Cerebral sinovenous thrombosis associated with head/neck infection in children: Clues for improved management

AIM

To compare paediatric patients with cerebral sinovenous thrombosis (CSVT) with and without head/neck infection to improve management of the condition.

METHOD

We conducted a bicentric retrospective study of consecutive children (neonates excluded) with radiologically confirmed CSVT, comparing children with a concurrent head/neck infection and children with other causes.

RESULTS

A total of 84 consecutive patients (46 males and 38 females) with a median age of 4 years 6 months (range 3 months-17 years 5 months) were included. Associated head/neck infection was identified in 65.4% of cases and represented the main identified CSVT aetiology. Children in the head/neck infection group displayed a milder clinical presentation and less extensive CSVT. Median time to complete recanalization was significantly shorter in this group (89 days [interquartile range 35-101] vs 112.5 days [interquartile range 83-177], p = 0.005). These findings were even more pronounced in the subgroup of patients with otogenic infection and no neurological sign.

INTERPRETATION

As CSVT in the setting of an otogenic infection and no neurological sign seems to represent a milder condition with a shorter course, these results suggest adapting current recommendations: consider earlier control imaging in paediatric otogenic CSVT, and shorter anticoagulant treatment if recanalization is obtained.

WHAT THIS PAPER ADDS

Children with cerebral sinovenous thrombosis related to head/neck infections have a milder clinical presentation. They also have a shorter recanalization time, especially if there is otogenic infection without neurological symptoms.

3D-planned corrective osteotomy of metacarpal arch disruption after Motec® wrist prosthesis

We report two cases of metacarpal arch disruption after Motec® total wrist arthroplasty, with hyperextension of the third metacarpal and dorsal protrusion of the head. Correction osteotomies of the adjacent metacarpals using preoperative 3D surgical planning were successful. This report seeks to shed light on the origin of this deformation and to recommend some operative precautions. It is important that surgeons should be aware of the existence of this complication, as disruption of the transverse metacarpal arch affects both grasp and hand esthetics. LEVEL OF EVIDENCE: IV.

AB1066 TREATMENT OF ACUTE CALCIUM DEPOSITS IN HAND AND WRIST WITH ANAKINRA

Background

Acute calcium deposits (ACD) of hydroxyapatite in hand and wrist are a rare cause of acute pain due to crystal-induced soft tissue inflammation. There are no standard management guidelines for this condition, which is frequently treated with non-steroid anti-inflammatory drugs or steroid infiltrations with variable efficacy, some patients presenting symptoms for several months1. Anakinra, an interleukin-1 receptor antagonist, showed non-inferiority compared to usual care in the treatment of acute gout arthritis in a randomized controlled study2 and demonstrated effectiveness in comorbid patients with recurrent crystal-related arthritis. Due to our local experience with anakinra to treat calcific periarthritis3, we started using anakinra in the treatment of selected patients with ACD in hand and wrist with severe pain.

Objectives

To report our experience with anakinra to treat ACD in hand and wrist in terms of efficacy and safety.

Methods

We retrospectively included all patients treated with anakinra for ACD in hand or wrist in our department in 2020. We extracted data on treatment duration, pain, range of motion, skin erythema, hypervascularization, oedema and X-ray findings when available.

Results

Ten patients (mean age 45, SD 11) were treated for ACD in hand or wrist with anakinra 100 mg per day for a mean duration of 2.7 days. We observed a fast and significant improvement of pain at rest on a 0-10 VAS scale (mean pain reduction at day 2 (SD): -3.9 (2.8), p=0.01). All patients were free of pain at rest after day 6 and at motion after day 21. Range of motion significantly improved at day 2 (+41° (24), mean (SD), p=0.03). We observed local erythema and oedema improvement from day 2 and a decrease in skin temperature from day 3. Calcifications decreased in size or disappeared in the majority of the patients. We did not observe any adverse events. Patients did not report recurrence after phone contact, 12 months after treatment.

Conclusion

Anakinra was associated with a significant clinical improvement after only two days of treatment of ACD in hand or wrist and may be considered to treat patients with this condition, especially those with contraindication to NSAIDs or glucocorticoids. Further controlled studies are needed to confirm our observations.

References

[1]Nikci V, Doumas C. Calcium deposits in the hand and wrist. J Am Acad Orthop Surg. 2015, 23: 87-94.

