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Background: Head injury is considered as a major health problem in developed and developing nations. Analysis of etiology, patterns, and outcome of head injury in trauma patient is essential for understanding and planning for better management. Materials and Methods: The prospective observational study carried out among patients who presented with head injury at the tertiary care hospital, Mumbai from July 2015 to July 2017. Demographic details recorded were age, sex, blood pressure on arrival, Glasgow Coma Scale (GCS) score, the interval between injury and admission, associated injury, co-morbidities, hospital stay, and outcome. Results: The age group at which maximum patients of head injury were admitted was 18-29 years (31%) followed by 40-49 years (21%). Eighty one percent patients were males and 19% patients were females, the male to female ratio being 4:1. Road traffic accidents (36% cases) were the commonest cause leading to acute head injury followed by accidental fall (21% cases). 47% patients presented with mild head injury according to GCS. Conclusion: Head injuries mainly caused by vehicular accidents and affect mainly the young men. Road traffic accidents were the commonest mode of head injury, but railway accident had the worst outcome in our study. Factors associated with outcome were Pre-hospital delay, GCS on arrival, Blood pressure on arrival, Associated injury, Need for ventilator support, CT scan findings.

Aims Incidence of gall stone disease is estimated at 10-15%of population. Intraoperative cholangiography (IOC) diagnose choledocholithiasis, delineates the anatomy of the biliary ducts, facilitate the dissection and reduces injuries. Our aim is to assess the feasibility and role of IOC and the incidence of choledocholithiasis in acute cholecystitis (ACC). Methods Retrospective analysis of prospectively collected data for patients admitted with ACC and undergoing same-hospital-stay laparoscopic cholecystectomy (LC). IOC was systematically attempted in all cases. Results 475cases included. Female to male ratio1.9:1. Conversion to open was done in 3 cases. Preoperative cholelithiasis was confirmed in 439cases versus 34cases with no stones. USS CBD abnormality (dilated or contain stone) found in 53 cases, out of which 8(15%) cases had CBD stones. Jaundice was found in 69cases, where 25(39%) cases had confirmed choledocholithiasis. IOC was successful in all cases except one. Abnormal IOC was found in 99(21%) cases. Of those; CBD stones were confirmed in 76 (77%) cases regardless the presence of cholelithisasis on USS. Empyema was found in 237 cases and it was associated with higher risk of abnormal IOC in 59(25%) cases where CBD stones were confirmed in 45(76%) cases. Cystic duct (CD) stones found in 80cases, of those 27(34%)cases had choledocholithiasis. Conclusions Females have double the risk of ACC. Preoperative jaundice and CD stones are stronger indicators than CBD diameter for presence of choledocholithiasis. The incidence of choledocholithiasis in ACC is (20-25%) regardless the presence of gall stones on USS. IOC is feasible and highly recommended in emergency LC.

RNA editing by adenosine deaminases acting on dsRNA (ADAR) has become of increasing medical relevance, particularly because aberrant ADAR1 activity has been associated with autoimmunity and malignancies. However, the role of ADAR1 in dendritic cells (DC), representing critical professional APCs, is unknown. We have established conditional murine CD11c Cre-mediated ADAR1 gene ablation, which did not induce general apoptosis in CD11c+ cells but instead manifests in cell type–specific effects in DC subpopulations. Bone marrow–derived DC subset analysis revealed an incapacity to differentiate CD103 DC+ in both bulk bone marrow and purified pre-DC lineage progenitor assays. ADAR1 deficiency further resulted in a preferential systemic loss of CD8+/CD103+ DCs, revealing critical dependency on ADAR1, whereas other DC subpopulations were moderately affected or unaffected. Additionally, alveolar macrophages were depleted and dysfunctional, resembling pulmonary alveolar proteinosis. These results reveal an unrecognized role of ADAR1 in DC subset homeostasis and unveils the cell type–specific effects of RNA editing.

