The efficacy of hypotonic and near-isotonic saline for parenteral fluid therapy given at low maintenance rate in preventing significant change in plasma sodium in post-operative pediatric patients: protocol for a prospective randomized non-blinded study

<p>Abstract</p> <p>Background</p> <p>Hyponatremia is the most frequent electrolyte abnormality observed in post-operative pediatric patients receiving intravenous maintenance fluid therapy. If plasma sodium concentration (p-Na⁺) declines to levels below 125 mmol/L in < 48 h, transient or permanent brain damage may occur. There is an intense debate as to whether the administered volume (full rate <it>vs. </it>restricted rate of infusion) and the composition of solutions used for parenteral maintenance fluid therapy (hypotonic <it>vs. </it>isotonic solutions) contribute to the development of hyponatremia. So far, there is no definitive pediatric data to support a particular choice of parenteral fluid for maintenance therapy in post-surgical patients.</p> <p>Methods/Design</p> <p>Our prospective randomized non-blinded study will be conducted in healthy children and adolescents aged 1 to 14 years who have been operated for acute appendicitis. Patients will be randomized either to intravenous hypotonic (0.23% or 0.40% sodium chloride in glucose, respectively) or near-isotonic (0.81% sodium chloride in glucose) solution given at approximately three-fourths of the average maintenance rate. The main outcome of interest from this study is to evaluate 24 h post-operatively whether differences in p-Na⁺between treatment groups are large enough to be of clinical relevance. In addition, water and electrolyte balance as well as regulatory hormones will be measured.</p> <p>Discussion</p> <p>This study will provide valuable information on the efficacy of hypotonic and near-isotonic fluid therapy in preventing a significant decrease in p-Na⁺. Finally, by means of careful electrolyte and water balance and by measuring regulatory hormones our results will also contribute to a better understanding of the physiopathology of post-operative changes in p-Na⁺in a population at risk for hyponatremia.</p> <p>Trial registration</p> <p>The protocol for this study is registered with the current controlled trials registry; registry number: <a href="http://www.controlled-trials.com/ISRCTN43896775">ISRCTN43896775</a>.</p

Seasonal Changes in Mood and Behavior Are Linked to Metabolic Syndrome

BACKGROUND: Obesity is a major public health problem worldwide. Metabolic syndrome is a risk factor to the cardiovascular diseases. It has been reported that disruptions of the circadian clockwork are associated with and may predispose to metabolic syndrome. METHODOLOGY AND PRINCIPAL FINDINGS: 8028 individuals attended a nationwide health examination survey in Finland. Data were collected with a face-to-face interview at home and during an individual health status examination. The waist circumference, height, weight and blood pressure were measured and samples were taken for laboratory tests. Participants were assessed using the ATP-III criteria for metabolic syndrome and with the Seasonal Pattern Assessment Questionnaire for their seasonal changes in mood and behavior. Seasonal changes in weight in particular were a risk factor of metabolic syndrome, after controlling for a number of known risk and potential confounding factors. CONCLUSIONS AND SIGNIFICANCE: Metabolic syndrome is associated with high global scores on the seasonal changes in mood and behavior, and with those in weight in particular. Assessment of these changes may serve as a useful indicator of metabolic syndrome, because of easy assessment. Abnormalities in the circadian clockwork which links seasonal fluctuations to metabolic cycles may predispose to seasonal changes in weight and to metabolic syndrome

