[Bedside percutaneous tracheostomy in critically ill medical patients: clinical characteristics, outcome and complications].

BACKGROUND: Tracheostomy is a surgical procedure, frequently used in patients with respiratory failure requiring prolonged mechanical ventilation. It is associated with fewer complications and may facilitate weaning from mechanical ventilation. Over the past 15 years, bedside percutaneous tracheostomy (PDT) has been widely employed as the primary method for performing tracheostomy in intensive care units. However, the ideal technique and timing for this procedure is still controversial. OBJECTIVES: To characterize the patients who underwent bedside percutaneous tracheostomy (PDT) in the Medical Intensive Care Unit (MICU) in terms of complications, clinical characteristics upon admission, short and long term outcome. METHODS: This retrospective cohort study included all patients hospitalized at the MICU from January 2003 to December 2007 who underwent bedside PDT. The patients' demographic data, past diagnosis, reason for admission to the ICU and a wide variety of data regarding procedure performance and complications were retrieved from the patients' charts. The information was subsequently computerized and analyzed. RESULTS: The study population included 126 patients who underwent bedside PDT. Overall, 63.5% were men and the average age was 59.8 years. Patients who survived for 30 days after the procedure had a lower burden of background morbidity as reflected by their Charlson score. The one year mortality rate was 56.6%, of which 70% of the patients died in the first month following the procedure. Overall complication rate was low and occurred in 9 patients (7.1%). There was no procedure-related mortality. The most common pathogens isolated from patients' sputum were Acinetobacter spp. and Pseudomonas aeruginosa. The survival rate was highest among the group of patients who underwent tracheostomy during the first 10 days after initiation of mechanical ventilation. CONCLUSIONS: Bedside PDT is a simple, safe and readily available procedure with low morbidity rates when performed by an experienced operator. However, long term outcome remains poor Survival rates were lower among patients who underwent the procedure within ten days of mechanical ventilation.

Development of a Solid-phase microextraction (SPME) Fiber protector and its application in flammable liquid residues analysis.

Solid-phase microextraction (SPME) has been established as a very powerful alternative to traditional extraction methods since its introduction in the early 1990s. The heart of the SPME device is an expensive thin and very delicate fused-silica fiber, coated with a thin polymer film. When extracted, the fiber may bend and break. Due to the fragility of the SPME fiber, a fiber protector device is proposed. The protector is easily assembled on the SPME device and can easily be removed by unscrewing for sampling to the injector. The SPME with the fiber protector was tested by headspace-SPME (HS-SPME) gasoline and diesel fuel vapor analyses. The results of the extractions with the SPME protector were compared with the results of the extractions by SPME without the protector. An enhancement to the lighter hydrocarbons was observed in the results with the protector but the method sensitivity was not altered. The SPME protector was easily cleaned from contaminant residues by ethyl acetate washings. The protector can be used for years and the fibers remain intact for hundreds of samplings.

An analytical method to identify traces of white phosphorus on burned victim clothes.

We report for the first time, the chemical identification of phosphorus on the remains of burned clothes taken from an injured woman. The woman was accidentally burned as a result of spontaneous combustion of a "stone" pebble-like material her daughter picked up innocently on a beach. The remains of the woman's clothes were analyzed by gas chromatograph mass spectrometer (GCMS) after headspace adsorption using solid phase microextraction (SPME). The results of this test showed that the injuries were due to phosphorus, leading to the understanding that the "stone" was actually white phosphorus. This method can help both forensic investigators in a crime scene investigation and physicians that need this information in order to give the correct treatment to their patient.

Cerebellar involvement in Langerhans' cell histiocytosis: a progressive neuropsychiatric disease.

We describe a 21-year-old patient who was being followed since the age of 3(1/2) years for Langerhans' cell histiocytosis. Although previously a bright and gifted student, the patient presented at age 16(1/2) with new-onset cerebellar neurologic signs, obsessive-compulsive disorder, and dementia. Findings on magnetic resonance imaging study of the brain were normal, but brain single photon emission computed tomography with technetium 99m ethylene cysteinate dimer showed markedly decreased cerebellar perfusion. This case is unique for the wide extent of the central nervous system involvement in Langerhans' cell histiocytosis, which has not been reported previously. Although obsessive-compulsive disorder has also been associated with several other cerebellar disorders, it is still unknown whether the cerebellum plays a role in its development. We suggest that in some cases, brain single photon emission computed tomography may be superior to magnetic resonance imaging for demonstrating cerebellar disorder in Langerhans' cell histiocytosis.

