RESUMEN
We hypothesized that beta-adrenergic stimulation with isoproterenol during continuous normothermic cardioplegic arrest would enhance the regenerative and regulatory function of the myocardium, resulting in improved cardiac function. We studied isolated rabbit hearts paced at approximately 200 beats per minute (bpm) and perfused by a support rabbit. We measured ventricular pressure over a range of ventricular volumes to determine maximal elastance (Emax) at baseline and 20 and 45 min after discontinuation of cardioplegia. Myocardial oxygen consumption (MVO2) measurements were performed simultaneously and during cardioplegic arrest. Hearts were prospectively randomized to receive either isoproterenol at 0.1 M or control in blinded fashion for 10 min during a 1-h continuous warm-blood cardioplegic arrest. Compared to control hearts, isoproterenol-treated hearts had trends toward longer time to first spontaneous heartbeat (control 141 +/- 43 vs. isoproterenol 200 +/- 74 s, p = .07), and longer time to capture of atrial pacing (control 214 +/- 52 vs. isoproterenol 288 +/- 91 s, p = .06). There was no difference observed in the MVO2 between isoproterenol-treated and control groups of hearts. MVO2 decreased during cardioplegia (p < .01), but there was no significant change in MVO2 during isoproterenol infusion during cardioplegic arrest. There was a significant reduction in Emax compared to baseline 20 min after discontinuation of cardioplegic arrest in both groups (control 7.3 +/- 1.7 mm Hg/microL vs. 9.0 +/- 1.7 mm Hg/microL, p = .02, isoproterenol-treated 6.8 +/- 2.8 mm Hg/microL vs. 8.2 +/- 2.6 mm Hg/microL, p = .01, respectively), with recovery of Emax by 45 min in control hearts only. We conclude that exposure of hearts to isoproterenol during warm cardioplegic arrest has a deleterious effect that may be mediated through mechanisms independent of increased myocardial oxygen consumption.
Asunto(s)
Agonistas Adrenérgicos beta/farmacología , Paro Cardíaco Inducido/efectos adversos , Corazón/fisiología , Isoproterenol/farmacología , Receptores Adrenérgicos beta/metabolismo , Animales , Temperatura Corporal , Femenino , Técnicas In Vitro , Contracción Miocárdica/fisiología , Conejos , Función Ventricular , Presión Ventricular/fisiologíaRESUMEN
BACKGROUND: Elevated total plasma homocysteine (tHcy) levels have been associated with vascular disease and higher mortality in patients with coronary artery disease. Graft coronary disease is a major cause of mortality in long-term survivors of heart transplantation, and hyperhomocysteinemia may be one of its causes. The objectives of our study were to establish the effectiveness of a 3 stage homocysteine-lowering algorithm in a group of 84 heart transplant (HTx) patients and to evaluate the effect of renal function on the response to homocysteine-lowering therapy. METHODS: Prospective treatment of 84 Htx patients (64 male; mean age, 48 +/- 13 years) with tHcy > 75th percentile consisted of a 3-stage treatment algorithm: Stage 1, folic acid (FA) 2 mg + vitamin (vit) B(12) 500 mcg daily; Stage 2, addition of vit B(6) 100 mg daily; Stage 3, increase FA to 15 mg daily. Serum creatinine (Cr) and tHcy levels were measured before treatment and 21 +/- 19 weeks after each stage of treatment. RESULTS: All 3 stages of treatment significantly lowered mean tHcy from 22.4 +/- 16.3 (mean +/- SD) micromol/liter to 16.3 +/- 6.7 micromol/liter (p < 0.00001), from 17.6 +/- 6.1 micromol/liter to 15.2 +/- 5.3 micromol/liter (p < 0.0001), and from 16.8 +/- 5.2 micromol/liter to 15.6 +/- 5.3 micromol/liter (p < 0.05), respectively. The average reduction from baseline was 38%. Creatinine levels did not change significantly during the study period. Total plasma homocysteine levels decreased below the 75th percentile in 55% of patients, with Cr levels significantly lower in this group of patients (126 +/- 36 micromol/liter vs 182 +/- 65 micromol/liter, p < 0.00001). However, we found no significant relationship between % change in tHcy and baseline Cr. CONCLUSIONS: In a group of 84 heart transplant patients with tHcy levels >75th percentile, treatment with FA and vit B(6) and B(12) according to a 3-stage algorithm resulted in statistically significant declines in mean tHcy levels. Overall, tHcy levels decreased 38%, with target tHcy levels <75th percentile achieved in 55% of the patients. The % change in tHcy was not related to Cr. Further studies are needed to correlate treatment of hyperhomocysteinemia with clinical endpoints, such as the time to development of transplant vasculopathy and long-term survival, and to define the most appropriate targets for therapy.
