Paediatric community-acquired septic shock: results from the REPEM network study

INTRODUCTION AND PURPOSE OF THE STUDY: With this study we aimed to describe a "true world" picture of severe paediatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included.

RESULTS

A 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). 'Severe' outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept).

CONCLUSION

The outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

[Infectious pathology: vulvovaginitis, sexually transmitted diseases, pelvic inflammatory disease, tubo-ovarian abscesses]

Sexually transmitted diseases are those where the principal path of infection is through intimate contact. Numerous patients attend Accidents and emergencies for this reason, both because of the clinical features and because of social implications. The most frequent symptoms are lower abdominal pain, vaginal bleeding or excessive or troubling vaginal flow. Vulvovaginites are one of the principal problems in the everyday clinical practice of gynaecology. A genital ulcer whose principal aetiology is herpes, followed by syphilis and chancroid, increases the risk of contracting HIV infection and alters the course of other sexually transmitted diseases. Inflammatory pelvic disease encompasses infections of the upper female genital tract. The importance of early diagnosis and suitable treatment is both due to the complications in its acute phase and to its sequels, which include chronic pain and sterility.

[Pneumomediastinum and extensive subcutaneous emphysema after normal labor]

Spontaneous pneumomediastinum associated with subcutaneous emphysema is a rare, though life-threatening, complication of late pregnancy and labor. We report the case of a primipara who, after undergoing normal labor and delivery of a normal-weight baby, developed pneumomediastinum and extensive subcutaneous emphysema with significant symptoms within minutes of delivery. This peripartum complication is usually self-limiting when the aggravating factors are no louguer present. Management includes strict monitoring of the patient and conservative treatment of symptoms.

Transcriptional feedback loop regulation, function, and ontogeny in Drosophila

The Drosophila circadian oscillator is composed of interlocked period/timeless (per/tim) and Clock (Clk) transcriptional feedback loops. These feedback loops drive rhythmic transcription having peaks at dawn and dusk during the daily cycle and function in the brain and a variety of peripheral tissues. To understand how the circadian oscillator keeps time and controls metabolic, physiological, and behavioral rhythms, we must determine how these feedback loops regulate rhythmic transcription, determine the relative importance of the per/tim and Clk feedback loops with regard to circadian oscillator function, and determine how these feedback loops come to be expressed in only certain tissues. Substantial insight into each of these issues has been gained from experiments performed in our lab and others and is summarized here.

Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient

STUDY DESIGN

Case report.

OBJECTIVE

To report an uncommon case of cerebral hemorrhage due to autonomic dysreflexia (AD) in a spinal cord injury (SCI) patient.

SETTING

Institut Guttmann, Neurorehabilitation Hospital in Barcelona, Spain.

CASE REPORT

An SCI patient developed AD due to urinary tract infection after surgery for a pressure sore. The hypertension was difficult to control and the case progressed to hypertensive encephalopathy. MRI of the brain was performed showing a hemorrhagic lesion on the left occipital area. The hypertension was finally controlled and the neurological status improved although with some cognitive deficits.

CONCLUSION

This is an uncommon case of cerebral hemorrhage due to AD, showing the importance of an adequate diagnosis and treatment of AD to avoid this life-threatening complication.

Determination of quinolones in water samples by solid-phase extraction and liquid chromatography with fluorimetric detection

A method is reported for the determination, in water samples, of 10 quinolones which are used as veterinary drugs. Analytes are isolated from samples by solid-phase extraction (SPE) and analysed by reversed-phase high-performance liquid chromatography using fluorimetric detection. A solid-phase extraction procedure based on retention on HBL OASIS cartridges and elution with a mixture of acetonitrile-water in basic medium is suitable for pre-concentration of the analytes. Pre-concentration factors up to 250 can be obtained. The quinolones are separated with an octyl silica-based column and mobile phases consisting of aqueous oxalic acid solutions and acetonitrile mixtures. The attained detection limits of the whole process are in the ng l(-1) level when 250 ml of water sample is processed. Recovery rates, from natural water samples spiked at 2060 ng l(-1) level, range from 70 to 100% and common standard deviation are about 6-12%.

