Evaluation of furosemide regimens in neonates treated with extracorporeal membrane oxygenation

INTRODUCTION: Loop diuretics are the most frequently used diuretics in patients treated with extracorporeal membrane oxygenation (ECMO). In patients after cardiopulmonary bypass (CPB) surgery, the use of continuous furosemide infusion is increasingly documented. Because ECMO and CPB are 'comparable' procedures, continuous furosemide infusion is used in newborns on ECMO. We report on the use of continuous intravenous furosemide in neonates treated with ECMO. METHODS: This was a retrospective observational study in neonates treated with continuous intravenous furosemide during ECMO. RESULTS: Thirty-one patients were included in the study. A median of 25 (9–149) hours after the start of ECMO, continuous furosemide therapy was started at a median rate of 0.08 (0.02–0.17) mg/kg per hour. The continuous furosemide dose was not changed in the individual patient. Seven patients received a furosemide bolus prior to, and five patients received additional loop diuretics during, the continuous infusion. Urine production before continuous furosemide therapy was not significantly different between patients who received a furosemide bolus prior to the infusion and those who did not receive this bolus (P = 0.2879). Although a positive effect of the 'loading' bolus was observed in urine output in the first 24 hours, there was no statistically significant difference in urine output (P = 0.0961) or in time (P = 0.1976) to reach a urine output of 6 ml/kg per hour between patients. After 24 hours, urine production remained a median of 6.2 ml/kg per hour irrespective of furosemide boluses. The forced diuresis was well tolerated as illustrated by stable haemodynamic parameters and a decrease in ECMO flow and vasopressor score over the observation period. CONCLUSION: This is the first report on continuous intravenous furosemide therapy in newborns treated with ECMO. The furosemide regimens used in this study varied widely in continuous and intermittent doses. However, all regimens achieved adequate urine output. An advantage of continuous, over intermittent, intravenous furosemide could not be documented. Furosemide dosing regimens should be developed for neonates treated with ECMO. In addition, therapeutic drug-monitoring studies are required to prevent furosemide toxicity because so far no data are available on serum furosemide levels in neonates treated with ECMO

Extreme spatial heterogeneity in carbonate accretion potential on a Caribbean fringing reef linked to local human disturbance gradients

This is the final version. Available on open access from Wiley via the DOI in this recordThe capacity of coral reefs to maintain their structurally complex frameworks and to retain the potential for vertical accretion is vitally important to the persistence of their ecological functioning and the ecosystem services they sustain. However, datasets to support detailed along-coast assessments of framework production rates and accretion potential do not presently exist. Here we estimate, based on gross bioaccretion and bioerosion measures, the carbonate budgets and resultant maximum accretion potential (RAPmax) of the shallow reef zone of leeward Bonaire – between 5 to 12 m depth – at unique fine spatial resolution along this coast (115 sites). Whilst the fringing reef of Bonaire is often reported to be in a better ecological condition than most sites throughout the wider Caribbean region, our data show that the carbonate budgets of the reefs and derived RAPmax rates varied3 considerably across this ~58 km long fringing reef complex. Some areas, in particular the marine reserves, were indeed still dominated by structurally complex coral communities with high net carbonate production (> 10 kg CaCO3 m-2 year-1 35 ), high live coral cover and complex structural topography. The majority of the studied sites, however, were defined by relatively low budget states (< 2 kg CaCO3 m-2 year-1 36 ) or were in a state of net erosion. These data highlight the marked spatial heterogeneity that can occur in budgets states, and thus in reef accretion potential, even between quite closely spaced areas of individual reef complexes. This heterogeneity is linked strongly to the degree of localized land-based impacts along the coast, and resultant differences in the abundance of reef framework building coral species. The major impact of this variability is that those sections of reef defined by low-accretion potential will have limited capacity to maintain their structural integrity and to keep pace with current projections of climate change induced sea-level rise (SLR), thus posing a threat to reef functioning, biodiversity and trophic cascades. Since many Caribbean reefs are more severely degraded than those found around Bonaire, it is to be expected that the findings presented here are rather the rule than the exception, but the study also highlights the need for similar high spatial resolution (along-coast) assessments of budget states and accretion potential to meaningfully explore increasing coastal risk at the country level. The findings also more generally underline the significance of reducing local anthropogenic disturbance and restoring framework-building coral assemblages. Appropriately focussed local preservation efforts may aid in averting future large-scale submergence of Caribbean coral reefs and will constrain the social and economic implications associated with the loss of reef goods and services.Ministry of Economic AffairsWageningen UniversityRoyal Netherlands Institute for Sea Researc

