Fentanyl bolus induces muscle tremors in sevoflurane-anaesthetized piglets

Intravenous fentanyl (10 mcg/kg) or saline (control) was randomly administered to 10 healthy sevoflurane-mono-anaesthetized piglets. Trembling was assessed by two blinded observers using a visual analogue scale (VAS) and a simple ordinal scale at baseline and 5 min (T5) after drug administration. If no trembling was observed at that time point, the opposite treatment was administered and piglets were re-evaluated after another 5 min (T10). Four out of five piglets showed trembling after fentanyl (T5), while none given saline showed any trembling. With fentanyl the VAS scores were significantly higher at T5 compared either with baseline or with the control treatment. Control animals received fentanyl after the 5 min evaluation and all piglets showed clear trembling afterwards. The median time after fentanyl administration until first muscle tremors was 51 (20–840) s. In summary, nine out of 10 sevoflurane-anaesthetized piglets showed muscle tremors after intravenous fentanyl. Tremors subsided over time and no specific treatment was necessary.

Nonnative forest insects and pathogens in the United States: Impacts and policy options

We review and synthesize information on invasions of nonnative forest insects and diseases in the United States, including their ecological and economic impacts, pathways of arrival, distribution within the United States, and policy options for reducing future invasions. Nonnative insects have accumulated in United States forests at a rate of ~2.5 per yr over the last 150 yr. Currently the two major pathways of introduction are importation of live plants and wood packing material such as pallets and crates. Introduced insects and diseases occur in forests and cities throughout the United States, and the problem is particularly severe in the Northeast and Upper Midwest. Nonnative forest pests are the only disturbance agent that has effectively eliminated entire tree species or genera from United States forests within decades. The resulting shift in forest structure and species composition alters ecosystem functions such as productivity, nutrient cycling, and wildlife habitat. In urban and suburban areas, loss of trees from streets, yards, and parks affects aesthetics, property values, shading, stormwater runoff, and human health. The economic damage from nonnative pests is not yet fully known, but is likely in the billions of dollars per year, with the majority of this economic burden borne by municipalities and residential property owners. Current policies for preventing introductions are having positive effects but are insufficient to reduce the influx of pests in the face of burgeoning global trade. Options are available to strengthen the defenses against pest arrival and establishment, including measures taken in the exporting country prior to shipment, measures to ensure clean shipments of plants and wood products, inspections at ports of entry, and post-entry measures such as quarantines, surveillance, and eradication programs. Improved data collection procedures for inspections, greater data accessibility, and better reporting would support better evaluation of policy effectiveness. Lack of additional action places the nation, local municipalities, and property owners at high risk of further damaging and costly invasions. Adopting stronger policies to reduce establishments of new forest insects and diseases would shift the major costs of control to the source and alleviate the economic burden now borne by homeowners and municipalities.

Impact of oxygen sources on performance of the Ventrain(®) ventilation device in an in vitro set-up

BACKGROUND

The Ventrain(®) (Dolphys Medical, Eindhoven, The Netherlands) is a disposable handheld ventilation device allowing active inspiration and expiration through a transtracheal catheter. This study investigated Ventrain(®) 's performance when used with different clinical oxygen sources in an in vitro set-up.

METHODS

Three anesthesia oxygen sources (wall-mounted flowmeter, respirator oxygen outlet port, and anesthesia ventilator circuit) were used at gas flow rates of 6, 9, 12, and 15 l/min. First, the sources' driving pressures (DP), the insufflation pressure (IP), and the flow at the catheter tip were measured using a gas flow analyzer. Tidal volumes (VT) delivered by the Ventrain(®) were assessed by the ASL5000 test lung (respiratory rate: 15 min(-1), I:E = 1:1, compliance: 100 ml/cmH2O, resistance: 3.06 cmH2O/l/s).

RESULTS

VT ranged from 82 to 483 ml for inspiration and 82 to 419 ml for expiration. Measured IP, flow, and VT were less dependent on the set gas flow rate but more on the source's DP. With rising DP the IP, the flow at the catheter tip and consequently VT increased. At an approximate target I:E ratio of 1:1, the ratio of inspiratory to expiratory VT increased with higher DP and gas flow rates.