The Southern Ocean is a critical component of Earth’s climate system, but its remoteness makes it challenging to develop a holistic understanding of its processes from the small to the large scale. As a result, our knowledge of this vast region remains largely incomplete. The Antarctic Circumnavigation Expedition (ACE, austral summer 2016/2017) surveyed a large number of variables describing the dynamic state of the ocean and the atmosphere, the freshwater cycle, atmospheric chemistry, ocean biogeochemistry and microbiology. This circumpolar cruise included visits to twelve remote islands, the marginal ice zone, and the Antarctic coast. Here, we use 111 of the observed variables to study the latitudinal gradients, seasonality, shorter term variations, the geographic setting of environmental processes, and interactions between them over the duration of 90 days. To reduce the dimensionality and complexity of the dataset and make the relations between variables interpretable, we applied a sparse Principal Component Analysis (sPCA), which describes environmental processes through 14 latent variables. To derive a robust statistical perspective on these processes and to estimate the uncertainty in the sPCA decomposition, we have developed a bootstrap approach. We identified temporal patterns from diurnal to seasonal cycles, as well as geographical gradients and “hotspots” of interaction. Our results establish connections of oceanic, atmospheric, biological and terrestrial processes in an innovative way, while confirming many well known relations of the Southern Ocean system. More specifically, we identify: the important role of the oceanic circulations, frontal zones, and islands in shaping the nutrient availability that controls biological community composition and productivity; that sea ice predominantly controls sea water salinity, dampens the wave field, and is associated with increased phytoplankton growth and net community productivity possibly due to iron fertilization and reduced light limitation; and clear regional patterns of aerosol characteristics emerged, stressing the role of the sea state, atmospheric chemical processing, as well as source processes near “hotspots” for the availability of cloud condensation nuclei and hence cloud formation. A set of key variables and their combinations, such as the difference between the air and sea surface temperature, atmospheric pressure, sea surface height, geostrophic currents, upper ocean layer light intensity, surface wind speed and relative humidity, played an important role in the majority of latent variables, highlighting their importance for a large variety of processes and the necessity for Earth System Models to represent them adequately. In conclusion, our study highlights the use of sPCA to identify key ocean-atmosphere interactions across physical, chemical, and biological processes and their associated spatio-temporal scales. The sPCA processing code is available as open-access and we believe that our approach is widely applicable to other environmental field studies.

To review demographics, effect of preoperative chemotherapy on tumour thrombus, imaging, operative strategy, and outcomes of 12 patients presenting with intracardiac extension of Wilms tumour thrombus. A retrospective audit was undertaken on patients with intracardiac extension of Wilms tumour. Patients were identified from the oncology database and information obtained on clinical presentation, stage, preoperative treatment, surgical procedures and complications, histology, and survival status. Ethics approval was obtained from the University of Cape Town Human Research Ethics Committee. From 1984 to 2016, 337 children with Wilms tumour were treated. Twelve (3.6%) had intracardiac extension of tumour thrombus, nine into the right atrium, and three into the right ventricle. Ultrasound, computerized tomography, magnetic resonance imaging, and echocardiograms were used to assess thrombus level. Patients were staged as stage III(8) and IV(4). All patients received preoperative chemotherapy. Thrombus retracted from the heart in two cases. One patient died preoperatively. Eleven underwent laparotomy, median sternotomy, and cardiopulmonary bypass (CPB). Four underwent cavectomy. Five required cavoatrial patches. Thrombus extending into the hepatic veins was extracted in five patients. There was one intraoperative complication and one perioperative death. Thrombus histology showed viable tumour in 9 of 11 patients. Three patients died of progressive disease. Seven patients are currently disease free. A combination of imaging is required to determine thrombus extent, and this facilitates surgical planning. Preoperative chemotherapy may cause thrombus regression, thus avoiding CPB. CPB offers appropriate conditions for safe tumour thrombus excision. Full management in centres with appropriately experienced staff and facilities for CPB is recommended.

