Molecular and Clinical Characteristics of Different Toxicity Rates in Anti-CD19 Chimeric Antigen Receptor T Cells: Real-World Experience

Commercially available anti-CD19 chimeric antigen receptor T cells (CARΤ cells) have offered long-term survival to a constantly expanding patient population. Given that novel toxicities including cytokine release syndrome (CRS) and neurotoxicity (ICANS) have been observed, we aimed to document the safety and toxicity of this treatment in a real-world study. We enrolled 31 adult patients referred to our center for CAR T therapy. Tisagenlecleucel was infused in 12 patients, axicabtagene ciloleucel in 14, and brexucabtagene autoleucel in 5. Cytokine release syndrome was noted in 26 patients while neurotoxicity was observed in 7. Tocilizumab was administered for CRS in 18 patients, along with short-term, low-dose steroid administration in one patient who developed grade III CRS and, subsequently, grade I ICANS. High-dose steroids, along with anakinra and siltuximab, were administered in only two MCL patients. With a median follow-up time of 13.4 months, nine patients were then in CR. The progression-free (PFS) and overall survival (OS) rates were 41.2% and 88.1% at one year, respectively. MCL diagnosis, which coincides with the administration of brexucabtagene autoleucel, was the only factor to be independently associated with poor OS (p < 0.001); meanwhile, increased LDH independently predicted PFS (p = 0.027).In addition, CRP at day 14 was associated with a poor OS (p = 0.001). Therefore, our real-world experience confirmed that commercial CAR T therapy can be administered with minimal toxicity.

High-Throughput Sequencing of the T-Cell Receptor Beta Chain Gene Repertoire in Chronic Lymphocytic Leukemia

High-throughput, next-generation sequencing (NGS) offers a unique opportunity for in-depth characterization of adaptive immune receptor repertoires. Nevertheless, limitations and pitfalls exist in every step of both the experimental and the analytical procedure, leading to discrepancies in the literature and incomprehensive and/or altogether misleading results. Thus, standardization of protocols in NGS immunogenetics is urgently needed.Here, we describe the experimental protocol that we developed for T-cell receptor beta chain (TRB) gene repertoire analysis in chronic lymphocytic leukemia, aiming to provide a reproducible and biologically meaningful output. Although optimized for TRBV-TRBD-TRBJ gene rearrangements, this protocol may be customized for other adaptive immune receptor sequences, as well.

Using NanoSIMS coupled with microfluidics to visualize the early stages of coral infection by Vibrio coralliilyticus

Background

Global warming has triggered an increase in the prevalence and severity of coral disease, yet little is known about coral/pathogen interactions in the early stages of infection. The point of entry of the pathogen and the route that they take once inside the polyp is currently unknown, as is the coral’s capacity to respond to infection. To address these questions, we developed a novel method that combines stable isotope labelling and microfluidics with transmission electron microscopy (TEM) and nanoscale secondary ion mass spectrometry (NanoSIMS), to monitor the infection process between Pocillopora damicornis and Vibrio coralliilyticus under elevated temperature.

Results

Three coral fragments were inoculated with ¹⁵N-labeled V. coralliilyticus and then fixed at 2.5, 6 and 22 h post-inoculation (hpi) according to the virulence of the infection. Correlative TEM/NanoSIMS imaging was subsequently used to visualize the penetration and dispersal of V. coralliilyticus and their degradation or secretion products. Most of the V. coralliilyticus cells we observed were located in the oral epidermis of the fragment that experienced the most virulent infection (2.5 hpi). In some cases, these bacteria were enclosed within electron dense host-derived intracellular vesicles. ¹⁵N-enriched pathogen-derived breakdown products were visible in all tissue layers of the coral polyp (oral epidermis, oral gastrodermis, aboral gastrodermis), at all time points, although the relative ¹⁵N-enrichment depended on the time at which the corals were fixed. Tissues in the mesentery filaments had the highest density of ¹⁵N-enriched hotspots, suggesting these tissues act as a “collection and digestion” site for pathogenic bacteria. Closer examination of the sub-cellular structures associated with these ¹⁵N-hotspots revealed these to be host phagosomal and secretory cells/vesicles.

Conclusions

This study provides a novel method for tracking bacterial infection dynamics at the levels of the tissue and single cell and takes the first steps towards understanding the complexities of infection at the microscale, which is a crucial step towards understanding how corals will fare under global warming.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1173-0) contains supplementary material, which is available to authorized users.

Restrictions in the T-cell repertoire of chronic lymphocytic leukemia: high-throughput immunoprofiling supports selection by shared antigenic elements

Immunoglobulin (IG) gene repertoire restrictions strongly support antigen selection in the pathogenesis of chronic lymphocytic leukemia (CLL). Given the emerging multifarious interactions between CLL and bystander T cells, we sought to determine whether antigen(s) are also selecting T cells in CLL. We performed a large-scale, next-generation sequencing (NGS) study of the T-cell repertoire, focusing on major stereotyped subsets representing CLL subgroups with undisputed antigenic drive, but also included patients carrying non-subset IG rearrangements to seek for T-cell immunogenetic signatures ubiquitous in CLL. Considering the inherent limitations of NGS, we deployed bioinformatics algorithms for qualitative curation of T-cell receptor rearrangements, and included multiple types of controls. Overall, we document the clonal architecture of the T-cell repertoire in CLL. These T-cell clones persist and further expand overtime, and can be shared by different patients, most especially patients belonging to the same stereotyped subset. Notably, these shared clonotypes appear to be disease-specific, as they are found in neither public databases nor healthy controls. Altogether, these findings indicate that antigen drive likely underlies T-cell expansions in CLL and may be acting in a CLL subset-specific context. Whether these are the same antigens interacting with the malignant clone or tumor-derived antigens remains to be elucidated.

Bosonic amplification of noise-induced suppression of phase diffusion

We study the effect of noise-induced dephasing on collisional phase diffusion in the two-site Bose-Hubbard model. Dephasing of the quasimomentum modes may slow down phase diffusion in the quantum Zeno limit. Remarkably, the degree of suppression is enhanced by a bosonic factor of order N/logN as the particle number N increases.

Anisotropic solitons in dipolar bose-einstein condensates

Starting with a Gaussian variational ansatz, we predict anisotropic bright solitons in quasi-2D Bose-Einstein condensates consisting of atoms with dipole moments polarized perpendicular to the confinement direction. Unlike isotropic solitons predicted for the moments aligned with the confinement axis [Phys. Rev. Lett. 95, 200404 (2005)10.1103/PhysRevLett.95.200404], no sign reversal of the dipole-dipole interaction is necessary to support the solitons. Direct 3D simulations confirm their stability.

Fiberoptic bronchoscopy and bronchoalveolar lavage for the evaluation of pulmonary disease in children with primary immunodeficiency and cancer

BACKGROUND

Patients with childhood cancer or primary immunodeficiencies (PID) are at high risk for developing pulmonary infections and non-infectious complications. The broad differential diagnoses and the critical condition of these patients often drive physicians to start broad-spectrum antibiotic therapy before a definite diagnostic procedure is performed. A definite diagnosis may be achieved in these situations by fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL).

PATIENTS AND METHODS

The records of 58 PIDs and cancer (immunocompromised group) pediatric patients who underwent 62 fiberoptic bronchoscopies between 2000 and 2004 were retrospectively reviewed and compared to 158 non-cancer patients who underwent 182 fiberoptic bronchoscopies during the same period.

RESULTS

The overall diagnostic rate achieved by macroscopic inspection of purulent secretions or hemorrhage, abnormal cell count, and infectious agent isolation in the immunocompromised patients was 84%. A definite organism was recovered in 53.2% of the patients. Probable infection defined as purulent secretions or abnormal cell count without infectious agent isolation was diagnosed in another 21% of the patients. The rate of complications was 30.6%. In the control group, the overall diagnostic rate was 76.9% (n.s) and an infectious agent was demonstrated in 12.1% (P < 0.001). Probable infection was diagnosed in 24.2% (n.s) while the rate of complications was lower (15%) (P < 0.01).

CONCLUSIONS

Rapid and accurate diagnoses were achieved in most procedures performed on immunocompromised patients. Although the rate of complications was higher in the immunocompromised group, they were usually very mild with no mortality. Based on these results, broncoalveolar lavage should be considered as an initial diagnostic tool in pediatric immunocompromised patients with pulmonary complications.

Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care

INTRODUCTION

Computerised physician order entry with clinical decision support system (CPOE+CDSS) is an important tool in attempting to reduce medication errors. The objective of this study was to evaluate the impact of a CPOE+CDSS on (1) the frequency of errors in ordering resuscitation (CPR) medications and (2) the time for printing out the order form, in a paediatric critical care department (PCCD).

METHODS

SETTING

An 18-bed PCCD in a tertiary-care children's hospital.

DESIGN

Prospective cohort study.

MEASURES

Compilation and comparison of number of errors and time to fill in forms before and after implementation of CPOE+CDSS. Time to fill in conventional, simulated and CPOE forms was measured and compared.

RESULTS

There were three reported incidents of errors among 13,124 CPR medications orders during the year preceding implementation of CPOE+CDSS. These represent errors that escaped the triple check by three independent staff members. There were no errors after CPOE+CDSS was implemented (100% error reduction for 46,970 orders). Time to completion of drug forms dropped from 14 min 42 s to 2 min 14s (p < 0.001).

CONCLUSIONS

CPOE+CDSS completely eliminated errors in filling in the forms and significantly reduced time to completing the form.

Incoherent matter-wave solitons and pairing instability in an attractively interacting Bose-Einstein condensate

The dynamics of matter-wave solitons in Bose-Einstein condensates (BEC) is considerably affected by the presence of a thermal cloud and the dynamical depletion of the condensate. Our numerical results, based on the time-dependent Hartree-Fock-Bogoliubov theory, demonstrate the collapse of the attractively interacting BEC via collisional emission of atom pairs into the thermal cloud, which splits the (quasi-one-dimensional) BEC soliton into two partially coherent solitonic structures of opposite momenta. These incoherent matter waves are analogous to optical random-phase solitons.

Nonlinear adiabatic passage from fermion atoms to boson molecules

We study the dynamics of an adiabatic sweep through a Feshbach resonance in a quantum gas of fermionic atoms. Analysis of the dynamical equations, supported by mean-field and many-body numerical results, shows that the dependence of the remaining atomic fraction Gamma on the sweep rate alpha varies from exponential Landau-Zener behavior for a single pair of particles to a power-law dependence for large particle number N. The power law is linear, Gamma is proportional to alpha, when the initial molecular fraction is smaller than the 1/N quantum fluctuations, and Gamma is proportional to alpha(1/3) when it is larger. Experimental data agree well with a linear dependence, but do not conclusively rule out the Landau-Zener model.

Conversion efficiency of ultracold fermionic atoms to bosonic molecules via Feshbach resonance sweep experiments

We explain why the experimental efficiency observed in the conversion of ultracold Fermi gases of 40K and 6Li atoms into diatomic Bose gases is limited to 0.5 when the Feshbach resonance sweep rate is sufficiently slow to pass adiabatically through the Landau-Zener transition but faster than "the collision rate" in the gas, and increases beyond 0.5 when it is slower. The 0.5 efficiency limit is due to the preparation of a statistical mixture of two spin states, required to enable s-wave scattering. By constructing the many-body state of the system we show that this preparation yields a mixture of even and odd parity pair states, where only even parity can produce molecules. The odd parity spin-symmetric states must decorrelate before the constituent atoms can further Feshbach scatter, thereby increasing the conversion efficiency; "the collision rate" is the pair decorrelation rate.

