Extubation failure after cardiac surgery in children with Down syndrome

Extubation failure (EF) after cardiac surgery is associated with poorer outcomes. Approximately 50% of children with Down syndrome (DS) have congenital heart disease. Our primary aim was to describe the frequency of EF and identify risk factors for its occurrence in a population of patients with DS after cardiac surgery. Secondary aims were to describe complications, length of hospital stay, and mortality rates. This report was a retrospective case-control study and was carried out in a national reference congenital heart disease repair center of Chile. This study includes all infants 0-12 months old with DS who were admitted to pediatric intensive care unit after cardiac surgery between January 2010 and November 2020. Patients with EF (cases) were matched 1:1 with children who did not fail their extubation (controls) using the following criteria: age at surgery, sex, and type of congenital heart disease. Overall, 27/226 (11.3%) failed their first extubation. In the first analysis, before matching of cases and controls was made, we found association between EF and younger age (3.8 months vs 5 months; p = 0.003) and presence of coarctation of the aorta (p = 0.005). In the case-control univariate analysis, we found association between an increased cardiothoracic ratio (CTR) (p = 0.03; OR 5 (95% CI 1.6-16.7) for a CTR > 0.59) and marked hypotonia (27% vs 0%; p = 0.01) with the risk of EF. No differences were found in ventilatory management.

CONCLUSIONS

In pediatric patients with DS, EF after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting the degree of cardiomegaly and hypotonia. Recognition of these factors may be helpful when planning extubation for these patients.

WHAT IS KNOWN

• Extubation failure after cardiac surgery is associated with higher morbidity and mortality rates. Some studies report higher rates of extubation failure in patients with Down syndrome.

WHAT IS NEW

• In children with Down syndrome, extubation failure after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting cardiomegaly and severe hypotonia.

One or two doses of hepatitis A vaccine in universal vaccination programs in children in 2020: A systematic review

BACKGROUND

Hepatitis A virus (HAV) is a global health concern as outbreaks continue to occur. Since 1999, several countries have introduced universal vaccination (UV) of children against HAV according to approved two-dose schedules. Other countries have implemented one-dose UV programs since 2005; the long-term impact of this schedule is not yet known.

METHODS

We conducted a systematic literature search in four electronic databases for data published between January 2000 and July 2019 to assess evidence for one-dose and two-dose UV of children with non-live HAV vaccines and describe their global impact on incidence, mortality, and severity of hepatitis A, vaccine effectiveness, vaccine efficacy, and antibody persistence.

RESULTS

Of 3739 records screened, 33 peer-reviewed articles and one conference abstract were included. Rapid declines in incidence of hepatitis A and related outcomes were observed in all age groups post-introduction of UV programs, which persisted for at least 14 years for two-dose and six years for one-dose programs according to respective study durations. Vaccine effectiveness was ≥95% over 3-5 years for two-dose programs. Vaccine efficacy was >98% over 0.1-7.5 years for one-dose vaccination. Antibody persistence in vaccinated individuals was documented for up to 15 years (≥90%) and ten years (≥74%) for two-dose and one-dose schedules, respectively.

CONCLUSION

Experience with two-dose UV of children against HAV is extensive, demonstrating an impact on the incidence of hepatitis A and antibody persistence for at least 15 years in many countries globally. Because evidence is more limited for one-dose UV, we were unable to draw conclusions on immune response persistence beyond ten years or the need for booster doses later in life. Ongoing epidemiological monitoring is essential in countries implementing one-dose UV against HAV. Based on current evidence, two doses of non-live HAV vaccines are needed to ensure long-term protection.

34. Impact of Universal Mass Vaccination Programs of Children Against Hepatitis a with 2-dose and 1-dose Schedules: A Systematic Literature Review

Background

With more than 100 million new hepatitis A (HepA) virus (HAV) infections estimated each year, HepA is a serious health concern worldwide. Several countries implemented 2- or 1-dose universal mass vaccination (UMV) programs of children with HAV vaccines. Here we present the first systematic review describing the impact of 2- and 1-dose UMV programs on HepA incidence and related health outcomes.

