51
|
Desai P, Guerra VC, Lilje C. Isolated Congenital Right Atrial Aneurysm: Monitoring Parameters for Asymptomatic Patients. World J Pediatr Congenit Heart Surg 2016; 11:NP7-NP10. [PMID: 28036232 DOI: 10.1177/2150135116682466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Isolated congenital right atrial aneurysm is rare. Indications for surgery in asymptomatic patients with moderate-size right atria remain controversial. Evidence in support of medical management and timing of prophylactic surgery is reviewed. We propose the use of three echocardiographic indices to help identify inappropriate atrial growth and facilitate surgical decision-making.
Collapse
Affiliation(s)
- Pooja Desai
- Department of Pediatrics (Cardiology), School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Vitor C Guerra
- Department of Pediatrics (Cardiology), School of Medicine, Tulane University Medical Center, New Orleans, LA, USA
| | - Christian Lilje
- Department of Pediatrics (Cardiology), School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| |
Collapse
|
52
|
Stevens RA, Butler BD, Kokane SS, Womack AW, Lin Q. Neonatal inhibition of Na +-K +-2Cl --cotransporter prevents ketamine induced spatial learning and memory impairments. Neurotoxicol Teratol 2016; 60:82-86. [PMID: 27826117 DOI: 10.1016/j.ntt.2016.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/24/2016] [Accepted: 11/04/2016] [Indexed: 02/04/2023]
Abstract
Prolonged ketamine exposure in neonates at anesthetic doses is known to cause long-term impairments of learning and memory. A current theoretical mechanism explains this phenomenon as being neuro-excitotoxicity mediated by compensatory upregulation of N-methyl-d-aspartate receptors (NMDARs), which then initiates widespread neuroapoptosis. Additionally, the excitatory behavior of GABAergic synaptic transmission mediated by GABAA receptors (GABAARs), occurring during the early neuronal development period, is proposed as contributing to the susceptibility of neonatal neurons to ketamine-induced injury. This is due to differential developmental expression patterns of Na+-K+-2Cl- co-transporter (NKCC1) and K+-Cl- co-transporter. Studies have shown that bumetanide, an NKCC1 inhibitor, allows neurons to become inhibitory rather than excitatory early in development. We thus hypothesized that bumetanide co-administration during ketamine treatment would reduce over excitation and protect the neurons from excitotoxicity. In this initial study, the Morris Water Maze test was used to assess the effects of co-administration of ketamine and bumetanide to neonatal Sprague-Dawley rats on long-term learning and memory changes seen later in life. It was revealed that bumetanide, when co-treated with ketamine neonatally, significantly impeded behavioral deficits typically seen in animals exposed to ketamine alone. Therefore, these findings suggest a new mechanism by which neonatal ketamine induced learning impairments can be prevented.
Collapse
Affiliation(s)
- Ryan A Stevens
- Department of Biology, College of Science, The University of Texas at Arlington, Arlington, TX, USA
| | - Brandon D Butler
- Department of Biology, College of Science, The University of Texas at Arlington, Arlington, TX, USA
| | - Saurabh S Kokane
- Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX, USA
| | - Andrew W Womack
- Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX, USA
| | - Qing Lin
- Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX, USA.
| |
Collapse
|
53
|
Abstract
Pre-clinical studies have consistently found that most general anaesthetics produce accelerated apoptosis in the developing brain. The effect has been seen in species ranging from the nematode to the non-human primate. A variety of other effects are also seen. There is also some evidence that animals exposed to anaesthesia are at increased risk of deficits in memory and learning. The effects are only seen with prolonged exposure. There are numerous problems in translating these findings to human clinical scenarios. Several human cohort studies have found an association between surgery in infancy and increased risk of poorer neurobehavioural outcome; however the possibility of confounding factors such as co-morbidity and surgery itself make it impossible to determine if these associations are due to anaesthesia toxicity. A recent trial and cohort studies suggest that an exposure of less than an hour does not increase the risk of poor outcome.
Collapse
Affiliation(s)
- Andrew Davidson
- Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Australia; Department of Anaesthesia, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia.
| |
Collapse
|
54
|
Lin EP, Lee JR, Lee CS, Deng M, Loepke AW. Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies. Neurotoxicol Teratol 2016; 60:117-128. [PMID: 27793659 DOI: 10.1016/j.ntt.2016.10.008] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/09/2016] [Accepted: 10/24/2016] [Indexed: 11/28/2022]
Abstract
Anesthetics that permit surgical procedures and stressful interventions have been found to cause structural brain abnormalities and functional impairment in immature animals, generating extensive concerns among clinicians, parents, and government regulators regarding the safe use of these drugs in young children. Critically important questions remain, such as the exact age at which the developing brain is most vulnerable to the effects of anesthetic exposure, whether a particular age exists beyond which anesthetics are devoid of long-term effects on the brain, and whether any specific exposure duration exists that does not lead to deleterious effects. Accordingly, the present analysis attempts to put the growing body of animal studies, which we identified to include >440 laboratory studies to date, into a translational context, by integrating the preclinical data on brain structure and function with clinical results attained from human neurocognitive studies, which currently exceed 30 studies. Our analysis demonstrated no clear exposure duration threshold below which no structural injury or subsequent cognitive abnormalities occurred. Animal data did not clearly identify a specific age beyond which anesthetic exposure did not cause any structural or functional abnormalities. Several potential mitigating strategies were found, however, no general anesthetic was identified that consistently lacked neurodegenerative properties and could be recommended over other anesthetics. It therefore is imperative, to expand efforts to devise safer anesthetic techniques and mitigating strategies, even before long-term alterations in brain development are unequivocally confirmed to occur in millions of young children undergoing anesthesia every year.
