Xenon as an adjuvant to sevoflurane anesthesia in children younger than 4 years of age, undergoing interventional or diagnostic cardiac catheterization: A randomized controlled clinical trial

Summary

Background

Xenon has repeatedly been demonstrated to have only minimal hemodynamic side effects when compared to other anesthetics. Moreover, in experimental models, xenon was found to be neuroprotective and devoid of developmental neurotoxicity. These properties could render xenon attractive for the anesthesia in neonates and infants with congenital heart disease. However, experience with xenon anesthesia in children is scarce.

Aims

We hypothesized that in children undergoing cardiac catheterization, general anesthesia with a combination of sevoflurane with xenon results in superior hemodynamic stability, compared to sevoflurane alone.

Methods

In this prospective, randomized, single-blinded, controlled clinical trial, children with a median age of 12 [IQR 3-36] months undergoing diagnostic/interventional cardiac catheterization were randomized to either general anesthesia with 50-65vol% xenon plus sevoflurane or sevoflurane alone. The primary outcome was the incidence of intraprocedural hemodynamic instability, defined as the occurrence of: (i) a heart rate change >20% from baseline; or (ii) a change in mean arterial blood pressure >20% from baseline; or (iii) the requirement of vasopressors, inotropes, chronotropes, or fluid boluses. Secondary endpoints included recovery characteristics, feasibility criteria, and safety (incidence of emergence agitation and postoperative vomiting.

Results

After inclusion of 40 children, the trial was stopped as an a priori planned blinded interim analysis revealed that the overall rate of hemodynamic instability did not differ between groups [100% in both the xenon-sevoflurane and the sevoflurane group. However, the adjuvant administration of xenon decreased vasopressor requirements, preserved better cerebral oxygen saturation, and resulted in a faster recovery. Xenon anesthesia was feasible (with no differences in the need for rescue anesthetics in both groups).

Conclusion

Our observations suggest that combining xenon with sevoflurane in preschool children is safe, feasible, and facilitates hemodynamic management. Larger and adequately powered clinical trials are warranted to investigate the impact of xenon on short- and long-term outcomes in pediatric anesthesia.

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Outstanding contribution to pediatric anesthesiology: An interview with Dr. Robert H. Friesen

Summary

Dr. Robert H. Friesen, (1946–) Professor of Anesthesiology, Children's Hospital Colorado, University of Colorado, Anschutz Medical Campus, has played a pivotal and pioneering role in the development of pediatric and congenital cardiac anesthesiology. His transformative research included the study of the hemodynamic effects of inhalational and intravenous anesthetic agents in the newborn and the effects of anesthetic agents on pulmonary vascular resistance in patients with pulmonary hypertension. As a model clinician-scientist, educator, and administrator, he changed the practice of pediatric anesthesia and shaped the careers of hundreds of physicians-in-training, imbuing them with his core values of honesty, integrity, and responsibility. Based on a series of interviews with Dr. Friesen, this article reviews a career that advanced pediatric and congenital cardiac anesthesia during the formative years of the specialties.

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An interdisciplinary approach to the development of accessible computer-administered measurement instruments

Publication date: Available online 4 September 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Susan Magasi, Mark Harniss, Allen W. Heinemann
Principles of fairness in testing require that all test takers, including people with disabilities, have an equal opportunity to demonstrate their capacity in the construct being measured. Measurement design features and assessment protocols can pose barriers for people with disabilities. Fairness in testing is a fundamental validity issue at all phases in the design, administration and interpretation of measurement instruments in clinical practice and research. There is limited guidance for instrument developers in how to develop and evaluate the accessibility and usability of measurement instruments. This paper describes a 6-stage iterative process for developing accessible computer-administered measurement instruments based on our work in several major measurement initiatives. Interdisciplinary teams of accessibility experts, content and measurement experts, information technology experts and people with disabilities should work together to ensure that measurement instruments are accessible and usable by a wide range of users. The development of accessible measurement instruments is not only an ethical requirement, it also ensures better science by minimizing measurement bias, missing data, and attrition due to mismatches between the target population and test administration platform and protocols.



