Impact of COVID-19 on interest in pediatric neurosurgery related symptoms, diseases, and treatments.

BACKGROUND: More and more often, patients use online resources to increase their knowledge/confidence in conventional medicine. Thus, the evaluation of the internet search trends may offer an insight into patients' perception of the healthcare system during the pandemic, especially for medical specialties with invasive interventions such as pediatric neurosurgery. METHODS: A total of 140 keywords representing a wide range of pediatric neurosurgery related symptoms/signs, diseases, and treatments were defined. Google Trends tool was queried for the predefined keywords within the United States from January 01, 2016, to November 17, 2020. Two periods in 2020, March 15 to July 4 and July 5 to October 31, were compared with similar periods over the preceding four years (2016-2019). We performed analyses in three sections: symptoms/signs, diseases, and treatments. RESULTS: Public interest has shifted from regular pediatric neurosurgery related symptoms/signs, diseases, and treatments to the ones related with neurological aspects of COVID-19 both in initial and short-term stages of the pandemic. CONCLUSIONS: Google Trends highlights that the link between neurosurgeon/pediatric patients/caregivers needs to be further empowered by growing educational efforts.

Periodontal treatment is more effective in gastric Helicobacter pylori eradication in those patients who maintain good oral hygiene.

OBJECTIVES: This study aimed to investigate the effect of periodontal treatment and oral hygiene on the eradication of gastric Helicobacter pylori. MATERIALS AND METHODS: In this clinical trial, the 98 patients with gastric H. pylori infection that were enrolled received either triple-therapy regimen only or triple-therapy regimen plus periodontal treatment given during triple therapy. Eradication of H. pylori was checked at 3 months, and then after therapy using the urea breath test. RESULTS: The triple-therapy plus periodontal treatment regime resulted in a 64.7% eradication rate, and the triple-therapy regime alone resulted in a 51.1% eradication rate (P = 0.17). Additionally, subgroup analysis indicated that the beneficial effect of periodontal treatment on the gastric H. pylori eradication rate improved if adequate plaque control was maintained (P = 0.02). Multivariate logistic regression analysis showed that post-treatment oral hygiene status [as indicated by the Oral Hygiene Index (OHI)] was associated with H. pylori eradication (P = 0.02), but not with pretreatment oral hygiene status (P = 0.24). Oral hygiene measures without periodontal treatment appear to have a limited impact on H. pylori eradication. Post-treatment oral hygiene level (OHI ≤ 1.25) had a positive effect on H. pylori eradication, increased the gastric eradication rate, with an OR of 3.19, and the oral H. pylori eradication rate, with an OR of 4.57. Furthermore, if periodontal treatment was unsuccessful in eliminating oral H. pylori, as tested using the Campylobacter-like organism test, the OR for the unsuccessful gastric eradication increased 64-fold. Conclusion This result illustrates that the key factors for achieving successful gastric H. pylori eradication are professional periodontal treatment and the patients' later adherence to an oral hygiene regimen.

Differential Resting-State Functional Connectivity of Striatal Subregions in Bipolar Depression and Hypomania.

Bipolar disorder (BP) is characterized by periods of depression (BPD) and (hypo)mania (BPM), but the underlying state-related brain circuit abnormalities are not fully understood. Striatal functional activation and connectivity abnormalities have been noted in BP, but consistent findings have not been reported. To further elucidate striatal abnormalities in different BP states, this study investigated differences in resting-state functional connectivity of six striatal subregions in BPD, BPM, and healthy control (HC) subjects. Ninety medication-free subjects (30 BPD, 30 BPM, and 30 HC), closely matched for age and gender, were scanned using 3T functional magnetic resonance imaging (fMRI) acquired at resting state. Correlations of low-frequency blood oxygen level dependent signal fluctuations for six previously described striatal subregions were used to obtain connectivity maps of each subregion. Using a factorial design, main effects for differences between groups were obtained and post hoc pairwise group comparisons performed. BPD showed increased connectivity of the dorsal caudal putamen with somatosensory areas such as the insula and temporal gyrus. BPM group showed unique increased connectivity between left dorsal caudate and midbrain regions, as well as increased connectivity between ventral striatum inferior and thalamus. In addition, both BPD and BPM exhibited widespread functional connectivity abnormalities between striatal subregions and frontal cortices, limbic regions, and midbrain structures. In summary, BPD exhibited connectivity abnormalities of associative and somatosensory subregions of the putamen, while BPM exhibited connectivity abnormalities of associative and limbic caudate. Most other striatal subregion connectivity abnormalities were common to both groups and may be trait related.

