Ear and Hearing

The Effect of Musical Training and Working Memory in Adverse Listening Situations Objectives: Speech-in-noise (SIN) perception is essential for everyday communication. In most communication situations, the listener requires the ability to process simultaneous complex auditory signals to understand the target speech or target sound. As the listening situation becomes more difficult, the ability to distinguish between speech and noise becomes dependent on recruiting additional cognitive resources, such as working memory (WM). Previous studies have explored correlations between WM and SIN perception in musicians and nonmusicians, with mixed findings. However, no study to date has examined the speech perception abilities of musicians and nonmusicians with similar WM capacity. The objectives of this study were to investigate (1) whether musical experience results in improved listening in adverse listening situations, and (2) whether the benefit of musical experience can be separated from the effect of greater WM capacity. Design: Forty-nine young musicians and nonmusicians were assigned to subgroups of high versus low WM, based on the performance on the backward digit span test. To investigate the effects of music training and WM on SIN perception, performance was assessed on clinical tests of speech perception in background noise. Listening effort (LE) was assessed in a dual-task paradigm and via self-report. We hypothesized that musicians would have an advantage when listening to SIN, at least in terms of reduced LE. Results: There was no statistically significant difference between musicians and nonmusicians, and no significant interaction between music training and WM on any of the outcome measures used in this study. However, a significant effect of WM on SIN ability was found on both the Quick Speech-In-Noise test (QuickSIN) and the Hearing in Noise Test (HINT) tests. Conclusion: The results of this experiment suggest that music training does not provide an advantage in adverse listening situations either in terms of improved speech understanding or reduced LE. While musicians have been shown to have heightened basic auditory abilities, the effect on SIN performance may be more subtle. Our results also show that regardless of prior music training, listeners with high WM capacity are able to perform significantly better on speech-in-noise tasks. The authors have no conflicts of interest to disclose. Received July 25, 2018; accepted May 8, 2019. Address for correspondence: Jillian Escobar, 5981 Andover Drive West, Hanover Park, IL 60133, USA. E-mail: jillian.escobar95@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Electro-Tactile Stimulation Enhances Cochlear-Implant Melody Recognition: Effects of Rhythm and Musical Training Objectives: Electro-acoustic stimulation (EAS) enhances speech and music perception in cochlear-implant (CI) users who have residual low-frequency acoustic hearing. For CI users who do not have low-frequency acoustic hearing, tactile stimulation may be used in a similar fashion as residual low-frequency acoustic hearing to enhance CI performance. Previous studies showed that electro-tactile stimulation (ETS) enhanced speech recognition in noise and tonal language perception for CI listeners. Here, we examined the effect of ETS on melody recognition in both musician and nonmusician CI users. Design: Nine musician and eight nonmusician CI users were tested in a melody recognition task with or without rhythmic cues in three testing conditions: CI only (E), tactile only (T), and combined CI and tactile stimulation (ETS). Results: Overall, the combined electrical and tactile stimulation enhanced the melody recognition performance in CI users by 9% points. Two additional findings were observed. First, musician CI users outperformed nonmusicians CI users in melody recognition, but the size of the enhancement effect was similar between the two groups. Second, the ETS enhancement was significantly higher with nonrhythmic melodies than rhythmic melodies in both groups. Conclusions: These findings suggest that, independent of musical experience, the size of the ETS enhancement depends on integration efficiency between tactile and auditory stimulation, and that the mechanism of the ETS enhancement is improved electric pitch perception. The present study supports the hypothesis that tactile stimulation can be used to improve pitch perception in CI users. ACKNOWLEDGMENTS: We thank our CI participants for their passionate participation in this study. J.H. designed and performed experiments, analyzed data, and wrote the article. B.S. created the testing software, processed testing stimuli, and edited the article. T.L. processed testing stimuli and edited the article. F.G.Z. designed the experiments and provided critical revision. All authors discussed the results and implications and commented on the artcile at all states. This work was supported by NIH Grants DC015587 (F.Z.) and DC014503 (J.H.). The authors have no conflicts of interest to disclose. Received July 6, 2018; accepted April 19, 2019. Address for correspondence: Juan Huang, PhD, Department of Biomedical Engineering, Johns Hopkins University, Clark 106, 3400 N. Charles Street, Baltimore, MD 21218, USA. E-mail: jhuang7@jhu.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Long-Term Sensorineural Hearing Loss in Patients With Blast-Induced Tympanic Membrane Perforations Objective: To describe characteristics of sensorineural hearing loss (SNHL) in patients with blast-induced tympanic membrane (TM) perforations that required surgery. Design: A retrospective review of hearing outcomes in those who had tympanoplasty for combat blast-induced TM perforations. These were sequential cases from one military otolaryngologist from 2007 to 2012. A total of 87 patients were reviewed, and of those, 49 who had appropriate preinjury, preoperative, and long-term audiograms were included. Those with pre-existing hearing loss were excluded. Preinjury audiograms were used to assess how sensorineural thresholds changed in the ruptured ears, and in the contralateral ear in those with unilateral perforations. Results: The mean time from injury to the final postoperative audiogram was 522 days. In the ears with TM perforations, 70% had SNHLs of 10 dB or less (by bone conduction pure tone averages). Meanwhile, approximately 8% had threshold shifts >30 dB, averaging 50 dB. The strongest predictor of severe or profound hearing loss was ossicular discontinuity. Thresholds also correlated with bilateral injury and perforation size. In those with unilateral perforations, the SNHL was almost always larger on the side with the perforation. Those with SNHL often had a low-to-mid frequency threshold shift and, in general, audiograms that were flatter across frequencies than those of a typical population of military personnel with similar levels of overall hearing loss. Conclusions: There is a bimodal distribution of hearing loss in those who experience a blast exposure severe enough to perforate at least one TM. Most ears recover close to their preinjury thresholds, but a minority experience much larger sensorineural threshold shifts. Blast exposed ears also tend to have a flatter audiogram than most service members with similar levels of hearing loss. ACKNOWLEDGEMENTS: The authors thank Shankar Sridhara and Sungjin Song for their previous work on this set of patients. The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The authors have no conflicts of interest to disclose. Received December 17, 2018; accepted April 23, 2019. Address for correspondence: Douglas Brungart, Walter Reed National Military Medical Center, Department of Audiology, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA. E-mail: douglas.s.brungart.civ@mail.mil Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Association Between Physiological Noise Levels and Speech Understanding in Noise Objectives: Traditionally, elevated hearing thresholds have been considered to be the main contributors to difficulty understanding speech in noise; yet, patients will often report difficulties with speech understanding in noise despite having audiometrically normal hearing. The purpose of this cross-sectional study was to critically evaluate the relationship of various metrics of auditory function (behavioral thresholds and otoacoustic emissions) on speech understanding in noise in a large sample of audiometrically normal-hearing individuals. Design: Behavioral hearing thresholds, distortion product otoacoustic emission (DPOAE) levels, stimulus-frequency otoacoustic emission levels, and physiological noise (quantified using OAE noise floors) were measured from 921 individuals between 10 and 68 years of age with normal pure-tone averages. The quick speech-in-noise (QuickSIN) test outcome, quantified as the signal-to-noise ratio (SNR) loss, was used as the metric of speech understanding in noise. Principle component analysis (PCA) and linear regression modeling were used to evaluate the relationship between the measures of auditory function and speech in noise performance. Results: Over 25% of participants exhibited mild or worse degree of SNR loss. PCA revealed DPOAE levels at 12.5 to 16 kHz to be significantly correlated with the variation in QuickSIN scores, although correlations were weak (R2 = 0.017). Out of all the metrics evaluated, higher levels of self-generated physiological noise accounted for the most variance in QuickSIN performance (R2 = 0.077). Conclusions: Higher levels of physiological noise were associated with worse QuickSIN performance in listeners with normal hearing sensitivity. We propose that elevated physiological noise levels in poorer speech in noise performers could diminish the effective SNR, thereby negatively impacting performance as seen by poorer QuickSIN scores. ACKNOWLEDGMENTS: The authors thank Drs. Uzma Wilson, Niall Klyn, Courtney Glavin, Jungmee Lee, Gayla Poling, and Ms. Vickie Hellyer along with many other collaborators for assistance with recruitment, data collection, and analysis. This work was supported by NIH/NIDCD grants no. R01DC008420 (to S. D. and J. S.) and Northwestern University. The authors have no conflicts of interest to disclose. Received May 11, 2018; accepted May 3, 2019. Address for correspondence: Samantha Stiepan, Northwestern University, Room 1–246, Francis Searle Building, 2240 Campus Drive, Evanston, IL 60208, USA. E-mail: smstiepan@u.northwestern.