Wireless, Skin-Interfaced Devices for Pediatric Critical Care: Application to Continuous, Noninvasive Blood Pressure Monitoring

Indwelling arterial lines, the clinical gold standard for continuous blood pressure (BP) monitoring in the pediatric intensive care unit (PICU), have significant drawbacks due to their invasive nature, ischemic risk, and impediment to natural body movement. A noninvasive, wireless, and accurate alternative would greatly improve the quality of patient care. Recently introduced classes of wireless, skin-interfaced devices offer capabilities in continuous, precise monitoring of physiologic waveforms and vital signs in pediatric and neonatal patients, but have not yet been employed for continuous tracking of systolic and diastolic BP-critical for guiding clinical decision-making in the PICU. The results presented here focus on materials and mechanics that optimize the system-level properties of these devices to enhance their reliable use in this context, achieving full compatibility with the range of body sizes, skin types, and sterilization schemes typically encountered in the PICU. Systematic analysis of the data from these devices on 23 pediatric patients, yields derived, noninvasive BP values that can be quantitatively validated against direct recordings from arterial lines. The results from this diverse cohort, including those under pharmacological protocols, suggest that wireless, skin-interfaced devices can, in certain circumstances of practical utility, accurately and continuously monitor BP in the PICU patient population.

Stenting of stenotic mesenteric arteries for symptomatic chronic mesenteric ischemia

Background: We report the results of our single center series of patients with chronic mesenteric ischemia (CMI) to determine the role of stenting in the management of patients. Patients and methods: We retrospectively reviewed all patients with CMI treated endovascularly with stent revascularisation from January 2008 to January 2011.CMI diagnosis was made according to clinical symptoms, including postprandial abdominal pain, food fear, and weight loss. Additionally, the diagnosis was confirmed by duplex ultrasonography and/or computed tomography angiography and/or contrast-enhanced magnetic resonance angiography. Results: All 45 patients presented with typical CMI symptoms: 45/45 (100 %) had postprandial pain, 31/45 (68.8 %) had a weight loss of more than 10 kilograms, and 11/45 (24.4 %) suffered from ischemic colitis combined with lower gastrointestinal bleeding. In three patients occlusion could not be crossed, therefore considered as technical failure. A total of 55 arteries were stented in the remaining 42 patients. Nineteen patients underwent SMA stenting alone, eight underwent celiac stenting, alone and three patients underwent stenting of inferior mesenteric artery (IMA) alone. We performed combined stenting of the celiac artery and superior mesenteric artery in ten patients, and one patient underwent a combined stenting of the celiac artery and the IMA. All three mesenteric arteries were stented in only one patient. Primary technical success was achieved in 42/45 (94.8 %) patients. Clinical symptom relief was achieved in 39/45 (86.6 %) patients with abdominal pain. Increased body weight was observed in 28/31 (90.3 %) patients with an average weight gain of 8.8 kilograms (5 - 12 kilograms), and 10/11 (90.9 %) patients recovered from ischaemic colitis/lower gastrointestinal bleeding. Conclusions: Stent revascularisation can be considered as the first-line therapy for patients with chronic mesenteric ischemia.

Late peripheral stent thrombosis due to stent fracture, vigorous exercise and hyporesponsiveness to clopidogrel

Late peripheral arterial stent thrombosis usually occurs due to haemodynamically relevant in-stent restenosis. However, late stent thrombosis may be multicausal. We report here the well-documented case of a 69-year-old man with acute thrombosis of the stented superficial femoral artery after a long-distance bicycle tour. Catheter-directed thrombolysis revealed a residual stenosis located at a stent fracture site. In addition, platelet function tests revealed an inadequate platelet response to clopidogrel. In conclusion, stent fracture, strenuous exercise and hyporesponsiveness to clopidogrel may have contributed to the development of late peripheral stent thrombosis.

