Topical instillation of vancomycin lowers the rate of CSF shunt infections in children.

INTRODUCTION: Shunt surgery in pediatric patients still bears a significant risk of infection, in addition to mechanical complications of the shunt system. Antibiotic-impregnated systems and perioperative antibiotics have been extensively studied for their potential to reduce shunt infections. We examined the effectiveness of intrawound application of vancomycin powder during shunt surgery. PATIENTS AND METHODS: Patient records of 78 primary shunt implantations at a mean age of 40 months were reviewed. In total, 52 patients (mean age 50 months) had been treated according to standard surgical and perioperative procedures (Std), whereas 26 patients (mean age 20 months) additionally had received topical application of vancomycin powder before wound closure (Vmc). Overall infection rate was 3.8%, in Std patients 5.8%, and in Vmc patients 0%. The rates of CSF fistula and revision surgery were similar in both groups (5.8% vs 8% and 23.1% vs. 30%, respectively). CONCLUSION: To the best of our knowledge, this is the first report on topical vancomycin instillation, indicating its efficacy for the prevention of shunt infection in pediatric patients. Further studies with a higher number of patients are needed to verify this finding.

Adult long-term outcome of patients after congenital hydrocephalus shunt therapy.

INTRODUCTION: Even though shunt surgery has been an established and widely accepted treatment for congenital hydrocephalus for five decades, long-term follow-up and functional outcome data is rare. PATIENTS AND METHODS: Sixty-nine patients were examined after congenital hydrocephalus had been treated between 1971 and 1987 at the Department of Pediatric Surgery (University of Leipzig) within the first 12 months of life. Median age of patients was 32 years (range 25-42 years). Patients agreed to undergo a contemporary hydrocephalus assessment. RESULTS: Seven patients (10.1%) became shunt-independent before adulthood. By the age of 20, 82% of the patients had needed at least one shunt revision, 100% by the age of 30. 21.7% of the primary valves (Spitz-Holter) remained intact without revision until today up to 35 years (mean functional intactness 23 years). Shunt infections occurred in 4.3% of primary implantations. 48% of the patients had a good functional outcome (mRS = 0-1). 40.9% of the patients attended regular school. In summary, 75% patients work on a daily basis. 44.6% live an independent life, 35.4% rely on parental supervision, and 20% depend on professional care institutions. CONCLUSION: Compared to the pre-shunt era, surgery within the first year of life is advantageous regarding visual function, educational progress, and social results. The outcome achieved throughout childhood remains stable during adult life as long as catastrophic events of shunt malfunction can be prevented. Epilepsy, motor deficits, acute shunt dysfunction, and problems of social integration as well as aging parental caregivers seem to be prominent factors of morbidity in adulthood.

[Age-dependent visceral medicine: paediatric visceral medicine - visceral medical paediatrics - considerations on the short bowel syndrome in childhood]. / Altersabhängige Viszeralmedizin: pädiatrische Viszeralmedizin - viszeralmedizinische Pädiatrie - Überlegungen zum Kurzdarmsyndrom im Kindesalter.

There are several reasons for the possible development of a short bowel syndrome, which, however, occurs only rarely. The main causes consist of extended intestinal resections in cases of congenital anomalies (e.g., gastroschisis, intestinal atresia or dysplasia) or ischaemic lesions due to a volvulus. In addition, an intestinal stoma at a more upper segment of the GI tract can result in the functional manifestation of a short bowel syndrome. The differentiation between temporary and persisting types is essential for initiation of an adequate treatment. Loss or exclusion of organic resorption area at the inner surface of the (small) intestine can be associated with numerous pathological consequences requiring treatment. As a principle consideration from the paediatric point of view, the potential of intestinal adaptation needs to be assessed. Basic conservative treatment options are parenteral and enteral nutrition regimens, in particular, to prevent complications (such as D-lactate acidosis). The main surgical approaches are the procedures called LILT (longitudinal intestinal lengthening and tailoring) according to Bianchi and STEP (serial transverse enteroplasty). The technique to create intestinal segments of antiperistalsis has been abandoned. Because of the encouraging results of intestinal transplantation, this novel treatment option has gained greater attention over the past few years and is now also an option for paediatric patients. The limiting factor and thus major complication is the central venous catheter for long-term treatment. Catheter-related complications are still the main reason for a considerable mortality in these children.

Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? Results of a prospective randomized experimental trial comparing three major antireflux operations in a porcine model.

