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INTRODUCTION: Breast MRI (bMRI) has become a standard of care (SOC) modality for both screening and diagnostic work-up of breast disease (1-2). Despite availability of larger bores, claustrophobia remains the most common reason for patients declining MRI (3). Anesthesia service can offer sedation during MRI improving patients’ acceptance. However, unlike routine MRI, bMRI is performed with patient positioned prone. Our anesthesiologists observed patients’ expectation of receiving general anesthesia, without understanding the risks associated with sedation/anesthesia in this particular setting and no prior trials of oral anxiolysis. OBJECTIVE: This project retrospectively reviewed bMRI exams with sedation for image quality and potential complication to identify areas for intervention such as provider education on anesthesiology risks in the bMRI environment and the implementation of an institution-approved oral anxiolysis program. METHODS: Patients receiving bMRI exams with sedation/anesthesia at a large academic cancer center were identified from the existing institutionally approved Report Imaging Quality Issue database after receiving institutional approval for this quality improvement project with waiver for consent obtained from Institution Review Board. Patient demographics, imaging data, and clinical notes were reviewed by two board certified breast radiologists with over 15 years of experience in MRI interpretation. Safety reports were reviewed in consensus between two radiologists and lead anesthesiologist for MRI department. RESULTS: Of 4844 bMRI exams, 33 were performed with sedation/anesthesia. Mean age was 60 years (range 37-77), with mean body mass index of 34 (range 21-45). Reason for anesthesia included claustrophobia in 13 (40%) patients, pain in 6 (18%), and 14 not clearly documented (42%). Eighteen of 33 (55%) exams were rated as poor quality, 7 (21%) as average, and 8 (24%) good or diagnostic. Most common reasons for poor quality included motion from snoring or pain and poor fat suppression due to body habitus. In 11/33 (33%), repeat imaging with still poor quality was documented in technologists’ comments. Length of exam appointment ranged from 52 – 155, average 90 minutes. Only one case documented facial bruising due to prone positioning and one case of positioning requiring up to 7 staff. DISCUSSION: Availability of on-site anesthesia has enabled some patients to receive bMRI. These patients present to MRI with expectation of sedation/anesthesia without understanding risks or prior trial of anxiolysis and most have a challenging body habitus contributing to difficulty in prone positioning and decreased image quality while under sedation/anesthesia. Development of an oral patient anxiolysis program and provider education may improve image quality and reduce utilization of anesthesia. Citation Format: H. T. Carisa Le-Petross, Shreyas Bhavsar, Marion E. Scoggins, Jia Sun, Thao Bui, Kyungmin Shin, Jason Stafford, Richard Carlson III, Beatriz Adrada. Safety of Breast MRI under General Anesthesia [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-05-04.

Background Endoscopic retrograde cholangiopancreatography (ERCP) patients typically receive either tubeless anesthesia or general endotracheal anesthesia (GETA). Patients receiving propofol-based total intravenous anesthesia (TIVA) are at higher risk of sedation-related adverse events (SRAEs) than patients receiving GETA, primarily due to the need for additional airway maneuvers. The increasing use of non-operating room (OR) anesthesia and the perception of a higher incidence of adverse outcomes in non-OR areas has led to the development of devices to improve safety while maintaining efficiency. The purpose of this study was to evaluate if the LMA Gastro™ could be used as a safe alternative to tubeless anesthesia for successfully completing ERCPs. Methods Eligible subjects were identified within the patient population at MD Anderson Cancer Center. Inclusion criteria consisted of adult patients (≥18 years old) scheduled for elective ERCP with TIVA. This was a prospective observational study in which the following data were collected: number of attempts and time to successful supraglottic airway (SGA) placement, vital signs, peripheral oxygen saturation (SpO2), median end-tidal CO2, practitioner satisfaction, and any complications. Results A total of 30 patients were included in this study. The overall rate of successful SGA placement within 3 attempts was 96.7% (95% confidence interval [CI], 82.8-99.9) or 29/30. The rate of successful ERCP with SGA placement within 3 attempts was 93.3% (95% CI, 77.9-99.2) or 28/30. Both the gastroenterologist and anesthesiologist reported satisfaction with the device in 90% of the cases (in 66.7% of the cases both anesthesiologist and gastroenterologist scored the device a 7/7 for satisfaction). Patients maintained an SpO2 of 95%-100% from induction to discharge, with the exception of 1 patient who had an SpO2 of 93%. The median end-tidal CO2 during the procedure for all patients was 35 mm Hg. Observed aspiration did not occur in any patient. Symptoms of hoarseness (13.3%), mouth soreness (6.7%), sore throat (6.6%), and minor bleeding/cuts/redness/change in taste to the tongue (3.3%) were determined through patient questioning before postanesthesia care unit (PACU) discharge. Conclusions Our study suggests that the LMA Gastro might be a safe alternative for ERCP procedures. There was a high level of practitioner satisfaction. Only minor complications, such as hoarseness, mouth or throat soreness, or minor trauma to the tongue were experienced by patients. Similar incidences of complications may occur with GETA and tubeless anesthesia. The procedure was well tolerated by all patients; all patients maintained adequate oxygenation and required only minimal blood pressure support.

