All that glitters is not gold: Mercury poisoning in a family mimicking an infectious illness.

Three siblings with inhalational elemental mercury toxicity presented with fever, rash, and upper respiratory tract symptoms. The patients were heavily exposed to elemental mercury that was spilled in their home and then vacuumed. Initial whole blood mercury levels were elevated at >200 µg/L, 153 µg/L and 130 µg/L (Mayo Clinic Laboratories lab reference range <9 µg/L) for Cases 1, 2, and 3, respectively. All three required chelation with succimer. Clinically significant elemental mercury toxicity can resemble an infectious illness. Severe morbidity and mortality can be prevented if heavy metal poisoning is considered early, through a detailed history including an environmental exposure history. For elemental mercury spills in the home, safe and effective clean-up steps are needed. Improved public health education is needed to prevent similar household exposures.

Bag Valve Mask Ventilation as a Perceptual-Cognitive Skill.

Objective This study used a high-fidelity infant mannequin to examine the relationship between the quality of bag valve mask ventilation (BVMV) and how providers of varying levels of experience use visual feedback (e.g., electronic vital signs) to guide their performance. Background BVMV is a common and critical procedure for managing pediatric respiratory emergencies. However, providers do not consistently deliver effective BVMV. Efforts to improve BVMV have ignored the question of how providers effectively use feedback often available during BVMV. Method Six expert and six novice respiratory therapists completed two simulations of an infant requiring BVMV. In one, the technology failed to display SpO2, an important but somewhat redundant visual cue. Eye movements, verbal reports, and ventilation rate (in breaths per minute) were measured in each simulation. Results Regardless of SpO2 availability, eye movements and verbal reports suggested that novices depended strongly on electronic vital signs and when SpO2 was absent ventilated at a faster rate (exceeding the recommended range of ventilation rates) than when SpO2 was present. Experts' ventilation rates were comparable and within the recommended range in both conditions. When SpO2 was absent, experts emphasized information from direct observation of the patient that novices neglected. Conclusion Individual differences in the use of feedback during BVMV contribute to the quality of BVMV. This work bears on the theoretical discussions involving the use of automation and nontechnological cues to guide performance. Application These results have the potential to expand the current understanding of factors underlying effective BVMV with implications for training novice providers.

Airway and vascular maturation stimulated by tracheal occlusion do not correlate in the rabbit model of diaphragmatic hernia.

BACKGROUND: In animal models of congenital diaphragmatic hernia (CDH), tracheal occlusion (TO) has induced maturation of both airway spaces and vascular structures. Airway and vascular response to TO are assumed to occur in parallel. This study aims to describe and measure the relationship between airway and vascular maturation induced by TO. METHODS: A rabbit model of CDH on gestational day (GD) 23 and TO on GD 28 (term = GD 31) has been used. Two study groups have been defined: DH (diaphragmatic hernia) and TO (DH treated with TO). Animals were collected on GD 30 and blood flow data of the pulmonary artery (pulsatility index (PI) and fractional moving blood volume) were ultrasonographically measured. Lung morphometry consisted of measurements of radial alveolar count (RAC) and arterial muscular thickness. RESULTS: Animals in the DH group (n = 9) had the worst hemodynamic parameters; their lungs were hypoplastic and had the thickest arterial muscular layer. Animals in the TO group (n = 10) had all these effects reversed. There were no correlations among hemodynamic, airway, and vascular parameters, except for RAC and PI (r = -0.528, P = 0.043). CONCLUSION: Airway and vascular maturation after TO appear to be uncorrelated effects. TO could trigger several pathways that separately regulate airway and vascular responses.

[Cancer in children from Chiapas state]. / Cáncer en niños residentes del estado de Chiapas.

In Chiapas, a total of 209 new cases of childhood cancers were registered between 1996 and 2007. Of these cases, 60.3% were composed of leukemias (32.1%), central nervous system tumors (CNST, 18.2%), and lymphomas (10.0%). Chiapas had the highest frequency of retinoblastoma (Rb, 9.6%). Not only did Chiapas have the highest incidence of childhood cancers overall (174.2) (all rates per 1000 000 children/year), but also the highest incidences of CNST, Rb, germ cell tumors, and carcinomas (32.5, 21.4, 10.9, and 4.2, respectively). By age, the highest incidence was found for those less than five years of age. The male/female ratio was 1.1. The incidence showed a trends to decrease (average annual percent change -9.8; CI 95% -13.6, -5.8). Of children with solid tumors, 58.7 % had been diagnosed with either stage III or IV.

