The combined maternal administration of magnesium sulfate and aminophylline reduces intraventricular hemorrhage in very preterm neonates

OBJECTIVE: To determine whether the adjunctive administration of aminophylline and magnesium sulfate to mothers at risk for preterm birth can reduce the rate of intraventricular hemorrhage in neonates born at less than 30 weeks of gestation. STUDY DESIGN: A prospective study was conducted to determine whether the rate of intraventricular hemorrhage was different in patients at risk for preterm delivery treated with ritodrine, magnesium sulfate, aminophylline, and corticosteroids (group A) versus patients treated with ritodrine and corticosteroids (group B). During the study period (January 1996 to December 2001), 125 patients enrolled in the study. Treatment was assigned by alternative allocation, and the study was designed to compare the rate of intraventricular hemorrhage in neonates born before the 30th week of gestation (primary outcome), 78 newborns in group A and 68 in group B. The proportion of neonates with intraventricular hemorrhage was calculated, and data were analyzed with Student t test, chi 2 , and logistic regression analysis. RESULTS: The frequency of severe respiratory distress syndrome needing surfactant replacement and high-pressure positive ventilation, patent ductus arteriosus, and retinopathy of prematurity was not different between the 2 groups. However, the rate of intraventricular hemorrhage was lower in neonates born before 30 weeks whose mothers received adjunctive aminophylline and magnesium sulphate (group A) than in the group that did not receive these 2 agents (group B). The overall frequency of intraventricular hemorrhage was 5.1% (4/78) versus 20.6% (14/68) ( P < .001), and the frequency of intraventricular hemorrhage grade 3-4 was 1.3% (1/78) versus 10.3 % (7/68; P < .001), respectively. CONCLUSION: Adjunctive maternal administration of aminophylline and magnesium sulfate was associated with a significant reduction in the rate of intraventricular hemorrhage in neonates born before 30 completed weeks.     

Canadian Consensus on cardiac transplantation in pediatric and adult congenital heart disease patients 2004: executive summary

Cardiac transplantation is an acceptable therapeutic option for the pediatric age group and for adult patients with congenital heart disease. There are a myriad of clinical diagnoses in these two patient populations. Survival has continued to improve, with graft half-lives of 14 years and greater in pediatric heart transplantation patients. There are issues unique to these patient populations in relation to heart transplantation for which the present document summarizes the relevant literature and presents management guidelines. Donor availability remains a major limiting factor in organ transplantation at present. Efforts need to be made to increase organ donor awareness, identify potential donors and aggressively manage marginal donors. Indications for transplantation and determination of timing of listing continue to be challenging due to a lack of evidence-based guidelines specifically for prognostic indices of outcome and pretransplant survival. The current status system for listing patients for transplantation does not necessarily reflect the typical clinical course of deterioration experienced by these two patient populations; therefore, consideration needs to be given to a parallel listing strategy. Evidence is accumulating pointing to an advantage to performing transplantations in patients in early infancy. ABO-incompatible heart transplantation has lead to a reduction in waiting time and waiting list mortality. Care of children after heart transplantation must take into consideration physical growth and multisystem development; stage of immunological maturation; intellectual, emotional and social maturation; educational activities; and other pediatric quality of life parameters. Post-transplantation issues are somewhat different, including rejection, coronary artery disease, malignancies and infections. Efforts need to be made to support multicentre trials to determine optimal treatment protocols.     

Type III intestinal metaplasia, Helicobacter pylori infection and gastric carcinoma risk index in an Italian series of 1750 patients

BACKGROUND/AIMS: To evaluate the utility of 2 biopsies of antrum and gastric body on routine endoscopy for the assessment of type III intestinal metaplasia (IM-3) and Helicobacter pylori (Hp), 1750 patients (pts) (895 males; 855 females) were considered from June'98 to June'00. METHODOLOGY: Specimens were graded 0 to 3 for atrophy, IM-3 and Hp. 610 pts treated previously with antibiotics or not eligible for biopsy were excluded from initial 2360 pts. RESULTS: IM-3 was found in 118 pts (6.7%), 100 pts (5.7%) only in the antrum. 10 of 355 pts (2.8%) with normal endoscopy and 47 of 702 (6.6%) with non-erosive endoscopic gastritis resulted IM-3 positive in the antrum. 709 pts (40.5%) were positive for Hp in antrum and/or corpus. The presence of Hp and IM-3 in the antrum was not correlated (p=0.99; Spearman test). A positive correlation (p=0.000) between duodenal ulcer and Hp was found when antral Hp positivity was taken into account. The gastric carcinoma risk index (GCRI) was found in 358 pts (20.4%); in this group 131 pts (36.6%) were Hp positive, 81 pts (22.65%) had IM-3 only in the antrum, 184 pts (51.4%) had atrophy. CONCLUSIONS: The incidence of IM-3 is low (6.7%) in routine endoscopy. Normal endoscopy doesn't exclude the presence of IM-3. Biopsy is necessary to discover IM-3 in the antrum in 5.3% of pts with normal or aspecific endoscopic gastritis. Application of the GCRI might be useful for identifying a group of patients carrying a higher risk for gastric carcinoma.     

Microalbuminuria, renal function and development of sustained hypertension: a longitudinal study in the early stage of hypertension

OBJECTIVE: Microalbuminuria (MA) is a marker of adverse outcome in hypertension. The aim of this study was to investigate the association of MA with cardiovascular risk factors and glomerular hyperfiltration in the early stage of hypertension and to assess its predictive value for the development of sustained hypertension requiring antihypertensive treatment. DESIGN AND PARTICIPANTS: We studied 1041 young stage 1 hypertensive subjects. Study variables were 24-h ambulatory blood pressure and heart rate, anthropometric measures, metabolic variables, creatinine clearance and lifestyle factors analyzed as a function of ascending urinary albumin measured from 24-h collections. Subjects were followed until they developed sustained hypertension and were eligible for antihypertensive medication according to current guidelines. SETTING: Seventeen outpatient clinics in Italy. RESULTS: Eighty-five percent of the subjects were normoalbuminuric, 9% had borderline MA, and 6% had overt MA. No between-group differences were found for age, body mass index, heart rate, lifestyle factors and biochemistry in both genders. Creatinine clearance was greater in the subjects with overt MA and borderline MA than in the normoalbuminuric subjects (P = 0.003 and 0.011, respectively). In a two-way ANCOVA, microalbuminuric subjects both with hyperfiltration (P < 0.001) and with normal filtration (P = 0.04) had higher 24-h systolic blood pressure than subjects with normoalbuminuria and normal filtration. In a Cox analysis, neither MA nor hyperfiltration were significant predictors of development of sustained hypertension. CONCLUSION: MA is not associated with an adverse metabolic risk profile in the early stage of hypertension. MA is associated with greater hemodynamic load and with glomerular hyperfiltration in this clinical setting, but does not help in predicting those subjects destined to develop sustained hypertension requiring antihypertensive therapy.     

Left ventricular unloading in a patient with end-stage cardiomyopathy and medically unresponsive pulmonary hypertension

Severe, medically unresponsive pulmonary hypertension (PHT) is considered to be a contraindication for orthotopic heart transplantation (OHT). Chronic left ventricular (LV) unloading using a left ventricular assist device (LVAD) might result in reversal of the elevated pulmonary vascular resistance (PVR), allowing successful OHT in such patients. In this study, we present a patient with end-stage ischemic cardiomyopathy and fixed, elevated PVR (7.1 Wood units) who underwent implantation of a Novacor LVAD (Baxter Healthcare Corp., Deerfield, IL, U.S.A.), with a subsequent reduction in PVR to 1.2 Wood units and successful OHT eleven months post-LVAD implantation. Three years after heart transplant, the patient still leads an active life with no right heart failure. In conclusion, OHT is not contraindicated in patients with end-stage heart failure and medically unresponsive PHT in the presence of elevated left atrial pressure. Left ventricular unloading should be considered in these patients to allow reversal of the elevated PVR before OHT.     

Segmental vertebral motion in the assessment of neck range of motion in whiplash patients

The purpose of this study was to obtain comparative data concerning the relative contribution of segmental cervical vertebral motion to the cervical range of motion (ROM) in whiplash and healthy subjects in an effort to evaluate the usefulness of X-ray analysis in future forensic and research efforts. Each subjects neck ROM was measured with an optoelectronic system and also by X-ray measurements of the angular rotation in flexion and extension. The X-rays were examined to calculate the angular movement in the sagittal plane of each of the functional units C2–C3 to C6–C7. The chronic whiplash subjects showed reduced total neck range in all directions as compared to healthy subjects (p<0.001). There was a reduced total angular rotation from flexion to extension between these two groups (p<0.01), but no significant difference, however, between chronic whiplash subjects and controls in the percentage contribution of each of the functional units C2–C3 to C6–C7 to this rotation. This data will now allow a design of trials where healthy subjects are asked to simulate restricted neck ROM while undergoing optokinetic and X-ray evaluation of segmental vertebral motion. We will be able to determine if simulators produce a similar pattern to chronic whiplash and healthy, non-simulating subjects, and thus determine if, at least for forensic and research purposes, this technique is useful in validating reported restricted neck range.     

Antithymocyte globulin induction allows a prolonged delay in the initiation of cyclosporine in heart transplant patients with postoperative renal dysfunction

The authors evaluated the efficacy of antithymocyte globulin (ATG) induction and delayed initiation of cyclosporine (CsA) in heart transplant (HTx) patients with postoperative renal dysfunction (RD). The authors compared 15 adult HTx patients with postoperative RD (serum creatinine [SCr] > or =150 microM) to 17 controls without postoperative RD. ATG was given daily (1.5 mg/kg/day for 5 days) in controls and every 2 to 5 days in RD patients (total lymphocyte count <200/mm). All patients received corticosteroids and mycophenolate mofetil. The initiation of CsA was delayed in RD patients until SCr had decreased to less than 150 microM (day 12 +/- 8 vs. 2 +/- 1, P<0.0001). One-year patient survival and acute rejection rates were 87% and 27% in RD patients and 88% and 59% in controls, respectively (P=not significant). SCr improved in RD patients and did not differ from controls after the first month. The authors' results suggest that marked prolongation of the period of ATG induction permits a safe delay in the initiation of CsA in HTx patients with postoperative RD.     

The combined use of extracorporeal life support and the Berlin Heart pulsatile pediatric ventricular assist device as a bridge to transplant in a toddler

There is a very limited published material about experience with long-term pediatric mechanical circulatory support as a bridge to heart transplant. We report on a 2-year-old, 12 kg boy admitted with 2-week history of low-grade fever, ear pain, pulmonary edema, and congestive heart failure. Trans-thoracic echocardiography confirmed severe myocardial dysfunction with a left ventricular ejection fraction of 0.20 and percentage shortening of 13. After 2 days of ventilatory and inotropic support, the patient continued to deteriorate and subsequently required femoro-femoral extracorporeal life support (ECLS). This was later complicated by a progressive coagulopathy and massive bleeding. On day 17, a pulsatile pediatric paracorporeal biventricular assist device (VAD) (Berlin Heart) was implanted. The patient's condition improved significantly with all coagulopathies corrected, and the patient was extubated 21 days later. After 109 days of bi-VAD support, the patient was successfully transplanted and discharged home 45 days post transplant. Our early experience with initial ECLS bridge to VAD and subsequently to transplant was encouraging. It allowed for additional time to select the ideal organ donor and optimize the recipient's comorbid condition and multiorgan failure. VAD provides an additional armamentarium of circulatory support in pediatric patients with severe heart failure.     

Holmium laser enucleation versus transurethral resection of the prostate. Are histological findings comparable?

PURPOSE: We investigated if an adequate histological diagnosis can be made from tissue after holmium laser enucleation of the prostate (HoLEP) and whether it is comparable to transurethral prostate resection (TURP) tissue findings in patients with benign prostatic hyperplasia. MATERIALS AND METHODS: We analyzed 40 HoLEP and 40 age matched TURP tissue specimens from patients who underwent 1 of the 2 procedures between January 2001 and August 2002. Each histological specimen was reviewed by a single pathologist. Preoperative prostate ultrasound volume, total serum prostatic specific antigen and postoperative tissue weight were evaluated. Microscopic histological diagnosis was assessed by standard histological techniques and immunohistochemical evaluation. RESULTS: Patients were comparable in terms of age and preoperative total serum prostate specific antigen. Tissue remaining following the procedure was estimated to be 36.3% of preoperative ultrasound volume after HoLEP and 52.8% after TURP (p <0.001). Incidental adenocarcinoma and high grade PIN of the prostate were diagnosed in a comparable percent of specimens in the 2 groups. Tissue thermal artifacts induced by the laser were mostly due to coagulation. Thus, the alterations were similar to those after TURP. CONCLUSIONS: Tissue quality is altered after HoLEP and TURP. General prostatic architecture was maintained in the majority of HoLEP histological specimens. A moderately higher percent of prostatic tissue obtained by the Ho laser is lost by vaporization and coagulation. Nevertheless, these differences do not seem to alter pathologist ability to detect incidental prostate cancer and PIN.     

Moyse Charas, Francesco Redi, the Viper and the Royal Society of London

We have described the 17th century dispute on the nature of the poison of the viper and its possible use as an antidote which arose between published in Britain at that time. We have also seen the reciprocal interest of Charas and members of the Royal Society in each other's work, and how Charas settled in England for a few years at the time of discrimination against the Huguenots in France. We prefer to leave any conclusions from this story to individual readers. However the dispute seems to be part of a transition from an animate view of the world to one where empirical methods do not appear to need to invoke 'spirits'. The story also seems to illustrate the limitation of experiments there can still be disagreement. If there is a the feeling that the subject is of interest, we can broaden it to cover scientific exchanges and connections between British and French Scholars in the field of pharmaceutical chemistry in the 17th and 18th centuries. At that time a number of pharmacists and scientists moved or corresponded between the two countries influencing one another. That was when modern chemistry gradually evolved out of traditional origins.