Electrophysiologic cardiac effects of the new local anesthetic IQB-9302 and of bupivacaine in the anesthetised dog

BACKGROUND

Local anesthetics are not free from potentially fatal complications. Therefore every new local anesthetic should be tested to demonstrate a lower, or at least similar, degree of toxicity over clinically used analogs. Most toxic effects from local anesthetics affect the cardiac electrophysiologic function, so the aim of this study was to characterize the electrophysiologic effects of a new long-acting local anesthetic (IQB-9302, Ciprocaine), and compare them with those of bupivacaine in the anesthetized dog.

METHODS

Eight Beagle dogs received three increasing infusion doses of either IQB-9302 or bupivacaine. Under isoflurane anesthesia, dogs were instrumented to monitor cardiovascular (cardiac output, arterial and venous blood pressures) and cardiac electrophysiologic data (sinus and atrioventricular (AV) node function, atrial, nodal and ventricular conduction times, and refractoriness).

RESULTS

Only the highest dose of both drugs induced hemodynamic or electrophysiologic alterations: cardiac output and heart rate were reduced while blood pressures remained unchanged. Atrial and intranodal conduction times and atrial refractoriness increased similarly with both anesthetics, but to a slightly lesser extent with IQB-9302. Significant increases in His-Purkinje and intraventricular conduction times were the most severe noxious effects and occurred only with large doses of either drug. IQB-9302 was slightly less toxic than bupivacaine and, unlike this latter drug, potentially fatal arrhythmias were not induced.

CONCLUSION

IQB-9302 has hemodynamic and cardiac electrophysiologic effects similar to those caused by bupivacaine. Nevertheless, slightly less toxic effects were derived from IQB-9302 administration than with bupivacaine, and, unlike the latter, the former might be less proarrhytmogenic. The new long-acting local anesthetic IQB-9302 may offer clinical advantages compared with bupivacaine.

The genome sequence of Schizosaccharomyces pombe

We have sequenced and annotated the genome of fission yeast (Schizosaccharomyces pombe), which contains the smallest number of protein-coding genes yet recorded for a eukaryote: 4,824. The centromeres are between 35 and 110 kilobases (kb) and contain related repeats including a highly conserved 1.8-kb element. Regions upstream of genes are longer than in budding yeast (Saccharomyces cerevisiae), possibly reflecting more-extended control regions. Some 43% of the genes contain introns, of which there are 4,730. Fifty genes have significant similarity with human disease genes; half of these are cancer related. We identify highly conserved genes important for eukaryotic cell organization including those required for the cytoskeleton, compartmentation, cell-cycle control, proteolysis, protein phosphorylation and RNA splicing. These genes may have originated with the appearance of eukaryotic life. Few similarly conserved genes that are important for multicellular organization were identified, suggesting that the transition from prokaryotes to eukaryotes required more new genes than did the transition from unicellular to multicellular organization.

[Oat-cell carcinoma of the tongue: report of a case]

We present a case of oat cell carcinoma of tongue in a 76 year old man with a squamous carcinoma of lung.

Cuticular structures and epidermal glands of Echinoderes cantabricus and E. hispanicus (Kinorhyncha, Cyclorhagida) with special reference to their taxonomic value

The body wall of two species of kinorhynchs, Echinoderes cantabricus and E. hispanicus, was examined with transmission and scanning electron microscopy, to determine accurately the nature, arrangement, and consistency of characters used for taxonomic purposes. Structural details of cuticular hairs, pectinate fringes, spines, tubules, and different cuticular scars are described and discussed. Two kinds of epidermal glands, types 1 and 2, are characterized according to the nature of their secretory products, their exact location and distribution in the trunk segments, and their possible value as taxonomic characters. The generally assumed function of tubules for the release of secretory product is analyzed and finally rejected in light of the different distribution of tubules and glands along the trunk and because of the absence of a clear anatomic relation between both structures. The cuticular features studied can be useful for taxonomic purposes because of their consistency, but some of them are difficult to access and evaluate and therefore must be used with caution.

Identification of genes that modify ataxin-1-induced neurodegeneration

A growing number of human neurodegenerative diseases result from the expansion of a glutamine repeat in the protein that causes the disease. Spinocerebellar ataxia type 1 (SCA1) is one such disease-caused by expansion of a polyglutamine tract in the protein ataxin-1. To elucidate the genetic pathways and molecular mechanisms underlying neuronal degeneration in this group of diseases, we have created a model system for SCA1 by expressing the full-length human SCA1 gene in Drosophila. Here we show that high levels of wild-type ataxin-1 can cause degenerative phenotypes similar to those caused by the expanded protein. We conducted genetic screens to identify genes that modify SCA1-induced neurodegeneration. Several modifiers highlight the role of protein folding and protein clearance in the development of SCA1. Furthermore, new mechanisms of polyglutamine pathogenesis were revealed by the discovery of modifiers that are involved in RNA processing, transcriptional regulation and cellular detoxification. These findings may be relevant to the treatment of polyglutamine diseases and, perhaps, to other neurodegenerative diseases, such as Alzheimer's and Parkinson's disease.

