Hyperacute Therapies for Childhood Stroke: A Case Report and Review of the Literature

Objective. The optimal management of pediatric patients with arterial ischemic stroke (AIS) is not known. Despite this, goal-oriented, time-sensitive therapies geared to rapid reestablishment of arterial blood flow are occasionally applied with beneficial effects. The inconsistent approach to AIS is in part due to a lack of knowledge and preparedness. Methods. Case report of a 12-year-old male with right middle cerebral artery (MCA) occlusion resulting in dense left hemiplegia and mutism and review of the literature. Intervention(s). Mechanical thrombectomy, intra-arterial administration of rt-PA, vasodilators, and platelet inhibitors, and systemic anticoagulation and subsequent critical care support. Results. Restoration of right MCA blood flow and complete resolution of neurologic deficits. Conclusion. We report the gratifying outcome of treatment of a case of AIS in a pediatric patient treated with hyperacute therapies geared to arterial recanalization and subsequent neurologic critical care and review the pertinent literature. Guidelines for the emergency room management of pediatric AIS from prospective, randomized trials are needed

Adjunctive Dexamethasone Affects the Expression of Genes Related to Inflammation, Neurogenesis and Apoptosis in Infant Rat Pneumococcal Meningitis

Streptococcus pneumoniae is the most common pathogen causing non-epidemic bacterial meningitis worldwide. The immune response and inflammatory processes contribute to the pathophysiology. Hence, the anti-inflammatory dexamethasone is advocated as adjuvant treatment although its clinical efficacy remains a question at issue. In experimental models of pneumococcal meningitis, dexamethasone increased neuronal damage in the dentate gyrus. Here, we investigated expressional changes in the hippocampus and cortex at 72 h after infection when dexamethasone was given to infant rats with pneumococcal meningitis. Nursing Wistar rats were intracisternally infected with Streptococcus pneumoniae to induce experimental meningitis or were sham-infected with pyrogen-free saline. Besides antibiotics, animals were either treated with dexamethasone or saline. Expressional changes were assessed by the use of GeneChip® Rat Exon 1.0 ST Arrays and quantitative real-time PCR. Protein levels of brain-derived neurotrophic factor, cytokines and chemokines were evaluated in immunoassays using Luminex xMAP® technology. In infected animals, 213 and 264 genes were significantly regulated by dexamethasone in the hippocampus and cortex respectively. Separately for the cortex and the hippocampus, Gene Ontology analysis identified clusters of biological processes which were assigned to the predefined categories “inflammation”, “growth”, “apoptosis” and others. Dexamethasone affected the expression of genes and protein levels of chemokines reflecting diminished activation of microglia. Dexamethasone-induced changes of genes related to apoptosis suggest the downregulation of the Akt-survival pathway and the induction of caspase-independent apoptosis. Signalling of pro-neurogenic pathways such as transforming growth factor pathway was reduced by dexamethasone resulting in a lack of pro-survival triggers. The anti-inflammatory properties of dexamethasone were observed on gene and protein level in experimental pneumococcal meningitis. Further dexamethasone-induced expressional changes reflect an increase of pro-apoptotic signals and a decrease of pro-neurogenic processes. The findings may help to identify potential mechanisms leading to apoptosis by dexamethasone in experimental pneumococcal meningitis

Measuring health-related quality of life for child maltreatment: a systematic literature review