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Prediction Model for Audiological Outcomes in Patients With GJB2 Mutations Objectives: Recessive mutations in GJB2 are the most common genetic cause of sensorineural hearing impairment (SNHI) in humans. SNHI related to GJB2 mutations demonstrates a wide variation in audiological features, and there has been no reliable prediction model for hearing outcomes until now. The objectives of this study were to clarify the predominant factors determining hearing outcome and to establish a predictive model for SNHI in patients with GJB2 mutations. Design: A total of 434 patients confirmed to have biallelic GJB2 mutations were enrolled and divided into three groups according to their GJB2 genotypes. Audiological data, including hearing levels and audiogram configurations, were compared between patients with different genotypes. Univariate and multivariate generalized estimating equation (GEE) analyses were performed to analyze longitudinal data of patients with multiple audiological records. Results: Of the 434 patients, 346 (79.7%) were homozygous for the GJB2 p.V37I mutation, 55 (12.7%) were compound heterozygous for p.V37I and another GJB2 mutation, and 33 (7.6%) had biallelic GJB2 mutations other than p.V37I. There was a significant difference in hearing level and the distribution of audiogram configurations between the three groups. Multivariate GEE analyses on 707 audiological records of 227 patients revealed that the baseline hearing level and the duration of follow-up were the predominant predictors of hearing outcome, and that hearing levels in patients with GJB2 mutations could be estimated based on these two parameters: (Predicted Hearing Level [dBHL]) = 3.78 + 0.96 × (Baseline Hearing Level [dBHL]) + 0.55 × (Duration of Follow-Up [y]). Conclusion: The baseline hearing level and the duration of follow-up are the main prognostic factors for outcome of GJB2-related SNHI. These findings may have important clinical implications in guiding follow-up protocols and designing treatment plans in patients with GJB2 mutations. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: We thank all the patients and their parents for participating in the study. P.-Y. C. and C.-C. W. ascertained clinical data, analyzed data, and wrote the article. Y.-H.L. and Y.-H.L. performed genetic examinations and analyses. L.-H.T. collected and analyzed audiological data. T.-H.Y. collected clinical data. P.-L.C. supervised the genetic examinations and analyses. T.-C.L. and C.-J.H. supervised the whole study and provided critical revision. This work was supported by research grants from the National Health Research Institute (NHRI-EX106-10414PC to C.-C.W.), the Ministry of Science and Technology of Taiwan (MOST 103-2628-B-002-009-MY4 to C.-C.W.), and National Taiwan University Hospital Yunlin Branch (NTUHYL106.N005 to P.-Y.C.). The authors have no conflicts of interest to disclose. Received May 23, 2018; accepted March 8, 2019. Address for correspondence: Chen-Chi Wu, Department of Otolaryngology, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei, Taiwan. E-mail: chenchiwu@ntuh.gov.tw Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Human Frequency Following Responses to Vocoded Speech: Amplitude Modulation Versus Amplitude Plus Frequency Modulation Objectives: The most commonly employed speech processing strategies in cochlear implants (CIs) only extract and encode amplitude modulation (AM) in a limited number of frequency channels. Zeng et al. (2005) proposed a novel speech processing strategy that encodes both frequency modulation (FM) and AM to improve CI performance. Using behavioral tests, they reported better speech, speaker, and tone recognition with this novel strategy than with the AM-alone strategy. Here, we used the scalp-recorded human frequency following responses (FFRs) to examine the differences in the neural representation of vocoded speech sounds with AM alone and AM + FM as the spectral and temporal cues were varied. Specifically, we were interested in determining whether the addition of FM to AM improved the neural representation of envelope periodicity (FFRENV) and temporal fine structure (FFRTFS), as reflected in the temporal pattern of the phase-locked neural activity generating the FFR. Design: FFRs were recorded from 13 normal-hearing, adult listeners in response to the original unprocessed stimulus (a synthetic diphthong /au/ with a 110-Hz fundamental frequency or F0 and a 250-msec duration) and the 2-, 4-, 8- and 16-channel sine vocoded versions of /au/ with AM alone and AM + FM. Temporal waveforms, autocorrelation analyses, fast Fourier Transform, and stimulus-response spectral correlations were used to analyze both the strength and fidelity of the neural representation of envelope periodicity (F0) and TFS (formant structure). Results: The periodicity strength in the FFRENV decreased more for the AM stimuli than for the relatively resilient AM + FM stimuli as the number of channels was increased. Regardless of the number of channels, a clear spectral peak of FFRENV was consistently observed at the stimulus F0 for all the AM + FM stimuli but not for the AM stimuli. Neural representation as revealed by the spectral correlation of FFRTFS was better for the AM + FM stimuli when compared to the AM stimuli. Neural representation of the time-varying formant-related harmonics as revealed by the spectral correlation was also better for the AM + FM stimuli as compared to the AM stimuli. Conclusions: These results are consistent with previously reported behavioral results and suggest that the AM + FM processing strategy elicited brainstem neural activity that better preserved periodicity, temporal fine structure, and time-varying spectral information than the AM processing strategy. The relatively more robust neural representation of AM + FM stimuli observed here likely contributes to the superior performance on speech, speaker, and tone recognition with the AM + FM processing strategy. Taken together, these results suggest that neural information preserved in the FFR may be used to evaluate signal processing strategies considered for CIs. ACKNOWLEDGMENTS: The authors thank Dr. Jackson Gandour for his assistance with statistical analysis. This work was supported by the National Institutes of Health (NIH), R01 DC008549 (A. K.) and the Department of Speech, Language, and Hearing Sciences, Purdue University. The authors have no conflicts of interest to disclose. Received January 24, 2019; accepted May 15, 2019. Address for correspondence: Ananthanarayan Krishnan, PhD, Department of Speech, Language, and Hearing Sciences, Purdue University, 715 Clinic Dr, Rm 3060, West Lafayette, In 47907, USA. E-mail: rkrish@purdue.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Ototoxic Potential of Cobalt From Metal-on-Metal Hip Implants: Objective Auditory and Vestibular Outcome Objectives: During the past decade, the initial popularity of metal-on-metal (MoM) hip implants has shown a progressive decline due to increasingly reported implant failure and revision surgeries. Local as well as systemic toxic side effects have been associated with excessive metal ion release from implants, in which cobalt (Co) plays an important role. The rare condition of systemic cobaltism seems to manifest as a clinical syndrome with cardiac, endocrine, and neurological symptoms, including hearing loss, tinnitus, and imbalance. In most cases described in the literature, revision surgery and the subsequent drop in blood Co level led to (partial) alleviation of the symptoms, suggesting a causal relationship with Co exposure. Moreover, the ototoxic potential of Co has recently been demonstrated in animal experiments. Since its ototoxic potential in humans is merely based on anecdotal case reports, the current study aimed to prospectively and objectively examine the auditory and vestibular function in patients implanted with a MoM hip prosthesis. Design: Twenty patients (15 males and 5 females, aged between 33 and 65 years) implanted with a primary MoM hip prosthesis were matched for age, gender, and noise exposure to 20 non-implanted control subjects. Each participant was subjected to an extensive auditory (conventional and high-frequency pure tone audiometry, transient evoked and distortion product otoacoustic emissions [TEOAEs and DPOAEs], auditory brainstem responses [ABR]) and vestibular test battery (cervical and ocular vestibular evoked myogenic potentials [cVEMPs and oVEMPs], rotatory test, caloric test, video head impulse test [vHIT]), supplemented with a blood sample collection to determine the plasma Co concentration. Results: The median [interquartile range] plasma Co concentration was 1.40 [0.70, 6.30] µg/L in the MoM patient group and 0.19 [0.09, 0.34] µg/L in the control group. Within the auditory test battery, a clear trend was observed toward higher audiometric thresholds (11.2 to 16 kHz), lower DPOAE (between 4 and 8 kHz), and total TEOAE (1 to 4 kHz) amplitudes, and a higher interaural latency difference for wave V of the ABR in the patient versus control group (0.01 ≤ p < 0.05). Within the vestibular test battery, considerably longer cVEMP P1 latencies, higher oVEMP amplitudes (0.01 ≤ p < 0.05), and lower asymmetry ratio of the vHIT gain (p < 0.01) were found in the MoM patients. In the patient group, no suggestive association was observed between the plasma Co level and the auditory or vestibular outcome parameters. Conclusions: The auditory results seem to reflect signs of Co-induced damage to the hearing function in the high frequencies. This corresponds to previous findings on drug-induced ototoxicity and the recent animal experiments with Co, which identified the basal cochlear outer hair cells as primary targets and indicated that the cellular mechanisms underlying the toxicity might be similar. The vestibular outcomes of the current study are inconclusive and require further elaboration, especially with respect to animal studies. The lack of a clear dose–response relationship may question the clinical relevance of our results, but recent findings in MoM hip implant patients have confirmed that this relationship can be complicated by many patient-specific factors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: L.L. has received funding from the Special Research Fund of Ghent University (BOF) (grant no. 01D33015) and is currently receiving funding from the Research Foundation Flanders (FWO) (grant no. 1170718N), as a predoctoral research fellow. L.L. performed the experiments, analyzed the data, and wrote the article. L.M., B.V., S.D.G., and R.V. assisted with the data analysis and critically reviewed the article during the complete writing process. C.V.D.S. and K.D.S. were responsible for the recruitment of patients with a metal-on-metal implant and reviewed the article during the complete writing process. I.D., H.K., R.L., and F.L.W. critically reviewed the article during the complete writing process. The authors have no conflict of interest to disclose. Received December 5, 2018; accepted March 31, 2019. Address for correspondence: Laura Leyssens, MSc, Department of Rehabilitation Sciences, University of Ghent, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium. E-mail: Laura.Leyssens@UGent.be Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Test-Retest Variability in the Characteristics of Envelope Following Responses Evoked by Speech Stimuli Objectives: The objective of the present study was to evaluate the between-session test-retest variability in the characteristics of envelope following responses (EFRs) evoked by modified natural speech stimuli in young normal hearing adults. Design: EFRs from 22 adults were recorded in two sessions, 1 to 12 days apart. EFRs were evoked by the token /susa∫ i/ (2.05 sec) presented at 65 dB SPL and