A multicentered prospective analysis of diagnosis, risk factors, and outcomes associated with pediatric ventilator-associated pneumonia.

OBJECTIVE: To assess risk factors and outcomes associated with pediatric ventilator-associated pneumonia. DESIGN: Multicentered prospective observational cohort. SETTING: Children's hospitals in the United States. PATIENTS: Mechanically ventilated patients less than 18 years old. MEASUREMENTS AND MAIN RESULTS: Prospective evaluation of the prevalence, risk factors, and outcomes of pediatric ventilator-associated pneumonia along with evaluation of diagnostic criterion for pediatric ventilator-associated pneumonia. The prevalence of pediatric ventilator-associated pneumonia was 5.2% (n = 2,082), for a rate of 7.1/1,000 ventilator days. Patients with ventilator-associated pneumonia had a longer unadjusted ICU length of stay (p < 0.0001) and increased length of mechanical ventilation by more than 11 days (p < 0.0001). After adjustment for patient factors, ICU length of stay (p = 0.03) and mechanical ventilation days (p = 0.001) remained significant. Patients with ventilator-associated pneumonia were almost three times more likely to die (p = 0.007). Independent risk factors for ventilator-associated pneumonia were reintubation and part-time ventilation. CONCLUSIONS: Pediatric ventilator-associated pneumonia is common in mechanically ventilated pediatric patients. These patients have longer length of stay, longer duration of mechanical ventilation, and increased risk for mortality.

Influence of S3 electrical stimulation on gastrointestinal dysfunction after spinal cord injury in rabbits.

OBJECTIVE: To investigate the effect of electrical stimulation to sacral spinal nerve 3 (S3 stimulation) on gastrointestinal dysfunction after spinal cord injury (SCI). METHODS: Six rabbits were taken as normal controls to record their gastrointestinal multipoint biological discharge, colon pressure and rectoanal inhibitory reflex. Electrodes were implanted into S3 in another 18 rabbits. Then the model of SCI was conducted following Fehling's method: the rabbit S3 was clamped to induce transverse injury, which was claimed by both somatosensory evoked potential and motion evoked potential. Two hours after SCI, S3 stimulation was conducted. The 18 rabbits were subdivided into 3 groups to respectively record their gastrointestinal electric activities (n=6), colon pressure (n=6), and rectum pressure (n=6). Firstly the wave frequency was fixed at 15 Hz and pulse width at 400 µs and three stimulus intensities (6 V, 8 V, 10 V) were tested. Then the voltage was fixed at 6 V and the pulse width changed from 200 µs, 400 µs to 600 µs. The response was recorded and analyzed. The condition of defecation was also investigated. RESULTS: After SCI, the mainly demonstrated change was dyskinesia of the single haustrum and distal colon. The rectoanal inhibitory reflex almost disappeared. S3 stimulation partly recovered the intestinal movement after denervation, promoting defecation. The proper stimulus parameters were 15 Hz, 400 µs, 6 V, 10 s with 20 s intervals and 10 min with 10 min intervals, total 2 h. CONCLUSION: S3 stimulation is able to restore the intestinal movement after denervation (especially single haustrum and distal colon), which promotes defecation.

[Sacral nerve stimulating on intestinal mucosal immune barrier function of rats with acute complete spinal cord injury].

