bluuebunny/crossref_metadata_2025 huggingface dataset:
IN VITRO COMPARISON OF THREE DIFFERENT MESH CONSTRUCTIONS
Authors: Weyhe Dirk , Belyaev Orlin , Buettner Goetz , Mros Kirsten , Mueller Christophe , Meurer Kirsten , Papapostolou Georgios , Uhl Waldemar
Published: August 2010

Background:  Material amount and pore size have been recently discussed as probable important determinants of biocompatibility of mesh implants used in hernia repair. This study aimed to find out whether other constructional parameters affect the extent of early foreign body reaction in vitro.

Materials and methods:  An NRK‐49F (mixed culture of normal rat kidney cells) fibroblast culture was incubated in the presence of a ‘light’ microporous mesh (35 g/m2, 0.25 mm thick), a ‘heavy’ polypropylene knitted mesh (95 g/m2, 0.55 mm thick) and a polypropylene/polyglactin composite mesh (35 g/m2, 0.5 mm thick). A mesh‐free cell suspension was used as a control group. Fibroblasts’ proliferation, invasion and apoptosis rates were measured by commercially available quantification tests. Levels of tumour necrosis factor‐α, transforming growth factor‐β1, interleukin (IL)‐1β, IL‐6 and IL‐10 secreted by the fibroblasts in the supernatant were dynamically measured in a time kinetics of 6–96 h.

Results:  Invasion potential as well as proliferation and apoptosis rates of fibroblasts were enhanced by all meshes. The composite mesh stimulated the cell turnover with correspondingly increased levels of IL‐6 and suppressed levels of transforming growth factor‐β1 significantly more than the two pure polypropylene meshes and the control group.

Conclusion:  Early biological response of fibroblasts as a major component of foreign body reaction was most affected by the filament construction of the mesh combining polypropylene with multifilament, partially absorbable polyglactin fibres. Material reduction did not weaken foreign body reaction. Confirming previous findings from animal experiments and clinical observations, the described in vitro model seems to be an appropriate primary tool for studying the biological tolerance towards meshes.
Brain infarction localized on left inferior temporal gyrus of presumed fetal onset
Authors: Yamamoto Yutaka , Kohno Yoshinori , Kato Zenichiro , Uchiyama Atsushi
Published: August 2010

Idiopathic perinatal cerebral infarction is recognized to be more common in the preterm infant than previously realized. However, the pathogenic mechanisms and the onset time remain unclear. We encountered an extremely low birth weight female infant with severe intrauterine growth retardation and brain infarction localized on the left inferior temporal gyrus. The onset of the infarction and the precise sequential changes were evaluated with blood data, cranial ultrasound imaging, computed tomography, magnetic resonance imaging and magnetic resonance angiography. This is the first published fetal case with brain infarction specifically localized on the left inferior temporal gyrus. Careful observation with serial brain imaging is indispensable for high‐risk infarction groups, such as preterm infants with severe intrauterine growth retardation, to detect neurological abnormality earlier and precisely.
Polypropylene mesh used for adjuvant reconstructive surgical treatment of advanced pelvic organ prolapse
Authors: Lin Tzu‐Yin , Su Tsung‐Hsien , Huang Wen‐Chu
Published: August 2010

Aim:  To elucidate the outcome of transvaginal pelvic reconstructive surgery using polypropylene mesh (Gynemesh; Ethicon, Somerville, NJ, USA) for patients with pelvic organ prolapse (POP) stage III or IV.

Methods:  Thirty‐nine patients who underwent transvaginal pelvic reconstructive surgery from September 2004 through December 2005 were collected and analyzed. All patients underwent pelvic reconstructive surgery with anterior and posterior colporrhaphy with Gynemesh reinforcement.

Results:  The average age of the patients was 64.1 years and average parity was 3.9. Thirty‐four patients had Pelvic Organ Prolapse Quantification (POP‐Q) stage 0, four patients had stage I, and one patient had stage II at a median follow‐up time of 18 months postoperatively. The success rate was 97.4%. Only one patient (2.6%) had recurrent genital prolapse (stage II) postoperatively. Quality of life was evaluated before and after the operations. The mean scores on the Urinary Distress Inventory‐6 (UDI‐6) and Incontinence Impact Questionnaire‐7 (IIQ‐7) were 5.0 ± 4.6 and 8.7 ± 6.2 before the operation and 3.0 ± 4.7 and 3.2 ± 5.6 after the operation, respectively (P = 0.03 and 0.01). The complication rate was 10.3 %, including one vaginal mesh erosion (2.6%), one dyspareunia (2.6%) and two prolonged bladder drainage (longer than 14 days, 5.1%). The mean duration of postoperative bladder drainage was 2.4 days and mean postoperative hospital stay was 5.1 days. Neither long‐term nor major complication was identified.

Conclusion:  Transvaginal pelvic reconstructive surgery with polypropylene mesh reinforcement is a safe and effective procedure for POP on 1.5 years' follow‐ up. It also has positive influence on quality of life.
Changes in heart rate patterns by lipopolysaccharide and intermittent hypoxia‐ischemia in 7‐day‐old rats
Authors: Yang Li , Sameshima Hiroshi , Ikenoue Tsuyomu
Published: August 2010

Aim:  We previously reported that lipopolysaccharide (LPS) and hypoxia‐ischemia (HI) act additively to induce brain damage in the developing rat model. The present study was undertaken to determine whether LPS‐HI‐induced brain damage is associated with changes in heart rate (HR) patterns.

Material & Methods:  Seven‐day‐old Wistar rats were administered LPS (1 mg/kg, n = 17) or saline (n = 15) intraperitoneally. After 4 h, the left common carotid artery was ligated and electrocardiogram electrodes were placed on the chest under ether anesthesia, followed by intermittent HI (8% oxygen for 6 min) at 10‐min intervals for a total of 10 times. Seven days later, rats were sacrificed and brains removed for histological examination. Neuronal damage for a single section was categorized as mild (≤25% of the surface area), moderate (25–50%) or severe (≥50%).

Results:  Brain damage was induced only in the LPS/HI group, which was statistically significant when compared to the saline/HI group. Baseline HR increased significantly due to LPS administration (P < 0.05). In the LPS/HI group, the amplitude of hypoxia‐driven tachycardia decreased significantly in the last 5 hypoxic episodes in brain‐damaged rats compared to rats with no visible damage (28 ± 1 vs 16 ± 2 bpm). Baseline HR variability was also suppressed significantly during the last five hypoxic episodes in brain‐damaged rats compared to rats with no visible damage.

Conclusions:  LPS administration caused a gradual decrease in baseline HR variability and blunted tachycardia in response to repetitive HI, suggesting these signs are indicative of future neonatal brain damage.
Postoperative concurrent chemoradiotherapy for the high‐risk uterine cervical cancer
Authors: Takeshita Shigeki , Kita Tsunekazu , Motoike Yoshiyuki , Umezawa Koichi , Sugisaki Soichi , Matsumoto Sachiyo , Matsumoto Yasuhiro , Ryo Eiji , Ayabe Takuya
Published: August 2010

Aim:  To determine whether concurrent chemoradiotherapy (CCRT) can improve the survival rate of high‐risk uterine cervical cancer.

Material & Methods:  We analyzed 16 cases of uterine cervical cancer that had undergone radical hysterectomy and pelvic lymphadenectomy from 2003 to 2008. The patients were eligible if they had histologically confirmed positive parametrial involvement, positive pelvic lymph nodes or non‐squamous cell carcinoma. They received 50 Gy of external beam radiotherapy (RT) for the pelvis which was combined with chemotherapy. Cisplatin was administered intravenously every 3 weeks at a dose of 70 mg/m2 during the RT. For renal function complication case, carboplatin was administered weekly. For control purposes, there were 14 cases treated in our hospital from 1995 to 2003 who had received only RT.

Results:  We did not find any statistically significant difference in the disease‐free survival rate between the CCRT group and the RT group. However, the overall survival rate was significantly higher for patients in the CCRT group compared with the RT group in positive lymph node cases and non‐squamous cell carcinoma cases. Adverse effects were more frequent in the CCRT group. Over grade 3 toxicities were manifested as leukopenia, diarrhea and anemia. There was no local recurrence in CCRT group patients.

Conclusion:  CCRT seems to be beneficial for improving the survival rate of either positive lymph node or non‐squamous cell carcinoma cases in high‐risk uterine cervical cancer patients.
Association of maternal serum high sensitive C‐reactive protein level with body mass index and severity of pre‐eclampsia at third trimester
Authors: Ertas Ibrahim E. , Kahyaoglu Serkan , Yilmaz Bulent , Ozel Murat , Sut Necdet , Guven Melih A. , Danisman Nuri
Published: August 2010

Aim:  To assess a maternal serum level of high sensitive C‐reactive protein (hs‐CRP) as a useful clinical parameter in prediction of pre‐eclampsia severity and, to evaluate the correlation between hs‐CRP and body mass index (BMI).

Material & Methods:  Using cross‐sectional study design, CRP was measured by a high sensitive immunoturbidimetric method between 24 and 40 weeks of gestation in normotensive controls (n = 115), in mild (n = 63) and severe (n = 34) pre‐eclamptic patients. The receiver operating characteristic analysis was used to estimate the optimal threshold score of hs‐CRP.

Results:  For disease severity evaluation, a hs‐CRP concentration of 9.66 mg/L was determined as cut‐off point with 88% sensitivity, 81% specificity, 71% positive predictive value and 92% negative predictive value. When all three groups of patients were adjusted for gestational age [24°/7–27,6/7 28°/7–33,6/7 34°/7–406/7] and BMI, hs‐CRP levels of severe pre‐eclamptic patients were significantly higher than mild ones and controls in the study group with BMI < 25 kg/m2 (P < 0.001). In the study group with BMI ≥ 25 kg/m2, only severe pre‐eclamptic patients between 28°/7 and 336/7 weeks of gestation had significantly higher hs‐CRP levels when compared with control and mild pre‐eclamptic group (P < 0.001). When the patients were subgrouped as high (≥9.66 mg/L) and low hs‐CRP group (<9.66 mg/L), adverse outcomes for hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome and intrauterine growth‐restricted baby were statistically significant higher in high hs‐CRP group (P = 0.004 and P < 0.001, respectively).

Conclusion:  Elevated level of hs‐CRP is a useful parameter in the severity of clinical risk of pre‐eclampsia in patients with BMI < 25 kg/m2 at third trimester.
The electronically‐controlled axis‐traction handle: Preliminary report
Authors: Perone Nicola
Published: August 2010

Aim:  The scope of this preliminary report is to illustrate the performance characteristics of an electronically‐controlled axis‐traction handle.

Material & Method:  Preclinical testing was conducted with a prototype of the innovative device, using a childbirth simulator.

Results:  The simulated forceps deliveries demonstrated that the innovative device allows the obstetrician to measure (unencumbered by dials, scales and cable connections) the traction applied, to be alerted when the preset 50 lbs (22.68 kg) safety limit is approached, and to generate a hard copy print‐out of the traction data.

Conclusion:  The electronically‐controlled axis‐traction handle represents a major technologic advance, that could help improve the training and safe practice of forceps deliveries.
Microsurgical training in a rat model: an approach and concept for gynecological surgeons
Authors: Kraemer Bernhard , Hoffmann Juergen , Wallwiener Markus , Wallwiener Christian , Rajab Taufiek Konrad
Published: August 2010

Aims:  This study aims to introduce a training program for microvascular anastomosis that includes an in vivo model which is elegant and effective.

Material & Methods:  The infrarenal abdominal aorta or inferior vena cava of anesthetized live Sprague–Dawley rats were dissected, clamped and divided. Two trainees each created 12 microsurgical anastomoses in six animals. The training effect was measured by comparing the time taken to perform the initial anastomoses with the final attempts for each trainee. Afterwards, each anastomosis was probed to check whether the procedure was successful.

Results:  The training model was practical and easy to set up. The average diameter of the aorta measured 1.5 mm and the vein measured 2.1 mm, which reflects the situation in human gynecological reconstructive surgery. The achieved training effect over the course of the training was highly significant. Arterial anastomosis time improved by an average of 8.5 min (P < 0.01) and venous anastomosis time improved by an average of 13.2 min (P < 0.01). The success rate for arterial anastomoses was 67%. In contrast, venous anastomosis was a more difficult exercise, with a success rate of 36% (P < 0.05).

Conclusion:  The study establishes a practicable in vivo model of microvascular anastomotic training for gynecologists.
Cesarean section and hernia repair: simultaneous approach
Authors: Gabriele Raimondo , Conte Marco , Izzo Luciano , Basso Luigi
Published: August 2010

Aim:  Hernias of the abdominal wall occurring during pregnancy are usually treated a few weeks after delivery. The aim of this study was to retrospectively evaluate the clinical outcome of inguinal or umbilical hernioplasty performed at the time of the cesarean section, and to compare the outcome of this group with a control population, who received a cesarean section alone.

Material & Methods:  We reviewed 28 women who developed an inguinal or umbilical hernia during pregnancy from January 1, 2000 to December 31, 2007 and who received a combined cesarean section and hernia repair, and we compared this group with 100 women (controls) who only received a cesarean section.

Results:  In the group of women who received a combined cesarean section and inguinal or umbilical hernia repair, median age was 23.8 years and hospital stay ranged from 3 to 5 days (versus 3–4 days for cesarean sections alone). The time employed for the combined surgical procedure was of 50 ± 7 min and 70 ± 4 min, respectively, for umbilical and inguinal hernia (versus 37.4 ± 12.6 min for cesarean sections alone). No complication was recorded during the perinatal and follow‐up periods, and no recurrences were observed.

Conclusion:  Our analysis suggests that cesarean section and hernia repair, performed in one session, avoids need for readmission to hospital, is safe, effective, and well accepted. It neither increases the complication rate nor prolongs the hospital stay, with clear advantages for both the patients and the hospital budget.
Transvaginal color Doppler study of uterine artery: Is there a role in chronic pelvic pain?
Authors: Somprasit Charintip , Tanprasertkul Chamnan , Suwannarurk Komsun , Pongrojpaw Densak , Chanthasenanont Athita , Bhamarapravatana Kornkarn
Published: August 2010

Aim:  To determine the value of transvaginal color Doppler study of uterine artery and investigate the differences in blood flow of uterine artery among women with chronic pelvic pain (CPP).

Material & Methods:  A total of 50 female patients were recruited. The study group consisted of 25 women with CPP of possible gynecological origin. Twenty‐five women without CPP made a control group. All women were examined using transvaginal color Doppler ultrasonogram after negative finding of pelvic examination. The mean pulsality index (PI) and resistant index (RI) of the uterine arteries were recorded and compared.

Results:  The mean ages were 36.6 ± 10.6 and 32.0 ± 6.7 years in the study group and control group, respectively. The duration of pain ranges from 6–48 months (mean, 14.8). The mean PI and RI values of the uterine arteries in patients with CPP were significantly lower than in the control group; PI = 2.12 ± 0.78, 2.76 ± 0.84 and RI = 0.79 ± 0.19, 0.89 ± 0.05, respectively (P < 0.05).

Conclusions:  Doppler flow indices demonstrated significant increase of uterine arteries vascularization in CPP women related to pelvic causes. Transvaginal ultrasound with noninvasive Doppler study could be a useful primary investigation for CPP women, especially when financial resource is an issue.
Heterogeneity of the supramammillary–hippocampal pathways: evidence for a unique GABAergic neurotransmitter phenotype and regional differences
Authors: Soussi Rabia , Zhang Nianhui , Tahtakran Siroun , Houser Carolyn R. , Esclapez Monique
Published: August 2010

The supramammillary nucleus (SuM) provides substantial projections to the hippocampal formation. This hypothalamic structure is involved in the regulation of hippocampal theta rhythm and therefore the control of hippocampal‐dependent cognitive functions as well as emotional behavior. A major goal of this study was to characterize the neurotransmitter identity of the SuM–hippocampal pathways. Our findings demonstrate two distinct neurochemical pathways in rat. The first pathway originates from neurons in the lateral region of the SuM and innervates the supragranular layer of the dorsal dentate gyrus and, to a much lesser extent, the ventral dentate gyrus. This pathway displays a unique dual phenotype for GABAergic and glutamatergic neurotransmission. Axon terminals contain markers of GABAergic neurotransmission, including the synthesizing enzyme of GABA, glutamate decarboxylase 65, and the vesicular GABA transporter and also a marker of glutamatergic neurotransmission, the vesicular glutamate transporter 2. The second pathway originates from neurons in the most posterior and medial part of the SuM and innervates exclusively the inner molecular layer of the ventral dentate gyrus and the CA2/CA3a pyramidal cell layer of the hippocampus. The axon terminals from the medial part of the SuM contain the vesicular glutamate transporter 2 only. These data demonstrate for the first time the heterogeneity of the SuM–hippocampal pathways, not only from an anatomical but also a neurochemical point of view. These pathways, implicated in different neuronal networks, could modulate different hippocampal activities. They are likely to be involved differently in the regulation of hippocampal theta rhythm and associated cognitive functions as well as emotional behavior.
Functional subdivision of feline spinal interneurons in reflex pathways from group Ib and II muscle afferents; an update
Authors: Jankowska Elzbieta , Edgley Steve A.
Published: August 2010

A first step towards understanding the operation of a neural network is identification of the populations of neurons that contribute to it. Our aim here is to reassess the basis for subdivision of adult mammalian spinal interneurons that mediate reflex actions from tendon organs (group Ib afferents) and muscle spindle secondary endings (group II afferents) into separate populations. Re‐examining the existing experimental data, we find no compelling reasons to consider intermediate zone interneurons with input from group Ib afferents to be distinct from those co‐excited by group II afferents. Similar patterns of distributed input have been found in subpopulations that project ipsilaterally, contralaterally or bilaterally, and in both excitatory and inhibitory interneurons; differences in input from group I and II afferents to individual interneurons showed intra‐ rather than inter‐population variation. Patterns of reflex actions evoked from group Ib and II afferents and task‐dependent changes in these actions, e.g. during locomotion, may likewise be compatible with mediation by premotor interneurons integrating information from both group I and II afferents. Pathological changes after injuries of the central nervous system in humans and the lineage of different subclasses of embryonic interneurons may therefore be analyzed without need to consider subdivision of adult intermediate zone interneurons into subpopulations with group Ib or group II input. We propose renaming these neurons ‘group I/II interneurons’.
A paradox: after stroke, the non‐lesioned lower limb motor cortex may be maladaptive
Authors: Madhavan Sangeetha , Rogers Lynn M. , Stinear James W.
Published: August 2010

What are the neuroplastic mechanisms that allow some stroke patients to regain high‐quality control of their paretic leg, when others do not? One theory implicates ipsilateral corticospinal pathways projecting from the non‐lesioned hemisphere. We devised a new transcranial magnetic stimulation protocol to identify ipsilateral corticospinal tract conductivity from the non‐lesioned hemisphere to the paretic limb in chronic stroke patients. We also assessed corticospinal tract degeneration by diffusion tensor imaging, and used an ankle tracking task to assess lower limb motor control. We found greater tracking error during antiphase bilateral ankle movement for patients with strong conductivity from the non‐lesioned hemisphere to the paretic ankle than for those with weak or no conductivity. These findings suggest that, instead of assisting motor control, contributions to lower limb motor control from the non‐lesioned hemisphere of some stroke survivors may be maladaptive.
Cerebral oxygenation monitoring using near infrared spectroscopy during controlled hypotension
Authors: SHEAR TORIN , TOBIAS JOSEPH D.
Published: August 2010

Background:  Controlled hypotension (CH) is used to limit intraoperative blood loss and decrease the need for homologous transfusions. Despite the efficacy of the technique, hypotension has the potential to affect cerebral perfusion and oxygen delivery. There are no data providing a direct measurement of cerebral oxygenation during this technique.

Methods:  The current study prospectively evaluated cerebral oxygenation during CH using near infrared spectroscopy. Nineteen patients ranging in age from 6 to 18 years were enrolled in the study. CH was provided using a combination of intravenous opioids and sevoflurane supplemented with labetolol as necessary.

Results:  There were a total of 268 readings obtained from the cerebral oximeter. The baseline cerebral oximeter reading was 81 ± 8% on the right and 82 ± 7% on the left. During CH (mean arterial pressure of 65–69, 60–64, 55–59, and <54 mmHg), the right cerebral oximeter values were 80 ± 9, 78 ± 8, 78 ± 10, and 84 ± 9%, respectively while the left cerebral oximeter values were 79 ± 7, 80 ± 7, 78 ± 8, and 78 ± 8%, respectively. Of the 268 readings, there were 11 points (4%) at which either the left or right cerebral oximeter was 10–19 less than the baseline value and no points at which the reading was 20 or more from the baseline value.

Conclusions:  Our preliminary data with a measurement of cerebral oxygenation demonstrates the safety of CH within the accepted mean blood pressure recommendations of 55–65 mmHg.
Nasal foreign bodies in children: a possible pitfall for the anesthesiologist
Authors: PIROTTE THIERRY , IKABU CORNEILLE
Published: August 2010

Based on a recent surprising case in our institution, we analyze the possible dislodgment of an unknown foreign body in the nose during nasotracheal intubation in children. Nasal foreign bodies made of inert material can remain unnoticed for a long period of time. In addition to inserting a close‐fitting suction catheter into the TT during its passage through the nasopharynx, we now suggest performing a pharyngoscopy when intubation is completed.
Epidural abscess following epidural analgesia in pediatric patients
Authors: LIN YUAN‐CHI , GRECO CHRISTINE
Published: August 2010

Epidural abscess following epidural analgesia is an unusual event especially in pediatric patients. Two patients presented with fever and local signs of infection without neurological deficit on day 4 after the initiation of epidural analgesia. Neuro‐imaging studies revealed epidural abscess. Both pediatric patients were treated successfully with intravenous antibiotics. One of the patients’ initial MRI was normal. However, the symptoms persisted and a followed‐up scan revealed epidural abscess. The other patient presented with worsening local indurations over the epidural insertion site and positive blood culture with Hemolytic streptococcus. Our experience suggests that neuro‐imaging study should be strongly considered to evaluate pediatric patients with suspicion of epidural abscess.
Isosulfan blue causes factitious methemoglobinemia in an infant1
Authors: BURGOYNE LAURA L. , W. JAY DENNIS , BIKHAZI GEORGE B. , DE ARMENDI ALBERTO J.
Published: August 2010

A 9 month‐old girl was given subcutaneous isosulfan blue to outline lymphatic channels during surgery for thoracic duct ligation. Her pulse oximetry values rapidly declined to a nadir of 85%, 35 min after dye injection. Arterial blood gases revealed methemoglobinemia ([MetHb] = 6.5%). Although abnormal pulse oximetry has already been reported in association with isosulfan blue, methemoglobinemia has not previously been reported. The absorption spectrum for isosulfan blue was determined and when superimposed on that of methemoglobin it was found to have an overlying peak. Interference by the dye was postulated to have caused the abnormal methemoglobin result. The phenomenon was simulated in vitro by adding isosulfan blue to whole blood, and analysing it in the same blood gas analyser as was used for the case, as well as another for comparison. One blood gas analyser reported elevated methemoglobin concentration and the other did not. The samples were sent to a reference laboratory using a chemical method to detect methemoglobin to confirm that the elevated methemoglobin level was spurious.
Randomized controlled trial of sevoflurane for intubation in neonates
Authors: HASSID SOPHIE , NICAISE CLAIRE , MICHEL FABRICE , VIALET RENAUD , THOMACHOT LAURENT , LAGIER PIERRE , MARTIN CLAUDE
Published: August 2010

Background:  Our aim was to determine whether sevoflurane can be used with safety and efficacy for anesthesia during intubation in term and preterm neonates in a prospective randomized‐controlled nonblinded study in a tertiary neonatal intensive care unit.

Methods:  Thirty‐three neonates were randomly allocated to receive sevoflurane (inspired concentrations varying from 2% to 5%) or no medication (preoxygenation with 100% oxygen alone) before intubation. Minute by minute heart rate (HR), mean arterial blood pressure, SpO2 and number of episodes of bradycardia (HR < 100 b·min−1) and desaturation (SpO2 < 85% for >30 s) were noted from 5 min before to 10 min after intubation. Operator experience, ease and number of attempts were noted.

Results:  No major adverse events were noted in the study group compared with the control group [hypotension (37.5% vs 37.5%, NS), number of desaturations [37.5% vs 44.5%, NS)]. Hypertension (25%, vs 56.3%P = 0.04) and incidence of bradycardias (8.3% vs 44.4%, P < 0.01) were greater in the control group. Intubation was easier in the study group: no movements: 95.5% vs 28% (P < 0.005); good glottis visualization: 73% vs 33% (P = 0.013). The failure rate was lower in the study group (25% vs 39%), but this difference was not statistically significant.

Conclusion:  Anesthesia for intubation with sevoflurane in neonates is well tolerated, even in the less mature. It facilitates the conditions for intubation and leads to fewer adverse events. Other studies are necessary to confirm these preliminary results.
Children with learning disabilities
Authors: COURTMAN SIMON P. , MUMBY D.
Published: August 2010

Children with learning disabilities can present numerous challenges in the acute hospital setting. This review article examines the causes and presentations of learning disability, and considers some of the management strategies employed when these children present for surgery.
Aprotinin and renal dysfunction after pediatric cardiac surgery
Authors: SZÉKELY ANDREA , SÁPI ERZSÉBET , BREUER TAMÁS , KERTAI MIKLÓS D. , BODOR GÁBOR , VARGHA PÉTER , SZATMÁRI ANDRÁS
Published: August 2010

Background: Aprotinin is a potent antifibrinolytic drug, which reduces postoperative bleeding and transfusion requirements. Recently, two observational studies reported increased incidence of renal dysfunction after aprotinin use in adults. Therefore, the aim of the study was to investigate the safety of aprotinin use in pediatric cardiac surgery patients.

Methods: Data were prospectively and consecutively collected from 657 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The database was assessed with regard to a possible relationship between aprotinin administration and dialysis and between aprotinin and postoperative renal dysfunction [defined as 25% decrease in the creatinine clearance (Ccr) compared with the preoperative value] by propensity‐score adjustment and multivariable methods.

Results: The incidence of dialysis (9.6% vs 4.1%;P = 0.005) and renal dysfunction (26.3% vs 16.1%;P = 0.019) was higher in patients who received aprotinin; however, propensity adjusted risk ratios were not significant [odds ratio (OR) of dialysis: 1.22; 95% confidence interval (CI) 0.46–3.22; OR of renal dysfunction 1.26; 95% CI: 0.66–1.92]. Aprotinin significantly reduced blood loss in the first postoperative 24 h. The main contributors of renal dysfunction were CPB duration, cumulative inotropic support, age, preoperative Ccr, amount of transfusion and pulmonary hypertension.

Conclusions: Despite the higher incidences of renal dysfunction and failure in the aprotinin group, an independent role of the drug in the development of renal dysfunction or dialysis could not be demonstrated in pediatric cardiac patients undergoing CPB.
Total spinal in an infant: can ‘dry taps’ occur with 20G Tuohy needles?
Authors: JONMARKER CHRISTER , ROWELL JONATHAN C. , JONMARKER OLOF
Published: August 2010

The loss‐of‐resistance technique was used to place a 20G epidural needle in the lumbar region in an anesthetized and paralyzed infant. There was no cerebrospinal fluid (CSF) leakage and a 24G catheter was inserted through the needle. At end of surgery, when the patient was breathing spontaneously and a bupivacaine bolus was given through the catheter, a total spinal block was identified. A bench test demonstrated that CSF leakage from a 20G needle can be delayed if CSF pressure is low and if air bubbles are present in the needle.
Adverse events and behavioral reactions related to ketamine based anesthesia for anorectal manometry in children
Authors: DALAL PRITI G. , TAYLOR DAN , SOMERVILLE NICOLA , SETH NEENA
Published: August 2010

Background:  Pediatric patients undergoing anorectal manometry require ketamine anesthesia as other anesthetic agents affect the anorectal sphincter tone. The aim of this prospective observational audit was to evaluate our practice and report the occurrence of adverse events and behavioral reactions related to the use of ketamine, propofol, and midazolam combinations.

Methods:  Eighty‐two consecutive pediatric patients (mean age 8.06 ± 3.43 years) undergoing anorectal manometry were audited over a 1‐year period. After a routine ketamine anesthetic some children were administered midazolam 0.1 mg·kg−1, at the discretion of the attending anesthetist. Children requiring anal stretch following manometry studies also received propofol 3–5 mg·kg−1. Intra‐ and postoperative adverse events, times to spontaneous awakening and discharge from the PACU were noted. Postoperative behavioral reactions were noted in the PACU and at follow‐up interviews on the first postoperative day and after a period of 1 month.

Results:  Following completion of the audit, all patients fell into one of the four groups depending on the anesthetic agents they received: K (ketamine only, n = 16), KM (ketamine and midazolam, n = 10), KP (ketamine and propofol, n = 27), and KPM (ketamine, propofol, and midazolam, n = 29). There was no difference in the occurrence of behavioral reactions between the four groups at the three stages of follow‐up. Overall, five patients reported ‘new onset’ nightmares that had resolved completely at the 3‐month follow‐up. The time to spontaneous awakening was shorter for K group (17.8 min ± 20.2) vs KPM group (61.7 min ± 24.4; P < 0.001). The times to discharge in minutes was also shorter in the K group (54.5 min, IQR 30–75 vs 90 min IQR 78–120; P < 0.001). Administration of propofol appeared to have an antiemetic effect [odds ratio (OR) 0.1, 95% confidence intervals (CI) 0.02–0.58, P < 0.009] in the recovery unit.

Conclusions:  Our study findings suggest that, besides significantly prolonging time to spontaneous awakening and PACU discharge, neither the use of midazolam, propofol, or combinations is beneficial in preventing the occurrence of behavioral reactions following ketamine anesthesia. Behavioral reactions were common but did not appear to be long‐term. Drug combinations with ketamine may have other benefits such as antiemesis.
Reversal of rocuronium‐induced neuromuscular blockade by pyridostigmine in patients with Duchenne muscular dystrophy
Authors: MUENSTER TINO , FORST JUERGEN , GOERLITZ PETER , SCHMITT HUBERT J.
Published: August 2010

Background:  The aim of this study was to investigate the effect and safety of pyridostigmine for the reversal of a neuromuscular block (NMB) in patients with Duchenne muscular dystrophy (DMD). In patients with DMD recovery from a rocuronium‐induced NMB is markedly delayed.

Methods:  Fourteen DMD patients (aged between 11 and 19 years) scheduled for elective scoliosis repair were studied. Following tracheal intubation without muscle relaxant, all patients received a single dose of rocuronium 0.6 mg·kg−1. NMB was monitored by acceleromyography at the adductor pollicis muscle. When the first twitch height (T1) of the train‐of‐four (TOF) had recovered to 25% seven patients received either pyridostigmine 0.1 mg·kg−1 (the anticholinergic drug with a long duration of action) or saline in a blinded manner. The times to attain TOF ratio of 0.9 were recorded. For comparison the Mann–Whitney U‐test was used.

Results:  Recovery to TOF ratio of 0.9 was significantly (P < 0.05) accelerated by pyridostigmine [84 (median), 57–141(range)] compared with controls (148, 84–243 min). The recovery time (time between T1 of 25% and TOF of 90%) was also significantly (P < 0.01) shortened by pyridostigmine (15, 8–49 vs 76, 43–144 min, respectively). Time to recovery of T1 to 90% was not different between the groups (108, 63–134 vs 169. 61–208 min, respectively).

Conclusions:  Pyridostigmine 0.1 mg·kg−1 effectively reversed a rocuronium‐induced NMB in DMD patients.
Raynaud’s phenomenon in a child presenting as oxygen desaturation during transfusion with cold blood
Authors: ZHANG XIAOPENG , COTÉ CHARLES J.
Published: August 2010

We report a case of Raynaud’s phenomenon (RP) triggered by transfusion of cold blood to a pediatric burn patient under general anesthesia. The child was febrile so a decision was made to not use a blood warmer. When the blood was rapidly administered the child suddenly developed ‘desaturation’. The child was placed on 100% oxygen, adequate ventilation assured, and the color of his oral mucosa assessed as ‘pink’. Placement of the oximeter on the opposite hand revealed 100% saturation. To our knowledge, this is the first case of apparent RP reported in a pediatric patient triggered by transfusion of cold blood.
Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery
Authors: TIROTTA CHRISTOPHER F. , MUNRO HAMISH M. , SALVAGGIO JANE , MADRIL DANIELLE , FELIX DONALD E. , RUSINOWSKI LYNDA , TYLER CRISTI , DECAMPLI WILLIAM , HANNAN ROBERT L. , BURKE REDMOND P.
Published: August 2010

Aim:  To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery.

Background:  The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population.

Methods/Materials:  Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation.

Results:  Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg·kg−1 vs 0.2 mg·kg−1, P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes.

Conclusions:  A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg·kg−1·h−1, a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.
Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale
Authors: BONG CHOON L. , NG AGNES S.B.
Published: August 2010

Background:  Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery.

Methods:  Three hundred sixteen children aged 2–12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation.

Results:  One hundred and thirty‐six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of ≥10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of ≥10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of ≥10 was 0.98, with a true‐positive rate (sensitivity) of 0.85 and a false‐positive rate (1‐specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening.

Conclusions:  The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of ≥10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.
The place of suxamethonium in pediatric anesthesia
Authors: RAWICZ MARCIN , BRANDOM BARBARA W. , WOLF ANDREW
Published: August 2010

Suxamethonium is a drug that promotes very strong views both for and against its use in the context of pediatric anesthesia. As such, the continuing debate is an excellent topic for a ‘Pro–Con’ debate. Despite ongoing efforts by drug companies, the popular view still remains that there is no single neuromuscular blocking drug that can match suxamethonium in terms of speed of onset of neuromuscular block and return of neuromuscular control. However, with this drug the balance of benefit vs risk and side effects are pivotal. Suxamethonium has significant adverse effects, some of which can be life threatening. This is particularly relevant for pediatric anesthesia because the spectrum of childhood diseases may expose susceptible individuals to an increased likelihood of adverse events compared with adults. Additionally, the concerns related to airway control in the infant may encourage the occasional pediatric anesthetist to use the drug in preference to slower onset/offset drugs. In the current environment of drug research, surveillance and licensing, it is debatable whether this drug would achieve the central place it still has in pediatric anesthesia. The arguments for and against its use are set out below by our two international experts, Marcin Rawicz from Poland and Barbara Brandom from USA. This will allow the reader an objective evaluation with which to make an informed choice about the use of suxamethonium in their practice.
The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants
Authors: EIFINGER FRANK , LENZE MIRIAM , BRISKEN KATRIN , WELZING LARS , ROTH BERNHARD , KOEBKE JÜRGEN
Published: August 2010

Objectives:  Thoracostomy tubes are widely used in neonatology. Complications occurred significantly more frequently in infants, especially neonates, than in adults. Principally, the access is the modified Buelau position which takes place in the anterior axillary line at the 4th or 5th intercostal space above the margin of the ribs.

Aim:  This study seeks to determine the characteristics and topographic conditions of the anatomical structures at the ventral and lateral thoracic wall in the preterm and term neonate.

Background:  Fifteen formalin‐fixed stillborns were prepared (nine male, six female, 28–43 weeks gestational age).

Methods/Materials:  The anatomical preparation involved the complete thoracic wall region.

Results:  In all preparations, a venous vessel was detected at the lateral wall and was identified as v. thoracoepigastrica without accompanying artery. Arteria (a.) and vena (v.) thoracica interna were regularly found close to the sternal plate on both sides between rib and fascia. With increasing gestational ages the course of the v. thoracoepigastrica varied significantly between the left and right thoracic wall. It was demonstrated that the v. thoracoepigastrica regularly arose within the abdominal or thoracic subcutaneous fat and drained into the v. subclavia. The variance between its course was almost 5–12 mm to the lateral or medial side. At both thoracic sides, no other organs or organ structures except lung parenchyma could be detected when using the Buelau position.

Conclusions:  The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants.
Insufflation vs intubation during esophagogastroduodenoscopy in children
Authors: HOFFMANN CLIFFORD O. , SAMUELS PAUL J. , BECKMAN EILEEN , HEIN ELIZABETH A. , SHACKLEFORD T. MICHAEL , OVERBEY EVELYN , BERLIN RICHARD E. , WANG YU , NICK TODD G. , GUNTER JOEL B.
Published: August 2010

Objectives:  We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation.

Background:  Optimum airway management during EGD in children remains undecided.

Methods/materials:  Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi‐square contingency tables or Fisher’s exact test as appropriate.

Results:  Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD.

Conclusions:  Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.
Metabolic changes during major craniofacial surgery
Authors: CHOI ARNWALD Y. S. , AHMAD NARGIS S. , De BEER DAVID A. H.
Published: August 2010

Objectives:  The purpose of this study was to document the degree and duration of perioperative metabolic disturbance during major craniofacial surgery in children.

Aim:  The aim was to quantify the degree and duration of perioperative metabolic disturbance and to determine the relationship between the metabolic changes and the duration of surgery and total volume of blood and colloid given during surgery.

Background:  These patients have the potential for massive blood loss and significant metabolic acidosis. Routine perioperative monitoring includes the serial measurement of base deficit (BD) as a marker of metabolic disturbance.

Methods/Materials:  All patients undergoing elective major craniofacial surgery were prospectively studied over a 10‐month period. BD from arterial blood gas analysis was measured at standardized intervals during the perioperative period. The duration of surgery and total volume of blood and colloid given intraoperatively were used as covariates in a multiple regression analysis.

Results:  Maximum recorded BD ranged from −3 to −20 (median −9). Median time taken to return to normal was 9.25 h (range 0–18 h). Median duration of significant BD was 3.8 h (range 0–20 h).

Conclusions:  Children undergoing major craniofacial surgery develop a varying degree of perioperative metabolic acidosis persisting for several hours. The maximum BD appears to be related to the amount of intraoperative blood loss and replacement rather than duration of surgery. As it is difficult to predict the extent and duration of metabolic acidosis for an individual patient, this study confirmed our current practice that all patients should be admitted to a neurosurgical high‐dependency unit postoperatively for overnight monitoring.