Hyperlactatemia on ICU admission : Comparison between direct admissions and inpatient transfers.

BACKGROUND: Hyperlactatemia is associated with increased mortality. Possible differences between patients directly admitted via the emergency department to the intensive care unit (ICU) and inpatient transfers to the ICU have not yet been investigated. MATERIALS AND METHODS: In this retrospective analysis, characteristics and outcomes between critically ill medical inpatient transfers and direct admissions with hyperlactatemia on ICU admission, defined as a blood lactate >2 mmol/l, were compared. RESULTS: A total of 1042 patients were included, with 424 inpatient transfers and 618 direct admissions. The median age of inpatient transfers and direct admissions was 67.0 and 70.5 years, respectively (P = 0.03). The median APACHE II score was 25 for inpatient transfers and 23 for direct admissions (P = 0.01). The median blood lactate on ICU admission for inpatient transfers and direct admissions was similar (3.6 vs. 3.5 mmol/l). Sepsis was more common among inpatient transfers than direct admissions (53.5 vs. 31.6%, P = 0.001). The ICU (39.6 vs. 28.8%, P < 0.001), hospital (56.8 vs. 38.3%, P < 0.001) and 28-day mortality (46.5 vs. 35.4%, P < 0.001) was significantly higher for inpatient transfers than direct admissions. Among the sepsis cohort, inpatient transfer, APACHE II score and elevated blood lactate were independent predictors of ICU mortality. CONCLUSION: Among medical ICU patients with admission hyperlactatemia, the median blood lactate was not significantly different between direct admissions and inpatient referrals. Inpatients with sepsis may have been referred to the ICU late.

Single-stick tunneled central venous access using the jugular veins in infants weighing less than 5 kg.

BACKGROUND: Despite the demonstrated feasibility of the single-stick technique in the femoral vein, its use in neonates and infants for placing central lines in internal and external jugular veins has not been reported. OBJECTIVE: Describe and assess the safety and efficacy of tunneled jugular central venous catheter placement performed under ultrasound (US) and fluoroscopic guidance in neonates and infants weighing <5 kg using the single-stick technique at three tertiary pediatric hospitals. MATERIALS AND METHODS: Thirty-three children weighing less than 5 kg received tunneled central venous access in either internal or external jugular veins using the single-stick technique. Patient history, procedural records and clinical follow-up documents were retrospectively reviewed. Complication rates were compared to those of 41 patients receiving single-stick femoral central lines. RESULTS: Technical complications occurred during one (3.0%) jugular placement with the patient having a failed right-side attempt with subsequent successful left-side placement. The catheters did not last the entire course of treatment in three (9.1%) patients with jugular lines. One patient had the catheter removed due to concern for infection, one catheter was accidentally removed during dressing changes, and one catheter was displaced and subsequently exchanged. Of patients receiving femoral central lines, 1 (2.4%) had a technical complication and 5 catheters (12.2%) did not last the entire course of treatment. CONCLUSION: The placement of tunneled central venous catheters in neonates/infants <5 kg is safe and technically feasible using the internal/external jugular vein via the single-stick technique. By theoretically reducing the risks of catheter infection by avoiding the diaper area and thrombosis by using larger veins, it may be preferable in certain patient populations.

[Low level laser therapy : A narrative literature review on the efficacy in the treatment of rheumatic orthopaedic conditions]. / Low-Level-Lasertherapie : Eine narrative Literaturübersicht zur Wirksamkeit bei der Behandlung rheumatologisch-orthopädischer Krankheitsbilder.

