General pediatric emergencies. Acute pulmonary edema.

This article focuses on three types of acute pulmonary edema in children: negative-pressure pulmonary edema, neurogenic pulmonary edema, and cardiogenic pulmonary edema.

Intramuscular rapacuronium in infants and children: a comparative multicenter study to confirm the efficacy and safety of the age-related tracheal intubating doses of intramuscular rapacuronium (ORG 9487) in two groups of pediatric subjects.

BACKGROUND: This multicenter, assessor, blinded, randomized study was conducted to confirm and extend a pilot study in which intramuscular rapacuronium was given to infants and children to confirm efficacy and to evaluate tracheal intubating conditions. METHODS: Ninety-six pediatric patients were studied in two groups: infants aged 1 to 12 months (n = 46) and children aged 1 to 3 yr (n = 50). Infants received 2.8 mg/kg and children 4.8 mg/kg of intramuscular rapacuronium during 1 minimum alveolar concentration halothane anesthesia. These two groups were studied in three subgroups, depending on the time (1.5, 3, or 4 min) at which tracheal intubation was attempted after the administration of intramuscular rapacuronium into the deltoid muscle. Neuromuscular data collected included onset time, duration of action, and recovery data during train-of-four stimulation at 0.1 Hz. Data were analyzed by the Cochran-Mantel-Haenszel procedure. RESULTS: The tracheal intubating conditions were deemed acceptable in 17, 36, and 64% of infants and 20, 47, and 71% of children at 1.5, 3, or 4 min, respectively. The mean values for % of control twitch height (T1) 2 min after rapacuronium in both groups were similar. The mean (SD) time required to achieve more than or equal to 95% twitch depression in infants was 6.0 (3.7) versus 5.5 (3.8) min in children. CONCLUSIONS: Only 27% of patients achieved clinically acceptable tracheal intubating conditions at 1.5 or 3 min after administration of 2.8 mg/kg and 4.8 mg/kg rapacuronium during 1 minimum alveolar concentration halothane anesthesia. Tracheal intubation conditions at 4 min were acceptable in 69% of subjects. The duration of action of 4.8 mg/kg of rapacuronium in children was longer than 2.8 mg/kg of rapacuronium in infants.

Intramuscular rocuronium in infants and children: a multicenter study to evaluate tracheal intubating conditions, onset, and duration of action.

BACKGROUND: This multicenter, assessor-blinded, randomized study was done to confirm and extend a pilot study showing that intramuscular rocuronium can provide adequate tracheal intubating conditions in infants (2.5 min) and children (3 min) during halothane anesthesia. METHODS: Thirty-eight infants (age range, 3-12 months) and 38 children (age range, 1 to 5 yr) classified as American Society of Anesthesiologists physical status 1 and 2 were evaluated at four investigational sites. Anesthesia was maintained with halothane and oxygen (1% end-tidal concentration if <2.5 yr; 0.80% end-tidal concentration if >2.5 yr) for 5 min. One half of the patients received 0.45 mg/kg intravenous rocuronium. The others received 1 mg/kg (infants) or 1.8 mg/kg (children) of intramuscular rocuronium into the deltoid muscle. Intubating conditions and mechanomyographic responses to ulnar nerve stimulation were assessed. RESULTS: The conditions for tracheal intubation at 2.5 and 3 min in infants and children, respectively, were inadequate in a high percentage of patients in the intramuscular group. Nine of 16 infants and 10 of 17 children had adequate or better intubating conditions at 3.5 and 4 min, respectively, after intramuscular rocuronium. Better-than-adequate intubating conditions were achieved in 14 of 15 infants and 16 of 17 children given intravenous rocuronium. Intramuscular rocuronium provided > or =98% blockade in 7.4+/-3.4 min (in infants) and 8+/-6.3 min (in children). Twenty-five percent recovery occurred in 79+/-26 min (in infants) and in 86+/-22 min (in children). CONCLUSIONS: Intramuscular rocuronium, in the doses and conditions tested, does not consistently provide satisfactory tracheal intubating conditions in infants and children and is not an adequate alternative to intramuscular succinylcholine when rapid intubation is necessary.