recorded from the vertex referenced to the neck. The token /susa∫ i/, spoken by a male with an average fundamental frequency [f0] of 98.53 Hz, was of interest because of its potential utility as an objective hearing aid outcome measure. Each vowel was modified to elicit two EFRs simultaneously by lowering the f0 in the first formant while maintaining the original f0 in the higher formants. Fricatives were amplitude-modulated at 93.02 Hz and elicited one EFR each. EFRs evoked by vowels and fricatives were estimated using Fourier analyzer and discrete Fourier transform, respectively. Detection of EFRs was determined by an F-test. Test-retest variability in EFR amplitude and phase coherence were quantified using correlation, repeated-measures analysis of variance, and the repeatability coefficient. The repeatability coefficient, computed as twice the standard deviation (SD) of test-retest differences, represents the ±95% limits of test-retest variation around the mean difference. Test-retest variability of EFR amplitude and phase coherence were compared using the coefficient of variation, a normalized metric, which represents the ratio of the SD of repeat measurements to its mean. Consistency in EFR detection outcomes was assessed using the test of proportions. Results: EFR amplitude and phase coherence did not vary significantly between sessions, and were significantly correlated across repeat measurements. The repeatability coefficient for EFR amplitude ranged from 38.5 nV to 45.6 nV for all stimuli, except for /∫/ (71.6 nV). For any given stimulus, the test-retest differences in EFR amplitude of individual participants were not correlated with their test-retest differences in noise amplitude. However, across stimuli, higher repeatability coefficients of EFR amplitude tended to occur when the group mean noise amplitude and the repeatability coefficient of noise amplitude were higher. The test-retest variability of phase coherence was comparable to that of EFR amplitude in terms of the coefficient of variation, and the repeatability coefficient varied from 0.1 to 0.2, with the highest value of 0.2 for /∫/. Mismatches in EFR detection outcomes occurred in 11 of 176 measurements. For each stimulus, the tests of proportions revealed a significantly higher proportion of matched detection outcomes compared to mismatches. Conclusions: Speech-evoked EFRs demonstrated reasonable repeatability across sessions. Of the eight stimuli, the shortest stimulus /∫/ demonstrated the largest variability in EFR amplitude and phase coherence. The test-retest variability in EFR amplitude could not be explained by test-retest differences in noise amplitude for any of the stimuli. This lack of explanation argues for other sources of variability, one possibility being the modulation of cortical contributions imposed on brainstem-generated EFRs. ACKNOWLEDGMENTS: This study was funded by a Collaborative Health Research Project grant from the Canadian Institutes of Health Research and the Natural Sciences and Engineering Research Council of Canada (grant no. 493836-2016). V.E. designed the study, performed the experiment, analyzed data, and wrote the article. D.P. discussed study design, helped with response analysis, and edited the article. S.S. and S.A. discussed results, and edited the article. The authors have no conflicts of interest to disclose. Received October 20, 2018; accepted March 8, 2019. Address for correspondence: Vijayalakshmi Easwar, 541 Waisman Centre, The University of Wisconsin-Madison, 1500 Highland Ave, Madison, WI 53705, USA. E-mail: veaswar@wisc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Revised Hearing Handicap Inventory and Screening Tool Based on Psychometric Reevaluation of the Hearing Handicap Inventories for the Elderly and Adults Objectives: The present study evaluates the items of the Hearing Handicap Inventory for the Elderly and Hearing Handicap Inventory for Adults (HHIE/A) using Mokken scale analysis (MSA), a type of nonparametric item response theory, and develops updated tools with optimal psychometric properties. Design: In a longitudinal study of age-related hearing loss, 1447 adults completed the HHIE/A and audiometric testing at baseline. Discriminant validity of the emotional consequences and social/situational effects subscales of the HHIE/A was assessed, and nonparametric item response theory was used to explore dimensionality of the items of the HHIE/A and to refine the scales. Results: The HHIE/A items form strong unidimensional scales measuring self-perceived hearing handicap, but with a lack of discriminant validity of the two distinct subscales. Two revised scales, the 18-item Revised Hearing Handicap Inventory and the 10-item Revised Hearing Handicap Inventory—Screening, were developed from the common items of the original HHIE/A that met the assumptions of MSA. The items on both of the revised scales can be ordered in terms of increasing difficulty. Conclusions: The results of the present study suggest that the newly developed Revised Hearing Handicap Inventory and Revised Hearing Handicap Inventory—Screening are strong unidimensional, clinically informative measures of self-perceived hearing handicap that can be used for adults of all ages. The real-data example also demonstrates that MSA is a valuable alternative to classical psychometric analysis. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and text of this article on the journal's Web site (www.ear-hearing.com). ACKNOWLEDGMENTS: The authors thank Jayne Ahlstrom for editorial assistance. The authors thank the subjects who participated in this study. This work was supported (in part) by research grant P50 DC000422 from NIH/NIDCD and by the South Carolina Clinical and Translational Research (SCTR) Institute, with an academic home at the Medical University of South Carolina, NIH/NCATS Grant number UL1 TR001450. This investigation was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR14516 from the NIH/NCRR. Portions of this article were presented at the Hearing Across the Lifespan 2018 conference, Cernobbio, Lake Como, Italy, June 7, 2018. The authors have no conflicts of interest to declare. Received December 31, 2018; accepted March 25, 2019. Address for correspondence: Christy Cassarly, Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon St., Ste 303, MSC 835, Charleston, SC 29425, USA. E-mail: cassarly@musc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effects of GJB2 or SLC26A4 Gene Mutations on Neural Response of the Electrically Stimulated Auditory Nerve in Children Objectives: This study aimed to (1) investigate the effect of GJB2 and SLC26A4 gene mutations on auditory nerve function in pediatric cochlear implant users and (2) compare their results with those measured in implanted children with idiopathic hearing loss. Design: Participants included 20 children with biallelic GJB2 mutations, 16 children with biallelic SLC26A4 mutations, and 19 children with idiopathic hearing loss. All subjects except for two in the SLC26A4 group had concurrent Mondini malformation and enlarged vestibular aqueduct. All subjects used Cochlear Nucleus devices in their test ears. For each subject, electrophysiological measures of the electrically evoked compound action potential (eCAP) were recorded using both anodic- and cathodic-leading biphasic pulses. Dependent variables (DVs) of interest included slope of eCAP input/output (I/O) function, the eCAP threshold, and eCAP amplitude measured at the maximum comfortable level (C level) of the anodic-leading stimulus (i.e., the anodic C level). Slopes of eCAP I/O functions were estimated using statistical modeling with a linear regression function. These DVs were measured at three electrode locations across the electrode array. Generalized linear mixed effect models were used to evaluate the effects of study group, stimulus polarity, and electrode location on each DV. Results: Steeper slopes of eCAP I/O function, lower eCAP thresholds, and larger eCAP amplitude at the anodic C level were measured for the anodic-leading stimulus compared with the cathodic-leading stimulus in all subject groups. Children with GJB2 mutations showed steeper slopes of eCAP I/O function and larger eCAP amplitudes at the anodic C level than children with SLC26A4 mutations and children with idiopathic hearing loss for both the anodic- and cathodic-leading stimuli. In addition, children with GJB2 mutations showed a smaller increase in eCAP amplitude when the stimulus changed from the cathodic-leading pulse to the anodic-leading pulse (i.e., smaller polarity effect) than children with idiopathic hearing loss. There was no statistically significant difference in slope of eCAP I/O function, eCAP amplitude at the anodic C level, or the size of polarity effect on all three DVs between children with SLC26A4 mutations and children with idiopathic hearing loss. These results suggested that better auditory nerve function was associated with GJB2 but not with SLC26A4 mutations when compared with idiopathic hearing loss. In addition, significant effects of electrode location were observed for slope of eCAP I/O function and the eCAP threshold. Conclusions: GJB2 and SLC26A4 gene mutations did not alter polarity sensitivity of auditory nerve fibers to electrical stimulation. The anodic-leading stimulus was generally more effective in activating auditory nerve fibers than the cathodic-leading stimulus, despite the presence of GJB2 or SLC26A4 mutations. Patients with GJB2 mutations appeared to have better functional status of the auditory nerve than patients with SLC26A4 mutations who had concurrent Mondini malformation and enlarged vestibular aqueduct and patients with idiopathic hearing loss. ACKNOWLEDGMENTS: We gratefully thank all subjects and their parents for participating in this study. J.L. participated in data collection and patient testing, prepared the initial draft of this article, provided critical comments, and approved the final version of this article. L.X., X.C., and R.W. participated in the data collection and patient testing, provided critical comments, and approved the final version of this article. X.B. conducted genetic tests in all study participants, provided critical comments, and approved the final version of this article. A.P. and Z.F. provided critical comments and approved the final version of this article. H.W. participated in designing this study, provided critical comments, and approved the final version of this article. S.H. designed the study, participated in data collection and patient testing, and drafted and approved the final version of this article. The authors have no conflicts of interest to declare. Received September 18, 2018; accepted March 17, 2019. Address for correspondence: Haibo Wang, Department of Otolaryngology—Head and Neck Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Duanxing West Road, Huaiyin, Jinan 250022, Shandong, People's Republic of China. E-mail: Whboto11@163.Com or Shuman He, Eye and Ear Institute, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA. E-mail: shuman.he@osumc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Conservation and Society

