MEDICAL LITERATURE has been deluged during the past few years with books and papers on penicillin; but a book which has been produced under the general editorship of Sir Alexander Fleming himself represents a complete and authoritative summary of penicillin therapy as it stands today.' The book contains a series of independent contributions by \"experienced and eminent men who have worked with penicillin in Great Britain\". Their opinions and practical methods differ slightly, and there is some overlapping; but these are not disadvantageous, comparison and contrast lending interest to the reading. In the first or general section of the book Fleming contributes two chapters, one on the history and development of penicillin, introducing some interesting sidelights in the romance of discovery, the other on the bacteriological control of penicillin therapy. In both chapters the information is set out in meticulous detail and with a clarity and simplicity which can be enjoyed by all readers. Fleming also gives the right perspective to the place of penicillin amongst the antibiotics and lays down the principles of treatment. Both chapters are well illustrated and are the most outstanding in the book. Included in this first section also are chapters on the chemistry and manufacture of penicillin and its pharmacy, pharmacology and methods of administration. The second section of the book is entirely clinical, giving each author's view on the use of penicillin therapy in a disease or an infection of some particular region of the body. The entire range of peniCillin-sensitive conditions is considered in twenty authoritative and clearly written chapters; these contain many references and illustrations. Dental and veterinary diseases are also given fairly full consideration. The final section is a condensed resume of much of the preceding chapters and is written for. the general practttioner. This chapter is superttuous: it does not contain enough detall to be of much practical value. The book as a Whole, however, will undoubtedly be considered a classical contribution to medical literature and is strongly recommended, not only because of the general interest of its topic, but as a reference book on penicillin therapy of hitherto unequalled excellence. The typography, although conforming to war economy standards, is clear and the paper is good. There is an excellent list of references and the index is satisfactory.

Gray's Anatomy

The last decade has evidenced a dramatic increase in the development and utilization of pediatric health-related quality of life (HRQOL) measures in an effort to improve pediatric patient health and well-being and determine the value of healthcare services. The emerging paradigm shift toward patient-reported outcomes (PROs) in clinical trials has provided the opportunity to further emphasize the value and essential need for pediatric patient self-reported outcomes measurement. Data from the PedsQL™ DatabaseSM were utilized to test the hypothesis that children as young as 5 years of age can reliably and validly report their HRQOL. The sample analyzed represented child self-report age data on 8,591 children ages 5 to 16 years from the PedsQL™ 4.0 Generic Core Scales DatabaseSM. Participants were recruited from general pediatric clinics, subspecialty clinics, and hospitals in which children were being seen for well-child checks, mild acute illness, or chronic illness care (n = 2,603, 30.3%), and from a State Children's Health Insurance Program (SCHIP) in California (n = 5,988, 69.7%). Items on the PedsQL™ 4.0 Generic Core Scales had minimal missing responses for children as young as 5 years old, supporting feasibility. The majority of the child self-report scales across the age subgroups, including for children as young as 5 years, exceeded the minimum internal consistency reliability standard of 0.70 required for group comparisons, while the Total Scale Scores across the age subgroups approached or exceeded the reliability criterion of 0.90 recommended for analyzing individual patient scale scores. Construct validity was demonstrated utilizing the known groups approach. For each PedsQL™ scale and summary score, across age subgroups, including children as young as 5 years, healthy children demonstrated a statistically significant difference in HRQOL (better HRQOL) than children with a known chronic health condition, with most effect sizes in the medium to large effect size range. The results demonstrate that children as young as the 5 year old age subgroup can reliably and validly self-report their HRQOL when given the opportunity to do so with an age-appropriate instrument. These analyses are consistent with recent FDA guidelines which require instrument development and validation testing for children and adolescents within fairly narrow age groupings and which determine the lower age limit at which children can provide reliable and valid responses across age categories.