BACKGROUND: In low level laser therapy (LLLT) low wattage lasers are used to irradiate the affected skin areas, joints, nerves, muscles and tendons without any sensation or thermal damage. Although the exact mechanism of its effect is still unknown, it seems beyond dispute that LLLT induces a variety of stimulating processes at the cellular level affecting cell repair mechanisms, the vascular system and lymphatic system. LLLT has been popular among orthopaedic practitioners for many years, whereas university medicine has remained rather sceptical about it. OBJECTIVES: Overview of studies on the efficacy of LLLT in the treatment of rheumatic orthopaedic conditions, i. e. muscle, tendon lesions and arthropathies. MATERIALS AND METHODS: Narrative literature review (PubMed, Web of Science). RESULTS: While earlier studies often failed to demonstrate the efficacy of LLLT, several recent studies of increasing quality proved the efficacy of LLLT in the treatment of multiple musculoskeletal pain syndromes like neck or lower back pain, tendinopathies (especially of the Achilles tendon) and epicondylolpathies, chronic inflammatory joint disorders like rheumatoid arthritis or chronic degenerative osteoarthritis of the large and small joints. In addition, there is recent evidence that LLLT can have a preventive capacity and can enhance muscle strength and accelerate muscle regeneration. CONCLUSION: LLLT shows potential as an effective, noninvasive, safe and cost-efficient means to treat and prevent a variety of acute and chronic musculoskeletal conditions. Further randomized controlled studies, however, are required to confirm this positive assessment.

X-ray absorption in pillar shaped transmission electron microscopy specimens.

The dependence of the X-ray absorption on the position in a pillar shaped transmission electron microscopy specimen is modeled for X-ray analysis with single and multiple detector configurations and for different pillar orientations relative to the detectors. Universal curves, applicable to any pillar diameter, are derived for the relative intensities between weak and medium or strongly absorbed X-ray emission. For the configuration as used in 360° X-ray tomography, the absorption correction for weak and medium absorbed X-rays is shown to be nearly constant along the pillar diameter. Absorption effects in pillars are about a factor 3 less important than in planar specimens with thickness equal to the pillar diameter. A practical approach for the absorption correction in pillar shaped samples is proposed and its limitations discussed. The modeled absorption dependences are verified experimentally for pillars with HfO2 and SiGe stacks.

Management of a Ventral Cerebrospinal Fluid Leak With a Lumbar Transforaminal Epidural Blood Patch in a Child With Persistent Postdural Puncture Headache: A Case Report.

OBJECTIVE: Postdural puncture headache (PDPH) is an uncommon sequel of lumbar puncture in children. When conservative treatment with bed rest, hydration, and caffeine are ineffective, epidural blood patches are recommended and are generally effective. The purpose of this report was to highlight that when lumbar epidural blood patches fail to eliminate PDPH, diagnostic evaluation should be performed and alternative treatment sought. CASE REPORT: An unusual case is described of an 11-year-old boy with PDPH, which was successfully managed with a ventral (anterior) epidural blood patch and epidural saline infusion after headache and other symptoms failed to resolve after conservative treatment and conventionally performed blood patches. CONCLUSIONS: Ineffectiveness of conservative measures and epidural blood patches performed posteriorly to resolve PDPH should lead the physician both to question the diagnosis of PDPH by pursuing radiographic confirmation of a cerebral spinal fluid leak and, furthermore, identification of its location to best direct further therapy.

An atypical presentation of necrotising fasciitis.

Necrotising fasciitis is a rare infection with a high mortality rate. Clinical manifestation may be influenced by an underlying disease state. We report a case of a 70-year-old man with an anaplastic large-cell lymphoma who presented with inconclusive signs of necrotising fasciitis following a neutropenic phase after chemotherapy. Surgical exploration did not reveal the typical macroscopic features of necrotising fasciitis. Microbiological investigations revealed Escherichia coli. The lack of massive tissue inflammation, probably due to the neutropenia in our patient, has not been described by other authors. Diagnostic uncertainties owing to masked or uncharacteristic signs in immune compromised patients may lead to a delayed surgical debridement, of which clinicians should be aware.

Survey of the use of peripherally inserted central venous catheters in neonates with critical congenital cardiac disease.