Asunto(s)
Trasplante de Corazón , Hiperhomocisteinemia/complicaciones , Hiperhomocisteinemia/terapia , Insuficiencia Renal/complicaciones , Adulto , Algoritmos , Creatinina/sangre , Femenino , Ácido Fólico/uso terapéutico , Humanos , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Piridoxina/uso terapéuticoRESUMEN
Three patients with diffuse large B-cell type of post-transplant lymphoproliferative disease after lung transplantation were treated with rituximab, an anti-CD20 monoclonal antibody. Treatment resulted in two complete remissions and one non-response.
Asunto(s)
Anticuerpos Monoclonales/administración & dosificación , Antineoplásicos/administración & dosificación , Neoplasias Pulmonares/tratamiento farmacológico , Trasplante de Pulmón , Linfoma de Células B/tratamiento farmacológico , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Complicaciones Posoperatorias/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales de Origen Murino , Antineoplásicos/efectos adversos , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Metástasis Linfática , Linfoma de Células B/diagnóstico por imagen , Linfoma de Células B Grandes Difuso/diagnóstico por imagen , Masculino , Complicaciones Posoperatorias/diagnóstico por imagen , Radiografía , Inducción de Remisión , RituximabRESUMEN
OBJECTIVES: To determine the prevalence of hyperhomocysteinemia in heart transplant recipients, and to assess the effect of renal function and immunosuppressive medication on total plasma homocysteine (tHcy) levels. BACKGROUND: Elevated plasma tHcy levels have been associated with increased risk of mortality in patients with established coronary artery disease. Graft coronary disease is the major cause of morbidity and mortality in long-term survivors of heart transplantation. The tHcy has been found to be elevated in heart and kidney transplant patients, however, the etiologic factors have not been clearly delineated. METHODS: The study group consisted of 70 heart transplant recipients (56 males, 14 females, mean age 53+/-13 years [range 17 to 69 years]). The parameters evaluated were fasting tHcy level, cumulative cyclosporine (CyA) dose, cumulative prednisone dose, serum creatinine, and time from transplantation. RESULTS: The mean fasting tHcy level was 20.5+/-10.2 micromol/L (range 5.2 to 59.0 micromol/L). Sixty-one (87%) had fasting tHcy levels greater than the seventy-fifth percentile of the general population (>12.2 micromol/L in males, and >10.1 micromol/L in females). There was no difference in mean post-transplant tHcy level between patients with and without coronary artery disease before transplantation (21.0+/-11.4 vs. 19.3+/-6.7 micromol/L, p = NS). There were significant relationships between the tHcy level and the serum creatinine (r = 0.76, p<0.001), and cumulative exposure to CyA (r = 0.31, p<0.01). There were no significant relationships between tHcy levels and cumulative prednisone dose, or time from transplantation. CONCLUSIONS: Fasting tHcy levels are markedly elevated in the majority of patients following heart transplantation, and are correlated to serum creatinine. Further studies are needed to determine other etiologic factors of elevated tHcy following heart transplantation, and to examine the impact of elevated tHcy on clinical outcomes.
