Pre-procedural high-pitch coronary CT angiography assessment of patients undergoing transcatheter aortic valve implantation (TAVI) without patient-specific adjustment: analysis of diagnostic performance.

AIM: To evaluate the ability to assess the coronary arteries using pre-procedural computed tomography (CT; high-pitch mode) in patients referred for transcatheter aortic valve implantation (TAVI). METHODS AND MATERIALS: CT and invasive coronary angiography (ICA) were performed pre-TAVI in 100 patients (46 women; 79 ± 5.9 years). CT was performed in prospectively ECG-triggered high-pitch mode after intravenous administration of 70 ml iodinated contrast medium. Image quality was assessed using a four-point scale (graded 0-3). Significant coronary artery stenosis (≥50% diameter) was graded as either present or absent by one observer and in one-third of patients by two observers independently. ICA was the standard of reference. Results were reported per segment and per patient. RESULTS: Twenty-two percent of patients had known coronary artery disease (CAD). In two cases, a coronary anomaly was detected. Diagnostic image quality (grade 1-3) was achieved in 30.3% of segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75%, 80.5%, 16%, and 98.5%, respectively. Significant coronary stenosis could be ruled out completely in all segments in three patients. The interrater agreement per patient was excellent (kappa = 1). CONCLUSION: Relevant coronary findings can frequently be observed in high-pitch TAVI-planning CT. Despite the limitations of the technique and in patients referred to pre-TAVI evaluation (rapid heart rate, coronary calcifications, etc.), a valid evaluation of coronary arteries is possible in a considerable proportion of segments with a high NPV; however, few studies were completely free of motion artefacts to dependably exclude CAD using this technique in this challenging group of patients.

[The effects of setting a standard in the acute pain therapy on a ward : Parameters for patient and provider satisfaction and cost structure (STANDAKU)]. / Auswirkung einer stationsweiten Standardisierung der Akutschmerztherapie : Parameter zur Patienten- und Providerzufriedenheit und Kostenstruktur (STANDAKU).

BACKGROUND: There is neither a "gold standard" nor commonly approved therapy goals in postoperative pain therapy. In a multi-center study, more than 80% of all patients treated stated that they suffered from postoperative pain. Moreover, patients evaluated the pain therapy as significantly worse than other medical or nursing practices. Therefore, there is a need for optimization in therapy for acute pain. OBJECTIVES: The goal of our project was to figure out if the introduction of a "pain treatment standard" would increase the satisfaction of patients, physicians, and nurses, and reduce the costs of pain-related medicine. MATERIALS AND METHODS: Overall, 2769 patients and 285 providers (202 nurses and 83 physicians) were polled. The medication costs in ten areas of the ward were evaluated and compared. The providers were offered a training course on the "pain standard" and it was officially introduced onto the wards. After some time, the satisfaction of patients and providers and the use of medicine were recorded again. RESULTS AND DISCUSSION: The maximum pain values declared by the patients significantly decreased after the introduction of the "pain standard." The satisfaction with pain therapy significantly increased for the patients and for the providers. The reported minimum pain values of the patients did not change significantly. The costs of pain medicine slightly increased. In general, there was a positive effect of introducing a "pain standard" for patients and providers.

What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

What are Palliative Care Physicians for Adults Taught on Palliative Care for Children? Paediatric Aspects in Palliative Care Curricula for Adults.

