Usefulness of gastric intramucosal pH for monitoring hemodynamic complications in critically ill children

OBJECTIVE: To assess the efficacy of gastric intramucosal pH for the evaluation of tissue perfusion and prediction of hemodynamic complications in critically ill children. DESIGN: Open prospective study without controls. SETTING: Pediatric intensive care unit (ICU) of a tertiary care university pediatric hospital. PATIENTS: Thirty critically ill children (16 boys and 14 girls), age range: 3 months-12 years. MEASUREMENTS AND RESULTS: A tonometry catheter was placed in the stomach of all patients on admission to the pediatric ICU. Simultaneous tonometry and arterial gas measurements were made on admittance and every 6-12 h throughout the study; a total of 202 measurements were made. The catheter was removed after extubation and/or when the patient was hemodynamically stable. Intramucosal pH was calculated using the Henderson-Hasselbalch equation based on the pCO2 of the tonometer and arterial bicarbonate. Intramucosal pH values between 7.30 and 7.45 were considered to be normal. The patient's condition was analyzed using the Pediatric Risk Mortality Score (PRISM). The relations between intramucosal pH and the presence of major hemodynamic complications (cardiopulmonary arrest, shock), minor hemodynamic complications (hypotension, hypovolemia or arrhythmia), death, PRISM score and the duration of the stay in the pediatric ICU were analyzed. Intramucosal pH on admission was 7.48 +/- 0.15 on average (range 7.04-7.68). Five patients (16%) had an intramucosal pH lower than 7.30 on admission; these patients did not have a higher incidence of hemodynamic complications. The 16 patients (53%) who had an intramucosal pH of less than 7.30 at some time during the course of their disease had more hemodynamic complications than the patients who did not have pH lower than 7.30 (p < 0.0001). Every case of cardiopulmonary arrest and shock was related to intramucosal pH of less than 7.30. Patients with major complications (cardiopulmonary arrest and shock) had lower intramucosal pHs than those with minor hemodynamic complications (p = 0.03); similarly, they had low intramucosal pH readings more often than those with minor complications (p = 0.0032). Intramucosal pH values less than 7.30 had a sensitivity of 90% and a specificity of 98% as a predictor of hemodynamic complications. There was no relation between intramucosal pH lower than 7.30 and either PRISM or the duration of the stay in the pediatric ICU. Patients with intramucosal pH less than 7.20 had a higher PRISM than the patients who did not have pH lower than 7.20 (p < 0.05). A patient who died during the study due to cardiopulmonary arrest had prior intramucosal pH measurements of 7.23 and 7.10, and three patients died of late complications after the end of the study. Hemodynamic complications were not detected with arterial pH. Gap pH (arterial pH-intramucosal pH) and standard pH measurements yielded the same results as gastric intramucosal pH. CONCLUSION: Intramucosal pH could provide a useful early indication of hemodynamic complications in critically ill children.     

Fetal Undernutrition Modifies Vascular RAS Balance Enhancing Oxidative Damage and Contributing to Remodeling

Fetal stress is known to increase susceptibility to cardiometabolic diseases and hypertension in adult age in a process known as fetal programming. This study investigated the relationship between vascular RAS, oxidative damage and remodeling in fetal programming. Six-month old Sprague-Dawley offspring from mothers that were fed ad libitum (CONTROL) or with 50% intake during the second half of gestation (maternal undernutrition, MUN) were used. qPCR or immunohistochemistry were used to obtain the expression of receptors and enzymes. Plasma levels of carbonyls were measured by spectrophotometry. In mesenteric arteries from MUN rats we detected an upregulation of ACE, ACE2, AT₁ receptors and NADPH oxidase, and lower expression of AT₂, Mas and MrgD receptors compared to CONTROL. Systolic and diastolic blood pressure and plasma levels of carbonyls were higher in MUN than in CONTROL. Vascular morphology evidenced an increased media/lumen ratio and adventitia/lumen ratio, and more connective tissue in MUN compared to CONTROL. In conclusion, fetal undernutrition indices RAS alterations and oxidative damage which may contribute to the remodeling of mesenteric arteries, and increase the risk of adverse cardiovascular events and hypertension.     