[2]Janssen CA, Oude Voshaar MAH, Vonkeman HE, et al. Anakinra for the treatment of acute gout flares: a randomized, double-blind, placebo-controlled, active-comparator, non-inferiority trial. Rheumatology. 2019 Jan 2.

[3]Zufferey P, Valcov R, Thomas M, et al. Efficacy of anakinra in acute hydroxyapatite calcification-induced joint pain: A retrospective study of 23 cases. Joint Bone Spine. 2019, 86: 83-8.

Figure 1:

Graph 1. Box plot of pain at rest (0-10 VAS scale) and range of motion (ROM) at day 0, 1, 2, 3, 7 and 21 after treatment with anakinra 100 mg per day.

Disclosure of Interests

None declared

High lead level in the Alps in XIXth century, learning from the analysis of 138 historical hair stands

Analysis of hair is known to provide useful information about environmental and toxic exposures. Very little historical use has been made of this type of investigation. Here we study 138 human hair samples from 19th century in France. In order to examine the potential association between contamination and historical health impacts, we characterized contamination by 33 elements in a set of hair strands sampled during the last quarter of the 19th century in the Savoy region of France. After a selected washing step on 138 hair strands conserved at the Museum National d'Histoire Naturelle in Paris (France), we assessed the presence of inorganics by ICP/MS, and lead level was higher than values reported in literature. We then compared concentrations and distributions between women and men, sampling locations and crossing gender and geographical origin. Hair lead level was high throughout Savoy at the end of the 19th century: significantly higher for people living in towns or industrial valleys, and lower for those of countryside and mountains areas. Environmental and economic changes (industrialization and urbanization with water adduction and leaded paints), living habits (kitchenware, cosmetics, wine, and tobacco), and local features (mines exploitation, railroad development, and industrialized narrow valleys) could be envisaged for explaining the level of lead contamination. In the same period, the two main industrial valleys of Savoy (Maurienne and Tarentaise) had high rates of endemic goiter and cretinism and among the highest hair lead levels. Other lines of evidence will need to be explore to investigate a possible link between historical Pb exposure and goiter in the study area.

Premedication with ketamine or propofol for less invasive surfactant administration (LISA): observational study in the delivery room

Less invasive surfactant administration (LISA) has become increasingly popular in neonatal intensive care units (NICUs), but there are currently no guidelines for the premedication prior to this procedure. The aim of this observational study was to compare the efficacy and tolerance of intravenous administrations of ketamine and propofol before LISA in neonates born before 30 weeks of gestational age (GA). The primary outcome was requirement of intubation within 2 h of the procedure. One hundred and fourteen infants, with respective GA and birthweight of 27.6 (26.4, 28.7) weeks and 940 (805, 1140) g, were prospectively included from January 2016 to December 2019. Drug doses were 1 (0.5, 1) mg/kg for ketamine and 1 (1, 1.9) mg/kg for propofol, providing comparable comfort during LISA (p = 0.61). Rates of intubation within 2 h were 5/52 after ketamine, and 5/62 after propofol [aOR 0.54 (0.11-2.68)]. No difference was observed for rates of intubation at 24 h and 72 h following LISA, mortality, or severe morbidity.Conclusion: Pending results from prospective trials, these findings suggest that ketamine or propofol can be used for premedication before LISA, as they show comparable efficacy and tolerance.Trial registration: This study was recorded on the National Library of Medicine registry (https:// clinicaltrials.gov / Identifier: NCT03705468). What is Known? • Less invasive surfactant administration (LISA) is increasingly used in spontaneously breathing premature infants supported with continuous positive airway pressure, but few data are available to guide adequate premedication for this procedure. What is New? • This observational study of 114 neonates, all less than 30-week gestational age and requiring surfactant without endotracheal tube in the delivery room, suggested that ketamine or propofol can be used for premedication before LISA with comparable efficacy and tolerance.

Efficacy and safety of methylphenidate on attention deficit hyperactivity disorder in children with Down syndrome

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common co-morbidity that affects up to 44% of children with Down syndrome (DS). There is a need for reliable, good quality research on the use of methylphenidate within this population. The objective of this study is to report our experience regarding the management of ADHD in these children using methylphenidate.

METHODS

This study is a retrospective observation of 21 children with DS, followed at Jérôme Lejeune Institute between 2000 and 2018. The diagnosis of ADHD was made using the Diagnostic and Statistical Manual of Mental Disorders criteria. Efficacy was measured as response or non-response on two main symptoms: attention/concentration and hyperactivity/impulsivity. Safety was evaluated by the presence or absence of side effects.