Asunto(s)
Creatinina/sangre , Trasplante de Corazón/efectos adversos , Homocisteína/sangre , Hiperhomocisteinemia/etiología , Inmunosupresores/uso terapéutico , Adolescente , Adulto , Anciano , Trastornos Cerebrovasculares/sangre , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/mortalidad , Enfermedad Coronaria/sangre , Enfermedad Coronaria/etiología , Enfermedad Coronaria/mortalidad , Femenino , Estudios de Seguimiento , Rechazo de Injerto/sangre , Rechazo de Injerto/inmunología , Rechazo de Injerto/prevención & control , Trasplante de Corazón/mortalidad , Humanos , Hiperhomocisteinemia/sangre , Hiperhomocisteinemia/mortalidad , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Pulmonary hypertension in patients with congestive heart failure (CHF) is a risk factor for increased mortality after orthotopic cardiac transplantation. Reversibility of elevated pulmonary vascular resistance (PVR) by pharmacologic agents predicts improved outcomes. Milrinone, a phosphodiesterase inhibitor with vasodilating and positive inotropic properties, has been shown to lower PVR in one previous study. However, no study has documented outcomes after cardiac transplantation in patients in whom reversibility of pulmonary hypertension was demonstrated after administration of milrinone. METHODS: We retrospectively reviewed 19 patients with CHF and pulmonary hypertension defined as PVR > or = 3 Wood units, PVRI (pulmonary vascular resistance index) > or = 4 resistance units, or TPG (transpulmonary gradient = mean pulmonary artery pressure--mean capillary wedge pressure) > or = 12 mmHg being assessed for cardiac transplantation. A sub-group of 14 patients with severe pulmonary hypertension defined as PVR > or = 4, PVRI > or = 6 and TPG > or = 15 was also examined. Milrinone was administered as a bolus (50 ug/kg) and hemodynamic parameters were measured at 5, 10 and 15 minutes. Six patients received cardiac transplants. RESULTS: Administration of milrinone significantly lowered PVR, PVRI, mean pulmonary artery pressure (PAM)(all p = 0.002) and pulmonary capillary wedge pressure (PCWP)(p = 0.006). Cardiac output (CO) increased significantly (p = 0.001). TPG did not change (p = 0.33). In patients with severe pulmonary hypertension, the magnitude of these changes was greater. In addition, TPG was significantly lowered (p = 0.02). CONCLUSION: Milrinone lowered PVR by decreasing PAM and increasing CO significantly. In addition, PCWP was significantly lowered. These finding confirm both vasodilatory and inotropic effects of milrinone. Patients with severe pulmonary hypertension had more pronounced effects. There were no deaths in the group of patients proceeding to cardiac transplantation. Our study demonstrates the efficacy of milrinone in lowering PVR as well as suggesting safety in use in patients undergoing cardiac transplantation.
Asunto(s)
Cardiotónicos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hipertensión Pulmonar/tratamiento farmacológico , Milrinona/uso terapéutico , Inhibidores de Fosfodiesterasa/uso terapéutico , Vasodilatadores/uso terapéutico , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón , Humanos , Hipertensión Pulmonar/cirugía , Pulmón/irrigación sanguínea , Masculino , Persona de Mediana Edad , Presión Esfenoidal Pulmonar/efectos de los fármacos , Estudios Retrospectivos , Factores de Riesgo , Seguridad , Tasa de Supervivencia , Resultado del Tratamiento , Resistencia Vascular/efectos de los fármacosRESUMEN
Advanced pulmonary disease is an unusual consequence of the intravenous injection of oral medications, usually developing over a period of several years. A number of patients with this condition have undergone lung transplantation for respiratory failure. However, a history of drug abuse is often considered to be a contraindication to transplantation in the context of limited donor resources. A patient with pulmonary talc granulomatosis secondary to intravenous methylphenidate injection who underwent successful lung transplantation and subsequently presented with recurrence of the underlying disease in the transplanted lung 18 months after transplantation is reported.
Asunto(s)
Estimulantes del Sistema Nervioso Central , Granuloma de Cuerpo Extraño/etiología , Enfermedades Pulmonares/etiología , Trasplante de Pulmón/patología , Metilfenidato , Abuso de Sustancias por Vía Intravenosa/complicaciones , Talco/efectos adversos , Biopsia , Contraindicaciones , Femenino , Granuloma de Cuerpo Extraño/cirugía , Humanos , Enfermedades Pulmonares/cirugía , Persona de Mediana Edad , RecurrenciaRESUMEN
Two infant boys with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) are reported. Presenting with neonatal intestinal obstruction, they underwent laparotomies that showed megacystis, microcolon, and aperistaltic shortened small bowel without any mechanical obstruction. Patient 1 gradually improved and is developing normally at home, on a normal diet without genitourinary or gastrointestinal complaints (now 11 years old). Patient 2, who underwent vesicoamniotic drainage antenatally, never developed adequate gastrointestinal or genitourinary function in spite of appropriate diversion and pharmacologic support. He showed progressive deterioration and died at the age of 7 months. Detailed histo-immuno- and ultrastructural pathology assessment, although confirming results in the existing literature in some aspects, showed previously unreported neuronal dysplastic changes associated with increased laminin and fibronectin. Although patient 1 showed ultrastructural features of vacuolar degeneration of smooth muscle as reported in the literature, patient 2 showed ultrastructural and histochemical evidence of excessive smooth muscle cell glycogen storage with severely reduced contractile fibres displaced to the extreme periphery of the cells, suggesting a fundamental defect of glycogen-energy utilization. A deficiency of fiber synthesis as the alternative primary defect is discussed. In both cases, a two-step genetic defect may explain the variability in clinical outcome and pathological findings.
