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Necrotizing enterocolitis (NEC) is a devastating gastrointestinal illness that affects high-risk populations such as those with congenital heart disease (CHD). A diagnosis of NEC, before and after cardiac surgery, can have serious and irreversible consequences. Here, we review perioperative management strategies that could potentially reduce the incidence of NEC in CHD. The literature is rich in investigative work regarding NEC in preterm infants; however, these data are extrapolated to infants with CHD. The pathogenesis of NEC in CHD is thought to be multifactorial, with splanchnic hypoperfusion being a major contributor. The data suggest that early enteral feeding with human milk, the use of probiotics, thoughtful use of red blood cell transfusions, and near-infrared spectroscopy may be useful tools in the prevention of NEC. NEC is an illness with the potential for high morbidity and mortality, particularly in CHD. Therefore, prevention of NEC should be the clinician’s focus when caring for these infants. Well-designed studies and evidence-based guidelines to standardize care in these infants are much needed to improve the outcome of NEC.

OBJECTIVES/HYPOTHESIS Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection. STUDY DESIGN Retrospective chart review. METHODS This is a retrospective chart review of infants (age

OBJECTIVES: The role of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the assessment of disease activity in systemic sclerosis (SSc) remains controversial. We sought to evaluate the relationship between clinical features of SSc and raised inflammatory markers and to determine if changes in ESR and CRP reflect changes in other disease features over time. METHODS: One thousand, five hundred and forty-five patients enrolled in the Australian Scleroderma Cohort Study were observed over a mean 3.52±2.91 years and assessed at 6,119 study visits. Generalised estimating equations were used to determine the relationship between ESR≥20mm/hr and CRP≥5mg/L and features of disease. The associations between change in inflammatory markers and change in skin scores and respiratory function tests were analysed. RESULTS: Overall, there was a significant association between raised ESR and forced vital capacity (FVC)

The advent and improvement of laparoscopic surgical techniques have led to expanded surgical and diagnostic indications for this technology in the pediatric patient. The anesthetic management in these cases poses special challenges due to pneumoperitoneum and extreme patient positioning (Nezhat et al., Nezhat’s video-assisted and robotic-assisted laparoscopy and hysteroscopy. Cambridge University Press, New York, 2013; Tanaka et al., Nezhat’s video-assisted and robotic-assisted laparoscopy and hysteroscopy. Cambridge University Press, New York, 2013). This chapter takes a close look at anesthetic challenges of pediatric and adolescent patients scheduled for laparoscopic surgery. It also describes preoperative considerations for pediatric surgery patients, including patient screening and premedication. Specific intraoperative and postoperative issues, including perioperative complications, pain management, and postoperative nausea and vomiting, all which are important for providing quality care and efficient patient experience, are discussed. The knowledge of the patient’s health status, along with the multiple physiologic changes that can occur and specific potential complications, allows the anesthesiologist to provide safer anesthesia care. This chapter provides an evidence-based overview of particular strategies in anesthesia care that have been utilized to improve the experience for pediatric and adolescent patients and their families.

Background and aims Postoperative pain relief management remains challenging post Caesarean section. the QLB has been shown to provide satisfactory analgesia post Caesarean section under neuraxial anaesthesia. However, its utility has not been demonstrated in patients who have received spinal morphine. the aim of this study is to assess the efficacy of the QLB as part of a multi modal analgesic regimen including spinal morphine post Caesarean section. Methods We performed a prospective, double-blind, placebo-controlled trial of 90 patients undergoing elective Caesarean section under spinal anaesthesia. Parturients were randomly allocated to receive a bilateral QLB or a sham block at the end of their surgery. the primary outcome was the difference in morphine PCA consumption over 24 hours after Caesarean section. Results There was no significant difference in morphine PCA consumption at 24 hours between the QLB group and control group (p = 0.986). There was a statistically significant reduction in VAS (Visual Analogue Scale) pain scores at 6 hours both at rest and at movement (p = 0.019, p = 0.014 respectively). There was no significant difference in VAS pain scores at any other timepoint up to 48 hours. Conclusions The QLB did not reduce morphine consumption at 24 hours but there was a reduction in VAS at 6 hours at rest and on movement. Increasing the local anaesthetic concentration and the addition of adjuncts could improve its analgesic profile when used in conjunction with spinal morphine.

