12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comorbidity patterns of 12-month mood, anxiety and alcohol disorders and socio-demographic factors associated with comorbidity were studied among the general population of six European countries.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional psychiatric epidemiological study in a representative sample of adults aged 18 years or older in Belgium, France, Germany, Italy, the Netherlands and Spain. The diagnostic instrument used was the Composite International Diagnostic Interview (WMH-CIDI). Data are based on 21 425 completed interviews.

RESULTS

In general, high associations were found within the separate anxiety disorders and between mood and anxiety disorders. Lowest comorbidity associations were found for specific phobia and alcohol abuse-the disorders with the least functional disabilities. Comorbidity patterns were consistent cross-nationally. Associated factors for comorbidity of mood and anxiety disorders were female gender, younger age, lower educational level, higher degree of urbanicity, not living with a partner and unemployment. Only younger people were at greater risk for comorbidity of alcohol disorder with mood, anxiety disorders or both.

CONCLUSION

High levels of comorbidity are found in the general population. Comorbidity is more common in specific groups. To reduce psychiatric burden, early intervention in populations with a primary disorder is important to prevent comorbidity.

DESMOPRESSIN FOR THE TREATMENT OF NOCTURNAL BEDWETTING IN PATIENTS WITH NEURAL TUBE CLOSURE DEFECTS

PURPOSE

We evaluated desmopressin (DDAVP) treatment in patients with neuropathic bladder secondary to neural tube closure defects (NTDs) and nocturnal incontinence.

MATERIALS AND METHODS

We selected 25 patients, that is 10 males (40%) and 15 females (60%), between ages 7 and 16 years (mean 9.8) with neuropathic bladder secondary to NTDs without a ventricular-peritoneal shunt. All had a low pressure bladder and presented with daytime continence between catheterizations but had persistent nocturnal urine loss 7 nights weekly. They underwent treatment with oral DDAVP according to a certain design, namely an initial dose of 0.2 mg for 3 weeks, which was increased to 0.3 or 0.4 mg for another 3 weeks in nonresponders. The average dose was 0.2 mg. At the effective minimal dose (bedwetting decrease greater than 50%) patients continued for 6 months and then decreased by intervals of 0.05 mg every 2 weeks. In the event of recurrence treatment continued for 1 year.

RESULTS

All patients responded to treatment during the nighttime hours except 1 who suspended treatment after 4 weeks. There were no adverse effects from DDAVP.

CONCLUSIONS

Treating nocturnal bedwetting with DDAVP in patients with NTDs was effective and safe. Nevertheless, to our knowledge treatment duration has not yet been determined.

Impairment of cardiopulmonary receptor sensitivity in the early phase of heart failure

OBJECTIVES

To characterise the efficiency of the cardiopulmonary baroreflex system in the early phase of heart failure and its relation to limitation of physical activity.

DESIGN

Forearm blood flow (venous occlusion plethysmography), vascular resistance, and central venous pressure (CVP), estimated from an antecubital vein, were measured in the supine position at baseline and 15 minutes after application of lower body negative pressure at -7 and -14 mm Hg (receptor downloading) or leg raising (receptor loading).

SUBJECTS

Heart failure patients without limitation (NYHA class I; n = 18) or with slight limitation of physical activity (NYHA class II; n = 13), and 11 healthy controls.

RESULTS

The efficiency of the cardiopulmonary baroreflex function, expressed by the slope of the relation between CVP changes and the corresponding changes of calculated forearm vascular resistance (gain), was reduced both in NYHA class I patients (mean (SD) -1.99 (0.83) v -2.78 (0.66) in controls; p < 0.05) and NYHA class II patients (-1.29 (0.5); p<0.001 v controls). However, change in peripheral vascular resistance during preload increase was similar in controls (-3.3 (0.9) units) and in NYHA class I patients (-3.3 (2.1) units; NS v controls), and was significantly reduced only in NYHA class II patients (-1.6 (1.3) units, p < 0.03 v controls). The gain in the cardiopulmonary reflex was related to the distance walked during the six minute corridor test.

