Critical Situations in Children, Adolescents and Young Adults with Terminal Cancer within the Home Setting.

BACKGROUND: Over the course of terminal cancer towards the end-of-life, children may experience symptoms that lead to distressing critical situations (CS) for the child and caregivers. METHODS: We analysed the records of 133 children cared for by our paediatric palliative care team (PPCT) from 01/98-12/09. A CS was defined as deterioration of a condition caused by a symptom, which was life-threatening or acutely scaring the patient (pt) or caregivers. RESULTS: The majority of pts who died sustained no CS. In 38 (28.6%) pts 45 CS occurred. These accumulated towards the end-of-life (62.2% within the last week). About two-thirds were anticipated. There was no clustering of CS during the night/weekend. Leading symptoms were neurological. In 4 CS a pre-hospital emergency physician was alerted. 5 pts were readmitted to hospital. Most CS (88.9%) could be controlled in the home setting. DISCUSSION: Despite anticipation, a relevant number of pts developed CS, which needed either additional medical intervention or other support by the PPCT. Considering the distressing and suffering character of status epilepticus and dyspnoea, it is important to thoroughly address these conditions in palliative care. CONCLUSION: Advanced planning, close contact, good communication, detailed parental information, and a 24-h on-call service can reduce CS in children with terminal cancer. CS are mainly manageable within the home setting. Treatment of CS should focus on the child's symptoms and wishes, and the needs of the whole family.

[Development of a specialised paediatric palliative home care service]. / Die Entwicklung einer spezialisierten ambulanten pädiatrischen Palliativversorgung.

In Germany annually 1,500-3,000 children die from life-limiting diseases. Symptoms and course of disease differ considerably depending on the character of the underlying disease. Due to the desire of the children and their families to spend the end of life at home a paediatric palliative home care service was founded at the university children's hospital of Duesseldorf. In the last 20 years a specialised paediatric palliative team evolved from an unstructured voluntary activity. Prospective aims are an area-wide professional supply of all paediatric palliative patients and the improvement of the cooperation with the resident paediatrician and paediatric palliative nursing services. Furthermore the establishment of networks as well as a proper communication among the professionals is inalienable.

[Out-patient palliative care of children with cancer and their families]. / Ambulante palliativmedizinische Versorgung krebskranker Kinder und ihrer Familien.

Pediatric palliative care is still in its beginning. Most children with life-threatening disorders succumb with incomplete symptom control under in-patient conditions. Due to the limited number of patients and large hospital-home distances the realization of out-patient concepts of palliative care especially for children and adolescents with cancer is purposeful and beneficial. In a pilot project such an a aforementioned concept of pediatric palliative care proved successfully working despite insufficient conditions. Guidelines of pediatric palliative care are to be defined at short notice in order to ascertain autonomy and mobility of patients aiming at highest possible quality of life. The recently initiated program of integrating ambulatory and in-patient care within the regulations set forth in Germany's last health care system reform offers the chance of palliative home care of children in their terminal phase of life.

Rhythmicity associated with a high degree of short-term synchrony of motor unit discharge in man.

A rhythmic modulation of motor unit discharge at 17-24 Hz has been observed in the tibialis anterior muscle of subjects who display a high degree of short-term synchrony. Motor unit discharges were recorded both from extensor digitorum communis in the arm and tibialis anterior in the leg during voluntary isometric contractions. Time domain analysis of motor unit discharges in both muscles revealed a prominent central peak in the cross-correlograms that was interpreted as short-term synchrony. In tibialis anterior, but not in extensor digitorum communis, the primary, central peak was accompanied by secondary peaks. These were symmetrically or unilaterally present at an average time lag of 52 ms (range 37-68 ms) with respect to the primary peak. In both muscles other peaks occurred at time lags equivalent to the mean interspike interval of motor unit discharge (range 80-150 ms). In all subjects frequency domain analysis of the discharges of pairs of motor units revealed prominent peaks of coherence in the range 17-24 Hz. The actual frequency matched closely the reciprocal of the time lag interval between primary and secondary peaks of the cross-correlogram of the same motor units. Coherence was less evident for motor unit discharges in extensor digitorum communis and no prominent peaks occurred in the range 17-24 Hz. We propose that the secondary peaks and the rhythmicity may involve recurrent inhibition activated by the synchronous discharge of motor units. The presence of this pattern of discharge in tibilias anterior but not extensor digitorum communis would fit with recent animal and human work suggesting that recurrent inhibition is poorly represented in certain distal muscles of the forelimb.