Identification of firearms holders by the [Fe(PDT)3](+2) complex. Quantitative determination of iron transfer to the hand and its dependence on palmar moisture levels.

Quantitative data are reported for the first time on the amounts of iron, which are transferred to the hand upon holding a firearm. Iron levels between 21-315 ng/cm2 were found on volunteers' palms after a single holding of a handgun. Determination of the iron traces was accomplished spectrophotometrically using 3-(2-pyridyl)-5,6-diphenyl-1,2,4-triazine (PDT) as a complexing agent. The transfer of iron from firearms to the palm was found to be, by and large a chemical (dissolution) rather than mechanical dislodgement. The prime factor that determines the amount of iron transferred from the firearm to the hand is the moisture level on the palm. These findings are likely to be of importance in courts of law, as well as in the war against terrorism and serious crime.

Delayed growth and puberty in patients with Gaucher disease type 1: natural history and effect of splenectomy and/or enzyme replacement therapy.

BACKGROUND: Growth retardation in childhood was only recently recognized as a prominent feature of Gaucher disease type 1, but there are few data on both the pubertal development and the final outcome of growth and sexual maturation. OBJECTIVE: To investigate the natural pattern of growth and puberty in patients with Gaucher disease type 1 and the effect of splenectomy and enzyme replacement therapy. METHODS: We retrospectively analyzed growth and puberty in 57 patients with Gaucher disease type 1; 52 were followed since childhood and/or prepuberty and 42 have reached sexual maturity and final height. In the analysis we considered severity of disease, time of splenectomy, and start of enzyme replacement therapy. RESULTS: Deceleration of growth at age 3-5 years was observed in 30 of 57 patients followed since early childhood while untreated: height-SDS decreased from -0.34 +/- 0.42 at age 0-3 years to -1.93 +/- 0.95 (P < 0.01) at age 7-10 years and was more pronounced with severe disease. A high prevalence (59.6%) of delayed puberty, which was more frequent with severe disease, was observed in 47 patients followed before and throughout puberty. No primary endocrine pathology was found. All patients, untreated as well as treated, with growth and pubertal delay had a spontaneous catch-up, achieved full sexual maturation, and most (83.3%) reached a final height within the range of parental height-standard deviation score. Splenectomy (partial and/or total) performed in 20 patients while still growing had a beneficial effect on growth, which was temporary in some and did not affect puberty. ERT improved growth in 11 patients who started therapy before puberty, as evidenced by a progressive increase in the height-SDS, and seemed to normalize the onset of puberty. CONCLUSIONS: Growth retardation in childhood and delay of puberty are characteristic of Gaucher disease type 1 and are more frequent with severe disease. There is a spontaneous catch-up later in life and most patients reach a final height within their genetic growth potential. Enzyme replacement therapy apparently normalizes growth and possibly also the onset of puberty.

Microbial and chemical characterization of underwater fresh water springs in the Dead Sea.

Due to its extreme salinity and high Mg concentration the Dead Sea is characterized by a very low density of cells most of which are Archaea. We discovered several underwater fresh to brackish water springs in the Dead Sea harboring dense microbial communities. We provide the first characterization of these communities, discuss their possible origin, hydrochemical environment, energetic resources and the putative biogeochemical pathways they are mediating. Pyrosequencing of the 16S rRNA gene and community fingerprinting methods showed that the spring community originates from the Dead Sea sediments and not from the aquifer. Furthermore, it suggested that there is a dense Archaeal community in the shoreline pore water of the lake. Sequences of bacterial sulfate reducers, nitrifiers iron oxidizers and iron reducers were identified as well. Analysis of white and green biofilms suggested that sulfide oxidation through chemolitotrophy and phototrophy is highly significant. Hyperspectral analysis showed a tight association between abundant green sulfur bacteria and cyanobacteria in the green biofilms. Together, our findings show that the Dead Sea floor harbors diverse microbial communities, part of which is not known from other hypersaline environments. Analysis of the water's chemistry shows evidence of microbial activity along the path and suggests that the springs supply nitrogen, phosphorus and organic matter to the microbial communities in the Dead Sea. The underwater springs are a newly recognized water source for the Dead Sea. Their input of microorganisms and nutrients needs to be considered in the assessment of possible impact of dilution events of the lake surface waters, such as those that will occur in the future due to the intended establishment of the Red Sea-Dead Sea water conduit.

