Paediatric trainees and the transportation of critically ill neonates: experience, training and confidence

AIM

To study the experience of, training in, and confidence in the transportation of critically ill neonates amongst paediatric trainees in one UK region.

DESIGN

An anonymized questionnaire was sent to all middle grades with paediatrics National Training Numbers from the Trent region.

RESULTS

The response rate was 78%. Less than half (45%) of the respondents reported receiving any training in the transportation of neonates, either in the UK or abroad; 45% (30/66) of the trainees reported having performed 10 or fewer neonatal transfers. The self-perceived confidence for transporting neonates was scored on a 10-point scale, to produce a "confidence score", the median score being 7 (IQ range 5, 8). Both as a group and individually, the trainee paediatricians were more confident in transporting neonates than older infants or children (p < 0.0001). Using multiple analysis of covariance, it was found that the most important and significant variables affecting the "confidence scores" for the inter-hospital transportation of critically ill neonates were receipt of any relevant transport training, and the current frequency of transports performed.

CONCLUSIONS

Many training-grade paediatricians lack both the experience and training in transporting critically ill neonates, factors that were found to affect their confidence in transferring sick neonates. As the overwhelming majority of neonatal transports in the UK are still arranged by individual units and performed by training-grade paediatricians, concerns regarding both the safety and effectiveness of the current service provision for the inter-hospital transfer of critically ill neonates remain valid.

Interpretation of congruent and incongruent affective communications in paranoid schizophrenia

OBJECTIVES

It was hypothesized that people with paranoid schizophrenia would differ from depressed and normal participants in their interpretation of complex communications in which the affect conveyed verbally was either congruent or incongruent with the affect conveyed non-verbally.

DESIGN

A 3 (group) x 3 (positive, negative, neutral facial expression) x 3 (positive, negative, neutral verbal content) experimental design was used. There were eight participants per group, and the paranoid and depressed groups comprised inpatients in an acute psychiatric facility for either their first or second psychiatric episode.

METHODS

Participants, tested individually, were asked to interpret the affect conveyed by the various communications presented.

RESULTS

All participants interpreted most of the communications in a similar way. Paranoid schizophrenia patients, however, differed in their interpretation of communications in which negative feelings were expressed verbally. In contrast to both the normal and depressed groups, the paranoid schizophrenia group interpreted these communications as virtually devoid of any affect whatsoever.

CONCLUSIONS

Paranoid schizophrenia patients show an information-processing bias in response to communications involving both congruent and incongruent negative verbal content. It is not obvious why the bias observed would be specific to negative verbal messages and not extend to negative non-verbal messages. Replication and further study are required.

How can thermal processing modify the antigenicity of proteins?

This paper is a brief review of thermally induced covalent modifications to proteins in foods, focussing mainly on the advanced glycation end-products (AGE) of the Maillard reaction. Most foods are subjected to thermal processing, either in the home or during their production/manufacture. Thermal processing provides many beneficial effects, but also brings about major changes in allergenicity. Far from being a general way to decrease allergenic risk, thermal processing is as likely to increase allergenicity as to reduce it, through the introduction of neoantigens. These changes are highly complex and not easily predictable, but there are a number of major chemical pathways that lead to distinct patterns of modification. Perhaps the most important of these is through the reaction of protein amino groups with sugars, leading to an impressive cocktail of AGE-modified protein derivatives. These are antigenic and many of the important neoantigens found in cooked or stored foods are probably such Maillard reaction products. A deeper understanding of thermally induced chemical changes is essential for more advanced risk assessments, more effective QC protocols, production of more relevant diagnostic allergen extracts and the development of novel protein engineering and therapeutic approaches to minimise allergenic risk.

Regional low-flow perfusion provides somatic circulatory support during neonatal aortic arch surgery

BACKGROUND

Regional low-flow perfusion has been shown to provide cerebral circulatory support during neonatal aortic arch operations. However, its ability to provide somatic circulatory support remains unknown.

METHODS

Fifteen neonates undergoing arch reconstruction with regional perfusion were studied. Three techniques were used to assess somatic perfusion: abdominal aortic blood pressure, quadriceps blood flow (near-infrared spectroscopy), and gastric tonometry.

