Search

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms. A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs. A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01–1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34–5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97–56.57, p

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU). This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher’s exact test, logistic regression, or unpaired T tests, as appropriate. One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5–42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7–4.1) p = 0.24). PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU).This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate.One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24).PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

Although the differential for hypercalcemia in the surgical patient is broad, a stepwise approach to the diagnosis and management will ensure adequate management of this common electrolyte abnormality. Hyperparathyroidism and malignancy account for 90% of hypercalcemic patients. Treatment is largely etiology specific and may be altered based on the presence or absence of associated symptoms.

Background: Improved healthcare and recent breakthroughs in technology have substantially reduced cancer mortality rates worldwide. Recent advancements in next-generation sequencing (NGS) have allowed genomic analysis of the human transcriptome. Now, using NGS we can further look into small non-coding regions of RNAs (sncRNAs) such as microRNAs (miRNAs), Piwi-interacting-RNAs (piRNAs), long non-coding RNAs (lncRNAs), and small nuclear/nucleolar RNAs (sn/snoRNAs) among others. Recent studies looking at sncRNAs indicate their role in important biological processes such as cancer progression and predict their role as biomarkers for disease diagnosis, prognosis, and therapy. Results: In the present study, we data mined publically available small RNA sequencing data from colorectal tissue samples of eight matched patients (benign, tumor, and metastasis) and remapped the data for various small RNA annotations. We identified aberrant expression of 13 miRNAs in tumor and metastasis specimens [tumor vs benign group (19 miRNAs) and metastasis vs benign group (38 miRNAs)] of which five were upregulated, and eight were downregulated, during disease progression. Pathway analysis of aberrantly expressed miRNAs showed that the majority of miRNAs involved in colon cancer were also involved in other cancers. Analysis of piRNAs revealed six to be over-expressed in the tumor vs benign cohort and 24 in the metastasis vs benign group. Only two piRNAs were shared between the two cohorts. Examining other types of small RNAs [sn/snoRNAs, mt_rRNA, miscRNA, nonsense mediated decay (NMD), and rRNAs] identified 15 sncRNAs in the tumor vs benign group and 104 in the metastasis vs benign group, with only four others being commonly expressed. Conclusion: In summary, our comprehensive analysis on publicly available small RNA-seq data identified multiple differentially expressed sncRNAs during colorectal cancer progression at different stages compared to normal colon tissue. We speculate that deciphering and validating the roles of sncRNAs may prove useful in colorectal cancer prognosis, diagnosis, and therapy.

Peripheral nerve injuries are common, debilitating, and costly. The human body’s innate regenerative capacity is slow, and nerves are often misguided. The purpose of this article is to review a specific cellular, regenerative engineering technique that holds promise for the treatment of peripheral nerve injuries. Over the past several decades, research has focused on the utilization of stem cells for peripheral nerve repair. More recently, stem cells collected from adipose tissue (adipose-derived stem cells or ADSCs) have gained traction due to their relative ease of collection and differentiation potential. Both undifferentiated and Schwann cell-like differentiated ADSCs have been used to seed conduits with variable results. Technical and ethical issues surrounding stem cells’ self-expansion potential and genetic makeup exist. Ultimately, randomized control trials and FDA approval will be required before widespread clinical translation in the US is realized.

Procedures in the neurointerventional suite can be divided into opening procedures and closing procedures, such as angioplasty for stroke, embolization for cerebral arterio-venous malformations or coiling for cerebral aneurysm. Different equipment and medications are available for each type of procedure with unique possible side effects and complications.

Cancer is the second leading cause of death in the United States and is a major public health concern worldwide. Basic, clinical and epidemiological research is leading to improved cancer detection, prevention, and outcomes. Recent technological advances have allowed unbiased and comprehensive screening of genome-wide gene expression. Small non-coding RNAs (sncRNAs) have been shown to play an important role in biological processes and could serve as a diagnostic, prognostic and therapeutic biomarker for specific diseases. Recent findings have begun to reveal and enhance our understanding of the complex architecture of sncRNA expression including miRNAs, piRNAs, lncRNAs, sn/snoRNAs and their relationships with biological systems. We used publicly available small RNA sequencing data that was derived from 24 triple negative breast cancers (TNBC) and 14 adjacent normal tissue samples to remap various types of sncRNAs. We found a total of 55 miRNAs were aberrantly expressed (p