Superior mesenteric artery (SMA) syndrome is an uncommon entity leading to compression of the duodenum between the aorta and the SMA. Normally the coeliac trunk and the superior mesenteric arteries have distinct origins from the abdominal aorta. The celiacomesenteric trunk (CMT) is the least frequently reported anatomic variation of all abdominal vascular anomalies. CMT denotes a common trunk of origin of the coeliac and superior mesenteric arteries. The coexistence of these anomalies has never been reported in the literature. We present a case of a 59-year-old man presenting with duodenal obstruction due to SMA syndrome with CMT. The aortomesenteric angle was 13 degrees and SMA-aorta distance was 8 mm. Patient underwent a gastrojejunostomy. After an uneventful recovery, the patient has been symptom free for 1-year follow-up.

The international Antarctic Circumnavigation Expedition (ACE), organised by the Swiss Polar Institute (SPI), took place in the austral summer of 2016 / 17. Departing from Cape Town in December 2016, the R/V Akademik Tryoshnikov sailed around the Southern Ocean, navigating the following route: Cape Town (20 December 2016) - Hobart (18 January 2017) via: Marion Island Iles de Crozet et Kerguelen Heard Island Hobart (22 January 2017) - Punta Arenas (22 February 2017) via: Mertz glacier Balleny Islands Mount Siple Scott Island Peter I Island Diego Ramírez Punta Arenas (26 February 2017) - Cape Town (19 March 2017) via: South Georgia South Sandwich Islands Bouvetøya Scientists from 22 distinct projects studied a wide range of disciplines, collecting data and samples from the Southern Ocean and a number of terrestrial sites on islands around Antarctica, as well as the continent itself. In this cruise report, the full details of the purpose of the cruise, on-board data and sample collection, and project methods and preliminary results are described., This document is compiled and edited from reports provided by many scientists from 22 distinct on-board projects who studied a wide range of disciplines, collecting data and samples from the atmosphere, the Southern Ocean and a number of terrestrial sites on islands around Antarctica, as well as the continent itself. The expedition was made possible by funding from the Swiss Polar Institute and Ferring Pharmaceuticals.

SummaryAim This study aimed to quantify the incidence of anesthesia-related and perioperative mortality at a large tertiary pediatric hospital in South Africa. Methods This study included all children aged

A standardized human model to study early pathogenic events in patients with psoriasis is missing. Activation of Toll-like receptor 7/8 by means of topical application of imiquimod is the most commonly used mouse model of psoriasis.We sought to investigate the potential of a human imiquimod patch test model to resemble human psoriasis.Imiquimod (Aldara 5% cream; 3M Pharmaceuticals, St Paul, Minn) was applied twice a week to the backs of volunteers (n = 18), and development of skin lesions was monitored over a period of 4 weeks. Consecutive biopsy specimens were taken for whole-genome expression analysis, histology, and T-cell isolation. Plasmacytoid dendritic cells (pDCs) were isolated from whole blood, stimulated with Toll-like receptor 7 agonist, and analyzed by means of extracellular flux analysis and real-time PCR.We demonstrate that imiquimod induces a monomorphic and self-limited inflammatory response in healthy subjects, as well as patients with psoriasis or eczema. The clinical and histologic phenotype, as well as the transcriptome, of imiquimod-induced inflammation in human skin resembles acute contact dermatitis rather than psoriasis. Nevertheless, the imiquimod model mimics the hallmarks of psoriasis. In contrast to classical contact dermatitis, in which myeloid dendritic cells sense haptens, pDCs are primary sensors of imiquimod. They respond with production of proinflammatory and TIn human subjects imiquimod induces contact dermatitis with the distinctive feature that pDCs are the primary sensors, leading to an IL-23/T

This article details how a small college of nursing affiliated with a faith-based health care corporation integrated the education of end-of-life care into a megacode simulation. Students participated in a high-fidelity simulated megacode scenario in which the simulator died. Following de-briefing, student groups participated in an additional scenario in which faculty coached them through postmortem care and interaction with a family member and a hospital chaplain. As a result of this multidimensional, interprofessional simulation, students developed heightened skill in applying basic life-saving measures, increased knowledge of and comfort with postmortem care, and increased awareness of the emotions elicited by the experience. [ J Nurs Educ. 2014;53(11):659–662.]

