Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study.

In this multicenter study, we investigated the kinetics of neutrophil recovery in relation to acuity and survival among 125 children undergoing allogeneic hematopoietic cell transplantation (allo-HCT) who required invasive mechanical ventilation (IMV). Recovery of neutrophils, whether prior to or after initiation of IMV, was associated with a significantly decreased risk of death relative to never achieving neutrophil recovery. A transient increase in acuity (by oxygenation index and vasopressor requirements) occurred among a subset of the patients who achieved neutrophil recovery after initiation of IMV; 61.5% of these patients survived to discharge from the intensive care unit (ICU). Improved survival among patients who subsequently achieved neutrophil recovery on IMV was not limited to those with peri-engraftment respiratory distress syndrome. The presence of a respiratory pathogen did not affect the risk of death while on IMV but was associated with an increased length of IMV (p < 0.01). Among patients undergoing HCT who develop respiratory failure and require advanced therapeutic support, neutrophil recovery at time of IMV and/or presence of a respiratory pathogen should not be used as determining factors when counseling families about survival.

Correction to: Acute respiratory failure and the kinetics of neutrophil recovery in pediatric hematopoietic cell transplantation: a multicenter study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Short-term surgical outcomes and histomorphological evaluation of thermal injury following palatoplasty performed with diode laser or air plasma device in dogs with brachycephalic airway obstructive syndrome.

Brachycephalic obstructive airway syndrome (BOAS) is a common disorder presenting enlarged soft palate, stenotic nares and abnormal turbinate growth. Surgical correction of BOAS abnormalities with caudal palatoplasty is an elective therapy. This prospective study aimed to compare the effect of an air plasma device and diode laser in dogs undergoing palatoplasty. Outcome measures were as follows: (1) intra-operative and immediate post-operative complications; (2) evaluation of thermal injury in histological tissue sections of the excised soft palate. Twenty dogs with enlarged soft palates underwent palatoplasty, using an air plasma device (n=10) and diode laser (n=10). Soft palate specimens underwent masked histopathological analysis to assess post-operative thermal injury. In this pilot study, no differences were observed in surgical times; all dogs were discharged 24h after surgery and had stable respiration. In the air plasma group, post-operative bleeding occurred in two cases and revision surgery was performed. No difference in thermal injury was observed using the two devices (P>0.05). The air-plasma device was a viable surgical option for palatoplasty in dogs with BOAS.

The potential role of magnetic resonance brain relaxometry in veterinary medicine: a preliminary study.

Magnetic Resonance (MR) is a non-invasive modality of choice for the evaluation of brain morphology, with superior performance as compared to other techniques. However, MR images are typically assessed qualitatively, thus relying on the experience of the involved radiologist. This may lead to errors of interpretation in the presence of subtle alterations and does not exploit the full potential of this technique as a quantitative diagnostic tool. To this end Magnetic Resonance Relaxometry (MRR), which is able to quantitively characterize the tissues under investigation through their relaxation rates, seems extremely promising. Many studies assessed the feasibility of relaxometry as a diagnostic tool in human brain disorders, with the most promising results obtained in the evaluation of neurodegenerative diseases and in the oncologic field. However, despite such extensive literature in human medicine, due to the lack of standardized protocols and the need of high-field MRI scanners, to date few studies have been performed on companion animals. In this work, first we describe relaxometry applications in human neuropathology and their possible extension to companion animals both in the experimental and clinical fields. Then, we present two experiments performed on a typical standard clinical scanner operating at 0.25 T to show that, despite the low field intensity, this technique may be promising even in the clinical setup. We tested the relaxometry protocol in a phantom study and then applied it to a real clinical case study. The results showed that this protocol used on a phantom led to a higher contrast, as compared to the standard approach. Furthermore, when applied to a real case study, this protocol revealed brain lesions undetected by the standard technique which were confirmed by a histopathological examination. These preliminary results are encouraging and support the development of this approach as an advanced diagnostic tool even in a clinical setting where low field MRI scanners are typically employed.

Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplant Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents: Part 2-Focus on Ascites, Fluid and Electrolytes, Renal, and Transfusion Issues

Even though hepatic veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic cell transplantation (HCT), there is paucity of research on the management of associated multiorgan dysfunction. To help provide standardized care for the management of these patients, the HCT Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators and the Supportive Care Committee of the Pediatric Blood and Marrow Transplant Consortium, collaborated to develop evidence-based consensus guidelines. After conducting an extensive literature search, in part 2 of this series we discuss the management of fluids and electrolytes, renal dysfunction; ascites, pleural effusion, and transfusion and coagulopathy issues in patients with VOD. We consider the available evidence using the GRADE criteria.

Evaluation of the dorsal acetabular coverage obtained by a modified triple pelvic osteotomy (2.5 pelvic osteotomy): an ex vivo study on a cadaveric canine codel.

OBJECTIVES: To evaluate the acetabular ventroversion obtained with a modified triple pelvic osteotomy (2.5 PO) compared with that resulting from standard double pelvic osteo-tomy (DPO). STUDY DESIGN: Ex vivo study. ANIMALS: Seven pelves obtained from skeletally mature dogs with a total body weight ranging from 26-41 kg were used. METHODS: Unilateral DPO technique and dorsal ischial mono-cortical osteotomy were performed on every right hemipelvis. Angular ventral rotation was measured by determining the relative orientation of two Kirschner wires placed in the ilial wing and in the dorsal acetabular rim. RESULTS: The mean angle of ventroversion was 9.5 ± 5.2 degrees for the DPO group (range 2.1-18.1) and 10.9 ± 4.8 degrees for the 2.5 PO group (range 4.1-19.5). The mean difference between the 2.5 PO and DPO was 1.5 ± 0.6 degrees (range 0.5-2.1). CONCLUSIONS: The 2.5 PO technique increased acetabular ventroversion versus DPO.

The care of critically ill children after hematopoietic SCT: a North American survey.

Although potentially curative, hematopoietic SCT (HSCT) is associated with significant morbidity. To improve outcomes, multicenter studies of critical illness in this patient population appear needed. To assist in the design of such studies, a survey was conducted to identify variations in care provided to critically ill pediatric HSCT patients. A survey was conducted of the highest volume pediatric HSCT centers in the United States (n=30) and Canada (n=4). One pediatric critical care medicine (PCCM) physician and one pediatric HSCT physician were surveyed at each institution. Analysis consisted of descriptive statistics. Thirty-three (29 United States/4 Canada) of 34 institutions responded. Although most HSCT units permit fluid boluses and nearly half permit some dose of dopamine, high-dose dopamine and other vasoactive infusions are rarely allowed there. Six institutions (21%) permit non-invasive ventilation on the HSCT unit. Criterion for PCCM consultation and therapies implemented before intubation vary significantly. High-frequency oscillatory ventilation and renal replacement therapy are commonly used for lung injury in patients failing conventional therapy. Variability exists in the location and type of therapy critically ill pediatric HSCT patients receive. Understanding this variability will help facilitate the design of clinical trials.

Combined intra-extra-articular technique for stabilisation of coxofemoral luxation. Preliminary results in two dogs.

OBJECTIVE: To report a new technique for repairing traumatic cranio-dorsal coxofemoral luxation in dogs. METHODS: Stabilisation of hip luxation was carried out in two dogs: a one-year-old male Border Collie and an eight-year-old female American Staffordshire Bull Terrier. A caudal approach was performed to expose the hip joint. Following this, a 2.5 mm hole was drilled through the acetabular wall at the original attachment of the round ligament, followed by a tunnel between the fovea capitis and the proximal third of the femur. Nylon tape was tied in a clove hitch knot around the femoral neck. The tape was placed as a bridge over the ischial spine to create an acetabular roof in order to increase articular stabilisation. RESULTS: Follow-up examinations were performed at 10, 40 and 90 days after surgery.The dogs did not show any signs of lameness, pain or reoccurrence of the luxation during any of the follow-up examinations. CLINICAL SIGNIFICANCE: This tape-technique enabled reinforcement of the acetabular roof which in turn increased the stability of the joint.

