Endobronchial valve treatment in chronic obstructive pulmonary disease: A qualitative study of patients' expectations

Objectives

Endobronchial valve (EBV) treatment is a treatment option for selected patients with severe chronic obstructive pulmonary disease (COPD) to reduce dyspnea and improve quality of life. However, the procedure is associated with risk of complications, and not all patients achieve the expected outcomes. The present study explores patients' expectations while waiting for EBV treatment.

Methods

Fifteen patients accepted for EBV treatment at Aarhus University Hospital in Denmark from October 2020 to June 2021 participated in a 30-min, semi-structured interview about (1) the experience of living with COPD and (2) expectations regarding EBV.

Results

Four themes were identified: a life of reduced quality; hopes and expectations; information about EBV; and perception of risks. Most patients described their lives as not worth living, and they hoped that EBV would give them their physical and social lives back, while also being aware that EBV would probably not work miracles. Patients' information seeking was influenced by their hopes and expectations to the treatment. They filtered out negative information, focusing on the hope for a positive outcome. This made them willing to run the risk of complications.

Conclusion

Living a life of considerably reduced quality, patients might have an increased focus on potential positive effects of EBV treatment while filtering out information about potential side effects. This might bias their decision-making process.

Particulate substrate retention in plug-flow and fully-mixed conditions during operation of aerobic granular sludge systems

Particulate substrate (X_B) is the major organic substrate fraction in most municipal wastewaters. However, the impact of X_B on aerobic granular sludge (AGS) systems is not fully understood. This study evaluated the physical retention of X_B in AGS sequencing batch reactor (SBR) during anaerobic plug-flow and then aerobic fully-mixed conditions. The influence of different sludge types and operational variables on the extent and mechanisms of X_B retention in AGS SBR were evaluated. X_B mass-balancing and magnetic resonance imaging (MRI) were applied. During the anaerobic plug-flow feeding, most X_B was retained in the first few cm of the settled sludge bed within the interstitial voids, where X_B settled and accumulated ultimately resulting in the formation of a filter-cake. Sedimentation and surface filtration were thus the dominant X_B retention mechanisms during plug-flow conditions, indicating that contact and attachment of X_B to the biomass was limited. X_B retention was variable and influenced by the X_B influent concentration, sludge bed composition and upflow feeding velocity (v_ww). X_B retention increased with larger X_B influent concentrations and lower v_ww, which demonstrated the importance of sedimentation on X_B retention during plug-flow conditions. Hence, large fractions of influent X_B likely re-suspended during aerobic fully-mixed conditions, where X_B then preferentially and rapidly attached to the flocs. During fully-mixed conditions, increasing floc fractions, longer mixing times and larger X_B concentrations increased X_B retention. Elevated X_B retention was observed after short mixing times < 60 min when flocs were present, and the contribution of flocs towards X_B retention was even more pronounced for short mixing times < 5 min. Overall, our results suggest that flocs occupy an environmental niche that results from the availability of X_B during aerobic fully-mixed conditions of AGS SBR. Therefore, a complete wash-out of flocs is not desirable in AGS systems treating municipal wastewater.

Direct and indirect economic and health consequences related to sarcoidosis in Denmark: A national register-based study

BACKGROUND

Sarcoidosis is a systemic disease that primarily affects the younger population. Longitudinal studies of the economic burden of sarcoidosis are scarce. This study evaluates overall the economic burden of sarcoidosis in Denmark before and after initial diagnosis.

METHODS

We identified patients with sarcoidosis in the Danish National Patient Registry (1998-2010). All controls were randomly selected and matched concerning age, gender and residence. Data on direct and indirect costs, including frequency of primary and secondary sector contacts and procedures, medication, unemployment benefits and social transfer payments were extracted from national databases for patients and controls.

RESULTS

We identified 9119 patients with sarcoidosis and 36,432 matching controls. Patients with sarcoidosis had significantly higher rates of health-related contacts, higher usage of medication and more received unemployment and social payments compared with controls. The total health expenses were significantly higher in the sarcoidosis group 11 years before and 11 years after diagnosis than among controls. Income from public transfer payments was significantly higher in the sarcoidosis group five years prior of diagnosis until nine years post diagnosis. Especially women between 40 and 59 years have a lower income than their controls.