Collapse
Affiliation(s)
- Erica P Lin
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Jeong-Rim Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Andreas W Loepke
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States; Neuroscience Program, University of Cincinnati, Cincinnati, OH 45267, United States.
| |
Collapse
|
55
|
Owens C, Li BK, Thomas KE, Irwin MS. Surveillance imaging and radiation exposure in the detection of relapsed neuroblastoma. Pediatr Blood Cancer 2016; 63:1786-93. [PMID: 27304424 DOI: 10.1002/pbc.26099] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/10/2016] [Accepted: 05/16/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND More than half of children with high-risk neuroblastoma (NB) will experience recurrence. Radiologic imaging is used for initial staging and during therapy to assess response. However, the role of surveillance imaging in the detection of relapse has not been well studied. Surveillance potentially results in high cumulative exposure to ionizing radiation, which may be associated with an increased risk of developing second malignancies. PROCEDURE We reviewed NB cases at our institution between 2000 and 2011. We calculated radiation exposure due to imaging (during diagnosis, treatment, and posttherapy surveillance) using cumulative effective dose (CED) estimates and determined whether cross-sectional imaging identified recurrences. RESULTS Fifty of 183 patients with NB experienced a recurrence. The median time from diagnosis to relapse was 1.20 years (range: 0.18-6.66 years). Most patients had evidence of metastases and only 4 of 50 patients presented with isolated primary tumor site recurrences. The mean CED prior to relapse was 125.2 mSv (range: 24.5-259.7), 64% of which was from computed tomography (CT) scans. Thirty-seven of 50 patients had clinically evident or measurable disease detected by X-ray (XR), ultrasound (US), or urinary catecholamines (UCats), and the addition of metaiodobenzylguanidine (MIBG) scans identified eight additional recurrences. Thus, cross-sectional imaging (CT/MRI, where MRI is magnetic resonance imaging) was only required to identify 10% (5/50) of cases. CONCLUSION Relapsed disease was detected in most patients by symptoms/exam, MIBG scan, UCats, and/or XR/US, supporting reduced use of CT imaging in posttherapy surveillance, thereby decreasing cumulative radiation dose. Refinement of surveillance imaging may be further guided by risk stratification, disease sites, and potentially biomolecular markers.
Collapse
Affiliation(s)
- Cormac Owens
- Division of Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.,Department of Paediatric Haematology-Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Bryan K Li
- Division of Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Karen E Thomas
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Meredith S Irwin
- Division of Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
56
|
Poor Zamany Nejat Kermany M, Roodneshin F, Ahmadi Dizgah N, Gerami E, Riahi E. Early childhood exposure to short periods of sevoflurane is not associated with later, lasting cognitive deficits. Paediatr Anaesth 2016; 26:1018-25. [PMID: 27397550 DOI: 10.1111/pan.12969] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND A detrimental effect of commonly used anesthetics on the neurodevelopmental and behavioral parameters has long been shown in young animals subjected to early childhood anesthesia. Epidemiologic studies suggest the possibility of a modestly elevated risk of adverse neurodevelopmental outcomes in children exposed to anesthesia during early childhood. However, these results are still preliminary and inconclusive. AIM To further elucidate the probability of occurrence of such adverse outcomes, we evaluated cognitive performance of children who underwent general anesthesia early in their childhood. METHOD One hundred and fifteen children aged 5-16 years with established glaucoma were included in the study. Of these, 68 children had a history of at least one general anesthesia with sevoflurane before age 3. Phonemic and semantic verbal fluency, and forward and backward digit span tests were performed to evaluate cognitive function in the study subjects. RESULTS The two-way anova revealed that all these variables showed significant changes in various age groups, but they were comparable among subjects with no, single, or multiple childhood anesthesia. CONCLUSION It can be concluded that brief periods of anesthesia with single anesthetic sevoflurane may be safe for children under age 3.