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Clinical benefits of joint mobilisation on ankle sprains: a systematic review and meta-analysis

Publication date: Available online 4 September 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Ishanka Weerasekara, Peter Osmotherly, Suzanne Snodgrass, Jodie Marquez, Rutger de Zoete, Darren A. Rivett
ObjectiveTo assess the clinical benefits of joint mobilisation on ankle sprains.Data sourcesMEDLINE, MEDLINE In Process, Embase, AMED, PsycINFO, CINAHL, Cochrane library, PEDro, Scopus, SPORTDiscus and Dissertations and Thesis were searched from inception to June, 2017.Study SelectionStudies investigating humans with a grade I or II lateral or medial sprains of the ankle in any pathological state from acute to chronic, who had been treated with joint mobilisation were considered for inclusion. Any conservative intervention was considered as a comparator. Commonly reported clinical outcomes were considered such as ankle range of movement, pain, and function. After screening of 1530 abstracts, 56 studies were selected for full text screening, and 23 were eligible for inclusion. Eleven studies on chronic sprains reported sufficient data for meta-analysis.Data ExtractionData were extracted using the participants, interventions, comparison, outcomes and study design approach. Clinically relevant outcomes (dorsiflexion range, proprioception, balance, function, pain threshold, pain intensity) were assessed at immediate, short term and long term follow-up points.Data SynthesisMethodological quality was assessed independently by two reviewers and most studies were found to be of moderate quality, with no studies rated as poor.Meta-analysis revealed significant immediate benefits of joint mobilisation compared to comparators on improving postero-medial dynamic balance (p=0.0004), but not for improving dorsiflexion range (p= 0.16), static balance (p = 0.96) or pain intensity (p= 0.45). Joint mobilisation was beneficial in the short term for improving weight-bearing dorsiflexion range (p= 0.003) compared to a control.ConclusionJoint mobilisation appears to be beneficial for improving dynamic balance immediately after application and dorsiflexion range in the short term. Long term benefits have not been adequately investigated.



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Contribution of transcranial magnetic stimulation to assessment of brain connectivity and networks

The brain operates in networks to carry out its function. At one level, information passes between neurons via synapses, and, at another level, information passes from region to region. Visual information flows from occipital areas to the parietal areas and then to the motor areas to properly move the arm and shape the hand to pick up an object. Olfactory information from the smell of coffee integrates with pleasant limbic memories to drive a decision to have another cup. If we want to understand how the brain works, we need to know its anatomical connectivity and what pathways are utilized in different functional tasks.

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Pallidal low β-low γ phase-amplitude coupling inversely correlates with Parkinson disease symptoms

β oscillatory activity (13-30 Hz) throughout the basal ganglia-thalamo-cortical (BGTC) motor network has been suggested to contribute to the pathophysiology and serve as a biomarker of Parkinson disease (PD) (Brittain and Brown, 2014; Brown, 2003; Crowell et al., 2012; Eusebio and Brown, 2007; Hammond et al., 2007; de Hemptinne et al., 2015; Kuhn et al., 2009; Little and Brown, 2014; Oswal et al., 2013; Weinberger et al., 2006). STN β power has been shown to be related to severity of rigidity and bradykinesia symptoms and to decrease in proportion to clinical improvement with treatment (Chen et al., 2010; Eusebio et al., 2011; Levy et al., 2002).

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Microspheres in gall bladder

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Italian Society of Digestive Endoscopy (SIED) Position Paper on the Non-Anaesthesiologist Administration of Propofol for Gastrointestinal Endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit.The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several Anaesthesiologist and Gastroenterologist societies but an Italian Position Paper taking into account the Italian law is lacking.

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Premenstrual Dysphoric Disorder in a Patient with Traumatic Brain Injury: A case report

We present a case of a 17 year old female who developed premenstrual dysphoric disorder (PMDD) after sustaining a severe traumatic brain injury (TBI) and review the diagnosis of PMDD. The patient developed symptoms of severe depression surrounding her menses months after sustaining severe TBI and was diagnosed with PMDD by a psychiatrist. She ultimately required antipsychotics for optimal symptom resolution. PMDD is a severe form of premenstrual syndrome with symptoms including irritability, anxiety and nonfatal suicidal behavior.

