A newborn with coronavirus (COVID-19) disease: A brief report

There are few neonates reported with COVID-19 disease. To date there is no clear evidence of vertical transmission of the virus before birth. We report a 4-day old infant born to an asymptomatic mother who developed infection with SARS-CoV-2, likely from contact with parents during the postnatal period.

On the use of drains in orthopedic and trauma

INTRODUCTION

The use of drains in trauma and Orthopaedic practice has been affected by the concept of evidence based medicine that has become accepted as standard of care for all surgical or medical practice, which questions all care processes that cannot be backed by evidence to be beneficial to the patient. There have been a large number of multi centre meta-analytical studies that found drains to be of little or no benefit in trauma and Orthopaedic operations. Because of these studies, there are few situations where drains are routinely used e.g. Calcaneal fractures in developed countries. Even major procedures like total knee and arthroplasties are being performed without drains. We set to find out whether such evidence can be found in our practice.

MATERIALS AND METHODS

Between 2004 and 2012, eighty six patients matched for sex and type of injury and operative procedures to be done were prospectively selected and assigned to use or no use of drains in their operations. Complications like haematoma, drain migration, infection, inadvertent drain stitching were observed in the two groups.

RESULTS

Eighty six major orthopaedic operations were studied. There was no evidence of occurrence of complication arising from non use of drains in the undrained group. Those patients whose wounds were drained had no need for drain change thus making the wound care less eventful

CONCLUSION

Postoperative wound drains make for neat postoperative period with less tissue swelling. There was no statistically significant differences between the drained and undrained wounds in terms of infection rates, haematoma or seroma formation.

Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss

BACKGROUND

Fractures resulting in segmental bone loss challenge the orthopedic surgeon. Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. In developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries.

MATERIALS AND METHODS

Over a period of six years all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs.

RESULT

Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustillo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur, which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. Graft incorporation was 80% in all treated patients.

CONCLUSION

Autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

The doctrine of informed consent in surgical practice

Physicians and other professionals in the field of medicine have to perform invasive and non-invasive procedures on patients as part of their duties. There is a legal basis upon which these procedures are done; this is called 'informed consent.' Sociocultural factors have strong influence on the sick role. These factors influence the application of informed consent in Nigeria.

Fixation of ankle arthrodesis in a national orthopaedic hospital in Nigeria

BACKGROUND

Internal fixation is currently preferred for ankle arthrodesis. There are, however, situations in which external fixation is a safer choice. This is a five-year retrospective study of ankle arthrodesis to assess the choice, technique and outcome of fixation methods used.

METHODS

Case notes and radiographs of patients with complete records who had ankle arthrodesis between January 1st, 2004 and December 31st 2008 were reviewed.

RESULTS

Twenty ankle arthrodeses in 20 patients were reviewed. External fixation, commonly with Charnley's device, was used in 95% of the arthrodeses. Initial alignment was lost in 62.5% of arthrodeses with Charnley's device without immediate short leg cast support. One tibiotalar arthrodesis done with a single screw had subtalarjoint penetration. Fusion and complication rates were 90% and 45% respectively. Foot and ankle oedema and pin-tract infection were the commonest complications.

CONCLUSION

External fixation was more commonly used than internal fixation because most of the patients had altered bone anatomy, wounds, active infection, or osteopenia. Charnley's device was the most commonly used external fixator and incorporating it in a short leg cast immediately after operation might improve its rotatory stability. The use of image intensifier is recommended for the placement of two crossed tibiotalar screws to avoid subtalar penetration.

Evolution of tidal volume requirement during the first 3 weeks of life in infants <800 g ventilated with Volume Guarantee

BACKGROUND

Volume-targeted ventilation is used in neonates to reduce volutrauma and inadvertent hyperventilation. Little is known about appropriate tidal volume (V(T)) settings in extremely low birthweight (ELBW) infants who remain intubated for extended periods.

