Standard Monitoring Research Articles

Real-world non-interventional post-authorization safety study of long-term use of burosumab in children and adolescents with X-linked hypophosphatemia: first interim analysis.

X-linked hypophosphatemia (XLH) is a rare, progressive disorder characterized by excess fibroblast growth factor 23 (FGF23), causing renal phosphate-wasting and impaired active vitamin D synthesis. Burosumab is a recombinant human monoclonal antibody that inhibits FGF23, restoring patient serum phosphate levels. Safety data on long-term burosumab treatment are currently limited. This post-authorization safety study (PASS) aims to monitor long-term safety outcomes in children and adolescents (1-17 years) treated with burosumab for XLH. This first interim analysis reports the initial PASS safety outcomes. A 10-year retrospective and prospective cohort study. This PASS utilizes International XLH Registry (NCT03193476) data, which includes standard diagnostic and monitoring practice data at participating European centers. At data cut-off (13 May 2021), 647 participants were included in the International XLH Registry; 367 were receiving burosumab, of which 67 provided consent to be included in the PASS. Mean (SD) follow-up time was 2.2 (1.0) years. Mean (SD) age was 7.3 (4.3) years (range 1.0-17.5 years). Mean duration of burosumab exposure was 29.7 (25.0) months. Overall, 25/67 participants (37.3%) experienced ⩾1 adverse event (AE) during follow-up; 83 AEs were reported. There were no deaths, no AEs leading to treatment withdrawal, nor serious AEs related to treatment. The most frequently reported AEs were classified as 'musculoskeletal and connective tissue disorders', with 'pain in extremity' most frequently reported, followed by 'infections and infestations', with 'tooth abscess' the most frequently reported. In this first interim analysis of the PASS, covering the initial 2 years of data collection, the safety profile of burosumab is consistent with previously reported safety data. The PASS will provide long-term safety data over its 10-year duration for healthcare providers and participants with XLH that contribute to improvements in the knowledge of burosumab safety. European Union electronic Register of Post-Authorisation Studies: EUPAS32190.

Optimizing caesarean section use and feasibility of implementing the Robson classification system: Perspectives of healthcare providers and policymakers.

In recent decades, caesarean section rates have increased dramatically worldwide and the reasons for this trend are not fully understood. This continuing trend has raised public health concerns regarding higher maternal and perinatal risks, high costs, healthcare efficiency, and inequality of services. The current study aimed to explore the perspectives and insights of healthcare providers and policymakers in the Israeli health system regarding the factors that drive caesarean section rates and the readiness and feasibility of implementing the Robson Ten Group Classification System for the first time. Semi-structured interviews were conducted (n = 12) with purposefully selected healthcare providers and policymakers in Israel. Data was analysed inductively using a thematic analysis approach. The findings reflected the "changing landscape" in childbirth practices and attitudes that contributes to the rising caesarean section rate, including childbirth at older ages, birth planning, and a transition toward a more collaborative decision-making approach to childbirth. The participants emphasized the lack of a standardized classification or consistent data monitoring of caesarean section in the Israeli health system. Additionally, enablers to implement the Robson Ten Group Classification System in Israel (ease of use, data collection and recording, and the allocation of resources and personnel), as well as barriers (concerns over workload, limited resources, budget implications, and technological complexity), were found. This study revealed the multifaceted factors shaping caesarean section rates within Israel and underscored the perceived need for evidence-based monitoring and informed decision-making in healthcare practices. Our findings support the conclusion that empirical evidence and clear data are crucial for effective caesarean section use and are currently lacking in Israeli hospitals. Thus, it is recommended to adopt a globally standardized, accepted, and effective tool-the Robson Ten Group Classification System-to accommodate the "changing landscape" in alignment with evolving medical and societal dynamics, which consequently will assist in optimizing caesarean section use.

Monitoring Memory B Cells by Next-Generation ImmunoSpot® Provides Insights into Humoral Immunity that Measurements of Circulating Antibodies Do Not Reveal.