Asunto(s)
Anomalías Múltiples , Colon/anomalías , Obstrucción Intestinal/patología , Vejiga Urinaria/anomalías , Anomalías Múltiples/cirugía , Colon/cirugía , Colon/ultraestructura , Metabolismo Energético , Resultado Fatal , Femenino , Fibronectinas/metabolismo , Glucógeno/metabolismo , Humanos , Lactante , Recién Nacido , Obstrucción Intestinal/cirugía , Laminina/metabolismo , Masculino , Microscopía Electrónica , Músculo Liso/metabolismo , Músculo Liso/ultraestructura , Peristaltismo , Embarazo , Síndrome , Vejiga Urinaria/cirugía , Vejiga Urinaria/ultraestructuraRESUMEN
A new amoxycillin/clavulanate regimen ('Augmentin-Duo' 400/57), to be given orally in two divided doses, has been proposed to overcome the inconvenience of tid dosing. This observer-blind, multicentre study randomised children aged two to 12 years with lower respiratory tract infection to seven days' treatment with either amoxycillin/clavulanate bid at a dose of 25/3.6mg/kg/day (221 patients) or the currently prescribed amoxycillin/clavulanate regimen of 20/5mg/kg/day tid (216 patients). Clinical success (cure) rates at follow up were 81.0% for the bid group and 77.8% for the tid group [difference 3.2%; 95% CI (-4.36, 10.80)], indicating that the regimens were of equivalent efficacy. Both regimens were well tolerated, and there was no statistically significant difference in the incidence of adverse experiences between the two groups. Compliance with study medication was high and similar for both groups (80% compliance: bid 90.0%; tid 87.0%).
Asunto(s)
Quimioterapia Combinada/administración & dosificación , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Administración Oral , Amoxicilina/administración & dosificación , Amoxicilina/uso terapéutico , Combinación Amoxicilina-Clavulanato de Potasio , Niño , Preescolar , Ácidos Clavulánicos/administración & dosificación , Ácidos Clavulánicos/uso terapéutico , Esquema de Medicación , Quimioterapia Combinada/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , MasculinoRESUMEN
This article is the second in a series that addresses the issues of "growing up in the hospital." Whereas the first article focused on the child and the complex growth and development issues surrounding indefinite hospitalization, this article will focus on the family, the philosophy of family-centered care, and how nursing practice can nurture this ideal when working with children who must "grow up in the hospital."
Asunto(s)
Niño Hospitalizado , Familia , Enfermería Pediátrica , Filosofía en Enfermería , Adaptación Psicológica , Niño , Niño Hospitalizado/psicología , Familia/psicología , Femenino , Humanos , Lactante , Masculino , Alta del Paciente , Relaciones Profesional-Familia , Relaciones entre HermanosRESUMEN
Major advances in medical research and technology have made it possible for many children with complex chronic illnesses to survive, including those who just a few years ago would have died (Hobbs & Perrin, 1985). One goal of health care professionals who care for these children is, and continues to be, discharge of the child to the family and community whenever possible. Complex medical and nursing care, elusive diagnoses, complicated psychosocial issues, and inconsistent community resources often mean discharge must be prolonged. Focusing on the creation of innovative methods for integrating the growth and developmental needs of these special children is a challenging and often overlooked aspect of our pediatric nursing practice. This article is one of a series that will address the issues of growing up in the hospital. What are the implications for the child, family, and professional nurse? What strategies can we devise to assist our patients through what may be a very lengthy and complex hospital course?
Asunto(s)
Desarrollo Infantil , Niño Hospitalizado/psicología , Enfermedad Crónica/psicología , Crecimiento , Planificación de Atención al Paciente , Adaptación Psicológica , Factores de Edad , Niño , Preescolar , Enfermedad Crónica/mortalidad , Enfermedad Crónica/enfermería , Necesidades y Demandas de Servicios de Salud , Humanos , Lactante , Recién Nacido , Alta del Paciente , Enfermería Pediátrica , SobrevivientesRESUMEN
This study evaluates the safety, efficacy, and technical problems of the new technique of endoscopy-guided balloon dilation (EGBD) in the treatment of strictures of the esophagus and its replacement. Between 1986 and 1990, the authors treated 33 children (aged 3 weeks to 20 years) with EGBD; 18 had esophageal strictures (primary esophageal atresia repair, 13; reflux esophagitis, 5), 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, 1), and 2 had caustic strictures. The majority (23 of 33) had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). EGBD was performed using flexible endoscopy and flouroscopic screening under general anesthesia. Endoscopy identified and resolved the errors or uncertainties of preoperative contrast studies in 7 patients, 5 of whom had colon interposition. EGBD was achieved in all 31 patients with esophageal or replacement strictures; the mean number of EGDB procedures per patient was 2.1 (range 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7 patients. Both patients with caustic strictures had esophageal perforation from EGBD (excessive inflation, 1; false passage of guide wire, 1). Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and resumed eating sooner. The authors conclude that EGBD is safe and effective for treating esophageal and replacement strictures but not caustic strictures.