Ultrastructure of the midgut and hindgut of Derocheilocaris remanei (Crustacea, Mystacocarida)

Ultrastructural features and structure of the midgut and hindgut of Derocheilocaris remanei were studied. The large endodermal midgut is differentiated into an anterior midgut and a posterior midgut separated by a conspicuous constriction. Both circular and longitudinal striated muscle bands surround the midgut, while the hindgut only presents longitudinal muscles. The limit between the midgut and the cuticle-lined hindgut is marked by a rectal valve. In cross-section, the short hindgut is triradiate and has a distinct Y-shaped lumen. The hindgut cuticular lining appears interrupted at the tip of every branch of the Y. Three different cell types are found in the midgut epithelium: basally located undifferentiated cells that give rise to the other two specialized cell types; secretory zymogen-like cells responsible for extracellular digestion and located mainly in the anterior midgut; and vacuolated cells, distributed all along the midgut and appearing to have several functions, including absorption, intracellular digestion, and nutrient transport. A single basic cell type forms the hindgut epithelium. The suggested function for the hindgut is the transport and ejection of waste products.

[Cemented fibroma of the maxillary sinus]

Cementifying fibroma is a benign fibro-osseous lesion with dental origin. We describe a case of cementifying fibroma of the maxillary sinus, an unusual location for this tumor.

[Round Table: Urticaria in relation to infections]

OBJECTIVES

1) To study the clinical and analytic features of infectious disease associated to urticaria in children. 2) To look into the probable etiology of the infectious disease. 3) To determine atopic predisposition and previous urticarial episodes and to rule out the involvement of antibiotics.

DESIGN

Transversal and observational study.

SETTING

Pediatric Allergy Outpatient Clinic of a tertiary Hospital.

PATIENTS

Forty-four children, aged 1 to 12 years with acute urticaria associated to clinically infectious or febrile illness attending an Emergency Pediatric Department.

INTERVENTION

Symptoms evaluation and physical examination in the seventh first days and follow over 3-6 weeks by the same physician.

MEASUREMENTS

Clinical features of urticaria (duration, angioedema associated); Clinic diagnosis of illness infectious (acute respiratory infection, gastroenteritis, febrile syndrome); white blood cells count, C-reactive protein, aminotransferases (AST, ALT), L-Y-glutamyl transferase; viral culture and antigen detection: enterovirus (EV), adenovirus, respiratory syncytial virus (RSV), parainfluenza 1, 2 and 3, influenza A y B and cytomegalovirus (CMV); serological assay: CMV, enterovirus, mycoplasma pneumoniae, Epstein-Barr, parvovirus B19.

RESULT

22 children (50%) are between 1-2 years old. 40 patients (90,9%) had symptoms of respiratory tract infection and only four patients had a pneumonia. The other 4 children had a gastroenteritis. The analytic was suggestive of viral infection in 35 (79.5%) and unknown on seven patients. In 20 children (45.4%) was identified a probable infection. The viral detection was positive in 3 patients: CMV, herpes simplex 1 and influenza A. Twenty microbiological findings for seventeen patients was found by serological criterion of probable infection: enterovirus (10); parvovirus B19 (4); Epstein-Barr (3) y mycoplasma (3). Evidence of a double serologic infection was found in three patients. In comparison with a serological control group encountered that acute urticaria during a infectious disease is significantly associated (p = 0.0054) to high titer to enterovirus by complement-fixation. The urticaria was associated with angioedema in 38.6% and 9 children (20.4%) related an previous similar episode. Twenty-one (47.7%) had been treated with antibiotics before development the urticaria. All patients was given the suspected antibiotic and no patient developed any adverse reaction.

CONCLUSIONS

The clinically infectious associated to urticarial rash in children, usually is a viral respiratory infections. Is more frequent at infant. In spite of antibiotic therapy is often related to development the urticaria, the subsequent challenge with the same antibiotic is good tolerated.