Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis

Importance

Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results.

Objective

To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children.

Data Sources

PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021.

Study Selection

Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded.

Data Extraction and Synthesis

Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model.

Main Outcomes and Measures

The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses.

Results

A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002).

Conclusions and Relevance

These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.

Drug abuse and prevention programs in 29 countries

In this paper, drug prevention programs in 29 countries are reviewed and summarized. The material was gathered from the reports that each country had prepared for the World Health Organization project on Guidelines for Drug Abuse Prevention. Each report provided a detailed schedule of background data on drug abuse and prevention programs in that country. The sophistication of prevention programs varies considerably from one country to another and depends on the degree and nature of the problem. An analysis of this material indicates that the seriousness of the drug problem is well recognized in some countries but not in others. In some of the latter countries it is obvious that no real problem exists, while in others little is known about the extent of the problem and little effort is spent in this area.

Patterns from dried drops as a characterisation and healthcare diagnosis technique, potential and challenges: A review

When particulate-laden droplets evaporate, they leave behind complex patterns on the substrate depending on their composition and the dynamics of their evaporation. Over the past two decades, there has been an increased interest in interpreting these patterns due to their numerous applications in biomedicine, forensics, food quality analysis and inkjet printing. The objective of this review is to investigate the use of patterns from dried drops as a characterisation and diagnosis technique. The patterns left behind by dried drops of various complex fluids are categorised. The potential applications of these patterns are presented, focussing primarily on healthcare, where the future impact could be greatest. A discussion on the limitations which must be overcome and prospective works that may be carried out to allow for widespread implementation of this technique is presented in conclusion.

Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study

BACKGROUND

Consensus regarding the safest mode of delivery and anesthetic management for parturients with Arnold Chiari malformation-I (ACM-I) remains controversial. This study assessed their anesthetic management and reported anesthetic complications during hospitalization for delivery.

METHODS

This was a multicenter, retrospective, cohort study of patients with ACM-I undergoing vaginal or cesarean delivery. Data were obtained from the electronic databases of four United States academic institutions using International Classification of Diseases (ICD) codes from 2007-2017 at three sites and 2004-2017 at one site. The primary outcome was anesthetic complications.

RESULTS

Data were analyzed for 185 deliveries in 148 patients. Diagnosis of ACM-I was made prior to delivery in 147 (80%) cases. Pre-delivery neurosurgical consultation for management of ACM-I was performed in 53 (36%) patients. Pre-existing symptoms were recorded for 89 (48%) of the deliveries. Vaginal deliveries occurred in 80 (43%) cases, and 62 women (78%) received neuraxial labor analgesia. Cesarean delivery was performed in 105 (57%) cases, of which 70 women (67%) had neuraxial anesthesia and 34 (32%) received general anesthesia. Post-dural puncture headache was reported in three (2%) patients who had neuraxial anesthesia, and in two (12%) patients with syringomyelia. There was one (3%) reported case of aspiration pneumonia with general anesthesia.

CONCLUSIONS

The findings suggest that anesthetic complications occur infrequently in patients with ACM-I regardless of the anesthetic management. Although institutional preference in anesthetic and obstetric care appears to drive patient management, the findings suggest that an individualized approach has favorable outcomes in this population.

Cytotoxicity and estrogenicity in simulated dental wastewater after grinding of resin-based materials

OBJECTIVE

This study evaluated the cytotoxic and estrogenic effects of dust and eluates released into simulated wastewater after grinding of dental resin-based materials.

METHODS

Four materials were used: ceram.x® universal, Filtek™ Supreme XTE, Lava™ Ultimate and Core-X™ flow. From each composite material, samples (5 × 2 mm, n = 50) were prepared according to the manufacturers' instructions. Lava™ Ultimate was used as blocks. All samples were ground to dust with a diamond bur (106 μm) and suspended in distilled water at 60 mg/mL. After storage for 72 h, the suspensions were separated into a soluble (eluate) and a particulate (dust) fraction. Eluates and dusts were evaluated for inhibition of Vibrio fischeri bioluminescence and cytotoxicity on human A549 lung cells (WST-1-Assay). The estrogenic activity was assessed by YES-Assay using Saccharomyces cerevisiae. Additionally, dental monomers (BisGMA, BisEMA, UDMA, TEGDMA, HEMA) and Bisphenol A were investigated.

