Laryngeal damage due to an unexpectedly large and inappropriately designed cuffed pediatric tracheal tube in a 13-month-old child

PURPOSE: To present a case of laryngeal damage in an infant caused by a too large and inappropriately designed cuffed tracheal tube. CLINICAL FEATURES: A 13-month-old child undergoing cardiac surgery was intubated with an uncuffed endotracheal tube with an internal diameter (ID) of 4.0 mm. Because of an important air leak around the tracheal tube during mechanical ventilation, a cuffed endotracheal tube ID 4.0 mm was inserted. The air leak with the tube cuff not inflated was acceptable at 25 cm H2O airway pressure. After extubation on the third postoperative day, the patient showed increasing stridor and respiratory deterioration. Fibreoptic laryngoscopy of the spontaneously breathing patient showed a large intra-laryngeal web. After surgical removal of the web, the child rapidly recovered and was discharged from the hospital on the 12th postoperative day. Inspection of the 4.0 mm (ID) cuffed tracheal tube revealed a cuff positioned inappropriately high and an increase of 0.7 mm in outer tube diameter compared to the 4.0 mm (ID) uncuffed tracheal tube from the same manufacturer. The tube cuff is likely to be situated within the larynx when placed in accordance to insertion depth formulas or radiological criteria, as used for uncuffed tracheal tubes in children. CONCLUSION: The larger than expected tracheal tube with its intra-laryngeal cuff position in a 13-month-old child likely caused mucosal damage and an inflammatory reaction within the larynx resulting in granulation tissue formation and fibrous healing around the tracheal tube.     

Inpatient mortality of hip fracture patients in the Veterans Health Administration.

Hip fractures among elderly people frequently result in permanent disabilities, nursing home placement, and death. The bulk of hip fracture research focuses on elderly women. Within the Veterans Health Administration (VHA), the majority of patients are men. There are no published national reports on hip fractures with large male samples, or on related inpatient mortality among veterans. This retrospective study of 13,546 veterans with hip fracture discharges from 1998-2002 found unadjusted mortality rates are higher in the VHA, compared with the general population. VHA patients tend to be older men in poor health who stay in the hospital longer Increased knowledge about the risks and outcomes associated with hip fractures in men could lead to improved primary and secondary injury-prevention programs. Rehabilitation nurses in acute care can be catalysts in proactively incorporating protective devices, screening for osteoporosis, and initiating lifestyle changes in their plans of care to optimize outcomes for hip fracture patients.     

Kidney Transplant in Black Recipients: Are African Europeans Different from African Americans?

Despite recent improvement, significant racial disparities in outcome still persist after renal transplantation among African American patients in the United States. This study evaluated the association of race and ethnicity with allograft outcomes in a French population of 952 Caucasian (Cauc) patients and 140 African European (AE) patients who underwent renal transplantation in our center between 1987 and 2003. Demographic characteristics were similar for the two cohorts other than cause of end-stage renal failure (more hypertension among AE and more polycystic kidney disease among Cauc) and cold ischemia time (significantly longer for AE). Immunosuppressive treatment was comparable between groups. There were no significant differences between AE and Cauc in the incidence of acute rejection (31% vs. 30%). At 5 years post-transplant, patient survival (93% vs. 92%), graft survival (83% in both groups) and graft function (creatinine clearance 48 mL/min vs. 45 mL/min) were also similar among the AE and Cauc patients. We demonstrate that ethnic origin does not affect outcome after renal transplantation in France. Therefore, differences observed in the United States cannot be only related to immunologic or pharmacologic factors. The results of renal transplantation in patients of African origin could be improved with universal immunosuppressive drug coverage.     

孤儿受体-雌激素受体相关受体(ERRs)在雌激素信号途径中的研究进展

雌激素是一种促进细胞有丝分裂的甾体激素，是女性生殖系统发育和功能维持的重要因素，此外在机体多种生理过程中均有重要作用。雌激素功能失常能够引发乳腺、子宫、心脏等多种疾病，特别是与内分泌相关的癌症。雌激素的多种生理效应通过的两种经典雌激素受体α和β传导（estrogen receptor α and β），核受体命名委员会（nuclear receptors nomenclature committee，NRNC）1999年命名为NR3A1和NR3A2，这两种受体均是核受体超家族（nuclear moeptor superfamily，NRs）的成员。     

Non-invasive temperature imaging of muscles with magnetic resonance imaging using spin-echo sequences

The application of spin-echo magnetic resonance imaging sequences on non-invasive temperature imaging for temperature mapping of human limbs is investigated. In an in vitro expriment performed on a meat sample, the equilibrium magnetisation P and the spin-lattice relaxation time T₁ are calculated from the values for the repetition time TR and the signal intensities obtained by a spin-echo sequence at different tissue temperatures tures as measured by a fibre-optic probe. T₁ is linearly correlated to the tissue temperature, and P is linearly correlated to the reciprocal value of the absolute temperature. Both effects, taken together, lead to a non-linear dependency of the signal intensity on temperature. Therefore a TR leading to maximum temperature dependency of the signal intensity is calculated and used in the futher experiments. In the in vivo experiments, the lower legs of two volunteers are cooled from outside. Images are acquired with a spin-echo sequence (1.5T, TR=1200 ms, TE=10 ms). A rise in signal intensity in the muscle with falling skin temperature is observed, particularly in more peripheral muscle layers. This study shows that spin-echo sequences can be used to monitor temperature changes and temperature differences in living muscle tissue.     

