Co-presentation of Posterior Reversible Encephalopathy Syndrome in a patient with Post Dural Puncture Headache

INTRODUCTION: Post Dural Puncture Headache (PDPH) is a well-known complication of neuraxial anesthesia, however the occurrence of seizures and vision loss within few days after dural puncture could be alarming. Posterior Reversible Encephalopathy Syndrome (PRES) is associated with reversible edema and leukoencephalopathy in the posterior parieto-occipital cortex. We report the co-presentation of PRES and PDPH after labor epidural analgesia. CASE PRESENTATION: 25-year-old multiparous African-American woman was admitted for evaluation of new onset seizures and headache in the postpartum period. She had a recent history of multiple needle insertion attempts and inadvertent dural puncture during epidural analgesia for delivery. Soon after delivery, she was diagnosed with PDPH and was treated with epidural blood patch, with no relief of symptoms. Six days later, she developed sudden onset transient blindness, seizures and altered sensorium and magnetic resonance imaging (MRI) of the brain revealed white matter changes suggestive of PRES. CONCLUSION: PRES is an uncommon complication of cerebrospinal fluid (CSF) leak and intracranial hypotension. We report the occurrence of PRES in a patient with no known risk factors, except a traumatic dural tap. Is it important to expand the differentials for headache after dural puncture to encompass PRES as a possibility, especially in patients with a delayed presentation of seizures and cortical blindness

Novel airway device Vie Scope in several pediatric airway scenario: A randomized simulation pilot trial

CONTEXT: Endotracheal intubation of pediatric patients is challenging, especially in the pre-hospital emergency setting and if performed by less experienced providers. Securing an airway should be achieved with a single intubation attempt, as each intubation attempt contributes to morbidity and mortality. A new airway device, the VieScope, was recently introduced into clinical market, but efficacy to reduced intubation attempts remains unclear thus far. OBJECTIVE: We aimed to compare endotracheal intubation by paramedics using the Vie Scope in different pediatric airway simulation conditions. METHODS: We conducted a randomized, cross-over simulation study. Following a theoretical and practical training session, paramedics performed endotracheal intubation in 3 different pediatric emergency scenarios: normal airway; tongue edema; cardiopulmonary resuscitation using the VieScope. Overall intubation success rate was the primary outcome. Secondary outcomes included number of intubation attempts, time to intubation, Cormack-Lehane grade, POGO score, and ease of use (using 1-100 scale). RESULTS: Fifty-five paramedics with at least 2 years of clinical experience and without any previous experience with the VieScope participated in this study. The overall intubation success rate was 100% in all 3 scenarios. The median intubation time was 27 (24-34) versus 27 (25-37) versus 29 (25-40) s for scenarios A, B, and C, respectively. In scenario A, all paramedics performed successful intubation with 1 single intubation attempt, whereas 2% of the paramedics had to perform 2 intubation attempts in scenario B and 9% in scenario C. CONCLUSIONS: Results of this simulation study indicate preliminary evidence, that the VieScope enables adequate endotracheal intubation in the pediatric setting. Further clinical studies are needed to confirm these results

Placenta Percreta; A Report On Surviving Death From The Bleeding Disaster!