Objective: To study the effects of sacral nerve root stimulation on intestinal mucosal immune barrier function in rat with acute complete spinal cord injury(SCI). Methods: Fifty-six Wistar rats were divided into Sham group(SG n=8), control group(CG 24 、 48、 72 h,n=8), and experimental group(EG 24、 48、 72 h,n=8). In CG and EG, according to Fehlings'method,we transected the spinal cord by the aneurysm clip and implanted electrodes into the third sacral foramina on the right side.We stimulated in intensity 4 V,the frequency of 15 Hz,and the pulse of 210 µs.The stimulation period was 2 hours,with 10 minutes stimulation and 10 minutes rest intermittently,twice a day at 8:00-10:00 am and 6:00-8:00 pm. The intestinal morphology was observed under light microscope and electron microscope. The protein expression levels of A20,NOD2,and CD68 by Western blot . Results: ① SCI caused impaired intestinal epithelial barrier function. The intestinal mucosa appeared different degree of damage in CG group; cell-cell connections between intestinal epithelial cells were destroyed; The escherichia coli and other antigen translocated through the injured epithelial cell , M cells, and the leakage to the lamina propria of intestinal villi, which were improved in EG after stimulation.② The expression of A20 in EG was increased ,which had statistical differences between CG or SG(P＜0.01); the expression ofA20 in CG was decreased, which had statistical differences between SG(P＜0.01).The expression of NOD2 in CG was increased, which had statistical differences between SG(24 h,72 h P＜0.05; 48 h P＜0.01);The expression of NOD2 in EG (48 h ,72 h)was decreased, which had statistical differences between CG(48 h P＜0.01,72 h P＜0.05). The expression of NOD2 in EG had no statistical differences between SG. The expression of CD68 in CG was increased,which had statistical differences between SG or EG(P＜0.01).The expression of CD68 in EG was increased in 24 h and 48 h groups ,which had statistical differences between SG(P＜0.01),but had no statistical differences in 72 h group. Conclusion: Sacral nerve root 3 electrostimulation can rehabilitate the peristalsis of intestine,decrease bacterial amount,reduce inflammatory response, enhance endogenous protection, protect the intestinal mucosal immune barrier function.

Long-term follow-up of patients with nonalcoholic fatty liver.

BACKGROUND & AIMS: Nonalcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of conditions ranging from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH) convincingly. NASH is the only subtype of NAFLD that has been shown to progress relatively, although these findings were reported from studies with short follow-up periods. We assessed the long-term outcomes of a NAFLD cohort. METHODS: Patients with NAFLD established by biopsy were identified in databases and categorized as NASH or non-NASH. Mortality data and causes of death were obtained from National Death Index Plus. The nonparametric Kaplan-Meier method with log-rank test and multivariate analyses with a Cox proportional hazard model were used to compare different NAFLD subtypes and to identify independent predictors of overall and liver-related mortality. RESULTS: Of 173 NAFLD patients (age at biopsy, 50.2 +/- 14.5 y; 39.9% male; 80.8% Caucasian; 28.9% with type II diabetes), 72 (41.6%) had NASH and 101 (58.4%) had non-NASH NAFLD. Over the follow-up period, the most common causes of death were coronary artery disease, malignancy, and liver-related death. Although overall mortality did not differ between the NAFLD subtypes, liver-related mortality was higher in patients with NASH (P < .05). Independent predictors of liver-related mortality included histologic NASH, type II diabetes, older age at biopsy, lower albumin levels, and increased levels of alkaline phosphatase (P < .05). CONCLUSIONS: This long-term follow-up evaluation of NAFLD patients confirms that NASH patients have increased liver-related mortality compared with non-NASH patients. In addition, patients with NAFLD and type II diabetes are especially at risk for liver-related mortality.

Metabolic syndrome after laparoscopic bariatric surgery.

BACKGROUND: Metabolic syndrome (MS) is common among morbidly obese patients undergoing bariatric surgery. The aim of this study was to assess the impact and predictors of bariatric surgery on the resolution of MS. METHODS: Subjects included 286 patients [age 44.0 +/- 11.5, female 78.2%, BMI 48.7 +/- 9.4, waist circumference 139 +/- 20 cm, AST 23.5 +/- 14.9, ALT 30.0 +/- 20.1, type 2 diabetes mellitus (DM) 30.1% and MS 39.2%] who underwent bariatric surgery. RESULTS: Of the entire cohort, 27.3% underwent malabsorptive surgery, 55.9% underwent restrictive surgery, and 16.8% had combination restrictive-malabsorptive surgery. Mean weight loss was 33.7 +/- 20.1 kg after restrictive surgery (follow up period 298 +/- 271 days), 39.4 +/- 22.9 kg after malabsorptive surgery (follow-up period 306 +/- 290 days), and 28.3 +/- 14.1 kg after combination surgery (follow-up period 281 +/- 239 days). Regardless of the type of bariatric surgery, significant improvements were noted in MS (p values from <0.0001-0.01) as well as its components such as DM (p values from <0.0001-0.0005), waist circumference (p values <0.0001), BMI (p values <0.0001), fasting serum triglycerides (p values <0.0001 to 0.001), and fasting serum glucose (p values <0.0001). Additionally, a significant improvement in AST/ALT ratio (p value = 0.0002) was noted in those undergoing restrictive surgery. Multivariate analysis showed that patients who underwent malabsorptive bariatric procedures experienced a significantly greater percent excess weight loss than patients who underwent restrictive procedures (p value = 0.0451). Percent excess weight loss increased with longer postoperative follow-up (p value <0.0001). CONCLUSIONS: Weight loss after bariatric surgery is associated with a significant improvement in MS and other metabolic factors.