Memory B cells (Bmem) provide the second wall of adaptive humoral host defense upon specific antigen rechallenge when the first wall, consisting of preformed antibodies originating from a preceding antibody response, fails. This is the case, as recently experienced with SARS-CoV-2 infections and previously with seasonal influenza, when levels of neutralizing antibodies decline or when variant viruses arise that evade such. While in these instances, reinfection can occur, in both scenarios, the rapid engagement of preexisting Bmem into the recall response can still confer immune protection. Bmem are known to play a critical role in host defense, yet their assessment has not become part of the standard immune monitoring repertoire. Here we describe a new generation of Bcell ELISPOT/FluoroSpot (collectively ImmunoSpot®) approaches suited to dissect, at single-cell resolution, the Bmem repertoire ex vivo, revealing its immunoglobulin class/subclass utilization, and its affinity distribution for the original, and for variant viruses/antigens. Because such comprehensive Bcell ImmunoSpot® tests can be performed with minimal cell material, are scalable, and robust, they promise to be well-suited for routine immune monitoring.

Reagent Tracker™ Platform Verifies and Provides Audit Trails for the Error-Free Implementation of T-Cell ImmunoSpot® Assays.

ELISPOT and FluoroSpot assays, collectively called ImmunoSpot assays, permit to reliable detection of rare antigen-specific T cells in freshly isolated cell material, such as peripheral blood mononuclear cells (PBMC). Establishing their frequency within all PBMC permits to assess the magnitude of antigen-specific T-cell immunity; the simultaneous measurement of their cytokine signatures reveals these T-cells' lineage and effector functions, that is, the quality of T-cell-mediated immunity. Because of their unparalleled sensitivity, ease of implementation, robustness, and frugality in PBMC utilization, T-cell ImmunoSpot assays are increasingly becoming part of the standard immune monitoring repertoire. For regulated workflows, stringent audit trails of the data generated are a requirement. While this has been fully accomplished for the analysis of T-cell ImmunoSpot assay results, such are missing for the wet laboratory implementation of the actual test performed. Here we introduce a solution for enhancing and verifying the error-free implementation of T-cell ImmunoSpot assays.

Comparison of Haemodynamic Stability and Early Recovery Characteristics of Desflurane versus Sevoflurane in Robotic Prostatectomy: A Randomised Clinical Study

Introduction: An ideal anaesthetic for robotic surgery would allow for a quick induction with minimal discomfort, as well as a short operation duration, quick recovery, and minimal aftereffects. Additionally, it would enable speedy recovery. Aim: To compare the haemodynamic stability and recovery characteristics of sevoflurane with desflurane for robotic surgery. Materials and Methods: The present randomised clinical study was conducted for four years from January 2019 to January 2023 and included 60 patients undergoing elective robotic radical prostatectomy and randomised into the group receiving desflurane (Group D) and that receiving sevoflurane (Group S). All patients were monitored using the Bispectral index (BIS) monitor, in addition to standard monitoring. General anaesthesia was administered using midazolam, fentanyl, propofol, atracurium, and either desflurane or sevoflurane based on the assigned group. Throughout the surgery, patients’ haemodynamic stability was monitored, and vital signs were recorded at induction, intubation, after assuming the Trendelenburg position, and at 30-minute intervals, until extubation. The inhalational agent was turned off at skin closure, and the time to spontaneous eye opening (T1), time to extubation (T2), and time to verbal response (T3) were noted. After the verbal response, patients were assessed based on the Modified Aldrete Score (MAS) with a threshold of ≥9. Pulse rate, blood pressure, BIS, and MAS were recorded during this time period. Data was presented as mean, frequency, and percentage. MAS comparison among the study groups was assessed using the Chi-square test. Demographic, haemodynamic, and BIS variables were compared using paired t-tests. Results: The mean age of patients in group S was 67.67±6.07 years, while in group D, it was 65.17±6.69 years. The time required for extubation after turning off the agent was significantly shorter in group-D compared to group-S, with a mean of 16.07±13.00 minutes in group-D and 21.71±9.07 minutes in group-S (p-value=0.0001). The percentage of patients achieving MAS >9 at five minutes was significantly higher in group D. Additionally, the use of both agents was not associated with any major complications. Conclusion: Desflurane as the inhalational agent ensures faster recovery in the early postoperative period and minimal changes in haemodynamic parameters compared to sevoflurane. However, sevoflurane has fewer complications compared to desflurane.