Association between the inception of a SAFE KIDS Coalition and changes in pediatric unintentional injury rates.

OBJECTIVE: To assess the relationship between the implementation of a SAFE KIDS Coalition and pediatric unintentional injury rates. SETTING: Shelby County, Tennessee. DESIGN: Retrospective observational analysis. PATIENTS: County residents nine years of age or younger presenting to the children's medical center, its emergency department, or its outpatient clinics from 1990-97. INTERVENTION: Implementation of a SAFE KIDS Coalition. MAIN OUTCOME MEASURES: Rates of unintentional injuries targeted by the SAFE KIDS Coalition that resulted in hospitalization or in death. Rates of motor vehicle occupant injuries that resulted in hospitalization or in death. Rates of non-targeted unintentional injuries, namely injuries secondary to animals and by exposure to toxic plants. Rates of severe injuries (defined as those targeted injuries that required hospitalization or resulted in death), and specifically, severe motor vehicle occupant injuries were compared before and after the inception of the coalition using Poisson regression analysis. RESULTS: The relative risk of targeted severe injury rates decreased after implementation of the coalition even after controlling for changes in hospital admission rates. Specifically, severe motor vehicle occupant injury rates decreased 30% (relative risk 0.70; 95% confidence interval 0.54 to 0.89) after initiation of the coalition. CONCLUSIONS: The implementation of a SAFE KIDS Coalition was associated with a decrease in severe targeted injuries, most notably, severe motor vehicle occupant injuries. Although causality cannot be determined, these data suggest that the presence of a coalition may be associated with decreased severe unintentional injury rates.

Bacillus cereus causing fulminant sepsis and hemolysis in two patients with acute leukemia.

PURPOSE: Hemolysis is so rarely associated with Bacillus cereus sepsis that only two very well documented cases have been reported. This article reports two unusual cases of Bacillus cereus sepsis with massive intravascular hemolysis in patients who had acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: A 20-year-old woman who was 9 weeks pregnant experienced a relapse of ALL. A therapeutic abortion was performed. During week 4 of reinduction the patient had abdominal pain, nausea, and vomiting, with severe neutropenia but no fever. Her condition deteriorated rapidly with cardiovascular collapse, acute massive intravascular hemolysis, and death within hours of the onset of symptoms. Blood cultures were positive for Bacillus cereus. Postmortem histologic examination and cultures revealed Bacillus cereus and Candida albicans in multiple organs. The second patient, a 10-year-old girl, presented with relapsed T-cell ALL. In the second week of reinduction, she had abdominal pain followed by hypotension. Again, no fever was noted. Laboratory studies showed intravascular hemolysis 12 hours after admission. Aggressive support was promptly initiated. Despite disseminated intravascular coagulation; cardiovascular, hepatic, and renal failure; and multiple intracerebral hypodense lesions believed to be infarcts, the patient recovered fully and resumed reinduction therapy. CONCLUSIONS: Bacillus cereus infection can have a fulminant clinical course that may be complicated by massive intravascular hemolysis. This pathogen should be suspected in immunosuppressed patients who experience gastrointestinal symptoms and should not be precluded by the absence of fever, especially if steroids such as dexamethasone are being given. Exchange transfusion may be lifesaving in Bacillus cereus septicemia associated with massive hemolysis.

Evolution of traumatically acquired infracristal ventricular septal defect.

Nonpenetrating traumatic rupture of the ventricular septum is rare. This case report describes the evolution of such a lesion documented by echocardiography and color flow Doppler. Included is a brief discussion of postulated mechanisms for this rare phenomenon.