Purpose We integrated a brachytherapy procedural workflow within an existing diagnostic 3.0-T (3T) MRI suite. This setup facilitates intraoperative MRI guidance for optimal applicator positioning, particularly for interstitial needle placements in gynecologic cases with extensive parametrial involvement. Methods and Materials Here we summarize the multidisciplinary collaboration, equipment, and supplies necessary to implement an intraoperative MRI-guided brachytherapy program; outline the operational workflow via process maps; and address safety precautions. We evaluate internal resource utilization associated with this progressive approach via time-driven activity-based costing methodology, comparing institutional costs to that of a traditional workflow (within a CT suite, followed by separate postprocedure MRI) over a single brachytherapy procedural episode. Results Resource utilization was only 15% higher for the intraoperative MRI-based workflow, attributable to use of the MRI suite and increased radiologist effort. Personnel expenses were the greatest cost drivers for either workflow, accounting for 76–77% of total resource utilization. However, use of the MRI suite allows for potential cost-shifting opportunities from other resources, such as CT, during the procedural episode. Improvements in process speed can also decrease costs: for each 10% decrease in case duration from baseline procedure time, total costs could decrease by roughly 8%. Conclusions This analysis supports the feasibility of an intraoperative MRI-guided brachytherapy program within a diagnostic MRI suite and defines many of the resources required for this procedural workflow. Longer followup will define the full utility of this approach in optimizing the therapeutic ratio for gynecologic cancers, which may translate into lower costs and higher value with time, over a full cycle of care.

Introduction About one-third of critically ill patients with acute kidney injury (AKI) develop persistently decreased kidney function, known as acute kidney disease (AKD), which may progress to chronic kidney disease (CKD). Although sepsis is the most common cause of AKI, little is known about sepsis-associated AKD. Methods Using data from a large randomized trial including 1341 patients with septic shock, we studied patients with stage 2 or 3 AKI on day 1 of hospitalization. We defined AKD as a persistently reduced glomerular filtration rate for >7 days. In addition to clinical data, we measured several urinary biomarkers (tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 [TIMP-2∗IGFBP7], neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], liver-type fatty acid binding protein, and type 4 collagen) at 0, 6, and 24 hours, to predict AKD. Results Of 598 patients, 119 (19.9%) died within 7 days, 318 (53.2%) had early reversal of AKI within the first 7 days, whereas 161 (26.9%) developed AKD. In patients with early reversal, 45 (14.2%) had relapsed AKI after early reversal, and only about one-third of these recovered. Among patients developing AKD, only 15 (9.3%) recovered renal function prior to discharge. Male sex, African American race, and underlying CKD were more predominant in patients developing AKD. None of the biomarkers tested performed well for prediction of AKD, although NGAL modestly increased the performance of a clinical model. Conclusions AKD is common in patients with septic shock, especially among African American males and those with underlying CKD. Existing AKI biomarkers have limited utility for predicting AKD but might be useful together with clinical variables. Novel predictive biomarkers for renal recovery are needed., Graphical abstract

“Papyrius Geminus Eleates,” ostensive author of an imaginative, reconditely humanist-stylish anti-scholastic polemic, Hermathena, seu de Eloquentiae victoria, narrating the allegorical triumph of E...