Directional "superradiant" collisions: bosonic amplification of atom pairs emitted from an elongated Bose-Einstein condensate

We study spontaneous directionality in the bosonic amplification of atom pairs emitted from an elongated Bose-Einstein condensate, an effect analogous to superradiant emission of atom-photon pairs. Using a simplified model, we make analytic predictions regarding directional effects for both atom-atom and atom-photon emission. These are confirmed by numerical mean-field simulations, demonstrating the feasibility of nearly perfect directional emission along the condensate axis. The dependence of the emission angle on the pump strength for atom-atom pairs is significantly different than for atom-photon pairs.

Bose-enhanced chemistry: amplification of selectivity in the dissociation of molecular Bose-Einstein condensates

We study the photodissociation chemistry of a quantum degenerate gas of bosonic triatomic ABC molecules, assuming two open rearrangement channels ( AB+C or A+BC). The equations of motion are equivalent to those of a parametric multimode laser, resulting in an exponential buildup of macroscopic mode populations. By exponentially amplifying a small differential in the single-particle rate coefficients, Bose stimulation leads to a nearly complete selectivity of the collective N-body process, indicating a novel type of ultraselective quantum degenerate chemistry.

Acute respiratory distress syndrome in children with malignancy--can we predict outcome?

PURPOSE

The purpose of this study was to delineate early respiratory predictors of mortality in children with hemato-oncology malignancy who developed acute respiratory distress syndrome (ARDS).

MATERIALS AND METHODS

We conducted a retrospective chart review of children with malignant and ARDS who needed mechanical ventilation and were admitted to a pediatric intensive care unit from January 1987 to January 1997.

RESULTS

Seventeen children with ARDS and malignancy aged 10.5 +/- 5.1 years were identified. Six of the 17 children (35.3%) survived. Sepsis syndrome was present in 70.6% of all the children. Peak inspiratory pressure, positive end-expiratory pressure (PEEP), and ventilation index values could distinguish outcome by day 3. A significant relationship between respiratory data and outcome related to efficiency of oxygenation, as determined by PaO(2)/FIO(2) and P(A-a)O(2), was present from day 8 after onset of mechanical ventilation.

CONCLUSIONS

Peak inspiratory pressure, PEEP, and ventilation index values could distinguish survivors from nonsurvivors by day 3. This may assist in early application of supportive nonconventional therapies in children with malignancy and ARDS.

Bose-Einstein condensates beyond mean field theory: quantum backreaction as decoherence

We propose an experiment to measure the slow log(N) convergence to mean field theory (MFT) around a dynamical instability. Using a density matrix formalism instead of the standard macroscopic wave function approach, we derive equations of motion which go beyond MFT and provide accurate predictions for the quantum break time. The leading quantum corrections appear as decoherence of the reduced single-particle quantum state.

[The sixth vital sign: end-tidal CO2 in pediatric trauma patients during transport]

Transport of pediatric trauma victims, within as well as between medical centers, has become a frequent event and an integral activity of pediatric critical care units. Monitoring patients during transport is of utmost importance, as an unstable environment poses an increased threat to the patient's stability. The level of monitoring and care should approximate that of the critical care unit. Monitoring end-tidal CO2 (EtCO2) has become routine for many pediatric intensive care unit patients but technical problems have limited its use during transport. Our transport team uses a transportable EtCO2 monitor of the side-stream type (NPB 75), requiring very small samples; midstream sampling overcomes humidity interference. The monitor is small and lightweight, operates on a rechargeable battery and is especially designed for the demanding environment of transport. From October 1997 through January 1999, 187 pediatric patients, 62 of whom were trauma victims, were transported for a total of 45 hours, including 2 hours of in-flight transport. Age range was 3 months to 16 years. Of the 53 monitored for EtCO2, in 9 (17%) monitoring resulted in a significant, immediate change of treatment during transport. We find EtCO2 an important adjunct in monitoring pediatric trauma patients during transport. In addition to conventional monitoring of heart rate, blood pressure, respiratory rate, body temperature and blood oxygen saturation, we suggest EtCO2 as the sixth vital sign that should be monitored.

Invasive meningococcal disease: patient and strain characteristics set new challenge for prevention and control

Differences in the course of invasive meningococcal disease, in prevalence, case-to-carrier ratio, geographical pattern, age distribution and antibiotic resistance have been related to major serogroups and their serotypes. The relationships between Neisseria meningitidis serogroups and clinical manifestation, outcome and patient characteristics are assessed. All hospitalized patients in six major hospitals in central Israel with a verified meningococcal disease during 1990-1994 were included (n = 66). Their personal and clinical data and the results of bacteriological and serological tests of their blood and cerebrospinal fluid (CSF) were recorded. Meningococci were isolated from both blood and CSF, from blood alone, and from CSF alone in 60.6%, 18.2%, and 21.2% of the cases, respectively. The highest proportion of isolations were from infants < 1 year (34.8%), followed by children aged 1 to 5 years (25.8%). Serogroup B prevailed in 62.1%, while groups C and W135 accounted for 28.8% and 9.1%, respectively. Serogroup B predominated in children < 1 year, while in patients aged 5-22 years, C strains were the major pathogen (P < 0.001). Serogroup B accounted for 93% of the cases of meningitis, 58% of meningococcemia and 42% of fulminant meningococcemia, while group C strains were the major cause of fulminant meningococcemia (50%). The overall case fatality rate was 7.6%: fulminant meningococcemia 8.3%, and meningococcemia 10%. It was concluded that N. meningitidis group C continues to account for almost a third of the cases of meningococcal disease and is the major cause of fulminant meningococcemia.

