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Mostert PF, Bos AP, van Harn J, de Jong IC. The impact of changing towards higher welfare broiler production systems on greenhouse gas emissions: a Dutch case study using life cycle assessment. Poult Sci 2022; 101:102151. [PMID: 36279609 PMCID: PMC9593752 DOI: 10.1016/j.psj.2022.102151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/21/2022] Open
Abstract
In the Netherlands, the Dutch Retail Broiler (DRB) and Better Life one Star (BLS) production systems have been introduced with the aim to improve broiler welfare. Simultaneously, retailers set targets for reduction of greenhouse gas (GHG) emissions in the whole broiler production chain. The GHG emissions of DRB and BLS may differ from conventional systems because of differences in slaughter age, feed intake, and diet composition. The aim of this study was to estimate GHG emissions of the conventional, DRB, and BLS production systems. A deterministic, spreadsheet based model was developed that included the breeder, hatchery, and broiler farm stages. First, the model calculates feed intake of different diets and energy use, based on performance objectives and literature. Selection of feed ingredients for the different types of diets was based on least cost formulation with nutritional constraints for each diet. Second, GHG emissions were estimated from cradle to broiler farm gate for processes along the broiler production chain by using life cycle assessment, and expressed as kg CO2-equivalents per kg live weight (kg CO2-eq/kg LW). Results showed that BLS (3.55 kg CO2-eq/kg LW) had lower GHG emissions compared to conventional (3.65 kg CO2-eq/kg LW) and DRB (3.98 kg CO2-eq/kg LW) at the broiler farm gate. Emissions from land use change (LUC) from feed production, mainly from soybean products, had highest impact on total GHG emissions (>50%) for the systems and these soybean products had the lowest inclusion in the diets of the BLS production system. Sensitivity analyses showed that variation in slaughter weight and feed intake could result in overlap of GHG emissions between systems. When soybean products were sourced from a country with low LUC emissions, conventional (1.37 kg CO2-eq/ kg LW) had the lowest GHG emissions and BLS (1.79 kg CO2-eq/kg LW) the highest. This study showed that origin of and including or excluding LUC emissions from soybean production results in different conclusions for achieving the GHG emissions reduction targets set by retailers.
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Affiliation(s)
- P F Mostert
- Wageningen Livestock Research, Wageningen University and Research, PO Box 338, 6700 AH Wageningen, the Netherlands.
| | - A P Bos
- Wageningen Livestock Research, Wageningen University and Research, PO Box 338, 6700 AH Wageningen, the Netherlands
| | - J van Harn
- Wageningen Livestock Research, Wageningen University and Research, PO Box 338, 6700 AH Wageningen, the Netherlands
| | - I C de Jong
- Wageningen Livestock Research, Wageningen University and Research, PO Box 338, 6700 AH Wageningen, the Netherlands
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2
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Schouten LR, van Kaam AH, Kohse F, Veltkamp F, Bos LD, de Beer FM, van Hooijdonk RT, Horn J, Straat M, Witteveen E, Glas GJ, Wieske L, van Vught LA, Wiewel MA, Ingelse SA, Cortjens B, van Woensel JB, Bos AP, Walther T, Schultz MJ, Wösten-van Asperen RM. Age-dependent differences in pulmonary host responses in ARDS: a prospective observational cohort study. Ann Intensive Care 2019; 9:55. [PMID: 31089908 PMCID: PMC6517452 DOI: 10.1186/s13613-019-0529-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/06/2019] [Indexed: 12/27/2022] Open
Abstract
Background Results from preclinical studies suggest that age-dependent differences in host defense and the pulmonary renin–angiotensin system (RAS) are responsible for observed differences in epidemiology of acute respiratory distress syndrome (ARDS) between children and adults. The present study compares biomarkers of host defense and RAS in bronchoalveolar lavage (BAL) fluid from neonates, children, adults, and older adults with ARDS. Methods In this prospective observational study, we enrolled mechanical ventilated ARDS patients categorized into four age groups: 20 neonates (< 28 days corrected postnatal age), 29 children (28 days–18 years), 26 adults (18–65 years), and 17 older adults (> 65 years of age). All patients underwent a nondirected BAL within 72 h after intubation. Activities of the two main enzymes of RAS, angiotensin converting enzyme (ACE) and ACE2, and levels of biomarkers of inflammation, endothelial activation, and epithelial damage were determined in BAL fluid. Results Levels of myeloperoxidase, interleukin (IL)-6, IL-10, and p-selectin were higher with increasing age, whereas intercellular adhesion molecule-1 was higher in neonates. No differences in activity of ACE and ACE2 were seen between the four age groups. Conclusions Age-dependent differences in the levels of biomarkers in lungs of ARDS patients are present. Especially, higher levels of markers involved in the neutrophil response were found with increasing age. In contrast to preclinical studies, age is not associated with changes in the pulmonary RAS. Electronic supplementary material The online version of this article (10.1186/s13613-019-0529-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura R Schouten
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Franziska Kohse
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany.,Department of Pharmacology and Therapeutics, School of Medicine and School of Pharmacy, University College Cork, Cork, Ireland
| | - Floor Veltkamp
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lieuwe D Bos
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Friso M de Beer
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roosmarijn T van Hooijdonk
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marleen Straat
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Esther Witteveen
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Gerie J Glas
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Luuk Wieske
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center of Experimental Molecular Medicine (CEMM), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Maryse A Wiewel
- Center of Experimental Molecular Medicine (CEMM), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Sarah A Ingelse
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bart Cortjens
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Job B van Woensel
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Thomas Walther
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany.,Department of Pharmacology and Therapeutics, School of Medicine and School of Pharmacy, University College Cork, Cork, Ireland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Roelie M Wösten-van Asperen
- Department of Pediatric Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands. .,Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
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3
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Flint RB, Brouwer CNM, Kränzlin ASC, Lie-A-Huen L, Bos AP, Mathôt RAA. Pharmacokinetics of S-ketamine during prolonged sedation at the pediatric intensive care unit. Paediatr Anaesth 2017; 27:1098-1107. [PMID: 29030928 DOI: 10.1111/pan.13239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND S-ketamine is the S(+)-enantiomer of the racemic mixture ketamine, an anesthetic drug providing both sedation and analgesia. In clinical practice, significant interpatient variability in drug effect of S-ketamine is observed during long-term sedation. AIMS The aim of this study was to evaluate the pharmacokinetic variability of S-ketamine in children aged 0-18 years during long-term sedation. Twenty-five children (median age: 0.42 years, range: 0.02-12.5) received continuous intravenous administrations of 0.3-3.6 mg/kg/h S-ketamine for sedation during mechanical ventilation. Infusion rates were adjusted to the desired level of sedation and analgesia based on the COMFORT-B score and Visual Analog Scale. Blood samples were drawn once daily at random time-points, and at 1 and 4 hours after discontinuation of S-ketamine infusion. Time profiles of plasma concentrations of S-ketamine and active metabolite S-norketamine were analyzed using nonlinear mixed-effects modeling software. Clearance and volume of distribution were allometrically scaled using the ¾ power model. RESULTS A total of 86 blood samples were collected. A 2-compartment and 1-compartment model adequately described the PK of S-ketamine and S-norketamine, respectively. The typical parameter estimates for clearance and central and peripheral volumes of distribution were: CLS-KETAMINE =112 L/h/70 kg, V1S-KETAMINE =7.7 L/70 kg, V2S-KETAMINE =545L/70 kg, QS-kETAMINE =196 L/h/70 kg, and CLS-NORKETAMINE =53 L/h/70 kg. Interpatient variability of CLS-KETAMINE and CLS-NORKETAMINE was considerable with values of 40% and 104%, respectively, leading to marked variability in steady-state plasma concentrations. CONCLUSION Substantial interpatient variability in pharmacokinetics in children complicates the development of adequate dosage regimen for continuous sedation.
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Affiliation(s)
- Robert B Flint
- Department of Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
| | - Carole N M Brouwer
- Pediatric Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Anne S C Kränzlin
- Pediatric Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Loraine Lie-A-Huen
- Department of Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert P Bos
- Pediatric Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
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4
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Geukers VG, Dijsselhof ME, Jansen NJG, Breur JMPJ, van Harskamp D, Schierbeek H, van Goudoever JB, Bos AP, Sauerwein HP. The effect of short-term high versus normal protein intake on whole-body protein synthesis and balance in children following cardiac surgery: a randomized double-blind controlled clinical trial. Nutr J 2015. [PMID: 26215396 PMCID: PMC4517637 DOI: 10.1186/s12937-015-0061-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Infants undergoing cardiac surgery are at risk of a negative protein balance, due to increased proteolysis in response to surgery and the cardiopulmonary bypass circuit, and limited intake. The aim of the study was to quantify the effect on protein kinetics of a short-term high-protein (HP) diet in infants following cardiac surgery. Methods In a prospective, double-blinded, randomized trial we compared the effects of a HP (5 g · kg−1 · d−1) versus normal protein (NP, 2 g · kg−1 · d−1) enteral diet on protein kinetics in children <24 months, on day 2 following surgical repair of congenital heart disease. Valine kinetics and fractional albumin synthesis rate (FSRalb) were measured with mass spectrometry using [1-13C]valine infusion. The Mann–Whitney U test was used to investigate differences between group medians. Additionally, the Hodges-Lehmann procedure was used to create a confidence interval with a point estimate of median differences between groups. Results Twenty-eight children (median age 9 months, median weight 7 kg) participated in the study, of whom in only 20 subjects isotopic data could be used for final calculations. Due to underpowering of our study, we could not draw conclusions on the primary outcome parameters. We observed valine synthesis rate of 2.73 (range: 0.94 to 3.36) and 2.26 (1.85 to 2.73) μmol · kg−1 · min−1 in the HP and NP diet, respectively. The net valine balance was 0.54 (−0.73 to 1.75) and 0.24 (−0.20 to 0.63) μmol · kg−1 · min−1 in the HP and NP group. Between groups, there was no difference in FSRalb. We observed increased oxidation and BUN in the HP diet, compared to the NP diet, as a plausible explanation of the metabolic fate of surplus protein. Conclusions It is plausible that the surplus protein in the HP group has caused the increase of valine oxidation and ureagenesis, compared to the NP group. Because too few patients had completed the study, we were unable to draw conclusions on the effect of a HP diet on protein synthesis and balance. We present our results as new hypothesis generating data. Trial registration Dutch Trial Register NTR2334.
