Cat Scratch Disease in a 1.5-year-old girl - Case report.

INTRODUCTION: The paper is a case report presenting Cat Scratch Disease (CSD) in a 1.5-year- old girl. Bartoneloses, including CSD, are a group of infectious diseases which are rarely detected, therefore there are no statistical data concerning the aetiology, and the incidence of CSD noted in Poland is low in comparison with other European countries. OBJECTIVE: The purpose of the paper is to discuss several problems related to CSD. MATERIAL AND METHODS: A 1.5-year-old girl who was seen in hospital for the sparing use of her left arm when crawling. X-rays showed osteolytic lesions which radiologists described as multi-ocular cyst or infection. As neither clinical examination nor laboratory investigations found pathological signs, the patient was followed-up on an ambulant basis. Repeated x-ray taken 4 weeks later showed increased periosteal proliferation accompanied by pain. The baby was admitted to the Clinic but additional investigations found no pathologies. The baby was consulted by a rheumatologist and haematologist; however, they did not facilitate a definitive diagnosis. As the baby developed, because of a thickening of the soft tissues on the dorsal side of the distal epiphisis in the forearm the doctors decided to inspect the condition operatively. Macroscopic examination found brownish granulated tissue. Suction drainage was inserted and a tissue sample was tested for aerobic and anaerobic bacteria, tuberculosis and borelliosis. The test results were negative. The baby was in good condition, was not pyrexial and suffered from less pain. The diagnostics was further expanded and the baby tested for yersinia, chlamydia, tuberculosis and bartonella, i.e. CSD. The postoperative wound healed soon and radiological bony lesions began to resolve. After a month, we received a positive bartonella test result, the baby tested positively for Bartonella henselae IgG class, which confirmed past or active infection of CSD. A repeated test for B. henselae taken 6 months later showed a lower level of antibodies. CONCLUSIONS: It should be remembered that CSD, which is an extremely rare infection, can be diagnosed despite mediocre clinical and radiological manifestations. Thus, in the case of infections of unexplained aetiology and mediocre manifestations diagnostics should include testing for Bartonella henselae.

Clavicle fracture associated with atlantoaxial rotatory displacement, type II in an 8-year-old girl: A case report.

RATIONALE: Fracture of the clavicle is a very common injury in children. However, association between clavicle fracture and atlantoaxial rotatory displacement is rarely observed. PATIENT CONCERNS: We present a case of an 8-year-old girl, who suffered a right clavicle fracture as a result of a sledge accident. Six weeks after figure of 8 casting for a right clavicle fracture, an 8-year-old girl was brought to the Pediatric Orthopedic Department due to torticollis. DIAGNOSES: Standard X-ray examination revealed nonunion of the clavicle without any clinical symptoms. Computed tomography (CT) examination was performed and subluxation of cervical vertebrae 1/cervical vertebrae 2 was detected. INTERVENTIONS: The use of Glisson's traction followed by a soft cervical collar resulted in the resolution of all the symptoms. Control CT and magnetic resonance imaging confirmed reduction. OUTCOMES: The patient fully recovered and currently is fully active. The neurological status of the child before and after procedure remained normal. LESSONS: Clavicle fracture rarely may be associated with atlantoaxial rotatory displacement. Therefore, careful examination including rotation of the neck is necessary to confirm that associations. Moreover, three-dimensional CT scan enables proper spine examination and provides correct diagnosis. As shown in available literature and as well in presented case report, none operative treatment is usually effective.

Volatile-based short-term sedation in cardiac surgical patients: a prospective randomized controlled trial.

OBJECTIVE: To evaluate the differences in extubation times in a group of cardiac surgical patients who were anesthetized and sedated with either IV propofol or inhaled volatile anesthetic agents. DESIGN: This was a prospective randomized controlled trial performed between September 2009 and August 2011. SETTING: Cardiovascular ICU within a tertiary referral university-affiliated teaching hospital. PATIENTS: One hundred forty-one patients undergoing coronary artery bypass graft surgery with normal or mildly reduced left ventricular systolic function. INTERVENTION: Participants were randomly assigned to receive anesthesia and postoperative sedation using IV propofol (n = 74) or inhaled volatile (isoflurane or sevoflurane) anesthetic agent (n = 67). MEASUREMENTS AND MAIN RESULTS: Patients sedated using inhaled volatile agent displayed faster readiness to extubation time at 135 minutes (95-200 min) compared with those receiving IV propofol at 215 minutes (150-280 min) (p < 0.001). Extubation times were faster within the volatile group at 182 minutes (140-255 min) in comparison with propofol group at 291 minutes (210-420 min) (p < 0.001). The volatile group showed a higher prevalence of vasodilatation with hypotension and higher cardiac outputs necessitating greater use of vasoconstrictors. There was no difference in postoperative pain scores, opioid consumption, sedation score, ICU or hospital length of stay, or patient mortality. CONCLUSIONS: Inhaled volatile anesthesia and sedation facilitates faster extubation times in comparison with IV propofol for patient undergoing coronary artery bypass graft surgery.