There are over two million laparotomies performed in the United States each year with an incisional hernia rate between 2% and 11%. A total of 100,000 ventral hernia repairs are undertaken each year with recurrences as high as 50%.Full thickness midline fascia incisions from the xiphoid to the pubic symphysis were made in rats. The fascia and/or muscular layer was sutured closed and a gel with 300 μM of sodium orthovanadate or saline was placed over the suture line with the skin closed over it. On day 10, 1-cm strips from the superior, middle, and inferior regions of the abdominal wall were tested for breaking strength and processed for histology.The mean wound breaking strength of vanadate-treated wounds was 18.6 ± 2.7 N compared with 9.4 ± 3.6 N for controls (P 0.0001). Similar quantities of granulation tissue were deposited in treated and control wounds. Fine green birefringence patterns, characteristic of immature connective tissue, were seen in control samples viewed with polarized light. In contrast, vanadate-treated wounds showed thick yellow-orange birefringence patterns characteristics of more mature connective tissue. Using α-smooth muscle actin immunostaining, myofibroblasts were prominent in control incisions, but few were identified in vanadate-treated incisions.In rat laparotomy wounds, a single application of vanadate increases wound breaking strength, through enhanced connective tissue organization. These combined data suggest topical application of vanadate immediately after fascial closure will increase wound strength, possibly reducing hernia recurrences in the repaired abdominal wall.

Case reports, case series and case control studies have looked at the use of phrenic nerve stimulators in the setting of high spinal cord injuries and central hypoventilation syndromes dating back to the 1980s. We evaluated the evidence related to this topic by performing a systematic review of the published literature. Search terms “phrenic nerve stimulation,” “phrenic nerve and spinal cord injury,” and “phrenic nerve and central hypoventilation” were entered into standard search engines in a systematic fashion. Articles were reviewed by two study authors and graded independently for class of evidence according to published guidelines. The published evidence was reviewed, and the overall body of evidence was evaluated using the grading of recommendations, assesment, development and evaluations (GRADE) criteria Balshem et al. (J Clin Epidemiol 64:401–406, 2011). Our initial search yielded 420 articles. There were no class I, II, or III studies. There were 18 relevant class IV articles. There were no discrepancies among article ratings (i.e., kappa = 1). A meta-analysis could not be performed due to the low quality of the available evidence. The overall quality of the body of evidence was evaluated using GRADE criteria and fell within the “very poor” category. The quality of the published literature for phrenic nerve stimulation is poor. Our review of the literature suggests that phrenic nerve stimulation is a safe and effective option for decreasing ventilator dependence in high spinal cord injuries and central hypoventilation; however, we are left with critical questions that provide crucial directions for future studies.

In previous studies, granulation tissue from subcutaneous sponge implants in rats receiving thymosin β4, a 43-amino acid actin-binding protein that advances wound repair, produced the unexpected absence of myofibroblast populations, along with uniform organized collagen fibers within the newly deposited connective tissue matrix. This result raised the question of whether the Tβ4 effect on blocking fibroblasts transformation into myofibroblasts a direct or indirect one. We report here work in progress to address this question. When human dermal fibroblasts are plated at low density, upon reaching confluence, they all express α smooth muscle actin (αSMA) within their cytoplasmic stress fibers, morphologically defining them as myofibroblasts. Treating low-density plated fibroblasts with Tβ4 prevents their expression of αSMA, as well as the generation an uneven distribution of microtubules within the cytoplasm. The speculation is that Tβ4 disruption of the distribution of microtubules alters the TGF-β-Smad signaling pathway, thus blocking fibroblast transformation into myofibroblasts.

Severed tendons can undergo regenerative healing, intrinsic tendon repair. Fibrillogenesis of chick tendon involves "collagen fibril segments" (CFS), which are the building blocks of collagen fibers that make up tendon fascicles. The CFS are 10.5 micron in length, composed of tropocollagen monomers arranged in parallel arrays. Rather than incorporating single tropocollagen molecules into growing collagen fibers, incorporating large CFS units is the mechanism for generating collagen fibers. Is intrinsic tendon repair through the reestablishment of tendon embryogenesis? Gentamicin treated 10-day-old chick embryo tendons released CFS were fluorescently tagged with Rhodamine (Rh). Organ cultured severed 14-day-old embryo tendon explants received Rh tagged CFS. At day 4 auto fluorescent tagged CFS were identified at the severed tendon ends by fluorescent microscopy. Accumulation of fluorescent tagged CFS was exclusively localized to the severed ends of tendon explants. Parallels between collagen fiber growth during embryonic fibrillogenesis and tendon repair reveal CFS incorporation is responsible for collagen fibers growth. CFS incorporation into frayed collagen fibers from severed tendons is the proposed mechanism for intrinsic tendon repair, which is an example of regenerative repair.

