Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience.

BACKGROUND: Successful combined Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) in the Same Session (LESS) has been reported in several studies in adult patients with choledocholithiasis. METHODS: This was a retrospective analysis of data collected prospectively in the Pediatric ERCP Database Initiative using REDCAP. Adverse events were recorded separately and were reviewed for this study. The primary outcome was the hospitalization days. Secondary outcomes included total duration of anesthesia, morbidity, time from diagnosis to procedure. RESULTS: Twenty-five patients underwent LESS, and 42 underwent the traditional ERCP followed by laparoscopic cholecystectomy. The groups were similar in age, weight, ASA. The median length of stay in the LESS group was 3 days, compared with 4 days (P = .32). Total procedure time was similar between the 2 groups, but anesthesia time was shorter in the LESS group (P = .0401). Morbidity was similarly low between the 2 groups. CONCLUSIONS: Relative to 2 interventions, a single session combining ERCP and laparoscopic cholecystectomy in pediatric patients is effective with a similar adverse event rate and length of stay. The use of a single sedation and reduced total anesthesia time are potential benefits of this approach. This modality may be considered for pediatric patients with choledocholithiasis with or without hemolytic disease.

CO2-limitation-inducible Green Recovery of fatty acids from cyanobacterial biomass.

Using genetically modified cyanobacterial strains, we engineered a Green Recovery strategy to convert membrane lipids into fatty acids for economical and environmentally sustainable biofuel production. The Green Recovery strategy utilizes lipolytic enzymes under the control of promoters induced by CO(2) limitation. Data indicate that strains of the cyanobacterium Synechocystis sp. PCC6803 engineered for Green Recovery underwent degradation of membrane diacylglycerols upon CO(2) limitation, leading to release of fatty acids into the culture medium. Recovered fatty acid yields of 36.1 × 10(-12) mg/cell were measured in one of the engineered strains (SD239). Green Recovery can be incorporated into previously constructed fatty-acid-secretion strains, enabling fatty acid recovery from the remaining cyanobacterial biomass that will be generated during fatty acid biofuel production in photobioreactors.

A single harmonised pharmacy process to improve clinical trial set-up times.

The UK has fallen from fourth to 10th place in the global ranking for clinical trial activities in the past 6 years. Due to the limited capacity of the clinical trial pharmacy workforce and delays in providing pharmacy approvals, pharmacy has been identified as one of the constraining services that delays the set-up and delivery of clinical trials. To tackle this problem, we developed a single pharmacy review process for multicentre trials across Greater Manchester (GM) and tested its feasibility and implementation in our region. A survey completed by each GM Trust suggests that this harmonised pharmacy review process for multicentre studies would expedite trial set-up time at each pharmacy site and standardise the pharmacy review process in GM. We therefore believe that this harmonised review process could potentially reduce pharmacy set-up time and reposition the UK in the global market for clinical trials.

Assessing Residency Applicants' Communication and Professionalism: Standardized Video Interview Scores Compared to Faculty Gestalt.

INTRODUCTION: The Association of American Medical Colleges has introduced the Standardized Video Interview (SVI) to assess the communication and professionalism skills of residency applicants to allow a more holistic view of applicants beyond academic performance. Initial data suggests scores are not correlated with academic performance and provide a new measure of applicant attributes. It is not currently known how the SVI compares to existing metrics for assessing communication and professionalism during the interview process. METHODS: Applicants to the University of Wisconsin Emergency Medicine Residency program were invited and interviewed without use of the SVI scores or videos. All faculty interviewers were blinded to applicants' SVI information and asked to rate each applicant on their communication and professionalism on a scale from 1-25 (faculty gestalt score), analogous to the 6-30 scoring used by the SVI. We transformed SVI scores to our 1-25 system (transformed SVI score) for ease of comparison and compared them to faculty gestalt scores as well as applicants' overall score for all components of their interview day (interview score). RESULTS: We collected data for 125 residency candidates. Each applicant received a faculty gestalt score from up to four faculty interviewers. There was no significant correlation of SVI scores with faculty gestalt scores (Spearman's rank correlation coefficient [rs] (123)=0.09, p=0.30) and no correlation with the overall interview score (rs(123)=0.01, p=0.93). Faculty gestalt scores were correlated positively with interview scores (rs(123)=0.65, p<0.01). CONCLUSION: SVI scores show no significant correlation with faculty gestalt scores of communication and professionalism. This could relate to bias introduced by knowledge of an applicant's academic performance, different types of questions being asked by faculty interviewers, or lack of uniform criteria by which faculty assess these competencies. Further research is needed to determine whether SVI scores or faculty gestalt correlate with performance during residency.