Asunto(s)
Cateterismo , Estenosis Esofágica/terapia , Esofagoplastia , Esofagoscopía , Adolescente , Adulto , Cateterismo/efectos adversos , Cateterismo/métodos , Niño , Preescolar , Estenosis Esofágica/diagnóstico por imagen , Estenosis Esofágica/etiología , Esofagitis Péptica/complicaciones , Humanos , Lactante , Recién Nacido , Complicaciones Posoperatorias , RadiografíaRESUMEN
Heterotopic gastric mucosa is reported in a sinus present since birth in the midline of the anterior two thirds of the tongue. Current theories concerning the presence of heterotopic mucosa in the oral cavity are presented and discussed.
Asunto(s)
Coristoma/patología , Mucosa Gástrica , Úlcera Péptica/etiología , Neoplasias de la Lengua/patología , Preescolar , Coristoma/complicaciones , Humanos , Masculino , Úlcera Péptica Hemorrágica/etiología , Neoplasias de la Lengua/complicacionesRESUMEN
Seven cases of neonatal ovarian cysts that presented over the past seven years were studied. Complications included torsion and rupture and usually occurred in cysts more than 5 cm in diameter. Surgical removal, either oophorectomy or cystectomy, was the treatment of choice. Because even cystectomy results in loss of normal ovarian tissue, and because spontaneous regression of cysts less than 5 cm in diameter can occur, a more conservative approach is now proposed. Regular ultrasonography alone is recommended if the cysts are less than 5 cm in diameter, and aspiration of the cysts followed by regular ultrasonographs if the cysts are more than 5 cm in diameter. Operation should be reserved for recurrent cysts or for those with complications. Cysts diagnosed antenatally may be aspirated in utero if there are signs of thoracic compression.
Asunto(s)
Quistes Ováricos/congénito , Femenino , Enfermedades Fetales/diagnóstico , Humanos , Recién Nacido , Quistes Ováricos/diagnóstico , Quistes Ováricos/terapia , Embarazo , Diagnóstico Prenatal , UltrasonografíaRESUMEN
Cysts and tumours of the ovary are not uncommon in childhood. In 33 years between 1950 and 1982 106 patients were operated on at Alder Hey Children's Hospital and the Royal Liverpool Children's Hospital. Of these 71 were pre-menarchal. The mode of presentation, pathology and diagnostic difficulties of the pre-menarchal lesions are reviewed. The value of ultrasound scanning has become apparent in recent years. Most cysts and tumours are benign, but dysgerminomas are the most common malignant tumours encountered. Even when there is evidence of spread of the tumour the prognosis in these remains reasonably good.
Asunto(s)
Quistes Ováricos/cirugía , Neoplasias Ováricas/cirugía , Adolescente , Castración , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Menarquia , Quistes Ováricos/complicaciones , Quistes Ováricos/diagnóstico , Neoplasias Ováricas/complicaciones , Neoplasias Ováricas/diagnóstico , Pubertad Precoz/etiologíaRESUMEN
Of 162 children with intestinal malrotation treated during a 13-year period, only 20 were first seen and treated outside the neonatal period. These presented with symptoms that were largely non-specific and there was a delay between the initial consultation and the making of the correct diagnosis of up to 5-years. The clinical features, radiologic findings and management are discussed, the importance of the history and radiographic findings stressed.
Asunto(s)
Obstrucción Intestinal/etiología , Intestinos/anomalías , Adolescente , Ciego/anomalías , Niño , Preescolar , Diagnóstico Diferencial , Duodeno/anomalías , Femenino , Herniorrafia , Humanos , Lactante , Recién Nacido , Obstrucción Intestinal/cirugía , Intestinos/cirugía , Yeyuno/anomalías , MasculinoAsunto(s)
Quiste Pancreático/cirugía , Seudoquiste Pancreático/cirugía , Niño , Drenaje , Femenino , Humanos , PalpaciónRESUMEN
Two siblings are presented in whom a recognized syndrome of functional small-bowel obstruction with malrotation and short small-bowel was diagnosed. The previously described association with pyloric stenosis was not present in our cases. They do, however, support the view that this syndrome has an autosomal recessive model of inheritance. A deficiency of argyrophil neurones in the myenteric plexus has been noted in this syndrome but more precise neurohistochemical studies are required to define the exact deficit involved.