A reusable, custom-made warming blanket prevents core hypothermia during major neonatal surgery

PURPOSE: To introduce a reusable model of neonatal forced air warming blanket for intraoperative use during major noncardiac neonatal surgery and to determine clinical efficacy of this reusable blanket compared with the commonly used disposable blankets. METHODS: Delivered air temperature and calorie uptake of standard thermal bodies within the reusable blankets, Bair Hugger(R) blanket model 530 and model 555 were studied. Also, an efficacy study was conducted in 90 neonatal patients scheduled for major noncardiac surgery comparing the reusable blanket, the Bair Hugger(R) blanket model 530 and passive heat conservation as a control. The covered reusable blanket was used as a rescue procedure if the core temperature was < 35.5 degrees C. RESULTS: Delivered air temperature and heat transfer from the covered reusable blanket did not differ significantly from those of the Bair Hugger(R) blanket model 530 and model 555 (despite 0.75 degrees C-1.2 degrees C of heat trapped under the sheet and 1.3 Kcal less energy transfer). Temperatures measured underneath patients (correlated to poorly perfused areas) were highest using the Bair Hugger(R) blanket model 555. The reusable blanket was efficacious in preventing intraoperative core hypothermia and not different from the Bair Hugger(R) blanket model 530. About 1/3 of the patients in the control group had presented a core temperature < 35.5 degrees C but were successfully rescued using the reusable blanket. No adverse events were associated with any of these warming methods. CONCLUSION: This study shows the clinical efficacy of our reusable blanket for the prevention of core hypothermia during major neonatal surgery, which is not different from commonly used disposable blankets.     

Innate immunity and its role against infections.

LEARNING OBJECTIVES: This article reviews current concepts of the innate immune system that offers protection against infections. It offers an overview for the readers to understand how innate immunity, consisting of different receptors, cells, and mediators recognizes pathogens and exerts protective function against pathogens. DATA SOURCES AND STUDY SELECTION: MEDLINE-search articles including original research papers, review articles, textbooks, and references identified from bibliographies of relevant articles. RESULTS AND CONCLUSIONS: The innate immune system is nonspecific immunity present since birth not requiring repeated exposure to pathogens. It is capable of differentiation between self and nonself. Because of its nonspecificity, it has a broad spectrum of resistance to infection. Further, it is thought to play an important role in the control of adaptive immunity by regulating co-stimulatory molecules and effector cytokines. Innate immunity includes pattern recognition molecules/receptors, antimicrobial peptides, the complement system, inflammatory mediators, and cytokines produced by immune cells. Pattern recognition molecules/receptors recognize pathogen-associated molecular patterns that are essential for microorganisms' survival and pathogenicity. Although innate immunity has recently gained increasing importance, further studies are necessary for a better understanding of its role.     

Hepatic fat content is a determinant of postprandial triglyceride levels in type 2 diabetes mellitus patients with normal fasting triglyceride

Postprandial hypertriglyceridemia is common in type 2 diabetes mellitus (T2D). Significant numbers of T2D patients who have normal fasting triglyceride (TG) have postprandial hypertriglyceridemia. The role of regional adipose tissue and adiponectin on postprandial TG responses in this group of T2D patients is unclear. This study aimed to examine the contribution of regional adipose tissue and adiponectin to the variation of postprandial TG responses in T2D patients who have normal fasting TG levels. Thirty-one Thai T2D patients who had fasting TG<1.7 mmol/L were studied. All were treated with diet control or sulphonylurea and/or metformin. None was treated with lipid-lowering agents. Mixed-meal test was performed after overnight fast. Plasma glucose, insulin, and TG were measured before and 1, 2, 3, and 4 hours after the test. Adiponectin was measured in fasting state. Visceral as well as superficial and deep subcutaneous abdominal adipose tissues were determined by magnetic resonance imaging, and hepatic fat content (HFC) was determined by magnetic resonance spectroscopy. Univariate and multivariate regression analyses of postprandial TG and regional adipose tissue and metabolic parameters were performed. The TG levels before and 1, 2, 3, and 4 hours after the mixed meal were 1.32+/-0.40 (SD), 1.40+/-0.41, 1.59+/-0.40, 1.77+/-0.57, and 1.80+/-0.66 mmol/L, respectively (P<.0001). The area under the curve (AUC) of postprandial TG was positively and significantly correlated with fasting TG (r=0.84, P<.0001) and log.HFC (r=0.456, P=.033) and was inclined to be correlated with log.deep subcutaneous adipose tissue (r=0.38, P=.05) and sex (r=0.326, P=.073). The AUC of postprandial TG was not correlated with age, body mass index, waist circumference, log.superficial subcutaneous adipose tissue, log.visceral adipose tissue, hemoglobin A1c, fasting glucose, AUC.glucose, log.fasting insulin, log.AUC.insulin, log.homeostasis model assessment%B, log.homeostasis model assessment of insulin resistance, and adiponectin. Only fasting TG (beta=.815, P<.0001) and log.HFC (beta=.249, P=.035) predicted AUC of postprandial TG in regression model (adjusted R2=0.84, P<.0001). In conclusion, in T2D patients with normal fasting TG, the increase of postprandial TG levels is directly determined by fasting TG level and the amount of hepatic fat.     

