Early mobilization in the pediatric intensive care unit: a systematic review

Children admitted to the pediatric intensive care unit (PICU) can experience significant morbidity as a consequence of mechanical ventilation and sedative medications. This morbidity could potentially be decreased with the implementation of activities to promote early mobilization during critical illness. The objective of this systematic review is to summarize the current evidence regarding rehabilitation therapies in the PICU and to highlight the knowledge gaps and avenues for future research on early mobilization in the PICU. Using a combination of controlled vocabulary and key word terms PubMed, CINAHL, and EMBASE databases were searched; no limiters were imposed on search strategies. Two reviewers abstracted data and assessed quality independently. From the 1928 articles identified in the search 168 abstracts were identified for full text review. Fifty-nine articles were chosen for data extraction and five were identified for inclusion in review. A sixth article was identified through expert clinician query. The studies were categorized into three groups based on the outcomes discussed: safety and feasibility, functional outcomes, and length of stay. A synthesis of the studies indicates that early rehabilitation in the PICU is safe and feasible with potential short and long-term benefits. Institutional, provider and patient-related barriers to initiation of early rehabilitation in the PICU are identified. Recommendations for future investigation include early rehabilitation protocols for children hospitalized in the PICU and identification of outcome measures.

Sweet taste and nutrient value subdivide rewarding dopaminergic neurons in Drosophila

Dopaminergic neurons provide reward learning signals in mammals and insects [1–4]. Recent work in Drosophila has demonstrated that water-reinforcing dopaminergic neurons are different to those for nutritious sugars [5]. Here, we tested whether the sweet taste and nutrient properties of sugar reinforcement further subdivide the fly reward system. We found that dopaminergic neurons expressing the OAMB octopamine receptor [6] specifically convey the short-term reinforcing effects of sweet taste [4]. These dopaminergic neurons project to the β′₂ and γ₄ regions of the mushroom body lobes. In contrast, nutrient-dependent long-term memory requires different dopaminergic neurons that project to the γ_5b regions, and it can be artificially reinforced by those projecting to the β lobe and adjacent α₁ region. Surprisingly, whereas artificial implantation and expression of short-term memory occur in satiated flies, formation and expression of artificial long-term memory require flies to be hungry. These studies suggest that short-term and long-term sugar memories have different physiological constraints. They also demonstrate further functional heterogeneity within the rewarding dopaminergic neuron population.

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Sweet taste and nutrient value recruit different reinforcing dopaminergic neurons

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Sweetness and nutrient value separately reinforce short- and long-term memories

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Reinforcement of short-term memory is not dependent on the state of hunger

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Acquisition and retrieval of long-term memory are hunger state dependent

Neuroimaging findings in sickle cell disease

At least 25% of individuals with sickle cell disease will have a neurological complication over their lifetime, often as early as in childhood. Neuroradiological findings in patients with sickle cell disease are common and include acute territorial infarction, silent ischaemia and intracranial haemorrhage. Imaging abnormalities are typically, but not always, manifestations of the underlying vasculopathy. Coexisting acute and chronic pathology may pose challenges to interpretation.

Balamuthia mandrillaris Encephalitis: Survival of a Child With Severe Meningoencephalitis and Review of the Literature

Balamuthia mandrillaris causes granulomatous amoebic encephalitis, which is frequently fatal. There are few reports of survival in children. A 4-year-old child developed severe meningoencephalitis with multiple intracranial ring-enhancing lesions. Empiric therapy was commenced after a biopsy was performed, and the patient had a good clinical response. Molecular testing and indirect immunofluorescence later confirmed the diagnosis of Balamuthia encephalitis. Diagnosis of Balamuthia encephalitis is often delayed. The literature is reviewed with particular reference to reported survival. Prompt tissue diagnosis and initiation of therapy are common features among survivors. In previous reports, miltefosine was not used to treat children, but it was well tolerated in this case and should be considered as a therapeutic option.

Postpartal subclinical endometritis alters transcriptome profiles in liver and adipose tissue of dairy cows

Transcriptome alterations in liver and adipose tissue of cows with subclinical endometritis (SCE) at 29 d postpartum were evaluated. Bioinformatics analysis was performed using the Dynamic Impact Approach by means of KEGG and DAVID databases. Milk production, blood metabolites (non-esterified fatty acids, magnesium), and disease biomarkers (albumin, aspartate aminotransferase) did not differ greatly between healthy and SCE cows. In liver tissue of cows with SCE, alterations in gene expression revealed an activation of complement and coagulation cascade, steroid hormone biosynthesis, apoptosis, inflammation, oxidative stress, MAPK signaling, and the formation of fibrinogen complex. Bioinformatics analysis also revealed an inhibition of vitamin B3 and B6 metabolism with SCE. In adipose, the most activated pathways by SCE were nicotinate and nicotinamide metabolism, long-chain fatty acid transport, oxidative phosphorylation, inflammation, T cell and B cell receptor signaling, and mTOR signaling. Results indicate that SCE in dairy cattle during early lactation induces molecular alterations in liver and adipose tissue indicative of immune activation and cellular stress.

