Air versus saline in the loss of resistance technique for identification of the epidural space

BackgroundThe success of epidural anaesthesia depends on correct identification of the epidural space. For several decades, the decision of whether to use air or physiological saline during the loss of resistance technique for identification of the epidural space has been governed by the personal experience of the anaesthesiologist. Epidural block remains one of the main regional anaesthesia techniques. It is used for surgical anaesthesia, obstetrical analgesia, postoperative analgesia and treatment of chronic pain and as a complement to general anaesthesia. The sensation felt by the anaesthesiologist from the syringe plunger with loss of resistance is different when air is compared with saline (fluid). Frequently fluid allows a rapid change from resistance to non-resistance and increased movement of the plunger. However, the ideal technique for identification of the epidural space remains unclear.ObjectivesTo evaluate the efficacy and safety of both air and saline in the loss of resistance technique for identification of the epidural space.To evaluate complications related to the air or saline injected.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE, EMBASE and the Latin American and Caribbean Health Science Information Database (LILACS) (from inception to September 2013). We applied no language restrictions. The date of the most recent search was 7 September 2013.Selection criteriaWe included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) on air and saline in the loss of resistance technique for identification of the epidural space.Data collection and analysisTwo review authors independently assessed trial quality and extracted data.Main resultsWe included in the review seven studies with a total of 852 participants. The methodological quality of the included studies was generally ranked as showing low risk of bias inmost domains, with the exception of one study, which did not mask participants. We were able to include data from 838 participants in the meta-analysis. We found no statistically significant differences between participants receiving air and those given saline in any of the outcomes evaluated: inability to locate the epidural space (three trials, 619 participants) (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.33 to 2.31, low-quality evidence); accidental intravascular catheter placement (two trials, 223 participants) (RR 0.90, 95% CI 0.33 to 2.45, low-quality evidence); accidental subarachnoid catheter placement (four trials, 682 participants) (RR 2.95, 95% CI 0.12 to 71.90, low-quality evidence); combined spinal epidural failure (two trials, 400 participants) (RR 0.98, 95% CI 0.44 to 2.18, low-quality evidence); unblocked segments (five studies, 423 participants) (RR 1.66, 95% CI 0.72 to 3.85); and pain measured by VAS (two studies, 395 participants) (mean difference (MD) -0.09, 95% CI -0.37 to 0.18). With regard to adverse effects, we found no statistically significant differences between participants receiving air and those given saline in the occurrence of paraesthesias (three trials, 572 participants) (RR 0.89, 95% CI 0.69 to 1.15); difficulty in advancing the catheter (two trials, 227 participants) (RR 0.91, 95% CI 0.32 to 2.56); catheter replacement (two trials, 501 participants) (RR 0.69, 95% CI 0.26 to 1.83); and postdural puncture headache (one trial, 110 participants) (RR 0.83, 95% CI 0.12 to 5.71).Authors' conclusionsLow-quality evidence shows that results do not differ between air and saline in terms of the loss of resistance technique for identification of the epidural space and reduction of complications. Applicability might be compromised, as most of the results described in this review were obtained from parturient patients. This review underlines the need to conduct well-designed trials in this field.

A MICROSTRAIN COMPARISON OF PASSIVELY FITTING SCREW-RETAINED AND CEMENTED TITANIUM FRAMEWORKS

Statement of problem. An imprecise fit between frameworks and supporting dental implants in loaded protocols increases the strain transferred to the periimplant bone, which may impair healing or generate microgaps.Purpose. The purpose of this study was to investigate the microstrain between premachined 1-piece screw-retained frameworks (group STF) and screw-retained frameworks fabricated by cementing titanium cylinders to the prefabricated framework (group CTF). This procedure was developed to correct the misfit between frameworks and loaded implants.Material and methods. Four internal hexagon cylindrical implants were placed 10 mm apart in a polyurethane block by using the surgical guides of the corresponding implant system. Previously fabricated titanium frameworks (n=10) were divided into 2 groups. In group STF, prefabricated machined frameworks were used (n=5), and, in group CTF, the frameworks were fabricated by using a passive fit procedure, which was developed to correct the misfit between the cast titanium frameworks and supporting dental implants (n=5). Both groups were screw-retained under torque control (10 Ncm). Six strain gauges were placed on the upper surface of the polyurethane block, and 3 strain measurements were recorded for each framework. Data were analyzed with the Student t test (alpha=.05).Results. The mean microstrain values between the framework and the implants were significantly higher for group STF (2517 me) than for group CTF (844 me) (P<.05).Conclusions. Complete-arch implant frameworks designed for load application and fabricated by using the passive fit procedure decreased the strain between the frameworks and implants more than 1 piece prefabricated machined frameworks.

