Preventing perioperative hypothermia in children through implementation of customised guidelines.

INTRODUCTION: Perioperative hypothermia (PH) is common in children and associated with adverse clinical outcomes. Guidelines to prevent PH are mainly developed for adults and differ among institutions. We aimed to evaluate the effectiveness of customised guidelines in reducing PH in our paediatric population and the impact of cost considerations on physician practice. METHODS: Patients aged ≤16 years undergoing general anaesthesia in our tertiary paediatric hospital were prospectively recruited in this cohort study. Patient demographics, surgical procedures, anaesthesia details and temperature control measures were recorded. Data collection occurred over four phases: Phases 1 and 2 comprised standard management, while Phases 3 and 4 occurred following guidelines implementation. Sensors for continuous core temperature monitoring were provided free to patients during Phases 1 and 3, but were charged during Phases 2 and 4. The main outcome was occurrence of PH, defined as core temperature <36°C at any point from induction of anaesthesia to discharge from the postanaesthetic care unit. The impact of guidelines implementation and cost considerations influencing physician practice on PH outcomes was also analysed. RESULTS: Data from 3917 patients was analysed (1766 in Phase 1, 679 in Phase 2, 706 in Phase 3 and 766 in Phase 4). Guidelines implementation decreased PH incidence from 11.0% to 6.79% (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50-0.80, P = 0.0002). Free sensors increased the odds of detecting PH (OR 1.48, 95% CI 1.17-1.88, P = 0.001). With guidelines implementation, there was greater reduction in PH with free sensors (OR 0.64, 95% CI 0.47-0.88, P = 0.0055) compared to chargeable sensors (OR 0.75, 95% CI 0.50-1.11, P = 0.1471). CONCLUSIONS: Customised guidelines facilitated a sustained reduction of hypothermia in our paediatric surgical patients, although its impact was reduced by cost considerations.

Association between Self-Stigma and Suicide Risk in Individuals with Schizophrenia: Moderating Effects of Self-Esteem and Perceived Support from Friends.

This cross-sectional study assessed the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk in individuals with schizophrenia. We included 300 participants (267 with schizophrenia and 33 with schizoaffective disorder). Suicide risk was assessed using items adopted from the suicide module of the Mini-International Neuropsychiatric Interview; self-stigma was assessed using the Self-Stigma Scale-Short; perceived support from friends was assessed using the Friend Adaptation, Partnership, Growth, Affection, and Resolve Index; and self-esteem was assessed using the Rosenberg Self-Esteem Scale. A moderation analysis was performed to examine the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk. The results indicated that self-stigma was positively associated with suicide risk after the effects of other factors were controlled for. Both perceived support from friends and self-esteem significantly reduced the magnitude of suicide risk in participants with self-stigma. Our findings highlight the value of interventions geared toward ameliorating self-stigma and enhancing self-esteem in order to reduce suicide risk in individuals with schizophrenia.

Development of local guidelines to prevent perioperative hypothermia in children: a prospective observational cohort study.

PURPOSE: Perioperative hypothermia (PH) is defined as core body temperature < 36°C during the perioperative period. The incidence of PH is not well established in children because of variations in perioperative temperature monitoring and control measures. We sought to 1) establish the incidence of pediatric PH, 2) assess its adverse outcomes, and 3) identify risk factors in our pediatric population to develop local guidelines for prevention of PH. METHODS: We conducted a prospective observational cohort study at a single tertiary hospital (KK Women's and Children's Hospital, Singapore) from June 2017 to December 2017 based on existing institutional practice. We recruited patients aged ≤ 16 yr undergoing surgery and determined the incidence and adverse outcomes of hypothermia. We identified risk factors for PH using univariate and multiple logistic regression analysis and used these to develop local guidelines. RESULTS: Of 1,766 patients analyzed, 213 (12.1%; 95% confidence interval, 10.6 to 13.7) developed PH. Among these cases of PH, only 4.5% would have been detected by a single measurement in the postanesthesia care unit (PACU). Adverse outcomes included a longer stay in the PACU (47 vs 39 min; P < 0.01), a higher incidence of shivering (7.1 vs 2.6%; P = 0.01), and more discomfort (3.8 vs 1.4%; P = 0.02) compared with normothermic patients. Risk factors for PH included preoperative temperature < 36°C, surgery duration > 60 min, ambient operating room temperature < 23.0°C, and several "high-risk" surgeries. Guidelines were developed based on these risk factors and customized according to clinical and workflow considerations. CONCLUSIONS: Perioperative hypothermia was a common problem in our pediatric population and was associated with significant adverse outcomes. Guidelines developed based on risk factors identified in the local context can facilitate workflow and implementation within the institution.