Major upper extremity replantations.

The usual mechanism of a major amputation creates a mutilating injury. Although survival rate is high, the functional results are guarded [1, 2]. The aim of this study is to review our experience with major upper extremity replantations performed between the years 1987-2007 with respect to the type of amputation as proposed by Chuang et al. [3]. 23 upper extremities were replanted in 22 patients (7 arms and 16 proximal forearms and elbows). All but one replanted parts survived. Out of 6 patients with arm replants 4 gained useful extremities and two had poor result after more than 2 years of rehabilitation and 17 additional surgical procedures. Out of 16 replanted forearms, after more than 2 years of rehabilitation period and 50 operations, useful extremity was achieved in 11 and poor result in 5. The main factor influencing functional result was the type of amputation according to Chuang et al. [3].

Identification of firearms handling by the [Fe(PDT)(3)](2+) complex: Chemical and time-dependent factors.

Handling of a gun results in the formation of invisible impressions, caused by transfer of iron traces to the skin surface. Visualization of these impressions is possible by spraying the palms with a solution of 3-(2-pyridyl)-5,6-diphenyl-1,2,4-triazine (PDT), which forms a magenta complex with iron(II) residues. Hence, mark intensity is directly related to the amounts of iron transferred to the palm. Palmar sweat plays a major role in iron transfer from the firearm to the hand. More factors, however, are involved in this process. Three time-dependent factors have been studied with relation to their effect on the developed mark: the gripping duration of the weapon; the time elapsed from the contact; and the rate of iron dissolution in aqueous solutions containing sweat components in physiological concentrations. We found that the amounts of iron transferred to the palm depend on both, the gripping period and the levels of palmar moisture. Thus, only a few seconds of gripping were required for developing good marks (corresponding to 80ngcm(-2) of iron) on highly-moistured hands, much longer gripping periods were necessary for developing marks of similar intensity on relatively dry hands. Experiments that aimed at studying the effect of sweat components on metallic iron dissolution were carried out in aqueous solutions. It was found that chloride ions in physiological concentrations remarkably enhanced the dissolution, while l-serine, the major amino acid in palmar sweat, had a detrimental effect on this process. Urea, another sweat component, had only a minor effect on the dissolution rate.

Median sternotomy wound complication: the effect of reconstruction on lung function.

The objective of the study was to evaluate the lung function of patients with median sternotomy wound complication during the early postmedian sternotomy period and to compare the long-term pulmonary effects of reconstruction using pectoralis major and rectus abdominis muscle flaps. The percentage of predicted, standardized forced vital capacity (FVC); the standardized forced expiratory volume in 1 second (FEV1), and FEV1/FVC ratios of 45 patients with a median sternotomy wound complication were evaluated before and at a mean time of 10.6 months after wound reconstruction. Both mean FVC and FEV1 increased after wound revision compared with the prereconstruction results (8.4% and 9.2% increase, respectively). Patients with painful chest wall movement had the worst (60%) mean FVC and FEV1 before reconstruction when compared with a nonpainful complication. Reconstruction with a muscle flap was followed by an increase of 8.6% and 7.3% in FEV1 and FVC, respectively, from prereconstruction results. However, long-term results indicate that these patients have a mild, restrictive impairment of their lung function tests (LFTs), with about 80% of the predicted FVC and FEV1. Among the muscle flaps, the best improvement and best long-term LFT results were after sternectomy and reconstruction with a pectoralis major muscle flap as compared with a rectus abdominis muscle flap. Sternectomy and reconstruction with a muscle flap is a well-tolerated procedure associated with improvement of lung function compared with prereconstruction values. A pectoralis major muscle flap should be the first choice for muscle flap reconstruction while a rectus abdominis muscle flap should be reserved only for patients with good LFTs before reconstruction.