CONCLUSION

The oxygen sources resulted in clinically different IP, flows, and VT delivered by the Ventrain(®) at given gas flow rates. This needs to be considered in a clinical emergency situation. Integrating an adjustable pressure valve into Ventrain(®) to allow regulation of the lowest necessary IP would make its use safer.

Highly mesoporous CsTaWO6via hard-templating for photocatalytic hydrogen production

Mesoporous CsTaWO₆ for photocatalytic hydrogen production has been prepared via hard-templating with a surface area of up to 115 m² g⁻¹.

Metastatic mammary carcinoma despite histologically negative sentinel lymph nodes: are there any indicators for estimating recurrence and metastasis rates?

OBJECTIVE

This study aimed to identify indicators for an increased frequency of recurrent or metastatic disease in women with mammary carcinoma staged negative for nodal involvement.

MATERIALS AND METHODS

202/270 patients (age: mean 57.5, range 24-83 years) with histologically confirmed early stage mammary carcinoma negative for metastasis to the sentinel lymph nodes (SLN) were observed with respect to their clinical course for a mean period of 3.6 years following SLN extirpation.

RESULTS

Forty of 202 patients with negative SLN underwent chemotherapy (38/188 in the recurrence-free group vs. 2/14 in the group with progressive disease) and 79% of both subcollectives did not undergo chemotherapy. Seven of 188 of patients in the recurrence-free group received immunotherapy and none of the patients in the group with disease progression were treated with this modality. One hundred sixty-two of 202 patients with negative SLN underwent hormone therapy, 157/188 in the recurrence-free group and 5/14 in the group with disease progression. One hundred sixty-four of 202 patients with negative nodal status received adjuvant radiation therapy of the affected breast, 156/188 in the recurrence-free group and 8/14 in the group with disease progression.

CONCLUSIONS

When assessing the risk profile for disease recurrence or the occurrence of metastatic disease, statistically significant differences with respect to disease progression were identified for the parameters chemo-, antibody, hormone, and radiation therapy. The preliminary observations of this study show that even those patients in an early disease stage and with negative SLNs profit from these adjuvant non-surgical therapy options.

Breastfeeding and breast cancer risk by receptor status--a systematic review and meta-analysis

BACKGROUND

Breastfeeding is inversely associated with overall risk of breast cancer. This association may differ in breast cancer subtypes defined by receptor status, as they may reflect different mechanisms of carcinogenesis. We conducted a systematic review and meta-analysis of case-control and prospective cohort studies to investigate the association between breastfeeding and breast cancer by estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status.

DESIGN

We searched the PubMed and Scopus databases and bibliographies of pertinent articles to identify relevant articles and used random-effects models to calculate summary odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

This meta-analysis represents 27 distinct studies (8 cohort and 19 case-control), with a total of 36 881 breast cancer cases. Among parous women, the risk estimates for the association between ever (versus never) breastfeeding and the breast cancers negative for both ER and PR were similar in three cohort and three case-control studies when results were adjusted for several factors, including the number of full-term pregnancies (combined OR 0.90; 95% CI 0.82-0.99), with little heterogeneity and no indication of publication bias. In a subset of three adjusted studies that included ER, PR, and HER2 status, ever breastfeeding showed a stronger inverse association with triple-negative breast cancer (OR 0.78; 95% CI 0.66-0.91) among parous women. Overall, cohort studies showed no significant association between breastfeeding and ER+/PR+ or ER+ and/or PR+ breast cancers, although one and two studies (out of four and seven studies, respectively) showed an inverse association.

CONCLUSIONS

This meta-analysis showed a protective effect of ever breastfeeding against hormone receptor-negative breast cancers, which are more common in younger women and generally have a poorer prognosis than other subtypes of breast cancer. The association between breastfeeding and receptor-positive breast cancers needs more investigation.

Ultrafast Photodetection in the Quantum Wells of Single AlGaAs/GaAs-Based Nanowires

We investigate the ultrafast optoelectronic properties of single Al0.3Ga0.7As/GaAs core-shell nanowires. The nanowires contain GaAs-based quantum wells. For a resonant excitation of the quantum wells, we find a picosecond photocurrent which is consistent with an ultrafast lateral expansion of the photogenerated charge carriers. This Dember-effect does not occur for an excitation of the GaAs-based core of the nanowires. Instead, the core exhibits an ultrafast displacement current and a photothermoelectric current at the metal Schottky contacts. Our results uncover the optoelectronic dynamics in semiconductor core-shell nanowires comprising quantum wells, and they demonstrate the possibility to use the low-dimensional quantum well states therein for ultrafast photoswitches and photodetectors.

