administered with fentanyl 50 μg. The model and simulations support that a combination of remimazolam 5 mg with fentanyl 50 μg is an appropriate dosing regimen and the dose of remimazolam does not need to be changed in elderly patients, but some elderly patients may have a longer duration of sedation.

Propofol with or without fentanyl for pain relief after transrectal ultrasound-guided prostate (TRUS-P) biopsy: a randomized controlled study

BackgroundPostoperative pain from transrectal ultrasound-guided prostate (TRUS-P) biopsy under sedation is often mild. Benefit of opioids used during sedation is controversial. ObjectiveThe objective was to compare numeric rating scale (NRS) score at 30 minutes after TRUS-P biopsy between patients receiving propofol alone or with fentanyl. MethodsWe randomly allocated 124 patients undergoing TRUS-P biopsy to receive either fentanyl 0.5 mcg.kg-1 (Group F) or normal saline (Group C). Both groups received titrated propofol sedation via Target-controlled infusion (TCI) with Schneider model until the Observer's Assessment of Alertness/Sedation (OAA/S) scale 0–1 was achieved. Hemodynamic variables, patient movement, postoperative pain score, patient and surgeon satisfaction score were recorded. ResultsOverall, most patients (97.5%) had no to mild pain. Group F had significantly lower median NRS score at 30 minutes compared to Group C (0 [0, 0] vs. 0 [0, 0.25], p = 0.039). More patients in Group C experienced pain (90% vs. 75.8%, p = 0.038). Perioperative hypotension was higher in group F (81.7%) compared to Group C (61.3%) (p = 0.013). Thirty-five (56.5%) patients in Group F and 25 (42.7%) patients in Group C had movement during the procedure (p = 0.240). Surgeon’s satisfaction score was higher in Group F (10 [9, 10]) than Group C (9 [9, 10]) (p = 0.037). ConclusionCombining low dose fentanyl with TCI propofol sedation may provide additional benefit on postoperative pain after TRUS-P biopsy, but results in perioperative hypotension. Fentanyl may attenuate patient movement during the procedure, which leads to greater surgeon’s satisfaction.

Analysis of influence factors of pharmacodynamics of propofol with target-controlled infusion during anesthetic recovery period.

To explore the pharmacodynamic (PD) characteristics of propofol during anesthetic recovery period with target-controlled infusion (TCI), and to identify the clinical variables related to the PD parameters. 20 patients scheduled for otolaryngology surgery were enrolled. After the surgery was finished, target effect site concentration was gradually decreased, blood samples were measured at 7 time points and the differences between the target and measured plasma concentration were compared. Observer's assessment of alertness/sedation (OAA/S) and Narcotrend index (NI) were used as two PD indicators by fitting sigmoid Emax model. Correlations between PD parameter and clinical variables were evaluated. Performance of the TCI system showed a positive bias at the end of the anesthesia sedation period and a negative bias in the anesthetic recovery period. PD parameters (EC50, r) calculated with OAA/S and NI were significantly different, EC50 of OAA/S was lower than EC50 of NI (1.53 ± 0.70 vs. 2.16 ± 0.99 µg/mL), r of OAA/S was higher than r of NI (57.07 ± 56.39 vs. 4.35 ± 4.42). Propofol dosage and hemodynamic parameters were significantly correlated with EC50 (OAA/S), lean body weight and gender were significantly correlated with EC50 (NI). NI provided a more stable and adequate assessment of the depth of anesthesia than OAA/S, and the influence factors should be taken into account for precise dosing.

Comparative evaluation of propofol and combination of propofol-dexmedetomidine in adjunct with topical airway anesthesia for rigid bronchoscopy: A randomized double-blinded prospective study.

