Perinatal stroke – literature review and case presentation

Centrul de Cercetare şi Telemedicina în Bolile Neurologice la Copii, Spitalul Clinic de Pediatrie, Sibiu, Universitatea “Lucian Blaga”, Sibiu, Facultatea de MedicinaSummary. The perinatal stroke, an ischemic or hemorrhagic event specific to the period 20th week gestational age and 28th postnatal days, is the most common cause of hemiplegic cerebral palsy. Characterized by significant morbidity, the perinatal stroke associates long-term neurological deficits: in motor, cognitive, behavioral, somatosensory, and language skills. The authors perform a review of the literature data and present the case of a 9-month-old infant diagnosed with presumed perinatal arterial ischemic stroke. The infant, with restrictive intrauterine growth and good postnatal adaptation, shows at the age of 4-5 months asymmetric, left dominant prehension. He refers late for specialized investigations due to the persistent chronic motor deficit in the right limbs, despite intensive physical therapy. The neurological examination confirms the diagnosis of spastic right hemiparesis and growth restriction including the cranial perimeter. The brain MRI reveals the chronic arterial vascular etiology, the aspect being suggestive of sequelae stroke in the deep and superficial territory of the left medium cerebral artery. Prothrombotic risk factors have not been identified. In evolution, the patient will associate symptomatic focal epilepsy and hyperkinetic behavior. Early initiation of multimodal rehabilitation therapy and multidisciplinary approach allowed improvement in motor deficit, limiting late orthopedic complications.Rezumat. Accidentul vascular cerebral perinatal reprezintă un eveniment ischemic sau hemoragic specifi c intervalului de vârstă între săptămâna 20 gestatională şi ziua 28 postnatal, fiind cea mai frecventă cauză de paralizie cerebrală hemiplegică. Caracterizat printr-o morbiditate semnificativă, AVC perinatal asociază deficite neurologice pe termen lung: motorii, cognitive, psihoafective, somatosenzoriale şi de limbaj. Autorii efectuează o trecere în revistă a datelor din literatura de specialitate şi prezintă cazul unui sugar de sex feminin în vârsta de 9 luni diagnosticat cu stroke ischemic arterial perinatal. Sugarul, cu restricţie de crestere intrauterină, cu adaptare postnatală bună, prezenta la vârsta de 4-5 luni prehensiune asimetrică, deficitară dreaptă. Se prezintă tardiv pentru investigatii de specialitate în contextul persistenţei deficitului motor cronic de hemicorp drept după integarea în program de kinetoterapie. Examenul neurologic confirmă diagnosticul de hemipareză dreaptă spastică, restricţie de crestere inclusiv a perimetrului cranian. IRM cerebral relevă etiologia vasculară arterială cronică, aspectul imagistic fiind sugestiv pentru AVC sechelar în teritoriul profund şi superficial al arterei cerebrale medii stângi. Nu au fost identificaţi factori de risc protrombotici. În evoluţie pacienta va asocia epilepsie focală simptomatică şi comportament hiperkinetic. Iniţierea timpurie a terapiei de reabilitare multimodală şi abordarea multidisciplinară a permis ameliorarea deficitului motor şi limitarea complicaţiilor tardive

Antioxidants (Resveratrol) - possible adjuvant therapy to prevent recurrence of febrile seizures

