Thoracic caudal epidural catheter localization using ultrasound guidance.

Caudal epidural catheters provide exceptional analgesia while avoiding or minimizing opioids. Historically, the catheter tip location (dermatomal level) was estimated or verified via epidurogram. According to the Pediatric Regional Anesthesia Database, the majority of caudal-to-thoracic epidural catheters are placed without imaging guidance or verification of the position of the catheter tip. Ponde et al demonstrated that catheter insertion depth was longer when using ultrasound guidance than when estimated by external measurement. We report a simple yet novel ultrasound approach for catheter localization.

Exosomal Lipid Biomarkers of Oligodendrocyte Pathology to Predict Scoliosis in Children with Cerebral Palsy.

Introduction: Cerebral Palsy (CP), the most common cause of disability in children, is phenotypically heterogeneous. Approximately 20% of cases develop severe scoliosis. A pathological hallmark of CP is periventricular leukomalacia (PVL), which is due to dysmyelination, suggesting the possibility of a lipidomic abnormality. Risk factors for CP include perinatal hypoxia, prematurity, multiple gestation, ischemia, infection, and maternal alcohol consumption. There is evidence for low serum levels of omega-3 (ω-3) fatty acids in CP patients, and separately in idiopathic scoliosis. Many effects of free fatty acids (FFAs) are mediated via specific G protein-coupled free fatty acid receptors (FFARs), which play essential roles as nutritional and signaling molecules. FFAs, including ω-3, and their receptors are involved in the development and metabolism of oligodendrocytes (OLs), and are critical to myelination. Thus, the cases of CP that will develop severe scoliosis might be those in which there is a deficiency of ω-3, FFARs, or other lipidomic abnormality that is detectable early in the plasma. If so, we might be able to predict scoliosis and prevent it with dietary supplementation. Methods: Blood samples were collected from four groups of patients at the Philadelphia Shriners Children's Hospital (SCH-P): 1) patients with CP; 2) severe scoliosis (>40o); 3) CP plus scoliosis; and 4) non-impaired controls stratified by age (2-18 yrs), gender, and race/ethnicity, under an IRB-approved protocol. Serum proteins and RNA were purified, and OL-derived exosomes (OL-Es) isolated, using myelin basic protein (MBP) as a late OL marker. Protein was used for the detection of MBP and FFAR by enzyme-linked immunosorbent assays (ELISAs), and by flow cytometry. RNA was assayed by digital droplet polymerase chain reaction (ddPCR) for OL markers and FFAR expression. Results: FFAR and MBP proteins were downregulated in each of the three patient groups compared to controls, and this difference was greatest in both patients with CP plus scoliosis. Conclusion: Altogether, MBP and FFAR levels were reduced in OL-Es from both children with CP plus scoliosis. The lipid abnormalities specific to CP with scoliosis were concentrated in OLs. Our data might i) suggest therapeutic targets to reduce dysmyelination and scoliosis in CP, ii) predict which children are at risk for developing scoliosis, iii) lead to therapeutic trials of fatty acids for CP and other dysmyelinating neurological disorders.

Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. the Perioperative Management of Adrenalectomy in a Jehovah's Witness Patient: a Case Report.

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah's Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Avoid suboptimal perioperative analgesia during major surgery by enhancing thoracic epidural catheter placement and hemodynamic performance.

Thoracic epidural analgesia (TEA) is an established gold standard for postoperative pain control especially following laparotomy and thoracotomy. The safety and efficacy of TEA is well known when the attention to patient selection is upheld. Recently, the use of fascial plane blocks (FPBs) has evolved as an alternative to TEA most likely because these blocks avoid problems such as neurological comorbidity, coagulation disorders, epidural catheter failure and hypotension due to sympathetic denervation. However, if an FPB is performed, postoperative monitoring and adjuvant treatments are still necessary. Also, the true efficacy of FPBs is questioned. Thus, should we prioritize less efficient analgesic regimens with FPBs when preventive treatment strategies for epidural catheter failure and hypotension exist for TEA? It is time to promote and underscore the benefits of TEA provided to patients undergoing major open surgical procedures. In our mind, FPBs and landmark-guided techniques should be limited to less extensive surgery and when either neuraxial blockade is contraindicated or resources for optimal epidural catheter placement and maintenance are not available.

Elevated carbon dioxide alters impacts of precipitation pulses on ecosystem photosynthesis and respiration in a semi-arid grassland.

Predicting net C balance under future global change scenarios requires a comprehensive understanding of how ecosystem photosynthesis (gross primary production; GPP) and respiration (Re) respond to elevated atmospheric [CO(2)] and altered water availability. We measured net ecosystem exchange of CO(2) (NEE), GPP and Re under ambient and elevated [CO(2)] in a northern mixed-grass prairie (Wyoming, USA) during dry intervals and in response to simulated precipitation pulse events. Elevated [CO(2)] resulted in higher rates of both GPP and Re across the 2006 growing season, and the balance of these two fluxes (NEE) accounted for cumulative growing season C uptake (-14.4 +/- 8.3 g C m(-2)). Despite lower GPP and Re, experimental plots under ambient [CO(2)] had greater cumulative uptake (-36.2 +/- 8.2 g C m(-2)) than plots under elevated [CO(2)]. Non-irrigated control plots received 50% of average precipitation during the drought of 2006, and had near-zero NEE (1.9 +/- 6.4 g C m(-2)) for the growing season. Elevated [CO(2)] extended the magnitude and duration of pulse-related increases in GPP, resulting in a significant [CO(2)] treatment by pulse day interaction, demonstrating the potential for elevated [CO(2)] to increase the capacity of this ecosystem to respond to late-season precipitation. However, stimulation of Re throughout the growing season under elevated [CO(2)] reduced net C uptake compared to plots under ambient [CO(2)]. These results indicate that although elevated [CO(2)] stimulates gross rates of ecosystem C fluxes, it does not necessarily enhance net C uptake, and that C cycle responses in semi-arid grasslands are likely to be more sensitive to changes in precipitation than atmospheric [CO(2)].

Social work interest in prevention: A content analysis of the professional literature.

Every day in the United States, over halfa million social workers provide services to people with health, mental health, and substance abuse problems in a fragmented system that emphasizes disease treatment over prevention. Powerful issues--including health inequities, population aging, globalization, natural disaster, war, and economic downturn--make the need for preventive approaches more critical than ever. Despite social work's historic commitment to enhancing human well-being and public health involvement, little is known about how social work currently views prevention or whether it is being addressed in the social work professional literature. To determine whether, and to what extent, prevention is addressed, discussed, and published in social work journals, the authors--all public health social work researchers-undertook a content analysis of nine peer-reviewed journals, analyzing all articles published from 2000 to 2005. A total of 1,951 articles were reviewed and coded for prevention according to specified criteria. A relatively small number--109 (5.6 percent)--were found to meet the criteria for being a prevention article, suggesting that prevention is still a minority interest area within social work.A renewed conversation about prevention in social work can enhance opportunities for strong social work participation in the transdisciplinary collaboration needed in this new era of health reform.