PLOS ONE: [sortOrder=DATE_NEWEST_FIRST, from=editorLink, sort=Relevance, q=editor:"Mercedes Susan Mandell"]PLOShttps://journals.plos.org/plosone/webmaster@plos.orgaccelerating the publication of peer-reviewed sciencehttps://journals.plos.org/plosone/search/feed/atom?sortOrder=DATE_NEWEST_FIRST&unformattedQuery=editor:%22Mercedes%20Susan%20Mandell%22&from=editorLink&sort=RelevanceAll PLOS articles are Open Access.https://journals.plos.org/plosone/resource/img/favicon.icohttps://journals.plos.org/plosone/resource/img/favicon.ico2024-03-28T22:10:35ZRegional anesthesia educational material utilization varies by World Bank income category: A mobile health application data studyVanessa MollEdward R. MarianoJamie M. KitzmanVikas N. O'Reilly-ShahCraig S. Jabaley10.1371/journal.pone.02448602021-02-01T14:00:00Z2021-02-01T14:00:00Z<p>by Vanessa Moll, Edward R. Mariano, Jamie M. Kitzman, Vikas N. O'Reilly-Shah, Craig S. Jabaley</p>
Introduction <p>Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level.</p> Methods <p>We retrospectively analyzed data collected from the free Android app “Anesthesiologist” from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block).</p> Results <p>Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic.</p> Conclusion <p>The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.</p>Anesthesia during deployment of a military forward surgical unit in low income countries: A register study of 1547 anesthesia casesQuentin MathaisAmbroise MontcriolJean CotteCéline GilClaire ContargyrisGuillaume LacroixBertrand PrunetJulien BordesEric Meaudre10.1371/journal.pone.02234972019-10-04T14:00:00Z2019-10-04T14:00:00Z<p>by Quentin Mathais, Ambroise Montcriol, Jean Cotte, Céline Gil, Claire Contargyris, Guillaume Lacroix, Bertrand Prunet, Julien Bordes, Eric Meaudre</p>
Background <p>Military anesthesia meets unique logistical, technical, tactical, and human constraints, but to date limited data have been published on anesthesia management during military operations.</p> Objective <p>This study aimed to describe and analyze French anesthetic activity in a deployed military setting.</p> Methods <p>Between October 2015 and February 2018, all patients managed by Sainte-Anne Military Hospital anesthesiologists deployed in mission were included. Anesthesia management was described and compared with the same surgical procedures in France performed by the same anesthesia team (hernia repair, lower and upper limb surgeries). Demographics, type of surgical procedure, and surgical activity were also described. The primary endpoint was to describe anesthesia management during the deployment of forward surgical teams (FST). The secondary endpoint was to compare anesthesia modalities during FST deployment with those usually used in a military teaching hospital.</p> Results <p>During the study period, 1547 instances of anesthesia were performed by 11 anesthesiologists during 20 missions, totaling 1237 days of deployment in nine different theaters. The majority consisted of regional anesthesia, alone (43.5%) or associated with general anesthesia (21%). Compared with France, there was a statistically significant increase in the use of regional anesthesia in hernia repair, lower and upper limb surgeries during deployment. The majority of patients were civilians as part of medical support to populations.</p> Conclusion <p>In the context of an austere environment, the use of regional anesthesia techniques predominated when possible. These results show that the training of military anesthetists must be complete, including anesthesia, intensive care, pediatrics, and regional anesthesia.</p>Use of rapid Model for End-Stage Liver Disease (MELD) increases for liver transplant registrant prioritization after MELD-Na and Share 35, an evaluation using data from the United Network for Organ SharingGuy N. BrockKenneth WashburnMichael R. Marvin10.1371/journal.pone.02230532019-10-03T14:00:00Z2019-10-03T14:00:00Z<p>by Guy N. Brock, Kenneth Washburn, Michael R. Marvin</p>
