Narcotics and sedatives use in the mechanical ventilation in preterm infants: Predictors and outcome.

BACKGROUND: Mechanical ventilation (MV) causes discomfort but whether it causes pain remains controversial. Around the world neonatal intensive care units (NICU) often utilize narcotics and/or sedatives during MV of vulnerable infants yet the association with adverse neonatal outcomes has not been adequately addressed. OBJECTIVE: Test for associations between the use of narcotics/sedatives during MV and mortality/morbidity in preterm infants in a large infant cohort in Canada. DESIGN/METHODS: Preterm infants born <35 weeks gestational age (GA) requiring MV for >24 hrs were identified retrospectively from the Canadian Neonatal Network database, 2010-12. Infants were categorized according to whether they received narcotics/sedatives for greater than 24 hours concurrently with MV. Infants were excluded if moribund on admission, had major congenital anomalies, diagnoses where narcotic administration is routine and suspected seizures. Multivariable logistic and linear regression analysis tested for association of narcotics/sedatives use during MV with mortality/morbidity (nosocomial infections, BPD, ROP, IVH) and length of MV. RESULTS: After exclusions the cohort included 2672 infants; 467(17%) exposed only to narcotics 101(4%) only to sedatives and 299(11%) to both. All models were adjusted for GA, gender, small for GA, SNAP-II score >20, multiple births, delivery mode, outborn, PDA status, MV type, use of high flow, muscle relaxant use, indwelling lines, caffeine and surfactant therapy. The composite mortality/morbidity, and MV days were significantly higher for MV infants exposed to narcotics, sedatives or both compared to infants not exposed. CONCLUSION: Mounting evidence of the adverse short and long-term impacts of narcotics/sedatives during MV supports the need for further work in alternative therapies.

Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline.

Background: For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods: Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results: Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions: Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Primary excision margins and sentinel lymph node biopsy in clinically node-negative melanoma of the trunk or extremities.

AIMS: For patients with early-stage melanoma, uncertainty exists regarding optimal surgical excision margins of the primary tumour and surgical management of the clinically node-negative lymph node basin. We describe the process of creating a provincial guideline for the treatment of node-negative melanoma of the trunk and extremities. The following research questions were addressed: What are the optimal excision margins for clinically node-negative cutaneous melanoma and should these patients undergo sentinel lymph node biopsy? MATERIALS AND METHODS: Outcomes were local and regional recurrence, overall and disease-free survival, and morbidity. The MEDLINE and EMBASE databases, National Guideline Clearinghouse, CMA Infobase and websites of guideline development organisations were systematically searched. Using the AGREE instrument, relevant guidelines were assessed and an updated literature search completed. A systematic review and practice guideline was written, reviewed and approved by the Melanoma Site Group and the Program in Evidence-based Care Report Approval Panel. External review by three melanoma experts was completed, as was an online consultation with healthcare professionals who were intended users of the guideline. RESULTS: One guideline was selected for adoption: the Australian Cancer Network National Health and Medical Research Council and the New Zealand Guidelines group 2008 melanoma guideline. An updated literature search was undertaken to include relevant studies published since the adopted guideline was completed. CONCLUSIONS: Excision margins range from 5mm to 2cm depending on the melanoma depth. Patients with a melanoma greater than 1.0mm in thickness should be given the opportunity to discuss sentinel lymph node biopsy to provide staging and prognostic information.

Keynes on population and economic growth.

PIP: This article discusses the evolution of Keynes's thinking on population based on an unpublished paper from 1914, "Is the Problem of Population a Pressing and Important One Now?" The paper is reported to have 39 pages, but in fact there are many missing page numbers. Keynes's "Essays in Biography" (1933) follows the basic structure and much of the verbal detail of the first 16 pages of "Population." Chapter 2 of the "Economic Consequences of the Peace" discusses the key ideas of "Population." The passages in "Population" and Chapter 2 were probably the sources of a fierce controversy in 1923-24 between Keynes and W.H. Beveridge over Keynes' neo-Malthusianism. "Population" was the basis for the three themes that were central to Keynes's writing on population. Keynes's framework shifted from a global perspective in "Population" to a progressively narrower focus in the 1930s on England and Wales. Keynes was stronger in his advocacy of birth control in "Population" compared to later writings. Keynes was concerned about the quality of population but disagreed on the methods of achieving this. Keynes argued that 75% of the world was not subject to Malthusian dynamics, and the other 25% had developed technology to relieve population pressure. "Population" sketches out the rudiments of the welfare implications of the great divide between North and South population growth rates. Keynes assumes that overpopulation in the South will be compensated for by the international market without consideration of income deficits. Keynes argues against pronatalism. The 1933 essay shows Keynes shift away from Malthus as population expert to Malthus as political economist. By 1937, Keynes had recanted and was very aware of the uncertainty of the economy. The author believes that it is unfortunate that this 1913-14 manuscript remains unknown and, if known, misunderstood.^ieng