Effect Analysis of WeChat Platform Combined with PBL Teaching Method for Standardized Training of Residents in Anesthesiology Department

Objective: To explore and analyze the effect of the WeChat platform combined with the PBL teaching method in the standardized training of anesthesia residents. Methods: 120 anesthesiology residents from January 2018 to the end of December 2019 were selected, and divided into a control group and an observation group of 60 each according to the time sequence of admission. The control group adopted the conventional teaching mode, and the observation group adopted the WeChat platform combined PBL teaching method. The scores of theoretical knowledge and anesthesia skills operation after training, the scores of the teaching interest survey, and the satisfaction with the teaching mode between the two groups were compared. Results: The scores of theoretical knowledge and anesthesia skills operation in the observation group were significantly higher than those in the control group, and the indicators of teaching interest in the observation group were also higher than those in the control group. The differences were statistically significant (P < 0.05). The satisfaction degree of the observation group was significantly higher than that of the control group, and the difference was also statistically significant (P < 0.05). Conclusion: The WeChat platform combined with the PBL teaching method is beneficial to improve the training effect of anesthesiology residents, stimulating autonomous learning ability, ensuring the effective practice of theoretical knowledge, and promoting them to move towards a higher standard of anesthesia skills.

Effect of remimazolam vs. propofol on hemodynamics during general anesthesia induction in elderly patients: Single-center, randomized controlled trial

The current study aimed to compare the effects between remimazolam and propofol on hemodynamic stability during the induction of general anesthesia in elderly patients.We used propofol at a rate of 60 mg/(kg·h)in the propofol group(group P)or remimazolam at a rate of 6 mg/(kg·h)in the remimazolam group(group R)for the induction.A processed electroencephalogram was used to determine whether the induction was successful and when to stop the infusion of the study drug.We measured when patients entered the operating room(T_(0)),when the induction was successful(T_(1)),and when before(T_(2))and 5 min after successful endotracheal intubation(T_(3)).We found that mean arterial pressure(MAP)was lower at T_(1–3),compared with T_(0) in both groups,but higher at T_(2) in the group R,whileΔMAP_(T0–T2) andΔMAP_(max) were smaller in the group R(ΔMAP_(T0–T2):the difference between MAP at time point T_(0) and T_(2),ΔMAP_(max):the difference between MAP at time point T_(0) and the lowest value from T_(0) to T_(3)).Cardiac index and stroke volume index did not differ between groups,whereas systemic vascular resistance index was higher at T_(1–3) in the group R.These findings show that remimazolam,compared with propofol,better maintains hemodynamic stability during the induction,which may be attributed to its ability to better maintain systemic vascular resistance levels.

Effects of sevoflurane on left ventricular function by speckletracking echocardiography in coronary bypass patients: A randomized trial

The present study aimed to dynamically observe the segmental and global myocardial movements of the left ventricle during coronary artery bypass grafting by transesophageal speckle-tracking echocardiography,and to assess the effect of sevoflurane on cardiac function.Sixty-four patients scheduled for the off-pump coronary artery bypass grafting were randomly divided into a sevoflurane-based anesthesia(AS)group and a propofolbased total intravenous anesthesia(AA)group.The AS group demonstrated a higher absolute value of left ventricular global longitudinal strain than that of the AA group at both T1(after harvesting all grafts and before coronary anastomosis)and T_(2)(30 min after completing all coronary anastomoses)(P<0.05).Moreover,strain improvement in the segment with the highest preoperative strain was significantly reduced in the AS group,compared with the AA group at both T1 and T_(2)(P<0.01).The flow of the left internal mammary artery-left anterior descending artery graft was superior,and the postoperative concentration of troponin T decreased rapidly in the AS group,compared with the AA group(P<0.05).Compared with total intravenous anesthesia,sevoflurane resulted in a significantly higher global longitudinal strain,stroke volume,and cardiac output.Sevoflurane also led to an amelioration in the condition of the arterial graft.Furthermore,sevoflurane significantly reduced strain improvement in the segmental myocardium with a high preoperative strain value.The findings need to be replicated in larger studies.