Dactinomycin potentiation of radiation pneumonitis: a forgotten interaction.

No mention of dactinomycin potentiation of pulmonary radiation was found in a review of the literature of the past 12 years. Before that, this complication was well described and investigators had calculated that dactinomycin increased the toxic effect of lung radiation by a factor of 1.3 and reduced the radiation tolerance of the lung by at least 20%. An example of such a toxic effect is described in the treatment of a 7-year-old girl with lung metastases from Ewing's sarcoma. The chemotherapy protocol followed contained cyclophosphamide, vincristine, dactinomycin, adriamycin, cisplatinum, VP16, and radiotherapy. The treatment was associated with fatal pulmonary fibrosis following the reintroduction of dactinomycin after radiotherapy. Our experience suggests that there is clinical significance to this complication in sarcoma therapy when dactinomycin-containing protocols are used with radiation in the treatment of pulmonary metastases.

Oral ondansetron: an effective ambulatory complement to intravenous ondansetron in the control of chemotherapy-induced nausea and vomiting in children.

One hundred children with non-central nervous system malignancies received ondansetron at initiation of chemotherapy and every 8 hours for 5 days after cisplatin-containing therapy and for 3 days after other chemotherapy. Ondansetron was administered orally except with the intravenous chemotherapy. For the chemotherapy days, 72 of 93 children (76%) had complete or major control of vomiting on their worst day, 25% with cisplatin-containing protocols, 60% with ifosfamide-containing protocols, and 82% with other protocols. For the overall period, 71 of 93 children (76%) reported complete or major control of vomiting on the worst day, 14% with cisplatin, 60% with ifosfamide, and 83% with other chemotherapy. All had mild or no nausea. Of the 355 chemotherapy days, 228 children (64%) were emesis free, 40% with cisplatin, 60% with ifosfamide, and 68% with other regimens. Of the overall period (541 days), 393 days were emesis free, 45% with cisplatin, 71% with ifosfamide, and 86% with other regimes. Sixty-nine patients were not hospitalized, and oral ondansetron was given when chemotherapy was completed. Of the 241 ambulatory chemotherapy days, 178 (74%) were emesis free. No significant toxicity was encountered. Oral ondansetron reduced hospitalization without reducing antiemetic efficiency in children.

Biologic and cytogenetic characteristics of leukemia in infants.

Clinical features, leukemic cell characterization, chromosomal findings, and treatment outcome were analyzed in a retrospective study of 30 cases with acute leukemia of infancy, 24 infants with acute lymphoblastic leukemia (ALL), and six cases with acute nonlymphoblastic leukemia (ANLL). Extensive bulky disease with organomegaly, central nervous system (CNS), and skin involvement were prominent features at diagnosis with a higher frequency in ANLL as compared to ALL. Four of six ANLL patients were classified as monocytic or myelomonocytic. In the ALL group nine of 24 (36%) were non-L1 morphology and six of 17 (33%) were common ALL antigen (CALLA) negative, the majority of them (five of six) were included in the non-L1 group. Immunophenotyping revealed four cases with early B-cell (three patients: Ia+B4+, and one patient: Ia+) and two cases with T-cell. Mixed lineage leukemia was found in five infants. Heavy chain immunoglobulin gene rearrangement was present in six cases tested, two CALLA+, two with Ia+B4+, and two were undifferentiated mixed lineage leukemia. Chromosomal aberrations were detected in ten of 18 patients, mostly in ANLL and CALLA negative ALL. Translocations were detected in six patients, involving 4q21-23 and 11q23 in three and two cases, respectively. The probability of five-year DFS were 27% for the whole group. The worst prognosis was observed in infants younger than 6 months of age, in whom the leukemia cell characteristics was compatible with stem cell: ANLL, very early pre-B, or undifferentiated mixed type. The chromosomal aberrations found in all cases included translocation with the seemingly nonrandom breakpoints at 4q21 and 11q23, and breakpoints that corresponded to known fragile sites. This finding may be suggestive of an underlying genetic predisposition associated with the poor prognosis of leukemia of infancy.

