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Background: Breast milk HIV-1 load is associated with clinical and subclinical mastitis, and both milk viral load and mastitis are associated with increased mother-to-child-transmission of HIV-1 through breastfeeding. Bacterial infections may cause clinical mastitis, but whether other copathogens common in HIV-1 infection are associated with subclinical mastitis or HIV-1 shedding is unknown., Design: A cross-sectional study of HIV-1-infected breastfeeding women in Zimbabwe was performed to examine the relationship between a wide range of breast coinfections, mastitis, and HIV-1 shedding., Methods: Breast milk was cultured for bacteria and fungi and tested by PCR for mycobacteria, mycoplasmas, human herpesvirus (HHV)-6, HHV-7, HHV-8, cytomegalovirus, Epstein-Barr virus, and HIV-1 RNA and DNA. Symptoms of clinical mastitis were documented and subclinical mastitis was identified by breast milk sodium concentration (Na) and leukocyte counts., Results: Coinfections of milk were not associated with clinical or subclinical mastitis in the 217 women studied. Detection of HIV-1 RNA, but not DNA, in breast milk was associated with cytomegalovirus concentration (odds ratio = 1.8, P = 0.002) and detection of Epstein-Barr virus (odds ratio = 3.8, P = 0.0003) but not other coinfections in multivariate analysis., Conclusion: Coinfection of breast milk with bacteria, fungi, or herpes viruses was not associated with mastitis. The associations between shedding of cytomegalovirus and Epstein-Barr virus with HIV-1 in milk suggest a local interaction between herpes virus infection and HIV-1 independent of mastitis. Cytomegalovirus and Epstein-Barr virus infections may impact HIV-1 shedding in breast milk and the risk of MTCT.

Hip subluxation and dislocation are well-recognized complications of spastic cerebral palsy. Alternatives for treatment include observation, bracing, or surgery. The purpose of this study is to compare the rates of reoperation and acetabular development after early soft tissue procedures with those of varus derotational osteotomies performed to maintain reduced hips in severely involved children. A series of 60 patients with spastic cerebral palsy and hip subluxation younger than 6 years who underwent primary bilateral hip surgery at one hospital between 1980 and 1996, with a minimum of 4 years of follow-up, were retrospectively reviewed. Fifty-two patients had spastic tetraplegia and 47 were nonambulators. Measures of proximal femoral and acetabular development were made via radiographic analysis. Twenty-two patients underwent primary bilateral soft tissue procedures. At a mean 6-year follow-up, there was modest improvement seen in mean femoral head coverage and little improvement seen in mean indices of acetabular development. Seventeen of these 22 patients (77%) underwent reoperation. Thirty-eight patients underwent primary bilateral varus derotational osteotomies. At a mean follow-up of 5 years, there was also modest improvement noted in mean femoral head coverage with little change in the mean indices of acetabular development. Twenty-eight of these 38 patients (74%) underwent reoperation. In this population of severely involved patients with spastic cerebral palsy, the reoperation rate was high. Acetabular remodeling did not reliably occur as a result of either early soft tissue or proximal femoral procedures when performed at an average age of 4 years.

Objective: To observe the effects of right carotid artery ligation and variations in extracorporeal life support (ECLS) flow on regional cerebral oxygenation index (rSO2i) measured using near infrared spectroscopy., Design: Prospective observational study., Setting: Tertiary children's hospital., Patients: Eleven neonatal and pediatric patients requiring veno-arterial ECLS support between June 2000 and March 2003., Interventions: Near infrared spectroscopy probe placement on left and right frontal regions of patients undergoing ECLS, before vessel cannulation or within 24 hrs of initiation of ECLS., Measurements and Main Results: Regional cerebral oxygenation was measured every minute for 72 hrs or until the patient was decannulated. The effect of cannulation on rSO2i from each hemisphere of the brain and the relationship between ECLS flow and rSO2i during ECLS support and "trialing off" periods were determined. Ligation of the right carotid artery resulted in a 12-25% decrease in rSO2i from baseline in the right frontal region for a duration ranging from 17 to 45 mins before returning toward baseline. No substantial change in the left frontal region rSO2i was detected during cannulation. Following this depression in rSO2i on the right, there was a transient increase above baseline in rSO2i observed in both hemispheres on initiating ECLS. No correlation between ECLS flow and rSO2i was found over the 72-hr period. Periods of "trialing off" ECLS were not related to any change in rSO2i in either hemisphere., Conclusions: This study demonstrated no relationship between ECLS flow and rSO2i changes during the 72-hr observation period. A brief period of cerebral oxygen desaturation of the right frontal region at the time of right carotid ligation was seen in all three study patients examined during cannulation, followed by an increased rSO2i with initiation of ECLS flow. Near infrared spectroscopy measurement may offer an important adjunct for neurologic monitoring of ECLS patients.

Placement of IV catheters is a painful and stressful procedure for children. J-Tip is a needle-less Food and Drug Administration approved injection system that can be used for delivery of local anesthetic before IV cannulation. In this study, we compared the effectiveness of J-Tip versus eutectic mixture of local anesthetics (EMLA) to facilitate IV cannulation and provide adequate analgesia before IV placement. Children 7-19 years of age (n = 116) were randomized to receive 0.25 mL of 1% buffered lidocaine with J-Tip (n = 57) or 2.5 g of EMLA (n = 59) before IV cannulation. Measurements of success of cannulation (number of attempts for IV placement) and pain (0-10 visual analog scale) at application of local anesthetic and at cannulation were performed. There was a significant (P = 0.0001) difference in pain ratings during IV cannulation between EMLA (median = 3) and the J-Tip (median = 0). Eighty-four percent of patients reported no pain at the time of J-Tip lidocaine application compared to 61% in the EMLA group at the time of dressing removal (P = 0.004). We did not find differences in the number of attempts for IV cannulation. J-Tip application of 1% buffered lidocaine before IV cannulation is not painful and has better anesthetic effectiveness compared with EMLA.

