Coronary Artery Z-scores in Febrile Children with Suspected Kawasaki's Disease-The Value of Serial Echocardiography.

BACKGROUND: Progressive enlargement of the coronary artery (CA) diameters on serial echocardiography can support diagnosis of Kawasaki's disease (KD) even CA dimensions are within the normal range. METHODS: A single-center, retrospective study compared mean Z-scores of the proximal CA internal diameters in children hospitalized with non-KD febrile illnesses (FCs) with those of KD patients. RESULTS: A total of 223 patients with suspicion of KD have been admitted over a period of 16 years and data were evaluable for 176 children. Distributions for age, sex, and body surface area were similar for both groups. FC had a significantly shorter duration of hospitalization, higher levels of hemoglobin, lower levels of liver transaminases, and segmented neutrophils, respectively. The majority of FC patients (75/82, 91.5%) had normal CA Z-scores (p < 0.001) and only 3 (3.7%) had CA Z-score ≥2.5 standard deviation (SD). In KD, subjects (46/94, 49.5%) had a CA dilation (Z-score ≥2.5 SD) and the maximum CA Z-score (Zmax) was significantly higher compared with FC patients (p < 0.001). On serial echocardiograms, FC patients showed a mild decrease, whereas KD patients developed a significant increase of CA Zmax (p < 0.001). Seven KD patients had a segmental dilation of a CA which has been confirmed by cardiac catheter. In FC, no segmental dilation of any CA was documented by echocardiography. CONCLUSION: This study found that mean CA dimensions in FCs were smaller and did not increase in serial echocardiograms compared with KD patients.

Metabolic and cardiovascular effects of body weight supported treadmill walking in healthy older adults.

BACKGROUND: The purpose of this study was to determine if body weight supported treadmill training (BWSTT) decreased metabolic and cardiovascular demand in older (50-74 years) healthy adults while walking a self-selected speed. The results of this study could impact clinician application to exercise therapy. METHODS: Twenty subjects (50% female, 58.3±7.3 years) completed 3, 5-minute treadmill walking trials at a self-selected pace, with 0%, 15%, and 30% body weight support (BWS). Blood pressure (BP), heart rate (HR), and oxygen uptake (V̇O2) were measured at rest, and during walking trials. Mean data from minutes 3-5 were analyzed for difference by repeated measures ANOVA and Bonferroni post-hoc test. RESULTS: At rest, HR was 70.8±8.2 bpm and BP was 126.8±12.2/84.3±8.6 mmHg. Mean walking speed was 67.1 m/min. Tested parameters during exercise trials were significantly (P<0.05) different from rest, but no significant differences were detected among the 3 exercise trials. CONCLUSIONS: In older adults walking at self-selected speeds, up to 30% BWS had no significant impact on metabolic or cardiovascular demand.

COVID-19 in 28-Week Triplets Caused by Intrauterine Transmission of SARS-CoV-2-Case Report.

Since the beginning of the COVID-19 pandemic, in-utero transmission of SARS-CoV-2 remains a rarity and only very few cases have been proven across the world. Here we depict the clinical, laboratory and radiologic findings of preterm triplets born at 28 6/7 weeks to a mother who contracted COVID-19 just 1 week before delivery. The triplets showed SARS-CoV-2 positivity right after birth, developed significant leukopenia and early-onset pulmonary interstitial emphysema. The most severely affected triplet I required 10 days of high-frequency oscillatory ventilation due to failure of conventional invasive ventilation, and circulatory support for 4 days. Despite a severe clinical course in two triplets (triplet I and II), clinical management without experimental, targeted antiviral drugs was successful. At discharge home, the triplets showed no signs of neurologic or pulmonary sequelae. Placental immunohistology with SARS-CoV-2 N-protein localized strongly to syncytiotrophoblast cells and, to a lesser extent, to fetal Hofbauer cells, proving intrauterine virus transmission. We discuss the role of maternal viremia as a potential risk factor for vertical transmission. To the best of our knowledge, our report presents the earliest unequivocally confirmed prenatal virus transmission in long-term surviving children, i.e., at the beginning of the third trimester.

Risk factors associated with cognitive impairment in patients after pediatric liver transplantation.