CONCLUSION

Sarcoidosis has a socioeconomic impact on adults especially during their prime working and providing years and this is evident several years prior to and post diagnosis. The authors advocate that further research should focus on identifying the proportion of patients with sarcoidosis that imposes the largest economic burden. Increased focus on early diagnosis and disease management may reduce the socioeconomic burden of sarcoidosis.

Screening tools for evaluation of depression in Chronic Obstructive Pulmonary Disease (COPD). A systematic review

Background: Anxiety and depression are common comorbid disorders in patients with chronic obstructive pulmonary disease (COPD), though estimates of their prevalence vary considerably. Depressive symptoms/depression are important comorbidities in COPD and an increasing interest is shown to these disorders. Depression may lead to reduced quality of life and increased morbidity and mortality. These statements underline the importance of implementing the use of screening instruments for depressive symptoms in a clinical setting.

This systematic review evaluates four commonly used screening tools for depression in COPD. Furthermore we assess the prevalence of depression in COPD in the evaluated studies.

Design: A literature search identified studies dealing with screening for depression in patients with COPD. We focused on the instruments: Beck Depression Inventory, Geriatric depression scale, Centre for Epidemiological Studies scale on Depression and Hospital and Anxiety Depression Scale.

Results: Overall prevalence of depression was 30%. Demographic variations and severity of COPD influenced prevalence. The inter-prevalence of the four screening tools was consistent. We found a low variation between studies using the same tool. Few studies used control groups or compared the screening tool to a psychiatrist evaluation.

Conclusions: This article calls for further investigation of the association between COPD and depressive symptoms. The subject is highly relevant for everyday life of patients with COPD and attention needs to be drawn to this issue in both an out- and in-patients.

pH measurements of FET-based (bio)chemical sensors using portable measurement system

In this study we demonstrate the sensing capabilities of a portable multiplex measurement system for FET-based (bio)chemical sensors with an integrated microfluidic interface. We therefore conducted pH measurements with Silicon Nanoribbon FET-based Sensors using different measurement procedures that are suitable for various applications. We have shown multiplexed measurements in aqueous medium for three different modes that are mutually specialized in fast data acquisition (constant drain current), calibration-less sensing (constant gate voltage) and in providing full information content (sweeping mode). Our system therefore allows surface charge sensing for a wide range of applications and is easily adaptable for multiplexed sensing with novel FET-based (bio)chemical sensors.

Mammography Screening - as of 2013

Introduction: Since 2008 the German Mammography Screening Programme has been available throughout Germany to all women aged between 50 and 69. The programme strictly follows the European Guidelines. There are controversial discussions in the media as well as in the specialised press. Materials and Methods: Overview of the available data with regard to an evaluation of randomised studies and with regard to quality-assured screening programmes in accordance with EU Guidelines (including data from 18 screening countries). Results: Positive effects of screening: reduction in mortality, less invasive treatment. Negative effects: False-positive diagnoses and biopsy recommendations, so-called overdiagnoses, radiation dose. Limits of screening: Interval carcinomas, incomplete reduction in mortality. A mathematical synopsis of the latest publications from the European screening programmes with the diagnosis rates in Germany determined from > 4.6 million screening examinations produces the following: a total of 10 000 mammograms are created for 1000 women (P) taking part in the Mammography Screening Programme (each of whom undergoes 10 mammograms in 20 years). Overall, the risk of triggering breast cancer through a mammogram is very clearly below the annual natural risk of suffering from breast cancer. In the German screening, of these 1000 women, an average of 288 women are called back once in 20 years as a result of changes that are ultimately benign (< 3 % per cycle). Of these, 74 of the 288 women undergo a biopsy due to a benign change (false-positive biopsy recommendations, usually punch or vacuum biopsies). According to EUROSCREEN, 71 carcinomas develop among participants (56 are discovered in the screening, 15 in the interval), and 67 carcinomas among non-participants (N-P) (in some cases, several years later) during this period. The 4 additional diagnoses among the Ps are referred to as overdiagnoses, as they do not contribute to a reduction in mortality (these participants die beforehand from other causes of death). With regard to the carcinomas that concern the screening periods, 11 women out of 1000 die among the Ps; there are 19 deaths among the N-Ps (within the observation period plus follow-up period). Discussion: The false-positive rate is unavoidable, but is far lower with mammography screening than with other methods. Overdiagnoses are to be expected with any early detection. All calculations require assumptions and are therefore highly discrepant. They have very low evidence levels. The radiation dose should not be an argument against screening when applied correctly due to the very low risk and significant benefits. Interval carcinomas indicate the limits of a mammography screening programme. False-negatives only represent a subset of the interval carcinomas and are not to be equated with them. There is a very high evidence level for a significant reduction in mortality through mammography screening. For the first time, an independent expert commission has confirmed the results of the randomised studies and the statement of the WHO from 2002 and their further validity. Participants can expect a reduction in mortality of 30 %. Data from the current European screening programmes confirm a mortality reduction of 43 %, corresponding to 8/19 saved lives among 71 women with breast cancer or 1000 asymptomatic Ps. Many additional Ps benefit from less invasive treatment due to the early detection. Conclusions: As a result of the risk/benefit ratio, mammography screening should absolutely be recommended to asymptomatic women aged between 50-69. High importance is given to the provision of education for women by the treating gynaecologists as regards the opportunities for quality-assured early detection available to them in the healthcare system.

