Use of caudal block for pain control following bone marrow harvest in children

PURPOSE

After the harvesting of bone marrow for use in transplantation, pain control needs are greatest in the first 12 to 24 hours. This is also the time during which systemic side effects of parenterally administered narcotics are greatest as a result of the recent general anesthetic. We examined the role of regional anesthesia as an adjunct to pain management in pediatric patients undergoing bone marrow harvest.

PATIENTS AND METHODS

Ten pediatric bone marrow donors were treated with intraoperative caudal blocks using bupivacaine or a combination of bupivacaine and morphine.

RESULTS

Donors who received regional anesthesia had a significant decrease in postoperative parenteral narcotic requirement and fewer systemic complications when compared with a control group of 10 age-matched children who did not receive the caudal block.

CONCLUSIONS

Regional anesthesia with caudal block can decrease the morbidity associated with bone marrow harvest in donors.

Testing for behavioral contagion in a case-control design

'Behavioral contagion' refers to an increased tendency for a behavior to be performed when socially related persons have already performed it. So understood, behavioral contagion may be involved in criminality, conduct disorder, drug abuse, suicide, and teenage pregnancy. In a recent paper we showed that contagion, when present, generates highly distinctive result patterns in survey data. These patterns allow one to infer that contagion is present even though it has not been directly observed. The present paper extends this approach to case-control designs, where, it will be shown, contagion has equally distinctive but different consequences. The analysis is illustrated with a Canadian study of conduct disorder and further evidence is presented that this condition is contagious. Limitations of the approach and alternative interpretations of results are discussed.

Lack of cognitive impairment in first-degree relatives of children with pervasive developmental disorders

OBJECTIVE

The objective of this study was to test the hypothesis that mild cognitive impairments aggregate in the unaffected first-degree relatives of probands with autism or pervasive developmental disorders (PDD).

METHOD

The unaffected siblings and parents of 52 PDD probands and 33 Down syndrome and low birth weight controls were administered a battery of psychometric tests. The tests included measures previously found to be depressed in siblings of autistic children as well as cognitive deficits seen in PDD subjects of normal IQ. In addition, the Vineland Adaptive Behavior Scales were administered to siblings to measure the social-communication impairments found in PDD.

RESULTS

Neither the siblings nor parents of the PDD probands demonstrated lower cognitive or adaptive behavior scores compared with controls. Developmental histories did not reveal greater rates of social, cognitive, or language delays, nor was there evidence to suggest that relatives of subgroups of PDD probands were different from each other.

CONCLUSION

These findings indicate that, apart from relatives with PDD, cognitive and social impairments do not aggregate in the families of PDD probands.

Effects of a nonenergy fat substitute on children's energy and macronutrient intake

To determine whether children adjusted their energy intake in response to covert manipulations in the proportion of energy from dietary fat, 24-h food intake of 29 2- to 5-y-old children was measured over four 2-d blocks. In this within-subject crossover design, in the first three meals of the first day of each block, children consumed foods containing dietary fat or a nonenergy fat substitute, which provided 10% of total daily energy intake. Children compensated for the missing energy; cumulative energy intake differed by only 100 kJ over 2 d. Substitution for dietary fat reduced the percent of energy from fat from 38.7% to 36.4%. Children's intake at individual meals was highly variable (mean CV 24.7%) relative to the variability of total daily energy intake (CV = 8.6%). To produce this pattern, children adjusted energy intake across successive meals. Use of a fat substitute at 10% of energy from dietary fat did not significantly reduce 24-h energy intake.

Impact on knowledge and practice of a multiregional long-term care facility infection control training program

BACKGROUND

Few affordable training opportunities are specifically designed for the long-term care facility infection control practitioner. There is also little evidence of the success of training in improving infection control practices. The Nebraska Infection Control Network developed a 2-day basic skills training program for Midwestern long-term care facility infection control practitioners that was later disseminated to eastern and western training sites. In this study we examined the effectiveness of the training program in terms of trainee knowledge and practice.

METHODS

From 1986 to 1990, a total of 17 courses conducted at the three sites were attended by a total of 266 infection control practitioners. Trainees completed a 40-item multiple choice test before and after training to evaluate their knowledge gain. Implementation of eight key infection control practices and time devoted to infection control duties were measured before training and at 3 and 12 months after training. Implementation of infection control practices was also evaluated in a second study, with infection control practitioners randomly assigned to trained and wait-control conditions.

RESULTS

Significant increases after training were found at each site for both knowledge and implementation measures. These increases were maintained at 12 months follow-up. Time devoted to infection control duties increased significantly at the midwest and western sites but not at the eastern site. In the second study, significant differences were found between the trained and the wait-control group in use of infection control practices, providing evidence for a causal relationship between training and increased use of practices.

