Incidence of adverse respiratory events after adjustment of clear fluid fasting recommendations to 1 h: a prospective, observational, multi-institutional cohort study.

BACKGROUND: Preoperative fasting reduces the risk of pulmonary aspiration during anaesthesia, and 2-h fasting for clear fluids has commonly been recommended. Based on recent evidence of shorter fasting times being safe, the Swiss Society of Paediatric Anaesthesia began recommending 1-h fasting for clear fluids in 2018. This prospective, observational, multi-institutional cohort study aimed to investigate the incidence of adverse respiratory events after implementing the new national recommendation. METHODS: Eleven Swiss anaesthesia institutions joined this cohort study and included patients aged 0-15 yr undergoing anaesthesia for elective procedures after implementation of the 1-h fasting instruction. The primary outcome was the perioperative (defined as the time from anaesthesia induction to emergence) incidence of pulmonary aspiration, gastric regurgitation, and vomiting. Data are presented as median (inter-quartile range; minimum-maximum) or count (percentage). RESULTS: From June 2019 to July 2021, 22 766 anaesthetics were recorded with pulmonary aspiration occurring in 25 (0.11%), gastric regurgitation in 34 (0.15%), and vomiting in 85 (0.37%) cases. No major morbidity or mortality was associated with pulmonary aspiration. Subgroup analysis by effective fasting times (<2 h [n=7306] vs ≥2 h [n=14 660]) showed no significant difference for pulmonary aspiration between these two groups (9 [0.12%] vs 16 [0.11%], P=0.678). Median effective fasting time for clear fluids was 157 [104-314; 2-2385] min. CONCLUSIONS: Implementing a national recommendation of 1-h clear fluid fasting was not associated with a higher incidence of pulmonary aspiration compared with previously reported data.

Intensive Care Unit Analgosedation After Cardiac Surgery in Children with Williams Syndrome : a Matched Case-Control Study.

OBJECTIVE: Cardiovascular abnormalities are common in patients with Williams syndrome and frequently require surgical intervention necessitating analgesia and sedation in a population with a unique neuropsychiatric profile, potentially increasing the risk of adverse cardiac events during the perioperative period. Despite this risk, the overall postoperative analgosedative requirements in patients with WS in the cardiac intensive care unit have not yet been investigated. Our primary aim was to examine the analgosedative requirement in patients with WS after cardiac surgery compared to a control group. Our secondary aim was to compare the frequency of major ACE and mortality between the two groups. DESIGN: Matched case-control study. SETTING: Pediatric CICU at a Tertiary Children's Hospital. PATIENTS: Patients with WS and age-matched controls who underwent cardiac surgery and were admitted to the CICU after cardiac surgery between July 2014 and January 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Postoperative outcomes and total doses of analgosedative medications were collected in the first six days after surgery for the study groups. Median age was 29.8 (12.4-70.8) months for WS and 23.5 (11.2-42.3) months for controls. Across all study intervals (48 h and first 6 postoperative days), there were no differences between groups in total doses of morphine equivalents (5.0 mg/kg vs 5.6 mg/kg, p = 0.7 and 8.2 mg/kg vs 10.0 mg/kg, p = 0.7), midazolam equivalents (1.8 mg/kg vs 1.5 mg/kg, p = 0.4 and 3.4 mg/kg vs 3.8 mg/kg, p = 0.4), or dexmedetomidine (20.5 mcg/kg vs 24.4 mcg/kg, p = 0.5 and 42.3 mcg/kg vs 39.1 mcg/kg, p = 0.3). There was no difference in frequency of major ACE or mortality. CONCLUSIONS: Patients with WS received similar analgosedative medication doses compared with controls. There was no significant difference in the frequency of major ACE (including cardiac arrest, extracorporeal membrane oxygenation, and surgical re-intervention) or mortality between the two groups, though these findings must be interpreted with caution. Further investigation is necessary to elucidate the adequacy of pain/sedation control, factors that might affect analgosedative needs in this unique population, and the impact on clinical outcomes.

Acute Hemodynamics in the Fontan Circulation: Open-Label Study of Vasopressin.