The Model for End-Stage Liver Disease (MELD) score has been successfully used to prioritize patients on the United States liver transplant waiting list since its adoption in 2002. The United Network for Organ Sharing (UNOS)/Organ Procurement Transplantation Network (OPTN) allocation policy has evolved over the years, and notable recent changes include Share 35, inclusion of serum sodium in the MELD score, and a ‘delay and cap’ policy for hepatocellular carcinoma (HCC) patients. We explored the potential of a registrant’s change in 30-day MELD scores (ΔMELD<sub>30</sub>) to improve allocation both before and after these policy changes. Current MELD and ΔMELD<sub>30</sub> were evaluated using cause-specific hazards models for waitlist dropout based on US liver transplant registrants added to the waitlist between 06/30/2003 and 6/30/2013. Two composite scores were constructed and then evaluated on UNOS data spanning the current policy era (01/02/2016 to 09/07/2018). Predictive accuracy was evaluated using the C-index for model discrimination and by comparing observed and predicted waitlist dropout probabilities for model calibration. After the change to MELD-Na, increased dropout associated with ΔMELD<sub>30</sub> jumps is no longer evident at MELD scores below 30. However, the adoption of Share 35 has potentially resulted in discrepancies in waitlist dropout for patients with sharp MELD increases at higher MELD scores. Use of the ΔMELD<sub>30</sub> to add additional points or serve as a potential tiebreaker for patients with rapid deterioration may extend the benefit of Share 35 to better include those in most critical need.Biophotonic detection of high order chromatin alterations in field carcinogenesis predicts risk of future hepatocellular carcinoma: A pilot studyRichard KalmanAndrew StawarzDavid NunesDi ZhangMart A. Dela CruzArpan MohantyHariharan SubramanianVadim BackmanHemant K. Roy10.1371/journal.pone.01974272018-05-17T14:00:00Z2018-05-17T14:00:00Z<p>by Richard Kalman, Andrew Stawarz, David Nunes, Di Zhang, Mart A. Dela Cruz, Arpan Mohanty, Hariharan Subramanian, Vadim Backman, Hemant K. Roy</p>
Purpose <p>Hepatocellular carcinoma (HCC) results from chronic inflammation/cirrhosis. Unfortunately, despite use of radiological/serological screening techniques, HCC ranks as a leading cause of cancer deaths. Our group has used alterations in high order chromatin as a marker for field carcinogenesis and hence risk for a variety of cancers (including colon, lung, prostate, ovarian, esophageal). In this study we wanted to address whether these chromatin alterations occur in HCC and if it could be used for risk stratification.</p> Experimental design <p>A case control study was performed in patients with cirrhosis who went on to develop HCC and patients with cirrhosis who did not develop cancer. We performed partial wave spectroscopic microscopy (PWS) which measures nanoscale alterations on formalin fixed deparaffinized liver biopsy specimens, 17 progressors and 26 non-progressors. Follow up was 2089 and 2892 days, respectively.</p> Results <p>PWS parameter disorder strength <i>L</i><sub>d</sub> were notably higher for the progressors (<i>L</i><sub>d</sub> = 1.47 ± 0.76) than the non-progressors (<i>L</i><sub>d</sub> = 1.00 ± 0.27) (p = 0.024). Overall, the Cohen’s d effect size was 0.907 (90.7%). AUROC analysis yielded an area of 0.70. There was no evidence of confounding by gender, age, BMI, smoking status and race.</p> Conclusions <p>High order chromatin alterations, as detected by PWS, is altered in pre-malignant hepatocytes with cirrhosis and may predict future risk of HCC.</p>Preoperative cardiac troponin level is associated with all-cause mortality of liver transplantation recipientsJungchan ParkSeung Hwa LeeSangbin HanHyun Sook JeeSuk-Koo LeeGyu-Seong ChoiGaab Soo Kim10.1371/journal.pone.01778382017-05-23T14:00:00Z2017-05-23T14:00:00Z<p>by Jungchan Park, Seung Hwa Lee, Sangbin Han, Hyun Sook Jee, Suk-Koo Lee, Gyu-Seong Choi, Gaab Soo Kim</p>