CONCLUSIONS

The training program was effective in producing improvements in knowledge and implementation of recommended infection control practices in long-term care facilities. These improvements were consistent across three diverse geographic areas. There were some specific geographic differences.

Perioperative effects of oral ketorolac and acetaminophen in children undergoing bilateral myringotomy

Prophylactic administration of analgesics before surgery can decrease the intraoperative anaesthetic requirement and decrease pain during the early postoperative period. In a double-blind, placebo-controlled study involving 90 healthy ASA physical status I or II children undergoing bilateral myringotomy, we compared the postoperative analgesic effects of oral acetaminophen and ketorolac, when administered 30 min before induction of anaesthesia. Patients were randomized to receive saline (0.1 ml.kg-1), acetaminophen (10 mg.kg-1) or ketorolac (1 mg.kg-1) diluted in cherry syrup to a total volume of 5 ml. Anaesthesia was induced and maintained with halothane and nitrous oxide via a face mask. Postoperative pain was assessed by a blinded observer using an objective pain scale. The three study groups were similar with respect to demographic data, duration of anaesthesia and surgery, induction behaviour, oxygen saturation, incidence of postoperative emesis and, recovery times. The ketorolac group had lower postoperative pain scores and required less frequent analgesic therapy in the early postoperative period compared with the acetaminophen and placebo groups. In contrast, there were no differences in pain scores or analgesic requirements between the acetaminophen and the placebo groups. We conclude that the preoperative administration of oral ketorolac, but not acetaminophen, provided better postoperative pain control than placebo in children undergoing bilateral myringotomy.

Self-reported anger in black high school adolescents

The purpose of this study was to explore the recognition and expression of anger in black high school adolescents. A total of 56 teens, aged 14-19 years, responded to questions about their recognition of anger, how and to whom they express anger, and to whom they refrain from expressing anger. They also stated their opinions about acceptable and unacceptable expressions of anger and its relationship to depression or suicide. Data were analyzed using frequency tabulations for all questions on the survey instrument. Specific variables of age, grade in school, gender, and family composition were analyzed by one-sample chi 2 tests (alpha set at 0.05). The study demonstrated 1) all the teens surveyed could recognize when they were angry; 2) most teens expressed anger to their friends, to their siblings, and to their mothers; 3) younger teens (ages 14-15 years) when compared to older teens (ages 18-19 years), identified mother as the one who made them angry; 4) females were more likely to feel like crying when angry; 5) females were more likely to feel like being silent when angry; 6) students from one- and two-parent homes did not differ in their expression of anger. Implications of this study include the recognition that anger is a natural, human emotion. Adolescents need to observe adults who can effectively manage behavior associated with anger. Problem solving skills, stress management techniques, and role play situations can be utilized as effective tools in the recognition and expression of anger in acceptable ways and in attempts at the prevention of dysfunctional anger.

Effects of olestra, a noncaloric fat substitute, on daily energy and fat intakes in lean men

Nutrient and energy intakes, hunger, and fullness were examined after the replacement of 36, 20, or 0 g fat in breakfast with olestra, a noncaloric fat substitute. Twenty-four lean, nondieting men (aged 21-30 y) participated in a placebo-controlled, three-condition crossover design. Self-selected, ad libitum intakes at lunch and dinner were monitored in the laboratory. Evening snacks and breakfast the next day were assessed through food diaries. Visual-analog-scale ratings including hunger and fullness were collected throughout the test days. Single-meal olestra substitution produced a significant dose-related reduction in the amount and percentage of energy from fat consumed daily with a reciprocal increase in carbohydrate intake. Daily energy intakes were not significantly different nor did ratings of hunger and fullness vary systematically between conditions. Consumption of olestra can reduce fat intake and increase carbohydrate intake without affecting total daily energy intake or usual patterns of hunger and fullness.

Behavioral contagion in sibships

A behavior is "contagious" if one person is more likely to exhibit it when a relevant other person has already done so. In this sense, behavioral contagion is commonly thought to contribute to many social problems, such as drug abuse and teenage promiscuity. In this paper we focus on behavioral contagion in sibships. Borrowing a model from the theory of contagious diseases, we show that contagion will cause prevalence to increase with sibship size. This model also allows us to estimate the magnitude of the contagious factor relative to non-contagious factors. Finally, we develop two statistical tests for the presence of contagion. Results are presented for participation in a skill-development program and four child-psychiatric conditions: neurosis, hyperactivity, somatization, and conduct disorder. Evidence is presented that program participation is probably contagious and conduct disorder possibly so. The other three child-psychiatric conditions are shown not to be contagious. Implications for research and practice are discussed.