An XPS and SEM evaluation of six chemical and physical techniques for cleaning of contaminated titanium implants

The purpose of the present study was to analyse clinically failed and retrieved implants prior to and after cleaning by means of scanning electron microscopy (SEM) and X-ray induced photoelectron spectroscopy (XPS) as compared to unused controls. Six different chemical and physical techniques for cleaning of contaminated titanium implants were evaluated: 1) rinsing in absolute ethanol for 10 min, 2) cleaning in ultrasonic baths containing trichloroethylene (TRI) and absolute ethanol, 10 min in each solution, 3) abrasive cleaning for 30 s, 4) cleaning in supersaturated citric acid for 30 s, 5) cleaning with continuous CO2-laser in dry conditions at 5 W for 10 s, 6) cleaning with continuous CO2-laser in wet conditions (saline) at 5 W for 10 s. SEM of failed implants showed the presence of contaminants of varying sizes and XPS showed almost no titanium but high carbon signals. XPS of unused titanium implants showed lower levels of titanium as previously reported, probably due to contamination of carbon which increased with time in room air. Cleaning of used implants in citric acid followed by rinsing with deionized water for 5 min followed by cleaning in ultrasonic baths with TRI and absolute ethanol gave the best results with regard to macroscopical appearance and surface composition. However, as compared to the unused implants the results from an element composition point of view were still unsatisfactory. It is concluded that further development and testing of techniques for cleaning of organically contaminated titanium is needed.     

Transjugular intrahepatic portosystemic shunting (TIPS) with balloon-expandable and self-expanding stents: Technical and clinical aspects after 3 1/2 years’ experience

Purpose To evaluate prospectively our experience with transjugular intrahepatic portosystemic shunt (TIPS) using four different metallic stents. Methods Between November 1991 and April 1995, 57 patients (41 men and 16 women; age 35–72 years, mean 54 years) underwent the TIPS procedure. Techniques for portal vein localization before and during TIPS were fluoroscopy, computed tomography (CT) studies, wedged hepatic venography, arterial portography, and ultrasound. After predilation we deployed balloon-expandable (n=48) and self-expanding (n=45) metallic stents. Fifteen patients underwent variceal embolization. Initial follow-up angiograms (mean 6.9 months, range 3–24 months) were obtained in 39 of these patients. Results Fifty-three patients (93%) had successful TIPS placement. The mean decrease in portal pressure was 42.7%. Besides fluoroscopy, the most helpful techniques for portal vein localization were venography and CT. Residual stenosis (n=1) and late shortening (n=4) of Wallstents resulted in shunt dysfunction. The technical problems encountered with the Palmaz stent resulted from its lack of flexibility. We combined balloon-expandable and self-expanding stents in 12 patients. The 30-day and late follow-up (mean 11.9 months) percutaneous reintervention rates were 11.3% and 64.2%, respectively. There were no clinically significant complications related to the TIPS insertions. Conclusion An ideal stent does not exist for TIPS, and the authors recommend combining a Palmaz stent with a flexible self-expanding stent.     

Systemic and peritoneal host defense in peritonitis

Most of the work of host defense has been carried out in mixed patient populations. It is now clear that elective preoperative surgical patients have totally different host defense capabilities as compared to posttrauma patients or those suffering from peritonitis. Specific cell-mediated immune studies need to be repeated in these 2 patient groups as well. What will contribute clinical relevance to these studies will be the means to correct the defects. If these defects or—more correctly termed—abnormalities of host defense are, indeed, important and contribute to an increased sepsis rate and mortality from sepsis in affected patients, then correcting them should reduce these complications. This hypothesis can only be tested when such means become available. The issues of most interest in the next few years will be the significance of serum albumin in host outcome, the role of immunomodulators, the involvement of cytokines in the overall process of host defense, and the use of specific nutritional support regimens targeted to the immune system.

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Resumen La mayor parte del trabajo sobre los mecanismos de defensa del huésped ha sido realizada en poblaciones mixtas de pacientes. Actualmente aparece claro que los pacientes preoperatorios electivos poseen una capacidad de defensa de huésped totalmente diferente que la de los pacientes en estado posttrauma o de aquellos con peritonitis. Aparece necesario realizar estudios específicos de inmunidad celular en estos 2 grupos de pacientes; aquello que aporte pertinencia clínica en tales estudios habrá de representar medios para corregir estos defectos. Si tales defectos, mejor denominados anormalidades en las defensas del huésped, son de verdad importantes y contribuyen a mayores tasas de infección y de mortalidad por sepsis en los pacientes afectados, su corrección debe resultar en reducción de estas complicaciones. Esta hipótesis sólo puede ser puesta a prueba cuando tales medios se hallen disponibles. Los aspectos de mayor interés en los próximos años serán el significado de la albúmina sérica en la evolución final del huésped, el papel de los inmunomoduladores, la participación de las citocinas en el proceso general de defensa del huésped, y el uso de regimenes especificos de soporte nutricional dirigidos hacia el sistema inmune.

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Résumé La plupart des travaux sur les mécanismes de défense ont été faits sur les populations mixtes. Il est à présent certain que les patients opérés électivement ont des mécanismes de défense préopératoire totalement différents de ceux des traumatisés ou des patients ayant une infection péritonéale. Les études immunologiques sur la médiation cellulaire spécifique méritent d'être refaites chez ces deux populations. Ce qui ressortira de ces études donnera les moyens de corriger les défauts ou plutôt les anomalies des mécanismes de défense qui contribuent à augmenter septicité et mortalité en rapport avec l'état septique. Cette hypothèse ne peut être vérifiée qu'avec ces moyens. Les questions les plus intéressantes dans les années à venir sera peut-être de connaître l'influence de l'albumine sérique sur l'évolution, le rôle des immunomodulaterus, celui des cytokinines dans le procédé global des mécanismes de défense, et celui de l'utilisation de l'alimentation spécifique pour améliorer le système immune.

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Supported in part by grants from the Medical Research Council of Canada and the Fonds de recherche de Santé.