Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report

INTRODUCTION

Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR.

METHODS

Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented.

RESULTS

Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively.

CONCLUSION

We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.

Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

Disturbance of primary producer communities disrupts the thermal limits of the associated aquatic fauna

Environmental fluctuation forms a framework of variability within which species have evolved. Environmental fluctuation includes predictability, such as diel cycles of aquatic oxygen fluctuation driven by primary producers. Oxygen availability and fluctuation shape the physiological responses of aquatic animals to warming, so that, in theory, oxygen fluctuation could influence their thermal ecology. We describe annual oxygen variability in agricultural drainage channels and show that disruption of oxygen fluctuation through dredging of plants reduces the thermal tolerance of freshwater animals. We compared the temperature responses of snails, amphipods, leeches and mussels exposed to either natural oxygen fluctuation or constant oxygen in situ under different acclimation periods. Oxygen saturation in channel water ranged from c. 0 % saturation at night to >300 % during the day. Temperature showed normal seasonal variation and was almost synchronous with daily oxygen fluctuation. A dredging event in 2020 dramatically reduced dissolved oxygen variability and the correlation between oxygen and temperature was lost. The tolerance of invertebrates to thermal stress was significantly lower when natural fluctuation in oxygen availability was reduced and decoupled from temperature. This highlights the importance of natural cycles of variability and the need to include finer scale effects, including indirect biological effects, in modelling the ecosystem-level consequences of climate change. Furthermore, restoration and management of primary producers in aquatic habitats could be important to improve the thermal protection of aquatic invertebrates and their resistance to environmental variation imposed by climate change.

Diel oxygen fluctuation drives the thermal response and metabolic performance of coastal marine ectotherms

Coastal marine systems are characterized by high levels of primary production that result in diel oxygen fluctuations from undersaturation to supersaturation. Constant normoxia, or 100% oxygen saturation, is therefore rare. Since the thermal sensitivity of invertebrates is directly linked to oxygen availability, we hypothesized that (i) the metabolic response of coastal marine invertebrates would be more sensitive to thermal stress when exposed to oxygen supersaturation rather than 100% oxygen saturation and (ii) natural diel fluctuation in oxygen availability rather than constant 100% oxygen saturation is a main driver of the thermal response. We tested the effects of oxygen regime on the metabolic rate, and haemocyanin and lactate levels, of velvet crabs (Necora puber) and blue mussels (Mytilus edulis), under rising temperatures (up to 24°C) in the laboratory. Oxygen supersaturation and photosynthetically induced diel oxygen fluctuation amplified animal metabolic thermal response significantly in both species, demonstrating that the natural variability of oxygen in coastal environments can provide considerable physiological benefits under ocean warming. Our study highlights the significance of integrating ecologically relevant oxygen variability into experimental assessments of animal physiology and thermal response, and predictions of metabolic performance under climate warming. Given the escalating intensity and frequency of climate anomalies, oxygen variation caused by coastal vegetation will likely become increasingly important in mitigating the effects of higher temperatures on coastal fauna.

Voltammetric Monitoring of Gold Nanoparticle Formation Facilitated by Glycyl-l-Tyrosine: Relation to Electronic Spectra and Transmission Electron Microscopy Images

Voltammetric techniques have been introduced to monitor the formation of gold nanoparticles produced via the reaction of the amino acid glycyl-L-tyrosine with Au(III) (bromoaurate) in 0.05 M KOH conditions. The alkaline conditions facilitate amino acid binding to Au(III), inhibit the rate of reduction to Au(0), and provide an excellent supporting electrolyte for voltammetric studies. Data obtained revealed that a range of time-dependent gold solution species are involved in gold nanoparticle formation and that the order in which reagents are mixed is critical to the outcome. Concomitantly with voltammetric measurements, the properties of gold nanoparticles formed are probed by examination of electronic spectra in order to understand how the solution environment present during nanoparticle growth affects the final distribution of the nanoparticles. Images obtained by the ex situ transmission electron microscopy (TEM) technique enable the physical properties of the nanoparticles isolated in the solid state to be assessed. Use of this combination of in situ and ex situ techniques provides a versatile framework for elucidating the details of nanoparticle formation.

