Reducing the anxiety of children undergoing surgery: Parental presence during anaesthetic induction

Objective : The primary aim was to determine whether child anxiety could be reduced by the presence of a parent during anaesthetic induction. Secondary aims involved clarification of the effect of the timing of parental separation, the use of premedication, the seriousness of the surgical procedure, and the flow-on effect of parental anxiety on the level of child anxiety.
Methodology : Subjects were obtained by approaching all parents of children aged from 1 to 8 years admitted for day surgery to a private hospital in Adelaide, South Australia during a 3 month period. Data pertaining to 74 children, representing a response rate of 80.4%, were obtained. Parents were instructed to rate the anxiety of their child for the period immediately prior to separation, and to then rate their own anxiety for the same period of time.
Results : Children accompanied during induction were less anxious than those who were not accompanied. Contrary to the belief that child anxiety might be reduced by allowing separation in the theatre holding bay area, it was demonstrated that child anxiety was higher in this group than when separation occurred in the ward. No relationship between premedication or operation severity and either child or parental anxiety was observed. However, parental anxiety was noted to be a significant predictor of child anxiety. Suggestions for a more detailed examination of the relationship between child and parental anxiety in future research were outlined.
Conclusions : It was concluded that there are benefits in allowing parents to be present during anaesthetic induction. However, the potential negative effect of parental anxiety must be acknowledged before parents are allowed to accompany their child as a matter of course.     

Monitoring of exposure to acrylonitrile by determination of N-(2-cyanoethyl)valine at the N-terminal position of haemoglobin

A selected ion monitoring gas chromatography-mass spectrometry(GC-MS) procedure was developed to determine the interactionproduct formed by acrylonitrile (ACN) with the N-terminal aminogroup in haemoglobin. The product, N-(2-cyanoethyl)valine (CEV),was analysed following its release from the protein by a modifiedEdman degradation procedure. Quantitation was achieved usingN-(2-cyanoe-thyl)-[²H₈]Val-Leu-Ser as internal standard. Thelimit of detection of the assay was 1 pmol CEV/g globin. A closeto linear dose-response relationship was found for adduct formationin rats treated with ACN by gavage. On the basis of a linearextrapolation, a dose of 1 mg/kg body wt yielded 248 pmol CEV/gglobin. Two groups of workers who were exposed to ACN contained1984 ± SD 2066 (n = 9) and 2276 ± SD 1338 (n =7) pmol CEV/g globin respectively. These values were highlysignificantly greater (P < 0.01 following a one-way analysisof variance with a logarithmic transformation of the data) thanthose in a group of control workers in the same factory (31.1± SD 18.5 pmol CEV/g globin, n = 11). The concentrationsof N-terminal CEV in globin samples from 13 smoking and 10 non-smokingmothers and from their newborns were determined. Adduct levelsin the smokers averaged 217 ± 85.1 pmol CEV/g globin,significantly higher than the levels in non-smokers, which wereundetectable. Individual values in the mothers were very highlycorrelated with the levels in their babies (which averaged 99.5± 53.8 praol CEV/g globin), which demonstrates that transplacentaltransfer of ACN occurs. Significant correlations were also foundbetween the number of cigarettes smoked per day by the motherand the CEV levels in both the mothers‘ and newborns’globin. There was, however, no correlation between the CEV levelsand those of the ethylene oxide adduct N-(2-hydroxyethyl)valinein samples from either the mothers or babies.     

An ultrasound system for simultaneous ultrasound hyperthermia and photon beam irradiation

: An existing ultrasound system has been adapted for simultaneous use with external photon beam irradiation. The system is being used to investigation the potential for increased biological benefit of simultaneously combined hyperthermia and external beam irradiation with currently achievable temperature distributions.

: An existing clinical ultrasound system has been modified for simultaneous operation with a ⁶⁰Co teletherapy machine. The generator, thermometry system, computer, and applicators are located inside the treatment room, while the monitor and system control are located at the control console. Two approaches have been used clinically to combine the two modalities. In the first approach, an en-face setup is used in which the ultrasound beam and the photon beam travel through the same window of entry to the tumor. This is achieved by a reflecting system designed to deflect the ultrasound to the tumor while positioning the ultrasound transducer outside the radiation beam. The reflecting system consists of water and water-equivalent materials except for a 1 mm sheet of polished brass that is used as the reflector. The relative pressure fields were measured in water at the same distance from the ultrasound source using a scanning hydrophone with and without the reflector at the two operating frequencies of the device (1.0 and 3.4 MHz) for two applicators. Radiation dosimetry measurements were performed to determine the relationship between ⁶⁰Co irradiation through the reflector and absorbed dose. In the second approach the ultrasound and the radiation beam travel into the tumor from different windows of entry such that the radiation beam passes through no portion of the water bolus prior to entering the patient. We have termed this approach the orthogonal approach. For both approaches, the radiation fraction is given in the middle of an uninterrupted 60-min hyperthermia treatment.

