Laser Extraction of a Trapped Infected Port Catheter in a Child Using Existing Experience from Pacemaker and ICD Lead Removal

A 9‐year‐old girl presented with systemic infection related to a Port‐a‐Cath system (PAC); therefore, the urgent removal of the PAC was indicated. However, the catheter was trapped and not extractable by conventional means. Using existing comprehensive experience in the removal of pacemaker and implantable cardioverter defibrillator leads, the entrapped PAC was successfully extracted by laser technique, thus avoiding open heart surgery. (PACE 2011; e9–e10)     

Changes in acid-base, electrolyte and hemoglobin concentrations during infusion of hydroxyethyl starch 130/0.42/6 : 1 in normal saline or in balanced electrolyte solution in children

Introduction: A balanced volume replacement strategy is a well established concept for correcting hypovolemia using plasma adapted isotonic crystalloid solutions with a physiological electrolyte pattern and acetate as bicarbonate precursor. Recently, third‐generation hydroxyethyl starch (HES) has also become available in a balanced electrolyte solution instead of normal saline. Therefore, in this prospective non‐interventional clinical study, the perioperative administration of HES 130/0.42/6 : 1 in normal saline (ns‐HES) and in balanced electrolyte solution (bal‐HES) was evaluated in children with a focus on acid‐base, electrolyte and hemoglobin changes. Methods: Following local ethics committee approval, pediatric patients aged up to 12 years with an ASA risk score of I–III undergoing perioperative administration of HES (ns‐HES from May 2006 to December 2007, bal‐HES from January 2008 to January 2009) were included. Patient demographics, the performed procedure, adverse drug reactions, hemodynamic data and the results of blood gas analysis were documented with a focus on changes in acid‐base, electrolyte and hemoglobin concentrations. Results: Of 396 enrolled patients (ASA I–III; age 2.3 ± 3, range day of birth – 12 years; body weight 10.8 ± 9, range 0.9–52 kg), 249 received ns‐HES and 147 bal‐HES (mean volume infused 9.9 ± 4 and 9.4 ± 6.9 ml·kg^?1, respectively). After HES infusion, hemoglobin decreased in both groups, whereas bicarbonate and base excess (BE) decreased only with ns‐HES and remained stable with bal‐HES (BE before infusion: ns‐HES ?1.8 ± 2.8, bal‐HES ?1.7 ± 2.7 mmol·l^?1; after infusion: ns‐HES ?2.6 ± 2.4; bal‐HES ?1.6 ± 2.6 mmol·l^?1, P < 0.05). Chloride (Cl) concentrations increased in both groups and were significantly higher with ns‐HES (Cl before infusion: ns‐HES 105.6 ± 3.7, bal‐HES 105.1 ± 2.8 mmol·l^?1; after infusion: ns‐HES 107.7 ± 3.2, bal‐HES 106.3 ± 2.9 mmol·l^?1, P < 0.01). No serious adverse drug reactions were observed. Conclusion: Infusion related iatrogenic acid‐base and electrolyte alterations can be minimized by using hydroxyethyl starch in a balanced electrolyte solution instead of normal saline.     

Relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy

Aim The aim of this study was to examine the relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy (CP) and to explore the moderation of this relationship by the severity of CP. Method Cross‐sectional analysis in a cohort study with a clinic‐based sample of children with CP (n=116; 76 males, 40 females; mean age 6y 3mo, SD 12mo, range 4y 8mo–7y 7mo) was performed. Gross motor capacity was assessed by the Gross Motor Function Measure (GMFM‐66). Daily‐life mobility was assessed using the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills Scale (FSS mobility) and Caregiver Assistance Scale (CAS mobility). Severity of CP was classified by the Gross Motor Function Classification System (48% level I, 17% level II, 15% level III, 8% level IV, 12% level V), type of motor impairment (85% spastic, 12% dyskinetic, 3% ataxic), and limb distribution (36% unilateral, 49% bilateral spastic). Results Scores on the GMFM‐66 explained 90% and 84% respectively, of the variance of scores on PEDI‐FSS mobility and PEDI‐CAS mobility. Limb distribution moderated the relationship between scores on the GMFM‐66 and the PEDI‐FSS mobility, revealing a weaker relationship in children with unilateral spastic CP (24% explained variance) than in children with bilateral spastic CP (91% explained variance). Interpretation In children aged 4 to 7 years with unilateral spastic CP, dissociation between gross motor capacity and daily‐life mobility can be observed, just as in typically developing peers.     

Primary extragonadal germ cell tumor of the prostate in a young man

We report on a case of malignant prostatic teratoma treated with radical cystoprostatectomy and cisplatin-based chemotherapy because of intraoperative tumor rupture. During chemotherapy the patient suffered acute myocardial infarction and was treated with percutanous coronarangiography and stenting.     

