Congenital toxoplasmosis and audiological outcome: from a case series to a suggestion of patient-based schedule

Introduction

Sensorineural hearing loss (SNHL) has been suggested to be possibly related to congenital toxoplasmosis (CT), although its prevalence varies from 0% to 26%. This variance appears to be dependent especially on early timing of treatment. However, the available data are based on outdated studies conducted on small groups of patients that lack homogeneity. Therefore, to establish evidence-based guidelines for audiologic monitoring in CT, we conducted a comprehensive evaluation of a large case series over a long period of time.

Patients and methods

This is a single-center, retrospective cohort that enrolled all infants and children who were exposed in utero to Toxoplasma gondii and/or congenitally infected between September 1980 and December 2022. They underwent standard serial audiological evaluations to detect possible SNHL at an early stage. The first evaluation was performed during the initial assessment to define the onset of congenital toxoplasmosis, with another evaluation conducted at least at 12 months of life.

Results

We collected data from 1,712 patients, and 183 (10.7%) were diagnosed with CT. Among these cases, 78 children (42.6%) presented with symptomatic CT at the onset, exhibiting ocular findings (21.1%), clinical cerebral manifestations (6.1%), and/or abnormal findings on neuroimaging (35.5%). Therapy was administrated at the onset in 164 patients (89.6%) with 115 of them starting treatment prior to 2.5 months of age (0-388, median 32.00 ± 92.352 days of life). Only one patient presented with SNHL at the onset, but this was apparently unrelated to CT. The median number of audiological assessments was 2.2 ± 1.543 (2-10). No patients developed any grade of delayed hearing loss, both in treated and untreated groups. The median age at last audiological evaluation was 2.3 ± 2.18 years (1-8), although the median follow-up period was 12.4 years (±6.3), ranging from 1 to 27 years.

Conclusions

Based on these data, it appears that SNHL may be less frequent in CT than previously assumed. We recommend conducting an audiological assessment at the onset (within the first 2.5 months of life) to comprehensively define the type of CT onset, and then conducting another evaluation within 9 months of life.

Congenital cytomegalovirus infection: the state of the art and future perspectives

Congenital cytomegalovirus (cCMV) infection is the most common congenital infection, with an estimated incidence of approximately one in 200 infants in high-income settings. Approximately one in four children may experience life-long consequences, including sensorineural hearing loss and neurodisability. Knowledge regarding prevention, diagnosis, and treatment increased in the recent years, but some challenges remain. In this review, we tried to summarize the current knowledge on both the obstetrical and pediatric areas, while also highlighting controversial aspects and future perspectives. There is a need to enhance awareness among the general population and pregnant women through specific information programs. Further research is needed to better define the classification of individuals at birth and to have a deeper understanding of the long-term outcomes for so defined children. Finally, the availability of valaciclovir medication throughout pregnancy, where appropriate, has prompted the assessment of a universal serological antenatal screening. It is recommended to establish a dedicated unit for better evaluation and management of both mothers and children.

Association between comorbidities and blood pressure trajectories in patients with hypertension

Background

Our knowledge of how to better manage elevated blood pressure in presence of comorbidities is limited; in part due to exclusion or underrepresentation of multimorbid patients from major clinical trials.

Purpose

To investigate the burden and types of comorbidities in patients with hypertension, to assess how such comorbidities and other variables affect blood pressure levels over time.

Methods

The study was conducted using linked electronic health records from the UK Clinical Practice Research Datalink study from its inception on 1 January 1985 to 30 September 2015. Using linked electronic health records, we compared systolic blood pressure levels among 295,487 patients with diagnosed hypertension by type and numbers of major comorbidities from at least 5 years before to up to 10 years after hypertension diagnosis. We used a multiple landmark cohort design in order to investigate associations prospectively with time-updated information that takes advantage of the dynamic nature of electronic health records.

Results

Time-updated multivariable linear regression analyses showed that the presence of more comorbidities was independently associated with lower blood pressure during follow-up. This negative association was not specific to particular types of comorbidities; although associations were stronger in those with pre-existing cardiovascular disease. Tracking patients backwards to years prior to hypertension diagnosis revealed that the association between comorbidities and blood pressure were even more pronounced in years before hypertension diagnosis. Despite substantial declines in blood pressure in the first year after diagnosis, subsequent changes were modest, with no evidence of a more rapid decline in those with more or specific types of comorbidities.

Conclusions

Blood pressure levels at which patients were diagnosed with hypertension varied substantially and were lower when patients had more comorbidities. This early selection bias was a key determinant of long-term differences in blood pressure by comorbidity status and provides an additional explanation for the lower blood pressure in multimorbid patients.

