Long-term systolic function in children and young adults after hematopoietic stem cell transplant.

Congestive heart failure and subclinical left ventricular systolic dysfunction (LVSD) affect long-term survivors of hematopoietic stem cell transplant (HSCT). Echocardiographic measurements of global longitudinal and circumferential strain have shown promise in identifying subclinical LVSD in cancer survivors. We analyzed echocardiograms in 95 children and young adults with malignancies or bone marrow failure syndromes performed before HSCT and 1-6 years after HSCT. We additionally measured the biomarkers soluble suppression of tumorigenicity-2 (sST-2) and cardiac troponin-I (cTn-I) in the same children through 49 days post HSCT. Ejection fraction (EF) after HSCT was unchanged from baseline (baseline: z-score -0.73 vs long-term follow up: -0.44, P=0.11). Global longitudinal strain was unchanged from baseline (-20.66 vs -20.74%, P=0.90) as was global circumferential strain (-24.3 vs -23.5%, P=0.32). Levels of sST-2 were elevated at all time points compared with baseline samples and cTn-I was elevated at days 14 and 28. Cardiac biomarkers at any time point did not correlate with long-term follow-up EF. In children and young adult survivors of HSCT, EF was unchanged in the first years after HSCT. Elevation in cardiac biomarkers occurring after HSCT suggest subclinical cardiac injury occurs in many patients and long-term monitoring for LVSD should continue.

The injured heart: early cardiac effects of hematopoietic stem cell transplantation in children and young adults.

We hypothesized that subclinical cardiac injury in the peri-transplant period is more frequent than currently appreciated in children and young adults. We performed echocardiographic screening on 227 consecutive patients prior to hematopoietic stem cell transplantation (HSCT), and 7, 30 and 100 days after transplant. We measured cardiac biomarkers cardiac troponin-I (cTn-I), and soluble suppressor of tumorigenicity 2 (sST2) prior to transplant, during conditioning, and days +7, +14, +28 and +49 in 26 patients. We subsequently analyzed levels of cTn-I every 48-72 h in 15 consecutive children during conditioning. Thirty-two percent (73/227) of patients had a new abnormality on echocardiogram. New left ventricular systolic dysfunction (LVSD) occurred in 6.2% of subjects and new pericardial effusion in 27.3%. Eight of 227 (3.5%) patients underwent pericardial drain placement, and 5 (2.2%) received medical therapy for clinically occult LVSD. cTn-I was elevated in 53.0% of all samples and sST2 in 38.2%. At least one sample had a detectable cTn-I in 84.6% of patients and an elevated sST2 in 76.9%. Thirteen of fifteen patients monitored frequently during condition had elevation of cTn-I. Echocardiographic and biochemical abnormalities are frequent in the peri-HSCT period. Echocardiogram does not detect all subclinical cardiac injuries that may become clinically relevant over longer periods.

Basiliximab treatment for autoimmune bowel disease in a pediatric heart transplant patient.

Autoimmune-mediated bowel disease has been reported after pediatric heart transplantation. Recognition and treatment of these patients has been difficult. We describe a patient who responded to steroids and basiliximab therapy after an inflammatory process secondary to abnormal T-cell activation. Our patient is a 28-month-old female who received a heart transplant at five wk of age. At 24 months post-transplant, she developed fever and bloody stools. Initial investigations were significant for an elevated ESR (>120) and CRP (15.2). Symptoms persisted despite bowel rest and mycophenolate discontinuation. Endoscopic evaluation revealed discontinuous ulcerative disease involving esophagus, terminal ileum, right and left colon, necessitating extensive bowel resection. She had additional airway inflammation leading to a TEF at the site of esophageal ulceration, requiring tracheostomy. Immune evaluation revealed autoimmune dysregulation that responded to parenteral methylprednisolone. Chronic basiliximab therapy allowed for successful weaning of steroids with sustained remission. She has been transitioned to sirolimus and tacrolimus maintenance immunosuppression with plans to discontinue basiliximab once off steroids. In conclusion, bowel disease in the setting of pediatric heart transplantation can be severe and refractory to traditional treatment methods. Tailoring immune therapy to activated T cells can result in remission. Basiliximab therapy was used in our patient to maintain steroid-induced remission, but long-term complications of this disease process are unknown.

Urban minority youth swimming (in)ability in the United States and associated demographic characteristics: toward a drowning prevention plan.

OBJECTIVE: To examine swimming ability and variables associated with swimming for US inner-city, minority children. Empirical research on minority children's swimming ability is non-existent, and drowning rates for this population are high. DESIGN: Cross-sectional survey research. Descriptive statistics were produced. Multiple regression was applied using significant demographic variables by swimming ability. SETTING: Six US cities were chosen (Chicago, Illinois; Houston, Texas; Memphis, Tennessee; Miami, Florida; Oakland, California; Philadelphia, Pennsylvania). Young Men's Christian Association (YMCA) facilities were used to solicit subjects. SUBJECTS: A large sample (n = 1680) was gathered, which targeted poor, minority children. Parents of children aged 4-11 years and adolescents (12-17 years) completed surveys that research team members or trained YMCA staff supervised during non-swimming YMCA programmes. RESULTS: African-American respondents reported a 57.5% "at risk" (unable to swim or uncomfortable in deep end of pool) swimming ability. Hispanic/Latino children confirmed a 56.2% "at risk" level as compared with 30.9% for white subjects. Age, sex, child's lunch programme, parental education and race variables were all significantly (p<0.05) related to swimming ability. Regression analysis revealed that all demographic variables fell into a significant model (p<0.001) as predictor variables. CONCLUSIONS: Poor minority children, specifically African-American and Hispanic/Latino, are at a significant disadvantage concerning swimming ability. Female subjects were notably more "at risk" regarding their swimming ability than male subjects. Age, race and socioeconomic factors (lunch programme and parental education) were significantly associated with children who have low swimming ability.