[Incidence and trends of neuroblastoma in Mexican children attending at Instituto Mexicano del Seguro Social]. / Incidencia y tendencia del neuroblastoma en niños derechohabientes del IMSS.

BACKGROUND: Neuroblastoma (NB) is the principal tumor of the sympathetic nervous system in children. OBJECTIVE: to describe the epidemiological and clinical characteristics of Mexican children with NB. METHODS: A population-based, prolective study, with data obtained from the Childhood Cancer Registry of the Instituto Mexicano del Seguro Social. The frequencies and incidence of the variables of the study were obtained by age and sex. The trend was calculated with the annual percentage of change. RESULTS: Of a total of 2758 children with cancer, 72 (2.6%) were identified in the Group IV, according to the International Classification of Childhood Cancer. The average incidence for NB was 3.8, the highest incidence was found in Guerrero. NB was highest in the group under one year of age (18.5). The male/female ratio was 1.1 and there was no trend toward an increase. Stages III and IV were presented in 88% of the cases. There was no association between the stages, the age at the TD, or the histological pattern. CONCLUSIONS: It is possible that the low incidence of NB in Mexican children is due to the difficulty in early diagnosis due the majority of the cases was diagnosed in the advanced stages.

Epidemiological and some clinical characteristics of neuroblastoma in Mexican children (1996-2005).

BACKGROUND: Neuroblastoma (NB) is the principal tumor of the sympathetic nervous system in children under one year of age. The incidence in developed countries is greater than that in developing countries. The aim of this article is to present the epidemiological and some clinical characteristics of Mexican children with NB. METHODS: A population-based, prolective study, with data obtained from the Childhood Cancer Registry of the Instituto Mexicano de Seguro Social. STATISTICAL ANALYSIS: The simple frequencies of the variables of the study and the annual average incidence (per 1,000,000 children/years) by age and sex were obtained. The trend was evaluated by calculating the annual percentage of change. The curves of Kaplan-Meyer were employed for the survival rate and the log-rank test was used to compare the curves. RESULTS: Of a total of 2,758 children with cancer registered during the period from 1996-2005, 72 (2.6%) were identified as having Group IV, defined according to the International Classification of Childhood Cancer. The incidence for NB was 3.8 per 1,000,000 children/year; NB was highest in the group of children under one year of age, followed by the group of children between the ages 1-4 years (18.5 and 5.4 per 1,000,000 children/years, respectively). The male/female ratio was 1.1 and there was no trend toward an increase. The time of diagnosis was 26 days (median), but varied according to the stage at diagnosis. Stages III and IV were presented in 88% of the cases. There was no association between the stage, the age at time of diagnosis, or the histological pattern. The overall five-year survival rate was 64%; the patients with stage I, II, III, or IVs did not die; and the five-year survival rate of cases in Stage IV was 40%. CONCLUSION: It is possible that the low incidence of neuroblastoma in Mexican children is due to the difficulty in diagnosing the cases with the best prognosis, some of which could have had spontaneous regression. There was no trend to an increase; the majority of the cases were diagnosed in the advanced stages; and the overall five-years survival rate was similar to that for developed countries.

[Cancer epidemiology in adolescents of 15 and 16-year-old]. / Epidemiología del cáncer en adolescentes de 15 y 16 años.