Mean SBP (mmHg) over time

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National Institute for Health Research Oxford Biomedical Research Centre, Rhodes Trust and Clarendon Fund

Pediatric cardiac computed tomography angiography: Expert consensus from the Filiale de Cardiologie Pédiatrique et Congénitale (FCPC) and the Société Française d'Imagerie Cardiaque et Vasculaire diagnostique et interventionnelle (SFICV)

This article was designed to provide a pediatric cardiac computed tomography angiography (CCTA) expert panel consensus based on opinions of experts of the Société Française d'Imagerie Cardiaque et Vasculaire diagnostique et interventionnelle (SFICV) and of the Filiale de Cardiologie Pédiatrique Congénitale (FCPC). This expert panel consensus includes recommendations for indications, patient preparation, CTA radiation dose reduction techniques, and post-processing techniques. The consensus was based on data from available literature (original papers, reviews and guidelines) and on opinions of a group of specialists with extensive experience in the use of CT imaging in congenital heart disease. In order to reach high potential and avoid pitfalls, CCTA in children with congenital heart disease requires training and experience. Moreover, pediatric cardiac CCTA protocols should be standardized to acquire optimal images in this population with the lowest radiation dose possible to prevent unnecessary radiation exposure. We also provided a suggested structured report and a list of acquisition protocols and technical parameters in relation to specific vendors.

4D flow MRI versus conventional 2D for measuring pulmonary flow after Tetralogy of Fallot repair

BACKGROUND

After tetralogy of Fallot (TOF) repair, pulmonary regurgitation and right ventricular function must be monitored. Conventional (2D) cardiac magnetic resonance (CMR) is currently the clinical reference method for measuring pulmonary regurgitation. However, 4DFlow CMR has been reported to provide a more comprehensive flow analysis than 2D CMR. We aimed to compare 4DFlow CMR to 2D CMR for assessing pulmonary regurgitation and flow, as well as aortic flow, in children and adults after surgical repair of TOF.

METHODS

Retrospective analysis of patients with repaired TOF admitted for cardiac MRI with 4DFlow acquisition from 2016 to 2018. Linear regression was used to assess correlations and Bland-Altman analyses were performed.

RESULTS

The 60 included patients had a mean age of 18.2 ± 10.4 years (range, 2-54 years). Significant correlations between the two techniques were found for pulmonary regurgitant fraction (R [2] = 0.6642, p < 0.0001), net pulmonary flow (R [2] = 0.6782, p < 0.0001), forward pulmonary flow (R [2] = 0.6185, p < 0.0001), backward pulmonary flow (R [2] = 0.8192, p < 0.0001), and aortic valve flow (R [2] = 0.6494, p < 0.0001). The Bland-Altman analysis showed no significant bias, narrow limits of agreement, and few scattered points. The correlation between pulmonary and aortic flow was better with 4DFlow CMR than with 2D CMR (R [2] = 0.8564, p < 0.0001 versus R [2] = 0.4393, p < 0,0001, respectively). Interobserver reliability was good.

CONCLUSION

These results establish the feasibility and reliability of 4DFlow CMR for assessing pulmonary flow in a large paediatric and adult population with repaired TOF. 4DFlow CMR may be more reliable than 2D MRI for pulmonary flow assessment after TOF repair.

Quasifree Neutron Knockout from ^{54}Ca Corroborates Arising N=34 Neutron Magic Number

Exclusive cross sections and momentum distributions have been measured for quasifree one-neutron knockout reactions from a ^{54}Ca beam striking on a liquid hydrogen target at ∼200  MeV/u. A significantly larger cross section to the p_{3/2} state compared to the f_{5/2} state observed in the excitation of ^{53}Ca provides direct evidence for the nature of the N=34 shell closure. This finding corroborates the arising of a new shell closure in neutron-rich calcium isotopes. The distorted-wave impulse approximation reaction formalism with shell model calculations using the effective GXPF1Bs interaction and ab initio calculations concur our experimental findings. Obtained transverse and parallel momentum distributions demonstrate the sensitivity of quasifree one-neutron knockout in inverse kinematics on a thick liquid hydrogen target with the reaction vertex reconstructed to final state spin-parity assignments.

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

BACKGROUND

Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies.

OBJECTIVES

The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use.

STUDY DESIGN

This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26⁺⁰ and 31⁺⁶ weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio.

RESULTS

Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal.

CONCLUSION

In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Imaging of congenital anomalies of the coronary arteries

Congenital abnormalities of the coronary arteries are extremely variable and include anomalies of their origin (atresia, anomalies of origin from the aorta or from the pulmonary artery), the course of the epicardiac coronary branches (intramural, myocardial bridge) and distal connections (coronary-cardiac chamber fistulae). In pediatric practice, the diagnosis relies on ultrasound which should be supplemented by additional cardiac imaging in most cases. Multidetector CT is the most widely used imaging technique to identify abnormal courses and relationships with the greater vessels. In this paper, the important diagnostic and prognostic features in the interpretation of coronary imaging in pediatric practice is discussed.

Surgical Pleth Index guided analgesia blunts the intraoperative sympathetic response to laparoscopic cholecystectomy

BACKGROUND

Surgical noxious stimuli generate a stress response with an increased sympathetic activity, potentially affecting the perioperative outcome. Surgical Pleth Index (SPI), derived from the pulse plethysmogram, has been proposed as a tool to assess nociception-antinociception balance. The relationship between SPI and autonomic nervous system (ANS) during general anesthesia is poorly understood and it is doubtful if SPI-guided analgesia may offer advantages over the standard clinical practice. The study was designed to evaluate if SPI-guided analgesia leads to a lower sympathetic modulation compared with standard clinical practice.

METHODS

Electrocardiographic wave, non-invasive blood pressure and SPI were recorded in ASA I-II patients undergoing elective laparoscopic cholecystectomy, randomized to receive SPI-guided analgesia or standard analgesia. Hemodynamic parameters, SPI, mean and variance of heart rate, low (LF) and high frequency (HF) spectral components of heart rate variability were measured at four time points: (T0) baseline, (T1) after induction of general anesthesia, (T2) after pneumoperitoneum insufflation and (T3) after pneumoperitoneum withdrawal.

RESULTS

SPI, hemodynamic and ANS parameters changed significantly in both groups during the study period (P<0.0001). At T2 SPI and markers of sympathetic modulation were significantly lower in SPI group (mean [SD] SPI 38.1 [15.3] vs. 48.1 [16.2] normalized units, P<0.05; LF 38 [8.6] vs. 56.2 [20.6] normalized units, P<0.01; LF/HF 1.01 [1.1] vs. 2.68 [2.07], P<0.01). There was no difference in remifentanil consumption, recovery time from anesthesia, or postoperative pain and complications.

CONCLUSION

SPI-guided analgesia led to a more stable sympathetic modulation but didn't seem to offer clinically relevant advantages over the standard clinical practice for laparoscopic cholecystectomy.

Preoperative autonomic nervous system analysis may stratify the risk of hypotension after spinal anesthesia

BACKGROUND

Studies on pregnant women undergoing cesarean delivery or elderly men scheduled for prostate brachytherapy have demonstrated the predictive value of heart rate variability (HRV) analysis for hypotension during spinal anesthesia. We conducted a prospective observational study to investigate if preoperative HRV analysis may have a role in identifying the risk of hypotension following spinal anesthesia in otherwise healthy patients.

METHODS

The study investigated 47 ASA physical status I-II patients aged between 18-50 years that underwent subarachnoid anesthesia for lower abdominal or orthopedic scheduled surgery. ECG was recorded from all subjects before the subarachnoid block. We analysed the autonomic nervous system modulation, measured by HRV analysis. The variables that were be considered were preoperative HRV total power, low frequency (LF) and high frequency (HF) heart beat oscillations and LF/HF ratio. The LF/HF ratio was dichotomized according to the median for sensitivity analysis. The lowest arterial pressure value between spinal anesthesia and the end of surgery was recorded.

RESULTS

The median LF/HF before anesthesia was 2.3. We considered two groups of 23 (LF/HF<2.3, group LOW) and 24 (LF/HF>2.3, group HIGH) patients respectively. Both groups had similar baseline demographic and hemodynamic variables. A high preoperative sympathetic outflow and loss of vagal modulation, as stated by LF/HF>2.3, was correlated with a relative risk of 7.7 (95%CI 1.04 to 56.6, p=0.023) of post-spinal hypotension.

CONCLUSIONS

Preoperative analysis of autonomic nervous system modulation might be useful to stratify the risk of post-spinal hypotension and it might indicate the need for careful monitoring or prophylactic fluids.

