Monitoring human cytomegalovirus infection in pediatric hematopoietic stem cell transplant recipients: using an affordable in‐house qPCR assay for management of HCMV infection under limited resources

Quantitative real‐time PCR (qPCR) assay is accepted as the method of choice for monitoring human cytomegalovirus (HCMV) infection in hematopoietic stem cell transplant recipients, but the high cost of commercial kits has hampered its use in many developing countries. In this study, an affordable in‐house qPCR was used to manage HCMV infection in pediatric patients and the diagnostic value of this method was compared with the conventional pp65 antigenemia assay. A total number of 1179 samples from 82 recipients were used in this study, and the effect of some potential risk factors on HCMV reactivation was evaluated. The qPCR was able to detect HCMV reactivation earlier and with higher sensitivity than antigenemia assay. Forty‐six episodes of reactivation were detected in 39 patients, of which all were detected by the qPCR assay, while only 21 episodes were diagnosed by antigenemia. The DNAemia level of 1284 IU/ml plasma was defined as the optimal cutoff value for starting pre‐emptive therapy. It was shown that the acute GVHD severity and the relationship of donor and recipient are the most significant risk factors for HCMV reactivation. The data suggest that the antigenemia method for monitoring HCMV reactivation could be substituted by the qPCR assay.     

The development of pediatric anesthesiology and critical care medicine at the Cincinnati Children's Hospital: an interview with Dr. Theodore Striker

Dr. Theodore W. ‘Ted’ Striker (1936–), Professor of Anesthesiology and Pediatrics at the University of Cincinnati, has played a pioneering role in the development of pediatric anesthesiology in the United States. As a model educator, clinician, and administrator, he shaped the careers of hundreds of physicians‐in‐training and imbued them with his core values of honesty, integrity, and responsibility.     

Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion

Aim:  To further investigate the effect of acupuncture in postoperative pain and emergence agitation in children undergoing bilateral myringotomy and tympanostomy tube (BMT) placement.
Background:  BMT insertion surgery in children is routinely performed under general anesthesia and is associated with a high incidence of postoperative pain and agitation upon emergence from anesthesia. Various medications have been investigated to alleviate the pain and agitation, which have been accompanied by high incidence of adverse effects. In children, anecdotal reports suggest that acupuncture may offer postoperative analgesia.
Methods/Materials:  This prospective randomized controlled trial is to evaluate the effectiveness of acupuncture to control pain and agitation after initial bilateral myringotomy tube placement in 60 nonpremedicated children. Acupuncture was applied at points LI-4 (he gu) and HT-7 (shen men) immediately after induction of anesthesia. A single-blinded assessor evaluated postoperative pain and agitation using CHEOPS and emergence agitation scale. Pain and agitation scores were significantly lower in the acupuncture group compared to those in the control group at the time of arrival in the post anesthesia care unit and during the subsequent 30 min.
Results:  Acupuncture treatment provided significant benefit in pain and agitation reduction. The median time to first postoperative analgesic (acetaminophen) administration was significantly shorter in the control group. The number of patients who required analgesia was considerably fewer in the acupuncture group than that in the control. No adverse effects related to acupuncture treatment were observed.
Conclusion:  Our study suggests that acupuncture therapy may be effective in diminishing both pain and emergence agitation in children after BMT insertion without adverse effects.     

Iatrogenic damage to the pediatric airway Mechanisms and scar development

Iatrogenic damage to the pediatric airway occurs rather often. Most injuries will heal without any sequelae because larynx and trachea of children tolerate considerable trauma. However, sometimes the injury is penetrating the mucosa and scar formation can lead to an obstruction of the airway which is followed by a tracheostomy and long term surgery. A great problem is the early detection of trauma since noisy breathing develops often late when scar formation has occluded more than 50% of the airway. A selection of photo documents of airway endoscopy out of more than 5000 photos from the years 1987–2007 were used to explain the development of injuries from minor lesions to large areas of necrosis of the mucosa of larynx and trachea of infants and children. The visualization of airway lesions might help to prevent iatrogenic damage.     

