Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Die Macht Gottes zum Heil : das Bibelverständnis von Johann Amos Comenius in einer Zeit der Krise und des Umbruches

Gegenstand dieser theologiegeschichtlichen Arbeit bildet die biblische Hermeneutik des mährischen Theologen, Pädagogen und letzten Bischofs der alten Brüderunität Johann Amos Comenius (Jan Amos Komenský, 1592-1670) im Kontext von Theologie, persönlicher Frömmigkeit und der Kirche. Im Zentrum steht Comenius' Verständnis des "Wortes Gottes", seine Exegese und die Art und Weise seiner Bezugnahme auf die Heilige Schrift. Darüber hinaus wird sein Bibelverständnis auch im Kontext der theologischen Traditionen der Böhmischen Reformation ("lex Christi") und der protestantischen Orthodoxie ("proprietates Sacrae Scripturae") untersucht und sein Einfluss auf die tschechische Theologie des 20. Jahrhunderts insbesondere im Werk des systematischen Theologen Josef L. Hromádka aufgezeigt. In der Dreiheit von Glaube, Liebe und Hoffnung als "essentialia" der christlichen Religion hat die Theologie von Comenius ihren Brennpunkt. Mit diesen drei essentialia antworten die Christen als Gemeinschaft von Pilgern auf das, was Gott ihnen enthüllt, "damit sie es wissen", was er ihnen gebietet, "damit sie es tun", und was er ihnen verheisst, "damit sie es von seiner Güte in diesem und im künftigen Leben erwarten" (Didactica magna). Einzig in einer Rückbesinnung auf diese Dreiheit sieht Comenius einen Ausweg aus den grausamen Wirren und den Folgen des Dreissigjährigen Krieges, welche ihn selbst Zeit seines Lebens zu einem Flüchtling machten. Als "Haggaeus redivivus" ruft er auf ihrer Grundlage auf zu allgemeiner Busse und zur Erneuerung der "praxis pietatis" in Leben und Erziehung und damit zu einer Reform von Kirche und Gesellschaft. This study in the field of the history of theology examines the biblical hermeneutics of the Moravian theologian, pedagogue and last bishop of the old Unitas Fratrum (Moravian Brethren), John Amos Comenius (Jan Amos Komenský, 1592-1670), in the context of theology, personal piety and the church. The focus lies on Comenius' understanding of the "Word of God", his exegesis and his way of referring to Holy Scripture. His understanding of the Bible is further examined in the context of the theological traditions of the Bohemian Reformation ("lex Christi") and Protestant orthodoxy ("proprietates Sacrae Scripturae") as well as in its impact on Czech theology in the 20th century, especially on the work of the Czech systematic theologian Josef L. Hromádka. The focal point of Comenius' theology is in the triad of faith, love and hope as "essentialia" of the Christian religion. Through these three "essentialia" Christians respond as a communion of pilgrims to what God has revealed to them, "in order that they know it", to what he commands them, "in order that they do it", and to what he promises them, "in order that they expect it through his grace in this life and in the life to come" (Didactica Magna). It is only in a return to reflecting on this triad that Comenius sees a way out of the cruel turmoil and the consequences of the Thirty Years' War, which turned him into a lifelong refugee. On this basis, acting as "Haggaeus redivivus", he calls for general repentance and a renewal of the "praxis pietatis" in life and in education and thus for a reform of church and society

A formative investigation assessing menstrual health literacy in professional women’s football

 The aim of this study was to assess and compare menstrual health literacy in professional women’s  football. A three-section questionnaire was completed by professional players (n = 25), development  players (n = 22) and staff (n = 19). The mean total knowledge score (out of 19) was lower for development  players (5.4 ± 2.9) than professional players (7.8 ± 3.2) and staff (9.1 ± 4.8) (p 50% correct answers. For each group, knowledge of the menstrual cycle (MC) was greater than knowl?edge of hormonal contraceptives (HC) (p < 0.001). Previous MC and HC education did not correspond to  higher knowledge scores in professional players (p = 0.823) or development players (p = 0.274). In  professional and development players, comfort of communication was influenced by the sex of whom  they were communicating with (p < 0.001), with a preference for females. In conclusion, results from the  present study suggest refined education strategies and new approaches are required for both players  and staff to improve menstrual health literacy in professional women’s football </p

Heme Binding by <i>Corynebacterium diphtheriae</i> HmuT: Function and Heme Environment

The heme uptake pathway (hmu) of <i>Corynebacterium diphtheriae</i> utilizes multiple proteins to bind and transport heme into the cell. One of these proteins, HmuT, delivers heme to the ABC transporter HmuUV. In this study, the axial ligation of the heme in ferric HmuT is probed by examination of wild-type (WT) HmuT and a series of conserved heme pocket residue mutants, H136A, Y235A, and M292A. Characterization by UV–visible, resonance Raman, and magnetic circular dichroism spectroscopies indicates that H136 and Y235 are the axial ligands in ferric HmuT. Consistent with this assignment of axial ligands, ferric WT and H136A HmuT are difficult to reduce while Y235A is reduced readily in the presence of dithionite. The FeCO Raman shifts in WT, H136A, and Y235A HmuT–CO complexes provide further evidence of the axial ligand assignments. Additionally, these frequencies provide insight into the nonbonding environment of the heme pocket. Ferrous Y235A and the Y235A–CO complex reveal that the imidazole of H136 exists in two forms, one neutral and one with imidazolate character, consistent with a hydrogen bond acceptor on the H136 side of the heme. The ferric fluoride complex of Y235A reveals the presence of at least one hydrogen bond donor on the Y235 side of the heme. Hemoglobin utilization assays showed that the axial Y235 ligand is required for heme uptake in HmuT

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Preoperative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended

Intraoperative transfusion practices in Europe

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

Background: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. Methods: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. Results: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. Conclusions: Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs