Isolated congenital tuberculosis otitis in a preterm infant

We report an unusual case of localized congenital tuberculosis otitis in a preterm infant. Unlike disseminated congenital cases, the manifestations of localized otitis are associated with a triad of signs: (i) regional lymphadenopathy in the absence of typical systemic features of tuberculosis; (ii) delayed onset of presentation; and (iii) refractory otitis unresponsive to conventional antimicrobial agents. The need for greater diligence in looking for neonatal tuberculosis is emphasized, especially in an ethnic or socioeconomic environment where the disease is prevalent. Congenital tuberculosis, otitis, preterm
PC Ng, Department of Paediatrics, Level 6, Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT, Hong Kong     

Massive transfusion exceeding 50 units of blood products in trauma patients

BACKGROUND: Massive transfusion of blood products in trauma patients can acutely deplete the blood bank. It was hypothesized that, despite a large allocation of resources to trauma patients receiving more than 50 units of blood products in the first 24 hours, outcome data would support the continued practice of massive transfusion. METHODS: A retrospective review of charts and registry data of trauma patients who received over 50 units of blood products in the first day was conducted for a 5-year period at a Level I trauma center. Patients were stratified into groups on the basis of the number of transfusions received. Results are expressed as mean +/- SD. Univariate analysis and multivariate logistic regression were used to identify those risk factors determined in the first 24 hours after admission that were predictive of mortality. Physiologic differences between survivors and nonsurvivors were also examined. RESULTS: Of 7,734 trauma patients admitted between July 1, 1995, and June 30, 2000, 44 (0.6%) received > 50 units of blood products in the first day. Overall mortality in these patients was 57%. There was no significant difference (p = 0.565, chi2) in mortality rate between patients who received > 75 units of blood products in the first day versus those who received 51 to 75 units. Multiple logistic regression analysis identified only one independent risk factor, base deficit > 12 mmol/L, associated with mortality. Base deficit > 12 mmol/L increases the risk of death by 5.5 times (p = 0.013; 95% confidence interval, 1.44-20.95). Neither the total blood product transfusion requirement in the first day nor the packed red blood cell transfusion amount in the first day were significant independent risk factors. Causes of the 25 deaths in this series included exsanguination in the operating room (n = 1) or in the surgical intensive care unit (n = 12), multiple organ failure/sepsis (n = 3), head injury (n = 3), respiratory failure (n = 2), cerebrovascular accident (n = 1), and other (n = 3). Of the survivors, 63% were discharged to home, 21% to rehabilitation, 11% to nursing home, and 5% to another acute care facility. Of the nonsurvivors, the mean Injury Severity Score was 43, 88% had a base deficit > 12 mmol/L, 68% had a Glasgow Coma Scale score < 8, and 64% had a Sequential Organ Failure Assessment score > 10. CONCLUSION: The 43% survival rate in trauma patients receiving > 50 units of blood products warrants continued aggressive transfusion therapy in the first 24 hours after admission.     

Chronic radiographic lung changes in children with vertically transmitted HIV-1 infection

OBJECTIVE: We prospectively studied children with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 to determine the incidence of chronic radiographic lung changes (CRC) and to correlate these changes with clinical assessments. SUBJECTS AND METHODS: Between 1990 and 1997, we scored 3050 chest radiographs using a standardized form. Group I children (n = 201) were HIV-1-infected at enrollment. Group II children (n = 512) were enrolled prenatally or before 28 days postpartum and subsequently subdivided into group IIa (n = 86), children identified as HIV-1-infected; and group IIb (n = 426), those who were HIV-1-uninfected. CRC were defined as parenchymal consolidations or nodular disease lasting 3 months or more or increased bronchovascular markings or reticular densities lasting 6 months or more. Morbidity was assessed by CD4 counts, viral load, the presence of low oxygen saturation, wheezing, tachypnea, crackles, and clubbing. RESULTS: The cumulative incidence of chronic radiographic lung changes in HIV-1-infected children was 32.8% by 4 years old, with increased bronchovascular markings or reticular densities being most common. Chronic changes were associated with lower CD4 cell counts and higher viral loads. Resolution of these chronic changes was associated with decreasing CD4 cell counts but not with lower rates of clinical findings, viral load, or difference in survival. CONCLUSION: With increased survival, CRC are becoming more common. The resolution of these changes may indicate immunologic deterioration rather than clinical improvement.     

High mobility group proteins 1 and 2 recognize chromium-damaged DNA

Chromium (Cr) is a human carcinogen and a potent DNA damaging agent. Incubation of DNA with CrCl3 resulted in dose-dependent binding of Cr to DNA and, at concentrations >20 microM, altered the electrophoretic mobility of a 100 bp oligonucleotide. We also demonstrate that high mobility group (HMG) proteins 1 and 2 bind Cr-damaged DNA (Cr-DNA). Protein binding was lesion density-dependent, with maximal binding to DNA treated with 100 microM CrCl3. HMG2 binds to Cr-DNA with a calculated Kd of approximately 10(-9) M. These proteins also bound DNA obtained from chromate-treated cells. These results suggest that the covalent attachment of Cr to DNA induces alterations in DNA structure which are recognized by HMG1 and HMG2. Therefore, these proteins may function as Cr-damaged DNA recognition proteins in vivo and as a consequence of binding, may play a role in directing the cellular response to Cr-DNA adduct formation.      

Sexual precocity: sex incidence and aetiology

The aetiology of 197 girls and 16 boys presenting with sexual precocity was reviewed. Ninety one girls and four boys had central precocious puberty (M:F 23:1); a cause was identified in all the boys but in only six girls. All boys with precocious puberty need detailed investigation; in girls investigation should be based on clinical findings, particularly the consonance of puberty.     

Reduction of sound levels with antinoise in MR imaging

A combination of active and passive techniques was used to reduce the sound levels in magnetic resonance imagers. These techniques were integrated into an existing audio system. Measurements of sound reduction varied with the protocol being used and averaged 9.9 dB with coaxial cabling and 14.2 dB with fiberoptic conduction of the feedback signal to a controller. Patient comfort and communication were improved.     

Nonsurgical and surgical treatment of obesity

An increasing number of morbidly obese patients are presenting for surgery, with the potential for increased perioperative morbidity and mortality. This article reviews surgical and nonsurgical options in the management of morbidly obese patients. Overweight and obese individuals should be treated with diet, exercise, and behavioral therapy. The failure of this approach is an indication for pharmacologic therapy. Bariatric surgery reduces obesity-related complications and reduces long-term morbidity, mortality, and health care resources use.