[Informed consent for standard procedures and for clinical research in paediatric anaesthesia]. / Consentement éclairé en anesthésie pédiatrique pour les soins courants et pour la recherche.

This short review is aimed at describing the particularities of consent in paediatric patients. For routine procedures, the consent of one of the parents is required whereas both parents should sign the consent for research protocols. In case of difficulties such as Jehovah witnesses or parental opposite opinions, doctors should ask the question to the judge in charge of protection of children. Consent or at least assent of minors enrolled in research protocols should be obtained provided their maturity is sufficient to understand correctly the purpose of clinical research.

Prospective evaluation of the factors effective on morbidity and mortality of the patients having liver resection surgeries.

BACKGROUND/AIMS: The objective of this study is to evaluate the factors effective on mortality and morbidity of the patients operated for liver tumor. METHODOLOGY: Thirty-four patients who were operated for liver tumor between January 1st 2008 and December 31st 2009 in Cerrahpasa Medical Faculty have been included in this study. Patient preoperative, perioperative and postoperative characteristics and the effects of these characteristics on mortality, morbidity and the length of hospital stay were evaluated. RESULTS: Most common postoperative complications during the study were fever and surgical site infection. Nineteen of the patients with blood loss over 1, 000 mL had the need for postoperative ICU treatment. The presence of concomitant disease, especially diabetes mellitus, liver disease and cardiovascular diseases and more than 2 units transfusion of erythrocyte suspension and fresh frozen plasma were considered related to mortality and morbidity. CONCLUSIONS: Patient preoperative, perioperative and postoperative characteristics affect patient morbidity and mortality in liver resection surgery. Diagnosing liver tumors early and thus reducing surgical site blood loss and use of blood products will decrease mortality and morbidity ratios after liver surgeries.

[What should we do and what should we not do after an anaesthetic accident. The point of view of a medical expert]. / Que faire et ne pas faire après un accident. Le point de vue d'un expert auprès des tribunaux.

Lawsuits following an anaesthetic accident are fortunately infrequent. Anaesthesiologists are mainly sued by parents when the accident led to death or permanent brain damage. The aims of this short review are to explain how the medical expert is chosen by the court, what are the goals of the mission given by the judge, and how to prepare the medical expertise.

Audit of protocols for treatment of paediatric burns in emergency departments in the Île de France.

INTRODUCTION: The main purpose of this study was to establish the existence and accuracy of protocols for treatment of children with burns in emergency departments (EDs) across the Île de France. In addition, we also analysed the incidence of paediatric burns. METHODS: A postal questionnaire was sent to 91 EDs in the Île de France. Data collected were: number of children with burns in 2005, the absence or presence of specific written protocols. The ED was asked to send a copy of the protocol for analysis. RESULTS: Forty-six EDs (50.5%) replied to the questionnaire. These EDs treated a total of 3258 children with burns, corresponding to 0.63% of paediatric pathologies in EDs. Amongst responding EDs, 48% had specific written protocols for the management of children with burns (but only in the larger EDs: >10000 patient visits/year). A written protocol for managing pain in children was present in 65% of cases. For analgesia, 80% used oxygen/nitrous oxide. Concerning second-step analgesics, six EDs 67% used a combination of paracetamol/codeine and only 22% used non-steroidal antiflammatory drug. Regarding third-step analgesics, 67% used nalbuphine while only 43% used morphine. CONCLUSION: 3,200 children were registered with burns in half of the region's EDs during 2005 (0.63% of paediatric consultations). The larger the ED the higher was the availability of specific written protocols. International recommendations appeared to be respected concerning dressings, management of pain being marked by an under-utilisation of morphine.

Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies.