A 34 year old G6P5 diagnosed with placenta previa percreta (fig 1) in her 2nd trimester was reviewed by a multidisciplinary team. Baby delivery was planned at 34 weeks gestation by cesarean hysterectomy(CH) immediately preceded by bilateral ureteral stents for anticipated surgical complexity. Patient received combined spinal and epidural (not activated) for the ureteric stenting with an aim to use the epidural for post-operative analgesia followed by general anesthesia and establishment of invasive lines and monitoring prior to start of CH. Soon after baby delivery, patient became hypotensive from severe hemorrhage. Massive transfusion protocol was instituted. After completion of hysterectomy, patient continued to bleed from multiple intraabdominal sites. While surgical hemostasis remained a challenge, patient developed PEA arrest. CPR was started with return of spontaneous circulation (ROSC) after chest compression for 2 minutes and 1mg of epinephrine. Following this, abdomen was packed with a decision to close secondarily after interventional radiology (IR) assisted intervention if necessary and hemodynamic stabilization. Intraoperatively, patient received a total of 29pRBCs, 22FFP, 4platelet & 3Cryo units with 21 L of crystalloids, 3.25 L of 5% albumin and 1.8L of cell saver with an estimated blood loss of 25L. Tranexamic acid and prothrombin complex concentrate was given. Thromboelastogram (TEG) and lab based coagulation profile was used intraoperatively to guide blood component transfusion. Serial blood gas analyses guided volume and electrolyte correction. In the ICU patient improved with no neurological insult or DIC. On postop day 1 IR found no active extravasations and surgical abdominal closure was performed. Epidural catheter was used for postoperative pain control and was removed on day 4. Patient was discharged on postop day 10.https://scholarlycommons.henryford.com/merf2020caserpt/1124/thumbnail.jp

Placenta Percreta: A Report On Surviving Death From The Bleeding Disaster!

https://scholarlycommons.henryford.com/merf2020caserpt/1001/thumbnail.jp

Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial

BACKGROUND: There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. METHODS: We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. RESULTS: Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P \u3c .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P \u3c .001) and 4.925 (IQR: 4.65-5.06; P \u3c .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. CONCLUSION: We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option

MEGAVERSE: Benchmarking Large Language Models Across Languages, Modalities, Models and Tasks

Recently, there has been a rapid advancement in research on Large Language Models (LLMs), resulting in significant progress in several Natural Language Processing (NLP) tasks. Consequently, there has been a surge in LLM evaluation research to comprehend the models' capabilities and limitations. However, much of this research has been confined to the English language, leaving LLM building and evaluation for non-English languages relatively unexplored. There has been an introduction of several new LLMs, necessitating their evaluation on non-English languages. This study aims to expand our MEGA benchmarking suite by including six new datasets to form the MEGAVERSE benchmark. The benchmark comprises 22 datasets covering 81 languages, including low-resource African languages. We evaluate several state-of-the-art LLMs like GPT-3.5-Turbo, GPT4, PaLM2, and Llama2 on the MEGAVERSE datasets. Additionally, we include two multimodal datasets in the benchmark and assess the performance of the LLaVa-v1.5 model. Our experiments suggest that GPT4 and PaLM2 outperform the Llama models on various tasks, notably on low-resource languages, with GPT4 outperforming PaLM2 on more datasets than vice versa. However, issues such as data contamination must be addressed to obtain an accurate assessment of LLM performance on non-English languages.Comment: 23 pages, 30 figures and 1 tabl