Methods

We systematically searched several databases for data published between Jan 2000–Jul 2019 (Figure 1). We assessed available evidence for 2- and 1-dose UMV programs with inactivated HAV vaccine in children worldwide, in terms of impact on HepA incidence, disease severity and mortality, vaccine efficacy, vaccine effectiveness and antibody persistence.

Figure 1. PRISMA flowchart

Results

3739 articles were screened and 34 studies were included in our analysis (Figure 1). 18 real-world studies in 9 countries showed that HepA incidence declined in all ages following introduction of 2-dose and 1-dose UMV programs and persisted for at least 14 years (2-dose) and at least 6 years (1-dose) (Figure 2). Evidence for 1-dose schedule was limited to only 3 studies. HAV related outcomes (disease severity, mortality) decreased after UMV with either 2-dose or 1-dose schedule. Vaccine effectiveness for the 2-dose schedules was ≥ 95% over 3–5 years. Vaccine efficacy for the 1-dose schedule was > 98% over 0.1–7.5 years. Anti-HAV antibody persistence in vaccinated children was documented up to 15 years with ≥ 90% seropositivity rates for the 2-dose schedule and up to 10 years with ≥ 74.3% seropositivity rates for the 1-dose schedule. Anti-HAV antibody GMC data is presented in Table 1.

Figure 2. Impact of vaccination on hepatitis A incidence in countries implementing 2-dose or 1-dose schedules (data from studies presenting ‘all ages’ incidence data)

Table 1. Anti-HAV antibody GMCs following vaccination with 2-dose and 1-dose schedules, data from studies included in our review

Conclusion

The implementation of 2- and 1-dose UMV programs against HAV induced decreases in disease incidence and related outcomes. Experience with 2-dose schedule is extensive, with wide geographical use, while evidence beyond 10 years for the 1-dose schedule has not yet been demonstrated. Continued and robust surveillance is needed to monitor the epidemiology, vaccine effectiveness, antibody persistence and protection (particularly in the absence of natural boosting) in order to have a strong, scientifically sound basis for decision makers when concluding on HepA prevention strategies in their countries.

Funding: GlaxoSmithKline Biologicals SA

Disclosures

Anar Andani, BSc, GSK group of companies (Employee, Shareholder) Eveline M. Bunge, PhD, GSK group of companies (Research Grant or Support) Fernanda Salgado, MD, MSc, GSK group of companies (Employee) Rosa C. van Hoorn, MSc, GSK group of companies (Research Grant or Support) Bernard Hoet, MD, FFPM, GSK group of companies (Shareholder)

Hepatitis A epidemiology in Latin American countries: a 2020 view from a systematic literature review

INTRODUCTION

The World Health Organization recommends vaccination against hepatitis A virus (HAV) for children aged 1 year and older in areas where endemicity has shifted from high to intermediate. There are no recent comprehensive reviews of the epidemiology of HAV infection in Latin America, but seroprevalence and socioeconomic data suggest that, with improved clean water and sanitation systems, countries are transitioning to intermediate endemicity.

AREAS COVERED

We conducted a systematic literature review of the epidemiology of HAV infection in 25 countries in the Latin American region, which included gray literature. We compiled data on HAV incidence and prevalence, including the identification of epidemiological changes observed in countries that established pediatric HAV vaccination programs.

EXPERT OPINION

We identified 59 relevant articles, including 34 peer-reviewed seroprevalence studies (12 recent studies from Brazil), three incidence studies, and six vaccine impact studies (three from Argentina). Based on the estimated age at midpoint of population immunity in each country, most have a high-intermediate, intermediate, or low-intermediate level of HAV endemicity, suggesting that national childhood immunization may be an appropriate disease prevention strategy. However, recent data were lacking for most countries. Improved data quality and continued epidemiological surveillance are required for this region.

