Search Results (221)

Background and Objectives: Vaginal natural orifice transluminal endoscopic surgery, vNOTES, has become an increasingly preferred minimally invasive option for benign hysterectomy. General anesthesia is still the routine choice, yet regional methods such as combined spinal epidural anesthesia may support a smoother postoperative course. Although the use of vNOTES is expanding, comparative information on anesthetic approaches remains limited, and its unique physiologic setting requires dedicated evaluation. To compare combined spinal epidural anesthesia with general anesthesia for benign vNOTES hysterectomy, focusing on postoperative nausea and vomiting, recovery quality, and intraoperative physiologic safety. Materials and Methods: This retrospective cohort study was conducted in a single center and identified women who underwent benign vNOTES hysterectomy between March 2024 and August 2025 from electronic medical records. Participants received either combined spinal epidural anesthesia or general anesthesia according to routine clinical practice. All patients were managed within an enhanced recovery pathway that incorporated standardized analgesia and prophylaxis for postoperative nausea and vomiting. The primary outcome was the incidence of postoperative nausea and vomiting during the first day after surgery. Secondary outcomes included time to discharge from the recovery unit, pain scores at set postoperative intervals, early functional recovery, patient satisfaction and physiologic parameters extracted from intraoperative monitoring records. Analyses were performed according to the anesthesia group documented in the medical files. Results: One hundred forty patients met inclusion criteria and were included in the analysis. Combined spinal epidural anesthesia was linked to a lower incidence of postoperative nausea and vomiting, a shorter stay in the post-anesthesia care unit, and reduced pain scores in the first 24 h (adjusted odds ratio 0.32, ninety five percent confidence interval 0.15 to 0.68). Early ambulation and oral intake were reached sooner in the combined spinal epidural group, with higher overall satisfaction also noted. Adherence to ERAS elements was similar between groups, with no meaningful differences in early feeding, mobilization, analgesia protocols or PONV prophylaxis. During the procedure, combined spinal epidural anesthesia produced more episodes of hypotension and bradycardia, while general anesthesia was linked to higher airway pressures and lower oxygen saturation. Complication rates within the first month were low in both groups. Conclusions: In this observational cohort study, combined spinal epidural anesthesia was associated with lower postoperative nausea, earlier recovery milestones and greater patient comfort compared with general anesthesia. Hemodynamic instability occurred more often with neuraxial anesthesia but was transient and manageable. While these findings point to potential recovery benefits for some patients, the observational nature of the study and the modest scale of the differences necessitate a cautious interpretation. They should be considered exploratory rather than definitive. The choice of anesthesia should therefore be individualized, weighing potential recovery benefits against the risk of transient hemodynamic effects. Larger and more diverse studies are needed to better define patient selection and clarify the overall risk benefit balance. These findings should be interpreted cautiously and viewed as hypothesis-generating rather than definitive evidence supporting one anesthetic strategy over another. Full article

At Animals Asia’s Vietnam Bear Rescue Center (VBRC), 40% of the current population has been diagnosed with systemic hypertension. Systemic hypertension lesions have led to fatal consequences in the form of aortic aneurysm and rupture. Historically, veterinarians were only able to diagnose systemic hypertension by identifying validated secondary structural heart and retinal lesions during annual health checks of anesthetized bears. In 2021, the VBRC began training bears for cooperative conscious blood pressure measurements to increase monitoring frequency and expedite the diagnosis of systemic hypertension in affected bears. The objective of this study was to evaluate a noninvasive method of blood pressure measurement in trained, cooperative Asiatic black bears. Indirect blood pressure measurements, using the oscillometric technique, were validated with direct arterial measurements in nine bears (6 male, 3 female, ages 13–22 years) undergoing anesthesia for annual health checks. Eleven trained bears at the VBRC without secondary lesions of systemic hypertension (6 male, 5 female, ages 7–23 years) were used to develop normal systolic ranges for Asiatic black bears using the indirect technique. Mean blood pressure measurements for this group of trained bears (n = 11) were 180.65 +/− 37 mmHg (95% CI: 126–255) systolic. These results suggest that indirect blood pressures may be a useful tool to monitor blood pressure in cooperative conscious bears at the VBRC. Full article

