Heart rate variability (HRV): From brain death to resonance breathing at 6 breaths per minute.

Heart rate variability (HRV) has been associated with various diseases and reflects autonomic cardiac control sensitive to central nervous system function. Examples of the heart-brain interaction are illustrated by extreme clinical conditions such as brain death, orthotopic heart transplantation, weaning from respirator support, and brain maturation in preterm infants. Interactions with the immune system document the importance of HRV for tumor growth and prognosis. Research linking HRV to the regulation of negative emotions including depression and anxiety document the sensitive influence of central commands on cardiac activity. Moreover, 0.1 Hz oscillations in the heart and the brain seem to be coupled, thus indicating central pacemakers on the heart rhythm. Moreover, low frequency oscillations in heart rate seem to be composed of two subcomponents presumably signaling different central-autonomic functions. We conclude by showing that breathing at 6 breaths/minute could induce coherence of the 0.1 Hz oscillations, thus facilitating physical and psychological function. The reviewed findings impressively demonstrate that central nervous system function modifies the rhythm of the heart and vice versa, suggesting that HRV could be a useful indicator of central-autonomic integration and that 0.1 Hz oscillations play a major role in physical and mental health via optimizing energy supply.

Cardiac and Pulmonary Cystic Echinococcosis With Massive Obstruction of the Pulmonary Vessel System in a 16-Year-Old Girl.

We describe herein the management of a 16-year-old girl with cystic echinococcosis of the right ventricle and massive obstruction of the pulmonary vessel system by parasitic metastatic dissemination. After resection of the cardiac cyst, pulmonary thromboendarterectomy was performed to remove parts of the obstructive parasitic material. The treatment reduced the elevated pulmonary arterial pressure, improving the patient's overall condition.

Effect of body position on ventilation distribution during PEEP titration in a porcine model of acute lung injury using advanced respiratory monitoring and electrical impedance tomography.

BACKGROUND: Lung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography. METHODS: After induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar. RESULTS: Induction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO2/FiO2): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO2): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO2 at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO2/FiO2 at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d. CONCLUSIONS: Prone position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.

The past 25 years of pediatric burn treatment in Graz and important lessons been learned. An overview.

INTRODUCTION: The aim of this study was to characterize the epidemiology of pediatric and adolescent burns admitted to the Children's Burns Unit at the Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria, between January 1st 1988 and December 31st 2012. METHODS: This is a retrospective review over the past 25-years and describes admission rate by gender and age groups, causes of burns, anatomical sites of burns, extent and depth of injury, length of hospital stay, child abuse and in-hospital mortality. RESULTS: In the studied 25 year-period, 1586 pediatric burn patients were admitted. 1451 patients were "acute" admissions, 64 "secondary" admissions and 71 patients did not fulfill the inclusion criteria. Of the 1451 patients, 930 (64%) were male and 521 (36%) female. The majority of patients - 880 or 60.6% - were children from 1 to 5 years of age. Domestic burns occurring at home resulted in 1164 (80.2%) of injuries and scalds were the most common type of thermal trauma with 945 (65.1%) patients. According to the extent of injury 1106 (76.2%) patients suffered burns of <10% with an median length of hospital stay of 3 days. 14 children (0.98%) - 8 girls and 6 boys - were confirmed victims of abuse and 4 patients (0.3%) died. CONCLUSION: The study provides a good opportunity to review changes in burn care over a long time period, at a single center, including children and adolescents, with stable surgical and rehabilitation staff. The data is also important for the design of prevention programs and establishment of burn care capacities, since the analysis showed no change in the incidence of burn related admissions over the time period studied.

Phototoxic plant burns: report of a case and review of topical wound treatment in children.

Acute photodermatitis provoked by skin contact with giant hogweed (Heracleum mantegazzianum) and exposure to ultraviolet radiation is a rare cause of phytophotodermatitis in children. We report the case of a 10-year-old girl with extensive photodermatitis after contact with giant hogweed and prolonged exposure to sunlight. The lesions involved 10% of the body surface area, mainly the lower extremities. After initial application of topical steroids to the skin erythema, the topical approach was changed due to extensive bullae. Debridement and temporary wound closure with an adequate dressing was undertaken. This is the first case report of application of Suprathel (PolyMedics Innovations, Denkendorf, Germany) on a phytophototoxic burn-like wound with a favorable outcome.

Transdermal uptake and organ distribution of silver from two different wound dressings in rats after a burn trauma.

