Central venous catheter-related thrombosis and thromboprophylaxis in children: a systematic review and meta-analysis

OBJECTIVES

In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also systematically reviewed the pediatric trials on thromboprophylaxis to evaluate its efficacy and to identify possible pitfalls in the conduct of these trials.

PATIENTS/METHODS

We searched MEDLINE, EMBASE, Web of Science and the Cochrane Central Register for Controlled Trials for articles published until December 2013. We included cohort studies and trials on patients aged 0-18 years with central venous catheters who underwent active surveillance for thrombosis with radiologic imaging. We estimated the pooled frequency of thrombosis and the pooled risk ratio (RR) with thromboprophylaxis by using a random effects model.

RESULTS

From 2651 articles identified, we analyzed 37 articles with 3128 patients. The pooled frequency of thrombosis was 0.20 (95% confidence interval [CI] 0.16-0.24). In 10 trials, we did not find evidence that heparin-bonded catheters (RR 0.34; 95%CI 0.01-7.68), unfractionated heparin (RR 0.93; 95% CI 0.57-1.51), low molecular weight heparin (RR 1.13; 95% CI 0.51-2.50), warfarin (RR 0.85; 95%CI 0.34-2.17), antithrombin concentrate (RR 0.76; 95% CI 0.38-1.55) or nitroglycerin (RR 1.53; 95%CI 0.57-4.10) reduced the risk of thrombosis. Most of the trials were either not powered for thrombosis or were powered to detect large, probably unachievable, reductions in thrombosis. Missing data on thrombosis also limited these trials.

CONCLUSIONS

Catheter-related thrombosis is common in children. An adequately powered multicenter trial that can detect a modest, clinically significant reduction in thrombosis is critically needed. Missing outcome data should be minimized in this trial.

The novel adjuvant CoVaccineHT increases the immunogenicity of cell-culture derived influenza A/H5N1 vaccine and induces the maturation of murine and human dendritic cells in vitro

A candidate influenza H5N1 vaccine based on cell-culture-derived whole inactivated virus and the novel adjuvant CoVaccineHT was evaluated in vitro and in vivo. To this end, mice were vaccinated with the whole inactivated influenza A/H5N1 virus vaccine with and without CoVaccineHT and virus-specific antibody and cellular immune responses were assessed. The addition of CoVaccineHT increased virus specific primary and secondary antibody responses against the homologous and an antigenically distinct heterologous influenza A/H5N1 strain. The superior antibody responses induced with the CoVaccineHT-adjuvanted vaccine correlated with the magnitude of the virus-specific CD4+ T helper cell responses. CoVaccineHT did not have an effect on the magnitude of the CD8+ T cell response. In vitro, CoVaccineHT upregulated the expression of co-stimulatory molecules both on mouse and human dendritic cells and induced the secretion of pro-inflammatory cytokines TNF-alpha, IL-6, IL-1beta and IL-12p70 in mouse- and IL-6 in human dendritic cells. Inhibition experiments indicated that the effect of CoVaccineHT is mediated through TLR4 signaling. These data suggest that CoVaccineHT also will increase the immunogenicity of an influenza A/H5N1 vaccine in humans.

Elective intra-aortic balloon counterpulsation during a high risk liver resection

SUMMARY

We present the case of a 65-year-old male with severe coronary artery disease and a single colorectal liver metastasis. An elective intra-aortic balloon pump (IABP) was inserted following induction of anaesthesia to reduce left ventricular workload during his liver resection. After an uneventful recovery he was discharged on day 5. We review the literature on the elective use of these devices in cardiac surgery in which it is becoming routine practice in high risk patients. However in non-cardiac surgery there have been only 15 published cases all in very high risk patients, with favourable outcomes. To our knowledge this is the first published case of the use of elective IABP during liver surgery.

The implications for responsibility of possible genetic factors in the explanation of violence

Genetic determinism is unlikely to be true of most human behaviour. The discovery of a genetically based disposition to violent behaviour would not automatically undermine a person's responsibility for such behaviour. The relevant question is not just whether the genetic disposition plays a causal role, but whether it is so strong as to be irresistible. This requires complex evaluation of different kinds of evidence. When genetic causes are combined with others, including environmental ones, the resulting picture of human behaviour may be a more determinist one than we are used to. Such a picture, if it came to be accepted, would not necessarily undermine responsibility. The everyday distinctions between what we can and cannot do would still survive. But understanding the full implications of such a picture would in some ways modify our attitudes and practices. Blame would take a different form, and retributive punishment might come to seen unacceptable.