Resisting Extinction: Purple Martins, Death, and the Future Lori L Jervis, Paul Spicer, William C Foster, Jeffrey Kelly, Eli Bridge Conservation and Society 2019 17(3):227-235 As a result of anthropogenically induced habitat destruction and climate change, the Eastern Purple Martin in North America has been transformed into a “backyard bird,” dependent on a network of “landlords” for nesting structures and protection from competitor species. While the orthodox approach to wildlife conservation tends to promote the continued existence of appropriate habitats, the conservation of the Eastern Purple Martin has hinged upon the continued existence of a specific human cultural behaviour. This landlording subculture, however, is now believed to be waning due to the aging demographics of the landlords themselves, threatening the long-term survival of the species. This article focuses on the relationships between 24 landlords—primarily older, white, southern US men—and their avian charges. The long-term bond between the birds and their human keepers meant that the landlords were confronting not only their own mortality but also the extinction of the birds to which they have devoted themselves. Their continuing struggles to recruit younger generations into landlording suggest the need for new models of martin conservation that can appeal to the post-domestic and internet savvy sensibilities of today's youth.

Negotiating the Taskscape. Relocating Human – Environmental Relationships in Conservation Proposals around Palm Forests in Uruguay Juan Martin Dabezies Conservation and Society 2019 17(3):236-249 Butia odorata palm forests of southern Uruguay face conservation problems. This species is the identity benchmark of the region and it represents an important source of income for local people who make food products to sell to tourists. To prevent the disappearance of the Butiá forests, different proposals have been developed to protect the ecosystem. These proposals focus on arguments such as aesthetic beauty and ecosystem services from a naturalistic perspective. Following the concept of taskscape developed by Ingold, T, I propose an alternative way of negotiating conservation of the Butiá landscape in terms of the overlap of features, affordances, tasks and temporality of the Butiá life.

Ontological Politics of Wildlife: Local People, Conservation Biologists and Guanacos Robert Petitpas, Cristian Bonacic Conservation and Society 2019 17(3):250-257 In this article, we analyse the politics behind human-wildlife relations, based on the different understanding of guanacos by local people and conservationists in Northern Chile. We use a political ontology framework to study the interactions between different ontologies of wildlife. The analysis is based on in-depth interviews, field observations, documents analyses, and personal experience in guanaco conservation research. The relation between guanacos and local people is characterised by frequent and material encounters and the presence of the animal in the domestic sphere through multiple uses. The conservationists account of guanacos is characterised by spatial distribution, population size, habitat, and threat assessments, and the application of universal categories to classify this species. These different relationships with guanacos are related to two different ontologies of wildlife. For conservationists, the nature-society dichotomy is clear— guanacos are defined in a nature without humans, and in order to protect them they should be kept away from human activities. On the contrary, for local people, nature and society are not worlds apart. Guanacos are neither totally wild nor totally domestic. Understanding these differences is important because these ontologies interact and affect each other. In this case, the conservationist ontology was dominant over the local one. Also, the interactions between ontologies affect and are affected by conservation action, and by the general socio-political context. A better understanding of local ontologies is an important step to improve the relationship between conservationists and local communities.

Outside the Frame: Looking Beyond the Myth of Garamba's LRA Ivory–Terrorism Nexus Kristof Titeca, Patrick Edmond Conservation and Society 2019 17(3):258-269 There have been widespread reports of elephant poaching by the Lord's Resistance Army (LRA) in Garamba National Park (GNP) in the Democratic Republic of the Congo (DRC), presenting a narrative that ivory poaching funds terror and that both can be solved by the same (military) intervention. This narrative distorts the complex dynamics. It identifies clear villains, edits out other poaching actors, and legitimises particular interventions. Poaching is portrayed as a moral, non-political issue and military intervention is portrayed as a logical outcome. The wider history and current context are neglected. The LRA's poaching threat, relative to other actors, is overemphasised. It ignores how the LRA poaching—real as it was—fits into a history of poaching caused by problems with state capacity and territorial control, including incursions by armed actors. The situation demands solutions that are more complex than merely defeating the LRA. More so, military intervention against the LRA has worsened poaching, due to state military implications in poaching. The article shows how the 'LRA ivory–terrorism' narrative is a discursive tool for particular agendas, which primarily allow particular interventions, legitimisation of resources, or wider readership. In this way, the actors involved create their own echo-chamber, which is less concerned with local dynamics and which does not include practical conservation actors in Garamba. The narrative has also begun to shift.

Reclaim Conservation: Conservation Discourse and Initiatives of the Rondas Campesinas, North-Eastern Peru Noga Shanee Conservation and Society 2019 17(3):270-282 Global conservation fails to stop or, as in most cases, even reduce the rapidly intensifying extinction crisis. Hence, alternatives to current dominant conservation ideologies and practices need to be explored. The Rondas Campesinas (Peasant Patrols) drive the largest and most influential grassroots movement in northeastern Peru, one of the most biodiverse and environmentally-threatened places on Earth. The environment is of paramount importance to the Rondas Campesinas and plays a central role in their culture. Rondas Campesinas members take on dynamic roles as leaders and initiators of conservation efforts in their local area, including creation of reserves, implementation of control of natural resource use and transnational extractive operations, and environmental education. This article argues that, although inexperienced, the Rondas Campesinas provide a template for effective in-situ conservation solutions, while highlighting the shortfalls of current mainstream conservation.