Silver-containing wound dressings are an integral part of wound therapy in adult and pediatric burn patients. The antimicrobial effect of silver is well known and has been described in numerous studies. Side effects are rarely reported from silver-containing wound care products, even though systemic absorption of silver has been shown by elevated levels of silver in the blood of patients after silver exposure during wound therapy. This animal study investigated the silver levels of blood and in which organs and tissues silver is detectable after long-term application of silver-containing wound dressings after a burn trauma. In male rats, a major full-thickness scald was created on their backs according to a standardized burn model. Two different silver-containing wound dressings (nanocrystalline silver [NCS] and silver sulphate foam [SSF]) were applied initially and changed every 7 days. Weekly blood drawings revealed an increase of blood silver in week three with significant higher values in the SSF compared with NCS group (Ag µg/kg 135.8 vs. 61.7; means; p ≤ 0.05). Thereafter, the NCS group showed significantly higher blood silver levels than the SSF group at week five (Ag µg/kg 192.3 vs. 81.3; means; p ≤ 0.01) and six (Ag µg/kg 168.2 vs. 32.9; means; p ≤ 0.01). After 6 weeks, the animals were sacrificed, and the organs and tissues were analyzed for their silver content by inductively coupled plasma mass-spectrometry. Silver was detectable in all analyzed organs and tissue samples, with higher silver values in parenchymatous organs in the NCS than SSF group (Ag µg/kg; spleen: 3,469 vs. 260; kidney: 3,186 vs. 289; liver: 2,022 vs. 313; means; p ≤ 0.05). Silver was also detectable in brain, testis, lung, heart, and muscle tissue.

A retrospective analysis of securing autologous split-thickness skin grafts with negative pressure wound therapy in paediatric burn patients.

BACKGROUND AND AIM: Deep dermal and full-thickness burn wounds are excised and grafted with split-thickness skin grafts. Especially in less compliant patients such as young children, conventional fixing methods can often be ineffective due to high mobility rates in this age group. The aim of this retrospective single-centre study was to give an overview of our experience in the fixation of autologous split-thickness skin grafts (ASTSGs) on burn wounds by negative pressure wound therapy (NPWT) in paediatric patients. METHODS: A retrospective analysis describing 53 paediatric patients with burns or burn-related injuries who were treated as 60 individual cases were conducted. All patients received ASTSGs secured by NPWT. RESULTS: Of the individual cases, 60 cases with a mean age of 8±6 years (the youngest was 3 months, the eldest was 24 years old) were treated in a single procedure with ASTSG and NPWT. Total burn surface area (TBSA) was, median (med) 4.5% (3.0-12.0%). The TBSA of deep dermal thickness to full-thickness (IIb-III°) burns was med 4.0% (2.0-6.0%). The TBSA treated with ASTSG and NPWT was med 3.5% (2.0-6.0%). Take rate was, med 96% (90-99%) with a total range of 70-100%. The only significant correlation that could be found was between the grafted TBSA and the take rate. The smaller the grafted TBSA the better the take rate resulted, as expected. In three cases, major complications were noted. CONCLUSION: To sum up our experience, the NPWT system has developed itself to be a constant, well-implemented and useful tool in securing ASTSGs to the wound bed. The main advantage of the technique is a much higher mobility of the patient compared to conventional fixation methods. The high compliance rate of an often challenging group of patients such as children recompenses possible higher costs compared to conventional fixation methods.

Differentiating inherited human herpesvirus type 6 genome from primary human herpesvirus type 6 infection by means of dried blood spot from the newborn screening card.

To differentiate active human herpesvirus type 6 (HHV-6) infection from inherited HHV-6 (iHHV-6), we analyzed dried blood spots from archived newborn screening cards in 3 patients with high HHV-6 DNA copy numbers. Two patients were positive for HHV-6 DNA as neonates suggesting iHHV-6. In 1 patient, the absence of HHV-6 DNA excluded iHHV-6.

Pacifier use does not alter the frequency or duration of spontaneous arousals in sleeping infants.

OBJECTIVE: It has been reported that pacifiers might reduce the risk of SIDS by favouring infants' arousability from sleep. We evaluated the influence of a pacifier on the frequency and duration of spontaneous arousals in healthy infants. METHODS: Polygraphic recordings were performed in 14 infants with an age of 51.7+/-19.9 days (means+/-SD) who regularly used a pacifier during sleep. Cortical and subcortical arousals were scored according to the recommendations of the "International Paediatric Work Group on Arousals." The number of arousals per 10-min-period and the duration of arousals were determined for periods of pacifier use as well as for periods after pacifier dislodgement and were compared with the data of 10 control infants (age 49.8+/-16.5 days) who never used a pacifier. RESULTS: Altogether, 211 arousals in pacifier users and 225 arousals in non-users were scored. In pacifier users, 2.0+/-1.6 arousals per 10-min-period with a duration of 12.2+/-3.0 s occurred during pacifier use, and 1.7+/-1.6 arousals per 10-min-period with a duration of 12.2+/-3.1s occurred during periods without pacifier. In pacifier non-users, 2.3+/-1.2 arousals per 10-min-period (duration 13.9+/-2.9s) were scored. The results did not show a significant difference concerning frequency and duration of spontaneous arousals between pacifier users and non-users. CONCLUSIONS: Our findings suggest that factors other than arousal mechanisms might be responsible for the efficacy of pacifiers in SIDS prophylaxis.