Background Sentinel lymph node biopsy (SNLB) is the standard of care in staging of melanoma and other skin cancers. Early studies used lymphazurin (LZ) for SLNB. A national shortage of LZ promoted methylene blue (MB) as an alternate stain. Objective This study compares complication rates between LZ and MB in SLNB patients, and the reliability dyes in locating sentinel lymph nodes. Methods Charts were reviewed for patients who underwent SLNB for skin cancers between September 2006 and November 2008 at Penn State Hershey Medical Center. The type and quantity of dye, the presence of blue stained sentinel nodes, and any complications were recorded. Results Ninety-three patients underwent SLNB (46 LZ, 47 MB). The amount of dye used was similar (avg. 0.93 ml LZ, 1.24 ml MB). The complication rate of LZ was 8.7%, and MB was 25.5%. There was significantly more (P = 0.003) skin graft complications in the MB patients (6/12) versus LZ (0/15). Conclusions There is a higher rate of complications with MB, especially with skin grafting. The reported risk of anaphylaxis with LZ has not been reported in volumes

Incisional wounds in rats treated locally with thymosin beta4 (Tbeta4) healed with minimal scaring and without loss in wound breaking strength. Treated wounds were significantly narrower in width. Polarized light microscopy treated wounds had superior organized collagen fibers, displaying a red birefringence, which is consistent with mature connective tissue. Control incisions had randomly organized collagen fibers, displaying green birefringence that is consistent with immature connective tissue. Immunohistology treated wounds had few myofibroblasts and fibroblasts with alpha smooth muscle actin (SMA) stained stress fibers. Polyvinyl alcohol sponge implants placed in subcutaneous pockets received either carrier or 100 microg of Tbeta4 on days 2, 3, and 4. On day 14, treated implants revealed longer, thicker collagen fiber bundles with intense yellow-red birefringence by polarized light microscopy. In controls, fine, thin collagen fiber bundles were arranged in random arrays with predominantly green birefringence. Controls contained mostly myofibroblasts, while few myofibroblasts appeared in Tbeta4 treated implants. Electron microscopy confirmed both cell types and the degree of collagen fiber bundle organization. Our results demonstrate that Tbeta4 treated wounds appear to mature earlier and heal with minimal scaring.

The evolution of modern anesthesia and surgical practices has been accompanied by enhanced supportive procedures in blood banking and transfusion medicine. There is increased focus on the preparation and the use of blood components including, but not limited to, preventing unnecessary type and screen/crossmatch orders, decreasing the time required to provide compatible red blood cells (RBCs), and reducing the waste of limited blood and personnel resources. The aim of this review is to help the anesthesiologist and surgical staff identify patients at highest risk for surgical bleeding. In addition, this review examines how anesthesia and transfusion medicine can efficiently and safely allocate blood components for surgical patients who require transfusions. The following databases were searched: PubMed, EMBASE, Google Scholar, and the Cochrane Library from January 1970 through March 2014. Subsequent reference searches of retrieved articles were also assessed. Several innovations have drastically changed the procedures by which blood is ordered, inventoried, and the speed in which blood is delivered for patient care. Before entering an operating room, patient blood management provides guidance to clinicians about when and how to treat preoperative anemia and intra- and postoperative strategies to limit the patient's exposure to blood components. Timely updates of the recommendations for blood orders (maximum surgical blood ordering schedule) have enhanced preoperative decision making regarding the appropriateness of the type and screen versus the type and crossmatch order. The updated maximum surgical blood ordering schedule reflects modern practices, such as laparoscopy, improved surgical techniques, and use of hemostatic agents resulting in a more streamlined process for ordering and obtaining RBCs. The electronic (computer) crossmatch and electronic remote blood issue have also dramatically reduced the amount of time required to obtain crossmatch-compatible RBCs when compared with the more traditional serologic crossmatch methods. These changes in blood banking methods have resulted in more efficient delivery of blood to surgical patients.