Collapse
Affiliation(s)
| | - Fatemeh Roodneshin
- Anesthesiology Department, Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Niloofar Ahmadi Dizgah
- Anesthesiology Department, Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ebrahim Gerami
- Ophthalmology Department, Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Esmail Riahi
- Physiology Department, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
57
|
Neurodevelopmental Assessment in Kindergarten in Children Exposed to General Anesthesia before the Age of 4 Years: A Retrospective Matched Cohort Study. Anesthesiology 2016; 125:667-677. [PMID: 27655179 DOI: 10.1097/aln.0000000000001245] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Animal studies demonstrate general anesthetic (GA) toxicity in the developing brain. Clinical reports raise concern, but the risk of GA exposure to neurodevelopment in children remains uncertain. METHODS The authors undertook a retrospective matched cohort study comparing children less than 4 yr of age exposed to GA to those with no GA exposure. The authors used the Early Development Instrument (EDI), a 104-component questionnaire, encompassing five developmental domains, completed in kindergarten as the outcome measure. Mixed-effect logistic regression models generated EDI estimates for single versus multiple GA exposure and compared both single and multiple exposures by the age of 0 to 2 or 2 to 4 yr. Known sociodemographic and physical confounders were incorporated as covariates in the models. RESULTS A total of 18,056 children were studied: 3,850 exposed to a single GA and 620 exposed to two or more GA, who were matched to 13,586 nonexposed children. In children less than 2 yr of age, there was no independent association between single or multiple GA exposure and EDI results. Paradoxically, single exposure between 2 and 4 yr of age was associated with deficits, most significant for communication/general knowledge (estimate, -0.7; 95% CI, -0.93 to -0.47; P < 0.0001) and language/cognition (estimate, -0.34; 95% CI, -0.52 to -0.16; P < 0.0001) domains. Multiple GA exposure at the age of 2 to 4 yr did not confer greater risk than single GA exposure. CONCLUSIONS These findings refute the assumption that the earlier the GA exposure in children, the greater the likelihood of long-term neurocognitive risk. The authors cannot confirm an association between multiple GA exposure and increased risk of neurocognitive impairment, increasing the probability of confounding to explain the results.
Collapse
|
58
|
Aksenov DP, Miller MJ, Li L, Wyrwicz AM. Eyeblink classical conditioning and BOLD fMRI of anesthesia-induced changes in the developing brain. Physiol Behav 2016; 167:10-15. [PMID: 27591109 DOI: 10.1016/j.physbeh.2016.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/21/2016] [Accepted: 08/29/2016] [Indexed: 01/19/2023]
Abstract
Millions of children undergo general anesthesia each year in the USA alone, and a growing body of literature from animals and humans suggests that exposure to anesthesia at an early age can impact neuronal development, leading to learning and memory impairments later in childhood. Although a number of studies have reported behavioral and structural effects of anesthesia exposure during infancy, the functional manifestation of these changes has not been previous examined. In this study we used BOLD fMRI to measure the functional response to stimulation in the whisker barrel cortex of awake rabbits before and after learning a trace eyeblink classical conditioning paradigm. The functional changes, in terms of activated volume and time course, in rabbits exposed to isoflurane anesthesia during infancy was compared to unanesthetized controls when both groups reached young adulthood. Our findings show that whereas both groups exhibited decreased BOLD response duration after learning, the anesthesia-exposed group also showed a decrease in BOLD response volume in the whisker barrel cortex, particularly in the deeper infragranular layer. These results suggest that anesthesia exposure during infancy may affect the intracortical processes that mediate learning-related plasticity.
Collapse
Affiliation(s)
| | | | - Limin Li
- NorthShore University HealthSystem, Evanston, IL, 60201, USA
| | - Alice M Wyrwicz
- NorthShore University HealthSystem, Evanston, IL, 60201, USA
| |
Collapse
|
59
|
Wang LY, Tang ZJ, Han YZ. Neuroprotective effects of caffeic acid phenethyl ester against sevoflurane‑induced neuronal degeneration in the hippocampus of neonatal rats involve MAPK and PI3K/Akt signaling pathways. Mol Med Rep 2016; 14:3403-12. [PMID: 27498600 DOI: 10.3892/mmr.2016.5586] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 06/24/2016] [Indexed: 11/06/2022] Open
Abstract
Millions of infants and children are exposed to anesthesia every year during medical care. Sevoflurane is a volatile anesthetic that is frequently used for pediatric anesthesia. However, previous reports have suggested that the administration of sevoflurane promotes neurodegeneration, raising concerns regarding the safety of its usage. The present study aimed to investigate caffeic acid phenethyl ester (CAPE) and its protective effect against sevoflurane‑induced neurotoxicity in neonatal rats. Rat pups were administered with CAPE at 10, 20 or 40 mg/kg body weight from postnatal day 1 (P1) to P15. The P7 rats were exposed to sevoflurane (2.9%) for 6 h. Control group rats received no sevoflurane or CAPE. Neuronal apoptosis was determined by terminal deoxynucleotidyl transferase dUTP nick‑end labeling assay. The expression levels of caspases (caspase‑3, ‑8 and ‑9), apoptotic pathway proteins [Bcl‑2‑associated X protein (Bax), B cell CCL/lymphoma 2 (Bcl‑2), Bcl‑2‑like 1 (Bcl‑xL), Bcl‑2‑associated agonist of cell death (Bad) and phosphorylated (p)‑Bad], mitogen‑activated protein kinases (MAPK) signaling pathway proteins [c‑Jun N‑terminal kinase (JNK), p‑JNK, extracellular signal‑regulated kinase (ERK)1/2, p‑ERK1/2, p38, p‑p38 and p‑c‑Jun] and the phosphoinositide 3‑kinase (PI3K)/Akt cascade were evaluated by western blotting following sevoflurane and CAPE treatment. In addition, the expression of cleaved caspase‑3 was analyzed by immunohistochemistry. CAPE significantly reduced sevoflurane‑induced apoptosis, downregulated the expression levels of caspases and pro‑apoptotic proteins (Bax and Bad) and elevated the expression levels of Bcl‑2 and Bcl‑xL when compared with sevoflurane treatment. Furthermore, CAPE appeared to modify the expression levels of MAPKs and activate the PI3K/Akt signaling pathway. Thus, the present study demonstrated that CAPE effectively inhibited sevoflurane‑induced neuroapoptosis by modulating the expression and phosphorylation of apoptotic pathway proteins and MAPKs, and by regulating the PI3K/Akt pathway.
