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Background: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. Aims: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. Methods: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target‐based care. Interventions included maxillary nerve blockade and enhanced intra‐ and postoperative medication regimens. Outcomes were displayed as statistical process control charts. Results: Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p <.0001) relative to our historical cohort (n = 63), with a mean difference of −0.33 ± 0.11 mg/kg (95% CI −0.55 to −0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p =.002), with a mean difference of −0.27 ± 0.09 mg/kg (95% CI −0.45 to −0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p =.02) relative to our historical cohort, with a mean difference of −3.81 ± 1.56 h (95% CI −6.9 to −0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. Conclusion: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay. [ABSTRACT FROM AUTHOR]

Background: Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics. Aims: The primary aim was to determine whether pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events. Methods: A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7‐18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified Induction Compliance Checklist, and satisfaction surveys, respectively. Chi‐squared, t tests, and regression models were used to analyze the results. Results: The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in postprocedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, P =.59), postprocedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater), or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96‐5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events. Conclusion: This study demonstrates no reduction in pain while using Virtual reality (VR) across a heterogeneous pediatric inpatient population undergoing vascular access. [ABSTRACT FROM AUTHOR]

There is growing evidence to support the perioperative use of nonopioid analgesic medications in the pediatric population,1 but the use of, and attitude toward, these agents among pediatric anesthesiologists is unknown. The most commonly utilized agents included acetaminophen, NSAIDs, dexmedetomidine, dexamethasone, and ketamine. We additionally observed that anesthesiologists who had undergone additional pain or regional anesthesia training utilized some agents at increased frequency, suggesting that general pediatric anesthesiologists are not utilizing nonopioid analgesics at every opportunity. [Extracted from the article]

Connectivity of the glycocalyx covering of small communities of Acidithiobacillus ferrooxidans bacteria deposited on hydrophilic mica plates was imaged by atomic force microscopy. When part of the coverage was removed by water rinsing, an insoluble structure formed by corrals surrounding each individual bacterium was observed. A collective ring structure with clustered bacteria (≥3) was observed, which indicates that the bacteria perceived the neighborhood in order to grow a protective structure that results in smaller production of exopolysaccharides material. The most surprising aspect of these collective corral structures was that they occur at a low bacterial cell density. The deposited layers were also analyzed by confocal Raman microscopy and shown to contain polysaccharides, protein, and glucoronic acid. Microsc. Res. Tech., 2008. © 2007 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

The objective was to establish whether the risk of trisomies 13, 18, and 21 (Patau, Edwards, and Down syndrome, respectively) in a subsequent pregnancy is raised for women who have had a previous pregnancy with trisomy 13, 18, or 21. Birth defect register data were used to investigate this issue. Pregnancy data from three Australian population-based birth defect registers contained 5,906 women with a previous trisomy 13, 18, or 21 pregnancy in whom there were 3,713 subsequent pregnancies, 75 of which were trisomic. Relative risk of subsequent trisomy at 15 weeks gestation was estimated by comparing the observed number of subsequent trisomies with the expected number of subsequent trisomies based on maternal age-related risk. There was evidence of increased risk of the same trisomy subsequent to a previous pregnancy with trisomy 13 or 18 (RR = 3.8 (1.5, 7.9)), the increase in risk being greater for women aged under 35 at the previous trisomic pregnancy (RR = 7.8 (2.1, 20.2)). There was also evidence of increased risk of trisomy 21 subsequent to previous trisomy 21 (RR = 2.2 (1.6, 2.9)), again higher in women under 35 at previous affected pregnancy (RR = 3.5 (2.1, 5.5)). There was a suggestion that the risk of a different trisomy subsequent to trisomy 21 may also be increased (RR = 1.4 (0.7, 2.5)). In conclusion, women who have had a previous trisomic pregnancy, particularly those under 35 years of age at the time, appear to be at an increased risk of future pregnancies being trisomic.

There has been a long-running debate about the association between paternal age and Down syndrome. Some studies have failed to adequately control for maternal age, and have suffered from high levels of missing paternal age, raising concerns over selection bias. This paper analyzes an anonymously case-controlled dataset with 98% complete parental age data, originally collected to investigate the association between parental exposure to radiation and Down syndrome. In our methods the cases and controls were matched on maternal age to within 6 months, and conditional logistic regression was used to estimate the odds ratio associated with a 10-year increase in paternal age. Our results showed the estimated odds ratio for a Down syndrome pregnancy associated with a 10-year increase in paternal age was 1.13, 95%CI (0.85, 1.52). There was no statistically significant evidence of an association between paternal age and Down syndrome, but the estimated association was positive. The size of the estimated effect is much smaller than the effect of maternal age., ((c) 2009 Wiley-Liss, Inc.)