RESULTS

Sixteen out of the 21 children (76%) showed improvement with methylphenidate. The average age of treatment onset in responding children was 8 years and 10 months versus 6 years and 3 months in non-responders (P = 0.05). Average dose/weight was significantly different in responders and non-responders (0.82 vs. 0.54 mg/kg/day, respectively; P = 0.03). Twelve children out of 21 (57%) experienced side effects; only three experienced side effects severe enough to require treatment interruption. Most common side effects were loss of appetite and difficulties in falling asleep.

CONCLUSION

Methylphenidate was effective and safe in treating ADHD in 76% of cases in children with DS, with few serious side effects to report. Early diagnosis of ADHD is important to improve the quality of life, learning, inclusion and socialisation of children with DS.

Near-Infrared Spectroscopy: A Tool for Diagnosing Necrotizing Enterocolitis at Onset of Symptoms in Preterm Neonates with Acute Gastrointestinal Symptoms?

OBJECTIVE

In premature neonates, bloody stools and/or abdominal distension with feeding intolerance may be inaugural signs of necrotizing enterocolitis (NEC). We assessed the ability of near-infrared spectroscopy (NIRS) to distinguish those neonates with NEC soon after the occurrence of these symptoms.

STUDY DESIGN

We prospectively collected NIRS measurements of abdominal and cerebral regional tissue oxygen saturation (r-SO₂), with values masked by an opaque cover. Two physicians, blinded to the NIRS data, determined whether the gastrointestinal symptoms were related to NEC 10 days after symptom onset.

RESULTS

Forty-five neonates with mean (standard deviation [SD]) gestational, birth weight and postnatal ages of 31 (3.9) weeks, 1,486 (794) g, and 18 (14) days were enrolled over 30 months. Gastrointestinal symptoms were related to NEC in 23 patients and associated with other causes in 22. Analysis of the 48 hours of monitoring revealed comparable abdominal r-SO₂ and splanchnic-cerebral oxygenation ratio (SCOR) in patients with and without NEC (r-SO2: 47.3 [20.4] vs. 50.4 [17.8], p = 0.59, SCOR: 0.64 [0.26] vs. 0.69 [0.24], p = 0.51). Results were unchanged after NIRS analysis in 6-hour periods, and restriction of the analysis to severe NEC (i.e., grade 2 and 3, 57% of the NEC cases).

CONCLUSION

In this study, NIRS monitoring was unable to individualize NEC in premature infants with acute gastrointestinal symptoms.

Dissemination of newborn behavior observation skills after Newborn Individualized Developmental Care and Assessment Program (NIDCAP) implementation

Aim

To assess nurses’ ability to observe newborn behaviour after in situ training provided by caregivers with advanced practice certification in the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).

Design

Prospective observational study.

Methods

Twelve nurses viewed 20‐min films showing the behaviour of 10 premature newborns before, during and after the usual caregiving. The behaviour was rated on an observation sheet with 88 items distributed into six systems. The responses were compared to the reference ratings established by two professionals certified for this programme.

Results

Despite less accurate observations during care and for some components, the nurses generally showed a satisfactory ability to observe newborn behaviour after training by NIDCAP expert professionals. The dissemination of observation skills among caregivers may result in an improved quality of patient care and better communication among professionals in a department of neonatology.

Reconstruction using vascularized extensor indicis proprius tendon

The choice of the donor tendon in tendon reconstruction of the hand theoretically influences the results of the surgery because of the interactions of its structure with the healing process. The objective of our study was to specify the surgical bases of vascularized extensor indicis proprius (EIP) in tendon reconstruction of the hand and to present its application from a series of observations. According to our observations, the EIP's vascularization arises from a branch of the 2nd dorsal metacarpal artery, 3-4 cm proximally to the metacarpophalangeal joint (MCP). We demonstrate the feasibility and effectiveness of a vascularized EIP graft for finger flexor tendon reconstruction, for defects of the extensor mechanism at the MCP joint level and for reconstruction of the extensor pollicis longus. Our biomimetic approach in tendon reconstruction has led us to factor in the complexity of the tendon and peritendinous structure. The use of vascularized EIP offers theoretical advantages for the tendon healing process, demonstrates encouraging first results with interesting versatility and very low iatrogenicity.