This study was aimed to evaluate the association between preoperative high-sensitivity cardiac troponin I (hs-cTnI) level and mortality in patients undergoing liver transplantation (LT). From January 2011 to May 2016, preoperative hs-cTnI level was measured in consecutive 487 patients scheduled for LT. Patients with elevated preoperative hs-cTnI were compared with those who had normal level. The primary outcome was all-cause death in follow-up period of 30 days to 1 year after operation. Of the 487 patients, 58 (11.9%) had elevated preoperative hs-cTnI and 429 (88.1%) had normal preoperative hs-cTnI. In multivariate analysis, the rate of 1-year mortality and 30-day mortality were higher in elevated preoperative hs-cTnI group (hazard ratio [HR], 3.69; confidence interval [CI] 95%, 1.83–7.42; p < 0.001, HR, 6.61; CI, 1.91–22.82; p = 0.003, respectively). After adjustment with inverse probability weighting (IPW), the incidence of 1-year mortality and 30-day mortality were higher in elevated group (HR, 4.66; CI, 3.56–6.1; p < 0.001, HR, 10.31; CI, 6.39–16.66; p < 0.001, respectively). In conclusion, this study showed that in patients who underwent LT, elevation of preoperative hs-cTnI level was associated with 1-year mortality and 30-day mortality.The Humidity in a Low-Flow Dräger Fabius Anesthesia Workstation with or without Thermal Insulation or a Heat and Moisture Exchanger: A Prospective Randomized Clinical TrialSergius A. R. de OliveiraLorena M. C. LucioNorma S. P. ModoloYoko HayashiMariana G. BrazLídia R. de CarvalhoLeandro G. BrazJosé Reinaldo C. Braz10.1371/journal.pone.01707232017-01-27T14:00:00Z2017-01-27T14:00:00Z<p>by Sergius A. R. de Oliveira, Lorena M. C. Lucio, Norma S. P. Modolo, Yoko Hayashi, Mariana G. Braz, Lídia R. de Carvalho, Leandro G. Braz, José Reinaldo C. Braz</p>
Background <p>During anesthesia, as compared with intensive care, the time of the tracheal intubation is much shorter. An inhaled gas minimum humidity of 20 mgH<sub>2</sub>O.L<sup>-1</sup> is recommended to reduce the deleterious effects of dry gas on the airways during anesthesia with tracheal intubation. The Fabius GS Premium® anesthesia workstation (Dräger Medical, Lübeck, Germany) has a built-in hotplate to heat gases in the breathing circuit. A heat and moisture exchanger (HME) is used to further heat and humidify the inhaled gas. The humidity of the gases in the breathing circuit is influenced by the ambient temperature. We compared the humidity of the inhaled gases from a low-flow Fabius anesthesia workstation with or without thermal insulation (TI) of the breathing circuit and with or without an HME.</p> Methods <p>We conducted a prospective randomized trial in 41 adult female patients who underwent elective abdominal surgery. The patients were allocated into four groups according to the devices used to ventilate their lungs using a Dräger Fabius anesthesia workstation with a low gas flow (1 L.min<sup>-1</sup>): control, with TI, with an HME or with TI and an HME (TIHME). The mean temperature and humidity of the inhaled gases were measured during 2-h after connecting the patients to the breathing circuit.</p> Results <p>The mean inhaled gas temperature and absolute humidity were higher in the HME (29.2±1.3°C; 28.1±2.3 mgH<sub>2</sub>O·L<sup>-1</sup>) and TIHME (30.1±1.2°C; 29.4±2.0 mgH<sub>2</sub>O·L<sup>-1</sup>) groups compared with the control (27.5±1.0°C; 25.0±1.8 mgH<sub>2</sub>O·L<sup>-1</sup>) and TI (27.2±1.1°C; 24.9±1.8 mgH<sub>2</sub>O·L<sup>-1</sup>) groups (<i>P</i> = 0.003 and <i>P</i><0.001, respectively).</p> Conclusions <p>The low-flow Fabius GS Premium breathing circuit provides the minimum humidity level of inhaled gases to avoid damage to the tracheobronchial epithelia during anesthesia. TI of the breathing circuit does not increase the humidity of the inhaled gases, whereas inserting an HME increases the moisture of the inhaled gases closer to physiological values.</p>The Cost of War on Public Health: An Exploratory Method for Understanding the Impact of Conflict on Public Health in Sri LankaSandy A. Johnson10.1371/journal.pone.01666742017-01-12T14:00:00Z2017-01-12T14:00:00Z<p>by Sandy A. Johnson</p>