OBJECTIVE: To describe the acute hemodynamic effect of vasopressin on the Fontan circulation, including systemic and pulmonary pressures and resistances, left atrial pressure, and cardiac index. DESIGN: Prospective, open-label, nonrandomized study (NCT04463394). SETTING: Cardiac catheterization laboratory at Lucile Packard Children's Hospital, Stanford. PATIENTS: Patients 3-50 years old with a Fontan circulation who were referred to the cardiac catheterization laboratory for hemodynamic assessment and/or intervention. INTERVENTIONS: A 0.03 U/kg IV (maximum dose 1 unit) bolus of vasopressin was administered over 5 minutes, followed by a maintenance infusion of 0.3 mU/kg/min (maximum dose 0.03 U/min). MEASUREMENTS AND MAIN RESULTS: Comprehensive cardiac catheterization measurements before and after vasopressin administration. Measurements included pulmonary artery, atrial, and systemic arterial pressures, oxygen saturations, and systemic and pulmonary flows and resistances. There were 28 patients studied. Median age was 13.5 (9.1, 17) years, and 16 (57%) patients had a single or dominant right ventricle. Following vasopressin administration, systolic blood pressure and systemic vascular resistance (SVR) increased by 17.5 (13.0, 22.8) mm Hg ( Z value -4.6, p < 0.001) and 3.8 (1.8, 7.5) Wood Units ( Z value -4.6, p < 0.001), respectively. The pulmonary vascular resistance (PVR) decreased by 0.4 ± 0.4 WU ( t statistic 6.2, p < 0.001), and the left atrial pressure increased by 1.0 (0.0, 2.0) mm Hg ( Z value -3.5, p < 0.001). The PVR:SVR decreased by 0.04 ± 0.03 ( t statistic 8.1, p < 0.001). Neither the pulmonary artery pressure (median difference 0.0 [-1.0, 1.0], Z value -0.4, p = 0.69) nor cardiac index (0.1 ± 0.3, t statistic -1.4, p = 0.18) changed significantly. There were no adverse events. CONCLUSIONS: In Fontan patients undergoing cardiac catheterization, vasopressin administration resulted in a significant increase in systolic blood pressure, SVR, and left atrial pressure, decrease in PVR, and no change in cardiac index or pulmonary artery pressure. These findings suggest that in Fontan patients vasopressin may be an option for treating systemic hypotension during sedation or general anesthesia.

Bronchopulmonary dysplasia.

Bronchopulmonary dysplasia is the most frequent adverse outcome of prematurity. Before implementation of antenatal steroids and surfactant therapy, bronchopulmonary dysplasia was mostly characterized by fibrotic, scarred, and hyper-inflated lungs due to pulmonary injury following mechanical ventilation and oxygen toxicity. With advances in neonatal medicine, this "old" bronchopulmonary dysplasia has changed to a "new" bronchopulmonary dysplasia characterized by an arrest in lung growth, leading to alveolar simplification and pulmonary vascular dysangiogenesis. While the old definition was based on the need for oxygen supplementation at a postnatal age of 28 days or at a corrected gestational age of 36 weeks, the newer definition looks at the mode of respiratory support required (eg, invasive versus noninvasive) and is then graded as mild, moderate, or severe. Patients with bronchopulmonary dysplasia may present with significantly impaired pulmonary function, reactive airway disease, or exercise intolerance. Over time, these patients may develop asthma or chronic obstructive pulmonary disease. The most serious long-term complication is the development of pulmonary vascular disease and pulmonary hypertension. Medical treatment often includes diuretics, steroids, bronchodilators, or oxygen supplementation and in the presence of pulmonary hypertension medication to decrease the pulmonary vascular resistance. Perioperative anesthetic risk is increased in children with pulmonary hypertension. These patients might require additional diagnostic imaging and plans for increased resource allocation such as postoperative intensive care admission.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care.

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Rabbit training model for establishing an emergency front of neck airway in children.

BACKGROUND: A 'cannot intubate, cannot oxygenate' (CICO) situation is rare in paediatric anaesthesia, but can always occur in children under certain emergency situations. There is a paucity of literature on specific procedures for securing an emergency invasive airway in children younger than 6 yr. A modified emergency front of neck access (eFONA) technique using a rabbit cadaver model was developed to teach invasive airway protection in a CICO situation in children. METHODS: After watching an instructional video of our eFONA technique (tracheotomy, intubation with Frova catheter over which a tracheal tube is inserted), 29 anaesthesiologists performed two separate attempts on rabbit cadavers. The primary outcome was the success rate and the performance time overall and in subgroups of trained and untrained participants. RESULTS: The overall success rate across 58 tracheotomies was 95% and the median performance time was 67 s (95% confidence interval [CI], 56-76). Performance time decreased from the first to the second attempt from 72 s (95% CI, 57-81) to 61 s (95% CI, 50-81). Performance time was 59 s (95% CI, 49-79) for untrained participants and 72 s (95% CI, 62-81) for trained participants. Clinical experience and age of the participants was not correlated with performance time, whereas the length of the tracheotomy incision showed a significant correlation (P=0.006). CONCLUSION: This eFONA training model for children facilitates rapid skill acquisition under realistic anatomical conditions to perform an emergency invasive airway in children younger than 2 yr.