The Readability of Online Patient Education Materials from Major Anesthesiology Associations and the American Society of Anesthesiologists

Background: As much as 80% of US adults search online for health related information. The value of the information is limited by the patients’ ability to comprehend it. Despite the recommendation by the American Medical Association (AMA) to provide all patient education materials (PEMs) at a 6th grade reading level, many online sources do not conform. This study aims to evaluate the readability of PEMs from major online sources for anesthesiology. Methods: We determined the readability of PEMs from five major anesthesiology organizations and twelve brochures from the American Society of Anesthesiologists (ASA) using ten validated readability scales. PEMs from the various anesthesiology websites were compiled into a single word document for analysis. The twelve patient education brochures from the ASA were downloaded and analyzed separately. We then grouped the twelve documents into one sample and compared it to the other anesthesiology association websites. Results: All of the PEMs provided by the ASA were determined to be higher than a 6th grade reading level with nine being at a 12th grade reading level or above. The PEMs of the five major anesthesiology association websites were beyond the 6th grade reading level with four out of five at greater than the 12th grade reading level. Conclusion: The results showed that the readability of PEMs provided by five major anesthesiology associations and the ASA was beyond the 6th grade. Therefore, the PEMs with improved readability in anesthesiology are needed.

High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

AIM To examine whether high-flow nasal oxygen(HFNO) availability influences the use of general anesthesia(GA) in patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasound(EUS) and associated outcomes.METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras(era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era(era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P < 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3(P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3(P < 0.001) but not between eras 1 and 2(P = 0.028) or 1 and 3(P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation(P ≤ 0.007) as was the anesthesia-only time(P ≤ 0.001).CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.

Neuroendocrine,epigenetic,and intergenerational effects of general anesthetics

The progress of modern medicine would be impossible without the use of general anesthetics(GAs).Despite advancements in refining anesthesia approaches,the effects of GAs are not fully reversible upon GA withdrawal.Neurocognitive deficiencies attributed to GA exposure may persist in neonates or endure for weeks to years in the elderly.Human studies on the mechanisms of the long-term adverse effects of GAs are needed to improve the safety of general anesthesia but they are hampered not only by ethical limitations specific to human research,but also by a lack of specific biological markers that can be used in human studies to safely and objectively study such effects.The latter can primarily be attributed to an insufficient understanding of the full range of the biological effects induced by GAs and the molecular mechanisms mediating such effects even in rodents,which are far more extensively studied than any other species.Our most recent experimental findings in rodents suggest that GAs may adversely affect many more people than is currently anticipated.Specifically,we have shown that anesthesia with the commonly used GA sevoflurane induces in exposed animals not only neuroendocrine abnormalities(somatic effects),but also epigenetic reprogramming of germ cells(germ cell effects).The latter may pass the neurobehavioral effects of parental sevoflurane exposure to the offspring,who may be affected even at levels of anesthesia that are not harmful to the exposed parents.The large number of patients who require general anesthesia,the even larger number of their future unexposed offspring whose health may be affected,and a growing number of neurodevelopmental disorders of unknown etiology underscore the translational importance of investigating the intergenerational effects of GAs.In this mini review,we discuss emerging experimental findings on neuroendocrine,epigenetic,and intergenerational effects of GAs.

Tea polyphenols inhibit the growth and angiogenesis of breast cancer xenografts in a mouse model

Objective:To investigate the anti-angiogenic effect of tea polyphenols(TPS)on breast cancer and normal tissues in a mouse model.Methods:Breast cancer was successfully implanted into 48 BALB/c mice,which were then randomly divided into a TP oral gavage group,a TP local injection group,a ginsenoside Rg3 group,and a model control group according to a random number table.The tumor inhibitory rates of each group were calculated,while microvessel density(MVD)and the expression of vascular endothelial growth factor(VEGF),basic fibroblast growth factor(bFGF),and tissue inhibitor of metalloproteinase(TIMP-2)were detected by immunohistochemistry.Results:TPs could inhibit the growth of breast cancer xenografts in the mouse model.The tumor inhibition rates of the TP oral gavage and TP local injection groups were 37.43%and 40.94%,respectively.Compared with the model control group,MVD and VEGF and bFGF expression was downregulated(all P<.05),whereas TIMP-2 expression was elevated in the TP oral gavage and TP local injection groups(P=.015 and P=.032).TPs showed no significant effect on MVD and VEGF and TIMP-2 expression in the heart,brain,and kidney of the mouse model.Conclusion:TPs can restrict the growth of breast cancer by specifically inhibiting the angiogenesis of breast tumor tissue while having little effect on the normal tissue of important organs including the heart,brain,and kidney.