Early results of treatment for congenital clubfoot using the Ponseti method.

The purpose of this study was to evaluate the early results of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot in patients treated in Children's Orthopaedic Clinic and Rehabilitation Department Medical University of Lublin between the years 2007-2011. Thirty-five patients with 47 idiopathic clubfeet were followed prospectively while being managed with the Ponseti method. Clubfoot severity was graded with use of the Dimeglio system. The initial correction was achieved, and early results were measured by using Pirani scoring method.

Quantification of mitral valve anatomy by three-dimensional transesophageal echocardiography in mitral valve prolapse predicts surgical anatomy and the complexity of mitral valve repair.

BACKGROUND: Three-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than two-dimensional (2D) TEE in the qualitative assessment of mitral valve (MV) prolapse (MVP). However, the accuracy of 3D TEE in quantifying MV anatomy is less well studied, and its clinical relevance for MV repair is unknown. METHODS: The number of prolapsed segments, leaflet heights, and annular dimensions were assessed using 2D and 3D TEE and compared with surgical measurements in 50 patients (mean age, 61 ± 11 years) who underwent MV repair for mainly advanced MVP. RESULTS: Three-dimensional TEE was more accurate (92%-100%) than 2D TEE (80%-96%) in identifying prolapsed segments. Three-dimensional TEE and intraoperative measurements of leaflet height did not differ significantly, while 2D TEE significantly overestimated the height of the posterior segment P1 and the anterior segment A2. Three-dimensional TEE quantitative MV measurements were related to surgical technique: patients with more complex MVP (one vs two to four vs five or more prolapsed segments) showed progressive enlargement of annular anteroposterior (31 ± 5 vs 34 ± 4 vs 37 ± 6 mm, respectively, P = .02) and commissural diameters (40 ± 6 vs 44 ± 5 vs 50 ± 10 mm, respectively, P = .04) and needed increasingly complex MV repair with larger annuloplasty bands (60 ± 13 vs 67 ± 9 vs 72 ± 10 mm, P = .02) and more neochordae (7 ± 3 vs 12 ± 5 vs 26 ± 6, P < .01). CONCLUSIONS: Measurements of MV anatomy on 3D TEE are accurate compared with surgical measurements. Quantitative MV characteristics, as assessed by 3D TEE, determined the complexity of MV repair.

Early complications and immediate postoperative outcomes of paravalvular leaks after valve replacement surgery.

OBJECTIVES: To evaluate the incidence of perivalvular leaks (PVLs) after valve replacement and assess its impact on immediate postoperative outcomes. DESIGN: A retrospective review. SETTINGS: A tertiary care university hospital. PARTICIPANTS: Four hundred forty-two consecutive patients undergoing aortic (AVR) and/or mitral (MVR) valve replacement. MEASUREMENTS AND MAIN RESULTS: All patients had comprehensive intraoperative transesophageal echocardiography. Follow-up transthoracic echocardiography was performed at 5 to 7 days and 1 year after surgery. PVLs were classified as trace, mild, moderate, and severe. Perioperative variables including demographic data, surgical characteristics including the degree of valve calcification, and postoperative outcomes were compared between patients with and without PVLs. Multivariate logistic regression analysis was used to identify the variables predictive of PVLs. PVLs were identified in a total of 53 (12%) patients, 29 (13%) after MVR and 24 (11%) after AVR. At the 1-year transthoracic echocardiographic follow-up, 2 (7%) of 27 patients had residual PVLs after MVR and none after AVR. The duration of cardiopulmonary bypass (CPB) was predictive of PVLs. The presence of PVLs was associated with postoperative sepsis. CONCLUSIONS: The incidence of PVLs was similar after MVR and AVR. Bioprosthetic MVR and mechanical AVR were associated with higher-incidence PVLs when compared with controls. Mitral annular calcification was a potential risk factor for PVLs with bioprosthetic valves. The prolonged CPB time was predictive of PVLs. After adjusting for covariates, the overall presence of PVLs was associated with an increased risk of sepsis after surgery.

The effect of nasogastric tube application during cardiac surgery on postoperative nausea and vomiting--a randomized trial.

OBJECTIVE: Postoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV. DESIGN: This study was a prospective randomized controlled trial. SETTING: University tertiary referral center. PARTICIPANTS: Two hundred two patients undergoing elective cardiac procedures. INTERVENTIONS: Patients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: One hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures. CONCLUSIONS: Use of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting.

