Safety and efficacy of a propofol and ketamine based procedural sedation protocol in children with cerebral palsy undergoing botulinum toxin A injections.

Background Pediatric patients with cerebral palsy (CP) often undergo intramuscular botulinum toxin (BoNT‐A) injections. These injections can be painful and may require procedural sedation. An ideal sedation protocol has yet to be elucidated. Objective To investigate the safety and efficacy of a propofol and ketamine based sedation protocol in pediatric patients with cerebral palsy requiring BoNT‐A injections. Design This is a retrospective chart review of children with CP undergoing propofol and ketamine based sedation for injections with botulinum toxin A. Setting The sedations took place in a procedural sedation suite at a tertiary children’s hospital from Feb 2013 through Sept 2017. Patients 164 patients with diagnoses of cerebral palsy were included in this study. Methods An initial bolus of 0.5 mg/kg ketamine followed by a 2 mg/kg bolus of propofol was administered with supplemental boluses of propofol as needed to achieve deep sedation during the intramuscular BoNT‐A injections. Main Outcome Measurements Propofol dosages, adverse events, serious adverse events, and sedation time parameters were reviewed. Results 345 sedations were successfully performed on 164 patients. The median total dose of propofol was 4.7 mg/kg (IQR 3.5, 6.3). Adverse events were encountered in 10.1% of procedures including hypoxemia responsive to supplemental oxygen (9.6%) and transient apnea (1.4%). The mean procedure time, recovery time and total sedation time were 10, 11 and 33 minutes, respectively. With regard to patient variables, including age, weight, dose of propofol, sedation time, and Gross Motor Function Classification System classification, there was no association with increased incidence of adverse events. Conclusion Our sedation protocol of propofol and ketamine is safe and effective in children with cerebral palsy undergoing procedural sedation for intramuscular injections with BoNT‐A. The adverse events encountered appeared to be related to airway and respiratory complications secondary to musculoskeletal deformities, emphasizing the importance of airway monitoring and management in these patients

A Backtracking-Based Algorithm for Computing Hypertree-Decompositions

Hypertree decompositions of hypergraphs are a generalization of tree decompositions of graphs. The corresponding hypertree-width is a measure for the cyclicity and therefore tractability of the encoded computation problem. Many NP-hard decision and computation problems are known to be tractable on instances whose structure corresponds to hypergraphs of bounded hypertree-width. Intuitively, the smaller the hypertree-width, the faster the computation problem can be solved. In this paper, we present the new backtracking-based algorithm det-k-decomp for computing hypertree decompositions of small width. Our benchmark evaluations have shown that det-k-decomp significantly outperforms opt-k-decomp, the only exact hypertree decomposition algorithm so far. Even compared to the best heuristic algorithm, we obtained competitive results as long as the hypergraphs are not too large.Comment: 19 pages, 6 figures, 3 table

Shots fired! Why is switching between organisational practices so difficult?

Jan-Kees Schakel, Paul C. van Fenema and Samer Faraj study a covert operation by the Dutch polic

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers

Background: Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. Methods: We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. Results: A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended. Conclusions: Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence

Pharmacokinetic interaction between prasugrel and ritonavir in healthy volunteers.

The new anti-aggregating agent prasugrel is bioactivated by cytochromes P450 (CYP) 3A and 2B6. Ritonavir is a potent CYP3A inhibitor and was shown in vitro as a CYP2B6 inhibitor. The aim of this open-label cross-over study was to assess the effect of ritonavir on prasugrel active metabolite (prasugrel AM) pharmacokinetics in healthy volunteers. Ten healthy male volunteers received 10 mg prasugrel. After at least a week washout, they received 100 mg ritonavir, followed by 10 mg prasugrel 2 hr later. We used dried blood spot sampling method to monitor prasugrel AM pharmacokinetics (C(max) , t(1/2) , t(max) , AUC(0-6 hr) ) at 0, 0.25, 0.5, 1, 1.5, 2, 4 and 6 hr after prasugrel administration. A 'cocktail' approach was used to measure CYP2B6, 2C9, 2C19 and 3A activities. In the presence of ritonavir, prasugrel AM C(max) and AUC were decreased by 45% (mean ratio: 0.55, CI 90%: 0.40-0.7, p = 0.007) and 38% (mean ratio: 0.62, CI 90%: 0.54-0.7, p = 0.005), respectively, while t(1/2) and t(max) were not affected. Midazolam metabolic ratio (MR) dramatically decreased in presence of ritonavir (6.7 ± 2.6 versus 0.13 ± 0.07) reflecting an almost complete inhibition of CYP3A4, whereas omeprazole, flurbiprofen and bupropion MR were not affected. These data demonstrate that ritonavir is able to block prasugrel CYP3A4 bioactivation. This CYP-mediated drug-drug interaction might lead to a significant reduction of prasugrel efficacy in HIV-infected patients with acute coronary syndrome