Historians of Asia on Political Violence

In the general opinion, Asia as a whole tends to be represented (and more often than not, to represent itself) as devoid of violence: look at Indian “non-violence”, Chinese Taoist “non-action”, Confucian “harmony”, Buddhist “love for peace” or Japanese “Zen philosophy”… This may fill the shelves of “Oriental wisdom” sections in our bookshops, but most historians do not buy into this kind of “feel good” projections and are acutely aware that any society whatsoever, wherever it is located, teems with violence, and that violence is part and parcel of any kind of polity. Furthermore, the political violence which is the topic of this volume is not just about war, it can take on very diverse forms, including, as will be shown by some of the articles presented here, iconic vandalism, distorted modes of interpretation, warped forms of ideological discourse, collective amnesia and negationism. The present volume is the second of the “Myriades d’Asies” series inaugurated with India-China: Intersecting Universalities. Just as the preceding one, it is a collection of articles resulting from an international conference organised by the Chair of Chinese Intellectual History in June 2019. As a reflection of the Collège de France spirit of public service intent on making knowledge available to all for free, all the volumes of the series are published online and in open access. Our hope is that these articles, written by eminent historians of Asia and from very different viewpoints which cut across vast expanses of time and space, will lead readers and researchers alike to reflect further on the multiple faces of political violence, as well as their infinite complexities, so as to avoid giving in to ideological and judgmental binaries that are the common junk food for non-thought. This seems to be increasingly essential today since the 21st century is supposed to be the century of Asia.In the general opinion, Asia as a whole tends to be represented (and more often than not, to represent itself) as devoid of violence: look at Indian “non-violence”, Chinese Taoist “non-action”, Confucian “harmony”, Buddhist “love for peace” or Japanese “Zen philosophy”… This may fill the shelves of “Oriental wisdom” sections in our bookshops, but most historians do not buy into this kind of “feel good” projections and are acutely aware that any society whatsoever, wherever it is located, teems with violence, and that violence is part and parcel of any kind of polity. Furthermore, the political violence which is the topic of this volume is not just about war, it can take on very diverse forms, including, as will be shown by some of the articles presented here, iconic vandalism, distorted modes of interpretation, warped forms of ideological discourse, collective amnesia and negationism. The present volume is the second of the “Myriades d’Asies” series inaugurated with India-China: Intersecting Universalities. Just as the preceding one, it is a collection of articles resulting from an international conference organised by the Chair of Chinese Intellectual History in June 2019. As a reflection of the Collège de France spirit of public service intent on making knowledge available to all for free, all the volumes of the series are published online and in open access. Our hope is that these articles, written by eminent historians of Asia and from very different viewpoints which cut across vast expanses of time and space, will lead readers and researchers alike to reflect further on the multiple faces of political violence, as well as their infinite complexities, so as to avoid giving in to ideological and judgmental binaries that are the common junk food for non-thought. This seems to be increasingly essential today since the 21st century is supposed to be the century of Asia

Subcostal Anterior Quadratus Lumborum Block Versus Epidural Block for Analgesia in Open Nephrectomy: A Randomized Clinical Trial

BACKGROUND: Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS: Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS: Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS: We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption

Association between early cumulative fluid balance and successful liberation from invasive ventilation in COVID-19 ARDS patients - insights from the PRoVENT-COVID study:a national, multicenter, observational cohort analysis

BACKGROUND: Increasing evidence indicates the potential benefits of restricted fluid management in critically ill patients. Evidence lacks on the optimal fluid management strategy for invasively ventilated COVID-19 patients. We hypothesized that the cumulative fluid balance would affect the successful liberation of invasive ventilation in COVID-19 patients with acute respiratory distress syndrome (ARDS). METHODS: We analyzed data from the multicenter observational 'PRactice of VENTilation in COVID-19 patients' study. Patients with confirmed COVID-19 and ARDS who required invasive ventilation during the first 3 months of the international outbreak (March 1, 2020, to June 2020) across 22 hospitals in the Netherlands were included. The primary outcome was successful liberation of invasive ventilation, modeled as a function of day 3 cumulative fluid balance using Cox proportional hazards models, using the crude and the adjusted association. Sensitivity analyses without missing data and modeling ARDS severity were performed. RESULTS: Among 650 patients, three groups were identified. Patients in the higher, intermediate, and lower groups had a median cumulative fluid balance of 1.98 L (1.27-7.72 L), 0.78 L (0.26-1.27 L), and - 0.35 L (- 6.52-0.26 L), respectively. Higher day 3 cumulative fluid balance was significantly associated with a lower probability of successful ventilation liberation (adjusted hazard ratio 0.86, 95% CI 0.77-0.95, P = 0.0047). Sensitivity analyses showed similar results. CONCLUSIONS: In a cohort of invasively ventilated patients with COVID-19 and ARDS, a higher cumulative fluid balance was associated with a longer ventilation duration, indicating that restricted fluid management in these patients may be beneficial. Trial registration Clinicaltrials.gov ( NCT04346342 ); Date of registration: April 15, 2020