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Introduction: Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged.Methods: This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand.Results: A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07).Conclusion: Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups. [ABSTRACT FROM AUTHOR]

Background: Tracheal tube tip and cuff positions of different cuffed paediatric tracheal tube brands in the trachea can vary with design.Methods: Data from three clinical studies with measured tracheal lengths were pooled in a database including 422 children aged from birth to 16 yr. Dimensional data of seven cuffed paediatric tracheal tube brands (ID 3.0-7.0 mm) were recorded. Positions of tracheal tube tip and upper cuff border were calculated for each of the 422 tracheas using depth mark based tracheal tube placement, placement of the tracheal tube tip at a calculated safety distance above the carina, and mid-tracheal tube placement. Percentage of accidental bronchial intubations and tracheal tube cuff positions in the subglottic or supraglottic region were calculated.Results: Depth mark based tracheal tube placement resulted in accidental bronchial intubation of up to 18% of cases and tracheal tube cuffs being placed in the subglottic region in up to 91%. Tracheal tube tip placement at a calculated safety distance resulted in up to 54% of tube cuffs placed too high. Mid-tracheal tube placement led to 100% subglottic or supraglottic tracheal tube cuff positions.Conclusions: All studied cuffed paediatric tracheal tubes have major design flaws potentially leading to airway complications. Tracheal tube manufacturers are urgently asked to improve the design of cuffed paediatric tracheal tubes. Alternative strategies for tracheal tube placement can allow safe tracheal tube placement of uncuffed but not of cuffed tracheal tubes. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to compare intubation depth using the Microcuff paediatric endotracheal tube (PET) placed with the intubation depth mark between the vocal cords with that of different published formulae/recommendations for nasotracheal intubation depth in children. Methods Children aged from birth to 10 yr undergoing elective surgery with nasotracheal intubation were included. Tracheal tubes were adjusted according to the intubation depth mark between the vocal cords using direct laryngoscopy. Nasal intubation depth was recorded and the distance ‘tube tip to carina’ was measured endoscopically. Based on the recorded nasal intubation depth and measured distance ‘tube tip to carina’, the position of tube tip and cuff was calculated according to six published formulae/recommendations. Results Seventy-six children were studied. For the Microcuff PET, the median tube tip advancement within the trachea was 52.9% (41.1–73.8%) of tracheal length. The shortest distance from the ‘tube tip to carina’ was 15 mm for a 3.5 mm internal diameter tube. If the six published formulae/recommendations had been used, this would have resulted in endobronchial tube placement in up to 9.1% of cases, and the tube tip would have been placed above the glottis in up to 2.6% of cases. The upper border of the cuff would have been placed in the subglottic area in up to 42.1% of cases and in a supraglottic position in up to 63.2% of cases. Conclusions This study indicates that nasal intubation with the intubation depth mark placed between the vocal cords was superior to formula-based nasotracheal tube positioning. The latter would result in a high rate of endobronchial intubations, excessively high cuff positions and even tracheal extubations. [ABSTRACT FROM AUTHOR]