Towards Convivial Conservation Bram Büscher, Robert Fletcher Conservation and Society 2019 17(3):283-296 Environmental conservation finds itself in desperate times. Saving nature, to be sure, has never been an easy proposition. But the arrival of the Anthropocene - the alleged new phase of world history in which humans dominate the earth-system seems to have upped the ante dramatically; the choices facing the conservation community have now become particularly stark. Several proposals for revolutionising conservation have been proposed, including 'new' conservation, 'half Earth' and more. These have triggered heated debates and potential for (contemplating) radical change. Here, we argue that these do not take political economic realities seriously enough and hence cannot lead us forward. Another approach to conservation is needed, one that takes seriously our economic system's structural pressures, violent socio-ecological realities, cascading extinctions and increasingly authoritarian politics. We propose an alternative termed 'convivial conservation'. Convivial conservation is a vision, a politics and a set of governance principles that realistically respond to the core pressures of our time. Drawing on a variety of perspectives in social theory and movements from around the globe, it proposes a post-capitalist approach to conservation that promotes radical equity, structural transformation and environmental justice and so contributes to an overarching movement to create a more equal and sustainable world.

Conserving Poverty: Destructive Fishing Gear Use in a Tanzanian Marine Protected Area Justin Raycraft Conservation and Society 2019 17(3):297-309 Drawing from ethnographic fieldwork, this paper attends to the persistent use of Destructive Fishing Gear (DFG) in a Marine Protected Area (MPA) in southeastern Tanzania. Based on participant observation, document analysis, in-depth interviews and focus group discussions conducted with villagers, I argue that the MPA has failed to eliminate the use of DFG because of its inability to address the historically-embedded political, economic, and sociocultural dimensions of DFG use in the inshore fishery. I contend that pre-existing and conservation-induced conditions of poverty drive the continued use of DFG inside the MPA. Such circumstances are framed by colonial and post-independence state-level development policies. They are also textured by breakdowns in customary marine tenure practices, changing beliefs about which types of fishing gear villagers consider to be traditional, and community-defined moral rights to fish for the fulfilment of basic material needs. I maintain that MPAs must take into account the anthropological complexities of poverty if they are to be effective.

The Wake of the Whale Benedict Singleton Conservation and Society 2019 17(3):310-311

The Patagonian Sublime: The Green Economy and Post-Neoliberal Politics Suchismita Das Conservation and Society 2019 17(3):312-313

Shooting a Tiger: Big-game Hunting and Conservation in Colonial India Tresa Abraham Conservation and Society 2019 17(3):314-315

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Anaesthesiology

Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey BACKGROUND The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN Online survey. SETIING A total of 38 countries within Europe. PARTICIPANTS Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement. Correspondence to Andrew F. Smith, Department of Anaesthetics, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK Tel: +00 44 7768 226361; e-mail: andrew.f.smith@mbht.nhs.uk © 2019 European Society of Anaesthesiology

Complex effects of continuous vasopressor infusion on fluid responsiveness during liver resection: A preliminary randomised controlled trial BACKGROUND Fluid responsiveness is an important factor to consider for fluid volume loading during major surgery. The effect of continuous vasopressor infusion on fluid responsiveness during prolonged major surgery is a concern. OBJECTIVE We hypothesised that continuous vasopressor infusion during major surgery might not exert significant effects on changes in stroke volume variation (SVV) following fluid bolus infusion, and thereby on fluid responsiveness. DESIGN Randomised controlled trial. SETTING University hospital from April 2014 to August 2016. PATIENTS Patients undergoing liver resection who were randomised to receive continuous intravenous infusion of phenylephrine (P group), norepinephrine (N group), or no vasopressor (C group) (n=17/group). Exclusion criteria were cardiac arrhythmia and severe cardiac, pulmonary or renal dysfunction. INTERVENTION Patients received 4 ml kg−1 fluid boluses of 6% hydroxyethyl starch solution when SVV was at least 12%. Vasopressors were administered continuously to maintain the systemic vascular resistance index at more than 1900 dyn s cm−5 m−2. MAIN OUTCOME MEASURES Cardiac index and SVV were measured using the FloTrac™/Vigileo™ system (Version 4.00). The number of fluid boluses with fluid responsiveness (i.e. >15% increase in cardiac index) was compared between groups using multilevel logistic regression analysis. RESULTS Numbers of fluid responsive boluses in the C, P and N groups were 12 (14%), 22 (34%) and 19 (27%), respectively. Odds ratios on fluid responsiveness for phenylephrine and norepinephrine compared with the control were 3.65 (97.5% confidence interval, 1.15 to 11.6; P = 0.012) and 2.56 (97.5% confidence interval, 0.82 to 8.00; P = 0.064), respectively. Decreases in SVV after fluid bolus infusion for the P and N groups were comparable with the C group (P = 0.23 and 0.53, respectively). CONCLUSION Continuous administration of phenylephrine increased fluid responsiveness during liver resection, suggesting complex effects of continuous vasopressor infusion involving changes in cardiac preload and afterload. TRIAL REGISTRATION UMIN000011024. Correspondence to Tsuneo Tatara, MD, Department of Anaesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Hyogo, Japan Tel: +81 798 45 6392; fax: +81 798 45 6393; e-mail: ttatara@hyo-med.ac.jp © 2019 European Society of Anaesthesiology

Effectiveness of a visual noise warning system on noise levels in a surgical ICU: A quality improvement programme BACKGROUND The effects of noise are harmful to patients in the ICU environment, and the latter are particularly noisy places. High noise levels seem to be a factor in sleep disturbance, which can, in turn, result in increased morbidity. LOCAL PROBLEM High noise levels are a recognised problem in ICUs worldwide. OBJECTIVE(S) The goal was to estimate the effect of a visual noise-warning system on noise levels in a surgical ICU before and after its implementation. DESIGN A quality improvement initiative. SETTING A 12-bedded surgical ICU in a tertiary care university hospital. PATIENTS A total of 148 adult nonintubated and nonsedated patients completed the study, during a 6-week period. INTERVENTION Noise levels were continuously recorded using a Type II sound level meter for 6 weeks. The study was divided into three phases. The first 2 weeks, baseline noise levels were measured (phase I). In week 3 of the study, a visual noise warning system (SoundEar II) that changed colour depending on noise levels within the ICU was installed and implemented (phase II). The alarm system was set to light up green at levels below 55 dBA, orange at levels between 55 and 60 dBA and red at levels above 60 dBA. The device was switched off at the beginning of week 5 and the sound level meter continued recording noise levels for another 2 weeks (phase III). RESULTS Mean night-time noise level was 55.98 dBA in the preintervention phase, 54.14 dB during the intervention, and 54.98 dBA in the postintervention phase. Mean noise level was reduced statistically significantly by 1.35 dBA, and there was a sustained reduction of 0.86 dBA from the baseline noise level 2 weeks after SoundEar II was switched off. CONCLUSION Visual noise warning systems can be effective in achieving a reduction in noise levels in critical care units. Correspondence to Miriam de Nadal, Department of Anesthesiology and Intensive Care, Hospital Universitari Vall d'Hebron, Ps Vall d'Hebron 119-129, 08035 Barcelona, Spain Tel: +34 932746004; e-mail: minadal@vhebron.net © 2019 European Society of Anaesthesiology

Comparison between the new fully automated viscoelastic coagulation analysers TEG 6s and ROTEM Sigma in trauma patients: A prospective observational study BACKGROUND Viscoelastic coagulation testing is increasingly used to diagnose trauma-induced coagulopathy. Two fully automated analysers, TEG 6s and ROTEM Sigma, were launched recently. No previous studies have compared these devices in trauma paients. OBJECTIVE The aim of this study was to evaluate whether both fully automatic devices deliver comparable results. DESIGN Prospective observational study. SETTING Level one trauma centre from August 2017 to September 2018. PATIENTS A total of 105 blood samples from 67 trauma patients were analysed simultaneously on TEG 6s and ROTEM Sigma. MAIN OUTCOME MEASURES TEG 6s assays kaolin (CK), RapidTEG (CRT), kaolin with heparinase (CKH) and functional fibrinogen were compared with ROTEM Sigma assays INTEM, EXTEM, HEPTEM and FIBTEM. TEG 6s functional fibrinogen level was compared with plasma fibrinogen concentration, measured using the Clauss method. Correlations were classified as weak (Spearman correlation coefficient 0.20 to 0.39), moderate (0.40 to 0.59), strong (0.60 to 0.79) or very strong (≥0.80). RESULTS The TEG 6s parameters reaction time, kinetic time and α-angle (CK, CRT and CKH assays) mostly showed strong correlations with the corresponding ROTEM parameters clotting time, clot formation time and α-angle (INTEM, EXTEM and HEPTEM assays). The exceptions were CRT reaction time vs. EXTEM clotting time, and CK α-angle vs. INTEM α-angle, which correlated moderately. Absolute values for many of these parameters showed significant differences between the two devices. Very strong correlations and similar absolute values were observed between TEG 6s maximum amplitude (CRT, CK and CKH assays) and ROTEM maximum clot firmness (EXTEM, INTEM and HEPTEM assays). Correlations were also very strong for functional fibrinogen maximum amplitude vs. FIBTEM maximum clot firmness and functional fibrinogen level vs. Clauss fibrinogen concentration, but absolute values were significantly different. CONCLUSION Strong to very strong correlations were observed between corresponding TEG 6s and ROTEM Sigma parameters. However, absolute values showed significant differences for most of the measurements. Correspondence to Herbert Schöchl, MD, Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr Franz Rehrl Platz 5, 5020 Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria E-mail: herbert.schoechl@auva.at Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

