Liposomal bupivacaine for ultrasound-guided rectus sheath blocks after midline laparotomy

Optimal pain management after open abdominal surgery is essential but can be difficult to achieve. The effects of inadequate analgesia go beyond the first few postoperative days; severe acute postoperative pain may contribute to the development of chronic postsurgical pain. Thoracic epidural analgesia is a traditional approach to the management of acute pain after open abdominal surgery but has multiple possible contraindications and can be technically challenging. In our hospital, we typically offer ultrasound-guided rectus sheath blocks with catheters when epidural analgesia is not feasible. However, the recent registration of long-acting liposomal bupivacaine in the Netherlands as well as logistical and equipment-related issues have led us to consider liposomal bupivacaine as an alternative to the use of catheters. Here, we present a short case series to describe our first clinical experiences with the use of liposomal bupivacaine in ultrasound-guided rectus sheath blocks after midline laparotomy for three patients in whom epidural insertion was contraindicated.</p

Comprehensive screening and quantification of veterinary drugs in milk using UPLC–ToF-MS

Ultra-performance liquid chromatography combined with time-of-flight mass spectrometry (UPLC–ToF-MS) has been used for screening and quantification of more than 100 veterinary drugs in milk. The veterinary drugs represent different classes including benzimidazoles, macrolides, penicillins, quinolones, sulphonamides, pyrimidines, tetracylines, nitroimidazoles, tranquillizers, ionophores, amphenicols and non-steroidal anti-inflammatory agents (NSAIDs). After protein precipitation, centrifugation and solid-phase extraction (SPE), the extracts were analysed by UPLC–ToF-MS. From the acquired full scan data the drug-specific ions were extracted for construction of the chromatograms and evaluation of the results. The analytical method was validated according to the EU guidelines (2002/657/EC) for a quantitative screening method. At the concentration level of interest (MRL level) the results for repeatability (%RSD < 20% for 86% of the compounds), reproducibility (%RSD < 40% for 96% of the compounds) and the accuracy (80–120% for 88% of the compounds) were satisfactory. Evaluation of the CCβ values and the linearity results demonstrates that the developed method shows adequate sensitivity and linearity to provide quantitative results. Furthermore, the method is accurate enough to differentiate between suspected and negative samples or drug concentrations below or above the MRL. A set of 100 samples of raw milk were screened for residues. No suspected (positive) results were obtained except for the included blind reference sample containing sulphamethazine (88 μg/l) that tested positive for this compound. UPLC–ToF-MS combines high resolution for both LC and MS with high mass accuracy which is very powerful for the multi-compound analysis of veterinary drugs. The technique seems to be powerful enough for the analysis of not only veterinary drugs but also organic contaminants like pesticides, mycotoxins and plant toxins in one single method

Between-centre differences in care for in-hospital cardiac arrest:a prospective cohort study

Abstract Background Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care. Methods A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres. Results After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001). Conclusion In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix

Exploring dust around HD142527 down to 0.025" / 4au using SPHERE/ZIMPOL

We have observed the protoplanetary disk of the well-known young Herbig star HD 142527 using ZIMPOL Polarimetric Differential Imaging with the VBB (Very Broad Band, ~600-900nm) filter. We obtained two datasets in May 2015 and March 2016. Our data allow us to explore dust scattering around the star down to a radius of ~0.025" (~4au). The well-known outer disk is clearly detected, at higher resolution than before, and shows previously unknown sub-structures, including spirals going inwards into the cavity. Close to the star, dust scattering is detected at high signal-to-noise ratio, but it is unclear whether the signal represents the inner disk, which has been linked to the two prominent local minima in the scattering of the outer disk, interpreted as shadows. An interpretation of an inclined inner disk combined with a dust halo is compatible with both our and previous observations, but other arrangements of the dust cannot be ruled out. Dust scattering is also present within the large gap between ~30 and ~140au. The comparison of the two datasets suggests rapid evolution of the inner regions of the disk, potentially driven by the interaction with the close-in M-dwarf companion, around which no polarimetric signal is detected.Comment: 11 pages, 7 figures, accepted for publication in A

