Search

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated inflammatory demyelinating encephalomyelitis with often monosymptomatic abrupt onset, followed by multifocal neurologic symptomatology depending on lesion-site. Diagnosis is made on the basis of characteristic magnetic resonance imaging (MRI) signal alterations. ADEM is sensitive to steroid therapy, immunoglobulins and plasmapheresis, presents usually a monophasic course and disappears completely after 2 or 3 weeks. Resolution of MRI lesions appears usually within 6 months of presentation. We report on a 14-year-old male, admitted to our Emergency Unit because of fever and acute urinary retention with a normal neurological examination. Urinary tract ultrasonography and mictional cystography were normal; electrophysiology showed a mild involvement of the peripheral nervous system and brain and spine MRI revealed disseminated areas of increased signal on T2-weighted sequences suggestive of ADEM. Steroid therapy brought about clinical recovery in a few days. Resolution of lesions on MRI after 4 months and absence of relapses during four-year clinical follow-up confirmed definitive diagnosis. Our case is interesting because, to our knowledge, this is the first literature report with acute urinary retention as predominant symptom in monosymptomatic forms. Another peculiar feature is the absence of associated neurologic symptomatology despite MRI evidence of important brain and spine alterations.

In this work we tried to analyse the different factors which cooperate to produce and maintain a shock condition; we considered in particular pathophysiology and haemodynamic features of the different types of shock and the pathophysiology of MOSF (multiple systems organ failure). Furthermore, we remembered peculiarities and effects of the "reperfusion syndrome" which can occur after cardiopulmonary resuscitation of the patient due to superoxides. Finally we outlined the substantial and significant differences between newborn and not newborn concerning the haemodynamic responses and the cardiocirculatory management in the newborn during shock treatment.

We selected a paediatric population with a high risk of nosocomial infection formed by 116 newborns (42.8%) and 155 not newborns (57.2%) admitted into the ICU of the Giannina Gaslini Institute during the period 1-1-1992-30-9-1992; we compared it with a reference paediatric population studied in the same department during the period 1-1-1987-30-6-1988 formed by 310 newborns (44.3%) and 391 not newborns (55.7%). The purpose of this study is to evaluate the possible change in the incidence of colonizations and ICU specific nosocomial infections, the possible increase of nosocomial infections by multiresistant Staphylococci and the appearance of new multiresistant germs. The two populations obviously present similar factors of high risk of nosocomial infection (naso-tracheal intubation, mechanical ventilation, total parenteral nutrition, surgical procedures, thoracic and/or abdominal prothesis, etc.). The obtained data have been examined with the Chi-square method. The incidence of colonizations remained unchanged while we noted a significant increase (10.3% compared to 4.9%-p > 0.0014) of the "ICU" specific nosocomial infections; the increase regarded mainly the neonatal population (18.9% compared to 7%-p > 0.00001). Significant increase of the nosocomial infections by multiresistant Staphylococcus (Staphylococcus haemolyticus) with in vitro and in vivo resistance to teicoplanin. Furthermore, presence in the performed study of multiresistant gram negative germs.

In the present study we try to analyze indications, contra-indication, side effects and limits of the use of extracorporeal circulation in neonatal and pediatric patients affected by reversible acute cardiorespiratory failure. The greatest experience on this technique has been achieved in the neonatal age (about 6000 newborns have been treated until now), while the employment in the pediatric age appears more recent (about 500 patients). Moreover, we focused on the drop-in criteria for neonatal and pediatric patients and on the clinical aspects and laboratory findings which can anticipate the surviving rate; the latter appears in any case much greater in the neonatal patient compared to the other pediatric ages.

We focused on the best timing and management when admitting into intensive care unit a pediatric patient with central nervous system infection. The modified scales for pediatric patients did not prove satisfactory and reliable for making such decision. In fact the final score is obtained by adding the partial scores regarding the different clinical aspects. That bears a loss of informations. For this reason we think that the cardiorespiratory and metabolic parameters, assessed in a period of time, may indicate the moment when it is necessary to start an intensive care in these patients, regardless of consciousness. We therefore discussed the monitoring precociously required in these patients after assessing the initial clinical status. We also discussed the intensive care procedure employed in severely ill patients with cardio-circulatory and metabolic problems due to septic shock caused by bacterial meningoencephalitis (infants) and meningitis (other pediatric ages). In patients affected by infectious or post-infective encephalitis with respiratory failure and/or brain edema, it is essential to apply the organ protection procedures and particularly neuroprotection.

We administered teicoplanin as specific antibiotic therapy for nosocomial "ICU specific" infections with methicillin-resistant Staphylococcus aureus and epidermidis (MRSA-MRSE). The above mentioned drug has been given to 20 patients (15 newborns and 5 not-newborns) admitted into intensive care unit during the years 1988, 1989, 1990 with MRSA-MRSE localized and/or systemic infection, affected by severe disease (RDS, pulmonary edema, congenital cardiac disease, cystic fibrosis) undergoing invasive procedures which presented high nosocomial infective risk (tracheal intubation, mechanical ventilation, venous and arterial cannulation, total parenteral nutrition, etc.). Complete recovery from systemic or localized infection (sepsis, low respiratory tract infection, high respiratory tract infection) occurred in 19 out of 20 patients, with a rate of success of 95%. Teicoplanin treatment lasted from a minimum of nine days to a maximum of thirty days. The dose was 5-6 mg/kg/die in one administration for the first three days, then 4 mg/kg/die. The tolerability of teicoplanin has proven satisfactory, since we had no major side effects during treatment and follow up.

We performed an epidemiological investigation owing to the appearance between February and March 1988, of subsequent MRSA infections in our ICU; we also started a checking scheme. At the same time we performed a retrospective-perspective study of 701 patients (310 newborns 391 not newborns) admitted into ICU from 1-1-1987 to 30-6-1988. This study allowed us to settle the presence of MRSA in ICU and the manner in which they become infected. From our study the 4.9% of our patients contracted hospital infections and the 34.2% of these were MRSA infections. The 39.7% of our colonized patients were MRSA. It is really significant the frequency of MRSA colonization (p less than 0.0005) among newborn patients compared with other age patients; in the meantime there is not statistical significance in the frequency of MRSA hospital infections among the two groups. The results of our study show that infections were probably transmitted by the hands of the members of staff and that the reservoir of MRSA are tracheostomized hosts or long term ventilated patients.

The authors describe 6 cases of Apple Peel Small Bowel observed in the last ten year experience in Institute G. Gaslini of Genoa, Italy. They make a precision on early diagnosis and on surgical treatment, which is original, and also on post-operatory medical treatment. The importance of making an optimal nutritional support with total and partial parenteral nutrition for long time is of great significance to have a better outcome and psycho-physical development in such patients.