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Immunosuppressant Medication Induced Lower Extremity Pain after Combined Liver and Kidney Transplant: A Case Report

Calcineurin inhibitors are imperative in the success of a transplanted organ. However, these immunosuppressants can lead to a rare complication known as calcineurin inhibitor induced pain syndrome (CIPS), which may not be recognized early and managed appropriately. We present a case of a 35-year-old female who underwent a combined liver/kidney transplant and developed lower extremity pain while being maintained on tacrolimus. This case illustrates a patient with previously reported characteristic clinical features of CIPS in addition to uncharacteristic neuropathic symptoms and imaging findings.

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How Prospective Physical Medicine and Rehabilitation Trainees Rank Residency Training Programs

From the inception of the National Resident Matching Program, multiple studies have investigated the factors applicants consider important to ranking prospective residency programs. However, only two previous studies focused on prospective physical medicine and rehabilitation (PM&R) trainees, and the most recent of these studies was published in 1993. It is unknown whether these previous studies are reflective of current prospective PM&R residents.

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Microspheres in gall bladder

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Italian Society of Digestive Endoscopy (SIED) Position Paper on the Non-Anaesthesiologist Administration of Propofol for Gastrointestinal Endoscopy

Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit.The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several Anaesthesiologist and Gastroenterologist societies but an Italian Position Paper taking into account the Italian law is lacking.

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Reliability of physical functioning tests in patients with low back pain: a systematic review.

The aim of this study was to provide a comprehensive overview of physical functioning tests in patients with low back pain (LBP) and to investigate their reliability.

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Activities performed and treatments conducted prior to consultation with a spine surgeon: Are patients and clinicians following evidence-based clinical practice guidelines?

Clinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal.

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Role of intraoperative radiotherapy in the treatment of sacral chordoma

Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. Till date, there are not any series available in literature combining surgery and intraoperative radiotherapy (IORT).

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Extra-foraminal microscopic assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations

BackgroundForaminal and extraforaminal lumbar disc herniations are uncommon. The main presentation is radicular pain related to the exiting nerve root at the affected level. Different approaches for surgical intervention have been described.PurposeTo evaluate the clinical outcome, complications recurrence and reoperation rate of extraforaminal microscopic assisted percutaneous nucleotomy with literature review focusing on complications and recurrence rateStudy DesignProspective cohort study done in a high flow spine center in GermanyPatient SampleBetween October 2012 and October 2015, 76 patients (35 females and 41 males) with foraminal or extraforaminal lumbar disc prolapse were operated upon.

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Hospital competitive intensity and perioperative outcomes following lumbar spinal fusion

Inter-hospital competition has been shown to influence adoption of surgical techniques and approaches, clinical patient outcomes, and healthcare resource utilization for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.

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Dynamic foraminal dimensions during neck extension and rotation in fusion and artificial disc replacement: an observational study

Changes in the dimensions of the cervical neural foramina (CNF) are considered to be a key factor in nerve root compression and development of cervical radiculopathy. However, to what extent foraminal geometry differs between patients who underwent anterior cervical discectomy and fusion (ACDF) and those who underwent total disc arthroplasty with an artificial disc (AD) during physiological motion is largely unknown.

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Multi-level posterior foraminotomy with laminoplasty versus laminoplasty alone for cervical spondylotic myelopathy with radiculopathy: a comparative study

Conventional laminoplasty is useful for expanding a stenotic spinal canal. However, it has limited use for the decompression of accompanying neural foraminal stenosis. As such, an additional posterior foraminotomy could be simultaneously applied, although this procedure carries a risk of segmental kyphosis and instability.

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Successful lumbar surgery results in improved psychological well-being: a longitudinal assessment of depressive and anxiety symptoms

Preoperative psychological symptoms predict surgical outcomes. The impact of surgical outcomes on psychological well-being, however, has not been delineated.

