IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H 2 O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H 2 O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO 2 Յ92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

68 Ga-DOTATATE PET/CT scanning is a widely accepted method for imaging of neuroendocrine tumors. This cross-sectional study was performed to review the first 8 y of patient data from a large 68 Ga-DOTATATE PET/CT database in order to establish the impact of the modality on patient treatment and survival. Methods: Demographic data, clinical outcome, survival, and change in management after 68 Ga-DOTATATE PET/CT were evaluated. Results: Between May 2005 and August 2013, 1,258 68 Ga-DOTATATE PET/CT scans were obtained in 728 patients with confirmed or suspected neuroendocrine tumors. In most patients, the primary site was located in the midgut (26.4%). Analysis of NET grading in patients with known histopathologic data revealed that 35.7% had NET grade G1, 12.2% G2, and 8.7% G3. The most common indications for 68 Ga-DOTATATE PET/CT were follow-up (24.4%) and initial tumor staging (23.4%). Of the 1,258 68 Ga-DOTATATE PET/CT scans completed, 75.7% were positive and 24.3% negative; there were 14 false-positive and 29 false-negative scans. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97%, 95.1%, 96.6%, 98.5%, and 90.4%, respectively. In 40.9% of patients, the treatment plan was changed after the scans, owing mainly to new, unexpected findings. Statistically significant differences in survival were shown between patients with G1, G2, and G3 grade tumors (P , 0.0001) and also between patients with bone metastasis versus patients with soft-tissue metastasis (P , 0.0001). Conclusion: 68 Ga-DOTATATE PET/CT scanning is safe and influences management in a large proportion of patients. Prognosis was dependent on tumor grade, and the presence of bone metastasis was associated with worse overall survival.

Abstract.The UV-LED mission demonstrates the precise control of the potential of electrically isolated test masses that is essential for the operation of space accelerometers and drag-free sensors. Accelerometers and drag-free sensors were and remain at the core of geodesy, aeronomy and precision navigation missions as well as gravitational science experiments and gravitational wave observatories. Charge management using photoelectrons generated by the 254nm UV line of Hg was first demonstrated on Gravity Probe B and is presently part of the LISA Pathfinder technology demonstration. The UV-LED mission and prior ground testing demonstrates that AlGaN UVLEDs operating at 255 nm are superior to Mercury vapor lamps because of their smaller size, lower power draw, higher dynamic range, and higher control authority. We show flight data from a small satellite mission on a Saudi Satellite that demonstrates AC charge control (UV-LEDs and bias are AC modulated with adjustable relative phase) between a spherical test mass and its housing. The result of the mission is to bring the UV-LED device Technology Readiness Level (TRL) to TRL-9 and the charge management system to TRL-7. We demonstrate the ability to control the test mass potential on an 89 mm diameter spherical test mass over a 20 mm gap in a drag-free system configuration. The test mass potential was measured with an ultra-high impedance contact probe. Finally, the key electrical and optical characteristics of the UV-LEDs showed less than 7.5% change in performance after 12 months in orbit.

Objective:This survey aimed to assess both the extent of practice and need for training in regional anesthesia among anesthesiologists in Saudi Arabia in 2012.Methods:We distributed an electronic survey among 382 anesthesiologists attending the bi-annual meetings of the Saudi Anesthetic Association, enquiring about their practice in regional anesthesia. Questions concerned the practice of regional anesthesia, use of ultrasound guidance, and the need for training workshops.Results:The response rate of anesthetists was 55.2% with most of them were males and had mean age of 25-50 years. Most anesthesiologists (88.2%) were practicing regional anesthesia frequently in the operating rooms (75.3%) rather than designated block room. From the respondents, only 14.2% did fellowship in regional anesthesia, 21.8% and 18.5% were using ultrasound and nerve stimulation guidance, respectively, 11.4% received formal training, and 86.3% were willing to attend training workshops on regional anesthesia. There was a significant negative correlation between the ultrasound users and their institutional positions (r=−0.191) (P=0.026).Conclusions:We believe that more could be done to improve the practice of regional anesthesia in the Kingdom of Saudi Arabia, including the implementation of formal training and conduction of more frequent specialized courses/workshops in the field of regional anesthesia with special reference to ultrasound regional anesthesia blockade techniques.

Background: Inadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The aim of this study to investigate whether critical respiratory events (CREs) that described in a modified Murphy’s criteria are significantly associated with residual neuromuscular blockade (RNMB).Method: A prospective cohort study from January to March 2017 from a tertiary hospital from Saudi Arabia for thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) were enrolled in the study. The Mann-Whitney U tests, Chi-Square tests and Independent-Samples T tests were used. The Train-of-four (TOF) ratios were measured upon arrival in the PACU by using Acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data, and the occurrence of postoperative CREs in the PACU were recorded.Results: 26 (86.7%) patients out of thirty in the study has received Rocuronium as NMBDs while Neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p= 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p= 0.046) and in patients with shorter duration of surgery (p= 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (P= 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (P= 0.047).Conclusion: This research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, optimal antagonism of neuromuscular blockade and routine quantitative neuromuscular monitoring are recommended to reduce the incidence of RNMB.