Search

Exposure to loud sound during leisure time is identified as a significant risk factor for hearing by health authorities worldwide. The current standard that defines unsafe exposure rests on the equal-energy hypothesis, according to which the maximum recommended exposure is a tradeoff between level and daily exposure duration, a satisfactory recipe except for strongly non-Gaussian intense sounds such as gunshots. Nowadays, sound broadcast by music and videoconference streaming services makes extensive use of numerical dynamic range compression. By filling in millisecond-long valleys in the signal to prevent competing noise from masking, it pulls sound-level statistics away from a Gaussian distribution, the framework where the equal-energy hypothesis emerged. Auditory effects of a single 4 hour exposure to the same music were compared in two samples of guinea pigs exposed either to its original or overcompressed version played at the same average level of 102 dBA allowed by French regulations. Apart from a temporary shift of otoacoustic emissions at the lowest two frequencies 2 and 3 kHz, music exposure had no detectable cochlear effect, as monitored at 1, 2 and 7 days post-exposure. Conversely, middle-ear muscle strength behaved differentially as the group exposed to original music had fully recovered one day after exposure whereas the group exposed to overcompressed music remained stuck to about 50% of baseline even after 7 days. Subsamples were then re-exposed to the same music as the first time and sacrificed for density measurements of inner-hair-cell synapses. No difference in synaptic density was found compared to unexposed controls with either type of music. The present results show that the same music piece, harmless when played in its original version, induces a protracted deficit of one auditory neural pathway when overcompressed at the same level. The induced disorder does not seem to involve inner-hair cell synapses., Competing Interests: Declaration of competing interest The authors have no competing interest to declare., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: There is uncertainty about the optimal videolaryngoscope for awake tracheal intubation in patients with anticipated difficult airway. The use of channelled and unchannelled videolaryngoscopy has been reported, but there is a lack of evidence on which is the best option., Methods: We conducted a randomised clinical trial to compare the efficacy of the C-MAC D-Blade® vs. Airtraq® in adult patients (aged ≥ 18 y) scheduled for elective or emergency surgery under general anaesthesia with anticipated difficult airway who required awake tracheal intubation under local anaesthesia and conscious sedation. The primary endpoint was the first-attempt tracheal intubation success rate. Secondary outcomes included the overall success rate; number of tracheal intubation attempts; Cormack and Lehane glottic view; level of difficulty (visual analogue score); patient discomfort (visual analogue score); and incidence of complications., Results: Ninety patients (70/90 male (78%); mean (SD) age 65 (12) y) with anticipated difficult airways were randomly allocated to C-MAC D-Blade or Airtraq videolaryngoscopy. First-attempt successful tracheal intubation rate was higher in patients allocated to the C-MAC D-Blade group compared with those allocated to the Airtraq group (38/45 (84%) vs. 28/45 (62%), respectively; p = 0.006). The proportion of patients' tracheas that were intubated at the second and third attempt was 4/45 (9%) and 3/45 (7%) in those allocated to the C-MAC D-Blade group compared with 14/45 (31%) and 1/45 (2%) in those allocated to the Airtraq group (p = 0.006). There was no significant difference in overall tracheal intubation success rate (C-MAC D-Blade group 45/45 (100%) vs. Airtraq group 43/45 (96%), p = 0.494)., Discussion: In patients with anticipated difficult airway, first-attempt awake tracheal intubation success rate was higher with the C-MAC D-Blade compared with Airtraq laryngoscopy. No difference was found between the two videolaryngoscopes in overall tracheal intubation success rate., (© 2024 Association of Anaesthetists.)

Objectives: Resective surgery is a potential therapeutic option for select patients with intractable focal epilepsy. However, the presence of ictal onset zones within or surrounding highly functional brain areas presents a surgical challenge, leading to poor seizure and functional outcomes. This report describes our experiences with awake mapping-tailored resection of epileptogenic areas involving eloquent cortices and evaluates their feasibility, tolerance, limitations, and significance., Methods: The study included patients who underwent surgery for drug-resistant focal epilepsy at our center under awake conditions. The surgical approach aimed to achieve maximum resection of preoperatively defined epileptogenic zones, considering the boundaries defined by surrounding functional areas. We collected data on preoperative evaluations, intraoperative tests and seizures, postoperative status epilepticus, and neurological functional outcomes., Results: We included 22 patients, 10 of whom had non-lesional epilepsy. Language, motor function, and sensory function were at risk in 19, 9, and 4 patients, respectively. Resection was performed as planned in 14 (63.6%) patients, while modifications were necessary in 8 (36.4%) patients due to functional constraints. The mean follow-up duration was 29.8 months. Sixteen (72.7%) patients achieved Engel class Ia outcomes, indicating seizure freedom, while none of the patients experienced clinically significant permanent postoperative neurological deficits., Significance: Resective surgery with intraoperative brain mapping under awake conditions was a valid treatment option for achieving a cure in cases of drug-resistant focal epilepsy, even in situations in which the condition is considered inoperable due to the risk of significant postoperative neurological deficits., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Objectives: The use of awake extracorporeal membrane oxygenation (ECMO, without intubation or sedation under ECMO support in patients with cardiogenic shock is growing rapidly because emerging clinical investigations indicates it may reduce morbidity associated with sedation and intubation. We systematically reviewed the efficacy of awake ECMO and provided evidence for clinical practitioners and researchers., Design: Systematic review and trial sequential meta-analysis based on observational studies., Data Sources: Data was retrieved from seven databases (PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database and Cochrane Library) up to 1 March 2024., Eligibility Criteria: We included observational studies that compared the differences in clinical outcomes between awake ECMO and non-awake ECMO in patients with cardiogenic shock., Data Extraction and Synthesis: Two reviewers rigorously conducted literature retrieval, screening and data extraction. The RevMan software was used for data synthesis., Results: Five retrospective observational studies involving 1044 patients with cardiogenic shock were included. Compared with non-awake ECMO, awake ECMO was associated with a lower mortality rate of patients with cardiogenic shock (OR=0.28; 95% CI, (0.15, 0.49); p<0.0001; I 2 =50%). Trial sequential analysis indicated that the sample mortality outcome reached the required information size. No significant differences were observed between the two groups on secondary outcomes such as the occurrence of ventilator-associated pneumonia, weaning from ECMO, tracheostomy, haemorrhage, thrombosis, limb ischaemia and nosocomial infection., Conclusions: Implementing awake ECMO may result in better clinical outcomes in patients with cardiogenic shock. Because of the limited sample sizes and potential bias of the current studies, more rigorously designed large-scale trials are urgently needed to verify the above findings., Prospero Registration Number: CRD42023407607., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Histamine, a neurotransmitter, plays a predominant role in maintaining wakefulness. Further, our previous studies showed that histamine N-methyltransferase (HNMT), a histamine-metabolising enzyme, is important for regulating brain histamine concentration. However, the effects of pharmacological HNMT inhibition on mouse behaviour, including the sleep-wake cycle and cataplexy, in a mouse model of narcolepsy have not yet been investigated. In the present study, we investigated the effects of metoprine, an HNMT inhibitor with high blood-brain barrier permeability, in wild-type (WT) and orexin-deficient (OxKO) narcoleptic mice. Metoprine increased brain histamine concentration in a time- and dose-dependent manner without affecting peripheral histamine concentrations. Behavioural tests showed that metoprine increased locomotor activity in both novel and familiar environments, but did not alter anxiety-like behaviour. Sleep analysis showed that metoprine increased wakefulness and decreased non-rapid eye movement (NREM) sleep through the activation of the histamine H1 receptor (H1R) in WT mice. In contrast, the reduction of rapid eye movement (REM) sleep by metoprine occurred independent of H1R. In OxKO mice, metoprine was found to prolong wakefulness and robustly suppress cataplexy. In addition, metoprine has a greater therapeutic effect on cataplexy than pitolisant, which induces histamine release in the brain, and has been approved for patients with narcolepsy. These data demonstrate that HNMT inhibition has a strong effect on wakefulness, demonstrating therapeutic potential against cataplexy in narcolepsy., (© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background/Objectives: A well-established association exists between the development of hypertension and sleep quality. The connection between self-reported sleep quality and the onset of hypertension is particularly significant in populations with metabolic deterioration, such as in Mexico. Methods: The Tlalpan 2020 Cohort was analyzed to explore this association. Clinical and anthropometric characteristics, along with the Medical Outcomes Study Sleep Scale (MOS-SS), were compared between participants who developed hypertension and those who did not over a follow-up period of 30.8 months. The potential role of poor sleep quality in the development of hypertension was assessed. Results: Among 1520 participants, 12% developed hypertension. These individuals had higher anthropometric and laboratory values and reported poorer sleep quality. An elevated sleep problems index was associated with a 50% higher relative risk of developing hypertension (OR: 1.5; 95% CI: 1.087 to 2.069). Additionally, self-reported snoring was associated with hypertension onset (36.3 vs. 43.3; p = 0.019). Conclusions: Poor sleep quality and respiratory disturbances during sleep increase the risk of developing hypertension. Furthermore, hypertension was associated with snoring, highlighting the importance of early interventions to improve sleep quality.