Left-sided migration of Sideris button atrial septal occluder device.

We report the case of a left-sided migrated 'Sideris button' atrial septal defect occlusion device 6 years post-implantation with a residual secundum atrial septal defect and left atrial mass. The aims of this case report are to highlight an uncommonly seen atrial septal occlusion device, the importance of a complete echocardiographic examination of the path traversed by the device to assess for local trauma to structures, and the additional anatomical information gained and diagnostic use of intraoperative 3D transoesophageal echocardiography.

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.

BACKGROUND: Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect. RESULTS: Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77). CONCLUSIONS: Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Prevalence of claustrophobia and magnetic resonance imaging after coronary artery bypass graft surgery.

BACKGROUND: The purpose of this study was to determine the prevalence of claustrophobia in patients undergoing magnetic resonance imaging (MRI) after coronary artery bypass graft (CABG) surgery. METHODS: After IRB approval, we conducted a substudy of a prospective randomized controlled clinical trial of 311 patients evaluating administration of tranexamic acid and early saphenous vein graft patency with MRI after conventional CABG surgery. Chest tube drainage was measured at 6, 12, and 24 hours after surgery. The rate of transfusion and the amount of red blood cells (RBC), fresh frozen plasma (FFP), and platelets transfused were recorded. RESULTS: A total of 237(76%) patients underwent MRI after surgery. 39 (14%, [95% CI, 10.2 to 18.0]) patients experienced severe anxiety caused by a fear of enclosed space in the MRI coil necessitating termination of the procedure. Patients with claustrophobia were on average 5 years younger. They were more likely to have diabetes mellitus and hypertension. Patients with claustrophobia had increased chest tube drainage during the postoperative period. The rate of blood product transfusion was similar between the two groups but patients with claustrophobia who were transfused received significantly more RBC and FFP than patients without claustrophobia. CONCLUSIONS: Postoperative claustrophobia and anxiety, leading to inability to undergo MRI, may be more common than previously described.

A comparison of aprotinin and lysine analogues in high-risk cardiac surgery.

BACKGROUND: Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic acid or aminocaproic acid in decreasing massive postoperative bleeding and other clinically important consequences. METHODS: In this multicenter, blinded trial, we randomly assigned 2331 high-risk cardiac surgical patients to one of three groups: 781 received aprotinin, 770 received tranexamic acid, and 780 received aminocaproic acid. The primary outcome was massive postoperative bleeding. Secondary outcomes included death from any cause at 30 days. RESULTS: The trial was terminated early because of a higher rate of death in patients receiving aprotinin. A total of 74 patients (9.5%) in the aprotinin group had massive bleeding, as compared with 93 (12.1%) in the tranexamic acid group and 94 (12.1%) in the aminocaproic acid group (relative risk in the aprotinin group for both comparisons, 0.79; 95% confidence interval [CI], 0.59 to 1.05). At 30 days, the rate of death from any cause was 6.0% in the aprotinin group, as compared with 3.9% in the tranexamic acid group (relative risk, 1.55; 95% CI, 0.99 to 2.42) and 4.0% in the aminocaproic acid group (relative risk, 1.52; 95% CI, 0.98 to 2.36). The relative risk of death in the aprotinin group, as compared with that in both groups receiving lysine analogues, was 1.53 (95% CI, 1.06 to 2.22). CONCLUSIONS: Despite the possibility of a modest reduction in the risk of massive bleeding, the strong and consistent negative mortality trend associated with aprotinin, as compared with the lysine analogues, precludes its use in high-risk cardiac surgery. (Current Controlled Trials number, ISRCTN15166455 [controlled-trials.com].).

Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery.