Identification of spore allergens from the indoor mould Aspergillus versicolor

BACKGROUND

Indoor mould growth and dampness are associated with respiratory health effects and allergies and several studies demonstrated that mainly Aspergillus versicolor and Penicillium expansum are responsible for indoor mould exposure. In contrast, commercialized test systems to diagnose allergic reactions to this mould species are not available. In this study, allergenic proteins from spores of the indoor relevant species A. versicolor and P. expansum should get detected and identified.

METHODS

We used two-dimensional (2D)-gel electrophoresis of spore proteins and immunoblotting with sera from patients participating in an epidemiologic study about indoor exposure of moulds and their influence on the development of allergies (ESTERSPEGA). Sera were screened for IgE antibodies specific for proteins from A. versicolor, A. fumigatus and P. expansum in one-dimensional blots and in 2D immunoblots. From the 2D gels, the corresponding spots were picked and identified by mass spectrometry.

RESULTS

More than 20 allergens from A. versicolor were identified; in particular, seven major allergens were selected, which were detected by more than 90% of the positive sera. The most abundant allergen was glyceraldehyde-3-phosphate dehydrogenase, followed by an unnamed protein, which displays a high homology to sobitol/xylose reductase. The other allergens were identified as catalase A, hypothetical protein AN6918.2, enolase, hypothetical protein AN0297.2 and a protein with homology to a fungal malate dehydrogenase.

CONCLUSIONS

The results indicate an important role of spore proteins from A. versicolor for sensitization against indoor moulds and identification of the major allergens might enable species-specific diagnosis of allergic reactions.

[Mammography screening]

Exclusive biannual mammography screening for women ages 50-69 years reduces the mortality from breast cancer among participants by 35%. Compared with 50% of clinically detected cancers, only 20% of carcinomas detected in screening have nodal metastases, and up to 55% of screening carcinomas are in the T1 stage of "minimal cancer." In many European countries (including Sweden, Norway, the Netherlands, and Great Britain), mammography screening programmes have been established for more than 10 years. In Germany, the aim is to establish, by 2008, a nationwide organised programme on the basis of the European Guidelines for Quality Assurance. This goal requires 80-100 mammography screening units. The first screening units went into use in 2005. Women between 50 and 69 years are invited to participate in 2-year intervals.

