Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke (CANVAS): Results of the CANVAS Pilot Randomized Controlled Trial

Background: The effect of choice of anesthesia on clinical outcome for endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) remains unclear. Methods: We conducted a pilot trial of 43 patients with acute anterior circulation ischemic stroke having EVT. Patients were randomly allocated to receive general anesthesia or conscious sedation. We documented the rate of recruitment and rate of conversion from conscious sedation to general anesthesia. In addition, we recorded the change in National Institute of Health stroke scale (NIHSS) on day 7, the rate of successful reperfusion and measured neurological function by certified researchers using modified Rankin Score (mRS 0 to 2) at 90 days. Results: The recruitment rate was 31.4% and majority of patients were excluded because of delay in hospital presentation and posterior circulation stroke. The rate of conversion from conscious sedation to general anesthesia was 18.2%. This was primarily related to excessive sedation and uncontrolled movement. Change in NIHSS score, rate of successful reperfusion and functional recovery were similar between groups. Conclusions: It was feasible to randomize AIS patients receiving either general anesthesia or conscious sedation for EVT. J.S. and F.L. contributed equally. Supported by the Beijing Municipal Administration of Hospitals Youth Program (code number: QML20150508), Ascent Plan (number: DFL20180502) Clinical Medicine Development of Special Funding Support (number: ZYLX201708) and China National key scientific research project (number: 2016YFC1301500). J.S., F.L., Y.P., Z.M., AW.G., M.T.V.C., and R.H.: helped with the study design and manuscript preparation. Y.P., and R.H.: equally contributed to the manuscript. J.S., F.L., Y.W., Y.Z., and Y.P.: involved in the data collection from neurosurgical anesthesia. L.Z. and Y.P.: helped with the data analyses. M.T.V.C. and R.H. are the members from the Editorial Board of Journal of Neurosurgical Anesthesiology. The remaining authors declare that they have nothing to disclose. Address correspondence to: Ruquan Han, MD, PhD, Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China (e-mail: ruquan.han@ccmu.edu.cn). Received July 24, 2018 Accepted October 22, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Retrospective Analysis of Perioperative Variables Associated With Postoperative Delirium and Other Adverse Outcomes in Older Patients After Spine Surgery

Background: The aim of this retrospective study was to identify perioperative variables predictive of the development of delirium in older surgical patients after spine surgery. Materials and Methods: We collected preoperative, intraoperative, and postoperative data on patients 65 years of age and above having spine surgery between July 1, 2015 and March 15, 2017. The primary outcome was the development of postoperative delirium. Data were analyzed using univariate and multivariable analysis. Results: Among the 716 patients included in this study 127 (18%) developed postoperative delirium. On multivariable analysis, independent predictors of postoperative delirium included older age (odds ratio [OR]=1.04; 95% confidence interval [CI], 1.00-1.09; P=0.048), American Society of Anesthesiologists physical status >2 (OR=1.89 [95% CI, 1.04-3.59]; P=0.042), metabolic equivalents of task

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Surgical outcome of jejunum-jejunum intussusception secondary to Rapunzel syndrome: a case report

Adult intestinal intussusception is a rare condition caused by the mechanical disruption of bowel motility. A bezoar is defined as indigestible material inside the gastrointestinal tract that develops into a t...

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Making a difference by changing health behaviors

As an alternative to a traditional cigarette, an electronic nicotine delivery system, or vaping, is becoming more popular around the globe. Over half of the world's population live in the 62 countries that have available mechanisms for vaping.^[1] In the case report, "Beliefs and reality of e-cigarette smoking," Menakuru et al report that an overwhelming 94% of 680 students said that e-cigarettes did not cause any harm to the body. They describe a patient who had never smoke a traditional cigarette. "[H]e admitted to smoking e-cigarettes throughout the day during his free time while driving, between meals and even during breaks at work…. His nicotine consumption would be about 192 mg/day." The patient lost his job and was unable to continue purchasing the necessary materials for vaping. As a result, the patient was diagnosed with nicotine withdrawal after presenting with "diaphoresis, restlessness, tachycardia, chills, nausea and a temperature of 38.3" which occurred after abrupt cessation of his smoking habits.

A study surveying marketing techniques for tobacco in countries across the globe, "detected substantially higher levels of tobacco marketing in the lower-income countries.^[2] The use is particularly pronounced among students.^[3] Despite some experts saying vaping is, "'95% safer'…. A BMJ report brought out the problems with the [claim, and]… can make one question [the experts'] scientific credibility." The case report quotes the multiple health risks associated with vaping, including the amount of nicotine, the inflammation present in the air was, and even toxic heavy metal exposure.

The World Health Organization Framework Convention on Tobacco Control (FCTC) released a report on electronic nicotine delivery systems.^[1] While the FCTC has long stood against traditional cigarettes, this report also took a strong stance on vaping. This is a method which is pushed by some as a healthy alternative to traditional tobacco, but its efficacy in stopping traditional cigarette use has never been shown. The FCTC invited all countries to combat the rapid expansion of vaping with education, forbidding sale to minors, limiting advertising, prosecuting false health claims and monitoring among other interventions.

The regulatory fight against tobacco has in many ways been successful in many locations. Vaping, however, presents a new public health challenge that many practitioners may not be prepared to face. As health care professionals, part of advocating for our patients is ensuring their safety against predatory corporations which would trade their life and health for financial gain. Political action, education and treatment all play roles this endeavor.

BMJ Case Reports invites authors to submit global health case reports that describe the effects of health behaviors. These cases could focus on:

• The factors contributing to these behaviors
• The perception and knowledge surrounding these behaviors
• Interventions that impact the behaviors of patients

Manuscripts may be submitted by students, physicians, nurses and allied health professionals to BMJ Case Reports at www.bmjcasereports.com. For more information, review our guidance on how to write a global health case report and look through our online collection

To read more about deleterious health behaviors at BMJ Case Reports, please review:

• Childhood obesity in Mexico: social determinants of health and other risk factors
• -Self-medication complicating pseudo membranous conjunctivitis
• Snorting the clivus away: an extreme case of cocaine-induced midline destructive lesion

To read more about health behaviors, and specifically nicotine use globally from other cited sources, please review:

^[1] World Health Organization. Provisional agenda item 4.4.2 Conference of the Parties to the WHO Framework Convention on Tobacco Control. Moscow, Russian Federation. Sixth Session, October 2014.

^[2]Savell E, Gilmore AB, Sims M, Mony PK, Koon T, Yusoff K, Lear SA, Seron P, Ismail N, Calik K, Rosengren A. The environmental profile of a community's health: a cross-sectional study on tobacco marketing in 16 countries. Bulletin of the World Health Organization. 2015;93:851-61.

^[3]Murthy VH. E-cigarette use among youth and young adults. JAMA pediatr 2017; 171:209.

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