In-vitro Permeability of the Human Nail and of a Keratin Membrane from Bovine Hooves: Influence of the Partition Coefficient Octanol/Water and the Water Solubility of Drugs on their Permeability and Maximum Flux

Penetration of homologous nicotinic acid esters through the human nail and a keratin membrane from bovine hooves was investigated by modified Franz diffusion cells in-vitro to study the transport mechanism. The partition coefficient octanol/water PC_Oct/w of the esters was over the range 7 to > 51000. The permeability coefficient P of the nail plate as well as the hoof membrane did not increase with increasing partition coefficient or lipophilicity of the penetrating substance. This indicates that both barriers behave like hydrophilic gel membranes rather than lipophilic partition membranes as in the case of the stratum corneum. Penetration studies with the model compounds paracetamol and phenacetin showed that the maximum flux was first a function of the drug solubility in water or in the swollen keratin matrix. Dissociation hindered the diffusion of benzoic acid and pyridine through the hoof membrane. Since keratin, a protein with an isoelectric point of about 5, is also charged, this reduction can be attributed to an exclusion of the dissociating substance due to the Donnan equilibrium. Nevertheless, the simultaneous enhancement of the water solubility makes a distinct increase of the maximum flux possible. In order to screen drugs for potential topical application to the nail plate, attention has to be paid mainly to the water solubility of the compound. The bovine hoof membrane may serve as an appropriate model for the nail.     

A Sensitive Assay for Studying Dopaminergic Activity in Cultures of Rat Pituitary Cells

The dopaminergic and antidopaminergic activity of drags is frequently assayed in pituitary cell cultures. Here we describe a modified version of the assay based on the use of pituitary cells from prepubertal female rats. Under our experimental conditions (50000 cells well^?1, 2-day culture and 2-h drug-exposure) the assay yielded high selectivity and sensitivity for drug dopaminergic activity. D₂ agonistic activity of bromocriptine could be observed at a concentration as low as 10^?15 m, the antagonistic activity of haloperidol at 10^?16 m. The assay also proved reproducible and simple enough for routine screening of dopaminergic activity. The assay enabled dopaminergic agonist and antagonist activity to be revealed at very low drug concentrations. The high sensitivity of the assay could be of advantage in studying dopaminergic activity in samples containing active substances present at low concentrations or for disclosing the activity of substances with low dopaminergic potency.     

Importance of Heart Rate During Exercise for Response to Cardiac Resynchronization Therapy

Background: Cardiac resynchronization therapy (CRT) is an established therapy for patients with severe heart failure and mechanical dyssynchrony. Response is only achieved in 60–70% of patients.
Objectives: To study exercise-related factors predicting response to CRT.
Methods: We retrospectively examined consecutive patients in whom a CRT device was implanted. All underwent cardiopulmonary exercise testing prior to implantation and after 6 months. The occurrence of chronotropic incompetence and heart rates exceeding the upper rate of the device, thereby compromising biventricular stimulation, was studied. Response was defined as a decrease in LVESV of 10% or more after 6 months.
Results: We included 144 patients. After 6 months 86 (60%) patients were responders. Peak VO₂ significantly increased in responders. Chronotropic incompetence was more frequently seen in nonresponders (21 [36%] vs 9 [10%], P = 0.03), mostly in patients in SR. At moderate exercise, defined as 25% of the maximal exercise tolerance, that is, comparable to daily life exercise, nonresponders more frequently went above the upper rate of the device (13 [22%] vs 2 [3%], P < 0.0001), most of whom were patients in permanent AF. Multivariate analysis revealed heart rates not exceeding the upper rate of the device during moderate exercise (OR 15.8 [3.3–76.5], P = 0.001) and nonischemic cardiomyopathy (OR 2.4 [1.0–5.7], P = 0.04) as predictive for response.
Conclusions: Heart rate exceeding the upper rate during moderate exercise is an independent predictor for nonresponse to CRT in patients with AF, whereas chronotropic incompetence is a predictor for patients in SR.     

Comparison of Different Regimens of Prednisone Therapy in Frequently Relapsing Nephrotic Syndrome

Abstract. The long-term results of four different regimens of prednisone therapy were compared in 32 children with steroid sensitive, frequently relapsing idiopathic nephrotic syndrome with minimal glomerular lesions on renal biopsy. Prednisone was adminstered according to the following dosage schedules: 1) long-term daily, 2) standard intermittent, 3) standard alternate-day, and 4) short-term daily. Over a mean observation period of 7 years patients without steroid dependency received a cumulative dosage of prednisone of 10 mg/m²/day and those with steroid dependency received 19 mg/m²/day. Relapse free intervals were the longest with long-term daily prednisone therapy compared to the other three regimens. In frequently relapsing patients without steroid dependency the relapse free intervals were similar with either intermittent or alternate-day prednisone therapy (median 75 d); however, they were significantly shorter with short-term prednisone therapy (median 33 d). In frequently relapsing patients with steroid dependency the time of remission was generally shorter than in patients without steroid dependency (median 25d vs. 69d) with no benefit of any of the different forms of short-term treatment.