Humans spend a third of their lives asleep. While the sleep-wake behaviors are primarily modulated by homeostasis and circadian rhythm, several ambient chemical and physical factors, including light, sound, odor, vibration, temperature, electromagnetic radiation, and ultrasound, also affect sleep and wakefulness. Light at different wavelengths has different effects on sleep and wakefulness. Sound not only promotes but also suppresses sleep; this effect is mediated by certain nuclei, including the pedunculopontine nucleus and inferior colliculus. Certain sleep-promoting odorants regulate sleep through the involvement of the olfactory bulb and olfactory tubercle. In addition, vibrations may induce sleep through the vestibular system. A modest increase in ambient temperature leads to an increase in sleep duration through the involvement of the preoptic area. Electromagnetic radiation has a dual effect on sleep-wake behaviors. The stimulation produced by the ambient chemical and physical factors activates the peripheral sensory system, which converts the chemical and physical stimuli into nerve impulses. This signal is then transmitted to the central nervous system, including several nuclei associated with the modulation of sleep-wake behaviors. This review summarizes the effects of ambient chemical and physical factors on the regulation of sleep and wakefulness, as well as the underlying neurobiological mechanisms., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Prone position has been proven to improve ventilation and oxygenation in infants. Currently, there are few reports of early prone position ventilation after pediatric liver transplantation. Here, we present our experience with prone position in an infant following living donor liver transplantation, in an attempt to improve oxygenation., Case Presentation: An 8-month-old boy, 7.5 kg, experienced two failed extubations that presented with Type II respiratory failure due to dyspnea, potentially caused by consolidation and airway secretions. To prevent the third failure of extubation, prone position ventilation was implemented after the third extubation on the 11th postoperative day. Oxygenation increased after each prone position session with no signs of transplant liver ischemia or other adverse outcomes. Following two days of continuous prone position, airway secretions decreased, and the infant was discharged from the ICU. The third extubation procedure was successful., Conclusions: Prone position ventilation may be effective in this infant without adverse events, indicating that early prone position is not absolutely contraindicated after pediatric liver transplantation. Therefore, more reasonable prone position strategies should be sought in infants undergoing liver transplantation., (© 2024. The Author(s).)

Introduction: Flexible bronchoscopy under anesthesia is a mainstay diagnostic tool for evaluating respiratory disorders in pediatric patients. While flexible bronchoscopy is generally regarded as a safe procedure with low risk for major complications, it does entail additional risks associated with the use of general anesthesia. The use of diagnostic awake flexible bronchoscopy in children is not well documented in current literature., Objectives: The objective of this case series is to investigate the feasibility and potential utility of awake flexible bronchoscopy in pediatric patients and to highlight important precautions and complications., Methods: This was a consecutive case series of patients who underwent an awake flexible bronchoscopy over a two year period at a tertiary children's hospital. Data collection included demographics, indications, number of attempts, scope findings, and complications. Successful attempts of flexible bronchoscopy were defined by visualization of the trachea and mainstem bronchi while failed attempts include if the scope entered the esophagus or if cough, vocal fold adduction, or movement prevented the scope from entering the trachea., Results: 11 patients were involved in this study (mean age 20 months, age range 0d to 5y 1m, 72 % male). Common indications for bronchoscopy were suspicion of foreign body (5, 45.4 %), chronic cough (4, 36.4 %), and stridor (4, 36.4 %). The mean number of attempts until successful was 1.72 (range 1-3). One patient experienced a 30-s episode of gagging with mucinous emesis. There were no other complications. One patient ultimately underwent another flexible bronchoscopy under general anesthesia to confirm the findings and to evaluate the tertiary bronchioles and another patient underwent a surgical resection of an oral mass under general anesthesia after awake flexible bronchoscopy., Discussion: Awake flexible bronchoscopy was well tolerated in this study and could serve as a useful diagnostic tool without necessitating anesthetic. However, further study is needed to compare awake flexible bronchoscopy with flexible bronchoscopy under general anesthesia. Additionally, the patients selected for this study were limited to those with minimal risk, such as patients without cardiac disease. Limitations of this technique include suboptimal visualization of subglottic region and limited diagnostic utility for sleep related airway pathologies and cases where therapeutic intervention is needed., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Elsevier B.V. All rights reserved.)

Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Bronchoscopy is a widely used technique for diagnostic and therapeutic purposes. Though it requires anesthesia, many options are available, depending on the patient's health status, the purpose of the procedure, and the type of bronchoscope used. One such health status is heart failure, a leading cause of death, and a common challenge of anesthesiology. We report a 60-year-old male patient who is a known case of heart failure with an ejection fraction of 15%, and an implanted cardioverter defibrillator, along with concurrent ischemic heart disease, diabetes mellitus, and hypertension, who presented complaining of dysphagia. This highly morbid patient was able to successfully undergo a bronchoscopic biopsy with nerve block anesthesia considering his inadequacy for conventional methods. This report aims to shed light on these challenging cases and alert anesthesiologists on how to manage such situations in patients with cardiac morbidities., (Copyright © 2024 Copyright: © 2024 Annals of Cardiac Anaesthesia.)

Objectives: Pre-sleep stress or hyperarousal is a known key etiological component in insomnia disorder. Despite this, physiological alterations during the sleep onset are not well-understood. In particular, insomnia and obstructive sleep apnea (OSA) are highly prevalent co-morbid conditions, where autonomic regulation may be altered. We aimed to characterize heart rate variability (HRV) during sleep onset as a potential measure of pre-sleep hyperarousal., Methods: We described the profile of pre-sleep HRV measures and explore autonomic differences in participants with self-reported insomnia disorder (with no OSA, n = 69; with mild OSA, n = 70; with moderate or severe OSA, n = 66), compared to normal sleep controls (n = 123). Heart rate data during the sleep onset process were extracted for HRV analyses., Results: During the sleep onset process, compared to normal sleep controls, participants with insomnia had altered HRV, indicated by higher heart rate (p = 0.004), lower SDNN (p = 0.003), reduced pNN20 (p < 0.001) and pNN50 (p = 0.010) and lower powers (p < 0.001). Participants with insomnia and moderate/severe OSA may have further deteriorated HRV outcomes compared to no/mild OSA patients with insomnia but differences were not significant. Insomnia itself was associated with significantly higher heart rate, lower pNN20, and lower high frequency power even after adjustment for age, gender, BMI and OSA severity., Conclusions: Participants with insomnia had lower vagal activity during the sleep onset period, which may be compounded by OSA, reflected in higher heart rates and lower HRV. These altered heart rate dynamics may serve as a physiological biomarker for insomnia during bedtime wakefulness, or as a potential tool to evaluate the efficacy of behavioral interventions which target bedtime stress., Competing Interests: Declaration of Competing interest The authors report no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

To prevent motion artifacts in small animal positron emission tomography (PET), animals are routinely scanned under anesthesia or physical restraint. Both may potentially alter metabolism and neurochemistry. This study investigates the feasibility of fully awake acquisition and subsequent absolute quantification of dynamic brain PET data via pharmacokinetic modelling in moving rats using the glutamate 5 receptor radioligand [ 11 C]ABP688 and point source based motion correction. Five male rats underwent three dynamic [ 11 C]ABP688 PET scans: two test-retest awake PET scans and one scan under anesthesia for comparison. Specific radioligand binding was determined via the simplified reference tissue model (reference: cerebellum) and outcome parameters BP ND and R 1 were evaluated in terms of stability and reproducibility. Test-retest measurements in awake animals gave reliable results with high correlations of BP ND (y = 1.08 × -0.2, r = 0.99, p < 0.01) and an acceptable variability (mean over all investigated regions 15.7 ± 2.4%). Regional [ 11 C]ABP688 BP ND s under awake and anesthetized conditions were comparable although in awake scans, absolute radioactive peak uptakes were lower and relative blood flow in terms of R 1 was higher. Awake small animal PET with absolute quantification of neuroreceptor availability is technically feasible and reproducible thereby providing a suitable alternative whenever effects of anesthesia are undesirable, e.g. in sleep research., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:Alexander Drzezga: Research support: Siemens Healthineers, Life Molecular Imaging, GE Healthcare, AVID Radiopharmaceuticals, Sofie, Eisai, Novartis/AAA, Ariceum TherapeuticsSpeaker Honorary/Advisory Boards: Siemens Healthineers, Sanofi, GE Healthcare, Biogen, Novo Nordisk, Invicro, Novartis/AAA, Bayer VitalStock: Siemens Healthineers, Lantheus Holding, Structured therapeutics, ImmunoGenPatents: Patent for 18 F-JK-PSMA- 7 (Patent No.: EP3765097A1; Date of patent: Jan. 20, 2021).

Study Objectives: Idiopathic hypersomnia (IH) is characterized by excessive sleepiness during the day, prolonged sleep at night, and difficulty waking up. The true prevalence of IH is uncertain. The International Classification of Sleep Disorders provides criteria for diagnosing IH; however, the definition has evolved. Managing IH involves using pharmacologic and nonpharmacologic approaches, although the most effective strategies are still unclear. The objective of this scoping review was to identify the extent, range, and nature of the available evidence, identify research gaps, and discuss the implications for clinical practice and policy., Methods: To conduct this review, a comprehensive search was conducted across scientific databases, without any restrictions on the date or study type. Eligible studies examined the effectiveness of pharmacologic and nonpharmacologic treatments for IH and reported the outcomes of these interventions. Data from the studies were screened, analyzed, and synthesized to provide an overview of the available literature landscape., Results: Fifty-one studies were included in this review, which used various methods and interventions. Pharmacological treatments, particularly modafinil, have been frequently studied and have yielded positive results. There is also emerging evidence for alternative medications such as low-sodium oxybate and pitolisant. Nonpharmacological approaches, such as cognitive behavioral therapy for hypersomnia and transcranial direct current stimulation have also shown promise in managing IH., Conclusions: This review highlights the complexity of managing IH symptoms and emphasizes the need for personalized multidisciplinary approaches. Pharmacological interventions are important in managing IH and can be complemented by nonmedication strategies. Larger-scale studies are necessary to advance our understanding of IH and to improve treatment outcomes., Citation: Saini V, Saini S. A scoping review of the evidence on pharmacological and nonpharmacological interventions for idiopathic hypersomnia. J Clin Sleep Med . 2024;20(10):1685-1704., (© 2024 American Academy of Sleep Medicine.)

