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Unidentified Mycobacterium species are sometimes detected in respiratory specimens. We identified a novel Tsukamurella species (Tsukamurella sp. TY48, RIMD 2001001, CIP 111916T), Tsukamurella toyonakaense, from a patient given a misdiagnosis of nontuberculous mycobacterial pulmonary disease caused by unidentified mycobacteria. Genomic identification of this Tsukamurella species helped clarify its clinical characteristics and epidemiology.

Abstract Background Transforming growth factor (TGF)-β is a multifunctional cytokine involved in cell differentiation, cell proliferation, and tissue homeostasis. Although TGF-β signaling is essential for maintaining blood vessel functions, little is known about the role of TGF-β in lymphatic homeostasis. Methods To delineate the role of TGF-β signaling in lymphatic vessels, TβRIIfl/fl mice were crossed with Prox1-CreERT2 mice to generate TβRIIfl/fl; Prox1-CreERT2 mice. The TβRII gene in the lymphatic endothelial cells (LECs) of the conditional knockout TβRIIiΔLEC mice was selectively deleted using tamoxifen. The effects of TβRII gene deletion on embryonic lymphangiogenesis, postnatal lymphatic structure and drainage function, tumor lymphangiogenesis, and lymphatic tumor metastasis were investigated. Results Deficiency of LEC-specific TGF-β signaling in embryos, where lymphangiogenesis is active, caused dorsal edema with dilated lymphatic vessels at E13.5. Postnatal mice in which lymphatic vessels had already been formed displayed dilation and increased bifurcator of lymphatic vessels after tamoxifen administration. Similar dilation was also observed in tumor lymphatic vessels. The drainage of FITC-dextran, which was subcutaneously injected into the soles of the feet of the mice, was reduced in TβRIIiΔLEC mice. Furthermore, Lewis lung carcinoma cells constitutively expressing GFP (LLC-GFP) transplanted into the footpads of the mice showed reduced patellar lymph node metastasis. Conclusion These data suggest that TGF-β signaling in LECs maintains the structure of lymphatic vessels and lymphatic homeostasis, in addition to promoting tumor lymphatic metastasis. Therefore, suppression of TGF-β signaling in LECs might be effective in inhibiting cancer metastasis.

Abstract The identification of cancer subtypes is important for the understanding of tumor heterogeneity. In recent years, numerous computational methods have been proposed for this problem based on the multi-omics data of patients. It is widely accepted that different cancer subtypes are induced by different molecular regulatory networks. However, only a few incorporate the differences between their molecular systems into the identification processes. In this study, we present a novel method to identify cancer subtypes based on patient-specific molecular systems. Our method realizes this by quantifying patient-specific gene networks, which are estimated from their transcriptome data, and by clustering their quantified networks. Comprehensive analyses of The Cancer Genome Atlas (TCGA) datasets applied to our method confirmed that they were able to identify more clinically meaningful cancer subtypes than the existing subtypes and found that the identified subtypes comprised different molecular features. Our findings also show that the proposed method can identify the novel cancer subtypes even with single omics data, which cannot otherwise be captured by existing methods using multi-omics data.

Abstract The current pandemic of SARS-CoV-2 has caused extensive damage to society. The characterization of SARS-CoV-2 profiles has been addressed by researchers globally with the aim of resolving this disruptive crisis. This investigation process is indispensable to understand how SARS-CoV-2 behaves in human host cells. However, little is known about the systematic molecular mechanisms involved in the effects of SARS-CoV-2 infection on human host cells. Here, we present gene-to-gene regulatory networks in response to SARS-CoV-2 using a Bayesian network. We examined the dynamic changes in the SARS-CoV-2-purturbated networks established by our proposed framework for gene network analysis, thus revealing that interferon signaling gradually switched to the subsequent inflammatory cytokine signaling cascades. Furthermore, we succeeded in capturing a COVID-19 patient-specific network in which transduction of these signals was concurrently induced. This enabled us to explore the local regulatory systems influenced by SARS-CoV-2 in host cells more precisely at an individual level. Our panel of network analyses has provided new insights into SARS-CoV-2 research from the perspective of cellular systems.

ABSTRACT Although serum anti-glycopeptidolipid (GPL)-core IgA antibody is a highly specific test for infection with Mycobacterium avium complex (MAC), Mycobacterium abscessus, and its subspecies abscessus, subsp. massiliense, and subsp. bolletii (MAB), its use for the definitive diagnosis of MAC pulmonary disease (PD) and MAB-PD are unknown. To clarify the diagnostic accuracy of the anti-GPL-core IgA antibody test among patients with radiologically suspected MAC-PD or MAB-PD who already have a single positive sputum culture test. The first isolations of MAC and MAB from patients with radiologically suspected MAC-PD or MAB-PD at the Osaka Toneyama Medical Center between January 2006 and December 2020 were collected. Patients were enrolled when their serum anti-GPL-core IgA antibody was measured during the 3 months before and after the first isolation. We retrospectively compared the results of anti-GPL-core IgA antibody testing with the final diagnoses based on the current guidelines. We included 976 patients for analysis. The serum anti-GPL-core IgA antibody was positive in 699 patients (71.6%). The positive predictive value of anti-GPL-core IgA antibody for the diagnosis of MAC-PD or MAB-PD was 97.4%. The median time required for the second positive culture after the first isolation was 51 days (interquartile range 12 to 196 days). The positive serum anti-GPL-core IgA antibody test allowed an early and definitive diagnosis of MAC-PD or MAB-PD in those who already had a single positive sputum culture test. IMPORTANCE To satisfy the microbiologic criteria of the current diagnostic guideline for nontuberculous mycobacterial pulmonary disease (PD), at least two positive sputum cultures of the same species of mycobacteria from sputum are required to avoid the casual isolation of mycobacteria. This study showed that the positivity of a serum anti-glycopeptidolipid (GPL)-core IgA antibody test has an excellent diagnostic ability among patients with radiologically suspected Mycobacterium avium complex (MAC)-PD or Mycobacterium abscessus (MAB)-PD who already had a single positive sputum culture test. The usage of single culture isolation plus anti-GPL-core IgA antibody as another diagnostic criterion has a time, cost, and effort-saving effect. Furthermore, it will facilitate the diagnosis of MAC-PD or MAB-PD in the early stage of disease because serum anti-GPL-core IgA antibody becomes high in these patients. Therefore, we proposed adding single culture isolation plus anti-GPL-core IgA antibody as “combined microbiological and serological criteria” to the diagnostic guidelines for MAC-PD and MAB-PD.