Effect of positive end-expiratory pressure ventilation on central venous pressure and intraoperative blood loss in patients undergoing laparoscopic hepatectomy

Objective:Tto investigate the effects of positive end-expiratory pressure(PEEP)ventilation on central venous pressure(CVP)and intraoperative blood loss in patients undergoing laparoscopic hepatectomy.Methods:46 cases of patients undergoing laparoscopic hepatectomy,25 cases of male,female 21 cases,ASAⅠ~Ⅲlevel,were randomly divided into two groups.In group A tidal volume was set to 6 ml/kg(Predicted Body Weight,PBW)and PEEP was set to 0 cmH2O.The tidal volume of group B was set as group A,PEEP was set to 8 cmH2O.CVP,MAP,and Ppeak were recorded in the supine position after intubation(T0),supine position after pneumoperitoneal(T1),anti-trendelenberg position after pneumoperitoneal(T2),supine position after surgery(T3),and Ddyn was calculated.The amount of nitroglycerin and the amount of blood loss were recorded.Results:Compared with group A,the CVP of group B was significantly increased at T1 and T2(P<0.05).Compared to T2 with T1 in group A and group B,CVP was decreased significantly(P<0.05).At T3,Cdyn in group B was significantly higher than that in group A(P<0.05).The amount of nitroglycerin in group B was significantly higher than that in group A(P<0.05).There was no significant difference in intraoperative fluid rehydration and blood loss between the two groups(P>0.05).Conclusion:PEEP with 8cmH2O can improve Ddyn in patients undergoing laparoscopic hepatectomy,but increased CVP.It requires more use of controlled low central venous pressure techniques to reduce intraoperative blood loss.

Treatments and limitations for methicillin-resistant Staphylococcus aureus: A review of current literature

Methicillin-resistant Staphylococcus aureus(MRSA)has remained a major threat to healthcare;in both hospital and community settings over the past five decades.With the current use of antibiotics for a variety of infections,including MRSA,emerging resistance is a major concern.Currently available treatments have restrictions limiting their use.These issues include,but are not limited to,side effects,cross-resistance,lack of understanding of pharmacokinetics and clinical pharmacodynamics,gradual increment in minimal inhibitory concentration over the period(MIC creep)and ineffectiveness in dealing with bacterial biofilms.Despite availability of various therapeutic options for MRSA,the clinical cure rates remain low with high morbidity and mortality.Given these challenges with existing treatments,there is a need for development of novel agents for MRSA.Along with prompt infection control strategies and strict implementation of antibiotic stewardship,cautious use of newer anti-MRSA agents will be of utmost importance.This article reviews the treatments and limitations of MRSA management and highlights the future path.

Comparison of Acoustic Respiration Rate, Impedance Pneumography and Capnometry Monitors for Respiration Rate Accuracy and Apnea Detection during GI Endoscopy Anesthesia

Study Objective: To assess the accuracy of respiration rate measurements and the ability to detect apnea by capnometry, impedance pneumography and a new method, acoustic respiration rate monitoring, in anesthetized patients undergoing gastrointestinal endoscopy procedures. Design: Prospective observational study. Setting: Endoscopy procedures laboratory. Patients: 98 patients scheduled for upper gastrointestinal endoscopy with propofol-based anesthesia. Interventions: Patients were monitored for respiration rate with acoustic respiration rate monitoring, capnometry and impedance pneumography and values were compared to the manual counting of breaths by observation of chest wall movements. Additionally, when any respiration rate monitor indicated a cessation of breathing for 30 seconds or greater, the presumed apnea was confirmed by direct observation of the patient for absence of chest wall movements. Measurements and Main Results: Bias and precision for respiration rate measurement was 0 ± 1.0 bpm for acoustic monitoring, 4.8 ± 15.1 bpm for capnometry and 0.4 ± 5.9 bpm for impedance pneumography. Sensitivity and specificity for detection of apnea was 73% and 93% for acoustic monitoring, 73% and 12% for capnometry and 45% and 93% for impedance pneumography. Conclusions: Acoustic respiration rate monitoring was found to be accurate for assessment of respiration rate and to have similar or better sensitivity and specificity for detection of apnea compared to capnometry and impedance pneumography in the setting of upper GI endoscopy.

