A Prospective Randomized Controlled Trial Using Virtual Reality in Pediatric Pre-intervention Echocardiograms to Decrease Child Anxiety and Fear.

Virtual reality (VR) as a distraction tool decreases anxiety and fear in children undergoing procedures, but its use has not been studied during transthoracic echocardiograms (TTEs). We hypothesized that VR in children undergoing pre-intervention TTEs decreases anxiety and fear and increases TTE study comprehensiveness and diagnostic accuracy when compared with standard distractors (television, mobile devices). Patients (6-18 years old) scheduled for pre-intervention TTEs at Lucile Packard Children's Hospital in 2021 and 2022 were prospectively enrolled and randomized to VR and non-VR groups. Patients completed pre- and post-TTE surveys using the Children's Anxiety Meter-State (CAM-S) and Children's Fear Scale (CFS). Patients, parents, and sonographers completed post-TTE experience surveys. TTEs were reviewed by pediatric cardiologists for study comprehensiveness and compared with electronic medical records for diagnostic accuracy. Among 67 enrolled patients, 6 declined VR, 31 randomized to the VR group, and 30 to the non-VR group. Anxiety (average CAM-S difference 0.78 ± 1.80, p = 0.0012) and fear (average CFS difference 0.36 ± 0.74, p = 0.0005) decreased in both groups. There was no difference between groups in the change in anxiety and fear pre- and post-TTE (p = 0.96-1.00). TTE study comprehensiveness and diagnostic accuracy were high in both groups. Procedure time (time in the echocardiography room) was less for the VR group (48.4 ± 18.1 min) than the non-VR group (58.8 ± 24.4 min), but without a statistically significant difference (p = 0.075). VR is similar to standard distractors and may decrease procedure time. Patients, parents, and sonographers rated the VR experience highly and encouraged its use with future procedures.

Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study.

Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

A prospective, observational validation of HRAD±, a novel pediatric affect and cooperation scale.

STUDY OBJECTIVE: HRAD± was developed to quickly assess pediatric perioperative affect and cooperation. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD± as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD± and predictive validity of induction HRAD± with emergence delirium. DESIGN: This was a prospective observational investigation. SETTING: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California. PATIENTS: A total of 197 patients were included in this investigation. Children 1-14 years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible. INTERVENTIONS: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence. MEASUREMENTS: RAs scored each mask induction using the following scales: HRAD±, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD±. IRR of HRAD± between the RAs as well as predictive validity of HRAD± to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated. MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r = 0.840, p < 0.0001) with moderate correlation to OSBD (r = 0.685, p < 0.0001) and ICC (-0.663, p < 0.0001). IRR was moderate for the affect and cooperation portion of the HRAD± scale, respectively (κ = 0.595 [p < 0.0001], κ = 0.478 [p < 0.0001]). A weak correlation was observed with PAED (r = 0.134 [p = 0.0597]) vs HRAD±. No correlations were observed between Watcha (r = 0.013 [p = 0.8559]) and Cravero and HRAD± scales (r = 0.002 [p = 0.9767]). CONCLUSIONS: HRAD± is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales.

Dry but Not Humid Thermal Processing of Aloe vera Gel Promotes Cytotoxicity on Human Intestinal Cells HT-29.

