Endovascular interventions training and credentialing for vascular surgeons

This article reviews issues concerning the training and credentialing of vascular surgeons in the use of endovascular techniques in the peripheral vascular system. These guidelines update a prior document that was published in 1993. They have been rewritten to accommodate the rapid evolution that has occurred in the field and to provide the appropriate requirements that a vascular surgeon should fulfill to be competent in the basic skills needed to safely and effectively perform all presently accepted diagnostic and therapeutic endovascular procedures.     

Assessing neuromuscular block at the larynx: the effect of change in resting cuff pressure and a comparison with video imaging in anesthetized humans

Neuromuscular block (NMB) at the larynx has been assessed by measuring the cuff pressure (CP) in an endotracheal tube (ETT) placed between the vocal cords. In this study, we evaluated the decrease in resting cuff pressure (RCP) after the administration of rocuronium and the effect of this decrease on the assessment of NMB, and we compared CP measurement with an alternative technique, video imaging (VI). In 20 patients, NMB was determined at the hand by mechanomyography and at the larynx initially by CP and subsequently by VI, recording images using a fiberoptic bronchoscope via a laryngeal mask. Train-of-four stimuli were applied at both sites. After baseline measurements, the ETT was replaced, and rocuronium was infused to achieve a steady-state 50% (n = 10) or 75% (n = 10) block at the hand. CP measurements were recorded before and after restoration of RCP to prerocuronium pressure, followed by further VI measurements. The mean RCP decreased from 21 +/- 4 to 12 +/- 5 mm Hg after rocuronium. At 50% block at the hand, the CP estimate of block at the larynx with reduced RCP was 62% +/- 18%, and that after restoring RCP was 29% +/- 13%; VI estimated 27% +/- 14% block. At 75% block at the hand, CP and VI estimated 52% +/- 11% and 46% +/- 9% block, respectively (RCP maintained). We conclude that RCP decreases after the administration of rocuronium, that restoring RCP significantly alters CP estimates of NMB, and that VI is in agreement with CP measurement if RCP is maintained at prerelaxant values. Implications: In this study, we show that a muscle relaxant-induced decrease in resting tension at the larynx may confound the assessment of neuromuscular block by cuff pressure measurement. The preliminary data suggest that video imaging may provide a suitable alternative to cuff pressure measurement to assess neuromuscular block at the larynx.     

Physiological variation and adaptability in human populations

This review traces some of the developments in population physiology based on contributions to the Annals over the last 25 years. Two broad themes are evident, physiological systems variation and adaptation, and by way of introduction an historical perspective of their relationship within human ecology is explored. Studies of physical fitness and work capacity, and the efforts to create standardized field procedures make up a number of the early papers. Longitudinal studies have provided reliable reference standards for Westernized populations, but are virtually non-existent for primitive groups. The relative importance of phenotypic and genotypic variations in working capacity have yet to be clearly defined. The level of habitual activity during childhood contributes to the development of ventilatory capacity though constitutional influences are of major importance. Variability in strength and motor performance of skeletal muscles are shown to have a direct bearing on aspects of growth, development and biological maturation. Physical and psychological stress in communities have been investigated. These and other studies contribute valuable data on the issue of stress, hypertension and cardiovascular morbidity and mortality. On the theme of human adaptability, high altitude populations, variations in thermal tolerance and adaptations in ageing populations have all received recent investigation. Highland people of all ages have considerably larger lung volumes than coastal dwellers. Haematological, biochemical and pulmonary function show adaptive phenomena that vary in different highland groups. In the tropical biome, more recent work includes the functional consequences of malnutrition, ethnic and cultural differences in work capacity, and the effects of endemic disease on physical performance. Annals of Human Biology papers have more recently contributed to investigations on morphological and physiological changes with human ageing. Though there is a decline in the ability to adapt to environmental stresses with age this may be met by changes in adaptational strategy in physiological systems.     

Carbon nanowalls deposited by inductively coupled plasma enhanced chemical vapor deposition using aluminum acetylacetonate as precursor

Well aligned carbon nanowalls, a few nanometers thick, were fabricated by continuous flow of aluminum acetylacetonate (Al(acac)₃) without a catalyst, and independent of substrate material. The nanowalls were grown on Si, and steel substrates using inductively coupled plasma-enhanced chemical vapor deposition. Deposition parameters like flow of argon gas and substrate temperature were correlated with the growth of carbon nanowalls. For a high flow of argon carrier gas, an increased amount of aluminum in the film and a reduced lateral size of the carbon walls were found. The aluminum is present inside the carbon nanowall matrix in the form of well crystallized nanosized Al₄C₃ precipitates.     

Pharmacokinetics of rocuronium during the three stages of liver transplantation

BACKGROUND: Little is known about the influence of liver transplantation on the pharmacokinetics of most anesthetic drugs. The authors determined the pharmacokinetics of rocuronium during liver transplantation and examined whether variability in pharmacokinetics could explain variability in recovery of neuromuscular function. METHODS: Twenty patients undergoing liver transplantation were given rocuronium, 600 microg/kg, after induction of anesthesia and again after perfusion of the transplanted liver. Plasma was sampled to determine rocuronium concentrations. Pharmacokinetic models were fit to rocuronium concentrations versus time data using a mixed-effects population approach. Various models permitted changes in clearance (Cl) or central compartment volume to account for changes in hepatic function and circulatory status during the paleohepatic, anhepatic, and neohepatic periods. Time to initial recovery of four twitches of the orbicularis oculi was determined. RESULTS: During the paleohepatic and anhepatic periods, the typical value of Cl was 2.47 ml x kg(-1) x min(-1) and was not influenced by the magnitude of preexisting liver disease (as evidenced by prothrombin time, bilirubin, serum albumin, alanine transaminase [ALT], and aspartate transaminase [AST]). During the neohepatic period, the typical value of Cl varied as a function of the duration of warm ischemia of the hepatic allograft and was 2.72 ml x kg(-1) x min(-1) for a patient with an average 60-min period of warm ischemia; time to neuromuscular recovery varied as a function of Cl. CONCLUSIONS: Despite prolonged hypothermic ischemia, the newly transplanted liver eliminates rocuronium as well as the diseased native liver (and comparably with historical control values). However, some patients had decreased rocuronium Cl during the neohepatic period, apparently a result of prolonged graft warm ischemia. The authors' finding of preservation of hepatic drug elimination in the hepatic allograft is consistent with limited data for other drugs evaluated during anesthesia.     

The believability of children and their interviewer's hearsay testimony: When less is more.

Hearsay testimony from children's interviewers is increasingly common in sexual abuse trials, but little is known about its effects on juries. In 2 studies, the authors examined college students' perceptions of 3 types of hearsay testimony (an actual interview with a child or an adult interviewer providing either the gist of what that child had said or a verbatim account of the interview). Interviewers were rated as more accurate and truthful than the children. The interview was rated as higher quality, and children's statements, including their false statements, were sometimes rated as more believable in the interviewer gist hearsay condition. Mock jurors reacted differently to various types of hearsay testimony, and interviewer gist testimony may favor a child's case. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Special Surveillance Breast Program: a model of intervention for women at high risk for breast cancer

The Special Surveillance Breast Program (SSBP) is a long-term, comprehensive, multidisciplinary program for women determined to be at high risk for the development of breast cancer. Because the women who attend this program are otherwise healthy but concerned about their risk for breast cancer, current and relevant information is required to address their concerns regarding the possibility of developing breast cancer. The purpose of this article is to describe the risk factors that indicate eligibility for the program, the structure of the program, and the results of an assessment that identified the needs of this special population.