Acute respiratory distress syndrome in children: a 10 year experience

BACKGROUND

Acute respiratory distress syndrome is a well-recognized condition resulting in high permeability pulmonary edema associated with a high morbidity.

OBJECTIVES

To examine a 10 year experience of predisposing factors, describe the clinical course, and assess predictors of mortality in children with this syndrome.

METHODS

The medical records of all admissions to the pediatric intensive care unit over a 10 year period were evaluated to identify children with ARDS. Patients were considered to have ARDS if they met all of the following criteria: acute onset of diffuse bilateral pulmonary infiltrates of non-cardiac origin and severe hypoxemia defined by < 200 partial pressure of oxygen during > or = 6 cm H2O positive end-expiratory pressure for a minimum of 24 hours. The medical records were reviewed for demographic, clinical, and physiologic information including PaO2/forced expiratory O2, alveolar-arterial O2 difference, and ventilation index.

RESULTS

We identified 39 children with the adult respiratory distress syndrome. Mean age was 7.4 years (range 50 days to 16 years) and the male:female ratio was 24:15. Predisposing insults included sepsis, pneumonias, malignancy, major trauma, shock, aspiration, near drowning, burns, and envenomation. The mortality rate was 61.5%. Predictors of death included the PaO2/FIO2, ventilation index and A-aDO2 on the second day after diagnosis. Nonsurvivors had significantly lower PaO2/FIO2 (116 +/- 12 vs. 175 +/- 8.3, P < 0.001), and higher A-aDO2 (368 +/- 28.9 vs. 228.0 +/- 15.5, P < 0.001) and ventilation index (43.3 +/- 2.9 vs. 53.1 +/- 18.0, P < 0.001) than survivors.

CONCLUSIONS

Local mortality outcome for ARDS is comparable to those in tertiary referral institutions in the United States and Western Europe. The PaO2/FIO2, A-aDO2 and ventilation index are valuable for predicting outcome in ARDS by the second day of conventional therapy. The development of a local risk profile may allow early application of innovative therapies in this population.

CT diagnosis of delayed presentation of congenital diaphragmatic hernia simulating massive pleuropneumonia

A case of an 11-month-old infant with a delayed presentation of congenital diaphragmatic hernia is reported. Incarceration of the herniated colon caused a misleading appearance on the chest X-ray which was interpreted as massive pleuropneumonia. Computed tomography, performed because of continuing deterioration in the clinical condition, showed fluid-filled bowel loops in the chest and dilated bowel loops with air-fluid levels in the abdomen, suggesting the correct diagnosis.

Programmed cell death of the dinoflagellate Peridinium gatunense is mediated by CO(2) limitation and oxidative stress

The phytoplankton assemblage in Lake Kinneret is dominated in spring by a bloom of the dinoflagellate Peridinium gatunense, which terminates sharply in summer [1]. The pH in Peridinium patches rises during the bloom to values higher than pH9 [2] and results in CO(2) limitation. Here we show that depletion of dissolved CO(2) (CO(2(dis))) stimulated formation of reactive oxygen species (ROS) and induced cell death in both natural and cultured Peridinium populations. In contrast, addition of CO(2) prevented ROS formation. Catalase inhibited cell death in culture, implicating hydrogen peroxide (H(2)O(2)) as the active ROS. Cell death was also blocked by a cysteine protease inhibitor, E-64, a treatment which stimulated cyst formation. Intracellular ROS accumulation induced protoplast shrinkage and DNA fragmentation prior to cell death. We propose that CO(2) limitation resulted in the generation of ROS to a level that induced programmed cell death, which resembles apoptosis in animal and plant cells. Our results also indicate that cysteine protease(s) are involved in processes that determine whether a cell is destined to die or to form a cyst.

Programmed cell death of the dinoflagellate Peridinium gatunense is mediated by CO(2) limitation and oxidative stress

The phytoplankton assemblage in Lake Kinneret is dominated in spring by a bloom of the dinoflagellate Peridinium gatunense, which terminates sharply in summer [1]. The pH in Peridinium patches rises during the bloom to values higher than pH9 [2] and results in CO(2) limitation. Here we show that depletion of dissolved CO(2) (CO(2(dis))) stimulated formation of reactive oxygen species (ROS) and induced cell death in both natural and cultured Peridinium populations. In contrast, addition of CO(2) prevented ROS formation. Catalase inhibited cell death in culture, implicating hydrogen peroxide (H(2)O(2)) as the active ROS. Cell death was also blocked by a cysteine protease inhibitor, E-64, a treatment which stimulated cyst formation. Intracellular ROS accumulation induced protoplast shrinkage and DNA fragmentation prior to cell death. We propose that CO(2) limitation resulted in the generation of ROS to a level that induced programmed cell death, which resembles apoptosis in animal and plant cells. Our results also indicate that cysteine protease(s) are involved in processes that determine whether a cell is destined to die or to form a cyst.

Adapting prognostic respiratory variables of ARDS in children to small-scale community needs

PURPOSE

The clinical literature on the incidence and subsequent mortality of adult respiratory distress syndrome (ARDS) has come primarily from the experiences of large tertiary referral centers, particularly in Western Europe and North America. Consequently, very little has been published on the incidence, management, and outcome of ARDS in smaller community-based intensive care units. We aimed to delineate early clinical respiratory predictors of death in children with ARDS on the modest scale of a community hospital.

MATERIALS AND METHODS

A retrospective chart review of children with ARDS needing conventional mechanical ventilation admitted to our pediatric intensive care unit from 1984 to 1997. The diagnosis of ARDS was based on acute onset of diffuse, bilateral pulmonary infiltrates of noncardiac origin and severe hypoxemia defined by partial pressure of oxygen <200 mm Hg during positive end-expiratory pressure (PEEP) of 6 cm H2O or greater for a minimum of 24 hours. Demographic, clinical, and physiological data including PaO2/ FIO2, A-aDo2, and ventilation index were retrieved.

