Background: The use of magnetic resonance imaging-guided high-intensity focused ultrasound (MR-HIFU) to deliver mild hyperthermia requires stable temperature mapping for long durations. This study ...evaluates the effects of respiratory motion on MR thermometry precision in pediatric subjects and determines the in vivo feasibility of circumventing breathing-related motion artifacts by delivering MR thermometry-controlled HIFU mild hyperthermia during repeated forced breath holds.
Materials and methods: Clinical and preclinical studies were conducted. Clinical studies were conducted without breath-holds. In phantoms, breathing motion was simulated by moving an aluminum block towards the phantom along a sinusoidal trajectory using an MR-compatible motion platform. In vivo experiments were performed in ventilated pigs. MR thermometry accuracy and stability were evaluated.
Results: Clinical data confirmed acceptable MR thermometry accuracy (0.12-0.44 °C) in extremity tumors, but not in the tumors in the chest/spine and pelvis. In phantom studies, MR thermometry accuracy and stability improved to 0.37 ± 0.08 and 0.55 ± 0.18 °C during simulated breath-holds. In vivo MR thermometry accuracy and stability in porcine back muscle improved to 0.64 ± 0.22 and 0.71 ± 0.25 °C during breath-holds. MR-HIFU hyperthermia delivered during intermittent forced breath holds over 10 min duration heated an 18-mm diameter target region above 41 °C for 10.0 ± 1.0 min, without significant overheating. For a 10-min mild hyperthermia treatment, an optimal treatment effect (TIR > 9 min) could be achieved when combining 36-60 s periods of forced apnea with 60-155.5 s free-breathing.
Conclusion: MR-HIFU delivery during forced breath holds enables stable control of mild hyperthermia in targets adjacent to moving anatomical structures.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Nusinersen (ISIS-SMNRx or ISIS 396443) is an antisense oligonucleotide drug administered intrathecally to treat spinal muscular atrophy. We summarize lumbar puncture experience in children with ...spinal muscular atrophy during a phase 1 open-label study of nusinersen and its extension. During the studies, 73 lumbar punctures were performed in 28 patients 2 to 14 years of age with type 2/3 spinal muscular atrophy. No complications occurred in 50 (68%) lumbar punctures; in 23 (32%) procedures, adverse events were attributed to lumbar puncture. Most common adverse events were headache (n = 9), back pain (n = 9), and post–lumbar puncture syndrome (n = 8). In a subgroup analysis, adverse events were more frequent in older children, children with type 3 spinal muscular atrophy, and with a 21- or 22-gauge needle compared to a 24-gauge needle or smaller. Lumbar punctures were successfully performed in children with spinal muscular atrophy; lumbar puncture–related adverse event frequency was similar to that previously reported in children.
A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, ...particularly among severely ill children. The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology.
These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement. Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time. Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.
The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on ...neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension.
A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol.
The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval CI, 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT).
RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.
The VeinViewer (Luminetx, Memphis, TN) helps identify veins by projecting an image of subcutaneous vasculature on the skin surface. We tested the primary hypothesis that VeinViewer use improves ...cannulation success by skilled nurses in pediatric patients with anticipated difficult IV access. A secondary goal was to evaluate the relationship between obesity and cannulation success.
Patients aged 0 to 18 years were included. Anticipated cannulation difficulty was evaluated with the difficult IV access score. All cannulations were performed by members of the Intravenous Access Team. Patients were randomized to: (1) routine IV catheter insertion; or (2) insertion facilitated by the VeinViewer. The primary outcome was first-attempt insertion success. The proportion of successful insertions was evaluated using Cochran-Mantel-Haenszel χ(2) analysis to adjust for any imbalanced baseline variables. The effect of obesity on cannulation success was evaluated with multivariable logistic regression.
Two hundred ninety-nine patients (49%) were randomly assigned to VeinViewer and 301 (51%) to routine cannulation. First-attempt cannulation success was 47% in patients assigned to VeinViewer vs 62% in patients assigned to routine cannulation, with an adjusted relative "risk" (95% confidence interval), of 0.76 (0.63-0.91). The Z-statistic of -3.6 crossed the "harm" boundary (Z < -2.41), with corresponding P value of 0.0003. The trial was stopped on statistical grounds since the harm boundary for the primary outcome was crossed. There was no association between first-attempt success and the 4-level categorization of obesity after adjusted for baseline variables (P = 0.94).
The VeinViewer worsened first-attempt IV insertion success by skilled nurses. Surprisingly, first-attempt success for IV cannulation was not worsened by obesity.
The objectives of this study are to determine the prevalence and relative risk (RR) of back pain and identify possible mechanisms of back pain among childhood acute lymphoblastic leukemia (ALL) ...survivors.
Surveys were mailed to 5 + -year survivors of childhood ALL aged 13 to 25 years. Survivors' siblings were also invited to participate in the study. Prevalence of back pain and hip pain among ALL survivors was determined and compared with siblings. Sex, treatment with radiation therapy, obesity, and physical activity were examined for an association with back pain and hip pain.
Forty-four of 99 (44.4%) ALL survivors reported back pain compared with 11 of 52 (21.2%) their siblings (P = 0.007; RR: 2.01; 95% confidence interval = 1.15-3.56). In contrast, 10 of 99 (10.1%) ALL survivors reported experiencing hip pain compared with 1 of 52 (2.0%) siblings experiencing hip pain P = 0.07; RR: 4.95 (0.65 to 37.57). Twenty-six of 43 female survivors reported back pain compared with 18 of 56 male survivors who reported back pain (P = 0.005). Obesity, physical activity, and treatment with radiation therapy were not associated with back pain or hip pain.
This is the first study demonstrating an increased frequency of back pain among survivors of childhood ALL. Future studies are needed to better define the causes of back pain among childhood ALL survivors.
Intrathecal analgesic drug therapy Farrow-Gillespie, Alan; Kaplan, Kimberly M
Current pain and headache reports,
02/2006, Letnik:
10, Številka:
1
Journal Article
Recenzirano
Intrathecal analgesic infusion therapy through an implantable pump system is a sophisticated medical therapy for those who suffer from chronic, severe pain who are unresponsive to traditional medical ...therapy. This article describes the patient selection and monitoring process and reviews available intrathecal medications and combinations.
To determine the effects of duration of fasting before elective surgery on gastric fluid pH and volume in children, a prospective, randomized, blinded study of 100 unpremedicated children, aged 1-14 ...yr, was undertaken. Each child was given 2 mL/kg of water orally and then fasted 2, 4, or 6 h preoperatively. After induction of anesthesia and tracheal intubation, gastric fluid was aspirated through a large-bore, multiorifice orogastric tube. Gastric fluid pH was measured using a calibrated PHM62 radiometer. Gastric fluid volume was the total volume of fluid aspirated from the stomach. The duration of fasting was between 2.0 and 8.5 h. We found that neither gastric fluid pH nor gastric fluid volume correlated with the duration of fasting. The mean (+/- SD) gastric fluid pH was 1.80 +/- 0.79 and the mean (+/- SD) gastric fluid volume was 0.56 +/- 0.39 mL/kg. Gastric fluid pH was less than 2.5 and volume greater than 0.4 mL/kg in 53% of children. We conclude that healthy children may receive 2 mL/kg of water up to 2 h before elective surgery without decreasing gastric fluid pH or increasing gastric fluid volume beyond values obtained after fasting for 6 h.
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