Analgesic management after thoracotomy for decortication in children: a retrospective audit of 83 children managed with a paravertebral infusion-based regime

BACKGROUND

It is important that postoperative analgesic management after thoracotomy is very effective in order to optimize postoperative recovery. A regional technique such as an epidural or a paravertebral catheter with an infusion of local anesthetic may be supplemented with systemically administered analgesic drugs in order to achieve satisfactory analgesia.

OBJECTIVE

The objective of this observational study was to evaluate whether a paravertebral infusion of local anesthetic delivered via a surgically placed catheter together with systemic analgesics is associated with low pain scores and satisfactory analgesia after thoracotomy for decortication in children.

METHODS

We performed a retrospective analysis of the notes and charts of 83 children admitted with empyema thoracis and managed with thoracotomy and decortication. We collected data on the doses of analgesic drugs (morphine, paracetamol, and ibuprofen) and details of paravertebral infusions, together with postoperative pain scores for the first 48 h after surgery, or earlier if the paravertebral infusion was stopped within 48 h of surgery. Poor quality analgesia was defined as a score of 7 or more on the Visual Analog/Smiley Faces Scale ('VAS/SF').

RESULTS

A total of 81 children were ASA 1 status and two were ASA 3 status. Analgesia comprised intravenous morphine at a mean dose of 20 μg·kg(-1) ·h(-1) , together with oral paracetamol (62.5 mg·kg(-1) /24 h) and ibuprofen (14.2 mg·kg(-1) /24 h). The mean paravertebral bupivacaine dose was 0.29 mg·kg(-1) ·h(-1) . Sixty-four patients (77.1%) had good quality analgesia, 17 (20.5%) patients had moderate quality analgesia, and only two patients (2.4%) had poor quality analgesia.

CONCLUSION

Analgesic outcomes with this regimen appear to be very satisfactory. It compares favorably with an epidural-based regimen.

Effect of sunn hemp (Crotalaria juncea L.) cutting date and planting density on weed suppression in Georgia, USA

A field study was conducted in 2008 and 2009 at the USDA, ARS, Plant Genetic Resources Conservation Unit in Griffin, GA, to investigate weed suppression by sunn hemp (Crotalaria juncea L). The objectives were to (1) evaluate the effects of apical meristem removal (AMR) at three dates [5, 6, and 7 wks after planting (WAP) on May 14, 2008 and May 21, 2009] and (2) assess the impact of seeding rates (11, 28, and 45 kg ha(-1)) on weed biomass reduction. Weed species were identified at 4, 8, and 12 wks after sunn hemp planting. Sunn hemp cutting date had no significant effect on weed suppression in 2008 but significant differences for grass weeds at 4, 8, and 12 WAP and for yellow nutsedge at 8 and 12 WAP did occur when compared to the control in 2009. In comparison to the sunn hemp-free control plot in 2009, all three seeding rates had reduced grass weed dry weights at 4, 8, and 12 WAP. The total mass of yellow nutsedge when grown with sunn hemp was reduced compared to the total mass of yellow nutsedge grown in the weedy check for all seeding rates at 8 and 12 WAP. Lower grass weed biomass was observed by 12 WAP for cutting dates and seeding rates during 2008 and 2009. Sunn hemp cutting date and seeding rate reduced branch numbers in both years. The reduction in sunn hemp seeding rates revealed a decrease in weed populations.

How does psychoeducation help? A review of the effects of providing information about Tourette syndrome and attention-deficit/hyperactivity disorder

Tourette syndrome (TS) and attention-deficit/hyperactivity disorder (ADHD) are common neurodevelopmental disorders that often co-occur. They are both stigmatized and misunderstood conditions. This review critically appraises studies examining interventions using psychoeducational approaches in TS and ADHD. Studies examining the impact of providing educational information (or diagnostic label) about TS and ADHD to parents, teachers and peers (child and adult) were identified by searching relevant electronic databases, reference lists and citations, and consulting colleagues. Twenty-two studies were identified, 20 of which involved teachers or peers. The studies indicate that providing educational information increases knowledge, positive attitudes and behaviours towards individuals with TS and ADHD. Provision of a diagnostic label alone appears insufficient. Parental education may improve treatment enrolment and adherence. While the findings are encouraging, there are a number of gaps in the literature. These include the effects of giving information to parents, whether changes are maintained over time, or are generalizable to the population. Studies are needed to investigate the optimal way to present educational information in everyday contexts in order to improve the lives of those with TS and ADHD.

