A 10-year experience in paediatric spontaneous cerebral hemorrhage: which children with headache need more than a clinical examination?

INTRODUCTION: When a child is seen in a clinic with a headache, stroke is certainly not the first on the list of differential diagnoses. In western countries, stroke is typically associated with adults and the elderly. Although rare, haemorrhagic strokes are not exceptional in the paediatric population, as their incidence is around 1/100 000/year. Prompt diagnosis is essential, since delayed treatment may lead to disastrous prognosis in these children. MATERIALS AND METHODS: This is a retrospective review of paediatric cases with spontaneous cerebral haemorrhage that presented in two university hospitals in the last ten years. The experience of these primary and tertiary referral centres comprises 22 consecutive cases that are analysed according to aetiology, presenting symptoms, treatment and outcome. RESULTS: 77% of the children diagnosed with haemorrhagic stroke presented with headaches. 41% of them had a sudden onset, while 9% developed headaches over a period of hours to weeks. While 9% presented only with headaches, the majority had either subtle (diplopia, balance problems) or obvious (focal deficits, unilateral weakness and decreased level of consciousness) concomitant neurological signs. 55% had an arteriovenous malformation (AVM), 18% had an aneurysm and 14% had a cavernous malformation. In 14% the aetiology could not be determined. The majority of haemorrhages (82%) were supratentorial, while 18% bled into the posterior fossa. All children underwent an emergency cerebral CT scan followed by specific investigations. The treatment was dependent on the aetiology as well as the mass effect of the haematoma. In 23% an emergent evacuation of the haematoma was performed. Two children (9%) died, and 75% had a favourable clinical outcome. CONCLUSION: Headaches in children are a common problem, and a small minority may reveal an intracranial haemorrhage with poor prognosis if not treated promptly. Although characterisation of headaches is more difficult in a paediatric population, sudden, unusual or intense headaches should lead to imaging work-up. Any neurological finding, even one as subtle as hemianopsia or dysmetria, should alarm the physician and should be followed by emergency imaging investigation. If the cerebral CT reveals a haemorrhage, the child should be referred immediately to a neurosurgical referral centre without further investigation. The outcome is grim for children presenting in coma with fixed, dilated pupils. The long-term result overall for children after spontaneous intracranial haemorrhage is not dismal and depends critically on specialised management

Effect of obesity and thoracic epidural analgesia on perioperative spirometry

Background. Lung volumes in obese patients are reduced significantly in the postoperative period. As the effect of different analgesic regimes on perioperative spirometric tests in obese patients has not yet been studied, we investigated the effect of thoracic epidural analgesia and conventional opioid-based analgesia on perioperative lung volumes measured by spirometry. Methods. Eighty-four patients having midline laparotomy for gynaecological procedures successfully completed the study. Premedication, anaesthesia and analgesia were standardized. The patients were given a free choice between epidural analgesia (EDA) (n=42) or opioids (n=42) for postoperative analgesia. We performed spirometry to measure vital capacity (VC), forced vital capacity, peak expiratory flow, mid-expiratory flow and forced expiratory volume in 1 s at preoperative assessment, 30-60 min after premedication and 20 min, 1 h, 3 h and 6 h after extubation. Results. Baseline values were all within the normal range. All perioperative spirometric values decreased significantly with increasing body mass index (BMI). The greatest reduction in VC occurred directly after extubation, but was less in the EDA group than in the opioid group: mean of −23(sd 8)% versus −30(12)% (P30) the difference in VC was significantly more pronounced than in patients of normal weight (BMI<25): −45(10)% versus −33(4)% (P<0.001). Recovery of spirometric values was significantly quicker in patients receiving EDA, particularly in obese patients. Conclusion. We conclude that EDA should be considered in obese patients undergoing midline laparotomy to improve postoperative spirometr

Effect of obesity and site of surgery on perioperative lung volumes

Background. Although obese patients are thought to be susceptible to postoperative pulmonary complications, there are only limited data on the relationship between obesity and lung volumes after surgery. We studied how surgery and obesity affect lung volumes measured by spirometry. Methods. We prospectively studied 161 patients having either breast surgery (Group A, n=80) or lower abdominal laparotomy (Group B, n=81). Premedication and general anaesthesia were standardized. Spirometry was measured with the patient supine, in a 30° head‐up position. We measured vital capacity (VC), forced vital capacity, peak expiratory flow and forced expiratory volume in 1 s at preoperative assessment (baseline), after premedication (before induction of anaesthesia) and 10-20 min, 1 h and 3 h after extubation. Results. Baseline spirometric values were all within the normal range. All perioperative values decreased significantly with increasing body mass index (BMI). The greatest reduction of mean VC (expressed as percentage of baseline values) occurred after extubation, and was more marked after laparotomy than after breast surgery (23 (sd 14)% vs 20 (14)%). Considering patients according to BMI (30), VC decreased after surgery by 12 (7)%, 24 (8)% and 40 (10)%, respectively. VC recovered more rapidly in Group A. Conclusion. Postoperative reduction in spirometric volumes was related to BMI. Obesity had more effect on VC than the site of surgery. Br J Anaesth 2004; 92: 202-