RESULTS

Fifty-six children with ARDS aged 8 +/- 5.5 years (range, 50 days to 21 years) were identified. The mortality rate was 50%. Early predictors of death included the peak inspiratory pressure (PIP), ventilation index, and PEEP on the third day after diagnosis: Nonsurvivors had significantly higher PIP (35.3 +/- 10.5 cm H2O vs 44.4 +/- 10.7 cm H2O, P < .001), PEEP (8 +/- 2.8 cm H2O vs 10.7.0 +/- 3.5 cm H2O, P < .01), and ventilation index (49.14 +/- 20.4 mm Hg x cm H2O/minute vs 61.6 +/- 51.1 mm Hg cm H2O/minute) than survivors. In contrast, PAO2/FIO2 and A-a DO2 were capable of predicting outcome by day 5 and thereafter.

CONCLUSIONS

A small-scale mortality outcome for ARDS is comparable to large tertiary referral institutions. The PIP, PEEP, and ventilation index are valuable for predicting outcome in ARDS by the third day of conventional therapy. The development of a local risk profile may assist in decision-making of early application of supportive therapies in this population.

Pharmacokinetics of endobronchial tolazoline administration in dogs

Tolazoline is a potent vasodilator of arteries and veins and has a powerful effect on the pulmonary vasculature, reducing hypoxic pulmonary vasoconstriction and lowering pulmonary artery pressure. Intravenous tolazoline lowers the mean pulmonary arterial pressure and resistance and increases the cardiac index when given to infants with persistent pulmonary hypertension (PPHN). Endotracheally administered tolazoline decreases mean pulmonary arterial pressure and pulmonary vascular resistance, and improves oxygenation without the harmful decline in the systemic arterial pressure. The purpose of our study was to examine the pharmacokinetic and pharmacodynamic characteristics of endobronchial tolazoline to determine the relationship between endobronchial tolazoline administration, plasma concentration, and its effects on the cardiovascular and respiratory systems. Tolazoline was administered endobronchially to seven dogs, and its serum concentration and the hemodynamic parameters were monitored for 270 min postdelivery. It was found that 15 sec after dosing, tolazoline plasma concentrations started to increase significantly above baseline levels, reaching a maximum of 9.3+/-8.0 microg x mL(-1) The volume of distribution was 1657+/-321 mL x kg(-1) after 1 2.4+/-1 6.6 min. The extent of tolazoline absorption was 319+/-38 microg x min(-1) mL(-1). The total body clearance was 10.9 +/-4.8 mL x min(-1) x Kg(-1) and the elimination half-life was 156+/-81 min. Endobronchial tolazoline produced an initial short-lived decrease in the mean blood pressure in all the dogs, but thereafter the blood pressure increased gradually above baseline levels. Immediately following endobronchial tolazoline a significant tachycardia developed, peaking at 90 min. Subsequently, the heart rate gradually decreased and stabilized at values above baseline for 200 min. We conclude that an endobronchial bolus dose of tolazoline is effectively absorbed, produces measurable pharmacological effects, and may be beneficial in the therapy of persistent pulmonary hypertension of the newborn.

[Head injuries in children--clinical characteristics as prognostic factors]

An unselected series of 200 consecutive cases of major head trauma in children aged 6 months to 16 years, seen during 4 years, was studied. Injuries were due to road accidents (40%), falls (30.5%) and other causes (29.5%), and were assessed clinically and by cranial CT. On admission the Glasgow Coma Score ranged from 4.72-11.65 and in addition to pupillary responses and brain stem reflexes, was a significant predictor of outcome. Brain edema, midline shift, intracranial hemorrhage and also hyperglycemia, hypokalemia and coagulopathy, were associated with poor outcome. While 17% died, 53% were discharged in good functional condition. Early identification of clinical features related to prognosis can help the caring team provide maximal support for patient and family.

Early prediction of neurological outcome after falls in children: metabolic and clinical markers

Falls are the foremost reason for non-fatal injuries and are second only to motor vehicle accidents in causing accidental death. The purpose of this study was to identify the clinical and metabolic predictors of the outcome of head injury caused by falls from a height. Medical records of 61 children who had been admitted to the paediatric intensive care unit from 1990 to 1993 after falling from a height were reviewed retrospectively. Outcomes were categorised as good, moderate, severe, and poor. Glasgow coma scores, pupillary responses, brain oedema, and midline shift are significantly associated with poor outcome (p < 0.05). Metabolic markers associated with poor outcome included hyperglycaemia and hypokalaemia. Children with a poor outcome had, at admission, significantly higher glucose concentrations compared with children with good outcomes (mean SD): 20.0 (7.1) v 9.31 (4.0) mmol/l, p < 0.01), and lower potassium concentrations compared with children with good, moderate, and severe outcomes (mean (SD): 2.8 (0.4) v 3.7 (0.4) mmol/l, p < 0.001, 3.5 (0.3) mmol/l, p < 0.01, and 3.41 (0.3) mmol/l, p < 0.05, respectively). These findings allow for an early allocation of effort and resources to children injured from such falls.

[Intrahospital transport of critically ill children]

Prospective evaluation of intrahospital transportation of 33 critically ill children to and from the pediatric intensive care unit was conducted over the course of a month. Factors contributing to risk of transport were assessed. There were 33 children (25 boys and 8 girls), 3 days to 15 years of age. Reasons for admission included: disease and trauma in 19, and status post operation in 11. The pretransport PRISM score was 4.84. 22 children (66.6%) were being mechanically ventilated and 10 (30.3%) were being treated with amines. Transport time ranged from 8-150 minutes. 15 of the transports (45.4%) were urgent and a special intensive care team escorted 22 (66.6%). Equipment mishaps and physiological deterioration occurred in 12 (36.3%) and 11 (30.3%) of the cases, respectively. The use of amines, mechanical ventilation, longer transport time and high PRISM score were all associated with physiological deterioration on transport.