Attitudes of patients, healthcare professionals and ethicists towards embryonic stem cell research and donation of gametes and embryos in Germany

Due to the Embryo Protection Act, creation of supernumerary embryos, as well as egg and embryo donation, is prohibited in Germany. Human stem cell research is regulated through the Act on stem cells that came into force in 2002. A cross-sectional survey of 101 IVF couples (n=202) in two fertility centres, and representative samples of healthcare professionals and ethicists (n=879), was carried out, and their attitudes towards embryonic stem cell research and donation of gametes and embryos compared. A clear majority of IVF couples favoured legalization of egg and embryo donation and embryonic stem cell research for various purposes. The willingness of couples to donate was related to purpose and to other independent influences. The majority of physicians voted for legalization of embryonic stem cell production from surplus embryos. Most human geneticists and obstetricians approved egg, but not embryo, donation to other couples. Ethicists and midwives were opposed to every kind of donation and research on surplus embryos. The IVF couples surveyed have positive attitudes towards donation and research using surplus embryos, whereas the healthcare professionals and ethicists are predominantly sceptical about most research activities destroying human embryos. This difference should be considered carefully in legal and ethical discussions on reprogenetics.

Herkunft und Bedeutung von Leptin und Neuropeptid Y (NPY) im Fruchtwasser zwischen der 14. - 18. Schwangerschaftswoche

INTRODUCTION

Leptin and neuropeptide Y (NPY) play important roles in the regulation of food intake, energy expenditure, hematopoesis and reproduction. The biological functions of leptin and NPY in fetal development, and their regulation during pregnancy by fetal and maternal factors remain poorly understood.

PATIENTS AND METHODS

From 55 women undergoing diagnostic amniocentesis between the 14th and 18th weeks of gestation samples of amniotic fluid were collected. In accord with the circadian rhythm of leptin secretion all amniocenteses were performed between 8.00 and 12.00 a. m. The concentrations of leptin and NPY in amniotic fluid were analysed using commercially available RIA's.

RESULTS

The amniotic fluid samples of 32 male and 23 female fetuses were determined and demonstrated no gender-dependent differences in leptin and NPY levels. No correlation was found between leptin/NPY and the maternal body mass index. NPY concentrations are lower in advanced gestational age pregnancies. Leptin levels revealed no differences with respect to gestational age.

CONCLUSION

Leptin and NPY levels were independent of fetal gender and maternal BMI. This provides clues for alternative regulatory mechanisms in leptin and NPY secretion. Compared to the data of adults, our findings show high leptin concentrations in the amniotic fluid in the presence of only minor amounts of white adipose tissues which might include the placenta. Our data including the observation of lower levels of NPY in more advanced gestational age support the idea of specific factors regulating leptin and NPY secretion into the amniotic fluid.

Rationale for a diagnostic chain in gestational breast tumor diagnosis

Due to the physiological tissue alterations of the breast during pregnancy and lactation the diagnosis of a breast tumor by palpation, imaging and fine-needle biopsy is difficult and often unreliable. The purpose of our study was to review the value of imaging (mammography and ultrasonography) and biopsy techniques in order to work out a reliable protocol for evaluating gestational tumors. We performed a retrospective analysis of 25 patients with clinical diagnosis of gestational breast tumors during a 4-year period from 1995 to 1999. Specimens were obtained by core biopsy for histological examination. Invasive breast cancer was diagnosed in five patients, malignant lymphoma of the skin in one patient. The tumors in the remaining 19 patients proved benign. The overall accuracy was 0.91 for conventional mammography, 0.76 for conventional and panoramic ultrasound and 0.48 for color-coded sonography. Mammography as the most reliable imaging method should be used to evaluate all patients in whom ultrasonographic findings are suspicious for tumor. Radiation phobia should not prevent the performance of mammography under these circumstances. Nevertheless, all pre-operative methods of diagnosing gestational breast tumors other than core biopsy are unreliable.

[Mammographic breast density and breast cancer risk during HRT]

Higher breast density leads to a higher risk of breast-cancer coming along with a reduced sensitivity of mammography, the most important method for early diagnosis of breast cancer. HRT leads to an increase in breast density in up to (1/3) of treated women. Combined regimes of estrogen-progestin show a stronger influence than estrogen only. Changes of breast density appear almost entirely within the first year of administration and seem to be reversible after suspension of treatment within a few weeks. A possible solution of the dilemma is to perform mammography in asymptomatic premenopausal women during the first half of the menstrual cycle. In women with increased breast density using HRT it is recommended to modify the combination of hormones, change the application mode, or suspend HRT for a short period of 3 weeks prior to mammography. In symptomatic women with dense breasts, additive breast ultrasound is strongly recommended to reduce the otherwise high rate of missed breast cancers.