Aloe vera products, both in food and cosmetics, are becoming increasingly popular due to their claimed beneficial effects, which are mainly attributed to the active compound acemannan. Usually, these end products are based on powdered starting materials. High temperatures during the drying process to obtain the starting materials have several advantages, like shortening the drying time, eliminating toxic aloin and reducing bacterial contamination. Nevertheless, there are two major drawbacks: first, at temperatures of 80 °C or higher, structural changes in acemannan, especially its deacetylation (>46%), are triggered, which does not happen at lower temperatures (14% at 60 °C); secondly, a toxic principle is formed at higher temperatures, resulting in a higher cytotoxicity. Thus, two temperature-dependent but opposing effects cause with a median cytotoxic concentration of CC50 = 0.4× a peak of cytotoxicity at 80 °C; at 60 °C this cytotoxic substance is not formed and at 100 °C aloin is more readily eliminated, resulting in a CC50 = 1.1× and CC50 = 1.4×, respectively. The cytotoxic substance generated by dry heat at 80 °C is not a modified polysaccharide because its polysaccharide-enriched alcohol-insoluble fraction is with CC50 = 0.9× less cytotoxic. Moreover, this substance is polar enough to be washed away with ethanol. Additionally, when Aloe gel is heated at 80 °C under humid conditions (pasteurization), the cytotoxicity does not increase (CC50 = 1.6×). Finally, to produce powdered starting materials from Aloe gel, it is recommended to use temperatures of around 60 °C in order to preserve the acemannan structure (and thus biological activity) and the low cytotoxicity.

Semivolatile endocrine-disrupting compounds in paired indoor and outdoor air in two northern California communities.

Interest in the health effects of potential endocrine-disrupting compounds (EDCs) that are high production volume chemicals used in consumer products has made exposure assessment and source identification a priority. We collected paired indoor and outdoor air samples in 40 nonsmoking homes in urban, industrial Richmond, CA, and 10 in rural Bolinas, CA. Samples were analyzed by GC-MS for 104 analytes, including phthalates (11), alkylphenols (3), parabens (3), polybrominated diphenyl ether (PBDE) flame retardants (3), polychlorinated biphenyls (PCBs) (3), polycyclic aromatic hydrocarbons (PAHs) (24), pesticides (38), and phenolic compounds (19). We detected 39 analytes in outdoor air and 63 in indoor air. For many of the phenolic compounds, alkylphenols, phthalates, and PBDEs, these represent some of the first outdoor measures and the first analysis of the relative importance of indoor and outdoor sources in paired samples. Data demonstrate higher indoor concentrations for 32 analytes, suggesting primarily indoor sources, as compared with only 2 that were higher outdoors. Outdoor air concentrations were higher in Richmond than Bolinas for 3 phthalates, 10 PAHs, and o-phenylphenol, while indoor air levels were more similar between communities, except that differences observed outdoors were also seen indoors. Indoor concentrations of the most ubiquitous chemicals were generally correlated with each other (4-t-butylphenol, o-phenylphenol, nonylphenol, several phthalates, and methyl phenanthrenes; Kendall correlation coefficients 0.2-0.6, p<0.05), indicating possible shared sources and highlighting the importance of considering mixtures in health studies.

Development of a personal dual-phase air sampling method for phthalate diesters.

Phthalates are used as plasticizers in many industrial and consumer products. Urinary biomonitoring has shown widespread human exposure to phthalates, with workers having especially high exposures. Phthalates can be present in workplace air as either aerosols or vapors depending on source materials, vapor pressure, and processing temperatures. We sought to develop a dual-phase air sampling method for 6 phthalates, dimethyl phthalate (DMP), diethyl phthalate (DEP), di-n-butyl phthalate (DBP), benzyl butyl phthalate (BzBP), di(2-ethylhexyl) phthalate (DEHP), and di-n-octyl phthalate (DnOP), adaptable to aerosol inlets with known particle collection characteristics. Collection media consisted of a quartz fiber filter and XAD-2 resin. Limit of detection (LOD) and limit of quantification (LOQ) were determined for each phthalate. Phthalate recoveries were evaluated at 3x, 10x and 30x the LOQ, and after storage at -21 degrees C and 21 degrees C. Media were Soxhlet extracted in 10% diethyl ether in hexanes along with an extraction surrogate, di-n-pentyl phthalate-d(4). Gas chromatography/mass spectrometry was performed to quantify the phthalate diesters using di(2-ethylhexyl) phthalate-d(4) as an internal standard. Estimated LODs were 1 microg per sample (BzBP, DEHP, and DnOP), 2 microg per sample (DMP and DBP), and 5 microg per sample (DEP). Mean recoveries under static conditions were 85-104% for DBP, BzBP, DEHP, and DnOP; but <70% for DMP and DEP at 3x and 10x the LOQ. After air was pulled through spiked samples, DMP and DEP recoveries improved to 74-81%. After storage for 62 days, phthalate recovery was better at -21 degrees C than at 21 degrees C. Method accuracy was best for DBP, BzBP, DEHP, and DnOP (range 11-18%), and less so for DMP (28%) and DEP (29%).