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Affiliation(s)
- Vincent G Geukers
- Pediatric Intensive Care Department H8-190, Emma Children's Hospital (EKZ), Academic Medical Center (AMC), Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | | | - Nicolaas J G Jansen
- Pediatric Intensive Care Department, Wilhelmina Children's Hospital (WKZ), University Medical Center Utrecht (UMCUtrecht), Lundlaan 6, 3584, EA, Utrecht, The Netherlands.
| | | | | | - Henk Schierbeek
- Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | - Johannes B van Goudoever
- Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands. .,Department of Pediatrics, VU University Medical Center, Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - Albert P Bos
- Pediatric Intensive Care Department H8-190, Emma Children's Hospital (EKZ), Academic Medical Center (AMC), Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | - Hans P Sauerwein
- Department of Endocrinology and Metabolism (emeritus), AMC, Amsterdam, The Netherlands.
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5
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van den Berg E, Bal SM, Kuipers MT, Matute-Bello G, Lutter R, Bos AP, van Woensel JBM, Bem RA. The caspase inhibitor zVAD increases lung inflammation in pneumovirus infection in mice. Physiol Rep 2015; 3:3/3/e12332. [PMID: 25780096 PMCID: PMC4393166 DOI: 10.14814/phy2.12332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Severe respiratory syncytial virus (RSV) disease is a frequent cause of acute respiratory distress syndrome (ARDS) in young children, and is associated with marked lung epithelial injury and neutrophilic inflammation. Experimental studies on ARDS have shown that inhibition of apoptosis in the lungs reduces lung epithelial injury. However, the blockade of apoptosis in the lungs may also have deleterious effects by hampering viral clearance, and importantly, by enhancing or prolonging local proinflammatory responses. The aim of this study was to determine the effect of the broad caspase inhibitor Z-VAD(OMe)-FMK (zVAD) on inflammation and lung injury in a mouse pneumovirus model for severe RSV disease. Eight- to 11-week-old female C57BL/6OlaHsd mice were inoculated with the rodent-specific pneumovirus pneumonia virus of mice (PVM) strain J3666 and received multiple injections of zVAD or vehicle (control) during the course of disease, after which they were studied for markers of apoptosis, inflammation, and lung injury on day 7 after infection. PVM-infected mice that received zVAD had a strong increase in neutrophil numbers in the lungs, which was associated with decreased neutrophil apoptosis. Furthermore, zVAD treatment led to higher concentrations of several proinflammatory cytokines in the lungs and more weight loss in PVM-infected mice. In contrast, zVAD did not reduce apoptosis of lung epithelial cells and did not affect the degree of lung injury, permeability, and viral titers in PVM disease. We conclude that zVAD has an adverse effect in severe pneumovirus disease in mice by enhancing the lung proinflammatory response.
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Affiliation(s)
- Elske van den Berg
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Suzanne M Bal
- Department of Respiratory Medicine and Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Maria T Kuipers
- Laboratory of Experimental Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Gustavo Matute-Bello
- Division of Pulmonary and Critical Care Medicine, the Center for Lung Biology, University of Washington, Seattle, Washington, USA
| | - René Lutter
- Department of Respiratory Medicine and Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert P Bos
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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6
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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7
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Mulder HD, Augustijn QJ, van Woensel JB, Bos AP, Juffermans NP, Wösten-van Asperen RM. Incidence, risk factors, and outcome of transfusion-related acute lung injury in critically ill children: A retrospective study. J Crit Care 2015; 30:55-9. [DOI: 10.1016/j.jcrc.2014.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/07/2014] [Accepted: 10/04/2014] [Indexed: 12/30/2022]
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Abstract
BACKGROUND In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents. OBJECTIVE To discuss who can best protect a child's interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership. METHODS We describe the case of a 3-year-old boy with acquired brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians. CONCLUSIONS Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Antje A Seeber
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjef K M Gevers
- Department of Health Law, Division of Public Health & Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital/Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dick L Willems
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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9
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Schene KM, van den Berg E, Wösten-van Asperen RM, van Rijn RR, Bos AP, van Woensel JBM. FiO2 predicts outcome in infants with respiratory syncytial virus-induced acute respiratory distress syndrome. Pediatr Pulmonol 2014; 49:1138-44. [PMID: 24347224 DOI: 10.1002/ppul.22974] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 11/13/2013] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Respiratory syncytial virus (RSV) infection can progress to acute respiratory distress syndrome (ARDS) in infants. ARDS is a life-threatening condition that is characterized by severe hypoxemia, defined as PaO(2)/FiO(2) ratio <300 mmHg. This ratio is used in many trials as the sole oxygenation criterion for ARDS. Recently, however, it has been shown in adults with ARDS that FiO(2), independently of the PaO(2)/FiO(2) ratio predicts mortality. Because epidemiology and outcome of ARDS differ strongly between children and adults, we determined if FiO(2) on admission (baseline FiO(2)) independently predicted the duration of mechanical ventilation (MV) and length of stay (LOS) in the pediatric intensive care unit (PICU) in infants with RSV-induced ARDS. DESIGN Retrospective observational study. SETTING A 14-bed pediatric intensive care unit. PATIENTS One hundred twenty-nine mechanically ventilated infants with RSV-induced ARDS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Independent predictors for outcome, including baseline FiO(2) and PEEP, were analyzed using the cox regression model. Endpoints were duration of MV and LOS in the PICU. A higher baseline FiO(2) was independently associated with a longer duration of MV (HR 0.12, CI 0.02-0.87, P = 0.036) and increased LOS in the PICU (HR 0.09, CI 0.01-0.57, P = 0.023). Neither baseline PEEP nor PaO(2)/FiO(2) ratio correlated with outcome. CONCLUSIONS FiO(2) level independently predicted outcome in infants with RSV-induced ARDS, whereas both PEEP and the PaO(2)/FiO(2) ratio did not. This suggests that FiO(2) should be taken into account in defining disease severity in infants with RSV-induced ARDS.
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Affiliation(s)
- Kiry M Schene
- Pediatric Intensive Care Unit, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
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10
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van den Berg E, Bem RA, Bos AP, Lutter R, van Woensel JBM. The effect of TIP on pneumovirus-induced pulmonary edema in mice. PLoS One 2014; 9:e102749. [PMID: 25047452 PMCID: PMC4105480 DOI: 10.1371/journal.pone.0102749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/20/2014] [Indexed: 01/14/2023] Open
Abstract
Background Pulmonary edema plays a pivotal role in the pathophysiology of respiratory syncytial virus (RSV)-induced respiratory failure. In this study we determined whether treatment with TIP (AP301), a synthetic cyclic peptide that mimics the lectin-like domain of human TNF, decreases pulmonary edema in a mouse model of severe human RSV infection. TIP is currently undergoing clinical trials as a therapy for pulmonary permeability edema and has been shown to decrease pulmonary edema in different lung injury models. Methods C57BL/6 mice were infected with pneumonia virus of mice (PVM) and received TIP or saline (control group) by intratracheal instillation on day five (early administration) or day seven (late administration) after infection. In a separate set of experiments the effect of multiple dose administration of TIP versus saline was tested. Pulmonary edema was determined by the lung wet-to-dry (W/D) weight ratio and was assessed at different time-points after the administration of TIP. Secondary outcomes included clinical scores and lung cellular response. Results TIP did not have an effect on pulmonary edema in different dose regimens at different time points during PVM infection. In addition, TIP administration did not affect clinical severity scores or lung cellular response. Conclusion In this murine model of severe RSV infection TIP did not affect pulmonary edema nor course of disease.