Background: Cancer is a major cause of deaths worldwide, despite improved healthcare and technologies. Recent advancements in genome sequencing have led to the rapid study of the whole transcriptome and small RNAs with their biological functions. Non-coding RNAs (ncRNAs) play an important role in biological processes that greatly impact biomarker development for diagnosis, prognosis, and therapy. Non-coding RNAs such as microRNAs (miRNA), Piwi-interacting-RNAs (piRNAs), small nuclear/nucleolar RNAs (sn/snoRNAs) have recently been studied to understand their biology and pathology. Results: In the present study, we used eight matched colorectal patient tissue samples (benign, tumor, and metastasis) small RNA sequencing data remapped for various small RNA annotation. We identified aberrant expression of 13 miRs in tumor and metastasis specimens [tumor vs benign group (19 miRs) and metastasis vs benign group (38 miRs)] of which five were upregulated, and eight were downregulated, during disease progression. We also investigated pathway analysis on abbarent expression of miRNAs, which showed majority of miRs involved in the colon other types of cancers. Further analysis of piRNAs revealed that six piRNAs in tumor vs benign and 24 in metastasis vs benign samples (commonly in both groups, only two piRNAs). Additionally, we examined other types of small RNAs [sn/snoRNAs, mt_rRNA, misc_RNA, nonsense mediated decay (NMD) and rRNA], we identified 15 in tumor vs benign and 104 metastasis vs benign and only four in commonly expressed. Conclusion: In summary, our results identified multiple sncRNAs during colorectal cancer progression which needs to be further validated and can be used for prognosis, diagnosis, and therapeutic potentials. Citation Format: Srinivas V. Koduru, Amit K. Tiwari, Sprague W. Hazard, Milind K. Mahajan, Dino J. Ravnic. Analysis of small RNA-seq data for differential expression of small noncoding RNAs in human colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4447. doi:10.1158/1538-7445.AM2017-4447

Background. Hyperoxic reperfusion from global ischemia worsens functional outcome because of oxygen radical-mediated injury. This study tested the hypothesis that hyperoxic reperfusion would exacerbate postischemic renal dysfunction. Methods. Twenty-nine healthy, uninephrectomized, male mongrel rabbits (Oryctolagus cuniculus) in 3 groups were subjected to 30 minutes of complete normothermic renal ischemia followed by reperfusion under hyperoxic or normoxic conditions. The groups were: hyperoxically reperfused (n = 8), normoxically reperfused (n = 8), hyperoxic sham (no ischemia, n = 5), and allopurinol-pretreated (50 mg/kg, intravenously), hyperoxically reperfused animals (n = 8). Plasma concentrations of creatinine, urea nitrogen and electrolytes were measured at 0, 24, 48, and 72 hours after ischemia and served as functional outcome markers. Histopathologic analysis of kidneys for injury was performed by an expert who was blinded to the procedures. Results. Plasma creatinine in hyperoxically reperfused rabbits was significantly elevated above normoxic ( P =.02) and sham ( P =.003) animals by 48 hours and remained elevated to 72 hours. Plasma urea nitrogen in hyperoxically reperfused rabbits was significantly elevated above the normoxic group ( P =.01), the sham group ( P =.02), and the allopurinol group ( P =.04) by 72 hours. These coincided with a significantly elevated histopathologic injury score in hyperoxically reperfused rabbits compared with sham ( P =.019), normoxic ( P =.035), and allopurinol-pretreated hyperoxically reperfused animals ( P =.037). Conclusions. Hyperoxic reperfusion exacerbates renal dysfunction after 30 minutes of complete normothermic ischemia. This dysfunction may be mediated by oxygen radical-related injury. (Surgery 2000;128:815-21.)

In previous studies, granulation tissue from subcutaneous sponge implants in rats receiving thymosin β4, a 43-amino acid actin-binding protein that advances wound repair, produced the unexpected absence of myofibroblast populations, along with uniform organized collagen fibers within the newly deposited connective tissue matrix. This result raised the question of whether the Tβ4 effect on blocking fibroblasts transformation into myofibroblasts a direct or indirect one. We report here work in progress to address this question. When human dermal fibroblasts are plated at low density, upon reaching confluence, they all express α smooth muscle actin (αSMA) within their cytoplasmic stress fibers, morphologically defining them as myofibroblasts. Treating low-density plated fibroblasts with Tβ4 prevents their expression of αSMA, as well as the generation an uneven distribution of microtubules within the cytoplasm. The speculation is that Tβ4 disruption of the distribution of microtubules alters the TGF-β-Smad signaling pathway, thus blocking fibroblast transformation into myofibroblasts.