CONCLUSIONS

A reduced tonic efficacy of the cardiopulmonary reflex system is already detectable in the early phase of heart failure, the impairment in acute response to preload increase being detectable only in symptomatic patients.

Renal size and function in patients with neuropathic bladder due to myelomeningocele: the role of growth hormone

PURPOSE

Patients with spina bifida have smaller kidneys than healthy individuals. We evaluated the correlation between small size and decreased renal function, and the possible role of growth hormone deficiency.

MATERIALS AND METHODS

A total of 54 patients (mean age 11.5 years, median 11, standard deviation +/- 4.52) were healthy except for neuropathic bladder due to spina bifida. Renal function was evaluated with mercaptoacetyltriglycine renal scintigraphy and creatinine clearance. Renal anatomy was evaluated with renal ultrasound and voiding cystourethrography. Serum insulin-like growth factor-1 (IGF-1) levels were measured in all patients with immunoradiometric assay. Renal measurements in our patients were compared using the Sutherland nomogram.

RESULTS

A total of 22 patients (41%) had smaller kidneys than normal subjects and 31 appeared to have creatinine clearance values lower than 120 ml per minute per 1.73 m2. The statistical comparison between kidney size and creatinine clearance was significant (p <0.05, r = 0.381). Scintigraphic data showed total effective renal plasma flow less than 568 ml per minute per 1.73 m2 body surface area (normal mean value for age). Comparison between effective renal plasma flow and creatinine clearance was significant (p <0.05, r = 0.31). Serum levels of IGF-1 were normal for age in all patients (mean 332.06 ng/ml, median 303.4, range 39.4 to 732.3).

CONCLUSIONS

The kidneys are smaller in patients with spina bifida than in healthy subjects when compared using the Sutherland nomogram. There is a significant correlation between smaller renal length and decreased renal function in all patients, even in those who are healthy except for neurogenic bladder secondary to spina bifida. IGF-1 levels were normal for age, and, therefore, these patients had no growth hormone deficiency. These findings call into question the hypothesis that growth hormone deficiency contributes to smaller kidney size. Other hypotheses can be suggested, such as a defect of embryological growth secondary to malformation, or the result of a defect in homocysteine-methionine metabolism.

[The management of the child with head injury: initial assessment]

In western countries, head injury is very important in public health; infact it is the main cause of mortality after infancy and a significant cause of long term disability. The patients with severe head injury needs an intensive care unit management, but the initial approach is a critical phase, too. In fact, it is demonstrated that trauma mortality and morbility are significantly reduced by a quick and well conducted approach. This article focuses the initial management of the injured child.

[The management of the child with head injury: our experience]

OBJECTIVES

To analyze the group of children admitted to our Pediatric Intensive Care Unit (PICU) for neurotrauma and describe the management algorithms adopted by us for pediatric head injury.

METHODS

All the children affected by head injury and admitted to PICU since november 1992 to november 2000 have been examined. Injury severity has been classified using the Glasgow Coma Score (GCS), while the long term neurological outcome with the Glasgow Outcome Score (GOS). We have described the clinical presentation, the kind and dynamics of injury and the clinical outcome one month after discharge.

RESULTS

210 children with head injury have been identified. Among them: 38 were affected by mild head injury, 50 by a moderate one and 122 by a severe one. The most frequent cause of injury has been represented by car accidents and motorbike or bicycle falls. The overall outcome has resulted good (GOS 4-5) in all children affected by mild or moderate head injury; on the other side, patients with severe injury have presented the following scores: GOS 1 (dead children) 14.7%, GOS 2 (persistent vegetative state) 1.6%, GOS 3 (severe disability) 22.2%, GOS 4 (mild disability) and GOS 5 (no disability) 61.5%.

CONCLUSION

A correct management of children with head injury helps clinicians to improve outcome and to reduce mortality. Therapeutics algorithms suggested by us could be useful for the management of this kind of patients, not only when they are affected by a severe head injury but, also, when they suffer from a mild one, that is the most common event in the emergency room departments.