Máxime "Max" Kuczyński: Father of Peruvian Public Health and of the 66th President of Peru

Máxime Kuczyński (1890-1967), a medical pioneer born in Poland, was renowned for his work in tropical medicine in the Peruvian jungle, especially on Bartonella baciliformis, the cutaneous form known as verruga peruana of deadly Oroya fever. His unique university training in anthropology, philosophy, and parasitology lead to a participatory observational method of practicing medicine. At the request of the Peruvian President, he ventured into the Peruvian Amazon in 1936 to establish a public health service in partnership with indigenous populations. In June 2016, his son Pedro Pablo Kuczyński, a former Prime Minister of Peru, was elected the 66th President of Peru.

What's eating you? scabies in the developing world

Scabies infestation is a major cause of impetigo and subsequent renal failure in the developing world, and efforts to eradicate widespread infestation are underway. Ivermectin, topical sulfur, and topical benzyl benzoate often are used to treat widespread outbreaks.

What's eating you? sticktight flea revisited

The sticktight flea (Echidnophaga gallinacea) earns its name by embedding its head in the host's skin. It has been found in many species of birds and mammals, including humans. The sticktight flea is found worldwide in the tropics, subtropics, and temperate zones, and it is the only representative of this genus found in the United States. Bites from fleas cause irritation and itching for hosts including humans, typically resulting in clusters of firm, pruritic, erythematous papules. Treatment can be tricky, as the fleas can be difficult to remove, and any flea-infested environments should be properly treated to prevent further bites.

Shedding light on onychomadesis

Onychomadesis is the proximal separation of the nail plate from the nail matrix due to a temporary cessation of nail growth. It can occur in children of all ages including neonates. Diagnosis is made clinically through palpation and inspection of the nail plate. Physicians should consider underlying associations. A review of the patient's history for any viral illnesses 1 to 2 months prior to nail changes often will help identify the causative disease. Onychomadesis typically is mild and self-limited. There is no specific treatment, but a conservative approach to management is recommended with treatment of any underlying causes and supportive care. Spontaneous nail regrowth usually occurs within 12 weeks and may occur faster in children. In this article, causes of onychomadesis are described, including the connection between hand-foot-and-mouth disease (HFMD) and onychomadesis. We also explore several theories of possible mechanisms for onychomadesis; however, the precise mechanism remains unclear and further investigation is needed.

[Helicobacter pylori: cagA analysis and vacA genotyping in Chile. Detection of a s2/m1 strain]

BACKGROUND

The genes cagA and vacA encode H pylori virulence factors.

AIM

To genotype these genes in H pylori strains isolated from patients with upper gastrointestinal symptoms.

MATERIAL AND METHODS

We studied 50 patients who underwent an upper gastrointestinal endoscopy, with positive culture for H pylori. Detection of cagA and vacA genotyping was done using polymerase chain reactions.

RESULTS

The gene cagA was detected in 19 samples (38%). Signal sequences s1 and s2 of vacA gene were detected in 16 samples each (32%). There was simultaneous amplification of s1 and s2 in 6 samples and they were not detected in 9 samples. The middle region of vacA was m1 in 9 samples, m2 in 29 samples and there was simultaneous amplification of m1 and m2 in 12 samples. In 16 samples (32%), more than one type of signal sequence or medial region was detected. Of those patients in whom vacA was the only genotype detected, 15 were s2/m2, 7 were s1/m1, 4 were s1/m2 and 1 was s2/m1.

CONCLUSIONS

In these patients, the infection with cagA- H pylori strains, predominates, the prevalence of infection with s1 or s2 strains is similar and the predominant medial region is m2.

