Real-time monitoring of human blood-brain barrier disruption

Chemotherapy aided by opening of the blood-brain barrier with intra-arterial infusion of hyperosmolar mannitol improves the outcome in primary central nervous system lymphoma. Proper opening of the blood-brain barrier is crucial for the treatment, yet there are no means available for its real-time monitoring. The intact blood-brain barrier maintains a mV-level electrical potential difference between blood and brain tissue, giving rise to a measurable electrical signal at the scalp. Therefore, we used direct-current electroencephalography ( DC-EEG) to characterize the spatiotemporal behavior of scalp-recorded slow electrical signals during blood-brain barrier opening. Nine anesthetized patients receiving chemotherapy were monitored continuously during 47 blood-brain barrier openings induced by carotid or vertebral artery mannitol infusion. Left or right carotid artery mannitol infusion generated a strongly lateralized DC-EEG response that began with a 2 min negative shift of up to 2000 mu V followed by a positive shift lasting up to 20 min above the infused carotid artery territory, whereas contralateral responses were of opposite polarity. Vertebral artery mannitol infusion gave rise to a minimally lateralized and more uniformly distributed slow negative response with a posterior-frontal gradient. Simultaneously performed near-infrared spectroscopy detected a multiphasic response beginning with mannitol-bolus induced dilution of blood and ending in a prolonged increase in the oxy/deoxyhemoglobin ratio. The pronounced DC-EEG shifts are readily accounted for by opening and sealing of the blood-brain barrier. These data show that DC-EEG is a promising real-time monitoring tool for bloodbrain barrier disruption augmented drug delivery.Peer reviewe

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

Publisher Copyright: © 2021 The AuthorsObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.Peer reviewe

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland

AbstractObjective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting.Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic.Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland. Abstract Objective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland

Incidence and predictive factors of spinal cord stimulation treatment after lumbar spine surgery

Introduction: Spinal cord stimulation (SCS) is recommended for the treatment of postsurgical chronic back and leg pain refractory to other treatments. We wanted to estimate the incidence and predictive factors of SCS treatment in our lumbar surgery cohort. Patients and methods: Three questionnaires (a self-made questionnaire, the Oswestry Low Back Pain Disability Questionnaire, and the Beck Depression Inventory) were sent to patients aged 18-65 years with no contraindications for the use of SCS, and who had undergone non-traumatic lumbar spine surgery in the Oulu University Hospital between June 2005 and May 2008. Patients who had a daily pain intensity of >= 5/10 with predominant radicular component were interviewed by telephone. Results: After exclusions, 814 patients remained in this cohort. Of those, 21 patients had received SCS by the end of June 2015. Fifteen (71%) of these received benefit and continued with the treatment. Complications were rare. The number of patients who replied to the postal survey were 537 (66%). Eleven of them had undergone SCS treatment after their reply. Features predicting SCS implantation were daily or continuous pain, higher intensities of pain with predominant radicular pain, more severe pain-related functional disability, a higher prevalence of depressive symptoms, and reduced benefit from pain medication. The mean waiting time was 65 months (26-93 months). One hundred patients were interviewed by telephone. Fourteen seemed to be potential SCS candidates. From the eleven patients who underwent SCS after responding to the survey, two were classified as potential candidates in the phone interview, while nine were other patients. Twelve patients are still waiting for treatment to commence. Conclusion: In our region, the SCS treatment is used only for very serious pain conditions. Waiting time is too long and it may be the reason why this treatment option is not offered to all candidates.Peer reviewe

Developing a supervised machine learning model for predicting perioperative acute kidney injury in arthroplasty patients