In Vitro Immunomodulatory Effect of Food Supplement from Aloe vera.

Food industries typically use Aloe vera as concentrated (100× to 200×) and dried powders in their final products. These powders are obtained by extrusion of Aloe inner leaf gel (ILG) or Aloe whole leaf (WLP); the juice is filtered through diatomaceous earth and activated carbon before spray drying at temperatures below 70 °C. In another process, Aloe inner leaf gel was dried at ~80 °C and mashed to a powder rich in high molecular weight fibres and soluble polysaccharides (ILF). In contrast to ILG and WLP, the ILF sample was cytotoxic for the human intestinal cell line Caco-2 (CC50 = 1 g/l), even at concentrations below the recommended dose for human consumption. At lower concentrations (250 mg/l) with LPS challenged macrophage-like THP-1 cells decreased by 40% the release of the anti-inflammatory cytokine IL-10, whereas the release of the proinflammatory cytokine IL-1ß increased by 35% (compared to untreated but challenged macrophage-like THP-1 cells). Unexpectedly, under the same conditions, the less cytotoxic ILG and WLP, both samples with a lower fibre content, significantly increased (up to 2.4 times) the release of IL-10, while the concentration of IL-1ß remained unaltered and of TNFα decreased by 35%. Even more interesting is that a treatment of the ILF sample with activated carbon reduced its cytotoxicity and increased the IL-10 release (3.1 times). Based on these results, we suggest applying an activated carbon treatment on Aloe-starting products, which have high fibre content and have received high temperature treatment, in order to reduce their cytotoxicity and improve their immunomodulatory properties.

Acetaminophen, pesticide, and diethylhexyl phthalate metabolites, anandamide, and fatty acids in deciduous molars: potential biomarkers of perinatal exposure.

The developing fetus is particularly vulnerable to adverse effects from pharmaceutical and exogenous chemical exposure. Deciduous teeth primarily form over specific periods from the second trimester in utero through the months after birth. We hypothesized that organic chemicals or their metabolites circulating in the bloodstream may sorb into forming dental tissues and remain stored in the tooth thereafter. Our aims were to devise analytical and preparation methods for potentially toxic or beneficial organic chemicals or metabolites in deciduous teeth and to estimate their detection frequencies. The analgesic acetaminophen was stored at greater concentration in a child's second molar than a first molar, consistent with intake, suggesting that acetaminophen concentration in molars may be a biomarker of acetaminophen exposure during molar formation. Chemicals detected by liquid chromatography/tandem mass spectrometry in molars of 21 typically developing children include the endocannabinoid anandamide (86% of children), acetaminophen (43%), and specific metabolites mono-2-ethylhexyl phthalate (MEHP, of plasticizer di-2-ethylhexyl phthalate, 29%), 3,5,6-trichloro-2-pyridinol (TCPy, of organophosphate (OP) insecticide chlorpyrifos, 10%), and 2-isopropyl-6-methyl-4-pyrimidinol (IMPy, of OP insecticide diazinon, 10%). None of these chemicals has previously been detected in human teeth. Molars from the two oldest subjects contained the largest concentrations of MEHP, TCPy, and IMPy. Potentially protective fatty acids detected by gas chromatography/mass spectrometry after derivatization include docosahexaenoic (19%), arachidonic (100%), and linoleic (100%). Validation studies are necessary to verify that each detected chemical in molars provides a biomarker of perinatal exposure.