Microangiopathic hemolytic anemia complicating a postneonatal pertussis pneumonia

The authors describe a 2-month-old female with microangiopathic hemolytic anemia complicating a pertussis pneumonia. The baby was admitted to the Pediatric Intensive Care Unit for monitoring and treatment. Remission occurred without sequelae, but multiple hemotransfusions were needed in the acute phase. This represents the first reported case of such a complication in childhood.

Pulmonary oedema caused by "liquid ecstasy" ingestion

In this case report we describe the first recorded case of alveolar gas exchange impairment caused by "liquid ecstasy" ingestion, and perhaps inhalation, by a 4 year old child. The pulmonary gas diffusion disturbance was sufficiently prolonged to raise the suspicion of a direct toxic effect on the alveolar-capillary membrane.

Phase extension to weaker reflections of proteins via a partial structure based tangent formula

When some molecular fragment is well located, the so called partial structure based tangent formula may be used to recovery the complete crystal structure. The formula has been extensively applied to small molecules and initial applications to proteins have also been performed. We will show in this paper that the formula may be successfully applied to macromolecules, to refine phase values and to extend the phase information to weaker reflections, even in absence of prior information (at atomic level) on part of the crystal structure. Experimental tests have been performed via a modified form of the program SIR2000.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) is a new cross-sectional study investigating the prevalence and the associated factors of mental disorders, as well as their effect on health-related quality of life and the use of services in six European countries. This paper describes the rationale, methods and the plan for the analysis of the project. A total of 22,000 individuals representative of the non-institutionalized population aged 18 and over from Belgium, France, Germany, Italy, the Netherlands and Spain are being interviewed in their homes. Trained interviewers use a computer-assisted personal interview (CAPI) including the most recent version of the Composite International Diagnostic Interview (CIDI, 2000), a well-established epidemiological survey for assessing mental disorders. This is the first international study using the standardized up-to-date methodology for epidemiological assessment. Sizeable differences in prevalence, impact and level of need that is met by the health services are expected. The analysis of these differences should facilitate the monitoring of ongoing mental health reform initiatives in Europe and provide new research hypotheses.

Cardiac Angiotensin II Formation in the Clinical Course of Heart Failure and Its Relationship With Left Ventricular Function

Abstract —In 76 patients with heart failure (HF) (New York Heart Association [NYHA] classes I through IV) and in 15 control subjects, cardiac angiotensin II (Ang II) generation and its relationship with left ventricular function were investigated by measuring aorta–coronary sinus concentration gradients of endogenous angiotensins and in a part of patients by studying 125 I-labeled Ang I kinetics. Gene expression and cellular localization of the cardiac renin-angiotensin system components, the density of AT 1 and AT 2 on membranes and isolated myocytes, and the capacity of isolated myocytes for synthesizing the hypertrophying growth factors insulin-like growth factor-I (IGF-I) and endothelin (ET)-1 were also investigated on 22 HF explanted hearts (NYHA classes III and IV) and 7 nonfailing (NF) donor hearts. Ang II generation increased with progression of HF, and end-systolic wall stress was the only independent predictor of Ang II formation. Angiotensinogen and angiotensin-converting enzyme mRNA levels were elevated in HF hearts, whereas chymase levels were not, and mRNAs were almost exclusively expressed on nonmyocyte cells. Ang II was immunohistochemically detectable both on myocytes and interstitial cells. Binding studies showed that AT 1 density on failing myocytes did not differ from that of NF myocytes, with preserved AT 1 /AT 2 ratio. Conversely, AT 1 density was lower in failing membranes than in NF ones. Ang II induced IGF-I and ET-1 synthesis by isolated NF myocytes, whereas failing myocytes were unable to respond to Ang II stimulation. This study demonstrates that (1) the clinical course of HF is associated with progressive increase in cardiac Ang II formation, (2) AT 1 density does not change on failing myocytes, and (3) failing myocytes are unable to synthesize IGF-I and ET-1 in response to Ang II stimulation.>

The influence of hemocoagulative disorders on the outcome of children with head injury

BACKGROUND

Although disseminated intravascular coagulation (DIC) and other hemocoagulative abnormalities are severe complications of head injury, their effect on clinical outcome remains unclear, particularly among children.

