Challenging rescue of a 4 years old boy with H1N1 infection by extracorporeal membrane oxygenator: A case report

Introduction: World Health Organization announced on April 2009 a public health emergency of international concern caused by swine-origin influenza A (H1N1) virus. Acute respiratory distress syndrome (ARDS) has been reported to be the most devastating complications of this pathogen. Extracorporeal membrane oxygenator (ECMO) therapy for patients with H1N1 related ARDS has been described once all other therapeutic options have been exhausted. Here, we report the case of a child (German, male) with H1N1-associated fulminate respiratory and secondary hemodynamic deterioration who was rescued by initial emergent ECMO established through a dialysis catheter and subsequent switch to central cannulation following median sternotomy. This report highlights several important issues. First, it describes a successful use of a dialysis catheter for the establishment of a veno-venous ECMO in an emergency case by child. Second, it highlights the importance of a closely monitoring of clotting parameters during ECMO therapy and third, if severe respiratory failure is complicated by cardiogenic shock, veno-atrial ECMO support via median sternotomy should be considered as a viable treatment option without further delay.     

Perinatal characteristics and risk of polio among Swedish twins

Perng W, Cnattingius S, Iliadou A, Villamor E. Perinatal characteristics and risk of polio among Swedish twins. Paediatric and Perinatal Epidemiology 2012; 26: 218–225. Prenatal exposure to adverse environmental conditions is related to increased adult mortality in regions where infections are highly prevalent, yet there is little evidence of the impact of perinatal conditions on the risk of severe infections throughout life. Using prospectively collected data from 21 604 like‐sexed Swedish twins of known zygosity born in 1926–1958, we examined the risk of polio in relation to perinatal characteristics using cohort and nested co‐twin case–control analyses. Polio incidence was determined through an interview in 1998, and linkage with the Swedish national inpatient and death registries. There were 133 cases of polio. In the cohort analysis, birth length, birthweight and head circumference were positively associated with polio risk. After adjustment for sex, birth year, gestational age at birth and within‐twin pair correlations, twins of shortest length (<44 cm) had a 67% ([95% CI: 6%, 88%]; P = 0.04) lower risk of polio compared with the reference group (47–49 cm). After additional adjustment for birth length, every 100‐g increase in birthweight was related to a 34% increased risk of polio ([95% CI: ?1%, 82%]; P = 0.06), and every 10‐mm increase in head circumference was related to a 17% greater risk of polio ([95% CI: 5%, 31%]; P = 0.004). In co‐twin control analyses among 226 disease‐discordant twins, birth length, birthweight and head circumference were 0.3 cm (P = 0.19), 84 g (P = 0.07) and 3 mm (P = 0.08) higher in cases than controls, respectively. Similar associations were observed among monozygotic (n = 84) and dizygotic (n = 142) twins. These findings suggest that early intrauterine growth restriction may be inversely related to the incidence of polio.     

From infancy to pregnancy: birth weight, body mass index, and the risk of gestational diabetes

Obesity is a risk factor for gestational diabetes, whereas the role of the mother’s birth weight is more uncertain. We aimed to investigate the combined effect of mothers’ birth-weight-for-gestational-age and early pregnancy Body Mass Index (BMI) in relation to risk of gestational diabetes. Between 1973 and 2006, we identified a cohort of 323,083 women included in the Swedish Medical Birth Register both as infants and as mothers. Main exposures were mothers’ birth-weight-for-gestational-age (categorized into five groups according to deviation from national mean birth weight) and early pregnancy BMI (classified according to WHO). Rates of gestational diabetes increased with adult BMI, independently of birth-weight-for-gestational-age. However, compared to women with appropriate birth-weight-for-gestational-age [appropriate-for-gestational age (AGA); ?1 to +1 SD] and BMI (<25.0), women with obesity class II-III (BMI?≥?35.0) had an adjusted odds ratio (OR) of 28.7 (95?% confidence interval, CI 17.0–48.6) for gestational diabetes if they were born small-for-gestational-age [small for gestational age (SGA); <?2SD], OR?=?20.3 (95?% CI 11.8–34.7) if born large-for-gestational-age [large-for-gestational-age (LGA); >2SD], and OR?=?10.4 (95?% CI 8.4–13.0) if born AGA. Risk of gestational diabetes is not only increased among obese women, but also among women born SGA and LGA. Severely obese women born with a low or a high birth-weight-for-gestational-age seem more vulnerable to the development of gestational diabetes compared to normal weight women. Normal pre-pregnancy BMI diminishes the increased risk birth size may confer in terms of gestational diabetes. Therefore, the importance of keeping a healthy weight cannot be overemphasized.     