In vitro antibacterial activity of Chilean red wines against Helicobacter pylori

The antibacterial activity of sixteen Chilean red wines (Cabernet Sauvignon, Cabernet Merlot, Cabernet Organic and Pinot Noir), and the active extracts of two randomly selected wines were assayed for their antibacterial activity on six strains of Helicobacter pylori isolated from gastric biopsies. The active fraction of the wines was obtained by dichloromethane extraction, and the antibacterial activity of the wines and extracts was evaluated by an agar diffusion method. All the red wines studied showed some antibacterial activity on the six strains of H. pylori, although the strains were heterogeneous in their susceptibility to each particular wine. The active fraction of the two wines selected also showed good activity against the strains tested. The main active compound was identified as resveratrol. The results presented indicate that Chilean red wines have antibacterial activity against H. pylori, which depends mainly on the presence of resveratrol.

Numerical modeling of facial aging

Facial aging is a biological phenomenon. Skin properties change with time, and gravity and facial expressions exert mechanical deformation. Knowledge of these alterations may suggest ways to reverse them by identifying the corresponding distortional forces. The aim of this study was to determine a pattern of change for parameters of the face during the aging process, based on the numerical fitting of measures from a sample of patients. The first aspect of this study was to define adequate facial parameters and means of measuring them. Subsequently, each parameter was defined individually, and these data were analyzed as a set. The sample for the research was restricted to a group of 40 white female patients with a history of limited exposure to the sun, with ages ranging from 25 to 65. The reason for choosing this sample was the availability of frontal pattern photographs at different ages. The parameters for each patient were measured at two different ages. A strong correlation was found between age and behavior of the parameters. This aging model can be verified qualitatively by comparing photographs of a patient with manipulated photographs simulating aging. The quantitative verification of the model was done through the comparison of the measured and the predicted parameters.

Central vein thrombosis in the antiphospholipid syndrome

We report the case of a 38 y old man with antiphospholipid syndrome and exceptionally extensive central vein thrombosis in the right internal jugular vein, superior vena cava, and both subclavian veins. In spite of intensive anticoagulation therapy there was only a partial response. We suggest the MR angiography be the reference standard for diagnosis in this type of patient.

The surgical importance of the dermocartilaginous ligament of the nose

The dermocartilaginous ligament of the nose, as first described by the senior author, has been shown to influence the equilibrium of the dorsum-tip relationship. In some noses, this is manifested by a residual convexity after routine rhinoplastic management of the osteocartilaginous structures. The anatomic findings are reported, and surgical considerations are analyzed. A system of classification based on the thickness of the ligament has been shown to be helpful in the intraoperative evaluation of this structure.

[Bacillary angiomatosis: report of 2 cases]

BACKGROUND

Epithelioid bacillary angiomatosis (EBA) was studied as an infectious disease associated to immunosuppressive states, establishing the bases for performing differential diagnosis with other pathologic processes.

METHODS

Two new cases of EBA in patients with human immunodeficiency virus infection (HIV) are presented. Diagnosis was performed by anatomopathologic study of the cutaneous lesions which had undergone biopsy.

RESULTS

In one of the cases bacillary structures were observed under electron microscopy. This patient also presented Kaposi sarcoma (KS) with histologic study being therefore necessary to perform differential diagnosis between these pathologic processes. Both patients presented good response to treatment with erythromycin.

CONCLUSIONS

1) EBA is an infectious disease of good prognosis with antibiotic treatment which fundamentally affects severely immunosuppressed patients with human immunodeficiency virus infection. 2) Biopsy is the only differential diagnostic method for this disease with other processes with similar clinical appearance and different prognosis as in Kaposi sarcoma which may even coexist in these patients.

[Reflections on the use of fluid dimethylpolysiloxan in plastic surgery of the head and neck]

The authors present retrospectively results and complications of 47 treatments with fluid dimethylpolysiloxane (silicone). The injections were not administered in the author's surgical department. The history of fluid silicone, its tissue reactions and the aesthetic results obtained are described. Different types of complications and their management are discussed. According to the authors' experience fluid dimethylpolysiloxane has not proved to be a proper material for plastic reconstructive and aesthetic treatment in the head and neck region.