BACKGROUND: Emergence agitation (EA) in children is increased after sevoflurane anaesthesia. The efficacy of prophylactic treatment is controversial. The aim of this study was to provide a meta-analysis of the studies of the pharmacological prevention of EA in children. METHODS: A comprehensive literature search was conducted to identify clinical trials that focused on the prevention of EA in children anaesthetized with sevoflurane, desflurane, or both. The data from each trial were combined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% confidence interval. I(2) statistics were used to assess statistics heterogeneity and the funnel plot and the Begg-Mazumdar test to assess bias. RESULTS: Thirty-seven articles were found which included a total of 1695 patients in the intervention groups and 1477 in the control ones. Midazolam and 5HT(3) inhibitors were not found to have a protective effect against EA [OR=0.88 (0.44, 1.76); OR=0.39 (0.12, 1.31), respectively], whereas propofol [OR=0.21 (0.16, 0.28)], ketamine [OR=0.28 (0.13, 0.60)], alpha(2)-adrenoceptors [OR=0.23 (0.17, 0.33)], fentanyl [OR=0.31 (0.18, 0.56)], and peroperative analgesia [OR=0.15 (0.07, 0.34)] were all found to have a preventive effect. Subgroup analysis according to the peroperative analgesia given does not affect the results. CONCLUSIONS: This meta-analysis found that propofol, ketamine, fentanyl, and preoperative analgesia had a prophylactic effect in preventing EA. The analgesic properties of these drugs do not seem to have a role in this effect.

Premedication with clonidine is superior to benzodiazepines. A meta analysis of published studies.

BACKGROUND: Premedication is considered important in pediatric anesthesia. Benzodiazepines are the most commonly used premedication agents. Clonidine, an alpha2 adrenoceptor agonist, is gaining popularity among anesthesiologists. The goal of the present study was to perform a meta-analysis of studies comparing premedication with clonidine to Benzodiazepines. METHODS: A comprehensive literature search was conducted to identify clinical trials focusing on the comparison of clonidine and Benzodiazepines for premedication in children. Six reviewers independently assessed each study to meet the inclusion criteria and extracted data. Original data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), 95% confidence intervals [95% CI] and statistical heterogeneity were accessed. RESULTS: Ten publications fulfilling the inclusion criteria were found. Premedication with clonidine, in comparison with midazolam, exhibited a superior effect on sedation at induction (OR=0.49 [0.27, 0.89]), decreased the incidence of emergence agitation (OR=0.25 [0.11, 0.58]) and produced a more effective early post-operative analgesia (OR=0.33 [0.21, 0.58]). Compared with diazepam, clonidine was superior in preventing post-operative nausea and vomiting (PONV). DISCUSSION: Premedication with clonidine is superior to midazolam in producing sedation, decreasing post-operative pain and emergence agitation. However, the superiority of clonidine for PONV prevention remains unclear while other factors such as nausea prevention might interfere with this result.

Cytokine profiles in primary and secondary pulmonary granulomas of Guinea pigs with tuberculosis.

The cytokine mRNA profiles of primary (arising from inhaled bacilli) and secondary (arising from hematogenous reseeding of the lung) granulomas from the lung lobes of bacillus Calmette-Guérin (BCG)-vaccinated and unimmunized guinea pigs challenged with virulent Mycobacterium tuberculosis by the pulmonary route were assessed in situ using laser capture microdissection (LCM) at 6 weeks after infection. The challenge dose chosen was so low that some lung lobes did not receive an implant from the airway. In unimmunized guinea pigs, some lobes contained either large, necrotic primary lesions or small, non-necrotic secondary lesions, or both. The lobes of BCG-vaccinated animals contained only non-necrotic primary tubercles, and no secondary lesions were visible. Real-time PCR analysis of the acquired RNA clearly demonstrated that primary tubercles from BCG-vaccinated guinea pigs were overwhelmed with mRNA from the anti-inflammatory cytokine, transforming growth factor (TGF)-beta, with some IFN-gamma and IL-12p40 mRNA. In contrast, primary lesions from unimmunized animals were dominated by proinflammatory TNF-alpha mRNA. The cytokine mRNA profile of secondary lesions from unimmunized animals was strikingly similar to the profile of primary lesions from BCG-vaccinated guinea pigs (i.e., a predominance of TGF-beta mRNA with some IL-12p40 and IFN-gamma mRNA), indicating that the lung lobes from which these lesions were retrieved had been naturally "vaccinated" by the time the bloodborne bacilli returned to the lung at 3 to 4 weeks after infection. Furthermore, cytokine mRNA analysis of splenic granulomas from nonvaccinated and vaccinated animals showed close resemblance to primary granulomas recovered from the lungs of the same animal, that is, high levels of TNF-alpha mRNA in unimmunized animals, and mostly TGF-beta mRNA in BCG-vaccinated guinea pigs. Taken together, these data indicate that mycobacteria returning to the lungs of unimmunized guinea pigs 3 to 4 weeks after infection induce a local cytokine response that is fundamentally different from the response to inhaled bacilli and is reminiscent of the primary response in a vaccinated animal.

Microdissection of the cytokine milieu of pulmonary granulomas from tuberculous guinea pigs.