: The system modifications did not impair the ability to effectively deliver ultrasound hyperthermia or ⁶⁰Co teletherapy. With the en-face approach the ultrasonic patterns generated with and without the reflector demonstrated that the ultrasound system maintained both a uniform and controllable heating pattern. The ⁶⁰Co beam had no effect on the performance of the thermocouple thermometers. The radiation beam is attenuated nearly uniformly by the reflector system. To date, 10 patients have been treated with the en-face approach and 12 have been treated with the orthogonal approach (90 treatments).

Conclusions: The clinical implementation of ultrasound hyperthermia simultaneous with ⁶⁰Co irradiation is technically and clinically feasible without any complications or hazards to the patient. The implementation of a reflecting device allows en-face delivery of both the ultrasound and ⁶⁰Co irradiation. Temperatures obtained during simultaneous treatments are comparable to those historically obtained during sequential treatments with the same commercial ultrasound device.     

Asthma at the interface: bridging the gap between general practice and a district general hospital

A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic.     

Acute bacterial maningitis in childhood: aspects of prehospital care in 687 cases

Some basic features of the prehospital management of children with acute bacterial meningitis were ascertained by a retrospective review of case notes. A diagnosis of intracranial infection was considered in 63% of general practitioners' referral letters and was more often considered for older than younger children. 47% of children had received antibacterial chemotherapy before hospital admission. Such treatment did not appear to have jeopardized the outcome. The possibility of delay in the admission of children to hospital at weekends is discussed.     

Hereditary coproporphyria and epilepsy

A 9-year-old boy with mental deterioration and epilepsy suffered an acute attack of hereditary coproporphyria associated with worsening of seizure control. Leucocyte coproporphyrinogen oxidase activity was undetectable in the patient during this attack, and was reduced in his mother, a latent case. The complex relationship between porphyria, epilepsy, and anticonvulsant drugs is discussed.     

Allergic bronchopulmonary aspergillosis complicating cystic fibrosis in childhood

Allergic bronchopulmonary aspergillosis, known to be associated with cystic fibrosis in older patients, occurred in 7 young atopic children with cystic fibrosis. The diagnosis was suggested by the onset of, or the increase in, asthmatic symptoms accompanied by major chest x-ray changes ranging from total collapse of a lung or lobe to extensive but changing areas of consolidation. Each of the children had a blood eosinophilia, positive type I skin tests to Aspergillus fumigatus, and reversible airways obstruction. Most had a positive type III skin test and circulating precipitins to A. fumigatus, with raised IgE levels which contained specific antibodies to the fungus on radioallergosorbent (RAST) test. None had advanced suppurative chest disease of cystic fibrosis. None was given specific antifungal agents; two received systemic treatment with corticosteroids, the other received additional drugs for their asthma. Two developed total collapse of one lung, one child being only 2 years old. Five have had recurrences of pulmonary shadowing typical of allergic aspergillosis but are not showing significant progression of their cystic fibrosis lung disease. Our experience suggests that there should be an increased awareness of this condition, particularly its association with extensive pulmonary collapse or consolidation in children with cystic fibrosis who are atopic.     

Cerebral tumor-like American trypanosomiasis in acquired immunodeficiency syndrome

Cerebral tumor-like American trypanosomiasis (CTLAT) is an uncommon complication of Chagas' disease, observed only in immunosuppressed patients. We assessed 10 human immunodeficiency virus-positive patients with Chagas' disease who presented with CTLAT. All patients had neurological involvement and 6 developed intracranial hypertension. Neuroimaging studies showed supratentorial lesions in 9 patients, being single in 8. One case had infratentorial and supratentorial lesions. Low CD4+ cell counts were observed in all the cases and in 6 of them CTLAT was the first manifestation of acquired immunodeficiency syndrome. Serological tests for Chagas' disease were positive in 6 of 8 patients. Trypanosoma cruzi was identified in all brain specimens and in three cerebrospinal fluid samples. CTLAT should be considered in the differential diagnosis of intracranial mass lesions in human immunodeficiency virus-positive patients and should be added to the list of acquired immunodeficiency syndrome-defining illnesses.     

Cardiac metastasis from a transitional cell carcinoma: a case report

We report the case of a patient with a metastatic tumor in the right ventricle, apparently derived from a transitional cell carcinoma. The patient presented with severe hypoxemia as a result of right-to-left shunt due to the position of the tumor and a patent foramen ovale. The clinical course of this case is presented and the pathophysiology of the physiological effects caused by the metastatic tumor is discussed. The literature concerning cardiac metastases is reviewed.