Outbreak of carbapenem-resistant Pseudomonas aeruginosa producing VIM-8, a novel metallo-beta-lactamase, in a tertiary care center in Cali, Colombia

The prevalence of imipenem resistance among Pseudomonas aeruginosa isolates at a 195-bed tertiary care medical center in Cali, Colombia, rose from 2% in 1996 to 28% in 1997 and to over 40% in 2003. Many isolates showed high-level multiresistance, and phenotypic characterization suggested the spread of a predominant strain with minor variants. Sixty-six resistant isolates collected between February 1999 and July 2003 from hospitalized patients (n = 54) and environmental samples (n = 12) were subjected to a fuller analysis. Genetic fingerprints were compared by pulsed-field gel electrophoresis (PFGE) of SpeI-digested genomic DNA, and bla(IMP) and bla(VIM) genes were sought by PCR. PFGE and serotyping indicated that 52 of the 66 isolates belonged to a single strain, with 82% similarity; the PFGE pattern for this organism was designated pattern A. Two further pairs of isolates represented single strains; the remaining nine isolates were unique, and in the case of one isolate, no satisfactory PFGE profile could be obtained. The pattern A isolates were mostly of serotype O12 and were highly resistant to imipenem (MICs, 32 to >256 microg/ml), with this resistance decreased eightfold or more in the presence of EDTA. They yielded amplicons with bla(VIM)-specific primers, and sequencing of DNA from a representative isolate revealed bla(VIM-8), a novel allele with three polymorphisms compared with the sequence of bla(VIM-2). Two of these nucleotide changes were silent, but the third determined a Thr139Ala substitution. Only 4 of 13 resistant isolates (2 clinical isolates and 2 environmental isolates) assigned to other PFGE types carried bla(VIM) alleles, whereas the others were less multiresistant and mostly had lower levels of imipenem resistance (MICs, < or =32 microg/ml) which was not significantly reduced by EDTA. No bla(IMP) alleles were detected. During 2003, when the environmental study was undertaken, serotype O12 isolates with bla(VIM) were recovered from sinks and stethoscopes in the most-affected units, although not from the hands of staff; the problem declined once these reservoirs were disinfected and hygienic precautions were reinforced.

Angiotensin-converting enzyme activity by canine pulmonary microvascular and central pulmonary artery endothelial cells exposed to hypoxia

To compare the amount of angiotensin-converting enzyme (ACE) activity in pulmonary artery endothelial cells from different sites and to examine the effect of severe hypoxia (less than 1% of O(2) in 5% CO(2) and 95% N(2)) on the ACE activity expressed by these cells, endothelial cells were harvested and cultured from canine main pulmonary artery by scraping the luminal surface of the artery and from canine pulmonary artery microvessels by infusing chilled buffer with microcarrier beads and 0.02% ethylenediamine tetraacetic acid (EDTA). ACE activity in cell lysates and culture medium was evaluated by fluorometric assay with hippuryl-L-histidyl-L-leucine as a substrate. ACE activity in cell lysates and postculture medium of pulmonary microvascular endothelial cells (PMVEC) was higher than in cell lysates and culture medium of central pulmonary artery endothelial cells (PAEC). However, hypoxia suppressed cellular ACE activity in both PAEC and PMVEC. The degree of suppression of ACE activity by hypoxia, which was determined as (ACE activity in normoxia - ACE activity in hypoxia)/ACE activity in normoxia x 100(%), was larger in PMVEC than in PAEC. The pulmonary microvasculature may be a greater source of ACE than central pulmonary artery, and the ACE activity of pulmonary microvascular endothelial cells seem to be sensitive to hypoxia, although the small diameter of the vessels improves conditions for interaction of blood-borne substance with endothelial enzymes.

Use of experiential methods to teach research in a pre-registration nursing curriculum

For nursing to become firmly established as a research-based profession, it is essential that all nurses are equipped with the skills to critique research literature. This demands the integration of research application into nursing curricula at all levels. In order for nursing problems to be effectively illuminated, it is important that a range of quantitative and qualitative approaches are utilised. This necessitates teaching material from across the range of relevant research paradigms. Many students commencing pre-registration courses have a limited knowledge of either nursing or research. Others have had a variety of previous experiences of research as a subject, some of which have generated negative stereotypes and disinterest. This paper will explore the challenges encountered when teaching research to students on a pre-registration advanced diploma course. The authors have developed a range of experiential exercises which attempt to explore research concepts in a meaningful way. The presentation of research principles is followed up by formative work linked to clinical placements. Discussion during feedback sessions allows for sharing of ideas and experiences within the group and facilitates critical reflection. The evaluation from this initiative has been positive and encouraging. A selection of the methods used and evaluation material will be presented.