Finite size effects in multilayered polymer systems: Development of PET lamellae under physical confinement

The glass transition temperature and the crystallization behaviour of poly(ethylene terephthalate) PET ultra-thin layers (a few tens of nm) within multilayered PET/polycarbonate (PC) coextruded films are investigated as a function of layer thickness by means of calorimetric measurements. Results are discussed in terms of reduced thickness and interface effects. The appearance and evolution of lamellar orientation upon isothermal crystallization of ultra-thin PET layers from the glassy state are explored based on real time small-angle X-ray scattering (SAXS) studies. Analysis of the SAXS measurements reveals that finite size effects hamper the crystallization process. However, the final lamellar structure is similar in both, the nanolayered PET and the bulk material. Results suggest that not only lamellar insertion but also some lamellar thickening contribute to the development of the final lamellar structure. Room temperature SAXS and wide-angle X-ray diffraction (WAXS) measurements indicate that two lamellar populations develop: edge-on lamellae are proposed to appear close to the interphases while flat-on lamellae, arising as a consequence of confinement, should be preferentially located in the layers core.     

Assessment of genomic damage in colorectal cancer by DNA fingerprinting: prognostic applications

PURPOSE: Here we evaluate the prognostic significance of the relative value of genomic damage assessed by DNA fingerprinting in colorectal cancer. MATERIALS AND METHODS: Sixty-three tumor and paired normal mucosa samples were included in the study. Genomic damage was assessed by comparative analysis of paired normal and tumor tissue DNA fingerprints by the arbitrarily primed polymerase chain reaction (AP-PCR). Decreases and increases of intensity in bands were computed and referred to the total number of visualized bands per case. An index reflecting the genomic damage fraction (GDF), with separated values for losses and gains, was obtained for each tumor. This index was used to determine molecular and clinicopathologic correlates after exclusion of eight cases displaying microsatellite instability. RESULTS: Fifty-five cases were considered for the statistical analysis. The average fraction of altered bands per tumor was 0.287+/-0.121. When losses and gains were computed separately, the average fraction of changes was 0.126+/-0.113 and 0.161+/-0.120, respectively. Tumors lacking a ras mutation showed an increased GDF, primarily because of a higher fraction of gains. Tumors that were at advanced Dukes' stages and that were poorly differentiated also displayed a higher GDF. Finally, disease-free survival was significantly diminished in tumors with a GDF greater than 0.314 (P < .001). The prognostic significance of the GDF was independent of Dukes' stage (Cox multivariate analysis, P = .005). CONCLUSION: The degree of genomic damage assessed by unbiased DNA fingerprinting correlates with genotypic, phenotypic, and clinical variables in colorectal carcinoma and may be useful in assessing prognosis in colorectal cancer.     

Diagnostic value of biliary acid serum levels in Gilbert syndrome

OBJECTIVE: The aim of the present work was to study the diagnostic value of the measurement of total serum bile acids in patients with Gilbert's syndrome as compared to the fasting test. PATIENTS AND METHODS: We have studied 17 patients, 12 males and 5 females, between the ages of 7 and 15 years. All patients showed a slight unconjugated hyperbilirubinemia (1.4 +/- 0.5 mg/dl) in the presence of repeated normal liver function test, including the total serum bile acids (7.47 +/- 2.3 mumol/l), and showed no evidence of hemolysis. A modified fasting test was performed in all of the patients. Serum bile acid levels (Merckotest, Merck Labs) and the biochemical parameters of liver function were determined before and after the fasting test. RESULTS: Our results show that to confirm the diagnosis of Gilbert's syndrome, the fasting test could be avoided in patients with increased unconjugated bilirubin levels if the basal levels of total serum bile acids are normal.     

A radius and ulna TW3 bone age assessment system

An end-to-end system to automate the well-known Tanner--Whitehouse (TW3) clinical procedure to estimate the skeletal age in childhood is proposed. The system comprises the detailed analysis of the two most important bones in TW3: the radius and ulna wrist bones. First, a modified version of an adaptive clustering segmentation algorithm is presented to properly semi-automatically segment the contour of the bones. Second, up to 89 features are defined and extracted from bone contours and gray scale information inside the contour, followed by some well-founded feature selection mathematical criteria, based on the ideas of maximizing the classes' separability. Third, bone age is estimated with the help of a Generalized Softmax Perceptron (GSP) neural network (NN) that, after supervised learning and optimal complexity estimation via the application of the recently developed Posterior Probability Model Selection (PPMS) algorithm, is able to accurately predict the different development stages in both radius and ulna from which and with the help of the TW3 methodology, we are able to conveniently score and estimate the bone age of a patient in years, in what can be understood as a multiple-class (multiple stages) pattern recognition approach with posterior probability estimation. Finally, numerical results are presented to evaluate the system performance in predicting the bone stages and the final patient bone age over a private hand image database, with the help of the pediatricians and the radiologists expert diagnoses.