AbstractBackground: Perioperative acute kidney injury (AKI) is challenging to predict and a common complication of lower limb arthroplasties. Our aim was to create a machine learning model to predict AKI defined by both serum creatinine (sCr) levels and urine output (UOP) and to investigate which features are important for building the model. The features were divided into preoperative, intraoperative, and postoperative feature sets.Methods: This retrospective, register-based study assessed 648 patients who underwent primary knee or hip replacement at Oulu University Hospital, Finland, between January 2016 and February 2017. The RUSBoost algorithm was chosen to establish the models, and it was compared to Naïve/Kernel Bayes and support vector machine (SVM). Models of AKI classified by either sCr levels or UOP were established. All the models were trained and validated using a five-fold cross-validation approach. An external test set was not available at the time of this study.Results: The performance of both the sCr level- and UOP-based AKI models improved when pre-, intra-, and postoperative features were used together. The best sCr level-based AKI model performed as follows: area under receiving operating characteristic (AUROC) of 0.91, (95% CI ± 0.02), area under precision-recall (AUPR) of 0.35 (95% CI ± 0.04) sensitivity of 0.88 (95% CI ± 0.03), specificity of 0.87 (95% CI ± 0.03), and precision o (95% CI ± 0.03). This model correctly classified 22 out of 25 patients with AKI. The best UOP-based AKI model performed as follows: AUROC of 0.98 (95% CI ± 0.02), AUPR of 0.48 (95% CI ± 0.04), sensitivity of 0.88 (95% CI ± 0.02), specificity of 0.93 (95% CI ± 0.03), and precision of 0.34 (95% CI ± 0.04). This model correctly classified 23 out of 26 patients with AKI. In the sCr-AKI models, estimated glomerular filtration rate (eGFR)-related features were most important, and in the UOP-based AKI models, UOP-related features were most important. Other important and recurring features in the models were age, sex, body mass index, ASA status, operation type, preoperative eGFR, and preoperative sCr level. Naïve/Kernel Bayes performed similarly to RUSBoost. SVM performed poorly. Conclusions: The performance of the models improved after the inclusion of intra- and postoperative features with preoperative features. The results of our study are not generalizable, and additional larger studies are needed. The optimal ML method for this kind of data is still an open research question.Abstract Background: Perioperative acute kidney injury (AKI) is challenging to predict and a common complication of lower limb arthroplasties. Our aim was to create a machine learning model to predict AKI defined by both serum creatinine (sCr) levels and urine output (UOP) and to investigate which features are important for building the model. The features were divided into preoperative, intraoperative, and postoperative feature sets. Methods: This retrospective, register-based study assessed 648 patients who underwent primary knee or hip replacement at Oulu University Hospital, Finland, between January 2016 and February 2017. The RUSBoost algorithm was chosen to establish the models, and it was compared to Naïve/Kernel Bayes and support vector machine (SVM). Models of AKI classified by either sCr levels or UOP were established. All the models were trained and validated using a five-fold cross-validation approach. An external test set was not available at the time of this study. Results: The performance of both the sCr level- and UOP-based AKI models improved when pre-, intra-, and postoperative features were used together. The best sCr level-based AKI model performed as follows: area under receiving operating characteristic (AUROC) of 0.91, (95% CI ± 0.02), area under precision-recall (AUPR) of 0.35 (95% CI ± 0.04) sensitivity of 0.88 (95% CI ± 0.03), specificity of 0.87 (95% CI ± 0.03), and precision o (95% CI ± 0.03). This model correctly classified 22 out of 25 patients with AKI. The best UOP-based AKI model performed as follows: AUROC of 0.98 (95% CI ± 0.02), AUPR of 0.48 (95% CI ± 0.04), sensitivity of 0.88 (95% CI ± 0.02), specificity of 0.93 (95% CI ± 0.03), and precision of 0.34 (95% CI ± 0.04). This model correctly classified 23 out of 26 patients with AKI. In the sCr-AKI models, estimated glomerular filtration rate (eGFR)-related features were most important, and in the UOP-based AKI models, UOP-related features were most important. Other important and recurring features in the models were age, sex, body mass index, ASA status, operation type, preoperative eGFR, and preoperative sCr level. Naïve/Kernel Bayes performed similarly to RUSBoost. SVM performed poorly. Conclusions: The performance of the models improved after the inclusion of intra- and postoperative features with preoperative features. The results of our study are not generalizable, and additional larger studies are needed. The optimal ML method for this kind of data is still an open research question

Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics

Peer reviewe

Depressive symptoms are associated with poor outcome for lumbar spine surgery

Peer reviewe

Single dose epidural hydromorphone in labour pain : maternal pharmacokinetics and neonatal exposure