SPECT-CT: applications in musculoskeletal radiology

This article reviews the technique, basic science principles and applications of integrated single photon emission CT (SPECT)-CT in musculoskeletal radiology. A review of the current evidence on the topic was undertaken, and selected clinical cases from the authors' institution have been used for illustration. SPECT-CT is a technology with emerging applications that offers technical advantages to image fusion of separately acquired SPECT and CT studies. The prevailing evidence indicates that there may be benefit in adding SPECT-CT to conventional imaging algorithms during the evaluation of some malignant and benign musculoskeletal conditions. SPECT-CT can improve both sensitivity and specificity by reducing equivocal interpretation in comparison to planar scintigraphy or SPECT alone. The evidence base for SPECT-CT in musculoskeletal radiology is still evolving. There is a lack of evidence comparing SPECT-CT with MRI in many key indications, and further research is required in these areas.

Maintaining medical professionalism at the heart of radiology

Professionalism is a complex blend of values, behaviours, ideals and obligations that are hard to define but recognizable when observed. This article reflects on medical professionalism as an entity, reviews the challenges it faces, and considers proactive ways of nurturing the concept of professionalism in radiology.

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience

OBJECTIVES

This retrospective study aimed to evaluate the diagnostic utility of ultrasound-guided core biopsy (USCB) in lymphoma of the head and neck, in particular whether core biopsy can provide sufficient diagnostic information for definitive treatment.

METHODS

All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment, i.e. the "index" diagnostic technique, was identified. Previous inconclusive or inadequate biopsies were noted. Pathology reports based on USCB were graded 0-3 according to diagnostic completeness and ability to provide treatment information.

RESULTS

Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients, clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision, and these were therefore also included as "index" biopsies. Overall therefore, 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical excision biopsy was the index modality in 104 cases.

CONCLUSION

In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

A technical note: pre-operative ultrasound-guided wire localization in head and neck surgery

Ultrasound-guided wire localization of impalpable lesions is a well-recognized technique in the management of breast pathology, but its use in the head and neck is not well described. Performed under local anesthesia, high-resolution ultrasound provides real-time imaging for accurate placement of the wire resulting in fewer complications. Wire localization can focus the surgical approach, which reduces operating time and minimizes trauma to surrounding tissues. In this technical note, we describe two cases of pre-operative ultrasound-guided wire localization to facilitate the surgical excision of impalpable neck lesions.

Erythropoietin protects against apoptosis and increases expression of non-neuronal cell markers in the hypoxia-injured developing brain

Erythropoietin (EPO) is a cytokine hormone with cytoprotective effects in many tissues including the brain. Although the benefits of administration of recombinant human EPO (rhEPO) for neonatal hypoxic brain injury have been demonstrated in neuronal tissue, the effect on non-neuronal cell populations is unclear. We tested the hypothesis that rhEPO would not only protect neuronal cells but also glial cells at a stage of brain development where their maturation was particularly sensitive, and also protect the vasculature. This was evaluated in a rat model of hypoxic injury. 1000 IU/kg rhEPO was delivered intraperitoneally at the start of 4 h hypoxia or normoxia. Treatment groups of neonatal rats (day of birth, at least N = 10 per group) were as follows: normoxia; normoxia plus rhEPO; hypoxia (8% FiO(2) delivered in temperature-controlled chambers); and hypoxia plus rhEPO. Day of birth in rats is equivalent to human gestation of 28-32 weeks. The effects of rhEPO administration, especially to non-neuronal cell populations, and the associated molecular pathways, were investigated. Apoptosis was increased with hypoxia and this was significantly reduced with rhEPO (p < 0.05). The neuronal marker, microtubule-associated protein-2, increased in expression (p < 0.05) when apoptosis was significantly reduced by rhEPO. In addition, compared with hypoxia alone, rhEPO-treated hypoxia had the following significant protein expression increases (p < 0.05): the intermediate filament structural protein nestin; myelin basic protein (oligodendrocytes); and glial fibrillary acidic protein (astrocytes). In conclusion, rhEPO protects the developing brain via anti-apoptotic mechanisms and promotes the health of non-neuronal as well as neuronal cell populations at a time when loss of these cells would have long-lasting effects on brain function.