15-Year trends in respiratory care of extremely preterm infants: Contributing factors and consequences on health and growth during hospitalization

OBJECTIVES

To review 15-year trends in respiratory care of extremely preterm infants managed in a tertiary perinatal center; to identify the factors contributing to their evolution; and to determine whether these changes had an impact on infant mortality, severe morbidity, and growth.

METHODS

Retrospective cohort study of infants born at 23 to 26 weeks' gestation between 2003 and 2017. Changes in respiratory care were assessed in three 5-year periods. Logistic regression was used to examine the factors associated with prolonged duration (ie, greater than the median) of invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and overall respiratory support (ORS), and those associated with adequate weight and head circumference growth.

RESULTS

Of the 396 actively treated neonates, 268 (68%) survived to discharge. Between the first and third periods, IMV duration decreased from 22 (6-37) to 4 (1-14.0) days (P < .001), that of NIV increased from 24 (14-34) to 56 (44-66) days (P < .001), and that of ORS from 50 (34-68) to 63 (52-77) days (P < .001). Study period (2003-2007 vs 2013-2017) was the main factor associated with prolonged IMV (P < .001). Use of high-flow nasal cannula was the main factor associated with prolonged NIV (P = .02) and ORS (P = .02). NIV duration was associated with adequate postnatal weight (P = .003) and head circumference (P = .03) growth. Severe morbidities in survivors, including bronchopulmonary dysplasia, and survival at hospital discharge were comparable across the study periods.

CONCLUSIONS

Respiratory management was characterized by a marked reduction in IMV. NIV withdrawal protocols are necessary to limit ORS duration while respecting postnatal growth requirements.

Imaging Study by Mass Spectrometry of the Spatial Variation of Cellulose and Hemicellulose Structures in Corn Stalks

The study used mass spectrometry imaging (MSI) to map the distribution of enzymatically degraded cell wall polysaccharides in maize stems for two genotypes and at several stages of development. The context was the production of biofuels, and the overall objective was to better describe the structural determinants of recalcitrance of grasses in bioconversion. The selected genotypes showed contrasting characteristics in bioconversion assays as well as in their lignin deposition pattern. We compared the pattern of cell wall polysaccharide degradation observed by MSI following the enzymatic degradation of tissues with that of lignin deposition. Several enzymes targeting the main families of wall polysaccharides were used. In the early stages of development, cellulose and mixed-linked β-glucans appeared as the main polysaccharides degraded from the walls, while heteroxylan products were barely detected, suggesting subsequent deposition of heteroxylans in the walls. At all stages and for both genotypes, enzymatic degradation occurred preferentially in nonlignified walls for all structural families of polysaccharides studied here. However, our results showed heterogeneity in the distribution of heteroxylan products according to their chemical structure: arabinosylated products were mostly represented in the pith center, while glucuronylated products were found at the pith periphery. The conclusions of our work are in agreement with those of previous studies. The MSI approach presented here is unique and attractive for addressing the histological and biochemical aspects of biomass recalcitrance to conversion, as it allows for a simultaneous interpretation of cell wall degradation and lignification patterns at the scale of an entire stem section.

Predicting value of prehospital body temperature for ICU admission of septic shock patients

To specify whether an association exists between pre-hospital body temperature collected by the emergency medical services (EMS) call centre, and intensive care unit (ICU) admission of patients with septic shock. An observational study based on data collected by the EMS of Paris. All septic shocks were included. Among, the 140 calls concerning septic shock, 22 patients (16%) were admitted to ICU. The mean core temperature was 37.4±1.6°C for ICU and 38.6±1.1°C (p<4.10^-5) for non-ICU patients. Using propensity score analysis, the relative risk for ICU admission of patients with pre-hospital fever or hypothermia was 0.31 and 2 respectively. The study highlights the potential usefulness of early temperature measurement in septic shock patients to allow early proper orientation.