AbstractIntroduction: Epidural hydromorphone could be useful in obstetric analgesia as there is a need for a more water-soluble opioid than sufentanil or fentanyl with prolonged analgesic effect. To our knowledge, the pharmacokinetics of epidural hydromorphone has not been evaluated in parturients.Materials and methods: In this pilot study, seven healthy parturients were given a single epidural dose of hydromorphone for labour pain. One parturient received 1.5 mg, two 0.75 mg and four 0.5 mg of hydromorphone hydrochloride. Dose was decreased due to nausea and pruritus. Hydromorphone’s effect, adverse effects and plasma concentrations were evaluated. Neonatal drug exposure was evaluated by umbilical vein and artery opioid concentration at birth. Neonatal outcomes were assessed using Apgar and the Neurologic Adaptive Capacity Score (NACS).Results: All patients received additional levobupivacaine doses on parturients’ requests. The first dose was requested at a median of 163 min (range 19–303 min) after hydromorphone administration. A total of 12 opioid related expected adverse events were reported by seven parturients. All newborn outcomes were uneventful. Hydromorphone’s distribution and elimination after single epidural dose seem similar to that reported for non-pregnant subjects after intravenous hydromorphone administration, but further research is required to confirm this observation.Conclusions: The optimal dose of hydromorphone in labour pain warrants further evaluation.Abstract Introduction: Epidural hydromorphone could be useful in obstetric analgesia as there is a need for a more water-soluble opioid than sufentanil or fentanyl with prolonged analgesic effect. To our knowledge, the pharmacokinetics of epidural hydromorphone has not been evaluated in parturients. Materials and methods: In this pilot study, seven healthy parturients were given a single epidural dose of hydromorphone for labour pain. One parturient received 1.5 mg, two 0.75 mg and four 0.5 mg of hydromorphone hydrochloride. Dose was decreased due to nausea and pruritus. Hydromorphone’s effect, adverse effects and plasma concentrations were evaluated. Neonatal drug exposure was evaluated by umbilical vein and artery opioid concentration at birth. Neonatal outcomes were assessed using Apgar and the Neurologic Adaptive Capacity Score (NACS). Results: All patients received additional levobupivacaine doses on parturients’ requests. The first dose was requested at a median of 163 min (range 19–303 min) after hydromorphone administration. A total of 12 opioid related expected adverse events were reported by seven parturients. All newborn outcomes were uneventful. Hydromorphone’s distribution and elimination after single epidural dose seem similar to that reported for non-pregnant subjects after intravenous hydromorphone administration, but further research is required to confirm this observation. Conclusions: The optimal dose of hydromorphone in labour pain warrants further evaluation

Potilasturvallisuuteen liittyvät asenteet ja käsitykset muodostuvat lääketieteen opiskelijoilla jo varhain