In this paper, we present a technique for parameterizing Leslie transition matrices from simple age and sex population counts, using an implementation of "Wood's Method" [wood]; these matrices can forecast population by age and sex (the "cohort component" method) using simple matrix multiplication and a starting population. Our approach improves on previous methods for creating Leslie matrices in two respects: it eliminates the need to calculate input demographic rates from "raw" data, and our new format for the Leslie matrix more elegantly reveals the population's demographic components of change (fertility, mortality, and migration). The paper is organized around three main themes. First, we describe the underlying algorithm, "Wood's Method," which uses quadratic optimization to fit a transition matrix to age and sex population counts. Second, we use demographic theory to create constraint sets that make the algorithm useable for human populations. Finally, we use the method to forecast 3,120 US counties and show that it holds promise for automating cohort-component forecasts. This paper describes the first published successful application of Wood's method to human populations; it also points to more general promise of constrained optimization techniques in demographic modeling.

Sentinel lymph node biopsy (SNLB) is the standard of care in staging of melanoma and other skin cancers. Early studies used lymphazurin (LZ) for SLNB. A national shortage of LZ promoted methylene blue (MB) as an alternate stain.This study compares complication rates between LZ and MB in SLNB patients, and the reliability dyes in locating sentinel lymph nodes.Charts were reviewed for patients who underwent SLNB for skin cancers between September 2006 and November 2008 at Penn State Hershey Medical Center. The type and quantity of dye, the presence of blue stained sentinel nodes, and any complications were recorded.Ninety-three patients underwent SLNB (46 LZ, 47 MB). The amount of dye used was similar (avg. 0.93 ml LZ, 1.24 ml MB). The complication rate of LZ was 8.7%, and MB was 25.5%. There was significantly more (P = 0.003) skin graft complications in the MB patients (6/12) versus LZ (0/15).There is a higher rate of complications with MB, especially with skin grafting. The reported risk of anaphylaxis with LZ has not been reported in volumes2 ml. The sentinel lymph node identification rate is historically similar between dyes, and in this study was noted to be higher with LZ.

Incisional wounds in rats treated locally with thymosin beta4 (Tbeta4) healed with minimal scaring and without loss in wound breaking strength. Treated wounds were significantly narrower in width. Polarized light microscopy treated wounds had superior organized collagen fibers, displaying a red birefringence, which is consistent with mature connective tissue. Control incisions had randomly organized collagen fibers, displaying green birefringence that is consistent with immature connective tissue. Immunohistology treated wounds had few myofibroblasts and fibroblasts with alpha smooth muscle actin (SMA) stained stress fibers. Polyvinyl alcohol sponge implants placed in subcutaneous pockets received either carrier or 100 microg of Tbeta4 on days 2, 3, and 4. On day 14, treated implants revealed longer, thicker collagen fiber bundles with intense yellow-red birefringence by polarized light microscopy. In controls, fine, thin collagen fiber bundles were arranged in random arrays with predominantly green birefringence. Controls contained mostly myofibroblasts, while few myofibroblasts appeared in Tbeta4 treated implants. Electron microscopy confirmed both cell types and the degree of collagen fiber bundle organization. Our results demonstrate that Tbeta4 treated wounds appear to mature earlier and heal with minimal scaring.

This study characterizes the Doppler signal from simulated microemboli of various sizes in blood mimicking fluid using spectral energy parameters. The goal of this research is to detect microemboli as a non-invasive diagnostic tool, or intra-operatively as a surgical aid. A dual beam diffraction-grating ultrasound probe operating at 10 MHz (Model Echoflow BVM-1, EchoCath, Inc., Princeton, NJ) was used with a flow phantom. Microemboli were polystyrene microspheres in 200 to 1000 micron diameters, in concentrations of 0.1, 0.5, and 1.0 per ml. Average flow velocities were 25, 50, 75, and 100 cm/sec. The distribution of peak values of the power spectrum at 2.5 msec windows was plotted over 15 seconds. The means of the distributions corresponding to the microspheres and background fluid were averaged for the four velocity conditions. Embolic peak spectral power ranged from approximately 12 to 25 dB relative to the background. A detection method based on these measurements is currently being developed.

