Extracellular matrix molecules exhibit unique expression pattern in the climbing fiber-generating precerebellar nucleus, the inferior olive.

Extracellular matrix (ECM) accumulates around different neuronal compartments of the central nervous system (CNS) or appears in diffuse reticular form throughout the neuropil. In the adult CNS, the perineuronal net (PNN) surrounds the perikarya and dendrites of various neuron types, whereas the axonal coats are aggregations of ECM around the individual synapses, and the nodal ECM is localized at the nodes of Ranvier. Previous studies in our laboratory demonstrated on rats that the heterogeneous distribution and molecular composition of ECM is associated with the variable cytoarchitecture and hodological organization of the vestibular nuclei and may also be related to their specific functions in gaze and posture control as well as in the compensatory mechanisms following vestibular lesion. Here, we investigated the ECM expression pattern in the climbing fiber-generating inferior olive (IO), which is functionally related to the vestibular nuclei. By using histochemical and immunohistochemical methods, the most characteristic finding was the lack of PNNs, presumably due to the absence of synapses on the perikarya and proximal dendrites of IO neurons. On the other hand, the darkly stained dots or ring-like structures in the neuropil might represent the periaxonal coats around the axon terminals of olivary synaptic glomeruli. We have observed positive ECM reaction for the hyaluronan, tenascin-R, hyaluronan and proteoglycan link protein 1 (HAPLN1) and various chondroitin sulfate proteoglycans. The staining intensity and distribution of ECM molecules revealed a number of differences between the functionally different subnuclei of IO. We hypothesized that the different molecular composition and intensity differences of ECM reaction is associated with different control mechanisms of gaze and posture control executed by the visuomotor-vestibular, somatosensory and integrative subnuclei of the IO.

Survival after gastrointestinal mucormycosis in a neonate.

Gastrointestinal mucormycosis has been reported more frequently in adults than in children. Due to the high mortality diagnosis is usually made at autopsy. Only one case of a neonate surviving this disease has been described. We report a premature infant presenting clinically with enterocolitis but lacking the radiological characteristics of necrotizing enterocolitis (NEC) Gastrointestinal mucormycosis was diagnosed on the histological specimen. The infant survived after surgery and 6 weeks of antifungal treatment. A high level of suspicion and early surgical intervention are necessary to make the correct diagnosis and commence appropriate treatment.

Alterations in theophylline metabolism during the first year of life.

Maturational changes in theophylline disposition were evaluated in 52 infants (gestational age, 24 to 40 weeks; postnatal age, 2 to 69 weeks) receiving maintenance theophylline therapy. Theophylline and metabolites were measured in serum and urine at steady state, and the influence of clinical parameters on the maturational changes was analyzed by multiple stepwise linear regression. Theophylline clearance and urine metabolite pattern reached adult values at 55 weeks' postconceptional age. Serum caffeine concentrations greater than 1 microgram/ml occurred in infants up to 50 weeks' postconceptional age. Disappearance of serum caffeine concentrations and maturation of theophylline clearance were primarily related (p < 0.001) to development of the demethylation pathway to 3-methylxanthine. Postconceptional age was the major factor (p < 0.001) explaining the interpatient variability in theophylline clearance (r2 = 0.57), serum caffeine to theophylline ratio (r2 = 0.46), and urinary excretion of theophylline (r2 = 0.51), caffeine (r2 = 0.49), 1,3-methyluric acid (r2 = 0.32), 1-methyluric acid (r2 = 0.53), and 3-methylxanthine (r2 = 0.58). Our findings indicate that postconceptional age rather than postnatal age should be used as a maturational marker during theophylline therapy in infancy.

Bayesian forecasting of gentamicin pharmacokinetics in pediatric intensive care unit patients.

