Mean affect and affect variability may interact to predict inflammation.

INTRODUCTION: Individuals with greater affect variability (i.e., moment-to-moment fluctuations possibly reflecting emotional dysregulation) are at risk for greater systemic inflammation, which is associated with cardiovascular disease. Some evidence suggests that affect variability is linked with poorer health indicators only among those with higher average levels of affect, particularly for positive affect (PA), and that associations may be non-linear. The present study sought to examine whether links between both PA and negative affect (NA) variability and inflammation are moderated by average level of affect. METHODS: Participants (N = 300, 50 % female, ages 21-70, 60 % non-Hispanic White, 19 % Hispanic, 15 % non-Hispanic Black) completed a lab assessment and provided a blood sample to measure systemic inflammation (i.e., TNF-α, IL-6, CRP). Affect was collected via a two-day ecological momentary assessment protocol where reports were collected about every 45-min during waking hours. Momentary affect ratings were averaged across both days (i.e., iM), separately for PA and NA, for each participant. Affect variability was calculated as the person-specific SD (i.e., iSD) of affect reports, separately for PA and NA. Linear and quadratic interactions were tested. Models included covariates for sex, race, and body mass index. RESULTS: There were significant interactions between NA iM and NA iSD predicting TNF-α (b = 6.54; p < 0.05) and between PA iM and PA iSD predicting IL-6 (b = 0.45; p < 0.05). Specifically, the association between these affect variability indicators and inflammatory markers were suggestive of a positive association among those with higher average affect but a negative association among those with lower average affect. There was no evidence of non-linear associations between affect and inflammation. DISCUSSION: Incorporating interactive effects between affect variability and average affect may be an important consideration in understanding affective-inflammatory associations.

Airway management of a child after tracheal resection.

PURPOSE: To report a strategy for minimizing airway risks and optimizing airway management in the post-reanastomosis phase of the anesthetic management of a patient undergoing tracheal reconstruction. CLINICAL FEATURES: A 14-yr-old boy with squamous cell carcinoma of his trachea underwent a tracheal resection and end-to-end reanastomosis for removal of tumour. This procedure was accomplished through a right thoracotomy. A thoracic epidural had been placed before induction of anesthesia through which 3 mg morphine and 10 ml bupivacaine 0.25% with epinephrine were administered during surgery. After chest wall closure the patient was allowed to recover spontaneous respiration and the trachea was extubated during deep anesthesia to eliminate airway response with coughing which might have stressed the anastomosis. An infusion of bupivacaine 0.0625% and morphine (100 microg x ml(-1)) was maintained until the third postoperative day. The patient had an unremarkable postoperative course and was discharged on the eighth postoperative day. CONCLUSION: In this case thoracic epidural analgesia and tracheal extubation during deep anesthesia was a safe and effective strategy for minimizing airway risks and optimizing airway management in after the reanastomosis phase of tracheal resection.

Patients with malignant osteopetrosis are at high risk of anesthetic morbidity and mortality.

UNLABELLED: The anesthetic literature contains no focused discussion of the perioperative management and risks of children with malignant autosomal recessive osteopetrosis (osteopetrosis). We retrospectively analyzed the perioperative morbidity and mortality rates encountered in the anesthetic management of children with osteopetrosis. We compared the perioperative mortality rate for this patient population with that for other pediatric patients in our institution and that reported in the literature for children and other high-risk patients. We also investigated the inability to intubate the tracheas of children with osteopetrosis compared with other pediatric patients in our institution. Using Fisher's exact test, patients with osteopetrosis were found to have a higher likelihood of perioperative mortality compared with other children or all ASA physical status III, but not ASA physical status IV, patients (P < 0.05). Finally, we discovered that children with osteopetrosis were more likely to have tracheas that could not be intubated than other pediatric patients in our institution. We conclude that children with osteopetrosis are at risk of adverse respiratory events and mortality associated with these adverse events. IMPLICATIONS: Osteopetrosis is a rare disease that increases perioperative morbidity and mortality. By performing a retrospective chart review, we found that this increased perioperative morbidity and mortality is primarily related to airway and respiratory factors. Anesthetic management strategies should consider the factors that cause the high frequency of adverse airway events in this patient population.

"One-stop" surgery: implications for anesthesiologists of an expedited pediatric surgical process.