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Affiliation(s)
- Elske van den Berg
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Reinout A. Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert P. Bos
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Rene Lutter
- Department of Respiratory Medicine and Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Job B. M. van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Schouten LR, Helmerhorst HJ, Wagenaar GT, Bos AP, Schultz MJ, Wösten-van-Asperen RM. Injurious ventilation has an age-dependent affect on the pulmonary renin-angiotensin system in LPS-challenged rats. Crit Care 2014; 18. [PMCID: PMC4069442 DOI: 10.1186/cc13525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- LR Schouten
- Academic Medical Center, Amsterdam, the Netherlands
| | | | - GT Wagenaar
- Leiden University Medical Center, Leiden, the Netherlands
| | - AP Bos
- Academic Medical Center, Amsterdam, the Netherlands
| | - MJ Schultz
- Academic Medical Center, Amsterdam, the Netherlands
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12
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Bruijn M, Jansen EM, Klapwijk T, van der Lee JH, van Rijn RR, van Woensel JBM, Bos AP. Association between C-reactive protein levels and outcome in acute lung injury in children. Eur J Pediatr 2013; 172:1105-10. [PMID: 23640022 DOI: 10.1007/s00431-013-2006-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 04/15/2013] [Indexed: 11/29/2022]
Abstract
UNLABELLED High plasma C-reactive protein (CRP) levels are associated with favorable outcome in adults with acute lung injury (ALI). The association between CRP levels and outcome has not been studied in ALI in children. We performed a historical cohort study in 93 mechanically ventilated children (0-18 years) with ALI. The CRP level within 48 h of disease onset was tested for association with 28-day mortality and ventilator-free days (VFD). Clinical parameters and ventilator settings were evaluated for possible confounding. Fourteen patients died within 28 days. The median (interquartile range) CRP level in nonsurvivors was 126 mg/L (64; 187) compared with 56 mg/L (20; 105) in survivors (p = 0.01). For every 10-mg/L rise in CRP level, the unadjusted odds (95% confidence interval (95% CI)) for mortality increased 8.7% (2.1-15.8%). Cardiovascular organ failure at onset of ALI was the strongest predictor for mortality (odds ratio, 30.5 (6.2-152.5)). After adjustment for cardiovascular organ failure, for every 10-mg/L rise in CRP level, the OR (95% CI) for mortality increased 4.7% (-2.7-12.6%; p = 0.22). Increased CRP levels were associated with a decrease in VFD (ρ = -0.26, p = 0.01). CONCLUSION increased plasma CRP levels are not associated with favorable outcome in ALI in children. This is in contrast with findings in adults with ALI.
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Affiliation(s)
- M Bruijn
- Pediatric Intensive Care Unit, Emma Children's Hospital/Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
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13
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Schene KM, van den Berg E, Wösten-van Asperen RM, van Rijn RR, Bos AP, van Woensel JBM. The predictive value of FiO2 for outcome of children with respiratory syncytial virus-induced acute respiratory distress syndrome. TIJDSCHR KINDERGENEESKUNDE 2013; 81:103. [PMID: 32288061 PMCID: PMC7103889 DOI: 10.1007/s12456-013-0100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K M Schene
- 333Pediatric Intensive Care Unit, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - E van den Berg
- 333Pediatric Intensive Care Unit, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - R M Wösten-van Asperen
- 333Pediatric Intensive Care Unit, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - R R van Rijn
- 334Department of Radiology, AMC, Amsterdam, The Netherlands
| | - A P Bos
- 333Pediatric Intensive Care Unit, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - J B M van Woensel
- 333Pediatric Intensive Care Unit, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
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14
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Abstract
Children with Down syndrome are at high risk for acute respiratory distress syndrome. In Down syndrome, both regulation of inflammation and apoptosis, important in acute respiratory distress syndrome pathophysiology, are abnormal. This has been linked to an imbalance in free radical scavengers. We investigated the expression of free radical scavengers and the effect of oxidative stress in terms of apoptosis and inflammation in respiratory epithelium from children with Down syndrome compared with control subjects. We cultured primary nasal epithelial cells from Down syndrome children (n=12) and controls (n=17) and exposed them to oxidative stress by supplementing superoxide. First we showed that the expression of the free radical scavengers CuZn-superoxide dismutase was 28% higher (p=0.06), catalase was 36% lower (p=0.04) and glutathione peroxidase was 73% lower (p=0.004) in Down syndrome children compared with controls. We found no significant difference in apoptosis, between Down syndrome and control subjects after exposure to oxidative stress. We also found no significant difference in levels of interleukin (IL)-1β, IL-6, IL-8, vascular endothelial growth factor and granulocyte colony-stimulating factor in primary nasal epithelial cell supernatant after exposure to oxidative stress between Down syndrome and control subjects. We found an imbalance in free radical scavengers in respiratory epithelial cells from children with Down syndrome, but this did not result in increased levels of either apoptosis or inflammation upon exposure to oxidative stress.
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Affiliation(s)
- Martijn Bruijn
- Emma Children's Hospital/Academic Medical Center, University of Amsterdam, Amsterdam
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15
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Bruijn M, von der Thüsen JH, van der Loos CM, de Krijger RR, van Loenhout RB, Bos AP, van Woensel JBM. Pulmonary epithelial apoptosis in fetal down syndrome: not higher than normal. Pediatr Dev Pathol 2012; 15:199-205. [PMID: 22369036 DOI: 10.2350/11-08-1080-oa.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Children with Down syndrome (DS) are at high risk for acute lung injury (ALI). Pulmonary epithelial apoptosis is an important factor in the pathophysiology of ALI. Whether the risk of ALI in DS is associated with a high level of pulmonary epithelial apoptosis is not known. We hypothesized that the percentage of apoptotic epithelial cells is higher in DS than in control lungs. Lung tissue sections from autopsies of 21 fetuses with DS and 12 controls were stained with antibodies against the epithelial marker pan-cytokeratin (CK) and apoptosis marker activated caspase-3 (aC3). Spectral imaging software was used to quantify the mean percentage of pixels that showed colocalization of CK and aC3. Mean (standard deviation [SD]) gestational age in weeks was 18.7 (1.4) in DS and 18.9 (2.0) in controls (P = 0.67). The mean (SD) percentage of CK-positive pixels was 27.2% (4.7%) in DS compared to 27.1% (6.2%) in controls (P = 0.97). The median (interquartile range [IQR]) percentage of CK-positive pixels that showed colocalization of aC3 was 0.16% (0.18%) in DS compared to 0.27% (0.24%) in controls (P = 0.45). The mean (SD) number of CK-positive pixels increased from 22.5% (5.2%) to 30.4% (4.6%) with the appearance of saccular morphology in controls but not in DS (P = 0.01). The percentage of apoptotic epithelial cells in DS fetal lungs does not differ from that in controls. However, we did find a difference in the development of epithelial structures between DS and controls that may be associated with anomalies in alveolar development found at birth in DS.
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Affiliation(s)
- Martijn Bruijn
- Emma Children's Hospital/Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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16
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Geukers VG, de Neef M, Dijsselhof ME, Sauerwein HP, Bos AP. Effect of a nurse-driven feeding algorithm and the institution of a nutritional support team on energy and macronutrient intake in critically ill children. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eclnm.2011.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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17
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Geukers VG, Li Z, Ackermans MT, Bos AP, Jinfeng L, Sauerwein HP. High-carbohydrate/low-protein-induced hyperinsulinemia does not improve protein balance in children after cardiac surgery. Nutrition 2012; 28:644-50. [PMID: 22261573 DOI: 10.1016/j.nut.2011.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 07/03/2011] [Accepted: 09/27/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In pediatric cardiac surgery, fluid-restricted low-protein (LoProt) diets account for cumulative protein deficits with increased morbidity. In this setting, we aimed to inhibit proteolysis by a high-carbohydrate (HiCarb)-intake-induced hyperinsulinemia and improve protein balance. METHODS The effect of a HiCarb/LoProt (glucose 10 mg · kg(-1) · min(-1)/protein 0.7 g · kg(-1) · d(-1)) versus a normal-carbohydrate (NormCarb)/LoProt (glucose 7.5 mg · kg(-1) · min(-1)/protein 0.3 g · kg(-1) · d(-1)) enteral diet on whole-body protein breakdown and balance was compared in a prospective, randomized, single-blinded trial in 24 children after cardiac surgery. On the second postoperative day, plasma insulin and amino acid concentrations, protein breakdown (endogenous rate of appearance of valine), protein synthesis (non-oxidative disposal of valine), protein balance, and the rate of appearance of urea were measured by using an isotopic infusion of [1-(13)C]valine and [(15)N(2)]urea. RESULTS The HiCarb/LoProt diet led to a serum insulin concentration that was three times higher than the NormCarb/LoProt diet (596 pmol/L, 80-1833, and 198 pmol/L, 76-1292, respectively, P = 0.02), without differences in plasma glucose concentrations. There were no differences in plasma amino acid concentrations, non-oxidative disposal of valine, and endogenous rate of appearance of valine between the groups, with a negative valine balance in the two groups (-0.65 μmol · kg(-1) · min(-1), -1.91 to 0.01, and -0.58 μmol · kg(-1) · min(-1), -2.32 to -0.07, respectively, P = 0.71). The serum cortisol concentration in the HiCarb/LoProt group was lower compared with the NormCarb/LoProt group (204 nmol/L, 50-544, and 532 nmol/L, 108-930, respectively, P = 0.02). CONCLUSION In children with fluid restriction after cardiac surgery, a HiCarb/LoProt diet compared with a NormCarb/LoProt diet stimulates insulin secretion but does not inhibit proteolysis further and therefore cannot be advocated for this purpose.
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Affiliation(s)
- Vincent G Geukers
- Pediatric Intensive Care Department, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands.