Augmentation of killing of Escherichia coli O157 by combinations of lactate, ethanol, and low-pH conditions

The acid tolerance of Escherichia coli O157:H7 strains can be overcome by addition of lactate, ethanol, or a combination of the two agents. Killing can be increased by as much as 4 log units in the first 5 min of incubation at pH 3 even for the most acid-tolerant isolates. Exponential-phase, habituated, and stationary-phase cells are all sensitive to incubation with lactate and ethanol. Killing correlates with disruption of the capacity for pH homeostasis. Habituated and stationary-phase cells can partially offset the effects of the lowering of cytoplasmic pH.

Characterization of commissural interneurons in the lumbar region of the neonatal rat spinal cord

Neurons with axons that extend to the contralateral side of the spinal cord--commissural interneurons (CINs)--coordinate left/right alternation during locomotion. Little is known about the organization of CINs in the mammalian spinal cord. To determine the numbers, distribution, dendritic morphologies, axonal trajectories, and termination patterns of CINs located in the lumbar spinal cord of the neonatal rat, several different retrograde and anterograde axonal tracing paradigms were performed with fluorescent dextran amines and the lipophilic tracer 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI). CINs with ascending (aCINs) and descending (dCINs) axons were labeled independently. The aCINs and dCINs occupied different but overlapping domains within the transverse plane. The aCINs were clustered into four recognizable groups, and the dCINs were clustered into two recognizable groups. All dCINs and most aCINs were located within the gray matter, with somata ranging from 10-30 microm in diameter and with large, multipolar dendritic trees. One group of aCINs was located outside the gray matter along the dorsal and dorsolateral margin and had dendrites that were nearly confined to the dorsolateral surface. All CIN axons traversed the ventral commissure at right angles to the midline. CIN axons coursed up to six or seven segments rostrally and/or caudally in the ventral and ventrolateral white matter and gave off collaterals over a shorter range, predominantly to the ventral gray matter. These findings show that the lumbar spinal cord of the neonatal rat contains substantial numbers of CINs with axon projections and collateral ranges spanning several segments and that CINs projecting rostrally vs. caudally have different distributions in the transverse plane. The study provides an anatomical framework for future electrophysiological studies of the spinal neuronal circuits underlying locomotion in mammals.

Cloning and characterization of MS5 from Arabidopsis: a gene critical in male meiosis

In this paper, we describe the cloning of the MS5 gene, a gene essential for male fertility in Arabidopsis. We previously defined the MS5 locus by characterizing an EMS-induced allele, ms5-1. We identified a new allele of MS5 (ms5-2) that was T-DNA-generated and used the T-DNA tag to clone the gene. Sequencing of mutant and wild-type alleles together with complementation of the ms5-1 mutant phenotype with a wild-type genomic clone confirmed the identity of the gene. Differences between the phenotypes of the two mutant alleles could be attributed to differences in mutant gene structure. The semi-dominant and dominant negative phenotypes of the ms5-2 mutant probably result from production of a truncated polypeptide. An unknown locus in Landsberg erecta can counteract the dominant negative phenotype of ms5-2. Mutations in MS5 cause the formation 'polyads'--tetrads with more than four pools of chromosomes after male meiosis. Similarities between the MS5 sequence and that of a number of proteins were found; two that may be significant were with a synaptonemal complex protein and with a regulatory subunit of a cyclin-dependent kinase. The MS5 gene is a member of a small gene family highly conserved amongst plant species.

Effect of dopamine on renal function after arteriography in patients with pre-existing renal insufficiency