BACKGROUND: Gastroesophageal reflux disease (GERD) is among the most common dysfunctions of the upper gastrointestinal tract. It interferes with quality of life and is a risk factor for the development of adenocarcinoma in the lower esophagus. Laparoscopic fundoplication is an effective treatment of GERD, but the physiologic mechanisms of the different available procedures had not been investigated to date. METHODS: In this study, 28 German Landrace pigs underwent baseline manometry and 24-h pH monitoring followed by myotomy to induce reflux esophagitis. After new-onset reflux was proved, the pigs were randomized to groups based on four treatments: total fundoplication, anterior hemifundoplication, posterior hemifundoplication, and control. On days 10 and 60 after the intervention, the effectiveness of the different fundoplication modifications was compared with that of the control subjects by 24-h pH monitoring manometry. Finally, the pigs were killed, after which the minimum volume and pressure required to breach the gastroesophageal junction were recorded. RESULTS: After myotomy, a significant increase in the reflux could be confirmed. The findings after fundoplication showed a significant decrease in the fraction of time that the pH fell below four and an increase in the vector volume compared with the measurement after myotomy. Total fundoplication and posterior hemifundoplication were highly effective, whereas measurements after anterior fundoplication still showed increased fraction times. Pharmacologic stimulation with pentagastrin showed an increase in the vector volume of the esophageal sphincter. CONCLUSIONS: Total fundoplication and posterior hemifundoplication are potent operations for the treatment of GERD. Anterior hemifundoplication reduces the reflux as well, but the effects are significantly less than with total and posterior fundoplication. Pharmacologic stimulation showed excellent results after posterior hemifundoplication, and a tendency to overcorrection was shown after total fundoplication.

[Laparoendoscopic single site cholecystectomy (LESS) in a 16-year-old girl: the way to go even in pediatric surgery?]. / Laparoendoskopische Single-Site-Cholezystektomie (LESS) bei einem 16-jährigen Mädchen: Ein Weg auch für die Kinderchirurgie?

The laparoscopic paradigm to place different ports according to ergonomic principles is presently challenged by laparoendoscopic single site surgery (LESS). Its objective is to perform a complex task with several instruments using only one access. However, this approach introduces distinct ergonomic problems and requires innovative technical solutions to allow for more complex surgical tasks. In paediatric surgery, this development has just begun. A 16-year-old girl presented with a symptomatic cholecystolithiasis. A multi-channel TriPort (Advanced Surgical Concepts) was introduced through a 20 mm umbilical incision for LESS cholecystectomy. Retraction of the gallbladder was facilitated by a straight grasper, which was inserted transabdominally. For exposition and triangulation a pre-bend dissector (5 mm, Olympus) was employed. Thus, the cystic duct and artery could be exposed, clipped (5mm) and divided. Finally, the gallbladder was dissected from its bed and extracted into a specimen bag. Operating time was 90 minutes and no intra- or postoperative complications occurred. In conclusion, a multi-channel port and angulated instruments during LESS cholecystectomy provided ergonomics close to conventional laparoscopic surgery. For smaller children though, this technology will have to be adapted to their geometry. Finally, even though LESS seems attractive, the present euphoria should not turn into scientific acceptance, until more experience is available and valid data have proven a benefit for patients of any age.

Ambulatory long-term pH monitoring in pigs.

BACKGROUND: pH monitoring has been established as the "gold standard" in the diagnosis of gastroesophageal reflux. Evaluation of experimental antireflux therapy should therefore also include this technique, but a suitable technique in an experimental model did not exist so far. The aim of our study was to establish a reliable method for the evaluation of an experimental reflux model in pigs. METHODS: A total of 33 German Landrace pigs with an average body weight of 56 (50.2-67.2) kg were included. pH monitoring was performed before and after open cardiomyotomy in each animal. All manipulations were performed under general anesthesia. After manometric localization of the gastroesophageal high-pressure zone, a standard pH probe was inserted into the pharynx through a small needle-punctured canal on the side of the animal's snout and placed under endoscopic guidance with the proximal sensor 3 cm above the lower esophageal sphincter (LES) and the distal sensor in the stomach for reference. The harness to carry the pH recorder on the animal's back consisted of a modified belly strap that enabled the animal to move around without limitation. For analysis the same threshold levels were defined as in humans. Gastroesophageal reflux was induced by cardiomyotomy. RESULTS: The placement of the standard pH probe was possible in all cases. Inserting the probe on the side of the snout left the animals free to nuzzle, which complies with the normal habits of pigs, without breaking the probes and without being compromised in their natural behavior. Repeated punctures for multiple measurements were easily feasible. We performed up to three examinations in each individual animal. Recording was performed for 48 h. A mean number of 67.3 (+/-9.7) acidic refluxes were registered. The mean number of long acidic refluxes was 3.2 (+/-0.75). For an average total time of 75.5 (+/-14.3) min the pH was below 4 accounting for a fraction time pH below 4 of 3.5% (+/-0.68%). Following cardiomyotomy the number of acidic refluxes increased significantly to 166.1 (+/-21.8) and the number of long refluxes to 17.74 (+/-3.35). The total time of pH below 4 increased to 371.3 (+/-62) min so that the fraction time pH below 4 was 14.5% ( p = 0.0006). CONCLUSION: pH monitoring should be mandatory in any investigation of antireflux therapy. Our method is easy and secure to perform. It is suitable for other gastrointestinal investigations (Bilitec, long-term manometry) that could be carried out using the same technique. The described data represent the basis for other investigations of experimental antireflux therapy.

[Toxicological evaluation of diagnostic methods used for poisoning with psychoactive substances]. / Ocena toksykologiczna metod diagnostycznych stosowanych w zatruciach srodkami psychoaktywnymi.