Collapse
Affiliation(s)
- Li-Yan Wang
- Department of Pediatric Surgery, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Zhi-Jun Tang
- Department of Orthopedics in Repair and Reconstruction, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Yu-Zeng Han
- Department of Pediatric Internal Medicine, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| |
Collapse
|
60
|
A Population-based Study Evaluating the Association between Surgery in Early Life and Child Development at Primary School Entry. Anesthesiology 2016; 125:272-9. [DOI: 10.1097/aln.0000000000001200] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
Background
It is unclear whether exposure to surgery in early life has long-term adverse effects on child development. The authors aimed to investigate whether surgery in early childhood is associated with adverse effects on child development measured at primary school entry.
Methods
The authors conducted a population-based cohort study in Ontario, Canada, by linking provincial health administrative databases to children’s developmental outcomes measured by the Early Development Instrument (EDI). From a cohort of 188,557 children, 28,366 children who underwent surgery before EDI completion (age 5 to 6 yr) were matched to 55,910 unexposed children. The primary outcome was early developmental vulnerability, defined as any domain of the EDI in the lowest tenth percentile of the population. Subgroup analyses were performed based on age at first surgery (less than 2 and greater than or equal to 2 yr) and frequency of surgery.
Results
Early developmental vulnerability was increased in the exposed group (7,259/28,366; 25.6%) compared with the unexposed group (13,957/55,910; 25.0%), adjusted odds ratio, 1.05; 95% CI, 1.01 to 1.08. Children aged greater than or equal to 2 yr at the time of first surgery had increased odds of early developmental vulnerability compared with unexposed children (odds ratio, 1.05; 95% CI, 1.01 to 1.10), but children aged less than 2 yr at the time of first exposure were not at increased risk (odds ratio, 1.04; 95% CI, 0.98 to 1.10). There was no increase in odds of early developmental vulnerability with increasing frequency of exposure.
Conclusions
Children who undergo surgery before primary school age are at increased risk of early developmental vulnerability, but the magnitude of the difference between exposed and unexposed children is small.
Collapse
|
61
|
Sun LS, Li G, Miller TLK, Salorio C, Byrne MW, Bellinger DC, Ing C, Park R, Radcliffe J, Hays SR, DiMaggio CJ, Cooper TJ, Rauh V, Maxwell LG, Youn A, McGowan FX. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016; 315:2312-20. [PMID: 27272582 PMCID: PMC5316422 DOI: 10.1001/jama.2016.6967] [Citation(s) in RCA: 553] [Impact Index Per Article: 69.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Exposure of young animals to commonly used anesthetics causes neurotoxicity including impaired neurocognitive function and abnormal behavior. The potential neurocognitive and behavioral effects of anesthesia exposure in young children are thus important to understand. OBJECTIVE To examine if a single anesthesia exposure in otherwise healthy young children was associated with impaired neurocognitive development and abnormal behavior in later childhood. DESIGN, SETTING, AND PARTICIPANTS Sibling-matched cohort study conducted between May 2009 and April 2015 at 4 university-based US pediatric tertiary care hospitals. The study cohort included sibling pairs within 36 months in age and currently 8 to 15 years old. The exposed siblings were healthy at surgery/anesthesia. Neurocognitive and behavior outcomes were prospectively assessed with retrospectively documented anesthesia exposure data. EXPOSURES A single exposure to general anesthesia during inguinal hernia surgery in the exposed sibling and no anesthesia exposure in the unexposed sibling, before age 36 months. MAIN OUTCOMES AND MEASURES The primary outcome was global cognitive function (IQ). Secondary outcomes included domain-specific neurocognitive functions and behavior. A detailed neuropsychological battery assessed IQ and domain-specific neurocognitive functions. Parents completed validated, standardized reports of behavior. RESULTS Among the 105 sibling pairs, the exposed siblings (mean age, 17.3 months at surgery/anesthesia; 9.5% female) and the unexposed siblings (44% female) had IQ testing at mean ages of 10.6 and 10.9 years, respectively. All exposed children received inhaled anesthetic agents, and anesthesia duration ranged from 20 to 240 minutes, with a median duration of 80 minutes. Mean IQ scores between exposed siblings (scores: full scale = 111; performance = 108; verbal = 111) and unexposed siblings (scores: full scale = 111; performance = 107; verbal = 111) were not statistically significantly different. Differences in mean IQ scores between sibling pairs were: full scale = -0.2 (95% CI, -2.6 to 2.9); performance = 0.5 (95% CI, -2.7 to 3.7); and verbal = -0.5 (95% CI, -3.2 to 2.2). No statistically significant differences in mean scores were found between sibling pairs in memory/learning, motor/processing speed, visuospatial function, attention, executive function, language, or behavior. CONCLUSIONS AND RELEVANCE Among healthy children with a single anesthesia exposure before age 36 months, compared with healthy siblings with no anesthesia exposure, there were no statistically significant differences in IQ scores in later childhood. Further study of repeated exposure, prolonged exposure, and vulnerable subgroups is needed.