Background: Securing the airway using a tube exchanger catheter is an important and useful technique in anesthesia. Its success is mainly hampered by tube tip impingement of laryngeal structures. Advancing the tracheal tube along its normal curvature via a tube exchanger catheter has a high risk of tube tip impingement mainly of right laryngeal structures. The authors achieved successful clinical experience by rotating the tracheal tube 90° anticlockwise (ventral tube tip position) before railroading the tube via a tube exchanger catheter or a fiber optic bronchoscope through the larynx. Aim: The aim of the study was to investigate the influence of the tracheal tube tip position while intubating an airway trainer over a tube exchange catheter. Material and methods: Volunteer anesthetists with varying years of professional experience were asked to intubate an intubation mannequin (Laerdal Airway Management Trainer) using the orotracheal route with an established tube exchange catheter (Cook Airway Exchange Catheter, 11F). Two different brands of tracheal tubes (Rüsch and Covidien, ID 7.0 mm) were used in a randomized order, each with the tracheal tube tip at first positioned right (90°), then ventrally (0°), left (270°) and finally dorsally (180°), resulting in eight intubation attempts for each participant. To ensure the correct tube tip position the tube was withdrawn before every intubation attempt until the tube tip position was visualized. The oropharnyx, larynx, trachea and tube were sufficiently lubricated with silicon spray (Rüsch Silikospray). The tube and airway exchange catheter size selection were made according to the clinical trial of Loudermilk et al. Successful endotracheal intubation without resistance was recorded for each tube tip position and tracheal tube brand. Results: In total 20 anesthetists (13 consultants and 7 residents) with a median of 9.5 years (range 3-37 years) of professional experience participated in the study. Overall 160 intubation attempts were performed, 2 participants showed no successful intubation attempts at all and 38 out of 160 intubation attempts (23.8 %) were successful. Intubation success with the tracheal tube tip placed ventrally (0°) was 60 % followed by the left (270°) and right (90°) tracheal tube tip positions with 27.5 % and 7.5 % intubation success, respectively. With the tube tip placed dorsally (180°) none of the 40 intubation attempts were successful. Intubation attempts with the Rüsch tube were more successful (28.8 %) than those with the Covidien tube (18.8 %). Placing the tracheal tube tip ventrally, the Rüsch tube was twice as successful as the Covidien tube with 16 (80 %) versus 8 attempts (40 %, p = 0.011). There was no correlation between professional experience and intubation success (p = 0.362). Conclusion: Tube insertion via an airway exchange catheter or a fiberoptic bronchoscope is a basic technique in anesthesia. Knowledge about the difficulties and their prevention are essential for every anesthetist. The gap between the airway exchange catheter, the fiber bronchoscope and the tube diameters is one of the major reasons for tube tip impingement. This investigation showed that intubation success via a tube exchange catheter, as investigated in an intubation mannequin, is considerably influenced by the tracheal tube tip position. A 90° anticlockwise rotation, placing the tracheal tube tip ventrally, considerably increased intubation success. This is of particular importance if an anesthesia department has no appropriately sized tube exchange catheters or fiber bronchoscope for every age group of patients. [ABSTRACT FROM AUTHOR]

Nonspecific interactions between proteins and polymersurfaceshave to be minimized in order to control the performance of biosensorsbased on immunoassays with particle labels. In this paper we investigatethese nonspecific interactions by analyzing the response of proteincoated magnetic particles to a rotating magnetic field while the particlesare in nanometer vicinity to a polymer surface. We use the fractionof nonrotating (bound) particles as a probe for the interaction betweenthe particles and the surface. As a model system, we study the interactionof myoglobin coated particles with oxidized polystyrene surfaces.We measure the interaction as a function of the ionic strength ofthe solution, varying the oxidation time of the polystyrene and thepH of the solution. To describe the data we propose a model in whichparticles bind to the polymer by crossing an energy barrier. The heightof this barrier depends on the ionic strength of the solution andtwo interaction parameters. The fraction of nonrotating particlesas a function of ionic strength shows a characteristic shape thatcan be explained with a normal distribution of energy barrier heights.This method to determine interaction parameters paves the way forfurther studies to quantify the roles of protein coated particlesand polymers in their mutual nonspecific interactions in differentmatrixes. [ABSTRACT FROM AUTHOR]

Development of steroid dependency represents a significant therapeutic challenge in steroid-sensitive nephrotic syndrome. Previous studies have shown conflicting results concerning the benefit of a 12-week treatment with cyclophosphamide (CPO), with 24%–67% of patients achieving long-term remission. We therefore analyzed the clinical response of 20 consecutive children with steroid-dependent nephrotic syndrome (SDNS) (12 male, median age at start of treatment 5.9 years, range 3.2–14.7 years) treated at our institution with CPO (2 mg/kg per day) for 12 weeks since 1989. Median duration of follow-up was 5.8 (range 1.1–9.25) years. Only 6 of 20 children (30%) showed a long-term remission of >2 years, while 14 of 20 (70%) developed relapses again. Of these, 12 patients (86%) again developed steroid dependency, requiring further alternative treatment. Our data show that a 12-week course of CPO leads to unfavorable results in the majority of patients with SDNS. We therefore conclude that there is a need for further optimization of therapy in SDNS. [ABSTRACT FROM AUTHOR]