The predictive performance of a one compartment Bayesian forecasting program was evaluated in pediatric intensive care unit patients with normal renal function. Gentamicin pharmacokinetic parameters were determined in 44 PICU patients (0.8 month to 14 years old) from all available serum concentrations and doses by nonlinear least squares regression. Population pharmacokinetic parameter estimates were established from 27 of the PICU patients. Mean prediction error (ME) and mean absolute error (MAE) for 2 future sets of peak and trough gentamicin serum concentrations with the use of the population parameter estimates with and without feedback were evaluated in the remaining 17 patients. Mean clearance (+/- SD) and volume of distribution for all 44 patients were 0.123 +/- 0.041 liter/hour/kg and 0.424 +/- 0.116 liter/kg, respectively. Bayesian forecasting of the second set of peak and trough concentrations with feedback from the first set of peak and trough concentrations resulted in smaller bias (peak ME, -0.15 mg/liter; trough ME, 0.13 mg/liter) and better accuracy (peak MAE, 0.91 mg/liter; trough MAE, 0.28 mg/liter) compared with the population parameter estimates alone (peak ME, 0.4 mg/liter; trough ME, 0.28 mg/liter; peak MAE, 1.21 mg/liter; trough MAE, 0.57 mg/liter). This study indicates that gentamicin volume of distribution in PICU patients is larger than non-PICU literature values. The Bayesian program, with specific population parameter estimates for PICU patients, provides accurate initial and subsequent predictions of gentamicin serum concentrations.

Diabetic ketoacidosis.

Transport of the pediatric patients with DKA to a tertiary care center may be safely accomplished with a thorough understanding of the conditions that may require it. The patient should be acutely stabilized and standard therapeutic regimens begun prior to and during transport. Careful attention to detail and close monitoring are essential to prevent further instability and morbidity.

Management of reactive airway disease.

The diagnosis of lower airway obstruction is one of the most frequent causes of admission to pediatric intensive care units. Morbidity and mortality have noticeably increased during the past decade. Although the exact causes of the increased morbidity and mortality are not clear, factors that have been implicated include underdiagnosis, delay in referral to the hospital, and inadequate treatment, particularly excessive reliance on bronchodilators and too little use of systemic steroids. A thorough understanding of the pathophysiology underlying the disease should lead to more effective management and decreased mortality and morbidity.

[Compartment syndrome after femoral contusion. Case report and review of the literature]. / Kompartmentsyndrom nach Oberschenkelkontusion. Kasuistik und Literaturübersicht.

Compartment syndromes of the lower arm and lower leg are quite well known by now and have been often described in the literature. Those of the upper arm and thigh are rarer and those after pure closed lesion of the soft parts of the thigh are the subject of only sporadic reports in the literature. A recently observed case of this kind prompted the present case report and review of the literature.

Intraosseous infusion: a re-discovered procedure as an alternative for pediatric vascular access.

The intraosseous infusion has numerous advantages over other techniques that provide vascular access during emergencies. It is a rapid and safe alternate route for fluid and certain drug administration in the infant or child. Few contra-indications or restrictions exist and the success rate for the technique is very high, even when performed by paramedical personnel, and the rate of complications is very low. At this time the technique should be reserved for children in crisis such as cardiac arrest, shock, trauma, life threatening status epilepticus, or any situation in which the potential benefit of rapid venous access outweighs the low incidence of complication. Intraosseous infusion is intended only for emergency resuscitation and stabilization, after which another route of vascular access should be sought. The technique may offer even more promise for those who rarely care for critically ill children, because this skill is easily mastered with even limited opportunity for practice.

Lower airway obstruction in the PICU.

Lower airway obstruction is one of the most frequent causes of admission to pediatric intensive care unit. A thorough understanding of the pathophysiology underlying the disease will lead to effective management and decreased mortality and morbidity.

Medication errors in neonatal and paediatric intensive-care units.

In a 4-year prospective quality assurance study, 315 iatrogenic medication errors were reported among the 2147 neonatal and paediatric intensive-care admissions, an error rate of 1 per 6.8 admissions (14.7%). The frequency of iatrogenic injury of any sort due to a medication error was 66/2147 (3.1%)--1 injury for each 33 intensive-care admissions. 33 (10.5%) errors were potentially serious, 32 (10.2%) caused mild patient injuries, and 1 patient had acute aminophylline poisoning after receiving five intravenous doses of the drug at a dosage ten times higher than prescribed, owing to a calculation error during dilution. A longitudinal monitoring system helps to identify iatrogenic complications due to medication errors and may help in implementing preventive measures.