Collapse
Affiliation(s)
- Lena S Sun
- Morgan Stanley Children's Hospital-New York Presbyterian, Columbia University Medical Center, New York, New York
| | - Guohua Li
- Mailman School of Public Health and College of Physicians and Surgeons, Columbia University, New York, New York
| | - Tonya L K Miller
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cynthia Salorio
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary W Byrne
- School of Nursing and College of Physicians and Surgeons, Columbia University, New York, New York
| | - David C Bellinger
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caleb Ing
- Morgan Stanley Children's Hospital-New York Presbyterian, Columbia University Medical Center, New York, New York
| | - Raymond Park
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerilynn Radcliffe
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen R Hays
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Timothy J Cooper
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Virginia Rauh
- Mailman School of Public Health, Columbia University, New York, New York
| | - Lynne G Maxwell
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahrim Youn
- Mailman School of Public Health, Columbia University, New York, New York
| | - Francis X McGowan
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
62
|
Abstract
To determine the associations between autism developmental profiles and cooperation with an oral health screening among preschool children with autism spectrum disorders (ASDs). A random sample of Special Child Care Centres registered with the Government Social Welfare Department in Hong Kong was selected (19 out of 37 Centres). All preschool children with ASDs were invited to participate in the oral health survey and 347 children agreed to participate (among 515 invited). A checklist of autism developmental profiles: (1) level of cognitive functioning, (2) social skills development, (3) communication skills development, (4) reading skills and (5) challenging behaviours was ascertained. Feasibility of conducting oral health screening in preschool children with ASDs was associated with their cognitive functioning (p = 0.001), social skills development (p = 0.002), communication skills development (p < 0.001), reading skills (p < 0.001) and challenging behaviours (p = 0.06). In regression analyses accounting for age (in months) and gender, inability to cooperate with an oral health screening was associated with high level of challenging behaviours (OR 10.50, 95 % CI 2.89-38.08, p < 0.001) and reduced cognitive functioning (OR 5.29, 95 % CI 1.14-24.61, p = 0.034). Age (in months) was positively associated with likelihood of cooperative behaviour with an oral health screening (OR 1.06, 95 % CI 1.03, 1.08, p < 0.001). Feasibility of conducting population-wide oral health screening among preschool children with ASDs is associated with their developmental profiles; and in particular levels of cognitive functioning, and challenging behaviours.
Collapse
|
63
|
Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, Stargatt R, Bellinger DC, Schuster T, Arnup SJ, Hardy P, Hunt RW, Takagi MJ, Giribaldi G, Hartmann PL, Salvo I, Morton NS, von Ungern Sternberg BS, Locatelli BG, Wilton N, Lynn A, Thomas JJ, Polaner D, Bagshaw O, Szmuk P, Absalom AR, Frawley G, Berde C, Ormond GD, Marmor J, McCann ME. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016; 387:239-50. [PMID: 26507180 PMCID: PMC5023520 DOI: 10.1016/s0140-6736(15)00608-x] [Citation(s) in RCA: 593] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial. METHODS In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98.6 (14.2) in the awake-regional group and 98.2 (14.7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0.169, 95% CI -2.30 to 2.64). The median duration of anaesthesia in the general anaesthesia group was 54 min. INTERPRETATION For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia. FUNDING Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).
Collapse
Affiliation(s)
- Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Melbourne Children's Trials Centre, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada; Department of Anesthesia, McGill University, Montreal, Canada
| | - Liam Dorris
- Mental Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK
| | - Robyn Stargatt
- School of Psychological Science, La Trobe University, Victoria, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Sarah J Arnup
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Rodney W Hunt
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Michael J Takagi
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Gaia Giribaldi
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Ida Salvo
- Department of Anesthesiology and Pediatric Intensive Care, Ospedale Pediatrico 'Vittore Buzzi', Milan, Italy
| | - Neil S Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - Britta S von Ungern Sternberg
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia
| | | | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Anne Lynn
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Joss J Thomas
- Department of Anesthesia, University of Minnesota, Minneapolis, MN, USA
| | - David Polaner
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Oliver Bagshaw
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK
| | - Peter Szmuk
- Department of Anesthesiology, Children's Medical Centre Dallas, Dallas, TX, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Charles Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gillian D Ormond
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
64
|
Chung W, Park S, Hong J, Park S, Lee S, Heo J, Kim D, Ko Y. Sevoflurane exposure during the neonatal period induces long-term memory impairment but not autism-like behaviors. Paediatr Anaesth 2015; 25:1033-45. [PMID: 26095314 DOI: 10.1111/pan.12694] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine whether neonatal exposure to sevoflurane induces autism-like behaviors in mice. BACKGROUND There are continuing reports regarding the potential negative effects of anesthesia on the developing brain. Recently, several studies suggest that neurotoxicity caused by anesthesia may lead to neurodevelopmental impairments. However, unlike reports focusing on learning and memory, there are only a few animal studies focusing on neurodevelopmental disorders after general anesthesia. Therefore, we have focused on autism, a representative neurodevelopmental disorder. METHODS Neonatal mice (P6-7) were exposed to a titrated dose of sevoflurane for 6 h. Apoptosis was evaluated by assessing the expression level of cleaved (activated) caspase-3. Autism-like behaviors, general activity, anxiety level, and long-term memory were evaluated with multiple behavioral assays. RESULTS Western blotting confirmed that neonatal exposure to sevoflurane increased the expression level of activated caspase-3, indicative of apoptosis. Mice exposed to sevoflurane also showed impaired long-term memory in fear tests. However, sevoflurane-exposed mice did not exhibit autism-like features in all of the following assays: social interaction (three-chamber test, caged social interaction), social communication (ultrasonic vocalization test), or repetitive behavior (self-grooming test, digging). There were also no differences in general activity (open field test, home cage activity) and anxiety (open field test, light-dark box) after sevoflurane exposure. CONCLUSIONS Our results confirm previous studies that neonatal sevoflurane exposure causes neurodegeneration and long-term memory impairment in mice. However, sevoflurane did not induce autism-like features. Our study suggests that mice are more vulnerable to long-term memory deficits than autism-like behaviors after exposure to sevoflurane.
