Editorial

No aspect of the practice of pediatric anesthesia is more essential than airway management. Pediatric anesthesiologists are the ‘go to’ specialists when infants and children with difficult airways present anywhere in the hospital. To our advantage, rapid technical advances have taken place during the past decades and the number of tools available to assist us in providing and maintaining a secure and stable airway has increased significantly. Until the 1970s tracheal intubation with a conventional laryngoscope or blind nasal intubation were the mainstays of establishing an artificial airway. The choice of endotracheal tubes was limited. During the past 20 years a remarkable assortment of equipment and novel techniques to facilitate optimal airway management have been developed. These include supraglottic airways, direct and fiberoptic laryngoscopes and transtracheal devices. Improved imaging of the airway prior to initiation of airway management, with CT and MRI, for example, and during airway manipulation and instrumentation, using fiberoptic cameras and portable video displays, is now widely used. While new developments in airway management have helped us improve the quality of care of our patients, new challenges have also arisen. Which techniques should we learn, teach and employ? Which endotracheal tubes should be utilized – uncuffed or cuffed, old or new design? Which of our patients need preoperative imaging of the airway and/or sleep studies? What are the risks of newer interventions, including novel airway devices and laser instruments

The Hopf Rings for KO and KU

We compute the mod two homology Hopf rings of the spectra KO and KU. The spaces in these spectra are the infinite classical groups and their coset spaces, and their homology was first calculated in the Cartan seminars, but the Hopf ring structure was first determined in the second author's unpublished PhD thesis. The presentation given here serves as an introduction to the first author's much more intricate work on the connective spectrum bo. The Hopf ring viewpoint turns out to be very convenient for understanding the homological effect of various maps between classical groups and fibrations of their connective covers.Comment: 20 pages; to appear in JPA

Improving pain management for children

Over the last 20 years it has been realised that neonates, infants and children experience pain and considerable stress responses to surgical and medical procedures which are harmful and cause fear, anxiety and distress(Walker, 2008). This thesis will describe a body of work published since 1992 whose aim has been to improve several aspects of pain management for children in terms of both efficacy and safety. The studies encompass research into the four main classes of analgesics used in paediatric clinical practice, namely local anaesthetics, opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. In addition, control of the stress responses to tracheal intubation and to surgery has been studied with the availability of newer potent short-acting opioid agents and the anaesthetic agent propofol. The total body of work described covers 41 peer reviewed publications with 14 index papers selected for more detailed consideration. Local anaesthetics Several studies included in this thesis demonstrate the efficacy and safety of local anaesthetics in children. The optimum dose of the amide local anaesthetic, lignocaine, was determined for preventing pain on intravenous injection of propofol in children(Cameron et al., 1992) and this resulted in the widespread adoption of propofol as an induction agent. Several studies of propofol in children were conducted and this led to the development of more accurate computer-controlled delivery for maintenance of anaesthesia in children down to age 1 year(Morton et al., 1988, Marsh et al., 1990, Morton, 1990a, Marsh et al., 1991, Doyle et al., 1993c, Runcie et al., 1993, Morton, 1998b, Varveris and Morton, 2002). Topical amethocaine (as a gel and as a phase-change patch) was evaluated in children(Doyle et al., 1993a, Lawson et al., 1995, Lawson and Morton, 1998) and found to have a significantly more rapid onset of action than EMLA cream. This gel is now widely used in the UK. For nerve block, the efficacy and safety of fascia iliaca compartment block in children was demonstrated(Doyle et al., 1997) and the additional safety margin provided by adding the vasoconstrictor adrenaline to the local anaesthetic solution was proved by very low peak plasma concentrations of local anaesthetic. This was also demonstrated for caudal epidural blockade in infants(Hansen et al., 2001). New amide local anaesthetics were introduced in the last decade and ropivacaine was shown to be safe and effective for caudal epidural blockade in children(Ivani et al., 1998a). A collaboration with Strathclyde University led to the development of a new micro-assay method for measurement of local anaesthetics in small volumes of plasma with applicability to neonatal age groups of patients where ethically allowable blood sampling volumes are very small(Stumpe et al., 2000). Opioids The technique of patient-controlled analgesia was studied in children with an open feasibility trial in 1990(Lawrie et al., 1990) using conventional electronic syringe pumps and a further innovative study of a disposable elastomeric reservoir device in 1992(Irwin et al., 1992). The optimum regimen for PCA in children was determined by a series of studies(Doyle et al., 1994a, Doyle et al., 1993d, Doyle et al., 1994c, Munro et al., 2002) and a subsequent trial demonstrated that PCA could be delivered by the subcutaneous route(Doyle et al., 1994b). A further collaboration with Strathclyde produced a microassay method for morphine and metabolites(Watson et al., 1995). These studies showed that PCA is very efficacious and safe for perioperative pain conrol in children from age 5 years upwards and this technique is now in routine use worldwide(Walker, 2008, APAGBI, 2008, Morton, 2007, Lonnqvist and Morton, 2005b). NSAIDs and Paracetamol Following the demonstration of the utility of PCA in children, the technique was used to assess the analgesic efficacy of the NSAID diclofenac and paracetamol in children(Morton and O'Brien, 1999). This showed diclofenac to be particularly efficacious in producing a 40% morphine-sparing effect in children. An innovative study of NSAID eye drops showed them to be as effective as local anaesthetic eye drops for providing analgesia after strabismus surgery in children(Morton et al., 1997). Dosing regimens for paracetamol have evolved in the last decade based on better information on developmental pharmacokinetics and elucidation of the mechanism of action(Arana et al., 2001, Ottani et al., 2006, Pickering et al., 2006, Anderson and Palmer, 2006). There is renewed interest in this decade with the availability of new IV formulations of this old drug. In 1999(Hansen et al., 1999) we contributed to the PK data for paracetamol in neonates and infants which was subsequently used by authors from New Zealand to determine the population PK parameters in this young age group(Anderson and Palmer, 2006). We collated the knowledge on dosing regimens in 2001 in a review(Arana et al., 2001) which has informed the current recommendations in the BNFC. A further collaboration with Strathclyde University led to the development of a microassay for paracetamol and its metabolites from blood spots which has been taken up by Medecins Sans Frontieres as a possible method to use in the field in developing countries(Oliveira et al., 2002). The morphine-sparing efficacy of paracetamol was shown to be less than that due to diclofenac in the study mentioned above under NSAIDs(Morton and O'Brien, 1999). Controlling the stress response Noxious stimuli produce a stress response. A series of studies has shown that using short acting opioids, tracheal intubation could be safely performed without the aid of muscle relaxant drugs in children(Steyn et al., 1994, O'Brien et al., 1998, Robinson et al., 1998). This technique is now widely practiced. Two studies explored methods to reduce the stress response to open heart surgery with cardiopulmonary bypass, one of the most potent surgical stressors. Propofol anaesthesia was shown to significantly ameliorate this response(Laycock et al., 1992) and the newer opioid remifentanil was shown to be as efficacious as the older drug fentanyl for this purpose(Bell et al., 2004). Audit, guidelines and protocols Two major analgesic techniques have been audited in large national projects looking at the risk of epidural infusions in children(Llewellyn and Moriarty, 2007) and opioid infusion techniques in children (Morton, 2008c) and the results show these techniques to be of comparable safety. The evidence from the past 20 years has recently been synthesised into a clinical guideline for management of postoperative and procedural pain in children which has highlighted good practice based on high quality evidence but also revealed a paucity of evidence in some fields(APAGBI, 2008). Guidelines for safer paediatric procedural sedation practice is also described(SIGN, 2004, Playfor et al., 2006). The implementation of guidelines relies on the development of a local protocol and the evolution of the acute pain relief service protocol in Glasgow is described.(Morton, 2008a