RéSUMé: OBJECTIF: L'hypothermie périopératoire (HP) est définie par une température corporelle centrale < 36 °C pendant la période périopératoire. L'incidence de l'HP chez les enfants n'est pas connue avec précision en raison des variations dans le suivi de la température périopératoire et des mesures de contrôle. Nous avons cherché à (1) déterminer l'incidence de l'HP pédiatrique, (2) évaluer ses effets préjudiciables et (3) identifier les facteurs de risque dans notre population pédiatrique afin d'élaborer des lignes directrices locales pour la prévention de l'HP. MéTHODES: Nous avons mené une étude de cohorte observationnelle prospective dans un seul hôpital de niveau tertiaire (KK Women's and Children's Hospital, Singapour) de juin 2017 à décembre 2017 sur la base des pratiques existantes dans l'établissement. Nous avons recruté des patients âgés de 16 ans ou moins subissant une intervention chirurgicale et nous avons déterminé l'incidence et les effets secondaires de l'hypothermie. Nous avons identifié les facteurs de risque de l'HP en utilisant des analyses de régression logistique monofactorielle et multifactorielle qui nous ont servi à élaborer ces lignes directrices locales. RéSULTATS: Parmi les 1 766 cas de patients analysés, 213 (12,1 %; intervalle de confiance à 95 % : 10,6 à 13,7) ont développé une HP. Parmi ceux-ci, seulement 4,5 % auraient été détectés par une mesure unique dans l'unité de soins post anesthésie (salle de réveil). Les événements indésirables ont inclus un séjour plus long en salle de réveil (47 contre 39 minutes; P < 0,01), une plus grande incidence de tremblements (7,1 % contre 2,6 %; P = 0,01) et plus d'inconfort (3,8 % contre 1,4 %; P = 0,02), comparativement aux patients normothermiques. Les facteurs de risque d'HP étaient, notamment, une température préopératoire < 36 °C, la durée de la chirurgie > 60 min, la température de la salle d'opération < 23,0°C et plusieurs chirurgies à « risque élevé ¼. Des lignes directrices ont été élaborées à partir de ces facteurs de risque et adaptées en tenant compte de considérations cliniques et des flux de travail. CONCLUSIONS: L'hypothermie périopératoire était un problème fréquent dans notre population pédiatrique et a été associée à des effets secondaires significatifs. Des lignes directrices élaborées en fonction de facteurs de risque dans un contexte local peuvent faciliter le flux de travail et leur mise en œuvre au sein d'un établissement.

Comparing the Psychometric Properties among Three Versions of the UCLA Loneliness Scale in Individuals with Schizophrenia or Schizoaffective Disorder.