Influence of gravitational sympathetic stimulation on the Surgical Plethysmographic Index

Surgical Plethysmographic Index (SPI), calculated from pulse photo-plethysmographic amplitude oscillations, has been proposed as a tool to measure nociception anti-nociception balance during general anesthesia, but it is affected by several confounding factor that alter the autonomic nervous system (ANS) modulation. We hypothesized that SPI may be mainly affected by sympathetic stimulation independently from nociception. We studied the effects of two sympathetic stimuli on SPI, delivered through passive head-up tilt at 45 and 90 degrees angles, in nine awake healthy adults. The sympathetic modulation was assessed by means of heart rate variability (HRV) analysis. Mean (SD) SPI significantly increased from baseline to 45 degrees [from 38.6 (13.7) to 60.8 (7.6), p<0.001)] and to 90 degrees angle tilt [82.3 (5.4), p<0.001]. The electrocardiographic mean R-to-R interval significantly shortened during both passive tilts, whereas systolic arterial pressure did not change during the study protocol. HRV changed significantly during the study protocol towards a predominance of sympathetic modulation during passive tilt. Gravitational sympathetic stimulation at two increasing angles, in absence of any painful stimuli, affects SPI in awake healthy volunteers. SPI seems to reflect the sympathetic outflow directed to peripheral vessels.

Insulator-metal transition of VO₂ ultrathin films on silicon: evidence for an electronic origin by infrared spectroscopy

We report on the first simultaneous observations of both electronic and structural temperature-induced insulator-to-metal transition (IMT) in VO2 ultrathin films, made possible by the use of broad range transmission infrared spectroscopy. Thanks to these techniques, the infrared phonon structures, as well as the appearance of the free carrier signature, were resolved for the first time. The temperature-resolved spectra allowed the determination of the temperature hysteresis for both the structural (monoclinic-to-rutile) and electronic (insulator-to-metallic) transitions. The combination of these new observations and DFT simulations for the monoclinic structure allows us to verify the direct transition from monoclinic (M1) to rutile and exclude an intermediate structural monoclinic form (M2). The delay in structural modification compared to the primer electronic transition (325 K compared to 304 K) supports the role of free charges as the transition driving force. The shape of the free charge hysteresis suggests that the primer electronic transition occurs first at 304 K, followed by both its propagation to the heart of the layer and the structural transition when T increases. This study outlines further the potential of VO2 ultrathin films integrated on silicon for optoelectronics and microelectronics.

A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study

BACKGROUND

A wide variability in the approach towards delirium prevention and treatment in the critically ill results from the dearth of prospective randomised studies.

METHODS

We launched a two-stage prospective observational study to assess delirium epidemiology, risk factors and impact on patient outcome, by enrolling all patients admitted to our Intensive Care Unit (ICU) over a year. The first step - from January to June 2008 was the observational phase, whereas the second one from July to December 2008 was interventional. All the patients admitted to our ICU were recruited but those with pre-existing cognitive disorders, dementia, psychosis and disability after stroke were excluded from the data analysis. Delirium assessment was performed according with Confusion Assessment Method for the ICU twice per day after sedation interruption. During phase 2, patients underwent both a re-orientation strategy and environmental, acoustic and visual stimulation.

RESULTS

We admitted a total of respectively 170 (I-ph) and 144 patients (II-ph). The delirium occurrence was significantly lower in (II-ph) 22% vs. 35% in (I-ph) (P=0.020). A Cox's Proportional Hazard model found the applied reorientation strategy as the strongest protective predictors of delirium: (HR 0.504, 95% C.I. 0.313-0.890, P=0.034), whereas age (HR 1.034, 95% CI: 1.013-1.056, P=0.001) and sedation with midazolam plus opiate (HR 2.145, 95% CI: 2.247-4.032, P=0.018) were negative predictors.

CONCLUSION

A timely reorientation strategy seems to be correlated with significantly lower occurrence of delirium.

A novel hepatocyte nuclear factor-1β (MODY 5) gene mutation in a Romanian boy with pancreatic calcifications, renal and hepatic dysfunction

We report a 12-years-old Romanian boy with a diagnosis of diabetes and renal insufficiency. Mutations in homeodomain-containing transcription factor hepatocyte nuclear factor (HNF-1β) have been reported in association with maturity-onset diabetes of the young (MODY 5) and early maturity-onset diabetes, progressive non-diabetic renal dysfunction and bilateral renal cysts. We found a new heterozygous mutation in HFN-1β located in the exon 3 (c.715 G>C; p.239R) associated to pancreatic calcifications. The importance of molecular diagnosis of MODY patients is reinforced and the need for a careful follow-up is stressed in order to monitor the progression of clinical manifestations and its correlation with the gene mutation.