Analysis of Structural Integrity Using an ARTMAP-Fuzzy Artificial Neural Network

This paper presents the application of artificial neural networks in the analysis of the structural integrity of a building. The main objective is to apply an artificial neural network based on adaptive resonance theory, called ARTMAP-Fuzzy neural network and apply it to the identification and characterization of structural failure. This methodology can help professionals in the inspection of structures, to identify and characterize flaws in order to conduct preventative maintenance to ensure the integrity of the structure and decision-making. In order to validate the methodology was modeled a building of two walk, and from this model were simulated various situations (base-line condition and improper conditions), resulting in a database of signs, which were used as input data for ARTMAP-Fuzzy network. The results show efficiency, robustness and accuracy.

O número de técnicos e técnicas que comandam equipes masculinas e femininas

It is known that gymnastics and sports, for the most part, were made by men for men, and its practice was almost exclusively for males, especially until the First World War. Vestiges of this strong male influence in sports still remain to this day, especially in leadership positions. It is clear that most sports, both male and female, are mostly coached by men. Thus, this study aimed to examine, through quantiqualitative research, the number of women and men who lead male and female volleyball, basketball and soccer elite teams, participating in the most important national championships, and the number of men and women graduated in physical education courses in Brazil in order to check a possible relationship between the low number of women working as a coach and the percentage of women graduated in physical education. For the acquisition of data, Internet searches were made on the sites of confederations, leagues and sports leagues selected for the study, and on the site of the National Institute of Educational Studies Anísio Teixeira (INEP). It was identified that the total number of graduates from 1995 to 2008 was 192,707, with 99,869 men and 92,838 women, showing a balance between these numbers, which did not happen with the numbers of male and female coaches. The data indicated that no women worked as a coach in male and female volleyball teams in the seasons 2006 to 2010, no woman worked as a coach in the male basketball teams in the seasons from 2000 to 2010, and only an average of 1.67 women led female basketball teams in the seasons 1998 to 2010, and no woman has ever worked as a coach for male soccer teams, while only an average of 2.67 women acted as a coach of female soccer teams. The difference between the number of men and women graduated in physical education is small and does not justify the low ...(Complete abstract click electronic access below)

Merleau-Ponty e a condição do natural em nós

In this paper, the aim is to highlight and analyze certain moments in the work of Merleau-Ponty when discussions took place about the condition of the natural in us. We mainly focus on the observed opposition between the evolutionist viewpoint adopted in The structure of Behavior and the perspective in the Phenomenology of Perception, based on the body as expression. We also look at studies on infantile prematuration and mention the characterization of the human body in the philosopher’s courses on the notion of nature. We underline the expressive dimension of the natural in us, which emerges from Merleau-Ponty’s formulations. In addition, we evidence the importance of psychoanalysis in the Merleau-Ponty’s treatment of the corporeity problem.

Dendrimer nanocarriers for transport modulation across models of the pulmonary epithelium

The purpose of this study was to determine the effect of PEGylation on the interaction of poly(amidoamine) (PAMAM) dendrimer nanocarriers (DNCs) with in vitro and in vivo models of the pulmonary epithelium. Generation-3 PAMAM dendrimers with varying surface densities of PEG 1000 Da were synthesized and characterized. The results revealed that the apical to basolateral transport of DNCs across polarized Calu-3 monolayers increases with an increase in PEG surface density. DNC having the greatest number of PEG groups (n = 25) on their surface traversed at a rate 10-fold greater than its non-PEGylated counterpart, in spite of their larger size. This behavior was attributed to a significant reduction in charge density upon PEGylation. We also observed that PEGylation can be used to modulate cellular internalization. The total uptake of PEG-free DNC into polarized Calu-3 monolayers was 12% (w/w) vs 2% (w/w) for that with 25 PEGs. Polarization is also shown to be of great relevance in studying this in vitro model of the lung epithelium. The rate of absorption of DNCs administered to mice lungs increased dramatically when conjugated with 25 PEG groups, thus supporting the in vitro results. The exposure obtained for the DNC with 25PEG was determined to be very high, with peak plasma concentrations reaching 5 mu gmL(-1) within 3 h. The combined in vitro and in vivo results shown here demonstrate that PEGylation can be potentially used to modulate the internalization and transport of DNCs across the pulmonary epithelium. Modified dendrimers thereby may serve as a valuable platform that can be tailored to target the lung tissue for treating local diseases, or the circulation, using the lung as pathway to the bloodstream, for systemic delivery.

Index of thermal stress for cows (ITSC) under high solar radiation in tropical environments

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