Honey bees switch mechanisms to drink deep nectar efficiently.

The feeding mechanisms of animals constrain the spectrum of resources that they can exploit profitably. For floral nectar eaters, both corolla depth and nectar properties have marked influence on foraging choices. We report the multiple strategies used by honey bees to efficiently extract nectar at the range of sugar concentrations and corolla depths they face in nature. Honey bees can collect nectar by dipping their hairy tongues or capillary loading when lapping it, or they can attach the tongue to the wall of long corollas and directly suck the nectar along the tongue sides. The honey bee feeding apparatus is unveiled as a multifunctional tool that can switch between lapping and sucking nectar according to the instantaneous ingesting efficiency, which is determined by the interplay of nectar-mouth distance and sugar concentration. These versatile feeding mechanisms allow honey bees to extract nectar efficiently from a wider range of floral resources than previously appreciated and endow them with remarkable adaptability to diverse foraging environments.

Introduction of transcatheter edge-to-edge repair in patients with congenital heart disease at a children's hospital.

BACKGROUND: Atrioventricular valve regurgitation (AVVR) is a devastating complication in children and young adults with congenital heart disease (CHD), particularly in patients with single ventricle physiology. Transcatheter edge-to-edge repair (TEER) is a rapidly expanding, minimally invasive option for the treatment of AVVR in adults that avoids the morbidity and mortality associated with open heart surgery. However, application of TEER in in CHD and in children is quite novel. We describe the development of a peri-procedural protocol including image-derived pre-intervention simulation, with successful application to four patients. AIMS: To describe the initial experience using the MitraClip system for TEER of dysfunctional systemic atrioventricular valves in patients with congential heart disease within a pediatric hospital. METHODS: A standardized screening and planning process was developed using cardiac magnetic resonance imaging, three dimensional echocardiography and both virtual and physical simulation. Procedures were performed using the MitraClip G4 system and patients were clinically followed post-intervention. RESULTS: A series of four CHD patients with at least severe AVVR were screened for suitability for TEER with the MitraClip system: three patients had single ventricle physiology and Fontan palliation, and one had repair of a common atrioventricular canal defect. Each patient had at least severe systemic AVVR and was considered at prohibitively high risk for surgical repair. Each patient underwent a standardized preprocedural screening protocol and image-derived modeling followed by the TEER procedure with successful clip placement at the intended location in all cases. CONCLUSIONS: The early results of our protocolized efforts to introduce TEER repair of severe AV valve regurgitation with MitraClip into the CHD population within our institution are encouraging. Further investigations of the use of TEER in this challenging population are warranted.

Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression.

Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage. Re-routing the innominate vein to the pulmonary venous atrium decompresses the thoracic duct, as atrial pressure is lower than systemic venous pressure in Fontan circulation. Transcatheter thoracic duct decompression is a new minimally invasive procedure that involves placing covered stents from the innominate vein to the atrium. Patients undergoing this procedure require multiple general anesthetics, presenting challenges in managing the sequelae of disordered lymphatic flow superimposed on Fontan physiology. We reviewed the first 20 patients at the Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for transcatheter thoracic duct decompression between March 2018 and February 2023. The patients ranged in age from 3 to 26 years. The majority had failed prior catheter-based lymphatic intervention, including selective embolization of abnormal lympho-intestinal and lympho-bronchial connections to treat lymphatic failure in a single compartment. Fourteen had failure in three lymphatic compartments. Patients were functionally impaired (ASA 3-5) with significant comorbidities. Concurrent with thoracic duct decompression, three patients required fenestration closure for the resultant decrease in oxygen saturation. Ten patients had improvement in symptoms, seven had no changes and three have limited follow up. Five (25%) of these patients were deceased as of January 2024 due to non-lymphatic complications from Fontan failure.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease.

BACKGROUND: Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children. METHODS: Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 µg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg. RESULTS: A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 µg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 µg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 µg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg. CONCLUSIONS: Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

Supporting early infant relationships and reducing maternal distress with the Newborn Behavioral Observations: A randomized controlled effectiveness trial.