RESULTS

Twelve patients required operation for hypoplastic left heart syndrome, and 3 required arch reconstruction with a biventricular repair. There was one death (7%). Abdominal aortic blood pressure was higher (12+/-3 mm Hg versus 0+/-0 mm Hg), and quadriceps blood volumes (5+/-24 versus -17+/-26) and oxygen saturations (57+/-25 versus 33+/-12) were greater during regional perfusion than during deep hypothermic circulatory arrest (p < 0.05). During rewarming, the arterial-gastric mucosal carbon dioxide tension difference was lower after circulatory arrest than after regional perfusion (-3.3+/-0.3 mm Hg versus 7.8+/-7.6 mm Hg, p < 0.05).

CONCLUSIONS

Regional low-flow perfusion provides somatic circulatory support during neonatal arch surgical procedures. Support of the subdiaphragmatic viscera should improve the ability of neonates to survive the postoperative period.

Respiratory function in operatic singing: effects of emotional connection

The respiratory patterns of five professional operatic singers when performing with "emotional connection" (EC) as if communicating to an audience were compared with "technical" (T) singing as if rehearsing. Recordings of the performances were played to experienced listeners to provide independent confirmation of the singers' intentions. The findings show that, in comparison with T singing, EC singing, especially in the aria task, used more air with a greater percentage of vital capacity (VC) expired per second, but without a simple association with sound pressure level (SPL) or breath (phrase) duration. These findings suggest that the performing state of mind itself can effect technical results in operatic singing. Pedagogical implications are discussed.

Stress response in infants undergoing cardiac surgery: a randomized study of fentanyl bolus, fentanyl infusion, and fentanyl-midazolam infusion

There have been significant changes in the management of neonates and infants undergoing cardiac surgery in the past decade. We have evaluated in this prospective, randomized, double-blinded study the effect of large-dose fentanyl anesthesia, with or without midazolam, on stress responses and outcome. Forty-five patients < 6 mo of age received bolus fentanyl (Group 1), fentanyl by continuous infusion (Group 2), or fentanyl-midazolam infusion (Group 3). Epinephrine, norepinephrine, cortisol, adrenocortical hormone, glucose, and lactate were measured after the induction (T1), after sternotomy (T2), 15 min after initiating cardiopulmonary bypass (T3), at the end of surgery (T4), and after 24 h in the intensive care unit (T5). Plasma fentanyl concentrations were obtained at all time points except at T5. Within each group epinephrine, norepinephrine, cortisol, glucose and lactate levels were significantly larger at T4 (P values < 0.01), but there were no differences among groups. Within groups, fentanyl levels were significantly larger in Groups 2 and 3 (P < 0.001) at T4, and among groups, the fentanyl level was larger only at T2 in Group 1 compared with Groups 2 and 3 (P < 0.006). There were no deaths or postoperative complications, and no significant differences in duration of mechanical ventilation or intensive care unit or hospital stay. Fentanyl dosing strategies, with or without midazolam, do not prevent a hormonal or metabolic stress response in infants undergoing cardiac surgery.

IMPLICATIONS

We demonstrated a significant endocrine stress response in infants with well compensated congenital cardiac disease undergoing cardiac surgery, but without adverse postoperative outcome. The use of large-dose fentanyl, with or without midazolam, with the intention of providing "stress free" anesthesia, does not appear to be an important determinant of early postoperative outcome.

Thyroid hormone promotes serine phosphorylation of p53 by mitogen-activated protein kinase

L-Thyroxine (T(4)) nongenomically promotes association of mitogen-activated protein kinase (MAPK) and thyroid hormone receptor TRbeta1 (TR) in the cell nucleus, leading to serine phosphorylation of the receptor. The oncogene suppressor protein, p53, is serine phosphorylated by several kinases and is known to interact with TRbeta1. We studied whether association of p53 and TR is modulated by T(4) and involves serine phosphorylation of p53 by MAPK. TR-replete 293T human kidney cells were incubated with a physiological concentration of T(4) for 10-90 min. Nuclear fractions were immunoprecipitated and the resulting proteins separated and immunoblotted for co-immunoprecipitated proteins. Activated MAPK immunoprecipitates of nuclei from T(4)-treated cells accumulated p53 in a time-dependent manner; T(4) and T(4)-agarose were more effective than T(3). T(4)-induced nuclear complexing of p53 and MAPK was inhibited by PD 98059 (PD) and U0126, two MAPK kinase (MEK) inhibitors, and was absent in cells treated with MEK antisense oligonucleotide and in dominant negative Ras cells. T(4) also caused nuclear co-immunoprecipitation of TRbeta1 and p53, an effect also inhibited by PD. Nuclear complexing of p53 and MAPK also occurred in HeLa cells, which lack functional TR. Constitutively activated MAPK caused phosphorylation of a recombinant p53-GST fusion protein in vitro; thus, p53 is a substrate for MAPK. An indicator of p53 transcriptional activity, accumulation of the immediate-early gene product, c-Jun, was inhibited by T(4). This T(4) effect was reversed by PD, indicating that the transcriptional activity of p53 was altered by T(4)-directed MAPK-p53 interaction.