Context:Rigid bronchoscopy (RB) procedures require continuous vigilance and monitoring. Such procedures warrant proper ventilation strategy and titration of potent short-acting anesthetics.Aims:To compare propofol with the propofol-dexmedetomidine in conjunction with topical airway anesthesia in two groups during spontaneous assisted ventilation on peri-procedural hemodynamic stability.Settings and Design:This prospective, randomized, double-blinded study was done on 40 patients who were randomized in two groups, 20 patients in each group; PS (Propofol+ Normal saline) and PD (Propofol+ Dexmedetomidine) group. All patients in both groups were induced with 1% IV propofol (1–3 mg/kg), IV midazolam (0.05 mg/kg), and IV fentanyl (2 μ/kg). PS group received propofol infusion for maintenance along with saline infusion 10 min before induction, whereas PD group also received propofol infusion for maintenance along with Injection dexmedetomidine infusion 10 min before induction. Outcome measured were heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO2), and post-procedure awakening using Modified Observer's Assessment of Alertness/Sedation (MOAAS) scale and complications.Results:In both the groups, MBP decreased significantly from baseline, however, when MBP were compared at the same time points between the groups there were no significant differences. In PD group, HR remained significantly lower when compared with baseline and at 6, 12, 18, and 24 min time points when compared with PS group. Number of patients who developed hypotension requiring vasoactive drugs, their mean dose and duration of hypotension were more in PD group, and they awoke with significant delay.Conclusions:Propofol is better than combination of propofol and dexmedetomidine when given in adjunct with topical airway anesthesia for RB in view of early awakening, lesser duration of intra-procedural hypotension, and lesser requirement of vasoactive agents.

Propofol versus midazolam for sedation during radiofrequency ablation in patients with hepatocellular carcinoma.

Background and AimStandardization of the sedation protocol during radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC) is needed. This randomized, single‐blind, investigator‐initiated trial compared clinical outcomes during and after RFA using propofol and midazolam, respectively, in patients with HCC.MethodsFew‐ and small‐nodule HCC patients (≤3 nodules and ≤3 cm) were randomly assigned to either propofol or midazolam. Patient satisfaction was assessed using a 100‐mm visual analog scale (VAS) (1 mm = not at all satisfied, 100 mm = completely satisfied). Sedation recovery rates 1, 2, 3, and 4 h after RFA were evaluated based on Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores; full recovery was defined as a MOAA/S score of 5.ResultsBetween July 2013 and September 2017, 143 patients with HCC were enrolled, and 135 patients were randomly assigned to the treatment group. Compared with midazolam, propofol exhibited similar median procedural satisfaction (propofol: 73.1 mm, midazolam: 76.9 mm, P = 0.574). Recovery rates 1 and 2 h after RFA were higher in the propofol group than in the midazolam group. Meanwhile, recovery rates observed 3 and 4 h after RFA were similar in the two groups. The safety profiles during and after RFA were almost identical in the two groups.ConclusionPatient satisfaction was almost identical in patients receiving propofol and midazolam sedation during RFA. Propofol sedation resulted in reduced recovery time compared with midazolam sedation in patients with HCC. The safety profiles of both propofol and midazolam sedation during and after RFA were acceptable.

The sea-level budget: an assessmentof observations at the Norwegian coast

Sea level is a major indicator of climate change and thus a key essential climate variable. The source of recent sea-level rise can be understood by measuring the ocean’s temperature, salinity, mass, and sea-surface height. Based on those observations, sea-level change is determined in terms of total sea level and its two major contributions, ocean-mass and steric (density-related) sea level. The sea-level budget is closed when the sum of the independent contributions agrees with the measurements of total sea level, indicating that the observations can be used to understand recent and predict future sea-level change.