Characteristics of bath-related burns in Japan.

A retrospective study of bath-related burn injuries was carried out at our institution. A total of 216 patients with burns were admitted between 1982 and 1996. Bath-related burns were identified in 58 patients (26.9%). The number of patients with bath-related burns increased throughout the study period. The percentage body surface area burned was 43.8 +/- 25.7% in the bath-related burn group and 27.3 +/- 28.3% in the bath-unrelated burn group. This difference was significant. There was no significant difference between the two groups with respect to mortality rate. The mechanism by which the patients sustained a bath-related burn clearly differed according to age. The percentage of burns which are bath-related and the severity of bath-related burns are higher in Japan than in any other country. This can be attributed to lifestyle, bathing systems, bathroom architecture, housing conditions and an increase in the elderly population. These burns can be prevented. Education based on this study will play a critical role in the prevention of the bath-related burn injuries.

Evaluation of a new operating room ventilator with volume-controlled ventilation: the Ohmeda 7900.

UNLABELLED: Changes in fresh gas flow (FGF) during volume-controlled ventilation with the circle system have clinically important effects on the ventilatory variables of children. Current operating room ventilators allow a portion of the FGF to be added to the delivered tidal volume. The Ohmeda 7900 (Madison, WI) ventilator was designed to compensate for changes in FGF. We compared this ventilator with a standard ventilator, the Ohmeda 7000. Twenty patients (13-56 kg) undergoing dental or lower extremity surgery were studied. A side-by-side comparison of the two ventilators was performed using each patient as his or her own control. Beginning with the 7900 ventilator, FGF was set at 3.0 L/min, and the inspiratory to expiratory ratio was set at 1:2. Respiratory rate and tidal volume were adjusted to achieve an ETCO2 of 30-40 mm Hg. After a 10-min period of stabilization, inspired minute ventilation (VI), expired minute ventilation (VE), and ETCO2 were measured. FGF was then increased to 6.0 L/min, and the measurements were repeated after 10 min; FGF was then decreased to 1.5 L/min, and measurements were repeated after 10 min. The patient was then ventilated with an Ohmeda 7000 ventilator, and the sequence was repeated. The Ohmeda 7000 ventilator demonstrated significant changes in VI, VE, plateau pressure, and ETCO2, with changes in FGF (P = 0.0039-0.0001). The Ohmeda 7900 ventilator demonstrated compensation for changes in FGF; there were no significant changes in VI, VE, and ETCO2. We conclude that the Ohmeda 7900 ventilator provides stable ventilatory variables regardless of alterations in FGF (1.5-6.0 L/min). IMPLICATIONS: In this study, we compared the effects of changing fresh gas flow on volume-controlled ventilation using two operating room ventilators (Ohmeda 7000 and Ohmeda 7900). The Ohmeda 7900, but not the Ohmeda 7000, provided stable ventilatory variables with fresh gas flows between 1.5 and 6.0 L/min.

Clinical characteristics of a newly developed ovarian tumour marker, galactosyltransferase associated with tumour (GAT).

In this study clinical studies were conducted on galactosyltransferase associated with tumour (GAT) as a newly developed marker of ovarian cancers. The positive rates of GAT with a cut-off value of 16 U/ml (which corresponds to the mean + 2 standard deviations (S.D.) for healthy females) were 4.7% for benign ovarian tumours, 4.5% for endometriosis and 45.9% for ovarian cancers. GAT showed a positive rate comparable to that of CA546 or CA72-4 among other tumour markers (CA602, CA125, CA546, CA72-4, STN and SLX) examined in ovarian cancers. However, it showed lower positive rates for benign ovarian diseases and, in particular, it gave the lowest positive rate for endometriosis among the aforementioned tumour markers. Furthermore, the receiver operating characteristic (ROC) analysis for discriminating between ovarian cancer and endometriosis showed a significantly high area under the curve (AUC) for GAT compared with that of the other markers. GAT showed the lowest correlation coefficients with other markers, and the positive rate and the diagnostic efficiency were increased by its combination assay with CA602 and/or CA546. Furthermore, the accuracy of the diagnosis of ovarian cancer improved by examining GAT after screening with CA602 or ultrasonography. These results suggest that GAT is a suitable marker for distinguishing ovarian cancers from benign gynaecological diseases, particularly endometriosis, and is useful for combination assay or secondary screening for ovarian cancers.