Defining role of atlantoaxial and subaxial spinal instability in the pathogenesis of cervical spinal degeneration: Experience with "only-fixation" without any decompression as treatment in 374 cases over 10 years.

The authors analyze their published work and update their experience with 374 cases of cervical radiculopathy and/or myelopathy related to spinal degeneration that includes ossification of the posterior longitudinal ligament (OPLL). The role of atlantoaxial and subaxial spinal instability as the nodal point of pathogenesis and focused target of surgical treatment is analyzed. During the period from June 2012 to November 2022, 374 patients presented with acute or chronic symptoms related to radiculopathy and/or myelopathy that were attributed to degenerative cervical spondylotic changes or due to OPLL. There were 339 males and 35 females, and their ages ranged from 39 to 77 years (average 62 years). All patients were treated for subaxial spinal stabilization by Camille's transarticular technique with the aim of arthrodesis of the treated segments. Atlantoaxial stabilization was done in 128 cases by adopting direct atlantoaxial fixation in 55 cases or a modified technique of indirect atlantoaxial fixation in 73 patients. Decompression by laminectomy, laminoplasty, corpectomy, discoidectomy, osteophyte resection, or manipulation of OPLL was not done in any case. Standard monitoring parameters, video recordings, and patient self-assessment scores formed the basis of clinical evaluation. During the follow-up period that ranged from 3 to 125 months (average: 59 months), all patients had clinical improvement. Of 130 patients who had clinical evidences of severe myelopathy and were either wheelchair or bed bound, 116 patients walked aided (23 patients), or unaided (93 patients) at the last follow-up. One patient in the series was operated on 24 months after the first surgery by anterior cervical route for "adjacent segment" disc herniation. No other patient in the entire series needed any kind of repeat or additional surgery for persistent, recurrent, increased, or additional related symptoms. None of the screws at any level backed out or broke. There were no implant-related infections. Spontaneous regression of the size of osteophytes was observed in 259 patients where a postoperative imaging was possible after at least 12 months of surgery. Our successful experience with only spinal fixation without any kind of "decompression" identifies the defining role of "instability" in the pathogenesis of spinal degeneration and its related symptoms. OPLL appears to be a secondary manifestation of chronic or longstanding spinal instability.

Photovoltaic inverter-based quantification of snow conditions and power loss

Snow is a significant challenge for photovoltaic (PV) systems at northern latitudes, where the pace of deployment is rapid but snow-related power losses can exceed 30% of annual production. Accurate snow-related power loss estimation methods for utility-scale sites can support snow mitigation strategies, inform resource planning and validate predictive snow-loss models. This study builds on our previous work on inverter-based detection of snow, and its implications for utility-scale power production, by validating the accuracy of our snow-loss method across different PV sites and system designs and highlighting its value in bringing greater visibility to PV plant operations in winter. Our estimation method is both novel and scalable, requiring only standard monitoring data to correlate snow-related losses with meteorological data. As demonstrated here, our validation method involved three main steps: 1) estimation of performance losses for multiple systems by comparing measured inverter data to modeled data; 2) application of a detection framework to identify which performance losses are snow-related; and 3) comparison of snow-related losses among three utility-scale sites differing in tilt angle. Results show that utility-scale systems at higher tilt angles consistently shed snow more quickly/completely than their lower-tilt counterparts. Further, monthly and seasonal snow losses are inversely and non-linearly correlated with tilt angle when normalized for cumulative snowfall. These results are consistent with the findings of previous studies and support the broad applicability of this method to fixed-tilt utility-scale PV systems around the world that routinely experience snow-related performance losses.