Centrul de Cercetare şi Telemedicină în Bolile Neurologice la Copii, Spitalul Clinic de Pediatrie Sibiu, Facultatea de Medicină, Universitatea “Lucian Blaga” SibiuFebrile Seizures (FS) are the most common epileptic type events in the pediatric age group. The risk of recurrence and their potential role in epileptogenesis entail the detection of the underlying mechanisms, thus identifying new therapeutic alternatives to the known antiepileptic prophylaxis. Recently increasing evidence justify the association between oxidative and nitrosative mitochondrial stress and epilepsy or FS. The FS are placed in the context of a persistent inflammatory process and in specific cases (hippocampal sclerosis) even as a promoter of neuronal destruction and epileptogenesis. A review of the literature supports in vivo studies in animal models and in humans with seizures the potential role of antioxidant therapy in limiting lesions induced by free radicals. Thus, as a potent antioxidant, Resveratrol is emerging as a possible complementary therapy in preventing recurrent CF and epileptigenesis. But in the pediatric practice its role remains controversial and its applicability limited despite a significant number of in vivo animal studies, due to fewer studies with human subjects. The recording of both prooxidant and antioxidant effect of this polyphenol in comparative studies on different organ (in the context of dose-dependent effect, variable affinity of the specific membrane receptors to transresveratrol and different levels of transition metals) requires further research.Convulsiile febrile (CF) reprezintă cele mai frecvente evenimente de tip epileptic la vârsta pediatrică. Riscul de recurenţă şi potenţialul rol în epileptogeneza al acestora motivează decelarea mecanismelor subiacente şi astfel identificarea de noi terapii adjuvante profilaxiei antiepileptice cunoscute. Recent tot mai multe dovezi justifică asocierea dintre stresul oxidativ şi nitrozativ mitocondrial, epilepsie sau CF, plasând CF în contextul unui proces inflamator persistent şi în cazuri specifice (scleroza hipocampică) chiar de promotor al distrucţiei neuronale şi al epileptogenezei. O trecere în revistă a literaturii de specialitate susţine în studii in vivo, pe modele animale de criză dar şi pe subiecţi umani, potenţialul terapiei antioxidante în limitarea leziunilor induse de radicalii liberi. Astfel, antioxidant potent, Resveratrolul se conturează ca posibilă terapie complementară în prevenţia recurenţei CF şi în epileptogeneza. Rolul său rămâne însă controversat, aplicabilitatea terapiei cu Resveratrol fiind limitată în practica pediatrică în pofida unui numar semnificativ de studii in vivo pe animale, datorită numărului redus de studii cu subiecţi umani. Consemnarea în studii comparative pe organe atât a efectelor antioxidante cât şi prooxidante ale acestui polifenol (în contextul efectului dependent de doza, timp, afinitate pentru transResveratrol a receptorilor membranari specifici şi de nivelul variabil al metalelor de tranziţie) impune continuarea cercetării

Comparative study on metal versus zirconium dioxide infrastructure manufacturing in prosthetic rehabilitation in the maxillary frontal zone

Prosthetic rehabilitation of the maxillary front teeth is an extremely laborious problem for the dental team, consisting of the dentist and the dental technician. If for the physiognomic component the most recommended materials are the ceramic masses, for the resistance substrate there are several variants. Conventional technologies using dental alloys and modern ones involving the use of zirconium dioxide can be used successfully in performing fixed prosthetic restorations in the maxillary frontal area, both options having both advantages and disadvantages, as we will describe in this material

Неэпилептические пароксизмальные расстройства и диагностические ошибки: вызов для врачей

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Departamentul Pediatrie, IMSP Institutul Mamei și Copilului, Universitatea din Sibiu, Facultatea de MedicinăObjective. This review has the aim of informing the pediatricians about the non epileptic paroxysmal events and of discussing the clinical discoveries, treatment, and differential diagnoses of non epileptic paroxysmal events. Methods. A search for ‘non-epileptic disorders’was completed. Here were included someobservational studies and reviews. Results. Non epileptic paroxysmal events are recurrent movement disorders with acute onset and ending, which is similar to epilepsy. The diagnosis can prevent unnecessary drug use and psychological damage. The duration, place, timing of the attacks, and state of conciousness may confuse pediatricians about the diagnosis of epilepsy and non epileptic paroxysmal events. Conclusion.The essence in the diagnosis is taking an accurate and detailed history. Wrong diagnosis can cause anxiety of both the family and the child, long term damages such as education or career planning problems.Цель. Этот обзор направлен на обсуждение клинических результатов, лечения и дифференциальной диагностики неэпилептических пароксизмальных явлений, а также на повышение осведомленности о неэпилептических пароксизмальных явлениях среди педиатров. Методы. Был завершен поиск ‘неэпилептических расстройств». Сюда были включены некоторые наблюдательные исследования и обзоры. Результаты. Неэпилептические пароксизмальные явления - это рецидивирующие двигательные расстройства с острым началом и окончанием, которые могут имитировать эпилепсию. Длительность, место, время приступов и состояние сознания могут ввести педиатров в заблуждение относительно диагноза эпилепсии и неэпилептических пароксизмальных явлений. Диагноз может предотвратить ненужное употребление таблеток и психологический ущерб. Вывод. Ключевым моментом в постановке диагноза является взятие точного и подробного анамнеза. Неправильный диагноз может вызвать тревогу как в семье, так и в ребенке, перебои в обучении ребенка, ограничения в планировании карьеры и необратимые повреждения в долгосрочной перспективе

