Citizen Science Reveals Unexpected Continental-Scale Evolutionary Change in a Model Organism

Organisms provide some of the most sensitive indicators of climate change and evolutionary responses are becoming apparent in species with short generation times. Large datasets on genetic polymorphism that can provide an historical benchmark against which to test for recent evolutionary responses are very rare, but an exception is found in the brown-lipped banded snail (Cepaea nemoralis). This species is sensitive to its thermal environment and exhibits several polymorphisms of shell colour and banding pattern affecting shell albedo in the majority of populations within its native range in Europe. We tested for evolutionary changes in shell albedo that might have been driven by the warming of the climate in Europe over the last half century by compiling an historical dataset for 6,515 native populations of C. nemoralis and comparing this with new data on nearly 3,000 populations. The new data were sampled mainly in 2009 through the Evolution MegaLab, a citizen science project that engaged thousands of volunteers in 15 countries throughout Europe in the biggest such exercise ever undertaken. A known geographic cline in the frequency of the colour phenotype with the highest albedo (yellow) was shown to have persisted and a difference in colour frequency between woodland and more open habitats was confirmed, but there was no general increase in the frequency of yellow shells. This may have been because snails adapted to a warming climate through behavioural thermoregulation. By contrast, we detected an unexpected decrease in the frequency of Unbanded shells and an increase in the Mid-banded morph. Neither of these evolutionary changes appears to be a direct response to climate change, indicating that the influence of other selective agents, possibly related to changing predation pressure and habitat change with effects on micro-climate

Pretreatment with nitrous oxide enhances induction of anesthesia with sevoflurane: A randomized controlled trial

Background and Aims: Inhalation anesthesia with sevoflurane may be enhanced by several drugs or techniques. The aim of the present study was to investigate the effect of nitrous oxide (N 2 O) pretreatment on the speed of anesthesia induction with sevoflurane. Material and Methods: Eighty patients scheduled for hysteroscopy under general anesthesia were randomly assigned to inhale for 10 min before induction 50% N 2 O in oxygen or air via a facemask. Anesthesia was induced with 7-8% sevoflurane in oxygen via a facemask. Bispectral index (BIS), end-tidal carbon dioxide (EtCO 2 ) tidal volume, respiratory rate, oxygen saturation (SpO 2 ), and heart rate were recorded every minute during the 10 min pretreatment periods and every 30 s during the first 300 s of induction with sevoflurane. During induction of anesthesia inspired and end-tidal sevoflurane concentrations were also recorded. Results: During the 10 min of inspired 50% N 2 O or air BIS, EtCO 2 , tidal volume, respiratory rate and heart rate values did not differ between the two groups except for the SpO 2 , which was higher in the N 2 O group (P < 0.001). During induction of anesthesia the N 2 O group exhibited lower BIS values (P = 0.001), being significant at 60-150 s (P < 0.001, P < 0.001, P = 0.002, P = 0.014) as well as at 270 s (P = 0.004). EtCO 2 and tidal volume were consistently lower in the N 2 O group (P = 0.001, P = 0.041 respectively) and respiratory rate was higher (P = 0.007). Conclusion: Our results show that pretreatment of the patients with 50% N 2 O for 10 min enhances the speed of induction with sevoflurane as assessed by the BIS monitoring

Use of rocuronium and sugammadex under neuromuscular transmission monitoring in a patient with multiple sclerosis

Multiple sclerosis (MS) is a potentially disabling disease characterized by demyelinating lesions in the central nervous system. One of the anesthetic challenges encountered in surgical patients with MS is the management of neuromuscular blockade (NMB) and its reversal. We report a case of a 31-year-old female patient suffering from MS, who underwent gynecological surgery under general anesthesia with sevoflurane, fentanyl, and rocuronium which was successfully reversed with sugammadex. Neuromuscular transmission (NMT) monitoring was used to guide the intraoperative doses of rocuronium and also the reversal of NMB by the use of sugammadex to ensure a safe tracheal extubation. In addition, delivered volatile was titrated according to anesthetic depth monitoring (Bispectral Index) while esophageal temperature was also monitored for the maintenance of normothermia. Postoperatively, a multimodal analgesic scheme offered a high-quality analgesia and sleep, minimization of anxiety, and increased patient satisfaction. At 1-month follow-up, the patient's course was uncomplicated without any MS exacerbation. We consider that the use of rocuronium and sugammadex under NMT monitoring may represent a useful and safe choice in patients with M.S. © 2017 Saudi Journal of Anesthesia | Published by Wolters Kluwer - Medknow