Anaesthesia and pain management for paediatric burns continues to challenge and frustrate healthcare professionals in this field of medicine. This review aims to provide some practical management strategies to enable the improved care of burned children. The pathophysiology of burns, toxic shock syndrome, inhalational injuries and perioperative care of paediatric burns is addressed.

This paper highlights the different options associated with asynchronous online discussion (AOD) use in health care education which may have an impact on their effectiveness. The review was carried out following a search of specific databases, websites, key journals, references and key authors. All studies published between 2006 and 2012 that met specific inclusion/exclusion criteria were subject to quality appraisal. Fourteen studies met the quality appraisal criteria: six qualitative, four quasi-experimental, one observational and three mixed methods. Data extraction coupled with narrative synthesis enabled the description of options that emerged and exploration of the relationships within and between studies. Study design as well as methodological quality was mixed. However, several useful factors emerged which may impact on effectiveness. These include (a) the mode of e-moderation (b) provision of AOD for participants in the clinical setting to critically reflect, analyse and resolve clinical issues and (c) increased amount of time spent reading the AOD (but not the number of discussion 'hits'). Research in this area appears to be in its infancy and one of the main recommendations is that further studies are required which focus on comparing the same type of AOD with and without a specific intervention in order to make any robust conclusions.

The purpose of this study is to evaluate a number of recently completed workplaces in the UK. The first aim is to assess the impact of various aspects of the workplace environment on users’ levels of stimulation. The body of previous research undertaken into the workplace environment, identified the aspects to be investigated. Samples of employees from the sixteen businesses were surveyed to determine their perceptions of the workplaces. The results were entered into a regression analysis, and the most significant predictors of perceived stimulation identified. The data also revealed a dramatic reduction in staff arousal levels from mornings to afternoons. Thus, there is a second aim to determine whether changes to significant aspects of the workplace environment during the day can counteract the reduction in users’ stimulation. Two further workplaces were studied to enable changes to be made over a 12-week period. A sample of employees completed questionnaires, and semi-structured interviews revealed the reasons behind the results. It was found that provision of artwork, personal control of temperature and ventilation and regular breaks were the most significant contributions to increasing stimulation after lunch; while user choice of layout, and design and décor of workspaces and break areas, were the most significant aspects at design stage.

Tuberculosis is a common problem in South Africa, and provides a number of challenges for the anaesthetist. Patients may present in a variety of ways. Constitutional and pulmonary symptoms are the most common. These may impact on fitness for surgery and choice of anaesthesia. Tuberculosis treatment has the potential for a number of significant drug interactions. These are primarily mediated through induction of the cytochrome P450 enzyme system by rifampicin. Guidelines for the prevention of tuberculosis in the theatre environment need to be followed to avoid placing staff and other patients in danger.

The use of intraoperative neurophysiological monitoring (INM) during spinal orthopaedic and neurosurgical procedures provides a challenge to the attending anaesthesiologist. Since all anaesthetic agents affect synaptic function, the choice of agent will be determined by the type of surgery and the INM modality employed. Halogenated volatile agents decrease evoked potential (EP) amplitude and increase latency, and should be avoided in modalities that pass through cortical tracts. The effect on EPs is apparent at minimum alveolar concentrations of 0.3-0.5. Intravenous agents affect EPs in a dose-dependent manner, and should be titrated to response. Total intravenous anaesthesia with propofol and remifentanyl is the preferred technique. The risk of propofol infusion syndrome has not been shown to affect the choice of this agent. Compound muscle action potentials are abolished by barbiturates, and should be avoided during motor-evoked potential (MEP) monitoring. Although somatosensory-evoked potentials are unaffected by muscle relaxants, they prevent the monitoring of MEPs and should be avoided during multimodal use. When paralysis is required to ensure patient safety, the train-of-four ratio should be kept at 2/4 twitches and a T1 response at 10-20% of baseline, with use of a closed-loop system.