Urinary diversion in children with pelvic tumors.

PURPOSE: The aim of this study was to investigate children presenting with malignant pelvic tumors obstructing the upper urinary tract. METHODS: Seventeen children with upper urinary tract obstruction by a malignant tumor were reviewed. A nephrostomy tube or Double J (DJ) stent was inserted into each obstructed urinary system and removed after tumor shrinkage and/or hydronephrosis regression. RESULTS: There were 9 boys and 8 girls in the study; the mean age and median follow-up were 5.7 years and 2.5 years, respectively. The most common obstructing tumor was rhabdomyosarcoma. Twelve children underwent diversion by nephrostomy tubes and 3 by DJ stents; 2 patients underwent resection of the tumors with ureteroureterostomy. Complications after the insertion of the stents included febrile urinary tract infections (UTI) or pyelonephritis in 4 of the children with DJ stents. In the nephrostomy group, febrile UTI developed in 3 and the tube fell out in 1, and was blocked in another. Of the 17 children, 9 have no evidence of disease, 2 are currently under treatment, and 6 died of cancer. CONCLUSIONS: The prognosis of children with malignant pelvic tumor obstructing the upper urinary system justifies urgent and optimal upper tract diversion, enabling chemotherapy to be started immediately.

Improved results in osteogenic sarcoma 1973-79 vs. 1980-86: analysis of results from a single center.

Analysis of treatment results in osteogenic sarcoma patients with classical limb primary tumors and without metastasis at diagnosis or major protocol violations showed improved prognosis with a minimum follow-up of over 5.5 years when divided by years of treatment for all event-free survivors. Twelve patients treated in 1980-86 had a 5-year disease-free survival of 67% and 9 treated in 1973-79 had a 5-year disease-free survival of 33% (P = 0.0368). The improvement appeared to reflect the increase in the intensity of the chemotherapy utilized. Definitive surgery, amputation or limb salvage did not affect the outcome. With these surgical approaches the disease-free survival was 67% and 60% respectively.

Central nervous system involvement in children with sarcoma.

OBJECTIVES: To summarize and analyze the experience in CNS involvement (CNSI) in children with sarcomas treated in the above-mentioned institutions. PATIENTS AND METHODS: From 1990 to 2001, all medical charts were retrospectively reviewed: 19 sarcoma patients (12 boys and 7 girls) were diagnosed with CNSI (4 osteogenic sarcomas, 11 Ewing sarcomas, 2 rhabdomyosarcomas, 1 alveolar soft part sarcoma and 1 mesenchymal chondrosarcoma). Mean age of all patients at the time of initial diagnosis was 14.9 years (range: 4-24 years), mean age at the time when CNSI was diagnosed was 16.9 years (range: 5.5-27 years). RESULTS: The frequency of CNSI among our patients was 6.17%. The following symptoms and signs (sometimes combined) presented: headache (10 patients), nausea and vomiting (6 patients), seizures (11 patients) and focal neurological signs (9 patients). The mean duration of time elapsed since diagnosis of CNSI till death or last follow-up was 5.2 months (SD: +/-5.7 months). Four patients received chemotherapy (CT) alone, 8 CT and radiotherapy (RT), 2 RT alone, 3 supportive treatment only, 1 CT and surgery and 1 surgery alone. Sixteen patients died; there was no significant difference in the duration of survival between those who were treated with RT or surgery (mean +/- SD: 6.77 +/- 6.56 months) and those who received only CT or supportive treatment (mean +/- SD: 2.60 +/- 2.94 months) (p = 0.07). Brain disease was the main cause of death in all but 1 patient who died 4 days after autologous bone marrow transplantation from uncontrolled sepsis. In 16 patients, CNSI was part of a metastatic disease. CONCLUSIONS: Among children with sarcoma, CNSI is encountered in 6.17% of cases. More effective therapy has to be developed in order to improve their outcome.