[Interventional methods in diagnostics of the breast -- a new vacuum biopsy system for the breast in routine clinical practice]

AIM

To evaluate the diagnostic potential of the new vacuum-assisted method VacuFlash (VF) in clinical routine of breast diagnostics.

METHOD

From april 2002 to march 2003, the new sonographically guided vacuum-assisted system VacuFlash was used in 75 patients with a BI-RADS 5 lesion (analogue). The patients were aged between 31-75 yrs (median: 51 yrs), the size of the lesions measured 8-33 mm (median: 14 mm). 5 specimens were taken from each lesion.

RESULTS

In 69 of the 75 lesions (92 %, respectively), malignancy was confirmed. In 8 lesions (8 %, resp.), we found a benign histology, confirmed by consecutive surgery.

CONCLUSION

The new vacuum-assisted device VacuFlash is a technically perfected and applicable diagnostic method. Especially in the view of the cost it has to be compared with high-speed core cut biopsy, the hand-held Mammotome system and open surgical biopsy. High-speed core cut biopsy seems to be the standard procedure in diagnostic percutaneous breast intervention to clarify sonographically detected breast lesions.

[Ultrasound examination of the breast with 7.5 MHz and 13 MHz-transducers: scope for improving diagnostic accuracy in complementary breast diagnostics?]

AIM

Complementary diagnostic methods in early diagnosis of breast cancer are used to increase diagnostic accuracy and minimize unnecessary invasive diagnostic procedures. Aim of the following prospective, open multicenter clinical study was to define the value of high-frequency breast ultrasound with 13 MHZ transducers compared to standard breast ultrasound with 7.5 MHz.

METHOD

Data of 810 female patients, aged 45 to 60 years, with 819 suspicious breast lesions evaluated by four participating centres between October 1996 and December 1997. Standardised breast ultrasound was performed uniformly using a AU4 IDEA diagnostic ultrasound system by Esaote-Biomedica in addition to a standardised procedure of clinical examination and standard-2view-mammography. Analysis of all aquired data and the correlating histopathological findings was done by means of descriptive statistics on the basis of an access datafile (Version 2.0).

RESULTS

The histopathological evaluation showed 435 benign and 384 malignant findings. Overall sensitivity and specificity of the clinical examination were 71.1 % and 88.9 % and for mammography 84.7 % and 76.5 %, respectively. Standard ultrasound with 7,5 MHz reached a sensitivity of 82,6 % and a specificity of 80.8 % high-frequency ultrasound with 13 MHz came to 87.2 % and 78.4 %, respectively. Regarding tumour size, mammography gave the highest sensitivity in detection of pre-invasive cancers (DCIS). High-frequency breast ultrasound (13 MHz) proved to have a higher diagnostic accuracy compared to standard breast ultrasound (7,5 MHz) regardless of tumour size. Sensitivity was especially improved in case of small invasive tumours (pT1a) with 78 % versus 56 %, respectively.

CONCLUSIONS

We conclude that high-frequency ultrasound is a valueable additive tool especially in the diagnosis of small tumours, improving diagnostic safety and reducing unnecessary invasive diagnostic procedures.

[Differential diagnosis of Poland-syndrome versus unilateral accentuated thelarche]

AIM

The syndrome was first described by Poland in 1841. It classically consists of unilateral muscular and osseous anomalies of the thorax and upper limb with defects of the ipsilateral breast and nipple. We report the value of panoramic-sonography in the diagnosis of this rare condition in three patients.

METHOD

The three girls, all born in 1990, were independently introduced to our unit of children and adolescent gynaecology because of unilateral "developmental defects" of the breasts at the beginning of puberty. To discriminate a Poland-Syndrome from unilateral accentuation of thelarche standardized clinical and sonographical examinations were performed.

RESULTS

In 2 cases we found unilateral aplasia of the glandular tissue of the breast with different distinction of mamilla and pectoralis muscle. The 3 (rd) case showed a hypoplastic breast development with osseous defects of the chest wall, aplasia of the pectoralis muscle and brachydaktylia.