Patterns of breath support in projection of the singing voice

Recordings of the rib cage and abdominal motions and acoustic output were obtained from five professional opera singers during performance of an aria recorded with two levels of voice projection. The condition of greater projection resulted in a significant increase in the acoustic power in the frequency band 2-4 kHz, relative to the power in the 0-2 kHz band, and a decrease in the mean expiratory flow, implying a move to more efficient vocalization with the greater projection. Also, the condition of greater projection resulted in a larger rib cage, particularly in the lateral dimension, but only a small decrease in the abdominal lateral dimension, suggesting that the greater abdominal support required for a larger projection is obtained by increased activation of abdominal muscles acting medially.

Thyroxine promotes association of mitogen-activated protein kinase and nuclear thyroid hormone receptor (TR) and causes serine phosphorylation of TR

Activated nongenomically by l-thyroxine (T(4)), mitogen-activated protein kinase (MAPK) complexed in 10-20 min with endogenous nuclear thyroid hormone receptor (TRbeta1 or TR) in nuclear fractions of 293T cells, resulting in serine phosphorylation of TR. Treatment of cells with the MAPK kinase inhibitor, PD 98059, prevented both T(4)-induced nuclear MAPK-TR co-immunoprecipitation and serine phosphorylation of TR. T(4) treatment caused dissociation of TR and SMRT (silencing mediator of retinoid and thyroid hormone receptor), an effect also inhibited by PD 98059 and presumptively a result of association of nuclear MAPK with TR. Transfection into CV-1 cells of TR gene constructs in which one or both zinc fingers in the TR DNA-binding domain were replaced with those from the glucocorticoid receptor localized the site of TR phosphorylation by T(4)-activated MAPK to a serine in the second zinc finger of the TR DNA-binding domain. In an in vitro cell- and hormone-free system, purified activated MAPK phosphorylated recombinant human TRbeta1 (). Thus, T(4) activates MAPK and causes MAPK-mediated serine phosphorylation of TRbeta1 and dissociation of TR and the co-repressor SMRT.

Depression Determines Illness Conviction and Pain Impact: A Structural Equation Modeling Analysis

OBJECTIVE

The present study sought to derive an algorithm using factor analysis and structural equation modeling (SEM) to describe headache and orofacial pain patients using measures of behavioral and psychological functioning. This investigation further examined whether the underlying factor structure differed in 3 presumed distinct diagnostic categories: myofascial, neuropathic, and neurovascular pain.

DESIGN

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Multidimensional Pain Inventory (MPI), Beck Depression Inventory-II (BDI-II), and visual analog scale for functional limitation (VAS-FL) were administered to the subjects. A split group design was used. Exploratory factor analysis (EFA) was used to describe distinct factor domains in the first group. Confirmatory factor analysis (CFA) using SEM tested this structure in the second group and described causal relationships between the revealed (latent) factors. Analysis of variance (ANOVA) was used to test for differences in demographic variables and diagnostic group factor structure.

SETTING

The Pain Center is a comprehensive, multidisciplinary pain medicine program at Cedars-Sinai Medical Center, Los Angeles, California.

SUBJECTS

Three hundred and ninety (N = 390) subjects were assigned to 1 of 3 diagnostic categories: myofascial pain syndrome, neuropathic pain, or neurovascular pain.

RESULTS

EFA revealed a 3-factor solution. The factors were labeled Depression, Illness Conviction, and Pain Impact, reflecting the content of their respective variables with highest loadings. CFA using SEM validated the 3-factor solution, and further revealed that Depression was a critical causal factor determining Illness Conviction and Pain Impact. No causal relationship was observed between Illness Conviction and Pain Impact. ANOVA found no differences in demographics. No difference in factor structure emerged for the 3 diagnostic categories.

CONCLUSIONS

Analysis derived a 3-factor solution. The factors were Pain Impact, Illness Conviction, and Depression. SEM revealed the critical causal pathway showing that Depression determined Illness Conviction and Pain Impact. We conclude that the main target for pain treatment is depression. No differences in factor structure were found for the 3 diagnostic categories of myofascial, neuropathic, or neurovascular pain. This suggests that psychological processes are similar in chronic headache and orofacial pain patients despite their presumed distinct underlying pathophysiological mechanisms. SME is a powerful methodology to construct causal models that has been underutilized in the pain literature.

