Novel Application of a Force Sensor during Sit-to-Stands to Measure Dynamic Cerebral Autoregulation Onset

Purpose: Current sit-to-stand methods measuring dynamic cerebral autoregulation (dCA) do not capture the precise onset of the time delay (TD) response. Reduced sit-to-stand reactions in older adults and individuals post-stroke could inadvertently introduce variability, error, and imprecise timing. We applied a force sensor during a sit-to-stand task to more accurately determine how TD before dCA onset may be altered. Methods: Middle cerebral artery blood velocity (MCAv) and mean arterial pressure (MAP) were measured during two sit-to-stands separated by 15 minutes. Recordings started with participants sitting on a force-sensitive resistor for 60 seconds, then asked to stand for two minutes. Upon standing, the force sensor voltage immediately dropped and marked the exact moment of arise-and-off (AO). Time from AO until an increase in cerebrovascular conductance (CVC = MCAv/MAP) was calculated as TD. Results: We tested the sensor in 4 healthy young adults, 2 older adults, and 2 individuals post-stroke. Healthy young adults stood quickly and the force sensor detected a small change in TD compared to classically estimated AO, from verbal command to stand. When compared to the estimated AO, older adults had a delayed measured AO and TD decreased up to ~50% while individuals post-stroke had an early AO and TD increased up to ~14%. Conclusion: The transition reaction speed during the sit to stand has the potential to influence dCA metrics. As observed in the older adults and participants with stroke, this response may drastically vary and influence TD.

Potency of propofol for inducing loss of consciousness in end-stage kidney disease patients

It can be difficult for anesthesiologists to determine the optimal dose of propofol for end-stage kidney disease (ESKD) patients due to changes in drug disposition. The purpose of this study was to evaluate the potency of propofol for inducing loss of consciousness in ESKD patients. Patients with normal kidney function (Control group, n = 15), those with ESKD (ESKD group, n = 15), and those with ESKD undergoing cervical epidural anesthesia (ESKD-CEB group, n = 15) were administered propofol by target-controlled infusion (TCI) using the Schneider model. The effect-site concentration (Ce) of propofol started at 0.5 μg/ml and increased in increments of 0.5 μg/ml until the patient did not respond to verbal commands. The relationship between the probability (P) of loss of consciousness and the Ce of propofol was analyzed in each group using logistic regression. The Ce values of propofol at the time of loss of consciousness were 4.3 ± 0.9, 3.7 ± 0.9, and 3.3 ± 1.0 μg/ml for the Control, ESKD, and ESKD-CEB* groups, respectively (*significant difference vs. control, P < 0.05). The estimated Ce50 values for lost ability to respond to verbal command were 4.56, 3.75, and 3.21 μg/ml for the Control, ESKD, and ESKD-CEB groups, respectively. In conclusion, when inducing anesthesia in ESKD patients, we recommend using an initial dose similar to that of patients with normal kidney function, or rather starting with a lower dose.

A COMPARATIVE STUDY OF KETOFOL (KETAMINE AND PROPOFOL) WITH PROPOFOL ALONE FOR RECOVERY IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY

Background: To compare the recovery in ketofol (ketamine and propofol) with propofol alone for vas in patients undergoing laparoscopic cholecystectomy Methods: Prospective, randomized, double blinded controlled trial. After approval by the research ethics committee and written informed valid consent of the patients, the proposed study was carried out for a period of one year in 60 patients , in ASA-I and ASA-II patients, aged between 19 to 60 years of either sex, who were posted for laproscopic cholecystectomy surgery at Indira Gandhi Medical College, Shimla. Results: Recovery profile was statistically significant for two groups. In group P after stopping infusion ,mean time for eye opening was 8.27 ± 1.28 which was less than group K ( 12.53 ± 1.48). Mean time of response to verbal command in group P(8.4 ± 1.19) was less than group K (12.5 ± 1.46) and mean time of extubation in group P (9.5 ± 1.25) was also less than group K (14.33 ± 1.52). Conclusion- Patients of Group P after stopping of infusion took less time for eye opening, obeying verbal command and also less time for extubation in comparison to group K . Keywords: Recovery, Propofol, Ketamine

Anesthetic management for a patient with myotonic dystrophy with remimazolam

Background Patients with myotonic dystrophy may have increased sensitivity to drugs used for anesthesia. We successfully managed general anesthesia in a patient with myotonic dystrophy using a novel intravenous anesthetic, remimazolam. Case presentation The patient was a 46-year-old man, 169 cm in height, and weighing 60 kg. He was diagnosed with myotonic dystrophy 5 years previously. Phacoemulsification for both eyes was scheduled under general anesthesia. Anesthesia was induced with remimazolam 6 mg/kg/h for 1 min and maintained by continuous infusion at 0.25 mg/kg/h during surgery, a 1/4 dose of the standard infusion rate, as indexed by a bispectral index (BIS). Six minutes after remimazolam discontinuation, the patient opened his eyes on verbal command with sufficient spontaneous respiration. Flumazenil (0.2 mg) was administered to boost the patient’s recovery. Conclusion In addition to the short-acting anesthetic remimazolam, the presence of the antagonist flumazenil enabled complete recovery from anesthesia, without postoperative complications.