/pdf/how-young-can-children-reliably-and-validly-self-report-33aa10dyzy.pdf

How young can children reliably and validly self-report their health-related quality of life?: An analysis of 8,591 children across age subgroups with the PedsQL™ 4.0 Generic Core Scales

Continuous real-time monitoring of the adequacy of cerebral perfusion can provide important therapeutic information in a variety of clinical settings. The current clinical availability of several non-invasive near-infrared spectroscopy (NIRS)-based cerebral oximetry devices represents a potentially important development for the detection of cerebral ischaemia. In addition, a number of preliminary studies have reported on the application of cerebral oximetry sensors to other tissue beds including splanchnic, renal, and spinal cord. This review provides a synopsis of the mode of operation, current limitations and confounders, clinical applications, and potential future uses of such NIRS devices.

Near-infrared spectroscopy as an index of brain and tissue oxygenation

Near infrared spectroscopy (NIRS) is an imaging technique used in both clinical and emergency medicine, as well as in research laboratories to quantify and measure the oxygenation status of human tissue non-invasively. This is done by monitoring in vivo changes of the oxygen saturation of hemoglobin molecules in the body, based on the absorbance of near-infrared light by hemoglobin. With regards to NIRS in human tissue, this chapter will primarily be concerned with discerning the oxygenation status of cerebral tissue. The importance of such a measure, especially in cerebral physiology, is that the human brain utilizes oxygen to continuously supply neurons with energy used for vital body functioning. In the absence of oxygen, as is the case during ischemic stroke or desanguination, cognitive and functional impairment resulting in death often occurs. NIRS technology makes it possible to apply critical safety thresholds with regards to cerebral tissue saturation in order to avoid dangerously low levels with the primary goal being to reduce mortality rates and cognitive deficits due to cerebral hypoxemia.

Near infrared spectroscopy.

. Bowler I, Djaiani G, Abel R, Pugh S, Dunne J, Hall J. A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. J Cardiothorac Vasc Anesth 2002; 16:709–714. [54] Brown J, McAtamney D. Remifentanil infusion for high-risk caesarean section. Int J Obstet Anesth 2003; 12:63–64. . Bruhn J, Bouillon TW, Radulescu L, et al. Correlation of approximate entropy, bispectral index, and spectral edge frequency 95 (SEF95) with clinical signs of ’anesthetic depth’ during coadministration of propofol and remifentanil. Anesthesiology 2003; 98:621–627. [13] Burmeister MA, Brauer P,Wintruff M, Graefen M, Blanc I, Standl TG. A comparison of anaesthetic techniques for shock wave lithotripsy: the use of a remifentanil infusion alone compared to intermittent fentanyl boluses combined with a low dose propofol infusion. Anaesthesia 2002; 57:877– 881. Burmeister MA, Standl TG, Wintruff M, Brauer P, Blanc I, Esch JSA. Dolasetron prophylaxis reduces nausea and postanaesthesia recovery time after remifentanil infusion duringmonitored anaesthesia care for extracorporeal shock wave lithotripsy. Br J Anaesth 2003; 90:194–198. Cavaliere F, Antonelli M, Arcangeli A, Conti G, Costa R, Pennisi MA, Proietti R. A low-dose remifentanil infusion is well tolerated for sedation in mechanically ventilated, critically-ill patients. Can J Anaesth 2002; 49:1088–1094.

Critical care: State of the art

We have compared the effect of increasing optode separation (range 0.7-5.5 cm) on the sensitivity of near infrared spectroscopy (NIRS) to discrete reductions in scalp and cerebral oxygenation in 10 healthy men (mean age 32, range 26-39 yr) using multichannel NIRS. During cerebral oligaemia (a mean reduction in middle cerebral artery flow velocity of 47%) induced by a mean reduction in end-tidal PCO2 of 2.4 kPa, the decrease in oxyhaemoglobin detected by NIRS became significantly greater with increasing optode separation (P

Cerebral near infrared spectroscopy: emitter-detector separation must be increased.