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Ill. electric company equips 240 trucks with AEDs

According to the American Heart Association, people who go into cardiac arrest while at work have only a 5-7 percent chance of surviving when an AED is not present

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Morphological description and morphometric analyses of the Upper Palaeolithic human remains from Dzudzuana and Satsurblia caves, western Georgia

Publication date: December 2017
Source:Journal of Human Evolution, Volume 113
Author(s): Cristiana Margherita, Gregorio Oxilia, Veronica Barbi, Daniele Panetta, Jean-Jacques Hublin, David Lordkipanidze, Tengiz Meshveliani, Nino Jakeli, Zinovi Matskevich, Ofer Bar-Yosef, Anna Belfer-Cohen, Ron Pinhasi, Stefano Benazzi




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Pleistocene fossil woods from the Okote Member, site FwJj 14 in the Ileret region, Koobi Fora Formation, northern Kenya

Publication date: Available online 4 September 2017
Source:Journal of Human Evolution
Author(s): Marion K. Bamford
On the eastern side of Lake Turkana in northern Kenya are extensive Plio-Pleistocene deposits containing a rich diversity of fossil mammals, hominins and flora within the radiometrically dated tuffaceous, lacustrine and fluvial sequence. Reconstruction of this landscape and paleoenvironment are part of an ongoing multinational and multidisciplinary human evolution project in the eastern Turkana Basin. Today there is a huge lake in the Rift Valley but it has fluctuated since the early Pliocene. Silicified wood is fairly common in some areas of the Koobi Fora Formation. One such site is FwJj 14E, alongside one of the tributaries of the Ileret River. Hominin hand and arm bones have been excavated from here in the Okote Member and dated at 1.56–1.36 Ma. The fossils are associated with hominin and bovid footprints. Sixty of the over 100 wood specimens collected have been sectioned and studied. In general the woods have large vessels and an average vulnerability index of 40, which implies a mesic megathermal environment with no water stress. Taxonomically the woods belong to large African families: Caesalpiniaceae (Didelotia idae), Combretaceae (Anogeissus sp.), Putranjivaceae (Euphorbiaceae; Drypetes sp.), Lamiaceae (cf Premna sp.), Malvaceae (Heritiera sp.) and Sapindaceae (Sapindoxylon sp.). Most of these taxa do not occur in the area today because now it is much drier and the local vegetation is predominantly Acacia-Commiphora-Salvadora shrubland. The reconstruction of the paleovegetation supports the interpretation from the fauna, namely, a tall riverine forest with shady refuge trees, possibly some edible fruits, and wooded grassland and more open bushland in the vicinity.



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Protective Effect of 1,25-Dihydroxy Vitamin D3 on Pepsin–Trypsin-Resistant Gliadin-Induced Tight Junction Injuries

Abstract

Background

Tight junction (TJ) injuries induced by pepsin–trypsin-resistant gliadin (PT–G) play an important role in the pathogenesis of celiac disease. Previously, 1,25-dihydroxy vitamin D3 (VD3) was reported to be a TJ regulator that attenuates lipopolysaccharide- and alcohol-induced TJ injuries. However, whether VD3 can attenuate PT–G-induced TJ injuries is unknown.

Aim

The aim of this study was to evaluate the effects of VD3 on PT–G-induced TJ injuries.

Methods

Caco-2 monolayers were used as in vitro models. After being cultured for 21 days, the monolayers were treated with PT–G plus different concentrations of VD3. Then, the changes in trans-epithelial electrical resistance and FITC-dextran 4000 (FD-4) flux were determined to evaluate the monolayer barrier function. TJ protein levels were measured to assess TJ injury severity, and myeloid differentiation factor 88 (MyD88) expression and zonulin release levels were determined to estimate zonulin release signaling pathway activity. Additionally, a gluten-sensitized mouse model was established as an in vivo model. After the mice were treated with VD3 for 7 days, we measured serum FD-4 concentrations, TJ protein levels, MyD88 expression, and zonulin release levels to confirm the effect of VD3.

Results

Both in vitro and in vivo, VD3 significantly attenuated the TJ injury-related increase in intestinal mucosa barrier permeability. Moreover, VD3 treatment up-regulated TJ protein expression levels and significantly decreased MyD88 expression and zonulin release levels.