Neonates with congenital cardiac disease are a special population. They are often critically ill, and need prolonged intravenous access. To date, no study has evaluated the efficacy and safety of peripherally inserted central venous catheters placed in this unique population. Our goal was to evaluate the use of such catheters in neonates with critical congenital cardiac disease, and to study features such as duration of use, reasons for removal of catheters, and complications. We inserted a total of 124 catheters in 115 neonates with critical congenital cardiac disease who were admitted to the Intensive Care Unit at Texas Children's Hospital from August 2002 to August 2004. The patients had a mean age of 10 days, and a mean weight of 3.1 kilograms. The peripherally inserted catheters were in place for a mean of 22.3 days. Therapy was completed in 76.6% patients at the time of removal of the catheter. The incidence of occlusion, dislodgement, and thrombus was 4.0%, 2.4%, and 1.6%, respectively. The infection rate was 3.6 per 1000 catheter-days, with a median onset on 37 days after placement. We conclude that central venous catheters, when inserted peripherally, provide reliable and safe access for prolonged intravenous therapy in neonates with critical congenital cardiac disease.

Use of a mechanical thrombectomy catheter for percutaneous extraction of renal fungal bezoars in a premature infant.

Fungal urinary tract infections are commonly encountered in the hospitalized neonate. Although these infections most commonly take the form of cystitis, the infection may be complicated by the formation of fungal bezoars, with subsequent urinary tract obstruction. In certain cases, endosurgical debulking or extraction of the fungal bezoar may be necessary. This is particularly challenging in neonates due to their often-compromised physiologic state and small size. We report a case of a premature infant with bilateral obstructing renal fungal bezoars in whom a percutaneous catheter-based thrombectomy system was used successfully to debulk the fungal burden.

Antibody levels against Chlamydia pneumoniae and outcome of roxithromycin therapy in patients with acute myocardial infarction. Results from a sub-study of the randomised Antibiotic Therapy in Acute Myocardial Infarction (ANTIBIO) trial.

BACKGROUND: Results of studies concerning prevention of cardiovascular disease by treatment with macrolide antibiotics targeting C. pneumoniae infection are still controversial. This study describes the results of different tests for infection with C. pneumoniae as well as the effect of treatment with roxithromycin in patients with acute myocardial infarction (AMI) in relation to their serostatus against C. pneumoniae. METHODS: We analysed blood of 160 patients who came from the ANTIBIOtic therapy after an AMI ( ANTIBIO-) study, a prospective, randomised, placebo-controlled, double-blind study to investigate the effect of roxithromycin 300 mg/OD for 6 weeks in patients with an AMI. Anti- Chlamydia IgG-, IgA-, and IgM-antibodies of these patients were analysed by means of different test systems. RESULTS: There was a good correlation between the two IgG and IgA methods (r = 0.900, p < 0.001 and r = 0.878, p < 0.001, respectively), but marked differences in the prevalence of positive tests. This resulted in only moderate concordance values, as expressed by the Kappa coefficients, for IgG kappa = 0.611 (95% CI = 0.498-0.724, p < 0.001) and for IgA kappa = 0.431 (95% CI: 0.322-0.540, p < 0.001). No significant association between positive C. pneumonia titers and the combined clinical endpoint during the 12 month follow-up could be found. In all test systems used, patients with positive anti- C. pneumoniae titers did not benefit from roxithromycin therapy (p = ns). CONCLUSION: Depending on the test system used, there are large differences in the prevalence of anti- C. pneumoniae seropositive patients. Clinical events during the 12 month follow-up after AMI did not depend on serostatus against C. pneumoniae and treatment with roxithromycin did not influence these events, independently of the serostatus against C. pneumoniae. However, the power of this subgroup analysis was low to detect small but significant differences.

Acetylcholinesterase in lumbar and ventricular cerebrospinal fluid.