Long-term outcome and colonic motility after the Duhamel procedure for Hirschsprung's disease

BACKGROUND/PURPOSE

The aim of this study was to investigate long-term functional outcome and colonic motility in children who had undergone the Duhamel-type operation for Hirschsprung's disease (HSCR).

METHODS

All patients (n = 91) who underwent the Duhamel or Lester Martin Modified Duhamel operation for HSCR from 1980 to 1991 were included in the study. Twenty-two healthy age-matched children were used as controls. Functional outcome was assessed by questionnaire (response rate 100%). Total and segmental colonic transit time (CTT) was determined using the saturation method (80% participation rate).

RESULTS

Outcome scores were significantly worse in the study group for patients with rectosigmoid (RS, P < .001), long segment (LS, P < .001), and total colonic (TC) aganglionosis (P < .05), when compared with controls. The CTT was significantly prolonged in the RS group (P = .01) compared with LS, TC, and control groups; this was caused by prolonged "rectosigmoid" transit in the RS group compared with controls (P = .012). There was a positive linear correlation (P = .0002) between age and outcome score in patients with RS disease unrelated to CTT. Nine patients required a late long-term enterostomy. A satisfactory outcome (defined as outcome score > or = 10th percentile of the control group, and absence of stoma or requirement for major revisional surgery) was seen in only 42% of patients overall and in 79% of patients over 14 years of age.

CONCLUSIONS

The Duhamel procedure, in common with other pull-through procedures, is associated with significant long-term morbidity, the aetiology of which is poorly understood.

Functional results following the antegrade continence enema procedure

BACKGROUND

Forty children who underwent the antegrade continence enema (ACE) procedure for faecal soiling were studied to determine factors predictive of outcome.

METHODS

There were four patient groups: (1) ambulant with spinal dysraphism (n = 13), (2) wheelchair bound with spinal dysraphism (n = 14), (3) ambulant with miscellaneous disorders (n = 11) and (4) wheelchair bound with miscellaneous disorders (n = 2). Effectiveness of the procedure was assessed using technical evaluation and quality-of-life improvement (QOLI) scores (0-5). Objective assessment included colonic transit time (CTT) and anorectal manometry. Median follow-up was 21 (range 5-37) months.

RESULTS

Some 28 of 40 children achieved continence. The procedure was reversed in four of 40 children. Of the other 36 children with a functioning ACE stoma, all reported improvement in quality of life (mean QOLI score 3.5). There were no significant differences in technical evaluation score, QOLI score, CTT, manometry findings or continence between ambulant groups and the wheelchair-bound group with miscellaneous disorders. QOLI score, anorectal squeeze pressure and continence were significantly poorer in those who were wheelchair bound with spinal dysraphism. Absent squeeze pressure was associated with poor outcome.

CONCLUSION

Wheelchair-bound children with spinal neuropathy have a poorer outcome following the ACE procedure. Although ACE is an effective method of promoting faecal continence, it is essential to determine the aetiology of incontinence and sphincter function before operation.

Effect of pre-milking teat dipping on clinical mastitis on dairy farms in England

Two trials were conducted to investigate the effect of pre-milking teat dipping (PMTD) on mastitis caused by environmentally associated pathogens. The first trial showed considerable variation in effect between herds, so a second, larger trial was conducted. In this second trial a comparison of the rate of clinical mastitis was made between nine matched pairs of dairy herds over 24 weeks of the winter housed period. All herds were near the national average incidence of mastitis before the trial. One member of each pair used their normal method of udder preparation throughout the trial and disinfected all teats after milking with an iodophor disinfectant. In the other nine herds the preparation of all teats, at all milkings, included dipping in a 0.25% available iodine disinfectant, which was left on the teat for 30 s. Every teat was then wiped with a paper towel before cluster attachment. There was no difference in the overall rate of mastitis or the incidence of mastitis caused by any particular type or group of pathogens between the trial groups of herds. Both groups showed a reduction in mastitis compared with the previous winter. Although there were apparent benefits in some pairs of herds there was no overall benefit. In comparison with the previous winter the control herds reported a greater reduction in mastitis than the PMTD herds. The effect of trial supervision on normal practice gave a benefit which overwhelmed any effect of PMTD. There appeared to be no effect of PMTD on the total bacterial count, cell count or iodine content of bulk tank milk. There appears to be no justification for wholesale use of PMTD although most farms and risk groups could benefit from better attention to conventional mastitis control.