Impact of Modified Anesthesia Management for Pediatric Patients With Williams Syndrome.

OBJECTIVE: This study compared the percent change in systolic blood pressure and the incidence of adverse cardiac events (ACEs; defined as cardiac arrest, cardiopulmonary resuscitation, arrhythmias, or ST-segment changes) during anesthesia induction in patients with Williams syndrome (WS) before and after implementation of a perioperative management strategy. DESIGN: Retrospective observational cohort study. SETTING: Single quaternary academic referral center. PARTICIPANTS: The authors reviewed the records of all children with WS at the authors' institution who underwent general anesthesia for cardiac catheterization, diagnostic imaging, or any type of surgery between November 2008 and August 2019. The authors identified 142 patients with WS, 48 of whom underwent 118 general anesthesia administrations. A historic group (HG) was compared with the intervention group (IG). INTERVENTIONS: Change in perioperative management (three-stage risk stratification: preoperative intravenous hydration, intravenous anesthesia induction, and early use of vasoactives). MEASUREMENTS AND MAIN RESULTS: The authors determined event rates within 60 minutes of anesthesia induction. Standardized mean difference (SMD) was calculated (SMD >0.2 suggests clinically meaningful difference). Sixty-seven general anesthesia encounters were recorded in the HG (mean age, 4.8 years; mean weight, 16.3 kg) and 51 in the IG (mean age, 6.0 years; mean weight, 18.2 kg). The change in systolic blood pressure was -17.5% (-30.0, -5.0) in the HG versus -9% (-18.0, 5.0) in the IG (p = 0.015; SMD = 0.419), and the incidence of ACEs was 6% in the HG and 2% in the IG (p = 0.542; SMD = 0.207). CONCLUSIONS: Preoperative risk stratification, preoperative intravenous hydration, intravenous induction, and early use of continuous vasoactives resulted in greater hemodynamic stability, with a 2% incidence of ACEs.

Revealing the diversity of amber source plants from the Early Cretaceous Crato Formation, Brazil.

BACKGROUND: Amber has been reported from the Early Cretaceous Crato Formation, as isolated clasts or within plant tissues. Undescribed cones of uncertain gymnosperm affinity have also been recovered with amber preserved in situ. Here, we provide multiple lines of evidence to determine the botanical affinity of this enigmatic, conspicuous cone type, and to better understand the diversity of amber-source plants present in the Crato Formation and beyond. RESULTS: A new taxon of amber-bearing pollen cone Araripestrobus resinosus gen. nov. et sp. nov. is described here from complete cones and characteristic disarticulated portions. The best-preserved cone portion has both in situ amber infilling the resin canals inside the preserved microsporophyll tissues and pollen of the Eucommiidites-type. This places this genus within the Erdtmanithecales, an incompletely known gymnosperm group from the Mesozoic. FTIR analysis of the in situ amber indicates a potential araucariacean conifer affinity, although affinity with cupressacean conifers cannot be definitely ruled out. Pyr-GC-MS analysis of the Araripestrobus resinosus gen. nov. et sp. nov. in situ fossil resin shows that it is a mature class Ib amber, thought to indicate affinities with araucariacean and cupressacean, but not pinaceous, conifers. This is the first confirmed occurrence of this class of amber in the Crato Formation flora and in South America, except for an archaeological sample from Laguna Guatavita, Colombia. CONCLUSIONS: The combined results of the cones' novel gross morphology and the analyses of the in situ amber and pollen clearly indicate that the new taxon of resinous gymnosperm pollen cones from the Crato Formation is affiliated with Erdtmanithecales. The cone morphology is very distinct from all known pollen cone types of this extinct plant group. We therefore assume that the plant group that produced Eucommiidites-type pollen is much more diverse in habits than previously thought. Moreover, the diversity of potential amber source plants from the Crato Formation is now expanded beyond the Araucariaceae and the Cheirolepidiaceae to include this member of the Erdtmanithecales. Despite dispersed Eucommiidites pollen being noted from the Crato Formation, this is the first time macrofossils of Erdtmanithecales have been recognized from the Early Cretaceous of South America.