Obstructive sleep apnea (OSA) is a chronic breathing disorder during sleep that affects 10-30% of adults in North America. The gold standard for diagnosing OSA is polysomnography (PSG). However, PSG has several drawbacks, for example, it is a cumbersome and expensive procedure, which can be quite inconvenient for patients. Additionally, patients often have to endure long waitlists before they can undergo PSG. As a result, other alternatives for screening OSA have gained attention. Speech, as an accessible modality, is generated by variations in the pharyngeal airway, vocal tract, and soft tissues in the pharynx, which shares similar anatomical structures that contribute to OSA. Consequently, in this study, we aim to provide a comprehensive review of the existing research on the use of speech for estimating the severity of OSA. In this regard, a total of 851 papers were initially identified from the PubMed database using a specified set of keywords defined by population, intervention, comparison and outcome (PICO) criteria, along with a concatenated graph of the 5 most cited papers in the field extracted from ConnectedPapers platform. Following a rigorous filtering process that considered the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach, 32 papers were ultimately included in this review. Among these, 28 papers primarily focused on developing methodology, while the remaining 4 papers delved into the clinical perspective of the association between OSA and speech. In the next step, we investigate the physiological similarities between OSA and speech. Subsequently, we highlight the features extracted from speech, the employed feature selection techniques, and the details of the developed models to predict OSA severity. By thoroughly discussing the current findings and limitations of studies in the field, we provide valuable insights into the gaps that need to be addressed in future research directions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Paraplegia after spinal cord ischemia is a devastating condition in the clinic. Here, we develop an awake rabbit model of spinal cord ischemia with delayed paraplegia and explore the influence of ambient temperature on the outcomes after injury., Methods: A total of 47 male rabbits were involved in the present study. Transient spinal cord ischemia was induced by occluding the infrarenal abdominal aorta of awake rabbits at different ambient temperatures. To find the optimal conditions for developing delayed paraplegia, hindlimb motor function after ischemia was evaluated between experiments., Results: The onset and magnitude of ischemic injury varied with the ambient temperature maintained during the peri-ischemia period. More serious spinal cord injury occurred when ischemia was induced at higher temperatures. At 18°C, 25-minute ischemia resulted in 74% of rabbits developing delayed paraplegia. At a temperature of 28°C or higher, most of the animals developed acute paraplegia immediately. While at 13°C, rabbits usually regained normal motor function without paraplegia., Conclusion: This awake rabbit model is highly reproducible and will be helpful in future studies of delayed paraplegia after spinal cord ischemia. The ambient temperature must be considered while using this model during investigation of therapeutic interventions., (© 2023 The Authors. Animal Models and Experimental Medicine published by John Wiley & Sons Australia, Ltd on behalf of The Chinese Association for Laboratory Animal Sciences.)

Introduction: The goal of surgical management in pediatric low-grade gliomas (pLGGs) is gross total resection (GTR), as it is considered curative with favorable long-term outcomes. Achieving GTR can be challenging in the setting of eloquent-region gliomas, in which resection may increase risk of neurological deficits. Awake craniotomy (AC) with intraoperative neurofunctional mapping (IONM) offers a promising approach to achieve maximal resection while preserving neurological function. However, its adoption in pediatric cases has been hindered, and barriers to its adoption have not previously been elucidated., Findings: This review includes two complementary investigations. First, a survey study was conducted querying pediatric neurosurgeons on their perceived barriers to the procedure in children with pLGG. Next, these critical barriers were analyzed in the context of existing literature. These barriers included the lack of standardized IONM techniques for children, inadequate surgical and anesthesia experience, concerns regarding increased complication risks, doubts about children's ability to tolerate the procedure, and perceived non-indications due to alternative monitoring tools., Conclusion: Efforts to overcome these barriers include standardizing IONM protocols, refining anesthesia management, enhancing patient preparation strategies, and challenging entrenched beliefs about pediatric AC. Collaborative interdisciplinary efforts and further studies are needed to establish safety guidelines and broaden the application of AC, ultimately improving outcomes for children with pLGG., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Awake prone positioning is studied extensively during Covid-19 pandemic, but there is very limited evidence on its utility in acute hypoxic respiratory failure caused by bacterial infections or other causes. The aim of our research is to evaluate the impact of awake prone positioning on outcomes in non-intubated adult patients with acute non-Covid19 hypoxemic respiratory failure., Methods: This is a multi-center randomized controlled trial (RCT) with a parallel-group design and a 1:1 allocation ratio. Adult patients, admitted to ICU and diagnosed with hypoxemic respiratory failure will be randomly allocated into intervention (awake prone position (APP)) or control group. Our hypothesis is that addition of awake prone positioning to standard oxygen, high flow oxygen therapy and non-invasive ventilation may reduce the need for mechanical ventilation in adult patients diagnosed with acute hypoxemic respiratory failure. Primary outcome is rate of endotracheal intubation; secondary outcomes include intensive care and hospital mortality, duration of mechanical ventilation, length of intensive care and hospital stay and health related quality of life post hospital discharge. Primary and secondary outcomes will be assessed at hospital discharge, 30, 90 days and 1 year following randomisation., Conclusion: The Hyper-AP study will assess the superiority of awake prone positioning versus standard treatment in spontaneously breathing ICU patients diagnosed with hypoxaemic respiratory failure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to describe our institutional use of a commercially available mixed reality viewer within a multi-disciplinary planning workflow for awake craniotomy surgery and to report an assessment of its usability., Materials and Methods: Three Tesla MRI scans, including 32-direction diffusion tensor sequences, were reconstructed with BrainLab Elements auto-segmentation software. Magic Leap mixed reality viewer headsets were registered to a shared virtual viewing space to display image reconstructions. System Usability Scale was used to assess the usability of the mixed reality system., Results: The awake craniotomy planning workflow utilises the mixed reality viewer to facilitate a stepwise discussion through four progressive anatomical layers; the skin, cerebral cortex, subcortical white matter tracts and tumour with surrounding vasculature. At each stage relevant members of the multi-disciplinary team review key operative considerations, including patient positioning, cortical and subcortical speech mapping protocols and surgical approaches to the tumour.The mixed reality system was used for multi-disciplinary awake craniotomy planning in 10 consecutive procedures over a 5-month period. Ten participants (2 Anaesthetists, 5 Neurosurgical trainees, 2 Speech therapists, 1 Neuropsychologist) completed System Usability Scale assessments, reporting a mean score of 71.5. Feedback highlighted the benefit of being able to rehearse important steps in the procedure, including patient positioning and anaesthetic access and visualising the testing protocol for cortical and subcortical speech mapping., Conclusions: This study supports the use of mixed reality for multidisciplinary planning for awake craniotomy surgery, with an acceptable degree of usability of the interface. We highlight the need to consider the requirements of non-technical, non-neurosurgical team members when involving mixed reality activities.