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18
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Wösten-van Asperen RM, Lutter R, Specht PA, Moll GN, van Woensel JB, van der Loos CM, van Goor H, Kamilic J, Florquin S, Bos AP. Acute respiratory distress syndrome leads to reduced ratio of ACE/ACE2 activities and is prevented by angiotensin-(1-7) or an angiotensin II receptor antagonist. J Pathol 2011; 225:618-27. [PMID: 22009550 DOI: 10.1002/path.2987] [Citation(s) in RCA: 236] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 08/03/2011] [Accepted: 08/12/2011] [Indexed: 12/20/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a devastating clinical syndrome. Angiotensin-converting enzyme (ACE) and its effector peptide angiotensin (Ang) II have been implicated in the pathogenesis of ARDS. A counter-regulatory enzyme of ACE, ie ACE2 that degrades Ang II to Ang-(1-7), offers a promising novel treatment modality for this syndrome. As the involvement of ACE and ACE2 in ARDS is still unclear, this study investigated the role of these two enzymes in an animal model of ARDS. ARDS was induced in rats by intratracheal administration of LPS followed by mechanical ventilation. During ventilation, animals were treated with saline (placebo), losartan (Ang II receptor antagonist), or with a protease-resistant, cyclic form of Ang-(1-7) [cAng-(1-7)]. In bronchoalveolar lavage fluid (BALF) of ventilated LPS-exposed animals, ACE activity was enhanced, whereas ACE2 activity was reduced. This was matched by enhanced BALF levels of Ang II and reduced levels of Ang-(1-7). Therapeutic intervention with cAng-(1-7) attenuated the inflammatory mediator response, markedly decreased lung injury scores, and improved lung function, as evidenced by increased oxygenation. These data indicate that ARDS develops, in part, due to reduced pulmonary levels of Ang-(1-7) and that repletion of this peptide halts the development of ARDS.
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Affiliation(s)
- Roelie M Wösten-van Asperen
- Department of Paediatric Intensive Care, Emma Children's Hospital/Academic Medical Centre, Amsterdam, The Netherlands.
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19
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Arah OA, Hoekstra JBL, Bos AP, Lombarts KMJMH. New tools for systematic evaluation of teaching qualities of medical faculty: results of an ongoing multi-center survey. PLoS One 2011; 6:e25983. [PMID: 22022486 PMCID: PMC3193529 DOI: 10.1371/journal.pone.0025983] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 09/14/2011] [Indexed: 11/19/2022] Open
Abstract
Background Tools for the evaluation, improvement and promotion of the teaching excellence of faculty remain elusive in residency settings. This study investigates (i) the reliability and validity of the data yielded by using two new instruments for evaluating the teaching qualities of medical faculty, (ii) the instruments' potential for differentiating between faculty, and (iii) the number of residents' evaluations needed per faculty to reliably use the instruments. Methods and Materials Multicenter cross-sectional survey among 546 residents and 629 medical faculty representing 29 medical (non-surgical) specialty training programs in the Netherlands. Two instruments—one completed by residents and one by faculty—for measuring teaching qualities of faculty were developed. Statistical analyses included factor analysis, reliability and validity exploration using standard psychometric methods, calculation of the numbers of residents' evaluations needed per faculty to achieve reliable assessments and variance components and threshold analyses. Results A total of 403 (73.8%) residents completed 3575 evaluations of 570 medical faculty while 494 (78.5%) faculty self-evaluated. In both instruments five composite-scales of faculty teaching qualities were detected with high internal consistency and reliability: learning climate (Cronbach's alpha of 0.85 for residents' instrument, 0.71 for self-evaluation instrument, professional attitude and behavior (0.84/0.75), communication of goals (0.90/0.84), evaluation of residents (0.91/0.81), and feedback (0.91/0.85). Faculty tended to evaluate themselves higher than did the residents. Up to a third of the total variance in various teaching qualities can be attributed to between-faculty differences. Some seven residents' evaluations per faculty are needed for assessments to attain a reliability level of 0.90. Conclusions The instruments for evaluating teaching qualities of medical faculty appear to yield reliable and valid data. They are feasible for use in medical residencies, can detect between-faculty differences and supply potentially useful information for improving graduate medical education.
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Affiliation(s)
- Onyebuchi A. Arah
- Department of Epidemiology, UCLA School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
- UCLA Center for Health Policy Research, Los Angeles, California, United States of America
- Department of Quality Management and Process Innovation, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost B. L. Hoekstra
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert P. Bos
- Department of Pediatrics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Kiki M. J. M. H. Lombarts
- Department of Quality Management and Process Innovation, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
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20
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van den Berg E, van Woensel JBM, Bos AP, Bem RA, Altemeier WA, Gill SE, Martin TR, Matute-Bello G. Role of the Fas/FasL system in a model of RSV infection in mechanically ventilated mice. Am J Physiol Lung Cell Mol Physiol 2011; 301:L451-60. [PMID: 21743025 DOI: 10.1152/ajplung.00368.2010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Infection with respiratory syncytial virus (RSV) in children can progress to respiratory distress and acute lung injury necessitating mechanical ventilation (MV). MV enhances apoptosis and inflammation in mice infected with pneumonia virus of mice (PVM), a mouse pneumovirus that has been used as a model for severe RSV infection in mice. We hypothesized that the Fas/Fas ligand (FasL) system, a dual proapoptotic/proinflammatory system involved in other forms of lung injury, is required for enhanced lung injury in mechanically ventilated mice infected with PVM. C57BL/6 mice and Fas-deficient ("lpr") mice were inoculated intratracheally with PVM. Seven or eight days after PVM inoculation, the mice were subjected to 4 h of MV (tidal volume 10 ml/kg, fraction of inspired O(2) = 0.21, and positive end-expiratory pressure = 3 cm H(2)O). Seven days after PVM inoculation, exposure to MV resulted in less severe injury in lpr mice than in C57BL/6 mice, as evidenced by decreased numbers of polymorphonuclear neutrophils in the bronchoalveolar lavage (BAL), and lower concentrations of the proinflammatory chemokines KC, macrophage inflammatory protein (MIP)-1α, and MIP-2 in the lungs. However, when PVM infection was allowed to progress one additional day, all of the lpr mice (7/7) died unexpectedly between 0.5 and 3.5 h after the onset of ventilation compared with three of the seven ventilated C57BL/6 mice. Parameters of lung injury were similar in nonventilated mice, as was the viral content in the lungs and other organs. Thus, the Fas/FasL system was partly required for the lung inflammatory response in ventilated mice infected with PVM, but attenuation of lung inflammation did not prevent subsequent mortality.
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Affiliation(s)
- Elske van den Berg
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
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21
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22
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de Vos MA, van der Heide A, Maurice-Stam H, Brouwer OF, Plötz FB, Schouten-van Meeteren AYN, Willems DL, Heymans HSA, Bos AP. The process of end-of-life decision-making in pediatrics: a national survey in the Netherlands. Pediatrics 2011; 127:e1004-12. [PMID: 21402634 DOI: 10.1542/peds.2010-2591] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to investigate how Dutch pediatric specialists reach end-of-life decisions, how they involve parents, and how they address conflicts. METHODS We conducted a national cross-sectional survey among pediatric intensivists, oncologists, neurologists, neurosurgeons, and metabolic pediatricians practicing in the 8 Dutch university hospitals. We collected information on respondents' overall opinions and their clinical practice. RESULTS Of the 185 eligible pediatric specialists, 74% returned the questionnaire. All responding physicians generally discuss an end-of-life decision with colleagues before discussing it with parents. In half of the reported cases, respondents informed parents about the intended decision and asked their permission. In one-quarter of the cases, respondents informed parents without asking for their permission. In the remaining one-quarter of the cases, respondents advised parents and consequently allowed them to have the decisive voice. The chosen approach is highly influenced by type of decision and type and duration of treatment. Conflicts within medical teams arose as a result of uncertainties about prognosis and treatment options. Most conflicts with parents arose because parents had a more positive view of the prognosis or had religious objections to treatment discontinuation. All conflicts were eventually resolved by a combination of strategies. In 66% of all cases, pain and symptom management were intensified before the child's death. CONCLUSIONS Within Dutch pediatrics, end-of-life decisions are team decisions. Pediatric specialists differ considerably in how they involve parents in end-of-life decision-making, ranging from benevolent paternalism to parental autonomy. Main conflict-solving strategies are taking more time and extending discussions.
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Affiliation(s)
- Mirjam A de Vos
- Department of Pediatrics, Academic Medical Centre/Emma Children's Hospital, PO Box 22660, 1100 DD Amsterdam, Netherlands.
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23
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Sillevis Smitt JH, van Woensel JBM, Bos AP. Skin lesions in children admitted to the paediatric intensive care unit: an observational study. Eur J Pediatr 2011; 170:1263-5. [PMID: 21365174 PMCID: PMC3175034 DOI: 10.1007/s00431-011-1436-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 02/15/2011] [Indexed: 11/30/2022]
Abstract
We analysed, by a prospective observational study over a 3-year period, the frequency and character of dermatological symptoms and diseases in children admitted to a tertiary general paediatric intensive care unit (PICU) of a university hospital. Skin problems were observed in 42 of 1,800 children admitted. There was a large variability in dermatological diseases in the PICU. In the majority (23/42), the skin problem was a dermatological manifestation of an underlying illness that caused admission to the PICU, e.g. infection, vasculitis or drug reaction. In four of the seven children who died, a direct relation between the dermatological disease and the cause of death could be established. Although the number of patients with relevant dermatological problems was limited, we believe that a skilled paediatric dermatologist is able to contribute to the effectiveness of diagnostic and therapeutic processes in paediatric intensive care patients.
