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Normal Values of High-resolution Manometry Parameters With Provocative Moves.
001). The number of patients who required opioid medication within 24 h of discharge was significantly reduced in the enhanced recovery cohort (41.1% vs 74.6%, P  less then 0.001). There were no significant differences in average pain scores (1.6 vs 1.9, P=0.037). CONCLUSIONS The implementation of an enhanced recovery program for cesarean delivery was associated with a significant reduction in postoperative opioid consumption throughout hospitalization, with average pain scores remaining less then 2. Implementation of this program was also associated with an increase in the number of patients who were opioid-free 24 h prior to discharge. BACKGROUND The effect that the route of maternal fentanyl administration has on placental transfer of drug to the neonate is not well studied. Plasma concentration ratios are an indicator of fetal exposure, relative to the mother. METHOD A cohort study (n=30) was conducted to measure fentanyl concentrations in maternal plasma, and arterial and venous cord blood, among women administered either intranasal or subcutaneous fentanyl for labour pain relief. Maternal and cord blood samples were collected within 30 min of birth to determine the fentanyl plasma concentration and to assess relative neonatal exposure. Neonatal outcomes were assessed by Apgar scores, need for resuscitation and nursery admission. The study was registered as ACTRN12618001012268. RESULTS Thirty paired samples were obtained from healthy parturients with uncomplicated term pregnancies. Highest observed umbilical venous and arterial concentrations were 0.71 ng/mL and 0.56 ng/mL, respectively, and fetal to maternal fentanyl plasma concentration ratios ranged between 0.23 and 0.73, indicating low fetal exposure. While the total intranasal fentanyl dose administered was significantly higher than the subcutaneous fentanyl dose, this did not result in a higher fetal to maternal ratio. All neonates in both groups had 5-min Apgar scores >7, two neonates required short-term stimulation and oxygen (unrelated to fentanyl) and no neonate was admitted to the nursery. CONCLUSION This study is the first to examine fetal and maternal fentanyl concentrations after subcutaneous administration. This research supports the safe use of fentanyl for labour analgesia for women. Exercise-associated hyponatremia (EAH) is defined by a serum or plasma sodium concentration below the normal reference range of 135 mmol·L-1 that occurs during or up to 24 h after prolonged physical activity. It is reported to occur in individual physical activities or during organized endurance events conducted in environments in which medical care is limited and often not available, and patient evacuation to definitive care is often greatly delayed. Rapid recognition and appropriate treatment are essential in the severe form to increase the likelihood of a positive outcome. To mitigate the risk of EAH mismanagement, care providers in the prehospital and in hospital settings must differentiate from other causes that present with similar signs and symptoms. EAH most commonly has overlapping signs and symptoms with heat exhaustion and exertional heat stroke. mTOR inhibitor Failure in this regard is a recognized cause of worsened morbidity and mortality. In an effort to produce best practice guidelines for EAH management, the Wilderness Medical Society convened an expert panel in May 2018. The panel was charged with updating the WMS Practice Guidelines for Treatment of Exercise-Associated Hyponatremia published in 2014 using evidence-based guidelines for the prevention, recognition, and treatment of EAH. Recommendations are made based on presenting with symptomatic EAH, particularly when point-of-care blood sodium testing is unavailable in the field. These recommendations are graded on the basis of the quality of supporting evidence and balanced between the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. INTRODUCTION "Critical separation" is a simple method for spacing searchers intended to produce a predictable probability of detection (POD). A more precise method, based on effective sweep width (W), has been adopted only slowly. Accurate PODs are critical in planning priorities in future operational periods. Therefore, it would be useful to know what POD a critical separation determination actually produces. METHODS Detection ranges (Rd) were measured on high- and low-visibility adult mannequins (stuffed Tyvek suits of varying colors) and a red helmet detected by 6 searcher volunteers. Conversion factors previously described in the literature were used to convert Rds into predicted Ws and the previously described logit model to convert Ws into PODs. RESULTS The Rds were 26±6 m (mean±SD) for the high-visibility mannequin, 15±5 m for the low-visibility mannequin, and 24±6 m for the helmet used in the critical separation determination. The predicted Ws were 47±15 m, 16±8 m, and 42±14 m, respectively. Critical separation would therefore result in predicted PODs of 67±17% or 32±16% for nonresponsive adults in high- versus low-visibility clothing. CONCLUSIONS Critical separation is a simple, quick way to array searchers in the field. The current study suggests that the value of critical separation in producing the 50% target POD will depend on the whether the search object used for the critical separation determination has a similar detectability/W to the actual target of the search effort. Still, the results from a critical separation determination may offer more predictability and reliability than the common practice of POD estimation by team leaders. INTRODUCTION Ultramarathon runners commonly endure musculoskeletal pain during endurance events. However, the effect of pain coping skills on performance has not been examined. METHODS A prospective observational study during three 250 km (155 mi), 6 stage ultramarathons was conducted. Finish line surveys were completed after each of the four 40 km (25 mi) and one 80 km (50 mi) stages of racing. Variables gathered included pain intensity, pain coping strategy use, pain interference, finishing position (quintile), and successful race completion. RESULTS A total of 204 participants (age 41.4±10.3 y; 73% male) reported average pain intensity of 3.9 (±2.0 SD) and worst pain intensity of 5.3 (±2.3) on a 0 to 10 scale. They used greater adaptive pain coping strategies (3.0±1.3) relative to maladaptive strategies (1.3±1.1). Worst pain and pain interference increased over each stage of the race for all runners (P less then 0.001), with worst pain being significantly different by finishing status (P=0.02). Although all runners endured increased pain and interference, the nonfinishers (28 [14%]) had significantly greater differences in changes in pain intensity (P less then 0.
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