Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications

Aims

Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery.

Methods

Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery. Primary endpoint: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used.

Results

Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively.

Conclusions

Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.     

Thyroid hormone, but not parathyroid hormone, partially restores glucocorticoid-induced growth retardation

Growth retardation is a serious side effect of long-term glucocorticoid (GC) treatment. In order to prevent or diminish this deleterious effect, a combination therapy including growth hormone (GH), a stimulator of bone growth, is often recommended. Parathyroid hormone (PTH) and thyroid hormone (T₄) are important hormonal regulators of bone growth, and might also be helpful anabolic agents for counteracting the negative effects of GCs. Therefore, we studied the interaction of GCs in combination with a single dose of either PTH or T₄ on GC-induced growth retardation. Dexamethasone (Dex) treatment of mice for four weeks induced a significant growth inhibition of body length and weight and weights of several organs. PTH or T₄ alone did not affect the normal growth pattern. However, T₄ could partially restore the Dex-induced growth inhibition, whereas PTH could not. Although PTH did not affect total body growth, it did affect the height of the proliferative zone, which could be counteracted by Dex. This contrasts with T₄ treatment alone or in combination with Dex, which both resulted in a disturbed morphology of the growth plate. IGF-I mRNA, one of the mediators of longitudinal bone growth, was present in proliferative and hypertrophic chondrocytes. However, its expression was not affected by any of the treatments. In conclusion, T₄ but not PTH can partially counteract the effects of Dex on general body growth, with possible implications for future treatments of GC-induced growth retardation. Additionally, both T₄ and PTH, alone or in combination with Dex, have differential effects on the morphology of the growth plate.This work was presented in part at the IPNA Seventh Symposium on Growth and Development in Children with Chronic Kidney Disease: The Molecular Basis of Skeletal Growth, 1–3 April 2004, Heidelberg, Germany     

Upregulation of CD40, CD80, CD83 or CD86 on alveolar macrophages after lung transplantation.

BACKGROUND: Alveolar macrophages (AMs) are known to be poor antigen-presenting cells, and lack the accessory molecules such as CD40, CD80 or CD86 to activate T cells. The question raised is about the potential changes in phenotypes after lung transplantation, particularly during acute rejection episodes. METHODS: The present study analyzed the phenotype of AMs longitudinally in 45 lung transplant patients, between August 1997 and April 2002, with a follow-up period of 27.2 +/- 2.5 (mean +/- SEM) months. There were 7.7 +/- 0.6 bronchoalveolar lavage (BAL) assessments performed per patient (i.e., 345 BALs), simultaneously with transbronchial biopsies. Transplantation was soon followed by a progressive upregulation of CD40 on 49.7 +/- 8% of AMs during the first month, and this marker remained elevated at 60 +/- 8% after 5 years. RESULTS: Both CD86 and CD80, as well as CD83, a marker of dendritic cells, were enhanced for most AMs during Grade A2 and A3 rejection episodes. A correlation was found between expression of CD83 and CD86, but not between CD1a and CD86. Immunohistology confirmed that CD40-positive cells in the alveoli corresponded to AMs and to some dendritic cells in the basal layers of the airways. In vitro studies showed that harvested AMs with these enhanced accessory molecules remained poor stimulators of allogeneic cells, a phenomenon that may be related to the ongoing immunosuppressive treatments. CONCLUSIONS: AM phenotypes showed marked changes during early or late acute rejection episodes, acquiring CD80, CD83 and CD86, while CD40 expression was further enhanced. This finding may provide clues on how to monitor the tolerance of transplanted lungs and may also provide new insights into the pathophysiology of lung transplantation.     