BACKGROUND: Soluble acetylcholinesterase (AChE, E.C. 3.1.1.7.) is released by neurons, glial and meningeal cells into the CSF. AChE activity in cerebrospinal fluid (CSF) is altered in various disorders of the nervous system. The objects of this study are to define a reference range for CSF AChE activity in human lumbar CSF, to prove that the enzyme activity does not depend on the blood/CSF barrier function, and to provide information about AChE in ventricular CSF. In addition, drugs used in neurosurgical care have been examined for their in vitro effects on CSF AChE activity to exclude interference with the test system. METHODS: We tested the AChE activity in 64 lumbar CSF samples collected from a clinically healthy population and in 169 ventricular CSF samples obtained from 90 neurosurgical patients. AChE activity was assayed with our inhibitor-free test procedure. RESULTS: The reference range determined for lumbar CSF AChE activity is 9.2-24.4 nmol/min per ml. Lumbar CSF AChE activity does not correlate with parameters characterising the status of the blood/CSF barrier. Ventricular puncture is only justified for underlying pathology making it impossible to provide reference data for ventricular CSF. Most measurements reveal ventricular enzyme activity below 4 nmol/min per ml. CONCLUSION: The results of this study suggest the utility of lumbar CSF AChE activity as a measure of specific secretory function in enzyme releasing cells of the nervous system.

Hypercalcemia and pancreatitis in a child with adynamic bone disease.

We report a 12-year-old boy receiving long-term peritoneal dialysis who developed marked hypercalcemia and pancreatitis. Hypercalcemia was successfully treated by conducting dialysis with non-calcium-containing dialysate fluid. Factors predisposing to the development of hypercalcemia included the presence of adynamic bone disease and the use of vitamin D and calcium carbonate therapy. This case is presented to emphasize potential complications that can be associated with the adynamic bone lesion in patients on peritoneal dialysis.

Cardioversion of atrial fibrillation in the elderly. ALKK-Study Group. Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausaerzte.

The purpose of this investigation was to define cardioversion success rates, frequency of complications of cardioversion, and current treatment practices in elderly patients (aged > or = 65 years) with atrial fibrillation (AF). The results were compared with those in younger patients (aged < 65 years). The investigation was a prospective multicenter observational study with 61 participating cardiology clinics. Consecutive patients in whom cardioversion of AF was planned had to be prospectively registered. Of 1,152 patients registered, 570 (49.5%) were < 65 years old (group 1) and 582 (50.5%) were > or = 65 years (group 2). The overall success rate of cardioversion on an intention-to-treat basis was 76.1% in group 1 and 72.7% in group 2 (p = 0.18). In multivariate analysis, left atrial size and New York Heart Association functional class before cardioversion were identified as predictors of success (p < 0.001, respectively; p = 0.025). These clinical factors were not equally distributed between the age groups: Left atrial size was larger in the elderly than in younger patients (44.0 +/- 6.4 mm vs 42.8 +/- 6.4 mm; p = 0.006) and a New York Heart Association functional class > or = II was more prevalent in group 2 than in group 1 (48.6% vs 29.6%; p < 0.001). The overall complication rates were not significantly different between the 2 groups (4.2% in group 1 vs 5.3% in group 2; p = 0.37). The frequency of patients who were adequately anticoagulated for cardioversion was 56.9% in age group 1 and 39.6% in age group 2 (p < 0.001). In chronic AF the same trend for age-dependent underuse of anticoagulation was observed. Age itself was not a predictor of cardioversion success and did not predispose to higher complication rates. Therefore, cardioversion should be considered in older patients with the same criteria and emphasis as in younger patients. Anticoagulation and antithrombotic medication is underused for cardioversion and in treating chronic AF, especially in elderly patients.

Allograft epiphysiodesis for slipped capital femoral epiphysis.