Comparison of ketorolac and morphine as adjuvants during pediatric surgery

The intraoperative use of opioid analgesics decreases the volatile anesthetic requirement and provides for pain relief in the early postoperative period. In a randomized double-blind, placebo-controlled study involving 95 ASA physical status 1 or 2 children (ages 5-15 yr) undergoing general anesthesia for elective operations, we compared postoperative analgesia following the intraoperative intravenous (iv) administration of ketorolac, a nonsteroidal antiinflammatory drug or morphine, an opioid analgesic. After induction of general anesthesia and before the start of the surgical procedure, children received equal volumes of saline, morphine (0.1 mg.kg-1, iv) or ketorolac (0.9 mg.kg-1, iv). Postoperative pain was evaluated by the child using a 10-cm linear visual analog scale (VAS) and by a blinded observer using both a VAS and an objective pain scale (OPS) in the postanesthesia care unit (PACU). There were no statistically significant differences in the VAS and OPS scores in the PACU or in the postoperative analgesic requirements in children receiving morphine or ketorolac. The placebo group had a significantly higher VAS and OPS score and required earlier and more frequent analgesic therapy in the PACU compared to the two analgesic groups. Patients receiving ketorolac had less postoperative emesis than those receiving morphine. We conclude that ketorolac (0.9 mg.kg-1) is an effective alternative to morphine (0.1 mg.kg-1) as an iv adjuvant during general anesthesia, and in the dose used in this study, is associated with less postoperative nausea and vomiting in children.

Specificity of effect in psychiatric research

In the last ten years the genes responsible for Huntington's disease and several other neurological disorders have been localized to specific chromosomes. Huntington's disease is now known to be caused by a gene on the short arm of chromosome 4. While these advances are welcome, they also pose a problem. All studies to date have been passive observational studies; none has been experimental. Arguably the most successful and significant attributions of cause in neurological history have been achieved by non experimental methods. This realization is somewhat disconcerting, considering that virtually all textbooks in epidemiology insist that true experiments (randomized trials) are the prime means of establishing cause. One cannot help but ask how these unauthorized successes were achieved. What are the principles of investigation that made them possible? In this paper we argue that the recent advances in neurological genetics, along with much else in human genetics, depend heavily on "specificity of effect." Just what this principle is and how it allows successful attribution of cause is explained. Various applications elsewhere in the medical and behavioural sciences and in psychiatry are discussed.

IQ and the genetics of autism

While there seems to be general agreement that genetic factors play some role in the etiology of autism, many important questions remain unresolved. The purpose of this paper is to review five issues with respect to the association between low IQ and autism from a familial-genetic viewpoint: (1) does IQ estimate the severity of the autistic genotype?; (2) what is the relationship between probands' and sibs' IQs?; (3) what is the relationship between parents' and probands' IQs?; (4) why do females with autism have lower IQs than males with the disorder?; and (5) does IQ vary with the cause of autism? With respect to each issue, possible resolutions are outlined, as are the implications for understanding the genetic mode of transmission. The review concludes with a possible model for the genetic etiology of autism.

Serum 25-hydroxyvitamin D concentrations of free-living subjects consuming olestra

The effect of olestra on vitamin D status was assessed in a 6-wk, double-blind, placebo-controlled study involving 202 free-living adults. Subjects consumed a total of 20 g/d of olestra or triglycerides in cookies eaten at each meal. A 20-micrograms ergocalciferol capsule was taken with each morning meal. Serum 25-hydroxyergocalciferol (25-OHD2) concentrations rose from approximately 5.7 to 39.0 and 31.7 nmol/L in the placebo and olestra groups, respectively, at week 6. At week 6, 25-OHD2 contributed 46-54% to total serum 25-OHD concentration compared with 11% at baseline. The 19% decrease in serum 25-OHD2 concentrations produced by olestra in this study is equivalent to a decrease of approximately 1.2 nmol/L under nonsupplemented dietary conditions. Ingesting 20 g olestra/d in the diet is thus not expected to affect vitamin D nutritional status.

Vitamin K status of free-living subjects consuming olestra

The potential for 20 g olestra/d to affect vitamin K status was assessed in a 6-wk study involving 202 free-living subjects. Functional prothrombin [Simplastin (S)-Ecarin (E) assay] concentrations and classical clotting times were unaffected by olestra. Initial S:E values were 0.80 and 0.79 for the olestra and placebo groups, respectively, compared with a value of 0.92 for normal reference plasma. At week 6 the value was 0.81 for both groups. Mean phylloquinone serum concentrations, expressed as differences from baseline, were not significantly different between groups. Weekly food diaries indicated that the average phylloquinone intake of the subjects was low, approximately 60 micrograms/d. Sensitive measures of vitamin K status were unaffected in a population where any significant decrease in phylloquinone bioavailability should have been reflected in those measures, indicating that 20 g olestra/d in the diet did not affect vitamin K status.