OBJECTIVES

To evaluate the frequency of hemocoagulative abnormalities and their influence on outcome among children with head injury.

STUDY DESIGN

We conducted a prospective observational study among 60 children with head injury, immediately evaluating severity of head injury (Glasgow Coma Scale, GCS); cerebral axial tomography; prothrombin time; activated partial thromboplastin time (aPTT); fibrinogen level; concentration of fibrin-fibrinogen degradation products (FDP), and platelet count. Two months after injury, we applied the Glasgow Outcome Score (GOS). Associations with GOS were evaluated using univariate and multivariate logistic models.

RESULTS

Among children with severe head injury, 22.2% (6/27) developed DIC, all of whom died and had shown severe brain edema. Among those with severe head injury yet without DIC, the mortality was only 14.2%. A low GOS was significantly and independently associated with a low GCS, multiple trauma, delayed aPTT, low fibrinogen level, elevated FDP and low platelet count. Brain edema was also associated with a low GOS, though not significantly.

CONCLUSIONS

In addition to GCS, type of trauma, type of brain lesion and certain coagulation abnormalities are predictors of GOS.

Intracranial hemorrhage at the onset of thrombotic thrombocytopenic purpura in an infant: therapeutic approach and intensive care management

Thrombotic thrombocytopenic purpura (TTP) is quite rare in infancy and must be treated intensively as a life-threatening disease. Diffuse vascular thromboses may occur, and neurologic involvement is a cornerstone of the diagnosis of TTP. We describe a case of an infant who presented with a sudden cerebral hemorrhage and subsequently developed the typical clinical features of TTP. Emergency treatment in the Pediatric Intensive Care Unit (PICU) consisted of plasma therapy and exchange-transfusion (EXT) to arrest the intravascular process and the exsanguinating blood loss. Exchange-transfusion is a life-saving procedure that is rarely performed after the neonatal age.

[Group cognitive behavior therapy in the routine care at a Psychiatric Ward of Diagnosis and Treatment]

OBJECTIVE

To describe a preliminary evaluation of a group CBT approach which has been fully integrated into the routine care for acute psychotic inpatients, admitted to a typically overburdened inner-city psychiatric general hospital unit.

DESIGN

The design is pre-post. A comparison of some indicators between the years preceding (1997) and following the beginning of the group therapy (1998) has been carried out.

SETTING

Psychiatric ward of S. Filippo Neri in Rome, in 1998.

METHOD

The study compared the rate of rehospitalization, the rate of compulsory admission, the use of physical restraints, the episodes of violent behaviour and the escape from the ward. During the last three months of 1998 patients' satisfaction was also measured.

RESULTS

Overall 385 patients attended the group therapy, 79% of all inpatients in the period, with an average number of 4 sessions per patient. 59% of participants in the group in 1998 had a diagnosis of schizophrenia or paranoid disorder. The total compulsory admissions declined by 1/3 (p < 0.001), the "revolving door" patients declined by 1/3 (p < 0.05), compulsory admissions in "revolving door" patients declined by 3/4 (p < 0.005), violent episodes by almost half (p < 0.001), physical restraints and patients escape from the ward almost disappeared. Patients' opinion about the participation to the group was excellent.

CONCLUSIONS

It is likely, but not sure, that the improvements were directly attributable to the introduction of the group treatment. Moreover, the group was clearly found to be useful by the majority of the participants. Some asked for further help of this type on discharge. These preliminary results are promising and make us confident they will act as stimuli for other colleagues to implement and evaluate this approach in other settings.

