Bloodstream infections in pediatric ECLS: usefulness of daily blood culture monitoring and predictive value of biological markers. The British Columbia experience

INTRODUCTION: The incidence of bloodstream infection (BSI) in extracorporeal life support (ECLS) is reported between 0.9 and 19.5%. In January 2006, the Extracorporeal Life Support Organization (ELSO) reported an overall incidence of 8.78% distributed as follows: respiratory: 6.5% (neonatal), 20.8% (pediatric); cardiac: 8.2% (neonatal) and 12.6% (pediatric). METHOD: At BC Children's Hospital (BCCH) daily surveillance blood cultures (BC) are performed and antibiotic prophylaxis is not routinely recommended. Positive BC (BC+) were reviewed, including resistance profiles, collection time of BC+, time to positivity and mortality. White blood cell count, absolute neutrophile count, immature/total ratio, platelet count, fibrinogen and lactate were analyzed 48, 24 and 0 h prior to BSI. A univariate linear regression analysis was performed. RESULTS: From 1999 to 2005, 89 patients underwent ECLS. After exclusion, 84 patients were reviewed. The attack rate was 22.6% (19 BSI) and 13.1% after exclusion of coagulase-negative staphylococci (n = 8). BSI patients were significantly longer on ECLS (157 h) compared to the no-BSI group (127 h, 95% CI: 106-148). Six BSI patients died on ECLS (35%; 4 congenital diaphragmatic hernias, 1 hypoplastic left heart syndrome and 1 after a tetralogy repair). BCCH survival on ECLS was 71 and 58% at discharge, which is comparable to previous reports. No patient died primarily because of BSI. No BSI predictor was identified, although lactate may show a decreasing trend before BSI (P = 0.102). CONCLUSION: Compared with ELSO, the studied BSI incidence was higher with a comparable mortality. We speculate that our BSI rate is explained by underreporting of "contaminants" in the literature, the use of broad-spectrum antibiotic prophylaxis and a higher yield with daily monitoring BC. We support daily surveillance blood cultures as an alternative to antibiotic prophylaxis in the management of patients on ECLS.

Exploration of the role of serum factors in maintaining bone mass during hibernation in black bears

Disuse osteoporosis is a condition in which reduced mechanical loading (e.g. bed-rest, immobilization, or paralysis) results in unbalanced bone turnover. The American black bear is a unique, naturally occurring model for the prevention of disuse osteoporosis. Bears remain mostly inactive for up to half a year of hibernation annually, yet they do not lose bone mechanical strength or structural properties throughout hibernation. The long-term goal of this study is to determine the biological mechanism through which bears maintain bone during hibernation. This mechanism could pinpoint new signaling pathway targets for the development of drugs for osteoporosis prevention. In this study, bone specific alkaline phosphatase (BSALP), a marker of osteoblast activity, and tartrate resistant acid phosphatase (TRACP), a marker of osteoclast number, were quantified in the serum of hibernating and active black bears. BSALP and TRACP decreased during hibernation, suggesting a balanced reduction in bone turnover. This decrease in BSALP and TRACP were correlated positively to serum adiponectin and inversely to serum neuropeptide Y, suggesting a possible role of these hormones in suppressing bone turnover during hibernation. Osteocalcin (OCN) and undercarboxylated OCN increased dramatically in the serum of hibernating bears. These increases were inversely correlated with adiponectin, glucose, and serotonin, suggesting that OCN may have a unique role in energy homeostasis during hibernation. Finally, MC3T3-E1 osteoblasts were cultured in the serum from active and hibernating bears, and seasonal cell responses were quantified. Cells cultured in serum from hibernating bears had a reduced caspase-3/7 response, and more living cells, after apoptotic threat. The caspase-3/7 response was positively correlated to serum adiponectin and to gene expression of OCN and Runx2, suggesting that reduced caspase-3/7 activity may be related to the reduced differentiation potential of osteoblasts in hibernation serum, and that adiponectin is a potential effector hormone. In summary, the activities of osteoblasts and osteoclasts are reduced during hibernation in bears. This reduced turnover is due, in part, to hormonal control. Further study of potential effectors adiponectin and neuropeptide Y may provide insight into the biological mechanism through which bears maintain bone throughout hibernation.