Lung fibroblasts from animals breathing 100% oxygen produce growth factors for alveolar type II cells

Type II cells were isolated from rats with a purity of 80-95% with less than 4% macrophages. These cells, after plating for approximately 16 h, were cultured with 50% RPMI 1640 and 50% (vol/vol) conditioned medium obtained from confluent hamster lung fibroblasts, together with 0.1% fetal calf serum (FCS). Conditioned media were obtained from either fibroblasts derived from normal hamsters breathing room air [normoxic-conditioned medium (NCM)] or from hamsters exposed for 4 days to 100% O2 [hyperoxic-conditioned medium (HCM)]. Controls consisted of 100% minimal essential medium (MEM) containing 0.1% FCS. Over a 96-h culture period, NCM stabilized cell populations but was unable to induce proliferation. In contrast, at low cell densities, HCM could cause a two- to threefold increase in type II cell number within 24-48 h after introduction. This effect could not be demonstrated at high cell densities. When tested with FCS concentrations ranging from 0 to 10%, maximum effects were obtained using 0.1-0.2% FCS. We conclude that lung fibroblasts from oxidant-injured hamsters produce growth factors that can stimulate at least one mitotic division in cultured type II cells, which are plated at low density. These factors are absent, or present in much lower concentration, in lung fibroblasts from normal animals.

Extracorporeal membrane oxygenation and indications for cardiopulmonary bypass in the neonate

Extracorporeal membrane oxygenation (ECMO) is a rescue technique used for term and near-term neonates who have respiratory failure that is unresponsive to conventional therapy. The complexity of the equipment necessitates intensive training of a specialized team before setting up an ECMO unit. An understanding of the physiology underlying ECMO and the criteria used for patient selection assists the nurse in identifying neonates who might benefit from the technique.

The effect of olestra on systemic levels of oral contraceptives

The effect of olestra, a nonabsorbable, noncaloric fat replacement, on the absorption and efficacy of a highly lipophilic oral contraceptive was investigated in a double-blind, placebo-controlled crossover study with 28 women. Subjects consumed 18 gm/day olestra for 28 days while taking an oral contraceptive containing 300 micrograms of norgestrel and 30 micrograms ethinyl estradiol (Lo/Ovral-28). Blood taken on days 12 to 14 of the treatment cycles was analyzed for ethinyl estradiol and norgestrel. There was no statistically significant difference in time to attain maximum concentration, maximum concentration, or area under the concentration-time curve between the olestra and placebo treatments for either drug component. Measurements of serum progesterone indicated that olestra ingestion did not reduce efficacy as indicated by ovulation. The data show that ingestion of 18 gm/day olestra did not affect the absorption or efficacy of the highly lipophilic oral contraceptive.

A physiologic approach to identifying neonates at risk for kernicterus

Nurses routinely assess skin color and serum bilirubin levels to identify newborns at risk for kernicterus. High serum bilirubin levels can be toxic to the central nervous system. Through careful evaluation, nurses can help prevent the occurrence of adverse consequences from hyperbilirubinemia. By understanding the physiologic principles involved in bilirubin metabolism and the transition that must be made at birth, nurses can help in identifying and assessing risk factors in the newborn.

Wound repair and the potential use of growth factors

Failure of wounds to heal increases the physical and financial burden of hospitalization and increases the work load for health care professionals. Although careful attention to nutrition (including adequate replacement of vitamins and trace mineral elements), tissue perfusion and oxygenation, and wound dressing and sanitation promote more rapid and complete healing, some wounds respond only slowly or not at all to these conventional treatment modalities. A group of polypeptide growth factors, including epidermal growth factor, platelet-derived growth factor, transforming growth factor beta, and basic fibroblast growth factor, have been found to promote or hasten healing in animal models. This technology is now moving into the clinical arena where its potential for human healing must be evaluated.

A newly identified iron binding protein in duodenal mucosa of rats. Purification and characterization of mobilferrin

An iron binding protein with an approximate molecular mass of 56,000 daltons was purified to homogeneity from homogenates of rat duodenal mucosa. The protein was biochemically and immunologically distinct from transferrin and ferritin and competitively bound cobalt, copper, zinc, and lead. Each molecule bound one molecule of iron with a Kd of 9 X 10(-5). Dissociation of iron and the protein was accelerated at acid pH. Using an immunogold method, the protein was identified in the apical cytoplasm of proximal small intestinal cells and was not observed elsewhere in the intestinal mucosa and in other body organs. It was named mobilferrin from its city of origin and to differentiate it from other previously identified iron binding proteins.