Apnoeic-hypopnoeic episodes during obstructive sleep apnoea are associated with histological nonalcoholic steatohepatitis.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) and obstructive sleep apnoea are associated with metabolic syndrome and atherosclerotic heart disease. This study evaluates the potential association between the NAFLD subtypes and a number of polysomnographical (PSG) parameters. METHODS: This study included patients undergoing bariatric surgery with extensive clinical and histological data for whom complete PSG data before surgery were also available. Excess alcohol intake and other causes of liver disease were excluded. Apnoea, hypopnoea and apnoea-hypopnoea index (AHI) were calculated as described previously. RESULTS: In this study, a total of 101 patients [77 nonalcoholic steatohepatitis (NASH) and 22 non-NASH controls] with PSG data were included (age 42.9 +/- 11.4 years, body mass index 51.6 +/- 9.5 kg/m(2), fasting serum glucose 117.4 +/- 53.4 mg/dl, fasting serum triglycerides 171.3 +/- 82.9 mg/dl, 58% hypertension and 33% diabetes mellitus). Subjects with histological NASH had significantly lower lowest desaturation (77 vs. 85%, P=0.006), lower mean nocturnal oxygen saturation (91 vs. 93%, P=0.05), higher AHI (35 vs. 22, P=0.03), higher respiratory disturbance index (46 vs. 21, P=0.02) and higher alanine aminotransferase/aspartate aminotransferase ratio (1.4 vs. 1.3, P=0.05) compared with non-NASH controls. In multivariate analysis, the lowest desaturation (P=0.04) was independently associated with histological NASH. Lowest desaturation and mean nocturnal oxygen saturation were significantly lower in subjects with fibrosis (76 vs. 85%, P=0.004 and 90.4 vs. 93.0%, P=0.02). CONCLUSIONS: Our results suggest that the frequent nocturnal hypoxic episodes in NAFLD patients may be a risk factor for developing NASH. Additional studies are needed to study the effect of optimizing sleep apnoea management on the outcomes of patients with NAFLD.

[The effects of sacral nerve root electrostimulation on the colon function and its mechanisms in a rat model of spinal cord injury].

OBJECTIVE: To study the effects of sacral nerve root electrostimulation (SNS) on the colon function and its mechanisms in rats with spinal cord injury (SCI). METHODS: One hundred and four Wistar rats were divided into three groups: A, B and C. A group ( n = 24) was divided into three subgroups (n = 8) for studying the bioelectricity: Normal group (NG), SCI group (SCI) and SCI group with SNS(SNS); B group( n = 24) was divided into three subgroups( n = 8) for studying the colon motility: NG, SCI and SNS. C group( n = 56) were divided into three groups for studying the change of morphology and neurotransmitters(SP and VIP): NG (n = 8), SCI (n = 24), and SNS (n = 24) . In SCI and SNS, included of three subgroups: 24, 48, 72 h after spinal cord injury (n = 8). RESULTS: In SCI group, the activity of bioelectricity in proximal and distal colon was reduced; the colon motility was lessened, and colon mucosa appeared different degree of damage; cell-cell connections between intestinal epithelial cells were destroyed. The expressions of substance P(SP) and vasoactive intestinal peptide (VIP) in colon were decreased obviously. SNS was found to activate the bioelectricity, promote the colon motility, improve the intestinal mucosal, and increase the expressions of SP and VIP. Conclusion: SNS can activate the peristalsis, rehabilitate the motility of denervated colon, protection of the intestinal mechanical barrier between intestinal epithelial cells and tight junction, rebuild the colon function through activating the bioelectricity and increase the expressions of SP and VIP.

Ultrastructural study on route of gut bacterial translocation in a rat after spinal cord injury.