Ceftriaxone alone or in Combination with Teicoplanin in the Management of Febrile Episodes in Neutropenic Children and Adolescents with Cancer on an Outpatient Base.

STUDY OBJECTIVE: This study prospectively investigated the outpatient once daily therapy with ceftriaxone alone or if necessary in combination with teicoplanin, in the treatment of infections in children and adolescents with chemotherapy-induced neutropenia or aplastic anemia. PATIENTS: 42 patients 1-22 years of age suffering from solid tumors, hematological and oncological diseases, with clinical signs of infection, increased serum CRP (> 1 mg/dl) and/or fever above 38.5 degrees C and neutropenia (WBC count and/or ANC < 1 x 10(9)/l) were included in this outpatient based study. One important exclusion criterion was poor clinical condition with symptoms of septic shock. METHODS: After bacterial, fungal and viral cultures had been obtained, single agent broad spectrum cephalosporin treatment was initiated with ceftriaxone applied once daily in a dose of 80 mg/kg body weight as short infusion over 30 min. Daily examinations included WBC, CRP, physical inspection and reassessment. In case of persistence or increase of fever and CRP, either outpatient management was carried on with teicoplanin added or patients were hospitalized and switched to combination antibiotic regimen. RESULTS: There were 64 febrile episodes in 42 patients. Single agent once daily broad spectrum cephalosporin was adequate in 43/64 (67%) of infectious episodes in neutropenic patients. For persisting or increased fever or CRP elevation, 9 patients were treated with ceftriaxone and teicoplanin successfully. Thus hospitalized was avoided in 52/64 (81%) of infectious episodes.

Short-term synchrony of motor unit discharge during weak isometric contraction in Parkinson's disease.

Short-term synchrony between the discharges of motor units has been assessed in Parkinson's disease (PD) and normal man. The discharges of single motor units were recorded in the extensor digitorum communis (EDC) muscle of the forearm or the tibialis anterior (TA) muscle of the leg during weak, voluntary isometric contraction. Short-term synchrony was defined as a narrow peak (total width less than 25 ms) in cross-correlograms constructed from the discharges of pairs of motor units. There was no difference in the incidence of short-term synchrony between PD and normal age-matched subjects for either the EDC or TA muscle. On average, 60% of pairs of motor units exhibited synchrony, but this varied between 0% and 100% for both groups. The amount of short-term synchrony was assessed as the probability (above chance) of discharge of one motor unit with respect to the other. In TA, but not EDC, this index was greater for PD than for normal subjects. The high indices of synchrony in TA in PD were not related to lower discharge rates of motor units. Parkinson's disease subjects, but not normal subjects, also showed broad correlations that were invariably associated with periodic discharges in the range 4-6 Hz. In some instances, a peak of short-term synchrony was observed superimposed on the broad correlation. The periodic correlograms were often associated with overt tremor which accompanied the contraction. Motor units occasionally discharged paired impulses (doublet discharges) with short interspike intervals of 5-15 ms (normal and PD) or, as a more persistent feature in PD, longer interspike doublets (20-60 ms) associated with periodic synchrony (4-6 Hz). The abnormal discharge characteristics of motor units are discussed in relation to the bulbospinal control of presynaptic drive to motor neurons in PD.

Motor unit discharge characteristics and short term synchrony in paraplegic humans.