Reducing distress for children during invasive procedures: randomized clinical trial of effectiveness of the PediSedate®

Background: Procedural pain control remains problematic for young children, especially during anxiety‐causing procedures for which children should not be deeply sedated. The PediSedate^® was designed to address this problem by delivering nitrous oxide in oxygen through a simple nosepiece, combined with an interactive video component, so that children can use attention and distraction with drug delivery. Objectives: We conducted a randomized clinical trial to evaluate the effectiveness of the PediSedate^® for reducing children’s behavioral distress in comparison with standard care in the emergency department. Secondary objectives were to assess children’s acceptance, cooperation, and pain. Methods: Thirty‐six children, aged 3–9 years old, who required invasive procedures associated with high levels of anxiety and low levels of pain such as sutures, IVs, and lumbar punctures were randomized to receive either the standard care or the PediSedate^®. The primary outcome was children’s distress (observational scale of behavioral distress) that was monitored before and during the procedure. Results: Children randomized to the PediSedate^® group had significantly less distress during invasive procedures (mean = 1.8, sd = 3.2) than children receiving standard care (mean = 9.3, sd = 5.6; anova , P < 0.0001). Also, children in the PediSedate^® group were more cooperative [χ²(1) = 22.05, P < 0.0001] and fewer children reported pain [χ²(1) = 14.45, P < 0.001]. Conclusions: Previous studies have demonstrated the effectiveness of nitrous oxide sedation alone for minimizing pain and distress during invasive procedures. We have found that delivering nitrous oxide sedation via a system combined with an interactive video component is also effective. Further studies should determine which factors are dominant and determine the specific failure rate for this delivery system in comparison with other systems.     

The development of a specialty: an interview with Dr. Mark C. Rogers,a pioneering pediatric intensivist

Dr. Mark C. Rogers (1942–), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long‐term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.     

Survival Advantage of Pediatric Recipients of a First Kidney Transplant Among Children Awaiting Kidney Transplantation

The mortality rate in children with ESRD is substantially lower than the rate experienced by adults. However, the risk of death while awaiting kidney transplantation and the impact of transplantation on long‐term survival has not been well characterized in the pediatric population. We performed a longitudinal study of 5961 patients under age 19 who were placed on the kidney transplant waiting list in the United States. Of these, 5270 received their first kidney transplant between 1990 and 2003. Survival was assessed via a time‐varying nonproportional hazards model adjusted for potential confounders. Transplanted children had a lower mortality rate (13.1 deaths/1000 patient‐years) compared to patients on the waiting list (17.6 deaths/1000 patient‐years). Within the first 6 months of transplant, there was no significant excess in mortality compared to patients remaining on the waiting list (adjusted Relative Risk (aRR) = 1.01; p = 0.93). After 6 months, the risk of death was significantly lower: at 6–12 months (aRR = 0.37; p < 0.001) and at 30 months (aRR 0.26; p < 0.001). Compared to children who remain on the kidney transplant waiting list, those who receive a transplant have a long‐term survival advantage. With the potential for unmeasured bias in this observational data, the results of the analysis should be interpreted conservatively.     

Survey of pediatric continuing professional development undertaken by consultant anesthetists1

Background: Whilst not all anesthetists have a regular pediatric commitment there is a need for out of hours cover of pediatric anesthesia. We have attempted to determine who covers pediatric anesthetic services in the District General Hospital setting. Methods: A postal survey of 170 consultant anesthetists in nine District General Hospitals was conducted looking at who is responsible for pediatric anesthetics and emergencies out of hours as well as pediatric anesthetic experience, resuscitation training and continuing professional development (CPD). Results: There was a 62% response rate with 98% of the consultants with on call duties also covering pediatric anesthetic emergencies. Fifty percent of consultants who responded were within 4 years of a pediatric‐specific resuscitation course, of which 93% had found it useful. However, 40% had never completed a pediatric resuscitation course or it could be considered out of date. Sixty‐three percent of consultants had had some sort of pediatric anesthetic update in the last 4 years. Conclusions: General anesthetists are responsible for elective and emergency anesthetics as well as the care of critically ill children outside of specialist centers. This is despite a proportion of these consultants not having regular pediatric experience, not having completed a recent pediatric resuscitation course and without pediatric anesthetic CPD.     

