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This chapter, reviews the basics for children undergoing epilepsy surgery. The authors discuss the incidence and types of seizures as well as various modalities for seizure suppression (e.g. ketogenic diet, vagal nerve stimulation). The chapter presents the surgical approaches to epilepsy surgery, MRI mapping followed by laser ablation and electrocorticography with mapping followed by surgical excision. The anesthetic implications related to these complex patients are presented.
This commentary highlights the observation that social motivation is usually an imprecisely specified construct. We suggest four social motivation conceptualizations across levels of analysis and explore where the target article situates among these. We then offer theoretical and practical guidance for operationalization and measurement of social motivation to support more comprehensive future research on this complex construct in the autism literature.
Malnutrition remains a leading contributor to the morbidity and mortality of children under the age of 5 years and can weaken the immune system and increase the severity of concurrent infections. Livestock milk with the protective properties of human milk is a potential therapeutic to modulate intestinal microbiota and improve outcomes. The aim of this study was to develop an infection model of childhood malnutrition in the pig to investigate the clinical, intestinal and microbiota changes associated with malnutrition and enterotoxigenic Escherichia coli (ETEC) infection and to test the ability of goat milk and milk from genetically engineered goats expressing the antimicrobial human lysozyme (hLZ) milk to mitigate these effects. Pigs were weaned onto a protein–energy-restricted diet and after 3 weeks were supplemented daily with goat, hLZ or no milk for a further 2 weeks and then challenged with ETEC. The restricted diet enriched faecal microbiota in Proteobacteria as seen in stunted children. Before infection, hLZ milk supplementation improved barrier function and villous height to a greater extent than goat milk. Both goat and hLZ milk enriched for taxa (Ruminococcaceae) associated with weight gain. Post-ETEC infection, pigs supplemented with hLZ milk weighed more, had improved Z-scores, longer villi and showed more stable bacterial populations during ETEC challenge than both the goat and no milk groups. This model of childhood disease was developed to test the confounding effects of malnutrition and infection and demonstrated the potential use of hLZ goat milk to mitigate the impacts of malnutrition and infection.
Hemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).
This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).
A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.
In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.
MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study. Prehosp Disaster Med. 2018;33(3):230–236.
Anomalous aortic origin of the coronary arteries is associated with exercise-induced ischaemia, leading some physicians to restrict exercise in patients with this condition. We sought to determine whether exercise restriction was associated with increasing body mass index over time. From 1998 to 2015, 440 patients ⩽30 years old were enrolled into an inception cohort. Exercise-restriction status was documented in 143 patients. Using linear mixed model repeated-measures regression, factors associated with increasing body mass index z-score over time, including exercise restriction and surgical intervention as time-varying covariates, were investigated. The 143 patients attended 558 clinic visits for which exercise-restriction status was recorded. The mean number of clinic visits per patient was 4, and the median duration of follow-up was 1.7 years (interquartile range (IQR) 0.5–4.4). The median age at first clinic visit was 10.3 years (IQR 7.1–13.9), and 71% (101/143) were males. All patients were alive at their most recent follow-up. At the first clinic visit, 54% (78/143) were exercise restricted, and restriction status changed in 34% (48/143) during follow-up. The median baseline body mass index z-score was 0.2 (IQR 0.3–0.9). In repeated-measures analysis, neither time-related exercise restriction nor its interaction with time was associated with increasing body mass index z-score. Surgical intervention and its interaction with time were associated with decreasing body mass index z-score. Although exercise restriction was not associated with increasing body mass index over time, surgical intervention was associated with decreasing body mass index z-score over time in patients with anomalous aortic origin of the coronary arteries.
2,4-dimethylamine salt (2,4-D) is a selective broadleaf herbicide commonly applied to turfgrass systems, including athletic fields, which can dislodge from treated vegetation. Building on previous research confirming 2,4-D dislodgeability is affected by management inputs, field research was initiated in 2014 and 2015 in North Carolina and Tennessee to quantify the effects of sprayer setup on dislodgeable 2,4-D foliar residue from hybrid bermudagrass, which is the most common athletic field playing surface in subtropical and tropical climates. More specifically, research evaluated dislodgeable 2,4-D foliar residue following spray applications (2.1 kg ae ha−1) at varying carrier volumes (187, 374, or 748 L ha−1) and nozzles delivering varying droplet sizes (fine=extended range [XR], coarse=drift guard, or extra coarse=air induction extended range [AIXR]). Overall, data suggest minimal 2,4-D dislodge occurs via soccer ball roll (3.6 m) outside the day of application; however, increasing carrier volume and droplet size can further decrease dislodgeable 2,4-D foliar residue. At 2 d after treatment (DAT), 3.87% of applied 2,4-D dislodged when applied at 187 L ha−1 compared to 2.05% at 748 L ha−1. Pooled over data from 1 to 6 DAT, 1.59% of applied 2,4-D dislodged following XR nozzle application compared to 1.13% with AIXR nozzle. While these are small numerical differences, dislodgeable residue was measured via one soccer ball roll, which is a repeated process within the sport and the additive effect of sprayer setup treatments can be employed by turfgrass managers to reduce potential human 2,4-D human exposure.