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Affiliation(s)
- J Henk Sillevis Smitt
- Department of Dermatology, A0-228, Academic Medical Center, University of Amsterdam, Postbox 22660, 1100 DD Amsterdam, The Netherlands.
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24
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Wösten-van Asperen RM, Lutter R, Specht PAC, van Woensel JB, van der Loos CM, Florquin S, Lachmann B, Bos AP. Ventilator-induced inflammatory response in lipopolysaccharide-exposed rat lung is mediated by angiotensin-converting enzyme. Am J Pathol 2010; 176:2219-27. [PMID: 20304959 DOI: 10.2353/ajpath.2010.090565] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Angiotensin-converting enzyme (ACE) mediates the ventilator-induced inflammatory response in healthy lungs via angiotensin II (Ang II). A rat model was used to examine the role of ACE and Ang II in the inflammatory response during mechanical ventilation of preinjured (ie, lipopolysaccharide [LPS]-exposed) lungs. When indicated, rats were pretreated with the ACE inhibitor captopril and/or intratracheal administration of LPS. The animals were ventilated for 4 hours with moderate pressure amplitudes. Nonventilated animals served as controls. ACE activity and levels of Ang II and inflammatory mediators (interleukin-6, Cytokine-induced Neutrophil Chemoattractant (CINC)-3, interleukin-1beta, and interleukin-10) were determined in bronchoalveolar lavage fluid (BALF). The localization of ACE and Ang II type 1 receptor in lung tissue was determined by immunohistochemistry. The role of the Ang II pathway was assessed by using its receptor antagonist Losartan. Mechanical ventilation of LPS-exposed animals increased ACE activity and levels of inflammatory mediators in BALF compared with ventilated nonexposed and LPS-exposed nonventilated animals. Blocking ACE by captopril attenuated the lung inflammatory response. Furthermore, increased ACE activity in BALF was accompanied by increased levels of Ang II and enhanced expression of its receptor on alveolar cells. Blocking the Ang II receptor attenuated the inflammatory mediator response to a larger extent than by blocking ACE. In conclusion, during mechanical ventilation ACE, via Ang II, mediates the inflammatory response of both healthy and preinjured lungs.
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Affiliation(s)
- Roelie M Wösten-van Asperen
- Department of Pediatric Intensive Care, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.
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25
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Bronner MB, Peek N, Knoester H, Bos AP, Last BF, Grootenhuis MA. Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child. J Pediatr Psychol 2010; 35:966-74. [PMID: 20150338 DOI: 10.1093/jpepsy/jsq004] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To study posttraumatic stress disorder (PTSD) in parents after unexpected pediatric intensive care unit (PICU) treatment of their child and to identify risk factors for its development. METHOD Parents completed PTSD questionnaires 3 and 9 months (N = 190) after PICU treatment. Risk factors included pretrauma data, medical data, social demographics and posttraumatic stress responses at 3 months. RESULTS In total, 30.3% of parents met criteria for subclinical PTSD and 12.6% for clinical PTSD at 3 months. Clinical PTSD prevalence rates did not change over time. At 9 months, 10.5% of parents still met criteria for PTSD. Number of earlier stressful life events, earlier psychosocial care and posttraumatic stress responses at 3 months predicted persistent subclinical and clinical PTSD. CONCLUSIONS PICU admission is a stressful event associated with persistent parental PTSD. Assessment of risk factors can facilitate detection of persistent PTSD for early intervention.
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Affiliation(s)
- Madelon B Bronner
- Psychosocial Department, Emma Children's Hospital AMC, The Netherlands.
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26
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Bem RA, van Woensel JBM, Lutter R, Domachowske JB, Medema JP, Rosenberg HF, Bos AP. Granzyme A- and B-cluster deficiency delays acute lung injury in pneumovirus-infected mice. J Immunol 2009; 184:931-8. [PMID: 20018616 DOI: 10.4049/jimmunol.0903029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Lower respiratory tract infection by the human pneumovirus respiratory syncytial virus is a frequent cause of acute lung injury in children. Severe pneumovirus disease in humans is associated with activation of the granzyme pathway by effector lymphocytes, which may promote pathology by exaggerating proapoptotic caspase activity and proinflammatory activity. The main goal of this study was to determine whether granzymes contribute to the development of acute lung injury in pneumovirus-infected mice. Granzyme-expressing mice and granzyme A- and B-cluster single- and double-knockout mice were inoculated with the rodent pneumovirus pneumonia virus of mice strain J3666, and were studied for markers of lung inflammation and injury. Expression of granzyme A and B is detected in effector lymphocytes in mouse lungs in response to pneumovirus infection. Mice deficient for granzyme A and the granzyme B cluster have unchanged virus titers in the lungs but show a significantly delayed clinical response to fatal pneumovirus infection, a feature that is associated with delayed neutrophil recruitment, diminished activation of caspase-3, and reduced lung permeability. We conclude that granzyme A- and B-cluster deficiency delays the acute progression of pneumovirus disease by reducing alveolar injury.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
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27
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Abstract
Animal production systems that offer outdoor access to the animals have become increasingly popular in the Western world due to the growing general discontent of consumers with conventional bioindustrial farming practices. These open production systems offer improved animal welfare but may create new problems for animal health, resulting in increased food safety risks from bacterial, viral, or parasitic infections or environmental contaminants. Examples of these new problems include increased Toxoplasma gondii infections in pigs and high dioxin levels in eggs from free-range hens. In this review, the relation between positive and negative points of free-range and organic livestock production systems is discussed with reference to production in The Netherlands. We investigated how proponents of more animal welfare friendly systems deal with potential negative issues in public and whether any risk communication is used. Generally, we found that the existence of a dilemma is disputed or avoided in communication with the consumer. This avoidance could be detrimental for public trust in alternative animal production systems, should problems occur. To prevent future problems, it will be necessary to communicate about the relevant types and sources of the food safety risks to the consumers. The responsibility for protecting food safety should be properly divided among the various parties involved: producers, processors, governments, nongovernmental organizations, and consumers.
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Affiliation(s)
- A Kijlstra
- Animal Sciences Group, Wageningen University and Research Centre, 8200 AB Lelystad, The Netherlands.
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Bronner MB, Kayser AM, Knoester H, Bos AP, Last BF, Grootenhuis MA. A pilot study on peritraumatic dissociation and coping styles as risk factors for posttraumatic stress, anxiety and depression in parents after their child's unexpected admission to a Pediatric Intensive Care Unit. Child Adolesc Psychiatry Ment Health 2009; 3:33. [PMID: 19832987 PMCID: PMC2770447 DOI: 10.1186/1753-2000-3-33] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 10/15/2009] [Indexed: 11/26/2022] Open
Abstract
AIM To study the prevalence of posttraumatic stress disorder (PTSD), anxiety and depression in parents three months after pediatric intensive care treatment of their child and examine if peritraumatic dissocation and coping styles are related to these mental health problems. METHODS This is a prospective cohort study and included parents of children unexpectedly admitted to the Pediatric Intensive Care Unit (PICU) from January 2006 to March 2007. At three months follow-up parents completed PTSD (n = 115), anxiety and depression (n = 128) questionnaires. Immediately after discharge, parents completed peritraumatic dissocation and coping questionnaires. Linear regression models with generalized estimating equations examined risk factors for mental health problems. RESULTS Over 10% of the parents were likely to meet criteria for PTSD and almost one quarter for subclinical PTSD. Respectively 15% to 23% of the parents reported clinically significant levels of depression and anxiety. Peritraumatic dissocation was most strongly associated with PTSD, anxiety as well as depression. Avoidance coping was primarily associated with PTSD. CONCLUSION A significant number of parents have mental health problems three months after unexpected PICU treatment of their child. Improving detection and raise awareness of mental health problems is important to minimize the negative effect of these problems on parents' well-being.
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Affiliation(s)
- Madelon B Bronner
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Anne-Marie Kayser
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
| | - Hendrika Knoester
- Department of Paediatric Intensive Care, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
| | - Bob F Last
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands,Department of Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martha A Grootenhuis
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
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Bem RA, Bos AP, Wösten-van Asperen RM, Bruijn M, Lutter R, Sprick MR, van Woensel JBM. Potential role of soluble TRAIL in epithelial injury in children with severe RSV infection. Am J Respir Cell Mol Biol 2009; 42:697-705. [PMID: 19635930 DOI: 10.1165/rcmb.2009-0100oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Lower respiratory tract infection by respiratory syncytial virus (RSV) is a frequent cause of acute lung injury in young children and infants. Studies in adults and animals suggest that tumor necrosis factor receptor (TNFR) ligands may mediate lung injury by causing apoptosis of epithelial cells. The main goal of the present study was to determine whether the TNF-related apoptosis-inducing ligand (Apo2L/TRAIL) pathway may be implicated in epithelial injury during severe RSV infection in children. We report elevated levels of soluble (s)TRAIL released by leukocytes in bronchoalveolar lavage fluid (BALF) of patients with RSV-associated respiratory failure (n = 22) as compared with mechanically ventilated patients without pulmonary illness (n = 7). Primary bronchial epithelial cells of children without pulmonary disease obtained by nonbronchoscopic cytobrushing expressed both death receptors TRAIL-R1 and -R2, and were found to be susceptible for cell death by human recombinant sTRAIL in vitro. Furthermore, BALF from a patient with RSV induced cell death in these cells, which was partly attenuated by inhibiting TRAIL signaling. These data suggest that the TRAIL pro-apoptotic pathway may contribute to lung epithelial injury in severe RSV infection in children.