BACKGROUND: "One-stop surgery" (OSS) allows pediatric patients to undergo initial surgical evaluation, anesthesia, surgery, and discharge home, on the same day. METHODS: Patients referred for umbilical hernia repair, circumcision, or central venous catheter removal completed a screening questionnaire, after which they were scheduled for initial surgical and anesthesia evaluation if eligible and had surgery if indicated on the same day. RESULTS: Three patients had comorbidity precluding OSS, two patients refused indicated surgery, two patients did not require surgery, and 12 patients did not keep their appointment. Eighty patients had surgery without complications. Average total time was significantly shorter for OSS than non-OSS for circumcision (120 vs 142 min) and umbilical hernia repair (139 vs 165 min) but similar for catheter removal (100 vs 109 min). All families were satisfied with OSS. CONCLUSIONS: One-stop surgery appears to be a safe, efficient, and convenient alternative to the traditional process for patients and their families.

One-stop surgery: evolving approach to pediatric outpatient surgery.

PURPOSE: Maximizing patient satisfaction is of prime importance in today's competitive outpatient surgery market. The authors recently devised a system, one-stop surgery, which simplifies outpatient surgery for pediatric patients and their families by combining the traditionally separate preoperative evaluation and subsequent operation into one visit. This report describes our initial experience with one-stop surgery. METHODS: Umbilical hernia repair, circumcision, and portacath removal were considered surgical procedures appropriate for our one-stop surgery pilot study. Medical information obtained by phone or fax from referring physicians was used to identify potential candidates. Families were contacted, precertified for their surgical procedure, and given nothing by mouth instructions. The day of surgery the child was evaluated by the attending pediatric surgeon. If the diagnosis was confirmed, and no contraindications to surgery were identified, the child immediately underwent the prescheduled surgical procedure. RESULTS: From April through October 1997, 61 children were scheduled for one-stop surgery. Nine patients (15%) were no shows, and one additional family opted not to proceed with circumcision. The remaining 51 children (83%) underwent their one-stop surgical procedure: umbilical hernia repair (n = 23), circumcision (n = 19), portacath removal (n = 8), and inguinal hernia repair (n = 1). No child had an anesthetic contraindication to surgery, and only one minor postoperative complication (wound hematoma) occurred. CONCLUSIONS: This pilot study has demonstrated that with appropriate patient screening and cooperation of the entire surgical team, a variety of outpatient surgical procedures can be handled using this one-stop surgery method. By combining one-stop surgery with our previously reported phone follow-up system, many minor surgical procedures can be managed with only one visit to the hospital. Decreasing the "hassle factor" of outpatient surgery for children and their families, who frequently live far from their closest children's hospital, while providing the highest quality of specialized surgical and anesthetic care, may potentially be a very powerful marketing tool for pediatric surgical specialists.

Pharyngeal flap necrosis as a cause of airway obstruction during induction of anesthesia.

Anesthesiologists should approach the airway carefully in the patient with a diagnosis of head and neck carcinoma, particularly if the patient has had previous surgery and reconstruction. Patients with head and neck carcinoma may be difficult intubations due to altered anatomy from the tumor or fibrotic changes because of radiation therapy. Our patient had had pharyngectomy and reconstruction with a pectoralis major skin flap. The patient returned to the operating suite for wide-excision pharyngectomy and had acute airway obstruction after induction of general anesthesia. The pectoralis flap had necrosed, pulling away from the pharyngeal wall and obstructing the patient's glottic opening.

Postdural puncture headache in paediatric oncology patients.

PURPOSE: Previous studies have not determined the correlation between dural puncture and postural headache in paediatric patients. Furthermore, no studies have evaluated the correlation between atypical headache and dural puncture in the paediatric population. Therefore, we prospectively analyzed the incidence of typical postdural puncture headache (PDPHA) and atypical headache in paediatric oncology patients following dural puncture. METHODS: The study population consisted of 66 paediatric patients undergoing 128 consecutive procedures, including 99 lumbar punctures and 29 bone marrow aspirations without concomitant lumbar puncture. Patients were prospectively randomized into four groups: Group I, preteens (< 13 yr) undergoing lumbar puncture, Group II, adolescents (13-21 yr) undergoing lumbar puncture, Group III, preteens undergoing bone marrow aspiration, and Group IV, adolescents undergoing bone marrow aspiration. The presence and description of headache was documented immediately after dural puncture or bone marrow aspiration, and on post-procedure days # 1, 3 and 5 by personnel blinded to the type of procedure. RESULTS: There was an increase in the incidence of headache (9.1%) after lumbar puncture in patients < 21 yr relative to patients undergoing bone marrow aspiration (P < 0.05). No difference was found between the incidence of typical PDPHA after dural puncture in preteens and adolescents. There was also no difference in the incidence of atypical headache after dural puncture or after bone marrow aspiration among preteens and adolescents. CONCLUSIONS: Paediatric patients experience an increased incidence of typical postdural puncture headache after dural puncture compared with age-matched patients undergoing bone marrow aspiration only. Atypical headache is relatively common in the paediatric population after dural puncture or bone marrow aspiration.