BACKGROUND: Children suffering from life limiting diseases are frequently cared for by adult palliative care teams due to missing paediatric structures in that field. However it is questionable whether palliative care curricula for physicians comprehensively cover issues of paediatric palliative care (PaedPC). AIM: To identify all PaedPC issues included in inter-professional or medical palliative care curricula (PCC) and to evaluate the breadth and quality of PaedPC issues covered in these curricula. DESIGN: Inter-professional or medical palliative care curricula (PCC) were identified by an extensive literature review in German and English using the search-engines Google as well as Medline, MedPilot and Pubmed. RESULTS: Worldwide 30 PCC were identified, with only 15 curricula mentioning any PaedPC issues. Of those 15 curricula, up to 22 PaedPC topics were highlighted in each. In 10 or more PaedPC following topics were highlighted: grief and bereavement in family, parents and siblings; communication with children; paediatric malignancies; pain management in PPC and pharmacology. In the majority of PCC curricula where PaedPC issues were identified the following topics were mentioned- grief and bereavement in the family, parents and siblings, communication with children, paediatric malignancies, paediatric pain management and pharmacology. CONCLUSIONS: The variability of inclusion of PaedPC issues and the lack of depth and standardisation of knowledge, skills and attitudes in PaedPC issues included in PCC curricula is not sufficient to guide adult palliative care physicians in their clinical work with children suffering from life limiting diseases.

Non-neurological, steroid-related adverse events in very low birth weight infants: a prospective audit.

BACKGROUND AND STUDY PURPOSE: To assess the incidence of cardiac and metabolic adverse events in very low birth weight (VLBW) infants receiving systematic steroids. PATIENTS AND METHODS: Prospective single centre audit in VLBW infants (<1,500 g) at the neonatal intensive care unit at the University Children's Hospital of Saarland, Germany. RESULTS: A total of 72 VLBW infants (38 female) were included in this report (mean birth weight: 967 ± 338 g; range: 320-1490 g). Birth weight, gestational age and Apgar scores were significantly lower in the steroid group (p <0.01). Mortality rate was 8/72 (7/34 in the steroid treated vs nontreated 1/38; odds ratio [OR]: 9.6; 95% confidence interval [CI]: 1.1-82.6 p = 0.02). In 34/72 infants, steroids were given (22 hydrocortisone alone; 12 combination of hydrocortisone and dexamethasone). The most common indication for use of steroids was respiratory distress syndrome (RDS) and respiratory insufficiency (30/34). Adverse events that occurred more often in the steroid group included hypertrophic cardiomyopathy (14/34 vs 0/38; p <0.001); thrombus formation (8/34 vs 1/38; OR: 11.4; 95% CI: 1.3-96.6; p <0.05), hyperglycaemia (27/34 vs 3/38; OR: 45.0; 95% CI: 10.6-190.4; p <0.01), hypernatraemia (15/34 vs 7/38; OR: 3.5; 95% CI: 1.2-10.1; p <0.05), and sepsis/infections (8/34 vs 1/38; OR: 11.4; 95% CI: 1.3-96.6; p <0.05). No significant differences were seen between hydrocortisone alone and the combination of hydrocortisone with dexamethasone. Birth weight and severity of RDS were predictors of steroid use (p <0.01). CONCLUSIONS: The use of steroids was significantly associated with severe short-term adverse events - most importantly hypertrophic cardiomyopathy and thrombus formation. These complications must be taken into consideration when administering steroids to VLBW infants.

Cardiogenic shock in a neonate with enterovirus myocarditis.

BACKGROUND: Left ventricular compromise in the neonate may be caused by birth asphyxia, metabolic disease, congenital heart disease, and systemic bacterial or viral infections. In rare cases, enterovirus infection may cause severe disease including cardiac, cerebral, hepatic and multi organ failure. PATIENTS AND METHODS: Case report. RESULTS: A 3-week-old neonate was admitted to our NICU in cardiogenic shock and severe lactic acidosis (ph: 6.9; serum lactate: 15 mmol/l, base excess: -19.8 mmol/l; pCO (2): 54.9 mm Hg). Serum troponin T was within the normal range; serum total creatinin phosphokinase was 57 U/l, CK-MB 110 U/l, LDH 762 U/l; pro-BNP: 64391 pg/ml was elevated. On echocardiography left ventricular function was depressed with a shortening fraction of 16%. The neonate was started on inotropes. There was gradual improvement over the following two weeks with normalisation of left ventricular output. PCR examination was positive for enterovirus. Other causes for left ventricular compromise (congenital heart disease, inborn errors of metabolism, etc.) were ruled out by adequate means. CONCLUSIONS: Enterovirus infection as a cause for myocarditis and cardiogenic shock should be taken into the differential diagnosis in neonates.