Mycolicibacterium mageritense (M. mageritense) is a rare species among rapidly growing mycobacteria, and M. mageritense pleurisy is very rare. Here, we report for the first time, an immunocompetent patient with pleurisy caused by M. mageritense. The patient had no history of immunodeficiency and no recurrence of lung cancer after surgery. However, 8 months after surgery, he developed a new lung shadow and pleurisy. Although whole-genome analysis of the colony cultured from the patient's pleural fluid revealed M. mageritense, we could not identify it in time, resulting in a poor outcome. M. mageritense pleurisy in this case might have occurred via a bulla rupture of the lung lesion because computed tomography of the patient's chest showed pneumothorax and a lung lesion in contact with thoracic cavity. This case emphasized that nontuberculous mycobacterial pleurisy should be considered in the differential diagnoses of pleural effusion even in immunocompetent patients. Advancement of comprehensive and rapid analyses of genomic data from clinical specimens will lead to better treatment strategies.

Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented. [ABSTRACT FROM AUTHOR]

Remdesivir is an antiviral drug for the treatment of coronavirus disease 2019 (COVID-19), and the sustained antiviral activity against Omicron variants of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been reported. In this single-center retrospective study, we first compared the clinical effectiveness of remdesivir-based therapy between Omicron and other variant phases of moderate COVID-19 in a real-world setting. Between Dec 2020 and July 2022, a total of 406 patients with COVID-19 pneumonia were treated with remdesivir-based therapy on admission. The oxygen deterioration rate after initiation of treatment significantly decreased in the Omicron variant phase compared to the alpha and delta variant phases. In an adjusted multivariate Cox proportional hazards model, Omicron variant phase was significantly associated with delayed oxygen deterioration and early recovery from hypoxia. These favorable outcomes during the Omicron variant phase, compared to previous variant phases, might be due to the attenuation and the popularization of vaccination.

Objective: To identify progress and challenges in the national response to tuberculosis (TB) in Solomon Islands through an epidemiological overview of TB in the country., Methods: A descriptive analysis was conducted using the national TB surveillance data for 2016-2022. Case notifications, testing data, treatment outcomes and screening activities were analysed., Results: The number of case notifications was 343 in 2022, with an average annual reduction of the case notification rate between 2016 and 2022 of 4.7%. The highest case notification rate was reported by Honiara City Council (126/100 000 population) in 2022. The number of people with presumptive TB tested by Xpert ® rapidly increased from zero in 2016 to 870 in 2022. Treatment success rate remained consistently high between 2016 and 2022, ranging from 92% to 96%. Screening for HIV and diabetes mellitus (DM) among TB patients in 2022 was 14% and 38%, respectively. Most patients (97%) were hospitalized during the intensive phase of treatment in 2022; in contrast, during the continuation phase, the proportion of patients treated at the community level increased from 1% in 2016 to 63% in 2022. Despite an increase in household contact investigations, from 381 in 2016 to 707 in 2021, the uptake of TB preventive treatment (TPT) was minimal (7% among eligible child contacts)., Discussion: This epidemiological analysis in Solomon Islands reveals both notable achievements and challenges in the country's TB programme. One major achievement is a potential actual reduction in TB incidence. Challenges identified were potential underdetection of cases in rural areas, suboptimal community-based care, and insufficient contact tracing and uptake of TPT. It is crucial to address these challenges (e.g. by optimizing resources) to advance the national TB response., Competing Interests: The authors have no conflicts of interest to declare., ((c) 2024 The authors; licensee World Health Organization.)

Introduction: Life-threatening hypoxemia during tracheal intubation is more likely to occur in children than adults due to its unique physiological and anatomical nature. Fiberoptic intubation is widely performed in children with difficult airways. However, mastery of fiberoptic intubation requires substantial training, and novice trainees need to attempt fiberoptic intubation in children at high risk of respiratory-related adverse events. Therefore, a safer method than traditional fiberoptic intubation for children with difficult airways is desirable for novice anesthesia trainees. This study aimed to compare the efficacy of video-assisted fiberoptic intubation (VAFI) with that of traditional fiberoptic intubation (FOI) in a high-fidelity pediatric simulator by medical professionals with no experience in tracheal intubation., Method: This randomized, controlled, simulation-based study was conducted in a tertiary-care pediatric hospital. Registered nurses working in the operating room were enrolled in this study and randomly assigned to either the FOI or VAFI groups. Participants in the FOI group performed fiberoptic intubation without the aid of any device, whereas those in the VAFI group used a video laryngoscope to obtain a better glottic view. The primary outcome was the time from the moment the tip of the flexible bronchoscope passed between the upper and lower incisors until the completion of tracheal intubation., Results: A total of 28 participants were enrolled in this study. There was no significant difference in the time until the completion of tracheal intubation between FOI and VAFI, with a median time of 55.0 seconds for FOI and 42.5 seconds for VAFI (P = 0.22). Secondary outcomes, including time until passing the vocal cord, the number of intubation attempts, and the first success rate, did not also illustrate the significant difference between the groups., Conclusion: This study did not demonstrate the superiority of VAFI over conventional FOI in a high-fidelity pediatric simulator by medical providers with no experience in tracheal intubation., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Isogai et al.)

Objective: The prevalence of obstructive sleep apnea (OSA) in Japan is 9% among males and 3% among females. Up to 2.5 million patients are estimated to suffer from the disease, but limited number of facilities are capable of carrying out polysomnography (PSG), leaving more than 80% of these individuals are undiagnosed. In recent years, the development of new portable sleep monitoring (PMs) devices has been remarkable. We evaluate the correlation between the results of the LS-140 PMs device (Fukuda Denshi Tech Co. Ltd.), released in 2017, and those of PSG., Methods: We obtained contemporaneous data from the same patients by equipping 58 patients with PMs (LS-140) devices while they underwent PSG. Our primary outcome was Case 2 of the intraclass correlation coefficient (ICC), i.e., the ICC (2.1). And we used a Bland-Altman analysis to compare the apnea-hypopnea index (AHI) given by PSG and the respiratory event index (REI) given by LS-140 and examined the sensitivity and specificity of the REI relative to the AHI in the diagnosis of OSA. We also carried out the same comparison but in terms of the presence or absence of periodic limb movements (PLMs)., Results: The ICC (2.1) between The REI and the AHI was 0.944, a rather high value (p<0.0001). The mean difference between AHI and REI values was -3.6 (p<0.0001), indicating a negative fixed bias. Sensitivity may decrease in groups with PLMs., Conclusion: The REI and the AHI are highly correlated, giving LS-140 sufficient diagnostic sensitivity and specificity to screen for OSA., Competing Interests: We received LS-140 devices from Fukuda Denshi Co., Ltd. for use in this study.