The use of polydimethylsiloxane for injection laryngoplasty

BACKGROUND: Injuries of the recurrent laryngeal nerve with consecutive vocal cord paralysis is a typical complication in chest, esophageal, thyroideal, and neck surgery. Glottic insufficiency secondary to such a lesion can be treated by endolaryngeal vocal cord augmentation (injection laryngoplasty). Many different substances have been used, often showing complications or disadvantages. This study reports on the use of injectable polydimethylsiloxane (PDMS), with special regard to the long-term results. METHODS: In this prospective study, 21 patients with unilateral vocal cord paralysis underwent injection laryngoplasty using PDMS at a volume of 0.5-1.0 ml. Preoperatively, 6 weeks and 12 months after the injection the following parameters concerning patients' voice were evaluated: Glottic closure by videolaryngostroboscopy, maximum phonation time, voice range, voice dynamic, jitter, shimmer, noise-to-harmonic-ratio, and roughness, breathiness, and hoarseness (RBH). In addition, patients were asked to give their own evaluation of how satisfied they felt with their voice and of the handicaps it caused them. RESULTS: Postoperatively an improvement was evident in all the parameters that were investigated, and this significant improvement was still in evidence for most of the parameters more than one year after the injection. In our study no complications were observed more than one year after injection. CONCLUSION: PDMS is a safe substance for injection laryngoplasty in unilateral vocal cord paresis. Objective and subjective parameters confirm its effectiveness. It is suitable for obtaining satisfying results in the reestablishment of the patient's voice and communication ability.

Postoperative sepsis in infants below 6 months of age

BACKGROUND: Sepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old. METHODS: We examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution. RESULTS: The rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05). CONCLUSIONS: Postoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigations.

Aseptic intussuscepted incidental appendectomy: three successful cases

BACKGROUND: Incidental appendectomy remains a controversial issue. We aimed to collect experience using a modified surgical technique that could be applied securely in infants. METHODS: We performed aseptic intussuscepted incidental appendectomy (AIIA) in three patients using a technique that is thought to assure appendix necrosis along with intact cecal wall. RESULTS: There was no perioperative morbidity due to AIIA in the three patients. In two infants the necrotic appendix was found in the diaper. One infant died secondary to diaphragmatic hernia. Autopsy with histological examination revealed that the cecum was intact along with appendix necrosis. CONCLUSIONS: Modified AIIA could securely be performed in the 3 reported cases. We advocate prospective evaluation of the method.

Unravelling the impact of microRNA on Amyotrophic Lateral Sclerosis (ALS) pathogenesis

ALS is the most common adult neurodegenerative disease that specifically affects upper and lower neurons leading to progressive paralysis and death. There is currently no effective treatment. Thus, identification of the signaling pathways and cellular mediators of ALS remains a major challenge in the search for novel therapeutics. Recent studies have shown that noncoding RNA molecules have a significant impact on normal CNS development and on causes and progression of human neurological disorders. To investigate the hypothesis that expression of the mutant SOD1 protein, which is one of the genetic causes of ALS, may alter expression of miRNAs thereby contributing to the pathogenesis of familial ALS, we compared miRNA expression in SH-SY5Y expressing either the wild type or the SOD1 protein using small RNA deep-sequencing followed by RT-PCR validation. This strategy allowed us to find a group of up and down regulated miRNAs, which are predicted to play a role in the motorneurons physiology and pathology. The aim of my work is to understand if these modulators of gene expression may play a causative role in disease onset or progression. To this end I have checked the expression level of these misregulated miRNAs derived from RNA-deep sequencing by qPCR on cDNA derived from ALS mice models at early onset of the disease. Thus, I’m looking for the most up-regulated one even in Periferal Blood Mononuclear Cell (PBMC) of sporadic ALS patients. Furthermore I’m functionally characterizing the most up-regulated miRNAs through the validation of bioinformatic-predicted targets by analyzing endogenous targets levels after microRNA transfection and by UTR-report luciferase assays. Thereafter I’ll analyze the effect of misregulated targets on pathogenesis or progression of ALS by loss of functions or gain of functions experiments, based on the identified up/down-regulation of the specific target by miRNAs. In the end I would define the mechanisms responsible for the miRNAs level misregulation, by silencing or stimulating the signal transduction pathways putatively involved in miRNA regulation.