Impact of a direct access occupational physiotherapy treatment service

BACKGROUND

Musculoskeletal disorders (MSDs) cause significant morbidity and absence from work for both manual and sedentary occupations.

AIMS

To examine the impact of a direct access physiotherapy treatment service in an occupational setting.

METHODS

This was a pilot study carried out as a service audit. Physiotherapy patients were assessed pre- and post-treatment using the work function score (WFS), a visual analogue scale for pain (VASP) and adjusted clinical score (ACS). Self-report questionnaires were completed on sickness absence, attendance at work and the World Health Organization (five) Well-being Index.

RESULTS

There were 231 participants. Patient improvement was reported in WFS (63%), ACS (84%) and VASP (94%). Compared with those who had one or two sessions, improvement was most likely after three to four sessions for WFS [odds ratio (OR): 4.5; 95% confidence interval: 1.4-14.3, P < 0.05], VASP (OR: 32.2; 95% confidence interval: 3.5-294.2, P < 0.01) and five to six sessions for ACS (OR: 6.9; 95% confidence interval: 1.9-25.9, P < 0.01). While the self-reported questionnaire response rate was low at 29%, respondents indicated that there was potential to reduce and prevent sickness absence and improve mental well-being.

CONCLUSIONS

Brief physiotherapy treatment for MSDs may have the potential to improve not only clinical status and pain as expected but also work function, psychological well-being and sickness absence. Further research is warranted to confirm these positive impacts and to endorse physiotherapy as an effective intervention in occupational settings and a useful component in rehabilitation and 'Fit for Work' programmes.

Psychiatric distress, risk behavior, and treatment enrollment among syringe exchange participants

The present study evaluated psychiatric distress as a predictor of treatment enrollment in out-of-treatment injection opioid users newly registered at the Baltimore Needle Exchange Program (BNEP). Study participants (n=281) completed the Addiction Severity Index (ASI), the Risk Assessment Battery (RAB), and the Symptom Checklist-90 (SCL-90-R), and were randomly assigned to one of three different conditions for 4 months that evaluated referral strategies designed to promote treatment interest and enrollment. The Global Severity Index (GSI) of the SCL-90 was used as a measure of psychiatric distress. A logistic regression showed that higher GSI scores predicted more treatment enrollment (Adjusted OR=2.15, CI=1.10-4.23, p<0.05), after controlling for study condition, demographic variables, syringe exchange site, and severity of drug use. The results suggest that the data from the assessment of psychiatric distress in syringe exchange settings can be used to support motivational strategies for encouraging syringe exchangers to seek substance abuse treatment.

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial

BACKGROUND

HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.

METHODS

In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.

FINDINGS

Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases).

INTERPRETATION

ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment.

FUNDING

UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

The effect of a depth gradient on the mating behavior, oviposition site preference, and embryo production in the zebrafish, Danio rerio

Captive zebrafish (Danio rerio) exhibit a limited repertoire of mating behaviors, likely due to the somewhat unnatural environment of aquaria. Observations in their natural habitat led us to believe that a depth gradient within the mating setup would positively affect fish mating. By tilting the tank to produce a depth gradient, we observed novel behaviors along with a preference for oviposition in the shallow area. Although we did not see an increase in the likelihood of a pair of fish to mate, we did see an increase in the embryo output in both adults and juveniles. In the adults, tilting led to a significant increase in embryo production (436 +/- 35 tilted vs. 362 +/- 34 untilted; p < 0.05). A similar effect was seen in juvenile fish as they progressed through sexual maturity. These results suggest that tilting of mating cages in the laboratory setting will lead to demonstrable improvements in embryo production for zebrafish researchers, and highlights the possibility of other manipulations to increase fecundity.

A re-appraisal of the morphological changes within the endometrium during menstruation: a hysteroscopic, histological and scanning electron microscopic study

BACKGROUND

The morphological changes occurring during the dynamic process of menstruation have previously been described only in terms of data derived from static sources, including histological and electron microscopic studies. Recent advances in pressure-controlled, continuous flow hysteroscopy permit dynamic images to complement the traditional modalities.