OBJECTIVE: To observe the ultrastructural change of the route of gut bacterial translocation in a rat with spinal cord injury (SCI). METHODS: Forty Wistar rats were divided into the following groups: control group and 3 SCI groups (10 in each group). The rats in the SCI groups were established SCI model at 24 h, 48 h, and 72 h after SCI. Small intestine mucous membrane tissue was identified and assayed by transmission electron microscope, scanning electron microscope and immunofluorescence microscopy. RESULTS: Small intestine mucous membrane tissue in control group was not damaged significantly, but those in SCI groups were damaged significantly. Proliferation bacteria in gut lumen attached on microvilli. The extracellular bacteria torn the intestinal barrier and perforated into the small intestinal mucosal epithelial cell. The bacteria and a lot of particles of the seriously damaged region penetrated into the lymphatic system and the blood system directly. Some bacteria were internalized into the goblet cell through the apical granule. Some bacteria and particles perforated into the submucosa of the M cell running the long axis of M cells through the tight junctions. In the microcirculation of mucosa, the bacteria that had already broken through the microvilli into blood circulation swim accompanying with erythrocytes. CONCLUSION: The routes of bacterial translocation interact and format a vicious circle. At early step, the transcellular pathway of bacterial translocation is major. Following with the destroyed small intestine mucous, the routes of bacterial translocation through the lymphatic system and the blood system become direct pathways. The goblet cell-dendritic cell and M cell pathway also play an important role in the bacterial translocation.

[The protective effects of sacral nerve electrostimulation on intestinal mucosal mechanical barrier in rats with spinal cord injury].

OBJECTIVE: To study the protective effects of sacral nerve root electrostimulation on intestinal mechanical barrier in rats with spinal cord injury (SCI). METHODS: Fifty six Wistar rats were divided into normal group, SCI control group and SCI group with sacral nerve root electrostimulation (8 rats in each subgroup at 24, 48, 72 h after spinal cord injury). The following experiments were performed respectively in rats from the 3 groups: bacteria culture from intestinal mesentery lymph nodes, liver, spleen, intestinal morphology observation and detection the protein expression level of ZO-1. RESULTS: The intestinal mucosa appeared different degree of damage in SCI control group; cell-cell connections between intestinal epithelial cells were destroyed; Endotoxin levels in blood and the number of bacterial translocation increased obviously. Sacral nerve stimulation was found toimprove the intestinal mucosal, reduce the endotoxin content in the blood to normal level and the decrease the incidences of bacterial translocation of the gut origin. The expression of tight junction protein ZO-1 of rat intestinal tissue had no statistical differences among the 3 groups. On the other hand, the distribution of tight junction protein ZO-1 appeared different degrees of scattered and irregular in the control group while that in the experimental group appeared different degree of improvement as determined by the immunohistochemistry of rat intestinal tissue. CONCLUSION: sacral nerve root electrostimulation can rehabilitate the peristalsis of denervated colon, promote defeacation and decrease bacterial amount, protection of the intestinal mechanical barrier between intestinal epithelial cells and tight junction, reducing the endotoxin content in the blood and suppressing bacterial translocation from the gut.

Comparison of activity level among patients with chronic liver disease.

PURPOSE: To determine whether self-reported maximal and daily activity levels are impaired among patients with nonalcoholic fatty liver disease (NAFLD), hepatitis C (HCV) and hepatitis B (HBV). METHODS: Clinicodemographic, diagnostic, self-report and standard laboratory data were obtained. Univariate, multivariate and regression analyses were performed comparing group maximal (Maximum Activity Score [MAS]) and daily activity scores (Adjusted Activity Score [AAS]), adjusted for age and gender. RESULTS: Two hundred twenty-two patients completed activity-level self-reports (mean age [52.4 ± 10.0 years], BMI [28.3 ± 6.58], 31.2% NAFLD, 48.3% HCV, 20.3% HBV). On multivariate analysis, significantly higher MAS (p < 0.05) and AAS in HBV patients correlated with absence of cirrhosis, younger age, male gender (higher MAS) and lower BMI (higher AAS). Lowest activity levels were found primarily in obese patients (p < 0.009). Compared with population norms, NAFLD and HCV cohorts scored mildly disabled on MAS; the HBV cohort scored low normal. Mild disability on AAS was observed in patients with HBV; moderate disability in those with NAFLD, HCV. CONCLUSIONS: All groups had significantly lower activity levels than population norms. Nonobese patients showed significantly less disability than obese patients. Patients with NAFLD and HCV are likely to have lower levels than those with HBV without cirrhosis. This presents an additional risk factor for disability and mortality. IMPLICATIONS FOR REHABILITATION: • Hepatitis B (HBV), hepatitis C (HCV), and nonalcoholic fatty liver disease (NAFLD) patients had significantly lower activity levels than expected for their age and gender, as measured by the Human Activity Profile (HAP). • Overweight and normal weight chronic liver disease (CLD) patients showed significantly less disability than obese chronic liver disease patients. • Patients with NAFLD and HCV are likely to participate in low levels of activity that require fewer metabolic equivalents for completion, adding an additional risk factor for disability and mortality. • Targeting low activity level in CLD patients, and decreasing BMI below the obesity threshold, may reduce disability and risk of mortality.