Reference values for healthy human myocardium using a T1 mapping methodology: results from the International T1 Multicenter cardiovascular magnetic resonance study

Background

T1 mapping is a robust and highly reproducible application to quantify myocardial relaxation of longitudinal magnetisation. Available T1 mapping methods are presently site and vendor specific, with variable accuracy and precision of T1 values between the systems and sequences. We assessed the transferability of a T1 mapping method and determined the reference values of healthy human myocardium in a multicenter setting.

Methods

Healthy subjects (n = 102; mean age 41 years (range 17–83), male, n = 53 (52%)), with no previous medical history, and normotensive low risk subjects (n=113) referred for clinical cardiovascular magnetic resonance (CMR) were examined. Further inclusion criteria for all were absence of regular medication and subsequently normal findings of routine CMR. All subjects underwent T1 mapping using a uniform imaging set-up (modified Look- Locker inversion recovery, MOLLI, using scheme 3(3)3(3)5)) on 1.5 Tesla (T) and 3 T Philips scanners. Native T1-maps were acquired in a single midventricular short axis slice and repeated 20 minutes following gadobutrol. Reference values were obtained for native T1 and gadolinium-based partition coefficients, λ and extracellular volume fraction (ECV) in a core lab using standardized postprocessing.

Results

In healthy controls, mean native T1 values were 950 ± 21 msec at 1.5 T and 1052 ± 23 at 3 T. λ and ECV values were 0.44 ± 0.06 and 0.25 ± 0.04 at 1.5 T, and 0.44 ± 0.07 and 0.26 ± 0.04 at 3 T, respectively. There were no significant differences between healthy controls and low risk subjects in routine CMR parameters and T1 values. The entire cohort showed no correlation between age, gender and native T1. Cross-center comparisons of mean values showed no significant difference for any of the T1 indices at any field strength. There were considerable regional differences in segmental T1 values. λ and ECV were found to be dose dependent. There was excellent inter- and intraobserver reproducibility for measurement of native septal T1.

Conclusion

We show transferability for a unifying T1 mapping methodology in a multicenter setting. We provide reference ranges for T1 values in healthy human myocardium, which can be applied across participating sites.

Electronic supplementary material

The online version of this article (doi:10.1186/s12968-014-0069-x) contains supplementary material, which is available to authorized users.     

The distribution and prognosis of anomalous coronary arteries identified by cardiovascular magnetic resonance: 15?year experience from two tertiary centres

Background

Aberrant coronary arteries represent a diverse group of congenital disorders. Post-mortem studies reveal a high risk of exercise-related sudden cardiac death in those with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an inter-arterial course. There is little documentation of lifetime history and long-term follow-up of patients with coronary artery anomalies.

Methods

Patients with anomalous coronary arteries undergoing cardiovascular magnetic resonance over a 15-year period were identified and classified by anatomy and course. Medical records were reviewed for major adverse cardiovascular events (MACE). Revascularisation or myocardial infarction counted only if occurring in the distribution of the anomalous artery.

Results

Consecutive patients with coronary artery anomalies were retrospectively identified (n = 172). Median follow-up time was 4.3 years (IQR 2.5–7.8, maximum 15.6). 116 patients had ACAOS of which 64 (55%) had an inter-arterial course (IAC) and 52 (45%) did not. During follow up 110 ACAOS patients were alive, 5 died and 1 lost to follow-up.ACAOS patients experienced 58 MACE events (5 cardiovascular deaths, 5 PCI, 24 CABG and 24 had myocardial infarction). 47 MACE events occurred in ACAOS with IAC and 11 in those without (p < 0.0001), the statistical difference driven by surgical revascularisation and myocardial infarction.

Conclusions

In life, patients with an anomalous coronary artery originating from the opposite sinus of Valsalva taking an IAC have higher rates of both myocardial infarction and surgical revascularisation during long-term follow up, compared to those without IAC.     

