Duration of mechanical ventilation after craniosynostosis repair reduces over time.

BACKGROUND: Pediatric craniosynostosis repair (CR) involves wide scalp dissections with multiple osteotomies and has been associated with significant morbidity. The aim of this study was to document the impact of perioperative complications on prolonged mechanical ventilation after CR. METHODS: Data were collected from the anesthesia records, Pediatric Intensive Care Unit (PICU) progress notes and discharge summaries. All the patients were transferred from the operating room sedated and on mechanical ventilation to the PICU. To highlight the determinants of prolonged mechanical ventilation we performed a logistic regression analysis.. RESULTS: Fifty-five patients underwent CR, but 6 were excluded due to incomplete records. The main intraoperative complications were: metabolic acidosis (32%), hypotension (20%), dural tears laceration (22%) and altered coagulation (18%). Metabolic acidosis (46%) and relative polycythemia (24%) were detected on arrival to the PICU. All children received intraoperative blood products and 23 (46%) were transfused in the postoperative period too. No infective complications were detected. The only determinant associated significantly with a prolonged mechanical ventilation was to have surgery in the first 5 years of the program (P=0.05) (95% CI 0.358-0.996). CONCLUSION: All life-threatening complications were intraoperative whereas only milder ones, such as hypercloremic and lactic acidosis were noticed in PICU. All children are alive without any neurological deficit. Even though we deal on a daily basis with complex surgical cases, only time, hence experience, showed an impact on prolonged mechanical ventilation.

Designs for correction and camouflage of bilateral clefts of the lip and palate.

The bilateral cleft anomaly is difficult to correct and camouflage because of the double lack of many important landmarks and the shortness of skin in the midvertical plane. A possible solution in patients who have some columella or in those of races not needing a long columella is the strap flap advancement of the nostril sills and alar bases. In all other cases, the forked flap is the method of choice for adequate correction and camouflage of the bilateral cleft lip-nose deformity.

Secondary aldosteronism documented by plasma renin and aldosterone circadian rhythm in subjects with kidney or heart transplantation.

The circadian rhythm (CR) of plasma renin activity (PRA), plasma aldosterone (PA), and plasma cortisol (PC) was investigated in 8 patients with kidney transplantation, and in 10 patients with heart transplantation. Ten clinically healthy subjects were studied as controls. The transplanted patients were all under cyclosporine treatment associated with prednisone (PDN). Time-qualified levels of PRA and PA were seen to be higher than normal in both groups of transplanted patients. The analysis of PRA and PA circadian rhythm provided evidence for a systematically higher level of within-day concentrations. The higher level of oscillation suggests the occurrence of a condition of hyperreninemic hyperaldosteronism. The higher levels of PRA and PA 24-h values show no periodicity. The finding suggests the abrogation of the rhythmic function for renin-aldosterone system. The disappearance of PRA-PA circadian rhythm seems to be attributable to a side effect of immunosuppressive therapy.

[Circadian rhythm of the renin-angiotensin-aldosterone system in subjects with kidney and heart transplants]. / Ritmo circadiano del sistema renina-angiotensina-aldosterone in soggetti con trapianto di rene e di cuore.

The present investigation evaluates the circadian rhythm of renin-angiotensin-aldosterone system (RAAS) in subjects with kidney (KTS) or heart (HTS) transplantation undergoing conventional therapy with prednisone and cyclosporine. RAAS circadian rhythmicity has been compared with the circadian cycle of cortisol as a marker rhythm. The chronobiological exploration has been performed by measuring the circulating levels of plasma renin activity (PRA), plasma aldosterone (PA), and serum angiotensin-converting-enzyme (SACE) and plasma cortisol (PC) in serial samplings collected six times over a 24-h span. Time-qualified levels of plasma cyclosporine (CYCL) have been established. The control group consisted of 10 normal subjects matching in age and sex. Individual data series were analysed by the Cosinor method. The chronobiometric estimates demonstrate the lack of a circadian rhythmicity for PRA, PA and SACE in KTS and HTS. The PC circadian rhythm is demonstrable in KTS, but not in HTS. The abolition of the RAAS circadian rhythm in both KTS and HTS seems to be attributable to the effects exerted by CYCL. The disappearance of the PC circadian rhythm may be due to the prednisone therapy that is administered twice a day in HTS but not in KTS. The asynchronous effects of this drug lead us to suggest that antirejection therapy may be optimized by administering prednisone and cyclosporine according to a chronomodulated scheme.

The role of indium-111 antimyosin (Fab) imaging as a noninvasive surveillance method of human heart transplant rejection.

The identification of rejection after heart transplantation in patients receiving cyclosporine immunosuppressive therapy requires the endomyocardial biopsy, an invasive method associated with a finite morbidity. To evaluate the role of indium-111 antimyosin (Fab) scintigraphy as a noninvasive surveillance method of heart transplant rejection, the Fab fragment of murine monoclonal antimyosin antibodies labeled with indium-111 was administered intravenously in 30 scintigraphic studies to 10 consecutive heart transplant recipients. Endomyocardial biopsy specimens were obtained 72 hours after each scintigraphic study. Nineteen scintigraphic studies had negative findings; no false negative finding was obtained. Eleven antimyosin scintigraphic studies had positive findings, and in these studies endomyocardial biopsy revealed mild rejection in two cases, moderate acute rejection with myocyte necrosis in two cases, myocyte necrosis as a consequence of ischemic injury in six cases, and possibly cytotoxic damage in one case. Antimyosin scintigraphy may represent a reliable screening method for the surveillance of heart transplant patients. In the presence of a negative finding from antimyosin scintigraphy, it may be possible to avoid endomyocardial biopsy. Conversely, in patients who have a positive finding from antimyosin scintigraphy, the endomyocardial biopsy is mandatory to establish the definitive diagnosis by histologic examination of the myocardium.

[24-hour behavior of T-lymphocyte subpopulations in patients with stable heart transplants receiving cyclosporin therapy]. / Comportamento di 24 ore delle sottopopolazioni T linfocitarie in soggetti con trapianto consolidato di cuore in terapia ciclosporinica.

In 10 heart transplanted subjects (HTS) undergoing conventional immunosuppressive cyclosporine therapy, in comparison with 10 normal subjects, the 24 hour patterns of T lymphocyte subpopulations, namely, OKT3 (total T lymphocytes), OKT4 (helper lymphocytes) and OKT8 (cytotoxic or suppressor) in relation to the circadian rhythms for plasma cortisol (marker rhythm) and to circulating levels of cyclosporine were studied. From the collected data, it can be deduced that the OKT3, OKT4, OKT8 subpopulations and the plasma cortisol level show 24-hour non-periodic variations. The lymphocyte subpopulations show a negative correlation with circulating levels of cyclosporine. The negative correlation is "selective" and "delayed" in that it is detectable at particular and non-coinciding hours. Plasma cortisol is also negatively correlated to plasma cyclosporine. Assessing the meaning of the lack of a circadian rhythm of the lymphocyte subpopulation in HTS undergoing conventional cyclosporine therapy, and taking into account the pharmacological time-stage dependency, we can emphasize the idea that the optimization of anti-rejection therapy with cyclosporine may and should be performed as a time-modulated treatment.