Acute, severe cardiomyopathy as main symptom of late-onset very long-chain acyl-coenzyme A dehydrogenase deficiency

A 5-year-old boy with late-onset very long-chain acyl-CoA-dehydrogenase (VLCAD) deficiency presented with acute cardiomyopathy, myopathy, gross myoglobinuria and normoglycaemia. The clinical course after diagnosis was favourable.

CONCLUSION

late-onset VLCAD deficiency may present as acute cardiomyopathy.

[The effects of a dose of epidural clonidine combined with intrathecal morphine for postoperative analgesia]

OBJECTIVE

To evaluate the effectiveness of a single bolus of epidural (ED) clonidine (C) associated with intrathecal morphine (M) on postoperative analgesia after cesarean section (CS).

DESIGN

Prospective double-blind randomized study.

SETTING

Obstetric department.

PATIENTS

Fourty patients ASA 1-2 submitted to combined spinal-epidural block (CSE) for CS.

INTERVENTIONS

A needle through needle set for CSE was used. The intrathecal block was induced with 2.7-3 ml of isobaric 0.5% bupivacaine (B) and 250 micrograms of M. After ED test with 0.5% B, a single bolus of C 150 micrograms in NS 10 ml (group C, n 20) or NS 10 ml as placebo (group P, n 20) was given through the ED catheter.

METHODS

The observation for 36 hours evaluated analgesia (VAS until the first dose of additional analgesic, total amount of analgesic and time of first analgesic request) and side effects (variations of arterial pressure and heart rate, motor block, sedation, nausea, vomiting, itching, respiratory depression). Groups were statistically compared.

RESULTS

In group C lower analgesic request (significantly between 12th and 18th hour) and significant delay of first request (22.5 +/- 4.1 h) were registered. VAS showed significant trend to opposite sign variations (downwards in group C, upwards in group P) at 1, 2 and 12 hours. In group C lower sistolic arterial pressure at 1 and 4 hours, denser motor block at 2 and 4 hours and mild sedation were observed.

CONCLUSIONS

A single ED bolus of C 150 micrograms after CS significantly enhances and prolongs the analgesic effect of M 250 micrograms without important side effects.

[Course and regression of HELLP syndrome]

The authors reported the outcome of a retrospective study of patients with HELLP syndrome to verify whether this pathology is a clinical entity with models of evolution, regression and well defined treatment. A total of 20 individual cases were reported at the Division of Obstetrics and Gynecology at the G. Gaslini Institute during the period from January 1990 to September 1995. All cases showed the normalisation of the various clinical and hematochemical parameters within a maximum of 8 days after birth. The rapid diagnosis, the immediate extraction of the fetus and appropriate medical treatment led to the prompt resolution of this severe pathology without the need for demolitive surgery frequently used in the past.

[Nosocomial infection caused by multiresistant Staphylococci in a neonatal and pediatric intensive care unit]

We selected a paediatric population with a high risk of nosocomial infection formed by 116 newborns (42.8%) and 155 not newborns (57.2%) admitted into the ICU of the Giannina Gaslini Institute during the period 1-1-1992-30-9-1992; we compared it with a reference paediatric population studied in the same department during the period 1-1-1987-30-6-1988 formed by 310 newborns (44.3%) and 391 not newborns (55.7%). The purpose of this study is to evaluate the possible change in the incidence of colonizations and ICU specific nosocomial infections, the possible increase of nosocomial infections by multiresistant Staphylococci and the appearance of new multiresistant germs. The two populations obviously present similar factors of high risk of nosocomial infection (naso-tracheal intubation, mechanical ventilation, total parenteral nutrition, surgical procedures, thoracic and/or abdominal prothesis, etc.). The obtained data have been examined with the Chi-square method. The incidence of colonizations remained unchanged while we noted a significant increase (10.3% compared to 4.9%-p > 0.0014) of the "ICU" specific nosocomial infections; the increase regarded mainly the neonatal population (18.9% compared to 7%-p > 0.00001). Significant increase of the nosocomial infections by multiresistant Staphylococcus (Staphylococcus haemolyticus) with in vitro and in vivo resistance to teicoplanin. Furthermore, presence in the performed study of multiresistant gram negative germs.