Early post-traumatic seizures in children with head injury

Post-traumatic seizures (PTS) can be a serious complication of head injury, because they can cause secondary brain damage through increased metabolic requirements, raised intracranial pressure, cerebral hypoxia, and/or excessive release of neurotransmitters. In children, early PTS are more frequent than late ones. In this retrospective study we conducted an epidemiological analysis and tried to identify potential risk factors for the onset of early PTS in children hospitalized for head injury in our Paediatric Intensive Care Unit. The severity of injury was assessed using the Glasgow Coma Scale (GCS), while the outcome of traumatized children was defined using the Glasgow Outcome Score (GOS). Early PTS were diagnosed in 15 out of the 125 children hospitalized (12%). Most of the children (73.3%), developed seizures within 24 h of the trauma (immediate PTS). Among the risk factors, a very important role was played by the severity of the injury; in fact, the incidence of early PTS among patients with GCS < or = 8 was ten times greater than that among children with GCS 13-15. Other risk factors that significantly influenced the onset of early PTS, were age (60% of children with early PTS were less than 3 years old) and severe cerebral edema. Overall, children with early PTS had a worse outcome than the other patients. In fact, 53% had a GOS of < or = 3 compared to 19.1% of those without early PTS (P<001). In particular, considering children with severe head injury, 80% of those with early PTS had a GOS of < or = 3, compared to 41% of those without early PTS (P<0.05). In conclusion, PTS can be a serious complication of head injury in children, because they can worsen secondary brain damage. Appropriate management of head-trauma patients must include suitable and immediate prophylaxis with anti-epileptic drugs.

SIR2000, a program for the automatic ab initio crystal structure solution of proteins

A new phasing procedure is described working both in direct and in reciprocal space. The procedure has been implemented into the program SIR2000, the heir to SIR99, and it is able routinely to solve ab initio crystal structures of proteins without any use of prior information and any user intervention. The moduli and the flow diagram of SIR2000 are also described and its efficiency tested on several protein diffraction data sets. Success has been attained for crystal structures with up to almost 2000 non-hydrogen atoms in the asymmetric unit and resolution higher than 1.2 A. The phasing process is analysed to provide a better insight into the role of the various steps of the procedure.

Early sequence of cardiac adaptations and growth factor formation in pressure- and volume-overload hypertrophy

To investigate the time sequence of cardiac growth factor formation, echocardiographic and hemodynamic measurements were performed at scheduled times, and mRNAs for angiotensinogen, prepro-endothelin-1 (ppET-1), and insulin-like growth factor I (IGF-I) were quantified with RT-PCR and localized with in situ hybridization in pigs (fluothane anesthesia) by use of pressure or volume overload (aortic banding and aorta-cava fistula, respectively). Relative peptide formation was also measured by radioimmunoassay. In pressure overload, angiotensinogen and ppET-1 mRNA overexpression on myocytes (13 times vs. sham at 3 h and 112 times at 6 h, respectively) was followed by recovery (12 h) of initially decreased (0.5-6 h) myocardial contractility. In volume overload, contractility was not decreased, the angiotensinogen gene was slightly upregulated at 6 h (6.7 times), and ppET-1 was not overexpressed. IGF-I mRNA was overexpressed on myocytes (at 24 h) in both volume and pressure overload (14 times and 37 times, respectively). In the latter setting, a second ppET-1 overexpression was detectable on myocytes at 7 days. In conclusion, acute cardiac adaptation responses involve different growth factor activation over time in pressure versus volume overload; growth factors initially support myocardial contractility and thereafter induce myocardial hypertrophy.

Safety and efficacy of remifentanil in craniosynostosis repair in children less than 1 year old

Few studies on analgesia with remifentanil (Rf) in children are available, and there are no data on the use of this drug in pediatric neurosurgery. Rf is a new mu-receptor opioid agonist, acting through the activation of pain inhibitory mechanisms. We conducted a prospective trial on the analgesic effects of Rf in 20 children less than 1 year of age undergoing a neurosurgical procedure for craniosynostosis repair. Rf was administered at doses of 0.25 microgram/kg/min, by continuous infusion, 1 h after admission to the pediatric intensive care unit (PICU). The treatment was prolonged for 12 h after the operation. The postoperative pain was evaluated in our PICU, comparing the changing of behavioral (AFS and CHEOPS score) and hemodynamic (heart rate, respiratory rate, systolic and diastolic blood pressure, oxygen saturation, O(2) and CO(2) partial pressure) parameters, before and after treatment with Rf. This drug showed a satisfactory pain control in all the children treated. No significant side effects were noticed, except for one episode of urinary retention. In conclusion, Rf appears to be safe and effective for the treatment of acute pain in the very young child submitted to craniosynostosis repair.

