Extracorporeal life support in paediatrics

Extracorporeal membrane oxygenation (ECMO) is a life support technique based on modifications of heart-lung bypass technology. It is used to support severe but potentially reversible pulmonary or cardiopulmonary failure. There is increasing use of the technique for neonates and a return of interest in its use for adults. The number of non-neonatal paediatric patients receiving pulmonary support with ECMO worldwide is, however, small, and survival rates average less than 50%. Initial experience in 15 patients aged 3 months to 5 years with a high survival and low morbidity is reported.     

Pathological complications of non-survivors of newborn extracorporeal membrane oxygenation

The pathology was reviewed of the early deaths identified from the first 50 neonates treated with extracorporeal membrane oxygenation (ECMO) during its introduction to the UK. Fifteen neonates died during or shortly after ECMO between August 1989 and June 1992. Data on 12 are presented (three did not have a postmortem examination). The clinical diagnoses at referral for ECMO were as follows: persistent pulmonary hypertension of the newborn (six infants), primary congenital pneumonia (one infant), community acquired pneumonia (two infants), birth asphyxia (one infant), respiratory distress syndrome (one infant), and meconium aspiration syndrome (one infant). In our group, at necropsy, five had significant haemorrhage (three intracranial, one pulmonary, one pericardial and intraventricular). Three of five infants with evidence of haemorrhage also had signs of sepsis. Six infants had evidence at necropsy of systemic sepsis, five showed evidence of severe anoxic brain injury, and four infants had cerebellar haemorrhages. Three infants had evidence of myocardial ischaemia. It is difficult to discriminate between the relative influence of the primary diagnosis, the mode of treatment, and the severity of presentation in the genesis of this pathology. It is likely that the extent and severity of some of the findings represent a pathological progression that would have been interrupted by the death of the patient, had ECMO not been instituted.     

Intracranial pressure in adult non-tumoral hydrocephalus.

Intracranial pressure (ICP) was monitored continuously for 48 hours in four patients with different types of non-tumoral adult hydrocephalus and classificated according to ICP recordings. It is emphasized that ICP monitoring is essential in the diagnosis of normal pressure hydrocephalus (NPH), since its possible to observe abnormal pressure recordings with morphological alterations which can be accompanied or not by periods of raised ICP. It is suggested that this method may help identify cases suitable for surgery.     

Midshaft clavicular non-unions treated with the Herbert cannulated bone screw

PURPOSE: To assess an alternative technique for the treatment of midshaft non-unions of the clavicle. METHODS: Five patients with symptomatic non-unions of the clavicle were treated with open reduction and intramedullary fixation by using a Herbert cannulated bone screw. Autogenous bone grafting was applied in one case and decortication in the other 4 cases. RESULTS: Review of the clinical and radiological documentation at a mean time of 13 months (range, 9-26 months) postoperatively shows that union was achieved in all 5 cases. There were no complications related to the operation, and no patient needed removal of the implant for protrusion, loosening, or any other cause. CONCLUSION: Midshaft non-unions of the clavicle can be treated successfully using the Herbert cannulated bone screw, which avoids the need for a second operation to remove the implant after bone union.     

Death in patients with permanent pacemakers for sick sinus syndrome

Background

Although more than one million patients in the United States have permanent pacemakers, little is known about their cause of death. We evaluated the cause of death in 404 patients who died in the Mode Selection Trial (MOST).

Methods

In MOST, patients received a dual-chamber pacemaker randomly programmed to either dual-chamber or ventricular pacing. The circumstances surrounding each death were reviewed by a clinical events committee, which used prospectively defined criteria to adjudicate the cause of death.

Results

A total of 2010 patients with a median age of 74 years were included. After a median follow-up of 33 months, 404 (20%) patients died, including 198 (49%) of noncardiac causes and 143 (35.4%) of cardiac causes. In 63 patients, the cause of death was unknown. Independent predictors of death through the use of a multivariable analysis were (1) demographic factors including age, male sex, and weight; (2) clinical factors including prior myocardial infarction, cardiomyopathy, New York Heart Association class III/IV, and the Charlson Comorbidity Index; and (3) scores from two measures of functional status, the Karnofsky Score and the Mini-Mental State Examination. Independent predictors of cardiovascular death were similar.

Conclusions

Patients treated with permanent pacemakers for sinus node dysfunction are elderly and have a substantial mortality rate, with more than half the classifiable deaths being noncardiac. Baseline demographic variables and scores from quality-of-life measures can identify patients with the highest risk of death.     