Research points to the significant impact of maternal distress on the parent-infant relationship and infant development. The Newborn Behavioral Observations (NBO) is a brief intervention supporting the infant, the parent and their relationship. This randomized controlled trial examined the effectiveness of the NBO in a population with antenatal distress and risk of postnatal depression (PND). Pregnant, first-time mothers with current anxiety or depression symptoms or past mental illness were recruited from two Australian hospitals. Participants received three NBO sessions in the first month of life plus treatment as usual (TAU), or, TAU-only. Outcomes assessed at infant age 4 months included mother-infant interaction quality; maternal anxiety and depression symptoms; and depression diagnosis. Of 111 pregnant individuals randomized, 90 remained eligible and 74 completed the trial (82.2% retention). There were intervention effects on emotional availability F(6, 67) = 2.52, p = .049, Cohen's d = .90, with higher sensitivity and non-intrusiveness in the intervention group (n = 40) than the comparison group (n = 34). There was an intervention effect approaching significance for anxiety symptoms at 4 months (p = .06), and a significant effect over time (p = .014), but not for depression symptoms. Anxiety and depression symptoms significantly reduced to sub-clinical levels within the intervention group only. There were fewer depression diagnoses (n = 6) than expected across groups, with no observed intervention effect. No adverse intervention effects were seen. Exploratory analysis of sensory processing sensitivity suggested differential susceptibility to distress and intervention benefits. The NBO was accepted and exerted meaningful effects on relationship quality and distress; and may enhance the infant's interaction experience and maternal emotional adjustment in at-risk populations.

La angustia materna tiene impacto en las relaciones progenitor-infante y el desarrollo del infante. Las Observaciones del Comportamiento del Recién Nacido (NBO) es una intervención breve para apoyar al infante, al progenitor y la relación entre ellos. Este ensayo controlado al azar examinó la eficacia de NBO en un grupo de población con angustia antenatal y riesgo de depresión postnatal. En dos hospitales australianos, se reclutaron madres embarazadas, primerizas, con síntomas presentes de ansiedad o depresión, o enfermedad mental anterior. Las participantes recibieron tres sesiones de NBO en el primer mes de vida más el tratamiento como se acostumbra (TAU), o sólo TAU. Entre los resultados evaluados a los 4 meses se incluye la calidad de la interacción madre-infante, la ansiedad materna y síntomas de depresión, así como el diagnóstico de depresión. De las 111 mujeres embarazadas seleccionadas al azar, 90 quedaron siendo elegibles y 74 completaron el ensayo (retención 82.2%). La intervención mejoró significativamente la disponibilidad de interacción emocional F(6,67) = 2.52, p = .049, puntaje Cohen d = .90, y redujo síntomas de ansiedad a lo largo del tiempo (p = .014) entre quienes completaron el grupo de intervención (n = 40) versus el grupo comparativo (n = 34). El grupo de intervención mostró significativas reducciones en ansiedad y síntomas de depresión a niveles subclínicos, tanto en el examen previo como en el posterior. En el diagnóstico de depresión, no se observaron efectos de intervención. No se dio ningún efecto adverso de intervención. El proceso sensorial de la sensibilidad diferenció entre susceptibilidad a la angustia y los beneficios de la intervención. La NBO tuvo efectos en la calidad de la relación y la angustia; y pudiera haber mejorado la experiencia de interacción del infante y el ajuste emocional materno en los grupos clínicos de población.