The detection of increased cerebral oxygenation secondary to cerebral hyperaemia, induced by hypercapnia has been studied in anaesthetised patients using a near infrared, reflectance mode, cerebral oxygenation monitor (Invos 3100 Somanetics, Troy, Michigan, USA). Two studies were performed, with and without a pneumatic scalp tourniquet, to distinguish between extracranial and intracranial changes in tissue oxygenation. In the control study a mean increase in end tidal CO2 of 23.1 mm Hg was accompanied by a mean increase in middle cerebral artery flow velocity of 116%. Regional cerebral oxygen saturation (rSO2) measured transcutaneously in the frontal distribution of the middle cerebral artery increased significantly from 70.5% to 74.6% (p = 0.001). During the second study with a scalp tourniquet inflated to maintain the extracranial tissues in a state of stable ischaemia a mean increase in end tidal CO2 of 22.3 mm Hg was accompanied by a mean increase in middle cerebral artery flow velocity of 121%. The change in rSO2 from 62.6% to 64.5% was not significant (p = 0.085). There was no correlation between the change in middle cerebral artery flow velocity and rSO2 in the control or scalp ischaemia group. This study shows that the Invos 3100 monitor is sensitive to tissue oxygenation but does not reliably detect changes in cerebral oxygenation as a result of profound cerebral hyperaemia. The contribution of extracerebral tissue to the attenuation of near infrared light and the lack of spatial resolution remain major problems to be overcome before this or other near infrared spectroscopy instruments can be introduced into clinical practice.

https://jnnp.bmj.com/content/jnnp/58/4/477.full.pdf

Extracerebral absorption of near infrared light influences the detection of increased cerebral oxygenation monitored by near infrared spectroscopy.

To test theoretical assumptions supporting the use of near-infrared spectroscopy (NIRS) in clinical practice, we examined the behaviour of NIR light transmission and attenuation in the human head. Sterile probes for emitting and detecting NIR light at a fixed separation of 40 mm were placed in turn on intact skin, skull, dura and cerebral cortex of 10 patients undergoing elective neurosurgery. In the first five patients, the detecting probe was moved through successive extracerebral layers with the emitter on the skin surface. In the second five patients, the process was reversed, with the emitting probe moved and the detector in the same place on the scalp. NIR intensity was measured at each tissue interface and compared with the intensity measured at the skin surface with all layers intact. Removal of bone and dura from the light path caused a significant reduction in detected intensity. The largest mean reduction in light intensity was a 14-fold decrease with removal of bone (unadjusted P

Behaviour of near-infrared light in the adult human head: implications for clinical near-infrared spectroscopy.

Objective. To examine the effect of two emitter-detector separations (2.7 and 5.5 cm) on the detection of changes in cerebral and extra-cerebral tissue oxygenation using near infrared spectroscopy (NIRS). Methods. Two NIR detectors were placed on the scalp 2.7 and 5.5 cm from a single NIR emitter. Changes in deoxyhaemoglobin (HHb), oxyhaemoglobin (O2Hb),oxidised cytochrome C oxidase (Cyt) and total haemoglobin (tHb) were recorded from each detector during the induction of cerebral oligaemia (transition from hypercapnia to hypocapnia) and scalp hyperaemia (following release of a scalp tourniquet). Results. Cerebral oligaemia (mean decrease in middle cerebral artery blood flow velocity of 44%) induced by a mean reduction in end tidal CO2 of 18 mmHg was accompanied by a significant increase in the spectroscopic signal for HHb and a decrease in the O2Hb signal. The signal change per unit photon path length detected at 5.5 cm was significantly greater for HHb (p = 0.007) than that detected at 2.7 cm. In contrast, the increase in all chromophores detected at 5.5 cm during scalp hyperaemia was significantly less than that detected at 2.7 cm (p < 0.001). Conclusions. The differing sensitivity of the proximal and distal channels to changes in cerebral and extra-cerebral oxygenation is compatible with theoretical models of NIR light transmission in the adult head and may provide a basis for spatially resolving these changes. The optimal emitter-detector separation for adult NIRS requires further investigation and may differ between individuals.

Sensitivity of Near Infrared Spectroscopy to Cerebral and Extra-Cerebral Oxygenation Changes is Determined by Emitter-Detector Separation

Near-infrared spectroscopy.

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