The involvement of miRNA Dysregulation in Amyotrophic Lateral Sclerosis

ALS is a neurodegenerative disease that specifically affects upper and lower motor neurons leading to progressive paralysis and death. There is currently no effective treatment. Thus, identification of the signaling pathways and cellular mediators of ALS remains a major challenge in the search for novel therapeutic approaches. Recent studies have shown that non-coding RNAs have a significant impact on normal CNS development and onset and progression of neurological disorders. Based on this evidence we specifically test the hypothesis that misregulation of miRNA expression is a common feature in familiar ALS. Hence, we are exploiting human neuroblastoma cell lines either expressing the SOD1(G93A) mutation or depleted from Fused in Sarcoma (FUS) as tools to investigate the role of miRNAs in familiar ALS. To this end we performed a genome-wide scale miRNA expression on these cells, using whole-genome small RNA deep-sequencing followed by quantitative real time validation (qPCR). This strategy allowed us to find a group of dysregulated miRNAs, which are predicted to play a role in the motorneurons physiology and pathology. We verified our data on cDNA derived from SOD1-ALS mice models at early stage of the disease and on cDNA derived from lymphocytes from a small group of ALS patients. In the future, we plan to define the mechanisms responsible for the miRNA dysregulation, by silencing or stimulating the signal transduction pathways putatively involved in miRNA expression and regulation.

CT myelography for diagnosis of brachial plexus avulsion in small animals

Avulsion of nerve roots of the brachial plexus can be diagnosed clinically, neurologically, radiographically and by electromyography. But like the myelography these techniques are inprecise for determination of the severity (partial or complete disruption) and the localization of the lesion. In human medicine the combination of computerized tomography with myelography shows high accuracy. Veterinary reports of experience in this field are not yet known. The aim of the present study was to demonstrate nerve root avulsions using myelography and computerized tomography. Three dogs and one cat with traumatic lesions of the brachial plexus were examined. The lesion could be seen in all patients. Thus CT-myelography results in an improved prognostic assessment of brachial plexus paralysis. Moreover, this technique could become one of the most important diagnostic methods for brachial plexus lesions involving nerve root reinsertion--neurotizations in veterinary medicine.

Neurotisation zur Behandlung von peripheren Nervenverletzungen beim Hund: 5 Fälle

Five dogs with peripheral nerve injuries (3 radial nerve and 2 peroneal nerve paralysis) were presented at the Small Animal Clinic of the Freie University in Berlin, Germany and were treated with a new surgical technique. The patients were examinated clinically, neurologically and an electromyographic examination was performed. The surgical technique consisted in a direct transposition of a sound nerve in a paralysed muscle. After 12 weeks, 4 dogs were able to use their leg in a correct fashion. One dog showed an improvement of the clinical signs but remained unable to bear weight on his leg.

Perineal incision into the corpus spongiosum penis to resolve persistent post urination haemorrhage after partial phallectomy

Partial phallectomy or en bloc resection are surgical methods to address pathological conditions of the penis and/or prepuce including neoplasia, trauma, habronemiasis, chronic paraphimosis or permanent penile paralysis, and priapism. Haemorrhage associated with urination is a common complication observed after penile surgery but usually resolves spontaneously without specific treatment. This report describes a case of post urination haemorrhage (PUH) that recurred with each urination and persisted without significant improvement for a period of 2 weeks following en bloc resection of the penis and the prepuce. A perineal incision (PI) into the corpus spongiosum of the penis (CSP) resolved PUH by decreasing the blood pressure in the CSP distal to the PI. We propose that PI of the CSP can be an effective method to address PUH after penile surgery and may decrease time of hospitalisation for horses affected with PUH after phallectomy procedures.

Congenital cervical kyphosis in two young sighthounds

Introduction: Cervical vertebral (C) malformation is rarely reported in large breed dogs. Congenital cervical kyphosis (CCK) may result from defects of vertebral segmentation, failure of formation or both. This report describes two cases of C3-C4 CCK in young sighthounds, treated surgically. Case description: An 18-month-old female Deerhound and a six-week-old female Borzoi dog were presented because of the complaints of reluctance to exercise and signs of of neck pain. Both dogs were neurologically normal. Diagnostic imaging revealed C3-C4 deformity, moderate kyphosis, and spinal canal stenosis associated with chronic spinal cord pressure atrophy. Both dogs underwent surgical treatment. Results: A staged two-step surgery starting with dorsal decompression was elected in the Deerhound. After the first surgical procedure, the dog developed focal myelomalacia and phrenic nerve paralysis and was euthanatized. A ventral distraction-fusion technique with two locking plates was performed in the Borzoi. This patient recovered uneventfully and long-term follow-up computed tomography revealed complete spondylodesis. Clinical significance: Until now, CCK has only been described in sighthounds. Congenital cervical kyphosis might be considered a differential diagnosis in these breeds that are presented with signs of cervical pain. Ventral realignment-fusion and bone grafting may be considered for surgical treatment, although the earliest age at which this procedure can and should be performed remains unclear.