CS Cha B: A disc-obscured M-type star mimicking a polarised planetary companion

Context. Direct imaging provides a steady flow of newly discovered giant planets and brown dwarf companions. These multi-object systems can provide information about the formation of low-mass companions in wide orbits and/or help us to speculate about possible migration scenarios. Accurate classification of companions is crucial for testing formation pathways. Aims. In this work we further characterise the recently discovered candidate for a planetary-mass companion CS Cha b and determine if it is still accreting. Methods. MUSE is a four-laser-adaptive-optics-assisted medium-resolution integral-field spectrograph in the optical part of the spectrum. We observed the CS Cha system to obtain the first spectrum of CS Cha b. The companion is characterised by modelling both the spectrum from 6300 \unicode{x212B} to 9300 \unicode{x212B} and the photometry using archival data from the visible to the near-infrared (NIR). Results. We find evidence of accretion and outflow signatures in H$\mathrm{\alpha}$ and OI emission. The atmospheric models with the highest likelihood indicate an effective temperature of $3450\pm50$ K with a $\log{g}$ of $3.6\pm0.5$ dex. Based on evolutionary models, we find that the majority of the object is obscured. We determine the mass of the faint companion with several methods to be between 0.07 $M_{\odot}$ and 0.71 $M_{\odot}$ with an accretion rate of $\dot{M} = 4 \times 10^{-11 \pm 0.4}$ Myr$^{-1}$. Conclusions. Our results show that CS Cha B is most likely a mid-M-type star that is obscured by a highly inclined disc, which has led to its previous classification using broadband NIR photometry as a planetary-mass companion. This shows that it is important and necessary to observe over a broad spectral range to constrain the nature of faint companionsComment: 9 pages, 6 figures, accepted for publication by A&

Fully automated screening of veterinary drugs in milk by turbulent flow chromatography and tandem mass spectrometry

There is an increasing interest in screening methods for quick and sensitive analysis of various classes of veterinary drugs with limited sample pre-treatment. Turbulent flow chromatography in combination with tandem mass spectrometry has been applied for the first time as an efficient screening method in routine analysis of milk samples. Eight veterinary drugs, belonging to seven different classes were selected for this study. After developing and optimising the method, parameters such as linearity, repeatability, matrix effects and carry-over were studied. The screening method was then tested in the routine analysis of 12 raw milk samples. Even without internal standards, the linearity of the method was found to be good in the concentration range of 50 to 500 µg/L. Regarding repeatability, RSDs below 12% were obtained for all analytes, with only a few exceptions. The limits of detection were between 0.1 and 5.2 µg/L, far below the maximum residue levels for milk set by the EU regulations. While matrix effects—ion suppression or enhancement—are obtained for all the analytes the method has proved to be useful for screening purposes because of its sensitivity, linearity and repeatability. Furthermore, when performing the routine analysis of the raw milk samples, no false positive or negative results were obtained

Perioperative outcome, long-term mortality and time trends in elderly patients undergoing low-, intermediate- or major non-cardiac surgery

Background: Decision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery. Methods: This observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel–Haenszel chi-square test. Results: Data of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients’ medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9–14.5) in 2004–2007 to 4.6 days (IQR 1.9–9.0) in 2016–2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3%. In the overall population 30-day mortality was high and constant during the study period (6.7%, ranging from 4.2 to 8.4%). Conclusion:Patients should not be withheld surgery solely based on their age. However, even for low-risk surgery, the mortality rate of more than 2% is substantial. Deciding whether older patients benefit from surgery should be based on the understanding of individual risks, patients’ wishes and a patient-centred plan.</p

The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg−1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy

Variable dynamics in the inner disk of HD 135344B revealed with multi-epoch scattered light imaging

This is the author accepted manuscript. The final version is available from American Astronomical Society via the DOI in this record.MB acknowledges funding from ANR of France under contract number ANR-16-CE31-0013 (Planet Forming Disks). SP acknowledges support from CONICYTGemini grant 32130007. SK acknowledges support from an STFC Rutherford fellowship (ST/J004030/1) and an ERC Starting Grant (Grant Agreement No. 639889)

Shadows cast on the transition disk of HD 135344B. Multiwavelength VLT/SPHERE polarimetric differential imaging

The protoplanetary disk around the F-type star HD 135344B (SAO 206462) is in a transition stage and shows many intriguing structures both in scattered light and thermal (sub-)millimeter emission which are possibly related to planet formation processes. We study the morphology and surface brightness of the disk in scattered light to gain insight into the innermost disk regions, the formation of protoplanets, planet-disk interactions traced in the surface and midplane layers, and the dust grain properties of the disk surface. We have carried out high-contrast polarimetric differential imaging (PDI) observations with VLT/SPHERE and obtained polarized scattered light images with ZIMPOL in R- and I-band and with IRDIS in Y- and J-band. The scattered light images reveal with unprecedented angular resolution and sensitivity the spiral arms as well as the 25 au cavity of the disk. Multiple shadow features are discovered on the outer disk with one shadow only being present during the second observation epoch. A positive surface brightness gradient is observed in the stellar irradiation corrected images in southwest direction possibly due to an azimuthally asymmetric perturbation of the temperature and/or surface density by the passing spiral arms. The disk integrated polarized flux, normalized to the stellar flux, shows a positive trend towards longer wavelengths which we attribute to large aggregate dust grains in the disk surface. Part of the the non-azimuthal polarization signal in the Uphi image of the J-band observation could be the result of multiple scattering in the disk. The detected shadow features and their possible variability have the potential to provide insight into the structure of and processes occurring in the innermost disk regions.Comment: Accepted for publication in A&A, 20 pages, 15 figure