METHODS

A prospective observational study of 15 women (age range 22-52 years) during various phases of active menstrual shedding and repair using the novel hysteroscopic plus histological and scanning electron microscopic approaches. The women had not taken hormonal therapy in the previous 2 months and all had regular menstrual cycles of 27-30 days.

RESULTS

For the first time, the hysteroscopic appearance of the endometrium during menstruation has been documented. This technique indicates that endometrial loss and regeneration are piecemeal processes that occur simultaneously in different areas of the uterine cavity. The exposed basalis endometrium is rapidly covered with a fibrinous mesh, upon and within which new surface epithelial cells develop. New epithelial cells appeared to arise from the underlying stromal cells rather than as epithelial outgrowths from the residual gland stumps as had previously been thought.

CONCLUSIONS

Endometrial surface epithelial regeneration is a rapid, localized and piecemeal process that appears to occur as a consequence of cellular differentiation from stromal cells within the residual basalis.

Transparent adult zebrafish as a tool for in vivo transplantation analysis

The zebrafish is a useful model for understanding normal and cancer stem cells, but analysis has been limited to embryogenesis due to the opacity of the adult fish. To address this, we have created a transparent adult zebrafish in which we transplanted either hematopoietic stem/progenitor cells or tumor cells. In a hematopoiesis radiation recovery assay, transplantation of GFP-labeled marrow cells allowed for striking in vivo visual assessment of engraftment from 2 hr-5 weeks posttransplant. Using FACS analysis, both transparent and wild-type fish had equal engraftment, but this could only be visualized in the transparent recipient. In a tumor engraftment model, transplantation of RAS-melanoma cells allowed for visualization of tumor engraftment, proliferation, and distant metastases in as little as 5 days, which is not seen in wild-type recipients until 3 to 4 weeks. This transparent adult zebrafish serves as the ideal combination of both sensitivity and resolution for in vivo stem cell analyses.

Early stage endometrial carcinoma--a study of management and outcome

The surgical management of early stage endometrial carcinoma is controversial. The benefits of pelvic lymphadenectomy and administration of radiotherapy in this group have been disputed. We aimed to document the experience of stage 1 endometrial carcinoma at the National Maternity Hospital during the 10 year period 1989-1998 and to evaluate and compare clinical outcomes between retrospectively-assigned low and high-risk tumour groups. Seventy seven women were diagnosed with Stage 1 endometrial carcinoma in this period. Thirty-nine women had low-risk and 38 had high-risk tumours. Women with high-risk tumours were older and had a higher rate of lymph-vascular space invasion by tumour on histological examination. Three women (3.9%) developed disease recurrence and died of their disease; one low-risk and two high-risk tumour patients. Survival without recurrence did not differ between the two risk groups. No consistent pattern existed in surgical staging between the two risk groups. A prospectively-assigned definition of risk would minimise variations in clinical practice by providing a basis for a more tailored approach to adjuvant treatments.

Increased cerebral lactate during hypoxia may be neuroprotective in newborn piglets with intrauterine growth restriction

Intrauterine growth restriction (IUGR) can increase susceptibility to perinatal hypoxic brain injury for reasons that are unknown. Previous studies of the neonatal IUGR brain have suggested that the cerebral mitochondrial capacity is reduced but the glycolytic capacity increased relative to normal weight (NW) neonates. In view of these two factors, we hypothesized that the generation of brain lactate during a mild hypoxic insult would be greater in neonatal IUGR piglets compared to NW piglets. Brain lactate/N-acetylaspartate (NAA) ratios and apparent diffusion coefficients (ADCs) were determined by proton magnetic resonance spectroscopy and imaging of the brain before, during and after hypoxia in seven neonatal piglets with asymmetric IUGR and six NW piglets. During hypoxia, IUGR piglets had significantly higher brain lactate/NAA ratios than NW piglets (P=0.046). The lactate response in the IUGR piglets correlated inversely with apoptosis in the thalamus and frontal cortex of the brain measured 4 h post hypoxia (Pearson's r=0.86, P<0.05). Apoptosis in IUGR piglets with high brain lactate was similar to that in the NW piglets whereas IUGR piglets with low brain lactate had significantly higher apoptosis than NW piglets (P=0.019). ADCs in the high lactate IUGR piglets were significantly lower during hypoxia than in all the other piglets. This signifies increased diffusion of water into brain cells during hypoxia, possibly in response to increased intracellular osmolality caused by high intracellular lactate concentrations. These findings support previous studies showing increased susceptibility to hypoxic brain injury in IUGR neonates but suggest that increased glycolysis during hypoxia confers neuroprotection in some IUGR piglets.