Application of remimazolam transversus abdominis plane block in gastrointestinal tumor surgery

BACKGROUND Transversus abdominis plane block(TAPB)is a block of the abdominal afferent nerve fibers between the internal oblique muscle and the transverse abdominal muscle achieved with local anesthetics.It can effectively block the conduction of the anterior nerve of the abdominal wall and exert a good analgesic effect.However,the effect of combining the block with remimazolam on anesthesia in patients undergoing gastrointestinal tumor surgery is still unclear.AIM To examine the effects of combining TAPB with remimazolam on the stress response and postoperative recovery of gastrointestinal tumor surgery patients.METHODS A retrospective analysis was conducted on the clinical data of 102 individuals diagnosed with gastrointestinal malignancies who underwent laparoscopic surgery under general anesthesia between April 2020 and June 2023.The patients were categorized into a control group(n=51),receiving remimazolam for general anesthesia,and an observation group(n=51),receiving TAPB combined with remimazolam for general anesthesia.A comparison was made between both groups in terms of hemodynamic parameters,stress markers,pain levels,recovery quality,analgesic effects,and adverse reactions during the perioperative period.RESULTS The observation group had significantly higher heart rates at time points 1 min after induction and upon leaving the operating room than the control group(P<0.05).The mean arterial pressure at time point T1 in the observation group was significantly higher than that in the control group(P<0.05).Five minutes after extubation,the levels of the hormones adrenaline and noradrenaline in the observation group were considerably lower than those in the control group(P<0.05).At 12 h,24 h,and 48 h following surgery,the visual analog scale scores of the observation group were considerably lower than those of the control group(P<0.05).The observation group had shorter awakening and extubation times and lower Riker sedation-agitation scale scores than the control group(P<0.05).The observation group exhibited considerably fewer effective pump presses,lower fentanyl dosages,and lower incidences of rescue analgesia within 24 h following surgery than the control group(P<0.05).CONCLUSION The application effect of TAPB combined with remimazolam general anesthesia in anesthesia of patients undergoing gastrointestinal tumor surgery is good,which is helpful to promote faster recovery after operation.

Research Status of Preemptive Analgesia and its Application in Clinical Anesthesia

The most effective treatment for postoperative pain is to reduce it by preventing or reducing the sensitivity and sensory disturbance on the central nervous system during the operation,prolonging the pain-relief time and reducing the use of analgesics.Preemptive analgesia refers to the intervention of central neuraxis sensitization and peripheral sensitization to prevent the expansion and spread of pain,so as to achieve postoperative pain-relief.In postoperative patient-controlled analgesia,preemptive analgesia has become a common treatment method for anesthesiologists.However,the clinical specifications for advanced analgesia are still lacking.Based on this,this paper reviews the use of advanced analgesia drugs and their clinical applications.

Lactate:a prospective target for therapeutic intervention in psychiatric disease

Although antipsychotics that act via monoaminergic neurotransmitter modulation have considera ble therapeutic effect,they cannot completely relieve clinical symptoms in patients suffering from psychiatric disorde rs.This may be attributed to the limited range of neurotransmitters that are regulated by psychotropic drugs.Recent findings indicate the need for investigation of psychotropic medications that target less-studied neurotransmitte rs.Among these candidate neurotransmitters,lactate is developing from being a waste metabolite to a glial-neuronal signaling molecule in recent years.Previous studies have suggested that cerebral lactate levels change considerably in numerous psychiatric illnesses;animal experiments have also shown that the supply of exogenous la ctate exerts an antidepressant effect.In this review,we have described how medications targeting newer neurotransmitte rs offer promise in psychiatric diseases;we have also summarized the advances in the use of lactate(and its corresponding signaling pathways)as a signaling molecule.In addition,we have described the alterations in brain lactate levels in depression,anxiety,bipolar disorder,and schizophrenia and have indicated the challenges that need to be overcome before brain lactate can be used as a therapeutic target in psychopharmacology.