Effects of probiotic and prebiotic on gastrointestinal motility in newborns

To fortify the biological role of milk formula has been suggested to use probiotics and prebiotics as functional components to mimic the effect of breast milk. The aim of this study was to evaluate the effects of prebiotic, probiotic added to a standard formula on gastrointestinal motility respect to placebo-formula. Cutaneous electrogastrography (EGG) and ultrasound gastric emptying (GE) were performed in 49 preterm newborns. 17 newborns were exclusively breast-fed; 32 were randomly assigned to receive prebiotic-added formula (0.8 g/dl of a mixture from scGOS and lcFOS, ratio 9:1) (10), a probiotic-added formula (L. reuteri at dose of 1x10(8) colony forming units (CFU) per day) (10), a formula with placebo (12) for 30 days. No difference was seen in the nutritional parameters and no adverse events were reported. After the intervention period, the prebiotic, probiotic, and breast milk groups showed a higher percentage of EGG slow wave propagation and faster gastric half emptying time respect to placebo group (ANOVAon ranks p<0.001; Dunn test vs control: prebiotic, probiotic and breast-milk vs placebo formula p<0.05; and ANOVA on ranks p=0.005; Dunn test vs control: prebiotic, probiotic and breast-milk vs placebo formula p<0.05, respectively). Feeding preterm infants with a formula supplemented with prebiotics or probiotics may stimulate gastric emptying and improve maturation of the EGG activity mimicking the effect of breast milk.

The effect of prebiotics in the management of neonatal hyperbilirubinaemia

BACKGROUND

Breast milk oligosaccharides such as galacto-oligosaccharides (scGOS) and fructo-oligosaccharides (lcFOS) can influence the intestinal microbial flora. The latter, in turn, can modulate several intestinal and extraintestinal functions, including bilirubin metabolism. Supplementing infant formula with a prebiotic mixture might then be a novel and safe intervention to manage mild neonatal hyperbilirubinaemia.

AIM

To investigate the effect of dietary supplementation with prebiotics on moderate hyperbilirubinaemia in healthy, term infants.

METHODS

A prospective, double-blind, clinical trial was performed on seventy-six consecutive newborns who were randomly assigned to receive a formula containing 0.8 g/dL of a mixture from scGOS and lcFOS (ratio 9:1), or maltodextrines as placebo for 28 days. Bilirubin levels were determined by the transcutaneous bilirubin measurement within 2 h after birth (T1), at 24, 48 and 72 h and at 5, 7, 10 and 28 days of life. The number of stool per day was also recorded.

RESULTS

Neonates receiving prebiotics showed a larger number of stools over all the duration of dietary intervention compared to that of those on placebo (Repeated Measures ANOVA p < 0.001; day 28 3.4 +/- 0.0.9 vs 1.7 +/- 0.9, respectively; Dunn test p < 0.05). Neonates whose formula was supplemented with prebiotics showed a lower transcutaneous bilirubin that was statistically significant from 72 h of life (5.46 +/- 1.6 vs 7.07 +/- 2.49, post hoc Dunn test, p < 0.05) throughout the duration of the dietary intervention (day 28 2.41 +/- 0.4 vs 2.85 +/- 0.5, post hoc Dunn test, p < 0.05).

CONCLUSION

The addition of prebiotics to standard infant diet might represent a novel strategy to help control neonatal hyperbilirubinaemia.

Effect of fentanyl on heart rate variability during spontaneous and paced breathing in healthy volunteers

BACKGROUND

Many studies have been conducted to assess the effects of fentanyl on the autonomic nervous system (ANS) by heart rate variability (HRV) analysis, but disagreement on the results is still present due to confounding influences introduced by concomitant administration of other drugs or opioid-related transitory respiratory depression. We performed a single-drug controlled-breathing study on healthy volunteers to assess the impact of fentanyl on ANS.

METHODS

HRV as a measure of sympathovagal balance was prospectively analyzed with an autoregressive model in 11 subjects during spontaneous and paced breathing (PB) at 20 breaths/min both before and after fentanyl 1 mcg/kg administration. HRV total power, sympathovagal balance (low-frequency/high-frequency ratio) and normalized spectral powers were considered (LFnu, HFnu).

RESULTS

Fentanyl led to a reduction of LFnu (from 55.2+/-23.3 to 43.2+/-24.1, P<0.05) without HFnu increase during PB. A decrease in R-R interval variance (from 3345.6+/-3333.4 to 1806.9+/-1328.6 ms(2), P<0.05) was shown after fentanyl administration during spontaneous but not PB. PB alone decreased the HRV total power and R-R interval variance.