Surfactant treatment in a pediatric burn patient with respiratory failure

This report describes surfactant treatment in a burned infant with severe respiratory failure. In this patient the instillation of surfactant rapidly improved compliance, oxygen index (OI), and alveolar-capillary oxygen gradient (AaDO2), while the need for oxygen supplementation and peak positive pressure drastically decreased. The treatment was repeated after 12 hours. Although the baby had severe clinical course complications as a Gram-negative sepsis and a subglottic stenosis, she was weaned from oxygen therapy and mechanical ventilation in few weeks. Surfactant dysfunctions seem to play a central role in the respiratory insufficiency of burned patients, and its exogenous replacements could improve their outcome.

Characterization of endothelin-1 receptor subtypes in isolated human cardiomyocytes

On cardiac membranes and isolated cardiomyocytes from the human heart, cell-type distribution and functional activities of endothelin-1 (ET-1) receptor subtypes were investigated by using binding methods and messenger RNA (mRNA) in situ hybridization. The ET-receptor antagonist BMS-182874 selectively and competitively inhibits ET(A) receptors both on isolated myocytes and ventricular membranes with approximately 1,300 times greater affinity for ET(A) than ET(B) subtypes. The [125I]-ET-1 specific binding revealed 42.851+/-2,546 receptors/myocyte with a prevalent proportion of ET(A)-receptor subtypes on both myocytes (84+/-2%) and ventricular membranes (66+/-3%). In situ hybridization studies revealed that mRNA for ET(A) receptors was expressed on both myocytes and nonmyocyte cells, whereas mRNA for ET(B) receptors was almost exclusively expressed on fibroblasts and endothelial cells. Specific binding of [125I]-ET-1 to both myocytes and ventricular membranes in the presence of specific ET(A) (BMS-182874) and ET(B) (BQ-788)-receptor antagonists showed a displacement of [125I]-ET-1 by unlabeled ET-1, which were significantly faster from ET(B) than from ET(A). This suggests a clearance function of ventricular ET(B) receptors.

Suicide among the elderly in Italy: a descriptive epidemiological study (1969 to 1994)

Data regarding the elderly suicide trend in Italy between 1969 and 1994 were analyzed from an epidemiological point of view in order to verify hypotheses on suicide risk factors in old age. The data were obtained from the National Register of the Institute of Health (Italy) and were standardized at 1971 for age and sex. For the purposes of the study, only data for people aged 70 years and over were considered. The elderly suicide rate increased from 274 per 1,000,000 in 1969 to 354.7 per 1,000,000 in 1994 in males and from 59.7 per 1,000,000 in 1969 to 82.1 per 1,000,000 in 1994 in females. In the three macroareas (northern, central, and southern regions, indicated as N, C, and S), it is possible to observe different trends. In both genders, N and C rates are the highest in Italy (tending to be similar), while S rates are lower and distinct from the others. The most marked increase was observed in the S male rate, whereas N and C rates show a remission after the rate increase in 1980. The most important finding to emerge from this study is the interruption in the tendency for suicide rates to increase in recent years (dating back to the mid-1980s) and the nonuniformity of the nationwide distribution of suicides.

