Common Complications of Dysregulated Inflammation in the Neonate

Preterm infants are faced with a multitude of challenges related to immature systems at delivery placing them at risk for both acute and chronic health conditions. A major component of the human immune system is the inflammatory process and the primary controllers of inflammation are cytokines. Cytokine expression is tightly regulated in the normal host immune response, but in neonates, particularly those born prematurely, the dysregulation is more the norm than the exception. A state in which the inflammatory systems are persistently activated can lead to chronic inflammation affecting the neonate systemically rather than targeting a specific location of illness, injury, or both. Serious neonatal morbidities including white matter injury, chronic lung disease, retinopathy of prematurity and necrotizing enterocolitis have been linked to this chronic inflammatory state. Through the use of a systems approach this article will serve as a focused review of these common neonatal complications. First, an overview explaining the human immune system and the complex process of inflammation will be presented with a focus on systemic neonatal response following acute and/or chronic inflammation. This review is important to promote an understanding of one of the multifactorial influences, inflammation, contributing to long term neonatal health challenges. Empirically supported nursing implications and recommended care strategies are highlighted.     

Adults with pediatric-onset spinal cord injury: part 1: prevalence of medical complications

OBJECTIVE: To determine the prevalence of medical complications of adults with pediatric-onset spinal cord injury (SCI) and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained spinal cord injuries at age 18 years or younger and were 24 years of age or older at interview. OUTCOME MEASURES: Prevalence of medical complications: Urinary tract infections (UTI) requiring intravenous antibiotics or hospitalization (severe UTI), pressure ulcers, hemorrhoids and rectal bleeding, chronic medical conditions, and hospitalizations in the past 3 years. Urinary stones, orchitis or epididymitis, pneumonia, ventilatory assistance, thromboembolism, and latex allergy since injury. Current experience with UTI, bladder and bowel incontinence, bowel program length, constipation or diarrhea, dysreflexia, and hyperhidrosis. RESULTS: Two hundred sixteen individuals were interviewed, with a mean age of injury of 14 years and a mean age at follow-up of 29 years. Most commonly experienced complications were UTI (74%), bowel incontinence (63%), pressure ulcers (44%), autonomic dysreflexia (42%), and respiratory complications (33%). Pressure ulcers were more common in men and latex allergy more common in women. Age at injury was not associated with any of the complications. Older age at interview was associated with orchitis or epididymitis, bowel incontinence, respiratory complications, thromboembolism, and chronic medical conditions; longer duration of injury was associated with these same complications, except for bowel incontinence. Greater neurologic impairment was related to UTI, severe UTI, stones, bowel incontinence, respiratory complications, autonomic dysreflexia, hyperhidrosis, latex allergy, and pressure ulcers. With the exception of latex allergy and UTI, Functional Independence Measure (FIM) scores were associated with the same factors as neurologic impairment. CONCLUSIONS: Medical complications are common sequelae for adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can be used to identify at-risk individuals.     

Adults with pediatric-onset spinal cord injury: part 2: musculoskeletal and neurological complications

OBJECTIVE: To determine the prevalence of musculoskeletal and neurological complications of adults with pediatric-onset spinal cord injuries (SCI), and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained SCI at < or = age 18 years and were > or = age 24 years at interview. OUTCOME MEASURES: Prevalence of musculoskeletal and neurological complications: fractures during the past 3 years; scoliosis; heterotopic ossification; hip dislocation or contractures; ankle contractures or pain; shoulder pain; elbow contractures or pain; pain at other sites; neurological deterioration; syringomyelia; and spasticity since injury. RESULTS: The 216 individuals who were interviewed had mean age at injury of 14 years and mean age at follow-up of 29 years. Most common complications were pain at any site (69%), spasticity (57%), shoulder pain (48%), scoliosis (40%), hip contractures (23%), and back pain (22%). There were no statistically significant associations between gender and the complications. Whites were more likely than nonwhites to experience pain. Younger age at injury was significantly associated with scoliosis and hip subluxation, and older age at injury was associated with ankle pain and spasticity. Older age at follow-up and longer duration of injury were both associated with elbow and shoulder pain, fractures, and neurological deterioration. Longer injury duration was also associated with hip subluxation and scoliosis. Ankle pain, elbow contractures, and spasticity were more common in those with tetraplegia, and hip contractures were associated with paraplegia. American Spinal Injury Association motor scores were significantly lower in those with elbow contractures and spasticity, and significantly higher in those with hip contractures and neurological deterioration. CONCLUSION: Musculoskeletal and neurological complications are common sequelae among adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can identify at-risk individuals.     

Morbidity and mortality of gastrectomy for cancer in Department of Veterans Affairs Medical Centers

BACKGROUND: The purpose of this study was to define risk factors that predict 30-day morbidity and mortality after gastrectomy for cancer in Veterans Affairs (VA) Medical Centers. METHODS: The VA National Surgical Quality Improvement Program prospectively collected data on 708 patients undergoing gastrectomy for cancer in 123 participating VA medical centers from 1991 to 1998. Independent variables included 68 preoperative patient characteristics and 12 intraoperative variables; the dependent variables were 21 defined adverse outcomes and death. Predictive models for 30-day morbidity and mortality were constructed by using stepwise logistic regression analysis. RESULTS: The 30-day morbidity rate was 33.3% (236 of 708). The overall 30-day mortality rate was 7.6% (54 of 708). Significant positive predictors of morbidity (P <.05) included current pneumonia, American Society of Anesthesiologists class IV (threat to life), partially dependent functional status, dyspnea on minimal exertion, preoperative transfusion, extended operative time, and increasing age. Significant positive predictors of mortality (P <.05) included do not resuscitate status, prior stroke, intraoperative transfusion, preoperative weight loss, preoperative transfusion, and elevated preoperative alkaline phosphatase level. CONCLUSIONS: Risk factors predicting morbidity and mortality rates at VA hospitals after gastrectomy for gastric cancer are reported by using a prospectively collected, multi-institutional database. Assigning relative weights to factors associated with adverse outcomes may help improve patient care.     

Toll-like receptor-4 signaling mediates pulmonary neutrophil sequestration in response to gram-positive bacterial enterotoxin

BACKGROUND: Toll-like receptors (TLRs) serve as mediators of innate immune responses to pathogen-associated molecular patterns (PAMPs) which include lipopolysaccharide (LPS) and staphylococcal enterotoxin B (SEB). TLR-4 is thought to act as the primary effector of LPS recognition and TLR-2 is thought to mediate responses to Gram-positive bacterial proteins. Chemokines such as macrophage inflammatory protein (MIP-2) are peptides that are responsible for lung neutrophil (PMN) sequestration following an infectious or inflammatory insult. Given the Gram-positive origin of SEB, we hypothesized that mice with altered TLR-4 signaling would exhibit no difference in lung PMN sequestration following SEB when compared to wild-type mice. METHODS: Wild-type and TLR-4 mutant mice were administered intratracheal saline, LPS (Escherichia coli 0.1 mg/kg), or SEB (1 mg/kg). After 24 h, lung PMN accumulation was determined by myeloperoxidase (MPO) assay and bronchoalveolar lavage fluid cell count (BALfcc). Total lung and BALf MIP-2 was measured by enzyme-linked immunosorbent assay. RESULTS: There was an increase in lung PMN accumulation (by both MPO and BALfcc) and MIP-2 following LPS and SEB in wild-type mice compared to saline-treated controls. In contrast, TLR-4 mice failed to exhibit an increase in lung MIP-2 or PMN accumulation following either LPS or SEB compared to wild-type mice. CONCLUSIONS: TLR-4 mutant mice are unresponsive to intratracheal LPS. SEB elicited an increase in lung MIP-2 and PMN accumulation in wild-type mice. However, TLR-4 mutant mice were protected from this process. This suggests that TLR-4 signaling may mediate the responses to other PAMPs in addition to LPS.     

P2X(7) receptors are expressed during mouse nephrogenesis and in collecting duct cysts of the cpk/cpk mouse.

BACKGROUND: Purinergic receptors are cell-surface molecules that bind extracellular nucleotides, notably ATP. The P2X family includes seven nonselective ion channels with one member, P2X(7), implicated in cytolytic pore formation and cell death. MATERIALS AND METHODS: We sought P2X(7) expression in mouse nephrogenesis and cpk/cpk renal cyst growth, conditions in which both proliferation and apoptosis are prominent. RESULTS: P2X(7) immunolocalized to condensed metanephric mesenchyme: both proliferation and apoptosis were detected in this compartment, assessed by proliferating cell nuclear antigen expression and propidium iodide-stained pyknotic nuclei respectively. Later in nephrogenesis, P2X(7) was detected in collecting ducts, a pattern persisting to maturity. A mesenchymal to epithelial shift of P2X(7) expression was also documented in ureter development. In cpk/cpk kidneys, P2X(7)-expressing collecting duct cysts dominated histology from two weeks until four weeks after birth, when animals die from uremia. In polycystic kidneys pyknotic nuclei were rarely identified in P2X(7)-expressing epithelia, but were detected between cysts, consistent with a non-apoptotic role for P2X(7) in cyst enlargement. CONCLUSION: P2X(7) is expressed during normal nephrogenesis and in a model of congenital polycystic kidney disease. Further experiments are necessary to define possible functions of P2X(7) in these settings.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.