Purpose <p>The direct impact of protracted conflict on population health and development is well understood. However, the extent of a war's impact on long-term health, and the opportunity costs, are less well understood. This research sought to overcome this gap by asking whether or not health outcomes in Sri Lanka would have been better in the absence of a 26-year war than they were in the presence of war.</p> Methods <p>A counterfactual model of national and district-level health outcomes was created for Sri Lanka for the period 1982 to 2002. At the national level, the model examined life expectancy, infant mortality rate (IMR), and maternal mortality ratios (MMR). At the district level, it looked at IMR and MMR. The model compared outcomes generated by the counterfactual model to actual obtained health outcomes. It looked at the rate of change and absolute values.</p> Results <p>The analysis demonstrated that war altered both rate of change and absolute health outcomes for the worse. The impact was most clearly evident at the district level. IMR was poorer than predicted in 10 districts; of these 8 were outside of the conflict zone. The MMR was worse than expected in 11 districts of which 9 were not in the conflict zone. Additionally, the rate of improvement in IMR slowed as a result of war in 16 districts whereas the rate of improvement in MMR slowed in 9.</p> Conclusion <p>This project showed that protracted conflict degraded the trajectory of public health in Sri Lanka and hurt population health outside of the conflict zone. It further provided a novel methodology with which to better understand the indirect impact of conflict on population health by comparing what is to what could have been achieved in the absence of war. In so doing, this research responded to two public health challenges by providing a tool through which to better understand the human and opportunity costs of war and by answering a call for new methodologies.</p>Retrospective Review of the Anaesthetic Management of Maxillectomies and Mandibulectomies for Benign Tumours in Sub-Saharan AfricaMichelle C. WhiteKatherine C. HornerPeggy S. Lai10.1371/journal.pone.01650902016-10-27T14:00:00Z2016-10-27T14:00:00Z<p>by Michelle C. White, Katherine C. Horner, Peggy S. Lai</p>
Background <p>Safe anaesthesia is a crucial component of safe surgical care, yet anaesthetic complications are common in resource-limited settings. We describe differences in anaesthetic needs for Mandibulectomy vs. Maxillectomy in three sub-Saharan African countries.</p> Materials and Methods <p>Retrospective review of patients undergoing minor Mandibulectomy, major Mandibulectomy, or Maxillectomy in Togo, Guinea and Republic of the Congo. Surgeries were performed on the <i>Africa Mercy</i>, an international non-governmental hospital ship. Primary outcomes were need for advanced airway management and intra-operative blood loss. Secondary outcomes were time under general anaesthesia and hospital length of stay. Multivariate regression determined the association between operation type and each outcome measure.</p> Results <p>105 patients were included (25 minor Mandibulectomy, 58 major Mandibulectomy, 22 Maxillectomy procedures). In-hospital mortality was 0%. 44/105 (41.9%) required an advanced airway management technique to achieve intubation, although in all cases this was anticipated prior to the procedure; no differences were noted between surgical procedure (p = 0.72). Operative procedure was a significant risk factor for intra-operative blood loss. Patients undergoing Maxillectomy lost on average 851.5 (413.3, 1289.8, p = 0.0003) mL more blood than patients undergoing minor Mandibulectomy, and 507.3 (150.3, 864.3, p = 0.007) mL more blood than patients undergoing major Mandibulectomy. Patients undergoing Maxillectomy had a significantly higher time under general anaesthesia than those undergoing minor Mandibulectomy. There was no significant difference in hospital length of stay between operation type.</p> Conclusion <p>Anaesthetic considerations for minor Mandibulectomy, major Mandibulectomy, and Maxillectomy differ with respect to intra-operative blood loss and time under general anaesthesia, but not need for advanced airway management or length of stay. Although advanced airway management was required in 41.9% of patients, there were no unanticipated difficult airways. With appropriate training and resources, safe anaesthesia can be delivered to patients from low-income countries requiring major head and neck surgery.</p>Building a 3D Virtual Liver: Methods for Simulating Blood Flow and Hepatic Clearance on 3D StructuresDiana WhiteDennis CoombeVahid RezaniaJack Tuszynski10.1371/journal.pone.01622152016-09-20T14:00:00Z2016-09-20T14:00:00Z<p>by Diana White, Dennis Coombe, Vahid Rezania, Jack Tuszynski</p>
