Impact of Cardiopulmonary Bypass and Aorta Cross Clamp Time on the Length of Mechanical Ventilation after Cardiac Surgery among Children: A Saudi Arabian Experience.

Aim Several factors determine the perioperative outcome besides the nature of the congenital heart defect. Prolonged mechanical ventilation (PMV) is a major factor that determines mortality, length of stay (LOS), residual disability, and other functional outcomes. We aim to determine the clinical variables predicting PMV and LOS in hospital, and specifically the impact from the duration of cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC). Method We conducted a retrospective review of the medical records of 413 children consecutively admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in one year at a single center. We collected demographic information (e.g., age, gender, and weight), perioperative variables, clinical outcomes, length of mechanical ventilation, high-frequency ventilator use, and mortality. We used logistic regression to analyze the data. PMV was defined as mechanical ventilation for longer than seven days. Results A total of 410 records were included in our study. We found no statistically significant association between CPB time and mechanical ventilation days. Forty-seven children had PMV, 362 did not have PMV. We found no statistically significant association between CPB time and mechanical ventilation days after adjusting for covariates. Reanalyzing the data with PMV defined as longer than four days produced the same results. Using a regression model to assess the variables via the least absolute shrinkage and selection operator for feature selection, we found no statistically significant association between ACC time and mechanical ventilation days after adjusting for covariates. Conclusion According to our results, CPB and ACC time are not associated with PMV or prolonged hospital LOS.

[Evaluation of Cutaneous Microcirculation at the Dorsum of the Hand within Different Age Groups - Implications for Wound Healing in Hand Surgery?]. / Evaluation der kutanen Mikrozirkulation des Handrückens im Alter - Implikationen für die Wundheilung in der Handchirurgie?

BACKGROUND: Cutaneous microcirculation has shown to play a key role in wound healing. Although healing disorders are still one of the most common complications in hand surgery, there still exists a lack of scientific research on possible age-related changes in cutaneous microcirculation at the dorsum of hand. HYPOTHESIS: Cutaneous microcirculation at the dorsum of the hand differs significantly between different age groups. METHODS: 53 healthy subjects were divided into 2 groups by age (Group A:<40 years, n=31 vs. Group B≥40 years, n=22). All subjects underwent measurement of the microcirculation at the dorsum of the hand with combined laser-Doppler and photo spectrometry. RESULTS: Cutaneous oxygen saturation was significantly higher in Group A than in Group B (A: 64.7±9.9% vs. B: 58.3±12.6%; p=0,044). In contrast, blood flow velocity was significantly higher in Group B (A: 43±19.6 AU vs. B: 56.7±21.1 AU; p=0.019). CONCLUSION: The hypothesis of this study was confirmed. This is the first study to show significant differences of cutaneous microcirculation at the dorsum of the hand within different age groups. Further clinical trials are needed in order to examine if delayed wound healing can be correlated to impaired cutaneous microcirculation at the dorsum of the hand.

Root causes for late presentation of severe neonatal hyperbilirubinaemia in Egypt.

This study aimed to understand the reasons for late presentation of cases of severe neonatal hyperbilirubinaemia. We administered a questionnaire to parents of 130 infants with severe jaundice admitted to Cairo University Children's Hospital neonatal intensive care unit at age > or = 6 days over an 18-month period. Although 125 infants (96.2%) were delivered in a health care facility, no discharge physical examination was performed in 99/125 cases (79.2%). No parent was given instructions about neonatal jaundice and no follow-up appointments were scheduled. Parents of 109 infants sought medical advice prior to hospital readmission; most babies were assessed clinically, but serum bilirubin was measured in only one-quarter of cases (28/109). Medical advice included placing the infant under a neon lamp at home (87/109 cases), advice to supplement breastfeeding (75/109) and prescribed medications, including vitamins (15/109). Increasing the availability of inexpensive point-of-care diagnostic instruments and phototherapy units in health care facilities are urgently needed.

Free flap microcirculatory monitoring correlates to free flap temperature assessment.

INTRODUCTION: Salvage rates of free flaps have been reported to be inversely related to the time interval between the onset of ischaemia and its clinical recognition. Consecutively, monitoring of free flaps remains of major importance. The aim of this study was to analyse the correlation of postoperative free flap microcirculation and free flap skin temperature as a potential tool of postoperative flap monitoring. HYPOTHESIS: Free flap skin temperature correlates to free flap capillary microcirculation. METHODS: Fifty-four free flaps were prospectively monitored during the study. Postoperative flap monitoring was performed using a regular digital infrared surface thermometer (Medisana FTD, Germany) simultaneously to microcirculatory assessment using combined Laser-Doppler and photospectrometry (Oxygen-to-see, Lea Medizintechnik, Germany). RESULTS: Mean microcirculatory blood flow was 105±35 arbitrary units (AU). Mean temperature was 34.9±2.2 °C. We found a significant correlation between free flap temperature and free flap capillary blood flow (Pearson correlation r=0.48; p<0.001) and postcapillary venous filling pressure (r=-0.32; p=0.021) in 54 free flaps. A 1 °C less free flap temperature was associated with a decrease of the mean microcirculatory capillary blood flow by 37 relative units. CONCLUSION: Our study demonstrates free flap skin temperature related to capillary microcirculation. Our primary hypothesis was confirmed. We postulate an acute temperature drop of 3 °C at the centre of the skin island as indicative of arterial thrombosis, whereas a 1-2 °C uniform temperature drop of the flap is indicative of venous compromise. Consecutively, free flap skin temperature assessment might be a reliable and inexpensive adjunct monitoring method in plastic reconstructive surgery to improve patients' safety.