HYPOTHESIS

The V(T) required to maintain adequate partial pressure of carbon dioxide (P(CO2) levels changes as the underlying disease evolves in infants ventilated for prolonged periods.

OBJECTIVE

To obtain normative data for V(T) associated with normocapnia in ELBW infants ventilated with Volume Guarantee over the first 3 weeks of life.

DESIGN/METHODS

Set and measured V(T), peak pressure, respiratory rate and blood gas values were extracted from the records of babies <800 g born January 2003 to August 2005 and ventilated with Volume Guarantee. Data were collected at the time of each blood gas measurement during days 1-2, 5-7 and 14-21. Only the V(T) corresponding to P(CO2) values within a defined normal range were included. Descriptive statistics were used to define the patient cohort. Mean V(T) and P(CO2) for each patient during each epoch was calculated, and these values were analysed by repeated-measures analysis of variance.

RESULTS

Twenty-six infants, mean (SD) birth weight 615 (104) g, were included. A total of 828 paired blood gas and V(T) sets were analysed: days 1-2 = 251; days 5-7 = 185; days 14-17 = 216; days 18-21 = 176. P(CO2) values (mean (SD)) rose from 44.0 (5.4) mm Hg on days 1-2 to 46.3 (5.2) mm Hg on days 5-7 and remained stable during days 14-17 and 18-21 (53.9 (6.8) and 53.9 (6.2) mm Hg, respectively). Mean exhaled V(T) rose from 5.15 (0.62) ml/kg on day 1 to 5.24 (0.71) ml/kg on days 5-7, 5.63 (1.0) ml/kg on days 14-17, and 6.07 (1.4) ml/kg on days 18-21 (p<0.05).

CONCLUSIONS

Despite permissive hypercapnia, V(T) requirement rises with advancing postnatal age in ELBW infants. The increase is greatest during the third week of life, which is probably due to distension of the upper airways (acquired tracheomegaly) and increasing heterogeneity of lung inflation (increased alveolar dead space).

Pulmonary oxygen consumption: a hypothesis to explain the increase in oxygen consumption of low birth weight infants with lung disease

OBJECTIVE

We determined pulmonary oxygen consumption (VO2lung) in low-birthweight infants with acute lung disease to help explain the greater whole-body oxygen consumption (VO2wb) in these infants with than in those without lung disease.

METHODS AND MATERIALS

Eleven infants (birth weight 1,076+/-364 g; gestational age 28+/-3 weeks) undergoing mechanical ventilation for respiratory distress syndrome were studied in their first week of life. We measured VO2wb by indirect calorimetry and simultaneously determined systemic oxygen uptake (VO2Fick) as the product of cardiac output (echocardiography) and the arterial-mixed venous oxygen content difference (cooximetry) assuming that VO2wb-VO2Fick accounts for VO2lung. Right atrial blood samples were used to determine mixed venous oxygenation, and infants were excluded if samples returned saturations greater than 89%.

RESULTS

VO2lung was 1.92+/-1.74 ml x kg(-1) x min(-1), representing 25% of their VO2wb (7.58+/-1.48 ml x kg(-1) x min(-1)). VO2lung was not correlated with clinical measures of acute disease severity. However, infants with the most severe changes on follow-up radiography (Edwards score 5 as assessed by radiologist blinded for VO2 data) all had a VO2lung level greater than 2.0 ml x kg(-1) x min(-1).

CONCLUSION

VO2lung can account for the elevated metabolic rate in low-birthweight infants with lung injury. We speculate that this reflects in part inflammatory pulmonary processes and may herald chronic lung disease.