CONCLUSIONS

Low-dose fentanyl administration in healthy volunteers leads to sympathetic and overall ANS modulation decrease, with a trend toward vagal activation.

Role of tricuspid regurgitation in fetal echocardiographic diagnosis of pulmonary atresia with intact ventricular septum

OBJECTIVE

Pulmonary atresia with intact ventricular septum (PAIVS) is a rare cardiac malformation with a broad spectrum of anatomical manifestations, varying from types suitable for biventricular repair to those with diminutive right ventricle and primitive ventriculocoronary connections (VCC), more suitable for single-ventricle palliation or heart transplantation. We sought to test whether tricuspid regurgitation is an easily detectable prenatal criterion with which to identify PAIVS patients at lower risk of needing postnatal single-ventricle palliation.

METHOD

We identified retrospectively patients with both fetal diagnosis and postnatal confirmation of PAIVS who were seen at Bambino Gesù Hospital between January 2000 and December 2006. Tricuspid valve/mitral valve (TV/MV) ratio, presence and severity of tricuspid regurgitation and direct visualization of VCC were evaluated by echocardiography both pre- and postnatally.

RESULTS

We identified 22 patients with a prenatal diagnosis of PAIVS. Four pregnancies were terminated and one fetus was lost to follow-up, leaving 17 patients for the analysis. Based on postnatal cardiac catheterization and/or echocardiography we divided our population in two groups: Group 1 included 10 patients with VCC; Group 2 included seven patients without VCC. At fetal echocardiography, tricuspid regurgitation was absent in all ten Group 1 patients and present in all seven Group 2 patients. VCC were seen directly in 6/10 Group 1 patients and in no Group 2 patients. A cut-off value of 0.56 for the TV/MV ratio was highly predictive of VCC during fetal life, with a sensitivity of 100% and a specificity of 90%.

CONCLUSIONS

The absence of tricuspid regurgitation in fetuses affected by PAIVS is a strong prenatal echocardiographic predictor of VCC, as is a TV/MV ratio < 0.56. Fetuses presenting with tricuspid regurgitation and relatively large right ventricle are at lower risk of needing single-ventricle palliation postnatally. This inforation could be helpful for appropriate prenatal counseling and postnatal decision-making.

Early hospital discharge of the healthy term neonate: the Italian perspective

AIM

An appropriate timing of hospital discharge of the healthy, term neonate represents a balance between birth medicalization and surveillance of immediate health hazards. In the absence of European recommendations, the authors have conducted a broad national survey on the current policies of neonatal discharge.

METHODS

A 13-item questionnaire was sent to 136 Italian birth centers. Quantitative variables were expressed as mean+/-range. Qualitative variables were expressed as frequencies. chi squared test was used for variables comparison.

RESULTS

Mean age at discharge for a vaginally delivered neonate was 72 hours. Twelve percent of centres would not schedule a follow-up appointment. Neonates born after a cesarean section were discharged at a mean age of 97 hours. Almost all centres (95/98) would discharge an healthy infant without risk factors for hyperbilirubinemia with a total serum bilirubin (TSB) of 13 mg/dL at 72 hours but 14.7% of these centers would not recheck TSB. The same healthy neonate would be discharged at the age of 45 hours with a TSB=10 mg/dL in 67/98 centers and in 11.9% of cases would not be rechecked.

CONCLUSION

Most Italian hospitals discharge healthy, term neonates born after spontaneous vaginal delivery (SVD) at over 72 hours of age. This policy should protect from missed diagnoses of clinical importance (e.g. hyperbilirubinemia). On the other hand, a prolonged hospitalization tends to increase maternal discomfort and medical costs. Implementing a protocol of home visits/clinic follow-up appointments after an earlier discharge may minimize health hazards and medical costs and optimizing the patient's feedback.

Italy versus the United Kingdom: differing styles for treating bacteremia in the critically ill patient, but who's right?

BACKGROUND

As no prospective, randomized, clinical trials (PRCTs) exist to inform decisions about antibiotic therapy for bacteraemia, ICUs have likely developed their own strategies. A multi-centre, multi-national questionnaire survey was used to assess variations in antibiotic strategy between ICUs in the United Kingdom (UK) and Italy.

METHODS

In January 2001, a detailed questionnaire regarding antibiotic policy was sent to international (e.g., European Society of Intensive Care Medicine, ESICM) and national societies (Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, GIVITI; Australia and New Zealand Intensive Care-Critical Trial Group, ANZIC-CTG; United Kingdom-Intensive Care Society, UK-ICS).

