Egidio Barbi

Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience

BACKGROUND & AIMS Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was

IgE-mediated food allergy in children

5.3 million. CONCLUSIONS EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Fatal allergy as a possible consequence of long-term elimination diet

Food allergy is a serious health issue affecting roughly 4% of children, with a substantial effect on quality of life. Prognosis is good for the most frequent allergens with almost all children outgrowing their allergy. However, the long-term implications for disease burden are substantial for children with persistent allergies (eg, peanuts, tree nuts, fish, and shellfish) and for those with high concentrations of milk, egg, and wheat IgE. Antigen avoidance has been the time-honoured approach both for prevention and treatment. However, findings from studies done in the past 5 years show that early contact with food can induce tolerance and desensitisation to foods. We review the epidemiology, natural history, and management of food allergy, and discuss the areas of controversy and future directions in research and clinical practice.

Pretreatment with intravenous ketamine reduces propofol injection pain.

Urticaria is a commondisorder that affects as many as 20% of the population at some point during their lifetime. Factors believed to cause or aggravate urticaria include drugs, foods, additives, connective tissue disorders and infections. It is well established that hepatitis B virus causes urticaria (1). Whether hepatitis C infection causes urticaria or not is still debated. There have been conflicting reports both in favour of (2,3) and against (4,5) hepatitis C virus (HCV) causing urticaria. Kanazawa and colleagues (2) reported a positive relationship between hepatitis C and urticaria. Nineteen of 79 patients tested were found to be positive for HCV. Subsequent studies however did not confirm such an association (4,5). We describe here a case of chronic intermittent urticaria caused by HCV. A 49-year-old Caucasian man presented with a typical history of recurrent urticaria of several months duration. There were no clues in the history apart from promiscuity, and all routine screening investigations were negative apart from an approximately three times raised alanine aminotransferase (ALT). In view of a history of multiple sexual partners and raised ALT, hepatitis serology was requested. Hepatitis C antibody was reported to be positive by both enzymelinked immunosorbent assay (ELISA) and microparticle enzyme immune assay. Results of ELISA for hepatitis B were negative.We conclude that HCV infection may have caused urticaria in this patient. There does not appear to be any clearcut evidence to affirm or refute a direct link between chronic urticaria and HCV infection in the literature. We suggest that HCV status should be checked in patients presenting with urticaria in areas with a high prevalence. It may not be cost-effective to perform routine screening forHCVwhere the prevalence of this infection is low, but should be considered where the history or laboratory tests suggest this possibility. Further studies are needed to establish any definite association, possible aetiopathogenic role and the cost implications of screening and therapy of HCV in chronic urticaria.

Coeliac disease, folic acid deficiency and epilepsy with cerebral calcifications.

Background Paediatric procedural sedation using propofol has been shown to be safe and effective and is widely used. Pain at the injection site is a frequent complaint and can be particularly distressing for children, especially for those undergoing repeated procedures. Ketamine has analgesic properties and can diminish the incidence of propofol infusion pain in adults. The aim of the study was to investigate whether pretreatment with ketamine would reduce infusion line pain in propofol sedation in children.

Comparison of three sites to check the pulse and count heart rate in hypotensive infants

ABSTRACT. Two cases of focal occipital epilepsy with cerebral calcifications poorly responsive to antiepileptic treatment are described. In both cases coeliac disease was diagnosed and folic acid deficiency documented. A gluten‐free diet and a brief supplementation with folic acid lead to a complete EEG and clinical normalization in one case and to a significant improvement of EEG and seizure control in the other.

Diagnostics and Therapeutic Insights in a Severe Case of Mevalonate Kinase Deficiency

Background:  Current international guidelines state that heart rate counted at the brachial pulse must be absent or <60 b.min−1 to diagnose cardiac arrest. Some data suggest that this site may not be the best to check cardiac activity. Hypotension is a likely real scenario of the need for chest compressions in infants. We compared the performance of three sites of pulse palpation (brachial, carotid, and femoral) for detecting and counting heartbeat in hypotensive infants.

Current concepts in management of pain in children in the emergency department

Mevalonate kinase deficiency is a rare inborn disorder of isoprenoid and sterol biosynthesis characterized by a recurrent autoinflammatory syndrome and, in most severe cases, psychomotor delay. Clinical manifestations can be very complex and, in some cases, mimic a chronic inflammatory disease. Diagnosis is also complex and often requires immunologic, genetic, and biochemical investigations. There is no standardized therapy, but biological agents could help to control inflammatory complaints in some cases. A severe case of mevalonate kinase deficiency that was associated with nephritis and successfully treated with anakinra (interleukin 1 receptor antagonist) is reported here, and new insights into diagnosis and therapy of this complex disorder are discussed.

Chronic inflammation in congenital cystic adenomatoid malformations. An underestimated risk factor

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Safety and efficacy of propofol administered by paediatricians during procedural sedation in children.

PURPOSE Congenital cystic malformations of the lung are more frequently diagnosed before birth, but guidelines for surgical management of asymptomatic cases are lacking. The aim of this article is to review our 10-year results with antenatally diagnosed congenital cystic adenomatoid malformations (CCAMs) to debate indications for early postnatal surgical management in asymptomatic patients. METHOD Twenty-four cases were reviewed; of these, 18 were operated on before 15 days of life for respiratory distress or mediastinal shift, whereas 6 were submitted to elective surgery at 3 months of age. RESULTS Twenty lobectomies and 4 atypical resections were performed. Two of the latter required a second surgery for incomplete primary perinatal resection. No postsurgical complications were reported. Nineteen (19/24) of the resected specimens showed signs of chronic inflammation. In the perinatal period, 100% (8 cases) of CCAM type II and 50% (8 cases) of CCAM type I resulted to be inflamed. Of the asymptomatic cases, 50% (3/6) were also found to be affected. No infections were detected at bacteriologic culture and bacterial debris was stained in 3 specimens. CONCLUSION In this series, a 79% incidence of pulmonary inflammation was detected. The CCAM type II resulted to be always involved in this process of inflammation. This was an unexpected finding, particularly in cases without mediastinal shift or respiratory distress. In light of these results, early postnatal treatment, at around 3 to 6 months of age, could be considered even in asymptomatic patients.