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Affiliation(s)
- Reinout A Bem
- Emma Children's Hospital, Academic Medical Center, Pediatric Intensive Care Unit, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
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Ehrlich TR, Von Rosenstiel IA, Grootenhuis MA, Gerrits AI, Bos AP. Long-term psychological distress in parents of child survivors of severe meningococcal disease. ACTA ACUST UNITED AC 2009; 8:220-4. [PMID: 16087557 DOI: 10.1080/13638490400022246] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study psychological distress in parents of child survivors of Severe Meningococcal Disease (SMD) after discharge of their child from the Paediatric Intensive Care Unit (PICU). METHODS This study approached parents of child survivors of SMD treated on the PICU between 1993-2001. Five cross-sectional groups were created for mothers and fathers separately. The five groups differed from each other by the period after discharge they entered the project (ranging from 3 months to 7 years after discharge). For research purposes, mothers and fathers (n = 192) individually completed the Goldberg General Health Questionnaire-30 (GHQ), measuring their level of psychological distress. STATISTICS Mean group scores were examined and a one-way-analysis of variance (ANOVA) performed to study differences between groups for mothers and fathers separately. In addition, percentages of parents with GHQ scores above cut-off were calculated and it was determined whether it differed from norm data. RESULTS Data reveal that both mothers and fathers experience high mean levels of psychological distress after discharge, showing no significant differences in group means over time. High percentages of parents experience psychological distress after discharge, if compared with the normal population. CONCLUSIONS Parents of child survivors of SMD experience profound and prolonged psychological distress after discharge. Future interventions should focus on follow-up care for this population to help them re-adjust after this stressful event.
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Affiliation(s)
- Tirtsa R Ehrlich
- Pediatric Psychosocial Department, Emma Children's Hospital/Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
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Bem RA, van Woensel JBM, Bos AP, Koski A, Farnand AW, Domachowske JB, Rosenberg HF, Martin TR, Matute-Bello G. Mechanical ventilation enhances lung inflammation and caspase activity in a model of mouse pneumovirus infection. Am J Physiol Lung Cell Mol Physiol 2008; 296:L46-56. [PMID: 18996903 DOI: 10.1152/ajplung.00467.2007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Severe infection with respiratory syncytial virus (RSV) in children can progress to respiratory distress and acute lung injury (ALI). Accumulating evidence suggests that mechanical ventilation (MV) is an important cofactor in the development of ALI by modulating the host immune responses to bacteria. This study investigates whether MV enhances the host response to pneumonia virus of mice (PVM), a mouse pneumovirus that has been used as a model for RSV infection in humans. BALB/c mice were inoculated intranasally with diluted clarified lung homogenates from mice infected with PVM strain J3666 or uninfected controls. Four days after inoculation, the mice were subjected to 4 h of MV (tidal volume, 10 ml/kg) or allowed to breathe spontaneously. When compared with that of mice inoculated with PVM only, the administration of MV to PVM-infected mice resulted in increased bronchoalveolar lavage fluid concentrations of the cytokines macrophage inflammatory protein (MIP)-2, MIP-1alpha (CCL3), and IL-6; increased alveolar-capillary permeability to high molecular weight proteins; and increased caspase-3 activity in lung homogenates. We conclude that MV enhances the activation of inflammatory and caspase cell death pathways in response to pneumovirus infection. We speculate that MV potentially contributes to the development of lung injury in patients with RSV infection.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Bronner MB, Knoester H, Bos AP, Last BF, Grootenhuis MA. Posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment compared to children who survived a major fire disaster. Child Adolesc Psychiatry Ment Health 2008; 2:9. [PMID: 18489798 PMCID: PMC2408565 DOI: 10.1186/1753-2000-2-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 05/20/2008] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The goals were to determine the presence of posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment, to identify risk factors for PTSD, and to compare this data with data from a major fire disaster in the Netherlands. METHODS Children completed the Dutch Children's Responses to Trauma Inventory at three and nine months after discharge from the paediatric intensive care unit (PICU). Comparison data were available from 355 children survivors who completed the same questionnaire 10 months after a major fire disaster. RESULTS Thirty-six children aged eight to 17 years completed questionnaires at three month follow-up, nine month follow-up, or both. More than one third (34.5%) of the children had subclinical PTSD, while 13.8% were likely to meet criteria for PTSD. Maternal PTSD was the strongest predictor for child PTSD. There were no significant differences in (subclinical) PTSD symptoms either over time or compared to symptoms of survivors from the fire disaster. CONCLUSION This study shows that a considerable number of children have persistent PTSD after PICU treatment. Prevention of PTSD is important to minimize the profound adverse effects that PTSD can have on children's well-being and future development.
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Affiliation(s)
- Madelon B Bronner
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Hendrika Knoester
- Department of Paediatric Intensive Care, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
| | - Bob F Last
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands,Department of Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martha A Grootenhuis
- Psychosocial Department, Emma Children's Hospital Academic Medical Center, University of Amsterdam, The Netherlands
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Knoester H, Bronner MB, Bos AP, Grootenhuis MA. Quality of life in children three and nine months after discharge from a paediatric intensive care unit: a prospective cohort study. Health Qual Life Outcomes 2008; 6:21. [PMID: 18331652 PMCID: PMC2292170 DOI: 10.1186/1477-7525-6-21] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 03/11/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Improved survival in children with critical illnesses has led to new disease patterns. As a consequence evaluation of the well being of survivors of Pediatric Intensive Care Units (PICU) has become important. Outcome assessment should therefore consist of evaluation of morbidity, functional health and Health Related Quality of Life (HRQoL). Awareness of HRQoL consequences and physical sequelae could lead to changes in support during the acute phase and thereafter. The aim of this study was to evaluate HRQoL in PICU survivors. METHODS Prospective follow-up study three and nine months after discharge from a 14-bed tertiary PICU. Eighty-one of 142 eligible, previously healthy children were included from December 2002 through October 2005. HRQoL was assessed with the TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL-PF) for children aged 1 to 6 years of age, the TNO-AZL Children's Quality of Life Questionnaire Parent Form (TACQOL-PF) for children aged 6 to 12 years of age, and the TNO-AZL Children's Quality of Life Questionnaire Child Form (TACQOL-CF) for children aged 8 to 15 years of age. The studied patients were compared with age appropriate normative data using non-parametric tests and effect sizes. RESULTS Thirty-one and 27 children, and 55 and 50 parents completed questionnaires respectively three and nine months after discharge. In 1-6 year old children parents reported more lung problems (3 and 9 months), worse liveliness (9 months) and better appetite and problem behaviour (3 months); in 6-12 year old children parents reported worse motor functioning (3 months); and 12-15 year old adolescents reported worse motor functioning (3 months). Large effect sizes indicating clinical significant differences in HRQoL with healthy control subjects were found on more domains. CONCLUSION In this small group of PICU survivors differences in HRQoL with the normative population exist three and nine months after discharge. Calculated effect sizes were smaller nine months after discharge. These changes suggest that HRQoL improves over time. More research is necessary but we believe that HRQoL assessment should be incorporated in follow-up programs of PICU survivors.
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Affiliation(s)
- Hendrika Knoester
- Paediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Madelon B Bronner
- Psychosocial Department, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Albert P Bos
- Paediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Martha A Grootenhuis
- Psychosocial Department, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Abstract
AIM To study the prevalence of posttraumatic stress in parents after an acute admission to a paediatric intensive care unit (PICU) and to determine risk factors for the development of posttraumatic stress. METHODS Parents completed posttraumatic stress questionnaires three months after their child's discharge. This questionnaire measures both symptoms of posttraumatic stress disorder (PTSD) and enables determination of the full psychiatric diagnosis of PTSD. Medical and demographic data concerning their child were gathered from physical evaluations three months after discharge. Of 250 eligible families, 144 (57.6%) participated in this study. The questionnaires were completed by 140 mothers and 107 fathers. RESULTS More than three-quarters of the parents experienced persistent symptoms of PTSD. In 21 mothers (15.0%) and 10 fathers (9.3%), the full psychiatric diagnosis of PTSD was determined. In six families, both parents had PTSD. Furthermore, a significant positive correlation was found between symptoms of PTSD of the mothers and the fathers. No obvious medical risk factors could be distinguished. CONCLUSION The unexpected admission of a child to a PICU is a stressful event associated with parental posttraumatic stress. Treatment should not end after discharge. Follow-up care is warranted and research should be focused on prevention of these symptoms.
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Affiliation(s)
- Madelon B Bronner
- Psychosocial Department, Emma Children's Hospital AMC, Amsterdam, The Netherlands.
