Prospective incidence study of bloodstream infection in infants and children with central venous catheters after cardiac surgery in Italy.

This prospective observational study was designed to assess the incidence of, risk factors for, and outcome of catheter-related bloodstream infection in children undergoing cardiac surgery. A staff specifically trained to handle the central venous catheters with proper aseptic techniques and an appropriate patient to medical staff ratio remain the most effective measures to prevent this infection.

Usage of triptans among migraine patients: an audit in nine GP practices.

A retrospective audit was carried out to investigate triptan usage over a period of one year among 360 adult patients with migraine in nine GP practices in the UK and the Republic of Ireland. Data from patient records were analysed, in conjunction with replies to a questionnaire about patients' perceptions of their migraine and its treatment. The majority of patients included in the audit were women (83%), and most patients (81%) were aged between 35 and 64 years. Most patients in the audit population (60%) were in the lowest band of triptan usage (1-36 tablets prescribed over 12 months); 7% had moderate usage (37-53 tablets). A minority of patients appeared to be taking triptans in higher quantities: about 15% of patients had been prescribed 54-94 triptan tablets over a year, 9% had received prescriptions for 95-149 tablets and 7% had received prescriptions for 150 or more tablets. These results indicated that some migraine patients were using triptans at higher than expected rates, and suggested that some patients might have been using their prescribed triptans inappropriately to treat a headache that they incorrectly perceived as migraine (e.g. chronic daily headache). Analyses were carried out to identify predictors of high usage. Predictors identified included the use of several other (non-triptan) medications to treat conditions other than migraine, one triptan dose being reported as sufficient to treat an attack, patient's perception of all headaches as migraine and lack of concern about taking too much medication. Patients identified as using triptans at a higher than expected rate can be called in for review of migraine diagnosis, identification of possible causes of any increased frequency of attacks, and investigation of suspected non-migrainous headaches, such as chronic daily headache and medication-induced headaches. For GPs, such actions would help achieve and maintain a high standard of care for their migraine patients, thus helping to contribute towards meeting the demands of the clinical governance agenda. Audit of triptan usage may also offer financial benefits for the practice, since helping patients to avoid the inappropriate use of triptans could lead to reductions in the overall costs of triptan prescribing within the practice. The high usage predictors could be developed into a checklist of potential indicators for GPs to identify patients who may become high users if prescribed triptans and who might require closer monitoring. We recommend that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Although triptans are generally safe and well tolerated, unnecessary use of any medication should be avoided.

Nosocomial infections in pediatric cardiac surgery, Italy.

OBJECTIVE: To evaluate the incidence of nosocomial infection (NI) in pediatric patients who received cardiothoracic surgery and to identify possible associated risk factors. DESIGN: Prospective observational study. SETTING: The cardiac surgery and cardiac intensive care units at the Regina Margherita Children's Hospital, Turin, Italy. PATIENTS: All patients who underwent surgery from July 20, 1998, to July 19, 1999, were enrolled, except patients with operative catheterization only. METHODS: Clinical data were collected daily from July 20, 1998, to July 19, 1999. NIs were diagnosed according to US Centers for Disease Control and Prevention criteria. RESULTS: 104 patients were included in the present study, 80 (76.9%) of whom underwent extracorporeal circulation. The NI ratio was 48.1% (50/104); the percentage of patients with NI was 30.8% (32/104): 23.1% developed one infection, 7.7% two or more. The rate of NI was 2.17 per 100 days of hospitalization (50/2,304). The most common pathogen was Pseudomonas aeruginosa. Important risk factors were length of preoperative admission >5 days, total length of admission >10 days, open chest during postoperative phase, and cyanotic heart disease. There was a significant association between sepsis and central venous catheterization for 3 days or more. Rate of sepsis was 19 per 1,000 catheter days (16/852). CONCLUSION: NIs represent a frequent complication for children who undergo heart surgery. Based on our data, we suggest decreasing the preoperative stay as much as possible. The higher NI incidence in patients with an open chest postoperatively suggests that an alternative antibiotic strategy should be considered for these patients.

Accidental hypothermia in a child.