Cystic lymphangioma in adults: can trauma be the trigger?

Cystic lymphangioma is a rare congenital anomaly of the lymphatic system. Most lesions present in infancy or early childhood with a swelling in the head and neck region. We report the case of a lady who presented with a cystic swelling in the suprascapular region that appeared after a fall on outstretched hands. Repeated aspiration and depomedrone injection failed to prevent recurrence. Surgical excision achieved complete removal, and histology showed the lesion as cystic lymphangioma, a rare condition to appear on the shoulder in an adult after trauma.

Treatment options for a patient experiencing pruritic rash associated with transdermal testosterone: a review of the literature.

A 22-year-old man with hypogonadotropic hypogonadism was receiving monthly intramuscular injections of testosterone replacement therapy. The patient refused to self-administer the injections because of discomfort, so the therapy was switched to testosterone patches. He experienced a pruritic, macular, erythematous rash underneath the reservoir area of two different transdermal formulations, which did not improve after pretreatment with topical corticosteroids. Eventually, he tolerated application of a testosterone gel and his serum testosterone levels returned to normal after 1 month of therapy. Commercially available and investigational testosterone products and therapeutic monitoring guidelines for androgen replacement are reviewed.

Congenital adrenal hyperplasia: epidemiology, management and practical drug treatment.

Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is a common disorder, and is characterised by a defect in cortisol biosynthesis with or without a defect in aldosterone synthesis and androgen excess. The classic form, also known as the severe form, occurs in 1:15,000 births worldwide, while the nonclassic or mild form occurs in approximately 1:1,000 births worldwide and is much more common (up to 1:20) in certain ethnic groups. In classic 21-hydroxylase deficiency, glucocorticoids are given in doses sufficient to suppress adrenal androgen secretion, and mineralocorticoids are given to normalise electrolytes and plasma renin activity. The management of CAH may be complicated by iatrogenic Cushing's syndrome, inadequately treated hyperandrogenism, or both. Prenatal treatment may decrease virilisation of the affected female foetus, but the efficacy and safety of treating CAH prenatally remains to be fully defined. Close clinical monitoring of growth and development is essential to optimise treatment outcome. New treatment approaches are currently under investigation in the most severely affected patients, while nonclassic CAH does not always require treatment.

A new tongue plate for use in oropharyngeal KTP laser surgery.

The KTP laser is used in both uvulopalatopharyngoplasty and tonsillectomy. However the need to use laser guarded endotracheal tubes represents a sizeable expense to the procedure. The authors describe a modified tongue plate to the oropharyngeal gag that covers all of the endo-tracheal tube, thus enabling the safe use of a non-laser guarded, PVC endotracheal tube. In over a hundred such procedures there has been no laser-related complications. The authors consider that the one off cost of this tongue plate and gag allows a more cost-effective method for performing laser-assisted uvulopalatopharyngoplasty and tonsillectomy.

Neutral phosphate-induced renal tubular metabolic alkalosis.

A severely burned patient receiving neutral phosphate supplement developed renal tubular alkalosis. This phenomenon is compared with the results of experimental observations on animals, reported in the literature. The physiologic mechanism, including the possible role of parathyroid hormone, is illustrated.

The effects of cGMP on fetal sheep pulmonary blood flow and lung liquid production.

This study was designed to determine the effects of a membrane permeant phosphodiesterase-resistant analog of cGMP on lung liquid production and pulmonary blood flow at the time of birth. Experiments were performed on seven fetal sheep prepared for chronic measurements of lung liquid production (Jv), pulmonary blood flow (Qp) and pressure, as well as systemic pressure. Injection of either 8-bromo-cGMP or saline were made via a catheter inserted in the left pulmonary artery. Experiments consisted of 1 h of control, 1 h of infusion, and 2 h of recovery. Data were analyzed by ANOVA and Newman-Keuls test. After infusion of 8-bromo-cGMP, Jv was decreased by 70 and 44% from control in h 3 and 4, respectively. Qp was elevated by 100 mL/min in h 2 and 3 and continued to be elevated by 50 mL/min in h 4. Saline infused animals showed no significant changes in Qp and Jv. This study demonstrates that 8-bromo-cGMP decreases lung liquid production and increases pulmonary blood flow in near term fetal sheep. Although blood flow increased in h 2, lung liquid production did not decrease at this time, suggesting a time dissociation between changes in pulmonary blood flow and lung liquid production. Thus, it is possible that a common transduction pathway involving cGMP may be responsible for lung liquid reduction and elevation of pulmonary blood flow at birth. However, Qp and Jv may not be causally related.