A comparison of three methods that assess tracheal tube leakage: leak conductance, fractional volume loss, and audible assessment

BACKGROUND

When intubating a child's trachea with an uncuffed tracheal tube (TT), it is current practice in anesthesia and intensive care to use the leak test to assess TT fit. The aim of this study is to compare three measures of assessing leak around uncuffed tracheal tubes in the PICU.

METHODS

We obtained institutional ethical permission and written informed consent, prior to any clinical investigation, from the parents of 135 children who had surgery for cardiac defects. On admission to the PICU, we measured leak by audible assessment, fractional volume loss, and leak conductance for each patient. Measurements of fractional volume loss and leak conductance were repeated every 4 h thereafter until extubation.

RESULTS

On admission to the PICU, calculated values of leak conductance were significantly different between each grade of audible leak (P < 0.001). Values of fractional volume loss were not significantly different between 'no leak' and 'small leak' grades of leak. Throughout the PICU stay, a significant correlation between mean leak conductance and mean fractional volume loss was found (0.86, 95% CI, 0.81-0.90). Significant agreement within time series of leak conductance and fractional volume recorded for each patient occurred in 47/128 cases (37%).

CONCLUSIONS

On admission to the PICU, values of leak conductance are more strongly associated with audible assessment than with fractional volume loss. Throughout PICU stay, leak conductance is associated with fractional volume loss. This study demonstrates that leak conductance, calculated from routinely available pressure and flow signals, has the potential to represent the characteristics of the leak interface between a TT and the trachea.

Abstract P2-10-05: Continuous association of a 200-gene prognostic risk score with probability of neoadjuvant chemotherapy response and translation from fresh frozen to FFPE tissue for clinical use

BreastPRS is a suite of complimentary gene signatures that resolves several of the significant limitations of current gene expression signatures in breast cancer. Notably, BreastPRS can accurately provide prognosis prediction, histological grade resolution and molecular subtyping of invasive breast cancer. The 200-gene prognostic component was previously validated in an independent retrospective series of 1,016 previously published fresh-frozen breast cancers and has now been applied to data from over 6,000 patients.

In part one of this study, a meta-analysis of 890 previously published neoadjuvant treated breast cancer patients was performed. A highly significant association was observed between prognosis risk group (high vs low), continuous risk score (0–100), and a patient's probability of achieving complete pathologic response with neoadjuvant chemotherapy. Data from both fine-needle-aspirate and biopsy tissue were included in the cohort. Notably, fewer than 10% of patients with the lowest (most favorable) pre-treatment BreastPRS prognosis scores achieve pCR. Probability of pCR was observed to increase steadily to over 40% for individuals with the highest prognosis scores.

In part two of the analysis, 50 paired fresh-frozen and FFPE tumors were profiled on whole genome microarrays containing all three signatures, in a CLIA-certified high throughput genomics laboratory. Results will be presented that highlight the consistency of the prognosis, grade and subtype signatures in clinically relevant FFPE tissue.

This suggests that BreastPRS, in addition to identifying 10-year recurrence risk, histologic grade and molecular subtype, may enable physicians to determine a patients benefit from receiving neoadjuvant chemotherapy with more granularity than current clinical or genomic methods.

Pig-shed air polluted by α-haemolytic cocci and ammonia causes subclinical disease and production losses

There is mounting evidence that bacteria originating from pigs degrade the environment of the pig shed and adversely affect the health of the animals and the pig-shed workers. α-haemolytic cocci (AHC) occur in pig-shed environments, but are regarded as commensals. Ammonia is also a component of the pig-shed environment, and is known to damage upper respiratory tract epithelia. The aim of this study was to determine whether polluted air in pig sheds adversely affected performance indicators in pigs. Modelling revealed a direct effect of AHC on voluntary feed intake and hence AHC are not commensal. No direct effect of ammonia on the pigs was detected, but the combination of AHC and ammonia stimulated the immune system in a progressive manner, and there were direct effects of immune stimulation on food intake and growth resulting in poorer feed-conversion efficiency, even though the effects remained subclinical. The authors conclude that exposure of the respiratory epithelia of pigs to viable AHC in the presence of ammonia redirects nutrients away from production and towards the immune system, explaining the impact of poor pig-shed hygiene on production parameters.