Background and study aims Endoscopic mucosal resection (EMR) is increasingly used for the treatment of large colonic polyps (≥ 20 mm). A drawback of EMR is local adenoma recurrence. Therefore, we studied the impact of argon plasma coagulation (APC) of the EMR edge on local adenoma recurrence. Patients and methods This was a retrospective study of patients with laterally spreading tumors (LST) ≥ 20 mm, who underwent EMR from January 2009 to August 2018 and follow-up endoscopic assessment. A cap-fitted endoscope was used to assess completeness of resection by systematically inspecting the EMR defect for any macroscopic disease. This was followed by forced APC of the resection edge followed by clip closure of the defect. Surveillance colonoscopy was performed at 6 months after resection to detect recurrence. Results Two hundred forty-six patients met the inclusion criteria. Most were female (53 %) and white (80 %), with a Median age of 64 years. Median polyp size was 35 mm (interquartile range, 30–45 mm). Most polyps were located in the right colon (77 %) and were removed by piecemeal EMR (70 %). Eleven patients (5 %) had residual tumor at the resection site. Conclusions We observed low adenoma recurrence after argon plasma coagulation of the EMR edge with a cap fitted colonoscope in patients with LST ≥ 20 mm of the colon, which requires further validation in a randomized controlled study.

This article discusses empirical evidence regarding the theoretical claims that Incentive Rate regulation for electricity distribution creates greater consumer value than Cost of Service in terms o...

William Feriby was an historic actor: Richard II's secretary between the “Revenge Parliament” of 1397–98 and the deposition of the king in September 1399; subsequently, a contributor to the deposition proceedings; and, finally, a rebel against Henry IV in January 1400. Feriby was also a literary figure, the author of an historical “Lament for Richard II,” amongst other things, written in a highly mannered style of a sort to indicate an interest on Feriby's part in the purely literary: imagination and form. Though Feriby's prose style is distinctive, he was not the only historic-historiographical figure who manifested an interest in the strictly literary at the same moment, ca. 1400. The writings of Adam Usk, Thomas Favent, the Historia vitae author, and Thomas Brinton—even the deposition proceedings and the documentary record of them (the “Record and Process”)—are comparably (though differently) literary. The relations between Ricardian history and literature can be reconceived, dialectically, by light of such evidence: the literature is historical and historic, but, also, the history itself and historiography are literary.

Background Several studies have examined the impact of anesthetics on cancer recurrence. Isoflurane but not desflurane has protumoral effects. We hypothesize the use of isoflurane but not desflurane during surgery for primary GBM is an independent predictor of disease progression and mortality. Methods 378 adult patients were included in the study. The progression free survival (PFS) and overall survival (OS) rates at 1 and 5 years were compared in patients who had either desflurane or isoflurane alone or in combination with propofol infusion. Multivariate analyses were conducted to test the association between preoperative, intraoperative and postoperative hyperglycemia with PFS and OS. Results Kaplan–Meier curves demonstrated similar survival in patients who had either desflurane or isoflurane. The use of a propofol infusion during surgery did not affect survival. Univariate analysis demonstrated that age, body mass index and the adjusted Charlson comorbidity score were associated with reduced survival. The multivariate analysis confirmed that age and BMI but not the type volatile anesthetic use were independent prognostic factors for PFS (HR, 95%CI: 1.07, 0.85–1.37, 9 = 0.531) and OS (HR, 95%CI: 1.13, 0.86–1.48, p = 0.531). Conclusion The use of isoflurane or desflurane during GBM surgery is not associated with reduced PFS or OS.

Background Several studies have examined the association between hyperglycemia in the first 10 to 12 weeks following surgery and postoperative survival in glioblastoma multiforme (GBM) patients. We hypothesize that episodes of hyperglycemia before, during and/or following surgery for primary GBM are independent predictors of disease progression and mortality. Materials and methods A total of 162 adult patients were included in the analysis. All patients received adjuvant temozolamide. The progression free survival (PFS) and overall survival (OS) rates at 1 and 5 years were analyzed using different glycemic cutoff values. Multivariate analyses were conducted to test the association between preoperative, intraoperative and postoperative hyperglycemia with PFS and OS. Results Kaplan-Meier curves revealed a trend toward increased PFS and OS with lower glucose concentrations with the exception of glucose concentrations >180 mg/dL in the intraoperative/postoperative day 0 time period. Univariate analysis of blood glucose levels did not demonstrate a statistically significant effect on PFS in any time period, however hyperglycemia was statistically significant for OS in the preoperative time period. Although, multivariate analysis showed no statistically significant association with hyperglycemia on PFS, a statistically significant decrease in OS was seen for plasma glucose concentrations >112 mg/dL (P=0.01) and >180 mg/dL (P=0.01) in the preoperative period. There was a decreasing effect on OS with blood glucose concentrations greater than the median in multiple time periods (P=0.02). Conclusions Preoperative hyperglycemia is associated with poor OS after GBM surgery.