RESULTS

Out of the 254 participating ICUs, 81 were from Italy and 32 were from the UK. In the UK, ICUs preferred to use a shorter course of mono-therapy compared to Italian ICUs when treating, a) primary bacteremia [7 (5-7) vs 10 (7-14), P<0.001]; b) UTI [5 (4-7) vs 8 (7-10), P<0.001]; c) Staphylococcus aureus [7 (5-12) vs 10 (7-15), P<0.001]; and d) Gram-negative bacteraemia associated with lines [6 (5-7) vs 10 (7-15), P<0.001], pneumonia [7 (5-7) vs 14 (10-15), P<0.001] and peritonitis [7 (5-9) vs 15 (10-15), P<0.000]. These differences in treatment strategy were likely correlated with the median inter-quartile range (IQR) of weekly input from a microbiologist or infectious disease specialist, which was more frequent in the UK compared to Italy [5 (2-6) vs 0 (0-1), P<0.001].

CONCLUSION

Possible influences accounting for the variations found between Italy and the UK are: 1) differences in interactions with microbiologists or infectious disease specialists, 2) historical/educational dogma, and 3) antibiotic resistance patterns. Further studies are necessary to determine the optimal approach to treating bacteremia.

A case of septic shock secondary to Corynebacterium aquaticum bacteremia occurring in an HIV-infected patient attending a promiscuous thermal SPA

Corynebacterium aquaticum, an environmental organism associated with fresh water, has very seldom proved to be a cause of infection, although it has increasingly been isolated from clinical specimens. This report describes an unusual case of bacteremia occurring in an HIV-infected patient, complicated by septic shock and secondary to an epididimo-orchitis. Combination therapy of levofloxacin and metronidazole was used successfully.

Critical care of HIV infected patients in the highly active antiretroviral therapy era

Since there are more than 150 000 Italians (about 25 for every 10,000 inhabitants) infected with HIV, Intensive Care Units (ICU) often come across patients who are HIV positive. The aim of this study was to provide current information on the epidemiology of human immunodeficiency virus (HIV)-infected patients admitted to ICU during the era of highly active antiretroviral therapy (HAART) and to review issues related to the administration of antiretroviral therapy relevant to the ICU staff. Overall mortality of critically ill HIV-infected patients in ICUs has decreased in the HAART era, and patients are more often admitted with non-HIV-related illnesses. Use of HAART in the ICU is difficult; however it may be associated with improved outcomes. More HIV-infected patients survive ICU admission and are less likely to be admitted to the ICU for related infections; in most cases, they need critical care for problems unrelated to HIV infection or for conditions related to HAART toxicity. ICU staff need to be familiar with HAART for the following reasons: 1) to recognize life-threatening toxicities unique to these drugs; 2) to avoid drug interactions, which are extremely common and potentially life-threatening; and 3) to avoid enhancing HIV drug resistance, an occurrence that could have devastating consequences for the patient after discharge from the ICU.

Risk factors for extended-spectrum beta-lactamase-producing Serratia marcescens and Klebsiella pneumoniae acquisition in a neonatal intensive care unit

We investigated the molecular epidemiology of gentamicin-resistant, extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae and Serratia marcescens, and risk factors associated with their acquisition in a neonatal intensive care unit (NICU) of a university hospital in Italy. During the study period (April-November 2004), S. marcescens was responsible for six infections and 31 colonisations, while K. pneumoniae was responsible for six infections and 103 colonisations. Concurrent isolation of both organisms occurred in 24 neonates. Molecular typing identified one major pulsed-field gel electrophoresis pattern each for S. marcescens and K. pneumoniae strains isolated during the study period. An 80 kb plasmid containing bla(SHV-12), bla(TEM-1) and aac(6')-Ib genes, isolated from both S. marcescens and K. pneumoniae strains, and showing identical restriction profiles, transferred resistance to third-generation cephalosporins to a previously susceptible Escherichia coli host. Birthweight, gestational age and use of invasive devices were significantly associated with S. marcescens and K. pneumoniae acquisition on univariate analysis, while empiric antimicrobial treatment with ampicillin and gentamicin, and duration of hospital stay, proved to be the only independent risk factors. In conclusion, conjugal plasmid transfer and empiric antimicrobial therapy with ampicillin and gentamicin might have contributed to the selection and spread of gentamicin-resistant ESBL-producing Enterobacteriaceae in the NICU.