Resection of a glioma from the dorsomedial frontal lobe, including the supplementary motor area (SMA), can result in postoperative SMA syndrome. SMA syndrome may occur during awake craniotomies. However, it is often difficult to intraoperatively distinguish between motor dysfunction due to pyramidal tract damage from that due to SMA syndrome. Patients with suspected intraoperative SMA syndrome are indifferent to their surroundings, have stiff facial muscles, and maintain a fixed gaze. We defined this condition as "apathetic look." The present study aimed to investigate whether intraoperative "apathetic look" is useful for identifying intraoperative SMA syndrome in patients with glioma close to motor-related areas, including the SMA, during awake craniotomy. This study included 33 consecutive patients with glioma included in the SMA. We excluded patients whose tumors extended to motor-related areas. We also assessed whether intraoperative SMA syndrome occurred in each patient. We evaluated the correlation between the occurrence of intraoperative SMA syndrome and various clinical factors, including intraoperative "apathetic look." Of the 33 patients, 12 had intraoperative SMA syndrome. Intraoperative "apathetic look" showed strong correlation with intraoperative SMA syndrome (p < 0.0001). Additionally, higher extent of resection (EOR) and resection of the corpus callosum showed a significantly higher incidence of intraoperative "apathetic look." All 12 patients with intraoperative SMA syndrome showed intraoperative "apathetic look" and recovered from SMA syndrome with high EOR. In conclusion, intraoperative "apathetic look" shows strong correlation with intraoperative SMA syndrome. Therefore, "apathetic look" may be a valuable indicator of intraoperative SMA syndrome during awake craniotomy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Breast cancer is the most prevalent cancer among women, often necessitating surgical intervention. While surgeries like lumpectomy can be performed under local anesthesia, more extensive procedures typically require general anesthesia. Awake breast cancer surgery has emerged as an alternative due to risks associated with general anesthesia and patient preference., Methods: This prospective observational study, conducted from July 2022 to July 2023, evaluated the effectiveness of ultrasound-guided fascial plane blocks for awake breast surgery. Patients aged 18-80 years undergoing unilateral breast surgery were included, following ethical committee approval and written informed consent. Exclusion criteria were prior breast surgery, coagulopathies, infections, allergies to local anesthetics, psychiatric disorders, body mass index over 40 kg/m², and chest deformities. The combination of interpectoral, pecto-serratus, and deep serratus plane blocks was used as the primary anesthetic method, with a superficial parasternal block added in cases where complete cutaneous coverage was not achieved., Results: Seventeen patients were enrolled. The primary outcome, sufficient surgical anesthesia without deep sedation, was achieved in 15 patients. The combination of the aforementioned blocks proved effective, with an average surgery duration of 59.66 min, and propofol requirements averaging 1.77 mg/kg/hour. Most patients reported high satisfaction levels, and no early or late block-related complications were observed., Conclusion: The combination of fascial plane blocks is a viable option for awake breast cancer surgery, potentially eliminating the need for more invasive anesthesia techniques. Further studies are necessary to confirm these findings in larger, homogeneous patient groups., (© 2024. The Author(s).)

Purpose: Converging evidence implicates the putamen in sleep-wake regulation. However, its role remains unclear. We hypothesized that metabolic abnormalities in the putamen are linked to insomnia disorder, which has not been previously addressed, and investigated putaminal N-acetylaspartate (NAA), choline (Cho), and creatine (Cr) in patients with insomnia disorder compared to healthy controls., Participants and Methods: In the present study, the concentrations of NAA, Cho, and Cr in the putamen of 23 patients with insomnia disorder and 18 healthy controls were determined using proton magnetic resonance spectroscopy. Sociodemographic, psychometric, and polysomnography data were obtained from all participants., Results: We found that the mean NAA/Cr ratio of the right putamen was significantly greater in the insomnia group compared to the control group and also greater than the left putamen within the insomnia group. The NAA/Cr ratio of the right putamen distinguished insomnia disorder from normal sleep with 78.3% sensitivity and 61.1% specificity. Furthermore, this ratio positively correlated with both objective and subjective insomnia severity and sleep quality., Conclusion: Our findings provide critical evidence for the dysfunctional putaminal metabolism of NAA/Cr in insomnia disorder, suggesting that the abnormal NAA/Cr ratio of the right putamen is linked to wakefulness in patients with insomnia disorder and may serve as a potential biomarker of insomnia disorder., Competing Interests: The authors declare that they have no conflicts of interest in this work. All authors have read and approved the final version for publication. This article is the authors’ original work, has not been previously published, and is not under consideration for publication elsewhere., (© 2024 Huang et al.)

Objective: Although radiofrequency ablation (RFA) is a safe and effective non-surgical treatment for benign thyroid nodules, injury to the recurrent laryngeal nerve (RLN), is a potential and feared complication. Intermittent voice checks have been proposed to monitor vocal cord (VC) function during RFA, but such assessment is highly subjective and effort-dependent., Methods: We are here reporting the methodological use of flexible laryngoscopy (FL) for VC monitoring during bilateral thyroid RFA treatment. The patient, a 35-year-old woman, was referred to the Endocrinology Unit for subclinical hyperthyroidism due to bilateral autonomously functioning thyroid nodules., Results: At the end of the treatment of the first nodule, the FL performed by an otorhinolaryngologist specialist allowed evaluating VC function and ruling out possible paralysis before proceeding with the contralateral RFA treatment. The patient was awake during the entire procedure and well tolerated the laryngoscopic examination. The TSH serum evaluations performed one month and 9 months after the procedure assessed an euthyroid state (TSH 3.2 mIU/L and 2.8 mIU/L, respectively)., Conclusion: During bilateral thyroid RFA the use of FL for VC monitoring treatment resulted in a safe, easy-to-perform, and effective strategy to minimize and anticipate RLN injury risk in the awake patient. The prevention of RLN damage is advisable in the case of single RFA treatment, while it should be strongly recommended when RFA is performed on bilateral nodules., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Teliti, Occhini, Fonte, Croce, Calì, Ripepi, Carbone, Rotondi and Chytiris.)