[Diffuse axonal lesions in childhood]

OBJECTIVE

About 48% of all primary traumatic intracranial lesions are represented by so-called Diffuse Axonal Injury (DAI): a pathologic condition characterized by multiple microscopic lesions and hemorrhage at the level of midline cerebral structures, in the subcortical grey matter, and/or within the brainstem. The natural history of DAI is depressing: 100% of the patients deteriorate rapidly to coma and approximately 50% die, while 50% remain in a vegetative state or with severe neurological deficits. In the present report, we describe the results of a study aimed to evaluating the cerebral hemodynamics and the neuroradiological findings observed in four children (6, 8, 10 and 12 years old) affected by DAI.

METHODS

All the patients had been admitted to the Pediatric Intensive Care Unit with Glasgow Coma Score (GCS) of 5. On admission, all patients underwent mechanical ventilation, antiedemigen and barbiturates therapy. Serial CT scan and Transcranial Doppler Sonography (TCD) examinations were carried out in all children. TCD of the middle cerebral arteries was performed through the temporal window. The children underwent insertion of a ventricular catheter for intracranial pressure monitoring. Follow-up time has been, respectively, 4 years, 3 years, 7 and 1 months.

RESULTS

The Glasgow Outcome Score (GOS) of three children is 2 (persistent vegetative state), while the GOS of the one child is 3 (severe neurological deficits).

CONCLUSION

DAI results in unfortunate prognosis and large health care costs. The proper medical management of this condition should be based on TCD and SjO2 and CEO2 evaluations, in order to monitor efficaciously the cerebral blood flow.

Prognostic implications of hyperglycaemia in paediatric head injury

Fifty children with head injury were evaluated in an attempt to establish a correlation between post-traumatic hyperglycaemia and long-term outcome. In all the patients, the blood glucose level was measured on admission and on the days following the trauma (threshold of normal value set at 150 mg/dl). Hyperglycaemia was seen more frequently in children with severe head injury than in those with mild and moderate head injury. It was present in 87.5% of the patients with a Glasgow Coma Score (GCS) < or =8 (the average blood glucose level on admission was 237.8+/-92 mg/dl), in 60% of the patients with a GCS of 9-12 (178+/-78.7 mg/dl) and only in 25% of those with a GCS of 13-15 (131.5+/-39 mg/dl). A close correlation was also seen between the outcome and the blood glucose level. In fact, the blood glucose on admission was higher in the patients with a poor outcome, i.e. in those having a Glasgow Outcome Score (GOS) of 2 or 3 and in those who died (GOS 1), than in the patients with a good outcome (GOS of 4 or 5). Finally, hyperglycaemia persisted beyond the first 24 h after trauma in all the children who died or who survived with a poor outcome. Hyperglycaemia, and especially its persistence over time, appears to be an important negative prognostic factor in children with head injury.

Acute hydrocephalus as a consequence of mumps meningoencephalitis

Aqueductal stenosis can result from mumps meningoencephalitis. We report a case of acute hydrocephalus from an aqueductal stenosis developed immediately after a clinically evident mumps infection. The patient, aged two years, was treated with an antiedema therapy, and a ventriculoperitoneal shunt was placed. His clinical conditions rapidly improved. Only mumps virus was found in his cerebrospinal fluid culture. This case probably represents the earliest hydrocephalus from mumps, among those reported in the literature.

Intraventricular streptokinase infusion in acute post-haemorrhagic hydrocephalus

Neonatal post-haemorrhagic hydrocephalus is a clinical condition with a high mortality and long-term morbidity. Its clinical management is difficult and not well standardized. We describe the case of a term baby suffering from acute intracranial hypertension caused by an intraventricular and thalamic haemorrhage. In this case, the external ventricular drain inserted to control intracranial pressure was ineffective because of repeated obstructions due to blood clots. Continuous intraventricular infusion of streptokinase of 20,000 U/day allowed quick lysis of the clots, drainage of the cerebrospinal fluid and relief from the coma. Although it did not prevent a permanent ventriculoperitoneal shunt, we obtained reabsorption of the intraventricular haemorrhage without rebleeding complications. We suggest the use of low-dose fibrinolytic infusion through an external drain for the treatment of acute intracranial hypertension following intraventricular haemorrhage in term infants.