Quadratus lumborum block has been shown to provide satisfactory analgesia after caesarean section performed under neuraxial anaesthesia. However, its efficacy has not been demonstrated in patients who have received intrathecal morphine. The aim of this study was to assess the efficacy of quadratus lumborum block as part of a multimodal analgesic regimen including intrathecal morphine. This was a prospective, double-blind, placebo-controlled trial. Participants were randomly allocated to receive bilateral quadratus lumborum block (40 ml levobupivacaine 0.25%) or sham block (control) after undergoing elective caesarean section under spinal anaesthesia. The primary outcome was 24-h morphine consumption measured by patient-controlled analgesia. Secondary outcomes included pain scores and quality of recovery. Data from 86 women were analysed. Median (IQR [range]) 24-h morphine consumption was similar in patients receiving quadratus lumborum block and sham block (12 (8-29 [0-68]) mg vs. 14 (5-25 [0-90]) mg, respectively; p = 0.986). There was a reduction in median (IQR [range]) visual analogue scale pain scores at 6 h with quadratus lumborum block compared with sham block both at rest (6 (0-14 [0-98]) mm vs. 14 (3-23 [0-64]) mm (p = 0.019); and on movement: 23 (10-51 [0-99]) mm vs. 44 (27-61 [2-94]) mm; (p = 0.014)). There was no difference in pain scores at any other time-point up to 48 h. When used in conjunction with intrathecal morphine and spinal anaesthesia, bilateral quadratus lumborum block does not reduce 24-h morphine consumption after caesarean section.

Objective To evaluate the hypothesis that feeding volumes exceeding 100 mL/kg/d and exposure to cow's milk formula preoperatively increase the risk for preoperative necrotizing enterocolitis (NEC) in infants with complex congenital heart disease. Study design All infants, of any gestational age, with an isolated cardiac lesion at high risk for NEC (ductal-dependent lesions, transposition of the great arteries, truncus arteriosus, and aorto-pulmonary window) admitted to Texas Children's Hospital from 2010 to 2016 were included. NEC was defined based on the modified Bell criteria. Feeding regimen information and relevant covariates were collected. Logistic regression was used to evaluate the association of feeding regimen and other potential risk factors with NEC. Results In this single-center, retrospective cohort of 546 infants, 3.3% developed Bell stage I-III NEC preoperatively. An exclusive unfortified human milk diet was associated with a significantly lower risk of preoperative NEC (OR 0.17, 95% CI 0.04-0.84, P = .03) in a multivariable regression model controlling for cardiac lesion, race, feeding volume, birth weight small for gestational age, inotrope use presurgery/pre-NEC, and prematurity. Feeding volumes exceeding 100 mL/kg/d were associated with a significantly greater risk of preoperative NEC (OR 3.05, 95% CI 1.19-7.90, P = .02). Conclusions The findings suggest that an unfortified exclusive human milk diet may reduce the risk of preoperative NEC in infants with complex congenital heart disease.