Awake tracheostomy is rare in the pediatric population. We describe the case of a 10-year-old male who underwent awake tracheostomy due to airway obstruction from an oropharyngeal rhabdomyosarcoma. Given the varying medical understanding and communication skills in children, advanced planning and interdisciplinary collaboration are essential to keep the patient calm and safe during awake tracheostomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To determine the outcome of awake surgery with combined spinal epidural in geriatric colon cancer patients with advanced comorbidity., Study Design: Quasi-experimental study. Place and Duration of the Study: Department of Anaesthesiology and Reanimation, Ankara Bilkent City Hospital, Ankara, Turkiye, from April 2022 to 2023., Methodology: Twenty-four American Society of Anaesthesiologists (ASA) I-II patients, aged 25-65 years and scheduled for colon cancer surgery were included in this research. All patients were observed preoperatively, at the operation room and at the postoperative surgery service. Spinal anaesthesia was planned for Group I and general anaesthesia for Group II. Ketofol (1:1) was administered to the combined spinal-epidural group, with a Ramsay sedation score of 3 after the spinal block. Epidural analgesia was planned for all patients. Patients' age, gender, weight, comorbidities, ASA risk scores, intraoperative haemodynamic parameters, bleeding amounts, colloid, crystalloid, and blood products were collected., Results: There was no significant difference between the demographic characteristics of both anaesthesia groups (p >0.05). The amount of bleeding was statistically lower in Group I than in the general anaesthesia group (p = 0.004). Oral intake, drain withdrawal, mobilisation, discharge times, and costs were similar in all groups (p >0.05)., Conclusion: The regional anaesthesia applications facilitate compliance with routine mobilisation, discharge procedures and prevent complications in abdominal surgery and its positive perioperative effects in patients with poor respiratory parameters, poor general condition, and high comorbidity in advanced age., Key Words: Regional anaesthesia, Spinal-epidural, Mobilisation, Pain, Colon cancer.

Hypoglossal nerve stimulation is a treatment option for patients with obstructive sleep apnea who are intolerant to positive airway pressure therapy. In the post-implant period, awake endoscopy with advanced programming (AEAP) can be employed to optimize apnea-hypopnea index reduction and/or patient comfort and usage. The report herein describes awake endoscopy with AEAP as a guide to providers involved in post-implant care. The first 5 consecutive patients were reviewed to provide general understanding of outcomes and safety when implementing such a protocolized approach., (© 2024 The Authors. Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background: Low-income countries (LICs) and lower-middle-income countries (LMICs) are presented with unique challenges and opportunities when performing awake craniotomy (AC) for brain tumors. These circumstances arise from factors that are financial, infrastructural, educational, personnel, and sociocultural in nature., Methods: We performed a systematic narrative review of series on AC for intra-axial brain tumors in LICs/LMICs using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the challenges and opportunities in these settings. The PubMed, Scopus, and Web of Science databases were searched., Results: After initially identifying 74 studies, inclusion-exclusion criteria were applied, leaving a total of 14 studies included in the review. These involved 409 patients who underwent AC in LICs/LMICs. These series were from India, Ghana, Nigeria, Iran, Pakistan, Morocco, the Philippines, and Egypt. The most common pathology encountered were gliomas (10-70%). Most studies (11/14, 78.5%) reported on their technique of cortical-subcortical mapping. All reported on motor mapping and 8 of these performed language mapping. The most common outcomes reported were seizure and neurologic deficits, and longest follow-up was at 1 year. Challenges noted were lack of equipment and trained personnel, need for validated tests for the local setting, and sociocultural factors. Opportunities identified were volume for training, technique innovation, and international collaboration., Conclusions: There are numerous challenges and opportunities that arise when performing AC in LICs/LMICs. A collaborative approach toward harnessing the opportunities, and seeking creative solutions to address the challenges, would provide an ideal mechanism toward advancing neurosurgical care and specialty worldwide., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: One of the pressing constraints in the treatment of arteriovenous malformations (AVM) is the potential development of new neurologic deficits, mainly when the AVM is in an eloquent area. The risk of ischemia when an en passage arterial supply is present is not negligible. In this regard, awake surgery holds promise in increasing the safety of low-grade AVM resection., Methods: We conducted a pilot trial on 3 patients with low-grade AVMs affecting speech areas to evaluate the safety of awake craniotomy using Conscious Sedation. Each feeder was temporarily clipped before the section. Also, we performed a systematic review to analyze the existing data about the impact of awake surgery in eloquent AVM resection., Results: None of the 3 patients presented with neurologic deficits after the procedure. Awake craniotomy was useful in 1 case, as it allowed the detection of speech arrest during the temporal clipping of 1 of the feeders. This vessel was identified as an en passage vessel, closer to the nidus. The second attempt revealed the feeder of the AVM, which was sectioned. Systematic review yielded 7 studies meeting our inclusion criteria. Twenty-six of 33 patients included in these studies presented with AVM affecting speech area. Only 2 studies included the motor evoked potentials. Six studies used direct cortical and subcortical stimulation. In all studies the asleep-awake-asleep technique was used., Conclusions: Awake craniotomies are safe procedures and may be helpful in avoiding ischemic complications in low-grade AVMs, either affecting eloquent areas and/or when en passage feeders are present., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: We describe our protocol and outcomes of awake robotic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anesthesia., Methods: We conducted a prospective study of 10 consecutive patients undergoing awake robotic single-level MIS-TLIF with the Mazor X robot. We prospectively collected patient-reported outcomes (back and leg pain visual analog scale and Oswestry Disability Index) preoperatively at 1-month and 1-year follow-ups and assessed fusion and screw placement accuracy with a 1-year computed tomography (CT) scan., Results: Median age was 61 years (interquartile range [IQR] = 57.7-66). Median body mass index was 27 kg/m 2 . No intraoperative complications were reported. Most (9/10) patients were discharged home, and 50% discharged on the day of surgery. Median length of stay was 16.5 hours (IQR = 5-35.5). Median follow-up was 12.5 months (IQR = 12-13.5), with 9 patients having at least 12-month follow-up, with CT scans documenting good screw placement (Gertzbein-Robbins grade A) and solid bony fusion. Median preoperative back pain visual analog scale score was 7.8 (IQR = 6.9-8) versus 1.5 (IQR = 0-3.2) at 1-month post operation, P < 0.01, and 0 (IQR = 0-1) at 1-year follow-up, P < 0.01; median preoperative leg pain 8 (IQR = 7.4-8) versus 0 (IQR = 0-1.2) at 1-month post operation, P < 0.01, and 0 (IQR = 0-2) at 1-year follow-up, P < 0.01; median preoperative Oswestry Disability Index 47.5 (IQR = 27.8-57.5) versus 4 (IQR = 0-16) at 1-month postoperation, P < 0.01, and 0 (IQR = 0-7) at 1-year follow-up, P < 0.01. Median preoperative disk height of the index level was 8 mm (IQR = 2.4-9.5) versus 11.4 mm (IQR = 9.2-11.2) postoperatively,P < 0.01. Median preoperative lordosis of the index level was 5 degrees (IQR = 3.4-8.5) versus 10.1 degrees (7.3-12.2) postoperatively, P < 0.01., Conclusions: Our study showed significant improvement in patient-reported outcomes at 1-month and 1-year follow-ups after awake robotic MIS-TLIF, as well as solid bony fusion on CT scans., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This article makes a case for examining dying person's visions during wakefulness and their dreams during sleep as separate and unique phenomena. The reason being that the mode of experience, for example, being visited by a deceased loved one while awake and conscious vs having a deceased loved one appear in a dream while asleep, may have a different impact on the dying person. A better understanding of the content and impact of waking visions and sleeping dreams, respectively, may be beneficial to both dying persons and their families., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness., Methods: The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care., Results: A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences., Conclusion: The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies obstructing airway access are at risk of airway management failure once they lose spontaneous respiration. Awake flexible scope intubation is considered the gold standard for controlling the airway in such patients. Following a feasibility trial involving 25 patients with challenging airways, this article presents a step-by-step protocol for awake nasotracheal intubation using a flexible video rhino-laryngoscope, which is significantly shorter than conventional intubating flexible scopes. The flexible video laryngoscope only exceeds the intubating tube length by a few centimeters, allowing the tube to closely follow the flexible scope during the procedure. Once the scope reaches the pharynx, it can be easily manipulated with one hand, enabling the operator to focus on the safe advancement of the scope-intubating tube assembly through the glottis. Based on previous results and experience gained, this article highlights the potential benefits of the technique: the opportunity for a minimally invasive "quick look" preoperatively to establish a final management plan, a more convenient and safer tool for navigating distorted anatomy with a lower chance of intubating tube impingement and airway injury, and a fast and smooth procedure resulting in improved patient satisfaction.

