Assessing pediatric anesthesia practices for volunteer medical services abroad.

BACKGROUND: Anesthetic techniques and problems in volunteer medical services abroad are different from those of either the developed countries from which volunteers originate or the host country in which they serve because of differences in patient population, facilities, and goals for elective surgery. Assessing outcomes is hampered by the transience of medical teams and the global dispersion of providers. We studied general anesthesia techniques and outcomes in a large international voluntary surgical program. METHODS: Anesthesia providers and nurses participating in care of patients undergoing reconstructive plastic and orthopedic surgery by Operation Smile over an 18-month period were asked to complete a quality assurance data record for each case. Incomplete data were supplemented by reviewing the original patient records. RESULTS: General anesthesia was used in 87.1% of the 6,037 cases reviewed. The median age was 5 yr (25th-75th percentiles: 2-9 yr). Orofacial clefts accounted for more than 80% of procedures. Halothane mask induction was performed in 85.6% of patients; 96.3% of patients had tracheal intubation, which was facilitated with a muscle relaxant in 19.3%. Respiratory complications occurred during anesthesia in 5.0% of patients and during recovery (postanesthesia care unit) in 3.3%. Arrhythmias requiring therapy occurred in 1.5%, including three patients to whom cardiopulmonary resuscitation was administered. Prolonged ventilatory support was required in seven patients. There was one death. Inadvertent extubation during surgery occurred in 38 patients. Cancellation of surgery after induction of anesthesia occurred in 25 patients. Overall, complications were more common in younger children. CONCLUSIONS: Our study showed that in this setting it is feasible to track anesthesia practice patterns and adverse perioperative events. We identified issues for further examination.

A novel sodium-hydrogen exchanger isoform-1 inhibitor, zoniporide, reduces ischemic myocardial injury in vitro and in vivo.

The cardioprotective efficacy of zoniporide (CP-597,396), a novel, potent, and selective inhibitor of the sodium-hydrogen exchanger isoform 1 (NHE-1), was evaluated both in vitro and in vivo using rabbit models of myocardial ischemia-reperfusion injury. In these models, myocardial injury was elicited with 30 min of regional ischemia and 120 min of reperfusion. Zoniporide elicited a concentration-dependent reduction in infarct size (EC(50) of 0.25 nM) in the isolated heart (Langendorff) and reduced infarct size by 83% (50 nM). This compound was 2.5- to 20-fold more potent than either eniporide or cariporide (EC(50) of 0.69 and 5.11 nM, respectively), and reduced infarct size to a greater extent than eniporide (58% reduction in infarct size). In open-chest, anesthetized rabbits, zoniporide also elicited a dose-dependent reduction in infarct size (ED(50) of 0.45 mg/kg/h) and inhibited NHE-1-mediated platelet swelling (maximum inhibition 93%). Furthermore, zoniporide did not cause any in vivo hemodynamic (mean arterial pressure, heart rate, rate pressure product) changes. Zoniporide represents a novel class of potent NHE-1 inhibitors with potential utility for providing clinical cardioprotection.

Aldose reductase inhibition alone or combined with an adenosine A(3) agonist reduces ischemic myocardial injury.

This study investigated whether aldose reductase (AR) inhibition with zopolrestat, either alone or in combination with an adenosine A(3)-receptor agonist (CB-MECA), reduced myocardial ischemic injury in rabbit hearts subjected to 30 min of regional ischemia and 120 min of reperfusion. Zopolrestat reduced infarct size by up to 61%, both in vitro (2 nM to 1 microM; EC(50) = 24 nM) and in vivo (50 mg/kg). Zopolrestat reduced myocardial sorbitol concentration (index of AR activity) by >50% (control, 15.0 +/- 2.2 nmol/g; 200 nM zopolrestat, 6.7 +/- 1.3 nmol/g). A modestly cardioprotective concentration of CB-MECA (0.2 nM) allowed a 50-fold reduction in zopolrestat concentration while providing a similar reduction in infarct size (infarct area/area at risk: control, 62 +/- 2%; 1 microM zopolrestat, 24 +/- 5%; 20 nM zopolrestat plus 0.2 nM CB-MECA, 20 +/- 4%). In conclusion, AR inhibition is cardioprotective both in vitro and in vivo. Furthermore, combining zopolrestat with an A(3) agonist allows a reduction in the zopolrestat concentration while maintaining an equivalent degree of cardioprotection.

Cleft palate closure in the neonate: preliminary report.

Our recent experience with cleft palate closure in the neonatal period (within 28 days of birth) is reviewed in this study. The research involved a series of 21 neonates who presented with untreated cleft palates and underwent a modified Veau-Wardill-Kilner palate closure by a single surgeon between 1991 and 1994. The postoperative clinical follow-up ranged from 8 to 37 months (mean 18 months). All complications discussed do not seem to occur more frequently when surgery is done at this age than at an older age. Our findings demonstrate that cleft palate closure can be safely performed in the neonatal period; we do not, however, recommend that the standard approach should be changed based on this preliminary report.

