Expression of blood group antigens on red cell microvesicles

The purpose of this study was to determine whether epitopes of the A, B, D, Fya, M, N, S, s, and K blood group antigens are present on microvesicle membranes shed by red cells during storage. Vesicles were isolated from outdated units of blood having and lacking the specified antigens. Diluted antisera were absorbed with fixed quantities of vesicles from red cells with the test antigen and red cells lacking that antigen (controls). The adsorbed and unadsorbed antisera were titrated and scored by using panel cells from persons known to be heterozygous for all the non-AB antigens. The mean titration scores following adsorption with the vesicles from A, B, D, M+N-, M-N+, S+s-, S-s+, and Fy(a+b-) units were appreciably lower than the control scores (0, 0, 3, 2, 2, 0, 4, and 4 vs. 19, 23, 34, 13, 12, 16, 18, and 29, respectively), which indicated the presence of these epitopes on the membrane of shed vesicles. The results following adsorption with K:1,2 vesicles were equivocal.     

Hospitalizations for critically ill children with traumatic brain injuries: a longitudinal analysis

OBJECTIVE: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment. DESIGN: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. SETTING: Hospital inpatient stays from all types of U.S. community hospitals. PARTICIPANTS: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits. CONCLUSIONS: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.     

Minimally invasive transoral catheter-assisted drainage of a danger-space infection

We report the case of a 3-year-old boy who was brought to the emergency department for evaluation of a prolonged upper respiratory infection and diminished neck movement. Computed tomography identified a unilocular abscess extending from the level of C2 inferiorly to the diaphragm at the level of the T9 vertebral body. We successfully treated this transcervical, transthoracic infection surgically via a transoral approach to the retropharyngeal abscess combined with catheter drainage and irrigation of the abscess cavity at a depth of 13 cm. At 25 months of follow-up, the patient exhibited no evidence of recurrent disease or postsurgical complications. In this article, we describe our minimally invasive technique for managing unusual deep-space neck infections in children.     

Detection of Candida species in vaginal samples in a clinical laboratory setting

OBJECTIVE: To present the detection rates of Candida species in vaginal samples from patients visiting physicians. METHODS: The presence of C. albicans, C. glabrata, C. parapsilosis and C. tropicalis in 3978 vaginal swabs from patients in six US states was detected by PCR amplification. RESULTS: Candida DNA was detected in 33.1% of the population studied. Of the 1316 positive samples, 80.2% contained C. albicans, 14.3% contained C. glabrata, 5.9% contained C. parapsilosis and 8.0% contained C. tropicalis. Comparing samples by patients' state of residence revealed an association with the detection of C. glabrata (p = 0.029). Comparing samples by patients' age revealed a decrease in the overall detection of Candida (p < 0.001) and C. albicans (p < 0.001), concomitant with an increase in the detection of C. glabrata (p < 0.001) and C. parapsilosis (p = 0.025). CONCLUSIONS: These results provide geographic- and age-specific data on four Candida species associated with vaginitis.     

Cannabis abuse is not a risk factor for treatment outcome in methadone maintenance treatment: a 1-year prospective study in an Israeli clinic

OBJECTIVE: We addressed the following questions. What are the current and lifetime prevalence of cannabis abuse in an Israeli methadone maintenance treatment (MMT) clinic? Does cannabis abuse change over time during MMT? Is cannabis abuse related to treatment outcome measures such as retention rate and the abuse of drugs? Is the abuse of cannabis related to psychopathology, HIV/HCV risk-taking and infectious diseases? Do cannabis abusers (CAs) have a different psychosocial and demographic profile than nonabusers (NCAs)? Is cannabis abuse part of a polydrug abuse tendency or a distinct substance of abuse? METHOD: Overlapping samples of either the entire clinic population (n = 283) or all the patients who had completed 1 year of MMT treatment (n = 196 of which 20 were re-entering) underwent random and twice-weekly observed urine analysis for various drugs of abuse, responded to self-report questionnaires (SCL-90-R; HIV/HCV risk-taking behaviours; n = 164), interviews (ASI, n = 176; SCID, n = 151) and hepatitis C and HIV testing (n = 149). RESULTS: Lifetime abuse prevalence was found in 75% and current abuse at MMT intake in 25%. Abuse did not increase significantly over a 1-year period. Cannabis abusers were found to be more often polydrug abusers than NCAs. Cannabis abusers did not suffer from more psychological distress, infectious diseases, and did not engage in more HCV/HIV risk-taking behaviour, nor did they leave treatment earlier than NCAs. CONCLUSIONS: Cannabis abuse MMT patients should be treated as polydrug abusers, although no specific influences of cannabis abuse on psychological and medical conditions of MMT patients have been observed. Treatment policy should take these results into consideration.     