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Bem RA, Bos AP, Bots M, Wolbink AM, van Ham SM, Medema JP, Lutter R, van Woensel JBM. Activation of the granzyme pathway in children with severe respiratory syncytial virus infection. Pediatr Res 2008; 63:650-5. [PMID: 18317234 PMCID: PMC7100119 DOI: 10.1203/pdr.0b013e31816fdc32] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Granzymes (Grs), serine proteases present in granules of effector lymphocytes, are involved in several host immune responses, including the activation of cell death and inflammatory pathways. The main goal of this study was to determine whether the local cell-mediated Gr pathway is activated during severe respiratory syncytial virus (RSV) lower respiratory tract illness (LRTI) in children. Tracheal aspirates (TA) from 23 children with RSV-LRTI and 12 controls without pulmonary disease were analyzed for Gr A and B. Bronchoalveolar lavage fluid samples from seven children with RSV-LRTI were analyzed for cellular expression of GrB. Levels of GrA and GrB in TA were significantly increased in RSV patients compared with controls and both Grs showed preserved activity. Gr levels correlated with the total leukocyte counts and IL-8 levels in the airways at several time points. However, no correlation between Gr levels and release of caspase-cleaved cytokeratin-18 was found. There was evidence for marked expression of GrB by both CD8(+) and CD4(+) T cells and natural killer cells in the respiratory tract. These findings suggest activation of the cell-mediated Gr pathway during severe RSV-LRTI in children.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Academic Medical Center, Amsterdam, 1100 DD, The Netherlands.
| | - Albert P Bos
- Pediatric Intensive Care Unit, Academic Medical Center, Amsterdam, 1100 DD The Netherlands
| | - Michael Bots
- Laboratory for Experimental Oncology and Radiobiology, Academic Medical Center, Amsterdam, 1100 DD The Netherlands
| | - Angela M Wolbink
- Department of Immunopathology, Academic Medical Center, Amsterdam, 1066 CX The Netherlands
| | - S Marieke van Ham
- Department of Immunopathology, Academic Medical Center, Amsterdam, 1066 CX The Netherlands
| | - Jan Paul Medema
- Laboratory for Experimental Oncology and Radiobiology, Academic Medical Center, Amsterdam, 1100 DD The Netherlands
| | - Rene Lutter
- Departments of Pulmonology and Experimental Immunology, Academic Medical Center, Amsterdam, 1100 DD The Netherlands
| | - Job B M van Woensel
- Pediatric Intensive Care Unit, Academic Medical Center, Amsterdam, 1100 DD The Netherlands
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Wösten-van Asperen RM, Lutter R, Haitsma JJ, Merkus MP, van Woensel JB, van der Loos CM, Florquin S, Lachmann B, Bos AP. ACE mediates ventilator-induced lung injury in rats via angiotensin II but not bradykinin. Eur Respir J 2007; 31:363-71. [PMID: 17959639 DOI: 10.1183/09031936.00060207] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventilator-induced lung injury is characterised by inflammation and apoptosis, but the underlying mechanisms are poorly understood. The present study proposed a role for angiotensin-converting enzyme (ACE) via angiotensin II (Ang II) and/or bradykinin in acute lung injury. The authors assessed whether ACE and, if so, Ang II and/or bradykinin are implicated in inflammation and apoptosis by mechanical ventilation. Rats were ventilated for 4 h with low- or high-pressure amplitudes in the absence or presence of the ACE inhibitor captopril. Nonventilated animals served as controls. ACE activity, Ang II and bradykinin levels, as well as inflammatory parameters (total protein, macrophage inflammatory protein-2 and interleukin-6) were determined. Apoptosis was assessed by the number of activated caspase-3 and TUNEL (terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate nick-end labelling)-positive cells. Bronchoalveolar lavage fluid ACE activity, levels of total protein, inflammatory parameters and the number of apoptotic cells were increased in the high-pressure amplitude group as compared with the control group. Blocking ACE activity by captopril attenuated inflammation and apoptosis in the latter group. Similar results were obtained by blocking Ang II receptors, but blocking bradykinin receptors did not attenuate the anti-inflammatory and anti-apoptotic effects of captopril. The current authors conclude that inflammation and apoptosis in ventilator-induced lung injury is, at least in part, due to angiotensin-converting enzyme-mediated angiotensin II production.
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Affiliation(s)
- R M Wösten-van Asperen
- Paediatric Intensive Care Dept, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands.
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Bruijn M, van der Aa LB, van Rijn RR, Bos AP, van Woensel JBM. High incidence of acute lung injury in children with Down syndrome. Intensive Care Med 2007; 33:2179-82. [PMID: 17673975 PMCID: PMC2092441 DOI: 10.1007/s00134-007-0803-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 07/06/2007] [Indexed: 01/11/2023]
Abstract
Objective Acute respiratory tract infection is a common reason for hospitalization in children with Down syndrome (CDS) and is characterized by a high morbidity. The severe course of disease in CDS may be related to a higher incidence of acute lung injury (ALI). This study evaluated the incidence of ALI and acute respiratory distress syndrome (ARDS) in mechanically ventilated CDS. Design and setting Retrospective cohort study in a pediatric ICU. Patients and participants Cases were all mechanically ventilated CDS admitted to our unit between January 1998 and July 2005. All mechanically ventilated patients without Down syndrome from January 1998 to January 2001 served as controls. Postoperative patients (cases and controls) and those with a cardiac left to right shunt were excluded. Measurements and results The main outcome measure was the incidence of ALI and ARDS. The criteria for ALI were met in 14 of 24 CDS (58.3%) in 41 of 317 of controls (12.9%; OR 9.4, 95% CI 3.9–22.6). The criteria for ARDS were met in 11 of 24 CDS (46%) and in 21 of 317 of controls (7%; OR 11.9, 95% CI 4.8–29.8). None of the CDS with ALI died; in the control group ten patients with ALI died. Conclusions CDS had a significantly higher incidence of ALI and ARDS than children without Down syndrome. The explanation for this remains to be elucidated; further study is necessary before clinical implications become clear.
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Affiliation(s)
- M Bruijn
- Emma Children's Hospital, Academic Medical Center, Pediatric Intensive Care Unit, PO Box 22660, 1100 DE Amsterdam, The Netherlands.
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Bos AP, van Zwieten MCB. Randomized, controlled trials in the emergency setting: a matter of physician-patient relationships, responsibility, and trust. Crit Care Med 2007; 35:979-80. [PMID: 17421105 DOI: 10.1097/01.ccm.0000257366.71279.e8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
CONTEXT Apoptosis of lung epithelial cells is implicated in the pathogenesis of acute lung injury. Most research on this subject has focused on adults. Very little is known about a potential interaction of this process with lung development in children. OBJECTIVE To summarize the current literature on lung epithelial cell apoptosis and common causes of acute lung injury in infants and young children and to identify new areas of research. DESIGN A Medline-based literature search. RESULTS AND CONCLUSIONS Few studies have focused on lung epithelial cell apoptosis during common causes of acute lung injury in children. Nevertheless, the limited literature suggests that this may be an important mechanism during respiratory distress syndrome of infants and viral respiratory tract infection. Apoptosis is an essential process during lung development and maturation. Insufficient attention has been paid to potential consequences of this for the short- and long-term outcomes of acute lung injury.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.
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Affiliation(s)
- Hendrika Knoester
- Paediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Boluyt N, Bollen CW, Bos AP, Kok JH, von Rosenstiel IA, Offringa M. [The practice guideline 'Volume suppletion in critically-ill neonates and children up to the age of 18 years' of the Dutch Paediatric Association]. Ned Tijdschr Geneeskd 2006; 150:2421-6. [PMID: 17131700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Hypovolaemia is the most common cause of circulatory failure in children. Treatment consists of volume suppletion with a crystalloid or colloid solution; which agent is the best in children is not clear. This evidence-based practice guideline formulates recommendations as to which fluid should be used for volume suppletion in critically-ill neonates and children up to the age of 18 years with hypovolaemia. Before the guideline development first-choice fluid for volume resuscitation was in 50% a colloid and in 50% a crystalloid solution for both neonatologists and paediatric intensivists. The neonatologists used human albumin as a priority, and the paeditric intensivists predominantly used a synthetic colloid. The guideline was developed on the basis of a comprehensive search and analysis of the literature according to the principles of evidence-based guideline development. The recommendations were formulated by a committee based on evidence from the literature and, when evidence from the literature was insufficient, on consensus after discussion in the committee. Since colloids are much more expensive than crystalloids and can give an anaphylactic reaction, their added value over crystalloids must be proven. In sick neonates and children, insufficient clinical trials have been done to reach the conclusion that colloids are more effective than crystalloids in hypovolaemia. A number of meta-analyses in adults revealed excess mortality in the group treated with albumin, but one recent, large, randomised study showed no difference in mortality. No added value could be demonstrated for the administration of synthetic colloids. On the basis of data from the literature and considerations regarding the applicability of evidence in adults to children and neonates, the side effects of resuscitation fluids, pathophysiology and costs, the first-choice fluid for neonates and children with hypovolaemia is isotonic saline. Albumin should not be used for the treatment of hypovolaemia. The volume to be administered and the infusion rate depend on the severity of the hypovolaemia and should be determined on an individual basis.
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Affiliation(s)
- N Boluyt
- Academisch Medisch Centrum/Universiteit van Amsterdam, Emma Kinderziekenhuis, Postbus 22.660, 1100 DD Amsterdam.