Background: Chronic hepatitis C is often a mild disease in children, but whether this is related to younger age or shorter duration of infection is unclear. Histologic severity has been shown to correlate with duration of infection regardless of age., Objectives: We compared histologic findings in children and adults with chronic hepatitis C while controlling for sex, duration of infection, hepatitis C virus (HCV)-RNA level, and genotype., Methods: Twenty-one children and 52 adults whose infection was less than 20 years in duration and who had undergone a liver biopsy were included. Two blinded liver pathologists reviewed the liver biopsies and scored inflammatory activity and fibrosis using the modified Knodell scoring system., Results: The groups were the same with respect to HCV-RNA level (P=0.8), and genotype (P=0.6) but differed in duration of disease (P=0.01) and sex composition (P=0.005). Covariate analysis showed no influence of genotype, duration of infection, or HCV-RNA level on outcome. In controlling for sex, children had significantly milder liver disease and alanine aminotransferase (ALT) elevations., Conclusions: With equal duration of infection, HCV-RNA level, and genotype, children have lower serum ALT levels and less severe liver disease than adults infected with HCV.

Unlabelled: Interventions such as heparin-coated circuits, epsilon-aminocaproic acid, and reduced shed blood reinfusion have shown mixed results when applied individually for limiting hemostatic activation during cardiopulmonary bypass (CPB). We compared coagulation and fibrinolytic activation during conventional CPB (control) (CTRL) using noncoated circuits, no antifibrinolytics, and open cardiotomy with a combined strategy (HAC) that used heparin-coated circuits, epsilon-aminocaproic acid, and closed cardiotomy. Blood samples were drawn before, during, and after CPB for primary coronary bypass grafting surgery from 9 CTRL patients and 10 HAC patients. Thrombin-antithrombin complex and fibrinopeptide A levels (markers of thrombin and fibrin generation) were reduced in the HAC versus CTRL group after 30 min of CPB (P < 0.05). Average tissue plasminogen activator (tPA) levels were significantly lower in the HAC group by 30 min on CPB (P < 0.05), resulting in preservation of plasminogen activator inhibitor (PAI)-1 during CPB (P < 0.05). D-Dimer, a measure of intravascular fibrin formation and removal, was reduced in the HAC group during and after CPB (P < 0.005). Overall, the combined strategy was associated with a reduction in CPB-induced increases in markers of thrombin generation, fibrin formation, tPA release, and fibrin degradation and better preservation of PAI-1., Implications: A combined approach during cardiopulmonary bypass (CPB) that uses heparin-coated circuits, epsilon-aminocaproic acid, and limited reinfusion of shed pericardial blood is associated with reduced activation of the coagulation and fibrinolytic systems that typically occurs during conventional CPB.

Objectives: Assessment of ventricular volume change is critical and can be difficult in the child with suspected shunt failure. Objective techniques described to measure ventricular volumes have used limited anatomic sampling or have been computationally intensive. Phantoms used to evaluate these techniques have used static volumes. The purpose of this study was to construct a computed tomography (CT) phantom to simulate changing ventricular volumes and to evaluate a new program to measure volumes., Methods: The phantom is 5 Foley catheters embedded in gelatin. The balloons were filled and then scanned at 15-mL increments from 0-300 mL. The program measures the voxels of specified density within a larger volume created by applying a region of interest to a stacked volume. Calculated volumes and percent changes were compared with actual volumes and percent changes., Results: Calculated volumes were consistently 7%-9% (mean: -7.8%) less than actual injected volumes across the entire 0- to 300-mL range. For true changes between -50% and +50%, all calculated changes were within +/-2.5% points of true percent change; for true changes between +50% and +100%, all calculated changes were within +/-5% points of true percent change., Conclusions: A dynamic CT phantom simulating changing ventricular volumes can be constructed from readily available materials. A new volumetric program accurately measures ventricular volumes and percent change from baseline across a wide range of volumes.

Objectives: Assessment of ventricular volume change is critical in the child with suspected shunt failure. Minimal increases may represent high pressures in the child with reduced ventricular compliance but are difficult to detect subjectively. Objective techniques described limit anatomic sampling and are time intensive. The purpose of this study was to develop a rapid technique to measure ventricular volumes in children with suspected shunt failure., Methods: Ventricular volumes were calculated in 12 children with baseline and emergent computed tomography scans performed for suspected shunt failure. Volumes and percent interval changes were correlated with clinical course. Two observers performed the volume analysis blinded to the clinical information; 1 observer performed the analysis twice. Time to perform the analysis was recorded for 5 studies., Results: The intraobserver and interobserver correlation coefficients were 0.99 and 0.96/0.97, respectively. The mean time to perform the analysis was 2 minutes 42 seconds. Median percent change in patients with and without shunt obstruction was +50% (range: +24%-+367%) and +2% (range: -22%-+36%), respectively. Among patients subjectively read as having stable ventricular sizes, volume changes of -11% to +32% were calculated., Conclusions: The technique has excellent intra- and interobserver correlation and is rapidly performed. The range of percent volume changes between patients with and without shunt malfunction overlaps. Subjective assessment of ventricular changes is significantly less sensitive than the volume calculation technique. The technique may be most useful in patients with decreased ventricular compliance in whom small interval changes may represent large pressure increases.