In this paper, we develop a spatio-temporal modeling approach to describe blood and drug flow, as well as drug uptake and elimination, on an approximation of the liver. Extending on previously developed computational approaches, we generate an approximation of a liver, which consists of a portal and hepatic vein vasculature structure, embedded in the surrounding liver tissue. The vasculature is generated via constrained constructive optimization, and then converted to a spatial grid of a selected grid size. Estimates for surrounding upscaled lobule tissue properties are then presented appropriate to the same grid size. Simulation of fluid flow and drug metabolism (hepatic clearance) are completed using discretized forms of the relevant convective-diffusive-reactive partial differential equations for these processes. This results in a single stage, uniformly consistent method to simulate equations for blood and drug flow, as well as drug metabolism, on a 3D structure representative of a liver.Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid AnalgesiaSabry AyadRovnat BabazadeHesham ElsharkawyVinayak NadarChetan LokhandeNatalya MakarovaRashi KhannaDaniel I. SesslerAlparslan Turan10.1371/journal.pone.01536752016-04-15T14:00:00Z2016-04-15T14:00:00Z<p>by Sabry Ayad, Rovnat Babazade, Hesham Elsharkawy, Vinayak Nadar, Chetan Lokhande, Natalya Makarova, Rashi Khanna, Daniel I. Sessler, Alparslan Turan</p>
Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.Copeptin as an Indicator of Hemodynamic Derangement and Prognosis in Liver CirrhosisAnnarein J. C. KerbertLen VerbekeFang W. T. ChiangWim LalemanJohan J. van der ReijdenWim van DuijnFrederik NevensRon WolterbeekBart van HoekHein W. VerspagetMinneke J. Coenraad10.1371/journal.pone.01382642015-09-17T14:00:00Z2015-09-17T14:00:00Z<p>by Annarein J. C. Kerbert, Len Verbeke, Fang W. T. Chiang, Wim Laleman, Johan J. van der Reijden, Wim van Duijn, Frederik Nevens, Ron Wolterbeek, Bart van Hoek, Hein W. Verspaget, Minneke J. Coenraad</p>
Background <p>Advanced liver cirrhosis is associated with systemic hemodynamic derangement leading to the development of severe complications associated with increased mortality. Copeptin is a stable cleavage product of the precursor of arginine vasopressin, a key-regulator in hemodynamic homeostasis. Copeptin is currently considered a reliable prognostic marker in a wide variety of diseases other than cirrhosis. The present study aimed to assess copeptin, both experimentally and clinically, as a potential biomarker of hemodynamic derangement and to evaluate its prognostic significance in cirrhosis.</p> Materials and Methods <p>Two studies were executed: 1) in 18 thioacetamide-induced cirrhotic rats and 5 control rats, plasma copeptin and hemodynamic measurements were performed, 2) in 61 cirrhotic patients, serum copeptin concentration was measured in samples collected at time of registration at the waiting list for liver transplantation. In 46 patients, also a second copeptin measurement was performed during follow-up while registered at the waiting list for liver transplantation. To determine the association of serum copeptin and clinical data with outcome, Cox proportional hazard regression analysis and Kaplan Meier analysis were performed.</p> Results <p>Plasma copeptin concentration was significantly higher in cirrhotic rats than in controls (1.6 ± 0.5 vs. 0.9 ± 0.1 pmol/L, p< 0.01) and was negatively correlated to the mean arterial blood pressure (r = -0.574, p = 0.013). In cirrhotic patients, serum copeptin concentration was high [11.0 (5.2–24.0) pmol/L] and increased significantly during the time of registration at the waiting list for liver transplantation. MELD and MELD-sodium score were significantly correlated to serum copeptin [MELD: (r = 0.33, p = 0.01), MELD-sodium: (r = 0.29, p = 0.02)], also at time of the second copeptin measurement [MELD and MELD-sodium: r = 0.39, p< 0.01]. In cirrhotic humans, serum copeptin concentration was significantly associated with outcome, independently of the MELD and MELD-sodium score. Patients with a low serum copeptin concentration at time of registration at the liver transplant waiting list had significantly better transplant-free survival rates at 3, 6 and 12 months of follow-up as compared to those with a high serum copeptin concentration (Log-rank: p< 0.01, p< 0.01 and p = 0.02 respectively).