Frequency of firing and regularity of discharge of human motor units, and short term synchrony between pairs of motor units, have been assessed in extensor digitorum communis (EDC) and tibialis anterior (TA) muscles in control subjects and in clinically complete paraplegic subjects. The discharge pattern of TA motor units in paraplegia ranged from extremely regular to very irregular for different motor units whereas in the control population, and in EDC of both groups, there was a narrow, but intermediate, range of regularity. There was little difference in the incidence and degree of short term synchrony (STS) in EDC between paraplegic and normal subjects. In contrast, virtually no STS of motor units was observed in the TA muscles of the paraplegic group whereas control subjects exhibited approximately the same amount of STS in their TA and EDC muscles. It is concluded that the extra burden placed on arm muscles in paraplegia does not change the amount of synchronisation between motor units. Furthermore, section of the spinal cord does not increase STS as predicted from lesions of the reticulospinal tract in cats. This may reflect the coincidental removal of supraspinal synchronising inputs of motoneurons or the reorganisation of synaptic inputs in chronic paraplegia.

[Study using non-invasive methods in prostheses of bovine pericardium in aortic position manufactured at the Ignacio Chávez National Institute of Cardiology]. / Estudio por procedimientos no invasivos de las prótesis de pericardio bovino en posición aórtica manufacturadas en el Instituto Nacional de Cardiología Ignacio Chávez.

We studied 28 patients to whom a prosthestic valve of bovine pericardium manufactured in the Instituto Nacional de Cardiología Ignacio Chávez (INCICH) were implanted in aortic position, from February 1983 to May 1985. We analyzed the clinic follow-up and the prosthetic function was studied by Phonocardiography, Echocardiography M mode, Two-Dimensional and pulsed wave Doppler recordings obtained before and after surgery. The patient were 26 males, 2 females whose age varied from 12 to 66 years. The aortic valve disease was rheumatic in 12, congenital in 11 and of other type in 5. After surgery 26 patients are in functional class I, one in class II and one died, but death was not related to prosthetic valve function. In the Phonocardiogram we observed significant diminution of the ventricular ejection time of 32 +/- 2 msec. to 29 +/- 2 msec. (P less than 0.05), the aortic valve opening sound was of less intensity than the valve closure sound, with relation between both of 0.53. All of them had a systolic ejection murmur. In the Echocardiogram we observed a significant decrease of the end diastolic diameter of 53 +/- 11 mm to 45 +/- 10 mm (P less than 0.05), the end systolic diameter decreased from 37 +/- 13 mm to 33 +/- 10 mm., but the difference was not significant. The aortic prosthetic flow by pulsed Doppler Echocardiography had a maximum velocity of 137 +/- 23 cm/sec., it represents a valvular gradient of 7.5 +/- 0.02 mmHg. Early diastolic regurgitant flow was recorded in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic study of valvular prosthesis]. / Estudio ecocardiográfico de las prótesis valvulares.

Eighty-six patients with valvular prosthesis (PV) were included in this study, 52 females and 34 males, from 9 to 55 years of age. The functional state of the PV was corroborated with catheterization, surgery or necropsy. The results of 92 PV were analyzed, of which 72 were in mitral position, including 49 dura mater valves (DMPV). In aortic position were 18, including 12 mechanical Bjork-Shilley (BS) and 2 in tricuspid position. The prostheses were classified in three groups: I. with regurgitation, II. with obstruction and III. without dysfunction. Of the 49 DMPV in mitral position 11 were in group I and 7 in group II. The echocardiogram revealed a diminished opening velocity in group II (255 +/- 41.2 mm/sec., P less than 0.001) as well as a diminished opening excursion (10.9 +/- 3.4 mm, P less than 0.02) and increased thickness of the leaflets (4.7 +/- 3.6 mm, P less than 0.05). Paradoxical interventricular septal movement was less frequent in group I (27.2%, P less than 0.05). Seventeen BS valves were in mitral position; of these 2 were classified in group I and the rest in group III, the opening velocity was increased (1200 mm/sec) in those of group I. None of the BS valves in aortic position were dysfunctional. No patients from group III died; mortality in groups I and II was 35%. In 5.1% of group III and 20% of groups I and II either no improvement or greater clinical deterioration was observed.