Artificial intelligence (AI) is rapidly transforming anesthesiology practice across perioperative settings. This review explores the evolution and implementation of hybrid decision-making models that integrate AI capabilities with human clinical expertise. From historical foundations to current applications, we examine how machine learning algorithms, deep learning networks, and big data analytics are enhancing anesthetic care. Key applications include perioperative risk prediction, AI-assisted patient education, automated analysis of clinical records, airway management support, predictive hemodynamic monitoring, closed-loop anesthetic delivery systems, and pain management optimization. In procedural contexts, AI demonstrates promising utility in regional anesthesia through anatomical structure identification and needle navigation, monitoring anesthetic depth via EEG analysis, and improving quality control in endoscopic sedation. Educational applications include intelligent simulators for procedural training and academic productivity tools. Despite significant advances, implementation challenges persist, including algorithmic bias, data security concerns, clinical validation requirements, and ethical considerations regarding AI-generated content. The optimal integration model emphasizes a complementary approach where AI augments rather than replaces clinical judgment—combining computational efficiency with the irreplaceable contextual understanding and ethical reasoning of the anesthesiologist. This hybrid paradigm reinforces the anesthesiologist’s leadership role in perioperative care while enhancing safety, precision, and efficiency through technological innovation. As AI integration advances, continued emphasis on algorithmic transparency, rigorous clinical validation, and human oversight remains essential to ensure that these technologies enhance rather than compromise patient-centered anesthetic care. Full article

Background/Objectives: Spinal anesthesia (SA) for cesarean section and epidural analgesia (EA) for vaginal delivery induce hemodynamic changes that may compromise maternal and fetal safety. In this observational, hypothesis-generating study, we used impedance cardiography (ICG) to characterize maternal hemodynamic responses to EA for labor versus SA for cesarean delivery and to describe hemodynamic profiles associated with commonly used local anesthetic and vasopressor regimens. Methods: In this observational study, 132 women at term were included (52 with epidural analgesia (EA), 80 with spinal anesthesia (SA)). Hemodynamic parameters were measured using the ICON electrical cardiometry monitor (Osypka Medical GmbH). ICON and oscillometric blood pressure (BP) monitoring captured cardiac index (CI), stroke volume (SV), heart rate (HR), systemic vascular resistance index (SVRI), and thoracic fluid content (TFC) at T0 (baseline), approximately 5 and approximately 10 min, skin incision, delivery, and oxytocin administration. Results: CI remained stable and comparable between EA and SA (3.9 ± 0.6 vs. 3.9 ± 0.6 L/min/m²; p = 0.530). SV was higher in EA (85.1 ± 11.3 vs. 78.1 ± 9.7 mL; p < 0.001), whereas HR was higher in SA (92.2 ± 12.9 vs. 85.8 ± 12.5 bpm; p = 0.009). In EA, ropivacaine and bupivacaine showed similar hemodynamic profiles. Within the SA cohort, women managed with phenylephrine infusion had lower CI and HR but higher MAP and SVRI compared with those receiving ephedrine boluses, consistent with the expected pharmacodynamic profiles of these agents. Conclusions: ICG was feasible and provided dynamic, noninvasive estimates of maternal cardiovascular adaptation during obstetric anesthesia. In this non-randomized, exploratory cohort, descriptive differences in hemodynamic profiles between vasopressor strategies were more pronounced than between local anesthetics. Phenylephrine-based management showed a pattern of higher BP and SVRI but lower CI and HR, whereas ephedrine-based management tended to preserve CI through chronotropic effects. Full article