CONCLUSION

The standardized panoramic sonography allowed an immediate and safe diagnosis without hazardous radiation exposure.

[LDL-Apheresis for the treatment of hyperchylomicronemia-induced pancreatitis]

Severe hyperchylomicronemia due to defects of lipoprotein lipase or apoC-II is a rare cause for acute pancreatitis. Food with a high content of fat, as well as alcoholic or hormonal influences, can lead to excessive hypertriglyceridemia. Especially hyperchylomicronemia due to hormonal influences during pregnancy are troublesome. Here, we are confronted with both the risk to the mother as well as the vital risk to the unborn. Conventional plasma apheresis has been used to successfully eliminate chylomicrons and, thus, the primary cause of chylomicron-induced pancreatitis. Most recently, we reported the use of selective LDL-apheresis in a 24-year-old pregnant woman (thirteenth week of pregnancy), who was admitted with the signs of acute pancreatitis to our hospital. The patient was known to have a history of severe hyperchylomicronemia and she had also been treated several years before for acute pancreatitis by LDL-apheresis. Her triglycerides were severely elevated (11500 mg/dl) and, in order to achieve a rapid decrease of chylomicrons, we decided to treat her by selective LDL-apheresis utilizing HELP-apheresis. The treatment was well tolerated and within half an hour the patient was free of any abdominal pain. However, due to the enormous triglyceride load, we needed to change the precipitate filters several times and at the end of the treatment triglyceride levels were 6600 mg/dl. Under a low-fat diet (<30 gram fat per day), the follow-up was uneventful and the patient delivered a healthy baby at the end of week 39. We conclude that LDL-apheresis is a safe and rapid procedure to eliminate chylomicrons in chylomicron-induced pancreatitis.

The influence of serum leptin concentration on bone mass assessed by quantitative ultrasonometry in pre and postmenopausal women

OBJECTIVE

the aim of this study was to evaluate the influence of serum leptin concentration on bone mass assessed by quantitative ultrasound (QUS) in a large sample of healthy pre and postmenopausal women.

DESIGN

555 healthy pre and postmenopausal (n=261 and n=294) women (mean age, 49.5+/-17.2 years) not on hormone replacement therapy were recruited on the occasion of a routine gynecological visit. Before entry to the study, all women had answered a detailed questionnaire on important risk factors and gave written informed consent. Speed of sound (SOS), broadband ultrasound attenuation (BUA) and stiffness index (SI) of the os Calcis were measured using the Achilles ultrasonometer (GE/lunar). We systematically investigated the relation of menopause, BMI and leptin on bone mass by allocating women into the following groups: (a) premenopausal women BMI<25 kg/m(2) (N=178); (b) premenopausal women BMI>25 kg/m(2) (N=83); (c) postmenopausal women BMI<25 kg/m(2) (N=125); and (d) postmenopausal women BMI>25 kg/m(2) (N=169). Additionally we investigated the relation of serum leptin concentrations, age and BMI on ultrasonometry variables by performing a multiple linear regression analyses.

RESULTS

in the initial analyses premenopausal women showed a significantly (P<0.001) lower mean age, weight, BMI, follicle stimulating hormone (FSH) and leptin concentration, a higher mean height, serum estradiol and ultrasonometry variables in comparison to postmenopausal women. Irrespective of the menopausal status, women with a BMI>25 kg/m(2) had significantly higher leptin concentrations (P<0.001) and BUA (P<0.05) whereas SOS and SI was not significant different, compared to women with a BMI<25 kg/m(2). The multiple linear regression analyses showed that only BMI but not Leptin was related to higher ultrasonometry variables, whereas increasing age was associated with a decrease in ultrasonometry variables. Furthermore, the multiple linear regression analyses confirmed that age and BMI were the only statistically significant independent predictor for ultrasonometry variables. There was no significant influence of leptin on ultrasonometry variables even after controlling for BMI or age, or BMI and age.

CONCLUSIONS

serum leptin concentrations are significantly higher in pre and postmenopausal obese women, compared with normal weight controls. Ultrasonometry variables are influenced by age and BMI but not by serum leptin concentrations.