Recognition of posed and genuine facial expressions of emotion in paranoid and nonparanoid schizophrenia

Most previous research reporting emotion-recognition deficits in schizophrenia has used posed facial expressions of emotion and chronic-schizophrenia patients. In contrast, the present research examined the ability of patients with acute paranoid and nonparanoid (disorganized) schizophrenia to recognize genuine as well as posed facial expressions of emotion. Evidence of an emotion-recognition deficit in schizophrenia was replicated, but only when posed facial expressions were used. For genuine expressions of emotion, the paranoid-schizophrenia group was more accurate than controls, nonparanoid-schizophrenia patients, and depressed patients. Future research clearly needs to consider the posed versus genuine nature of the emotional stimuli used and the type of schizophrenia patients examined.

A randomized, double-blinded study of remifentanil versus fentanyl for tonsillectomy and adenoidectomy surgery in pediatric ambulatory surgical patients

We compared, in a double-blinded manner, the anesthetic maintenance and recovery properties of remifentanil with a clinically comparable fentanyl-based anesthetic technique in pediatric ambulatory surgical patients. Anesthesia was induced with either halothane or sevoflurane and nitrous oxide and oxygen. Patients were randomized (computer generated) to receive either remifentanil or fentanyl in a blinded syringe with nitrous oxide and oxygen in one of four possibilities: halothane/remifentanil, halothane/fentanyl, sevoflurane/remifentanil or sevoflurane/fentanyl. In patients receiving remifentanil, a placebo bolus was administered, and a continuous infusion (0.25 microg. kg(-1). min(-1)) was begun. In patients receiving fentanyl, a bolus (2 microg/kg) was administered followed by a placebo continuous infusion. The time from discontinuation of the anesthetic to extubation, discharge from the postanesthesia care unit (PACU), and discharge to home, as well as pain scores, were assessed by a blinded nurse observer. Systolic blood pressure and heart rate were noted at selected times, and adverse events were recorded. Remifentanil provided faster extubation times and higher pain-discomfort scores. PACU and hospital discharge times were similar. There were no statistical differences among the groups for adverse events. There were statistically, but not clinically, significant differences in hemodynamic variables. We noted that continuous infusions of remifentanil were intraoperatively as effective as bolus fentanyl. Although patients could be tracheally extubated earlier with remifentanil, this did not translate to earlier PACU or hospital discharge times. In addition, remifentanil was associated with higher postoperative pain scores. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children.

IMPLICATIONS

This is a study designed to examine the efficacy and safety of a short-acting opioid, remifentanil, when used in pediatric patients. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children.

Differential induction of tumor necrosis factor alpha and manganese superoxide dismutase by endotoxin in human monocytes: role of protein tyrosine kinase, mitogen-activated protein kinase, and nuclear factor kappaB

A mutant Escherichia coli lipopolysaccharide (LPS) lacking myristoyl fatty acid markedly stimulates the activity of manganese superoxide dismutase (MnSOD) without inducing tumor necrosis factor alpha (TNFalpha) production by human monocytes (Tian et al., 1998, Am J Physiol 275:C740.), suggesting that induction of MnSOD and TNFalpha by LPS are regulated through different signal transduction pathways. The protein tyrosine kinase (PTK)/mitogen-activated protein kinase (MAPK) pathway plays an important role in the LPS-induced TNFalpha production. In the current study, we determined the effects of PTK inhibitors, genistein and herbimycin A, on the induction of MnSOD and TNFalpha in human monocytes. Genistein (10 microg/ml) and herbimycin A (1 microg/ml) markedly inhibited LPS-induced protein tyrosine phosphorylation, phosphorylation and nuclear translocation of MAPK (p42 ERK, extracellular signal-regulated kinase), and increases in the steady state level of TNFalpha mRNA as well as TNFalpha production. In contrast, at similar concentrations, genistein and herbimycin A had no effect on the LPS-induced activation of nuclear factor kappaB (NFkappaB) and induction of MnSOD (mRNA and enzyme activity) in human monocytes. In addition, inhibition of NFkappaB activation by gliotoxin and pyrrodiline dithiocarbamate, inhibited LPS induction of TNFalpha and MnSOD mRNAs. These results suggest that (1) while PTK and MAPK are essential for the production of TNFalpha, they are not necessary for the induction of MnSOD by LPS, and (2) while activation of NFkappaB alone is insufficient for the induction of TNFalpha mRNA by LPS, it is necessary for the induction of TNFalpha as well as MnSOD mRNAs.