[Use of echocardiography in the diagnosis of atrial myxoma]. / La utilidad de la ecocardiografía en el diagnostico del mixoma auricular.

The experience at the National Institute of Cardiology with atrial myxoma from 1944 to 1980 is presented; twelve patients were diagnosed, 8 females and 4 males, their age varied from 14 to 66 years. The tumor was inside the left atrium (LA) in 10 patients and in the right atrium (RA) in two. The diagnosis was confirmed by surgery or postmortem study. The symptoms and physical examination simulated mitral stenosis in the cases with myxoma of the LA, and pulmonary stenosis and Ebstein's anomaly in the two cases with RA myxoma. Symptoms of atrioventricular occlusion or embolic accident occurred by 5 patients and 3 of them died. The tumor was a postmortem discovery in the first cases, the next ones were an operatory surprise and the last ones were diagnosed by echocardiography. The advent of this technic has been definitive, all 7 patients studied by this method were diagnosed; in one the catheterism was interpreted as mitral stenosis and in other, during this procedure, cardiac arrest developed. The surgical removal of the tumor was successful in the nine patients that were operated. A correct and early diagnosis as well as an urgent surgical approach are necessary. With echocardiographic demonstration of the tumor, one patient died while he was waiting for surgical treatment.

[Effects of sotalol on ventricular function]. / Efecto del sotalol sobre la función ventricular.

There were studied 31 patients 20 of them sanes and 11 with sustained systemic arterial hypertension to whom it was administered propranolol and sotalol in different periods. By means of phonomechanocardiographic study it was observed that the contractile heart function didn't present alterations in the sane patients, with the administration of the two drugs. Sotalol produced significative changes with depression of contractility in hypertense patients, even though there were no alterations of the "pump" function. It is probably on account that hypertensive cardiopathy per se has a minor functional myocardiac reserve and the negative inotropic effect is made evident with greater clearness. The fall of the elevation velocity of radial pulse (EVRP) in the two groups, suggests the increase of vascular resistances by the peripheric beta blockade.

[Phonomechanocardiographic study of congestive myocardiopathy]. / El estudio fonomecanocardiográfico de la miocardiopatía por dilatación (congestiva).

There were studied 14 patients with congestive myocardiopathy demonstrated by cardiac catheterism at nine, echocardiogramme at five and/or necropsy at four. There were registered mytral insufficiency blowings at thirteen and tricusp insufficiency blowings at five. Of them, there were 11 that presented pathologic noises III and IV. Right apexcardiogramme showed growth of such cavity at the twelve patients that were studied. "a" index of the same precordiogramme had qualitative correlation with systolic pulmonary pression. Apexcardiogramme showed ventricular growth at twelve from thirteen patients and "a" index was also qualitatively correlated with direct deermination of the left ventricule's telediastolic pression. Chronocardiometry was anormal at all of them. Short expulsive period, long pre-expulsive period, expulsion's fraction diminution reckoned by this method and systolic quotient, all of them diminished, translated the cardiac expense fall by "pump" fail. Elongation of pre-isosystolic phase, isosystolic phase, true isosystolic phase, and diminution of ventricular pression's elevation middle velocity and contractility index were consequences of myocardic contraction's bad quality. Decrement of ventricular pression's elevation velocity, added to the important elevation of left ventricle's final diastolic pression determined the "pseudonormality" of IIa-0 interval, and of the integrated isovolumetric pression. Shortening of fast filled's phase is explained by a minor ventricular filled in order to the volume's increase and diastolic pression's increase (Board VII). By last, shortening of Q-IIa interval, coinciding with the cardiac frecuence's increase is explained by catecolamins' increased secretion like compensating mechanism of chronic cardiac insufficiency. Phonomechanocardiogramme is useful for entity's diagnostic and it informs about ventricular disfunction which characterise the suffering.

[Phonomechanocardiographic parameters of the ventricular function in the healthy adult]. / Parámetros fonomecanocardiográficos de la función ventricular en el sujeto adulto sano.