A comparison of nasal intermittent versus continuous positive pressure delivery for the treatment of moderate respiratory syndrome in preterm infants

AIM

Nasal continuous positive airway pressure and nasal intermittent positive pressure ventilation have both been proposed as a form of gentle respiratory support for neonatal respiratory distress syndrome. We have compared these two respiratory support methods in the management of early stages of mild-moderate, neonatal respiratory distress syndrome.

METHODS

A prospective, randomized trial was performed enrolling 88 consecutive preterm infants with mild to moderate respiratory distress syndrome matched for birthweight, gestational age, sex, admission FiO2 and Apgar scores. Nasal continuous positive airway pressure was delivered at a pressure of 4-6 cmH2O. Infants on intermittent pressure were put on ventilatory rates of 40 breaths per minute. Peak pressures of 14-20 cmH2O and end-expiratory pressures of 4-6 cmH2O were used judging clinically the chest cage expansion.

RESULTS

Although there were no differences in the PaO2 values between the groups, infants treated with nasal intermittent positive pressure ventilation showed a significantly lower pCO2 values than those in the continuous pressure group (40+/-2 vs 58+/-4 mmHg, P<0.05). Also a significantly lower incidence of apnoeic episodes (number of episodes/hour 0.4+/-0.2 vs 0.9+/-03; P<0.05) and a shorter respiratory support in the nasal intermittent positive pressure ventilation group were observed. No difference in severe abdominal distension or need of endotracheal intubation was noted.

CONCLUSIONS

In the present clinical setting, the use of nasal positive airway pressure in an intermittent way is associated to a more physiological arterial carbon dioxide tension, less apnoea and a shorter duration of respiratory support when compared with continuous pressure delivery by the same route.

Changes of arterial hemodynamics in patients with type 2 diabetes mellitus or impaired glucose tolerance

AIM

The aim of our study was to evaluate the arterial hemodynamics in patients with type 2 diabetes mellitus or impaired glucose tolerance without clinical or Doppler evidence of peripheral arterial disease, in order to early detect vascular damage.

METHODS

We studied 20 subjects (12 men and 8 women, aged between 48 and 62 years) with type 2 diabetes mellitus (Group 1), 20 subjects (11 men and 9 women, aged between 49 and 61 years) with reduced glucose tolerance (Group 2), and 20 normal subjects (10 men and 10 women, aged between 48 and 62 years) (Group 3). Each subject underwent strain-gauge plethysmography and the following parameters were evaluated: rest flow (RF); peak flow (PF); PF/RF ratio; time to peak flow (tPF); half-time (t 1/2) and total time (tT) of hyperemic response; basal vascular resistances (BVR) and minimal vascular resistances (MVR).

RESULTS

There was no difference among groups in RF, but maximal postischemic flow was reduced in patients with diabetes and with impaired glucose tolerance. The MVR showed a similar behavior, while the basal ones were increased only in the diabetic group. Finally, the t1/2 and the tT of the hyperemic response, that reflect arteriolar reactivity, were significantly reduced, if compared with controls. No significant differences between Group 1 and 2 were found.

CONCLUSIONS

These results confirm the presence of hemodynamic modifications in the vascular bed of both diabetics and patients with impaired glucose tolerance, as compared with normal subjects.

Iloprost treatment in patients with Raynaud's phenomenon secondary to systemic sclerosis and the quality of life: a new therapeutic protocol

OBJECTIVES

To evaluate the clinical efficacy and the effects on the quality of life of iloprost, a prostacyclin analogue, used according to a new protocol in patients with Raynaud's phenomenon secondary to systemic sclerosis.

METHODS

In this randomized study, we treated 30 patients with iloprost, given by intravenous infusion, at progressively increasing doses (from 0.5 to 2 ng/kg/min) over a period of 6 h each day for 10 days in two consecutive weeks, with repeated cycles at regular intervals of 3 months for 18 months. The results were compared with those obtained in 30 other patients who received the same drug but with different dosing schemes.

RESULTS

The total average daily duration of the attacks, the average duration of a single attack and the average daily frequency of the attacks were reduced significantly in all treatment groups, but the comparison between the groups demonstrated significant differences between patients treated with the new protocol and the others at later times (12 and 18 months). The effects on the quality of life in the group treated with the new protocol, evaluated with the Short Form-36, demonstrated a marked improvement regarding both the scale relating to the physical aspect of the illness and, especially, the scale relating to the mental aspect.

CONCLUSIONS

In patients with systemic sclerosis, cyclic intravenous iloprost infusion is efficacious in the treatment of Raynaud's phenomenon. The protocol that we used, compared with others, not only has favourable clinical effects but also leads to a marked improvement in the quality of life.