Facies and faunal assemblage changes in response to the Holocene transgression in the Lagoon of Mayotte (Comoro Archipelago, SW Indian Ocean)

This paper documents the facies change in response to the Holocene transgression within five sediment cores taken in the lagoon of Mayotte, which contain a Type-1 depositional sequence (lowstand, transgressive and highstand deposits underlain by an erosive sequence boundary). Quantitative compositional analysis and visual examination of the bioclasts were used to document the facies changes. The distribution of the skeletal and non-skeletal grains in the lagoon of Mayotte is clearly controlled by (1) the rate and amplitude of the Holocene sea-level rise, (2) the pre-Holocene basement topography and (3) the growth-potential of the barrier reef during sea-level rise, and the changes in bathymetry and continuity during this period. The sequence boundary consists of the glacial karst surface. The change-over from the glacial lowstand is marked by the occurrence of mangrove deposits. Terrigenous and/or mixed terrigenous-carbonate muds to sandy muds with a mollusc or mollusc-ostracod assemblage dominate the transgressive deposits. Mixed carbonate-siliciclastic or carbonate sand to gravel with a mollusc-foraminifer or mollusc-coral-foraminifer assemblage characterize the early highstand deposits on the inner lagoonal plains. The early highstand deposits in the outer lagoonal plains consist of carbonate muds with a mollusc-foraminifer assemblage. Late highstand deposits consist of terrigenous muds in the nearshore bays, mixed terrigenous-carbonate sandy muds to sands with a mollusc-foraminifer assemblage on the inner lagoonal plains and mixed muds with a mollusc-foraminifer assemblage on the outer deep lagoonal plains. The present development stage of the individual lagoons comprises semi-enclosed to open lagoons with fair or good water exchange with the open ocean

Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Background: The mortality for children with prolonged stay in pediatric intensive care units (PICU) is much higher than overall mortality. The incidence of withdrawal or limitation of therapy in this group is unknown. Purpose: To assess mortality and characteristics of children admitted for ≥28 days to our ICU, and to describe the extent to which limitations of care were involved in the terminal phase preceding death. Methods: For the period 2003 to 2005 clinical data were collected retrospectively for children with prolonged stay (defined as ≥28 days) in a medical/surgical PICU of a university children's hospital. Results: In the PICU, 4.4% of the children (116/2,607, equal gender, mean age 29 days) had a prolonged stay. Median (range) stay was 56 (28-546) days. These children accounted for 3% of total admissions and occupied 63% of total admission days. Mortality during admission for this group was fiv

Bryozoans are Major Modern Builders of South Atlantic Oddly Shaped Reefs

Supplementary information accompanies this paper at https://doi.org/10.1038/s41598-018-27961-6.In major modern reef regions, either in the Indo-Pacific or the Caribbean, scleractinian corals are described as the main reef framework builders, often associated with crustose coralline algae. We used underwater cores to investigate Late Holocene reef growth and characterise the main framework builders in the Abrolhos Shelf, the largest and richest modern tropical reef complex in the South Western Atlantic, a scientifically underexplored reef province. Rather than a typical coralgal reef, our results show a complex framework building system dominated by bryozoans. Bryozoans were major components in all cores and age intervals (2,000 yrs BP), accounting for up to 44% of the reef framework, while crustose coralline algae and coral accounted for less than 28 and 23%, respectively. Reef accretion rates varied from 2.7 to 0.9 mm yr−1, which are similar to typical coralgal reefs. Bryozoan functional groups encompassed 20 taxa and Celleporaria atlantica (Busk, 1884) dominated the framework at all cores. While the prevalent mesotrophic conditions may have driven suspensionfeeders’ dominance over photoautotrophs and mixotrophs, we propose that a combination of historical factors with the low storm-disturbance regime of the tropical South Atlantic also contributed to the region’s low diversity, and underlies the unique mushroom shape of the Abrolhos pinnacles.We thank CNPq/FAPES-Sisbiota/PELD, CAPES/IODP, CAPES/Ciências do Mar, and ANP/Brasoil for long term project funding. We also thank ICMBio for research permits and field logistic support, and Conservation International for providing and authorizing the use of the IKONOS image. JMW and JCB are International Visiting Researcher at UFES and JBRJ, supported by the Science Without Borders program. Zá Cajueiro provided invaluable field support and Ronaldo Francini, Carlos Janovitch and Lucio Engler helped in the drilling operations. This is a contribution from the Rede Abrolhos (abrolhos.org)