Cohort studies have suggested that the use of statins is associated with decreased risk of glioma formation and mortality. Here, a cohort of patients with glioblastoma multiforme (GBM) was analyzed to further investigate associations between preoperative use of statins and recurrence, and progression free and overall survival. Patients who had surgery for GBM (N = 284) were followed up for a median of 18.1 months. Seventy-eight patients were taking statins preoperatively while the rest were not. Cox proportional hazards models adjusted for several covariates of interest were applied before and after propensity score matching. Compared with statin users, those not taking the lipid-lowering drugs had similar progression free survival before (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.70–1.26; p = 0.68) and after propensity score matching (HR 0.95, 95% CI 0.67–1.35; p = 0.68). Mortality was similar between both groups of patients before (HR 0.94, 95% CI 0.70–1.22; p = 0.73) and after propensity score matching (HR 1.13, 95% CI 0.78–1.64; p = 0.49). Age and dexamethasone use were independent prognostic factors of survival. Contrary to previously published evidence, this study could not find an association between preoperative statin use and longer survival in GBM patients. Due to the small number of patients and retrospective nature of the study, further work is needed to understand the role of perioperative statins in GBM patients.

When at the conclusion of the Confessio amantis of John Gower (c. 1330–1408) the protagonist Amans is revealed to be old and hoar, Gower’s representation of Amans’s impotence depends on the now little-known elegies of Maximianus (fl. c. 525). A contemporary and critic of Boethius (c. 480–524), Maximianus uses his poems for recounting his sexual activities and erectile dysfunction. Although (or possibly because) Maximianus was pornographic, his writing became a standard school-text in late medieval Western Europe, and his influence can be traced in a number of Middle English poets, including Geoffrey Chaucer (c. 1343–1400) and now Gower. At a crucial concluding point of the Confessio, Gower quotes Maximianus.

Bacterial resistance to antibiotics continues to be a grave threat to human health. Because antibiotics are no longer a lucrative market for pharmaceutical companies, the development of new antibiotics has slowed to a crawl. The World Health Organization reported that the 8 new bacterial agents approved since July 2017 had limited clinical benefits. While a cohort of biopharmaceutical companies recently announced plans to develop 2-4 new antibiotics by 2030, we needn’t wait a decade to find innovative antibiotic candidates. Essential oils (EOs) have long been known as antibacterial agents with wide-ranging arsenals. Many are able to penetrate the bacterial membrane and may also be effective against bacterial defenses such as biofilms, efflux pumps, and quorum sensing. EOs have been documented to fight drug-resistant bacteria alone and/or combined with antibiotics. This review will summarize research showing the significant role of EOs as nonconventional regimens against the worldwide spread of antibiotic-resistant pathogens. The authors conducted a 4-year search of the US National Library of Medicine (PubMed) for relevant EO studies against methicillin-resistant Staphylococcus aureus, multidrug-resistant (MDR) Escherichia coli, EO combinations/synergy with antibiotics, against MDR fungal infections, showing the ability to permeate bacterial membranes, and against the bacterial defenses listed above. EOs are readily available and are a needed addition to the arsenal against resistant pathogens.