Conclusions

VD3 has protective effects against PT–G-induced TJ injuries both in vitro and in vivo, which may correlate with the disturbance of the MyD88-dependent zonulin release signaling pathway.

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Clinical Course of Partial Virologic Response with Prolonged Tenofovir Therapy in Nuclos(t)ides-Naïve Patients with Chronic Hepatitis B

Abstract

Background/Aims

The clinical course of chronic hepatitis B (CHB) patients with partial virologic response (PVR) during tenofovir disoproxil fumarate (TDF) therapy remains unclear.

Methods

We retrospectively investigated the long-term clinical outcomes of TDF treatment in nucleos(t)ides-naïve CHB patients, particularly in those with PVR.

Results

A total of 391 patients treated with TDF therapy for more than 12 months were included. Virologic response (VR) was achieved in 341 patients (87.2%). PVR was evident in 127 (45.3%) of the 391 patients. Multivariate logistic regression analysis using selected baseline factors identified absolute HBV DNA levels at baseline (OR 0.496; 95% CI 1.369–1.969) and HBeAg positivity (OR 0.622; 95% CI 1.096–3.167) as factors significantly associated with PVR. During continuous prolonged TDF therapy, 127 (71.8%) of 177 patients with PVR achieved VR. The cumulative rates of VR in patients with PVR at 12, 24, and 36 months were 42.4, 79.7, and 90.2%, respectively. Serum HBV DNA level at week 24 was significantly associated with VR in patients with PVR.

Conclusions

The vast majority of CHB patients with PVR achieved VR through prolonged TDF therapy, although the time to achieve VR was delayed in those with PVR. This suggests that adjustment of TDF therapy in patients with PVR is unnecessary.

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Treatment Response and Outcome with Two Different Prednisolone Regimens in Autoimmune Hepatitis

Abstract

Background

Beyond available guidelines, therapy of autoimmune hepatitis (AIH) shows wide variation among physicians. We compared two regimens for treatment naive AIH: one recommended protocol with an initial prednisolone dose of 30 mg/day and our own 40 mg/day prednisolone with a slow dose tapering protocol. We analyzed the safety, response rates, and outcomes for two groups of treated patients.

Patients and Methods

We retrospectively evaluated data of 71 AIH patients including, group I (n = 32, prednisone 30 mg/day) and group II (n = 39, prednisone 40 mg/day). All patients also received azathioprine.

Results

The frequency of complete biochemical response was significantly higher in group II than in group I (69.2 vs. 43.8%, p = 0.031) after 3 months of therapy, but not after 6 and 12 months (79.5 vs. 59.4%, p = 0.065 and 89.5 vs. 80.6%, p = 0.30). In patients with severe interface hepatitis, the complete response rates were significantly higher in group II than in group I after 3 (63.6 vs. 23.1%, p = 0.02) and 6 months (72.7 vs. 38.5%, p = 0.046), but not after 12 months of therapy (86.4 vs. 69.2%, p = 0.221). Relapses were observed in 50% of group I and in 35.9% of group II during maintenance therapy (p = 0.23). Overall survival was significantly better in group II than in group I (100 vs. 87.5%, log-rank, p = 0.048). No severe steroid-related side effects were observed in either group.

Conclusions

Our real-world experience suggests that an initial prednisolone dose of 40 mg/day with a slower tapering protocol induces earlier biochemical response, tends to result in less relapses during maintenance, and is associated with a better disease outcome.

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A Prospective Evaluation of Ileocecal Valve Dysfunction and Intestinal Motility Derangements in Small Intestinal Bacterial Overgrowth

Abstract

Background

Small intestinal bacterial overgrowth (SIBO) is an increasingly recognized clinical syndrome; however, its etiophathogenesis is poorly understood. We hypothesized that loss of gastric acid, a delayed intestinal transit, and ileocecal valve dysfunction may contribute to the genesis of this syndrome.

Aims

Our primary aim was to assess these parameters using wireless motility capsule (WMC) testing and to correlate them with the presence or absence of SIBO.