C and N stable isotope variation in urine and milk of cattle depending on the diet

The stable carbon and nitrogen isotopic composition of urine and milk samples from cattle under different feeding regimes were analysed over a period of six months. The isotope ratios were measured with isotope ratio mass spectrometry (IRMS). The delta13C values of milk and urine were dependent on different feeding regimes based on C3 or C4 plants. The delta13C values are more negative under grass feeding than under maize feeding. The delta 13C values of milk are more negative compared to urine and independent of the feeding regime. Under grass feeding the analysed milk and urine samples are enriched in 13C relative to the feed, whereas under maize feeding the 13C/12C ratio of urine is in the same range and milk is depleted in 13C relative to the diet. The difference between the 15N/14N ratios for the two feeding regimes is less pronounced than the 13C/12C ratios. The delta 15N values in urine require more time to reach the new equilibrium, whereas the milk samples show no significant differences between the two feeding regimes.

Expression of Inhibin/activin Subunits alpha (-α), beta A (-β A) and beta B (-β B) in Placental Tissue of Normal and Intrauterine Growth Restricted (IUGR) Pregnancies

During human pregnancy the placenta produces a variety of proteins like steroid hormones and their receptors that are responsible for the establishment and ongoing of the feto-placental unit. Inhibins are dimeric glycoproteins, composed of an alpha-subunit and one of two possible beta-subunits (beta (A) or beta (B)). Aims of the present study were the determination of the frequency and tissue distribution patterns of the inhibin/activin subunits in human placental tissue of normal pregnancies and pregnancies complicated with fetal growth restriction (IUGR). Slides of paraffin embedded placental tissue were obtained after delivery from patients diagnosed with IUGR (n = 6) and normal term placentas (n = 8). Tissue samples were fixed and incubated with monoclonal antibodies inhibin/activin-subunits -alpha, -beta (A), -beta (B). Intensity of immunohistochemical reaction on the slides was analysed using a semi-quantitative score and statistical analysis was performed (P<0.05). A significant lower expression of the inhibin-alpha subunit in IUGR extravillous trophoblast compared to normal pregnancies was observed, while the inhibin-alpha immunostaining was significantly upregulated in syncytiotrophoblast. Additionally, a significant down-regulation of inhibin-beta (B) subunit in extravillous trophoblast cells in IUGR syncytiotrophoblast cells was demonstrated. A co-localisation of inhibin-alpha and the beta-subunits was also observed, suggesting a production and secretion of intact inhibin A and inhibin B. Although the precise role of these inhibin/activin subunits in human placenta and IUGR pregnancies is still unclear, they could be involved in autocrine/paracrine signalling, contributing to several aspects like angiogenesis and tissue remodelling.

Expression of inhibin/activin subunits alpha (-alpha), betaA (-betaA), and betaB (-betaB) in placental tissue of normal, preeclamptic, and HELLP pregnancies

During human pregnancy the placenta produces a variety of proteins for the establishment of the fetoplacental unit, including inhibins and activins. Inhibins are dimeric glycoproteins, composed of an alpha-subunit and one of two possible beta-subunits (betaA or betaB). Aims of the present study were (a) the determination of the frequency and tissue distribution patterns of the inhibin/activin subunits in human placental tissue of normal pregnancies and pregnancies complicated with preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and (b) the assessment of a combined expression of inhibin-alpha- and both beta-subunits (betaA-and betaB-subunits) using double immunofluorescence technique. A significant lower expression of the inhibin-alpha subunit in preeclamptic and HELLP placental tissue compared to normal pregnancies was observed, while the inhibin-alpha immunostaining was significantly upregulated in syncytotrophoblast. Additionally, we demonstrated a significant down-regulation of inhibin-betaB subunit in extravillous trophoblast cells between normal and preeclamptic compared to HELLP placental tissue, while inhibin-betaA-subunit was significantly higher in preeclamptic syncytotrophoblast cells. A colocalization of inhibin-alpha and the beta-subunits could be demonstrated, suggesting a production and secretion of intact inhibin A and inhibin B. Therefore, inhibin A and activin A might be useful markers in preeclampsia. Valuable parameters in HELLP syndrome could be inhibin A, rather than inhibin B, and activin B. Furthermore, the lower betaB-subunit production in extravillous trophoblast cells demonstrates that this subunit might have an important role in the pathogenesis of HELLP syndrome. Additionally, the higher production of the betaA-subunit in syncytotrophoblast cells suggest a higher production of activin A rather than inhibin A in preeclampsia that might be utilized as a marker of placental function.