Pallister-Killian Syndrome (PKS) as a Cause of Mental Retardation.

Pallister-Killian syndrome (PKS; OMIM: # 601803) is a rare sporadic syndrome of multiple congenital anomalies attributable to the presence of a de novo mosaic supernumerary isochromosome 12p [i(12p)]. The syndrome presents with a recognizable pattern of findings including: pigmentary skin changes, characteristic facial features (sparse anterior scalp hair, flattened midface, macrostomia, and coarsening of the facial features), and developmental delay. The developmental phenotype of PKS is quite variable, but most are considered to fall into the profound range of developmental retardation. We report on two individuals with classical features of PKS. Notably, in one child the neuropsychological development was significantly more favourable than commonly reported in the literature. This illustrates the loose correlation between geno- and phenotype in PKS.

Acupuncture to alleviate chemotherapy-induced nausea and vomiting in pediatric oncology - a randomized multicenter crossover pilot trial.

BACKGROUND: We investigated whether acupuncture as a supportive antiemetic approach reduces the need for antiemetic rescue medication during highly emetogenic chemotherapy in pediatric oncology. We report on a multicenter crossover study at 5 tertiary hospitals in Germany. PROCEDURE: Twenty-three children (13.6 y,+/- 2.9) receiving highly emetogenic chemotherapy for treatment of solid malignant tumors were included. Patients were randomly allocated to receive acupuncture treatment during either the second or third identical chemotherapy course together with standard antiemetic medication. The main outcome measure was the amount of additional antiemetic medication during chemotherapy. Secondary outcome measure was the number of episodes of vomiting per course. RESULTS: Fourty-six chemotherapy courses with or without acupuncture were compared. The need for rescue antiemetic medication was significantly lower in acupuncture courses compared to control courses (p=0.001) Episodes of vomiting per course were also significantly lower in courses with acupuncture (p=0.01). Except for pain from needling (4/23) no side effects occurred. Patients acceptance of acupuncture was high. CONCLUSIONS: Acupuncture as applied here seems to be effective in preventing nausea and vomiting in pediatric cancer patients.

Vasopressin in catecholamine-refractory shock in children.

Severe septic and cardiogenic shock is associated with a high mortality in neonates, children and adolescents. Common therapies include the administration of fluids and the use of conventional inotropes. However, in severe forms of shock, cardio-circulatory failure may be secondary to profound vasoparalysis and unresponsive to conventional therapies. We reviewed the literature on the use of arginine-vasopressin (AVP) and terlipressin (TP) as a rescue therapy in neonates, children and adolescents with catecholamine-refractory shock or cardio-circulatory arrest. We identified 17 reports (11 case series, 6 case reports) on a total of 109 patients. Only two studies were prospective. The age of treated patients ranged from extremely low birth weight infants of 23 weeks' gestation to a 19-year-old adolescent. The most common indication for either drug was catecholamine-refractory septic shock (nine reports). Commonly reported responses following AVP/TP administration were a rapid increase in systemic arterial blood pressure, an increase in urine output, and a decrease in serum lactate. In most reports, AVP and TP had a significant impact on the required dose of inotropes which could be reduced. Despite the use of AVP/TP, mortality was high (52/109). In view of the limited number of paediatric patients treated with AVP/TP, no definite recommendations on their use in children with severe forms of cardio-circulatory failure can be issued. There is a need for larger prospective trials assessing the efficacy and safety profiles of these drugs in a defined setting. Until more data are available, and taking into consideration the detrimental impact catecholamine-refractory shock has on children, the use of AVP/TP as a rescue therapy should be considered on an individual basis.

Recent trends in the burden of alcohol intoxication on pediatric in-patient services in Germany.