Artificial intelligence and computer simulation models in critical illness

Widespread implementation of electronic health records has led to the increased use of artificial intelligence(AI)and computer modeling in clinical medicine.The early recognition and treatment of critical illness are central to good outcomes but are made difficult by,among other things,the complexity of the environment and the often non-specific nature of the clinical presentation.Increasingly,AI applications are being proposed as decision supports for busy or distracted clinicians,to address this challenge.Data driven“associative”AI models are built from retrospective data registries with missing data and imprecise timing.Associative AI models lack transparency,often ignore causal mechanisms,and,while potentially useful in improved prognostication,have thus far had limited clinical applicability.To be clinically useful,AI tools need to provide bedside clinicians with actionable knowledge.Explicitly addressing causal mechanisms not only increases validity and replicability of the model,but also adds transparency and helps gain trust from the bedside clinicians for real world use of AI models in teaching and patient care.

Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit

BACKGROUND With the recent change in the definition(Sepsis-3 Definition)of sepsis and septic shock,an electronic search algorithm was required to identify the cases for data automation.This supervised machine learning method would help screen a large amount of electronic medical records(EMR)for efficient research purposes.AIM To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care patients.METHODS A supervised machine learning method was developed based on culture orders,Sequential Organ Failure Assessment(SOFA)scores,serum lactate levels and vasopressor use in the intensive care units(ICUs).The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical ICU.This was then validated in an independent cohort of 100 patients.We compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded reviewers.Disagreement was resolved by a critical care clinician.A SOFA score≥2 during the ICU stay with a culture 72 h before or after the time of admission was identified.Sepsis versions as V1 was defined as blood cultures with SOFA≥2 and Sepsis V2 was defined as any culture with SOFA score≥2.A serum lactate level≥2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 respectively.RESULTS In the derivation subset of 100 random patients,the final machine learning strategy achieved a sensitivity-specificity of 100%and 84%for Sepsis-1,100%and 95%for Sepsis-2,78%and 80%for Septic Shock-1,and 80%and 90%for Septic Shock-2.An overall percent of agreement between two blinded reviewers had a k=0.86 and 0.90 for Sepsis 2 and Septic shock 2 respectively.In validation of the algorithm through a separate 100 random patient subset,the reported sensitivity and specificity for all 4 diagnoses were 100%-100%each.CONCLUSION Supervised machine learning for identification of sepsis and septic shock is reliable and an efficient alternative to manual chart review.

Critical care practice in India:Results of the intensive care unit need assessment survey(ININ2018)

BACKGROUND A diverse country like India may have variable intensive care units(ICUs)practices at state and city levels.AIM To gain insight into clinical services and processes of care in ICUs in India,this would help plan for potential educational and quality improvement interventions.METHODS The Indian ICU needs assessment research group of diverse-skilled individuals was formed.A pan-India survey"Indian National ICU Needs"assessment(ININ 2018-I)was designed on google forms and deployed from July 23rd-August 25th,2018.The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories(UTs).In addition to emails and phone calls,social medial applications-WhatsApp™,Facebook™and LinkedIn™were used to remind and motivate providers.By completing and submitting the survey,providers gave their consent for research purposes.This study was deemed eligible for category-2 Institutional Review Board exempt status.RESULTS There were total 134 adult/adult-pediatrics ICU responses from 24(83%out of 29)states,and two(28%out of 7)UTs in 61 cities.They had median(IQR)16(10-25)beds and most,were mixed medical-surgical,111(83%),with 108(81%)being adult-only ICUs.Representative responders were young,median(IQR),38(32-44)years age and majority,n=108(81%)were males.The consultants were,n=101(75%).A total of 77(57%)reported to have 24 h in-house intensivist.A total of 68(51%)ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio.More than 80%of the ICUs were open,and mixed type.Protocols followed regularly by the ICUs included sepsis care,ventilator-associated pneumonia(83%each);nutrition(82%),deep vein thrombosis prophylaxis(87%),stress ulcer prophylaxis(88%)and glycemic control(92%).Digital infrastructure was found to be poor,with only 46%of the ICUs reporting high-speed internet availability.CONCLUSION In this large,national,semi-structured,need-assessment survey,the need for improved manpower including;in-house intensivists,and decreasing patient-tonurse ratios was evident.Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized.Additionally,subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Selective nerve block for the treatment of neuralgia in Kummell’s disease:A case report