Little is known about the factors related to return to work (RTW) in patients with peri-operative lung cancer (LC). This study aimed to investigate whether pre-operative physical performance is associated with early RTW in patients with peri-operative LC. A total of 59 patients who wished to resume work after lung resection surgery were included and were divided into three groups: early RTW (within 14 days after discharge), delayed RTW (within 15-90 days), and non-RTW (failure of RTW within 90 days). The early RTW group had significantly lower scores on the modified Medical Research Council dyspnea scale (mMRC) and significantly higher scores on the Euro Quality of Life 5-Dimension 3-Level (EQ-5D-3L) than the non-RTW group. Multivariate logistic regression analysis showed that EQ-5D-3L scores were significantly associated with early RTW, and mMRC scores and knee extensor strength tended to be associated with early RTW. Better pre-operative quality of life, mild dyspnea, and greater lower limb muscle strength tended to be associated with early RTW in patients with peri-operative LC.

Propolis is a resinous mixture of substances collected and processed from various botanical sources by honeybees (Apis mellifera). We previously found that propolis collected on Jeju Island, located off the southern coast of Korea, originates from a single plant, Angelica keiskei KOIDZUMI (Ashitaba). A. keiskei has been well-studied as a health food and has been reported to promote nerve growth factor (NGF) production. Propolis formed from the resin of A. keiskei is expected to have a similar promotional effect on NGF production. NGF is a potential pharmacological agent for Alzheimer's disease. In this study, the effects of an ethanolic extract of propolis from Jeju Island (EEPJ) on NGF secretion and cell viability in T98G human glioblastoma cells were evaluated. Ethanolic extracts of propolis from Brazil (Baccharis type) and from Uruguay (Populus type) were also studied for comparison. We found that EEPJ significantly increased NGF secretion in the cells in a concentration-dependent manner. Furthermore, the effects of 27 compounds previously isolated from EEPJ were also evaluated. Several compounds were found to have a promotion effect on NGF secretion, and the structure-activity relationships of the compounds were considered relative to their promotional effect on NGF biosynthesis. The promotional effect of EEPJ is a characteristic biological activity that is not present with other propolis types, so the propolis from Jeju Island may have potential applications as a therapeutic candidate for Alzheimer's disease., (© 2021. The Japanese Society of Pharmacognosy.)

Background: Pneumothorax is one complication of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS-TBB). We sought to clarify the risk factors for pneumothorax after EBUS-GS-TBB under fluoroscopic guidance., Methods: We retrospectively reviewed data from 916 patients who underwent EBUS-GS-TBB at Fujita Health University Hospital. We evaluated the following risk factors for pneumothorax after EBUS-GS-TBB: patient characteristics (sex, age, and pulmonary comorbidities); lesion data (location, size, existence of ground-glass opacities [GGOs], pleural involvement, computed tomography [CT] bronchus sign, visibility on fluoroscopy, and EBUS findings); final diagnosis; years of bronchoscopist experience; and guide sheath size. Univariate and multivariate logistic regression analyses were performed., Results: Among the 916 patients, 30 (3.28%) presented with pneumothorax. With a univariate analysis, factors that independently predisposed to pneumothorax included lesions containing GGOs, lesions in sagittal lung segments on fluoroscopy, lesions that were not visible on fluoroscopy, and infectious lesions. A univariate analysis also showed that lesions in the right upper lobe or left upper division, as well as malignant lesions, were less likely to lead to pneumothorax. Age, underlying pulmonary disease, CT bronchus sign, EBUS findings, bronchoscopist experience, and guide sheath size did not influence the incidence of pneumothorax. A multivariate analysis revealed that only lesions containing GGOs (odds ratio [OR] 6.47; 95% confidence interval [CI] 2.13-19.6, P = 0.001) and lesions in lung segments with a sagittal orientation on fluoroscopy (OR 2.47; 95% CI 1.09-5.58, P = 0.029) were significant risk factors for EBUS-GS-TBB-related pneumothorax., Conclusions: EBUS-GS-TBB of lesions containing GGOs or lesions located in sagittal lung segments on fluoroscopy correlate with a higher pneumothorax risk.

Background: Delayed identification of infiltration and dysfunction of peripheral intravenous (PIV) access can lead to serious consequences during general anesthesia in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound during general anesthesia in children to detect and confirm the correct PIV access and to evaluate the accuracy of this method., Methods: This was a single-center, preliminary study that was conducted in children (<18 years) who were scheduled for elective surgeries between October 2019 and March 2020. Rater anesthesiologists judged the change in precordial Doppler sound (S test) before and after injection of 0.5 mL/kg of normal saline (NS) via PIV. Blood flow velocity before and after NS injection was recorded, and multiple cutoff points were set to analyze the accuracy of detecting the infiltration and dysfunction of PIV catheter (V test)., Results: The total incidence of peripheral infiltration and dysfunction of PIV catheter was 7/512 (1.4%). In the S test, the sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver-operating characteristic curves (AUCs) were 5/7 (71.4%; 95% confidence interval [CI], 29.0%-96.3%), 490/505 (97.0%; 95% CI, 95.1%-98.3%), 24.0, 0.29, and 0.84, respectively. The V test showed that the reasonable threshold of blood flow velocity change was 1.0 m/s, with sensitivity, specificity, positive and negative likelihood ratios, and AUC of 4/7 (57.1%; 95% CI, 18.4%-90.1%), 489/505 (96.8%; 95% CI, 94.9%-98.2%), 18.0 and 0.44, and 0.84, respectively., Conclusions: This preliminary study demonstrated that precordial Doppler ultrasound is a feasible, easy-to-use, and noninvasive technique with good accuracy to confirm the correct PIV access during general anesthesia in children. However, its accuracy requires further evaluation., Competing Interests: The authors have declared that no competing interests exist.