Development of a novel method to predict disability after head trauma in children

Background/Purpose: Although analysis of functional independence measures (FIM) at discharge are useful for assessing extent of disability in head-injured children, there is no reliable method to predict the severity of disability at the time of admission. The authors developed a novel method to predict severe disability after head trauma on admission. Methods: Head-injured patients, 2 to 16 years old, with FIM recorded at discharge (n = 3,491) were identified in our state trauma database for the period from 1993 through 1996. Patients categorized as completely dependent by one or more of the FIM (Feeding, Locomotion, Expression, Transfer Mobility, Social Interaction) were classified as disabled. Probability of disability (P_D) was estimated based on regression weights for Glasgow Coma Scale (GCS), Injury Severity Score (ISS), age, and number of anatomic regions injured. Observed to expected disability rates were compared using a test data set of 2,553 patients entered in the database between 1997 through 1999. Results: There was no statistically significant difference between observed and expected disability across all P_D intervals, which suggests that the P_D accurately predicted disability. Conclusions: P_D offers a novel and reliable method for early prediction of likelihood of disability in children who sustain head trauma. Routine use of the P_D may lead to earlier intervention to improve long-term results in head-injured children. J Pediatr Surg 38:482-485.     

Drotrecogin alfa (activated) in patients with severe sepsis presenting with purpura fulminans, meningitis, or meningococcal disease: a retrospective analysis of patients enrolled in recent clinical studies

Introduction

We report data from adult and pediatric patients with severe sepsis from studies evaluating drotrecogin alfa (activated) (DrotAA) and presenting with purpura fulminans (PF), meningitis (MEN), or meningococcal disease (MD) (PF/MEN/MD). Such conditions may be associated with an increased bleeding risk but occur in a relatively small proportion of patients presenting with severe sepsis; pooling data across clinical trials provides an opportunity for improving the characterization of outcomes.

Methods

A retrospective analysis of placebo-controlled, open-label, and compassionate-use trials was conducted. Adult patients received infusions of either DrotAA or placebo. All pediatric patients (<18 years old) received DrotAA. 189 adult and 121 pediatric patients presented with PF/MEN/MD.

Results

Fewer adult patients with PF/MEN/MD met cardiovascular (68.3% versus 78.8%) or respiratory (57.8% versus 80.5%) organ dysfunction entry criteria than those without. DrotAA-treated adult patients with PF/MEN/MD (n = 163) had an observed 28-day mortality rate of 19.0%, a 28-day serious bleeding event (SBE) rate of 6.1%, and an intracranial hemorrhage (ICH) rate of 4.3%. Six of the seven ICHs occurred in patients with MEN (three of whom were more than 65 years old with a history of hypertension). DrotAA-treated adult patients without PF/MEN/MD (n = 3,088) had an observed 28-day mortality rate of 25.5%, a 28-day SBE rate of 5.8%, and an ICH rate of 1.0%. In contrast, a greater number of pediatric patients with PF/MEN/MD met the cardiovascular organ dysfunction entry criterion (93.5% versus 82.5%) than those without. DrotAA-treated PF/MEN/MD pediatric patients (n = 119) had a 14-day mortality rate of 10.1%, an SBE rate of 5.9%, and an ICH rate of 2.5%. DrotAA-treated pediatric patients without PF/MEN/MD (n = 142) had a 14-day mortality rate of 14.1%, an SBE rate of 9.2%, and an ICH rate of 3.5%.

Conclusion

DrotAA-treated adult patients with severe sepsis presenting with PF/MEN/MD had a similar SBE rate, a lower observed 28-day mortality rate, and a higher observed rate of ICH than DrotAA-treated patients without PF/MEN/MD. DrotAA-treated pediatric patients with severe sepsis with PF/MEN/MD may differ from adults, because all three outcome rates (SBE, mortality, and ICH) were lower in pediatric patients with PF/MEN/MD.     

Operative nuances of myelomeningocele closure

ALTHOUGH ADVANCES IN prenatal care and diagnosis have reduced the incidence of spina bifida, repair of neural tube defects remains one of the standard cases encountered by pediatric neurosurgeons. The operative techniques used in closure of these congenital defects have remained essentially unchanged during the past 2 decades; however, the operative nuances for closure often are based on the variability in configuration and size of the open defects, which can present a challenge. Repair of the open spinal dysraphism may require only a simple closure, but extensive dissection and reconstruction of the neural, meningeal, fascial, and epidermal tissues, including the use of specialized vascularized flaps, may be required in some cases. In this article, we briefly describe the preoperative evaluation, decision process, and standard techniques for the repair of myelomeningocele and myeloschisis.