Collapse
Affiliation(s)
- Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Saegeun Park
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Korea
| | - Jiso Hong
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Korea
| | - Sangil Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Soomin Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Junyoung Heo
- Department of Biochemistry, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Daesoo Kim
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| |
Collapse
|
65
|
Zhang H, Du L, Du Z, Jiang H, Han D, Li Q. Association between childhood exposure to single general anesthesia and neurodevelopment: a systematic review and meta-analysis of cohort study. J Anesth 2015; 29:749-57. [PMID: 26002228 DOI: 10.1007/s00540-015-2030-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/04/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many studies have been done to seek the relationship between general anesthesia and neurodevelopment in pediatrics. However, there is no unified conclusion, especially single anesthesia affecting a child before 3 and 4 years. The association between anesthesia and neurodevelopment is studied using a meta-analysis. METHODS We summarized the currently available evidence by searching PubMed, EMBASE, and the Cochrane library over the past 10 years. An evaluation of neurodevelopment including learning disability, behavioral disorders, and cognitive problems was conducted. We estimated the synthesized hazard ratios (HR) and 95 % confidence interval (CI) according to inter-study heterogeneity and analyzed the factors for this association using meta-regression method. RESULTS Thirteen eligible studies met the inclusion criteria. The neurodevelopment damage was associated with single general anesthesia before age of 4 (adjusted HR 1.28 95 % CI 1.10-1.45). The pooled adjusted HR was 1.17 (95 % CI 1.07-1.28, p = 0.001) before 4 years old after the influence analysis and the adjusted HR was 1.18 (95 % CI 1.07-1.30, p = 0.001) before 3 years old. There was no significant difference between 3 and 4 years exposed to single general anesthesia (HR3/HR4 = 1.008, p = 0.9). Due to limitations of retrospective studies, prospective investigations are needed to determine whether anesthesia is causative. CONCLUSIONS The current evidence suggests a modestly elevated risk of neurodevelopmental disorders exists in children near 3 years of age. A single general anesthesia is relatively safe after 3 years, as the outcome is very close before 3 and 4 years old.
Collapse
Affiliation(s)
- Haifeng Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, China
| | - Lili Du
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical College, Xuzhou, China
| | - Zijing Du
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, China
| | - Hao Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, China
| | - Dong Han
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, China.
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, Huangpu District, Shanghai, 200011, China
| |
Collapse
|
66
|
Devroe S, Lemiere J, Van de Velde M, Gewillig M, Boshoff D, Rex S. Safety and feasibility of xenon as an adjuvant to sevoflurane anaesthesia in children undergoing interventional or diagnostic cardiac catheterization: study protocol for a randomised controlled trial. Trials 2015; 16:74. [PMID: 25886748 PMCID: PMC4350978 DOI: 10.1186/s13063-015-0587-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 02/02/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Xenon has minimal haemodynamic side effects when compared to volatile or intravenous anaesthetics. Moreover, in in vitro and in animal experiments, xenon has been demonstrated to convey cardio- and neuroprotective effects. Neuroprotection could be advantageous in paediatric anaesthesia as there is growing concern, based on both laboratory studies and retrospective human clinical studies, that anaesthetics may trigger an injury in the developing brain, resulting in long-lasting neurodevelopmental consequences. Furthermore, xenon-mediated neuroprotection could help to prevent emergence delirium/agitation. Altogether, the beneficial haemodynamic profile combined with its putative organ-protective properties could render xenon an attractive option for anaesthesia of children undergoing cardiac catheterization. METHODS/DESIGN In a phase-II, mono-centre, prospective, single-blind, randomised, controlled study, we will test the hypothesis that the administration of 50% xenon as an adjuvant to general anaesthesia with sevoflurane in children undergoing elective cardiac catheterization is safe and feasible. Secondary aims include the evaluation of haemodynamic parameters during and after the procedure, emergence characteristics, and the analysis of peri-operative neuro-cognitive function. A total of 40 children ages 4 to 12 years will be recruited and randomised into two study groups, receiving either a combination of sevoflurane and xenon or sevoflurane alone. DISCUSSION Children undergoing diagnostic or interventional cardiac catheterization are a vulnerable patient population, one particularly at risk for intra-procedural haemodynamic instability. Xenon provides remarkable haemodynamic stability and potentially has cardio- and neuroprotective properties. Unfortunately, evidence is scarce on the use of xenon in the paediatric population. Our pilot study will therefore deliver important data required for prospective future clinical trials. TRIAL REGISTRATION EudraCT: 2014-002510-23 (5 September 2014).