RESULTS

All eluates showed inhibition of V. fischeri bioluminescence at concentrations above 1.1 mg/mL (p < 0.05). The activity of the eluates of ceram.x® universal and Filtek™ Supreme XTE was significantly higher than Lava™ Ultimate and Core-X™ flow (p < 0.05). In the WST-1-Assay, all materials induced cytotoxic effects at concentrations of 0.1 mg/mL (p < 0.05), while no significant differences were detected among them. The tested materials revealed no estrogenic activity. All dental monomers and Bisphenol A showed concentration dependent cytotoxic effects (p < 0.05), whereas only Bisphenol A induced an estrogenic effect (p < 0.01).

SIGNIFICANCE

Dust and eluates of resin-based dental materials released into wastewater exert bactericidal and cytotoxic effects in vitro. However, they reveal no estrogenic effect.

Phytochemical relationship of Euphorbia helioscopia and Euphorbia pulcherrima with Lactuca sativa

Allelopathy is an important phenomenon that modifies the ecosystem. A plant can enhance or reduce the growth of other plant due to the presence of a number of allelochemicals in its different parts. Euphorbia helioscopia and Euphorbia pulcherrima are medicinal plant species. Both these species are collected from wild resources for various purposes. To reduce the pressure on wild population, it is important to bring them into cultivation. Therefore, the allelopathic effects of E. helioscopia and E. pulcherrima on the growth of lettuce seeds were studied. Three different concentrations (2%, 4% and 6%) of five different solvents (methanol, acetone, ethyl acetate, n-hexane and distilled water) were used to estimate the allelopathic potential of the above-mentioned Euphorbia species. Results indicated a non-significant growth inhibitory effect of both plants on lettuce seeds. Different extracts reduced the growth of test plant to some extent but this inhibition was not significant. From the observed results, it was concluded that the studied Euphorbia species, being medicinally important crops, can be introduced as intercrop with other cash crops.

Genetic diversity of functional food species Spinacia oleracea L. by protein markers

Exploration of genetic diversity contributes primarily towards crop improvement. Spinaciaoleracea L. is a functional food species but unfortunately the genetic diversity of this vegetable is still unexplored. Therefore, this research was planned to explore the genetic diversity of S. oleracea by using morphological and protein markers. Protein profile of 25 accessions was generated on sodium dodecyl sulphate polyacrylamide gel. Total allelic variation of 27 bands was found. Out of these, 20 were polymorphic and the rest of the bands were monomorphic. Molecular weights of the bands ranged from 12.6 to 91.2 kDa. Major genetic differences were observed in accession 20541 (Peshawar) followed by 20180 (Lahore) and 19902 (AVRDC). Significant differences exist in the protein banding pattern. This variation can further be studied by advanced molecular techniques, including two-dimensional electrophoresis and DNA markers.

Juvenile hormone stimulated tyrosine kinase-mediated protein phosphorylation in the CNS of the silk worm, Bombyx mori

In vitro studies with the larval CNS of the silkworm, Bombyx mori revealed the phosphorylation of a 48-kDa protein, which was not dependent on cyclic nucleotides. Studies also revealed modest phosphorylation of this protein by a calcium-dependent but calmodulin-independent mechanism. However, phosphorylation of this protein was greatly enhanced in the presence of juvenile hormone (JH) I by a calcium-independent mechanism. This stimulatory effect of JH was seen in both homogenates as well as in intact CNS of Bombyx. Immunoblotting studies revealed the cross-reaction of this 48-kDa protein with phosphotyrosine monoclonal antibody and the phosphorylation of this protein was inhibited by genistein. This study suggests that the 48-kDa protein is a substrate for tyrosine kinase. The phosphorylation of this protein was also observed in other larval tissues such as salivary gland, fat body, and epidermis of Bombyx.