Background Crawford Williamson Long (1815 to 1878) was the first to use ether as an inhaled anesthetic for surgical operations. By not publishing his discovery for 7 yr, his pioneering work was largely overshadowed by that of Horace Wells (1815 to 1848), Charles Thomas Jackson (1805 to 1880), and William Thomas Green Morton (1819 to 1868). As a result, sites commemorating Long’s discovery are not offered the same recognition as those affiliated with Wells or Morton. Methods We highlight sites in Athens, Danielsville, and Jefferson, Georgia, that honor the first man to regularly use ether as an anesthetic agent. Extensive site visits, examination of museum artifacts, and genealogical research were used to obtain information being presented. Results Historic Oconee Hill Cemetery in Athens is where Long and members of his family are buried. Established in 1856, it is closely linked to the history of Athens and the University of Georgia (Athens, Georgia). The main site we describe is the Crawford W. Long Museum, located in Jefferson, Georgia, which opened to the public in 1957. It has undergone extensive renovations and holds an expansive collection of Long’s family heirlooms and personal artifacts. In addition, it displays an impressive art collection, depicting Long, surgical procedures, members of Long’s family, and homes associated with him. Visitors to the museum may also enjoy a walking audio tour that highlights the life of Long and his contribution to medicine. Conclusions We provide information on sites and artifacts that honor Georgia’s most celebrated physician. Much of this has not been published before, and it is our hope that Crawford Williamson Long’s legacy receives the attention it richly deserves.

Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt® and Storz DCI® video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines.Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt® video laryngoscopy, or Storz DCI® video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant.Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2-43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7-26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2-2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4-2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2-2.1; P = 0.48).Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

V. Thakkar, W. Stevens, D. Prior, J. Byron, K. Patterson, P. Hissaria, O. Moore, J. Roddy, J. Zochling, J. Sahhar, P. Nash, K. Tymms, P. Youssef, S. Proudman and M. Nikpour Department of Rheumatology, Department of Cardiology, St Vincents Hospital, Melbourne, Royal Adelaide Hospital – Immunology Directorate, Adelaide, Department of Rheumatology, Royal Perth Hospital, Perth, Department of Rheumatology, The Menzies Institute, Hobart, Department of Rheumatology, Monash Medical Centre, Melbourne, Sunshine Coast Rheumatology – Research Unit, Maroochydore, Department of Rheumatology, Canberra Rheumatology, Canberra, Department of Rheumatology, Royal Prince Alfred Hospital, Sydney and Department of Rheumatology, Royal Adelaide Hospital, Adelaide, Australia.

The purpose of this work was to develop a topical formulation of imiquimod, a novel immune response modifier, to induce local cytokine production for the treatment of external genital and perianal warts. A pH-solubility profile and titration data were used to calculate a pKa of 7.3, indicative of a weak base. Solubility experiments were conducted to identify a solvent that dissolves imiquimod to achieve a 5% formulation concentration. Studies to select surfactants, preservatives, and viscosity-enhancing excipients to formulate an oil-in-water cream indicated that fatty acids were the preferred solvent for topical imiquimod formulations, and isostearic acid (ISA) was selected. A relationship existed between the fatty acid composition of four commercially available ISA sources and the solubility of imiquimod. A combination of polysorbate 60, sorbitan monostearate, and xanthan gum was used to produce a physically stable cream. The preservative system included parabens and benzyl alcohol to meet the USP criteria for preservative activity. An in vitro method was developed to demonstrate that imiquimod was released from the formulation. Topical application of the formulation induced local cytokine activity in mice.

Rodent oligodendrocytes have a unique susceptibility among glia to the lytic effects of complement, due in part to a deficiency in CD59 (protectin), a key surface inhibitor of the complement membrane attack complex (MAC). The possibility that shedding of CD59 by human oligodendrocytes contributes to complement-mediated oligodendrocyte injury in inflammatory demyelinating disease has been investigated by estimating levels of CD59 in cerebrospinal fluid samples from 12 patients with demyelinating disease of the central nervous system and 13 with other neurological diseases. No significant differences were found between patients and controls, or between patients with active and those with clinically inactive demyelinating disease, providing no direct support for oligodendrocyte shedding of CD59 in multiple sclerosis.

