American College of Chest Physicians consensus statement on the respiratory and related management of patients with Duchenne muscular dystrophy undergoing anesthesia or sedation.

This statement on the management of patients with Duchenne muscular dystrophy (DMD) undergoing procedural sedation or general anesthesia represents the consensus opinion of a multidisciplinary panel convened under the auspices of the American College of Chest Physicians. Expert recommendations on this subject are needed for several reasons. First, patients with DMD have an increased risk of complications when they undergo sedation or general anesthesia. In addition, due to improved cardiopulmonary therapies, patients with DMD are experiencing an unprecedented duration of survival. As a result, it is more common for them to require procedures involving sedation or general anesthesia. The risks related to anesthesia and sedation for DMD patients include potentially fatal reactions to inhaled anesthetics and certain muscle relaxants, upper airway obstruction, hypoventilation, atelectasis, congestive heart failure, cardiac dysrhythmias, respiratory failure, and difficulty weaning from mechanical ventilation. This statement includes advice regarding the highly interrelated areas of respiratory, cardiac, GI, and anesthetic management of patients with DMD undergoing general anesthesia or procedural sedation. The statement is intended to aid clinicians involved in the care of patients with DMD and to be a resource for other stakeholders in this field, including patients and their families. It is an up-to-date summary of medical literature regarding this topic and identifies areas in need of future research.

Pediatric "body packing".

BACKGROUND: Recent events in the United States have led to increased security at national borders, resulting in an unexpected increase in drug seizures. In response, drug smugglers may begin using children as couriers, including using them as "body packers." OBJECTIVE: To look at the occurrence of body packing, the concealing of contraband within the human body, which is well documented in adults, in the pediatric literature. PATIENT REPORTS: Two cases of pediatric body packing, in boys aged 16 years and 12 years. Patient 1, a 16-year-old boy, presented with findings consistent with opioid intoxication after arriving in the United States on a transcontinental flight. His mental status improved after he received naloxone hydrochloride, and he subsequently confessed to body packing heroin. He was treated with a naloxone infusion and aggressive gastrointestinal decontamination. He ultimately passed 53 packets of heroin, one of which had ruptured. He recovered uneventfully. Patient 2, a 12-year-old boy, presented to the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, and he confessed to body packing heroin. He was treated with whole-bowel irrigation and activated charcoal, and he subsequently passed 84 packets. He also recovered uneventfully. CONCLUSIONS: We report the first 2 cases of body packing in the pediatric literature and review the diagnosis and management of this clinical entity. Pediatricians should be aware that body packing, regrettably, is not confined to the adult population.

Orthopaedic recertification.

This report summarizes a symposium presented at the 2001 Annual Meeting of the American Orthopaedic Association that was designed to assess the current status of recertification by the American Board of Orthopaedic Surgery (ABOS) and to determine how it will change in the near future. Recertification is a process whereby the general public is assured of quality medical care by a competent and knowledgeable physician. As a professional organization, we have an obligation to provide quality care. The nature of the public demand for standards ensuring competence and the history of recertification in orthopaedic surgery are examined. The recertification of commercial airline pilots is reviewed, as it provides a model of an unrelated but highly skilled profession requiring intellectual and technical proficiency. The goals and plans of the American Board of Medical Specialties (ABMS), which encompasses the views of all twenty-four major specialty boards including orthopaedic surgery, are reviewed. Finally, the future plans of the ABOS for recertification are considered.

Central retinal artery occlusion by proxy: a cause for sudden blindness in an airline passenger.

The use of gas media in ophthalmologic procedures is relatively commonplace. Scleral buckle and pneumatic retinopexy procedures using air-gas mediums are a widely accepted treatment for retinal detachment. We present a patient who had a scleral buckle with pneumatic retinopexy performed and subsequently flew in a commercial airliner 2 wk later. The patient experienced sudden blindness due to central retinal artery occlusion brought about by expansion of the air bubble when the aircraft reached cruise altitude and a cabin pressure of 8000 ft. The intraocular pressure exceeded the central artery pressure thereby collapsing the artery. The patient's symptoms were relieved when an onboard flight surgeon identified the problem and the cabin pressure was reset to 2000 ft. Flying after an ophthalmic procedure that incorporates intraocular gas may have complications due to the bubble expansion in accordance with Boyle's Law. The ophthalmologic surgeon must be diligent in forewarning patients of the potential complications of flying for weeks to months after a procedure that utilizes intraocular gas.

Heat shock inhibits tnf-induced ICAM-1 expression in human endothelial cells via I kappa kinase inhibition.

The pulmonary vascular endothelium plays a critical role in lung inflammation. As a result of proinflammatory cytokine expression, adhesion molecules are upregulated on the surface of the endothelial cells. Adhesion molecules facilitate recruitment of leukocytes and thus, have been targeted for potential anti-inflammatory strategies. Prior induction of the stress response through thermal stimulation, or heat shock, alters proinflammatory gene expression by attenuating NF-kappaB signaling. As intercellular adhesion molecule-(ICAM) 1 expression is, in part, NF-kappaB-dependent, we hypothesized that heat shock would inhibit ICAM-1 expression. Heat shocking endothelial cells resulted in heat shock protein (HSP) expression as measured by HSP-70 induction, and decreased TNF-alpha-induced ICAM-1 expression in a manner that appeared to be transcriptionally mediated. Following heat shock, decreased TNF-alpha-induced NF-kappaB activation was observed and was associated with preservation of IkappaB-alpha and a decrease in phosphorylated IkappaB-alpha that correlated to inhibition of I kappa kinase (IKK) activity. Interestingly, exposing respiratory epithelial cells to heat shock, which results in NF-kappaB inhibition, did not affect TNF-induced ICAM-1 expression. We conclude that heat shock decreases endothelial cell ICAM-1 expression via inhibition of IKK activity.

Persistent abnormal lung function after childhood empyema.

OBJECTIVE: The purpose of this study was to examine pulmonary function tests in children at various time points in their recovery from empyema. DESIGN: Cross-sectional study. SETTING: Academic Children's Hospital. PATIENTS: Pediatric patients with a diagnosis of empyema between 1992-2000. RESULTS: A total of 45 pulmonary function tests were carried out in 36 study participants. Within 3 months of hospital discharge, 91% of pulmonary function tests demonstrated a restrictive pattern with a mean forced vital capacity (FVC) of 69.2 +/- 4% and a mean total lung capacity (TLC) of 74.9 +/- 4% of predicted. The incidence of restriction in pulmonary function significantly decreased over time and for patients tested > 1 year from hospital discharge the mean FVC was 87.1 +/- 2% and the mean TLC 95.0 +/- 2% of predicted. However, 19% of the patients tested > 1 year from discharge demonstrated a mild restrictive pattern and 16% demonstrated a mild obstructive changes. Patients with abnormal lung function > 1 year from hospital discharge did not demonstrate any signs or symptoms of respiratory insufficiency . CONCLUSION: There is a high incidence of restrictive patterns in lung function for children tested within 3 months from hospital discharge for empyema. The incidence of restrictive patterns decreased significantly over time and most patients tested >1 year from hospital discharge demonstrated normal lung function.