AIMS: To elicit data on alcohol intoxications requiring in-patient treatment in children and adolescents in Germany between 2000 and 2002. DESIGN AND PARTICIPANTS: An ex-post analysis was performed to assess the number of children and adolescents (age 10-17 years) with acute alcohol intoxications requiring in-patient hospital treatment (> or =24 hours). SETTING: 22 major children hospitals in Germany. FINDINGS: The number of acute alcohol intoxications requiring in-patient treatment increased from 227 in 2000 to 313 in 2001 (+37.9%; p*<.01) and 350 in 2002 (+10.6%; p*<.05). 10-12 year-old children comprised 2.2%, adolescents aged 13-14 years 28.6%, and adolescents aged 15-17 years 69.2% of the study population. The most significant increase was seen in adolescents aged 13-14 years (2001: +35.9%, and 2002: +19.3%; p*<.05), and 15-17 years (2001: +59.1%, and 2002: +10.1%; p*<.05). The percentage of female patients increased from 34.1% in 2000 to 41.9% in 2001 and 49.8% in 2002 (p*<.05). Mean time spent in the hospital was 1.7 days (range: 1 day-->4 days). DISCUSSION AND CONCLUSIONS: This is one of the very few studies that provide epidemiological data on the specific issue of alcohol intoxications in children and adolescents that require in-patient treatment. Apparently, gender differences seem to play a minor role in alcohol-related hospital admissions. Our data demonstrate that excessive alcohol consumption remains an issue of concern in this age cohort.

Unintentional household poisoning in children.

Despite the major reduction in fatal paediatric poisonings that has been achieved in industrialised countries over the last few decades, unintentional paediatric poisoning remains a major public health issue worldwide. In this article, we aim to provide clinicians dealing with poisoned children an overview of the problem and specific guidance on the identification and management of significant poisoning. Substances most frequently ingested by children in the developed world include household chemicals, medication, and plants. Although the great majority of such poisonings have no or limited clinical effects, it puts substantial burden on health care systems. Importantly, a few poisons can kill after ingestion of very small amounts. Unintentional poisoning in developing countries can be much more serious, following ingestion of kerosene, caustic agents, herbal remedies, insecticides or herbicides. Management of symptomatic patients involves supportive care, if available the administration of antidotes, and the removal of the offending drug from the body. Recent position papers on gastric decontamination indicate that such interventions are only rarely necessary. To further reduce the number of deaths and disabilities in the industrialised world and to begin to have an effect in the developing world, much more work is required to both identify and implement prevention strategies to reduce the number of cases of paediatric poisoning.

Effect of propofol on seizure-like phenomena and electroencephalographic activity in children with epilepsy vs children with learning difficulties.

There is an ongoing debate as to whether propofol exhibits pro- or anticonvulsant effects, and whether it should be used in patients with epilepsy. We prospectively assessed the occurrence of seizure-like phenomena and the effects of intravenous propofol on the electroencephalogram (EEG) in 25 children with epilepsy (mean (SD) age: 101 (49) months) and 25 children with learning difficulties (mean (SD) age: 52 (40) months) undergoing elective sedation for MRI studies of the brain. No child demonstrated seizure-like phenomena of epileptic origin during and after propofol sedation. Immediately after stopping propofol, characteristic EEG changes in the epilepsy group consisted of increased beta wave activity (23/25 children), and suppression of pre-existing theta rhythms (11/16 children). In addition, 16 of 18 children with epilepsy and documented EEG seizure activity demonstrated suppression of spike-wave patterns after propofol sedation. In all 25 children with learning difficulties an increase in beta wave activity was seen. Suppression of theta rhythms occurred in 11 of 12 children at the end of the MRI study. In no child of either group was a primary occurrence or an increase in spike-wave patterns seen following propofol administration. The occurrence of beta wave activity (children with learning difficulties and epilepsy group) and suppression of spike-wave patterns (epilepsy group) were transient, and disappeared after 4 h. This study demonstrates characteristic, time-dependent EEG patterns induced by propofol in children with epilepsy and learning difficulties. Our data support the concept of propofol being a sedative-hypnotic agent with anticonvulsant properties as shown by depression of spike-wave patterns in children with epilepsy and by the absence of seizure-like phenomena of epileptic origin.