Les recherches pointent vers un impact important de la détresse maternelle sur la relation parent-nourrisson et le développement du nourrisson. Les Observations Comportementale du Nouveau-né (abrégé ici OCN en français) est une intervention courte soutenant le nourrisson, le parent et leur relation. Cet essai contrôlé randomisé a examiné l'efficacité de l'OCN chez une population clinique avec une détresse anténatale et un risque de dépression postnatale. Des mères primipares enceintes avec des symptômes d'anxiété et de dépression ou de dépression passée ont été recrutées dans deux hôpitaux australiens. Les participants ont reçu trois séances OCN durant le premier mois de vie plus un traitement habituel ou seulement un traitement habituel. Les résultats ont été évalués à l'âge de quatre mois du nourrisson, y compris la qualité de l'interaction mère-nourrisson, l'anxiété maternelle, la dépression et les symptômes de stress de parentage, et le diagnostic de dépression. De 111 participantes enceintes randomisées, 90 sont demeurées éligibles et 74 ont complété l'étude (82,2% de rétention). On a trouvé des effets de l'intervention sur la disponibilité émotionnelle F(6, 67) = 2,52, p = ,049, d = ,90 de Cohen, avec une sensibilité plus élevée et un caractère non intrusif dans le groupe d'intervention (n = 40) dans le groupe de comparaison (n = 34). Il y avait des différences de groupe importantes dans les niveaux d'anxiété au fil du temps (p = ,014). L'anxiété et les symptômes de dépression ont été très largement réduits à des niveaux subcliniques au sein du groupe d'intervention. Aucun effet négatif d'intervention n'a été observé. Une analyse exploratoire de sensibilité du traitement sensoriel a révélé une susceptibilité différentielle à la détresse et aux bénéfices de l'intervention. L'OCN a été acceptée et a produit des effets significatifs sur la qualité de la relation et la détresse, et peut améliorer l'expérience d'interaction du nourrisson et l'ajustement émotionnel maternel chez les populations cliniques.

Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study.

OBJECTIVES: The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants. DESIGN: Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry. SETTING: Four Pediatric Heart Network Collaborative Learning Study active-site hospitals. PATIENTS: Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras. CONCLUSIONS: We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.

Drinking made easier: honey bee tongues dip faster into warmer and/or less viscous artificial nectar.

Optimal concentrations for nectar drinking are limited by the steep increase in the viscosity of sugar solutions with concentration. However, nectar viscosity is inversely related to temperature, which suggests there are advantages to foraging from flowers that are warmer than the surrounding air. The honey bee (Apis mellifera L.) dips nectar using a hairy tongue. However, the microscopic dynamics of the tongue while the bee ingests nectar of varying concentration, viscosity and temperature are unknown. In this study, we found that honey bees respond to the variation of nectar properties by regulating dipping frequency. Through high-speed imaging, we discovered that the honey bee traps warmer sucrose solutions with a quicker tongue. The honey bee dips the warmest and most dilute solution (40°C and 25% w/w sucrose) 1.57 times as fast as the coldest and thickest solution (20°C and 45% w/w sucrose). When the viscosity of different sucrose concentrations was kept constant by adding the inert polysaccharide Tylose, honey bees dipped nectar at constant frequency. We propose a fluid mechanism model to elucidate potential effects on sucrose intake and show that higher dipping frequency can increase the volumetric and energetic intake rates by 125% and 15%, respectively. Our findings broaden insights into how honey bees adapt to foraging constraints from the perspective of tongue dynamics, and demonstrate that elevated intrafloral temperatures and lower nectar viscosity can improve the volumetric and energetic intake rates of pollinators.

Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects.

OBJECTIVES: In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center. DESIGN: Quality improvement project. SETTING: High volume cardiac center, tertiary care children's hospital. PATIENTS: Neonates undergoing Norwood operation. INTERVENTIONS: The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients. MEASUREMENTS AND MAIN RESULTS: One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02). CONCLUSIONS: This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.

Clinical Update in Pediatric Sepsis: Focus on Children With Pre-Existing Heart Disease.