Compartment Syndrome as a Complication of the Lithotomy Position

Compartment syndrome is a rare but serious complication of surgical procedures performed in the lithotomy position. Preventive measures include careful placement of the patient’s legs and limited elevation. Early diagnosis is based on vigilance and close postoperative follow-up, especially after prolonged surgery. Finally, postoperative analgesia does not delay the diagnosis, if the patient’s needs are assessed carefully. Keywords: Compartment pressure, compartment syndrome, hypoperfusion, lithotomy position "El Síndrome de Compartimiento como Complicación de la Posición de Litotomía" RESUMEN El síndrome de compartimiento es una complicación rara pero seria de los procedimientos quirúrgicos realizados en posición de litotomía. Las medidas preventivas incluyen colocación cuidadosa de las piernas de la paciente y elevación limitada. El diagnóstico temprano se basa en la vigilancia y el seguimiento cercano post-operatorio, especialmente luego de una cirugía prolongada. Finalmente, la analgesia post-operatoria no demora el diagnóstico, si las necesidades de la paciente son evaluadas con cuidado. Palabras claves: Presión de compartimiento, síndrome de compartimiento, hipoperfusión, posición de litotomí

Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery

Context: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality. Aims: We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists. Settings and Design: This was a retrospective, single center study. Subjects and Methods: The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists. Statistical Analysis: One-way analysis of variance was used for normally and Kruskal-Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test. Results: The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons. Conclusions: The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period. © 2017 Saudi Journal of Anesthesia | Published by Wolters Kluwer - Medknow

The role of dexmedetomidine as an additive to intravenous regional anesthesia: A systematic review and meta-analysis

Background: Intravenous Regional Anesthesia (IVRA) is a reliable and cost-effective anesthetic method for minor surgical procedures to the extremities. Limitations of this block include tourniquet discomfort, short duration of anesthesia, and absence of postoperative analgesia. Dexmedetomidine has been used as an adjuvant to minimize these negative characteristics with inconclusive results. Aim: To perform a systematic review of the existing evidence on the role of dexmedetomidine as an additive to intravenous regional anesthesia in upper limb surgery. Study Design: Systematic Review and Meta-analysis. Methods: The databases searched were MEDLINE, Embase, PubMed, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials databases, and clinicaltrials. gov (1990-2019). Seven randomized controlled trials (RCTs) were included. We analyzed the duration of analgesia, onset time of sensory and motor block, intraoperative tourniquet pain scores, the incidence of tourniquet pain, need for rescue analgesia, intraoperative rescue analgesia consumption, sedation scores, postoperative pain scores, and anesthesia quality. Results: Intraoperative analgesia duration (MD 11.08 min; 95% CI 5.42, 16.75; P < .0001) was longer and sensory block onset time (MD −2.10 min; 95% CI −3.345, −0.86; P = .00009) was shorter in the dexmedetomidine group. Anesthesia quality scores (MD 0.58; 95% CI 0.47, 0.70; P < .00001) and postoperative sedation scores (MD 1.03; 95% CI 0.88, 1.24; P < .00001) were significantly higher. There was a significant reduction in intraoperative rescue analgesia consumption (MD −19.70 mg; 95% CI −24.15, −15.26; P < .00001) in the dexme-detomidine group. The risk of tourniquet pain as well as postoperative pain scores were lower in favor of dexmedetomidine. The addition of dexmedetomidine to IVRA slightly increased the risk of sedation. A limitation of our study is that some of the interesting outcomes derive from a small number of RCTs. Conclusion: The addition of dexmedetomidine to IVRA ameliorates the block’s characteristics and carries a low risk of potential side effects. © 2021, Galenos Publishing House. All rights reserved