Empirical Evidence of Diminishing Payoff from Successive Generations of Information Systems

Previous research has focused on a number of important variables that can influence the observed payoffs from information systems investments. In the current investigation conducted in the spring of 2002, personal, on-site interviews were conducted in 138 small and medium sized businesses. Vendor involvement in systems development was less related to systems cost than previously. Unfortunately, vendor involvement was unrelated to any of the four measures of systems success in the entire sample. Further analysis revealed a strong relationship between information system generation and payoffs. Specifically, there appeared to be a point of diminishing return with subsequent generations of information technology

Variscan sourcing of Westphalian (Pennsylvanian) sandstones in the Canobie Coalfield, UK

The zircon age spectrum in a sample from the Canonbie Bridge Sandstone Formation (Asturian) of southern Scotland contains two main peaks. One is Early Carboniferous in age (348– 318 Ma), and corresponds to the age of igneous activity during the Variscan Orogeny. The other is of late Neoproterozoic to early Cambrian age (693–523 Ma), corresponding to the Cadomian. Together, these two groups comprise 70 % of the zircon population. The presence of these two peaks shows unequivocally that a significant proportion of the sediment was derived from the Variscides of western or central Europe. The zircon population also contains a range of older Proterozoic zircons and a small Devonian component. These could have been derived from the Variscides, but it is possible that some were locally derived through recycling of northerly derived sandstones of Devonian–Carboniferous age. The zircon age data confirm previous suggestions of Variscide sourcing to the Canonbie area, made on the basis of petrographical, heavy mineral and palaeocurrent evidence, and extend the known northward distribution of Variscan-derived Westphalian sediment in the UK

MEROPS: the peptidase database

Peptidases (proteolytic enzymes) and their natural, protein inhibitors are of great relevance to biology, medicine and biotechnology. The MEROPS database () aims to fulfil the need for an integrated source of information about these proteins. The organizational principle of the database is a hierarchical classification in which homologous sets of proteins of interest are grouped into families and the homologous families are grouped in clans. The most important addition to the database has been newly written, concise text annotations for each peptidase family. Other forms of information recently added include highlighting of active site residues (or the replacements that render some homologues inactive) in the sequence displays and BlastP search results, dynamically generated alignments and trees at the peptidase or inhibitor level, and a curated list of human and mouse homologues that have been experimentally characterized as active. A new way to display information at taxonomic levels higher than species has been devised. In the Literature pages, references have been flagged to draw attention to particularly ‘hot’ topics