SEPSIS REMAINS one of the most common causes of childhood morbidity, mortality, and higher healthcare costs, with over 75,000 hospital admissions in the United States and an estimated 4 million cases worldwide per year. While standardized criteria to define sepsis are in flux, the general concept of sepsis is a severe infection that results in organ dysfunction. Although sepsis can affect previously healthy children, those with certain pre-existing comorbid conditions, including congenital and acquired heart disease, are at higher risk for both developing sepsis and having a poor outcome after sepsis. Multiple specialists including intensivists, cardiologists, surgeons, and anesthesiologists commonly contribute to the management and outcome of sepsis in children. In this article, the authors examine the evolving epidemiology of pediatric sepsis, including the subset of patients with underlying heart disease; contrast pediatric and adult sepsis; review the latest hemodynamic guidelines for management of pediatric septic shock and their application to children with heart disease; discuss the role of mechanical circulatory support; and review key aspects of anesthetic management for children with sepsis.

Mentalisation Amongst Maternal and Child Health Nurses Using the Newborn Behavioural Observations With Infant-mother dyads: A Qualitative Study.

PURPOSE: This study explored Maternal and Child Health Nurses' (MCHN) mentalisation processes towards infant-mother dyads when using the Newborn Behavioural Observations (NBO) system in practice. DESIGN AND METHODS: Ten Australian MCHNs (female; aged 31-66 years), who had used the NBO clinically within the last 12 months, were recruited from a database of NBO-trained practitioners. Interpretative phenomenological analysis of one-on-one semi-structured interviews explored MCHNs experiential meaning-making. RESULTS: Analysis of the data produced four main themes: reflections regarding the dyad, personal reflections, reflection into action, and professional identity and future practice. MCHNs reported that the NBO's focus on the pre-verbal infant provided them with an added dynamic to consultations outside of the practitioner-caregiver relationship. Thus, they were able to provide holistic and collaborative relationship support to infant-mother dyads. Emotional satisfaction and pride in profession were also reported; in current literature, these factors have been found to reduce burnout in primary care providers. CONCLUSIONS: The NBO appears to promote practitioner mentalisation, offering MCHNs a framework and confidence to apply infant mental health theory practically. PRACTICE IMPLICATIONS: The NBO offers potential benefits to child and family health nursing practice, and other primary care providers, who offer infant mental health and relationship support as part of their work with families in the first three months. The NBO also provides a means to shift from prescriptive to mentalisation-based, infant-inclusive, and individualised practice.

Damaging Variants in Proangiogenic Genes Impair Growth in Fetuses with Cardiac Defects.

OBJECTIVE: To determine the impact of damaging genetic variation in proangiogenic pathways on placental function, complications of pregnancy, fetal growth, and clinical outcomes in pregnancies with fetal congenital heart defect. STUDY DESIGN: Families delivering a baby with a congenital heart defect requiring surgical repair in infancy were recruited. The placenta and neonate were weighed and measured. Hemodynamic variables were recorded from a third trimester (36.4 ± 1.7 weeks) fetal echocardiogram. Exome sequencing was performed on the probands (N = 133) and consented parents (114 parent-child trios, and 15 parent-child duos) and the GeneVetter analysis tool used to identify damaging coding sequence variants in 163 genes associated with the positive regulation of angiogenesis (PRA) (GO:0045766). RESULTS: In total, 117 damaging variants were identified in PRA genes in 133 congenital heart defect probands with 73 subjects having at least 1 variant. Presence of a damaging PRA variant was associated with increased umbilical artery pulsatility index (mean 1.11 with variant vs 1.00 without; P = .01). The presence of a damaging PRA variant was also associated with lower neonatal length and head circumference for age z score at birth (mean -0.44 and -0.47 with variant vs 0.23 and -0.05 without; P = .01 and .04, respectively). During median 3.1 years (IQR 2.0-4.1 years) of follow-up, deaths occurred in 2 of 60 (3.3%) subjects with no PRA variant and in 9 of 73 (12.3%) subjects with 1 or more PRA variants (P = .06). CONCLUSIONS: Damaging variants in proangiogenic genes may impact placental function and are associated with impaired fetal growth in pregnancies involving a fetus with congenital heart defect.