TiivistelmäLähtökohdat: Potilasturvallisuuden kehittäminen edellyttää työelämään siirtyvien opiskelijoiden asenteisiin vaikuttamista. Tämän tutkimuksen tavoitteena oli selvittää, millaisia käsityksiä, tietoja ja asenteita oli potilasturvallisuudesta.Menetelmät: Vuosina 2016–2018 Oulun lääketieteellisen tiedekunnan kolmannen vuoden opiskelijat täyttivät vapaaehtoisen kyselylomakkeen, joka sisälsi 22 potilasturvallisuuteen liittyvää väittämää. Vastausvaihtoehdot olivat 1–5 (1 = täysin eri mieltä, 5 = täysin samaa mieltä).Tulokset: Täytetyn lomakkeen palautti 153/417 (36,7 %) opiskelijaa. Heistä 96,7 % piti potilasturvallisuutta sekä avointa ilmapiiriä tärkeinä. 96,1 % piti virheitä väistämättöminä, ja 73,4 % ajatteli lääkärien toiminnan voivan vaikuttaa virheiden syntyyn. Opiskelijoista 96,7 % aikoi työskennellä huolellisemmin virheen tapahduttua. Varhaisen potilasturvallisuuteen liittyvän opetuksen suurempi määrä oli yhteydessä myönteisiin asenteisiin potilasturvallisuutta kohtaan.Päätelmät: Opiskelijoiden asenteet näyttävät kehittyneen prekliinisessä vaiheessa ilman tietoista opetusta. Opetuksen suunnittelussa tulee panostaa pitkällä aikavälillä tapahtuvaan jatkuvaan oppimiseen opintojen alusta lähtien.AbstractMedical students’ knowledge and perceptions about patient safety develop in the preclinical yearsBackground: To improve patient safety culture, the attitudes of graduating medical students need to be influenced. The purpose of this study was to find out what kind of perceptions, attitudes and knowledge medical students had about patient safety before they received education on the subject.Methods: From 2016 to 2018, third-year medical students from the University of Oulu filled in a voluntary questionnaire consisting of 22 questions related to patient safety. All survey questions utilized a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).Results: The questionnaire was returned by 153 of 417 students (36.7%). Evaluation of the questionnaires showed that 96.7% of students considered patient safety and an open workplace environment to be important, 96.1% thought errors were inevitable, 73.4% thought that doctors were able to prevent medical errors by their own actions at work, and 96.7% of students planned to pay more attention at work after having experienced medical errors. There was a positive correlation between received patient safety education and positive attitudes towards patient safety.Conclusions: The findings of this study suggest that medical students’ attitudes towards patient safety develop before they receive education about the subject in their clinical studies. Continuous learning about patient safety should be emphasized in teaching throughout medical school, and it should be considered when developing new curricula.Tiivistelmä Lähtökohdat: Potilasturvallisuuden kehittäminen edellyttää työelämään siirtyvien opiskelijoiden asenteisiin vaikuttamista. Tämän tutkimuksen tavoitteena oli selvittää, millaisia käsityksiä, tietoja ja asenteita oli potilasturvallisuudesta. Menetelmät: Vuosina 2016–2018 Oulun lääketieteellisen tiedekunnan kolmannen vuoden opiskelijat täyttivät vapaaehtoisen kyselylomakkeen, joka sisälsi 22 potilasturvallisuuteen liittyvää väittämää. Vastausvaihtoehdot olivat 1–5 (1 = täysin eri mieltä, 5 = täysin samaa mieltä). Tulokset: Täytetyn lomakkeen palautti 153/417 (36,7 %) opiskelijaa. Heistä 96,7 % piti potilasturvallisuutta sekä avointa ilmapiiriä tärkeinä. 96,1 % piti virheitä väistämättöminä, ja 73,4 % ajatteli lääkärien toiminnan voivan vaikuttaa virheiden syntyyn. Opiskelijoista 96,7 % aikoi työskennellä huolellisemmin virheen tapahduttua. Varhaisen potilasturvallisuuteen liittyvän opetuksen suurempi määrä oli yhteydessä myönteisiin asenteisiin potilasturvallisuutta kohtaan. Päätelmät: Opiskelijoiden asenteet näyttävät kehittyneen prekliinisessä vaiheessa ilman tietoista opetusta. Opetuksen suunnittelussa tulee panostaa pitkällä aikavälillä tapahtuvaan jatkuvaan oppimiseen opintojen alusta lähtien.Abstract Medical students’ knowledge and perceptions about patient safety develop in the preclinical years Background: To improve patient safety culture, the attitudes of graduating medical students need to be influenced. The purpose of this study was to find out what kind of perceptions, attitudes and knowledge medical students had about patient safety before they received education on the subject. Methods: From 2016 to 2018, third-year medical students from the University of Oulu filled in a voluntary questionnaire consisting of 22 questions related to patient safety. All survey questions utilized a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Results: The questionnaire was returned by 153 of 417 students (36.7%). Evaluation of the questionnaires showed that 96.7% of students considered patient safety and an open workplace environment to be important, 96.1% thought errors were inevitable, 73.4% thought that doctors were able to prevent medical errors by their own actions at work, and 96.7% of students planned to pay more attention at work after having experienced medical errors. There was a positive correlation between received patient safety education and positive attitudes towards patient safety. Conclusions: The findings of this study suggest that medical students’ attitudes towards patient safety develop before they receive education about the subject in their clinical studies. Continuous learning about patient safety should be emphasized in teaching throughout medical school, and it should be considered when developing new curricula