Contrast media-induced nephropathy is one of the leading causes of hospital-acquired renal failure, occurring most frequently in patients with pre-existing renal insufficiency. We prospectively studied 55 patients with chronic renal insufficiency (serum creatinine concentration 1.4 to 3.5 mg/dl) who underwent abdominal aortography and arteriography of the lower extremities. The patients were randomized into two groups. Group 1, 28 patients, received dopamine 2.5 mcg/kg beginning 1 hour before arteriography and continuing for 12 hours. Group 2 received an equal volume of saline for the same period of time. Serum creatinine and 12-hour creatinine clearance were measured before arteriography and for 4 consecutive days afterward. Acute contrast-induced decrease in renal function was defined as increase in the baseline serum creatinine concentration > or = 0.5 mg/dl. On day 1 postarteriography the serum creatinine increased from baseline .193 mg/dl for controls while the dopamine group decreased slightly from baseline .018 mg/dl (p = 0.002). Excepting day 1 postarteriography, there was no statistical difference between groups, and serum levels for both groups increased linearly from baseline across time (dopamine p = 0.028, control p = 0.025). In patients with pre-arteriography baseline serum levels greater than or equal to 2.0 mg/dl, however, the increase in serum creatinine from baseline levels was consistently and significantly greater in the control group through the fourth day (0.012 < or = p < or = 0.049). Creatinine clearance did not change significantly from baseline after arteriography in the dopamine group (baseline versus days 1 through 4, 0.238 < or = p < or = 0.968); however, the control group showed a significant linear decrease in creatinine clearance from baseline through the fourth day after arteriography (p = 0.016). Dopamine infusion prevented a rise in serum creatinine 24 hours after angiography in patients with pre-existing renal insufficiency, and protected against contrast-induced decrease in renal function in patients whose baseline serum creatinine was > or = 2.0 mg/dl.

Molecular analysis of cellulose biosynthesis in Arabidopsis

Cellulose, an abundant, crystalline polysaccharide, is central to plant morphogenesis and to many industries. Chemical and ultrastructural analyses together with map-based cloning indicate that the RSW1 locus of Arabidopsis encodes the catalytic subunit of cellulose synthase. The cloned gene complements the rsw1 mutant whose temperature-sensitive allele is changed in one amino acid. The mutant allele causes a specific reduction in cellulose synthesis, accumulation of noncrystalline beta-1,4-glucan, disassembly of cellulose synthase, and widespread morphological abnormalities. Microfibril crystallization may require proper assembly of the RSW1 gene product into synthase complexes whereas glucan biosynthesis per se does not.

T1a and T1b breast cancer: a twelve-year experience

To understand the prevalence of axillary node metastasis and survival of patients with T1a and T1b breast cancers, we reviewed the experience at a large community hospital. All patients in the William Beaumont Hospital tumor registry with breast cancer treated between January 1983 and November 1995 were evaluated for tumor size, age, cell type, and the presence or absence of axillary node disease. Long-term survival was evaluated in patients treated between 1983 and 1992. The patients were defined as premenopausal or postmenopausal based on age (49 years or less, premenopausal; 50 years or greater, postmenopausal). Of the 4590 patients treated for breast cancer from 1983 to 1995, 915 had tumors 1.0 cm or less in size. Of 181 patients who had T1a cancer, 27 were premenopausal, and 154 were postmenopausal. Twenty-three premenopausal patients had axillary lymph nodes examined, two (8.7%) had histologically positive lymph nodes. Of 118 postmenopausal patients who had axillary nodes examined, six (5.1%) had positive lymph nodes. In those with T1b tumors, 130 patients were premenopausal; 604 patients were postmenopausal. Of these, 119 premenopausal patients had axillary nodes examined, and 29 (24.4%) had positive lymph nodes. Of 464 postmenopausal patients who had axillary nodes examined, 66 (14.2%) had positive nodes. The overall, disease-free, and tumor-specific survival rates for patients with T1a tumors were 93.8, 87.5, and 93.8 per cent (premenopausal) and 86.2, 95.4, and 95.4 per cent (postmenopausal), respectively. These survival rates for patients with T1b tumors were 87.8, 87.8, and 91.1 per cent (premenopausal) and 82.9, 88.5, and 92.9 per cent (postmenopausal), respectively. Premenopausal T1b patients had a higher rate of nodal involvement than postmenopausal T1b patients (P = 0.011). Postmenopausal T1b patients had a higher nodal metastasis rate than postmenopausal T1a patients (P = 0.01). T1b patients had a higher rate of axillary involvement than did T1a patients (P = 0.0018). Based on the rate of axillary lymph node metastasis and survival statistics, there may be a role for axillary node dissection in select patients with tumors less than 1.0 cm. in size.

Gastro-aortic fistula: an uncommon complication of Nissen fundoplication

We report a case of and review the literature concerning primary gastro-aortic fistula secondary to erosion of a gastric ulcer into the thoracic aorta in a patient with a previous Nissen fundoplication. Treatment consisted of excision of the fistula with closure of the gastric and aortic defects. This rare cause of upper gastrointestinal bleeding is life threatening, and a high level of suspicion is necessary to make the diagnosis and initiate early, aggressive surgical treatment.