Antibodies to neuron-specific antigens in children with autism: possible cross-reaction with encephalitogenic proteins from milk, Chlamydia pneumoniae and Streptococcus group A

We measured autoantibodies against nine different neuron-specific antigens and three cross-reactive peptides in the sera of autistic subjects and healthy controls by means of enzyme-linked immunosorbent assay (ELISA) testing. The antigens were myelin basic protein (MBP), myelin-associated glycoprotein (MAG), ganglioside (GM1), sulfatide (SULF), chondroitin sulfate (CONSO4), myelin oligodendrocyte glycoprotein (MOG), alpha,beta-crystallin (alpha,beta-CRYS), neurofilament proteins (NAFP), tubulin and three cross-reactive peptides, Chlamydia pneumoniae (CPP), streptococcal M protein (STM6P) and milk butyrophilin (BTN). Autistic children showed the highest levels of IgG, IgM and IgA antibodies against all neurologic antigens as well as the three cross-reactive peptides. These antibodies are specific because immune absorption demonstrated that only neuron-specific antigens or their cross-reactive epitopes could significantly reduce antibody levels. These antibodies may have been synthesized as a result of an alteration in the blood-brain barrier. This barrier promotes access of preexisting T-cells and central nervous system antigens to immunocompetent cells, which may start a vicious cycle. These results suggest a mechanism by which bacterial infections and milk antigens may modulate autoimmune responses in autism.

Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation

OBJECTIVE

To test the hypothesis that the need to attain immobility during pediatric sedation for procedures determines the depth of sedation, which cannot always be predicted.

DESIGN

A retrospective review of sedation documents of 301 consecutive sedations of pediatric patients undergoing various procedures

SETTING

Division of Critical Care sedation service within a children's hospital.

MEASUREMENTS AND MAIN RESULTS

The medical records and sedation forms of our most recent 301 consecutive sedations were retrospectively reviewed. Based on the data gathered, the patients were categorized according to their achieved level of immobility, their level of consciousness according to the definitions of the American Academy of Pediatrics, the procedures for which sedation was administered, and the sedatives used. A total of 125 males and 89 females received 301 sedations. Their ages ranged from 22 days to 29 years (mean 7 y + 6 y). We recognized four categories of immobility for procedures. In category 1, some motion was allowed during painless and noninvasive procedures to the extent that it did not risk the patient nor hinder the successful performance of the procedures. In category 2, the patients were kept motionless during painless and noninvasive procedures. In category 3, the patients were kept motionless during painful and invasive procedures with the addition of local anesthetic. In category 4, the patients remained motionless throughout their painful or invasive procedure without the use of local anesthetics. There were 32, 10, 156 and 103 sedations in each category, respectively. Conscious sedation (CS) was observed in six sedations (19%) in category 1 of immobility; it was observed in none (0%) in category 2, in 4 sedations (2.6%) in category 3, and in 1 sedation (1%) in category 4. Deep sedation (DS) was noted in 26 category 1 sedations (81%), in 10 category 2 sedations (100%), in 136 category 3 sedations (87%), and in 63 category 4 sedations (61%). General anesthesia (GA) was only observed in categories 3 and 4 in 16 sedations (10%) and 39 sedations (38%), respectively. Intravenous (IV) ketamine, as a single agent or in combination with other agents, was the most frequently used sedative (88%) followed by IV benzodiazepines (64%), propofol (39%), opiates (15%), and barbiturates (5%). A total of 59 (19%) adverse events were encountered during the 301 sedations. In categories 1 and 2, no adverse event (0%) was encountered. In category 3, 19 adverse events took place (32%), and 40 adverse events (68%) (P< 0.05) occurred in category 4.

CONCLUSIONS

Pediatric sedation results in 4 categories of immobility. Complete immobility during painful and invasive procedures is associated with a higher incidence of adverse events. The depth of sedation (ie, CS, DS, or GA) required to achieve each category of immobility is unpredictable and varies from patient to patient. Thus, granting a limited sedation authority (conscious sedation only) to physicians may be of limited practical value.