Enhancing the effects of neurofeedback training: the motivational value of the reinforcers

The brain activity that is measured by electroencephalography (EEG) can be modified through operant conditioning, specifically using neurofeedback (NF). NF has been applied to several disorders claiming that a change in the erratic brain activity would be accompanied by a reduction of the symptoms. However, the expected results are not always achieved. Some authors have suggested that the lack of an adequate response may be due to an incorrect application of the operant conditioning principles. A key factor in operant conditioning is the use of reinforcers and their value in modifying behavior, something that is not always sufficiently taken into account. This work aims to clarify the relevance of the motivational value versus the purely informational value of the reinforcer. In this study, 113 subjects were randomly assigned two different reinforcer conditions: a selected reinforcer—the subjects subjectively selected the reinforcers—or an imposed reinforcer— the reinforcers were assigned by the experimenter—and both groups undertook NF sessions to enhance the sensorimotor rhythm (SMR). In addition, the selected reinforcer group was divided into two subgroups: one receiving real NF and the other one sham NF. There were no significant differences between the groups at baseline in terms of SMR amplitude. After the intervention, only those subjects belonging to the selected reinforcer group and receiving real NF increased their SMR. Our results provide evidence for the importance of the motivational value of the reinforcer in Neurofeedback succes

The prevalence of urinary tract infection in children with febrile seizures

Clinical Pediatric Hospital Sibiu, Center for Research in Neurological Diseases in Children, Sibiu, Romania, Lucian Blaga University of Sibiu, Romania, State University of Medicine and Pharmacy, Chisinau, Republic of MoldovaInfecţiile de tract urinar reprezintă afecţiuni bacteriene comune în copilărie şi un important factor precipitant al convulsiilor febrile. În contextul unui tablou clinic nespecific al infecţiei de tract urinar la vârstele mici, cunoaşterea prevalenţei acestora la pacienţii cu convulsii febrile ar permite o evaluare optimă a contextului infecţios. Acest studiu a fost realizat pentru a determina prevalența infectiilor de tract urinar în rândul copiilor cu convulsii febrile. Studiul prospectiv a inclus un număr de 136 pacienţi internaţi în Spitalul de Pediatrie Sibiu, cu 197 convulsii febrile distincte. Au fost identificaţi 20 pacienţi (10,2%) cu infecţie de tract urinar, majoritatea băieţi (60%). În lotul nostru infecţia de tract urinar reprezintă a treia cauză infecţioasă a convulsiilor febrile, după infecția acută de căi respiratorii superioare (72,1%) şi infecția acută de căi respiratorii inferioare (14,2%). În primul an de viaţă predomină sexul masculin (80%). O treime din pacienţii cu infecţie de tract urinar şi convulsii febrile au fost oligosimptomatici, tabloul clinic fiind limitat la febră. Doar 20% din pacienţi au prezentat simptome urinare. Agenţii patogeni cel mai frecvent izolaţi au fost bacteriile de origine enterică, respectiv E coli (45%), Proteus mirabilis (25%), Enterobacter spp. (10%) şi, izolat, Enterococcus spp. Prevalenţa ridicată a infecţiei de tract urinar în cazul pacienţilor cu convulsii febrile, împreună cu tabloul clinic oligosimptomatic sau nespecific al infecţiei de tract urinar la categoria de vârstă mică sugerează că infecţia de tract urinar trebuie luată în considerare în cazul tuturor pacienţilor cu convulsii febrile. În concluzie, recomandăm efectuarea de rutină a uroculturii în cazul acestor pacienţi.Urinary tract infections are common bacterial diseases in childhood and a major precipitating factor of febrile seizures. Considering the nonspecific clinical picture of urinary tract infection at an early age, knowing their prevalence in patients with febrile seizures would allow an optimal assessment of the infectious context. This study was conducted to determine the prevalence of urinary tract infections among children with febrile seizures. The prospective study included a number of 136 patients hospitalized in the Sibiu Pediatric Hospital with 197 distinct febrile seizures. 20 patients (10.2%) with urinary tract infection were identified, most of them boys (60%). In our group urinary tract infection is the third infectious cause of febrile seizures, after acute upper respiratory tract infection (72.1%) and acute lower respiratory tract infection (14.2%). In the first year of life, urinary tract infection is more frequent in males (80%). One third of patients with urinary tract infection and febrile seizures were oligosymptomatic, with a clinical picture limited to fever. Only 20% of patients had urinary symptoms. The most commonly isolated pathogens were enteric bacteria, respectively E coli (45%), Proteus mirabilis (25%), Enterobacter spp. (10%) and, isolated, Enterococcus spp. The high level of urinary tract infection in patients with febrile seizures, together with the oligosymptomatic or nonspecific clinical picture of urinary tract infection in the young age suggest that urinary tract infection should be considered in all patients with febrile seizures. In conclusion, we recommend routine urine culture in these patients