</p> Conclusions <p>Circulating copeptin levels are elevated in rats and humans with cirrhosis. Copeptin is independently associated with outcome in cirrhotic patients awaiting liver transplantation.</p>Changes in Surgical Site Infections after Living Donor Liver TransplantationMasaki YamamotoShunji TakakuraYoshitsugu IinumaGo HottaYasufumi MatsumuraAki MatsushimaMiki NagaoKohei OgawaYasuhiro FujimotoAkira MoriYasuhiro OguraToshimi KaidoShinji UemotoSatoshi Ichiyama10.1371/journal.pone.01365592015-08-31T14:00:00Z2015-08-31T14:00:00Z<p>by Masaki Yamamoto, Shunji Takakura, Yoshitsugu Iinuma, Go Hotta, Yasufumi Matsumura, Aki Matsushima, Miki Nagao, Kohei Ogawa, Yasuhiro Fujimoto, Akira Mori, Yasuhiro Ogura, Toshimi Kaido, Shinji Uemoto, Satoshi Ichiyama</p>
Surgical site infections (SSIs) are a major threat for liver transplant recipients. We prospectively studied SSIs after living donor liver transplantation (LDLT) at Kyoto University Hospital from April 2001 to March 2002 (1<sup>st</sup> period) and from January 2011 to June 2012 (2<sup>nd</sup> period). We investigated the epidemiology of SSIs after LDLT and determined the differences between the two periods. A total of 129 adult recipients (66 during the 1<sup>st</sup> period and 63 during the 2<sup>nd</sup> period) and 72 pediatric recipients (39 and 33) were included in this study. The SSI rates for each period were 30.3% (1<sup>st</sup> period) and 41.3% (2<sup>nd</sup> period) among the adult recipients and 25.6% and 30.3% among the pediatric recipients. The overall rates of 30-day mortality among adult transplant recipients with SSIs were 10.0% (1<sup>st</sup> period) and 3.9% (2<sup>nd</sup> period). No pediatric recipient died from SSIs after LDLT in either period. The incidence of <i>Enterococcus faecium</i> increased from 5.0% to 26.9% in the adults and from 10.0% to 40.0% in the pediatric patients. Extended-spectrum β-lactamase-producing Enterobacteriaceae were emerging important isolates during the 2<sup>nd</sup> period. For this period, a univariate analysis showed that ABO incompatibility (<i>P</i> = 0.02), total operation duration (<i>P</i> = 0.01), graft-to-recipient body weight ratio (GRWR [<i>P</i> = 0.04]), and Roux-en-Y biliary reconstruction (<i>P</i><0.01) in the adults and age (<i>P</i> = 0.01) and NHSN risk index (<i>P</i> = 0.02) in the children were associated with SSI development. In a multivariate analysis, lower GRWR (<i>P</i> = 0.02) and Roux-en-Y biliary reconstruction (<i>P</i><0.01) in the adults and older age (<i>P</i> = 0.01) in the children were independent risk factors for SSIs during the 2<sup>nd</sup> period. In conclusion, SSIs caused by antibiotic resistant bacteria may become a major concern. Lower GRWR and Roux-en-Y biliary reconstruction among adult LDLT recipients and older age among pediatric LDLT recipients increased the risk of developing SSIs after LDLT.Comparison of the I-Gel and the Laryngeal Mask Airway Proseal during General Anesthesia: A Systematic Review and Meta-AnalysisSun Kyung ParkGeun Joo ChoiYun Suk ChoiEun Jin AhnHyun Kang10.1371/journal.pone.01194692015-03-26T14:00:00Z2015-03-26T14:00:00Z<p>by Sun Kyung Park, Geun Joo Choi, Yun Suk Choi, Eun Jin Ahn, Hyun Kang</p>