Determination of the beta- branching ratio of 64Cu by mass spectrometric investigations of the decay products in neutron transmuted copper

The beta- branching ratio of 64Cu was determined by investigating the resulting decay products in copper doped by neutron transmutation. The numbers of 64Zn and 64Ni atoms were analyzed using isotope dilution analysis combined with thermal ionization mass spectrometry. A beta- branching ratio of (38.06+/-0.30)% was obtained, which agrees with the study of Kawada (Appl. Radiat. Isot. 37 (1) (1986) 7) to a higher accuracy. However, our result differs from the value cited in the NUDAT database of (39.0+/-0.3)%.

Contribution of ICP-IDMS to the certification of antimony implanted in a silicon wafer--comparison with RBS and INAA results

A thin-layer reference material for surface and near-surface analytical methods was produced and certified. The surface density of the implanted Sb layer was determined by Rutherford backscattering spectrometry (RBS), instrumental neutron activation analysis (INAA), and inductively coupled plasma isotope dilution mass spectrometry (ICP-IDMS) equipped with a multi-collector. The isotopic abundances of Sb (121Sb and 123Sb) were determined by multi-collector ICP-MS and INAA. ICP-IDMS measurements are discussed in detail in this paper. All methods produced values traceable to the SI and are accompanied by a complete uncertainty budget. The homogeneity of the material was measured with RBS. From these measurements the standard uncertainty due to possible inhomogeneities was estimated to be less than 0.78% for fractions of the area increments down to 0.75 mm2 in size. Excellent agreement between the results of the three different methods was found. For the surface density of implanted Sb atoms the unweighted mean value of the means of four data sets is 4.81 x 10(16) cm(-2) with an expanded uncertainty (coverage factor k = 2) of 0.09 x 10(16) cm(-2). For the isotope amount ratio R (121Sb/123Sb) the unweighted mean value of the means of two data sets is 1.435 with an expanded uncertainty (coverage factor k = 2) of 0.006.

SI-traceable certification of the amount content of cadium below the ng g(-1) level in blood samples by isotope dilution ICP-MS applied as a primary method of measurement

The development and implementation of a method for the certification of cadmium in blood samples at low ng g(-1) and sub ng g(-1) levels is described. The analytical procedure is based on inductively coupled plasma isotope dilution mass spectrometry (ICP-IDMS) applied as a primary method of measurement. Two different sample digestion methods, an optimized microwave digestion procedure using HNO3 and H2O2 as oxidizing agents and a high-pressure asher digestion procedure, were developed and compared. The very high salt content of the digests and the high molybdenum content, which can cause oxide-based interferences with the Cd isotopes, were reduced by a chromatographic matrix separation step using an anion-exchange resin. All isotope ratio measurements were performed by a quadrupole ICP-MS equipped with an ultrasonic nebulizer with membrane desolvator. This sample introduction set-up was used to increase sensitivity and minimize the formation of oxides (less MoO+ interference with the Cd isotopes). Because of the very low Cd concentrations in the samples and the resulting need to minimize the procedural blank as much as possible, all sample-processing steps were performed in a clean room environment. Detection limits of 0.005 ng g(-1) Cd were achieved using sample weights of 2.7 g. The method described was used to recertify the cadmium content of three different blood reference materials from the Community Bureau of Reference (BCR) of the European Commission (BCR-194, BCR-195, BCR- 196). Cadmium concentrations ranged between approximately 0.2 ng g(-1) and approximately 12 ng g(-1). For these materials, SI-traceable certified values including total uncertainty budgets according to ISO and Eurachem guidelines were established.