There are multiple recent reports of an association between anxious/depressed (A/D) symptomatology and the rate of cerebral cortical thickness maturation in typically developing youths. We investigated the degree to which anxious/depressed symptoms are tied to age-related microstructural changes in cerebral fiber pathways. The participants were part of the NIH MRI Study of Normal Brain Development. Child Behavior Checklist A/D scores and diffusion imaging were available for 175 youths (84 males, 91 females; 241 magnetic resonance imagings) at up to three visits. The participants ranged from 5.7 to 18.4 years of age at the time of the scan. Alignment of fractional anisotropy data was implemented using FSL/Tract-Based Spatial Statistics, and linear mixed model regression was carried out using SPSS. Child Behavior Checklist A/D was associated with the rate of microstructural development in several white matter pathways, including the bilateral anterior thalamic radiation, bilateral inferior longitudinal fasciculus, left superior longitudinal fasciculus, and right cingulum. Across these pathways, greater age-related fractional anisotropy increases were observed at lower levels of A/D. The results suggest that subclinical A/D symptoms are associated with the rate of microstructural development within several white matter pathways that have been implicated in affect regulation, as well as mood and anxiety psychopathology.
Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.
To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.
Randomized, prospective study.
Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.
Patients undergoing surgery.
Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.
A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82–1.40], P=.626).
The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.
Indaziflam is a PRE herbicide for annual broadleaf and grass control in turfgrass systems and requires a 40-wk minimum interval between application and overseeding perennial ryegrass. Currently, activated-charcoal application is recommended to reduce that interval; however, preliminary evaluations determined activated charcoal alone was not a robust mitigation practice for successful establishment during perennial ryegrass overseeding. Field research was conducted in North Carolina and Tennessee to evaluate various mitigation practices to effectively overseed perennial ryegrass into indaziflam-treated turfgrass areas. Immediately following indaziflam application (53 g ai ha−1), two scenarios were created by delivering 0 or 0.3 cm H2O before mitigation practice. Irrigated plots were air-dried before conducting mitigation practices. Evaluated mitigation practices included scalping (0.6 cm cut height; debris removed), verticutting (1.25 cm depth; debris removed), and activated-charcoal application (167 kg ha−1 applied as an aqueous slurry in 3,180 L ha−1), evaluated individually and in each two-way combination in the order scalp followed by (fb) activated charcoal, scalp fb verticut, or verticut fb activated charcoal. Twenty-four hours after mitigation practice completion, perennial ryegrass was seeded (976 kg ha−1) and maintained as a golf course fairway. Overall, perennial ryegrass cover was reduced ≥ 93% at 8 and 20 wk after treatment (WAT) when no mitigation practices were performed. Stand-alone mitigation practices variably improved perennial ryegrass establishment; however, no practice provided acceptable results for end users. Combining mitigation practices improved overseeding establishment, most notably by adding activated charcoal application or verticutting to scalping before irrigation. Across experimental runs and locations, scalp fb activated-charcoal application before irrigation reduced perennial ryegrass cover 22 to 27% at 20 WAT. Results from this research suggest mitigation practices in addition to the currently recommended activated-charcoal application should be performed by turfgrass managers to improve perennial ryegrass overseeding establishment in indaziflam-treated turfgrass areas.
We have obtained deep g, r, and i-band Subaru and ultra-deep 3.6 μm IRAC images of parts of the multiply-wrapped stellar stream around the nearby edge-on galaxy NGC 5907. We have fitted the surface brightness measurements of the stream with FSPS stellar population synthesis models to derive the metallicity and age of the brightest parts of the stream. The resulting relatively high metallicity ([Fe/H] = −0.3) is consistent with a major merger scenario but a satellite accretion event cannot be ruled out.