[Results of early external ventricular diversion in posthemorrhagic ventricular dilatation in the newborn]

OBJECTIVE AND DESIGN

The authors report the outcome of early treatment with long-term external ventricular drainage (EVD) of progressive post-hemorrhagic ventricular dilatation (PPHVD), following peri-intraventricular hemorrhage (PIVH) in a population of preterm newborns.

SETTING

Neonatal Intensive Care Unit (NICU) of a Children's Hospital.

PATIENTS

Twenty-one preterms of 29.6 +/- 2.4 weeks of gestational age, weighing at birth 1443 +/- 445 g, mechanically ventilated, submitted to early EVD because of PPHVD following PIVH of III (n 11) e IV (n 10) grade.

METHODS

PPHVD was diagnosed on the basis of US and TC findings. An external liquoral drainage suitable, for its technical characteristics, to be maintained for a long period of time and peculiar anesthesiologic, intra and postoperative treatments were utilized.

RESULTS

EVD was placed at 21 +/- 5.8 days of life and maintained for 40 +/- 16 days. In all cases reduction of ventricular size was observed. One case (5%) developed liquoral infection and recovered with antibiotic therapy. No obstruction or dislocation of the ventricular catheter occurred. During EVD 3 patients (14%) died because of respiratory complications. After the normalization of cerebrospinal fluid (CSF), a "permeability test" was performed to assess the canalization of the liquoral system. Seven patients (33.5%) underwent ventriculo-peritoneal shunt (VPS) and 11 (52.5%) became shunt-free.

CONCLUSIONS

Our results indicate that long-term use of EVD has a low risk of complications, avoids the need for transcutaneous tips and allows monitoring of CSF characteristics. Furthermore EVD protects the brain from liquoral hypertension, while waiting for a possible recurrence of natural CSF circulation, and is associated with a low number of definitive VPS.

[Fatal neonatal listeriosis after maternal infection acquired with ingestion of fresh home-made cheese]

The authors report on a newborn admitted to the Intensive Care Unit of Gaslini Institute for serious respiratory insufficiency who died on the third day of life because of a sepsis due to Listeria monocytogenes. The authors focus on the patient's history and clinical picture and on the histological evaluation of the lesions observed. The importance of infection in pregnancy and the possible severe consequences of listeriosis on the foetus are underlined, stressing the need for early diagnosis and adequate treatment.

[Serum levels of IgG subclasses in critically ill premature infants treated with intravenous immunoglobulins]

Fifty eight premature infants, all needing intensive care and mechanical ventilation, were randomly allocated to two groups. Intravenous immunoglobulins (IVIG, 500 mg/kg Sandoglobulin) were administered to Group 1 while Group 2 received saline as placebo. IgG subclass serum levels were evaluated in both groups on admission, after two hours from the end of IVIG or saline infusion and from day 3 to 7 from birth. IgG subclasses were also measured in 10 healthy term neonates during the first day of life. Results show that after 2 hours from the end of IVIG administration all IgG subclasses reach levels comparable to term neonates. Comparing IgG values between treated and untreated preterm neonates it was observed that on day 3 only IgG1 and IgG3 subclasses were significantly higher in Group 1 than in Group 2. At day 5 no differences were observed between the two groups. IgG2 subclass rose reaching a significant difference between the two groups ad day 5 and 7. Our data show that IVIG single dose (500 mg/kg) administration doesn't produce a constant elevation in all IgG subclasses during the first week of life in the critically ill preterm infant.

[The relationship between ligation of the ductus arteriosus and intracranial hemorrhage in preterm infants]

Surgical closure of patent ductus arteriosus (PDA) and perioperative time have been proposed as conditions of increased risk of peri-intraventricular hemorrhage (PVH-IVH) in preterm infants. We examined by pre- and postoperative ultrasound (US) scan 15 low birth-weight neonates who underwent PDA ligation within the first two weeks of life. They were assessed with regard to clinical state, perioperative management and development of PVH-IVH. Fourteen did not show onset or extension of intracranial hemorrhage in the immediate postoperative period. One patient developed a wide III grade IVH in the 24 perioperative hours. His conditions were particularly severe, suggesting that many factors such as acidosis, hypoxia, hypercapnia and hypotension might have combined to lead to hemorrhage. We conclude that PDA ligation is not likely to increase the risk of PVH-IVH per se.