CONTROLLING AS A COMPONENT OF PROJECT MANAGEMENT IN AGRO-INDUSTRIAL PRODUCTION

The subject of the research is the study of controlling as an integral part of project management in agricultural production. Methodology. The study used general scientific methods, in particular: theoretical generalisation; methods of analysis and synthesis; statistical analysis; graphical method (for visual display of the study results). The article presents results of substantiation of expediency of application of controlling in management of agricultural production projects. Сonclusion. Project management controlling is an essential tool for achieving success and sustainability in the implementation of projects, carrying out systematic planning, control and analysis of economic activities at the level of the entire organisation. The cooperation between controlling and project management is crucial for the effectiveness and efficiency of projects, and the implementation of controlling is a strategic step to achieve common strategic goals and increase the sustainability of the activity. Project management in agriculture requires specific approaches, and controlling is vital to achieving successful results. The key aspects of controlling are financial monitoring, adaptation to seasonality and project cycles, quality and standards monitoring, risk management and consideration of environmental approaches. Five key elements of project management controlling in the agricultural sector determine the effectiveness of project implementation. The schedule allows for accurate resource planning and control over project execution. Effective resource management helps to stay within the budget, risk analysis helps to avoid negative impacts, change control prevents unexpected expansion of the project scope, and measuring performance against critical indicators allows to evaluate project performance. The system of controlling is manifested in the union of all subsystems and blocks of controlling, where their interaction is aimed at the strategic goals of the company. This approach takes into account the importance of system integration and alignment with strategic goals for successful business management.

Social and Psychological Long-Term Consequences of NMDA Receptor Encephalitis (SAPIENCE) - from patients’ views to patient-centred care

Background and target population: NMDA receptor encephalitis is a rare autoimmune disease with severe neurological and neuropsychiatric symptoms but typically a good functional neurological outcome. Nevertheless, most patients suffer long-term cognitive, psychological, and social impairments that have a significant impact on their well-being and occupational or educational activities-this is of particular concern given the young age of patients (median 21 years). However, because the disease was only recently discovered (2007), these psychosocial effects have not been systematically studied and the resulting impact on patients is not adequately appreciated. The SAPIENCE study is an international scientific project funded by the European Joint Program that aims to characterize the long-term cognitive and psychosocial consequences of this rare disease. The leader of the consortium is Prof. Carsten Finke, Charite Berlin. The Polish team, coordinated by Prof. Donata Kurpas, is responsible for the development of standard protocols, monitoring and training of staff in the study centers where the data are collected, and the corresponding qualitative data analysis.
 Study Design/Methods: Patients will be extensively studied at three European study sites in three consecutive project levels. Stage 1 includes in-depth on-site interviews and focus groups (n=30). Stage 2 develops a semi-structured short-form interview and includes on-site neuropsychological testing (n=150). Stage 3 includes an international online survey of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and disease progression information (n=300). Stages 1-3 will support each other in developing structured interviews, survey questions, and treatment guidelines.
 Results/Outcomes: At Level 1, we will identify themes and narratives that influence patients' quality of life and their experience of coping with the disease. At Level 2, we will identify neuropsychological outcomes in the largest cohort of NMDAR encephalitis patients in the world to date, including executive function, memory, and spatial navigation performance, which have been identified as key areas of impairment. At Level 3, we will examine subjective outcomes and individual predictors of post-acute disease progression.
 Based on Stages 1-3, we will develop international consensus guidelines for post-acute care of NMDARE patients.
 Impact: This project is the first to bridge the gap between standardized assessment and individual patient experience in the long-term follow-up of patients with autoimmune encephalitis. By incorporating the patient perspective into medical decision-making, current and future NMDAR encephalitis patients will benefit from the implementation of the diagnostic and treatment guidelines developed in this project for patient-centered post-acut

Monitoring the Cardiotoxic Effects of Bedaquiline in Older Children and Adolescents with Multiple and Extensive Drug Resistance

The objective: to evaluate expanded monitoring of cardiovascular disorders in older children and adolescents with multiple drug resistant tuberculosis receiving bedaquiline (Bq) as a part of anti-tuberculosis therapy.Subjects and Methods: A cohort retrospective-prospective study (2015-2021) was conducted, which included 36 patients aged 13-17 years old who received Bq. The prospective part included 19 patients (Main Group), they underwent extended monitoring (EM) of cardiotoxic reactions; this extended monitoring program was developed in Central Tuberculosis Research Institute. The retrospective part included 17 patients (Control Group), in whom cardiotoxic reactions were assessed using standard monitoring recommended by the Russian Society of Phthisiologists at that time. The relationship between the studied risk factor (monitoring by standard ECG) and the outcome (Bq discontinuation) was assessed using the Pearson χ2 test.Results. Prolongation of the QTc interval > 0.440 ms was noted in 17.6% of cases in Control Group and it was regarded as a cardiotoxic effect of Bq, the drug was discontinued. In Main Group, prolongation was noted in 47.3% of cases which was considered a functional disorder of the cardiovascular system according to EM, the drug was not discontinued, χ2 = 3.896; p = 0.049. EM can be used in older children and adolescents with multiple drug resistant respiratory tuberculosis, which will make it possible to safely include Bq to chemotherapy regimens.