Applying FAIR Principles to Plant Phenotypic Data Management in GnpIS

GnpIS is a data repository for plant phenomics that stores whole field and greenhouse experimental data including environment measures. It allows long-term access to datasets following the FAIR principles: Findable, Accessible, Interoperable, and Reusable, by using a flexible and original approach. It is based on a generic and ontology driven data model and an innovative software architecture that uncouples data integration, storage, and querying. It takes advantage of international standards including the Crop Ontology, MIAPPE, and the Breeding API. GnpIS allows handling data for a wide range of species and experiment types, including multiannual perennial plants experimental network or annual plant trials with either raw data, i.e., direct measures, or computed traits. It also ensures the integration and the interoperability among phenotyping datasets and with genotyping data. This is achieved through a careful curation and annotation of the key resources conducted in close collaboration with the communities providing data. Our repository follows the Open Science data publication principles by ensuring citability of each dataset. Finally, GnpIS compliance with international standards enables its interoperability with other data repositories hence allowing data links between phenotype and other data types. GnpIS can therefore contribute to emerging international federations of information systems.

Facilitated tucking during early neonatologist-performed echocardiography in very preterm neonates

AIM

To assess the effect of facilitated tucking (FT), a nonpharmacologic nursing intervention, on echocardiographic parameters and infant comfort collected prospectively during neonatologist-performed echocardiography.

METHODS

Echocardiography was performed twice, in standard conditions and with FT; the order was randomised by computer. Echocardiography provided data on pulmonary artery flow and pressure, right and left ventricular function, and persistent ductus arteriosus. Comfort was assessed by a behavioural scale of pain, variations in heart rate (HR) and SpO₂ , and a newborn infant parasympathetic evaluation index based on the high-frequency variability in HR.

RESULTS

Fifty newborns, with mean gestational age of 28 [26.6-29.0] weeks and mean birthweight of 950 [780-1190] g, were studied at a postnatal age of 13 [9-27] hours. FT was associated with longer acceleration time/right ventricular ejection time in the main pulmonary artery (p = 0.006), reduced averaged HR variations (p = 0.03) and lower pain scores (p < 0.001). The other haemodynamic parameters and the parasympathetic index were not influenced by FT.

CONCLUSION

Echocardiography performed soon after birth in very premature neonates may generate mild discomfort. FT during echocardiography is associated with lower pulmonary artery pressures and improves infant's comfort during this examination.

Occurence of legacy and novel brominated flame retardants in food and feed in France for the period 2014 to 2016

Determination of the occurrence levels of legacy and novel BFRs is today required to better understand the trends of BFRs contamination in food consecutive to the EU PBDEs restrictions and to proceed to a recent human food exposure in parallel. Therefore, concentrations of a large set of brominated flame retardants (BFRs) (n = 27) including PBDEs, HBCDDs, TBBPA and novel flame retardants (nBFRs) have been determined in more than 600 food and feed samples collected between 2014 and 2016 in the context of French monitoring plans. Although legacy BFRs had already been studied in France, such a survey constituted the very first determination of nBFRs occurrence in foodstuffs at the national level. The concentration levels measured in fish and fish products were in general higher than in the other food categories. PBDEs were detected in 70% of the samples and were observed as the most abundant congeners (representing 80% of the sum of the monitored BFRs), while α-HBCDD could also be considered as a predominant congener (up to 26% of the sum of the monitored BFRs in fishes). nBFRs concentration levels were most of the time below the LOQ, except PBT, PBBz and HBBz which were more frequently detected at low levels. Also investigated in the study, BRPs exhibited high concentration levels in crustaceous (maximum value > 2700 pg/g ww).

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

PURPOSE

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.

METHODS

A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH₂O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.

RESULTS

From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.

CONCLUSION

In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

[Congenital myotonic dystrophy type I in a very premature neonate: ethical concerns]

The congenital form of myotonic dystrophy type I (CDM1) corresponds to a>1500 expansion of an unstable trinucleotide (CTG) repeat. Two prognostic factors predict the risk of death in early infancy: maturity of less than 35 weeks of gestation and neonatal invasive ventilation for more than 30 days.

OBSERVATION

The case of a 29-week-old premature female infant, conceived by in vitro fertilization, is reported. Generalized hypotonia led to the diagnosis of the disease. Ethical concertation about withdrawal or maintenance of intensive care was engaged, taking into account the prolonged ventilation, the degree of prematurity, and the parental wishes for maximum care. The infant was extubated after 2 months. At 17 months, motor development and precursors of language were delayed, and difficulties in feeding had required a gastrostomy.

DISCUSSION

Technical advances in neonatal intensive care now allow CDM1 children to survive prolonged ventilation. The signification of such ventilatory needs on patient outcome, particularly for motor handicaps, speech and language delay, and mental deficiency, remains uncertain. The potential impact of in vitro fertilization on disease expression may also be considered.