Ophthalmologic complications after intraoral local anesthesia

INTRODUCTION The first ophthalmologic complication in conjunction with a dental anesthesia was reported in 1936. The objective of the present study was a detailed analysis of case reports about that topic. MATERIAL AND METHODS After conducting a literature search in PubMed this study analyzed 108 ophthalmologic complications following intraoral local anesthesia in 65 case reports with respect to patient-, anesthesia-, and complication- related factors. RESULTS The mean age of the patients was 33.8 years and females predominated (72.3%). The most commonly reported complication was diplopia (39.8%), mostly resulting from paralysis of the lateral rectus muscle. Other relatively frequent complications included ptosis (16.7%), mydriasis (14.8%) and amaurosis (13%). Ophthalmologic complications were mainly associated with block anesthesia of the inferior alveolar nerve (45.8%) or the posterior superior alveolar nerve (40.3%). Typically, the ophthalmologic complications in conjunction with intraoral local anesthesia had an immediate to short onset, and disappeared as the anesthesia subsided. DISCUSSION AND CONCLUSION The increased number of ophthalmologic complications after intraoral local anesthesia in females may suggest a gender effect. Double vision (diplopia) is the most frequently described complication, which is usually completely reversible like the other reported ophthalmologic complications.

Honey Bee Apis mellifera Parasites in the Absence of Nosema ceranae Fungi and Varroa destructor Mites

Few areas of the world have western honey bee (Apis mellifera) colonies that are free of invasive parasites Nosema ceranae (fungi) and Varroa destructor (mites). Particularly detrimental is V. destructor; in addition to feeding on host haemolymph, these mites are important vectors of several viruses that are further implicated as contributors to honey bee mortality around the world. Thus, the biogeography and attendant consequences of viral communities in the absence of V. destructor are of significant interest. The island of Newfoundland, Province of Newfoundland and Labrador, Canada, is free of V. destructor; the absence of N. ceranae has not been confirmed. Of 55 Newfoundland colonies inspected visually for their strength and six signs of disease, only K-wing had prevalence above 5% (40/55 colonies = 72.7%). Similar to an earlier study, screenings again confirmed the absence of V. destructor, small hive beetles Aethina tumida (Murray), tracheal mites Acarapis woodi (Rennie), and Tropilaelaps spp. ectoparasitic mites. Of a subset of 23 colonies screened molecularly for viruses, none had Israeli acute paralysis virus, Kashmir bee virus, or sacbrood virus. Sixteen of 23 colonies (70.0%) were positive for black queen cell virus, and 21 (91.3%) had some evidence for deformed wing virus. No N. ceranae was detected in molecular screens of 55 colonies, although it is possible extremely low intensity infections exist; the more familiar N. apis was found in 53 colonies (96.4%). Under these conditions, K-wing was associated (positively) with colony strength; however, viruses and N. apis were not. Furthermore, black queen cell virus was positively and negatively associated with K-wing and deformed wing virus, respectively. Newfoundland honey bee colonies are thus free of several invasive parasites that plague operations in other parts of the world, and they provide a unique research arena to study independent pathology of the parasites that are present.

Transdiaphragmatic Resuscitative Open Cardiac Massage: Description of the Technique and a First Case-Series of an Alternative Approach to the Heart

Abstract BACKGROUND: The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure. METHODS: All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm--approximately at 2 o'clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa. RESULTS: A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge. CONCLUSIONS: In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.

Ophthalmic complications and local anesthesia. Pathophysiology and types of eye complications after intraoral dental anesthesia, and clinical recommendations

The present article reviews the different types of ophthalmologic complications following administration of intraoral local anesthesia. Since the first report by Brain in 1936, case reports about that topic have been published regularly in the literature. However, clinical studies evaluating the incidence of ophthalmologic complications after intraoral local anesthesia are rarely available. Previous data point to a frequency ranging from 0.03% to 0.13%. The most frequently described ophthalmologic complications include diplopia (double vision), ptosis (drooping of upper eyelid), and mydriasis (dilatation of pupil). Disorders that rather affect periorbital structures than the eye directly include facial paralysis and periorbital blanching (angiospasm). Diverse pathophysiologic mechanisms and causes have been reported in the literature, with the inadvertent intravascular administration of the local anesthetic considered the primary reason. The agent as well as the vasopressor is transported retrogradely via arteries or veins to the orbit or to periorbital structures (such as the cavernous sinus) with subsequent anesthesia of nerves and paralysis of muscles distant from the oral cavity. In general the ophthalmologic complications begin shortly after administration of the local anesthesia, and disappear once the local anesthesia has subsided.