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van Woensel JBM, Bos AP, Lutter R, Rossen JWA, Schuurman R. Absence of human metapneumovirus co-infection in cases of severe respiratory syncytial virus infection. Pediatr Pulmonol 2006; 41:872-4. [PMID: 16850438 DOI: 10.1002/ppul.20459] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
It has been suggested that co-infection of human metapneumovirus (hMPV) in severe respiratory syncytial (RSV) virus bronchiolitis is very common. To evaluate the epidemiology of hMPV co-infection in children with severe lower respiratory tract infection caused by RSV virus. This was an observational cohort study in which hMPV and RSV viral load was measured by RT-PCR in tracheal specimens from the target population. hMPV could not be detected in any of the 30 mechanically ventilated children with RSV lower respiratory tract infection. Our study suggests that hMPV co-infection is not very common in severe RSV lower respiratory tract infection.
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Affiliation(s)
- J B M van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
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Dahlem P, Bos AP, Haitsma JJ, Schultz MJ, Wolthuis EK, Meijers JCM, Lachmann B. Mechanical ventilation affects alveolar fibrinolysis in LPS-induced lung injury. Eur Respir J 2006; 28:992-8. [PMID: 16837499 DOI: 10.1183/09031936.06.00133104] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the present study was to determine the effects of mechanical ventilation on alveolar fibrin turnover in lipopolysaccharide (LPS)-induced lung injury. In a randomised controlled trial, Sprague-Dawley rats (n = 61) were allocated to three ventilation groups after intratracheal LPS (Salmonella enteritidis) instillations. Group I animals were subjected to 16 cmH(2)O positive inspiratory pressure (PIP) and 5 cmH(2)O positive end-expiratory pressure (PEEP); group II animals to 26 cmH(2)O PIP and 5 cmH(2)O PEEP; and group III animals to 35 cmH(2)O PIP and 5 cmH(2)O PEEP. Control rats (not mechanically ventilated) received LPS. Healthy rats served as a reference group. Levels of thrombin-antithrombin complex (TATc), D-dimer, plasminogen activator inhibitor (PAI) activity and PAI-1 antigen in bronchoalveolar lavage fluid were measured. LPS-induced lung injury increased TATc, D-dimer and PAI activity and PAI-1 antigen levels versus healthy animals. High pressure-amplitude ventilation increased TATc concentrations. D-dimer concentrations were not significantly raised. Instead, PAI activity increased with the amplitude of the pressure, from 0.7 U.mL(-1) in group I to 3.4 U.mL(-1) in group II and 5.0 U.mL(-1) in group III. There was no change in PAI-1 antigen levels. In conclusion, mechanical ventilation creates an alveolar/pulmonary anti-fibrinolytic milieu in endotoxin-induced lung injury which, at least in part, might be due to an increase in plasminogen activator inhibitor activity.
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Affiliation(s)
- P Dahlem
- Dept of Anaesthesiology, Erasmus MC-Faculty Rotterdam, Rotterdam, Amsterdam.
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Boluyt N, Bollen CW, Bos AP, Kok JH, Offringa M. Fluid resuscitation in neonatal and pediatric hypovolemic shock: a Dutch Pediatric Society evidence-based clinical practice guideline. Intensive Care Med 2006; 32:995-1003. [PMID: 16791662 DOI: 10.1007/s00134-006-0188-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 04/12/2006] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop a clinical practice guideline that provides recommendations for the fluid, i.e. colloid or crystalloid, used for resuscitation in critically ill neonates and children up to the age of 18 years with hypovolemia. METHODS The guideline was developed through a comprehensive search and analysis of the pediatric literature. Recommendations were formulated by a national multidisciplinary committee involving all stakeholders in neonatal and pediatric intensive care and were based on research evidence from the literature and, in areas where the evidence was insufficient or lacking, on consensus after discussions in the committee. RESULTS Because of the lack of evidence in neonates and children, trials conducted in adults were considered. We found several recent meta-analyses that show excess mortality in albumin-treated groups, compared with crystalloid-treated groups, and one recent large randomized controlled trial that found evidence of no mortality difference. We found no evidence that synthetic colloids are superior to crystalloid solutions. CONCLUSIONS Given the state of the evidence and taking all other considerations into account, the guideline-developing group and the multidisciplinary committee recommend that in neonates and children with hypovolemia the first-choice fluid for resuscitation should be isotonic saline.
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Affiliation(s)
- Nicole Boluyt
- Department of Pediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
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Sluiter JK, Bos AP, Tol D, Calff M, Krijnen M, Frings-Dresen MHW. Is staff well-being and communication enhanced by multidisciplinary work shift evaluations? Intensive Care Med 2005; 31:1409-14. [PMID: 16132886 DOI: 10.1007/s00134-005-2769-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Accepted: 07/25/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study the implementation of multidisciplinary structured work shift evaluations at a pediatric intensive care unit (PICU) to enhance team communication. DESIGN AND SETTING Prospective, repeated measurements design, comparison of pre/post measurements and process measures in a Dutch tertiary care, university-affiliated PICU. PARTICIPANTS All 61 PICU staff members. INTERVENTIONS Implementing multidisciplinary structured work shift evaluations. Before the implementation phase the PICU team received feedback training and eight participants (four physicians, four nurses) were trained as "work shift evaluation leader." MEASUREMENTS AND RESULTS Outcome measures covered: (a) quality and process of the implementation through prestructured checklists during the 3 months of implementation, (b) a subjective evaluation of a feedback training on team communication as anticipated action and on the level of communication (about patients and with colleagues), and (c) emotional exhaustion complaints and work-related fatigue. The interdisciplinary structured work shift evaluations were implemented successfully as planned during the work shift; all staff were trained ahead, and the process was followed almost completely. Almost two-thirds (62%) of the staff felt a positive influence on team communication. Almost all staff members (92%) were satisfied regarding communication with their colleagues after the intervention, compared to 76% before. Emotional exhaustion in the PICU team decreased significantly after the implementation, but no differences in work-related fatigue levels were found. CONCLUSIONS As organizational change the implementation of a multidisciplinary structured work shift evaluation at a PICU was successful and team communication improved. Emotional exhaustion decreased during the study period.
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Affiliation(s)
- Judith K Sluiter
- Coronel Institute for Occupational and Environmental Health, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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van Woensel JBM, Biezeveld MH, Hack CE, Bos AP, Kuijpers TW. Elastase and granzymes during meningococcal disease in children: correlation to disease severity. Intensive Care Med 2005; 31:1239-47. [PMID: 16010574 DOI: 10.1007/s00134-005-2720-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Accepted: 06/21/2005] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the levels of human neutrophil elastase and lymphocyte-derived granzymes A and B in relation to disease severity in children with meningococcal disease. DESIGN Clinical observational cohort study. SETTING Paediatric intensive care unit. PATIENTS All patients with meningococcal disease during the study period were included. MEASUREMENTS AND RESULTS Blood sampling was done on the day of admission and on days 3 and 7. Assays for elastase and granzymes were done with ELISA. Sixty-one patients were included: 19 having distinct meningitis; 17 meningitis and shock; and 25 fulminant septicaemia. On admission levels of elastase were increased in all patients, being highest in those with fulminant septicaemia and lowest in those with distinct meningitis. Granzyme A (although marginally) and granzyme B levels were only increased in patients with shock. In 20 of the 28 patients admitted for > or = 3 days elastase decreased from admission ("rapid-decrease" group). In the remaining 8 patients, elastase started to decrease after 2 days ("slow-decrease" group). Patients of the "slow-decrease" group had a higher temperature up to day 4, needed more respiratory support (mean airway pressure in cm H2O on days 3 and 4: p=0.02 and p<0.01, respectively), and more circulatory support (>2 inotropic agents on day 3; p=0.04) compared with the "rapid-decrease" group. CONCLUSIONS Human neutrophil elastase and granzyme B are related with disease severity during the initial phase of meningococcal disease and prolonged neutrophil activation is associated with the extent of organ dysfunction during the period thereafter.
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Affiliation(s)
- Job B M van Woensel
- Paediatric Intensive Care Unit, Emma Children's Hospital, Academic Medical Center, P.O. Box 22660, 1100DD Amsterdam, The Netherlands.
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van den Broek AJM, Gemke RJBJ, Bos AP, Heij HA. [Late presentation of congenital diaphragmatic hernia]. Ned Tijdschr Geneeskd 2005; 149:1081-5. [PMID: 15932131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
A boy aged 6 months and a girl aged 9 months were admitted due to vomiting, among others, and a boy aged 11 months due to pneumonia. It turned out that they had a congenital diaphragmatic hernia. Primary operative repair was performed successfully in all patients, followed by recovery. The older boy experienced a relapse nearly 1 year later, which was treated by surgical correction. Most congenital diaphragmatic hernias present directly after birth, with cyanosis and respiratory distress. However, 10-20% of the cases are discovered after this period. In these children diagnosis can be difficult because of the diverse symptoms such as vomiting, feeding difficulties, tachypnoea or recurrent respiratory tract infections. Physical signs include the absence of breath sounds or the presence of bowel sounds in the chest. Chest X-ray, contrast upper gastrointestinal series or ultrasound imaging confirms the diagnosis. Delay in treatment can lead to complications such as necrosis of the bowel. In young children with acute or chronic respiratory infections or gastrointestinal complaints, a congenital diaphragmatic defect should be considered.
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Affiliation(s)
- A J M van den Broek
- Afd. Kindergeneeskunde, Emma Kinderziekenhuis/Academisch Medisch Centrum, Amsterdam
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