CONCLUSION

CDM1 is a severe condition, but variability in clinical manifestations and absence of genotype-phenotype correlation result in problems predicting prognosis at the individual level. Ethical issues about the level of care, notably for tracheostomy and gastrostomy, should be adapted to each case, in partnership with parents.

Evidence for a vasomotor cyclo-oxygenase dependent mechanism of sensitization at the cutaneous level

AIMS

Current-induced vasodilation (CIV) is an axon-reflex response observed during monopolar current application such as iontophoresis. Cyclo-oxygenase derivates (COD) participate in CIV and act as sensitizing agents at the anodal level. Mechanisms involved during cathodal current application (CCA) are partially unknown. In a randomized double-blind crossover trial, we tested in 16 healthy subjects (i) the influence of the inter-stimulation interval (I-I) by comparing CIV following all-at-once 10 s CCA against 2 × 5 s CCA with intervals ranging from15 s-16 min and (ii) the participation of COD in CIV using 1 g aspirin or placebo intake.

METHODS

Measurements were repeated 2 h and 14 days after treatment. Laser Doppler flowmetry assessed cutaneous blood flow, reported in multiples of baseline.

RESULTS

Before treatment, peak vasodilation 10 min after the last current application (CVCstim2 ) increased compared with baseline whatever the I-I. Increase in CVCstim2 from baseline was greater for the 4 min (9.4 (5.3, 10.9) times; median (1(st) percentile, 3(rd) percentile)) and higher I-Is compared with all-at-once delivery (3.0 (2.1, 4.3) times, P < 0.05). The response was similar after placebo but aspirin abolished this vasodilation (increase by 1.2 (1.1, 1.3) times for all-at-once delivery and by 1.5 (1.3, 1.7) ± 0.3 times for 4 min interval, 2 h after aspirin intake) that recovered after 14 days.

CONCLUSIONS

This confirms the participation of COD in CIV with CCA and their sensitizing action. This model can represent an attractive way to study the axon-reflex and sensitizing function of COD in humans.

High-flow nasal cannula: recommendations for daily practice in pediatrics

High-flow nasal cannula (HFNC) is a relatively new device for respiratory support. In pediatrics, HFNC use continues to increase as the system is easily set up and is well tolerated by patients. The use of nasal cannula adapted to the infant’s nares size to deliver heated and humidified gas at high flow rates has been associated with improvements in washout of nasopharyngeal dead space, lung mucociliary clearance, and oxygen delivery compared with other oxygen delivery systems. HFNC may also create positive pharyngeal pressure to reduce the work of breathing, which positions the device midway between classical oxygen delivery systems, like the high-concentration face mask and continuous positive airway pressure (CPAP) generators. Currently, most of the studies in the pediatric literature suggest the benefits of HFNC therapy only for moderately severe acute viral bronchiolitis. But, the experience with this device in neonatology and adult intensive care may broaden the pediatric indications to include weaning from invasive ventilation and acute asthma. As for any form of respiratory support, HFNC initiation in patients requires close monitoring, whether it be for pre- or inter-hospital transport or in the emergency department or the pediatric intensive care unit.

[Endothelial function: role, assessment and limits]

For several years, detecting and preventing cardiovascular diseases have become a major issue. Different methods have been developed to evaluate endothelial function. Endothelial dysfunction is one of the first steps leading to atherosclerosis. This review presents an insight into endothelial function, the interests of its assessment and methods for studying endothelial function. To date, the vascular endothelium must be considered as a specific organ with its own functions that contribute to the homeostasis of the cardiovascular system. Endothelial dysfunction typically corresponds to a decrease of nitric oxide NO bioavailability. Biological or physico-chemical methods may be used to assess dysfunction. Biological methods allow measuring NO metabolites and pro-inflammatory and vasoconstrictor mediators released by the endothelium. The physico-chemical methods include intra-coronary injections, plethysmography, flow-mediated dilation (FMD), digital plethysmography and optical techniques using laser (laser Doppler single-point, laser Doppler imager, laser speckle contrast imaging) that can be coupled with provocation tests (iontophoresis, microdialysis, post-ischemic hyperemia, local heating). The principle of each technique and its use in clinical practice are discussed. Studying endothelial dysfunction is a particularly promising field because of new drugs being developed. Nevertheless, assessment methodology still needs further development to enable reliable, non-invasive, reproducible, and inexpensive ways to analyze endothelial dysfunction.