A systematic review of randomised controlled trials investigating prehabilitation before major intra-abdominal cancer surgery: An analysis of prehabilitation content and outcome measures BACKGROUND Although prehabilitation programmes for patients undergoing major intra-abdominal cancer surgery have been shown to improve pre-operative physical fitness, the conclusions regarding any postoperative benefits are inconsistent. OBJECTIVES The aim of this study was to evaluate the content of and the outcome measures used in studies of prehabilitation programmes for these patients. It was hypothesised that the content of prehabilitation programmes is often therapeutically invalid, and that the postoperative outcomes assessed are inadequate to evaluate the impact of complications. DESIGN A systematic review of randomised controlled trials. DATA SOURCES Studies published between January 2009 and January 2019 were retrieved from PubMed, Embase and PEDro. ELIGIBILITY CRITERIA Studies were included when they investigated the effects of prehabilitation in patients undergoing intra-abdominal surgery for cancer, reported pre-operative and/or postoperative outcome measures and were conducted as a randomised controlled trial. Studies for which the full text was not available were excluded, as were studies of patients undergoing nonabdominal cancer surgery. RESULTS Eight studies (565 patients) were included. Therapeutic validity was low in five studies. Most studies included low-risk surgical patients and considerable variation was observed between prehabilitation programmes in terms of supervision, training context, frequency, intensity, duration and training type. Objective monitoring of training progression was typically not performed, and most trials did not include nutritional or psychological support. Postoperative complications were reported in seven studies, but no study reported the impact of postoperative complications, nor on long-term postoperative outcomes. CONCLUSION The content of prehabilitation programmes was heterogeneous. Studies with a high therapeutic validity found unequivocal evidence that prehabilitation had beneficial effects on postoperative outcomes. Future research should focus on adequate selection and inclusion of high-risk surgical patients and provide personalised and probably multimodal (partly) supervised prehabilitation, with objective monitoring of progress. Measuring the incidence and impact of postoperative complications may contribute to demonstrating the clinical value of prehabilitation. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Correspondence to Bart C. Bongers, PhD, Maastricht University, Department of Nutrition and Movement Sciences, P.O. Box 616, 6200 MD Maastricht, The Netherlands Tel: +0031433882236; e-mail: bart.bongers@maastrichtuniversity.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly: A randomised controlled trial BACKGROUND Neuraxial ultrasound might improve the efficacy of spinal anaesthesia but this has not been tested for the paramedian approach in the elderly. OBJECTIVE The current study aims to assess whether the ultrasound-assisted paramedian technique can decrease the number of needle passes required for success compared with the landmark-guided paramedian technique in the elderly. DESIGN Prospective randomised controlled study. SETTING Single-institution, tertiary-level hospital in Seoul, Republic of Korea from October 2017 to January 2018. PATIENTS Eighty patients aged at least 60 years undergoing orthopaedic surgery. INTERVENTION All received paramedian spinal anaesthesia by either the landmark-guided or preprocedural ultrasound-assisted technique. MAIN OUTCOME MEASURES The number of needle passes required for successful dural puncture. RESULTS The number of needle passes (median [interquartile range]) was significantly lower (1.0 [1.0 to 2.0] vs. 4.5 [2.0 to 7.0]) and the success rate at first pass significantly higher at 65.0 vs. 17.5% in the ultrasound compared with the landmark group (both P < 0.001). The ultrasound-assisted technique required a longer time for establishing landmarks 117.5 [85.5 to 150.7] vs. 17.5 [14.0 to 23.0] s, and for total procedure 181.5 [133.5 to 212.5] vs. 92.5 [62.5 to 176.5] s, but a shorter time for administering spinal anaesthesia 39.5 [31.5 to 71.3] vs. 77.0 [45.8 to 136.5] s (all P < 0.001) than the landmark-guided technique. The ultrasound group showed lower periprocedural pain scores 3 [2 to 4] vs. 4 [4 to 6] (P = 0.009) and discomfort scores 2 [0 to 3] vs. 5 [2 to 6] (P = 0.003) than the landmark group. CONCLUSION Compared with the landmark-guided paramedian technique, the ultrasound-assisted paramedian technique decreases the number of needle manipulations and periprocedural pain and discomfort scores in the elderly. Our results suggest that neuraxial ultrasonography facilitates the performance of spinal anaesthesia in the elderly. TRIAL REGISTRATION NCT03316352. Correspondence to Jin-Tae Kim, Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea E-mail: jintae73@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Bilateral subcostal transversus abdominis plane block does not improve the postoperative analgesia provided by multimodal analgesia after laparoscopic cholecystectomy: A randomised placebo-controlled trial BACKGROUND Laparoscopic cholecystectomy might be considered minor surgery, but it may result in severe postoperative pain. Subcostal transversus abdominis plane (TAP) block, which produces long-lasting supra-umbilical parietal analgesia, might improve analgesia after laparoscopic cholecystectomy. OBJECTIVE We investigated whether subcostal TAP block would reduce opioid consumption and pain after laparoscopic cholecystectomy in patients provided with multimodal analgesia. DESIGN A randomised, placebo-controlled, double-blind study. SETTING The study was conducted at a university teaching hospital from December 2017 to June 2018. PATIENTS Sixty patients scheduled for laparoscopic cholecystectomy were included. Anaesthesia and postoperative analgesia (etoricoxib, paracetamol, ketamine and dexamethasone) were standardised. INTERVENTION After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral subcostal TAP block with 20 ml of levobupivacaine 0.375% and epinephrine 5 μg ml−1 or 0.9% saline with epinephrine 5 μg ml−1. MAIN OUTCOME MEASURES Opioid consumption in the recovery room and during the first 24 h after surgery were recorded. Postoperative somatic and visceral pain scores, fatigue and nausea were measured. Intra-operative end-tidal concentrations of sevoflurane (FETSEVO) were also recorded. RESULTS Twenty-four hour postoperative opioid consumption were similar in both groups: 21.2 mg (95% CI 15.3 to 27.1) vs. 25.2 (95% CI 15.1 to 35.5) oral morphine equivalent in the levobupivacaine and 0.9% saline groups, respectively; P = 0.48. No significant between-group differences were observed with regards to parietal (P = 0.56) and visceral (P = 0.50) pain scores, fatigue and nausea. FETSEVO was slightly lower in the levobupivacaine group (P < 0.01). CONCLUSION Subcostal TAP block does not improve the analgesia provided by multimodal analgesia after laparoscopic cholecystectomy. It allows for a small reduction in intra-operative sevoflurane requirements. CLINICAL TRIAL REGISTRATION NCT0339153 Correspondence to Jean L. Joris, MD, PhD, Department of Anaesthesiology, CHU Liège, Domaine du Sart Tilman, Avenue de l'hôpital Bat B35, Liège B-4000, Belgium. Tel: +32 4 3667180; fax: +32 4 3667636; e-mail: jean.joris@chuliege.be © 2019 European Society of Anaesthesiology