During this retrospective investigation, use of freeze-dried irradiated allograft for achieving epiphysiodesis in patients with Grade I or Grade II slipped capital femoral epiphyses was evaluated. The study reviewed 40 grafting procedures in 33 patients: 20 patients were boys and 13 were girls, whose average age was 13 years old. The group included 31 Grade I slips and 9 Grade II slips. Six were unstable and 34 were stable. Procedure time averaged 1 hour 57 minutes and blood loss averaged 360 ml. The average time to complete physeal closure was 28 weeks. An incomplete bony physeal bridge, apparent at an average 11 weeks, may impart earlier stability. Thirty-eight cases had followup averaging 3 years 6 months. At most recent evaluation, according to the Harris hip rating system, 35 hips had excellent ratings, 1 had a good rating, and 2 had fair ratings. Six patients were identified with major postoperative complications, including 1 case each of segmental avascular necrosis, chondrolysis, femoral neck fracture, subtrochanteric hip fracture, bilateral progressive coxa vara deformities requiring corrective osteotomies, and a unilateral progressive coxa vara deformity. The senior author (TLS) currently uses a fluoroscopically guided percutaneous lateral approach, a cannulated reaming system, and freeze-dried irradiated cortical allograft. The procedure promotes premature physeal closure. Allograft epiphysiodesis is an alternative operating technique for treating patients with a slipped capital femoral epiphysis.

Familial total ophthalmoplegia with iris transillumination (a neurocristopathy).

A family with total (internal and external) ophthalmoplegia had associated iris transillumination. No abnormal visual-evoked response brain lateralization indicative of albinism was found. On the basis of avian chimera experiments showing iris muscles to be derived from neural crest cells, we proposed a neurocristopathic theory to explain all clinical findings in this family.

John Caffey Award paper. Avascular necrosis: early MR imaging and histologic findings in a canine model.

To examine the early MR and histologic changes of avascular necrosis, we surgically devascularized the distal femur of adult beagle dogs and performed short TR/short TE MR imaging and histologic examinations. MR showed increasing areas of low signal, and histologic examination showed changes of fat necrosis, inflammatory infiltrate, and fibrocytic and bony repair. These processes were divided into four stages. Stage 1 is seen in the first days after surgery and consists of homogeneous high signal on MR and only subtle histologic changes of early fat necrosis. Stage 2, seen by 7 days after surgery, shows linear low-signal areas within the high-signal marrow on MR and fat necrosis and an inflammatory infiltrate on histologic sections. Stage 3, seen by 16 days after surgery, shows patchy low signal occupying more of the marrow on MR with a fibrocytic infiltrate on histologic sections. Stage 4, seen by 23 days after surgery, shows a more homogeneous low and intermediate signal on MR and histologic findings of more organized fibrocytes and the onset of new bone formation. Using this model, we have proved that MR imaging can show marrow changes as soon as 1 week after the onset of avascular necrosis. Whereas MR imaging showed a progression of increasing areas of low signal, the histologic findings seen during this time were diverse, including inflammatory infiltration (a previously unreported finding), fat necrosis, and fibrocytic and osseous repair.

Airway evaluation in children with use of ultrafast CT: pitfalls and recommendations.

Ultrafast computed tomographic (CT) evaluation of the airway can be performed with either 50-msec low-resolution images (cine CT) or 100-msec high-resolution images (high-resolution CT). To determine the best imaging strategy for ultrafast CT of the pediatric airway, the authors prospectively compared ultrafast CT and endoscopy in 20 children. Both studies were performed in 11 patients; cine CT alone was performed in six and high-resolution CT alone in three. Six patients had normal anatomy. Six patients had focal tracheal stenoses, four had tracheomalacia or laryngomalacia, one had a laryngoesophageal cleft, one had irregularity and narrowing in the subglottic area, one had laryngeal papillomas, and one had focal stenosis with stoma granuloma. Cine CT results agreed with those of endoscopy in 10 of 17 cases. In five cases focal stenosis was misinterpreted with cine CT as tracheomalacia. High-resolution CT results agreed with those of endoscopy in 10 of 14 cases. The results of a technique that combined high-resolution CT for the entire airway and cine CT at selected areas agreed with those of endoscopy in 10 of 11 cases; only a tracheoesophageal cleft was missed with the combined technique. For the greatest diagnostic accuracy with ultrafast CT in evaluation of the pediatric airway, both cine and high-resolution modes should be used.