BACKGROUND Neuralgia is frequently noted in patients with Kummell’s disease,and its mechanism is complex,rendering it challenging to treat.Percutaneous kyphoplasty(PKP)has been widely used to treat osteoporotic vertebral compression fractures with satisfactory outcomes.However,it is not optimal for managing severely collapsed vertebrae,as cement injection may not be feasible.This report describes the use of a selective nerve block for the treatment of neuralgia caused by severely collapsed vertebrae in a patient with Kummell’s disease.CASE SUMMARY In our patient,three vertebrae were involved.The collapse of T11 was particularly severe.After managing T8 and T9 using PKP,these two segments were effectively strengthened;consequently,back pain was significantly relieved.However,the structure and strength of T11 could not be effectively restored using a minimally invasive surgical method because there was little room for cement injection.This caused obvious neuralgia according to the postoperative status of the PKP.Thus,we performed selective nerve blocks for the treatment of neuralgia,which resulted in satisfactory outcomes.CONCLUSION Selective nerve block may be a possible therapeutic strategy for neuralgia due to severely collapsed vertebrae in Kummell’s disease.

A Patient with Trisomy 15 and Subglottic Tracheal Granuloma: Anesthetic Management for Emergency Rigid Bronchoscopy

Trisomy 15 is a rare genetic disorder presenting unique anesthetic challenges. This is a case of a patient with Trisomy 15 and unrepaired ventriculo-septal defect presented for emergent removal of a subglottic tracheal granuloma. Developed anesthetic plan allowed the patient to breathe spontaneously with a combination of inhalational and intravenous anesthetics. Our technique offered optimal operating conditions and adequate depth of anesthesia. The important points of the case include an understanding of the physical characteristics of a patient with Trisomy 15 and unrepaired ventriculo-septal defect and an anesthetic plan for emergent removal of an obstructing subglottic granuloma via rigid bronchoscopy.

Unexpected Increase in Arterial to End-Tidal CO₂Gradient in a Child Undergoing Embolization of MAPCAs

A 17-month-old infant with multiple aorto-pulmonary collateral arteries (MAPCAs) and pulmonary hypertension presented for diagnostic catheterization. On the day of the procedure, the infant was asymptomatic with oxygen saturation in the 90’s on 1.0 L/min O2 nasal cannula. His parents denied any recent illness. During the procedure, one coil was inadvertently embolized into the right lung resulting in markedly increased pulmonary artery pressures. The Pa-etCO2 gradient increased to 25 mmHg from a baseline of 2 mmHg. Therapy was initiated to reduce the PaCO2. The patient could not be weaned from mechanical ventilation due to elevated PA pressures.

A Case of Posttraumatic Cervical Dystonia Treated with OnabotulinumtoxinA

Cervical dystonia (CD) is a condition that typically presents with cervical muscle spasm, producing head tilt and cervical rotation. CD is most often idiopathic, however, in a small number of patients, CD occurs within one day to one year after mild to severe trauma. This type of CD is further classified as posttraumatic CD. OnabotulinumtoxinA (Botox) injections are considered to be a controversial treatment for posttraumatic CD and have produced variable result. This report describes the case of a 32-year-old female presenting with a two year history of posttraumatic CD and associated head, neck, and shoulder pain after obtaining a severe head injury during a motorcycle accident. OnabotulinumtoxinA was used to successfully treat her posttraumatic CD muscle spasms and associated chronic pain. Three months after her first and second ONA treatments, the patient reported at least 50% improvement in her overall pain symptoms and a noticeable reduction in cervical paraspinal muscle spasms.