A comparison between the dental health of 3-year-old children living in fluoridated Huddersfield and non-fluoridated Dewsbury in 1989

A study was undertaken to compare the prevalence of dental caries and developmental defects of enamel between 3-year-old children who were lifelong residents of fluoridated areas of Huddersfield (1 ppm F) and non-fluoridated Dewsbury (less than 0.3 ppm F). An interview was also conducted with the parents of the children to provide information regarding previous dental experiences. The study populations were identified using the national child health system. The mean dmft was 0.30 in Huddersfield and 0.74 in Dewsbury. The percentage of children who had experienced dental caries and the percentage with carious teeth were significantly lower in the fluoridated area. The Dewsbury children had suffered more toothache. There was a significantly higher number of children in Huddersfield with diffuse enamel defects on their upper and lower first molars. This study has also demonstrated that the national child health system provides a method for obtaining a random sample of pre-school children from the general population, thus avoiding the problems associated with studies using selected populations. Fluoridation in Huddersfield ceased in October 1989 and it is hoped that this decision will be reversed as soon as possible.

Somatic cell counts of ewes' milk

The somatic cell counts of ewes' milk were determined by an electronic particle counter (Coulter Counter). Of 1408 apparently normal milk samples, 98.2% had a somatic cell count lower than 1.0 x 10(6) cells/ml and 85.8% of 254 bacteriologically positive samples had a count higher than 1.0 x 10(6) cells/ml. Values exceeding 1.0 x 10(6) cells/ml are indicative of subclinical mastitis, if samples were collected from clinically healthy mammary glands.

Studies on the incidence of clinical mastitis and blood levels of vitamin E and selenium in dairy herds in England

In a trial conducted in the south of England in January to February 1989, blood samples were obtained from nine dairy herds with more than 30 cases of clinical mastitis/100 cows and from nine herds with less than 30 cases/100 cows during the previous 12 months. Whole blood glutathione peroxidase (GSHPx) activity and plasma vitamin E concentration were determined for 12 cows in each herd. The mean (+/-sd) values for the herds with the lower incidence of mastitis were 7.57 +/- 1.86 micrograms/ml plasma vitamin E and 23.8 +/- 22.8 U/ml rbc GSHPx activity, compared with 7.74 +/- 1.69 micrograms/ml plasma vitamin E and 20.61 +/- 8.8 U/ml rbc GSHPx activity for the herds with the higher incidence of the disease. These values indicate that the vitamin E levels were generally adequate but that some animals and herds had low GSHPx activities, suggesting that their diets may have contained inadequate selenium. The activities of GSHPx and the vitamin E levels in plasma were not significantly different in the two groups of herds, and no relationship was found between the two nutrients and the incidence of clinical mastitis. However, there was a significant negative correlation between the activity of GSHPx and the bulk milk cell counts in the herds with a low incidence of mastitis suggesting that there was an association between the incidence of subclinical mastitis or inflammation and the selenium status of these herds.

The milk progesterone test as an aid to the diagnosis of cystic ovaries in dairy cows

Two field trials were carried out by five experienced veterinary surgeons to evaluate the milk progesterone test as an aid to the differential diagnosis of cystic ovaries in dairy cows. Of 200 cystic cows, 71 per cent were diagnosed clinically as follicular and 29 per cent as luteal cases; 80 per cent of the cases occurred in the six winter months November to April. The progesterone assay indicated that the diagnosis was correct in 84 per cent of the follicular cases but only 54 per cent of the luteal cases. Seventy-four per cent of the confirmed cystic cases responded to treatment within two weeks according to milk progesterone tests and there were no significant treatment differences. Overall, 80 per cent of the cows became pregnant on average 38 days after treatment having received an average of 1.70 inseminations each. Milk yield data in the first trial indicated that the cystic cows were not significantly higher yielders than their herd-mates.