Purpose: Continuous cerebrovascular reactivity monitoring in both neurocritical and intra-operative care has gained extensive interest in recent years, as it has documented associations with long-term outcomes (in neurocritical care populations) and cognitive outcomes (in operative cohorts). This has sparked further interest into the exploration and evaluation of methods to achieve an optimal cerebrovascular reactivity measure, where the individual patient is exposed to the lowest insult burden of impaired cerebrovascular reactivity. Recent literature has documented, in neural injury populations, the presence of a potential optimal sedation level in neurocritical care, based on the relationship between cerebrovascular reactivity and quantitative depth of sedation (using bispectral index (BIS)) - termed BISopt. The presence of this measure outside of neural injury patients has yet to be proven., Methods: We explore the relationship between BIS and continuous cerebrovascular reactivity in two cohorts: (A) healthy population undergoing elective spinal surgery under general anesthesia, and (B) healthy volunteer cohort of awake controls., Results: We demonstrate the presence of BISopt in the general anesthesia population (96% of patients), and its absence in awake controls, providing preliminary validation of its existence outside of neural injury populations. Furthermore, we found BIS to be sufficiently separate from overall systemic blood pressure, this indicates that they impact different pathophysiological phenomena to mediate cerebrovascular reactivity., Conclusions: Findings here carry implications for the adaptation of the individualized physiologic BISopt concept to non-neural injury populations, both within critical care and the operative theater. However, this work is currently exploratory, and future work is required., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Handheld optical coherence tomography (HH-OCT) can image awake, young children but lacks integrated segmentation/analysis software. OCT imaging of eyes with optic neuropathies demonstrates ganglion cell layer (GCL) and ganglion cell complex (GCC) thinning, with a normal or thickened inner nuclear layer (INL). We compared pediatric normative data with GCL/INL and GCC/INL ratios from HH-OCT macular scans of awake young children with clinically diagnosed optic neuropathies., Methods: Macular HH-OCT from awake children with optic neuropathies was prospectively obtained using Bioptigen (Leica Microsystems, Wetzlar, Germany). The GCL, GCC, and INL were manually measured by two readers using ImageJ from single-line macular scans at the thickest points nasal and temporal to the fovea, respectively, and the GCL/INL and GCC/INL ratios were calculated and compared with normative data., Results: HH-OCT images from 17 right eyes of 17 children (mean age, 4.3 ± 2.9 years) with optic neuropathies were analyzed. Mean nasal (17 eyes) and temporal (16 eyes) GCL/INL ratios with optic neuropathies were 0.44 ± 0.38 (95% CI, 0.26-0.62) and 0.26 ± 0.22 (95% CI, 0.15-0.36), respectively. Corresponding normative GCL/INL ratios are 1.26 ± 0.20 (95% CI, 1.19-1.34) and 1.23 ± 0.27 (95% CI, 1.13-1.33), respectively (P < 0.0001). Severe thinning precluded GCL measurements in 2 eyes nasally and 5 eyes temporally, resulting in GCL measurements of zero. Mean nasal (17 eyes) and temporal (16 eyes) GCC/INL ratios were 1.93 ± 0.70 (95% CI,1.60-2.27) and 1.67 ± 0.44 (95% CI,1.46-1.87). Corresponding normative ratios are 2.85 ± 0.38 (95% CI, 2.71-2.99) and 2.87 ± 0.42 (95% CI, 2.70-3.03), respectively (P < 0.0001)., Conclusions: GCL/INL and GCC/INL ratios calculated from single-line macular HH-OCT scans in awake young children with optic neuropathies differ significantly from normative values and may thus have utility in helping to establish a diagnosis of optic neuropathy., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: Awake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes., Methods: In this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events., Results: In total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12-14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2-8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42-0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37-0.86), and for mortality was 0.63 (0.42-0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups., Conclusion: Prolonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF., (© 2024. The Author(s).)

Background: Awake craniotomy (AC) is standard of care for lesions of eloquent brain areas. One important complication during AC is occurrence of intraoperative seizure (IOS), reported to occur among 3.4-20% of the patients. In this study, we report our experience with IOS during AC for resection of gliomas of the language eloquent regions and evaluate the predisposing factors and consequences., Methods: Patients who underwent AC for language related regions of the dominant hemisphere from August 2018 to June 2021 were enrolled. The rate of IOS during AC and relationship between predisposing factors and IOS were evaluated., Results: Sixty-five patients were enrolled (mean age: 44.4±12.5 years). Among 6 patients with IOS (9.2%), only one needed conversion to general anesthesia (GA) due to repeated seizures; while in the remaining 5, AC accomplished successfully despite one seizure attack in the awake phase. Tumor location (especially premotor cortex lesions, P=0.02, uOR:12.0, CI: 1.20-119.91), higher tumor volume (P=0.008, uOR: 1.9, CI: 1.06-1.12) and a functional tumor margin during surgery (P=0.000, uOR: 3.4, CI: 1.47-12.35) were significantly linked with IOS., Conclusions: Occurrence of IOS was associated with a longer ICU stay after surgery and worse immediate neurological outcome, but had no impact on the late neurological status. IOS can usually be managed during AC without need to converting to GA. Those with larger tumors, frontal premotor lesions and positive brain mapping are susceptible to IOS. Early neurological deterioration observed after IOS, seems to be transient with no major long-term consequence on the neurological outcome.