The porin and the permeating antibiotic: A selective diffusion barrier in gram-negative bacteria

Gram-negative bacteria are responsible for a large proportion of antibiotic resistant bacterial diseases. These bacteria have a complex cell envelope that comprises an outer membrane and an inner membrane that delimit the periplasm. The outer membrane contains various protein channels, called porins, which are involved in the influx of various compounds, including several classes of antibiotics. Bacterial adaptation to reduce influx through porins is an increasing problem worldwide that contributes, together with efflux systems, to the emergence and dissemination of antibiotic resistance. An exciting challenge is to decipher the genetic and molecular basis of membrane impermeability as a bacterial resistance mechanism. This Review outlines the bacterial response towards antibiotic stress on altered membrane permeability and discusses recent advances in molecular approaches that are improving our knowledge of the physico-chemical parameters that govern the translocation of antibiotics through porin channel

A clinician’s guide to management of intra-abdominal hypertension and abdominal compartment syndrome in critically ill patients

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901

Diagnosis and management of respiratory adverse events in the operating room

Perioperative respiratory adverse events cause more than three-quarters of all perioperative critical incidents in pediatric anesthesia and approximately half of anesthesia-related cardiac arrests. We can define seven main clinical types of perioperative respiratory adverse events: upper airway obstruction, laryngospasm, bronchospasm, severe persistent cough, apnea, stridor, and oxygen desaturation. Depending on the definitions used for preoperative respiratory adverse events and the cohort of children examined, the incidence varies between 8 and 21 %. This review discusses the recognition and treatment of perioperative respiratory adverse events. Furthermore, it provides guidance on how to identify children who are at increased risk for developing perioperative respiratory adverse events and how to tailor the perioperative anesthetic management for the individual child in order to minimize the risk of perioperative respiratory adverse events

Anti-infectives in Drug Delivery-Overcoming the Gram-Negative Bacterial Cell Envelope.

Infectious diseases are becoming a major menace to the state of health worldwide, with difficulties in effective treatment especially of nosocomial infections caused by Gram-negative bacteria being increasingly reported. Inadequate permeation of anti-infectives into or across the Gram-negative bacterial cell envelope, due to its intrinsic barrier function as well as barrier enhancement mediated by resistance mechanisms, can be identified as one of the major reasons for insufficient therapeutic effects. Several in vitro, in silico, and in cellulo models are currently employed to increase the knowledge of anti-infective transport processes into or across the bacterial cell envelope; however, all such models exhibit drawbacks or have limitations with respect to the information they are able to provide. Thus, new approaches which allow for more comprehensive characterization of anti-infective permeation processes (and as such, would be usable as screening methods in early drug discovery and development) are desperately needed. Furthermore, delivery methods or technologies capable of enhancing anti-infective permeation into or across the bacterial cell envelope are required. In this respect, particle-based carrier systems have already been shown to provide the opportunity to overcome compound-related difficulties and allow for targeted delivery. In addition, formulations combining efflux pump inhibitors or antimicrobial peptides with anti-infectives show promise in the restoration of antibiotic activity in resistant bacterial strains. Despite considerable progress in this field however, the design of carriers to specifically enhance transport across the bacterial envelope or to target difficult-to-treat (e.g., intracellular) infections remains an urgently needed area of improvement. What follows is a summary and evaluation of the state of the art of both bacterial permeation models and advanced anti-infective formulation strategies, together with an outlook for future directions in these fields

eLearning resources to supplement postgraduate neurosurgery training.