Background: Quantifying intraoperative nociceptive responses under general anesthesia remains challenging, particularly during complex procedures such as spinal surgery. The Nociception Level (NoL) index is a multiparametric tool designed to reflect the dynamic balance between nociception and analgesia in anesthetized patients. This study aimed to evaluate NoL fluctuations during predefined phases of spinal surgery and assess their relationship to anesthetic administration. Methods: This prospective observational study enrolled 44 adult patients undergoing lumbar discectomy, laminectomy, or spinal fusion under remifentanil–propofol anesthesia. Continuous NoL monitoring was performed using the PMD100™ system. Sixteen anatomically and procedurally defined surgical phases were analyzed. The primary outcome was the mean NoL value in each phase. The secondary outcome was the association between NoL values and intraoperative infusion rates of remifentanil and propofol. Repeated-measures ANOVA with Bonferroni correction was used for phase comparisons. Results: Mean NoL values remained within the target range (10–25) in most phases. However, significant elevations were observed during pedicle screw insertion (mean 27.9, SD ± 17.7), cage insertion (27.6, SD ± 10.5), and flavectomy (28.0, SD ± 27.0), indicating increased nociceptive burden. The lowest NoL values occurred during skin closure (16.6, SD ± 11.2) and discectomy (18.0, SD ± 2.8). Propofol and remifentanil infusion rates remained within standard clinical ranges but were slightly elevated during high-NoL phases. Conclusions: Despite standardized anesthesia, distinct nociceptive peaks were observed during specific stages of spinal surgery. These findings suggest that NoL monitoring may help identify high-nociception phases and guide tailored analgesic strategies. Future randomized trials are warranted to assess whether protocolized NoL-guided anesthesia improves intraoperative management and postoperative outcomes. Full article

Tricuspid atresia (TA) is a cyanotic congenital heart defect defined by agenesis of the tricuspid valve and resultant right ventricular hypoplasia, representing 1.4–2.9% of congenital heart disease. Survival depends on interatrial and interventricular shunts that permit systemic and pulmonary blood flow, with staged surgical palliation culminating in the Fontan procedure. While surgical advances have improved long-term outcomes, Fontan circulation remains a delicate physiology characterized by preload dependence, elevated pulmonary vascular resistance, chronic venous hypertension, and a prothrombotic state. These features predispose patients to arrhythmias, lymphatic complications, hepatic congestion, and progressive circulatory failure. For anesthesiologists, perioperative management of TA and Fontan patients is uniquely complex. Anesthetic considerations include meticulous preload optimization, modulation of systemic and pulmonary vascular resistance, and ventilatory strategies that minimize adverse effects on venous return. Additional challenges include the high risk of air embolism, individualized anticoagulation needs, and hemodynamic sensitivity to patient positioning. Preoperative evaluation with echocardiography and electrocardiography provides critical insight into anatomy and physiology, while intraoperative planning must emphasize goal-directed fluid management, careful agent selection, and tailored ventilation. Postoperatively, vigilant monitoring, effective pain control, and prevention of complications are essential. This review synthesizes classification systems, pathophysiology, and the evolution of surgical palliation, while emphasizing anesthetic principles for the perioperative care of patients with TA and Fontan circulation. As survival improves and the population of Fontan patients expands, a nuanced understanding of this physiology is essential for optimizing outcomes across cardiac and non-cardiac surgical settings. Full article

Ethyl chloride, a volatile anesthetic with high abuse potential, remains forensically undercharacterized postmortem. In an inhalation model (n = 30), male Wistar rats were exposed to 86,000 ppm ethyl chloride under real-time PID monitoring; blood, lung, liver and brain (plus exploratory adipose, kidney, muscle) were sampled at 0, 2, 4, 6 and 12 h postmortem. A matrix-matched HS-GC-FID method was validated (Eurochem): linearity (R² = 0.9947–0.9965), LOD 0.01–0.02 ng/μL, LOQ 0.04–0.06 ng/μL, precision RSD 3.9–5.1%, recovery 90–104%, full selectivity against common volatiles. Lung yielded the highest concentrations overall; a significant decline occurred in lung between 2 h and 4 h (Pillai’s Trace p = 0.034). Concentrations became increasingly irregular ≥6 h across tissues. Early autopsy sampling, preferably within ≤6 h, optimizes ethyl chloride detectability. The validated matrix-matched HS-GC-FID protocol provides a cost-effective, robust alternative to MS platforms for volatile screening in routine forensic practice and supports prioritizing lung for analysis. Full article