<p>Abstract</p> <p>Background</p> <p>Child maltreatment causes substantial morbidity and mortality in the U.S. Morbidity associated with child maltreatment can reduce health-related quality of life. Accurately measuring the reduction in quality of life associated with child maltreatment is essential to the economic evaluation of educational programs and interventions to reduce the incidence of child maltreatment. The objective of this study was to review the literature for existing approaches and instruments for measuring quality-of-life for child maltreatment outcomes.</p> <p>Methods</p> <p>We reviewed the current literature to identify current approaches to valuing child maltreatment outcomes for economic evaluations. We also reviewed available preference-based generic QOL instruments (EQ-5D, HUI, QWB, SF-6D) for appropriateness in measuring change in quality of life due to child maltreatment.</p> <p>Results</p> <p>We did not identify any studies that directly evaluated quality-of-life in maltreated children. We identified 4 studies that evaluated quality of life for adult survivors of child maltreatment and 8 studies that measured quality-of-life for pediatric injury not related to child maltreatment. No study reported quality-of-life values for children younger than age 3.</p> <p>Currently available preference-based QOL instruments (EQ-5D, HUI, QWB, SF-6D) have been developed primarily for adults with the exception of the Health Utilities Index. These instruments do not include many of the domains identified as being important in capturing changes in quality of life for child maltreatment, such as potential for growth and development or psychological sequelae specific to maltreatment.</p> <p>Conclusion</p> <p>Recommendations for valuing preference-based quality-of-life for child maltreatment will vary by developmental level and type of maltreatment. In the short-term, available multi-attribute utility instruments should be considered in the context of the type of child maltreatment being measured. However, if relevant domains are not included in existing instruments or if valuing health for children less than 6 years of age, direct valuation with a proxy respondent is recommended. The choice of a proxy respondent is not clear in the case of child maltreatment since the parent may not be a suitable proxy. Adult survivors should be considered as appropriate proxies. Longer-term research should focus on identifying the key domains for measuring child health and the development of preference-based quality-of-life instruments that are appropriate for valuing child maltreatment outcomes.</p

Recommendations for dental care in a situation of SARS-COV-2 pandemic and post-pandemic

La Odontología es una de las cinco profesiones más expuestas a contraer COVID-19, debido a la exposición -durante las actividades clínicas-al contacto con sangre, saliva, aerosoles, manipulación de sustancias potencialmente nocivas. El conocimiento de los riesgos propios de su entorno tiene como objetivo último evitar que los odontólogos y las personas vinculadas a la práctica profesional provoquen -por desconocimiento, inobservancia o falta de apropiación de los saberes-contagios y/o impactos desfavorables para ellos y el ambiente. Al minimizar el riesgo y la posibilidad de infecciones cruzadas se evitarán mayores contagios, en el contexto actual, sin desatender las emergencias odontológicas.publishedVersionFil: Allende Posse, María. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Arévalo, Paola. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Bojanich, Alejandra. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Bono, A. Colegio Odontológico de la Provincia de Córdoba; Argentina.Fil: Busleiman, Federico. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Castillo, Beatriz. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Castillo, Graciela. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Castillo, María Cristina. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Ermoli, J. Colegio Odontológico de la Provincia de Córdoba; Argentina.Fil: Flores, N. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Gigena, Pablo. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Girardi, Mónica. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Gutvay, Ada. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Herrera, Analía. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Huespe Rico, Verónica. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Irazuzta, María Laura. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Martínez, Dora. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Moriconi, E. Provincia de Córdoba. Ministerio de Ciencia y Tecnología; Argentina.Fil: Pereyra, María Eugenia. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Priotto, Elba. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Raya Tonetti, G. Provincia de Córdoba. Ministerio de Ciencia y Tecnología; Argentina.Fil: Rezzónico, M. S. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Scatena, Gabriela. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Vera, Mónica. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina.Fil: Zorrilla, Inés. Universidad Nacional de Córdoba. Facultad de Odontología. Equipo de Investigación en Higiene y Bioseguridad y Centro de Bioseguridad; Argentina

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients

Current Opinions in Pediatric Septic Shock

Objectives: Our aim is to describe the current clinical practice related to the management of septic shock (SS). Methods: Review of medical literature using the MEDLINE database. Articles were selected according to their relevancy to the objective and according to the author’s opinion. Summary of the findings: The outcome from SS is dependent on an early recognition and a sequential implementation of time-sensitive goal-directed therapies. The goals of the resuscitation are rapid restoration of micro circulation and improved organ tissue perfusion. Clinical and laboratory markers are needed to assess the adequacy of the treatments. Initial resuscitation involves the use of isotonic solutions (>60ml/kg) either crystalloid (normal saline) or colloid infusion often followed by vasoactive medications. Altered pharmacokinetics and pharmacodynamics responses dictate that vasoactive agents should be adjusted to achieve predetermined goals. An assessment of central venous pressure complements clinical and serological findings to tailor therapies. Elective airway instrumentation and mechanical ventilation as well as adjunctive therapy with stress dose of corticosteroid are indicated in selected populations. In neonates, a special attention to the presence of electrolyte imbalance and increase pulmonary vascular resistance needs to be considered early. Conclusions: Septic shock hemodynamic is a changing process that requires frequent assessment and therapeutic adjustments