A glycoprotein E gene-deleted bovine herpesvirus 1 as a candidate vaccine strain

A bovine herpesvirus 1 (BoHV-1) defective in glycoprotein E (gE) was constructed from a Brazilian genital BoHV-1 isolate, by replacing the full gE coding region with the green fluorescent protein (GFP) gene for selection. Upon co-transfection of MDBK cells with genomic viral DNA plus the GFP-bearing gE-deletion plasmid, three fluorescent recombinant clones were obtained out of approximately 5000 viral plaques. Deletion of the gE gene and the presence of the GFP marker in the genome of recombinant viruses were confirmed by PCR. Despite forming smaller plaques, the BoHV-1△gE recombinants replicated in MDBK cells with similar kinetics and to similar titers to that of the parental virus (SV56/90), demonstrating that the gE deletion had no deleterious effects on replication efficacy in vitro. Thirteen calves inoculated intramuscularly with BoHV-1△gE developed virus neutralizing antibodies at day 42 post-infection (titers from 2 to 16), demonstrating the ability of the recombinant to replicate and to induce a serological response in vivo. Furthermore, the serological response induced by recombinant BoHV-1△gE could be differentiated from that induced by wild-type BoHV-1 by the use of an anti-gE antibody ELISA kit. Taken together, these results indicated the potential application of recombinant BoHV-1 △gE in vaccine formulations to prevent the losses caused by BoHV-1 infections while allowing for differentiation of vaccinated from naturally infected animals.

Chylothorax and chylous ascites. Clinical utility of planar scintigraphy and tomographic imaging with SPECT/CT

The aim was to analyze conventional planar scintigraphy and SPECT/CT in patients clinically suspicious for chylothorax or chylous ascites. Lymphoscintigraphy was performed for two reasons: first, to help diagnose chylothorax or -abdomen, by demonstrating diffuse uptake in fluid accumulations, and then secondly, to detect the site of leakage to test the prediction that additional use of SPECT/CT-technique improves upon the diagnostic value of planar lymphoscintigraphy in the baseline detection of thoraco-abdominal lymphatic disorders.

PATIENTS, MATERIAL, METHODS

From 7/2008-7/2014 a total of 24 consecutive patients (8 woman, 16 men; age, range 31-79 years) presenting with clinical symptoms suspicious for chylothorax and/or chylous ascites were examined by planar lymphoscintigraphy (n = 26) and additional tomographic SPECT/CT- (n = 22) or SPECT-technique (n = 2).

RESULTS

Chylothorax could be scintigraphically confirmed in n = 9, chylous ascites in n = 5 scintigraphies, and excluded in n = 10 patients. In all planar scintigraphy findings of pathological lymph drainage regions (n = 14), SPECT/CT delivered additional relevant information, notably the anatomic localization of the lymphatic leakage. For the baseline detection of thoraco-abdominal lymphatic transport disorders, lymphoscintigraphy showed sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 80%.

CONCLUSIONS

Our findings show that due to the particular advantages presented by tomographic separation of overlapping sources, SPECT/CT specifies better the anatomical sites, improving the localization of lymphatic leakage in aid of planning surgical re-interventions.

Higher fibrinogen concentrations for reduction of transfusion requirements during major paediatric surgery: A prospective randomised controlled trial

BACKGROUND

Hypofibrinogenaemia is one of the main reasons for development of perioperative coagulopathy during major paediatric surgery. The aim of this study was to assess whether prophylactic maintenance of higher fibrinogen concentrations through administration of fibrinogen concentrate would decrease the volume of transfused red blood cell (RBCs).

METHODS

In this prospective, randomised, clinical trial, patients aged 6 months to 17 yr undergoing craniosynostosis and scoliosis surgery received fibrinogen concentrate (30 mg kg(-1)) at two predefined intraoperative fibrinogen concentrations [ROTEM(®) FIBTEM maximum clot firmness (MCF) of <8 mm (conventional) or <13 mm (early substitution)]. Total volume of transfused RBCs was recorded over 24 h after start of surgery.