Levels of IL-12p40, TNFalpha, TGFbeta, IFNgamma and IL-10 mRNA were assessed by laser capture microdissection followed by quantitative real-time PCR in the pulmonary granulomas of unimmunized and BCG-vaccinated guinea pigs infected by aerosol with virulent Mycobacterium tuberculosis. Lesions microdissected from unimmunized guinea pigs were overwhelmed by the pro-inflammatory TNFalpha mRNA at both 3 and 6 weeks post infection, indicating the struggle to control the mounting infection. The cytokine profile of granulomas from vaccinated guinea pigs shifted from type 1 cytokine mRNA (IFNgamma and IL-12p40) at 3 weeks to a predominantly anti-inflammatory environment (TGFbeta mRNA) at 6 weeks. The relative proportions of cytokine mRNA transcripts in the periphery of the granuloma were different from the centre, reflecting differences in cell composition and architecture. Moreover, analysis of the individual lung lobes at 6 weeks post infection suggests that heterogeneity exists in the cytokine profile between the lobes of the lung.

Reflex pupillary dilatation in response to skin incision and alfentanil in children anaesthetized with sevoflurane: a more sensitive measure of noxious stimulation than the commonly used variables.

BACKGROUND: Estimation of analgesia in anaesthetized children is often imprecise, and consequently, anaesthesiologists commonly evaluate children's response to surgical stimulation by movement or haemodynamic changes. In adults reflex pupillary dilatation has been demonstrated to be a very sensitive measure of noxious stimulation, correlated with opioid concentrations. The autonomic nervous control changes with age, raising the hypothesis that mechanisms involved in pupillary autonomic functions regarding both sympathetic and parasympathetic components may also differ between adults and children. In this pilot study, we tested the hypothesis that the pupillary reflex dilatation might allow assessment of noxious stimulation and analgesic effect of alfentanil in children under sevoflurane anaesthesia, as an alternative to haemodynamic and bispectral measures. METHODS: After sevoflurane induction, 24 children were maintained in steady-state conditions at 1.5 MAC of sevoflurane in O(2)-N(2)O (50-50). An intense noxious stimulation was provided by standardized skin incision on the lower limb. A bolus of alfentanil (10 microg kg(-1)) was administered either 1 min (n=16) or 2 min (n=8) after skin incision. Haemodynamic values, bispectral index (BIS) and pupillary diameter (PD) were recorded just before stimulation and at 30-60 s intervals during 4 subsequent minutes. RESULTS: In all children PD increased significantly after noxious stimulation [+200 (40)%, at 60 s]. In contrast, mean heart rate and blood pressure increased only 11 (7)% and 10 (8)% respectively, 60 s after stimulation. BIS did not change significantly. In all children, alfentanil injection induced a rapid decrease of PD and restored pre-incision values in 2 min. CONCLUSION: PD is a more sensitive measure of noxious stimulation than the commonly used variables of heart rate, arterial blood pressure and BIS in children anaesthetized with sevoflurane.

Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair.

BACKGROUND: A new intravenous (i.v.) formulation of paracetamol and propacetamol (prodrug of paracetamol) were compared to determine tolerance and relative analgesic efficacy during the first 6 h after inguinal hernia repair performed under general anesthesia combined with ilioinguinal block in children. METHODS: A total of 183 ASA I or II in-patients, aged 1-12 years, admitted for unilateral inguinal hernia repair were randomized to receive in a double-blind design either i.v. paracetamol 15 mg.kg(-1) (n = 95) or propacetamol 30 mg.kg(-1) (n = 88) for postoperative pain relief as soon as pain intensity was greater than 30 on a 100 mm visual analog scale. All patients were evaluated for efficacy and tolerance. Efficacy was evaluated between 15 min and 6 h after the start of the 15 min infusion. RESULTS: The most frequently reported adverse event was injection site pain, which was significantly reduced in the new formulation group (i.v. paracetamol 14.7% vs propacetamol 33.0% of children, P = 0.005). No significant difference was obtained between treatments on pain relief (PR), pain intensity difference (PAID) from baseline, and objective pain scale intensity difference (OPSD). Also, treatment effects did not differ significantly for maximum values and weighted sums of PR, PAID (investigator and child rated), OPSD, time to first request for rescue medication, proportion of children requesting rescue medication, and investigators' global treatment satisfaction. CONCLUSION: A single infusion of i.v. paracetamol 15 mg.kg(-1) produced analgesia similar to a single infusion of propacetamol 30 mg.kg(-1) following inguinal hernia repair in children. Paracetamol i.v. 15 mg.kg(-1) was better tolerated at the injection site than propacetamol.