Sickle cell disease (SCD) is the most common inherited haematological disorder, producing a mutation of the haemoglobin molecule known as haemoglobin S (HbS). The presence of HbS in the erythrocyte makes it prone to sickling — a process that may lead to vaso-occlusive injury, haemolysis and a hypercoagulable state. Sickling is precipitated by dehydration, hypoxia, hypothermia, acidosis and low flow situations. Over time, multi-organ damage develops with significant morbidity and mortality. Paediatric patients with SCD and congenital heart defects may require anaesthesia for corrective cardiac surgery on cardiopulmonary bypass (CPB). During the perioperative period these high-risk patients may suffer significant complications when exposed to the conditions that favour erythrocyte sickling. This case series details experience of four paediatric patients with SCD who underwent corrective cardiac surgery at Red Cross War Memorial Children’s Hospital. The pathophysiology is discussed and the perioperative management of transfusion, cardiopulmonary bypass and temperature regulation is highlighted.Keywords: anaesthesia, cardiopulmonary bypass, sickle cell anaemia, sickle cell disease, transfusion

The new results available this year from a number of neutrino experiments bring into stronger focus the details in the ‘Standard Model’ of neutrino oscillations described by the PMNS mixing matrix. However, the parameters are still not known to very high precision. The next few years look bright for accelerator neutrino experiments, with much action occurring in the near future. We still have to wait a little longer, however, to be sure, but making educated guesses is needed to make plans for the future.

Ductal spasm is a rare yet important complication of device occlusions of patent ductus arteriosus. Spasm may result in failure of the procedure, under-sizing of the device, or embolisation of the implanted device as the spasm resolves after the procedure. We describe a novel protocol that rapidly and completely reversed the spasm in eight prematurely born infants who experienced ductal spasm during cardiac catheterisations for patent ductus arteriosus occlusion.In total, eight infants born between 25 and 34 weeks of gestation presented for transcatheter patent ductus arteriosus occlusion between 13 and 87 months of age. All eight patients experienced ductal spasm either immediately before, during, or soon after induction of anaesthesia or only after entering the ductus arteriosus with a catheter. After detection of the spasm, the anaesthetist, in each case, changed the mode of anaesthesia from inhaled sevoflurane to total intravenous anaesthesia with propofol, reduced the inhaled oxygen fraction to 21%, and initiated a continuous intravenous infusion of prostaglandin E1.The first two steps (total intravenous anaesthesia and FiO2 0.21) resulted in only partial relaxation of the spasm. Complete relaxation was attained after intravenous prostaglandin E1 infusions of only 10–15 minutes’ duration. While maintaining this protocol, six ducti were successfully occluded and two were considered to be unsuitable for device occlusion and were referred for surgery.Ductal spasm during transcatheter occlusion may be reliably resolved and the procedure safely completed by a simple anaesthetic protocol, including the continuous infusion of intravenous prostaglandin E1.

Objective: To investigate whether supplementing older men with vitamins B 12 , B 6 , and folic acid improves cognitive function. Methods: The investigators recruited 299 community-representative hypertensive men 75 years and older to a randomized, double-blind controlled clinical trial of folic acid, vitamin B 6 , and B 12 supplementation vs placebo over 2 years. The primary outcome of interest was the change in the cognitive subscale of the Alzheimer9s Disease Assessment Scale (ADAS-cog). A secondary aim of the study was to determine if supplementation with vitamins decreased the risk of cognitive impairment and dementia over 8 years. Results: The groups were well-balanced for demographic and biochemical parameters. There was no difference in the ADAS-cog change from baseline to 24 months between the placebo (0.8, SD 4.0) and vitamins group (0.7, SD 3.4). The adjusted scores in the treatment groups did not differ over time (placebo 0.2 lower, z = 0.71, p = 0.478). There was a nonsignificant 28% decrease in the risk of cognitive impairment (odds ratio 0.72, 95% confidence interval 0.25–2.09) and dementia (hazard ratio 0.72, 95% confidence interval 0.29–1.78) over 8 years of follow-up. Conclusions: The daily supplementation of vitamins B 12 , B 6 , and folic acid does not benefit cognitive function in older men, nor does it reduce the risk of cognitive impairment or dementia. Classification of evidence: This study provides Class I evidence that vitamin supplementation with daily doses of 400 μg of B 12 , 2 mg of folic acid, and 25 mg of B 6 over 2 years does not improve cognitive function in hypertensive men aged 75 and older.