Vasoconstrictor action of angiotensin I-convertase and the synthetic substrate (Pro11,D-Ala12)-angiotensin I.

A chymase (also referred to as angiotensin I-convertase) specific for the conversion of angiotensin (Ang) I to Ang II has been identified in human heart. This serine protease is also present in dog and marmoset vasculature. We examined the vasoconstrictor effects of Ang II putatively generated from an angiotensin-converting enzyme (ACE)-resistant convertase synthetic substrate (SUB) in vivo and in vitro. In marmosets, SUB (7 to 700 micrograms/kg i.v.) or Ang I (0.1 to 30 micrograms/kg) caused similar dose-dependent increases in mean arterial pressure (10 to 100 mm Hg) and decreases in heart rate. Pressor effects of SUB were slightly attenuated at low (but not high) doses by captopril (CAP, 1 mg/kg i.v.) and blocked by losartan (5 mg/kg i.v.); in contrast Ang I pressor effects were substantially blocked by both. In isolated canine superior mesenteric artery, Ang I-induced contraction was eliminated by losartan and reduced but not eliminated by 10 mumol/L CAP. When combined with the serine protease inhibitor chymostatin, CAP eliminated Ang I-induced contraction, but chymostatin alone had no effect. SUB-induced contraction was not blocked by CAP but was equally blocked by chymostatin (25 mumol/L) alone or by the combination of CAP (10 mumol/L) and chymostatin (25 mumol/L); losartan (10 mumol/L) eliminated SUB-induced responses. Previous studies have suggested that Ang I-convertase is important for production of Ang II in the heart. Our results are consistent with a potential role for Ang I-convertase in the production of Ang II in the vasculature, resulting in Ang II-mediated vasoconstriction.

Cartilaginous histology of the cleft lip nose: proving the extrinsic etiology.

In an effort to prove the etiology of the cleft lip nasal deformity, 23 patients with unilateral cleft lip underwent biopsy through the midportion of the columella from mucosa to mucosa. This tissue "sandwich" contained an internal control of cleft and noncleft medial crus cartilage. With the use of special stains and examination under the microscope at low, medium, and high powers, sections were evaluated on the basis of presence of abnormal chondrocytes, number of binucleate chondrocytes, number of nucleated chondrocytes, number of lacunae, perichondrial thickness, and cartilage thickness. In each specimen examined, there were no significant differences between cleft and noncleft sides, proving histologically the previous subjective observation that the deformity is extrinsic, due to distortion of the lower lateral cartilage by abnormal vectors of force.

Prosthetic replacement of the condylar head for temporomandibular joint disease.

Temporomandibular joint replacement was performed in 8 adults who had intraarticular ankylosis, 6 who had end-stage osteoarthritis, and 12 who had rheumatoid arthritis. Three methods of replacement were used; an ulnar head prosthesis (8 patients), an interpositional implant (11 patients), and a Proplast-coated metallic prosthesis (7 patients). The mean age of the 26 patients (19 women and 7 men) at surgery was 38 years (range 17 to 58 years), and the mean follow-up was 36 months (range 3 to 84 months). Relief of pain was experienced by 23 patients, and maintenance or improvement of incisal opening was experienced by 21. Prosthetic replacement of the condylar head for end-stage disease is highly successful in the patients for whom it is indicated.

Cancer of the floor of the mouth and buccal cavity.

The ability of the surgeon to use the entire armamentarium of reconstructive techniques is essential in head and neck reconstruction. Each modality has its advantages and disadvantages. The decision of which technique to use is, of course, left to the individual surgeon's best judgment. Many new ideas will be explored in the future as the challenge of reconstruction awaits the perfect answer.

The kleeblattschadel deformity: neurologic outcome with early treatment.

Despite its alarming appearance, the kleeblattschadel anomaly, when it occurs in the absence of a recognizable mental retardation syndrome, is not associated with primary abnormalities of the central nervous system. Early medical and surgical efforts may result in a satisfactory cosmetic and neurologic outcome.

Pectoralis "paddle" myocutaneous flaps. The workhorse of head and neck reconstruction.

The pectoralis paddle myocutaneous flap is extremely dependable and provides an added advantage of covering the vital structures of the neck with adequate length without excessive bulk. The donor defect is more acceptable than any we have previously encountered. The use of this skin muscle paddle in irradiated necks has distinct advantages. In addition, the ability to carry bony segments for use in mandibular reconstruction proved a distinct advantage in the two cases in which it was used.

Uses of the trapezius and sternomastoid myocutaneous flaps in head and neck reconstruction.

Both of these myocutaneous flaps can supplant forehead and deltopectoral flaps, in certain indications. They are additional arterialized flaps for the armamentarium of the reconstructive surgeon, and can be useful in many repairs in the head and neck region.