Complement 5a receptor inhibition improves renal allograft survival

Complement activation plays a key role in mediating apoptosis, inflammation, and transplant rejection. In this study, the role of the complement 5a receptor (C5aR) was examined in human renal allografts and in an allogenic mouse model of renal transplant rejection. In human kidney transplants with acute rejection, C5aR expression was increased in renal tissue and in cells infiltrating the tubulointerstitium. Similar findings were observed in mice. When recipient mice were treated once daily with a C5aR antagonist before transplantation, long-term renal allograft survival was markedly improved compared with vehicle-treatment (75 versus 0%), and apoptosis was reduced. Furthermore, treatment with a C5aR antagonist significantly attenuated monocyte/macrophage infiltration, perhaps a result of reduced levels of monocyte chemoattractant protein 1 and the intercellular adhesion molecule 1. In vitro, C5aR antagonism inhibited intercellular adhesion molecule 1 upregulation in primary mouse aortic endothelial cells and reduced adhesion of peripheral blood mononuclear cells. Furthermore, C5aR blockade markedly reduced alloreactive T cell priming. These results demonstrate that C5aR plays an important role in mediating acute kidney allograft rejection, suggesting that pharmaceutical targeting of C5aR may have potential in transplantation medicine.     

Occult tumor cells in lymph nodes as a predictor for tumor relapse in pancreatic adenocarcinoma

Background and aims Occurrence of tumor relapse is frequent in patients with pancreatic cancer despite the absence of residual tumor detectable at primary surgery and in histopathological examination. Therefore, it has to be assumed that current tumor staging procedures fail to identify minimal amounts of disseminated tumor cells, which might be precursors of subsequent metastatic relapse. The aim of this study was to assess the prognostic impact of minimal tumor cell spread detected in lymph nodes classified as “tumor-free” in routine histopathologic evaluation. Materials and methods A total of 154 “tumor-free” lymph nodes from 59 patients with pancreatic cancer who underwent intentionally curative tumor resection were examined by immunohistochemistry for disseminated tumor cells. Results Fifty (32.5%) of the “tumor-free” lymph nodes obtained from 36 (61%) patients displayed disseminated tumor cells. Multivariate survival analysis revealed that the presence of disseminated tumor cells in “tumor-free” lymph nodes is an independent prognostic factor for both a significantly reduced relapse-free survival (p = 0.03) and overall survival (p = 0.02). Conclusions The frequent occurrence and prognostic impact of immunohistochemically identifiable disseminated tumor cells in lymph nodes of patients with operable pancreatic cancer supports the need for a refined staging system of excised lymph nodes, which should include immunohistochemical examination.     

Tramadol infusion for postthoracotomy pain relief: a placebo-controlled comparison with epidural morphine

We compared continuous IV tramadol as an alternative to neuraxial or systemic opioids for the management of postthoracotomy pain in a prospective, randomized, double-blinded, controlled study. General anesthesia was supplemented by thoracic epidural analgesia with 0.25% bupivacaine. At rib approximation, patients received one of the following: IV tramadol (150-mg bolus followed by infusion, total 450 mg/24 h, n = 29), epidural morphine (2 mg, then 0.2 mg/h, n = 30), or patient-controlled analgesia (PCA) morphine only (n = 30). All patients received PCA morphine and rescue morphine as necessary postoperatively. For the first 24 h, pain and sedation scores and respiratory, cardiovascular, and side effect measures were monitored. There was no significant difference in pain scores and PCA morphine use between tramadol and epidural morphine. Pain scores at rest and on coughing were lower in the Tramadol and Epidural Morphine groups than in the PCA Morphine group at various time points over the first 12 h. The Tramadol and Epidural Morphine groups used significantly less hourly PCA morphine than the PCA Morphine group at specific time points in the first 10 h. Vital capacities in the Tramadol group were significantly closer to baseline values at the 20-h point than in the PCA Morphine group. We conclude that an intraoperative bolus of tramadol followed by an infusion was as effective as epidural morphine and avoided the necessity of placing a thoracic epidural catheter. IMPLICATIONS: A prospective, randomized, double-blinded, placebo-controlled study of postthoracotomy pain relief showed that IV tramadol in the form of a bolus followed by continuous infusion was as effective as epidural morphine. The use of tramadol avoids the necessity of placing a thoracic epidural catheter.     

Natural progression of gait in children with cerebral palsy

Twenty-eight children with cerebral palsy had two gait analyses an average of 4.4 years apart with no surgical intervention between the tests. The effects of growth and age were examined using three-dimensional kinematics, temporal and stride parameters, and clinical examination measures. Kinematic changes showed decreases in hip, knee, and ankle sagittal plane ranges of motion (ROM), peak hip flexion in swing, and peak knee flexion over time. Temporal and stride parameters showed declines in timing of toe off, cadence, and walking velocity. Clinical measures showed declines in hip abduction ROM (knees flexed and extended), popliteal angle, and sagittal plane ankle ROM (knees flexed and extended). Overall results showed that gait function in these individuals with cerebral palsy decreased longitudinally with respect to temporal/stride measures, passive ROM, and kinematic parameters compared with a group of individuals who had had orthopaedic intervention.     