The paediatric airway demands respect, and appropriate and safe management of this delicate structure is of utmost importance. With development of polyvinyl chloride (PVC) in the 1960s, uncuffed endotracheal tubes (ETTs) replaced tracheostomies for long-term intubation and ventilation in the intensive care unit (ICU). Since then, uncuffed ETTs have traditionally been used in infants and children under the age of eight (or even ten) years for both short- and long-term intubation in theatre and ICU. Cuffed ETTs were not considered appropriate in this age group, and until fairly recently many manufacturers of ETTs did not produce cuffed sizes smaller than a 5 mm internal diameter (ID). However, debate in the literature over the last decade questions this teaching, some saying that the routine use of uncuffed ETTs in infants and children is not based on scientific evidence. It is clear that the strongly emerging role of cuffed ETTs in the paediatric population has come to the fore.

“Few conditions are more devastating to the physical, emotional, and social health of an infant or child than epidermolysis bullosa. The disease is actually a group of congenital abnormalities of the skin, and it encompasses a variety of genetic abnormalities of proteins that mediate adhesion of the skin. These abnormalities result in fragile skin that blisters, causing pain, deformity, social and emotional disability, susceptibility to infection and cancer, and shortened life. Children with epidermolysis bullosa require lifelong support and understanding from physicians (both specialists and g eneralists), from clinical support personnel, and most important, from their families.”1

Objectives: To describe the processes used to develop an instrument to assess cognition in the older Indigenous community of the Kimberley region of Western Australia, given the diverse history and culture of the region. Methods: Cognition questions were discussed with Indigenous organisations, councils, linguists, interpreters and health professionals. Existing assessment tools were reviewed. The cognition questions and the way in which they were approached were trialled with older Indigenous participants. Results: Questions to assess cognition were developed and incorporated into the Kimberley Indigenous Cognitive Assessment (KICA) instrument, which has since been demonstrated to be a valid and reliable assessment of cognition in older Indigenous Australians in the Kimberley. Conclusion: The KICA-Cog questions in the KICA survey tool provide the first specific instrument for assessing cognitive decline in older Indigenous Australians. This instrument, or a modification of this instrument, is likely to have broader applicability across Indigenous communities in Northern Australia.

An important feature of atopic asthma is the T cell–driven late phase reaction involving transient bronchoconstriction followed by development of airways hyperresponsiveness (AHR). Using a unique rat asthma model we recently showed that the onset and duration of the aeroallergen-induced airway mucosal T cell activation response in sensitized rats is determined by the kinetics of functional maturation of resident airway mucosal dendritic cells (AMDCs) mediated by cognate interactions with CD4+ T helper memory cells. The study below extends these investigations to chronic aeroallergen exposure. We demonstrate that prevention of ensuing cycles of T cell activation and resultant AHR during chronic exposure of sensitized rats to allergen aerosols is mediated by CD4+CD25+Foxp3+LAG3+ CTLA+CD45RC+ T cells which appear in the airway mucosa and regional lymph nodes within 24 h of initiation of exposure, and inhibit subsequent Th-mediated upregulation of AMDC functions. These cells exhibit potent regulatory T (T reg) cell activity in both in vivo and ex vivo assay systems. The maintenance of protective T reg activity is absolutely dependent on continuing allergen stimulation, as interruption of exposure leads to waning of T reg activity and reemergence of sensitivity to aeroallergen exposure manifesting as AMDC/T cell upregulation and resurgence of T helper 2 cytokine expression, airways eosinophilia, and AHR.