Background: Rocuronium-induced injection pain causes withdrawal movements. These movements may cause accidental disruption of indwelling needles. Generic rocuronium contains low-acid concentration buffer solution compared with original rocuronium. In animal experiments, it has been suggested that the difference of the buffer solution may alleviate injection pain. The purpose of this study was to identify the difference of injection pain between original and generic rocuronium in pediatric population., Material and Methods: Patients ranging in age from 1 to 15 years, American Society of Anesthesiologists physical status I or II, undergoing elective surgeries were randomly allocated to two groups; generic rocuronium group (Group R) and original rocuronium (Eslax®) group (Group E). Following anesthetic induction with oxygen, nitrous oxide, and sevoflurane, original or generic rocuronium (1 mg/kg) was administered via intravenous catheter. The difference of vital signs and withdrawal movement associated with rocuronium injection were evaluated., Results: A total of 64 patients were included in the study. Three patients were excluded. Twenty-nine patients were assigned to Group E and 32 patients to Group R. There was no significant difference in mean arterial pressure and heart rate. No withdrawal movements were observed in both groups., Conclusion: There was no significant difference in injection pain between original and generic rocuronium under inhalational induction., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Saudi Journal of Anesthesia.)

Background: Mass drug administration (MDA) of 20 mg/kg (maximum 1 g in adults) azithromycin for ocular Chlamydia trachomatis (CT) infection is a key component of the WHO trachoma elimination strategy. However, this dose may be suboptimal in Mycoplasma genitalium infection and may encourage emergence of antimicrobial resistance (AMR) to azithromycin., Objectives: To determine the effect of MDA for trachoma elimination on M. genitalium prevalence, strain type and azithromycin resistance., Methods: A secondary analysis of CT-negative vulvovaginal swabs from three outpatient antenatal clinics (Honiara, Solomon Islands) from patients recruited either pre-MDA, or 10 months post-MDA in two cross-sectional surveys was carried out. Swabs were tested for M. genitalium infection using Fast Track Diagnostics Urethritis Plus nucleic acid amplification assay. M. genitalium -positive samples were subsequently tested for azithromycin resistance by sequencing domain V of the 23S rRNA DNA region of M. genitalium and underwent phylogenetic analysis by dual locus sequence typing., Results: M. genitalium prevalence was 11.9% (28/236) in women pre-MDA and 10.9% (28/256) 10 months post-MDA (p=0.7467). Self-reported receipt of azithromycin as part of MDA was 49.2% in women recruited post-MDA and 17.9% (5/28) in those who tested M. genitalium positive. Of samples sequenced (21/28 pre-MDA, 22/28 post-MDA), all showed a macrolide susceptible genotype. Strain typing showed that sequence types diverged into two lineages, with a suggestion of strain replacement post-MDA., Conclusion: A single round of azithromycin MDA in an island population with high baseline M. genitalium prevalence did not appear to impact on either prevalence or azithromycin resistance, in contrast to reported decreased genital CT prevalence in the same population. This may be due to limitations such as sample size, including CT-negative samples only, and low MDA coverage. Further investigation of the impact of multiple rounds of MDA on M. genitalium azithromycin AMR in antibiotic experienced and naïve populations is warranted., Competing Interests: Competing interests: MAH, EMHE and STS disclose having received funding outside the submitted work from Atlas Genetics, Alere, Cepheid, SpeeDx, Mologic and Sekisui. MJP discloses having received funding outside the submitted work from Atlas Genetics, Alere, Cepheid and Sekisui. AVN discloses having received funding outside the submitted work from Alere, Cepheid, SpeeDx and Sekisui. EMHE discloses their membership of the Becton Dickinson 'Provision of Sexual Health in the UK' advisory board. All other authors have nothing to disclose., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The prevalence of pediatric obstructive sleep apnea (OSA) has increased concurrently with the increasing prevalence of obesity. We have previously validated a short questionnaire predicting the occurrence of OSA on polysomnography (PSG). This follow-up study assessed the utility of the questionnaire in predicting postoperative outcomes., Methods: Children undergoing surgery and completing a sleep study were prospectively screened for OSA using a short questionnaire. Procedures within 1 year of PSG were included in the analysis. Questionnaires were scored according to a cutoff previously deemed optimal for predicting OSA (apnea-hypopnea index ≥ 5) on the sleep study. Postoperative outcomes included prolonged (>60 min) length of stay (LOS) in the post-anesthesia care unit (PACU) and oxygen requirement in the PACU., Results: The study cohort included 185 patients (100/85 male/female) age 8 ± 4 years, undergoing adenotonsillectomy (n = 109), other ear, nose, and throat (ENT) procedures (n = 18), or non-ENT procedures (n = 58). There were 45 patients with OSA documented by PSG and 122 patients identified as likely to have OSA according to questionnaire responses (89% sensitivity, 41% specificity). PACU LOS was prolonged in 55/181 (30%) cases and supplemental oxygen was used in the PACU in 29/181 (16%) cases. In separate multivariable models, supplemental oxygen use in the PACU was more common if a patient scored ≥2/6 points on the short questionnaire scale (OR = 5.0; 95% CI: 1.3, 19.9; p = 0.023) or if the patient was diagnosed with OSA on PSG (OR = 4.6; 95% CI: 1.6, 13.5; p = 0.005). Neither OSA on PSG nor questionnaire score ≥2/6 were associated with prolonged PACU stay., Conclusion: Both OSA diagnosis based on the AHI and the questionnaire scale achieved comparable predictive value for the need for oxygen use in the PACU. The utility of the questionnaire in predicting rare adverse events (e.g., unplanned admission or rapid response team activation) remains to be determined. Our preliminary results support using a brief questionnaire scale for preoperative risk stratification among children with suspected OSA who have not had a formal sleep study., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Intraoperative abnormalities of coagulation function may occur for various reasons. In most scenarios, treatment is directed by laboratory parameters. Unfortunately, standard laboratory testing may take 1-2 h. The purpose of the current study was to evaluate a point-of-care testing device (CoaguChek ® XS System) in pediatric patients., Methods: Patients ranging in age from 2 to 18 years, undergoing posterior spinal fusion (PSF) or cardiac surgery using cardiopulmonary bypass (CPB) were eligible for inclusion. After CPB and/or the surgical procedure, 2.8 ml of blood was obtained and simultaneously tested on both the standard laboratory apparatus and the CoaguChek ® XS System., Results: The study cohort consisted of 100 patients (50 PSF and 50 cardiac cases) with 13 cases excluded, leaving 87 patients (49 PSF and 38 cardiac cases) for analysis. In PSF cases, reference laboratory international normalized ratio (INR) ranged from 0.98 to 1.77 while CoaguChek ® XS INR ranged from 1.0 to 1.3. The correlation coefficient was 0.69. The results of the Bland-Altman analysis showed a bias of 0.09, precision of 0.1, and 95% limits of agreement ranging from -0.11 to 0.28. In cardiac cases, reference INR ranged from 1.68 to 14.19, while CoaguChek ® XS INR ranged from 1.4 to 7.9. The correlation coefficient was 0.35. The results of the Bland-Altman analysis showed a bias of -1.8, precision of 2.1, and 95% limits of agreement ranging from -6.0 to 2.4., Conclusions: INR values obtained from CoaguChek ® XS showed a moderate correlation with reference laboratory values within the normal range. However, in the presence of coagulopathy, the discrepancy was significantly greater, thereby making the CoaguChek ® XS clinically unreliable.