We report a case of severe accidental hypothermia (24.8 degrees C) in a seven-year-old child due to prolonged exposure to low temperatures and temporary contact with river water. When the patient was seen in hospital, bradycardia (30.min-1), bradypnoea (5. min-1), scarcely reacting pupils, and Glasgow Coma Scale=3 were noted. For rewarming minimally invasive techniques (humidified warmed gases and intravenous solutions at 40 degrees C) were employed with a very successful outcome.

[Indwelling central venous catheters after discontinuation of therapy and risk of infection in children with cancer]. / Permanenza del catetere venoso centrale dopo la sospensione della terapia e rischio infettivo in bambini affetti da neoplasia.

In this retrospective study we report the incidence of CVC-related infections in a pediatric oncology population during the off therapy period. We analysed 128 children with oncologic diseases (solid tumors and leukemia), 78 boys and 50 girls, aged 1 to 21 years, who maintained the CVC in situ at least 6 months after the cessation of chemotherapeutic protocols. Seventy-eight patients had a single lumen Broviac-Hickman CVC, 8 patients had a double lumen Broviac-Hickman and 42 a implantable port device. The permanence of CVC in situ after discontinuation of treatment varied between 6 and 24 months. CVC was removed in 5 patients that presented a CVC-related infection, respectively 6, 6, 6, 7 and 10 months from discontinuation of therapy, in 85 patients because was considered no more necessary. 38 patients are still with CVC in situ; in this group 11 patients relapsed more than 6 months after discontinuation of the therapy and were analysed until the time of relapsed. The result of our study show that the incidence of CVC related infections in patients off therapy is very low. Considering the discomfort that frequent blood withdrawals cause to children and the relapse risk, we think that CVC may be maintained in situ more than 6 months after discontinuation of the therapy without risks for the patients.

Hematological studies in children with Down syndrome.

Previous studies have reported erythrocyte macrocytosis in adults and children with Down syndrome (DS), the significance of which remains unclear. We compared hematological parameters of 50 DS children aged 2 to 15 years, divided into three age groups, with those of 68 aged-matched healthy children. Patients with DS had a significantly increased mean corpuscular volume (MCV) and hemoglobin in all groups when compared with the controls. Erythrocyte creatine content, hexokinase (Hk) activity, erythrocyte and serum folates, vitamin B12, haptoglobin, serum iron, and ferritin were tested. All of these parameters were not significantly different from those of the control group. We conclude that macrocytosis may not be an expression of reduced red cell survival but rather of an altered folate remethylation pathway, secondary to enhanced cystathionine beta-synthase (CBS) activity, the gene for which is present on chromosome 21.

[Use of central venous catheters implanted subcutaneously in children with neoplasms]. / Uso dei cateteri venosi centrali ad impianto sottocutaneo in bambini con malattia neoplastica.

The use of totally implantable right atrial catheters was evaluated in pediatric oncology patients. From September 15, 1987 to March 31, 1989, 26 catheters were inserted in patients (1 year to 20 years of age) with the following diagnosis: acute leukemia (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6) and other solid tumors (5). Total number of catheter days was 5,475. The catheters were maintained for a mean of 210 days (range 10-534). Complications included: documented local infection in 1 patient, successfully treated with antibiotics without removing the catheter and transient obstructions resolved with injection of heparin or urokinase in other children. The use of these right atrial catheters has been widely accepted by patients and families as well as by the health team. Complications have been minimal. Our experience confirms that these catheters contribute to improving quality of life in pediatric patients with neoplasms.

[The external left jugular vein as an access for placement of long-term permanent central venous catheters in children]. / La vena giugulare esterna sinistra quale accesso per il posizionamento di cateteri venosi centrali adatti a lunga permanenza in pazienti pediatrici.

We consider the approach through the left external jugular vein v/s right external jugular vein (Heinbach-Ivey technique) for the placement of central venous catheters (Broviac Hickman type and others) in pediatric patients. Between January '84 and February '87, 65 central venous catheters were inserted using the Heinbach Ivey technique. In 24.6% of the cases we failed and had to place the catheter through the right internal jugular vein. Between March '87 and November '88, 72 catheters were inserted through the left external jugular vein, only 5 through the left internal jugular vein, with a failure rate of 6%. Our data show that a more favourable anatomy makes easier and quicker the correct placement of a central venous catheter through a left external jugular vein approach.