The UCLA Loneliness Scale (Version 3; UCLA-LSV3) is widely used for assessing loneliness. Nevertheless, the validity of this scale for assessing loneliness in individuals with schizophrenia or schizoaffective disorder has not been determined. Additionally, studies validating the eight-item and three-item versions of UCLA-LSV3 have not included individuals with severe mental illness; therefore, whether the short versions are comparable to the full 20-item version of UCLA-LSV3 for this population is unclear. The present study examined the unidimensional structure, internal consistency, concurrent validity, and test-retest reliability of the Chinese versions of UCLA-LSV3 (i.e., 20-item, 8-item, and 3-item versions) to determine which version is most appropriate for assessing loneliness in individuals with schizophrenia or schizoaffective disorder in Taiwan. A total of 300 participants (267 with schizophrenia and 33 with schizoaffective disorder) completed the scales, comprising UCLA-LSV3, the Center for Epidemiological Studies Depression Scale (CES-D), the suicidality module of the Kiddie Schedule for Affective Disorders and Schizophrenia-Epidemiological Version (K-SADS-E), and the family and peer Adaptation, Partnership, Growth, Affection, and Resolve (APGAR) index. Construct validity was evaluated through confirmatory factor analysis. The three versions of UCLA-LSV3 were compared with the CES-D, the suicidality module of the K-SADS-E, and the family and peer APGAR index to establish concurrent validity. The results indicated that all three versions of UCLA-LSV3 exhibited acceptable to satisfactory psychometric properties in terms of unidimensional constructs, concurrent validity, and test-retest reliability. The full version of UCLA-LSV3 had the best performance, followed by the eight-item version and the three-item version. Moreover, the three versions had relatively strong associations with each other. Therefore, when deliberating which version of UCLA-LSV3 is the best choice for assessing loneliness in individuals with schizophrenia or schizoaffective disorder, healthcare providers and therapists should consider time availability and practicality.

Anaesthetic modality and post-surgical oncological outcomes for paediatric tumours: is there a link?

INTRODUCTION: Children with solid organ tumours often present for curative surgery. Even with the best surgical technique, micrometastases can occur. Preclinical studies support the postulation that neuraxial anaesthesia maintains the body's immune and inflammatory milieu against metastasis. However, human retrospective adult studies showed varying results, and no study has been done in children. We aimed to find out if intraoperative epidural, perioperative opioid and volatile dose are associated with relapse-free survival (RFS) in children with solid organ tumours. METHODS: This is a retrospective cohort study of 126 children from a tertiary paediatric unit who were diagnosed with solid organ tumours (neuroblastoma, hepatoblastoma or sarcoma) over a 16-year period. RFS, stratified by tumour subtypes, was estimated using the Kaplan-Meier method. Adjusted hazard ratios (aHRs) were obtained from multivariable Cox regression models after taking potential covariates into account. RESULTS: Of 126 children with solid organ tumours (51.6% neuroblastoma, 34.9% sarcoma and 13.5% hepatoblastoma), 53.2% received combined general anaesthesia (GA)/epidural. A total of 21 (31.3%) and 20 (33.9%) patients relapsed during the study period in the combined GA/epidural group and the GA alone group, respectively. Patients with sarcoma receiving combined GA/epidural had a clinically meaningful lower risk of relapse compared to patients receiving GA alone (aHR 0.51, 95% confidence interval 0.14-1.79), although this was not statistically significant. CONCLUSION: Our study demonstrated some clinically meaningful associations, especially in paediatric sarcoma patients. Overall, however, there was no statistically significant association between epidural use and an improved RFS.

Publisher Correction: The Extended Polydimensional Immunome Characterization (EPIC) web-based reference and discovery tool for cytometry data.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Perioperative Temperature Management in Children: What Matters?

