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Several methods have been described to locate the epidural space, but the loss-of-resistance (LOR) technique is the most commonly used. Expert opinion states that LOR to air is the best medium for neonates and infants. We conducted a Canada-wide postal survey to determine the current state of practice for placement of epidural catheters in pediatric patients. Two hundred and nine surveys were distributed to academic pediatric anesthesiologists across Canada. The survey was limited to six questions and was anonymous. The response rate was 62.2%. LOR was the method of choice for 124/130 anesthesiologists (95.4%). LOR to normal saline was the medium of choice for all age groups, although LOR to air and LOR to air/saline gained in popularity with increasing patient age. The majority of anesthesiologists do not change their LOR technique for different patient ages or level of epidural insertion. Most responders ranked 'training' as the most important determinant of practice, whereas 'departmental guidelines' were considered the least important. No complication attributable to the LOR technique used was reported. LOR to normal saline is the preferred method for identification of the epidural space in children of all age groups. The suggestion by experts that LOR to air should be used in neonates and infants was not supported by the practice of pediatric anesthesiologists across Canada.

Objective To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids. Method A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device. Main outcome Measure(s) Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores. Results Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac. Conclusions Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.

This book advances a serious consideration of how the goals and practices of psychology can be informed and enriched by Buddhist traditions that transcend the individual to consider the interconnectedness of all things, and the responsibility we have towards each other. Individualistic and psychotherapeutic applications of Buddhism in psychology are examined, followed by a bold step into the community arena, with consideration given to the intersection between community psychology and Buddhist approaches to empowerment, social change, and prevention. The emerging perspective of individuals and communities, empowered and ready to engage the millennium, ultimately has global implications for the future of humankind.

The association of coronary arterial calcification with cardiovascular morbidity and mortality is well-recognized. Lower limb arterial calcification (LLAC) is common in PAD but its impact on subsequent health is poorly described. We aimed to determine the association between a LLAC score and subsequent cardiovascular events in patients with symptomatic peripheral arterial disease (PAD). LLAC scoring, and the established Bollinger score, were derived from a database of unenhanced CT scans, from patients presenting with symptomatic PAD. We determined the association between these scores outcomes. The primary outcome was combined cardiac mortality and morbidity (CM/M) with a secondary outcome of all-cause mortality. 220 patients (66% male; median age 69 years) were included with follow-up for a median 46 [IQR 31-64] months. Median total LLAC scores were higher in those patients suffering a primary outcome (6831 vs. 1652; p = 0.012). Diabetes mellitus (p = 0.039), ischaemic heart disease (p = 0.028), chronic kidney disease (p = 0.026) and all-cause mortality (p = 0.012) were more common in patients in the highest quartile of LLAC scores. The area under the curve of the receiver operator curve for the LLAC score was greater (0.929: 95% CI [0.884-0.974]) than for the Bollinger score (0.824: 95% CI [0.758-0.890]) for the primary outcome. A LLAC score ≥ 4400 had the best diagnostic accuracy to determine the outcome measure. This is the largest study to investigate links between lower limb arterial calcification and cardiovascular events in symptomatic PAD. We describe a straightforward, reproducible, CT-derived measure of calcification-the LLAC score.

Symptomatic, partial-thickness rotator cuff tears (sPTRCT) are problematic. This study tested the hypothesis that management of sPTRCT with injection of fresh, uncultured, unmodified, autologous, adipose-derived regenerative cells (UA-ADRCs) is safe and more effective than injection of corticosteroid even in the long run. To this end, subjects who had completed a former randomized controlled trial were enrolled in the present study. At baseline these subjects had not responded to physical therapy treatments for at least 6 weeks, and were randomly assigned to receive respectively a single injection of UA-ADRCs (n = 11) or a single injection of methylprednisolone (n = 5). Efficacy was assessed using the ASES Total score, pain visual analogue scale (VAS), RAND Short Form-36 Health Survey and range of motion at 33.2 ± 1.0 (mean ± SD) and 40.6 ± 1.9 months post-treatment. Proton density, fat-saturated, T2-weighted MRI of the index shoulder was performed at both study visits. There were no greater risks connected with injection of UA-ADRCs than those connected with injection of corticosteroid. The subjects in the UA-ADRCs group showed statistically significantly higher mean ASES Total scores than the subjects in the corticosteroid group. The MRI scans at 6 months post-treatment allowed to “watch the UA-ADRCs at work”.

Background Obesity is a growing epidemic. Weight control interventions can achieve weight loss, but most is regained over time. Stigma and low quality of life are significant problems that are rarely targeted. Purpose A new model aimed at reducing avoidant behavior and increasing psychological flexibility, has shown to be relevant in the treatment of other chronic health problems and is worth examining for improving the lives of obese persons. Methods Patients who had completed at least 6 months of a weight loss program ( N  = 84) were randomly assigned to receive a 1-day, mindfulness and acceptance-based workshop targeting obesity-related stigma and psychological distress or be placed on a waiting list. Results At a 3-month follow-up, workshop participants showed greater improvements in obesity-related stigma, quality of life, psychological distress, and body mass, as well as improvements in distress tolerance, and both general and weight-specific acceptance and psychological flexibility. Effects on distress, stigma, and quality of life were above and beyond the effects due to improved weight control. Mediational analyses indicated that changes in weight-specific acceptance coping and psychological flexibility mediated changes in outcomes. Conclusion Results provide preliminary support for the role of acceptance and mindfulness in improving the quality of life of obese individuals while simultaneously augmenting their weight control efforts.