Eleven people were killed and 60 injured in the Enniskillen bombing of November 1987. Survivors were psychologically appraised six months and one year later. At six months 50% had developed post-traumatic stress disorder (PTSD). This group comprised more females than males. However, all victims had high scores on the GHQ. We found no correlation between psychological injury (as measured by the GHQ) and physical injury (as measured by the ISS), calling into question previous assertions.

Two three-way crossover studies were done to characterize the drug release characteristics of Monospan (3M Pharmaceuticals, St. Paul, MN) capsules, a new once-a-day theophylline formulation. In the first study, 22 healthy males received single 450-mg doses of Monospan in the presence and absence of a high-fat breakfast; the same dose of Somophyllin (Fisons, Rochester, NY) immediate-release liquid was given to fasted subjects as a reference. The second study involved 29 healthy males given a single dose of 900 mg of Monospan in the presence and absence of the same high-fat meal; Theo-24 (G. D. Searle and Co., Skokie, lL) capsules were given to fasted subjects as a reference. The results of both studies showed that food did not affect the absorption of theophylline from Monospan; peak concentration, time to peak concentration, and area under the serum concentration-time curve were all unchanged. The absorption rates were similar with both strengths and dietary conditions and showed that theophylline was absorbed slowly from Monospan at a constant rate (~3.2%/h) over 24 h. Absorption continued past 24 h, and the extent of absorption from Monospan compared with that from each reference averaged 88% or higher. A good correlation (r > 0.980) was observed for Monospan between the amount absorbed in vivo and the amount released in the in vitro dissolution test, a result that demonstrates the precise rate control of Monospan. We conclude that Monospan is a suitable once-a-day formulation that can be taken without regard to food.

The case records of 499 victims of civil and terrorist violence were examined, and the presence or absence of post-traumatic stress disorder (PTSD) and associated features recorded. The results support the face, and predictive, validities of PTSD. ‘Acting as if the event were reoccurring’ and 'survivor guilt’ seemed not to be characteristic symptoms, and the homogeneity of the emotional state in PTSD was questionable. Only marital disharmony and suicidal behaviour were associated complications. PTSD seemed to be found in a wide range of stressors, but the danger in over-reliance on results from combat veterans is emphasised.

The sample studied was a group of 643 adults each seeking compensation for "Nervous Shock" and seen by a single Belfast psychiatrist for medico-legal assessment. Demographic information, risk factors, diagnosis, type of incident, symptoms and outcome were recorded for each patient. From the symptoms recorded, a subgroup of 23% were identified as suffering from Post-Traumatic Stress Disorder (PTSD) as defined in DSM III. This subgroup tended to be older, included more females, had more depressive symptoms and had more severe, prolonged disturbance. The findings document our experience of PTSD in the special context of Northern Ireland and suggest it may be a more useful term in describing psychological reaction to violence than the nebulous concept of "Nervous Shock" used at present by our courts.

A case report with ultrastructural analysis of an apocrine carcinoma of the breast is presented. The key finding with electron microscopy is numerous large mitochondria with abundant incomplete cristae. The ultrastructure of this tumor is compared to the ultrastructure of apocrine cells in the skin, oncocytes, and apocrine metaplastic cells of the breast. The apocrine carcinoma cells have some of the features of typical metaplastic breast epithelium and some features of oncocytes. Their exact origin remains open to speculation.

This study is an attempt to evaluate the psychiatric sequelae in victims of violence in Northern Ireland between 1979 and 1984. Seven hundred and nineteen consecutive referrals for medico-legal reports were investigated using detailed analysis of case records. These clients were all seeking compensation for psychological injury allegedly sustained following a violent incident. Details of demographic data, diagnosis and utilization of treatment services were recorded. Clients showed a high rate of anxiety and depressive reactions and neuroses, with notable infrequency in the diagnosis of hysteria and phobic neurosis. A large number of people were prescribed drugs, a significant percentage continuing to take these for over one year. The significance of these results is discussed with regard to the issues of compensation neurosis and ‘nervous shock’.