Collapse
Affiliation(s)
- Sarah Devroe
- Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Jurgen Lemiere
- Department of Child and Adolescent Psychiatry, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Paediatric Haemato-Oncology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Marc Van de Velde
- Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Marc Gewillig
- Department of Paediatric and Congenital Cardiology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Derize Boshoff
- Department of Paediatric and Congenital Cardiology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Steffen Rex
- Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
67
|
Sulkowski JP, Cooper JN, Duggan EM, Balci O, Anandalwar SP, Blakely ML, Heiss K, Rangel S, Minneci PC, Deans KJ. Does timing of neonatal inguinal hernia repair affect outcomes? J Pediatr Surg 2015; 50:171-6. [PMID: 25598118 PMCID: PMC4298703 DOI: 10.1016/j.jpedsurg.2014.10.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to examine practice variability and compare outcomes between early and delayed neonatal inguinal hernia repair (IHR). METHODS Patients admitted to neonatal intensive care units with a diagnosis of IH who underwent IHR by age 1 year in the Pediatric Health Information System from 1999 to 2011 were included. IHR after the index hospitalization was considered delayed. Inter-hospital variability in the proportion of delayed repairs and differences in outcomes for each group were compared. A propensity score matched analysis was performed to account for baseline differences between treatment groups. RESULTS Of the 2030 patients identified, 32.9% underwent delayed IHR with significant variability in the proportion of patients having delayed repair across hospitals (p<0.0001). More patients in the delayed group had a congenital anomaly or received life supportive measures prior to IHR (all p<0.01), and 8.2% of patients undergoing delayed repair had a diagnosis of incarceration at repair. More patients in the early group underwent reoperation for hernia within 1 year (5.9% vs. 3.7%, p=0.02). Results were similar after performing a propensity score matched analysis. CONCLUSIONS Significant variability in practice exists between children's hospitals in the timing of IHR, with delayed repair associated with incarceration and early repair with a higher rate of reoperation.
Collapse
Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eileen M Duggan
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Ozlem Balci
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | | | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Kurt Heiss
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Shawn Rangel
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH.
| |
Collapse
|
68
|
Martin BD, McClung A, Denning JR, Laine JC, Johnston CE. Intrathecal Anomalies in Presumed Infantile Idiopathic Scoliosis: When Is MRI Necessary? Spine Deform 2014; 2:444-447. [PMID: 27927403 DOI: 10.1016/j.jspd.2014.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 02/04/2014] [Accepted: 03/10/2014] [Indexed: 11/19/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To determine the rate of abnormal magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS) and the rate of neurosurgical intervention in those patients, and to develop a guideline concerning when to obtain an MRI. SUMMARY OF BACKGROUND DATA The reported rate of intrathecal anomalies associated with presumed IIS varies in the literature (12% to 50%). Conclusions have led to conflicting recommendations concerning when an MRI is indicated. METHODS After appropriate internal review board approval, the authors retrospectively reviewed the medical records of patients from a single institution meeting the inclusion criteria: presumed idiopathic curve with a magnitude of ≥20°, age <36 months at diagnosis, normal neurologic examination, and presentation between 2002 and 2010. The authors reviewed the MRI findings, whether neurosurgical intervention took place, and the orthopedic treatment course (observation, brace, cast, or surgery). RESULTS A total of 56 patients were identified and reviewed; 43 had had an MRI. Seven of 43 patients were found to have an anomaly (16.2%). A fatty filum was identified in 2 patients, a syrinx in 3, Chiari I malformation in 2, and a tethered cord in 1 (this patient also had a syrinx). Two of the 7 patients required neurosurgical intervention (28%). Patients who did not have an MRI were statistically younger, had smaller Cobb angles, and required less orthopedic treatment. CONCLUSIONS The incidence of intrathecal anomalies (16.2%) at the authors' institution was similar to previously published reports; however, the need for neurosurgical intervention was significantly lower in this study (28%). For younger patients with small curves (<30°) who do not require orthopedic treatment, MRI under sedation can be delayed or avoided. Clinical judgment should be the determinant for whether to use MRI when evaluating patients with presumed IIS.
Collapse
Affiliation(s)
- Benjamin D Martin
- Department of Orthopedic Surgery, Children's National Medical Center, 111 Michigan Avenue, Washington, DC 20010, USA
| | - Anna McClung
- Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219, USA
| | - Jaime R Denning
- Department of Orthopedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229, USA
| | - Jennifer C Laine
- Department of Orthopedic Surgery, Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN 55101, USA
| | - Charles E Johnston
- Texas Scottish Rite Hospital, 2222 Welborn Street, Dallas, TX 75219, USA.
| |
Collapse
|
69
|
Abstract
We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.
Collapse
|
70
|
Abstract
PURPOSE OF REVIEW Children and their parents typically present to pediatricians to discuss treatment options for melanocytic nevi, nevus sebaceus, port-wine stains, and hemangiomas. Each of these conditions may be medically managed, but in some situations surgical intervention may be preferable. RECENT FINDINGS Although recent studies have improved our understanding of melanoma risk among patients with congenital nevi, prospective trials are needed to more accurately assess whether surgical excision mitigates this risk. The risk of basal cell carcinoma within nevus sebaceus appears to be low, but more conclusive data requires further studies with modern immunohistochemical analysis. Pulsed dye laser is effective for treating port-wine stains, although the optimal timing is controversial. While oral and topical beta blockers have revolutionized the treatment of proliferating infantile hemangiomas, laser and/or surgical excision are useful in selected situations. SUMMARY Excisional and/or laser surgery are indicated for certain common dermatologic conditions in children, although the optimal timing of these interventions is often subjective. Pediatricians should be familiar with why and when to refer patients for surgery of these common dermatological conditions.