Objectives <p>Conflicting results have been reported for the i-gel and the laryngeal mask airway proseal (LMA-P) during general anesthesia. The objective of the current investigation was to compare the efficacy and safety of the i-gel vs. the LMA-P during general anesthesia.</p> Methods <p>Two authors performed searches of MEDLINE, EMBASE, CENTRAL, and Google Scholar to identify randomized clinical trials that compared the LMA-P with the i-gel during general anesthesia. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg's funnel plot and Egger's linear regression test.</p> Results <p>Twelve randomized clinical trials met the eligibility criteria. There were no significant differences in insertion success rate at the first attempt (risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97, 1.06), ease of insertion (RR 1.14, 95% CI 0.93, 1.39), oropharyngeal leak pressure (OLP) (MD -1.98, 95% CI -5.41, 1.45), quality of fiberoptic view (RR 1.00, 95% CI 0.91, 1.10) and success rate of gastric tube insertion (RR 1.07, 95% CI 0.98, 1.18) between the i-gel and the LMA-P, respectively. The i-gel had a shorter insertion time than the LMA-P (MD -3.99, 95% CI -7.13, -0.84) and a lower incidence of blood staining on the device (RR 0.26, 95% CI 0.14, 0.49), sore throat (RR 0.28, 95% CI 0.15, 0.50) and dysphagia (RR 0.27, 95% CI 0.10, 0.74).</p> Conclusions <p>Both devices were comparable in ease of insertion to insert and both had sufficient OLP to provide a reliable airway. Only a few minor complications were reported. The i-gel was found to have fewer complications (blood staining, sore throat, dysphagia) than the LMA-P and offers certain advantages over the LMA-P in adults under general anesthesia.</p>Serum Autotaxin Is a Parameter for the Severity of Liver Cirrhosis and Overall Survival in Patients with Liver Cirrhosis – A Prospective Cohort StudyThomas PleliDaniel MartinBernd KronenbergerFriederike BrunnerVerena KöberleGeorgios GrammatikosHarald FarnikYolanda MartinezFabian FinkelmeierSandra LabochaNerea FerreirósStefan ZeuzemAlbrecht PiiperOliver Waidmann10.1371/journal.pone.01035322014-07-25T14:00:00Z2014-07-25T14:00:00Z<p>by Thomas Pleli, Daniel Martin, Bernd Kronenberger, Friederike Brunner, Verena Köberle, Georgios Grammatikos, Harald Farnik, Yolanda Martinez, Fabian Finkelmeier, Sandra Labocha, Nerea Ferreirós, Stefan Zeuzem, Albrecht Piiper, Oliver Waidmann</p>
Background <p>Autotaxin (ATX) and its product lysophosphatidic acid (LPA) are considered to be involved in the development of liver fibrosis and elevated levels of serum ATX have been found in patients with hepatitis C virus associated liver fibrosis. However, the clinical role of systemic ATX in the stages of liver cirrhosis was unknown. Here we investigated the relation of ATX serum levels and severity of cirrhosis as well as prognosis of cirrhotic patients.</p> Methods <p>Patients with liver cirrhosis were prospectively enrolled and followed until death, liver transplantation or last contact. Blood samples drawn at the day of inclusion in the study were assessed for ATX content by an enzyme-linked immunosorbent assay. ATX levels were correlated with the stage as well as complications of cirrhosis. The prognostic value of ATX was investigated by uni- and multivariate Cox regression analyses. LPA concentration was determined by liquid chromatography-tandem mass spectrometry.</p> Results <p>270 patients were enrolled. Subjects with liver cirrhosis showed elevated serum levels of ATX as compared to healthy subjects (0.814±0.42 mg/l vs. 0.258±0.40 mg/l, P<0.001). Serum ATX levels correlated with the Child-Pugh stage and the MELD (model of end stage liver disease) score and LPA levels (r = 0.493, P = 0.027). Patients with hepatic encephalopathy (P = 0.006), esophageal varices (P = 0.002) and portal hypertensive gastropathy (P = 0.008) had higher ATX levels than patients without these complications. Low ATX levels were a parameter independently associated with longer overall survival (hazard ratio 0.575, 95% confidence interval 0.365–0.905, P = 0.017).</p> Conclusion <p>Serum ATX is an indicator for the severity of liver disease and the prognosis of cirrhotic patients.</p>Continuous Quality Improvement in Daily Clinical Practice: A Proof of Concept StudyJonathan A. LorchVictor E. Pollak10.1371/journal.pone.00970662014-05-20T14:00:00Z2014-05-20T14:00:00Z<p>by Jonathan A. Lorch, Victor E. Pollak</p>
Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6–8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1–2; epoetin decreased from month 4. By months 16–18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were $22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost.