bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery
Authors: Fanelli G. , Casati Dr.A. , Aldegheri G. , Beccaria P. , Berti M. , Leoni A.
Published: January 2009

Background: Cardiovascular function was assessed in 20 ASA I‐II patients, scheduled for elective orthopaedic surgery with tourniquet in order to compare the haemodynamic changes induced by unilateral spinal anaesthesia and combined sciaticofemoral nerve block.

Methods: After baseline measurement of cardiovascular parameters, patients were randomized to receive unilateral spinal anaesthesia or combined sciatico‐femoral nerve block. Spinal anaesthesia was obtained by 8 mg of hyperbaric bupivacaine 0.5% slowly injected (speed=0.02 ml s‐1) through a 25‐G Whitacre spinal needle with the bevel orientated towards the dependent side and patients lying on their operated side for 15 min (group S, n=10). Combined sciatico‐femoral nerve block was obtained by 7 mg kg‐1 of mepivacaine 2% (group NB, n = 10). Haemodynamic variables were recorded 5, 10, 15, and 30 min after anaesthetic injection before surgery was started.

Results: Anthropometric data, duration of surgery and acceptability of anaesthetic techniques were similar in the 2 groups. In 8 patients of group S, spinal block was restricted to the operated side (pinprick test and Bromage scale), while the other 2 patients developed bilateral spinal block after being turned supine. NB patients showed no haemodynamic changes during the study, whereas patients in group S showed a small but significant decrease of mean arterial blood pressure (P<0.002 vs baseline and P<0.04 vs NB), cardiac index (P<0.01 vs baseline and P0.01 vs NB), and stroke volume index (P<0.01 vs baseline and P<0.01 vs NB).

Conclusion: Both sciatico‐femoral and unilateral spinal blockade provide adequate anaesthesia for unilateral leg surgery with tourniquet. The former technique affects cardiovascular performance less than the latter one.
Effects of high thoracic epidural anaesthesia on the peripheral airway reactivity in dogs
Authors: Yuan H. B. , Tang G. J. , Kou Y. R. , Lee T. Y.
Published: January 2009

Background: It has been speculated that epidural anaesthesia may induce bronchoconstriction via the mechanism of a sympathetic blockade. However, this hypothesis has not been confirmed by any experimental evidence. Therefore, we investigated the effects of high thoracic epidural anaesthesia with neural sympathetic blockade on basal airway resistance and airway reactivity in response to bronchoconstrictive stimuli in a canine periphery lung model.

Methods: Acetylcholine (Ach, 8 μg kg‐1 i.v.) or histamine (His, 3 μg kg‐1 i.v.) was administered to 7 anaesthetized mongrel dogs before and after thoracic epidural anaesthesia. Successful neuronal sympathectomy was confirmed by nitroglycerin test. The changes of peripheral airway resistance (Rp), haemodynamics, cardiac output (CO), and the recovery time for Rp from peak returning to baseline in each challenge were studied.

Results: Thoracic epidural anaesthesia altered neither the baseline Rp nor the peak Rp evoked by Ach or His. However, the recovery time of the Rp was prolonged significantly after epidural anaesthesia (P<0.01) and correlated inversely with the CO in response to Ach or His challenge (Ach, r=0.542; His, r=0.651).

Conclusions: Our results suggest that epidural anaesthesia with neural sympatheticblockade has no influence on the basal peripheral airway resistance; however, it prolongs the airway reactivity to Ach or His challenge, probably by the mechanism of reducing CO.
Patients' desire for information about anaesthesia: Danish attitudes
Authors: Bugge K. , Bertelsen F. , Bendtsen A.
Published: January 2009

Background: Patients' desire for information about anaesthesia has been examined in a number of Commonwealth countries but not in Scandinavia. A questionnaire was distributed to form a basis for giving Danish patients more appropriate preoperative information.

Methods: 201 preoperative patients in Denmark were asked to complete a questionnaire. The patients were divided into subgroups according to: age, gender, residential origin, ASA group, educational level, type of anaesthesia planned and number of previous anaesthetics.

Results: Patients from a city area required significantly more information than patients from a rural/urban area about pre‐medication drugs, drips/catheters, pain/pain relief and complications. Men more than women preferred to know about dangerous complications. Information about pain /pain relief, duration of anaesthesia, and influence of anaesthesia on daily activities such as eating, drinking, mobilisation was given the highest priority, while unpleasant information such as about complications and needles was given the lowest priority. Meeting the anaesthetist and information about alternative methods of anaesthesia and premedication drugs were given only moderate priority. Ranking information in Denmark was significantly correlated with Scotland, Canada and Australia, despite profound differences in priority. More often than Danish patients, Australian patients felt they had right to know, and especially about complications.

Conclusion: Patients from a city area required more information than patients from a rural/urban area. Information about the influence on daily activities was preferred to unpleasant information. Ranking information in Denmark was correlated with a number of Commonwealth countries.
Propofol sedation and gastric emptying in volunteers
Authors: Hammas B. , Hvarfner A. , Thörn S.‐E. , Wattwil M.
Published: January 2009

Background: The purpose of this study was to evaluate the effects of light propofol sedation on gastric emptying and orocecal transit time (OCT).

Methods: Ten healthy male volunteers were studied on 2 occasions separated by at least 1 week and were randomly allocated to receive either propofol sedation or i.v. saline as a control. During propofol sedation the volunteers were sedated to grade 2–3 on a 5‐grade scale. This was achieved by a propofol infusion of 5 mg kg‐1 h‐1 initially, which was then titrated down to a dose of 2.4±0.7 mg kg‐1 h‐1 Paracetamol absorption was used as an indirect measure of the rate of gastric emptying and OCT was determined by use of the hydrogen breath test after ingestion of raffinose. Student's t‐test for paired samples was used and the results are presented as means± SD.

Results:During propofol sedation the maximum concentration of paracetamol (Cmax) was 115±26.8μl/L, time to peak concentration (Tmax) 50±38.8 min, and the area under the curve during the first 60 min (AUC604793±1538 μmolXmin/L, versus Cmax 99±20.8, Tmax 69±41.9 and AUC60 3897±1310 during saline infusion. These differences were not statistically significant. OCT was significantly shorter during the control study, 180±32.4 min, than during propofol sedation, 217±64.9 min (P<0.05).

Conclusion: This study in volunteers has shown that gastric emptying of liquids seems uninfluenced by light propofol sedation. OCT was slightly prolonged during light propofol sedation.
Air contamination of a closed anesthesia circuit
Authors: Mizuno K. , Sumiyoshi R.
Published: January 2009

Closed‐circuit anesthesia (CCA) has certain advantages such as decreased cost, decreased anesthetic gas pollution, improved in‐halational gas humidity and temperature in comparison to conventional inhalational anesthesia using a high fresh gas flow, i.e. more than 2 L. min‐1, with a semi‐closed breathing circuit. The main disadvantage of CCA is the possibility of hypoxic anesthetic gas delivery. This potentially lethal situation is caused by an insufficient oxygen flow rate for the body metabolism or by the accumulation of inactive gas, usually nitrogen, within the breathing circuit in spite of a sufficient oxygen concentration in the fresh gas supply to the breathing circuit. In the latter case, the accumulation of inactive gas may also lead an increased risk of awareness because of its dilution effect on the concentrations of inhalational anesthetics. We herein present a case of air contamination of the breathing circuit through a sampling line of an anesthetic gas monitor. The air caused a decrease in the oxygen concentration during closed circuit anesthesia.
Unilateral vocal cord paralysis following endotracheal intubation
Authors: LaursenM.D R. J. , Larsen K. M. , Mølgaard J. , Kolze V.
Published: January 2009

The present report describes a case of postoperative paralysis of the left recurrent laryngeal nerve in a patient undergoing surgery at a site far from the anatomic course of the nerve. Possible aetiological factors, symptoms, management and prophylaxis are discussed.
Inhibition by midazolam of the adrenergic function in the isolated canine mesenteric vein
Authors: Kobayashi Y. , Muldoon S. M. , Kiyose M. , Hagiwara T. , Kumasaka S. , Okabe E.
Published: January 2009

Background:Midazolam has been reported to cause hypotension or to depress sympathetic activity following intravenous injection. However, little information is available concerning the mechanism of these effects. The aim of the present study was to determine the effects of midazolam on release of noradrenaline (NA) at nerve terminals and on receptors in the venous smooth muscle.

Methods:The effect of midazolam at nerve terminals was examined by measuring the amount of NA release from superfused canine mesenteric vein helical strips during electrical stimulation (ES; 5 Hz, 2 ms, 9V). The NA was quantified by high‐performance liquid chromatography with electrochemical detection; tension development evoked by ES was also recorded simultaneously. In a separate series of experiments, ring preparations from the isolated vein were mounted in Krebs‐Ringer solution for isometric tension recording to assess the effect of midazolam on α‐adrenoceptors.

Results:Application of tetrodotoxin (10−6M) or replacement of superfusate with Ca2+‐free solution decreased both the release of NA and the tension development evoked by ES. Yohimbine (5X10−8M) increased the ES‐evoked release of NA, whereas it decreased tension development in the vein strips. Midazolam (10−4M) did not affect either the basal release of NA or the basal tension, but inhibited both the NA release (P<0.01) and the tension development (P<0.01) during ES; midazolam at 10−5M inhibited the tension development (P<0.05) but had no effect on NA release. In the ring preparations, midazolam (10−5and 10−4M) attenuated responses to NA (a mixed α1‐and α2‐adrenoceptor agonist, 10−8to 10−3M), phenylephrine (the α1‐adrenoceptor agonist, 10−8to 10−3M) and 5‐bromo‐6‐[2‐imidazolin‐2yl‐amino]‐quinoxaline (UK14304; the α2‐adrenoceptor agonist, 10−7to 10−3M) in a dose‐dependent manner.

Conclusion:The data obtained in the present study suggest that midazolam at 10−4M may reduce venous tone by inhibiting the release of NA from sympathetic nerve endings and both α2‐ and α2‐adrenoceptor mediated smooth muscle contractions. It is also postulated that a stage of the post‐receptor transduction mechanism linked to the venous smooth muscle contraction may be more sensitive to midazolam than the NA release mechanism at nerve terminals since midazolam at the low concentration tested inhibited ES‐evoked tension development with no effect on the release of NA.
Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis
Authors: Fruergaard K. , Viby‐Mogensen J. , Berg H. , El‐Mahdy A. M.
Published: January 2009

Background: Routine perioperative monitoring with accelero‐myography might prevent residual block, whereas routine tactile evaluation of the response to train‐of‐four (TOF) nerve stimulation does not. The purpose of this prospective, randomised and blinded study was to evaluate the effect of manual evaluation of the response to double burst stimulation (DBS3.3) upon the incidence of residual block.

Methods: Sixty adult patients scheduled for elective abdominal surgery were included in the study. Pancuronium 0.08 to 0.1 mg kg−1 was given for relaxation and tracheal intubation. For maintenance of neuromuscular block, pancuronium 1–2 mg was administered. The patients were randomly allocated into two groups. In group DBS (double burst stimulation) the degree of block during anaesthesia was assessed by manual evaluation of the response to TOF nerve stimulation. During reversal, when no fade was detectable in the TOF response, the stimulation pattern was changed to DBS3.3. The trachea was extubated when the anaesthetist judged the neuromuscular function to have recovered adequately and no fade in the DBS3.3 response could be felt. In group CC (clinical criteria) patients were managed without the use of a nerve stimulator, and the level of neuromuscular block and reversal were evaluated solely on the basis of clinical criteria. In both groups, the TOF ratio was measured by mechanomyography immediately after tracheal extubation. Also, the ability to sustain head lift for 5 s, to protrude the tongue, to open the eyes, and to lift one arm to the opposite shoulder were tested.

Results: The TOF ratio, as measured immediately after tracheal extubation, was significantly lower in group CC than in group DBS (means: 0.68 and 0.78, respectively), and the incidence of residual neuromuscular block defined as a TOF ratio <0.7 was significantly higher in group CC than in group DBS (57 and 24%, respectively). The time from the first TOF measurement until the TOF ratio reached 0.8 was significantly longer in group CC than in group DBS (means: 11.5 and 6.2 min, respectively). No significant differences between the two groups of patients were found in duration of anaesthesia, in times from end of surgery to injection of neostigmine, tracheal extubation or TOF ratio 0.8, in dose of pancuronium, or in any other postoperative variable.

Conclusion: Routine perioperative manual evaluation of the responses to TOF and DBS3.3 decreased the incidence and the degree of residual block following the use of pancuronium. It did not, however, exclude clinically significant residual paralysis, nor did it influence the amount of pancuronium used during the operation, the duration of anaesthesia or the time from end of surgery to tracheal extubation or to sufficient recovery of neuromuscular function (TOF=0.8).
Use of the laryngeal mask airway during ophthalmic surgery results in stable circulation and few complications: a prospective audit
Authors: Ates̨ Y. , Alanoĝlu Z. , Uysalel A.
Published: January 2009

Background: This study was performed to investigate airway complications related to Laryngeal Mask Airway (LMA) use in a selected group of paediatric patients undergoing ophthalmic surgery.

Methods: Ninety‐four paediatric patients were enrolled. LMA was inserted under deep general anaesthesia with the standard technique previously described by Brain. Complications during induction, insertion of the LMA, maintenance of anaesthesia, removal of the LMA, emergence and on the first postoperative day were recorded. Failure of insertion, desaturation, laryngospasm, bronchospasm, vomiting, bucking, dislocation of the LMA, breath‐holding, and coughing were noted.

Results: There was no significant age‐related difference in successful insertion ratio of the LMA. In two patients (2%), the LMA could not be inserted with three attempts and tracheal intubation was performed. Laryngospasm was recorded in three patients (3%), leading to desaturation in two patients (SaO295%) during insertion of the LMA. During maintenance of anaesthesia bucking occurred in one patient (1%). After removal of the LMA, incidence of early desaturation following upper airway suctioning was higher in patients with a history of frequent upper respiratory tract infection (P<0.01). Five patients (5%) had laryngospasm following the LMA removal; breath‐holding and coughing were noted in 21 (22%) patients. Circulatory reactions to insertion and removal of the LMA were minimal. The incidence of sore throat on the first postoperative day was only 1%.

Conclusion: LMA can be regarded as a safe product for airway maintenance during ophthalmic surgery with a stable circulation and few complications.
1 MAC‐incision sevoflurane prevents explicit awareness during surgical skin incision and tracheal intubation
Authors: Mollestad K. E. , Heier T. , Steen P. A. , Raeder J. C.
Published: January 2009

Background: This study tested the hypothesis that 1 MAC‐incision anesthesia secures unconsciousness during surgical skin incision and tracheal intubation.

Methods: Twenty patients scheduled for gynecological laparotomy were anesthetized with sevoflurane as the sole agent. At 1 MAC‐incision steady‐state conditions, the patients were observed for autonomic /movement responses and wakefulness (response to verbal commands) in the 1‐min period following surgical skin incision and tracheal intubation.

Results: Blood pressure and heart rate increased significantly secondary to both stimuli, and significantly more after tracheal intubation than skin incision. Ten and 19 patients moved in response to skin incision and tracheal intubation, respectively. None of the patients showed wakefulness.

Conclusion: It is concluded that 1 MAC‐incision sevoflurane secures unconsciousness during surgical skin incision and tracheal intubation.
Changing preoperative fasting policies: Impact of a national consensus
Authors: Fasting S. , SØReide E. , Ræder J. C.
Published: January 2009

Background: Liberalisation of preoperative fasting rules has been discussed and recommended in the anaesthesia literature in recent years. In Norway, a national consensus on this issue was reached in 1993. The aim of the present study was to investigate whether a national consensus on fasting recommendations led to a change in fasting policies in Norwegian anaesthesia departments.

Methods: A questionnaire on preoperative fasting routines was sent to all Norwegian anaesthesia departments in 1993 and repeated in 1996.

Results: Written local guidelines for preoperative fasting were present in 85% of the institutions in both surveys. Of the hospitals, 69% had changed their local guidelines after the national consensus. In 1996 more hospitals allowed less than 6 h fasting for clear liquids in children (93% versus 71% in 1993; P<0.005). A similar tendency was noted in adults (79% versus 63% in 1993; P=0.1). In contradiction to the national guidelines, 31% of the departments reported that they allowed less than 6 h fasting after a light breakfast in the morning of surgery in 1996. The corresponding number for 1993 was 21% (ns).

Conclusion: The new, consensus‐based national fasting guidelines have been associated with a change towards more liberal fasting policies in Norwegian departments of anaesthesia. However, as not all local changes were supported by the national consensus, other sources of information were used when local policies were decided.
Respiration during emergence from anaesthesia with desflurane/N2O vs. desflurane/air for gynaecological laparoscopy
Authors: Einarsson S. G. , Cerne A. , Bengtsson A. , Stenqvist O. , Bengtson J. P.
Published: January 2009

Background: The complications related to anaesthesia usually occur in the early postoperative period. Hypercapnia and hypoxaemia may result from any persistent depression of the respiratory drive relative to the metabolic demand. The purpose of this study was to compare the respiratory effects of desflurane anaesthesia with or without nitrous oxide during the period of emergence.

Methods: Twenty patients scheduled for a standardised surgical procedure, laparoscopic hysterectomy, were randomly allocated to anaesthesia with 1.3 MAC of desflurane/N2O (Group 1) or desflurane alone (Group 2), with 10 patients in each group. Times of resumption of spontaneous breathing and extubation were recorded and elimination rates of carbon dioxide, end‐tidal concentrations of desflurane and N2O, and blood gases were measured.

Results: Spontaneous breathing was resumed in both groups when pH had decreased by about 0.07 and PaCO2 increased by about 1.4 kPa compared with the values at the end of 1.3 MAC anaesthesia with controlled normoventilation. There were no significant differences between the groups with regards to extubation time, 6 vs. 13 min, or total MAC value at extubation, 0.20 vs. 0.19 in Group 1 and 2, respectively. Neither did the groups differ in minute ventilation, end‐tidal carbon dioxide, oxygen concentrations, or blood gases. CO2 elimination decreased in both groups from about 220 ml 70 kg−1 min−1 at the end of anaesthesia to a lowest value of about 160 ml 70 kg−1 min−1.

Conclusion: The respiratory profiles during recovery from gynaecological laparoscopy with either desflurane/N2O or desflurane anaesthesia were similar with fast resumption of spontaneous breathing, short time to extubation, and no signs of CO2 retention.
Puncture technique and postural postdural puncture headache. A randomised, double‐blind study comparing transverse and parallel puncture
Authors: Flaatten H. , Thorsen T. , Askeland B. , Finne M. , Rosland J. , Hansen T. , Rønhovde K. , Wisborg T.
Published: January 2009

Background: This clinical study was conducted in order to investigate the effect of two different orientations of the bevel during dural puncture on development of postural postdural puncture headache (PPDPH).

Methods: Two hundred and eighteen patients aged 18 to 50 years scheduled lor minor non‐obstetric surgery using spinal anaesthesia (SA) were included in this randomised, double‐blind study. Dural puncture was performed using a 0.42 mm O.D. (27‐g) Quincke spinal needle with the orientation of the bevel parallel or transverse relative to the longitudinal axis of the dural cylinder. All patients were blinded with regard to the puncture technique, and so was the anaesthesiologist performing a telephone interview 5 to 7 days postoperatively. The occurrence and duration of headache, backache and other complaints were recorded. Headache was classified as PPDPH or non‐PPDPH, and intensity of the headache was registered using a numerical rating scale (NRS) from 0 to 10.

Results: Two hundred and twelve patients with a mean age of 35.3 years completed the study, 106 in each group. The two groups were comparable with regard to mean age, sex, local anaesthetics used and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 4/106 patients (3.8%) in the parallel group and 24/106 (22.6%) in the transverse group (P<0.0002). Postoperative backache occurred in 31 and 20 patients (parallel compared to transverse) (NS).

Conclusions: Dural puncture with the bevel of the needle transverse to the longitudinal axis of the dural cylinder gave significantly more cases of PPDPH than puncture with the bevel parallel to this axis even when using a 27‐g Quincke needle. When using Quincke bevelled needles care must be taken to assure that the orientation of the bevel is parallel to the longitudinal axis of the dural sac.
How many parents should we let into the operating room?
Authors: KAIN ZEEV N. , MACLAREN JILL , WEINBERG MEGAN , HUSZTI HEATHER , ANDERSON CYNTHIA , MAYES LINDA
Published: January 2009

Objective:  This study compared anxiety of children with one and two parents present at anesthesia induction.

Methodology:  Baseline measures of parent and child anxiety were obtained; parents were randomly assigned to the two study groups. Validated and reliable tools were used to assess the outcomes of interest.

Results:  We found that observed anxiety of children as well as compliance of children with the induction process was not different between the two study groups. Parent’s anxiety was also evaluated using two‐way anova with repeated measures. A group by time interaction was demonstrated and parents in the one‐parent group reported significantly higher anxiety than parents in the two‐parents group (M = 48.6, sd = 13.1 vs M = 39.7, sd = 11.5, P < 0.02).

Conclusions:  We conclude that while allowing two parents into the operating rooms does not affect observed child anxiety, it does reduce parent self‐reported anxiety. As the presence of multiple parents during invasive medical procedures is in congruence with family centered‐care we recommend that institutions examine this modality.
Life threatening medullary injury following adenoidectomy and local anesthetic infiltration of the operative bed
Authors: HERSHMAN ELI , HALBERTHAL MICHAEL , GOLDSHER DORIT , GOLZ AVISHAI , BAR‐JOSEPH GAD
Published: January 2009

Objective:  To draw attention to a rare, life threatening complication of a rather common procedure, namely medullary injury following adenoidectomy and local anesthetic infiltration of the operative bed.

Design:  Case report.

Setting:  A tertiary pediatric critical care unit.

Patient:  A healthy 7‐year‐old girl underwent adenoidectomy and local anesthetic infiltration of the adenoid bed with lidocaine and adrenaline. In the recovery room, nystagmus, dysarthria, dyspnea, inability to cough and right hemiparesis were noticed. Because of her inability to remove secretions tracheal intubation was performed, followed by severe, life threatening respiratory failure.

Interventions:  Tracheal intubation, hemodynamic support, prolonged mechanical ventilation, nitric oxide, and tracheostomy.

Conclusion:  In children, local anesthetic infiltration of the adenoid bed may cause life‐threatening medullary injury and its routine use should be re‐considered.
Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities
Authors: KANNIKESWARAN NIRUPAMA , MAHAJAN PRASHANT V. , SETHURAMAN USHA , GROEBE ANNA , CHEN XINGUANG
Published: January 2009

Background:  There are few studies on sedation medication requirements and sedation related adverse events in developmentally disabled children.

Objectives:  The objectives of our study were to compare sedation medication received and sedation related adverse events for brain magnetic resonance imaging (MRI) between children with and without developmental disabilities. We hypothesized that developmentally disabled children would require increased doses of sedative medications and will have increased frequency of adverse events when compared with normal children.

Methods:  We conducted a retrospective chart review on children 1–18 years, who required sedation for an elective brain MRI. Children were excluded if they required sedation for diagnostic imaging other than brain MRI, belonged to ASA category >3, or required general anesthesia. Data on developmental status, demographics and details of sedation medications received along with adverse events were collected.

Results:  About 53.5% (260/486) of the patients were classified as developmentally disabled. Pentobarbital and fentanyl were the two most common medications used for sedation in children with and without developmental disability. There was no difference in the mean dosages of pentobarbital (3.02 mg·kg−1 vs 3.06 mg·kg−1; P = 0.2) and fentanyl (1.01 mcg·kg−1 vs 1.02 mcg·kg−1; P = 0.81) in the two groups. There was a threefold increased incidence of hypoxia noted in children with developmental disability (11.9% vs 4.9%; P < 0.01). Presence of developmental disability alone was significantly associated with sedation related hypoxia (OR = 3.2, 95% CI: 1.8, 6.94; P < 0.01).

Conclusions:  Children with developmental disabilities have similar requirements for sedation medications but are three times more likely to experience hypoxia when compared with normal children.
Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial
Authors: GOLAN G. , TIGHE P. , DOBIJA N. , PEREL A. , KEIDAN I.
Published: January 2009

Objective:  To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention.

Methods:  This was a randomized, controlled, and blinded study conducted with children 3–8 years of age undergoing general anesthesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mg·kg−1 oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading.

Results:  The clown group had a statistically significant lower modified‐Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns’ effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups.

Conclusions:  This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced.
Normal control charts with nonparametric safeguard
Authors: Albers Willem , Kallenberg Wilbert C. M.
Published: January 2009

Parameter estimation causes a considerable stochastic error in standard Shewhart charts. This problem can be solved using suitable correction factors. However, if the normality assumption itself fails, in addition a non‐vanishing model error occurs. By then, a nonparametric alternative, such as the recently proposed MIN chart, might be a better idea throughout. However, for those reluctant to give up on the Shewhart chart, a third possibility is offered here. One sticks with this traditional chart as long as the data suggest that the resulting model error is acceptable. Only if this is not the case, the MIN chart kicks in and as such serves as a nonparametric safeguard.
THROUGH A DIFFERENT LENS: RETHINKING THE ROLE OF SEXUAL DIFFERENCE IN THE THEOLOGY OF HANS URS VON BALTHASAR
Authors: SAIN BARBARA K.
Published: January 2009

Sexual difference plays a pivotal role in Balthasar's thought, as an analogy for the Trinity and as an analogy for the relation between Christ and the church. This essay examines the influence of the analogy of being on his interpretations of these analogies, his understanding of created masculinity, and his use of the language of sexual difference for the Holy Spirit. Ultimately many of Balthasar's best insights about human love as an analogy for divine love can be retained without connecting femininity uniquely with creation, and his trinitarian theology provides the best interpretive key for doing so.
“BE NOT OVERCOME BY EVIL, BUT OVERCOME EVIL WITH GOOD”—AN ORIENTATIONAL APPROACH TO SUFFERING AND EVIL
Authors: GOCKEL MATTHIAS
Published: January 2009

I discuss two recent books by Ingolf U. Dalferth, which consider the problem of suffering and evil. Dalferth argues that evil is defined by events where someone experiences ills, not by an act of the will or an evil intention, as Kant thought. Suffering is seen in relation to evil, evil in relation to God, and God in relation to the history of Jesus Christ, in whom God created new life through the overcoming of evil. Christianity shall proclaim the end of evil, not the end of suffering. Dalferth contends that nothing connects human beings as strongly as the common experience of evil. Unfortunately, he does not elaborate on the problem of sin, especially in relation to God.
Current debates in global strategy
Authors: Peng Mike W. , Pleggenkuhle‐Miles Erin G.
Published: January 2009

Debates help drive research forward. This paper is unique in its review of four current debates in the global strategy arena: (1) cultural vs institutional distance; (2) global vs regional geographic diversification; (3) convergence vs divergence in corporate governance; and (4) domestic vs overseas corporate social responsibility. For each debate, the history is tracked and the emerging tension highlighted. By introducing both sides of four lively and timely debates, the paper provides an innovative way of reviewing the literature and helping to advance the field. It is argued that an underlying theme connecting these four diverse debates is the institution‐based view of global strategy.
Short incubation with methyl aminolevulinate for photodynamic therapy of actinic keratoses
Authors: Braathen LR , Paredes BE , Saksela O , Fritsch C , Gardlo K , Morken T , Frølich KW , Warloe T , Solér AM , Ros A‐M
Published: January 2009

Background  Photodynamic therapy (PDT) using methyl aminolevulinate (MAL) is an effective first‐line treatment for actinic keratoses. A reduced incubation period may have practical advantages.

Objective  This study aims to evaluate the effect of incubation time (1 vs. 3 h), MAL concentration (160 mg/g vs. 80 mg/g) and lesion preparation in the setting of MAL‐PDT for treatment of actinic keratosis (AK).

Design  Open, randomized, parallel‐group multicentre study.

Setting  Outpatient dermatology clinics.

Subjects  One hundred and twelve patients with 384 previously untreated AK. Most lesions (87%) were located on the face and scalp and were thin (55%) or moderately thick (34%).

Methods  Lesions were debrided, and MAL cream (160 mg/g or 80 mg/g) was applied before illumination with red light (570–670 nm; light dose, 75 J/cm2). Patients were followed up at 2 and 3 months. Sixty patients (54%) were re‐treated and assessed at 6 months.

Main outcome  Complete lesion response rates 3 and 12 months after last treatment.

Results  For lesions on the face/scalp, lesion complete response rates were 78% for thin AK and 74% for moderately thick AK lesions after 1 h vs. 96% and 87% after 3 h incubation with MAL 160 mg/g. Lesion recurrence rates at 12 months after two treatments were similar [19% (3 of 16) with 1 h vs. 17% (3 of 18) with 3 h 160 mg/kg MAL‐PDT] and lower than for 80 mg/g MAL‐PDT (44–45%).

Conclusion  MAL‐PDT using a 1‐h incubation may be sufficient for successful treatment of selected AK lesions.

Conflicts of interest

Lasse R Braathen consults for Photocure and has received speaker honoraria from Photocure and Galderma. Trond Warloe is a co‐inventor of the corresponding patent and is a minor share holder of Photocure ASA. Tore Morken has been paid as a chairman of a Photocure‐sponsored symposium. Bruno E Paredes, Olli Saksela, Clemens Fritsch, Kerstin Gardlo, Karin W Frölich, Ana M Solér and Ann‐Marie Ros do not have any relevant conflict of interest, financial or otherwise.
Endothelial CD200 is heterogeneously distributed, regulated and involved in immune cell–endothelium interactions
Authors: Ko Ya‐Chen , Chien Hsiung‐Fei , Jiang‐Shieh Ya‐Fen , Chang Chiu‐Yun , Pai Man‐Hui , Huang Jian‐Pei , Chen Hui‐Min , Wu Ching‐Hsiang
Published: January 2009

CD200 is a highly glycosylated cell surface protein containing two immunoglobulin superfamily domains in the extracellular region and performs immunosuppressive activities. It is widely distributed in various tissues including the vascular endothelium. We report here the distribution of CD200 in rat endothelia from different vascular beds. Endothelial CD200 immunoreactivity was weakly expressed in most arteries but was intensely expressed in the arterioles, most veins and venules, as well as continuous and fenestrated capillaries. The distribution of CD200 in the sinusoidal and lymphatic endothelia was variable. Immunoelectron microscopic studies revealed that endothelial CD200 varied considerably not only in different microvasculatures but also in the membrane domains at the subcellular level. Endothelial CD200 expression was differentially regulated by lipopolysaccharide in cell types both in vivo and in vitro. Functional assessments of endothelial CD200 suggested that the physical binding between CD200 and CD200 receptor (CD200R) was involved in T‐cell adhesion to the endothelium but not in macrophage–endothelium interaction. In the latter, however, CD200 agonist, a synthetic peptide from complementarity‐determining region 3 of mouse CD200, may trigger CD200R signaling in macrophages to suppress their adhesion to the endothelium. Our findings demonstrate that the distribution, subcellular localization, and lipopolysaccharide‐regulation of endothelial CD200 are heterogeneous, and provide evidence elucidating the functional roles of endothelial CD200 during tissue inflammation.
Cytoskeletal proteins in thymic epithelial cells of the Australian lungfish Neoceratodus forsteri
Authors: Mohammad Mohammad G. , Raftos David A. , Joss Jean
Published: January 2009

The vertebrate thymus consists of distinctive subpopulations of epithelial cells that contain a diverse repertoire of cytoskeletal proteins. In this study of the thymus in the Australian lungfish, Neoceratodus forsteri, immunohistochemistry was used to distinguish the cytoskeletal proteins present in each class of thymic epithelial cell. A panel of antibodies (Abs), each specific for a different cytoskeletal polypeptide (keratins, vimentin, desmin, actin and tubulins), was used on paraffin and ultrathin resin sections of thymus. Ab AE I (reactive against human type I cytokeratins (CK) 14, 16 and 19) selectively stained the cytoplasm of capsular, trabecular and the outermost epithelial cells of Hassall's corpuscles. Anti‐CK 10 Abs strongly labelled the capsular epithelial cells and less than 20% of cortical and medullary epithelial cells. The anti‐50‐kDa desmin Ab did not react with any thymic cells, whereas the anti‐53‐kDa desmin Ab labelled some capsular, cortical and medullary thymic epithelial cells. The anti‐vimentin Ab stained most of the capsular and ~60% of the cortical epithelium. Thymic nurse cells and Hassall's corpuscles were found to be devoid of actin, which was strongly detected in medullary and perivascular epithelium. Both α and β tubulins were detected in all thymic cells. This study extends the concept of thymic epithelial heterogeneity. The complexity of thymic epithelium in N. forsteri may indicate a relationship between thymic epithelial subpopulations and the thymic microenvironment. These data identify anti‐keratin Abs as a valuable tool for studying differentiation and ontogeny of the thymic epithelium in N. forsteri.
Comparative microanatomy of the orbicularis oris muscle between chimpanzees and humans: evolutionary divergence of lip function
Authors: Rogers Carolyn R. , Mooney Mark P. , Smith Timothy D. , Weinberg Seth M. , Waller Bridget M. , Parr Lisa A. , Docherty Beth A. , Bonar Christopher J. , Reinholt Lauren E. , Deleyiannis Frederic W.‐B. , Siegel Michael I. , Marazita Mary L. , Burrows Anne M.
Published: January 2009

The orbicularis oris muscle plays a role in the production of primate facial expressions and vocalizations, nutrient intake, and in some non‐human primates it is used as a prehensile, manipulative tool. As the chimpanzee (Pan troglodytes) is the closest living relative of humans, a comparison of the orbicularis oris muscle between these species may increase our understanding of the morphological specializations related to the differing functional demands of their lips and the factors responsible for their divergent evolution. To this end, this study compares the microanatomy of the mid‐line upper fibers of the orbicularis oris muscle between chimpanzees and humans. A mid‐line portion of the orbicularis oris muscle was harvested from the upper lips of three chimpanzee and five human cadavers. The sampled blocks included the area between the lateral borders of the nasal alar cartilages in both species. Each sample was processed for paraffin histology, sectioned and stained with a variety of protocols. Sections were examined for fiber direction and relative thickness of muscle layers. Ratios of cross‐sectional connective tissue area vs. cross‐sectional muscle tissue area, muscle fiber diameter and relative dermal thickness were calculated for each species. In both species, a clear pars marginalis layer was recognized, contrary to previous reports that only humans possess this layer. In chimpanzees, the relative fiber diameter and relative amount of muscle tissue (i.e. based on ratio of connective tissue area : muscle tissue area) were significantly (P < 0.05) greater than in humans. In contrast, measurements of relative dermal thickness showed that humans have a greater average dermal thickness of the upper lip than chimpanzees. Taken together, these results suggest that both human and chimpanzee orbicularis oris muscle upper fibers meet the specific functional demands associated with their divergent vocal and facial display repertoires, the development of human speech, and the use of the upper lip as a prehensile tool in chimpanzees.
Pelvic and thigh musculature in frogs (Anura) and origin of anuran jumping locomotion
Authors: Přikryl Tomáš , Aerts Peter , Havelková Pavla , Herrel Anthony , Roček Zbyněk
Published: January 2009

Comparative analysis of the anuran pelvic and thigh musculoskeletal system revealed that the thigh extensors, responsible for the initial phase of jump, the propulsive stroke in swimming and, if used asynchronously, also for walking, are least affected by the transformations observed between anurans and their temnospondyl ancestors (as reflected in contemporary caudates). The iliac shaft and urostyle, two of the most important anuran apomorphies, represent skeletal support for muscles that are mostly protractors of the femur or are important in attaining a crouching position, a necessary prerequisite for rapid escape. All of these muscles originate or insert on the iliac shaft. As the orientation of the pubis, ischium and ilium is the same in anurans, caudates and by inference also in their temnospondyl ancestors, it is probable that the pelvis was shifted from the sacral vertebra posteriorly along the reduced and stiffened tail (urostyle) by the elongation of the illiac shaft. Thus, the original vertical orientation of the ilium was maintained (which is also demonstrated by stable origins of the glutaeus maximus, iliofemoralis and iliofibularis on the tuber superius) and the shaft itself is a new structure. A review of functional analysis of anuran locomotion suggests some clear differences from that in caudates, suggesting that terrestrial jumping may have been a primary locomotor activity, from which other types of anuran locomotion are derived.
Development of the mandibular condylar cartilage in human specimens of 10–15 weeks’ gestation
Authors: Mérida Velasco J. R. , Rodríguez Vázquez J. F. , De la Cuadra Blanco C. , Campos López R. , Sánchez Montesinos , Mérida Velasco J. A.
Published: January 2009

This study analyses some morphological and histological aspects that could have a role in the development of the condylar cartilage (CC). The specimens used were serial sections from 49 human fetuses aged 10–15 weeks. In addition, 3D reconstructions of the mandibular ramus and the CC were made from four specimens. During weeks 10–11 of development, the vascular canals (VC) appear in the CC and the intramembranous ossification process begins. At the same time, in the medial region of the CC, chondroclasts appear adjacent to the vascular invasion and to the cartilage destruction. During weeks 12–13 of development, the deepest portion of the posterolateral vascular canal is completely surrounded by the hypertrophic chondrocytes. The latter emerge with an irregular layout. During week 15 of development, the endochondral ossification of the CC begins. Our results suggest that the situation of the chondroclasts, the posterolateral vascular canal and the irregular arrangement of the hypertrophic chondrocytes may play a notable role in the development of the CC.
The developmental clock of dental enamel: a test for the periodicity of prism cross‐striations in modern humans and an evaluation of the most likely sources of error in histological studies of this kind
Authors: Antoine Daniel , Hillson Simon , Dean M. Christopher
Published: January 2009

Dental tissues contain regular microscopic structures believed to result from periodic variations in the secretion of matrix by enamel‐ and dentine‐forming cells. Counts of these structures are an important tool for reconstructing the chronology of dental development in both modern and fossil hominids. Most studies rely on the periodicity of the regular cross‐banding that occurs along the long axis of enamel prisms. These prism cross‐striations are widely thought to reflect a circadian rhythm of enamel matrix secretion and are generally regarded as representing daily increments of tissue. Previously, some researchers have argued against the circadian periodicity of these structures and questioned their use in reconstructing dental development. Here we tested the periodicity of enamel cross‐striations – and the accuracy to which they can be used – in the developing permanent dentition of five children, excavated from a 19th century crypt in London, whose age‐at‐death was independently known. The interruption of crown formation by death was used to calibrate cross‐striation counts. All five individuals produced counts that were strongly consistent with those expected from the independently known ages, taking into account the position of the neonatal line and factors of preservation. These results confirm that cross‐striations do indeed reflect a circadian rhythm in enamel matrix secretion. They further validate their use in reconstructing dental development and in determining the age‐at‐death of the remains of children whose dentitions are still forming at the time of death. Significantly they identify the most likely source of error and the common difficulties encountered in histological studies of this kind.
The fascia of the limbs and back – a review
Authors: Benjamin Mike
Published: January 2009

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body‐wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.