How Accurate Are Pediatric Emergency Tapes? A Comparison of 4 Emergency Tapes With Different Length-Based Weight Categorization.

OBJECTIVE: Pediatric emergency tapes have been developed to support paramedics and emergency physicians when dosing drugs and selecting medical equipment in pediatric emergency situations. The aim of this study was to compare the accuracy of 4 pediatric emergency tapes to correctly estimate patient's weight based on a large population of patients. METHODS: Patients undergoing general anesthesia between January 2012 and March 2015 with documented age, sex, body weight, and length were identified from the electronic anesthesia patient data management system of the Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland. Weight estimation by means of the Broselow-Tape, the Pädiatrisches Notfalllineal, the Paulino System, and the Kinder-Sicher were compared with true patient's weight. Percentages of estimated body weight within a ±10% and ±20% interval were calculated. Data are median (interquartile range) or count (percent); statistical calculations were done with McNemar and Bonferroni correction. RESULTS: A total of 3307 patients were identified with complete data sets, 1930 (58.4%) were male, median age was 4.1 years (1.1-8.2 years), median length 101.0 cm (74.0-126.0 cm) and median patient weight 15.8 kg (9.2-25.0 kg). The proportion weight estimation within the ±10% and the ±20% interval was the highest in the Broselow-Tape with 54.0% and 81.5% (P < 0.001 and P = 0.003), followed by the Pädiatrisches Notfalllineal (50.5% and 79.8%), Paulino System (49.9% and 78.0%) and Kinder-Sicher (48.2% and 77.5%). CONCLUSIONS: The overall accuracy of all 4 emergency tapes tested is poor and including a larger number of weight categories does not necessarily increase accuracy. Other strategies have to be developed to improve weight estimation in pediatric emergency situations.

Pediatric airway dimensions-A summary and presentation of existing data.

BACKGROUND: Age-related pediatric airway dimension reference values for cricoid, tracheal, and bronchial diameters as well as tracheal and bronchial lengths are essential for distinguishing normal from pathological airway findings and for manufacturing and selecting appropriately sized airway equipment. AIM: The aim of this work was to summarize and present existing pediatric airway dimension data for the larynx, trachea, and main stem bronchi from fetus to adolescence. METHODS: A systematic literature search was carried out using PubMed, Scopus, Embase, and Google Scholar. Publications containing original data on pediatric airway dimensions as mean or median in tabular form and spanning narrow age groups of 1 or 2 years were included in our study. Original data such as diameters, lengths, and cross-sectional areas of trachea, cricoid, left and right main bronchi in fetuses and children were collected and presented as figures. RESULTS: Pediatric airway dimension data were gathered and compiled from 15 studies fulfilling the inclusion criteria. Data were obtained from different measurement methods such as autopsy, chest X-ray, computed tomography, magnetic resonance imaging, rigid and flexible bronchoscopy as well as ultrasound examinations. There was considerable variation among age-related data due to biologic heterogeneity, different presentation of data, different definitions, and various measurement techniques. CONCLUSION: This investigation revealed heterogeneous data on pediatric airway dimensions, making it impossible to compile them into standard reference values for airway dimensions. New studies with structured and standardized measurements and data presentation in large populations of children are required to provide more valid pediatric airway dimension data.

Carnivorous leaves from Baltic amber.

The fossil record of carnivorous plants is very scarce and macrofossil evidence has been restricted to seeds of the extant aquatic genus Aldrovanda of the Droseraceae family. No case of carnivorous plant traps has so far been reported from the fossil record. Here, we present two angiosperm leaves enclosed in a piece of Eocene Baltic amber that share relevant morphological features with extant Roridulaceae, a carnivorous plant family that is today endemic to the Cape flora of South Africa. Modern Roridula species are unique among carnivorous plants as they digest prey in a complex mutualistic association in which the prey-derived nutrient uptake depends on heteropteran insects. As in extant Roridula, the fossil leaves possess two types of plant trichomes, including unicellular hairs and five size classes of multicellular stalked glands (or tentacles) with an apical pore. The apices of the narrow and perfectly tapered fossil leaves end in a single tentacle, as in both modern Roridula species. The glandular hairs of the fossils are restricted to the leaf margins and to the abaxial lamina, as in extant Roridula gorgonias. Our discovery supports current molecular age estimates for Roridulaceae and suggests a wide Eocene distribution of roridulid plants.