OBJECTIVE: to present the frequency of different types of cancer in adolescents with 15 and 16-year-old treated at the Instituto Mexicano del Seguro Social (IMSS) in Mexico City (MC) hospitals. METHODS: it was an observational and prolective study. During January 1 of 1996 to December 31 of 2005, were analyzed new cases of adolescents of 15 and 16-year-old with malignant neoplasms in adolescents at IMSS. The neo-plasms were grouped according with the International Classification of Childhood Cancer; they were stratified by age, sex, and place of residence, and the frequency of these variables were obtained. RESULTS: a total of 207 cases were registered. Leukemias were more frequent with 55 cases (26.6%); the second place was for bone tumors with 36 cases (17.4%) and the third place were lymphomas with 32 cases (15.5%). There were not cases of retinoblastoma and renal tumors; only 8 cases of carcinomas (3.9%) were registered. The greatest frequency was observed in males with 116 cases (56.0%), with male/female ratio of 1.3:1. Mexico City and State of Mexico were more frequent places of residence with 70.5% of cases. Near of forty nine percent of cases (48.8%) with solid tumors were diagnosed in III or IV stages. CONCLUSIONS: the pattern of cancer was different from older adolescents (15 to 19-year-old), it is necessary to conduct studies of survey in order to determine epidemiology of cancer in the Mexican adolescents.

Incidence of cancer in children residing in ten jurisdictions of the Mexican Republic: importance of the Cancer registry (a population-based study).

BACKGROUND: In 1996, Mexico started to register cases of childhood cancer. Here, we describe the incidence of cancer in children, residing in ten Mexican jurisdictions, who were treated by the Instituto Mexicano del Seguro Social (IMSS). METHODS: New cases of childhood cancer, which were registered prospectively in nine principal Medical Centers of IMSS during the periods 1998-2000 (five jurisdictions) and 1996-2002 (five jurisdictions), were analyzed. Personnel were specifically trained to register, capture, and encode information. For each of these jurisdictions, the frequency, average annual age-standardized incidence (AAS) and average annual incidence per period by sex and, age, were calculated (rates per 1,000,000 children/years). RESULTS: In total 2,615 new cases of cancer were registered, with the male/female ratio generally >1, but in some tumors there were more cases in females (retinoblastoma, germ cells tumors). The principal groups of neoplasms in seven jurisdictions were leukemias, central nervous system tumors (CNS tumors), and lymphomas, and the combined frequency for these three groups was 62.6 to 77.2%. Most frequently found (five jurisdictions) was the North American-European pattern (leukemias-CNS tumors-lymphomas). Eight jurisdictions had AAS within the range reported in the world literature. The highest incidence was found for children underless than five year of age. In eight jurisdictions, leukemia had high incidence (>50). The AAS of lymphomas was between 1.9 to 28.6. Chiapas and Guerrero had the highest AAS of CNS tumors (31.9 and 30.3, respectively). The frequency and incidence of neuroblastoma was low. Chiapas had the highest incidence of retinoblastoma (21.8). Germ-cell tumors had high incidence. CONCLUSION: The North American-European pattern of cancers was the principal one found; the overall incidence was within the range reported worldwide. In general but particularly in two jurisdictions (Yucatán and Chiapas), it will be necessary to carry out studies concerning the causes of cancer in children. Due to the little that is known about the incidence of cancer in Mexican children, it will be necessary to develop a national program to establish a cancer registry for the whole of the country.

[General and specific incidence of cancer among children affiliated to the Mexican Institute of Social Security]. / Incidencia general y específica de cáncer en niños derechohabientes del IMSS.

OBJECTIVE: To determine the epidemiology of cancer among children from eleven Mexican states affiliated to Mexican Social Security Institute (Instituto Mexicano del Seguro Social, IMSS). METHODS: 2663 Cases of children with cancer were prospectively registered between 1996 and 2002 in the main IMSS medical centers. The cases were classified according to the International Classification for Childhood Cancer. The general and specific cancer incidences (rate per million children/year, age standardized) were obtained. RESULTS: The principal groups of cancer in nine states were leukemias, lymphomas and central nervous system tumors (CNST). In eight states, the incidence was similar than reported worldwide (100 to 180); Chiapas had the highest incidence (203.5). Leukemias had higher incidence in seven States (>50). The highest incidences of CNST were observed in Chiapas and Guerrero (31.9 and 30.3); The incidence of neuroblastoma was low. Chiapas showed the highest incidence of retinoblastoma, bone tumors and carcinomas (21.8, 12.2 and 5.9 respectively); Puebla had the highest incidence of liver tumors (11.3) in which stages III and IV were the most frequent (67.8 %). CONCLUSIONS: The main groups of cancer in Mexican children were leukemias, CNST, and lymphomas. Some states had high incidence; more than 50 % of children with solid tumors were diagnosed in advanced stages.

