Multifaceted highly targeted sequential multidrug treatment of early ambulatory high-risk SARS-CoV-2 infection (COVID-19).

The SARS-CoV-2 virus spreading across the world has led to surges of COVID-19 illness, hospitalizations, and death. The complex and multifaceted pathophysiology of life-threatening COVID-19 illness including viral mediated organ damage, cytokine storm, and thrombosis warrants early interventions to address all components of the devastating illness. In countries where therapeutic nihilism is prevalent, patients endure escalating symptoms and without early treatment can succumb to delayed in-hospital care and death. Prompt early initiation of sequenced multidrug therapy (SMDT) is a widely and currently available solution to stem the tide of hospitalizations and death. A multipronged therapeutic approach includes 1) adjuvant nutraceuticals, 2) combination intracellular anti-infective therapy, 3) inhaled/oral corticosteroids, 4) antiplatelet agents/anticoagulants, 5) supportive care including supplemental oxygen, monitoring, and telemedicine. Randomized trials of individual, novel oral therapies have not delivered tools for physicians to combat the pandemic in practice. No single therapeutic option thus far has been entirely effective and therefore a combination is required at this time. An urgent immediate pivot from single drug to SMDT regimens should be employed as a critical strategy to deal with the large numbers of acute COVID-19 patients with the aim of reducing the intensity and duration of symptoms and avoiding hospitalization and death.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.

INTRODUCTION: Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. METHODS: All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. RESULTS: We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. CONCLUSIONS: In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

Crime prevention and active living.

This paper addresses the question of whether crime is a barrier to active living and if it is, what can be done about it? The authors introduce a theoretical model that addresses how crime might influence physical activity behavior. The core components of the model are: situational characteristics, crime and disorder, fear of crime or disorder, and physical activity. These variables are thought to be moderated through psychological, demographic, environmental and other factors. Research questions that derive from the model are featured.

Anaesthetic management of infants with glycogen storage disease type II: a physiological approach.

Pompe or Glycogen Storage Disease type II (GSD-II) is a genetic disorder affecting both cardiac and skeletal muscle. Historically, patients with the infantile form usually die within the first year of life due to cardiac and respiratory failure. Recently a promising enzyme replacement therapy has resulted in improved clinical outcomes and a resurgence of elective anaesthesia for these patients. Understanding the unique cardiac physiology in patients with GSD-II is essential to providing safe general anaesthesia.

Paediatric regional anaesthesia--what makes a difference?

Regional anaesthetic techniques are useful for providing post-operative pain control for ambulatory surgery in children. This chapter focuses on unique features of paediatric anatomy and physiology that allow successful performance of these techniques. An overview of the effective use of long-acting local anaesthetics in children is presented. Combinations of local anaesthetics and adjunct medications that prolong caudal blockade, the most commonly performed paediatric block, are reviewed, with a goal of providing prolonged analgesia with minimal side-effects. An overview of the use of peripheral nerve blockade and specific recommendations for the use of these blocks in children is also presented.

Prediction of tracheal tube size in children using multiple variables.

BACKGROUND: Tracheal tube (TT) size selection in children is important to avoid complications. Formulae utilizing age and physical characteristics to predict appropriate tube size are not entirely predictive. METHODS: Using an automated anaesthesia record keeper database, the anaesthetic records of 8504 children, aged up to 7 years, who required tracheal intubation, were reviewed. Age, height and weight data were related to TT size. The total number of patients whose age, height and weight were independently available was 8396, 3929 and 7823, respectively. The number having all three variables was 3814. A linear regression analysis was performed for patients with all three variables and for each variable individually. RESULTS: Tracheal tube size is best predicted using multivariate analysis and, for any child aged up to 7 years, is represented by the formula: 2.44 + (age x 0.1) + (height x 0.02) + (weight x 0.016). Formulae utilizing these variables individually are also reviewed. CONCLUSIONS: Prediction of TT size is best accomplished using multiple variables. Further prospective study is suggested.

Office-based anesthesia for children.

The use of office-based surgery and anesthesia will continue to grow. The anesthesia community has embraced the opportunity to become a driving force of office-based surgery and has organized into rapidly growing groups that promote safe practice in the office setting. The Society for Office-Based Anesthesia was developed to continuously improve patient safety and outcomes in office surgery. This group has an active Web site (www.soba.org) that allows for online discussions and widespread participation in working toward the society's stated goal. This Web site may be used as a reference for physicians in the process of considering the move to office-based anesthesia. The advantages of office-based anesthesia are numerous. The financial incentives are tremendous and the convenience to the patient and surgeon is important. For office anesthesia to be successful in children, patient safety, proof of improved outcomes, and family and surgeon satisfaction must be the goals. Anesthesia providers must continue to take active roles in organizing the office environment to ensure that safety is paramount. As the field grows, additional ways to study and improve the overall care children receive in the office should be sought. In the near future, office practice for surgery and anesthesia for children undergoing minor procedures should be a safe and effective alternative to current practices.