Investigation of Embodied Language Processing on Command-Swallow Performance in Healthy Participants

Purpose During videofluoroscopic examination of swallowing, patients commonly are instructed to hold a bolus in their mouth until they hear a verbal instruction to swallow, which usually consists of the word swallow and is commonly referred to as the command swallow condition. The language-induced motor facilitation theory suggests that linguistic processes associated with the verbal command to swallow should facilitate the voluntary component of swallowing. As such, the purpose of the study was to examine the linguistic influences of the verbal command on swallowing. Method Twenty healthy young adult participants held a 5-ml liquid bolus in their mouth and swallowed the bolus after hearing one of five acoustic stimuli presented randomly: congruent action word ( swallow ), incongruent action word ( cough ), congruent pseudoword ( spallow ), incongruent pseudoword ( pough ), and nonverbal stimulus (1000-Hz pure tone). Suprahyoid muscle activity during swallowing was measured via surface electromyography (sEMG). Results The onset and peak sEMG latencies following the congruent action word swallow were shorter than latencies following the pure tone and pseudowords but were not different from the incongruent action word. The lack of difference between swallow and cough did not negate the positive impact of real words on timing. In contrast to expectations, sEMG activity duration and rise time were longer following the word swallow than the pure tone and pseudowords but were not different from cough . No differences were observed for peak suprahyoid muscle activity amplitude and fall times. Conclusions Language facilitation was observed in swallowing. The clinical utility of the information obtained in the study may depend on the purposes for using the command swallow and the type of patient being assessed. However, linguistic processing under the command swallow condition may alter swallow behaviors and suggests that linguistic inducement could be useful as a compensatory technique for patients with difficulty initiating oropharyngeal swallows.

The influence of induction speed on the frontal (processed) EEG

The intravenous injection of the anaesthetic propofol is clinical routine to induce loss of responsiveness (LOR). However, there are only a few studies investigating the influence of the injection rate on the frontal electroencephalogram (EEG) during LOR. Therefore, we focused on changes of the frontal EEG especially during this period. We included 18 patients which were randomly assigned to a slow or fast induction group and recorded the frontal EEG. Based on this data, we calculated the power spectral density, the band powers and band ratios. To analyse the behaviour of processed EEG parameters we calculated the beta ratio, the spectral entropy, and the spectral edge frequency. Due to the prolonged induction period in the slow injection group we were able to distinguish loss of responsiveness to verbal command (LOvR) from loss of responsiveness to painful stimulus (LOpR) whereas in the fast induction group we could not. At LOpR, we observed a higher relative alpha and beta power in the slow induction group while the relative power in the delta range was lower than in the fast induction group. When concentrating on the slow induction group the increase in relative alpha power pre-LOpR and even before LOvR indicated that frontal EEG patterns, which have been suggested as an indicator of unconsciousness, can develop before LOR. Further, LOvR was best reflected by an increase of the alpha to delta ratio, and LOpR was indicated by a decrease of the beta to alpha ratio. These findings highlight the different spectral properties of the EEG at various levels of responsiveness and underline the influence of the propofol injection rate on the frontal EEG during induction of general anesthesia.

Comparative Analysis of the Effect of the Different Adaptations of the Squat Exercise on the Knee Frontal Plane Projection Angle

Closed kinetic chain exercises have been employed in rehabilitation and muscle strengthening programs, such as squatting. During the movement of the squat dynamic valgus, a change that affects all kinematics of the lower limb, tends to become exacerbated, necessitating adaptations in order to minimize the biomechanical disorder. Although studies have shown the effectiveness of squatting exercises, there is a lack of evidence to demonstrate, comparatively, the effectiveness of different adaptations in the decrease of dynamic valgus. The objective of the study was to evaluate to identify the efficacy of different adaptations in squatting exercise in the reduction of dynamic valgus. Therefore, study volunteers (n = 30) performed three types of squats: free squatting, squatting with elastic band and squatting with verbal command. The dynamic valgus wasmeasured by the knee frontal plane projection angle during the squatting movements, through captured images and analyzed by the software Tracker and ImageJ. Despite more cases in women, in both sexes, free squatting presented greater cases of medicalization of the knee than in comparison to the other two adaptations. Although both squat adaptations presented positive results, only squatting with verbal command showed a significant reduction of the dynamic valgus pointing out that this is the best adaptation treated. Keywords: Genu Valgum. Exercise Therapy. Motor Activity. Resumo Exercícios de cadeia cinética fechada vêm sendo empregados em programas de reabilitação e fortalecimento muscular, como é o caso do agachamento. Durante o movimento de agachamento o valgo dinâmico, alteração que afeta toda cinemática do membro inferior, tende a se tornar exacerbado, sendo necessárias adaptações com o intuito de minimizar o distúrbio biomecânico. Embora estudos tenham mostrado a eficácia dos exercícios de agachamento, faltam evidências que demonstrem, comparativamente, a efetividade de diferentes adaptações na minimização do valgo dinâmico. O objetivo do estudo foi identificar a eficácia de diferentes adaptações na execução do exercício de agachamento na redução do valgo dinâmico. Para tanto, os voluntários do estudo (n=30) três tipos de agachamentos: agachamento livre, agachamento com banda elástica e agachamento com comando verbal. O valgo dinâmico foi mensurado mediante o ângulo de projeção no plano frontal do joelho durante os movimentos de agachamento, através de imagens capturadas e posteriormente analisadas pelos softwares Tracker e ImageJ. Apesar de mais casos em mulheres, em ambos os sexos, o agachamento livre apresentou maiores casos de medicalização do joelho do que nas outras duas adaptações. Embora ambas adaptações de agachamento apresentaram resultados positivos, apenas o agachamento com comando verbal apresentou redução significativa do valgo dinâmico, apontando ser esta a melhor adaptação tratada. Palavras-chaves: Geno Valgo. Terapia por Exercício. Atividade Motora.