Whole body MRI in the diagnosis of chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is a diagnosis of exclusion primarily in children and adolescents. As part of the essential criteria for the diagnosis of CRMO, multifocal lesions must be identified. We present the case of an 11-year-old boy with CRMO, whose diagnosis was facilitated by the use of whole body magnetic resonance imaging (WBMR), but not isotope bone scanning.

Evaluation of a dynamic armrest for hydraulic-actuation controller use

The efficacy of a newly designed dynamic armrest was evaluated during joystick operation of a typical North American hydraulic-actuation joystick. The dynamic design was evaluated against a stationary armrest condition as well as no armrest condition. Electromyography (EMG) and subjective measurements were used to make the evaluation. The dynamic armrest, which mimics the natural pendulation of a joystick operator's arm in the forward and backward directions, was shown to significantly decrease the muscular activation in the upper trapezius, posterior deltoid, and anterior deltoid (p ≤ 0.01) over a stationary armrest. A questionnaire revealed that subjects significantly (p = 0.01) preferred the dynamic armrest design over either a standard armrest or no armrest with 17 of 21 operators preferring the dynamic armrest. Ratings from the questionnaire indicated that subjects felt that the dynamic armrest required less effort, was more comfortable, and was more effective than either of the other two armrest conditions.

Nernst response of the Landau tubes in graphite across the quantum limit

We report on a study of the Nernst effect in graphite extended up to 45 T. The Nernst response sharply peaks when a Landau tube is squeezed inside the thermally fuzzy Fermi surface and presents a temperature-independent fixed point when the tube flattens to a single ring. Beyond the quantum limit, the onset of the field-induced phase transition leads to a drastic drop in the Nernst response signaling the sudden vanishing of Landau tubes. The magnitude of this drop suggests the destruction of multiple Landau tubes possibly as a result of simultaneous nesting of the electron and hole pockets.

Upper gastrointestinal bleeding: a Jamaican perspective

BACKGROUND

Upper gastrointestinal bleeding (UGIB) remains one of the most common clinical life-threatening emergencies which is associated with a high morbidity, mortality and medical care costs.

OBJECTIVES

This study reviews the clinical features, management and outcomes of patients with UGIB seen at the University Hospital of the West Indies (UHWI), Jamaica, between January 2006 and December 2008.

METHODS

Patients with UGIB admitted to the medical wards of the UHWI, Jamaica, between January 2006 and December 2008 were reviewed. Consecutive patients admitted with a confirmed diagnosis of UGIB were selected for analysis. Data collected included age, gender presenting complaints, risk factors, clinical features and management. Endoscopic findings, treatment and outcomes were also reviewed.

RESULTS

There were 104 patients, with a mean age of 55 years, admitted with UGIB. There were significantly more men than women (73 vs 31). Retching and vomiting were the most common presenting complaints followed by melaena and haemetemesis. Non-steroidal anti-inflammatory drug use was present in 28% of patients. Overall, 80% of patients had upper GI endoscopy (EGD) and 40% were done within 24 hours of admission. The median time for performing EGD was 24 hours (mean 46 hours). The leading causes of UGIB were duodenal ulcer (28%), erosive gastritis (20%) and gastric ulcer (13%). Proton pump inhibitors (PPI) were given to 95 (91%) patients intravenously. Blood transfusion was given to 40% of patients. The mortality was 5.7%, rebleeding occured in 4.8% of patients and 5% underwent surgery. The average duration of hospital stay was 6.6 days.

CONCLUSION

Upper gastrointestinal bleeding was more common in men of middle age in this study. Proton pump inhibitors were used in most patients. The overall mortality of 5.7% is similar to other series. Early EGD and use of endoscopic therapy may lead to a decrease in mortality in high risk patients.