Spontaneous breathing trial predicts successful extubation in infants and children.

OBJECTIVE: To assess the value of a spontaneous breathing trial (SBT) using a flow-inflating bag in predicting extubation success. Secondary goals were to evaluate the positive and negative predictive accuracy of a 15-min SBT. DESIGN: Prospective, blinded, clinical study. SETTING: Pediatric intensive care unit (ICU) of a university hospital PATIENTS: Infants and children intubated for >or=24 hrs. INTERVENTIONS: Patients who met defined criteria for extubation underwent a 15-min SBT connected to a flow-inflating bag set to provide 5 cm H2O continuous positive airway pressure. MEASUREMENTS AND MAIN RESULTS: Seventy patients underwent the SBT. Respiratory rate, heart rate, blood pressure, and pulse oxygen saturations were recorded at baseline and at 5 and 15 mins into the SBT. The ICU physicians were blinded to the results of the SBT, and all patients were extubated at the end of the trial. Patients were observed for the next 24 hrs, and the need for noninvasive ventilation or reintubation (i.e., extubation failure) was recorded.Sixty-four patients (91%) passed the SBT with a subsequent extubation failure rate of 7.8% (only 1.6% required reintubation). Six of the 70 (9%) patients enrolled failed the trial, but half were extubated successfully. Successful completion of the SBT has a 95% sensitivity for predicting successful extubation with a positive predictive value of 92% and an odds ratio of 12 (95% confidence interval, 1.3, 53.7). The specificity of the SBT was 37% with a negative predictive value of 50%. Logistic regression analysis revealed a significant association between passing the SBT and extubation success (p = .017). CONCLUSIONS: A 15-min flow-inflating bag SBT represents a practical, reliable bedside test that has 95% sensitivity for predicting extubation success in pediatric ICU patients. A trial failure is associated with but does not accurately predict extubation failure.

Intratracheal pressure: a more accurate reflection of pulmonary airway pressure in pediatric patients with respiratory failure.

OBJECTIVES: Peak inflation pressure (PIP) on many ventilators (P(vent)), measured distal to the exhalation limb or Y-piece of the breathing circuit, is assumed as the pressure applied to the airways and lungs. However, in vitro studies show P(vent) data are spurious. There are no studies evaluating the accuracy of P(vent) data for pediatric patients with acute respiratory failure. We hypothesized that intratracheal airway pressure (P(T)) is more accurate than P(vent) and that by using P(vent), abnormally increased imposed resistive work of breathing (WOBi) may go undetected. DESIGN: Prospective and descriptive study. SETTING: A pediatric intensive care unit at a university hospital. PATIENTS: Twenty-one pediatric patients with respiratory failure requiring mechanical ventilation. INTERVENTIONS: All patients were intubated with a commercially available endotracheal tube (ETT) with a pressure measuring the lumen opening at the distal end used for measuring P(T). Pressure/flow sensors positioned between the ETT and Y-piece measured tidal volume (V(T)) and flow rate. P(vent) data were recorded as displayed on the ventilator. WOBi was measured by integrating P(T) and V(T) data. RESULTS: PIP at P(vent) and P(T) were 26 +/- 8 cm H(2)O and 19 +/- 7 cm H(2)O, respectively (p < .05). P(T) measurements averaged 27% less than P(vent). The relationship between P(vent)-P(T) (pressure drop across the breathing circuit and ETT) and flow rate during spontaneous inhalation was highly correlated (r = .80, p < .002), indicating the greater the flow rate, the greater the pressure drop and WOBi. WOBi, ranging from 0.04-1.5 J/L, was measured in 52% of the patients. CONCLUSIONS: P(vent) significantly overestimates PIP. Moreover, P(vent) data does not allow for recognition of increased WOBi for many patients. Clinicians need to be aware of the limitations of P(vent) data and consider using ETTs that allow measurement of P(T), a more accurate reflection of pulmonary airway pressure.