[Analgesic efficacy of ketorolac and fentanyl in pediatric intensive care]

OBJECTIVE

To evaluate the efficacy of the two different drugs (Ketorolac and Fentanyl), used singularly or in association, in the management of postoperative pain in Picu.

STUDY DESIGN

A randomized and prospective study.

METHODS

52 children were randomly assigned to receive intravenous Ketorolac and/or Fentanyl, according to four different analgesic treatments: A) Ketorolac 1.2 mg/kg every six hrs; B) Ketorolac 1.2 mg/kg (bolus) + 0.21 mg/ kg/hr; C) Fentanyl 1 gamma/kg/hr; D) Fentanyl 1 gamma/kg/hr + Ketorolac 0.21 mg/kg/hr. Each protocol was given to 13 children. The efficacy of treatments were evaluated by child's behaviour (Affective Facial Scale and CHEOPS score) and hemodynamical parameters (systolic and diastolic blood pressure, breathing rate, heart rate, oxygen saturation and oxygen arterial pressure) and analysed by statistical analysis.

RESULTS

The children treated with protocol B (Ketorolac in continuous in infusion) showed better pain relief in respect to those treated with protocol A (Ketorolac in bolus), while the most efficient analgesia was obtained with the association of the two analgesic drugs (protocol D). Two cases of bradycardia, one case of hyperazotemia and one case of transaminase increase were noted.

CONCLUSION

Ketorolac presents a good efficient analgesia, particularly evident when administered in continuous intravenous infusion. However, the association of this NSAID with an opioid drug can be favourably proposed in postoperative pain therapy of moderate to severe grade, since the confirmed analgesic efficacy is not aggravated by important side effects.

Salicylate intoxication using a skin ointment

Acute percutaneous salicylate intoxication is a rare event in children but can happen with a skin disease where salicylic acid, used as a keratolytic ointment, can be absorbed transcutaneously. Until now, few cases of transcutaneous salicylate intoxication have been reported in the literature. Our case report is about a 5-year-old girl with lamellar ichthyosis and an acute salicylate transcutaneous intoxication after the application of a skin ointment. The child had a fever, hyperpnoea with respiratory alkalosis, comatose state and oculogyric crisis. We would like to emphasize the danger of applying salicylic acid in children with extensive skin diseases and, therefore, it is advisable to measure the plasma salicylic levels so as to prevent eventual salicylate toxicity.

Recurrent apparent life-threatening event relieved by glossopexy

An infant with repaired esophageal atresia presented with several apparent life-threatening events (ALTEs). He had upper airway instability, gastroesophageal reflux (GER), and tracheomalacia. Oxygen breathing test results showed a modest increase in arterial Po2 consistent with the development of an intrapulmonary shunt from absorption collapse of some hypoventilated areas of the lung. Glossopexy was followed by improvement in upper airway stability, normal oxygen test, and disappearance of ALTE. These findings support the concept that upper airway instability, obstructive apnea, lower airway instability, absorption collapse, massive intrapulmonary shunt, and ALTE are the result of a cascade reaction. The authors conclude that infants with ALTE associated with obstructive apnea and O2 shunting require glossopexy to reduce the risk of sudden death.

Relationship between autoimmune thyroid disease Rand Alzheimer's disease

Alzheimer's Disease (AD) is a particular form of degenerative dementia probably due to deposit in the brain cortex of a non soluble protein called beta-A4 amyloid in senile plaque form. beta A4 is an aberrant mutant proteolytic product of Amyloid Protein Precursor (APP) codified on chromosome 21. Trisomy 21 is responsible for Down's Syndrome (DS). Down's patients have been shown to develop a form of Alzheimer's after 50 years of age, and high blood levels of antithyroid antibodies are also present in a significant percentage of these cases. In the present investigation, antithyroid antibody titres have been studied by means of RIA in group of 34 AD patients. As compared to 30 non-demented controls, AD subjects showed a significant increase in the mean values of antithyroglobulin (TgAb) and antimicrosomial (MCSAb) autoantibodies. The physiopathological relationship regarding this association is discussed.