System level modeling and analysis of TNF-α mediated sphingolipid signaling pathway in neurological disorders for the prediction of therapeutic targets

Sphingomyelin (SM) belongs to a class of lipids termed sphingolipids. The disruption in the sphingomyelin signaling pathway is associated with various neurodegenerative disorders. TNF-α, a potent pro-inflammatory cytokine generated in response to various neurological disorders like Alzheimer's disease (AD), Parkinson's disease (PD), and Multiple Sclerosis (MS), is an eminent regulator of the sphingomyelin metabolic pathway. The immune-triggered regulation of the sphingomyelin metabolic pathway via TNF-α constitutes the sphingomyelin signaling pathway. In this pathway, sphingomyelin and its downstream sphingolipids activate various signaling cascades like PI3K/AKT and MAPK/ERK pathways, thus, controlling diverse processes coupled with neuronal viability, survival, and death. The holistic analysis of the immune-triggered sphingomyelin signaling pathway is imperative to make necessary predictions about its pivotal components and for the formulation of disease-related therapeutics. The current work offers a comprehensive in silico systems analysis of TNF-α mediated sphingomyelin and downstream signaling cascades via a model-based quantitative approach. We incorporated the intensity values of genes from the microarray data of control individuals from the AD study in the input entities of the pathway model. Computational modeling and simulation of the inflammatory pathway enabled the comprehensive study of the system dynamics. Network and sensitivity analysis of the model unveiled essential interaction parameters and entities during neuroinflammation. Scanning of the key entities and parameters allowed us to determine their ultimate impact on neuronal apoptosis and survival. Moreover, the efficacy and potency of the FDA-approved drugs, namely Etanercept, Nivocasan, and Scyphostatin allowed us to study the model's response towards inhibition of the respective proteins/enzymes. The network analysis revealed the pivotal model entities with high betweenness and closeness centrality values including recruit FADD, TNFR_TRADD, act CASP2, actCASP8, actCASP3 and 9, cytochrome C, and RIP_RAIDD which profoundly impacted the neuronal apoptosis. Whereas some of the entities with high betweenness and closeness centrality values like Gi-coupled receptor, actS1PR, Sphingosine, S1P, actAKT, and actERK produced a high influence on neuronal survival. However, the current study inferred the dual role of ceramide, both on neuronal survival and apoptosis. Moreover, the drug Nivocasan effectively reduces neuronal apoptosis via its inhibitory mechanism on the caspases.

Microanatomy of the digestive tract, hooves and some visceral organs of addax antelope (Addax nasomaculatus) following a concentrate or forage feeding regime

Subacute ruminal acidosis is a common disease in captive non-domesticated ruminants and is mainly diagnosed by rumen fluid pH and rumen histology. Furthermore, differences in ruminant gastrointestinal histology have been hypothesized to correlate with the browser-grazer continuum. Twelve surplus addax antelope (Addax nasomaculatus) were divided into two groups, fed either their usual diet, consisting of a concentrate feed with a limited amount of hay, or a diet of unlimited hay only, for 3 months. After culling, descriptive and morphometric histology and pH measurements were compared between groups. Significant variations in cellular subpopulations were noted between groups, with roughage-fed individuals presenting primarily with balloon cells of the Stratum corneum and living layer cell vacuolization, whereas parakeratosis and intermediate-type cells were more frequent in the concentrate-fed group. Lesions typical of subacute ruminal acidosis were significantly more pronounced in concentrate-fed individuals. Ruminal pH measurements did not differ significantly, but were more consistent in forage-fed individuals, indicating a more stable reticuloruminal environment. The results indicate that ruminal histology may be more appropriate in assessing ruminal health compared to a single post-mortem pH measurement. It is proposed that Stratum corneum balloon cells may indicate cell maturation and not, as previously assumed, hyperfunction. Concentrate-fed individuals scored higher on the presence of inflammatory cells on hoof corium histology. The study further emphasizes the adaptability of ruminant digestive tract microanatomy in adult animals even after a short period of time and the positive effects an increased roughage diet may have in populations of captive grazing ruminants.