A smartphone application to determine body length for body weight estimation in children: a prospective clinical trial.

The aim of this study was to test the feasibility and accuracy of a smartphone application to measure the body length of children using the integrated camera and to evaluate the subsequent weight estimates. A prospective clinical trial of children aged 0-<13 years admitted to the emergency department of the University Children's Hospital Zurich. The primary outcome was to validate the length measurement by the smartphone application «Optisizer¼. The secondary outcome was to correlate the virtually calculated ordinal categories based on the length measured by the app to the categories based on the real length. The third and independent outcome was the comparison of the different weight estimations by physicians, nurses, parents and the app. For all 627 children, the Bland Altman analysis showed a bias of -0.1% (95% CI -0.3-0.2%) comparing real length and length measured by the app. Ordinal categories of real length were in excellent agreement with categories virtually calculated based upon app length (kappa = 0.83, 95% CI 0.79-0.86). Children's real weight was underestimated by physicians (-3.3, 95% CI -4.4 to -2.2%, p < 0.001), nurses (-2.6, 95% CI -3.8 to -1.5%, p < 0.001) and parents (-1.3, 95% CI -1.9 to -0.6%, p < 0.001) but overestimated by categories based upon app length (1.6, 95% CI 0.3-2.8%, p = 0.02) and categories based upon real length (2.3, 95% CI 1.1-3.5%, p < 0.001). Absolute weight differences were lowest, if estimated by the parents (5.4, 95% CI 4.9-5.9%, p < 0.001). This study showed the accuracy of length measurement of children by a smartphone application: body length determined by the smartphone application is in good agreement with the real patient length. Ordinal length categories derived from app-measured length are in excellent agreement with the ordinal length categories based upon the real patient length. The body weight estimations based upon length corresponded to known data and limitations. Precision of body weight estimations by paediatric physicians and nurses were comparable and not different to length based estimations. In this non-emergency setting, parental weight estimation was significantly better than all other means of estimation (paediatric physicians and nurses, length based estimations) in terms of precision and absolute difference.

Diverse early dwarf mistletoes (Arceuthobium), ecological keystones of the Eocene Baltic amber biota.

PREMISE OF THE STUDY: Extant dwarf mistletoes (Arceuthobium M. Bieb., Viscaceae) are hemiparasites with complex roles in nature. They are one of the most severe pests in northern hemisphere conifer forests, but they also enhance the structural complexity and species diversity of the forests. Here, we describe the first pre-Miocene macrofossils of dwarf mistletoes. The fossils from Eocene Baltic amber provide new insights into the morphological evolution of the Arceuthobium lineage and its paleobiogeography. METHODS: The amber inclusions were investigated with light microscopy and compared with extant Viscaceae and to historic descriptions of lost Baltic amber fossils with affinities to Viscaceae. KEY RESULTS: Six fossil species of the Arceuthobium lineage, A. johnianum comb. nov., A. mengeanum comb. nov., A. conwentzii sp. nov., A. groehnii sp. nov., A. viscoides comb. nov. and A. obovatum sp. nov., occurred in source forests of Baltic amber, representing the oldest macrofossil evidence of dwarf mistletoes. They share morphological features of their bracts, internodes, fruits, and stomata with extant Arceuthobium. Differences from extant dwarf mistletoes, such as the perianth merosity, the nonfusion of squamate bracts and presence of oblanceolate expanded leaves, indicate their affiliation to an ancient lineage of the genus. CONCLUSIONS: The occurrence of six species of dwarf mistletoes in a single amber deposit suggests Arceuthobium was a keystone taxon of the Baltic amber source area. As in extant conifer forests, they probably influenced the structural complexity of the forest, not only leading to more open woodlands but also increasing species diversity, at least at a microhabitat scale.

Impact of endotracheal tube shortening on work of breathing in neonatal and pediatric in vitro lung models.