This study evaluated the effects of varying medetomidine doses on a tiletamine-zolazepam and tramadol anesthetic combination in dogs. The objective was to assess how medetomidine influences anesthesia depth, cardiovascular function, and recovery quality. Dogs were assigned to one of three treatment groups: tiletamine-zolazepam and tramadol without medetomidine (TZT), additional 10 µg/kg medetomidine (TZTM10), or additional 20 µg/kg medetomidine (TZTM20). Each dog received an intramuscular injection of 0.1 mL/kg of the designated solution. The formulation for TZT contained 25 mg/mL tiletamine and zolazepam and 40 mg/mL tramadol, while TZTM10 and TZTM20 received the same solution with additional medetomidine at 100 and 200 µg/mL, respectively. Onset time, anesthetic time, analgesic time, recovery quality, and physiological parameters, including heart rate, blood pressure, respiratory rate, oxygen saturation, and body temperature, were evaluated. Medetomidine extended analgesic time in a dose-dependent manner and improved recovery quality while maintaining stable respiratory function. While TZT provided adequate anesthesia for minor non-invasive procedures, the inclusion of medetomidine in TZTM resulted in enhanced anesthetic stability for simple surgical procedures such as gonadectomy. These findings suggest that TZTM20 is a viable anesthetic protocol, though careful patient monitoring remains essential due to its cardiovascular effects. Full article

Background: Spontaneous ventilation with intubation (SVI) during video-assisted thoracoscopic surgery (VATS) has been introduced as a hybrid technique that combines the physiological benefits of spontaneous breathing with the safety of a secured airway. However, its application in patients with chronic obstructive pulmonary disease (COPD) remains controversial due to concerns about hypercapnia, hypoxemia, and dynamic hyperinflation. To date, no study has directly compared COPD and non-COPD patients undergoing VATS lobectomy under SVI using identical anesthetic and surgical protocols. Methods: A prospective observational study was conducted between January 2022 and December 2024 at a single tertiary thoracic surgery center. A total of 36 patients undergoing elective VATS lobectomy with SVI were included and divided into two groups: COPD (n = 17) and non-COPD (n = 19), based on GOLD criteria. All patients were intubated with a double-lumen tube and allowed to maintain spontaneous ventilation during one-lung ventilation (OLV) after recovery from neuromuscular blockade. Arterial blood gas (ABG) samples were collected at four predefined time points (T1–T4), and intraoperative respiratory parameters, hemodynamics, spontaneous ventilation time, and spontaneous ventilation fraction (SpVent%) were recorded. Postoperative outcomes, including ICU stay, complications, and conversion to controlled ventilation, were analyzed. Statistical comparisons were performed using t-test, Mann–Whitney U test, chi-square test, and ANCOVA with adjustment for age, sex, BMI, and FEV₁%. Results: All 36 procedures were successfully completed under SVI without conversion to controlled mechanical ventilation or thoracotomy. Baseline demographics were comparable between COPD and non-COPD patients regarding age (68.4 ± 6.9 vs. 67.8 ± 7.1 years; p = 0.78) and BMI (27.1 ± 4.6 vs. 26.3 ± 4.2 kg/m²; p = 0.56), while pulmonary function was significantly lower in COPD patients (FEV₁/FVC 53.8% (IQR 47.5–59.9) vs. 82.4% (78.5–85.2); p < 0.001). The duration of spontaneous ventilation was significantly longer in the COPD group (82 ± 14 min vs. 58 ± 16 min; p < 0.001), and remained significant after ANCOVA adjustment (β = +23.7 min; p = 0.001). The SpontVent% was higher in COPD patients (80% [70–90] vs. 60% [45–80]), showing a trend toward significance (p = 0.11). Intraoperative permissive hypercapnia was well tolerated: peak PaCO₂ levels at T3 were higher in COPD (52 ± 6 mmHg) than in non-COPD patients (47 ± 5 mmHg; p = 0.06), without pH dropping below 7.25 in either group. No significant differences were observed in mean arterial pressure, oxygen saturation, ICU stay (1.1 ± 0.4 vs. 1.0 ± 0.5 days; p = 0.48), or postoperative complication rates (p = 0.67). All patients were extubated in the operating room. Conclusions: Intubated spontaneous ventilation during VATS lobectomy is feasible and safe in both COPD and non-COPD patients when performed by experienced teams. COPD patients, despite impaired baseline lung function, were able to maintain spontaneous breathing for significantly longer periods without developing severe hypercapnia, acidosis, or hemodynamic instability. These findings suggest that SVI may represent a lung-protective alternative to fully controlled one-lung ventilation, particularly in hypercapnia-adapted COPD patients. Further multicenter studies are warranted to validate these results and define standardized thresholds for CO₂ tolerance, patient selection, and intraoperative monitoring during SVI. Full article