Evaluation of Intranasal Administration of Dexmedetomidine during Therapeutic Extraction

Aim: The purpose of this study was to evaluate the effectiveness of intranasal administration of dexmedetomidine during therapeutic extraction.Materials and Methods: The study design is a split mouth double blinded randomized control trial. Patients who visited the department of oral and maxillofacial surgery for the therapeutic extraction of premolars were assessed for enrollment. Each subject participated in two surgical sessions, with the extraction of premolars of the upper and lower quadrant of the same side during a single session. A week later subjects were asked to report back for the extraction of the upper and lower premolar on the contralateral side. The patients were randomized by a computer generated number into two groups. Group A received intranasal dexmedetomidine (100 mcg/ml) and group B received intranasal saline at the first session. An alternate regimen was used during the second session during which group A received intranasal saline and in group B intranasal dexmedetomidine was administered. A mucosal atomization device was used to deliver the drug. Pain from local anesthesia infiltration was rated on the numerical rating scale from 0 (no pain) to 10 (worst pain imaginable). Sedation status was measured using the Observer's Assessment of Sedation. Blood pressure and heart rate of the patient were also monitored.Original Research ArticleXavier et al.; JPRI, 32(18): 112-119, 2020; Article no.JPRI.59782113Results: A total of 14 patients were involved in the study. Observer assessment scale indicated that significant sedation was obtained in group A when compared to group B. Compared to group B there was a significant reduction in heart rate and blood pressure in group A at the end of 10 minutes and 40 minutes. These parameters were normalized to the baseline at the end of 60 minutes. There was no significant difference in pain score noted during the local anesthesia infiltration. None of the patients had bradycardia, hypotension, and respiratory depression in this trial.Conclusion: In this study, we conclude that the intranasal administration of dexmedetomidine controls the patient's fear and anxiety during the therapeutic extraction but not the pain during the administration of local anesthesia.

Psychomotor Recovery Following Remimazolam-induced Sedation and the Effectiveness of Flumazenil as an Antidote

PurposeRemimazolam tosylate (HR-7056) is a novel ester-type benzodiazepine with ultrafast onset of effect. The compound is being developed for sedation induction and maintenance during anesthesia. It was approved for procedural anesthesia in December 2019 by the National Medical Products Administration of China. Previous studies have reported on remimazolam's effects on consciousness and cognition. Although the time to full psychomotor recovery after remimazolam-mediated sedation is critical for decisions regarding hospital discharge, relevant clinical evidence is still lacking. This study investigated the residual psychomotor effects of remimazolam and their recovery from sedating treatment in 2 simulated clinical settings: (1) single-dose administration for sedation initiation; and (2) constant rate infusion for sedation maintenance. MethodsA single-ascending-dose, parallel-group, midazolam-controlled study and a 2-way crossover study evaluating the reversal effect of flumazenil versus placebo after a 2-h constant rate infusion were conducted with HR-7056 in 87 Chinese healthy volunteers; the studies used a double-blind, randomized trial design. A battery of psychomotor tests was administered before dosing and several times postdose over 4–6 h. Pharmacokinetic, sedation, and safety assessments were performed throughout the studies. FindingsAfter bolus infusion, the Bispectral Index score decreased in a concentration-dependent manner with HR-7056, accompanied by a sharp drop of Modified Observer's Assessment of Alertness/Sedation score. The recovery of consciousness was much faster with HR-7056 than with midazolam. During the constant rate infusion, the Bispectral Index score was maintained between 40 and 60 with an average plasma remimazolam concentration of ~1000 ng/mL. Subjects' performance in saccadic and smooth pursuit eye movement, body sway, test of choice reaction time, and word recall was significantly impaired after single-dose midazolam and after constant rate infusion of remimazolam. The end-of-infusion injection of flumazenil shortened the median time to full alertness to 3.5 min and effectively reversed psychomotor and cardiovascular dysfunction. ImplicationsThe study results showed quicker psychomotor recovery from sedation in the remimazolam-treated group. The moderate and short-lasting residual effect of remimazolam after 2-h conscious sedation proposes a need for psychomotor assessment(s) before hospital discharge. ClinicalTrials.gov identifiers: NCT01970072 and NCT03444480.