BACKGROUND: Work of breathing accounts for a significant proportion of total oxygen consumption in neonates and infants. Endotracheal tube inner diameter and length significantly affect airflow resistance and thus work of breathing. While endotracheal tube shortening reduces endotracheal tube resistance, the impact on work of breathing in mechanically ventilated neonates and infants remains unknown. AIM: The objective of this in vitro study was to quantify the effect of endotracheal tube shortening on work of breathing in simulated pediatric lung settings. We hypothesized that endotracheal tube shortening significantly reduces work of breathing. METHODS: We used the Active-Servo-Lung 5000 to simulate different clinical scenarios in mechanically ventilated infants and neonates under spontaneous breathing with and without pressure support. Endotracheal tube size, lung resistance, and compliance, as well as respiratory settings such as respiratory rate and tidal volume were weight and age adapted for each lung model. Work of breathing was measured before and after maximal endotracheal tube shortening and the reduction of the daily energy demand calculated. RESULTS: Tube shortening with and without pressure support decreased work of breathing to a maximum of 10.1% and 8.1%, respectively. As a result, the calculated reduction of total daily energy demand by endotracheal tube shortening was between 0.002% and 0.02%. CONCLUSION: In this in vitro lung model, endotracheal tube shortening had minimal effects on work of breathing. Moreover, the calculated percentage reduction of the total daily energy demand after endotracheal tube shortening was minimal.

Economic aspects of intraoperative coagulation management targeting higher fibrinogen concentrations during major craniosynostosis surgery.

BACKGROUND: Results of a previously published study demonstrated a significant decrease in transfusion requirements and calculated blood loss for pediatric major craniosynostosis surgery, if a ROTEM(®) FIBTEM trigger of <13 mm (early substitution group) was applied as compared to a trigger of <8 mm (conventional group). The aim of this study was a posthoc analysis of the costs for this coagulation management. METHODS: The total volume as well as the number of units or bags for all transfused blood products and coagulation factors were recorded for each case. The number of laboratory and point-of-care coagulation tests was also analyzed. Total blood product costs were calculated according to the local prices per unit. RESULTS: The total cost for all transfused/administered blood products/coagulation factors per patient was a median of 1023EUR (IQR 850EUR-1058EUR) in the early substitution group as compared to a median of 910EUR (IQR 719EUR-1351EUR) in the conventional group (P = 0.81). No difference in the number of coagulation tests performed was observed. CONCLUSION: In this study, the use of a higher fibrinogen trigger was not linked to a significant increase in total costs for transfused blood products and coagulation factors, and may offer an economically equivalent approach to coagulation management.

Gastric ultrasound as a preoperative bedside test for residual gastric contents volume in children.

BACKGROUND: Emergency situations and conditions with impaired gastric emptying enhance the risk of perioperative pulmonary aspiration due to increased residual gastric contents volume (GCV). Gastric ultrasonographic (US) measurement of the gastric antral cross-sectional area (CSA) has been proposed to estimate preanesthetic GCV. However, only few healthy children and fasted pediatric patients have been investigated so far, predicting GCV with considerable imprecision. This study aimed to compare GCV assessed by US in different patient positions for measuring CSA, using magnetic resonance imaging (MRI) as reference, and to evaluate its potential as diagnostic test. METHODS: Healthy volunteer children were examined in a crossover design on 2 days. After baseline examination, they received a light breakfast, followed by 7 ml·kg-1 clear fluid after 2 or 4 h. Gastric emptying was examined with MRI over 4 or 6 h, respectively. US was performed immediately after MRI in right lateral decubital (RLD) and supine with upper body elevated (SUBE) positions. Correlation coefficients (Pearson R; 95%CI) between CSA and body weight corrected GCV (GCVw ) as determined by MRI volumetry were calculated. Data are presented as median (range). RESULTS: Eighteen children aged 9.8 (6.8-12.2) years had 72 US examinations completed. CSA was 401 (101-1311) mm2 and 271 (118-582) mm2 , and R between CSA and GCVw was 0.76 (0.76-1) and 0.57 (0.41-0.88) for the RLD and SUBE positions, respectively. The corresponding GCVw was 2.1 (0.1-13.8) ml·kg-1 . A linear regression model from RLD was similar to one previously derived. Bland-Altman analysis and ROC plots are presented. CONCLUSION: CSA correlated with GCVw in healthy children over a wide range of gastric filling, with the RLD position clearly superior to the SUBE position, confirming a previously derived formula. Although direct calculation of GCVw is imprecise, this technique has the potential to become a diagnostic risk assessment test.

Intubation with VivaSight or conventional left-sided double-lumen tubes: a randomized trial.

