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Study Objective: Comparison of the TetraGraph (TG) and TOFscan (TS) for monitoring recovery from neuromuscular blockade in the Post Anesthesia Care Unit (PACU)., Design: Randomized, multicenter trial., Setting: PACU in three tertiary care hospitals., Patients: 120 patients (40 per site) receiving neuromuscular blockade during elective surgery., Interventions: Patients were enrolled preoperatively and intraoperative neuromuscular blockade management was at the discretion of the anesthesiologist. Upon arrival to the PACU, patients were randomized to have either TG or TS placed on their dominant hand. The alternate device (TS or TG) was placed on the non-dominant hand. Following simultaneous ulnar nerve stimulation on each arm, the response of the adductor pollicis was measured., Measurements: Train-of-four ratios (TOFRs) were obtained upon arrival to the PACU (t = 0), after 5 min (t = + 5) and after +10 min (t = + 10)., Main Results: There was there was no significant difference in the mean TOFRs obtained with the TG and TS at t = 0 (0.97 ± 0.18 vs 0.94 ± 0.13, P = 0.06, respectively) and t = + 5 (0.96 ± 0.20 vs 0.95 ± 0.12, P = 0.29, respectively). At (t = + 10), there was a statistically significant difference in mean TOFRs obtained with the TG and TS, (0.99 ± 0.14 vs 0.94 ± 0.12, P < 0.001, respectively). The bias between devices at t = 0 was estimated to be 0.03 (95% CI, -0.29 to 0.35, P = 0.26); at t = + 5 min, it was estimated to be 0.02 (95% CI, -0.36 to 0.40, P = 0.54); and at t = +10 min, it was estimated to be 0.05 (95% CI, -0.25 to 0.36, P = 0.77)., Conclusions: TS and TG provide interchangeable quantitative measurements once the TOF ratio has returned to a value of 0.90 or greater in the PACU., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine whether opioids during the first 24 postoperative hours were significantly altered when receiving intravenous (IV) acetaminophen during that time compared with those receiving placebo (normal saline)., Methods: One hundred forty patients undergoing any type of craniotomy were randomly assigned to receive either 1 g of IV acetaminophen or placebo upon surgical closure, and every 6 hours thereafter, up to 18 hours postoperatively. Analgesic requirements for the first 24 postoperative hours were recorded. Time to rescue medications in the postanesthesia care unit (PACU)/intensive care unit (ICU), amount of rescue medication, ICU and hospital lengths of stay, number of successful neurological examinations, sedation, delirium, satisfaction, and visual analog scale pain scores were also recorded., Results: Compared with the placebo group, more patients in the IV acetaminophen group (10/66 [15.2%] vs. 4/65 [6.2%] in the placebo group) did not require opioids within the first 24 postoperative hours, but this did not reach significance (odds ratio, -9.0%, 95% confidence interval -20.5% to 1.8%; P = 0.166). Both groups had similar times to rescue medications, amounts of rescue medications, ICU and hospital lengths of stay, numbers of successful neurological examinations, sedation, delirium, satisfaction scores, visual analog scale pain scores, and temperatures within the first 24 postoperative hours., Conclusions: The opioid requirements within the first 24 postoperative hours were similar in the placebo and acetaminophen groups. This study is informative for the design and planning of future studies investigating the management of postoperative pain in patients undergoing craniotomies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Designing and producing novel proteins that fold into stable structures and provide essential biological functions are key goals in synthetic biology. In initial steps toward achieving these goals, we constructed a combinatorial library of de novo proteins designed to fold into 4-helix bundles. As described previously, screening this library for sequences that function in vivo to rescue conditionally lethal mutants of Escherichia coli (auxotrophs) yielded several de novo sequences, termed SynRescue proteins, which rescued four different E. coli auxotrophs. In an effort to understand the structural requirements necessary for auxotroph rescue, we investigated the biophysical properties of the SynRescue proteins, using both computational and experimental approaches. Results from circular dichroism, size-exclusion chromatography, and NMR demonstrate that the SynRescue proteins are α-helical and relatively stable. Surprisingly, however, they do not form well-ordered structures. Instead, they form dynamic structures that fluctuate between monomeric and dimeric states. These findings show that a well-ordered structure is not a prerequisite for life-sustaining functions, and suggests that dynamic structures may have been important in the early evolution of protein function., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Surgery in the beach chair position (BCP) may reduce cerebral blood flow and oxygenation, resulting in neurological injuries. The authors tested the hypothesis that a ventilation strategy designed to achieve end-tidal carbon dioxide (E'(CO₂)) values of 40-42 mm Hg would increase cerebral oxygenation (Sct(O₂)) during BCP shoulder surgery compared with a ventilation strategy designed to achieve E'(CO₂) values of 30-32 mm Hg., Methods: Seventy patients undergoing shoulder surgery in the BCP with general anaesthesia were enrolled in this randomized controlled trial. Mechanical ventilation was adjusted to maintain an E'(CO₂) of 30-32 mm Hg in the control group and an E'(CO₂) of 40-42 mm Hg in the study group. Cerebral oxygenation was monitored continuously in the operating theatre using near-infrared spectroscopy. Baseline haemodynamics and Sct(O₂) were obtained before induction of anaesthesia, and these values were then measured and recorded continuously from induction of anaesthesia until tracheal extubation. The number of cerebral desaturation events (CDEs) (defined as a ≥20% reduction in Sct(O₂) from baseline values) was recorded., Results: No significant differences between the groups were observed in haemodynamic variables or phenylephrine interventions during the surgical procedure. Sct(O₂) values were significantly higher in the study 40-42 group throughout the intraoperative period (P<0.01). In addition, the incidence of CDEs was lower in the study 40-42 group (8.8%) compared with the control 30-32 group (55.6%, P<0.0001)., Conclusions: Cerebral oxygenation is significantly improved during BCP surgery when ventilation is adjusted to maintain E'(CO₂) at 40-42 mm Hg compared with 30-32 mm Hg., Clinical Trial Registration: ClinicalTrials.gov NCT01546636., (© The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Here, we report the NMR structure of the actin-binding domain contained in the cell adhesion protein palladin. Previously, we demonstrated that one of the immunoglobulin domains of palladin (Ig3) is both necessary and sufficient for direct filamentous actin binding in vitro. In this study, we identify two basic patches on opposite faces of Ig3 that are critical for actin binding and cross-linking. Sedimentation equilibrium assays indicate that the Ig3 domain of palladin does not self-associate. These combined data are consistent with an actin cross-linking mechanism that involves concurrent attachment of two actin filaments by a single palladin molecule by an electrostatic mechanism. Palladin mutations that disrupt actin binding show altered cellular distributions and morphology of actin in cells, revealing a functional requirement for the interaction between palladin and actin in vivo., (© 2013 Elsevier Ltd. All rights reserved.)