Background: Adenotonsillectomy is one of the most commonly performed operative procedures in children. It is imperative to find the most efficient and cost-effective methods of practice to facilitate operating room management while maintaining patient safety. We investigated the efficiency of two different approaches of tracheal extubation in pediatric patients following adenotonsillectomy at two tertiary care pediatric hospitals with large surgical volumes. The primary aim of the study was to determine the difference in the operating room time according to the institutional practice of tracheal extubation in the postanesthesia care unit (PACU) as compared to the operating room., Methods: After obtaining IRB approval, a retrospective chart review was performed over a 12-month period at two large, tertiary care children's hospitals including the first hospital, where patients undergo tracheal extubation in the operating room after completion of the surgical procedure and a second hospital, where patients are brought directly to the PACU and undergo tracheal extubation in the PACU by nurses, with immediate availability of the pediatric anesthesiology faculty. Patients ≤12 years of age undergoing adenotonsillectomy were eligible for inclusion in the study. Patients with significant cardiopulmonary disease or scheduled for recovery in the critical care unit were excluded. Patient demographics, total time in the operating room, surgical time, total time in the PACU, and, when applicable, time until tracheal extubation, were noted., Results: The study cohort included 672 patients from the first hospital and 700 patients from the second hospital. Average operating room time was 17 min shorter at the first hospital than at the other, with most of the difference due to a reduction in the time between surgery end and transport from the operating room. PACU times were also 26 min shorter at the first hospital than at the second children's hospital., Conclusion: Tracheal extubation in the PACU is an efficient use of operating room time and resources., (© 2017 John Wiley & Sons Ltd.)

A lactic acid (LA)-producing strain of the hyper-lignin-degrading fungus Phanerochaete sordida YK-624 with the lactate dehydrogenase-encoding gene from Bifidobacterium longum (Blldh) was constructed. When the endogenous pyruvate decarboxylase gene-knocked down and Blldh-expressing transformant was cultured with beech wood meal, the transformant was able to successively delignify and ferment the substrate. Supplementation of calcium carbonate into the culture medium, significantly increased the level of LA accumulation. Direct LA production (at 0.29g/l) from wood was confirmed, and additional inclusion of exogenous cellulase in this fermentation yielded significant further improvement in LA accumulation (up to 1.44g/l). This study provides the first report of direct production of LA by fermentation from woody biomass by a single microorganism, and indicates that transgenic white-rot fungi have a potential use for development of simple/easy applications for wood biorefinery., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: The white-rot fungus Phlebia sp. MG-60 shows valuable properties such as high ethanol yield from several lignocellulosic materials, although white-rot fungi commonly degrade woody components to CO2 and H2O. In order to identify genes involved in ethanol production by Phlebia sp. MG-60, we compared genes differentially expressed by the ethanol producing fungus Phlebia sp. MG-60 and the model white-rot fungus Phanerochaete chrysosporium under ethanol fermenting and non-fermenting conditions using next-generation sequencing technologies., Results: mRNAs from mycelia of Phlebia sp. MG-60 and P. chrysosporium under fermenting and non-fermenting conditions were sequenced using the MiSeq system. To detect differentially expressed genes, expression levels were measured in fragments per kilobase of exon per million mapped reads (FPKM). Differentially expressed genes were annotated using BLAST searches, Gene Ontology classifications, and KEGG pathway analysis. Functional analyses of differentially expressed genes revealed that genes involved in glucose uptake, glycolysis, and ethanol synthesis were widely upregulated in Phlebia sp. MG-60 under fermenting conditions., Conclusions: In this study, we provided novel transcriptomic information on Phlebia sp. MG-60, and these RNA-seq data were useful in targeting genes involved in ethanol production for future genetic engineering.

Background: Recent years have seen an increase in the use of dexmedetomidine in pediatric patients presenting for surgical procedures. However, only a limited number of studies have evaluated its effects on the QT interval in this patient group. To address this lack of knowledge, we have evaluated the effects of dexmedetomidine on the QT interval in children receiving sevoflurane anesthesia., Methods: This study was a prospective case-control study in which pediatric patients presenting for anesthetic care were divided into two groups--the dexmedetomidine (D) and control (C) groups. Three electrocardiograms (ECGs) were obtained on each patient, including a baseline ECG (T1) prior to anesthetic induction and an ECG after the induction of anesthesia with sevoflurane (T2). In group D, the third ECG was obtained 2 min after the administration of dexmedetomidine, which in turn was started immediately after the T2 ECG reading (T3D); in group C, it was obtained 2 min after the T2 reading (T3C). Statistical analysis was performed using analysis of variance to compare the QT intervals at the three time points outlined above., Results: A total of 50 patients were recruited to the study, ranging in age from 1 to 16 [mean 7.9 ± 4.1 (SD) years]. There were 25 patients in group C and 25 in group D. There were no statistical differences in the demographics between the 2 groups. In group C, the QTc was noted to increase progressively with the administration of sevoflurane (T3C vs. T1; P = 0.006). In group D, following the administration of dexmedetomidine, there was a significant decrease in the QTc relative to the post-induction value [436 ± 25 (T2) vs. 418 ± 17 ms (T3D); P < 0.01]., Conclusion: A progressive lengthening of the QTc interval following the administration of sevoflurane was observed in the control group. In the dexmedetomidine group, there was a significant shortening of the QTc interval following the administration of dexmedetomidine compared to the length of the post-induction QTc interval and when compared to the control group.