What medical providers need to elevate outpatient care for adolescents and young adults with binge-eating disorder: A novel protocol.

Binge-eating disorder (BED) in adolescents and young adults is underrecognized and understudied and no standardized guidelines exist for medical providers caring for this population. To highlight the lack of extant evidence, we examine the demographic characteristics of youth with BED in an academic eating disorders (EDs) program and primary care clinic and describe the needs of their medical care providers. A retrospective chart review was conducted for patients who met criteria for BED from July 2021 to June 2022. We surveyed their medical providers to understand their needs in caring for this population. A multidisciplinary team with expertise in the care of youth with EDs amalgamated current evidence in caring for youth with BED into a protocolized care schema designed for implementation in the outpatient medical setting. Eighteen youth with BED were reviewed, 14 identified as female, 3 as male, and 1 as "Other." Average age was 15.4 (2.7) years old, and mean body mass index was 35.90 (8.25). 33.3% (6) patients identified as White/Caucasian, followed by 22.2% (4) Hispanic/Latinx. Eleven of 18 were privately insured. The most common medical recommendations were for regular meals and snacks and for individual psychotherapy. Medical providers desired more education about identification and management of youth with BED. To address the lack of medical care guidelines for youth with BED, recommendations in this Forum include: increased education for medical providers, standardized medical monitoring, an emphasis on psychotherapy, and a weight-inclusive orientation. Adolescents and young adults with BED are underrecognized and undertreated. Little is known about the characteristics of these patients and the medical care these patients receive within academic EDs program. For the first time, preliminary recommendations for medical care are provided.

Literature review on the need for a protocol for hemodynamic monitoring of critical patients in Ecuador

The proper management of critically ill patients, especially in terms of cardiovascular system handling and homeostasis, requires efficient hemodynamic monitoring. Although countries such as Spain and Argentina have developed advanced programs for monitoring these alterations, Ecuador lacks a standardized protocol in this area, limiting the ability to provide optimal care. This study aimed to demonstrate the importance of establishing a specific protocol for the hemodynamic monitoring of critically ill patients in Ecuador. Through an extensive bibliographic review using various sources such as Google Scholar, institutional repositories of UNIANDES and the Technical University of Ambato, as well as databases like Scielo, Elsevier, Medline, and Pubmed, relevant information was collected and analyzed. The results highlighted the critical relevance of hemodynamic monitoring to detect early alterations in the cardiovascular function of critically ill patients, significantly improving clinical outcomes through timely and appropriate interventions. Implementing a hemodynamic monitoring protocol would not only improve the safety and prognosis of these patients but also provide a basis for more informed clinical decision-making. In conclusion, the study emphasizes the urgent need to develop and adopt a standardized hemodynamic monitoring protocol in Ecuador, with the aim of optimizing care and improving health outcomes in critically ill patients, especially in the context of challenges such as COVID-19 and future pandemics