Fishery anesthetics are extensively employed in aquaculture to mitigate stress and reduce mortality during handling, transportation, and processing of farmed fish. While they enhance operational efficiency and reduce economic losses for fish merchants, the potential residual presence of these anesthetics raises concerns regarding human health risks and environmental impact. This review examines six commonly used anesthetics in aquaculture—eugenol, MS-222, benzocaine, 2-phenoxyethanol, diazepam, and quinaldine—focusing on their mechanisms of action, application risks, ecotoxicological effects, and methods for residue analysis. The objective is to promote the safe and informed application of these anesthetics, mitigate their biological toxicity, and minimize their ecological impact. Furthermore, the review provides technical insights into monitoring and managing anesthetic residues in aquaculture to ensure the safety of aquatic products and safeguard environmental health while also supporting the development of sustainable aquaculture practices. Full article

Anesthetic protocols for non-invasive immobilization of Black Vultures (Coragyps atratus) and Turkey Vultures (Cathartes aura) for procedures lasting up to two hours are lacking. This study directly evaluated the safety and efficacy of a multimodal anesthetic protocol in 11 Black Vultures and 4 Turkey Vultures undergoing electroretinography (ERG). Vultures were anesthetized with intramuscular dexmedetomidine (5 μg/kg), midazolam (0.2 mg/kg), butorphanol (0.2 mg/kg), and ketamine (5 mg/kg) (DMBK), followed by isoflurane induction and maintenance. All vultures were mechanically ventilated to maintain consistent end-tidal CO₂. Monitored parameters included sedation and recovery quality, heart and respiratory rates, hemoglobin oxygen saturation, non-invasive blood pressure, body temperature, and end-tidal concentrations of CO₂, isoflurane, and oxygen. All vultures achieved profound sedation with smooth induction and a median isoflurane maintenance concentration of 1.4% for approximately two hours. Recovery was rapid and uneventful. Heart rates ranged from 60 to 119 beats/min. Mean arterial blood pressure averaged 149 mmHg in Black Vultures and 158 mmHg in Turkey Vultures, with Turkey Vultures showing significantly higher diastolic pressure. A second-degree heart block was detected in one Black Vulture but required no treatment. All ERG procedures were completed successfully. The DMBK protocol provided profound sedation in both species, maintained key cardiorespiratory parameters, including heart rate and arterial blood pressure, within a clinically acceptable range throughout isoflurane maintenance, and enabled uneventful rapid recovery. These findings support DMBK with the cardiorespiratory monitoring system as a safe and effective regimen for anesthetizing vultures and likely other similarly sized raptors requiring non-invasive immobilization. Full article

Background/Objectives: Postoperative nausea and vomiting (PONV) are common after general anesthesia (GA) and, in patients undergoing vitreoretinal surgery, may be triggered by the oculocardiac reflex (OCR) leading to the oculoemetic reflex (OER). Inadequate dosing of intravenous rescue opioid analgesics may further provoke OCR. Adequacy of Anesthesia (AoA) monitoring enables optimized titration of intravenous rescue opioid analgesics, while preemptive intravenous or peribulbar analgesia may reduce opioid use. This study evaluated the impact of preemptive paracetamol or peribulbar block (PBB) combined with AoA-guided GA on the incidence of PONV, OCR, and OER in patients undergoing vitreoretinal surgery. Methods: A total of 185 patients were randomized to four groups: GA with AoA-guided intraoperative rescue opioid analgesia plus a single intravenous dose of paracetamol 1 g, or PBB using 1% ropivacaine, 0.5% bupivacaine, or a 1:1 mixture of 0.5% bupivacaine/2% lidocaine. Data from 175 patients were analyzed. Results: AoA-guided GA yielded an OCR incidence of 11.4% and PONV incidence of 4%. PBB, regardless of anesthetic solution, did not significantly reduce intraoperative rescue opioid analgesia requirements or the incidence of PONV, OCR, or OER compared with intravenous paracetamol. Notably, no PONV occurred in patients with three Apfel risk factors (predicted risk ≈ 61%) who received PBB. Conclusions: No overall advantage of PBB over intravenous paracetamol was observed. It may, however, benefit patients at high PONV risk. Full article