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Exploring Inflammatory Status in Febrile Seizures Associated with Urinary Tract Infections: A Two-Step Cluster Approach

Background: Urinary tract infections (UTIs) are considered common facilitating factors, along with other infections, in triggering febrile seizures (FS). The main purpose of our study was to identify specific inflammatory patterns of UTI cases from other infections in a specific cluster, using a combination of inflammatory biomarkers to differentiate UTIs from other bacterial diseases triggering FS. Method: This prospective study included a number of 136 patients with 197 distinct FS events, from patients hospitalized in the Pediatric Clinical Hospital Sibiu, among which 10.2% were diagnosed with UTIs. Results: In one-third of the patients with UTIs (20 cases), the symptoms were limited to fever and FS. Using two-step cluster analysis, a distinct UTI inflammatory pattern has emerged: highest platelet values (PLT), median value 331 × 103/mm3 and intermediate C-reactive protein (CRP), median value 15 mg/dL, platelet distribution width (PDW), median value 9.65%, platelet-large cell ratio (P-LCR), median value 14.45%, mean platelet volume (MPV), median value 8.60 fL and neutrophil-to-lymphocyte values (NLR), median value 3.64. Furthermore, higher PDW (median value 12.25%), P-LCR (median value 28.55%), MPV (median value 10.40 fL), CRP (median value 74.00 mg/dL) and NLR values (median value 4.11) were associated mainly (85.7%) with bacterial lower respiratory infections. UTIs were highly unlikely in these patients with significantly increased CRP values and normal values of platelet indices. Conclusions: Considering the nonspecific clinical picture of UTIs at an early age, to optimize the management of FS, a fast diagnosis of UTI is mandatory. The analysis of the inflammatory biomarker clusters (rather than individual parameters) correlated with urine leukocyte and nitrite stick evaluation for specific age groups could help in identifying even oligosymptomatic UTIs patients. The study limitation (20 UTI cases) recommends future multicentric trials on larger datasets to validate the model

Stress Hyperglycemia as Predictive Factor of Recurrence in Children with Febrile Seizures

Stress hyperglycemia and hyperlactatemia are commonly referred to as markers of stress severity and poor outcome in children with severe acute illness or febrile seizures. Our prospective study aimed to explore the risk factors for stress hyperglycemia and the predictive value of stress hyperglycemia for febrile seizure recurrence. We evaluated as risk factors for blood glucose level, serum lactate, acid–base status, and the clinical parameters relevant to the severity of the infectious context or to febrile seizure event: fever degree, fever duration, seizure type and aspect, seizure duration, and recurrence. Among 166 febrile seizures events in 128 children, the prevalence of stress hyperglycemia (blood glucose >140 mg/dl) was 16.9%. The comparison of the stress versus non-stress hyperglycemia groups revealed lower pH (median (interquartile range): 7.46 (7.37, 7.53) vs. 7.48 (7.42, 7.53), p = 0.049), higher lactate levels (30.50 mg/dl (15, 36) vs. 19.50 mg/dl (15, 27), p = 0.000), slightly lower HCO3 (20.15 (20.20, 21.45) vs. 21.35 (20, 22.40), p = 0.020) in the stress hyperglycemia group. Multiple logistic regression analysis showed that prolonged febrile seizures (>15 min), recurrent febrile seizure (>1 seizure), focal seizure type, body temperature ≥39.5 °C and higher lactate values were significantly associated with stress hyperglycemia. These findings suggest a particular acute stress reaction in febrile seizures, with stress hyperglycemia playing an important role, particularly in patients with a recurrent seizure pattern. A more complex future approach linking pathogenic mechanisms and genetic traits would be advised and could provide further clues regarding recurrence pattern and individualized treatment