The intertropical convergence zone modulates intense hurricane strikes on the western North Atlantic margin

© The Author(s), 2016. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Scientific Reports 6 (2016): 21728, doi:10.1038/srep21728Most Atlantic hurricanes form in the Main Development Region between 9°N to 20°N along the northern edge of the Intertropical Convergence Zone (ITCZ). Previous research has suggested that meridional shifts in the ITCZ position on geologic timescales can modulate hurricane activity, but continuous and long-term storm records are needed from multiple sites to assess this hypothesis. Here we present a 3000 year record of intense hurricane strikes in the northern Bahamas (Abaco Island) based on overwash deposits in a coastal sinkhole, which indicates that the ITCZ has likely helped modulate intense hurricane strikes on the western North Atlantic margin on millennial to centennial-scales. The new reconstruction closely matches a previous reconstruction from Puerto Rico, and documents a period of elevated intense hurricane activity on the western North Atlantic margin from 2500 to 1000 years ago when paleo precipitation proxies suggest that the ITCZ occupied a more northern position. Considering that anthropogenic warming is predicted to be focused in the northern hemisphere in the coming century, these results provide a prehistoric analog that an attendant northern ITCZ shift in the future may again return the western North Atlantic margin to an active hurricane interval.This research was supported by NSF Awards: OCE-1519578, OCE-1356708, BCS-1118340

Can we improve outcome of congenital diaphragmatic hernia?

This review gives an overview of the disease spectrum of congenital diaphragmatic hernia (CDH). Etiological factors, prenatal predictors of survival, new treatment strategies and long-term morbidity are described. Early recognition of problems and improvement of treatment strategies in CDH patients may increase survival and prevent secondary morbidity. Multidisciplinary healthcare is necessary to improve healthcare for CDH patients. Absence of international therapy guidelines, lack of evidence of many therapeutic modalities and the relative low number of CDH patients calls for cooperation between centers with an expertise in the treatment of CDH patients. The international CDH Euro-Consortium is an example of such a collaborative network, which enhances exchange of knowledge, future research and development of treatment protocols

Lung function in school-aged congenital diaphragmatic hernia patients; a longitudinal evaluation

Objective: Children with congenital diaphragmatic hernia (CDH) are at risk for pulmonary morbidity. Data on longitudinal evaluation of lung function in CDH are scarce. We hypothesized that CDH patients would have impaired lung function that worsens over time. We evaluated lung function and its determinants at ages 8 and 12 years. Methods: Dynamic and static lung volumes, and diffusion capacity were measured. Extracorporeal membrane oxygenation (ECMO) treatment, the standardized European neonatal treatment protocol, patch repair, duration of ventilation, type of initial mechanical ventilation, and nitric oxide treatment were entered as covariates in linear mixed models with standard deviation score (SDS) lung function parameters (FEV1, FEF 25-75, and K CO) as dependent variables. Results: Seventy-six children (27 ECMO-treated) born between 1999 and 2009 performed 113 reliable lung function tests. Severity of airflow obstruction deteriorated significantly from age 8 to 12 years: estimated mean difference (95% confidence interval [CI]) SDS FEV1 was −0.57 (−0.79 to −0.36) and SDS FEF25-75 was −0.63 (−0.89 to −0.37), both P <.001. Static lung volumes were within normal range and unchanged over time: estimated mean difference (95% CI) SDS TLC −0.27 (−0.58 to 0.04); P =.085. SDS KCO was below normal at 8 and 12 years and remained stable: −0.06 (−0.22 to 0.35); P =.648. These observations were irrespective of ECMO treatment. FEV1 and FEF25-75 were negatively associated with duration of ventilation (P <.001). Baseline data were not related with TLC or KCO. Conclusions: CDH patients should be followed into adulthood as they are at risk for worsening airflow obstruction and decreased diffusion capacity at school age, irrespective of ECMO treatment

Whiting–related sediment export along the Middle Miocene carbonate ramp of Great Bahama Bank.

International audienc