Haemodynamic changes during high spinal anaesthesia in children having open heart surgery

BACKGROUND: This prospective series examined the haemodynamic effects of high spinal anaesthesia in combination with light general anaesthesia in infants and children undergoing open heart surgery who were candidates for immediate or early postoperative extubation. METHODS: After midazolam premedication and sevoflurane inhalation induction, 30 patients, aged 7 months to 13 years, who were undergoing open heart surgery, received spinal anaesthetics with 0.5% tetracaine D10 mixed with morphine. The spinal blocks were placed at the L2,3 or L3,4 interspace with cephalad spread being promoted by positioning the patient in 30 degrees of Trendelenburg for a minimum of 10 min. Maintenance of anaesthesia was with isoflurane 0.2-0.5% in 70% nitrous oxide to maintain heart rate and blood pressure within 20% of postinduction baseline values. Haemodynamic values were recorded at predetermined timed intervals and intraoperative events up to and including aortic cannulation. For analysis of the data, patients were divided into four age groups (< 1 years, 1-3 years, 4-6 years and > 7 years). RESULTS: Haemodynamic stability was demonstrated in all four age groups. Statistically significant slowing of the heart rate did occur in the groups older than 1 year at 25 min, although clinically significant bradycardia requiring treatment never occurred. Hypotension did occur during specific surgical manipulations but recovered spontaneously. Atropine, fluid boluses and vasopressors were never used. At the conclusion of surgery, all patients met extubation criteria and could move all four extremities. CONCLUSIONS: High spinal anaesthesia with hyperbaric tetracaine and morphine in combination with light general anaesthesia is well tolerated haemodynamically by the paediatric population studied.     

Psychopathology and sexual trauma in childhood and adulthood

This study evaluates the occurrence of psychopathology among 97 women who (1) experienced sexual abuse in childhood only, (2) were raped in adulthood only, (3) experienced both childhood sexual abuse and rape in adulthood, or (4) experienced no sexual trauma. Women were recruited from advertisements and assessed using the Structured Clinical Interview for DSM-IV (SCID-I/P) and the Modified PTSD Symptom Scale Self-Report. Women who reported sexual trauma were significantly more likely to exhibit psychopathology than controls. Being sexually victimized in childhood and raped in adulthood was associated with a particular risk for substance dependence.     

Evaluation of Tissue-Engineered Skin (Human Skin Substitute) and Secondary Intention Healing in the Treatment of Full Thickness Wounds after Mohs Micrographic or Excisional Surgery

BACKGROUND: Human Skin Substitute (Apligraf, Organogenesis, Inc., Canton, MA) is a bi-layered tissue-engineered living biological dressing developed from neonatal foreskin. It consists of a bovine collagen matrix containing human fibroblasts with an overlying sheet of stratified human epithelium containing living human keratinocytes. Human Skin Substitute (HSS) appears to be immunologically inert, and has shown usefulness in the treatment of chronic and acute wounds. OBJECTIVE: Primary objectives were to evaluate the safety and efficacy of HSS in the treatment of full-thickness wounds in a prospective case series. Secondary objectives were to determine the rate of complete wound reepithelialization, incidence of complete wound healing, pain at wound site, overall cosmetic outcome, and patient satisfaction. METHODS: Fourteen patients were enrolled in the study, of which 12 were evaluable. HSS was applied in a blinded fashion to 6 of the patients immediately following Mohs or excisional surgery for skin cancer. The remaining 6 patients were allowed to heal by secondary intention. Both groups were evaluated at weekly appointments until complete reepithelialization occurred. During each evaluation, wound quality was assessed through the Vancouver Burn Scar Assessment Scale by the investigator and an independent blinded dermatologist. The investigator, blinded observer, and patient further evaluated the cosmetic outcome of the wound through the use of a Visual Analog Scale over a 6-month period. RESULTS: HSS patients and secondary intention patients were equivalent in comorbid factors such as pain, erythema, edema, exudate, infection, or hematoma between the groups. The incidence of complete wound healing at 6 months was 100% for both groups. Both groups also appeared to heal at similar rates, as defined by the complete reepithelialization of the wound. HSS patients ultimately resulted in more pliable and less vascular wounds as defined by the Vancouver Burn Scar Assessment Scale. Patient satisfaction with cosmetic outcome in both groups was positive at 6 months. CONCLUSIONS: HSS appears to be a safe, well-tolerated biological dressing with equivalent comorbid factors to secondary intention healing. HSS, however, seems to produce a more pliable and less vascular scar than those developed through healing by secondary intention. HSS also appears to produce more satisfactory cosmetic results when compared to secondary intention healing.     