Pitfalls in diagnosing brain death in infancy.

A 3-year-old child with phenotypic trisomy 18 syndrome survived 26 days after a cardiopulmonary arrest, secondary to an acute viral illness. The child was deeply comatose. No barbiturates, other sedatives, or aminoglycoside antibiotics had been recently administered. The child was normothermic with adequate cardiovascular function. Brain stem function was absent, as assessed by testing of brain stem reflexes. Serial cerebral radionuclide angiograms (CRAG) documented intact cerebral blood flow while electrocerebral silence (ECS) was present on two consecutive EEG recordings within 24 hours. Preservation of intracranial circulation was confirmed by rapid rotational computed tomographic (CT) scans. Cranial CT scans also revealed communicating hydrocephalus, and bilateral basal ganglia hemorrhages. This unusual case illustrates discordance between apparent irreversible loss of cortical function as indicated by electrocerebral silence with preserved cerebral blood flow. The implications of these apparent paradoxical events will be discussed in the context of defining brain death in children.

[Clean field-technique to reduce the local air contamination level in operating rooms. Clinical experiences in accident surgery (author's transl)]. / Das Reinfeldverfahren zur lokalen Keimreduzierung in Operationsräumen. Klinische Erfahrungen in der Unfallchirurgie.

A newly developed technique to reduce the local air contamination level in operating rooms is described. After physical and hygienic evaluations a mobile clean field-equipment has been used at 97 traumatic operations. At 66 operations about 300 aerobiological samples of the contaminated room air and simultaneously of clean field-air at the wound site were collected. It is shown that the bacterial level of clean field-air is comparable with those levels in a sterile operating enclosure. The advantages of the new technique and first experiences under practical operating conditions are discussed.

[Treatment of intertrochanteric fractures by Pohl's screw (author's transl)]. / Die Behandlung pertrochanterer Frakturen mit der Pohlschen Laschenschraube.

The dynamic slide osteosynthesis of Pohl - a single acting method - is compared to other methods of operations. 103 patients with intertrochanteric fractures of the femur were treated by "Pohlsche Laschenschraube". The average age of patients was 76.7 years. The average stay in our hospital lasted 43 days. 16.5% of the patients died. 27 patients were examined two years after operation. The further study is based on clinical documents.

[Complications after total hip endoprosthesis: fracture of the femur and simultaneous fracture of the cement mount of the acetabulum (author's transl)]. / Komplikationen der Hüftgelenkstotalprothese: Femurfraktur und gleichzeitiger Bruch der Zementverankerung der Pfannenprothese.

Report about a rare complication after total hip endoprosthesis with a simultaneous rupture of the cement mount in the acetabulum (due to a trauma) and a fracture of the femur. The x-rays and the intraoperative findings were interpreted erroneously; therefore the diagnosis was delayed. A second operation was needed to reimplant the acetabulum. During the same operation a wrong position of the prosthesis (outward rotation) had to be corrected.

[Arthrography in humeroscapular peri-arthritis]. / Arthrografie bei Periarthritis humeroscapularis

Degenerative changes in the shoulder joint affect the capsule much more frequently than might be expected and are not seen on a plain radiograph. Arthrography of the shoulder has become of increasing significance in view of modern surgical management. Arthrography is used particularly to demonstrate a tear of the rotator cuff (especially the supra spinatus and infra spinatus). It also shows other important abnormalities which cause pain on movement, such as adhesions, tight capsule and the formation of septa. The indications, technique and necessary records, as well as typical pathological findings, are demonstrated in forty shoulder arthrograms. Hemuro-scapular peri-arthritis is a collective term for complex, primarily degenerative or posttraumatic, changes including peri-articular calcification. Demonstration of calcification alone does not justify the radiological diagnosis of humeroscapular peri-arthritis.