Unlabelled: Primary hyperoxaluria type 2 (PH2) is a rare disease with only 24 patients reported in the literature so far. It should be considered in any patient presenting with urolithiasis or nephrocalcinosis due to hyperoxaluria. The metabolic defect is deficiency of D-glycerate dehydrogenase/glyoxylate reductase leading to characteristic hyperoxaluria and excretion of L-glycerate, the cornerstone of diagnosis of PH 2. Although development of terminal renal failure seems to be less prevalent than in PH 1, recent reports indicate that chronic as well as terminal renal insufficiency may occur. Therefore specific therapeutic measures should aim at reduction of urinary calcium oxalate saturation by potassium citrate or pyrophosphate to reduce the incidence of nephrolithiasis and nephrocalcinosis and thus improve renal survival. Secondary complications (obstruction, urinary tract infections and pyelonephritis) must be avoided. In patients with terminal renal failure isolated renal transplantation seems to carry a high risk of disease recurrence.Conclusion: PH 2 is a rare but important cause of urolithiasis and nephrocalcinosis; long-term follow up is necessary, since the renal prognosis may be worse than previously anticipated. [ABSTRACT FROM AUTHOR]

Primary hyperoxaluria type 2 (PH2) is a rare disease with only 24 patients reported in the literature so far. It should be considered in any patient presenting with urolithiasis or nephrocalcinosis due to hyperoxaluria. The metabolic defect is deficiency of d-glycerate dehydrogenase/glyoxylate reductase leading to characteristic hyperoxaluria and excretion of l-glycerate, the cornerstone of diagnosis of PH 2. Although development of terminal renal failure seems to be less prevalent than in PH 1, recent reports indicate that chronic as well as terminal renal insufficiency may occur. Therefore specific therapeutic measures should aim at reduction of urinary calcium oxalate saturation by potassium citrate or pyrophosphate to reduce the incidence of nephrolithiasis and nephrocalcinosis and thus improve renal survival. Secondary complications (obstruction, urinary tract infections and pyelonephritis) must be avoided. In patients with terminal renal failure isolated renal transplantation seems to carry a high risk of disease recurrence.Conclusion PH 2 is a rare but important cause of urolithiasis and nephrocalcinosis; long-term follow up is necessary, since the renal prognosis may be worse than previously anticipated. [ABSTRACT FROM AUTHOR]

To date there are no data concerning IgG subclasses in children with preterminal chronic renal failure (CRF), although a reduction of total serum IgG, including its major subclasses IgG1 and IgG2, has been demonstrated in patients on peritoneal dialysis (PD). Therefore we studied total IgG, IgA, IgM, and IgG subclasses in preterminal CRF (n = 25), PD (n = 22) patients, and 13 agematched healthy children and also compared results with age-related normal values previously established in 226 healthy children. While total IgG, IgA, IgM, and IgG 1 were comparable, there was a significant deficiency of IgG2 in children both with preterminal CRF and on PD compared with controls. Moreover, the prevalence of IgG2 deficiency compared with age-related normal values was significantly increased not only in PD but also in preterminal CRF patients. We conclude that there are alterations in serum IgG subclasses in children with CRF, with IgG2 deficiency not restricted to PD, but being present in the preterminal state as well. [ABSTRACT FROM AUTHOR]

Although nephrocalcinosis is a classical finding in primary hyperoxaluria type 1 (PH 1) associated with a poor renal survival it is exceptional in patients with PH type 2 (PH 2) , characterized by a more favorable outcome . We describe an 8-month-old girl who suffered from recurrent urinary tract infections. Imaging studies revealed a profound corticomedullary nephrocalcinosis with no evidence of calculi. Urinary oxalate and D-glycerate excretion were massively elevated, while urinary glycolate or glyoxylate could not be detected, confirming the diagnosis of PH 2. Although the nephrocalcinosis progressed radiologically, renal function remained stable for over 2 years. Only further follow-up will show whether the associated nephrocalcinosis worsens the prognosis of our patient and of PH 2 in general. [ABSTRACT FROM AUTHOR]

Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disorder that causes sudden death in young athletes. Loss-of-function mutations of desmosomal proteins including plakoglobin are linked with ARVC and ventricular arrhythmias in trained mice. Intensive endurance training increases atrial arrhythmias in rats. We tested endurance-trained heterozygous plakoglobin deficient (Plako+/-) mice for atrial arrhythmia susceptibility.Methods: Plako+/- mice and WT littermates underwent group swim-training for total average swimming times of 50 hours over 8 weeks. Echocardiography was carried out before and after this period. Hearts were rapidly excised and perfused with Krebs solution and left atrial monophasic action potentials were recorded. Inter-atrial activation times (AT) and action potential durations (APDs) were measured during right atrial pacing at 100ms fixed-rate cycle lengths. An 8-pulse train followed by a single extrastimulus, was used to assess atrial arrhythmia inducibility.Results: Training increased left ventricular wall width (mm) by 13% in WT and Plako+/- mice (WT: 0.58±0.01 vs 0.66±0.01*; Plako+/-: 0.58±0.02 vs 0.66±0.01*). Right ventricular parameters e.g. RV diameter (mm) was increased after training, in Plako+/- (1.77±0.03) vs. WT (1.51±0.03)*. The number of hearts with induced atrial arrhythmias longer than 1sec, was greater in Plako+/- (6/13) than WT (0/8*; figure). AT, atrial weights, LA APD90 and refractoriness did not differ between genotypes. Hearts of trained Plako+/- mice were also more susceptible to induced ventricular arrhythmias than trained WT mice (WT: 1/12; Plako+/-: 7/15 hearts*). *p<0.05.Conclusion: Our findings suggest that defective cell-cell contact proteins predispose to training-induced atrial arrhythmias. [ABSTRACT FROM AUTHOR]

An abstract for the article "Durable occlusion of a ruptured venous aneurysm after partial transarterial embolization of the upstream pial arteriobvenous malformation," by M. Kemper, C. Farley, H. Kocaeli et al. is presented.

Pleural empyema is a serious condition leading to a significant burden on health care systems due to protracted hospitalisations. Treatment ranges from non-surgical interventions such as antibiotic therapy and chest tube placement to thoracoscopic or open surgery. Various risk factors which impact outcomes have been investigated. The RAPID (renal, age, purulence, infection source, and dietary factors) score is a clinical risk score which identifies patients at risk of death and may be used to formulate individual treatment strategies accordingly. All patients undergoing surgical interventions for empyema at a major tertiary medical centre in Germany from 2017 to 2020 were analysed. The aim was to identify perioperative risk factors which significantly impact treatment outcomes but are currently not included in the RAPID score. 245 patients with pleural empyema surgically treated at the Department of General, Visceral and Thoracic Surgery at the University Medical Centre, Hamburg, Germany (admitted from January 2017 to April 2020) were retrospectively analysed. All patients which received either minimally invasive or open thoracic surgery were included. Epidemiological as well as perioperative data was analysed to identify risk factors which impact long-term overall outcomes. 90-day mortality rate was the primary endpoint. The mean age was 59.4 years with a bimodal distribution. There was a male predominance across the cohort (71.4% compared to 28.6%), with no significant differences across ages below or above 60 years. 53 (21.6%) patients died within the first 90 days. Diabetes type 1 and 2, renal replacement therapy, immunosuppression, postoperative bleeding, intraoperative transfusion as well as microbiologically confirmed bacterial invasion of the pleura all led to higher mortality rates. Higher RAPID scores accurately predicted higher 90-day mortality rates. Modifying the RAPID score by adding the comorbidities diabetes and renal replacement therapy significantly increased the predictive value of the score. We demonstrated various perioperative and patient related risk-factors not included in the RAPID score which negatively impact postoperative outcome in patients receiving surgical treatment for pleural empyema. These should be taken into consideration when deciding on the best course of treatment. If confirmed in a prospective study including non-surgical patients with a significantly larger cohort, it may be worth considering expanding the RAPID score to include these. [ABSTRACT FROM AUTHOR]

Abstract: The use of mycophenolate mofetil (MMF) in combination with cyclosporin A (CsA) and steroids is well established after kidney transplantation (Tx) in children. A 9-yr-old girl with primary hyperoxaluria type 1 and systemic oxalosis underwent a combined kidney and liver Tx at our institution. The post-operative immunosuppression consisted of CsA, prednisolone, and MMF. Four weeks post-transplant the girl suffered from a severe urinary tract infection caused by Pseudomonas aeruginosa, when the serum immunoglobulin G (IgG) concentration was found to be critically low (< 1.53 g/L). Additionally, there was an isolated B-cell depletion (240/µL) at that time. In the following course, the B-cell count was significantly diminished until the MMF was stopped 13 weeks post-transplant. As a result of the very low serum IgG concentration, intravenous immunoglobulin (IVIG) substitution was necessary. There was no significant loss of immunoglobulins in the ascites and urine and no other medication with possible side-effects on B cells was given. We suggest that MMF can lead to suppressed IgG production by B cells and can cause a defective differentiation into mature B cells. In vitro studies demonstrated these effects of MMF on B cells, but no in vivo cases of this phenomenon have been reported. B-cell counts and serum IgG concentrations returned to normal values after discontinuing the MMF. As we can assume that the observed B-cell dysfunction and depletion were MMF related, we suggest that serum IgG concentrations should be monitored when MMF is used after solid-organ Tx. [ABSTRACT FROM AUTHOR]