OBJECTIVES: To determine whether vitamin D supplementation can reduce the incidence of falls and fractures in older people in residential care who are not classically vitamin D deficient. DESIGN: Randomized, placebo-controlled double-blind, trial of 2 years’ duration. SETTING: Multicenter study in 60 hostels (assisted living facilities) and 89 nursing homes across Australia. PARTICIPANTS: Six hundred twenty-five residents (mean age 83.4) with serum 25-hydroxyvitamin D levels between 25 and 90nmol/L. INTERVENTION: Vitamin D supplementation (ergocalciferol, initially 10,000 IU given once weekly and then 1,000 IU daily) or placebo for 2 years. All subjects received 600 mg of elemental calcium daily as calcium carbonate. MEASUREMENTS: Falls and fractures recorded prospectively in study diaries by care staff. RESULTS: The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, the incident rate ratio for falling was 0.73 (95% confidence interval (CI) 50.57‐0.95). The odds ratio for ever falling was 0.82 (95% CI 50.59‐1.12) and for ever fracturing was 0.69 (95% CI 50.40‐1.18). An a priori subgroup analysis of subjects who took at least half the prescribed capsules (n 5540), demonstrated an incident rate ratio for falls of 0.63 (95% CI 50.48‐0.82), an odds ratio (OR) for ever falling of 0.70 (95% CI 50.50‐0.99), and an OR for ever fracturing of 0.68 (95% CI 50.38‐1.22). CONCLUSION: Older people in residential care can reduce their incidence of falls if they take a vitamin D supplement for 2 years even if they are not initially classically vitamin D deficient. J Am Geriatr Soc 53:1881–1888, 2005.

Anaesthesia for conjoined twin surgery, whether prior to or for separation, is an enormous challenge to the paediatric anaesthesiologist. The site and complexity of the conjunction will affect airway management, acquisition of vascular access, the extent of blood loss, and the number of surgical specialties involved. Preoperative assessment and planning, with interdisciplinary communication and cooperation, is vital to the success of the operations. These twins require a dedicated team of anaesthetists for each child, and, consequently, duplication of all monitoring and equipment in one operating room is necessary. Meticulous attention to detail, monitoring, and vigilance are mandatory. Planning for the postoperative period in the intensive care unit (ICU), as well as the babies’ reconstruction and rehabilitation, is essential from the time of the initial admission.

The Red Cross War Memorial Children's Hospital, Cape Town, South Africa is the only dedicated children's hospital in sub-Saharan Africa and, as such, is the referral hospital for complex procedures from this region. Fifteen sets of conjoined twins have presented for separation from 1991 to 2002, and a total of 34 sets since 1964. Anaesthesia for procedures on conjoined twins is a demanding, exacting and meticulous exercise, whether prior to or during separation. Anaesthesia forms part of the multidisciplinary management of the babies. Emphasis is laid on preoperative assessment, goal-directed planning of theatre and the staff involved in the surgery, duplication of all equipment necessary for anaesthetizing and monitoring two infants in one operating room, and having plans in place to avoid overcrowding. Challenges encountered in anaesthesia for these twins include identifying anatomical conjunctions, airway management, acquiring vascular access, the potential for enormous blood loss, and maintaining normothermia. Planning for the postseparation period and the reconstruction and rehabilitation of the babies is essential from the time of their initial admission. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team.

A boy with a suspected lymphoid malignancy presented with gross head and neck lymphadenopathy, a middle mediastinal mass, and rapidly worsening airway obstruction. General anaesthesia was required for definitive histopathological diagnosis. The combination of nasopharyngeal obstruction, malignant infiltration of the tonsils and pharynx, laryngeal displacement, and potential tracheal compression put this patient at extreme risk for perioperative airway complications. Risk assessment, and the impact of anaesthesia on pharyngeal neuromechanical function and mediastinal masses are discussed. Caution with volatile anaesthetic agents is recommended in the patient with an inherently unstable pharynx and/or trachea, in whom airway patency relies on a spontaneously breathing technique and intact airway reflexes.