The increasing emergence of legislation providing for minors' consent for health care furnishes a range of basic medical, legal, and social issues which require the thoughtful consideration of physicians caring for youth. The legislative provisions referred to account for a variety of consent situations ranging from the care of a specific illness or disorder to the dramatic lowering of the age for which consent for health care can be given. The ultimate conflict in the matter of minor's consent is between the basic rights and responsibilities of parents concerning their children and the emergence of the concept that youths have the right to make decisions relating to their bodies and their care. When the preservation of privacy and confidentiality affects the utilization of health care by youth, the conflict must be resolved. Not only have state legislatures provided varying opportunities to resolve some of these issues, but also two major health organizations concerned with the health of youth have provided model acts which would serve as a basis for enabling young people to consent for confidential, comprehensive health care. In recent years society has demonstrated a tendency to permit young people to determine a variety of aspects of their own affairs well before the traditional age of majority. In regard to health decisions, a number of situations have emerged in which the rights of youths deserve consideration. These include circumstances in which the person might avoid health care if the parents have to be informed, when a communication breakdown between the young person and the parents has taken place, if a need for emergency care occurs when parents cannot be reached, or when young people are living away from home in an adult life style. Legislative responses to the sociohealth concerns affecting youth do not take a moral or judgmental position, nor do they infer a lessening of the importance of family integrity. They do respond to a number of reality health matters with high incidence which have emerged, particularly in the past decade. These laws do not require physicians to treat young people on their own consent, nor do they forbid physicians from informing parents if this is considered in the best interest of the patient. Furthermore, it is important for the physician to persuade youths to involve their parents and gain their support and understanding. Minors' consent can serve to restore interrupted communication between young people and their families. The appearance and evolution of the "emancipated minor" and the "mature minor" concepts is recognition of the capacity of the adolescent to determine his own affairs and give an informed consent. The age at which human beings reach maturity is variable, and competent decision making is not assured by arrival at a certain chronological age.

As a result of the sharp rise in venereal disease during the past decade, which seriously threatens the health of our young people, pediatricians must become actively involved: 1. in the prompt identification, treatment, and epidemiologic control of venereal disease in young people and newborn infants; 2. in developing and promoting social legislation related to the treatment of minors; 3. in encouraging and participating in effective educational programs for youth on venereal disease. A heightened alertness to the possibility of venereal disease is required by every physician.

Young people who find themselves in juvenile court facilities constitute a group who traditionally have displayed a high incidence of health problems. Many have had inadequate care in the past, and enter with preexisting medical and dental conditions. Whether or not they are in good physical health, they often are handicapped in the area of mental health. The conditions which necessitate removing them from their homes and placing them in institutions may aggravate, or even cause, physical and mental health problems. When society undertakes to remove children and youth from their homes and place them in institutions away from the care of their parents, it assumes certain obligations. Among these obligations is care of their physical and mental health. Health programs in juvenile court facilities must be broad and comprehensive and must go beyond the mere provision of medical care. The extent of the health care which should be offered to an individual will depend on the length of time he is in the institution. But, every institution which confines juveniles should have a health program designed to protect and promote the physical and mental well-being of residents, to discover those in need of short-term or long-term medical and dental treatment, and to contribute to their rehabilitation by appropriate diagnosis and treatment and provision of continuity of care following release. The standards given here are designed to attain these goals. ADMINISTRATIVE STRUCTURE OF THE HEALTH PROGRAM Health Council 1. Each institution should have a multidisciplinary health council to set the policies of the health program. 2. The council may be organized within the institution or by the authority which operates the institution.

Whereas, certain minors are not obtaining adequate medical, dental, or other health care due to current legal and medical obstacles, Whereas, providers of medical, dental, and other health care are now vulnerable to legal action for giving care to minors, Whereas, there is a need for coordination, stimulation, and support of access to medical, dental, and other health care for certain minors in need of such care without violating the rights of parents to protect and promote their minors' health, Be It Enacted by the Legislature of the State of-----,as follows: Section 1. For the purposes of this act: (1) "Minor" means any person under the age of majority as defined by the State statute or under 18 years of age, whichever is lower; (2) "Health Professional" means state licensed physician, psychologist, dentist, osteopathic physician, nurse, and other licensed health practitioner; (3) "Health Services" means health services specified by the state, appropriately delivered by different health professionals including examination, preventive and curative treatment, operation, hospilization (admission or discharge), giving or receiving blood and blood derivatives, receiving organ transplantation, pledging donation of organs after death, the use of anesthetics, and receiving contraceptive advice and devices; (4) The masculine shall include the feminine. Section 2. Any person who reaches the age of majority or 18 years of age or is on active duty with or has served in any branch of the Armed Forces of the United States shall be considered an adult in so far as the consent for health services is concerned.

The pediatrician can be useful to the young person with a drug problem if he: (1) is aware of the different motivations for drug abuse by adolescents and how to approach them, (2) recognizes the need for confidentiality, (3) provides factual information in a non-authoritarian manner and listens and counsels as indicated, and (4) manipulates the environment-to relieve school and family pressures and to help youngsters find better challenges. Drug abuse in children and adolescents is a major source of concern to parents, educators, law enforcement agencies, and physicians. For the pediatrician as well as the others, a challenge exists to find more appropriate ways of help for young people who turn to drug abuse for the answer that is not there.