Efficacy of ketamine hydrochloride sedation in children for interventional radiologic procedures.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of ketamine hydrochloride sedation in children younger than 11 years old who underwent short interventional radiologic procedures. SUBJECTS AND METHODS: Two hundred eleven children, 3 days to 10 years old, were given Ketalar (ketamine hydrochloride; Parke-Davis, Morris Plains, NJ), either 2 mg/kg i.v. (114 patients) or 3 mg/kg intramuscularly (i.m.) (97 patients). Atropine sulfate (Fujisawa USA, Deerfield, IL) (0.01 mg/kg i.v. or 0.02 mg/kg i.m.) was added in all patients to control secretions. Patients were monitored with continuous pulse oximetry and with automatic blood pressure cuffs. Respiratory rate and heart rate were recorded every 5 min. Adequacy of sedation was graded by the radiologist. Induction time, procedure time, recovery time, and adverse effects were recorded. RESULTS: Sedation was considered excellent and the procedures were completed in 191 patients (91%). The sedation was considered light but the procedures were completed in the remaining 20 patients (9%). No sedation failures were observed. Average induction time was 45 sec for the i.v. procedure and 4 min for the i.m. procedure. Average recovery time was 18 min for the i.v. procedure and 25 min for the i.m. procedure. Average procedure time for both methods was 25 min. Hemoglobin saturation remained at or greater than 95% in 200 patients (94%). Transient desaturation below 95% occurred in 11 patients (5%). The airway was manipulated to improve ventilation (head, neck, and jaw lifts) and supplemental oxygen was given via nasal cannula or mask. The episodes lasted only a few seconds and oxygen saturation promptly returned to a level greater than 95%. A 7-week-old male infant who had been born prematurely at 32 weeks' gestation experienced apnea. Ventilation was assisted for several breaths and the patient promptly recovered. We observed only minor cardiovascular changes in all patients. CONCLUSION: Ketamine hydrochloride provides excellent sedation and analgesia in young children. The short induction time, rapid recovery, and minimal respiratory depression are features that make this sedative ideal for interventional radiology.

Traumatic laceration of the intracranial vertebral artery causing fatal subarachnoid hemorrhage: case report.

A 36-year-old man who had been drinking alcohol had a fatal subarachnoid hemorrhage immediately after suffering a moderate craniofacial injury. Autopsy revealed a 3-mm longitudinal laceration of the left intracranial vertebral artery proximal to the posterior inferior cerebellar artery. There was no finding of arterial dissection. We discuss the mechanisms of the traumatic laceration of the vertebral artery in relation to traumatic dissection of the vertebral artery.

[Long survival after removal of a huge brain tumor which had metastasized from a lung cancer: case report].

Patients with large metastatic brain tumors are considered to have poor prognosis. We report a case of a patient with more than 33 months survival after complete resection of a huge temporal tumor which had metastasized from a lung cancer. A 57-year-old woman presented left hemiparesis and disturbance of consciousness. Magnetic resonance images revealed a huge cystic mass lesion in the right temporal lobe. After a macroscopically complete excision of the tumor, she received radiation therapy (whole brain 50 Gray). She had received lung surgery for the primary lung cancer, 2 years prior to brain metastasis. Histological examination showed papillary tubular adenocarcinoma which was similar to the previously resected lung cancer. Thirty three months after the resection of the intracranial tumor, she has no neurological deficits and no signs of recurrence of either brain tumor or lung tumor. We discuss the size of metastatic brain tumor and the postoperative prognosis of patients with metastatic brain tumor.