The effects of cardiopulmonary bypass on remifentanil kinetics in children undergoing atrial septal defect repair

Cardiopulmonary bypass (CPB) can greatly influence the pharmacokinetics of opioids. This study investigated the pharmacokinetic profile of remifentanil in 12 pediatric patients undergoing CPB for repair of an atrial septal defect. All patients received remifentanil (5 microg/kg) over 1 min into a peripheral vein both before the onset of CPB and after the discontinuation of CPB. Arterial blood samples were obtained at defined time periods, and remifentanil concentration was determined using high-performance liquid chromatography ultraviolet detection. The pharmacokinetic profiles both before and after bypass were determined in all 12 patients. There was no change in the volume of distribution at steady state, the volume of the central compartment, or the alpha- and beta-elimination half-life. Although the clearance values increased 20% in the postbypass period (from 38.7 +/- 9.6 to 46.8 +/- 14 mL x kg(-1) x min(-1), there was no meaningful change in the coefficient of variation (from 25% to 30%).

IMPLICATIONS

After cardiopulmonary bypass the clearance of remifentanil increases in children. However, the relative lack of change in the coefficient of variation suggests that remifentanil should be a predictable drug in the postcardiopulmonary bypass period.

Gender differences in autobiographical memory for childhood emotional experiences

Research to date has paid remarkably little heed to gender differences in autobiographical memory. To redress this, the author examined memory for childhood events in adult men and women remembering back to childhood, and in children themselves. Five studies were conducted, and results revealed that females consistently recalled more childhood memories than males did and were generally faster in accessing the memories recalled. Furthermore, the gender difference observed was specific to memories of events associated with emotion and was apparent across a diverse range of emotions experienced by both the self and others. The overall pattern of findings obtained is consistent with the proposition that gender-differentiated socialization processes influence the content and complexity of representations of autobiographical emotional events in memory. To some extent, then, autobiographical memory appears to be a socially constructed phenomenon.

Microemulsion of seal oil markedly enhances the transfer of a hydrophobic radiopharmaceutical into acetylated low density lipoprotein

Four different microemulsions differing in their core lipid component (triolein, canola oil, squalene, or seal oil) and containing 1,3-dihydroxypropan-2-one 1,3-diiopanoate (DPIP), a potential radioimaging probe, were prepared by means of ultrasonication. The DPIP microemulsions were incubated with acetylated human low density lipoprotein (AcLDL) and the amount of DPIP transferred into AcLDL was examined. The amount of DPIP in the microemulsions expressed as DPIP/oil (w/w) was dependent on the core lipid component of the microemulsion in the order of seal oil (0.19+/-0.04, mean +/- standard deviation) > squalene (0.15+/-0.02) > canola oil (0.12+/-0.02) > triolein (0.07+/-0.004). With the exception of canola oil, all microemulsions were effective in enhancing the transfer of DPIP into AcLDL in comparison with commonly used methods, i.e., direct diffusion and detergent solubilization. DPIP in seal oil resulted in the highest amount of DPIP transferred into AcLDL [309.16+/-34.82 vs. 203.19+/-64.51 using squalene and 151.31+/-28.54 using triolein (DPIP molecules per AcLDL particle)]. For the first time, oil from harp seals, was studied as a major core lipid component of formulating pharmaceutical microemulsions. DPIP in seal oil resulted in the highest transfer of DPIP into AcLDL which is likely due to the highest DPIP concentration found in this microemulsion as well as the high fluidity of seal oil.

Thyroid hormone induces activation of mitogen-activated protein kinase in cultured cells

Thyroid hormone [L-thyroxine (T4)] rapidly induced phosphorylation and nuclear translocation (activation) of mitogen-activated protein kinase (MAPK) in HeLa and CV-1 cells in the absence of cytokine or growth factor. A pertussis toxin-sensitive and guanosine 5'-O-(3-thiotriphosphate)-sensitive cell surface mechanism responsive to T4 and agarose-T4, suggesting a G protein-coupled receptor, was implicated. Cells depleted of MAPK or treated with MAPK pathway inhibitors showed reduced activation of MAPK and of the signal transducer and activator of transcription STAT1alpha by T4; they also showed reduced T4 potentiation of the antiviral action of interferon-gamma (IFN-gamma). T4 treatment caused tyrosine-phosphorylated MAPK-STAT1alpha nuclear complex formation and enhanced Ser-727 phosphorylation of STAT1alpha, in the presence or absence of IFN-gamma. STAT1alpha-deficient cells transfected with STAT1alpha containing an alanine-for-serine substitution at residue 727 (STAT1alphaA727) showed minimal T4-stimulated STAT1alpha activation. IFN-gamma induced the antiviral state in cells containing wild-type STAT1alpha (STAT1alphawt) or STAT1alphaA727; T4 potentiated IFN-gamma action in STAT1alphawt cells but not in STAT1alphaA727 cells. T4-directed STAT1alpha Ser-727 phosphorylation is MAPK mediated and results in potentiated STAT1alpha activation and enhanced IFN-gamma activity.