Quantitative sexing (Q-sexing) technique for animal sex-determination based on X chromosome-linked loci: Empirical evidence from the Siberian tiger

Here we report a mammal sexing procedure based on the detection of quantitative differences between females and males in the X-linked loci (quantitative sexing, Q-sexing). This novel technique was validated using samples from Siberian tigers (Panthera tigris altaica) whose sexes were known. The Q-sexing technique relies on the fact that amplifications proceeding exclusively from the two X chromosomes in a female mammal should reach the threshold cycle (CT) in a real-time quantitative real time polymerase chain reaction (qPCR) assay sooner than amplifications from the single male X chromosome. Nevertheless, given that the amplification efficiency may vary between samples, results have to be calibrated to a marker that does not vary in copy number between the sexes (for example, an autosomal-linked locus). For this purpose we used quantitative real time polymerase chain reaction (RT qPCR) assays to quantify the amount of three specific Siberian tiger microsatellite markers (X-/Y- and autosomal-linked loci) in individual samples in order to determine the sex of an animal. A difference of one CT between the X and the autosome-linked loci was detected in males, but no such difference was present in female samples. The Q-sexing technique unambiguously separates female from male Siberian tigers. The future of RT qPCR is bright as technology is becoming ever more rapid, cost-effective, easier to use and capable of processing higher throughputs. Thus, we expect that our novel technique for animal sexing will have a wide applicability, although further studies are still needed to adapt it to other animal species using specific primers.Key words: Polymerase chain reaction (PCR), quantitative real time polymerase chain reaction (qPCR), quantitative sexing, Siberian tiger

Festschrift für Hans Hisch zum 65. Geburtstag gewidmet von seinen Freunden, Kollegen und Schülern. Wien: Selbstverl. des Instituts für Orientalistik 1996

BACKGROUND: One of the main aims of forensic investigation is the detection and location of people and substances of interest, such as missing people and illegal drugs. Dogs (Canis lupus var. familiaris) have had an important role in legal and forensic investigations for decades; nonetheless canines’ keen sense of smell has never been utilized in either the surveillance or control of wildlife diseases. The rapid removal and treatment of infected carcasses and/or sick animals is a key task in the management of infectious diseases, but it is usually difficult or impractical to carry out in the wild. RESULTS: In this paper we report on a study running over a period of 15 years, in which - for the first time to our knowledge - two disease-detector dogs were trained to follow the scent of Sarcoptes-infected animals and to find carcasses, even under the snow, and apparently no false positives were detected in fieldwork. Sarcoptic mange-detector dogs were used to collect the carcasses of 292 mangy wild animals and to identify, separate from their herd, and capture 63 mange-infected wild animals in the Italian Alps. CONCLUSIONS: Properly trained disease-detector dogs are an efficient and straightforward tool for surveillance and control of sarcoptic mange in affected wild animal populations

Practice Variation in the Immediate Postoperative Care of Pediatric Kidney Transplantation: A National Survey

Introduction Advances in organ allocation, surgical technique, immunosuppression, and long-term follow-up have led to a significant improvement in kidney transplant outcomes. Although there are clear recommendations for several aspects of kidney transplant management, there are no pediatric-specific guidelines for immediate postoperative care. The aim of this survey is to examine practice variations in the immediate postoperative care of pediatric kidney transplant patients. Methods We surveyed medical directors of Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)-affiliated pediatric intensive care units regarding center-specific immediate postoperative management of pediatric kidney transplantation. Results The majority of PALISI centers admit patients to the pediatric intensive care unit postoperatively, and 97% of the centers involve a pediatric nephrologist in immediate postoperative care. Most patients undergo invasive hemodynamic monitoring; 97% of centers monitor invasive arterial blood pressure and 88% monitor central venous pressure. Most centers monitor serum electrolytes every 4 to 6 hours. Wide variation exists regarding blood pressure goal, fluid replacement type, frequency of obtaining kidney ultrasound, and use of prophylactic anticoagulation. Conclusion There is consistent practice across PALISI centers in regards to many aspects of immediate postoperative management of pediatric kidney transplantation. However, variation still exists in some management aspects that warrant further discussions to reach a national consensus

Tractable Combinations of Global Constraints

We study the complexity of constraint satisfaction problems involving global constraints, i.e., special-purpose constraints provided by a solver and represented implicitly by a parametrised algorithm. Such constraints are widely used; indeed, they are one of the key reasons for the success of constraint programming in solving real-world problems. Previous work has focused on the development of efficient propagators for individual constraints. In this paper, we identify a new tractable class of constraint problems involving global constraints of unbounded arity. To do so, we combine structural restrictions with the observation that some important types of global constraint do not distinguish between large classes of equivalent solutions.Comment: To appear in proceedings of CP'13, LNCS 8124. arXiv admin note: text overlap with arXiv:1307.179