Comparative evaluation of speech disorders and verbal and non verbal communication within two groups of patients: patients with facial paralysis (FP) and those who had undergone hypoglosso-facial anastomosis (HFA)

INTRODUCTION: Speech disorders were often allotted to hypoglossal-facial anastomosis (HFA) without being clearly shown. We have compared patients with a peripheral facial paralysis at those with HFA. AIMS OF THE STUDY: Retrospective study comparing verbal communication (articulation) and non-verbal within two groups of patients: patients with patient FP versus with HFA. PATIENTS AND METHODS: 10 patients with idiopathic FP versus 7 patients with HFA took part in this study. The series of tests includes an evaluation of the motor possibilities, bilabial pressure measurement (for the patients with FP), speech capacities and finally an evaluation of the verbal and non-verbal communication from a scale of satisfaction. RESULTS: The results highlight: the presence of real speech disorders (permanent) among patients with FP and their absence among patients having profited from HFA; a real satisfaction of the HFA versus FP on the quality of life compared to daily tasks, more specifically concerning verbal and food skills. CONCLUSION: The HFA is not responsible for speech disorders, and makes undeniable improvements confirmed subsequently by the patients.     

Vesicular GABA transporter mRNA expression in the dentate gyrus and in mossy fiber synaptosomes

In the normal granule cells of the dentate gyrus, glutamate and both gamma-aminobutyric acid (GABA) and glutamic acid decarboxylase (GAD) coexist. GAD expression is increased after seizures, and simultaneous glutamatergic and GABAergic neurotransmission from the mossy fibers to CA3 appears, supporting the hypothesis that GABA can be released from the mossy fibers. To sustain GABAergic neurotransmission, the amino acid must be transported into synaptic vesicles. To address this, using RT-PCR we looked for the presence and regulation of expression of the vesicular GABA transporter (VGAT) mRNA in the dentate gyrus and in mossy fiber synaptosomes of control and kindled rats. We found trace amounts of VGAT mRNA in the dentate gyrus and mossy fiber synaptosomes of control rats. In the dentate gyrus of kindled rats with several seizures and of control rats subject to one acute seizure, no changes were apparent either 1 or 24 h after the seizures. However, repetitive synaptic or antidromic activation of the granule cells in slices of control rats in vitro induces an activity-dependent enhancement of VGAT mRNA expression in the dentate. Surprisingly, in the mossy fiber synaptosomes of seizing rats, the levels of VGAT mRNA were significantly higher than in controls. These data show that the granule cells and their mossy fibers, besides containing machinery for the synthesis of GABA, also contain the elements that support its vesiculation. This further supports the notion that local synaptic molecular changes enable mossy fibers to release GABA in response to enhanced excitability.     

我国胫骨远端骨折经MIPPO与切开复位内固定治疗的系统评价

目的：系统评价我国小切口复位内固定术（MIPPO）与切开复位内固定治疗胫骨远端骨折的疗效与安全性。方法计算机检索中国知网（CNKI：2003年9月-2013年5月）、万方数据库（2003年9月-2013年5月）、维普数据库（2003年9月-2013年5月）,中国生物医学数据库及超星电子图书。手工检索国内近五年来发表于《中华骨科杂志》、《中国矫形外科杂志》及《临床骨科杂志》等各骨科杂志及相关杂志的相关文献。收集所有相关 MIPPO与切开复位内固定治疗胫骨远端骨折的随机对照试验及半随机对照试验,采用 Cochrane协作网提供的软件 RevMan5．0进行系统评价。结果共纳入12篇随机对照试验及半随机对照试验,共733例患者,纳入研究质量评价结果为 B级10篇,C级2篇。系统评价结果显示,与切开复位内固定组相比,MIPPO 组术中失血量少[SMD＝-4．46,95％CI（-5．87,-3．05）,P ＜0．05];骨折愈合时间短[SMD＝-1．54,95％CI（-2．02,-1．06）,P＜0．05];术后优良率高[RR＝1．22,95％CI（1．13,1．32）,P ＜0．05],但两组手术时间比较差异无统计学意义。结论采用 MIPPO术治疗胫骨远端骨折具有明显的优势,值得临床推广。但由于该系统评价尚存在一定的局限性,故需要大量严格的、大样本量的、多中心性的,并且采用正确的随机、盲法、分配隐藏以及对失访与退出的患者进行正确的意向性分析（ITT分析）等文献研究来进一步论证。     

Serum ferritin levels after renal transplantation: a prospective study

A prospective study was made of the evolution of serum ferritin levels in 112 renal transplant recipients with good graft function. The rise in hemoglobin value is accompanied by a decrease in basal serum ferritin levels which are lowest at the sixth month: 54.9 (2-1,516) vs. 109.6 (21-4,420) micrograms/l, p less than 0.001 (Xg and range). After this time, ferritin values increase, although they do not reach basal levels. Evolution after transplantation is mainly determined by the previous state of iron stores at the time of transplantation. While in the patients with high basal serum ferritin values these gradually decreased during the follow-up period, patients with low basal serum ferritin levels tend to replenish their iron stores after renal transplantation. These differences disappear at the third year when serum ferritin values are similar in all groups. An association between persistence of posttransplant anemia and low serum ferritin levels is observed. This event is not clinically relevant as anemia disappears in almost all cases and dietary iron is enough to normalize serum ferritin levels.