RESULTS

Thirty children who underwent craniosynostosis surgery and 19 children who underwent scoliosis surgery were treated per protocol. During craniosynostosis surgery, children in the early substitution group received significantly less RBCs (median, 28 ml kg(-1); IQR, 21 to 50 ml kg(-1)) compared with the conventional fibrinogen trigger of <8 mm (median, 56 ml kg(-1); IQR, 28 to 62 ml kg(-1)) (P=0.03). Calculated blood loss as per cent of estimated total blood volume decreased from a median of 160% (IQR, 110-190%) to a median of 90% (IQR, 78-110%) (P=0.017). No significant changes were observed in the scoliosis surgery population. No bleeding events requiring surgical intervention, postoperative transfusions of RBCs, or treatment-related adverse events were observed.

CONCLUSIONS

Intraoperative administration of fibrinogen concentrate using a FIBTEM MCF trigger level of <13 mm can be successfully used to significantly decrease bleeding, and transfusion requirements in the setting of craniosynostosis surgery, but not scoliosis.

CLINICAL TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT01487837.

Constitutional mismatch repair-deficiency and whole-exome sequencing as the means of the rapid detection of the causative MSH6 defect

BACKGROUND

Cases of children with more than one type of cancer either diagnosed simultaneously or successively, rarely occur in pediatric oncology. A second malignant neoplasm may be caused by mutagenic effects of the treatment of the primary malignancy and/or may point towards an underlying genetic cancer susceptibility syndrome. One example of such a syndrome is constitutional mismatch repair-deficiency, (CMMR-D) which carries an increased risk of various tumors including childhood hematologic malignancies and Lynch syndrome associated tumors. Timely diagnosis of CMMR-D is crucial, since this diagnosis has implications for the entire family.

PATIENT

We report the case of a 15-year-old girl who was born to consanguineous parents. At the age of 20 months she was diagnosed with a T-cell non-Hodgkin lymphoma. Treatment was given according to NHL-BFM 95. 12 years later, an invasive adenocarcinoma of the colon was surgically removed which relapsed shortly afterwards.

METHODS

Whole-exome sequencing of germline DNA was employed to rapidly detect the underlying mutation in this suspected CMMR-D patient.

RESULTS

After a short turnaround time of less than 3 weeks, the diagnosis of CMMR-D could be confirmed by the identification of a homozygous 29-bp deletion in MSH6 (exon 6), which was confirmed by independent methods.

CONCLUSIONS

We demonstrate that "bed-side" whole-exome sequencing is both feasible and cost-effective and may be the method of choice to rapidly uncover the genetical basis of (inherited) diseases.

[Nalbuphine in pediatric anesthesia]

Efficient and safe pediatric perioperative pain therapy in the context of a multimodal pain therapy concept requires a slight to moderate opioid analgesic. Nalbuphine is a nearly ideal opioid for this purpose due to its unique pharmacological properties as a μ-receptor antagonist/κ-receptor agonist and a high safety profile. Nalbuphine is used clinically primarily in postoperative pain therapy administered as a bolus, continuous infusion and patient-controlled analgesia. Furthermore, it is administered in different regimens for pediatric diagnostic and interventional sedation.

Magnetic resonance imaging versus lymphoscintigraphy for the assessment of focal lymphatic transport disorders of the lower limb: first experiences

PURPOSE

To compare the diagnostic accuracy of magnetic resonance imaging (MR-lymphangiography) and lymphoscintigraphy for assessment of focal lesions of the peripheral lymphatic system. Patients with focal lymphatic transport disorders might benefit from surgi-cal interventions.

PATIENTS, METHODS

We examined by lymphoscintigraphy and MR-lymphangiography a total of 85 lower limbs in 46 consecutive patients (33 women; mean age 41 years; range 9-79 years) presenting with uni- or bilateral lymphedema. MR-lymphangiographies were obtained at isotropic sub-millimeter resolution with a 3.0 Tesla magnet after injection of gadolinium contrast medium. MR-lymphangiography was reviewed by radiologists, whereas lymphoscintigraphy was reviewed by nuclear medicine physicians. The images were examined for localization and distribution of any focal lesions of the lymphatic vessel system. Diagnostic accuracy of the MR-approach was calculated relative to the lymphoscintigraphy gold standard.