Background and Objectives: Ultrasound (US)-guided peripheral regional anesthesia (pRA) is gaining increasing importance in emergency medicine as an effective, low-ridsk alternative to general anesthesia (GA), procedural sedation (PS), or opioid therapy. By enabling rapid, direct pain management in the emergency department (ED), pRA can help preserve scarce surgical and anesthetic resources and, in some cases, avoid inpatient admissions. The aim of this study was to analyze the indications, techniques, and clinical impact of pRA in the orthopedic-focused ED of an affiliated hospital. Materials and Methods: All pRA and PS procedures performed over a six-year period were retrospectively reviewed among 35,443 orthopedic-trauma emergency patients. pRA was carried out under US guidance with standardized monitoring. Diagnoses, block techniques, effectiveness, and complications were analyzed descriptively. Results: A total of 1292 patients (3.7%) underwent either pRA (n = 1117; 3.2%) or PS (n = 175; 0.5%). pRA was performed in 22% of cases for interventions such as reductions or extensive wound management. In 78%, pRA was applied for analgesia, for example, in the diagnostic work-up and treatment of non-immediately operable fractures, lumbago, or arthralgia. The most common pRA techniques were brachial plexus blocks (54%) and femoral nerve blocks (25%). Fascial plane blocks (6.1%) and paravertebral blocks (1.5%) were rarely used. PS was performed in 175 of 1292 patients (13%), although pRA would have been feasible in 159 of these cases. No complications of pRA were observed, and GA could routinely be avoided. Conclusions: US-guided pRA proved to be an effective and safe alternative to PS, GA, or systemic analgesia for selected indications, allowing immediate treatment without the need for operative capacities. To ensure safe application, these techniques should be an integral part of the training curriculum for ED personnel. Full article

Background/Objectives: Scoliosis surgery in pediatric patients, particularly those with neuromuscular disorders, is associated with increased perioperative risk due to respiratory insufficiency, cardiovascular comorbidities, and nutritional deficiencies. This review aims to summarize current evidence-based approaches to anesthetic management in this vulnerable population. Methods: A comprehensive literature review was conducted focusing on anesthetic strategies and multidisciplinary protocols used in the perioperative care of children with neuromuscular conditions undergoing scoliosis surgery. Emphasis was placed on intraoperative neurophysiological monitoring (IONM), blood conservation techniques, and Enhanced Recovery After Surgery (ERAS) principles. Results: Key management strategies include individualized preoperative risk assessment, use of total intravenous anesthesia (TIVA) to preserve IONM signal integrity, and the implementation of blood conservation methods such as antifibrinolytic therapy and intraoperative cell salvage. Additional perioperative considerations include maintaining normothermia, careful positioning, and multimodal analgesia. Postoperative care should incorporate structured respiratory support and early mobilization within the ERAS pathway to promote recovery and reduce complications. Conclusions: The perioperative care of pediatric patients with neuromuscular scoliosis undergoing spinal surgery requires a multidisciplinary and individualized anesthetic approach. Adherence to evidence-based protocols, including TIVA, blood management strategies, and ERAS principles, is essential for minimizing perioperative complications and improving outcomes in this high-risk group. Full article

Background: Intraoperative neurophysiological monitoring (IONM) has become an invaluable tool for spinal deformity surgery. This study aims to present our experience of using transcranial motor evoked potential (Tc-MEP) as an IONM tool in adolescent idiopathic scoliosis patients undergoing navigation-assisted deformity correction and explore the potential risk factors associated with false-positive and true-positive IONM findings. Methods: A retrospective study was conducted in 103 patients (mean age 16.2 ± 4.0 years) undergoing corrective surgery for spinal deformity. All pediatric spinal deformity correction surgeries at the center were performed by a single senior spine surgeon, utilizing navigation and Tc-MEP to enhance the neurological safety profile. The sensitivity and the specificity of Tc-MEP were calculated. Results: Of the total cases, 87 patients (84.5%) exhibited no IONM signal alert and did not experience any postoperative neurological deficits, representing true negatives. There were no false-negative cases, which gives a negative predictive value of 100%. Significant IONM signal alerts were observed in 16 patients (15.5%), but only two patients (1.9%) experienced a postoperative motor deficit, representing true positives, which yielded a positive predictive value of 12.5%. Conclusions: This study demonstrated the sensitivity and specificity of Tc-MEP to be 100% and 86.3%, respectively, with a false-positive rate of 13.7%. Blood loss was the only factor significantly associated with IONM alerts, while age, gender, surgical duration, and anesthetic modality showed no significant differences. Full article