Aims: The parabrachial nucleus (PBN) promotes wakefulness states under general anesthesia. Recent studies have shown that glutamatergic neurons within the PBN play a crucial role in facilitating emergence from anesthesia. Our previous study indicates that vesicular glutamate transporter 2 (vglut2) expression neurons of the PBN extend into the extended amygdala (EA). However, the modulation of PBN vglut2 -EA in general anesthesia remains poorly understood. This study aims to investigate the role of PBN vglut2 -EA in alterations of consciousness during sevoflurane anesthesia., Methods: We first validated vglut2-expressing neuron projections from the PBN to the EA using anterograde tracing. Then, we conducted immunofluorescence staining of c-Fos to investigate the role of the EA involved in the regulation of consciousness during sevoflurane anesthesia. After, we performed calcium fiber photometry recordings to determine the changes in PBN vglut2 -EA activity. Lastly, we modulated PBN vglut2 -EA activity under sevoflurane anesthesia using optogenetics, and electroencephalogram (EEG) was recorded during specific optogenetic modulation., Results: The expression of vglut2 in PBN neurons projected to the EA, and c-Fos expression in the EA was significantly reduced during sevoflurane anesthesia. Fiber photometry revealed that activity in the PBN vglut2 -EA pathway was suppressed during anesthesia induction but restored upon awakening. Optogenetic activation of the PBN vglut2 -EA delayed the induction of anesthesia. Meanwhile, EEG recordings showed significantly decreased δ oscillations and increased β and γ oscillations compared to the EYFP group. Furthermore, optogenetic activation of the PBN vglut2 -EA resulted in an acceleration of awakening from anesthesia, accompanied by decreased δ oscillations on EEG recordings. Optogenetic inhibition of PBN vglut2 -EA accelerated anesthesia induction. Surprisingly, we found a sex-specific regulation of PBN vglut2 -EA in this study. The activity of PBN vglut2 -EA was lower in males during the induction of anesthesia and decreased more rapidly during sevoflurane anesthesia compared to females. Photoactivation of the PBN vglut2 -EA reduced the sensitivity of males to sevoflurane, showing more pronounced wakefulness behavior and EEG changes than females., Conclusions: PBN vglut2 -EA is involved in the promotion of wakefulness under sevoflurane anesthesia. Furthermore, PBN vglut2 -EA shows sex differences in the changes of consciousness induced by sevoflurane anesthesia., (© 2024 The Author(s). CNS Neuroscience & Therapeutics published by John Wiley & Sons Ltd.)

Objectives: Many sleep-wake behaviors have been associated with cognition. We examined a panel of sleep-wake/activity characteristics to determine which are most robustly related to having low cognitive performance in midlife. Secondarily, we evaluate the predictive utility of sleep-wake measures to screen for low cognitive performance., Methods: The outcome was low cognitive performance defined as being >1 standard deviation below average age/sex/education internally normalized composite cognitive performance levels assessed in the Hispanic Community Health Study/Study of Latinos. Analyses included 1006 individuals who had sufficient sleep-wake measurements about 2years later (mean age=54.9, standard deviation= 5.1; 68.82% female). We evaluated associations of 31 sleep-wake variables with low cognitive performance using separate logistic regressions., Results: In individual models, the strongest sleep-wake correlates of low cognitive performance were measures of weaker and unstable 24-hour rhythms; greater 24-hour fragmentation; longer time-in-bed; and lower rhythm amplitude. One standard deviation worse on these sleep-wake factors was associated with ∼20%-30% greater odds of having low cognitive performance. In an internally cross-validated prediction model, the independent correlates of low cognitive performance were: lower Sleep Regularity Index scores; lower pseudo-F statistics (modellability of 24-hour rhythms); lower activity rhythm amplitude; and greater time in bed. Area under the curve was low/moderate (64%) indicating poor predictive utility., Conclusion: The strongest sleep-wake behavioral correlates of low cognitive performance were measures of longer time-in-bed and irregular/weak rhythms. These sleep-wake assessments were not useful to identify previous low cognitive performance. Given their potential modifiability, experimental trials could test if targeting midlife time-in-bed and/or irregular rhythms influences cognition., (Copyright © 2024 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions., Methods: This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs., Results: Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120)., Conclusion: Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs., Level of Evidence: 2 Laryngoscope, 134:3732-3740, 2024., (© 2024 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: To inquire into clinical practices perceived to mitigate patients' intraoperative distress during awake craniotomies., Methods: This mixed-methods study involved administration of Amsterdam Preoperative Anxiety and Information Scale and PTSD Checklist prior to the awake craniotomy to evaluate anxiety and information-seeking related to the procedure and symptoms of PTSD. Generalized Anxiety Disorder Scale and Depression Module of the Patient Health Questionnaire were administered before and after the procedure to evaluate generalized anxiety and depression. Patient interviews were conducted 2-weeks postprocedure and included a novel set of patient experience scales to assess patients' recollection of intraoperative pain, overall distress, anxiety, distress due to noise, perception of empowerment, perception of being well-prepared, overall satisfaction with anaesthesia management, and overall satisfaction with the procedure. Qualitative data were analysed using conventional content analysis., Results: Participants ( n  = 14) had undergone an awake craniotomy for tissue resection due to primary brain tumours or medically-refractory focal epilepsy. Validated self-report questionnaires demonstrated reduced levels of generalized anxiety (pre mean = 8.66; SD  = 6.41; post mean= 4.36; SD  = 4.24) following the awake craniotomy. Postprocedure interviews revealed very high satisfaction with the awake craniotomy and anaesthesia management and minimal levels of intraoperative pain, anxiety, and distress. The most stressful aspects of the procedure included global recognition of medical diagnosis, anxiety provoked by unfamiliar sights, sounds, and sensations, a perception of a lack of information or misinformation, and long periods of immobility. Important factors in alleviating intraoperative distress included the medical team's ability to promote patient perceptions of control, establish compassionate relationships, address unfamiliar intraoperative sensations, and deliver effective anaesthesia management., Conclusion: Compassion, communication, and patient perception of control were critical in mitigating intraoperative distress. Clinical practice recommendations with implications for all clinicians involved in patient care during awake craniotomies are provided. Use of these interventions and strategies to reduce distress are important to holistic patient care and patient experiences of care and may improve the likelihood of optimal brain mapping procedures to improve clinical outcomes during awake craniotomies.