Adult diet does not compensate for impact of a poor larval diet on stress resistance in a tephritid fruit fly.

Adult holometabolous insects may derive metabolic resources from either larval or adult feeding, but little is known of whether adult diets can compensate for deficiencies in the larval diet in terms of stress resistance. We investigated how stress resistance is affected and compensated for by diet across life stages in the marula fruit fly Ceratitis cosyra (Diptera: Tephritidae). Larvae were fed diets containing either 8% torula yeast, the standard diet used to rear this species, or 1% yeast (low protein content similar to known host fruit). At emergence, adults from each larval diet were tested for initial mass, water content, body composition, and desiccation and starvation resistance or they were allocated to one of two adult diet treatments: sucrose only, or sucrose and yeast hydrolysate. The same assays were then repeated after 10 days of adult feeding. Development on a low protein larval diet led to lower body mass and improved desiccation and starvation resistance in newly emerged adults, even though adults from the high protein larval diet had the highest water content. Adult feeding decreased desiccation or starvation resistance, regardless of the diet provided. Irrespective of larval diet history, newly emerged, unfed adults had significantly higher dehydration tolerance than those that were fed. Lipid reserves played a role in starvation resistance. There was no evidence for metabolic water from stored nutrients extending desiccation resistance. Our findings show the possibility of a nutrient-poor larval environment leading to correlated improvement in adult performance, at least in the short term.

Results of a phase 1 multicentre investigation of dexmedetomidine bolus and infusion in corrective infant cardiac surgery.

BACKGROUND: Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS: We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS: Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS: When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION: NCT01915277.

Prenatal yoga for young women a mixed methods study of acceptability and benefits.

BACKGROUND: High rates of psychological-distress, trauma and social complexity are reported among young pregnant women. At the Royal Women's Hospital, Australia, young pregnant women acknowledge wanting tools to improve maternal wellbeing yet remain challenging to engage in antenatal education and support. While yoga is a widely accepted and participated activity in pregnancy, with demonstrated benefits for adult pregnant women, adolescent women are often excluded from both these yoga interventions and related pregnancy studies. METHODS: This mixed methods study examined the acceptability and benefits of yoga for young women. We recruited 30 participants aged under 24 years, who were offered twice a week, one-hour voluntary prenatal yoga sessions throughout their pregnancy. A medical file audit gathered baseline demographics, pre and post yoga session surveys were administered and brief individual interview were conducted with study participants. RESULTS: While 26 study participants were positive about the availability of a yoga program, only 15 could attend yoga sessions (mean = 8 sessions, range 1-27). No differences were found in the demographic or psychosocial factors between those who did and did not attend the yoga sessions. The medical file audit found that 60% of all the study participants had a documented history of psychological distress. Barriers to participation were pragmatic, not attitudinal, based on the timing of the group sessions, transport availability and their own health. All study participants identified perceived benefits, and the yoga participants identified these as improved relaxation and reduction of psychological distress; labour preparation; bonding with their baby in utero; and social connectedness with the yoga group peers. CONCLUSIONS: This study demonstrated yoga was acceptable to young pregnant women. For those who did participate in the sessions, yoga was found to decrease self-reported distress and increase perceived skills to assist with their labour and the birth of their baby. The provision of accessible yoga programs for pregnant young women is recommended.

Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study.

OBJECTIVES: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING: Five children's hospitals. PATIENTS: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.