Desire for perioperative information and parental ethnicity

Objectives: To examine the role of ethnicity, language, and socioeconomic variables in parental desire for information regarding children’s surgery. Aim: To compare anesthetic and surgical information desired between English‐ and Spanish‐speaking White and Hispanic mothers of children undergoing outpatient surgery. Background: Parents report wanting to receive detailed information regarding children’s preoperative care; however, variables such as parent ethnicity and language spoken have not been accounted for in understanding desire for information. Methods/Materials: One hundred and eighty‐one mothers of children undergoing outpatient surgery, elective surgery, and general anesthesia were recruited and categorized into one of three groups: English‐speaking White (ESW, n = 79), English‐speaking Hispanic (ESH, n = 63), and Spanish‐speaking Hispanic (SSH, n = 39). In addition to providing demographic questionnaire, mothers completed the Parental Desire for Information (PDI) questionnaire, a 14‐item measure of surgery and anesthesia‐related statements. Results: Overall, mothers desired receiving information about the majority of the items on the PDI. As compared to ESW mothers, SSH mothers and ESH mothers were overrepresented in the ‘have a right to know’ response option, with significant differences existing in items concerning alternative methods of anesthesia, details of needles used, and location of PACU and OR. Conclusions: Anesthesiologists should tailor the provision of preoperative information based on ethnicity and language of mothers involved. Ethnic and language differences shown in this study may exist in other populations as well.     

How do pediatric anesthesiologists define intraoperative hypotension?

Introduction: Although blood pressure (BP) monitoring is a recommended standard of care by the ASA, and pediatric anesthesiologists routinely monitor the BP of their patients and when appropriate treat deviations from ‘normal’, there is no robust definition of hypotension in any of the pediatric anesthesia texts or journals. Consequently, what constitutes hypotension in pediatric anesthesia is currently unknown. We designed a questionnaire‐based survey of pediatric anesthesiologists to determine the BP ranges and thresholds used to define intraoperative hypotension (IOH). Methods: Members of the Society of Pediatric Anesthesia (SPA) and the Association of Paediatric Anaesthetists (APA) of Great Britain and Ireland were contacted through e‐mail to participate in this survey. We asked a few demographic questions and five questions about specific definitions of hypotension for different age groups of patients undergoing inguinal herniorraphy, a common pediatric surgical procedure. Results: The overall response rate was 56% (483/860), of which 76% were SPA members. Majority of the respondents (72%) work in academic institutions, while 8.9% work in institutions with fewer than 1000 annual pediatric surgical caseload. About 76% of respondents indicated that a 20–30% reduction in baseline systolic blood pressure (SBP) indicates significant hypotension in children under anesthesia. Most responders (86.7%) indicated that they use mean arterial pressure or SBP (72%) to define IOH. The mean SBP values for hypotension quoted by SPA members was about 5–7% lower across all pediatric age groups compared to values quoted by APA members (P = 0.001 for all age groups). Conclusions: There is great variability in the BP parameters used and the threshold used for defining and treating IOH among pediatric anesthesiologists. The majority of respondents considered a 20–30% reduction from baseline in SBP as indicative of significant hypotension. Lack of a consensus definition for a common clinical condition like IOH could have implications for patient care as well as future clinical research.     

Current perspectives on treatment of perioperative hemodynamic instability and hypotension

Overall, there are numerous causes of hypotension in the perioperative period. The approach to definitive treatment must be tailored to the child's unique anatomy and physiology, as well as the current factors presumed to be eliciting the hypotensive state. It is imperative to consider both routine and lesion‐specific etiologies to the current hypotensive episode. Lastly, when employing pharmacologic therapy for hypotension, there are often multiple combinations of medications that can reasonably be used to achieve the desired hemodynamic effects.     

Pediatric Organ Transplantation and Risk of Premalignant and Malignant Tumors in Sweden

Increased cancer risks are well documented in adult organ transplant recipients. However, the spectrum of malignancies and risk in the pediatric organ transplant population are less well described. We identified all solid organ transplanted patients aged <18 in Sweden between 1970–2007 (n = 536) in the National Patient Register and linked to the Cancer Register. Nationwide rates were used to calculate standardized incidence rate ratios and 95% CI estimating the association between transplant and cancer during maximum 36 years of follow‐up. Nearly 7% of pediatric solid organ transplant recipients developed a premalignant or malignant tumor during follow‐up. Transplantation was associated with an increased risk of any cancer (n = 24, SIR = 12.5, 95% CI: 8.0–18.6): non‐Hodgkin lymphoma (NHL) (n = 13, SIR = 127, 95% CI: 68–217), renal cell (n = 3, SIR = 105, 95% CI: 22–307), vulva/vagina (n = 3, SIR = 665, 95% CI: 137–1934) and nonmelanoma skin cancers (n = 2, SIR = 64.7, 95% CI: 7.8–233.8). NHL typically appeared during childhood, while other tumors were diagnosed during adulthood. Apart from short‐term attention toward the potential occurrence of NHL, our results suggest cancer surveillance into adulthood with special attention to skin, kidneys and the female genitalia.