Background: The clinical practice of pediatric anesthesiology has changed with a transition to the use of cuffed endotracheal tubes (ETTs) in infants and children. The monitoring of intracuff pressure has been suggested as one means to limit the potential for damage to the tracheal mucosa. The current study evaluates the accuracy of a novel, color-coded syringe device which provides three zones (green, clear, and red) to estimate the intracuff pressure., Method: The study was conducted in two phases. Phase 1 was an in vitro study where cuffed ETTs of sizes 4.0 mm, 5.0 mm and 6.0 mm ID were placed into polyvinylchloride tubing of appropriate sizes. A manometer and the syringe device were simultaneously attached to measure the intracuff pressure at the middle of the 3 different zones on the device (red, clear, and green). Phase 2 was an in vivo study where the syringe device and the manometer were simultaneously attached to the pilot balloon to measure the intracuff pressure and the corresponding zone on the color-coded syringe following endotracheal intubation. Statistical analysis included a descriptive reporting of the mean ± SD, median, range, and 95% confidence intervals (CI) of the actual intracuff pressure readings at the three zones of the syringe device during both its in vitro and in vivo use., Results: For phase 1 of the study, the 95% CI for the green, clear, and red zones were 21.5-21.8, 29.2-29.5, and 46.5-47.4 cmH2O respectively. This correlated well with the manufacturer reported values of 20-30, 30-40, and 40-60 cmH2O for the 3 zones (green, clear, and red respectively). Phase 2 of the study included 200 patients ranging in age from 0.1 to 21.8 years (6.7 ± 5.1 years) and in weight from 4.0 to 129.1 kilograms (29.4 ± 23.3 kgs). The size of the ETTs ranged from 3.0 to 7.0 mm ID. The intracuff pressure measured by the manometer ranged from 4 to 65 cmH2O (27.6 ± 9.7 cmH2O). The 95% CI for the green, clear, and red zones were 20.5-21.7, 27.7-29.1, and 41.2-46.5 cmH2O respectively. There was no significant differences noted when comparing different patient ages or sizes of ETT., Conclusion: The current study demonstrates a clinically acceptable correlation between the zones on this novel, color-coded syringe device and the actual measurement of the intracuff pressure obtained by a manometer for both in vitro and in vivo use. This device is a simple, reliable, portable and affordable method to monitor intracuff pressure.

Background: With the development of newer polyurethane cuffed endotracheal tubes (cETTs), there has been a shift in clinical practice among pediatric anesthesiologists. Despite improvements in design, excessive inflation of the cuff can still compromise tracheal mucosal perfusion. Several perioperative factors can affect the intracuff pressure (CP), and there is no consensus on safe CP in pediatric patients undergoing repair of congenital cardiac disease (CHD) utilizing cardiopulmonary bypass (CPB). In the current study, the CP was continuously monitored in pediatric patients undergoing surgery for CHD., Methods: After IRB approval, this observational study was conducted on pediatric patients who underwent repair of CHD using CPB with a cETT in place. After anesthetic induction and endotracheal intubation, the cuff was inflated using the air leak technique while maintaining a continuous positive airway pressure of 20 cmH2 O. After inflation, the CP was continuously monitored throughout the procedure. In addition, temperature and mean arterial pressure (MAP) were also recorded., Results: The study included 33 patients who ranged in age from 1 month to 15.3 years. Their weight ranged from 4.0 to 83.6 kg. Six patients were excluded from the analysis due to the need to add or remove air from the cuff, leaving 27 patients for data analysis for cuff pressure over time. The baseline CP at the time of inflation was 16.1 ± 7.6 cmH2 O. With the use of CPB and initiation of hypothermia, when compared to the baseline, the CP decreased by -0.7 ± 5.8 cmH2 O at 35-37°C, -9.1 ± 8.4 cmH2 O at 31-33°C, -7.8 ± 6.2 cmH2 O at 27-29°C, and -11.1 ± 6.0 cmH2 O at <27°C. With rewarming, the CP increased back to the baseline level (-3.5 ± 7.0 cmH2 O)., Conclusion: There was a significant decrease in the CP during CPB and associated hypothermia. This may offer some protection for mucosal perfusion during CPB which is usually associated with lower than normal MAP. However, the decrease in the CP may compromise the tracheal seal which may not offer the intended protection for the airway from aspiration., (© 2015 John Wiley & Sons Ltd.)