Data on cognitive function after pLT are rare, particularly regarding children with cognitive impairment. From 2016 to 2018, we evaluated cognitive function in 36 patients after pLT aged 6-17 years with the WISC IV (at least 1 year after transplantation) and analyzed potential risk factors for cognitive impairment (IQ < 70) by means of retrospective medical data (peri-, intra-, and post-operative factors, and donor and specific organ data of the primary liver transplant) on an exploratory base. At a median age of 9.6 years (range = 6-16.9), 22% of patients were cognitive impaired (IQ < 70; including five untestable patients with severe cognitive impairment). Children tested with the WISC IV scored within the lower normal range but differed significantly from normal population. Strongest associations showed infections at pLT, development of severe sepsis requiring intensive care within the first 6 months after pLT, neurological complications within the first 10 days and the occurrence of CPR during or after pLT, and as early laboratory variables pH value on day 0 after pLT. In our analysis, neither intraoperative factors nor donor-specific factors seemed to influence cognitive outcome. In our small cohort, medical complications before and after pLT but not transplantation itself had an influence on cognitive outcome. As such, children experiencing medical problems before and in the early post-operative phase after pLT should be closely evaluated in larger samples regarding their neurological and psychomotor development during vulnerable phases and should receive early educational support to improve long-term cognitive function.

Acute Kidney Injury and Renal Regional Oxygen Saturation During Pediatric Liver Transplantation.

BACKGROUND Kidney injury is a complication among children undergoing liver transplantation (pLTx). Cystatin C serum concentration seems to be superior to creatinine-based determination of kidney injury in adults and children. Near-infrared spectroscopy (NIRS) technology provides non-invasive and real-time measurement of renal tissue oxygenation. Here, we compared renal tissue oximetry (rSrO2) with conventional diagnostic criteria cystatin C and creatinine concentration in children undergoing pLTx. MATERIAL AND METHODS rSrO2 was measured intraoperatively in children undergoing pLTx over the left kidney, and was statistically compared with pre- and postoperative serum creatinine and cystatin C concentrations. RESULTS rSrO2 was affected by hemoglobin concentration, bilirubin concentration, and FiO2. Statistical analysis demonstrated that rSrO2 was significantly reduced in children with preoperative pathologic increased cystatin C concentrations compared to children without (63.7±4.3 vs. 53.4±4.9, p<0.05). We did not detect a significant difference in rSrO2 between children who developed postoperative renal impairment, either determined by increased postoperative cystatin C concentration, creatinine concentration, or the pRIFLE criteria. Intraoperative increase or decrease in rSrO2 did not predict the development of postoperative kidney injury. CONCLUSIONS In children with liver failure undergoing pLTx, a preoperative decrease in rSrO2 indicates compromised renal function. However, intraoperative rSrO2 is not predictive of postoperative kidney injury.

Massive Pulmonary Embolism after a Short Episode of Physical Restraint in an Adolescent Psychiatric Patient.

Medical restraints, when used for short periods of time, can pose additional risk for deep vein thrombosis in adolescent psychiatric patients. The problem is often unrecognized, and there is a lack of awareness of this potential risk. However, as associated major adverse events may result in fatal outcomes, an individual patient's risk for deep vein thrombosis should be assessed and prophylactic anticoagulation may be indicated.

Risk factors for chylothorax and persistent serous effusions after congenital heart surgery.

OBJECTIVES: This study evaluated the various risk factors for chylothorax and persistent serous effusions (>7 days) after congenital heart surgery and developed equations to calculate the probability of their occurrence. METHODS: We performed a retrospective review of different medical databases at the University Hospital of Erlangen between January 2014 and December 2016. Full model regression analysis was used to identify risk factors, and prediction algorithms were set up to calculate probabilities. Discriminative power of the models was checked with the help of C-statistics. RESULTS: Of 745 operations on 667 patients, 68 chylothoraxes (9.1%) and 125 persistent pleural effusions (16.8%) were diagnosed. Lowest temperature [P = 0.043; odds ratio (OR) 0.899], trisomy 21 (P = 0.001; OR 5.548), a higher vasoactive inotropic score on the day of surgery (P = 0.001; OR 1.070) and use of an assist device (P = 0.001; OR 5.779) were significantly associated with chylothorax. Risk factors for persistent serous effusions were a given or possible involvement of the aortic arch during the operation (P = 0.000; OR 3.982 and 2.905), univentricular hearts (P = 0.019; OR 2.644), a higher number of previous heart operations (P = 0.014; OR 1.436), a higher vasoactive inotropic score 72 h after surgery (P = 0.019; OR 1.091), a higher central venous pressure directly after surgery (P = 0.046; OR 1.076) and an aortic cross-clamp time >86 min (P = 0.023; OR 2.223), as well as use of an assist device (P = 0.002; OR 10.281). The prediction models for both types of effusions proved to have excellent discriminative power. CONCLUSIONS: Persistent serous effusion is associated with a higher vasoactive inotropic score 72 h after surgery, an aortic cross-clamp time >86 min and elevated central venous pressure directly after surgery, which, in combination, potentially indicate cardiac stress. The developed logistic algorithm helps to estimate future likelihood.