The American Academy of Pediatrics is deeply concerned with the increasing social health problems in today's society, particularly those that relate to the function of the family as a unit and to the behavior of its children and youth. Some of the signs of the serious social, moral, and ethical crisis facing us are: increasing illegitimacy, early marriage, dangerous drug use, rising incidence of venereal disease, family fragmentation manifested in divorce, and lack of restraint within the mass media in presenting sexually stimulating material to young and immature persons. It is the Academy's conviction that all segments of the society of responsible adults, lay and professional, must mobilize now in support of personal and collective action to help children and adolescents grow to a healthy maturity as intellectually, socially, and sexually secure individuals. We join with other national organizations, such as the National Congress of Parents and Teachers, the American Medical Association, the National Education Association, and support the interfaith statement of the nation's major religions in officially supporting health education, including family life and sex education. We urge programs that will create a vigorous and healthy social climate in which family life can flourish and which foster mature sexual behavior in each individual. With this larger goal in mind, we propose and endorse the following general programs and actions. 1. Every concerned adult, lay or professional, must be encouraged to examine his own values and behaviors in order to develop an openness which permits a meaningful rapport with children and youth.

Phenotypic, karyotypic, and developmental homology between affected children of carriers of an inverted insertion (9) (q22.1q34.3q34.1) led to recognition of a new chromosome syndrome: dup 9q34. Individuals with dup 9q34 have slight psychomotor retardation, understand simple directions, and acquire a limited vocabulary. In childhood, many are hyperactive. Clinical features include low birth weight, normal birth length, and initial poor feeding and thriving. Musculo-skeletal systems are affected: there are joint contractures, long thin limbs, and striking arachnodactyly. There is abnormal implantation of the thumb, increased space between the first and second fingers, and excess digital creases. Marfan syndrome was a provisional diagnosis for several cases prior to cytogenetic analysis. Cardiovascular and ocular systems are minimally affected, erythema and heart murmurs occur, and ptosis and strabismus are frequent, but lens dislocation is not observed. Features at birth include: dolichocephaly, facial asymmetry, narrow horizontal palpebral fissures, microphthalmia, prominent nasal bridge, small mouth, thin upper lip with down-turned corners, and slight retrognathia. In older children, retrognathia is diminished and the nose becomes long and narrow. The new culture and chromosome banding techniques enable sorting of cases with the distal dup 9q phenotype into two groups. The cases with a longer dup 9q are more likely to develop with life-threatening congenital anomalies. The cases with the shorter dup 9q34 have a less severe long-term prognosis and will benefit, together with their parents, from special education. Female carriers of the inv ins(9) (q22.1q34.3q34.1) have about a 31% risk in each pregnancy to conceive a fetus affected by the dup 9q34 syndrome. A comparable figure is not yet available for male carriers.

Blood leukocytes from a patient with T-cell immunodeficiency failed to respond to stimulation with phytohemagglutinin (PHA) in vitro although ample lymphocytes were present. Leukocytes from this patient were mixed in various proportions with normal leukocytes, and the mixtures were stimulated with PHA and cultured for three days. There was no restoration of PHA responsiveness of the patient's cells in the presence of normal cells. This would indicate that the defect in the patient's cell population was not due to the absence of any facilitating factor or cooperative function that could be provided by normal T cells or other blood leukocytes. Since in thymic aplasia the patient's own cells are rapidly restored to normal PHA responsiveness by an unknown facilitating factor after thymic transplantation, we suggest that this mixed-cell culture method might differentiate between patients who need a bone marrow transplant and those who will respond to a thymus transplant.

This communication greatly exceeds the limit of 300 words we try to impose on correspondents. In view of the interest of the subject, and to encourage discussion in these columns by members of the A.A.P. Committee on Youth and others, that restriction has been lifted. For the Committee on Youth, Dr. Hazard comments as follows: One of the goals in developing "A Model Act Providing for Consent of Minors for Health Services" was to stimulate the health and legal communities into action regarding the unique and often very difficult situation in which the young person finds him or herself when they have a health problem.