Progress in controlling mastitis in England and Wales

Mastitis in England and Wales has been controlled over the past 20 years while the average size of dairy herds has doubled to 65 cows. The incidence of clinical mastitis has been reduced from approximately 120 to 150 cases per 100 cows to less than 50 cases. The limited data on the prevalence of subclinical mastitis indicate that it has been reduced from over 50 per cent of cows infected to less than half this level. The application of the major mastitis control measures on the farm has doubled over the period 1973 to 1983 and had reached 66 to 90 per cent for individual measures by 1983. The national mean cell count in milk has been reduced from 573,000 to 352,000 cells/ml between 1971 and 1986, and the proportion of herds having annual mean cell counts below 300,000 cells/ml has increased from 15.7 per cent to 40.7 per cent in the last eight years.

Testing for antibiotic residues in milk

Milk from dairy farms in England and Wales has been tested regularly for antibiotic residues since 1965. The sensitivity of the test organism was 0.02 iu/ml penicillin or equivalent until the change to 0.01 iu/ml in January 1986. In 1984-85, 99.6 per cent of the 2,000,000 milk samples tested passed the test and there was an average of 695 failures per month. From 7500 on-farm investigations over the two years 1983-85 the most frequent reasons suggested by farmers for their test failures were not withholding milk for the full withdrawal period (19.3 to 16.5 per cent) and accidental transfer of milk (16.3 to 16.7 per cent). Lactating and dry cow intramammary antibiotic preparations were held responsible for rather over 50 per cent and 25 per cent respectively of the failures in both years.

Use of a new and rapid milk progesterone assay to monitor reproductive activity in the cow

A new and rapid enzyme-amplified immunoassay (AELIA) has been developed for the measurement of progesterone in milk. The AELIA system is a non-isotopic method that gives results within 35 minutes. Milk progesterone concentrations measured in 10 cows sampled daily at various stages of the reproductive cycle were very similar to those recorded by a validated radioimmunoassay. The results show that the speed and sensitivity of the AELIA system would make it possible to diagnose pregnancy rapidly at about 24 days after insemination, to predict the onset of behavioural oestrus from decreasing progesterone values during the third week after a preceding oestrus, and to obtain a daily record of milk progesterone levels in animals treated for infertility of ovarian origin.

Intramammary antibiotic preparations and their withholding times

The test for antibiotic residues in milk carried out by the Milk Marketing Board (MMB) of England and Wales was increased in sensitivity from 0.02 iu/ml penicillin or equivalent to 0.01 iu/ml on January 1, 1986. The Veterinary Products Committee (VPC) has just completed a review of those intra-mammary antibiotic preparations which had licences of right. When assessing data for product licences the VPC decided that the concentration of antibiotic residues in milk should not exceed the concentrations listed in the 1969 Report of the Joint FAO/WHO Expert Committee on Food Additives. In this publication the level of 0.006 ppm for penicillin corresponds to 0.01 iu/ml which is the level that the MMB will also be using.

Use of a conductivity meter for the detection of subclinical mastitis

The conductivity of milk from 164 cows in four herds was measured. There were significant differences between the normal and the mastitic quarters in each of the four herds. However, there was a marked difference in conductivity levels between the herds, the mean conductivity of the normal quarters in one herd being higher than that of the mastitic quarters in another herd. In a trial using a hand-held mastitis detector on 123 cows from three herds, 91 per cent of the 106 mastitic quarters were detected. However, 33 per cent of the 315 normal quarters also gave a positive reading.

Methicillin-resistant Staphylococcus aureus in an Australian teaching hospital

A survey was undertaken of all isolations of methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MRSA) at a large Australian teaching hospital over a 12 month period. All methicillin-resistant isolations obtained from the Casualty and Outpatient clinics were from staff members or patients with recent hospital contact. Twenty per cent of all methicillin-resistant isolations from in-patients were from specimens taken within 2 days of the patient's admission. Each of these patients had had hospital contact within the previous 4 months and it is assumed that the majority of them reintroduced the organism into the hospital. Such patients may provide an important means by which infection control procedures are bypassed. Patients who were relatively more likely to become infected or colonized with methicillin-resistant than with methicillin-sensitive strains included the elderly and those with postoperative wound infections (especially after orthopaedic or vascular surgery), spinal injuries, peripheral vascular disease, chronic skin ulcers or chronic diseases of the respiratory or urinary tracts. Eleven per cent of MRSA wound isolates and 15 per cent of sputum isolates were associated with serious infections requiring specific treatment, emphasizing the ability of these strains to produce serious illness. A small proportion of staff and asymptomatic patients were found to harbour MRSA and the importance of these individuals in facilitating cross-infection requires further investigation.