Collapse
Affiliation(s)
- Julianne A Mann
- Department of Dermatology and Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
71
|
Woo KI, Kim YD, Kim YH. Surgical treatment of severe congenital ptosis in patients younger than two years of age using preserved fascia lata. Am J Ophthalmol 2014; 157:1221-1226.e1. [PMID: 24582995 DOI: 10.1016/j.ajo.2014.02.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate the clinical outcome of a frontalis sling using preserved fascia lata in the treatment of vision-obscuring congenital ptosis in patients less than 2 years of age. DESIGN Retrospective, interventional case series. METHODS The study was conducted in an institutional setting and included 82 patients with visual axis-obscuring congenital ptosis. All patients underwent frontalis sling surgery with preserved fascia lata between November 1994 and December 2008, and had a minimum follow-up of 6 months. Visual and surgical outcomes were assessed by reviewing clinical photographs and medical charts. Surgical outcomes were defined as good, fair, or poor, based on the postoperative lid level. RESULTS The mean age at surgery was 15.3 ± 4.8 months. After a mean follow-up of 54.8 ± 41.4 months, 64 patients (78.0%) showed good or fair surgical outcomes. Reoperation was performed in 16 of the patients with poor or fair results. Amblyopia was treated postoperatively in 75 of the 82 patients (91.5%) and had improved in 65 patients at the last follow-up. Postoperative entropion was identified in 5 cases, all of which were treated successfully. No other significant complications occurred. CONCLUSIONS For patients younger than 2 years of age, preserved fascia lata may be an appropriate substitute for autogenous fascia lata in frontalis sling surgery. Its long-term stability may enable a permanent effect in a certain proportion of patients, and may not require secondary surgery, which is common with synthetic materials.
Collapse
|
72
|
Wise-Faberowski L, Quinonez ZA, Hammer GB. Anesthesia and the developing brain: relevance to the pediatric cardiac surgery. Brain Sci 2014; 4:295-310. [PMID: 24961762 PMCID: PMC4101478 DOI: 10.3390/brainsci4020295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/02/2014] [Accepted: 04/05/2014] [Indexed: 01/29/2023] Open
Abstract
Anesthetic neurotoxicity has been a hot topic in anesthesia for the past decade. It is of special interest to pediatric anesthesiologists. A subgroup of children potentially at greater risk for anesthetic neurotoxicity, based on a prolonged anesthetic exposure early in development, are those children receiving anesthesia for surgical repair of congenital heart disease. These children have a known risk of neurologic deficit after cardiopulmonary bypass for surgical repair of congenital heart disease. Yet, the type of anesthesia used has not been considered as a potential etiology for their neurologic deficits. These children not only receive prolonged anesthetic exposure during surgical repair, but also receive repeated anesthetic exposures during a critical period of brain development. Their propensity to abnormal brain development, as a result of congenital heart disease, may modify their risk of anesthetic neurotoxicity. This review article provides an overview of anesthetic neurotoxicity from the perspective of a pediatric cardiac anesthesiologist and provides insight into basic science and clinical investigations as it relates to this unique group of children who have been studied over several decades for their risk of neurologic injury.
Collapse
Affiliation(s)
- Lisa Wise-Faberowski
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
| | - Zoel A Quinonez
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
| | - Gregory B Hammer
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA 94305, USA.
| |
Collapse
|
73
|
Zhou Z, Ma D. Anaesthetics-induced neurotoxicity in developing brain: an update on preclinical evidence. Brain Sci 2014; 4:136-49. [PMID: 24961704 PMCID: PMC4066242 DOI: 10.3390/brainsci4010136] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/06/2014] [Accepted: 03/04/2014] [Indexed: 01/13/2023] Open
Abstract
Every year millions of young people are treated with anaesthetic agents for surgery and sedation in a seemingly safe manner. However, growing and convincing preclinical evidence in rodents and nonhuman primates, together with recent epidemiological observations, suggest that exposure to anaesthetics in common clinical use can be neurotoxic to the developing brain and lead to long-term neurological sequelae. These findings have seriously questioned the safe use of general anaesthetics in obstetric and paediatric patients. The mechanisms and human applicability of anaesthetic neurotoxicity and neuroprotection have remained under intense investigation over the past decade. Ongoing pre-clinical investigation may have significant impact on clinical practice in the near future. This review represents recent developments in this rapidly emerging field. The aim is to summarise recently available laboratory data, especially those being published after 2010, in the field of anaesthetics-induced neurotoxicity and its impact on cognitive function. In addition, we will discuss recent findings in mechanisms of early-life anaesthetics-induced neurotoxicity, the role of human stem cell-derived models in detecting such toxicity, and new potential alleviating strategies.
Collapse
Affiliation(s)
- Zhaowei Zhou
- Section of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK.
| | - Daqing Ma
- Section of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK.
| |
Collapse
|