Perioperative management of hereditary arrhythmogenic syndromes

Patients with inherited cardiac channel disorders are at high risk of perioperative lethal arrhythmias. Preoperative control of symptoms and a multidisciplinary approach are required for a well-planned management. Good haemodynamic monitoring, adequate anaesthesia and analgesia, perioperative maintenance of normocarbia, normothermia, and normovolaemia are important. In congenital long QT syndrome, torsades de pointes should be prevented with magnesium sulphate infusion and avoidance of drugs such as droperidol, succinylcholine, ketamine, and ondansetron. Propofol and epidural anaesthesia represent safe choices, while caution is needed with volatile agents. In Brugada syndrome, β-blockers, α-agonists, and cholinergic drugs should be avoided, while isoproterenol reverses the ECG changes. Propofol, thiopental, and volatiles have been used uneventfully. In congenital sick sinus syndrome, severe bradycardia resistant to atropine may require isoproterenol or epinephrine. Anaesthetics with vagolytic properties are preferable, while propofol and vecuronium should be given with caution due to risk of inducing bradyarrhythmias. Neuraxial anaesthesia should produce the least autonomic imbalance. Arrhythmogenic right ventricular dysplasia/cardiomyopathy induces ventricular tachyarrhythmias, which should be treated with β-blockers. Generally, β-adrenergic stimulation and catecholamine release should be avoided. Halothane and pancuronium are contraindicated, while large doses of local anaesthetics and epinephrine should be avoided in neuraxial blocks. In catecholaminergic polymorphic ventricular tachycardia, β-blocker treatment should be continued perioperatively. Catecholamine release and β-agonists, such as isoproterenol, should be avoided. Propofol and remifentanil are probably safe, while halothane and pancuronium are contraindicated. Regional anaesthesia, without epinephrine, is relatively safe. In suspicious cardiac deaths, postmortem examination and familial screening are recommended. © The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved

Impact of anaesthetic drugs and adjuvants on ECG markers of torsadogenicity

Drug-induced prolongation of cardiac repolarization may trigger malignant ventricular arrhythmias, such as torsade de pointes. The duration of QT interval, QT corrected for heart rate (QTc), JT interval, QT dispersion (QTd), QT variability index, and transmular dispersion of repolarization (TDR) are ECG markers of torsadogenicity. All volatiles, especially isoflurane and desflurane, have been found to prolong QTc and QTcd, while sevoflurane has probably no effects on TDR. Among i.v. anaesthetics, propofol seems superior due to its minimal effects on QTc and TDR; moreover, a decrease in QTc and QTcd has been demonstrated in many studies. Regarding opioids, fentanyl, alfentanil, and remifentanil produce no effects on QTc, while sufentanil, at high doses, may induce QT prolongation. Succinylcholine, but not the non-depolarizing neuromuscular blockers, produces QTc prolongation which can be attenuated by opioids and β-blockers. Reversal of neuromuscular block with anticholinesterase-anticholinergic combinations has been associated with significant QTc prolongation, while such an effect has not been demonstrated for sugammadex, even at high doses. Local anaesthetics have probably no intrinsic action on duration of repolarization; nevertheless, an extensive subarachnoid sympathetic block may increase the duration of QTc. On the contrary, thoracic epidural anaesthesia has been associated with a decrease in both QTc and TDR. Among adjuvants, midazolam seems to have no effect on QTc and TDR, while commonly used antiemetics, such as droperidol, domperidone, and most 5-HT 3 antagonists, produce significant QT prolongation. The effects of anaesthetic drugs and techniques on electrocardiographic torsadogenic markers should be considered in the perioperative management of patients with preexisting repolarization abnormalities. © 2013 © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]

Perioperative management of patients with pre-excitation syndromes

Patients with pre-excitation abnormalities are at a high risk for life-threatening perioperative arrhythmias. In Wolff-Parkinson-White syndrome, the anaesthetics used for invasive diagnostic testing/ablation, should not affect cardiac electrophysiology; propofol, sevoflurane, fentanyl, sufentanil, alfentanil are suitable. In non-ablative surgery, propofol, sevoflurane, isoflurane, fentanyl, alfentanil, sufentanil have been used safely. Among neuromuscular blockers, cis-atracurium, rocuronium and vecuronium are good choices. Ketamine, pancuronium and pethidine should be avoided because of their sympathomimetic actions. Anticholinergic/ anticholinesterase combinations for neuromuscular block reversal should preferably be omitted, while sugammadex seems more attractive. In regional anaesthesia, addition of epinephrine and high sympathetic blocks should be avoided. Hypotension should be treated with pure alpha-adrenergic agonists. Other preexcitation abnormalities associated with different accessory pathways are the Mahaim Fiber and Lown-Ganong-Levine syndrome. Sympathetic activation should be avoided. Total intravenous anaesthesia with propofol probably represents the safest option. A careful anaesthetic plan and close cooperation with cardiologists are mandatory for successful management. © 2018, Editura Clasium. All rights reserved