Gender differences in autobiographical memory for childhood emotional experiences

Research to date has paid remarkably little heed to gender differences in autobiographical memory. To redress this, the author examined memory for childhood events in adult men and women remembering back to childhood, and in children themselves. Five studies were conducted, and results revealed that females consistently recalled more childhood memories than males did and were generally faster in accessing the memories recalled. Furthermore, the gender difference observed was specific to memories of events associated with emotion and was apparent across a diverse range of emotions experienced by both the self and others. The overall pattern of findings obtained is consistent with the proposition that gender-differentiated socialization processes influence the content and complexity of representations of autobiographical emotional events in memory. To some extent, then, autobiographical memory appears to be a socially constructed phenomenon.

Thyroid hormone promotes the phosphorylation of STAT3 and potentiates the action of epidermal growth factor in cultured cells

We have examined the effects of l-thyroxine (T4) on the activation of signal transducer and activator of transcription 3 (STAT3) and on the STAT3-dependent induction of c-Fos expression by epidermal growth factor (EGF). T4, at a physiological concentration of 100 nM, caused tyrosine phosphorylation and nuclear translocation (i.e. activation) of STAT3 in HeLa cells in as little as 10-20 min. Activation by T4 of STAT3 was maximal at 30 min (15+/-4-fold enhancement; mean+/-S.E.M.) in 18 experiments. This effect was reproduced by T4-agarose (100 nM) and blocked by CGP 41251, genistein, PD 98059 and geldanamycin, inhibitors of protein kinase C (PKC), protein tyrosine kinase (PTK), mitogen-activated protein kinase (MAPK) kinase and Raf-1 respectively. Tyrosine-phosphorylated MAPK also appeared in nuclear fractions within 10 min of treatment with T4. In the nuclear fraction of T4-treated cells, MAPK immunoprecipitate also contained STAT3. The actions of T4 were similar in HeLa and CV-1 cells, which lack thyroid hormone receptor (TR), and in TR-replete skin fibroblasts (BG-9). T4 also potentiated the EGF-induced nuclear translocation of activated STAT1alpha and STAT3 and enhanced the EGF-stimulated expression of c-Fos. Hormone potentiation of EGF-induced signal transduction and c-Fos expression was inhibited by CGP 41251, geldanamycin and PD 98059. Therefore the non-genomically induced activation by T4 of STAT3, and the potentiation of EGF by T4, require activities of PKC, PTK and an intact MAPK pathway.

Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion

This double-blinded study was undertaken to prospectively evaluate the role of halothane and sevoflurane and the use of IV ketorolac on the anesthetic emergence in a group of children undergoing bilateral myringotomy with pressure equalization tube procedures. Two-hundred ASA physical status I and II patients were premedicated with nasal midazolam (0.2 mg/kg) and randomized to one of four groups (Group 1 - halothane and ketorolac; Group 2 - halothane and placebo; Group 3 - sevoflurane and ketorolac; Group 4 - sevoflurane and placebo). A blinded nurse observer characterized the quality of the anesthetic emergence and recorded the incidence of emesis and the use of pain medications in the recovery room. There were no differences in age, weight, previous anesthetic experience, or duration of anesthesia among the four groups. There was no difference in the incidence of emergence agitation for patients anesthetized with sevoflurane compared with halothane, regardless of whether they received ketorolac or placebo. Regardless of the anesthetic, the incidence of emergence agitation was significantly less in patients who received ketorolac compared with patients who received placebo. The incidence of emesis in the recovery room, the total 24-h incidence of emesis, and the use of at-home pain medications were similar in all four groups.

IMPLICATIONS

We conclude that the incidence of emergence agitation in children undergoing ultrashort anesthetic procedures is similar for sevoflurane and halothane and that ketorolac markedly diminishes emergence agitation and/or pain behavior.