Echocardiographic diagnosis of congenital coronary artery abnormalities in a continuous series of adolescent football players.

BACKGROUND: Sudden cardiac death (SCD) in children and adolescents is rare. Several studies have reported a higher risk of SCD during athletic competition. High risk congenital coronary artery abnormalities are the second leading cause of SCD in young athletes in the USA. Echocardiographic assessment of coronary arteries has not been routinely used in screening programmes for junior athletes so far. DESIGN: Prospective cohort study in 1045 consecutive adolescent elite football players. METHODS: All athletes underwent a standardized cardiovascular screening protocol with a medical history, a physical examination, 12-lead resting electrocardiogram and a complete transthoracic 2D-echocardiography. RESULTS: Two athletes (0.19%) showed a high-risk coronary artery abnormality (CAA) with a right coronary artery originating abnormal from the aorta and coursing inter-arterial. Low-risk CAAs were found in 16 athletes (1.53%). There was an ectasia of the left coronary artery (+3.9z and +4.3z) and a fistula from the left coronary artery in two cases (0.19%), respectively. In 1.05% ( n = 11) we found a high take-off (2.3-6.8 mm) and in one case (0.096%) there was a tangential take-off of the right main coronary artery. Variants of coronary arterial anatomy were identified in 335 of 1045 athletes (32.06%). CONCLUSION: Basic pre-participation screening tests including 12-lead or exercise electrocardiogram do not safely identify high-risk CAAs. In adolescent athletes an expert cardiologist is able to describe the origin and the proximal course of the coronary arteries and identify major abnormalities in most of the cases by transthoracic 2D-echocardiography.

Liver transplantation during infancy: No increased rate of neurological complications.

pLT is a highly standardized therapy for children with end-stage liver disease and liver-based metabolic diseases. However, NCs after transplantation occur and especially younger children are considered as more vulnerable and susceptible to NCs. Up to now, detailed data particularly for the very young age group do not exist. We therefore retrospectively studied NCs in children after pLT under age of 24 months. Forty children aged between 19 days and 22 months were evaluated according to type of NC and potential risk factors. NCs occurred in 8/40 patients (20%). All experienced new-onset seizures and in 1/6 surviving patients, seizures evolved into epilepsy. Other NCs were intracerebral abscess (1/8 patients) and subdural hemorrhage (1/8 patients). The overall 3-year mortality rate was 10% (4/40 patients). Significant risk factors for NCs and therefore seizures were HAT (P = 0.020), total surgery time (P = 0.009), retransplantation (P < 0.001), period of catecholamine therapy (P = 0.024), period of mechanical ventilation (P = 0.014), and period of sedation (P = 0.010). Our study is the first to provide detailed information on NCs after pLT in children under 24 months of age. The incidence of NCs in this particular group of very young patients was not increased compared to previously published data of children of all ages. Main NC was new-onset seizure. In the surviving infants, prognosis of seizure was excellent and the risk of developing epilepsy was low. Even more, the occurrence of NCs did not significantly affect mortality or survival in this particular age group.

Carotid Artery Dissection With Associated Territory Stroke After a Minor Head Trauma in a Healthy 4-Month-Old Child.