RESULTS

There was substantial correlation of results by the two modalities (κ = 0.62). MR-lymphangiography had sensitivity of 68%, specificity of 91%, positive predictive value of 82%, and negative predictive value of 83%.

CONCLUSIONS

Imaging findings of both lymphoscintigraphy and MR-lymphangiography showed good diagnostic accuracy. MR-lymphangiography proved more information about anatomic location of focal lesions of the lymphatic vessels, but use of MR-lymphangiography is currently constrained due to the requirement for off-label subcutaneous injection of gadolinium chelates. Consequently, and due to its superior sensitivity lymphoscintigraphy remains the most common imaging method to assess functional lymphatic disorders of the lower limb.

[Intubation with a tube exchanger on an intubation trainer. Influence of tube tip position on successful intubation]

BACKGROUND

Securing the airway using a tube exchanger catheter is an important and useful technique in anesthesia. Its success is mainly hampered by tube tip impingement of laryngeal structures. Advancing the tracheal tube along its normal curvature via a tube exchanger catheter has a high risk of tube tip impingement mainly of right laryngeal structures. The authors achieved successful clinical experience by rotating the tracheal tube 90° anticlockwise (ventral tube tip position) before railroading the tube via a tube exchanger catheter or a fiber optic bronchoscope through the larynx.

AIM

The aim of the study was to investigate the influence of the tracheal tube tip position while intubating an airway trainer over a tube exchange catheter.

MATERIAL AND METHODS

Volunteer anesthetists with varying years of professional experience were asked to intubate an intubation mannequin (Laerdal Airway Management Trainer) using the orotracheal route with an established tube exchange catheter (Cook Airway Exchange Catheter, 11F). Two different brands of tracheal tubes (Rüsch and Covidien, ID 7.0 mm) were used in a randomized order, each with the tracheal tube tip at first positioned right (90°), then ventrally (0°), left (270°) and finally dorsally (180°), resulting in eight intubation attempts for each participant. To ensure the correct tube tip position the tube was withdrawn before every intubation attempt until the tube tip position was visualized. The oropharnyx, larynx, trachea and tube were sufficiently lubricated with silicon spray (Rüsch Silikospray). The tube and airway exchange catheter size selection were made according to the clinical trial of Loudermilk et al. Successful endotracheal intubation without resistance was recorded for each tube tip position and tracheal tube brand.

RESULTS

In total 20 anesthetists (13 consultants and 7 residents) with a median of 9.5 years (range 3-37 years) of professional experience participated in the study. Overall 160 intubation attempts were performed, 2 participants showed no successful intubation attempts at all and 38 out of 160 intubation attempts (23.8 %) were successful. Intubation success with the tracheal tube tip placed ventrally (0°) was 60 % followed by the left (270°) and right (90°) tracheal tube tip positions with 27.5 % and 7.5 % intubation success, respectively. With the tube tip placed dorsally (180°) none of the 40 intubation attempts were successful. Intubation attempts with the Rüsch tube were more successful (28.8 %) than those with the Covidien tube (18.8 %). Placing the tracheal tube tip ventrally, the Rüsch tube was twice as successful as the Covidien tube with 16 (80 %) versus 8 attempts (40 %, p = 0.011). There was no correlation between professional experience and intubation success (p = 0.362).

CONCLUSION

Tube insertion via an airway exchange catheter or a fiberoptic bronchoscope is a basic technique in anesthesia. Knowledge about the difficulties and their prevention are essential for every anesthetist. The gap between the airway exchange catheter, the fiber bronchoscope and the tube diameters is one of the major reasons for tube tip impingement. This investigation showed that intubation success via a tube exchange catheter, as investigated in an intubation mannequin, is considerably influenced by the tracheal tube tip position. A 90° anticlockwise rotation, placing the tracheal tube tip ventrally, considerably increased intubation success. This is of particular importance if an anesthesia department has no appropriately sized tube exchange catheters or fiber bronchoscope for every age group of patients.