Current management of inadvertent dural taps occurring during the siting of epidurals for pain relief in labour. A survey of maternity units in the United Kingdom.

A postal survey of all maternity units in the UK was conducted to gain information regarding the management of inadvertent dural taps occurring during the sitting of epidurals for pain relief in labour. Of the units surveyed only 58.5% had a written protocol for the management of dural taps. Following their occurrence, 99% of the units resited the epidural and in 22%, the midwives continued to give the top-ups. In only one-third of this latter group was the dose of the top-up reduced. In 46% of the units, patients who had a dural tap were allowed to push in the second stage of labour. As prophylaxis against the development of headache, 70% of the units infused crystalloids into the epidural space, whereas only 8.6% were in favour of an early prophylactic blood patch.

Current practice of epidural analgesia during normal labour. A survey of maternity units in the United Kingdom.

A postal survey of all maternity units in the United Kingdom was conducted to gain information regarding policies for epidural analgesia for labour. The average epidural rate was 19.7% and 78% of units offered a 24-h service. The majority of units inserted the epidural with the patient in the lateral position, using a midline approach, with loss of resistance to air and saline being used almost equally. Most units used 3 ml of 0.5% bupivacaine as a test dose, and only 10% of units used adrenaline in the test dose. The use of adrenaline in subsequent top-ups was infrequent. Bupivacaine 0.5% was used most frequently for the initial and the second stage top-up, whereas 0.25% was most often used during the first stage of labour. Midwife top-ups were allowed in 75% of units and in only 14% of cases was this from a local anaesthetic reservoir. Epidural analgesia using a continuous infusion of anaesthetic was routinely used in 28% of units, mostly with 0.125% bupivacaine; about half of these units did so because midwives were unable to perform top-ups. Routine use of epidural opioids was most frequent when anaesthetic infusions were used, otherwise it was uncommon.

Anaesthesia for the obstetric trainee.

The practice of obstetric anaesthesia and analgesia ranges from the sublime to the ridiculous. Try to contrast the satisfaction of having produced an effective epidural block with the agonizing personal loneliness of failing to intubate at emergency caesarean section, and you may begin to understand our position: we either love it or loathe it.

Maternal morbidity associated with in utero transfer.

OBJECTIVE: To determine the extent of maternal morbidity associated with in utero transfer. DESIGN: Retrospective study of 190 consecutive cases over two years. SETTING: Liverpool Maternity Hospital. PATIENTS: 190 Pregnant women were transferred to the hospital under the in utero transfer arrangements from district general hospitals both within and outside the Mersey region. The women admitted were divided into two categories: those in threatened or established uncomplicated preterm labour and those who may or may not have been in threatened or established preterm labour but who had coexisting complicating factors affecting the mother or fetus, or both. INTERVENTIONS: Planned delivery of the fetus if indicated and arrangements for appropriate postpartum care of the mother. MAIN OUTCOME MEASURE: Assessment of the progress of labour and, if appropriate, resuscitation of the mother. RESULTS: Women who were transferred with no coexisting disease (124) had relatively uncomplicated deliveries whereas those transferred with coexisting diseases (66) exhibited considerable morbidity and 17 of these required prolonged intensive monitoring after delivery. CONCLUSIONS: In utero transfer in healthy mothers may have benefits for babies born very prematurely. If mothers have coexisting disease, however, the desirability of transfer should be reviewed urgently in the light of the considerable maternal morbidity associated with these problems. In these cases transfer may introduce an additional hazard.

Failure of a ventilator alarm to detect patient disconnection.

An East Ventilator pressure monitor, Model VPM, used with an East Radcliffe PNA I Ventilator, failed to detect a patient disconnection at the distal end of the catheter mount. An investigation was undertaken to show why this system failed by measuring pressure and flow whilst using a variety of catheter mounts. It was concluded that the use of the East Ventilarm pressure monitor in conjunction with a pressure generator ventilator is unsuitable for detecting disconnections at the distal end of the catheter mount, the most frequent site of disconnection. Possible alternative methods of detecting this type of disconnection are suggested.

The Liverpool urban obstetric flying squad: changing patterns of practice 1965-84.

Obstetric flying squads operate from most maternity units in the United Kingdom. The 20 years from 1965 to 1984 saw 860 calls being made to the obstetric flying squad in the Liverpool urban area, with striking changes occurring in both the number of calls made and the reasons for making the calls. Management of the problems encountered has now become almost exclusively conservative, with such procedures as blood transfusion and general anaesthesia being virtually eliminated from practice.