Complete population transfer to and from a continuum and the radiative association of cold Na atoms to produce translationally cold Na2 molecules in specific vib-rotational states

We demonstrate the feasibility of a laser induced complete population transfer to and from a continuum of states. We study the two-photon dissociation of v = 28; J = 1,...,10 sodium dimers. We demonstrate that using just a pair of "counter intuitively" ordered pulses we can dissociate 100% of the molecules in an ensemble. The scheme is shown to be stable with respect to the initial choice of rotational level and to fluctuations in the laser frequency and intensity. We also study the reverse phenomenon of complete population transfer from the continuum. We perform calculations on the radiative association of Na atoms to form the Na2 molecule in specific vib-rotational states. It is shown that two pulses of 20 nsec duration and as little as 6 MW/cm 2 peak power can photo-associate more than 98% of the atoms within a (pulse and velocity determined) relative effective distance, to yield Na2 molecules in the chosen v = 28; J = 10 vib-rotational state. This means that given a density of 10 16 atoms/cm 3 and a temperature of 7K, a 10Hz pulsed laser source of the above parameters can con- vert half of all the Na atoms in the ensemble to v = 28; J = 10 Na2 molecules within 15 seconds of operation.

Gunshot wounds in brains of children: prognostic variables in mortality, course, and outcome

A retrospective study of 51 children presenting with craniocerebral gunshot lesions was carried out to identify predictors of outcome. The patients ranged in age from 2 months to 17 years, with a mean of 14.5 years. The outcome was good in 20 patients, and seven and four were moderately and severely disabled, respectively. Twenty patients died. Statistical analysis showed prognostic significance of the admission Glasgow Coma Score (GCS), computerized tomographic findings of intraventricular hemorrhage and midline shift, and metabolic abnormalities, including hypokalemia and hyperglycemia. These prognostic factors may have implications regarding counseling of families, utilization of resources, and organ transplantation.

Ventilation index and outcome in children with acute respiratory distress syndrome

The purpose of this investigation was to determine the predictive value of the ventilation index (VI) in children with acute respiratory distress syndrome (ARDS). We performed a 10-year retrospective chart review of children who were admitted to the Pediatric Intensive Care Unit with a diagnosis of ARDS. Acute respiratory distress syndrome was defined as acute onset of diffuse, bilateral pulmonary infiltrates of noncardiac origin, and severe hypoxemia, defined as the ratio of the arterial partial pressure of oxygen to the fraction of inspired oxygen of <200 and a positive end expiratory pressure of 6 cmH2O or greater. Records of daily arterial blood gas results and ventilator settings were reviewed, and the ventilation index (VI=partial pressure of arterial CO2 x peak airway pressure x respiratory rate/1,000) was calculated each time the measurements were made. These values were correlated with outcome (survival or nonsurvival). The VI was not different at the time of diagnosis of ARDS in the patients who lived, compared with those who subsequently died. However, by 3 to 5 days after study entry, the VI of nonsurvivors was significantly higher than for survivors (P < 0.05). The VI for survivors remained between 30 and 35 throughout the study period, whereas the VI of nonsurvivors continued to increase with time. A VI of >65 predicted death with a specificity and positive predictive value of >90% on days 3 through 9. We conclude that the VI provides a reliable prognostic marker in children with ARDS, and its increase above 65 indicates a need for orderly intervention with alternative modalities of care.

Severe acute asthma in a community hospital pediatric intensive care unit: a ten years' experience

BACKGROUND

The clinical literature on the incidence and subsequent mortality of asthma has come primarily from the experiences of large tertiary referral centers, particularly in Western Europe and North America. Consequently, very little has been published on the incidence, management, and outcome of asthma in smaller, community-based intensive care units.

OBJECTIVES

The purpose of this study was to explore the course and outcome of children with acute severe asthma treated within a community hospital PICU compared with those described in the literature from larger tertiary referral centers.

DESIGN

A retrospective analysis of 49 asthmatic children admitted to the Pediatric Intensive Care Unit (PICU) over a 10-year period was performed.

MEASUREMENTS AND RESULTS

The mean age was 5.2 years (range 2 months to 16 years), and the male:female ratio was 3:1. Duration of symptoms prior to admission to hospital was less than 24 hours in 60.4% of the patients. The majority of patients was not treated with either inhaled or oral steroids before admission. Drugs used in the PICU included nebulized beta2-agonists, theophylline, steroids, intravenous salbutamol, and intravenous isoproterenol. Although a pharmacologic approach was successful in the majority of patients, intubation and mechanical ventilation were necessary for progressive hypercapnea, exhaustion, and cardiorespiratory arrest in 11/49 of these patients. The average stay in the ICU for our patient group was 2.4 days. Intubated patients had a mean average stay of 3.5 days. Two patients had pneumothorax related to positive pressure ventilation, requiring chest tube insertion for drainage. There were no deaths among the 49 patients admitted to our PICU.

CONCLUSIONS

These data show that for acute severe asthma, outcome is comparable in a community PICU to a tertiary referral institution. We conclude that early ICU admission along with close monitoring is important in reducing morbidity and mortality in children with severe asthma.

Local application of honey for treatment of neonatal postoperative wound infection

Honey has been described in ancient and modern medicine as being effective in the healing of various infected wounds. In this report we present our experience in nine infants with large, open, infected wounds that failed to heal with conventional treatment. Conventional treatment was defined as having failed if after > or = 14 d of intravenous antibiotic and cleaning the wound with chlorhexidine 0.05% W/V in aqueous solution and fusidic acid ointment the wound was still open, oozing pus, and swab cultures were positive. All infants showed marked clinical improvement after 5 d of treatment with topical application of 5-10 ml of fresh unprocessed honey twice daily. The wounds were closed, clean and sterile in all infants after 21 d of honey application. There were no adverse reactions to the treatment. We conclude that honey is useful in the treatment of post-surgical wounds that are infected and do not respond to conventional systemic and local antibiotic treatment.

Vipera palaestinae snake envenomations: experience in children

In Israel, Vipera palaestinae (V. palaestinae) is the most common venomous snake, accounting for 100-300 reported cases of envenomation every year. However, V. palaestinae snakebites in children have not been extensively investigated. The demographic features, treatment and outcome of V. palaestinae envenomation in 37 children treated in two medical centers over a 9 year period were retrospectively reviewed. The victims age ranged from 2-18 years with a mean age of 8.9 years. Twenty-nine children were males and eight were females. Twenty-one patients resided in rural areas, and 16 children were living in urban areas. Twenty-three (63%) of the patients were bitten on the lower limb; Twelve (33%) on the upper limb, and two on the head or neck (4%). Using a grading scale of one to three from minimal to severe envenomation, 15 (40.5%), 15 (40.5%) and 7 (19%) patients had mild, moderate and severe envenomation, respectively. Major complications of envenomation that were manifested after arrival consisted of compartment syndrome (two patients) and respiratory dysfunction (two patients). Specific monovalent antiserum for the treatment of V. palaestinae bite was given to 16 children (43%) of whom, four patients were in the severe group, seven and five in the moderate and mild groups respectively. No patient suffered a significant infection, tissue loss, permanent disability or death. We conclude that early ICU admission along with close monitoring and antivenom therapy is important in reducing morbidity and mortality in children systemically envenomed by V. palaestinae.

Epinephrine pharmacokinetics and pharmacodynamics following endotracheal administration in dogs: the role of volume of diluent

OBJECTIVE

to define the optimal volume of dilution for endotracheal(ET) administration of epinephrine (EPI).

DESIGN

prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine (1, 2, 5, and 10 ml of normal saline).

SETTING

large animal research facility of a university medical center.

SUBJECTS AND INTERVENTIONS

epinephrine (0.02 mg/kg) diluted with four different volumes (1, 2, 5, and 10 ml) of normal saline was injected into the ET tube of five anesthetized dogs. Each dog served as its own control and received all four volumes in different sequences at least 1 week apart. Arterial blood samples for plasma epinephrine concentration and blood gases were collected before and 0.25, 0.5, 0.75, 1, 2, 3, 4, 5, 10, 15, 20, 25, 30 and 60 min after drug administration. Heart rate and arterial blood pressure were continuously monitored with a polygraph recorder.

MEASUREMENTS AND MAIN RESULTS

higher volumes of diluent (5 and 10 ml) caused a significant decrease of PaO2, from 147 +/- 8 to 106 +/- 10 torr, compared with the lower volumes of diluent (1 and 2 ml), from 136 +/- 10 to 135 +/- 7 torr (P < 0.05). These effects persisted for over 30 min. Mean plasma epinephrine concentrations significantly increased within 15 s following administration for all the volumes of diluent. Mean plasma epinephrine concentrations, maximal epinephrine concentration (Cmax) and the coefficient of absorption (Ka) were higher in the 5 and 10 ml groups. The time interval to reach maximal concentration (Tmax) was shorter in the 5 and 10 ml groups. Yet these results were not significantly different. Heart rate, systolic and diastolic blood pressures did not differ significantly between the groups throughout the study.

CONCLUSIONS

Dilution of endotracheal epinephrine into a 5 ml volume with saline optimizes drug uptake and delivery without adversely affecting oxygenation and ventilation.

Extubation failure due to post-extubation stridor is better correlated with neurologic impairment than with upper airway lesions in critically ill pediatric patients

The incidence of post-extubation stridor (PES) in a pediatric intensive care unit (PICU) and the need for reintubation is not known. Predictors of success on a subsequent extubation attempt and the efficacy of dexamethasone treatment prior to a subsequent extubation attempt are not established. In a prospective randomized double blind-controlled study in two PICU's in a university children's hospital setting, of 5,566 admissions over 35-months, we identified 32 patients who failed primary extubation and were reintubated for PES. Twenty-six patients were enrolled in the study and three subsequently excluded. Twelve were randomized to receive dexamethasone and 11 received sodium chloride placebo. Fifteen patients succeeded study extubation and eight failed. Of those receiving dexamethasone, nine patients succeeded and three failed. Of those receiving placebo, six patients succeeded and five failed. There was a poor correlation between anatomical abnormalities of the airway and failure of study extubation. Extubation failure was better correlated with neurologic impairment in the patients. We present a stridor score and demonstrate that it is an excellent predictor of success versus failure for the study extubation. Dexamethasone pre-treatment did not reduce stridor score. We are unable to conclude if dexamethasone pre-treatment reduces extubation failure. We speculate that neurologic impairment leads to extubation failure in critically ill pediatric patients.

Urine samples from disposable diapers: an accurate method for urine cultures

BACKGROUND

The method of collection of the urine sample is of paramount importance in making a diagnosis of urinary tract infection in infants and children. Squeezing urine out of disposable diapers can provide a urine sample that can be used to detect chemical abnormalities as well as a specimen suitable for microscopic examination. To date there have been no reported studies on the use of this technique for urine culture as compared with samples collected by suprapubic aspiration and catheterization.

METHODS

Urine was obtained from 38 infants aged under 2 years who presented with fever with no obvious cause. All infants had urine collected either by catheterization or suprapubic aspiration and by extraction from a disposable diaper. The urine samples were cultured using standard bacteriologic techniques.