Background: Patients with end-stage renal disease (ESRD) often present to the Emergency Department with a multitude of complaints. Abnormal vital signs and a chief complaint of pain can produce a diagnosis ranging from a cardiac etiology to an infectious source., Objectives: Our goal is to discuss a case in which an ESRD dialysis patient presented with a rare, life-threatening emergency., Case Report: A 55-year-old man with ESRD presented with acute abdominal pain and hypotension caused by a spontaneous retroperitoneal hemorrhage., Conclusion: This case report demonstrates the necessity of having broad differential diagnoses when evaluating patients with ESRD., (Copyright © 2013 Elsevier Inc. All rights reserved.)

In the United States more than 1.5 million pulmonary artery catheters (PACs) are inserted each year. Of these, approximately 55% are placed in high-risk surgical and trauma patients. Most clinicians believe that PAC use is beneficial in guiding therapy and may improve outcome. Despite these beliefs and hundreds of published articles related to PACs, appropriate use and impact on outcome remain unclear. A review of the current literature reveals conflicting data and significant flaws in most study designs. Inadequate sample size, lack of randomization, lack of standardization of therapies to PAC data, and deficiencies in user knowledge all significantly limit interpretation of clinical trials. Despite these deficiencies and the need for better-designed investigations, it is the opinion of the authors that access to hemodynamic data provided by the PAC, coupled with accurate interpretation of the data, may lead to reduced perioperative morbidity and mortality.

Study Objectives: To prospectively assess the impact of a liberalized preoperative fasting policy on operating room (OR) utilization., Study Design: Prospective cohort study involving data collection before and after a change in nil per os (NPO) policy., Setting: Academic teaching hospital., Patients: 5,420 consecutive outpatients and AM admissions., Interventions: Data collection was done on all adult patients who presented to our OR suite over two 15-week periods. During the first 15-week period, patients were instructed to drink no liquids after midnight (control group, n = 2,646). In the second 15-week period, patients were allowed to consume unlimited clear fluids until 2 to 3 hours prior to surgery (study group, n = 2,774)., Measurements and Main Results: We found no difference between the control and study groups in the number of cases cancelled (0 in each group) or delayed (8 vs. 9; relative risk [RR] = 1.07, 95% confidence interval [CI] = 1.000 to 1.148) due to noncompliance with fasting guidelines. There was no difference between the groups in the number of cases of aspiration (0 in each group). In the control group, significantly more episodes of regurgitation were noted (12 vs. 9; RR = 0.715, 95% CI = 0.535 to 0.955) and more rapid-sequence/awake intubations were performed (119 vs. 51; RR = 0.409, 95% CI = 0.306 to 0.546) than in the study group., Conclusions: Liberalizing a preoperative fasting policy and allowing patients to consume unrestricted clear fluids up until 3 hours before their scheduled time of surgery did not affect their compliance with fasting requirements. No increase in cancellations or delays of surgical procedures due to inappropriate oral intake was observed.

Chloroquine has been the treatment of choice for vivax malaria for more than 40 years. Lately, several case-reports have suggested the emergence of resistance to chloroquine in Plasmodium vivax in Papua New Guinea and Indonesia. We undertook prospective treatment and prophylaxis trials of chloroquine in children and adults with vivax malaria living in Irian Jaya (Indonesia New Guinea). 46 villagers with P vivax parasitaemia were treated with chloroquine by mouth (25 mg base/kg body weight divided over 3 days) and followed up for 14 days. Parasitaemia cleared initially but recurred within 14 days in 10 (22%) subjects. All recurrences were in children younger than 11 years, 7 of whom were younger than 4 years; the failure rate among children under 4 was 70%. 7 of the patients with recurrences were given a second course of chloroquine. In all, the infections initially cleared but recurrent parasitaemia developed in 5 (71%) within 14 days. Whole-blood chloroquine concentrations were consistently above those previously shown to cure P vivax blood infections (90 micrograms/L whole blood). Subjects whose initial infections cleared and who had no parasitaemia on day 14 received weekly prophylaxis with chloroquine. Despite the presence of expected blood chloroquine concentrations, P vivax parasitaemia developed in 9 of 17 subjects receiving prophylaxis during 8 weeks of follow-up (median time to parasitaemia 5.3 weeks). Chloroquine can no longer be relied upon for effective treatment or chemoprophylaxis of P vivax blood infections acquired in this part of New Guinea.