Management of hypocalcemia following thyroid surgery in children.

Introduction: Pediatric post-thyroidectomy hypocalcemia management varies significantly from hospital to hospital. The current study has two aims: first, we evaluate demographic data in all pediatric patients submitted to thyroid surgery in our Spanish tertiary hospital over 20 years; secondly, we describe the way that hypocalcemia was diagnosed and treated in that period and present a multidisciplinary protocol for perioperative management of this condition. Methods: This is a retrospective and observational study of all patients from 0 to 16 years old who underwent thyroid surgery from 2000 to 2020 at our institution. Demographic, surgical and electrolyte data were recorded from the electronic database. Results: From 2000 to 2016, pediatric thyroid surgery at our institution was performed on 33 patients without a consistent approach or standard electrolyte management. A protocol for perioperative management of these patients was introduced in 2017, and applied to 13 patients. In 2019, the protocol was assessed and updated following a case of symptomatic hypocalcemia. From 2000 to 2016, 47 pediatric patients in all underwent thyroid surgery. We registered eight asymptomatic hypocalcemias. One child developed symptomatic hypocalcemia. Two patients have permanent hypoparathyroidism. Discussion: Our incidence of general complications following thyroidectomy was low; hypocalcemia was the most prevalent. All the cases of hypocalcemia submitted to the protocol were identified early by iPTH measurements. Intraoperative iPTH levels and percentage drop from baseline could help stratify patients according to their risk of hypocalcemia. High risk patients require immediate postoperative supplementation, including calcitriol and calcium carbonate.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population. METHODS: From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance. RESULTS: The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m2) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair. CONCLUSION: Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

Feasibility of a Local Anesthesia Program for Inguinal Hernia Repair at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. METHODS: A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t-test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. RESULTS: OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). CONCLUSIONS: LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA.

Re-assessing causality between energy consumption and economic growth.

The energy consumption-growth nexus has been widely studied in the empirical literature, though results have been inconclusive regarding the direction, or even the existence, of causality. These inconsistent results can be explained by two important limitations of the literature. First, the use of bivariate models, which fail to detect more complex causal relations, or the ad hoc approach to selecting variables in a multivariate framework; and, second, the use of linear causal models, which are unable to capture more complex nonlinear causal relationships. In this paper, we aim to overcome both limitations by analysing the energy consumption-growth nexus using a Flexible Fourier form due to Enders and Jones (2016). The analysis focuses on the US over the period 1949 to 2014. From our results we can conclude that, where the linear methodology supports the neutrality hypothesis (no causality between energy consumption and growth), the Flexible Fourier form points to the existence of causality from energy consumption to growth. This is contrary to the linear analysis, suggesting that lowering energy consumption would adversely affect US economic growth. Thus, by employing the Flexible Fourier form we find the conclusions can be quite different.

Dual-stage peat beds in small community wastewater treatment.

In this study, the quality of water treated by two dual-stage peat bed systems was compared with a single-stage system, and a costs analysis was performed. The experiment was carried out on a pilot scale using pre-treated urban wastewater. The pilot setup consisted of a single-stage system with a hydraulic loading of 0.6 m(3)/m(2)d, and two dual-stage systems. The first of these worked with hydraulic loadings of 1.2 and 0.6 m(3)/m(2)d for the initial and second stages respectively. For the second dual-stage system hydraulic loadings were 1.8 and 0.9 m(3)/m(2)d. In comparison with the single-stage system, the dual-stage systems produced effluents with a substantial improvement in physicochemical quality (suspended solids, COD and BOD) and microbiological quality (faecal and total coliforms). Quality parameters were similar to a conventional system, meeting the legislative standards of European Union Directive 271/91 for wastewater treatment. Total costs of the peat-bed systems showed a reciprocal X-model regression depending on the average daily volume of urban wastewater to be treated, with a tendency towards convergence of costs between the single and dual-stage systems. The main problem with the dual-stage systems is the greater surface area required for their installation, which can be estimated by linear regression depending on the average volume of water to be treated per day.