Vitamin D, parathyroid hormone levels and bone mineral density in community-dwelling older women: The Rancho Bernardo Study

Vitamin D (25(OH)D) increases the efficiency of intestinal calcium absorption. Low levels of serum calcium stimulate the secretion of parathyroid hormone (PTH), which maintains serum calcium levels at the expense of increased bone turnover, bone loss and increased risk of fractures. We studied the association between 25(OH)D and PTH levels, and their associations with bone mineral density (BMD), bone loss, and prevalence of hip fractures in 615 community-dwelling postmenopausal aged 50–97 years. Mean level of 25(OH)D and PTH were 102.0 nmol/l±35.0 nmol/l and 49.4 ng/l±23.2 nmol/l, respectively; 49% of women were current hormone therapy users. The overall prevalence of vitamin D insufficiency (25(OH)D<50 nmol/l) was 2%, and prevalence of high PTH levels (>65 ng/l) was 17.4%. In multiple linear regression analyses hip BMD was negatively and independently associated with PTH levels ( p =0.04), and positively and independently associated with 25(OH)D levels ( p =0.03). There were only 23 women (3.7%) who experienced a hip fracture. In age-adjusted analyses there were no significant differences of 25(OH)D and PTH levels by hip fracture status. Across the entire range of values, the overall correlation between 25(OH)D and PTH was moderate ( r =–0.20). However, after the threshold vitamin D level of 120 nmol/l, all PTH values were below 65 ng/l. Further studies are necessary to identify the optimal vitamin D levels necessary to prevent secondary hyperparathyroidism.     

Elevated Alkaline Phosphatase Prior to Transarterial Chemoembolization for Neuroendocrine Tumors Predicts Worse Outcomes

Introduction

We hypothesized that an elevated preoperative alkaline phosphatase (AP) predicted worse outcomes for patients undergoing transarterial chemoembolization (TACE) for neuroendocrine tumor (NET) liver metastases.

Methods

We reviewed all patients who underwent TACE for metastatic NET between 2009 and 2013. Survival was evaluated using preprocedure variables.

Results

One hundred and nine patients underwent 210 TACE procedures. The average age was 57.7 years (range 20–78). Primary sites included pancreas (N?=?20), other gastrointestinal (N?=?52), lung (N?=?9), and unknown (N?=?28). The tumor was grade 1 in 68 (62 %), grade 2 in 21 (19 %), and grade 3 in 3 (3 %). Extrahepatic disease was present in 54 (50 %) and greater than 50 % hepatic tumor burden by imaging in 63 (58 %). Elevated bilirubin occurred in 8 (7 %), elevated AP in 22 (20 %), elevated ALT in 21 (19 %), and elevated AST in 41 (38 %). Univariate predictors included tumor grade (43 vs 27 vs 21 months, p?=?0.015), hepatic tumor burden (59 vs 37 months, p?=?0.009), and elevated AP (59 vs 23 months, p?<?0.001). On multivariate analysis, only elevated AP (p?=?0.001) predicted worse survival.

Conclusions

Elevated AP prior to TACE for metastatic NET portends a worse survival outcome, even more so than tumor grade or extent of hepatic disease.

     

Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.     

Caregiver-Care Recipient Relationship Closeness is Associated With Neuropsychiatric Symptoms in Dementia

Objective

Closer caregiver-care recipient (CG-CR) relationships are associated with better cognitive and functional abilities, activities of daily living (in persons with dementia), and lower informal care costs.

The association between degenerative hip joint pathology and size of the gluteus maximus and tensor fascia lata muscles

The aim of this study was to obtain, using Magnetic Resonance Imaging (MRI), muscle volume measurements for the gluteus maximus (upper: UGM and lower: LGM portions) and tensor fascia lata (TFL) muscles in both healthy subjects (n = 12) and those with unilateral osteoarthritis (OA) of the hip (mild: n = 6, and advanced: n = 6). While control group subjects were symmetrical between sides for the muscles measured, subjects with hip joint pathology showed asymmetry in GM muscle volume dependent on stage of pathology. The LGM demonstrated atrophy around the affected hip in subjects with advanced pathology (p < 0.05), however asymmetry of the UGM (p < 0.01) could be attributed largely to hypertrophy on the unaffected side, based on between group comparisons of muscle volume. TFL showed no significant asymmetry, or difference compared to the normal control group. This study highlights the functional separation of UGM and LGM, and the similarities of the UGM and TFL, both superficial abductors appearing to maintain their size around the affected hip. Further research is required to determine the specific changes occurring in the deeper abductor muscles. This information may assist in the development of more targeted and effective exercise programmes in the management of OA of the hip.