A survey of metacercariae in cyprinoid fish in Nakhon Ratchasima,northeast Thailand

Metacercariae were recovered from freshwater fish taken from a stream in Lum Cha Muak, Nakhon Ratchasima Province, northeast Thailand during the year 2000. Seventy-nine cyprinoid fish comprising 3 species (52 Puntius leiacanthus, 22 Cyclocheilichthys armatus, and 5 Hampla dispar) were collected. The prevalence of infection with metacercariae was 51.9%. Only two genera of metacercariae were found: Haplochinae spp and Heterophyidae spp. Haplochinae metacercariae were found in all 3 species of fish, giving rates of infection of 95.5%, 20% and 1.9% for Puntius leiacanthus, Cyclocheilichthys armatus and Hampla dispar respectively. Heterophyidae metacercariae were found only in Puntius leiacanthus, whose infection rate was 30.77%. There were fish intected at the rate of 3.8% with unclassified metacercariae. Interestingly, no fish infected with Opisthorchis viverrini metacercariae were found, which is at odds with previous reports from Thailand in which a higher infection rate was given. This is the first report of fish infected with Haplorchinae spp in Thailand.     

Effect of bupivacaine with epinephrine wound instillation for pain relief after pediatric inguinal herniorrhaphy and hydrocelectomy

BACKGROUND AND OBJECTIVES: To evaluate the effect of a 20- or 60-second instillation period using 0.5% bupivacaine with epinephrine for pain relief after pediatric inguinal herniorrhaphy and hydrocelectomy. METHODS: In a randomized, double-blind study, 103 children (aged 1 to 12 years, American Society of Anesthesiologists [ASA] physical status I or II) were allocated into 4 groups after induction of anesthesia. Group 1: normal saline 0.25 mL/kg instilled, which remained in the wound for 20 or 60 seconds before wound closure. Group 2: 0.25 mL/kg 0.5% bupivacaine with epinephrine 5 microg/mL instilled, which remained in the wound for 20 seconds. Group 3: the same quantity and dose of drug 2 instilled as group, but remained in the wound for 60 seconds. Group 4: an ilioinguinal and iliohypogastric block performed before operation using 0.5 mL/kg 0.25% bupivacaine with epinephrine. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Aldrete-Kroulik recovery scores were used to monitor postoperative pain and recovery status. Analgesic was given when the CHEOPS score was >/= 7 despite other supportive therapy. RESULTS: The number of patients requiring analgesics within 2 hours in group 1 (73.1%) was more than groups 2, 3, and 4 (23.1%, 20.8%, and 16%, respectively, P <.001). The median time to first analgesic in group 1 (50 minutes) was also less than groups 2, 3, and 4 (420, 525, and 425 minutes, respectively, P <.0001). CONCLUSION: 0.5% Bupivacaine with epinephrine for as short an instillation period as 20 or 60 seconds can provide a good analgesic alternative after herniorrhaphy and hydrocelectomy in pediatric patients. All studied blocks had comparable duration of action.     

The role of NK cells in the development of autoantibodies

The systemic lupus erythematosus (Sle1) interval from the NZM2410 mouse strain has been shown to be responsible for high levels of autoantibody production against antinuclear antibodies (ANA) when transferred into C57BL/6 mice. B cells derived from the B6.Sle1 strain are required for the production but help from both T-dependent and independent sources have been documented. Using radiation chimeras constructed in a strain of mice that is chronically depleted of Natural killer (NK) cells, but not NKT cells, we have examined the role of NK cells in the development of ANA in this context. Our results show that in the presence of intact T cell help depletion of NK cells does not affect ANA production. However, when T cell help is compromised, the prevalence of animals producing ANA is significantly decreased suggesting that NK cells can provide help for the T-independent production of ANA. Further experiments provide a possible mechanism for the NK-cell dependence.     