Background We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis. Methods This was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h. Results We enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p

To test the association between the use of scalp blocks for malignant brain tumor craniotomy and survival. This is a retrospective study conducted in a tertiary academic center. Demographic, intraoperative and survival data from 808 adult patients with malignant brain tumors was included in the analysis. Patients were divided in those who received an Intraoperative use of scalp block or not. The progression free survival (PFS) and overall survival (OS) rates were compared in patients who had and had not scalp blocks. Kaplan-Meier method was used for time-to-event analysis including recurrence free survival and overall survival. Multivariate analyses before and after propensity score matching were conducted to test the association between different covariates including scalp blocks with PFS and OS. Five hundred and ninety (73%) of the patients had a scalp block. Before PSM, patients with a scalp block were more likely to have an ASA physical status of 3–4, recurrent tumors and receive adjuvant radiation. Patients with scalp block showed no significant reduction in intraoperative opioids. After adjusting for significant covariates, the administration of a scalp block was not associated with an increase in PFS (HR, 95%CI = 0.98, 0.8–1.2, p = 0.892) or OS (HR, 95%CI = 1.02, 0.82–1.26, p = 0.847) survival. This retrospective study suggests that the use of scalp blocks during brain tumor surgery is not associated with patients’ longer survival.

Uncertainties surrounding the continued operation of older coal generation units, the increased penetration of renewable resources, and the aging or retirement of certain nuclear units have exposed vulnerabilities in the natural gas supply chain. The increased availability and low price of natural gas for electric generation in many parts of the United States compounds them by increasing the economic pressure on various non-gas-fired base-load generation plants. Our growing dependence on natural gas as a primary fuel for electricity generation offers environmental and efficiency benefits, but it also presents operational challenges for independent system operators (ISOs) and regional transmission organizations (RTOs) that depend on the natural gas pipeline and storage network to facilitate reliability objectives. During the peak heating season, pipeline congestion can result in interruptions of gas deliveries to those gas-fired generators lacking primary firm entitlements. Scheduling restrictions associated with the provision of nonfirm transportation for gas-fired generators stress the capability of the electric system to meet demand and maintain operating reserves, as RTOs must quickly replace output from more efficient natural gas-fueled combined-cycle plants and quick-start peakers to maintain electric reliability. In this article, we address the gas-electric interdependencies across the Eastern Interconnection that are the subject of a multitarget research project sponsored by the U.S. Department of Energy (DOE) with the participation of PJM Interconnection, Midcontinent Independent System Operator (MISO), New York Independent System Operator (NYISO), ISO New England (ISO-NE), TVA, and the Independent Electricity System Operator of Ontario (IESO), collectively known as the participating planning authorities (PPAs).

Background Cancer cells can produce lactate in high concentrations. Two previous studies examined the clinical relevance of serum lactate as a biomarker in patients with brain tumors. Patients with high-grade tumors have higher serum concentrations of lactate than those with low-grade tumors. We hypothesized that serum lactic could be used of biomarker to predictor of survival in patients with glioblastoma (GB). Methods This was a retrospective study. Demographic, lactate concentrations and imaging data from 275 adult patients with primary GB was included in the analysis. The progression free survival (PFS) and overall survival (OS) rates were compared in patients who had above and below the median concentrations of lactate. We also investigated the correlation between lactate concentrations and tumor volume. Multivariate analyses were conducted to test the association lactate, tumor volume and demographic variables with PFS and OS. Results The median serum concentration of lactate was 2.3 mmol/L. A weak correlation was found between lactate concentrations and tumor volume. Kaplan–Meier curves demonstrated similar survival in patients with higher or lower than 2.3 mmol/L of lactate. The multivariate analysis indicated that the intraoperative levels of lactate were not independently associated with changes in survival. On another hand, a preoperative T1 volume was an independent predictor PFS (HR 95%CI: 1.41, 1.02–1.82, p = 0.006) and OS (HR 95%CI: 1.47, 1.11–1.96, p = 0.006). Conclusion This retrospective study suggests that the serum concentrations of lactate cannot be used as a biomarker to predict survival after GB surgery. To date, there are no clinically available serum biomarkers to determine prognosis in patients with high-grade gliomas. These tumors may produce high levels of lactic acid. We hypothesized that serum lactic could be used of biomarker to predictor of survival in patients with glioblastoma (GB). In this study, we collected perioperative and survival data from 275 adult patients with primary high-grade gliomas to determine whether intraoperative serum acid lactic concentrations can serve as a marker of prognosis. The median serum concentration of lactate was 2.3 mmol/L. Our analysis indicated the intraoperative levels of lactate were not independently associated with changes in survival. This retrospective study suggests that the serum concentrations of lactate cannot be used as a biomarker to predict survival after GB surgery.