[Endothelial function: role, assessment and limits]

For several years, detecting and preventing cardiovascular diseases have become a major issue. Different methods have been developed to evaluate endothelial function. Endothelial dysfunction is one of the first steps leading to atherosclerosis. This review presents an insight into endothelial function, the interests of its assessment and methods for studying endothelial function. To date, the vascular endothelium must be considered as a specific organ with its own functions that contribute to the homeostasis of the cardiovascular system. Endothelial dysfunction typically corresponds to a decrease of nitric oxide NO bioavailability. Biological or physico-chemical methods may be used to assess dysfunction. Biological methods allow measuring NO metabolites and pro-inflammatory and vasoconstrictor mediators released by the endothelium. The physico-chemical methods include intra-coronary injections, plethysmography, flow-mediated dilation (FMD), digital plethysmography and optical techniques using laser (laser Doppler single-point, laser Doppler imager, laser speckle contrast imaging) that can be coupled with provocation tests (iontophoresis, microdialysis, post-ischemic hyperemia, local heating). The principle of each technique and its use in clinical practice are discussed. Studying endothelial dysfunction is a particularly promising field because of new drugs being developed. Nevertheless, assessment methodology still needs further development to enable reliable, non-invasive, reproducible, and inexpensive ways to analyze endothelial dysfunction.

Perfusion index and its dynamic changes in preterm neonates with patent ductus arteriosus

AIM

The perfusion index (PI) and its dynamic change during respiration, and supressed the plethysmographic variability index (PVI), are calculated from pulse oximetry, and these indexes were recently proposed for continuous and noninvasive assessment of peripheral perfusion in neonates. We aimed to assess the effect of patent ductus arteriosus (PDA) on PI and PVI, according to ductal Doppler flow pattern.

METHODS

Forty-five neonates with median (Q25-75) gestational age (GA) and birthweight of 27 (25-28) weeks and 857 (750-1080) grams, respectively, were assessed prospectively using serial echocardiography and pulse oximetry during the first postnatal week.

RESULTS

Perfusion index increased from 0.70 (0.50-1.05) at day 1 to 1.50 (1.0-2.00) at day 7 (p < 0.01) and was not influenced by ductal flow pattern. PVI was 22 (18-27) and did not vary during the study period but differed according to ductal flow pattern, with lower values in the growing and pulsatile groups compared with the pulmonary hypertension (p < 0.05), closing and closed groups (p < 0.01).

CONCLUSIONS

Ductal persistence and flow pattern did not affect PI but did affect PVI in preterm neonates of less than 29 weeks of GA. Future studies are needed to establish the usefulness of PVI in the early detection and management of PDA in preterm neonates.

Cutaneous microvascular functional assessment during exercise: a novel approach using laser speckle contrast imaging

Cardiovascular diseases are often revealed during exercise and are associated with cutaneous blood flow (CBF) dysfunction. Studies of CBF during exercise are consequently of interest. Laser speckle contrast imaging (LSCI) allows for non-contact and real-time recording of CBF at rest. We tested whether LSCI could allow the study of CBF during a cycling exercise using a specific signal treatment procedure that removes movement-induced artefacts from the LSCI raw signal. We recorded the baseline CBF and peak post-occlusive reactive hyperaemia (PORH) from the cutaneous forearm using LSCI and the mean blood pressure before and during cycling (80 W at 70 rpm) in nine healthy subjects. We determined the cross-correlation coefficient r between LSCI traces obtained before and during cycling and before and after a specifically designed signal processing technique. The results are presented as the median (25th-75th centile) and expressed as the cutaneous vascular conductance (laser speckle perfusion units (LSPU) per millimetre of mercury). Cross-correlation r increased from 0.226 ± 0.140 before to 0.683 ± 0.170 after post-processing. After signal processing, the peak PORH during exercise was reduced [0.38 (0.30-0.52) LSPU/mmHg] compared with the peak PORH during the non-exercise phase [0.69 (0.63-0.74) LSPU/mmHg, p < 0.01], whereas no difference was found between the baseline values. With adequate signal processing, LSCI appears valuable for investigating CBF during exercise. During constant-load lower limb cycling exercise, the upper limb peak PORH is reduced compared with the peak PORH during non-exercise. The underlying mechanisms warrant further investigations in both healthy (trained) subjects and diseased (e.g., coronary heart disease) patients.