In a previous statement approved by the Executive Board of the American Academy of Pediatrics, and subsequently by the House of Delegates of the American Medical Association, the American College of Obstetricians and Gynecologists emphasized the magnitude of the problem of teenage pregnancy and the responsibilities of professionals involved in the care of these young people. Rapid changes in contemporary attitudes and in legislation have caused many physicians and their patients to consider abortion as an acceptable solution to an unwanted pregnancy in adolescent girls. These changes place a heavy responsibility on pediatricians and other physicians caring for adolescents, particularly in regard to their special need for compassionate and considerate understanding. Although the American Academy of Pediatrics prefers neither to sanction nor to forbid the use of abortion to terminate an unwanted pregnancy in the teen-age girl, it does have the responsibility to insist that physicians considering this recourse provide for appropriate counseling and support for these adolescent girls and other involved persons, including the young fathers. In circumstances where the pediatrician is unable to provide adequate counseling support, he should act as the pivotal person in arranging for a social worker, pastor, or other experienced counselor to conduct this essential of care, both before and after the procedure. Consistent with his accredited role in preventive medicine, the pediatrician must make certain that adequate information and sex counseling are available to his teenage patients. Contraceptive advice and prescription for the sexually active teenage girl should be accompanied by investigation and alteration of contributing issues wherever possible.

In October 1970, the Academy identified itself with those who favored Separating marijuana from the group of drugs subject to stringent narcotic laws. It recommended that individuals who were found to be in possession of the drug for personal use, or were present where the drug was being used, should be charged with a misdemeanor rather than a felony.1 Subsequently, the Committee on Drugs in a statement on drug abuse legislation noted its concern with marijuana.2 This position is based on the fact that marijuana is clearly not a narcotic and does not appear to have a potential for physical dependence. It should not be construed, however, as favoring the legalization of marijuana. A decision in this regard must await the development of further research on the properties of the drug. The potency of marijuana has not been standardized and may vary widely. Furthermore, anecdotal accounts exist of the adulteration of marijuana with other chemical agents to produce a more profound effect. It has therefore been difficult to determine with precision the effects of marijuana as it is commonly used. The limited research findings that are currently available would not appear to indicate any significant harmful physical effects from the smoking by humans of moderate amounts of plain marijuana. The recent report from the Department of Health, Education and Welfare3 states that "although the state of intoxication is frequently vivid as described by the (marijuana) user, an observer may see little change from a normal state. Mild states of intoxication often go completely undetected. Physiological changes are notably minimal."

The plan of the Committee, as a follow-up to its statement on Venereal Disease and the Pediatrician, is to distribute to each member of the Academy the most recent recommendations of the Venereal Disease Branch of the Center for Disease Control. This will include the treatment of gonorrhea and syphilis, both congenital and acquired.

Problems relating to human reproduction are among the critical issues of our time, and it is appropriate that pediatricians contribute to the solution of these problems. The changing dimensions of comprehensive pediatric care, more specifically the significant numbers of pregnancies being reported in young persons, support this position. For example, national statistics show that 44% of all pregnancies occur in persons under 20, and one out of four mothers on Aid to Families with Dependent Children in New York is pregnant before 16. At least four roles can be identified for the pediatrician: 1. Genetic counseling: the pediatrician has already become proficient in giving knowledge to parents of the incidence of inborn errors of metabolism, chromosomal abnormalities, and other problems associated with genetic inheritance patterns. 2. Sex education: he often provides sex education to individual patients, families, and parents, in addition to teaching groups in his own practice and in schools, churches, or youth organizations. 3. Family planning and pregnancy counseling: he may provide assistance in these areas in behalf of the parents or adolescents. This assistance may involve a wide range of clinical advice and treatment, including the concept of spacing (rhythm method), contraceptive devices, or oral medication, whatever is considered most suitable for the individual. All alternatives for dealing with an unwanted pregnancy should be seriously discussed with the teenage girl and the other persons involved, including the parents if feasible. The pediatrician is in a unique position by the nature of his close association and relationship with the adolescent patient to provide this important personal service.

In 1938 the American Academy of Pediatrics took formal action and defined the age limits of pediatric practice as follows (Journal of Pediatrics, 13:127 and 13:266, 1938): The practice of pediatrics begins at birth and extends well into adolescence and in most cases it will terminate between the sixteenth and eighteenth year of life. In 1969, the Council on Pediatric Practice asked the Executive Board to up date this statement, and the Executive Board referred it to the Council on Child Health. After extensive review of several statements proposed by the Committee on Youth, the Council on Child Health recommended the following statement, which has been approved by the Executive Committee of the Academy for publication as official policy of the American Academy of Pediatrics. PEDIATRICS The purview of pediatrics includes the growth, development, and health of the child and therefore begins in the period prior to birth when conception is apparent. It continues through childhood and adolescence when the growth and developmental processes are generally completed. The responsibility of pediatrics may therefore begin during pregnancy and usually terminates by 21 years of age.