Sexual assault in dating relationships

This article focuses on acquaintance rape, which under Canadian law constitutes a form of sexual assault. Frequency of acquaintance rape often is underestimated due to under-reporting, resulting in a local perception that acquaintance rape rarely occurs in a small Canadian community. A survey was conducted to determine whether acquaintance rape does occur in this community. One hundred sixty-four male and female students from grades 8-12 completed a questionnaire. Twenty-six percent of respondents reported being forced into some type of sexual activity. Based on the survey, this article explores the type of force used, the relationship between acquaintance rape and use of alcohol and drugs, and the relationship between acquaintance rape and the ability to indicate to a partner to stop a behavior. Results confirmed a need to develop programs to prevent rather than merely respond to issues of sexual assault on a date.

The Internet: a new instrument in a virtual "doctor's bag"

The Internet is a valuable professional tool, and savvy physicians should understand its strengths and weaknesses. This worldwide network of networks allows doctors to communicate using any of several common Internet tools-electronic mail, mailing lists, newsgroups, telnet, file transfer protocol, gopher, and the World Wide Web. Many sites on the World Wide Web are expressly designed for physicians, although users must be careful to evaluate information for accuracy and currency. In Connecticut, physicians can use CHIME-Net, which provides access to the Internet and easy exchange of financial and patient data. Physicians ready to plunge into the Internet should consult their hospital library or information services department for more information.

Generation of activated natural killer (A-NK) cells in patients with chronic myelogenous leukaemia and their role in the in vitro disappearance of BCR/abl-positive targets

Activated natural killer (A-NK) cells, a subset of CD56(dim)CD3- lymphocytes, are obtained from PBMC of normal donors by adherence to plastic and culture in the presence of IL2. In this study we tested the feasibility of generating A-NK cells in patients with Ph+ chronic myeloid leukaemia (CML). Cultures obtained from patients with early chronic phase (ECP; n=7) contained a mean (+/-SD) of83 +/- 7% of CD3- cells, and those from patients with advanced chronic phase (ACP; n=7) contained 27+/-33% CD56+CD3- cells. In three patients with leukaemia in a blastic phase (BP) it was only possible to obtain one culture enriched in CD56+CD3- cells (81%). Cellular aggregates of myeloid cells and large granular lymphocytes were observed in early A-NK cell cultures. Paired freshly-adherent and cultured A-NK cells were tested for the presence of BCR/abl mRNA by RT-PCR. The BCR/abl+ cells were detected in all 12 preparations of the freshly adherent A-NK cells tested. In 6/12 the BCR/abl+ cells were no longer detectable by RT-PCR on day 14 of culture. Both proliferation and antileukaemic cytotoxicity were significantly higher (P=0.002 and P=0.029, respectively) in the BCR/abl- cultures than those in the six BCR/abl+ cultures. 5/6 BCR/abl- cultures were highly enriched in A-NK cells on day 14, and 1/6 contained predominantly CD56+CD3+ cells. Only 2/6 BCR/abl + cultures were enriched in A-NK cells on day 14, but they had poor cytotoxicity and a low proliferative index. Myeloid cells (CD33+) were more frequently detected in the BCR/abl+ than BCR/abl- A-NK cell cultures (P=0.028). These observations suggest that: (1) populations of benign A-NK cells can be generated from the peripheral blood of CML patients; (2) the ability to generate A-NK cells is impaired in patients with advanced CML; and (3) the ability to generate A-NK cells with antileukaemic activity correlates with the disappearance of BCR/abl+ cells from these cultures.

Bedside tracheostomy in the intensive care unit

OBJECTIVE

To prove that tracheostomy performed at the bedside in the intensive care unit is a safe, cost-effective procedure.

DESIGN

Retrospective review of all adult patients undergoing elective bedside tracheostomy in the intensive care unit between January 1983 and December 1988. Two hundred four patients were identified.

SETTING

A private 1200-bed tertiary care center with a 120-bed critical care facility.

MAIN OUTCOME MEASURES

Major and minor perioperative complications, cost savings, and comparison of risk between bedside tracheostomy and that performed in the operating room.

RESULTS

There were six major complications (2.9%): one death due to tube obstruction, two bleeding episodes requiring reoperation, one tube entrapment requiring operative removal, one nonfatal respiratory arrest, and one bilateral pneumothorax; and seven minor complications (3.4%): five episodes of minor bleeding, one tube dislodgement in a tracheostomy with a well-developed tract, and one episode of mucus plugging. One late complication (tracheal stenosis) was identified.

CONCLUSIONS

Bedside tracheostomy in the intensive care unit can be performed with morbidity and mortality rates comparable to operative tracheostomy. In addition, it provides a significant cost savings for the patient.