Comparative studies on the certification of reference materials by ICPMS and TIMS using isotope dilution procedures

A comparison of different isotope dilution mass spectrometric (IDMS) procedures using inductively coupled plasma mass spectrometry (ICPMS) and thermal ionization mass spectrometry (TIMS) was carried out to examine the degree of equivalence between the used procedures in terms of requirements for reference material certification. The comparison was based on the measurement results and their uncertainties. The sample used in this study is a pure zinc metal to be certified by the Bureau Communie de Référence (BCR) for amount contents of different trace elements. This study focuses on cadmium and thallium. The TIMS values contributed to the certified values. To guarantee identical conditions as far as possible for the procedures under investigation, the samples were split into subsamples after spiking and digestion took place. Thus, every IDMS procedure started with an identical set of samples. In total, four different IDMS procedures and one external calibration procedure using internal standardization as an example of routine analysis were applied. The IDMS procedures divide in a group with and a group without trace/matrix separation. Multicollector TIMS (TI-MC-MS) and multicollector ICPMS (ICP-MC-MS) were used in combination with trace/matrix separation, whereas quadrupole ICPMS (ICP-QMS) and ICP-MC-MS were also applied to nonseparated samples. All IDMS results agree well within their combined uncertainties, while some results from the external calibration procedure do not. IDMS results obtained by ICPMS without separation are comparable to those obtained by TI-MC-MS with separation regarding precision and accuracy. The smallest uncertainties were achieved using ICP-MC-MS in combination with trace/matrix separation.

Comparative performance study of ICP mass spectrometers by means of U "isotopic measurements"

The performance of four commercially available ICPMS instruments of three different types was compared by means of uranium "isotopic measurements". Examined were two quadrupole sector (different generation, different manufacturer), one single detector double focusing magnetic sector and one multiple collector double focusing magnetic sector instruments. The same samples of the IRMM-072 series were used under routine conditions to measure the 233U/235U and the 233U/238U ratios which, in these samples, vary over almost three orders of magnitude from approximately 1 to approximately 2 x 10(-3). Within expanded (k = 2) uncertainties, good agreement was observed between the certified values and the data internally corrected for mass-discrimination effects. The magnitude of the evaluated uncertainties was different for each type of instrument. With the multiple collector instrument, expanded uncertainties varied from +/- 0.04% to +/- 0.24% for the 233U/235U ratio, and from +/- 0.08% to +/- 0.27% for the 233U/238U ratio. They were approximately 1 to 5 times larger with the single detector magnetic sector instrument, and approximately 10 to 25 times larger with both quadrupole sector instruments. With the multiple collector instrument, repeatability of the measurements seemed to be limited by the difficulty of correcting properly for instrumental background, whereas with the single detector magnetic sector instrument the counting statistics was the only limitation (on smallest ratios). Apparent mass-discrimination was clearly found to be larger but more reproducible (and hence easier to correct for) in the case of magnetic sector instruments than for both quadrupole sector instruments. If space charge effects were the main source of mass-discrimination for all instruments, these results are in contradiction with the hypothesis of the size of mass-discrimination decreasing with the acceleration voltage. With the single detector magnetic sector instrument in particular (when operated by changing the ion energy only), our results pointed at more than only one major source of mass-discrimination, with variable size depending on the ratios measured.

Minor craniofacial anomalies in children. Comparative study of a qualitative and quantitative evaluation

Measurement of various craniofacial structures was compared with clinical assessment of craniofacial anomalies. Different diagnostic groups of children were studied. Anomalies were seen more often in patients with congenital heart defect, mental retardation and multiple congenital anomalies syndromes than in control children. Comparative study of quantitative data and qualitative (clinical) assessment showed some agreement but also many discrepancies. Therefore, in describing craniofacial anomalies both methods should be used. This is particularly true in the differential diagnosis of multiple congenital anomalies syndromes and variant familial developmental patterns.