Background: First generation cephalosporins are commonly used as antibiotic prophylaxis prior to surgery. Patients labeled as penicillin-allergic are often precluded from receiving cephalosporins because of an allergic cross-reactivity. The aims of this study were to evaluate the clinical practice for surgical prophylaxis at Nationwide Children's Hospital and to determine the incidence of adverse effects and allergic reactions when using cephalosporins in patients labeled as penicillin-allergic., Methods: A retrospective chart review was performed to identify patients who were allergic to penicillin, penicillin antibiotic family, who required surgical treatment for an existing medical condition, and received an antibiotic to prevent surgical site infection., Results: Five hundred thirteen penicillin-allergic patients were identified, encompassing 624 surgical cases. Cephalosporins were administered in 153 cases (24.5%) with cefazolin used 83% of the time. Only one documented case of nonanaphylactic reaction was reported. Clindamycin was the most common cephalosporin substitute (n=387), and the reported adverse reaction rate was 1.5%. No cases of anaphylaxis were documented., Conclusions: Our data suggest that the administration of cephalosporins for surgical prophylaxis following induction of anesthesia in a patient with a known or reported penicillin-allergy appears appropriate and results in a lower adverse event rate that when clindamycin is administered., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: This study sought to determine the prevalence of common bacterial sexually transmitted infections, including Chlamydia trachomatis and Neisseria gonorrhoeae, in women attending clinics in the Solomon Islands., Methods: We conducted a sexual health survey among women attending three nurse-led community outpatient clinics in August 2014, to establish the prevalence of bacterial sexually transmitted infections in female clinic attenders in Honiara, Solomon Islands. Vaginal swab samples were tested for infection with C. trachomatis and N. gonorrhoeae using a commercial strand displacement amplification assay. Serum samples were tested for syphilis., Results: We enrolled 296 women, aged 16-49, attending three clinics. Knowledge of safe sexual practices was high but reported condom usage was low. The prevalence of infection with C. trachomatis was 20%. The prevalence of infection with N. gonorrhoeae and syphilis were 5.1% and 4.1%, respectively., Conclusions: Bacterial sexually transmitted infections are a major health problem in the Solomon Islands. Interventions are urgently needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: With the introduction of redesigned cuffed endotracheal tubes (ETTs), there has been an increasing trend toward their use in pediatric patients. Despite improvements in design, an unintended and prolonged hyperinflation of the cuff can compromise tracheal mucosal perfusion. The current study prospectively monitors changes in intracuff pressure continuously in pediatric patients undergoing prolonged surgical procedures., Methods: The study was conducted on pediatric patients who were scheduled to undergo prolonged surgical procedures (more than 4h) with a cuffed ETT. After placement of the cuffed ETT, the cuff was inflated using the air-leak test with a CPAP of 20cmH2O in the anesthesia circuit. After inflation, the inflating port of the pilot balloon was connected to the transducer of the invasive pressure monitoring device using our previously described technique to continuously measure the intracuff pressure. Measurements were recorded every 15min for the first 1h, and then every 30min throughout the surgical procedure., Results: The study cohort included 30 patients who ranged in age from 1.2 to 17.6 years and in weight from 9.4 to 113.4kg. There were 16 boys and 14 girls. The size of the cuffed ETT ranged from 3.5mm to 8.0mm ID. The baseline intracuff pressure at the time of inflation was 17.6±8.8cmH2O. The absolute change in the intraoperative intracuff pressure when compared to the baseline intracuff pressure ranged from -25.8 to +16.3cmH2O. In 9 patients (30%), the decrease of the intracuff pressure was ≥10cmH2O. In 6 patients (20%), the increase of the intracuff pressure was ≥10cmH2O. In 5 of 30 patients (17%), the absolute intracuff pressure was greater than 30cmH2O at least once intraoperatively. In no patient, did the intracuff pressure remain the same as the baseline throughout the procedure., Conclusion: We noted significant variations in the intracuff pressure during prolonged surgical procedures. These unintended changes, both increases and decreases, may impact the perioperative course of patients. Our study suggests the need for continuously monitoring intracuff pressure if a cuffed ETT is used in children for prolonged surgical procedures., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Controlled hypotension is one means to limit or avoid the need for allogeneic blood products. Clevidipine is a short-acting, intravenous calcium channel antagonist with a half-life of 1 to 3 minutes due to rapid metabolism by non-specific blood and tissue esterases. To date, there are no prospective evaluations with clevidipine in the pediatric population. We prospectively evaluated the dosing requirements, efficacy, and safety of clevidipine for ontrolled hypotension during spinal surgery for neuromuscular scoliosis in the pediatric population., Methods: Patients undergoing posterior spinal fusion for neuromuscular scoliosis were eligible for inclusion. The study was an open label, observational study. Maintenance anesthesia included desflurane titrated to maintain a bispectral index at 40 to 60 and a remifentanil infusion. Motor and somatosensory evoked potentials were monitored intraoperatively. When the mean arterial pressure (MAP) was ≥ 65 mmHg despite remifentanil at 0.3 mcg/kg/min, clevidipine was added to maintain the MAP at 55 to 65 mmHg. Clevidipine was initiated at 0.25 to 1 mcg/kg/min and titrated up in increments of 0.25 to 1 mcg/kg/min every 3 to 5 minutes to achieve the desired MAP., Results: The study cohort included 45 patients. Fifteen patients (33.3%) did not require a clevidipine infusion to maintain the desired MAP range, leaving 30 patients including 13 males and 17 females for analysis. These patients ranged in age from 7.9 to 17.4 years (mean ± SD: 13.7 ± 2.2 years) and in weight from 18.9 to 78.1 kg (mean ± SD: 43.4 ± 14.2 kg). Intraoperatively, the clevidipine infusion was stopped in 6 patients as the surgeon expressed concerns regarding spinal cord perfusion and requested a higher MAP than the study protocol allowed. The data until that point were included for analysis. The target MAP was initially achieved at a mean time of 8.9 minutes. Sixteen of the 30 patients (53.3%) achieved the target MAP within 5 minutes. Heart rate (HR) increased from a baseline of 83 ± 16 to 86 ± 15 beats per minute (mean ± SD) (p=0.04) with the administration of clevidipine. No patient had a HR increase ≥ 20 beats per minute or required the administration of a β-adrenergic antagonist. The duration of the clevidipine administration varied from 8 to 527 minutes (mean ± SD: 160 ± 123 minutes). The maintenance infusion rate of clevidipine varied from 0.25 to 5.0 mcg/kg/min (mean ± SD: 1.4 ± 1.1 mcg/kg/min). Clevidipine was paused a total of 43 times in the 30 cases. In 18 of the 30 patients (60%), the clevidipine infusion was temporarily paused more than once due to a MAP < 55 mmHg. A fluid bolus was administered to only 1 patient to treat the low MAP. No patient required the administration of a vasoactive agent for hypotension. When the clevidipine infusion was discontinued as controlled hypotension was no longer required, the MAP returned to baseline or ≥ 65 mmHg within 10 minutes in 12 of the 30 patients (40%)., Conclusions: Clevidipine can be used to provide controlled hypotension during posterior spinal fusion. The response of the MAP, both the onset and duration of action, were rapid. Although titration of the infusion with occasional pauses of administration may be needed, excessive hypotension was not noted.

