Procoagulant activity in children with community acquired pneumonia, pleural effusion and empyema.

UNLABELLED: In patients with community-acquired pneumonia (CAP), bacterial-cell-wall-derived fragments may induce the coagulation cascade. To contribute to the knowledge of underlying mechanisms, we have studied the fibrinolytic activity in children with CAP and parapneumonic effusions. PATIENTS AND METHODS: Twenty previously healthy children admitted to our Department with CAP were studied; with (n = 11) or without (n = 9) pleural effusion (PPE). We also investigated 10 children with empyema. In all children we analyzed coagulation and fibrinolytic parameters and compared the results to nine controls. RESULTS: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were not significantly modified in the three groups as compared to controls (P = 0.975, P = 0.535, respectively). The fibrinogen levels were significantly increased in respect to the control group (P < 0.0001). The median values of D-dimer showed an increasing trend that was statistically significant: children with pneumonia 244 microg/L, with pneumonia and PPE 751 microg/L and with empyema 2003 microg/L, in respect to values (48 microg/L) of our control group (P < 0.0001). CONCLUSION: The results suggest that plasma level of D-dimer can give an additional contribution for the evaluation of the severity of CAP and its complications in children.

[Thoracoscopy: the pediatric experience in Padua]. / Toracoscopia: esperienza pediatrica a Padova.

INTRODUCTION: Thoracoscopy is an important option in the treatment of many thoracic pathologies; its use in children, however, is still limited. We have retrospectively evaluated the thoracoscopic activity in our pediatric surgery department in the last six years. METHODS AND PROCEDURES: Video-Assisted Thoracoscopy (VATS) has been routinely adopted in our institutions since 1997. The data of 115 patients who have undergone VATS were reviewed and analysed. RESULTS: There were 47 males and 68 females. Mean age at surgery was 66.08 (SD: 58.23) months. Mean body weight at surgery was 21.85 (SD: 16.26) Kg. The patients were divided in four groups according to the pathologies: Patent Ductus Arteriosus (PDA) (n = 95), Pleural Empyema (n = 14), Mediastinal Mass (n = 3) and Lung Disease (n = 3). Complicances were seen in two patients in the PDA group (one laryngeal nerve paralysis and one chylothorax) and one in the pleural empyema group (post-operative bleeding which required blood transfusion). CONCLUSIONS: VATS can be performed safely and with minimal morbidity. In our experience, early and late complications turned out to be quite low. This survey would support on-going development of thoracoscopy in children.

Myocardial carnitine palmitoyltransferase I as a target for oxidative modification in inflammation and sepsis.

CPT I (outer membrane carnitine palmitoyltransferase I) is a crucial enzyme in myocardial substrate selection. Two isoforms exist in the heart, the liver (L-) and muscle (M-) isoforms, which have different kinetic characteristics and alter in relative amounts during the neonatal/weaning/adult transition. CPT I is a point for control and regulation of fatty acid oxidation via modulation of its activity by malonyl-CoA, the concentration of which is set by acetyl-CoA carboxylase, AMP-activated protein kinase and malonyl-CoA decarboxylase in response to, for example, alterations in glucose supply. Systemic inflammatory responses and sepsis lead to myocardial dysfunction as part of multiple system organ failure. We have shown that: (i) myocardial CPT I activity is inhibited during neonatal sepsis; (ii) on the basis of inhibitor studies this inhibition appears to be of M-CPT I rather than L-CPT I; (iii) nitration of M-CPT I occurs, probably by peroxynitrite, and this may be responsible for the decrease in CPT I activity; (iv) myocardial CPT I activity is also inhibited in another model of systemic inflammatory response, namely intestinal ischaemia/reperfusion injury, but this can prevented by whole-body moderate hypothermia. Inhibition of M-CPT I would be predicted to alter myocardial substrate selection but there are several questions that remain to be answered.

Use of urokinase in childhood pleural empyema.

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.

[Values of white blood cell count in the diagnosis of acute appendicitis]. / Utilità della leucometria nella diagnosi di appendicite acuta.

BACKGROUND: The diagnosis of acute appendicitis remains a critical challenge for paediatric surgeons. White Blood Cell (WBC) count, once considered a basic exam, is still routinely performed in most institutions, despite its lack of accuracy. Aim of this study is to assess the additional value of WBC count in the diagnosis of acute appendicitis. METHODS: We retrospectively reviewed the charts of children who underwent appendectomy for acute appendicitis in the last two years at our institution. In the patients treated in 1999 (Group A), WBC count was assessed routinely after admission. The surgeons relied on leukocytosis as well as on clinical findings and on ultrasound abdominal scan for the diagnosis of acute appendicitis. In the patients treated in 2000 (Group B), blood cell count was not tested or deliberately ignored by the surgeons. RESULTS: There were 65 children in Group A and 70 in Group B; the two groups of patients were similar in terms of gender (p = 0.989) and age (p = 0.758). Criteria for operation were similar in the two groups (p = 0.222). No differences were found in the number of perforated (p = 0.989) and normal (p = 0.217) appendixes in the two groups as well as in the duration of hospital stay after surgery (p = 0.849). CONCLUSIONS: WBC count at admission has no proven additional value in the diagnosis of acute appendicitis and can be omitted without modifying diagnostic pathway and without affecting diagnostic accuracy.