INTRODUCTION: Double-lumen endotracheal tubes (DLTs), which are commonly used for single-lung ventilation during surgery, are difficult to insert. In addition, they often move during surgical lung manipulation which can cause life-threatening complications. Flexible bronchoscopy is used routinely to establish and confirm proper DLT placement. The newly designed VivaSight DLT has an integrated camera, allowing continuous visualization of its position in the trachea. We hypothesized that the time to intubation using the VivaSight DLT would be faster than with a conventional DLT. METHODS: We enrolled 40 adults scheduled for thoracic surgery. Patients were randomized to conventional DLT (n = 20) or VivaSight DLT (n = 20). Time to intubation was our primary outcome. Secondary outcomes were insertion success without flexible bronchoscopy, frequency of tube displacement, ease of insertion, quality of lung collapse, postoperative complaints, and airway injuries. RESULTS: Time [mean (SD)] to successful intubation was significantly faster with the VivaSight DLT [63 (58) sec] compared with the conventional DLT [97 (84) sec; P = 0.03]. The VivaSight DLTs were correctly inserted during all attempts. When malpositioning of the VivaSight DLT occurred, it was easily remedied, even in the lateral position. The devices were comparable with respect to postoperative coughing, hoarseness, and sore throat. Airway injuries tended to be more common with the VivaSight DLT, although this study was underpowered for airway injuries. CONCLUSION: The VivaSight DLT camera allowed faster insertion and facilitated initial positioning. It also confirmed proper tube positioning intraoperatively and facilitated repositioning when necessary. This trial was registered at clinicaltrials.gov: NCT01807676.

Arthropods in amber from the Triassic Period.

The occurrence of arthropods in amber exclusively from the Cretaceous and Cenozoic is widely regarded to be a result of the production and preservation of large amounts of tree resin beginning ca. 130 million years (Ma) ago. Abundant 230 million-year-old amber from the Late Triassic (Carnian) of northeastern Italy has previously yielded myriad microorganisms, but we report here that it also preserves arthropods some 100 Ma older than the earliest prior records in amber. The Triassic specimens are a nematoceran fly (Diptera) and two disparate species of mites, Triasacarus fedelei gen. et sp. nov., and Ampezzoa triassica gen. et sp. nov. These mites are the oldest definitive fossils of a group, the Eriophyoidea, which includes the gall mites and comprises at least 3,500 Recent species, 97% of which feed on angiosperms and represents one of the most specialized lineages of phytophagous arthropods. Antiquity of the gall mites in much their extant form was unexpected, particularly with the Triassic species already having many of their present-day features (such as only two pairs of legs); further, it establishes conifer feeding as an ancestral trait. Feeding by the fossil mites may have contributed to the formation of the amber droplets, but we find that the abundance of amber during the Carnian (ca. 230 Ma) is globally anomalous for the pre-Cretaceous and may, alternatively, be related to paleoclimate. Further recovery of arthropods in Carnian-aged amber is promising and will have profound implications for understanding the evolution of terrestrial members of the most diverse phylum of organisms.

Estimating the Phanerozoic history of the Ascomycota lineages: combining fossil and molecular data.

The phylum Ascomycota is by far the largest group in the fungal kingdom. Ecologically important mutualistic associations such as mycorrhizae and lichens have evolved in this group, which are regarded as key innovations that supported the evolution of land plants. Only a few attempts have been made to date the origin of Ascomycota lineages by using molecular clock methods, which is primarily due to the lack of satisfactory fossil calibration data. For this reason we have evaluated all of the oldest available ascomycete fossils from amber (Albian to Miocene) and chert (Devonian and Maastrichtian). The fossils represent five major ascomycete classes (Coniocybomycetes, Dothideomycetes, Eurotiomycetes, Laboulbeniomycetes, and Lecanoromycetes). We have assembled a multi-gene data set (18SrDNA, 28SrDNA, RPB1 and RPB2) from a total of 145 taxa representing most groups of the Ascomycota and utilized fossil calibration points solely from within the ascomycetes to estimate divergence times of Ascomycota lineages with a Bayesian approach. Our results suggest an initial diversification of the Pezizomycotina in the Ordovician, followed by repeated splits of lineages throughout the Phanerozoic, and indicate that this continuous diversification was unaffected by mass extinctions. We suggest that the ecological diversity within each lineage ensured that at least some taxa of each group were able to survive global crises and rapidly recovered.