Background: Duchenne muscular dystrophy (DMD) possesses many potential challenges for anesthetic care. Invasive and noninvasive procedures with corresponding sedation or general anesthesia are frequent and necessary for affected patients. There remains a need for a better agent or agents for procedural sedation in patients with comorbid diseases. This study prospectively evaluated a combination of ketamine with two different doses of dexmedetomidine for sedation during muscle biopsy in patients with DMD., Methods: Dexmedetomidine 1.0 or 0.5 μg·kg(-1) was administered as a loading dose over 3 min followed by a continuous infusion of 1.0 or 0.5 μg·kg·h(-1). Ketamine (1 mg·kg(-1)) was administered along with the dexmedetomidine loading dose. As the procedure commenced, additional doses of ketamine (0.5 mg·kg(-1)) were administered as needed. Sedation scores, hemodynamic data, operative times, and recovery times were recorded., Results: The study cohort included a total of 53 bicep, deltoid, or anterior tibialis muscle biopsies in 19 boys including 24 in the dexmedetomidine 1.0 μg·kg(-1) group and 29 in the dexmedetomidine 0.5 μg·kg(-1) group. Mean age and weight were 9.7 ± 1.4 years and 33.3 ± 7.7 kg in the dexmedetomidine 1.0 μg·kg(-1) group and 8.8 ± 1.8 years and 30.2 ± 10.8 kg in the dexmedetomidine 0.5 μg·kg(-1) group. No significant changes in blood pressure were noted. A decrease in heart rate (HR) occurred after the loading dose of dexmedetomidine in both groups. The HR was significantly lower in the dexmedetomidine 1.0 μg·kg(-1) group compared with the dexmedetomidine 0.5 μg·kg(-1) group. Total recovery time to discharge was significantly shorter in the dexmedetomidine 0.5 μg·kg(-1) group than the dexmedetomidine 1.0 μg·kg(-1) group (146 ± 65 vs 174 ± 58 min; P = 0.03), although the total ketamine dose was significantly greater in the dexmedetomidine 0.5 μg·kg(-1) group (3.7 ± 1.0 vs 2.0 ± 0.5 mg·kg(-1); P < 0.01). There were no episodes of apnea or hypoventilation; however, a jaw thrust was needed in one patient in the dexmedetomidine 1.0 μg·kg(-1) group., Conclusion: The combination of dexmedetomidine and ketamine is safe and effective for moderately painful procedures with limited respiratory and cardiovascular effects in a high-risk patient population. Dexmedetomidine 0.5 μg·kg(-1) as a loading dose with ketamine followed by a continuous infusion of dexmedetomidine at 0.5 μg·kg(-1) ·h(-1) achieved an adequate sedation level with shorter total recovery times in the perioperative unit compared with a higher dose regimen of dexmedetomidine (1.0 μg·kg(-1) loading dose followed by an infusion at 1.0 μg·kg(-1) ·h(-1))., (© 2014 John Wiley & Sons Ltd.)

Background: Over the past few years, there has been a change in clinical practice with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in pediatric patients. These changes have led to concerns regarding unsafe intracuff pressures in pediatric patients, which may result in postoperative morbidity. To avoid these issues, it is generally suggested that the intracuff pressure be maintained at ≤30 cmH2 O. The current study prospectively assesses the changes in intracuff pressure related to alterations in head and neck position in pediatric patients., Methods: Patients less than 18 years of age, undergoing surgery, requiring endotracheal intubation with a cuffed ETT were eligible for inclusion. No alteration in the technique of anesthetic induction or maintenance was required for the study. Following endotracheal intubation and inflation of the cuff with the head and neck in a neutral position, the intracuff pressure was measured. The intracuff pressure was then subsequently measured with the head turned to the right, head turned to the left, head and neck flexed, and head and neck extended., Results: A total of 200 patients were included in the study resulting in a total of 1000 intracuff pressure readings. When compared to the neutral position, the intracuff pressure increased in 545 instances (68.1%) with changes in position of the head and neck. An increase in intracuff pressure was noted more frequently and to the greatest degree with head and neck flexion. The pressure decreased in 153 instances (19.1%), most frequently with neck extension., Conclusion: Significant changes in the intracuff pressure occur with changes in head and neck position. In several cases, this resulted in a significant increase in the intracuff pressure. For prolonged cases with the head and neck turned from the neutral position, the intracuff pressure should be measured following patient positioning to ensure that the intracuff pressure is within the clinically recommended range., (© 2013 John Wiley & Sons Ltd.)

Background: During perioperative care, the continuous measurement of blood pressure (BP) provides superior physiologic monitoring to intermittent techniques. However, such monitoring requires placement of an intraarterial catheter, which may be time-consuming or associated with adverse events and technical difficulty. A noninvasive, continuous BP monitoring device has been studied in the adult population. This study prospectively assesses its accuracy in pediatric patients, weighing 20-40 kg., Methods: The technology evaluated is the CNAP™ Monitor 500, developed by CNSystems AG (Graz, Austria). The study cohort included pediatric patients weighing between 20 and 40 kg, scheduled for surgery for which arterial line (AL) placement was planned. Systolic (sBP), diastolic (dBP), and mean arterial (MAP) blood pressure readings were captured from the AL and the CNAP™ device every minute during anesthetic care., Results: The study cohort consisted of 20 patients (11 weighing between 30 and 40 kg and 9 weighing between 20 and 29.9 kg) with a mean age of 9.8 ± 3.4 years (range, 6-16 years) and weight of 29.8 ± 6.1 kg (range, 20.9-38.7 kg). There were a total of 1076 pairs each of sBP, dBP, and MAP values in the 20-29.9 kg group. The absolute difference between the sBP, dBP, and MAP was 9.8 ± 8.5, 6.8 ± 5.3, and 6.7 ± 6.2 mmHg, respectively. The correlation coefficient between the AL and the CNAP™ device was 0.48, 0.60, and 0.64 for the sBP, dBP, and MAP, respectively. The CNAP™ values (sBP, dBP, MAP) were ≤5 mmHg from the AL values in 38.6%, 48.5%, and 55.0% of the values, respectively. In the 30-40 kg group, there were a total of 2737 pairs of sBP, dBP, and MAP values. The absolute difference between the sBP, dBP, and MAP was 11.5 ± 9.3, 7.5 ± 5.3, and 7.9 ± 6.6 mmHg, respectively. The correlation coefficient between the arterial cannula and the CNAP™ device was 0.48, 0.45, and 0.51 for the sBP, dBP, and MAP, respectively. CNAP™ readings were ≤5 mmHg from the AL values (sBP, dBP, MAP) in 29.0%, 41.9%, and 40.5% of the values, respectively., Conclusion: Although some variation in its accuracy was noted, the CNAP™ device provides a noninvasive and continuous blood pressure reading which appears to be within clinically useful limits. It may be that modification of the finger cuffs is needed to improve its absolute accuracy as our clinical experience demonstrated that achieving an effective fit with the cuffs was at times difficult., (© 2013 John Wiley & Sons Ltd.)

Neuroblastomas are the most common, non-central nervous system tumor of childhood. Similar to pheochromocytomas, they are derived from neural crest cells and therefore retain the potential to synthesize catecholamines. Unlike pheochromocytomas, however, perioperative issues related to blood pressure instability with hypertension are uncommon. We report details of a 3-year-old child with a neuroblastoma who developed severe hypertension and end-organ effects after induction of anesthesia. The association of such problems with neuroblastoma is reviewed and options for perioperative care presented.