Risk factors for mortality in paediatric cardiac ICU patients managed with extracorporeal membrane oxygenation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation is frequently used in patients with cardiac disease. We evaluated short-term outcomes and identified factors associated with hospital mortality in cardiac patients supported with veno-arterial extracorporeal membrane oxygenation. METHODS: A retrospective review of patients supported with veno-arterial extracorporeal membrane oxygenation at a university-affiliated children's hospital was performed. RESULTS: A total of 253 patients with cardiac disease managed with extracorporeal membrane oxygenation were identified; survival to discharge was 48%, which significantly improved from 39% in an earlier era (1995-2001) (p=0.01). Patients were categorised into surgical versus non-surgical groups on the basis of whether they had undergone cardiac surgery before or not, respectively. The most common indication for extracorporeal membrane oxygenation was extracorporeal cardiopulmonary resuscitation: 96 (51%) in the surgical group and 45 (68%) in the non-surgical group. In a multiple covariate analysis, single-ventricle physiology (p=0.01), duration of extracorporeal membrane oxygenation (p<0.01), and length of hospital stay (p=0.03) were associated with hospital mortality. Weekend or night shift cannulation was associated with mortality in non-surgical patients (p=0.05). CONCLUSION: We report improvement in survival compared with an earlier era in cardiac patients supported with extracorporeal membrane oxygenation. Single-ventricle physiology continues to negatively impact survival, along with evidence of organ dysfunction during extracorporeal membrane oxygenation, duration of extracorporeal membrane oxygenation, and length of stay.

Nutritional Physiology and Ecology of Honey Bees.

Honey bees feed on floral nectar and pollen that they store in their colonies as honey and bee bread. Social division of labor enables the collection of stores of food that are consumed by within-hive bees that convert stored pollen and honey into royal jelly. Royal jelly and other glandular secretions are the primary food of growing larvae and of the queen but are also fed to other colony members. Research clearly shows that bees regulate their intake, like other animals, around specific proportions of macronutrients. This form of regulation is done as individuals and at the colony level by foragers.

Neurological Injury and Cerebral Blood Flow in Single Ventricles Throughout Staged Surgical Reconstruction.

BACKGROUND: Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown. METHODS: Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction. RESULTS: One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients (P<0.05). BDG patients had significantly higher cerebral blood flow than did Fontan patients. The odds of discovering brain injury with adjustment for surgical stage as well as ≥2 coexisting lesions within a patient decreased (63%-75% and 44%, respectively) with increasing amount of cerebral blood flow (P<0.05). In general, there was no association of oxygen delivery (except for ventriculomegaly in the BDG group) or carbon dioxide reactivity with neurological injury. CONCLUSIONS: Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO2 reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135081.

Hearing Loss after Cardiac Surgery in Infancy: An Unintended Consequence of Life-Saving Care.

OBJECTIVES: To investigate the prevalence of hearing loss after cardiac surgery in infancy, patient and operative factors associated with hearing loss, and the relationship of hearing loss to neurodevelopmental outcomes. STUDY DESIGN: Audiologic and neurodevelopmental evaluations were conducted on 348 children who underwent repair of congenital heart disease at the Children's Hospital of Philadelphia as part of a prospective study evaluating neurodevelopmental outcomes at 4 years of age. A prevalence estimate was calculated based on presence and type of hearing loss. Potential risk factors and the impact of hearing loss on neurodevelopmental outcomes were evaluated. RESULTS: The prevalence of hearing loss was 21.6% (95% CI, 17.2-25.9). The prevalence of conductive hearing loss, sensorineural hearing loss, and indeterminate hearing loss were 12.4% (95% CI, 8.8-16.0), 6.9% (95% CI, 4.1-9.7), and 2.3% (95% CI, 0.6-4.0), respectively. Only 18 of 348 subjects (5.2%) had screened positive for hearing loss before this study and 10 used a hearing aid. After adjusting for patient and operative covariates, younger gestational age, longer postoperative duration of stay, and a confirmed genetic anomaly were associated with hearing loss (all P < .01). The presence of hearing loss was associated with worse language, cognition and attention (P <.01). CONCLUSIONS: These findings suggest that the prevalence of hearing loss in preschool children after heart surgery in infancy may be 20-fold higher than in the 1% prevalence seen in the general population. Younger gestational age, presence of a genetic anomaly, and longer postoperative duration of stay were associated with hearing loss. Hearing loss was associated with worse neurodevelopmental outcomes.

Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship.

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.