Chronic intermittent hyperoxia alters the development of the hypoxic ventilatory response in neonatal rats.

Chronic exposure to sustained hyperoxia alters the development of the respiratory control system, but the respiratory effects of chronic intermittent hyperoxia have rarely been investigated. We exposed newborn rats to short, repeated bouts of 30% O2 or 60% O2 (5 bouts h(-1)) for 4-15 days and then assessed their hypoxic ventilatory response (HVR; 10 min at 12% O2) by plethysmography. The HVR tended to be enhanced by intermittent hyperoxia at P4 (early phase of the HVR), but it was significantly reduced at P14-15 (primarily late phase of the HVR) compared to age-matched controls; the HVR recovered when individuals were returned to room air and re-studied as adults. To investigate the role of carotid body function in this plasticity, single-unit carotid chemoafferent activity was recorded in vitro. Intermittent hyperoxia tended to decrease spontaneous action potential frequency under normoxic conditions but, contrary to expectations, hypoxic responses were only reduced at P4 (not at P14) and only in rats exposed to higher O2 levels (i.e., intermittent 60% O2). Rats exposed to intermittent hyperoxia had smaller carotid bodies, and this morphological change may contribute to the blunted HVR. In contrast to rats exposed to intermittent hyperoxia beginning at birth, two weeks of intermittent 60% O2 had no effect on the HVR or carotid body size of rats exposed beginning at P28; therefore, intermittent hyperoxia-induced respiratory plasticity appears to be unique to development. Although both intermittent and sustained hyperoxia alter carotid body development and the HVR of rats, the specific effects and time course of this plasticity differs.

Role of TrkB during the postnatal development of the rat carotid body.

Brain-derived neurotrophic factor (BDNF) supports innervation of the carotid body by neurons projecting from the petrosal ganglion. Although carotid body glomus cells also express TrkB, BDNF's high affinity receptor, the role of BDNF in carotid body growth and O2 sensitivity has not been studied. Neonatal rats were treated with the TrkB antagonist K252a (100 µg kg(-1), i.p., b.i.d.) or vehicle on postnatal days P0-P6 and studied on P7. Carotid body volume was decreased by 35% after chronic K252a (P<0.001); a reduction in carotid body size was also elicited using the more selective TrkB antagonist ANA-12 (500 µg kg(-1), i.p., b.i.d.). In contrast, single-unit chemoafferent responses to 5% O2, measured in vitro, were unaffected by chronic K252a administration. Normoxic and hypoxic ventilation, measured by head-body plethysmography, were also normal after chronic K252a administration, but acute K252a administration produced a slower, deeper breathing pattern during the transition into hypoxia. These data suggest that BDNF regulates postnatal carotid body growth but does not influence the development of glomus cell O2 sensitivity.

Elite female athletes' ventilatory compensation to decreased inspired O2 during the wingate test.