Rapid Induction of COOLing in Stroke Patients (iCOOL1): a randomised pilot study comparing cold infusions with nasopharyngeal cooling

Introduction

Induction methods for therapeutic cooling are under investigated. We compared the effectiveness and safety of cold infusions (CI) and nasopharyngeal cooling (NPC) for cooling induction in stroke patients.

Methods

A prospective, open-label, randomised (1:1), single-centre pilot trial with partially blinded safety endpoint assessment was conducted at the neurointensive care unit of Heidelberg University. Intubated stroke patients with an indication for therapeutic cooling and an intracranial pressure (ICP)/temperature brain probe were randomly assigned to CI (4°C, 2L at 4L/h) or NPC (60L/min for 1 h). Previous data suggested a maximum decrease of tympanic temperature for CI (2.1L within 35 min) after 52 min. Therefore the study period was 1 hour (15 min subperiods I-IV). The brain temperature course was the primary endpoint. Secondary measures included continuous monitoring of neurovital parameters and extracerebral temperatures. Statistical analysis based on repeated-measures analysis of variance.

Results

Of 221 patients screened, 20 were randomized within 5 months. Infusion time of 2L CI was 33 ± 4 min in 10 patients and 10 patients received NPC for 60 min. During active treatment (first 30 min), brain temperature decreased faster with CI than during NPC (I: -0.31 ± 0.2 versus -0.12 ± 0.1°C, P = 0.008; II: -1.0 ± 0.3 versus -0.49 ± 0.3°C, P = 0.001). In the CI-group, after the infusion was finished, the intervention no longer decreased brain temperature, which increased after 3.5 ± 3.3 min. Oesophageal temperature correlated best with brain temperature during CI and NPC. Tympanic temperature reacted similarly to relative changes of brain temperature during CI, but absolute values slightly differed. CI provoked three severe adverse events during subperiods II-IV (two systolic arterial pressure (SAP), one shivering) compared with four in the NPC-group, all during subperiod I (three SAP, one ICP). Classified as possibly intervention-related, two cases of ventilator failure occurred during NPC.

Conclusions

In intubated stroke patients, brain cooling is faster during CI than during NPC. Importantly, contrary to previous expectations, brain cooling stopped soon after CI cessation. Oesophageal but neither bladder nor rectal temperature is suited as surrogate for brain temperature during CI and NPC. Several severe adverse events in CI and in NPC demand further studying of safety.

Trial registration

ClinicalTrials.gov NCT01573117. Registered 31 March 2012

     

Transactivation via the human glucocorticoid and mineralocorticoid receptor by therapeutically used steroids in CV-1 cells: a comparison of their glucocorticoid and mineralocorticoid properties

BACKGROUND: Glucocorticoids (GCs) are commonly used for long-term medication in immunosuppressive and anti-inflammatory therapy. However, the data describing gluco- and mineralo-corticoid (MC) properties of widely applied synthetic GCs are often based on diverse clinical observations and on a variety of in vitro tests under various conditions, which makes a quantitative comparison questionable. METHOD: We compared MC and GC properties of different steroids, often used in clinical practice, in the same in vitro test system (luciferase transactivation assay in CV-1 cells transfected with either hMR or hGRalpha expression vectors) complemented by a system to test the steroid binding affinities at the hMR (protein expression in T7-coupled rabbit reticulocyte lysate). RESULTS AND CONCLUSIONS: While the potency of a GC is increased by an 11-hydroxy group, both its potency and its selectivity are increased by the Delta1-dehydro-configuration and a hydrophobic residue in position 16 (16-methylene, 16alpha-methyl or 16beta-methyl group). Almost ideal GCs in terms of missing MC effects, as defined by our in vitro assay, are therefore prednylidene, budesonide, beclomethasone and betamethasone.The MC potency of a steroid is increased by a 9alpha- or a 6alpha-fluoro substituent. A hydrophilic substituent in position 16 (like 16-hydroxylation in triamcinolone) decreases both MC and GC properties. As no substituent that leads to an isolated reduction of GC activity could be characterized in our experiments, 9alpha-fluorocortisol, the most frequently used steroid for MC substitution, seems to be the best choice of available steroids for this purpose.