Toxicological diagnosis in cases of intoxication with psychoactive substances known in clinical and forensic toxicology requires appropriate laboratory studies. The paper pertains evaluation of the currently employed techniques of quantitative and qualitative analysis of psychoactive substances in a biological material. Usefulness of the most frequently applied screening (immunochemical) approaches and the confirmation (physicochemical) techniques was evaluated against the validation criteria, relating to the specificity, detection limit and sensitivity of the discussed substances.

Chemical characterization of decomposition products of pyrazolidinedione-3,5 derivatives. Part 1: Identification of decomposition products and mechanism of degradation of 4-prenyl-1,2-diphenyl-3,5-pyrazolidine-dione in an aqueous solution.

From an aqueous solution of 4-prenyl-1,2-diphenyl-3,5-pyrazolidinedione sodium salt (Prenazone) subjected to accelerated ageing at 80 degrees C in anaerobic and in aerobic conditions the following decomposition products were isolated: N,N'-diphenylhydrazide-5-methyl-4-hexenoic acid,N,N'-diphenylhydrazide-2-carboxy-5-methyl-4-hexenoic acid, N,N'-diphenylhydrazide-2-carboxy-2-hydroxy-5-methyl-4-hexenoic acid, trans- and cis-azobenzene. The isolated compounds were identified by means of thin-layer chromatography, elemental analyses, UV, IR spectrophotometry and taking into consideration their chemical transformations. A decomposition mechanism of Prenazone Sodium in aqueous solutions maintained at 80 degrees C is proposed.

Chemical characterization of decomposition products of pyrazolidinedione-3,5 derivatives. Part 2: Chemical transformations of 4-prenyl-1,2-diphenyl-3,5-pyrazolidinedione (prenazone) and its main decomposition product N,N'-diphenylhydrazide-2-carboxy-5-methyl-4-hexenoic acid in sulphuric acid concentrated.

4-Prenyl-1,2-diphenyl-3,5-pyrazolidinedione (prenazone) in the medium of sulphuric acid concentrated (92-98%) undergoes an intramolecular rearrangement to 6',6'-dimethyl-4',5'-dihydropyrane-[2',3'-d]-1,2-diphenyl-3-pyrazolinone. The main decomposition product of prenazone, formed due to the hydrolytic process in the above conditions, undergoes changes according to two parallel reactions. First, it is hydrolyzed to prenylmalonic acid and hydrazobenzene which is subsequently transformed to benzidine. The second reaction proceeds via cyclization to form prenazone as well as 6',6-dimethyl-4',5'-dihydropyrane [2',3'-d]-1,2-diphenyl-3-pyrazolinone.

Chemical investigation of decomposition processes of pyrazolidine-3,5-dione derivatives. Part 3. Kinetics and mechanism of degradation of ketazone in aqueous solutions and solid phase.

Kinetics of decomposition of Ketazone were studied in the Britton-Welford buffer solutions under anaerobic conditions, as well as in the solid state. The sequential type of reaction was found and the first order rate constants for hydrolysis (k1) and decarboxylation (k2) processes were calculated by the so-called "subtraction technique". Thermodynamic parameters were used for prediction of ketazone stability at 20 degrees C. S-shaped curves were obtained from the data of solid state kinetic studies. The decomposition products of Ketazone were isolated and identified by means of TLC, elemental analysis, UV and IR spectra and by their appropriate chemical transformations. The mechanisms of decomposition of Ketazone sodium in aqueous solutions and its acidic form in solid state are proposed.

Kinetics of drug decomposition. Part 38. Hydrolysis and autoxidation of sodium phenylbutazone and aminophenazone in binary kinetic system.

The kinetics of hydrolysis and autoxidation of sodium phenylbutazone (PhB-Na) and aminophenazone (APh) was studied in ammonia-acetate, Carmody and Welford buffers at different buffer concentration, pH, ionic strengths and temperatures. The reaction in N2 atmosphere and under a constant O2 pressure, carried out in calibrated ampoules, followed the first order reaction kinetics. The assay of PhB-Na and APh in the presence of their degradation produces was carried out spectrophotometrically in the degraded solutions.

Analysis of drug decomposition products. Part 34. Gas chromatography method for quantitative determination of METET in the presence of its sulfoxide.

Gas chromatographic method for the determination of METET in the presence of its oxydation product sulfoxide was worked out. The gas chromatographic conditions were: gas chromatograph--Chrom4CSSR,FID,N2-flow20--30cm3/min glass, column 100 cm, phi 0-2 cm, 10% SE-30 on Chromosorb W 100/120 mesh, temp. 180--200 degrees C. The determination was carried by means of internal standard (phenylbutazone--PhB--1,2-diphenyl 4n-butyl pyrazolidino-3,5-dione or aminophenazone--APh--1-phenyl-2,3-dimethyl-4-dimethylamino-pyrazolone-5) and the calibration curve was prepared. The ratio of peak heights for the determined comound and the standard was considered. The error of the METET determination expressed as standard percentage deviation was sr = 2--3% at n = 10.