Agitation and changes of Bispectral Index and electroencephalographic-derived variables during sevoflurane induction in children: clonidine premedication reduces agitation compared with midazolam.

BACKGROUND: This double-blind randomized study was undertaken to assess agitation, Bispectral Index (BIS) and EEG changes during induction of anaesthesia with sevoflurane in children premedicated with midazolam or clonidine. METHODS: Children were allocated randomly to receive rectal midazolam 0.4 mg kg(-1) (n=20) or oral clonidine 4 microg kg(-1) (n=20) as premedication. Rapid induction of anaesthesia was achieved with inhalation of sevoflurane 8% in nitrous oxide 50%-oxygen 50%. After tracheal intubation, the children's lungs were mechanically ventilated and the inspired sevoflurane concentration was adjusted to achieve an end-tidal fraction of 2.5%. The EEG and BIS were recorded during induction until 10 min after tracheal intubation. The EEG was analysed using spectral analysis at five points: baseline, loss of eyelash reflex, 15 s before the nadir of the BIS (BIS(nadir)), when both pupils returned to the central position (immediately before intubation), and 10 min after intubation. RESULTS: Agitation was observed in 12 midazolam-treated and five clonidine-treated patients (P=0.05). At baseline, EEG rhythms were slower in the clonidine group. Induction of anaesthesia was associated with similar EEG changes in the two groups, with an increase in total spectral power and a shift towards low frequencies; these changes were maximal around the end of the second minute of induction (BIS(nadir)). When the pupils had returned to the central position, fast EEG rhythms increased and BIS was higher than BIS(nadir) (P<0.05). In both groups, agitation was associated with an increase in slow EEG rhythms at BIS(nadir). CONCLUSIONS: Compared with midazolam, clonidine premedication reduced agitation during sevoflurane induction. During induction with sevoflurane 8% (oxygen 50%-nitrous oxide 50%), the nadir of the BIS occurred at the end of the second minute of inhalation. Agitation was associated with a more pronounced slowing of the EEG rhythms at BIS(nadir) compared with inductions in which no agitation was observed. The BIS may not follow the depth of anaesthesia during sevoflurane induction in children.

Remifentanil infusion for cleft palate surgery in young infants.

BACKGROUND: The residual depressant effect of opioid is a major concern in infants scheduled for cleft palate repair. Remifentanil is associated with a fast and predictable recovery, independent of age. METHODS: About 40 infants in the 2-12 month age range were prospectively enrolled in this open study, to receive either remifentanil (infusion starting at 0.25 microg x kg(-1) x min(-1)) or sufentanil as part of a balanced anaesthesia regimen. Isoflurane was maintained at an endtidal concentration of 1.2% in oxygen and nitrous oxide and the opioid dosing was titrated to autonomic responses. Postoperative pain relief was provided by morphine infusion. Morphine administration started intraoperatively in the remifentanil group. RESULTS: Consistent haemodynamic stability was achieved throughout surgery in both groups. Infants of the remifentanil group required, on average, lower concentrations of isoflurane than children of the sufentanil group (1.2 +/- 0.2% vs 1.7 +/- 0.3%, P < 0.001). The median time from last suture to tracheal extubation was 12.5 min (5-25 min) in the remifentanil group and 15.0 min (10-30 min) in the sufentanil group. There was no evidence of hyperalgesia or enhanced morphine consumption in the remifentanil group compared with the sufentanil group. Postoperative pain scores were even lower in the remifentanil group, compared with the sufentanil group, soon after arrival in the postanaesthesia care unit. CONCLUSIONS: Remifentanil-based anaesthesia appeared well suited for primary cleft palate repair in young infants.

[Airway protection in children with a full stomach]. / La protection des voies aériennes supérieures chez l'enfant à estomac plein.

Recent surveys have reevaluated the risk of aspiration of gastric content during anesthesia in pediatric patients. Emergency, bowel obstruction and inadequate depth of anesthesia are the main high-risk situations. Airway protection requires the placement of cuffed tracheal tube. Cuffed tubes were considered as non-useful in children aged less than 6 to 8 years. They are however more frequently employed even in infants. Internal diameter of cuffed tubes should be reduced compared to uncuffed tubes. It is recommended to monitor cuff pressure if nitrous oxide is used during anesthesia. Crash induction is described with special reference to pediatric specificities.