There are studied several phonomechanocardiographic parameters of ventricular function and the obtained values in a normal patients' lot. It is analyzed the semiology of those data which offer information about pre-charge (apexcardiogramme's "a" index) of the myocardiac contractile state (true isosvstolic phase, ventricular pression's elevation middle velocity, integrated isovolumetric pression, and contracility index) and of its "pump" function (expulsion fraction); in the same way it is discussed the measurement's potential utility of diastolic intervals. It is emphasized the value that these parameters' measurement can have to know cardiac capacity and the affectation this can have by pharmacologic influence or by the ilnes.

[Phonomechanocardiography of constrictive pericarditis]. / Estudio fonomecanocardiográfico de la pericarditis constrictiva.

There were studied 19 constrictive pericarditis cases demonstrated by anatomist study. It was evident, at all of them, systemic veiny hypertension's syndrome. "Extinguished" cardiac noises and "quiet" heart only appeared at the 42% of the cases. 73% of patients were found with important incapacity. Lyan's pericardic protodiastolic crack was registered at the 75% of the cases and only at 2 cases (10.9%) it was found reinforcement of pulmonary noise II. It is agree with the haemodynamic discovery of pulmonary pression's light elevation. Characteristically, precordiogrammes showed great "A" wave, and it was agree with telediastolic pression's elevation of the two ventricles obtained by catheterism. Phlebogramme was characteristic of systemic veiny hypertension by impediment of ventricular filled at all the studied cases. Measurement of cardiac cycle's phases showed diminution at PE, Blumberger's intrasystolic quotient, left expulsion fraction (Carrard's method) and ventricular pression's elevation middle velocity (VPEMV). By the contrary Weissler's index was found elevated. Eventhough found ciphers could be considered like bordering normal values, there is a difference statistically significance in relation with the values that were found in sane subjects. These discoveries were interpreted in the base that the patient's heart with constrictive pericarditis acts at the curve's ascendent part of the ventricular function because it has incapacity to utilize Starling's mechanism. Process' chronicity produces myocardic atrophy by "discuss" and, by this, ventricular function's improvement can be no immediate to pericardiectomy. Apexcardiogramme shows the impedement to ventricular filled with its diastolic morphology which is very similar to intracavitary pression's curve ("square root's image"). It is postuled the hypothesis that these sicks do not develop important pulmonary hypertension, because right ventricle's poor diastolic distension impides generation of major expense and systolic pression and, by other side, the impedement to ventricular filled has repercussion over right auricle and systemic veiny territory much more distensible, with the known clinical consequences.

[Phonomechanocardiography of 141 healthy patients]. / Estudio fonomecanocardiográfico de 141 sujetos sanos.

When studying 141 normal persons of both sexes we checked acoustic phenomena and measured the sistolic intervals. We discuss here the presence of blowing anorganic phenomena and sounds III and IV among the general public. We develop equations of regression to correct the electromechanic sistole (QIIA) and the left ventricular ejection time (LVET) the registered values being different from those published by other researchers. Last of all we analyse semiology and the interpretation of the sistolic phases of the cardiac cycle using them in a routinary way and stressing its value and limitations, specially when used to get a better knowledge of the state of the myocardial functions.

[Silent mitral stenosis (report of 8 cases)]. / Estenosis mitral "muda" (presentación de ocho casos).

We studied eight cases of mitral "mute" stenosis we had discovered through echocardiogram, and analysed its clinical behaviour, the various findings in exploration, and electrocardiographic, radiologic, phonomecanocardiographic and echocardiographic changes. We mention the most notable signs for the suspected diagnosis of this kind of stenosis and the importance they have in the alleviation of this illness--frequently a very severe one, through surgical treatment. When mitral stenosis is not recognized in time through a precise diagnosis, turns to be a potentially lethal illness a short time after being diagnosed as a pulmonary arterial hypertension. We highly recommend the use of echocardiography for the diagnosis of mitral "mute" stenosis, because it has proved to be a inocuous, easy to obtain and very sensible way of diagnosing.