PURPOSE: The purpose of this study was to determine if anaerobic performance as measured by the Wingate is decremented in elite female athletes when fraction of inspired oxygen is decreased from 20.9% to 10%. METHOD: Nine collegiate female soccer players (Mweight = 63.2 ± 10 kg, Mheight = 164 ± 4.7 cm, Mage = 18.6 ± 0.5 year) performed 1 Wingate test under each condition separated by at least 24 hr. Oxygen consumption was measured breath by breath using a Sensor-Medics metabolic cart. Postexercise blood lactates were measured using the finger-stick method. During normoxic and hypoxic (10% inspired oxygen [O2]) conditions, participants inhaled air from a 300-L weather balloon during the 30-s test. RESULTS: Peak power, minimum power, average power, postexercise blood lactate, preexercise and postexercise blood O2 saturation, and total O2 consumed during exercise and during recovery were not statistically different between conditions. However, the Fatigue Index and peak ventilation were significantly greater during hypoxia than normoxia (35 ± 11% vs. 27 ± 9% & 91.6 ± 14.2 L/min vs. 75.2 ± 11.1 L/min, respectively, p < .05, Cohen's d = - 0.80 and - 1.29, respectively). Ventilation was elevated during hypoxia within 5 s of beginning the Wingate and remained elevated throughout exercise. This increased ventilation was sufficient to maintain oxygen consumption during exercise. CONCLUSION: Under hypoxic conditions, the ventilatory response to the Wingate test is perhaps more important than aerobic capacity per se in determining whether or not Wingate performance is decremented.

Postnatal development of eupneic ventilation and metabolism in rats chronically exposed to moderate hyperoxia.

Newborn rats chronically exposed to moderate hyperoxia (60% O2) exhibit abnormal respiratory control, including decreased eupneic ventilation. To further characterize this plasticity and explore its proximate mechanisms, rats were exposed to either 21% O2 (Control) or 60% O2 (Hyperoxia) from birth until studied at 3-14 days of age (P3-P14). Normoxic ventilation was reduced in Hyperoxia rats when studied at P3, P4, and P6-7 and this was reflected in diminished arterial O2 saturations; eupneic ventilation spontaneously recovered by P13-14 despite continuous hyperoxia, or within 24h when Hyperoxia rats were returned to room air. Normoxic metabolism was also reduced in Hyperoxia rats but could be increased by raising inspired O2 levels (to 60% O2) or by uncoupling oxidative phosphorylation within the mitochondrion (2,4-dinitrophenol). In contrast, moderate increases in inspired O2 had no effect on sustained ventilation which indicates that hypoventilation can be dissociated from hypometabolism. The ventilatory response to abrupt O2 inhalation was diminished in Hyperoxia rats at P4 and P6-7, consistent with smaller contributions of peripheral chemoreceptors to eupneic ventilation at these ages. Finally, the spontaneous respiratory rhythm generated in isolated brainstem-spinal cord preparations was significantly slower and more variable in P3-4 Hyperoxia rats than in age-matched Controls. We conclude that developmental hyperoxia impairs both peripheral and central components of eupneic ventilatory drive. Although developmental hyperoxia diminishes metabolism as well, this appears to be a regulated hypometabolism and contributes little to the observed changes in ventilation.

Chronic hyperoxia and the development of the carotid body.

Preterm infants often experience hyperoxia while receiving supplemental oxygen. Prolonged exposure to hyperoxia during development is associated with pathologies such as bronchopulmonary dysplasia and retinopathy of prematurity. Over the last 25 years, however, experiments with animal models have revealed that moderate exposures to hyperoxia (e.g., 30-60% O(2) for days to weeks) can also have profound effects on the developing respiratory control system that may lead to hypoventilation and diminished responses to acute hypoxia. This plasticity, which is generally inducible only during critical periods of development, has a complex time course that includes both transient and permanent respiratory deficits. Although the molecular mechanisms of hyperoxia-induced plasticity are only beginning to be elucidated, it is clear that many of the respiratory effects are linked to abnormal morphological and functional development of the carotid body, the principal site of arterial O(2) chemoreception for respiratory control. Specifically, developmental hyperoxia reduces carotid body size, decreases the number of chemoafferent neurons, and (at least transiently) diminishes the O(2) sensitivity of individual carotid body glomus cells. Recent evidence suggests that hyperoxia may also directly or indirectly impact development of the central neural control of breathing. Collectively, these findings emphasize the vulnerability of the developing respiratory control system to environmental perturbations.