Heparin improves gas exchange during experimental acute lung injury in newborn piglets

Although intrapulmonary fibrin deposition is a pathognomonic feature of acute lung injury, it remains uncertain whether thrombin inhibitors affect clinically important outcomes. We hypothesized that both heparin and antithrombin (AT) concentrate improve gas exchange during experimental respiratory distress syndrome. We also tested whether combination therapy is more beneficial than monotherapy. Forty-eight newborn piglets were randomized within 12 litters to one of four groups in a factorial design: (1) AT; (2) heparin; (3) AT plus heparin; (4) untreated control animals. After lung lavage and 4 h of barovolutrauma, mechanical ventilation was continued for 24 h during which ventilator pressures and inspired oxygen were adjusted to maintain normal blood gases. The arterial/ alveolar oxygen tension ratio (a/A ratio) and the ventilator efficiency index (VEI) at 18 and 24 h were compared by repeated measures analysis of variance (ANOVA). In contrast to our hypothesis, only heparin improved gas exchange, and we found little evidence of an interaction with AT. The a/A ratio was 0.48 +/- 0.27 (mean +/- SD) in the presence of heparin versus 0.33 +/- 0.26 in its absence; p = 0.01. Corresponding VEI was 0.30 +/- 0.12 versus 0.25 +/- 0.14; p = 0.04. Hyaline membrane formation was also decreased in heparin-treated animals (p = 0.02).

[18F]fluorodeoxyglucose uptake in neonatal acute lung injury measured by positron emission tomography

The objective of this study was to evaluate positron emission tomography (PET) of [18F]fluorodexoyglucose (18FDG) uptake as a measure of neonatal acute lung injury. Inasmuch as intrapulmonary sequestration of neutrophils is a hallmark of acute lung injury, quantification of neutrophil activity using 18FDG may offer a novel, in vivo technique to examine the progression and resolution of this disease. Ten newborn piglets were studied: six received bronchoalveolar lavage followed by 4 h of high pressure ventilation of create acute lung injury. Four healthy piglets served as controls. 18FDG (0.8 mCi/kg; 29.6 MBq) was given i.v. and PET (ECAT 953/31, Siemens) was performed for 90 min. During PET, all animals were sedated, paralyzed, and ventilated to maintain normal blood gases. The time course of radioactivity in lung regions and in plasma was used to calculate the rate constant for the metabolic trapping of 18FDG in tissue according to the method of C. S. Patlak. Median 18FDG influx constants were significantly higher in injured piglets (0.0187 min-1) than in control piglets (0.0052 min-1) (p < 0.01). Moreover, consistent with the 18FDG uptake data, injured piglets had moderate to severe injury on lung histology whereas control piglets had only slight and focal histologic changes. We conclude that PET of 18FDG uptake is an accurate, readily repeatable in vivo measure of neonatal acute lung injury.

Preparing the bowel for colonoscopy

Bowel preparation methods for total colonoscopy in children generally involve whole gut irrigation with electrolyte lavage solutions, which in most children will require hospitalisation for nasogastric tube administration. The aim of the study was to determine the efficacy of oral bisacodyl combined with a single phosphate enema as a bowel preparation regimen in children. In an open prospective trial, 30 children (aged 18 months-15 years) were given oral bisacodyl on each morning of the two days before colonoscopy. The children were maintained on a normal diet. A phosphate enema was administered on the morning of the procedure. The adequacy of bowel preparation was graded as grade I if no faecal material was encountered, grade II if small amounts of faecal material were present in scattered locations, and grade III if there was poor preparation with faecal material precluding satisfactory visualisation of the bowel mucosa. Eight children (26.6%) had minor abdominal cramps when taking bisacodyl, but all had a previous history of similar pain. Five children (16.6%), all under 5 years of age, cried during the administration of phosphate enema. Bowel preparation was considered excellent (grade I) in 26 (86.6%) and good (grade II) in four (13.3%). In all patients adequate visualisation of the bowel mucosa was obtained. Oral bisacodyl combined with a single phosphate enema provides an ideal method of preparing the bowel for total colonoscopy. This preparation allows colonoscopy to be carried out as a day case procedure in children while maintaining them on a normal diet.