Inadvertent perioperative hypothermia is common and associated with increased risk of perioperative complications. Adult data drives most guidelines for pediatric perioperative temperature management and does not consistently demonstrate effectiveness in children. This study aims to identify risk factors for hypothermia and determine the effectiveness of current interventions in the pediatric population. METHODS: We carried out a prospective observational study in children undergoing anesthesia in our tertiary pediatric unit. We included 869 patients (<16 y) undergoing emergency/elective surgeries over 2 months. Our team recorded the incidence of hypothermia (tympanic core temperature < 36°C) within 15 minutes of arrival to the postanesthetic care unit. We collected data such as patient demographic, surgical, anesthetic (including monitoring and warming measures used), and operating theater (OT) temperature. We performed statistical analysis to identify risk factors associated with hypothermia. RESULTS: Postoperative hypothermia incidence was 12.3% (107/869). The mean core temperature on arrival to the postanesthetic care unit was 36.6°C (+SD 0.45) in normothermic patients versus 35.6°C (+SD 0.34) in hypothermic patients. Multivariable analysis identified starting ambient OT temperature [odds ratio (OR) = 0.83, confidence interval (CI): 0.71-0.96; P = 0.010], intraoperative temperature monitoring (OR = 0.49, CI: 0.28-085; P = 0.011), use of occlusive dressing (OR = 0.35, CI: 0.15-0.85; P = 0.020), and active forced-air warming (OR = 0.42, CI: 0.25-0.70; P = 0.001) as factors independently protective of postoperative hypothermia. Hypothermia occurred less frequently with emergency vs. elective procedures (OR 0.43, CI: 0.21-0.91; P = 0.026). CONCLUSIONS: Routine core temperature monitoring and active forced-air warming are useful measures to prevent hypothermia. Additionally, occlusive covers and controlling ambient OT temperature are cost-effective and safe methods to reduce inadvertent hypothermia.

Kinectin-dependent ER transport supports the focal complex maturation required for chemotaxis in shallow gradients.

Chemotaxis in shallow gradients of chemoattractants is accomplished by preferential maintenance of protrusions oriented towards the chemoattractant; however, the mechanism of preferential maintenance is not known. Here, we test the hypothesis that kinectin-dependent endoplasmic reticulum (ER) transport supports focal complex maturation to preferentially maintain correctly oriented protrusions. We knocked down kinectin expression in MDA-MB-231 cells using small interfering RNA and observed that kinectin contributes to the directional bias, but not the speed, of cell migration. Kymograph analysis revealed that the extension of protrusions oriented towards the chemoattractant was not affected by kinectin knockdown, but that their maintenance was. Immunofluorescence staining and live-cell imaging demonstrated that kinectin transports ER preferentially to protrusions oriented towards the chemoattractant. ER then promotes the maturation of focal complexes into focal adhesions to maintain these protrusions for chemotaxis. Our results show that kinectin-dependent ER distribution can be localized by chemoattractants and provide a mechanism for biased protrusion choices during chemotaxis in shallow gradients of chemoattractants.

Pulmonary aspiration under GA: a 13-year audit in a tertiary pediatric unit.

INTRODUCTION: Pulmonary aspiration is a known risk of general anesthesia. We aim to find out the incidence, risk factors, and outcome of pulmonary aspiration in our pediatric population. METHODS: Since 2000, all critical incidents are reported on a standardized audit form. All cases with pulmonary aspiration being reported as a critical incident were identified and their case notes traced to look at the perioperative details. RESULTS: From 2000 to 2013, a total of 102 425 pediatric cases were done in our hospital. Twenty-two cases were reported to have aspirated during anesthesia giving an incidence of 0.02% (1 in 4655). Majority (59.0%) of the children were between the ages of 3-12 and of ASA 1 (54.5%). None of them had any history of pulmonary aspiration. Of the 22 cases, 12 occurred during induction, three during maintenance, three during emergence, three during recovery, and one occurred preinduction. Twelve cases had intravenous induction while the rest received inhalational induction. The type of induction does not appear to affect the incidence of aspiration (OR 1.139 95% CI: 0.457-2.818 P = 0.76). Two cases were found to have a difficult airway during induction and 45.5% were emergency operations. Emergency surgeries put the patient at a higher risk of aspiration (OR 4.321 95% CI: 1.735-10.687 P = 0.001). No mortality was reported. Surgery was canceled for one patient, two had unplanned admissions, seven were admitted to high dependency unit or intensive care unit with two requiring postoperative ventilation. CONCLUSION: The incidence of aspiration under general anesthesia in our hospital is comparable to published reports. Our audit highlights the fact that pulmonary aspiration although rare mostly occur in healthy ASA 1 and 2 children with no prior history. Emergency surgeries put the patient at a higher risk of aspiration. They occurred usually during induction, a process which tends to be variable (in technique and duration) for pediatric patients.