BACKGROUND: In an increasingly complex and competitive professional environment, improving methods to educate neurosurgical residents is key to ensure high-quality patient care. Electronic (e)Learning resources promise interactive knowledge acquisition. We set out to give a comprehensive overview on available eLearning resources that aim to improve postgraduate neurosurgical training and review the available literature. MATERIAL AND METHODS: A MEDLINE query was performed, using the search term "electronic AND learning AND neurosurgery". Only peer-reviewed English-language articles on the use of any means of eLearning to improve theoretical knowledge in postgraduate neurosurgical training were included. Reference lists were crosschecked for further relevant articles. Captured parameters were the year, country of origin, method of eLearning reported, and type of article, as well as its conclusion. eLearning resources were additionally searched for using Google. RESULTS: Of n = 301 identified articles by the MEDLINE search, n = 43 articles were analysed in detail. Applying defined criteria, n = 28 articles were excluded and n = 15 included. Most articles were generated within this decade, with groups from the USA, the UK and India having a leadership role. The majority of articles reviewed existing eLearning resources, others reported on the concept, development and use of generated eLearning resources. There was no article that scientifically assessed the effectiveness of eLearning resources (against traditional learning methods) in terms of efficacy or costs. Only one article reported on satisfaction rates with an eLearning tool. All authors of articles dealing with eLearning and the use of new media in neurosurgery uniformly agreed on its great potential and increasing future use, but most also highlighted some weaknesses and possible dangers. CONCLUSION: This review found only a few articles dealing with the modern aspects of eLearning as an adjunct to postgraduate neurosurgery training. Comprehensive eLearning platforms offering didactic modules with clear learning objectives are rare. Two decades after the rise of eLearning in neurosurgery, some promising solutions are readily available, but the potential of eLearning has not yet been sufficiently exploited

Business-IT-Alignment in Gemeinden – Qualitative Forschung anhand dreier größerer Berner Gemeinden

Durch die elektronische Vernetzung und die zunehmende Komplexität der IT in Verwaltungsorganisationen und insbesondere Gemeinden nimmt die Bedeutung des Business-IT- Alignments (BIA) zu. Je besser die Ausrichtung der IT am Business, so die Annahme, desto höher ist die Nutzenstiftung durch die IT. Allerdings wird dem BIA sowohl von Firmen als auch öffentlichen Verwaltungen häufig immer noch zu wenig Beachtung geschenkt [LB99], [LPB99]). Eine frühere Untersuchung zeigte, dass bei großen Gemeinden das BIA in der Regel besser ausgebildet ist als bei kleinen [BET13], [WEB14]. Aus diesem Grund beschäftigt sich der vorliegende Beitrag mit dem Thema BIA bei drei großen anonymisierten Berner Gemeinden A, B und C. Deren BIA wird qualitativ und auf Basis eines auf Basis der Literatur abgeleiteten spezifischen Reifegradmodells für das BIA in Gemeinden untersucht. Basierend auf Letzterem erfolgt die Ableitung eines Interviewleitfadens. Das Ziel des vorliegenden Beitrags ist es, die Ausprägungsund Wirkungsarten des strategischen und operativen BIA in großen Gemeinden vertiefter zu untersuchen. Im Hauptteil des vorliegenden Beitrags werden die verschiedenen BIA-Ausprägungen der untersuchten Gemeinden analysiert. Mittels des entwickelten Reifegradmodells ist feststellbar, welche Ausprägung das BIA den Gemeinden hat. Aus der Analyse geht hervor, dass die Reifegradkriterien bezogen auf die Informatik-Abteilungen der untersuchten Gemeinden einen tiefen bis mittleren Reifegrad aufweisen. Dies ist u.a. darauf zurückzuführen, dass die vorhandenen Strategie-Dokumente keinen Bezug zu Legislaturzielen der Gemeinden haben und dazu auch keinen Beitrag leisten. Weiter mangelt es teilweise an der Zusammenarbeit und der Kommunikation mit den internen Informatikkunden (Direktionen). Auch operative Gremien werden als Mittel zum BIA nicht bestmöglich eingesetzt. Zudem sehen sich die Informatik-Abteilungen häufig selbst nur als Dienstleister und Enabler, was ihr Verhalten beeinflusst und sie im proaktiven Handeln hemmt

Integrating DFM with CAD through Design Critiquing

The increasing focus on design for manufacturability (DFM) in research in concurrent engineering and engineering design is expanding the scope of traditional design activities in order to identify and eliminate manufacturing problems during the design stage. Manufacturing a product generally involves many different kinds of manufacturing activities, each having different characteristics. A design that is good for one kind of activity may not be good for another, for example, a design that is easy to assemble may not be easy to machine. One obstacle to DFM is the difficulty involved in building a single system that can handle the various manufacturing domains relevant to a design. In this paper we propose an architecture for integrating CAD with DFM. As the designer creates a design multiple critiquing systems analyze its manufacturability with respect to different manufacturing domains such as machining, fixturing, assembly, and inspection. Using this analysis, each critiquing system offers advice about potential ways of improving the design and an integration module mediates conflicts among the different critiquing systems in order to provide feedback to improve the overall design. We anticipate that this approach can be used to build a multi-domain environment that will allow designers to create higher-quality products that can be more economically manufactured. This will reduce the need for redesign and reduce product cost and lead time. (Also cross-referenced as UMIACS-TR-94-96