The airway mucosal response to allergen in asthma involves influx of activated T helper type 2 cells and eosinophils, transient airflow obstruction, and airways hyperresponsiveness (AHR). The mechanism(s) underlying transient T cell activation during this inflammatory response is unclear. We present evidence that this response is regulated via bidirectional interactions between airway mucosal dendritic cells (AMDC) and T memory cells. After aerosol challenge, resident AMDC acquire antigen and rapidly mature into potent antigen-presenting cells (APCs) after cognate interactions with T memory cells. This process is restricted to dendritic cells (DCs) in the mucosae of the conducting airways, and is not seen in peripheral lung. Within 24 h, antigen-bearing mature DCs disappear from the airway wall, leaving in their wake activated interleukin 2R+ T cells and AHR. Antigen-bearing activated DCs appear in regional lymph nodes at 24 h, suggesting onward migration from the airway. Transient up-regulation of CD86 on AMDC accompanies this process, which can be reproduced by coculture of resting AMDC with T memory cells plus antigen. The APC activity of AMDC can be partially inhibited by anti-CD86, suggesting that CD86 may play an active role in this process and/or is a surrogate for other relevant costimulators. These findings provide a plausible model for local T cell activation at the lesional site in asthma, and for the transient nature of this inflammatory response.

We examined the relationship between thermal preference (selected body temperature or “Tsel") and microhabitat temperature of a nocturnal, alpine weta Hemideina maori (Orthoptera: Anostostomatidae), in the southern part of New Zealand. To examine diel variation in thermal preference, we measured Tsel five times over a 24‐h period in the laboratory and compared these temperatures to weta microhabitat temperatures in the wild. Tsel ranged from 4.3 to 29.3°C, but the distribution of temperatures was skewed, towards the cooler end of the thermal gradient, with an overall median and mean of c. 13°C. The frequency of Tsel values was bimodal, with peaks at a relatively narrow range of cool temperatures between 5 and 8°C (33%) and at a slightly broader range of warmer temperatures between 13 and 21 °C (52%). Tsel values did not vary with time of day, but differed significantly between individuals. Comparisons with microhabitat temperature showed that weta at 1250 m a.s.l. on the Rock and Pillar Range, Ot...

SummaryBackground NP is a biomarker that has been used in the diagnosis, management, and prognostication of a number of cardiovascular disorders in the pediatric population. The physiological role of this hormone is to allow the myocardium to adapt to stress or strain imposed by a volume and/or pressure load. Objective The aim of this study was to determine the utility of preoperative and postoperative NP to predict outcome in pediatric patients undergoing cardiac surgery for structural congenital heart disease. Method We conducted a systematic review by searching three electronic databases using the search terms ‘paediatric’ or ‘pediatric’ and ‘B-type natriuretic peptide’. Twenty peer-reviewed papers were included in the study. Results Preoperative NP levels were associated with the severity of cardiac failure in several studies. Preoperative NPs also correlated with early postoperative outcome measures such as duration of cardiopulmonary bypass, duration of mechanical ventilation, presence of low cardiac output syndrome, length of stay in the intensive care unit and in one study, death. Early (within 24 h) postoperative NPs showed a stronger correlation than preoperative NPs to early postoperative adverse events. Conclusion NPs provide a simple, noninvasive and complementary tool to echocardiography that can be used to assist clinicians in the assessment and management of pediatric patients with congenital heart disease in the perioperative period.

1. What is pragmatics?2. Speech acts3. Conversational implicature4. Approaches to pragmatics5. Pragmatics and indirectness6. Theories of politeness7. The construction of meaning

The African child is particularly vulnerable to disease and injury, and subsequently, to pain and suffering. Factors such as inadequate training, language barriers, cultural diversity, limited resources and the burden of disease prevents sick and injured children from receiving basic pain care. This situation can only be rectified by providing pre and post graduate training on the safe use of analgesic preparations, the availability of drugs and government support.