Treatment of severe localized cerebral vasospasm following recurrent hemorrhage from middle cerebral artery aneurysm--case report.

A 52-year-old female presented with localized but severe cerebral vasospasm induced by recurrent aneurysmal subarachnoid hemorrhage. The middle cerebral artery (MCA) aneurysm was clipped and the subarachnoid hematoma evacuated 1 day after recurrent hemorrhage. The cerebral vasospasm, localized in a region near the MCA aneurysm, was reduced by papaverine and nicardipine vasodilating agents delivered via an Ommaya cerebrospinal fluid reservoir placed at craniotomy.

Mouse monoclonal antibodies which recognize a human (beta 1-4)galactosyl-transferase associated with tumor in body fluids.

Mouse monoclonal antibodies against human (beta 1-4)galactosyl-transferase (GalT) purified from human ovarian tumor effusion fluids were prepared and characterized. GalT purified from normal human plasma showed a single diffused band in nondenaturing polyacrylamide gel electrophoresis, but GalT purified from human ovarian tumor effusion fluids showed several oligomeric bands and a monomeric band in nondenaturing polyacrylamide gel electrophoresis. These oligomeric bands were dissociated into monomer by urea treatment and polymerized by a 2-mercaptoethanol treatment. Nine monoclonal antibodies (MAb) were prepared by immunization of purified GalT from human ovarian tumor effusion fluids and classified into three groups. Type I MAbs (MAb8611, MAb8913, and MAb8919) reacted only to the GalT monomer. Type II MAbs (MAb4880, MAb8507, and MAb8628) reacted to both the GalT monomer and the GalT polymer. Type III MAbs (MAb7907, MAb8513, and MAb8677) reacted only to the GalT polymer. These MAbs except MAb7907 could recover GalT enzyme activity from effusion fluids by immunoprecipitation. A fraction passed through MAb8513 affinity chromatography still showed reactivity to MAb8919, demonstrating that an epitope of MAb8513 resides on a minor part of GalT. A sandwich immunoassay (MAb8513-MAb8628HRP) was developed, and serum samples from ovarian cancer patients and benign ovarian patients were tested. The levels of sandwich immunoassay of serum samples from cancer were elevated significantly compared to those from benign and did not necessarily correlate to total GalT enzyme activity in serum samples. These results suggested that MAb8513 (Type III) might recognize a unique GalT associated with tumor (GAT).

Complementary DNA cloning for galactosyltransferase associated with tumor and determination of antigenic epitopes recognized by specific monoclonal antibodies.

The galactosyltransferase associated with tumor (GAT) was the name given to the isoenzyme that tends to polymerize resulting in slower moving in a nondenaturing polyacrylamide gel electrophoresis than normal (beta 1-4)galactosyltransferase (normal GalT). A complementary DNA (cDNA) library was constructed from a human ovarian cancer cell line, RMG-I, which secreted an amount of GAT into the culture supernatant and screened with monoclonal antibodies (MAbs) against GAT and normal GalT. One of six cDNA clones, UG86-1, encoded an epitope recognized by a GAT-specific MAb, 8513. Recombinant proteins expressed by UG86-1 in Escherichia coli also had antigenic epitopes recognized by the other MAbs against normal GalT. The 229-base pair nucleotide sequence encoded by UG86-1 was identical to the stem region sequence of HGT832 which encodes a full-length cDNA of human GalT. Using recombinant proteins directed by deletion mutant cDNAs, the antigenic epitopes recognized by each MAb were determined. The epitope of MAb8628, which reacts to both the GAT and normal GalT, was localized to the COOH-terminal side of proteolytic cleavage site where the membrane-bound form enzyme is cleaved to be converted to soluble forms, while MAb8513 epitope was at the NH2-terminal side from this cleavage site between the COOH-terminal end of the membrane-binding domain and the cleavage site. These results demonstrate that GAT is produced by aberrant proteolytic cleavage at the different site, closer to the membrane-binding domain, from the normal GalT.