Completion thyroidectomy versus total thyroidectomy: is there a difference in complication rates? An analysis of 350 patients

BACKGROUND: This study compared our experience with completion thyroidectomy (CT) and total thyroidectomy (TT) in the management of well-differentiated thyroid cancer (WDTC). We compared complication rates and analyzed the implications of the intraoperative management of the parathyroid glands. STUDY DESIGN: We performed a retrospective cohort study comparing outcomes between patients undergoing CT and TT between January 1994 and December 2004. All patients had surgery for either suspected or confirmed WDTC on fine-needle aspiration. RESULTS: There were 201 CTs and 149 TTs. Mean hospital stays were 4.5 and 3.5 days for the CT and TT groups, respectively (p=0.001). Temporary recurrent laryngeal nerve paresis occurred in 2.0% (4 of 201) and 3.3% (5 of 149) of patients in the CT and TT groups, respectively. There was one (0.5%) case of permanent recurrent laryngeal nerve paralysis in the CT group. Permanent hypoparathyroidism rates were 2.5% and 3.3% in the CT and TT groups, respectively. There was no difference between the two groups in terms of total numbers of parathyroid glands autotransplanted (p=0.63) or present in the specimen (p=0.26). CONCLUSIONS: Completion thyroidectomy is a safe and appropriate option in the management of select cases of WDTC in which a definitive preoperative or intraoperative diagnosis is not available. But it requires a longer hospitalization, so it has implications for both hospital resources and the patients involved.     

Ventilation heterogeneity is a major determinant of airway hyperresponsiveness in asthma, independent of airway inflammation

BACKGROUND: Airway hyperresponsiveness is the ability of airways to narrow excessively in response to inhaled stimuli and is a key feature of asthma. Airway inflammation and ventilation heterogeneity have been separately shown to be associated with airway hyperresponsiveness. A study was undertaken to establish whether ventilation heterogeneity is associated with airway hyperresponsiveness independently of airway inflammation in subjects with asthma and to determine the effect of inhaled corticosteroids on this relationship. METHODS: Airway inflammation was measured in 40 subjects with asthma by exhaled nitric oxide, ventilation heterogeneity by multiple breath nitrogen washout and airway hyperresponsiveness by methacholine challenge. In 18 of these subjects with uncontrolled symptoms, measurements were repeated after 3 months of treatment with inhaled beclomethasone dipropionate. RESULTS: At baseline, airway hyperresponsiveness was independently predicted by airway inflammation (partial r2 = 0.20, p<0.001) and ventilation heterogeneity (partial r2 = 0.39, p<0.001). Inhaled corticosteroid treatment decreased airway inflammation (p = 0.002), ventilation heterogeneity (p = 0.009) and airway hyperresponsiveness (p<0.001). After treatment, ventilation heterogeneity was the sole predictor of airway hyperresponsiveness (r2 = 0.64, p<0.001). CONCLUSIONS: Baseline ventilation heterogeneity is a strong predictor of airway hyperresponsiveness, independent of airway inflammation in subjects with asthma. Its persistent relationship with airway hyperresponsiveness following anti-inflammatory treatment suggests that it is an important independent determinant of airway hyperresponsiveness. Normalisation of ventilation heterogeneity is therefore a potential goal of treatment that may lead to improved long-term outcomes.     

Controversies in Thyroid Pathology: Thyroid Capsule Invasion and Extrathyroidal Extension

Introduction and Design  

Endocrine pathologists, surgeons, and oncologists who manage patients with thyroid carcinomas confront many critical dilemmas. Controversies surrounding diagnostic criteria that distinguish benign from malignant thyroid follicular lesions have been brought to the attention of this community. In this article, we confront another controversy, the definition of a thyroid “capsule” to clarify what constitutes extrathyroidal extension (ETE) and its clinical significance in the management of patients with differentiated thyroid carcinomas.