The Evolution of Extracellular Fibrillins and Their Functional Domains

Fibrillins constitute the major backbone of multifunctional microfibrils in elastic and non-elastic extracellular matrices, and are known to interact with several binding partners including tropoelastin and integrins. Here, we study the evolution of fibrillin proteins. Following sequence collection from 39 organisms representative of the major evolutionary groups, molecular evolutionary genetics and phylogeny inference software were used to generate a series of evolutionary trees using distance-based and maximum likelihood methods. The resulting trees support the concept of gene duplication as a means of generating the three vertebrate fibrillins. Beginning with a single fibrillin sequence found in invertebrates and jawless fish, a gene duplication event, which coincides with the appearance of elastin, led to the creation of two genes. One of the genes significantly evolved to become the gene for present-day fibrillin-1, while the other underwent evolutionary changes, including a second duplication, to produce present-day fibrillin-2 and fibrillin-3. Detailed analysis of several sequences and domains within the fibrillins reveals distinct similarities and differences across various species. The RGD integrin-binding site in TB4 of all fibrillins is conserved in cephalochordates and vertebrates, while the integrin-binding site within cbEGF18 of fibrillin-3 is a recent evolutionary change. The proline-rich domain in fibrillin-1, glycine-rich domain in fibrillin-2 and proline-/glycine-rich domain in fibrillin-3 are found in all analyzed tetrapod species, whereas it is completely replaced with an EGF-like domain in cnidarians, arthropods, molluscs and urochordates. All collected sequences contain the first 9-cysteine hybrid domain, and the second 8-cysteine hybrid domain with exception of arthropods containing an atypical 10-cysteine hybrid domain 2. Furin cleavage sites within the N- and C-terminal unique domains were found for all analyzed fibrillin sequences, indicating an essential role for processing of the fibrillin pro-proteins. The four cysteines in the unique N-terminus and the two cysteines in the unique C-terminus are also highly conserved

Persistent left superior vena cava: Review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients

Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device

On paediatric regional anaesthesia : The use of paravertebral blockade, aspects on plasma protein binding, and systemic toxicity of local anaesthetics

Paediatric regional anaesthesia has gained widespread popularity during recent yearsbecause of an excellent potential for intra- and postoperative pain relief and reduction of thesurgically induced stress response. The aim of the present thesis was to adapt and develop thetechnique of paravertebral blockade (PVB) for the safe use in paediatric patients and also toinvestigate aspects on plasma protein binding and toxicity of local anaesthetic drugs whichmight be of importance in the special settings of paediatric anaesthesia. The optimal landmarks for puncture of the thoracic paravertebral space (PVS) was derivedfrom computed tomography and clinical measurements and were found to correlate well withpatient weight (r = 0.94-0.95). The lateral distance from the spinous process and the depthfrom the skin to the PVS can be calculated from the equations: lateral distance (mm) = 0.12kg + 10.2 and depth (mm) = 0.53 kg + 21.2. Retrospective data indicate that the PVB iscapable of providing similar postoperative pain relief in children undergoing renal surgery withan unilateral incision compared to lumbar epidural blocks. In a prospective multi-centre studythe failure rate and complications associated with PVB were studied in a mixed population ofadult and paediatric patients and PVB was found comparable in these aspects to otherestablished alternative regional techniques. Plasma concentrations of lidocaine after bolusinjection (5 mg . kg-1 ) and subsequent infusion (2.5 mg .kg-1 h-1 ) of lidocaine with adrenalineinto the PVS were found to be well below the levels associated with side effects or toxicity. In vitro studies of the effects of hypothermia and haemodilution on the plasma proteinbinding (PPB) of lidocaine, assessed by ultrafiltration, were carried out on blood collectedfrom healthy, medication free, adult volunteers. A significant reduction in PPB could beobserved between 37 and 24 ¡C but a further decrease in temperature did not cause anyaddition reduction in PPB. Even moderate degrees of dilution of the plasma phase of the bloodwill cause a decrease in PPB but the PPB was not found to be affected by changes inhaemotocrit. In order to confirm a clinical impression of side effects or even early signs ofcentral nervous system toxicity in ex-premature infants undergoing awake caudal anaesthesia,unblinded assessments of behavioural changes before and twenty minutes after the performanceof a caudal block with bupivacaine (3.1 mg . kg-1) were compared with blinded evaluations ofsimultaneously performed EEG recordings. An integrated evaluation of the findings supportthe occurrence of systemic side effects and signs of early CNS toxicity at plasma concentra-tions of bupivacaine within the 0.56-1.62 . mg ml-1 range.The current thesis delineate the use of paravertebral blockade in paediatric patients and hasalso elucidated some aspects of plasma protein binding and toxicity of local anaesthetic drugsthat are of special interest in paediatric regional anaesthesia.Key words: Anesthesia, regional, paravertebral; Children, infants; Local anesthetics,bupivacaine, lidocaine; Pharmacokinetics; Plasma protein binding; Side effects; Toxicity.PA Lönnqvist: On paediatric regional anaesthesia: The use of paravertebral blockade, aspectson plasma protein binding, and systemic toxicity of local anaesthetics. Stockholm 1996.ISBN 91-628-1974-