Manual therapy in diaphragm muscle: effect on respiratory muscle strength and chest mobility

Introduction: Manual therapy uses the hands as a form of healing, being a manipulation for therapeutic purposes. However, there is little evidence of its effects on the respiratory system. Objective: To describe the effect of manual therapy on the diaphragm, on respiratory muscle strength and on the mobility of the thoracic cavity. Method: Descriptive, longitudinal, interventional and quantitative research, performed at the Cardiopneumofunctional Physical Therapy Laboratory of the Federal University of Ceará (UFC). The sample consisted of 40 sedentary female students, aged between 18 and 35 years of the Physiotherapy course of the UFC. The following techniques were performed: “diaphragm lift” and double diaphragm. Data collection was performed in three steps, on the same day and by the same researcher, under a homogeneous verbal command. It was considered statistically significant value of p≤0,05. Results: After applying the techniques, a comparative analysis was performed, which demonstrated a statistically significant difference in the maximum expiratory pressure, with p< 0,0001, and all the coefficients of the cirtometry, being p<0,0025 (axillary), p<0,0085 (xiphoid) and p<0,0005 (basal). Conclusion: Manual therapy techniques performed on the diaphragm exert an influence on muscle strength due to the increase in maximum expiratory pressure and in the mobility of the thoracic cavity, reflected in the increase of the coefficients of the cirtometry.

Effect of Low-Dose Dexmedetomidine on the Anesthetic and Recovery Profile of Sevoflurane-Based Anesthesia in Patients Presenting for Supratentorial Neurosurgeries: A Randomized Double-Blind Placebo-Controlled Trial

Background Dexmedetomidine could be a suitable adjuvant in neuroanesthesia due to its analgesic and anesthetic-sparing properties with the added advantage of facilitating intraoperative neuromonitoring. However, its recovery profile is still debated upon, as in neuroanesthesia, a prompt recovery is essential for postoperative neurologic assessment. We designed this study to evaluate the effect of dexmedetomidine on the anesthetic and recovery profile of patients presenting for supratentorial neurosurgeries. Materials and Methods Forty adult patients undergoing supratentorial surgeries were recruited in this prospective, randomized, double-blinded study and were divided into two groups: group S and group SD. Both groups received sevoflurane and fentanyl for maintenance, whereas group SD alone received a low dose of dexmedetomidine infusion. Recovery parameters, opioid consumption, Richmond Agitation–Sedation Scale (RASS) and visual analogue scale (VAS) scores, incidence of nausea and vomiting, and intraoperative hemodynamics were analyzed. Results There were no statistically significant differences between the groups S and SD in case of recovery parameters—time taken (in minutes, presented as median with interquartile range [IQR]) for (1) eye-opening to command: 9.5 (8–18) versus 22.5 (5–47.5) (p = 0.414); 2) following verbal command: 10.5 (8.25–29.5) versus 25 (10–28.75) (p = 0.512); (3) extubation: 11 (9.25–22) versus 25 (10–30) (p = 0.277); and (4) getting oriented to place, time, and date: 23 (20–52.75) versus 27.5 (25–36.5) (p = 0.121). Fentanyl consumption was significantly less in group SD (451 ± 39.3) versus group S (524.3 ± 144.1) (p = 0.034). The median RASS score with IQR and the median VAS scores with IQR were comparable between the groups at all time points. Of the 20 patients in group S, 5 had complaints of nausea and vomiting compared with none in the group SD, although it was not statistically significant. The hemodynamic parameters did not show a significant difference between the groups except for a surge in mean arterial pressure at 30 minutes in group S. Conclusion Low-dose dexmedetomidine as an adjuvant to sevoflurane- and fentanyl-based anesthesia could provide stable hemodynamics and lesser anesthetics and opioid consumption, without adversely affecting the recovery profile in patients undergoing supratentorial neurosurgical procedures.