Use of Suprathel dressing in a young infant with TEN.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are potentially life-threatening skin disorders. We report that a 3-month-old infant, a patient with toxic epidermal necrolysis, who in addition to a standard resuscitation protocol for burns received treatment with Suprathel (PolyMedics Innovations GmbH, Filderstadt, Germany) and fatty gauze as topical wound dressings in the form of a whole body cover with complete recovery. This is the first case report of Suprathel being used successfully in a baby with toxic epidermal necrolysis.

Correlation between EEG burst-to-burst intervals and HR acceleration in preterm infants.

One objective of this paper is to confirm the coupling between heart rate (HR) changes and electroencephalographic (EEG) bursts (as reported for the first time in Pfurtscheller et al. [K. Pfurtscheller, G.R. Müller-Putz, B. Urlesberger, W. Müller, G. Pfurtscheller, Relationship between slow-wave EEG bursts and heart rate changes in preterm infants, Neurosci. Lett. 385 (2) (2005) 126-130]) in a larger group of preterm infants. Other objectives are to report on semi-automatic detection of burst-to-burst intervals (BBI, time period between the onsets of 2 consecutive EEG bursts) and on correlations between BBI and HR changes. A group of 34 preterm infants with a conceptional age (CA) of 35.9+/-0.6 weeks (mean+/-S.D.) was studied. Periods with a length of about 10 min with low HR variability and discontinuous EEG were selected from long-term EEG and ECG registrations and analyzed. From the automated detection of EEG bursts, an estimate for the mean burst-to-burst interval was obtained. EEG trials with a duration of 16s and a single EEG burst in the middle, were selected and averaged together with the corresponding instantaneous HR trials. It was found that preterm infants without evidence of neurological deficit and with normal development revealed a mean BBI of 13.4+/-2.6s (mean+/-S.D.) and a HR increase of 1.7+/-0.9 bpm (mean+/-S.D.) during the occurrence of EEG bursts. This HR increase is comparable with the earlier reported increase of 1.9+/-0.8 bpm. A significant negative correlation of r=0.453 (p<0.01) was found between BBI and HR increase and a positive correlation between CA and HRV (r=0.438, p<0.01) and between CA and HRI (r=0.452, p<0.01).

Synchronous occurrence of EEG bursts and heart rate acceleration in preterm infants.

Continuous and simultaneous registration of electroencephalogram (EEG) and heart rate (HR) pattern in preterm infants can give information about the functioning of central nervous system and the integrity of the autonomic nervous system. The developmental and behavioural state determine the pattern of EEG activity. A discontinuous EEG activity also known as 'Tracé alternant' (TA) in preterm infants is accompanied by a low heart rate variability (HRV). It was found that electroencephalographic bursts of slow waves during TA are coupled with an acceleration of the HR. In this study, this synchronous behaviour of EEG bursts and HR is described for the first time in a group of preterm infants with a mean conceptional age (CA) of 36 weeks.

Relationship between slow-wave EEG bursts and heart rate changes in preterm infants.

The objective of the study is to explore interactions between cortical and autonomic functions in the first weeks of postnatal life. We investigated the behaviour of one-channel electroencephalogram (EEG) patterns and heart rate (HR) dynamics in preterm infants. In a group of 15 healthy preterm infants with a mean conceptional age (CA) of 36 weeks and a mean postnatal age of 17.5 days simultaneous registration of amplitude integrated EEG (aEEG) and HR pattern was performed during interfeeding intervals. Periods with a discontinuous EEG activity and a low heart-rate variability (HRV) were selected for further processing and averaging. It was found that spontaneous activity transients (SATs) or slow wave EEG bursts during "Tracé alternant" (TA) can be accompanied by an HR acceleration of 1-2% (mean: 1.9, range: 0.6-3.5 beats/min) lasting approximately 5s (mean, range: 3.6-7.1s). The aim of the study is to give evidence of a coherent behaviour of EEG bursts and HR in the developing nervous system of preterm infants.

[Semiautomatic procedure for the investigation of synchronized activity of EEG and heart rate--examination of preterm births]. / Semiautomatisches Verfahren für die Untersuchung des synchronen Verhaltens von EEG--und Herzraten-Mustern bei Frühgeborenen.

Recordings of the electroencephalogram (EEG) and of the heart rate variability (HRV) of preterm neonates can give important information on the actual state of the nervous system. Both signals, EEG and HRV, are affected by parameters such as gestational age, stage of maturation and behavioral state. This work describes a method for automatic detection of slow wave EEG-bursts and a tool to average changes in the EEG and the corresponding heart rate. The detection is based on the hjorth activity (HA), calculated from the EEG. HA spikes (HAS) are identified by the determination of the beginning and end of existing spikes. HAS maxima and the time between two consecutive HAS are the basis for the triggering of the bursts. EEG power and time synchronized HR changes are averaged with a time window length of 20 s. Resultant, HR increase and duration are determined. These parameters, obtained by the automatic detection, proved to be comparable to the results of an expert.