Background: Airway exchange catheters (AEC) and fiberoptic bronchoscopes (FOB) for tracheal intubation are selected so that there is only a minimal gap between their outer and inner diameter of endotracheal tube (ETT) to minimize the risk of impingement during airway instrumentation. This study aimed to test the ease of passage of FOBs and AECs through paediatric ETT of different sizes and from different manufacturers when using current recommendations for dimensional equipment compatibility taken from text books and manufacturers information.Methods: Twelve different brands of cuffed and uncuffed ETT sized ID 2.5 to 5.0 mm were evaluated in an in vitro set-up. Ease of device passage as well as the locations of an impaired passage within the ETT were assessed. Redundant samples were used for same sized ETT and all measurements were triple-checked in randomized order.Results: In total, 51 paired samples of uncuffed as well as cuffed paediatric ETT were tested. There were substantial differences in the ease of ETT passage concordantly for FOBs and AECs among different manufacturers, but also among the product lines from the same manufacturer for a given ID size. Restriction to passage most frequently was found near the endotracheal tube tip or as a gradually increasing resistance along the ETT shaft.Conclusions: Current recommendations for dimensional equipment compatibility AECs and FOBs with ETTs do not appear to be completely accurate for all ETT brands available. We recommend that specific equipment combinations always must be tested carefully together before attempting to use them in a patient. [ABSTRACT FROM AUTHOR]

Controlled trials of m TOR inhibitors in children following solid organ transplantation are scarce, although evidence from prospective single-arm studies is growing. Everolimus with reduced CNI therapy has been shown to be efficacious and safe in de novo pediatric kidney transplant patients in prospective trials. Prospective and retrospective data in children converted from CNI therapy to m TOR inhibition following kidney, liver, or heart transplantation suggest preservation of immunosuppressive efficacy. Good renal function has been maintained when m TOR inhibitors are used de novo in children following kidney transplantation or after conversion to m TOR inhibition with CNI minimization. m TOR inhibition with reduced CNI exposure is associated with a low risk for developing infection in children. Growth and development do not appear to be impaired during low-dose m TOR inhibition, but more studies are required. No firm conclusions can be drawn as to whether m TOR inhibitors should be discontinued in children requiring surgical intervention or whether m TOR inhibition delays progression of hepatic fibrosis after pediatric liver transplantation. In conclusion, current evidence suggests that use of m TOR inhibitors in children undergoing solid organ transplantation is efficacious and safe, but a number of issues remain unresolved and further studies are required. [ABSTRACT FROM AUTHOR]

Summary Infection with sorbitol-fermenting Shiga toxin-producing Escherichia coli O157:H- (sf STEC O157:H-) is rare, but emerging in Europe. The pathogen is typically isolated from paediatric patients with life-threatening haemolytic uraemic syndrome (HUS). It is unclear whether this observation primarily reflects the pathogen's virulence or its complex laboratory diagnosis, not routinely conducted in diarrhoeal patients. In summer 2009, four boys living in the same suburb in Germany developed diarrhoea-associated HUS: three were infected by sf STEC O157:H- and one died. We conducted two analytical epidemiological studies, an extensive search for diarrhoeal cases in potentially exposed groups, and an environmental investigation. Outbreak cases were residents of the suburb diagnosed with HUS, sf STEC O157:H- infection, or both between 24 July 2009 and 25 August 2009. Overall, we ascertained eight cases with a median age of 4 years (range: from 8 months to 9 years). Stool screening of 220 persons led to the identification of only four additional cases: two asymptomatic carriers and two diarrhoeal cases. HUS was strongly associated with visiting a local playground in July, particularly on 16th July (odds ratio = 42.7, P = 0.002). No other commonality, including food, was identified, and all environmental samples ( n = 24) were negative. In this localized non-foodborne outbreak, the place of likely infection was a local playground. Sf STEC O157:H- infection apparently limits itself rarely to diarrhoeal illness and progresses frequently to HUS. Therefore, detection of and response to this hypervirulent pathogen primarily relies on HUS surveillance. [ABSTRACT FROM AUTHOR]