Measuring magnetic susceptibility of particulate matter collected on filters

The magnetic susceptibility (κ) of particulate matter (PM) is a useful tool in estimation concentration of iron-rich particles and provides useful information on the emission sources and pathways of spread of PM in the atmosphere. However, there is currently no established protocol for measuring the magnetic susceptibility of PM collected on filters used in standard monitoring of PM concentration. This paper presents a step-by-step process for collecting PM on filters in automatic samplers and measuring their κ. The procedure outlines requirements for data quality, measurement uncertainty, exposure time and conditions, and the amount of material collected on the filters. The study analyzed a 2-year dataset of magnetic susceptibility measurements by MFK-1 kappabridge (Agico, Czech Republic) for PM10 and PM2.5 collected at two locations, Warsaw and Cracow, in Poland using low-volume PM samplers. By strictly following the procedure for conditioning filters, measuring magnetic susceptibility and mass of PM, the study found that it is possible to obtain repeatable data with good measurement accuracy and acceptable errors. This makes magnetic susceptibility an additional reliable parameter for tracking of emission sources of iron-rich particles. Successful implementation of this magnetic method as a standard procedure for monitoring PM in addition to the PM mass collected on filters could be used to analyze sources of emission of Fe-particles and their contribution to the PM mass, especially in urban and industrial environments.

Discussion on How to Improve Food Safety and Quality

China's food safety quality control system is not sound, the relevant laws and regulations are not perfect, and it is difficult to carry out hazard evaluation. A traceability system has not yet been established, food quality and safety are unsatisfactory, and poisoning incidents occur from time to time. The serious situation urgently requires China to build a scientific and standardized quality and safety monitoring system as soon as possible to ensure that China's food safety meets the needs of the national economy and people's healthy lives.

How NIRS can predict the outcome of patient in low systemic pressure: a case series

Mitral valve replacement (MVR) is a surgical procedure to treat mitral regurgitation (MR). As there is an increase in the afterload in the postoperative period, patients tend to have low cardiac output syndrome. This condition may limit oxygen delivery to body tissues. Improved venous saturation has been linked to positive neurological outcomes. Near-infrared spectroscopy (NIRS) is the new technique to monitor regional oxygenation in real time. This study reports on four patients who underwent MVR due to a combination of severe mitral stenosis (MS) and mild MR. All patients had complaints of dyspnea on exertion to unbearable chest pain. Physical and work-up examination led to a diagnosis of decompensated heart failure, concomitant valve disorder, fluid overload, and cardiomegaly. Preoperative catheterization to stratify the risks of the procedure was done on all four patients. The surgery planned was cardiopulmonary bypass (CPB) with standard monitoring and additional NIRS measurement. The measurement of mean arterial pressure (MAP) and NIRS were tightly monitored and maintained in each patient, with the use of vasoactive agents. All four patients suffered unstable hemodynamics and were admitted to intensive care unit with the support of mechanical ventilation and other supportive therapies. Cerebral perfusion can reach the baseline normal value even though in low cardiac output syndrome, and NIRS can predict the outcome of the patients better than the conservative monitoring.
 Key words: CPB; Low Systemic Pressure; Cerebral perfusion; Mitral Valve Replacement; NIRS.
 Citation: Purwoko, Permana SA, Dewi FH, Prihandana PA. How NIRS can predict the outcome of patient in low systemic pressure: a case series. Anaesth. pain intensive care 2023;27(6):757−762; DOI: 10.35975/apic.v27i6.2350
 Received: May 29, 2023; Reviewed: September 20, 2023; Accepted: October 30, 2023

CURRENT PROBLEMS OF IMPLEMENTATION OF MONITORING MEASURES ON THE QUALITY OF EDUCATION IN A TEACHING UNIVERSITY

The essence of the phenomenon of monitoring the quality of education is revealed, which is considered as a research process that requires constant and standardized monitoring of various aspects of the provision of educational services; analysis of received information to identify changes and prevent the occurrence of negative phenomena; regular evaluation and forecasting of the further development of the higher education system. The peculiarities of monitoring the quality of education in institutions of higher education are traced using the example of internal and external monitoring at the Poltava National Pedagogical University named after V.G. Korolenko in accordance with the general goals of the strategic priorities of the institution's development. It is noted that the analysis of monitoring results allows to monitor the real situation of educational activity in the institution of higher education, to forecast its improvement, to make managerial decisions regarding the correction of selected strategies for ensuring the quality of the educational process.
 Attention is focused on the principles of monitoring the quality of education. The need to develop for higher education institutions, along with general, local principles that reflect the specifics of these institutions and the professional competencies that are formed by them, is substantiated. The authors propose to introduce as a local principle of monitoring the quality of education in pedagogical higher education institutions the principle of its professionally determined organization, which means an orientation towards increasing the subjectivity of the students of pedagogical education in the course of monitoring, expanding the forms of their participation in it. In this way, monitoring the quality of education, in addition to its direct purpose, acquires the essence of another resource for the formation of the professional competence of the future teacher in practical personally and professionally significant activities.