RESULTS

Five infants had a urinary tract infection, as shown by a pure growth of more than 10(5) colonies/mL of a single species of bacterium. In all the cases the same result was obtained from both the diaper urine sample and the sample obtained by suprapubic aspiration or catheter. In 31 infants the urine samples collected by both techniques (diaper and catheter or suprapubic aspiration) were negative, and in only 2 infants did the diaper specimen yield a positive result, while the urine obtained by suprapubic aspiration or catheter was sterile.

CONCLUSIONS

Urine obtained from a disposable diaper can provide a valid sample for diagnosing urinary tract infection. The technique is simple, and can be carried out readily in ambulatory settings with minimal equipment and expense.

Pediatric craniocerebral wounds from plastic bullets: prognostic implications, course, and outcome

OBJECTIVE

To review our experience with craniocerebral injuries caused by plastic bullets, and to delineate prognostic factors for outcome.

DESIGN

Retrospective case series of 29 patients presenting with plastic bullet-induced craniocerebral lesions.

SETTING

Pediatric intensive care department of a tertiary care center.

MEASUREMENTS AND MAIN RESULTS

Outcome was poor in 10 patients, good in 11, and two and six patients were moderately and severely disabled, respectively. Statistical analysis showed prognostic significance of the admission Glasgow Coma Scale score, computed tomographic findings of intraventricular hemorrhage and midline shift, and metabolic studies including hypokalemia and hyperglycemia.

CONCLUSIONS

Plastic bullet-induced craniocerebral injuries carry a lower morbidity and mortality rate compared with other gunshot wounds. However, plastic bullets do incur a significant risk of injury. Their use should be carefully regulated.

Torticollis: an unusual presentation of spontaneous pneumomediastinum

Torticollis is a common clinical sign encountered by pediatricians in a wide variety of childhood illnesses including those from traumatic, neurologic, infectious, inflammatory, and psychogenic causes. We describe a case of spontaneous pneumomediastinum (SPM) manifested as acute torticollis. To the best of our knowledge, torticollis as a result of spontaneous pneumomediastinum has not yet been described. Pneumomediastinum should be included in the differential diagnosis of torticollis.

Spontaneous pneumomediastinum in children: clinical and natural history

Investigation of the clinical characteristics and natural history of nine children with spontaneous pneumomediastinum (SPM) was conducted at the Tel Aviv University Sheba Medical Centre between 1984 and 1994. Most cases occurred in the setting of a valsalva-type manoeuvre, while symptoms and signs on admission were mainly chest pain, dyspnoea, neck pain, subcutaneous emphysema, and Hamman's sign. Three clinical patterns concerning longterm sequelae were identified: patients without any long-term sequelae, patients with a tendency to airway hyperreactivity and subclinical asthma, and patients in whom SPM was the presenting feature of their asthma.

CONCLUSION

Close personal follow up, including pulmonary function tests, should be designed for all children with Spontaneous pneumomediastinum.

A controlled intervention in reduction of redundant hospital days

BACKGROUND

Inappropriate use of hospital services, in the form of unjustified hospital stay days (HSD), constitutes a major burden on a health budget. Reduction of unjustified HSD was achieved in a medical ward in a previous intervention study.

METHODS

A controlled intervention aimed at reducing unjustified hospital stay was performed on 155 paediatric inpatients and 248 controls, by applying pre-set criteria for hospitalization and comparing to results in previous studies.

RESULTS

Unjustified stay was decreased from 32.6% to 14.8% on the study ward, and from 25.7% to 19.3% on the control ward. The children on both wards did not differ significantly in rates of subsequent out of hospital mortality, re-admission, and the subjective evaluation of health by their parents one month following discharge.

CONCLUSIONS

This study demonstrates that despite the fact that the per cent of unjustified HSD on a paediatric wars is much lower than on medicine or surgery, a significant reduction in unjustified stay can be achieved by intervention programme.

Intrathecal baclofen for severe torsion dystonia in a child

The successful use of intrathecal baclofen, a structural analogue of gamma-aminobutyric acid, is described in the treatment of a 9-year-old boy with intractable torsion dystonia, not responding to conservative treatment. To our knowledge, this is the first reported case of continuous intrathecal baclofen for hereditary torsion dystonia. This case suggests that a continuous intrathecal infusion of baclofen may facilitate remission of intractable torsion dystonia, and provides a basis for further investigation of the treatment of intractable childhood dystonia.

Laceration of the phrenic artery. A life-threatening complication after repair of pectus excavatum

We report a case of life-threatening hemothorax three months after surgical repair of pectus excavatum. Angiography revealed the hemorrhage to originate from a laceration of the phrenic artery secondary to dislodgment of the metal strut used for the repair. Awareness of this rare complication in patients after repair of pectus excavatum is required.

[Chloral hydrate--is it safe?]

Chloral hydrate is widely used as a sedative or hypnotic, especially in geriatric and pediatric patients. In therapeutic doses blood pressure and respiration are only minimally affected. We describe a 9-year-old boy in whom a life-threatening cardiac arrhythmia dominated the clinical presentation of chloral hydrate intoxication. In spite of its widespread use, the dangers of chloral hydrate overdosage, especially cardiac arrhythmias, are not sufficiently appreciated.

Plain radiography for diagnosis of gastrointestinal perforation in immune-compromised children--is it enough?

Gastrointestinal perforation is a surgical emergency in the pediatric patient and any delay in diagnosis might be hazardous. In immunocompromised children, the clinical signs of perforation may be blunted. We describe a child with acute lymphoblastic leukemia (ALL) and a perforated appendix and ileum in whom computerized tomography (CT) revealed extraluminal air that was not initially identified on plain abdominal film. Our case demonstrates the importance of early abdominal CT and ultrasound examination in detecting these potentially lethal complications.