Cremophor RH40-PEG 400 microemulsions as transdermal drug delivery carrier for ketoprofen

The aim of this study was to prepare novel microemulsion for transdermal drug delivery of ketoprofen (KP). The microemulsion composed of ketoprofen as model drug, isopropyl myristate (IPM) as oil phase, surfactant mixture consisting of polyoxyl 40 hydrogenated castor oil (Cremophor RH40) as surfactant and polyethylene glycol 400 (PEG400) as co-surfactant at the ratio 1:1, and water were prepared. The viscosity, droplet size, pH, conductivity of microemulsions, and skin permeation of KP through shed snake skin were evaluated. The particle size, pH, viscosity and conductivity of microemulsions were in the range of 114-210 nm, 6.3-6.8, 124-799 cPs and 1-45 μS/cm, respectively. The ratio of IPM, and surfactant mixture played the important role in the skin permeation of KP microemulsions. As the amount of surfactant mixture and IPM increased, the skin permeation of KP decreased. The formulation composed of 30% IPM, 45% surfactant mixture and 25% water showed the highest skin permeation flux. The incorporation of terpenes in the 2.5% KP microemulsions resulted in significant enhancement in skin permeation of KP. The rank order of enhancement ratio for skin permeation enhancement of terpenes was α-pinene > limonene > menthone. The results suggested that the novel microemulsion system containing IPM, water, Cremophor RH40:PEG400 and terpenes can be applied for using as a transdermal drug delivery carrier.     

How do Thai children and adolescents describe asthma symptoms?

Prevalence of childhood asthma appears to be increasing worldwide. In Thailand, the prevalence of childhood asthma increased from 4.2% to 13% within the past decade. The last epidemiologic survey in Thailand utilized the International Study of Asthma and Allergies in Childhood (ISAAC) phase I questionnaire translated into Thai language. Language in the questionnaire can affect the reliability and validity of results of the survey. The purpose of this study is to determine common Thai wordings actually used by Thai children and adolescents to describe wheeze, chest tightness, shortness of breath and dyspnea. Sixty asthmatic Thai children, aged 9.2–18 years with asthmatic attacks less than 1 yr prior to the study, and 178 age‐matched controls were recruited into the study. Asthmatic children spontaneously expressed their terms describing their asthma symptoms (in Thai) and then answered a preoutlined questionnaire regarding asthma terminology during an interview session after viewing the severe attack scene of the International ISAAC video questionnaire. Controls responded only to the preoutlined questionnaire after viewing the video scene. Of the 60 asthmatic children (38 males and 22 females, mean age 11.9 yr), 75% had their last asthmatic attacks within 2 months prior to the study. Wheeze was referred to as ‘’ and ‘/wi:d/’ in 50% and 33% of patients, respectively, and ‘’ in 93.8% among controls. Using only the word ‘/wi:d/’ in our previous ISAAC‐I survey, as it sounded like the English word ‘wheeze’, it appears that up to 67% of the cases could have been missed. Dyspnea was referred to as rapid breathing and feeling tired in 78.2% of cases and as rapid and difficult breathing in 76.3% of controls. Chest tightness was referred to as chest discomfort in 65.7%. Shortness of breath was referred to as not being able to catch a breath, too short a breath, not enough breath and feeling suffocated in 88.8%. Local terms for asthma symptoms should be established and validated into each language to obtain reliable epidemiologic data.     

Complications of peritoneal dialysis in children with Eagle-Barrett syndrome

Eagle Barrett syndrome (EBS) is characterized by the triad of abdominal muscle deficiency, urinary tract abnormalities, and cryptorchidism. Approximately 25% of patients with EBS progress to end-stage renal disease. It is speculated that the abdominal muscular defects in EBS pose technical problems in achieving successful peritoneal dialysis (PD). In this retrospective analysis, we reviewed the medical records of EBS and non-EBS PD patients cared for at Rainbow Babies and Children's Hospital from 1985 to 2002; 5 EBS and 9 non-EBS patients were analyzed. PD duration, total complication rates, and catheter usage rates in the two groups were not significantly different. The two most frequent complications were peritonitis and catheter mechanical malfunction during 103 patient-months in EBS patients and 296 patient-months in non-EBS patients. Peritonitis occurred 1 episode every 20.6 patient-months and 14.8 patient-months in EBS and non-EBS patients, respectively. The time from PD initiation to onset of any complication, including first peritonitis, was not significantly different in the two groups. Although the age at PD initiation was significantly different between the groups, there was no correlation between age at onset of PD and complication rates or time to first complication. Despite their abdominal muscle defects, EBS patients do not have more-frequent PD complications.     

Predictor of core hypothermia and the surgical intensive care unit

Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0 degrees C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0 degrees C, <35.5 degrees C, and <35.0 degrees C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82-10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67-41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66-26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41-91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05-10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48-13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87-10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89-0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15-0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51-0.88). In conclusion, the incidence of core hypothermia (Tc <36.0 degrees C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia. IMPLICATIONS: In an effort to decrease the frequent incidence of core hypothermia at the time of admission to the general surgical intensive care unit, this prospective study showed that high ASA physical status, the use of a combined epidural and general anesthesia, surgery lasting longer than 2 h, and extensive surgery were the important risk factors, whereas heavier body weight, higher preoperative body temperature, and warmer ambient operating room temperature were important protective factors.