Internal carotid artery (ICA) dissections with associated stroke are rare events in infants. The usual pathomechanisms include direct trauma to the artery, blunt intraoral trauma, or child abuse. We describe the case of a 4-month-old male patient with ICA dissection and associated middle cerebral artery territory infarction associated with hyperextension/hyperrotation after a minor head injury. Upon treatment with anticoagulants, the patient showed significant improvement of the left-sided hemiparesis. Hemorrhagic transformation that presented shortly after middle cerebral artery infarction did not further increase under heparin treatment and prevented further embolism. In conclusion, hyperextension and/or hyperrotation in minor head trauma is a possible pathomechanism for ICA dissection in infants. However, the scenario is extremely rare, and to our best knowledge, this is the first report describing it. In our patient, anticoagulation did not worsen hemorrhagic transformation.

Astym Therapy Improves Bilateral Hamstring Flexibility and Achilles Tendinopathy in a Child with Cerebral Palsy: A Retrospective Case Report.

PURPOSE: The purpose of this case report was to describe the use of Astym therapy to improve hamstring flexibility and Achilles tendinopathy in a child with cerebral palsy. CASE DESCRIPTION: An eight-year-old female with cerebral palsy was referred to physical therapy for the treatment of bilateral hamstring inflexibility and Achilles tendinopathy. Treatment focused on an Astym therapy protocol of eccentric exercise, stretching, active and passive range of motion, gait training, and a home exercise program. The patient underwent a total of 11 physical therapy treatment sessions. OUTCOMES: At the conclusion of treatment, the patient demonstrated improved resting muscle tone in bilateral lower extremities with active 90/90 hamstring flexibility measured at 165° and ankle dorsiflexion active range of motion of 5° without pain at 0° and 90° knee flexion. The patient exhibited an improved gait pattern with even stride length and diminished genu recurvatum, decreased pain with standing and walking, discontinued use of ankle-foot orthoses, and improved activity tolerance and overall function for daily activities. DISCUSSION: The results of this case report indicate that physical therapy rehabilitation utilizing an Astym therapy protocol can successfully achieve gains in flexibility and strength and allow for improved function of bilateral lower extremities in a patient with cerebral palsy. CONCLUSION: Based on the findings of this case report, clinicians should consider the use of Astym therapy in treating musculoskeletal soft tissue dysfunction in pediatric patients with cerebral palsy.

Procalcitonin in the Early Course Post Pediatric Cardiac Surgery.

OBJECTIVE: Procalcitonin has emerged as a promising infection marker, but previous reports from small-sized studies suggest nonspecific elevation of procalcitonin after pediatric heart surgery. As procalcitonin is increasingly used as a marker for infection in the PICU, the aim of this study was to identify factors associated with postoperative procalcitonin elevation and to investigate the role of procalcitonin as an early marker of outcome after cardiac surgery. DESIGN: Prospective observational study. SETTING: Single, tertiary referral PICU. PATIENTS: Patients aged 0-16 years following cardiac surgery with or without cardiopulmonary bypass. INTERVENTIONS: Procalcitonin was measured in all patients at admission to PICU, and on postoperative day 1 and 2. Outcome variables included major adverse event, length of stay in PICU, postoperative renal failure requiring temporary dialysis, duration of mechanical ventilation and duration of inotropic support. A major adverse event was defined as cardiac arrest, need for postoperative extracorporeal life support or death within 3 months of cardiac surgery. MEASUREMENTS AND MAIN RESULTS: In 221 included patients who underwent 232 operations, procalcitonin at admission to PICU was significantly associated with mechanical ventilation prior to surgery (p = 0.001), preoperative myocardial dysfunction (p = 0.002), duration of cardiopulmonary bypass (p < 0.001), intraoperative cross-clamp time (p = 0.015), and serum lactate at admission (p < 0.001). Patients suffering a major adverse event and patients with postoperative renal failure had significantly higher procalcitonin levels at admission to PICU (p = 0.04 and 0.01, respectively). Furthermore, procalcitonin levels at admission correlated significantly with the length of stay in the PICU (p = 0.005), time on mechanical ventilation (p = 0.03), and duration of inotropic support (p = 0.02). CONCLUSIONS: Elevated levels of procalcitonin in the early phase after pediatric cardiac surgery are a marker for increased risk for major adverse events and postoperative renal failure and increased postoperative morbidity.

Veno-arterial extracorporeal membrane oxygenation support for severe cardiac failure in a pediatric patient with intracranial hemorrhage after spontaneous aneurysmatic rupture.