The Role of Invasive Hemodynamic Monitoring in Patients with Severe Mitral Regurgitation Undergoing Herniorrhaphy Operation

Background: Mitral regurgitation (MR) indeed presents challenges during noncardiac surgeries, especially as the severity of MR tends to increase with age and poses a higher risk of perioperative complications. Accurate hemodynamic monitoring becomes crucial in these cases to manage potential complications effectively. However, the standard monitoring in MR conditions during operation, such as TEE, is not always available, but there are other options for invasive monitoring, such as arterial lines, which provide accurate hemodynamic monitoring.
 Case presentation: A 64-year-old, male, presented with Reponible Lateral Inguinal Hernia with comorbid of severe mitral and tricuspid regurgitation alongside congestive heart failure. The patient was premedicated with fentanyl 25 mcg intravenously, followed by oxygen supplementation with 3 lpm nasal cannula and insertion of the arterial line. Anaesthesia was performed using a lumbar epidural technique, with the insertion of an epidural catheter in the L1-L2 intervertebral space, Reponible Lateral Inguinal Hernia. The local anesthesia agent chosen was plain bupivacaine with a concentration of 0.5% and a volume of 8 ml. The onset of action of epidural anesthesia is achieved within 20 minutes as long as the operation reaches a total blockade as high as T8. The patient is monitored with standard monitors and an artery line during surgery. There were no complaints of shortness of breath, chest heaviness, or chest pain felt by the patient during the operation.
 Conclusion: Epidural anesthesia technique can provide stable hemodynamics in patients with severe mitral-tricuspid regurgitation and congestive heart failure and hemodynamic monitoring plays an important role postoperatively to prevent further deterioration and maintain stability.

Research on the application of electroencephalogram-derived bispectral index in cardiac surgery

Monitoring the depth of anesthesia during cardiac surgery is a complex and difficult task. Alongside the conventional standard and advanced monitoring instruments, the EEG bispectral index (BIS) has proven more effective in reducing intraoperative consciousness incidents. Additionally, it offers the benefits of diminishing the requirement for anesthetic drugs and detecting cerebral ischemia. Nevertheless, pertinent evidence indicates that BIS requires improvement in various clinical scenarios. This article provides a comprehensive introduction to the principles of BIS, deliberates on the pros and cons of its clinical application, and explores methods for enhancing its efficacy. BIS fits an optimal number by fitting the mixed information from the EEG. It is widely used in drug application, depth monitoring of anesthesia and evaluation of consciousness state, but low temperature, electronic interference, and systematic error will affect it, and the standardized use and application of new technology will help to enhance its efficacy.

The Influence of the International Labour Organization on International Law and State Practice: An Analytical Study

This study aims to provide a comprehensive examination of the International Labour Organization's (ILO) institutionalization of international labour standards and its significant impact on the development of international law. It commences with a historical exploration of the ILO, emphasizing the crucial role of its tripartite structure in establishing and overseeing international labour standards, including the fundamental principles and rights at work. The study highlights the positive effects of these standards on the social and economic welfare of workers. Additionally, it delves into the essential ILO conventions and declarations, shedding light on the significance of “soft law” instruments, such as widely adopted ILO recommendations. The study also investigates the ILO's collaborations with other United Nations agencies and regional organizations, illustrating its effective role in promoting the implementation and monitoring of international labour standards, specifically in the context of Saudi Arabia. In summary, this study argues that the ILO has played a substantial role in formulating fundamental international labour standards that encompass economic, social, and cultural rights, as well as the eradication of workforce discrimination, predating the United Nations’ human rights framework. It underscores the ILO’s pioneering efforts in recognizing labour rights as human rights and its active promotion of social justice and the economic well-being of workers worldwide. Through its comprehensive analysis, this study underscores the importance and influence of the ILO's work within the realm of international law. keywords: International law, international labour organisation, international labour standards, decent work, social justice, Saudi Arabia

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum.

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.