BACKGROUND: Patients with aortic atheroma are at increased risk for neurological injury after coronary artery bypass graft (CABG) surgery. We sought to determine the role of epiaortic ultrasound scanning for reducing cerebral embolic load, and whether its use leads to changes of planned intraoperative surgical management in patients undergoing CABG surgery. METHODS: Patients >70-yr-of-age scheduled for CABG surgery were prospectively randomized to either an epiaortic scanning (EAS) group (aortic manipulation guided by epiaortic ultrasound) or a control group (manual aortic palpation without EAS). All patients received a comprehensive transesophageal echocardiographic examination. Transcranial Doppler (TCD) was used to monitor the middle cerebral arteries for emboli continuously from 2 min before aortic cannulation to 2 min after aortic decannulation. Neurological assessment was performed with the National Institute of Health stroke scale before surgery and at hospital discharge. The NEECHAM confusion scale was used for assessment and monitoring of patient global cognitive function on each day after surgery until hospital discharge. RESULTS: Intraoperative surgical management was changed in 16 of 55 (29%) patients in the EAS group and in 7 of 58 (12%) patients in the control group (P = 0.025). These changes included adjustments of the ascending aorta cannulation site for cardiopulmonary bypass (CPB), the avoidance of aortic cross-clamping by using ventricular fibrillatory arrest during surgery, or by conversion to off-pump surgery. During surgery, 7 of 58 (12%) patients in the control group crossed over to the EAS group based on the results of manual aortic palpation. The median [range] TCD detected cerebral embolic count did not differ between the EAS and control groups during aortic manipulations (EAS, 11.5 [1-516] vs control, 22.0 [1-160], P = 0.91) or during CPB (EAS, 42.0 [4-516] vs control, 63.0 [5-758], P = 0.46). The NEECHAM confusion scores and National Institute of Health stroke scale scores were similar between the two groups. CONCLUSIONS: These results show that the use of EAS led to modifications in intraoperative surgical management in almost one-third of patients undergoing CABG surgery. The use of EAS did not lead to a reduced number of TCD-detected cerebral emboli before or during CPB.

External compression of superior vena cava after the replacement of ascending aorta.

We present a rare complication after open-heart surgery resulting in compression of the superior vena cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology. A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT obstructions. A comprehensive TEE exam should always be performed, and all the structures should be visualized for the proper diagnosis and management of patients after cardiac surgery.

Continuous-flow cell saver reduces cognitive decline in elderly patients after coronary bypass surgery.

BACKGROUND: Cerebral microembolization during cardiopulmonary bypass may lead to cognitive decline after cardiac surgery. Transfusion of the unprocessed shed blood (major source of lipid microparticulates) into the patient during cardiopulmonary bypass is common practice to reduce blood loss and blood transfusion. Processing of shed blood with cell saver before transfusion may limit cerebral microembolization and reduce cognitive decline after surgery. METHODS AND RESULTS: A total of 226 elderly patients were randomly allocated to either cell saver or control groups. Anesthesia and surgical management were standardized. Epiaortic scanning of the proximal thoracic aorta was performed in all patients. Transcranial Doppler was used to measure cerebral embolic rates. Standardized neuropsychological testing was conducted 1 week before and 6 weeks after surgery. The raw scores for each test were converted to Z scores, and then a combined Z score of 10 main variables was calculated for both study groups. The primary analysis was based on dichotomous composite cognitive outcome with a 1-SD rule. Cognitive dysfunction was present in 6% (95% confidence interval, 1.3% to 10.7%) of patients in the cell saver group and 15% (95% confidence interval, 8% to 22%) of patients in the control group 6 weeks after surgery (P=0.038). The severity of aortic atheroma and cerebral embolic count were similar between the 2 groups. CONCLUSIONS: The present report demonstrates that processing of shed blood with cell saver results in clinically significant reduction in postoperative cognitive dysfunction after cardiac surgery. These findings emphasize the clinical importance of lipid embolization in contributing to postoperative cognitive decline in patients exposed to cardiopulmonary bypass.

Effects of alveolar recruitment on arterial oxygenation in patients after cardiac surgery: a prospective, randomized, controlled clinical trial.

OBJECTIVE: Pulmonary atelectasis and hypoxemia remain considerable problems after cardiac surgery. The objective of this study was to determine the efficacy of consecutive vital capacity maneuvers (C-VCMs) to improve oxygenation in patients after cardiac surgery. STUDY DESIGN: Randomized, controlled clinical trial. SETTING: Tertiary referral teaching center. PARTICIPANTS: Ninety-five patients requiring elective cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTION: Patients were randomly allocated to either C-VCM or control groups. In the C-VCM group, lung inflation at pressure of 35 cmH(2)O was sustained for 15 seconds before separation from CPB and at 30 cmH(2)O for 5 seconds after admission to the intensive care unit (ICU). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the ratio of arterial oxygen tension to inspired oxygen fraction measured at the following predetermined time intervals: after induction of anesthesia, 15 minutes after separation from CPB, after admission to the ICU, after 3 hours of positive-pressure ventilation, after extubation, and before ICU discharge. C-VCM resulted in better arterial oxygenation extending from the immediate postoperative period to approximately 24 hours after surgery at the time of ICU discharge. There were no significant adverse events related to C-VCM application. CONCLUSION: C-VCM is an effective method to reduce hypoxemia associated with the formation of atelectasis after cardiac surgery with CPB.

The anesthesiologist's role in adults with congenital heart disease.

Anesthesia for adults with congenital heart disease has many challenging physiologic considerations. Collaborative relationships of a multidisciplinary team including cardiology, cardiac surgery, anesthesiology, and intensive care are essential to ensure positive outcomes in this population for noncardiac and cardiac surgery.