INTRODUCTION: Extracorporeal life support in adult patients with extended intracranial hemorrhage is controversial. In pediatric patients, it has traditionally been considered a contraindication as systemic anticoagulation may worsen the hemorrhage and neurological outcome. CASE HISTORY: We present a nine-year-old female patient who was admitted with extended intracranial hemorrhage after spontaneous rupture of an aneurysm. On day four after the emergency craniotomy, she required veno-arterial extracorporeal membrane oxygenation for septic shock. Using an adapted anticoagulation protocol aimed at lower activated partial thromboplastin time target values, we did not observe any new bleeding or clotting complications during systemic anticoagulation and the patient had good neurological recovery. CONCLUSION: Extracorporeal life support with low dose systemic anticoagulation can be considered as a treatment option in pediatric patients after craniotomy for intracranial aneurysmatic hemorrhage.

Strength cycle training: effects on muscular strength and aerobic conditioning.

The strength cycle ergometer has been proposed as a method of simultaneously increasing aerobic conditioning and muscular strength, because of its unique capacity of disengaging the pedal crank, thus allowing for concurrent single-leg cycling. The purpose of this study was to assess the aerobic and muscular strength effects of strength cycle training (SCT), comparing it to similar standard cycle training. A total of 28 recreationally-trained adult subjects (9 men, 19 women) were paired for VO2peak and randomly assigned to either SCT or Monark cycle training (MCT). Subjects trained 3 days per week following a progressive interval protocol for 9 weeks under supervised conditions. Training intervals (5 minutes' duration) consisted of 3 minutes of standard cycling at an intensity of 60-85% of maximum heart rate (HRmax), and 2 minutes of either the disengaged cycling mode (SCT) or standard cycling plus 30 W (MCT). Subjects began training for a total of 25 minutes per session, progressing to 45 minutes per session by study's end. Prior to and following training, subjects were measured for VO2peak; submaximal VO2, heart rate (HR), RPE, power output, and knee and ankle isokinetic strength. Training resulted in significant (p < or = 0.05) increases in VO2peak (14.5%) and submaximal power output (11%), and significant reductions in submaximal VO2, HR, and RPE in both groups. Significant increases in bilateral isokinetic knee extension (4-6%) and left ankle plantar flexion (10.5%) were noted following training in both groups. No group differences were detected in any variable. Although the strength cycle effectively increased aerobic function and resulted in modest selected increases in lower-extremity muscular strength, these changes were not different from those seen using a similar standard cycling protocol.

Comparison of whole blood interleukin-8 and plasma interleukin-8 as a predictor for sepsis in postoperative patients.

OBJECTIVE: Interleukin-8 (IL-8, also known as neutrophil-activating peptide 1, NAP1 and CXCL8, CXC chemokine ligand 8) is recognized as a potent effector of neutrophil functions. IL-8 is a major response factor following NfkB activation by cytokines or lipopolysaccharide and several different cell types T lymphocytes, monocytes, epithelial and endothelial cells secrete this polypeptide. IL-8 is not to be determined at significant concentrations in plasma due to its receptor binding but may play a major role in tissues. The prediction of sepsis is a major and current field of research in the treatment of surgical patients. The aim of this study was to compare the determination of IL-8 in whole blood cell lysates (whole blood IL-8) and in plasma for the prediction of sepsis in postoperative intensive care. DESIGN: Whole blood IL-8, IL-8 in plasma, and CRP were measured in the daily routine monitoring of 84 patients in a surgical intensive care unit. Sepsis was defined by the criteria of the Society of Critical Care Medicine (SCCM). For comparison the APACHE II score (APACHE=Acute Physiology and Chronic Health Evaluation) was calculated. The diagnostic value of the three tests was compared by receiver operating characteristic (ROC) curves. RESULTS: Whole blood IL-8 showed higher areas under the curve (AUC) than IL-8 in plasma and CRP. The ROC curves for the APACHE II scores gave similar results. CONCLUSIONS: Sepsis is a complex disease and is induced by systemic infection of patients suffering from systemic inflammatory response syndromes (SIRS). Therefore, the identification of infection or the host response to infection is of crucial importance. The prediction of an individual marker or interleukin or its binding to surface proteins is not necessarily indicative for sepsis. In cases with unequivocally identified bacterial infections, the current results suggest that whole blood IL-8 may have a similar diagnostic accuracy as plasma levels. Of note, this technique needs less blood and is not being affected by hemolysis.