Methods

We prospectively evaluated 30 consecutive patients at a tertiary care center with suspected SIBO, diagnosed by lactulose hydrogen breath testing (LBT), and small bowel aspirate microbiology. Patients underwent WMC testing to assess ileocecal junction pressure (ICJP), small bowel transit time (SBTT), and regional gastrointestinal pH.

Results

Thirty patients completed testing; 15 had a positive LBT, and 11 had a positive aspirate culture. As compared with LBT-negative patients, ICJP was lower (27.8 vs. 72.7 mmHg, p = 0.027), SBTT was longer (10.0 vs. 1.1 h, p = 0.004), gastric pH was higher (3.63 vs. 2.42, p < 0.01), and small bowel pH was higher (6.96 vs. 6.61, p = 0.05). A hypotensive ICJP (<46.61 mmHg) was more prevalent in LBT-positive patients as compared with LBT-negative patients (73.3 vs. 14.29%, p = 0.003). Logistic regression models were used to assess the magnitude of each measured WMC parameter and the presence of SIBO. p values ≤0.05 were considered statistically significant.

Conclusions

Patients with SIBO have significantly lower ICJP, prolonged SBTT, and a higher gastrointestinal pH as compared to those without SIBO. These abnormalities may play different roles in the pathogenesis of SIBO, facilitating more targeted treatment to prevent recurrences of SIBO.

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Exposé: Different Faces of a Bleeding Giant Duodenal Ulcer

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The phenylephrine concentration-response relationship for blood pressure after nasal delivery in children

Summary

Background

Intranasal phenylephrine is commonly used to vasoconstrict the nasal mucosa, reducing bleeding associated with nasotracheal intubation or endoscopic sinus surgery. There are few data quantifying either absorption pharmacokinetics or phenylephrine concentration effect on blood pressure in children.

Methods

Published observations of plasma concentration and blood pressure changes after phenylephrine nasal administration (0.1 mL kg⁻¹, 0.25% or 0.5%) in children (n = 52, 2-12 years, 10-40 kg) were pooled with those in adults (23-81 years) given phenylephrine 2.5% (n = 10) and 10% (n = 10) eyedrops. Further pharmacokinetic (PK) data were available from healthy volunteers given oral phenylephrine 10 mg alone, with blood for concentration assay taken at 5, 15, 30, 45 minutes and 1, 2, 3, 6 hours (n = 28). Intravenous time-concentration data were available from four healthy volunteers given phenylephrine 1 mg and who had blood taken for assay on 17 occasions over the subsequent 4 hours. Data were analyzed using an integrated pharmacokinetic-pharmacodynamic (PK-PD) model using nonlinear mixed-effects models. Allometry, scaled to a 70-kg person, was used for PK size standardization. Effect was described using an E_MAX model.

Results

A two-compartment model was used to fit PK data while an additional compartment, linked by an equilibration half-time (T_1/2keo), was used to describe effect. PK parameter estimates for the nasal formulation were clearance (CL) 160 L h⁻¹, central volume of distribution (V1) 13.3 L, intercompartment clearance (Q) 25.3 L h⁻¹, peripheral volume of distribution (V2) 225 L, absorption half-time (Tabs) 6.2 minutes, absorption lag time (Tlag) 1.5 minutes, and bioavailability (F) 0.183. Bioavailability and absorption of the ophthalmic solution were concentration dependent (F 0.13, Tabs 5.5 minutes for 2.5% solution; F 0.15, Tabs 9.6 minutes for 10% solution). Absorption of the oral formulation was slow (Tabs 48 minutes) with poor bioavailability (F 0.0128). The pediatric PD interrogation revealed a baseline mean arterial pressure of 60 mm Hg, a maximum effect (E_MAX) of 25 mm Hg, and an EC₅₀ of 10.3 μg L⁻¹. The effect on vasculature was immediate and T_1/2keo was not estimable.

Conclusion

Absorption of phenylephrine through the nasal mucosa was rapid and similar to the ophthalmic formulation. Bioavailability was also similar to the ophthalmic formulation. The maximum effect (E_MAX) in children was half that in adults (E_MAX 50 mm Hg).

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