A rapid direct radioimmunoassay for the measurement of oestrone sulphate in the milk of dairy cows and its use in pregnancy diagnosis

A radioimmunoassay for oestrone sulphate in unextracted samples of milk has been developed. The assay was validated by comparison with a method involving hydrolysis and extraction. The direct assay was used to measure oestrone sulphate in milk samples taken at weekly intervals throughout pregnancy in a commercial dairy herd. Concentrations of oestrone sulphate increased approximately 100 days after insemination and were maintained throughout the remainder of pregnancy in the range of 1.85-3.70 nmol/l.

Pregnancy diagnosis in dairy herds in England and Wales

A survey of 1692 dairy farmers in England and Wales in 1979 revealed that 14.2 per cent had veterinary pregnancy diagnoses carried out on more than half their cows, 43.8 per cent on less than half and 42.0 per cent had none. The results showed a considerable increase in the use of pregnancy diagnosis since a survey in 1969. Farmers with larger herds tended to make more use of pregnancy diagnosis and there were also some regional differences. In 64.6 per cent of herds pregnancy diagnosis was carried out during the third and fourth months of pregnancy; 93.3 per cent of herds in which more than half the cows were diagnosed were examined before the fourth month. Owners of pedigree herds used pregnancy diagnosis more than commercial herd owners. The milk progesterone assay pregnancy test was used by 4.3 per cent of farmers on more than half their cows, and by a further 1.9 per cent of farmers on some cows. More than 75 per cent of farmers using the milk progesterone test also used veterinary pregnancy diagnosis in their herds.

Monitoring pre-service reproductive status in dairy cows

Combinations of oestrus detection, ovarian palpation and milk progesterone assays were used to monitor pre-service reproductive status of cows in two dairy herds over two successive years. Non-cyclical cows were identified as having no luteal tissue in their ovaries on two occasions 10 days apart. Absence of luteal tissue was determined by the presence of basal mild progesterone initially followed either by a repeat of this result or by failure to palpate a corpus luteum per rectum. In the period 32 to 56 days post partum the number of non-cyclical cows on farm A years 1 and 2 was eight out of 31 (25 . 5 per cent), and 10 out of 62 (16 . 1 per cent) and on farm B years 1 and 2 was 10 out of 68 (14 . 7 per cent) and 11 out of 85 (12 . 9 per cent) respectively. The farm A herd was high yielding, (average lactation 6380 litres), whereas the farm B herd was of average yield (4717 litres). In both herds 60 day milk yield was not related to cyclical status of pre-service cows. There was however a trend toward a greater proportion of young cows being non-cyclical. With the exception of a prolonged calving to conception interval for farm A in year 1, whether a pre-service cow was cyclical or not had no effect on when the cow was first served or on when the animal conceived. The routine incorporation of pre-service monitoring to herd fertility control programmers may however be of value in recognising the incidence of non-cyclical cows and giving an early indication of oestrus detection efficiency.

Immune conservation: a possible consequence of the mechanism of interferon-induced antibody suppression

The effect of interferon preparations on the development of single clones of antibody-forming cells generated against sheep red blood cells in mouse spleen cell cultures has been studied. It was found that the presence of interferon had no effect on either the number or the size of clones which developed early in the in vitro antibody response. At the peak of the response (day 3), a decrease in the number but not in the size of clones was observed in interferon-treated compared to control cultures, while by day 4 both the size and number of clones were significantly decreased. These findings indicate that interferon appears to affect only nonactivated B cell precursors by preventing them from becoming activated and commencing clonal expansion. Early responding precursors, which are in cell cycle, presumably having been previously activated in vivo, are refractory to interferon-induced suppression in vitro. The way in which this immunosuppressive activity of interferon might be of great advantage to an animal as a means of "immune conservation" during viral infections is discussed.