Preprocedural Pool Testing Strategy for Dentistry during the COVID-19 Pandemic

INTRODUCTION

Aerosol-generating procedures (AGPs) put the dental health care professionals (DHCPs) at a greater risk for acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In late June 2020, the Centers for Disease Control and Prevention advised elective dental procedures provision to asymptomatic patients while mandating strict infection control protocol and suggested the use of preprocedural testing as an adjunct. A cost-effective method for mass preprocedural testing is pool testing, which has specificity and sensitivity similar to polymerase chain reaction. This article aims to assess the outcomes and utility of incorporating preprocedural testing protocol for SARS-CoV-2 in dental clinics before providing AGPs.

METHOD

The patients who were recommended AGPs where rubber dam placement was not possible were advised to undergo preprocedural testing for SARS-CoV-2. Pool testing strategy was employed, and patients were asked to get tested 48 h before the day of the procedure.

RESULTS

Out of a total of 1,000 patients, who presented from June 2020 to late July 2020, 464 were recommended dental procedures. In 194 of 464, AGPs could not be performed under rubber dam isolation; therefore, the patients were advised to get a preprocedural pool test. In total, 111 patients deferred the procedure and testing. Out of 83 who got tested, 7 were positive for SARS-CoV-2, 5 of whom were tested in early June 2020 and 2 in late July 2020.

CONCLUSION

Pool testing within its limitations can be a useful preprocedure test in asymptomatic low-risk patients for AGP in dentistry, especially when the disease prevalence is low or moderate (<10%). It has the potential of reducing testing costs significantly while conserving reagent and other resources. Preprocedure testing, however, also gives rise to certain ethical concerns that also need to be addressed.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding which preprocedure testing approach they wish to use when performing aerosol-generating procedures in asymptomatic patients with consideration of cost sensitivity and specificity values.

Distribution of Suicides in India: A Decadal Data Analysis (2011-2020)

Background

India accounts for a significant proportion of suicide deaths globally. As per the Global Burden of Disease Study, India’s share of global suicides from 1990 to 2016 increased from 25·3% to 36·6% among women and 18·7% to 24·3% among men. However, medical factors are not the sole contributors to the suicide burden.

Methods

I analyze decadal data (2011-2020) on suicides in India provided by National Crime Records Bureau. This data contains the distribution of suicidal deaths based on age groups, causes, professions, gender, and residence zones.

Results

The analysis suggests that individuals aged ‘15-29 years’ were most affected (35.05%) by suicides, followed by those aged ‘30-44 years’ (32.61%). Family problems contribute to the highest burden of suicides among both these age groups. Such deaths can be attributed to personal reasons. Suicides due to dowry disputes are exclusive to women. Also, women report the highest instances of suicides due to marriage-related issues. While suicides due to drug abuse, bankruptcy, unemployment, poverty, and property disputes were mainly reported among males. In 2020, the rise in annual suicide rate was found to be highest among business persons (29.43%), especially tradesmen (49.9%) and vendors (26.11%) against other businesses (12.13%). Other professions which witnessed a steep rise in annual suicide rates in 2020 were agricultural laborers (17.90%) and daily wage earners (15.76%). This increase in suicide rates may be linked to economic reasons post lockdown imposition during the Covid-19 outbreak in 2020.

Conclusions

Women commit suicide mainly due to marriage-related causes, while men are more vulnerable to suicide due to economic factors. Not all suicides can be traced back to diagnosed mental illnesses. A significant proportion of suicides are attributed to personal, economic, and social problems. The insights generated from this analysis can help identify the vulnerable groups and target the much-needed interventions.

Key messages

• Suicide is a multifaceted problem involving various personal, economic, cultural, and social factors, besides medical reasons.

• Multidimensional strategies targeted at vulnerable groups could be potentially effective in curbing suicide rate.