Efficacy and safety of surgery for lumbar disc herniation in patients aged 80 and older.

AIM: To evaluate the efficacy and safety of surgery for lumbar disc herniation in patients aged 80 or older. MATERIAL AND METHODS: Operative time (OT), intraoperative estimated blood loss (EBL), length of hospital stay (LOS), and complication rate (CR) were used to assess safety of surgery. The Visual Analog Scale (VAS), the Oswestry disability index (ODI) and the North American Spine Society Outcome Questionnaire (NASS-Q) were used to evaluate the clinical effectiveness. RESULTS: There were significant differences between the very elderly and the middle-aged group in LOS (P < 0.001), but not in OT, EBL and CR (all P > 0.05). The preoperative, post-operative and final follow up VAS and ODI scores were not significantly different between the two groups (each P > 0.05). However, the VAS and ODI scores were significantly improved after surgery and at ultimate follow up compared with those before surgery (all P < 0.001). Satisfaction with outcome was expressed by 39 (86.7%) of 45 very elderly patients. CONCLUSION: Conventional laminectomy, discectomy and/or spinal fusion surgery is a feasible, safe and effective treatment in patients over age 80 with lumbar disc herniation compared with middle-aged patients.

Nutritional assessments of patients with non-alcoholic fatty liver disease.

BACKGROUND: Obesity is not only associated with nonalcoholic fatty liver disease (NAFLD) but it also adversely affects the progression of other liver diseases. There are limited data regarding the dietary habits of patients with chronic liver disease. METHODS: Nutrition surveys containing 13 different food groups were mailed. Nutrition scores were calculated based on weekly servings. Foods were also divided into USDA food pyramid categories with conversion of each group into calories expended. Clinico-demographic data were available. NAFLD patients were compared to patients with chronic viral hepatitis. RESULTS: A total of 233 subjects were included: age 52.5 +/- 10.0 years, Body mass index (BMI) 28.1 +/- 6.5, MS 24.2%, 31.8% NAFLD, 48.1% hepatitis C virus (HCV), and 20.2% hepatitis B virus (HBV). Six nutrition indices were different among the groups. NAFLD and HCV consumed more low-nutrient food (p = 0.0037 and 0.0011) and more high-sodium food than HBV (p = 0.0052 and 0.0161). Multivariate analysis showed that NAFLD and HCV consumed more high-fat sources of meat/protein than HBV (p = 0.0887 and 0.0626). NAFLD patients consumed less calories from fruits compared to HCV and HBV patients (p = 0.0273 and 0.0023). Nine nutrition indices differed according to BMI. Univariate analysis showed that obese/overweight patients consumed more high-fat sources of meat/protein (p = 0.0078 and 0.0149) and more high-sodium foods (p = 0.0089 and 0.0062) compared to the normal-weight patients. In multivariate analysis, normal-weight patients consumed more fruits than obese (p = 0.0307). Overweight patients also consumed more calories of meat and oil than normal-weight patients (p = 0.0185 and 0.0287). CONCLUSION: NAFLD and HCV patients have similar dietary habits. Patients with HBV have the healthiest dietary habits. Specific dietary interventions should focus on decreasing intake of low-nutrient and high-sodium food, as well as high-fat sources of meat/protein.