Effects of goal-directed crystalloid vs. colloid fluid therapy on microcirculation during free flap surgery: A prospective randomised clinical trial BACKGROUND Macro, and microcirculatory effects of crystalloids and colloids are difficult to compare, because interventions to achieve haemodynamic stability seldom follow similar criteria. OBJECTIVES Our aim was to compare the effects of crystalloids and colloids on the microcirculation during free flap surgery when management was guided by detailed haemodynamic assessment. DESIGN A prospective randomised, controlled clinical trial. SETTINGS The investigation was performed at the University of Szeged, Hungary. PATIENTS Patients undergoing maxillofacial tumour resection and free flap reconstruction were randomised into groups treated with either intra-operative crystalloid (Ringerfundin, n = 15) or colloid (6% hydroxyethyl starch, HES, n = 15) solutions. INTERVENTIONS Macrohaemodynamics were monitored by a noncalibrated device (PulsioFlex-PULSION). Central venous oxygen saturation, venous-to-arterial PCO2-gap, lactate levels and urine output were measured hourly. Maintenance fluid was Ringerfundin (1 ml kg−1 h−1), and a multimodal, individualised, approach-based algorithm was applied to guide haemodynamic support. Hypovolaemia was treated with Ringerfundin or HES fluid boluses, respectively. The microcirculatory effects were assessed by laser-Doppler flowmetry (PeriFlux 5000 LDPM), with the probe placed on the flap and on a control area. Measurements were performed after the flap was prepared, then 1 and 12 h later. MAIN OUTCOME MEASURES The primary end-point was microcirculatory perfusion as determined by laser-Doppler flowmetry. RESULTS There was no difference between the groups regarding patient characteristics. Both groups remained haemodynamically stable throughout due to the use of approximately a 1.5 times higher total fluid volume in the Ringerfundin group than in the HES group: mean ± SD: 2581 ± 986 and 1803 ± 497) ml, respectively, (P = 0.011). There was no significant difference in the microcirculatory blood flow between the groups. CONCLUSION Our results showed that when fluid management was guided by detailed haemodynamic assessment, more crystalloid than colloid was needed to maintain haemodynamic stability, but there was no difference between the effects of crystalloids and colloids on the microcirculation. TRIAL REGISTRATION ClinicalTrials.gov (NCT03288051). Correspondence to Ildikó László, Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis St., Szeged 6725, Hungary; E-mail: laszlo.ildiko@med.u-szeged.hu © 2019 European Society of Anaesthesiology

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial BACKGROUND It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation. OBJECTIVE The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients. DESIGN Prospective observational study. SETTING Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand. PATIENTS Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy. INTERVENTIONS Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5). MAIN OUTCOME MEASURES Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA. RESULTS From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically. CONCLUSION Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass. TRIAL REGISTRATION The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216. Correspondence to Benno von Bormann, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok 10700, Thailand Tel: +66 918825723/+66 24197990; e-mail: bvb@jodu.de © 2019 European Society of Anaesthesiology

Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial BACKGROUND Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation. OBJECTIVE The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures. DESIGN A randomised controlled trial. SETTING Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden. PARTICIPANTS Thirty healthy volunteers. INTERVENTIONS Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction. MAIN OUTCOME MEASURES A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures. RESULTS The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP. CONCLUSION Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02238691. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Correspondence to Per Cajander, Department of Anaesthesia and Intensive Care Örebro University Hospital, Södra Grev-Rosengatan, 701 85, Örebro, Sweden Tel: +46 19 602 03 53; e-mail: per.cajander@regionorebrolan.se © 2019 European Society of Anaesthesiology

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Magnetic Resonance Imaging Clinics of North America

Cardiovascular MR Imaging: Current Status and Future Directions Publication date: Available online 23 May 2019 Source: Magnetic Resonance Imaging Clinics of North America Author(s): Clerio F. Azevedo, Roberto C. Cury

Foreword Publication date: Available online 18 May 2019 Source: Magnetic Resonance Imaging Clinics of North America Author(s): Suresh K. Mukherji

Automated Quantitative Stress Perfusion in a Clinical Routine Publication date: Available online 13 May 2019 Source: Magnetic Resonance Imaging Clinics of North America Author(s): Kristopher D. Knott, Juliano Lara Fernandes, James C. Moon

The Role of Cardiac MR Imaging in the Assessment of Patients with Cardiac Amyloidosis Publication date: Available online 9 May 2019 Source: Magnetic Resonance Imaging Clinics of North America Author(s): Filipe Penna de Carvalho, Fernanda Erthal, Clerio Francisco de Azevedo

Discoid Meniscus in the Pediatric Population:: Emphasis on MR Imaging Signs of Instability Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): Ricardo Restrepo, Miriam D. Weisberg, Rachel Pevsner, Stephen Swirsky, Edward Y. Lee

MR Imaging Evaluation of Pediatric Genital Disorders:: MR Technologic Overview and Interpretation Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): Jennifer K. Son, Sumera Ali, Noor Al Khori, Edward Y. Lee

MR Imaging Evaluation of Inflammatory Bowel Disease in Children:: Where Are We Now in 2019 Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): Gary R. Schooler, Nathan C. Hull, Alisha Mavis, Edward Y. Lee

Pediatric Renal Neoplasms:: MR Imaging–Based Practical Diagnostic Approach Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): A. Luana Stanescu, Patricia T. Acharya, Edward Y. Lee, Grace S. Phillips

Hepatobiliary MR Imaging in Children:: Up-to-Date Imaging Techniques and Findings Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): Nathan C. Hull, Gary R. Schooler, Edward Y. Lee

Pediatric Cardiac MR Imaging:: Practical Preoperative Assessment Publication date: May 2019 Source: Magnetic Resonance Imaging Clinics of North America, Volume 27, Issue 2 Author(s): Giuseppe Muscogiuri, Pal Suranyi, Marwen Eid, Akos Varga-Szemes, Lewis Griffith, Gianluca Pontone, Uwe Joseph Schoepf, Carlo N. De Cecco

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Trauma and Acute Care Surgery

Hypoxia/reoxygenation decreases endothelial glycocalyx via reactive oxygen species and calcium signaling in a cellular model for shock Background Ischemia/reperfusion injury (IRI) has been shown to cause endothelial glycocalyx (EG) damage. Whether the hypoxic/ischemic insult or the oxidative and inflammatory stress of reperfusion plays a greater part in glycocalyx damage is not known. Furthermore, the mechanisms by which IRI causes EG damage have not been fully elucidated. The aims of this study were to determine if hypoxia alone or hypoxia/reoxygenation (H/R) caused greater damage to the glycocalyx, and if this damage was mediated by reactive oxygen species (ROS) and Ca2+ signaling. Methods Human umbilical vein endothelial cells (HUVECs) were cultured to confluence and exposed to either normoxia (30 minutes), hypoxia (2% O2 for 30 minutes), or H/R (30 minutes hypoxia followed by 30 minutes normoxia). Some cells were pretreated with ROS-scavengers TEMPOL, MitoTEMPOL, Febuxostat, or Apocynin, or with the Ca2+ chelator BAPTA or Ca2+ channel blockers 2-APB, A967079, Pyr3, or ML204. Intracellular ROS was quantified for all groups. EG was measured using fluorescently-tagged wheat germ agglutinin and imaged with fluorescence microscopy. Results Glycocalyx thickness was decreased in both hypoxia and H/R groups, with the decrease being greater in the H/R group. TEMPOL, MitoTEMPOL, BAPTA, and 2-APB prevented loss of glycocalyx in H/R.ROS levels were likewise elevated compared to normoxia in both groups, but were increased in the H/R group compared to hypoxia alone. BAPTA did not prevent ROS production in either group. Conclusions In our cellular model for shock, we demonstrate that while hypoxia alone is sufficient to produce glycocalyx loss, hypoxia/reoxygenation causes a greater decrease in glycocalyx thickness. Under both conditions damage is dependent on ROS and Ca2+ signaling. Notably, we found that ROS are generated upstream of Ca2+, but that ROS-mediated damage to the glycocalyx is dependent on Ca2+. Study Type Basic science Level of Evidence Not applicable Author contribution statement: O.J.W. Conceived the study design, performed experiments, analyzed data, and wrote the manuscript. J.K.F. Conceived the study design, analyzed and interpreted data, and wrote the manuscript. L.A.R. aided in data acquisition. M.A.H. analyzed data. R.H.D. analyzed data. J.T.P. analyzed data. A.S. analyzed and interpreted data. C.G. conceived the study design and interpreted data. J.C.D. conceived the study design and interpreted data. Corresponding author: Olan Jackson-Weaver, Ph.D., Tulane School of Medicine, 1430 Tulane Ave, Dept. of Surgery, SL-22, New Orleans, LA 70112, Email: ojacksonweaver@tulane.edu, Phone: 504-988-2306, Fax: 504-988-3683 Conflicts of interest: No conflicts of interest are declared. This manuscript was presented at the 49th Annual Meeting of the Western Trauma Association, March 3-8, 2019, in Snowmass, CO, Scientific Session 3, March 5th. © 2019 Lippincott Williams & Wilkins, Inc.

Transition from Abdominal Aortic and Junctional Tourniquet (AAJT) to Zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is feasible with hemodynamic support after porcine class IV hemorrhage BACKGROUND Traumatic hemorrhage remains a major cause of death in rural civilian and combat environments. Potential interventions to control hemorrhage from the pelvis and lower junctional regions include the Abdominal Aortic and Junctional Tourniquet (AAJT) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). The AAJT requires low technical skills and may thus be used by non-medical professionals, but is associated with time dependent ischemic complications. In combination with delayed patient evacuation, it may therefore be deleterious. Transition to zone 3 REBOA in higher levels of care may be a possibility to maintain hemostasis, mitigate adverse effects and enable surgery in patients resuscitated with the AAJT. It is possible that a transition between the interventions could lead to hemodynamic penalties. Therefore, we investigated the feasibility of replacing the AAJT with zone 3 REBOA in a porcine model of uncontrolled femoral hemorrhage. METHODS Domestic pigs (n=12) averaging 57 kg were exposed to a class IV uncontrolled hemorrhage from the common femoral artery. The animals were randomized to 60 min AAJT (n=6) or 30 min AAJT with transition to 30 min zone 3 REBOA. Hemodynamic-, and metabolic parameters and ultra-sonographic measurements of the common femoral artery were collected. RESULTS Transition from AAJT to zone 3 REBOA caused a significant decrease in mean arterial pressure (25 mm Hg). Hemostasis was maintained. The common femoral artery diameter decreased by 1,8 mm (38%) after hemorrhage and further 0,7 mm (23%) after aortic occlusion. CONCLUSION Transition from AAJT to zone 3 REBOA after a class IV bleeding is feasible with hemodynamic support. Vascular access to the femoral artery for REBOA insertion poses a technical challenge after hemorrhage and AAJT application. LEVEL OF EVIDENCE level IV, Laboratory animal study. Correspondence: Dr Andreas Brännström, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, SE-118 83 Stockholm, Sweden, Phone: +46 735 411 875, E-mail: andreas.brannstrom@ki.se Conflicts of interests: None © 2019 Lippincott Williams & Wilkins, Inc.

Big Problems in Little Patients: Nationwide Blunt Cerebrovascular Injury Outcomes in the Pediatric Population Background Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. Methods We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000-2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. Results 1182 cases of BCVI were identified, yielding an incidence of 0.21%. Patients were predominately male (69%), mean age 15±5years. Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (<11y) had significantly lower ISS and decreased severe associated injuries (all p<0.01), they had a similar mortality rate (10%) versus the older cohort. Additionally, the stroke rate was significantly higher among the younger patients versus their older peers (29% mortality for <11y vs. 15% for ≥11y, p<0.01). Only 4 of 7 commonly utilized risk factors were associated with BCVI overall, but none were significantly associated with BCVI in younger children (<11y). Conclusion This represents the first nationwide assessment of BCVI in the pediatric population. Pediatric BCVI carry considerable mortality and stroke risk. Despite being less severely injured, younger children (<11y) had similar a mortality rate and a significantly higher stroke rate compared to older pediatric patients. Furthermore, commonly utilized adult screening criteria had limited utility in the younger cohorts. These findings suggest pediatric BCVI may require screening and treatment protocols that are significantly different than currently utilized adult-based programs. Level of Evidence Level III, Prognostic/Epidemiological Study Name and Address for Correspondence: Matthew J. Martin, MD, FACS, Trauma and Emergency Surgery Service, Scripps Mercy Medical Center, 550 Washington Street, Suite 641, San Diego, CA 92103, (619) 299-2600, traumadoc22@gmail.com There are no conflicts of interest to declare for any author as regards to this manuscript. This paper was presented at the 49th Annual Meeting of the Western Trauma Association in Snowmass, CO on Friday, March 8, 2019. There are no further disclosures. © 2019 Lippincott Williams & Wilkins, Inc.

Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

Short-Term vs. Long-Term Trauma Mortality: A Systematic Review STRUCTURED ABSTRACT Background Trauma is the leading cause of death in the United States for persons under 44 years and the 4th leading cause of death in the elderly. Advancements in clinical care and standardization of treatment protocols have reduced 30-day trauma mortality to less than 4%. However, these improvements do not seem to correlate with long-term outcomes. Some reports have shown a greater-than-20% mortality rate when looking at long-term outcomes. The aim of this study was to systematically review the incongruence between short- and long-term mortality for trauma patients. Methods For this systematic review, we searched the Cochrane Library, EMBASE, Ovid Medline, Google Scholar, and Web of Science database to obtain relevant English, German, French, and Portuguese articles from 1965 to 2018. Results Trauma patients have decreased long-term survival when compared to the general population and when compared to age-matched cohorts. Post-discharge trauma mortality is significantly higher (mean 4.6% at 3-6 months, 15.8% at 2-3 years, 26.3% at 5-25 years) compared to controls (mean 1.3%, 2.2% and 15.6%, respectively). Patient comorbidities likely contribute to long-term trauma deaths. Trauma patients discharged to a skilled nursing facility have worse mortality compared to those discharged either to home or a rehabilitation center. In contrast to data available which illustrate that short-term mortality has improved, quality of evidence was not sufficient to determine if any improvements in long-term trauma mortality outcomes have also occurred. Conclusions The decreased short-term mortality observed in trauma patients does not appear correlated with decreased long-term mortality. The extent to which increased long-term trauma mortality is related to the initial traumatic insult – versus rising population age and comorbidity burden as well as sub-optimal discharge location – requires further study. Level of Evidence Level IV Study Type Systematic Review These authors contributed equally to this work, Lynn M. Frydrych, Toby P. Keeney-Bonthrone Conflict of Interest and Sources of Funding: All authors declare no conflicts of interest. LMF would like to acknowledge T32 HL007517, which supported her during her research fellowship. TPKB would like to acknowledge TL1TR000435 and TL1TR002242, which supported him during his research year. MJD would like to acknowledge the 2015 Research and Education Foundation Scholarship from the American Association for the Surgery of Trauma, the 2016 Research Scholarship from the Shock Society, and the 2017 Faculty Early Career Investigator Research Fellowship from the American Surgical Association Foundation which funded this research. Correspondence should be directed to: Matthew J. Delano, M.D., Ph.D., Assistant Professor of Surgery, University of Michigan, Department of Surgery, Division of Acute Care Surgery, University Hospital, 1C340D, 1500 E. Medical Center Dr, SPC 5033, Ann Arbor, Michigan 48109-5033, (734) 936-3662, (734) 936-9657, Email:mjdelano@med.umich.edu © 2019 Lippincott Williams & Wilkins, Inc.

LESSER SAC FLUID AFTER BLUNT TRAUMA No abstract available

Execute on the Vision: Pyramids and Mirages in Shifting Sands No abstract available

Patients with Acute Cholecystitis Should be Admitted to a Surgical Service Background In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Methods Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. 190 lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay, time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Results Patients admitted to surgical (n=106) versus medical (n=84) service had shorter mean LOS (1.4 vs 2.6 days), shorter time from admission to surgery (0.4 vs 0.8 days), and shorter time from surgery to discharge (0.8 vs 1.1 days). Surgical service patients had fewer CT (38% vs 56%) and MRI (5% vs 16%) studies. Cholangiography (30 vs 25%) and ERCP (3 vs 8%) rates were similar. Surgical service patients had 39% lower median total costs ($7787 vs $12572). Conclusions Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. This is a retrospective comparative study without negative criterion and thus Level III evidence. The study type is "Therapeutic/Care Management." Presented at the 88th Annual Meeting of the Pacific Coast Surgical Association, February 17-20, 2017 in Indian Wells, California Ning Lu, Present address: Ryder Trauma Center, Jackson Memorial Hospital, 1800 NW 10th Ave, Miami, FL, 33136 USA Walter L. Biffl, Present address: Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., La Jolla, CA, 92037, USA No conflicts of interest. Funding: There are no sources of funding. Correspondence: Walter L. Biffl, MD, 9888 Genesee Ave., MC LJ601, La Jolla, CA 92037, 858-626-6362, 858-626-6354, Biffl.walter@scrippshealth.org © 2019 Lippincott Williams & Wilkins, Inc.

Evaluation and Management of Abdominal Gunshot Wounds: A Western Trauma Association Critical Decisions Algorithm No abstract available

Predisposed to Failure? The Challenge of Rescue in the Medical Intensive Care Unit Background Medical Intensive Care Unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases. Methods All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality. Results Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p<0.05). Damage control procedures were performed in 64 patients (34%), with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (OR 13.07, 95%CI 2.86,59.79). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (OR 5.13, 95%CI 1.11,23.77). Conclusions Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk. Level of Evidence Level III Prognostic and Epidemiological Name / Address for Correspondence: Alexandra Briggs, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. Tel: 603.650.8050. Fax: 603.650.8030 Presentation: Oral Presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September, 2018 in San Diego, California Disclosures: The authors have no conflicts of interest. © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com