Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1–6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Ozonized water generator based on coaxial dielectric-barrier-discharge in air

A coaxial dielectric-barrier-discharge (DBD) as an ozonized water reactor system has been developed and described. It operates in the air at an atmospheric pressure. In the reactor one of the dielectric layers is flowing water. Ozone and ozonized water are generated in the same volume of the discharge. The ozone production and its dissolution in the water simultaneously occur leading to increases of the reactor efficiency. Filamentary 50 Hz DBD has been performed using up to 20 kV applied voltage. The obtained ozone concentrations correspond to the values typically suggested for the treatment of potable and wastewater. The efficiency can be further increased by addition of small amount of the oxygen in the DBD device. The periodical time dependence of the dissolved ozone concentration in Danube water is found and discussed. (C) 2004 Elsevier Ltd. All rights reserved

The addition of deep hyperthermia to gemcitabine-based chemoradiation may achieve enhanced survival in unresectable locally advanced adenocarcinoma of the pancreas

Introduction Driven by the current unsatisfactory outcomes for patients with locally advanced pancreatic cancer (LAPC), a biologically intensified clinical protocol was developed to explore the feasibility and efficacy of FOLFORINOX chemotherapy followed by deep hyperthermia concomitant with chemoradiation and subsequent FOLFORINOX chemotherapy in patients with LAPC. Methods Nine patients with LAPC were treated according to the HEATPAC Phase II trial protocol which consists of 4 cycles of FOLFORINOX chemotherapy followed by gemcitabine-based chemoradiation to 56 Gy combined with weekly deep hyperthermia and then a further 8 cycles of FOLFORINOX chemotherapy. Results One grade three related toxicity was reported and two tumours became resectable. The median overall survival was 24 months and 1 year overall survival was 100%. Conclusions Intensification of chemoradiation with deep hyperthermia was feasible in nine consecutive patients with LAPC

Radiotherapy for Melanoma: More than DNA Damage

Despite its reputation as a radioresistant tumour, there is evidence to support a role for radiotherapy in patients with melanoma and we summarise current clinical practice. Melanoma is a highly immunogenic tumour and in this era of immunotherapy, there is renewed interest in the potential of irradiation, not only as an adjuvant and palliative treatment, but also as an immune stimulant. It has long been known that radiation causes not only DNA strand breaks, apoptosis, and necrosis, but also immunogenic modulation and cell death through the induction of dendritic cells, cell adhesion molecules, death receptors, and tumour-associated antigens, effectively transforming the tumour into an individualised vaccine. This immune response can be enhanced by the application of clinical hyperthermia as evidenced by randomised trial data in patients with melanoma. The large fraction sizes used in cranial radiosurgery and stereotactic body radiotherapy are more immunogenic than conventional fractionation, which provides additional radiobiological justification for these techniques in this disease entity. Given the immune priming effect of radiotherapy, there is a strong but complex biological rationale and an increasing body of evidence for synergy in combination with immune checkpoint inhibitors, which are now first-line therapy in patients with recurrent or metastatic melanoma. There is great potential to increase local control and abscopal effects by combining radiotherapy with both immunotherapy and hyperthermia, and a combination of all three modalities is suggested as the next important trial in this refractory disease

Removal of phenol and chlorophenols from water by new ozone generator

Presence of phenol in river water occasionally disturbs the production of drinking water. Phenol often originated from coal power plants or pesticides. New ozone generator [Kuraica et al., Vacuum, 73 (2004) 705] was used for removal of phenol and chlorophenols from water. The ozone generator was based on coaxial dielectric-barrier-discharge and operated in the air at an atmospheric pressure. Flowing water was one of dielectric layers. Ozone and ozonized water were generated in the same volume of the discharge. This type of ozone generator has considerable advantages in comparison with the classical ones. In this paper five experiments were described, three with bidistilled water and two with different water samples from river Danube. In all cases, 5 L of water containing 6 mg/L of corresponding phenol was passed once through the ozonizer. The concentration of dissolved ozone in water was 7-40 mg/L. The ozonization lasted 1 h, but the total contact time was up to 94 h. In all cases, before and after the treatment of water with ozone, the concentration of corresponding phenol [Standard Methods for Examination of Water and Wastewater, method 510 13, Chloroform Extraction Method, American Public Health Association, Washington, 1985, p. 558], dissolved and residual ozone [Standard Methods for Examination of Water and Wastewater, Methods 2-41, 2-42 (dissolved ozone) Iodometric Method; method 4-104 (ozone residual) Indigo Colorimetric Method, American Public Health Association, Washington, 1995] were determined by standard methods. In experiments with distilled water most of the phenol was removed during ozonization (89.5%). After 24 and 96 h the percentage of removed phenol increased to 93.3 and 98.9%, respectively. With 4-chlorophenol and 2,4-dichlorophenol, 99.8 and 98.9% of corresponding phenols were removed. In experiments with two different water samples from Danube, the phenol was also mostly removed during ozonization, 76.7 and 80.0%, respectively

Degradation of Aqueous Phenol Solutions by Coaxial Dbd Reactor

Solutions of 2-chlorophenol, 4-chlorophenol and 2,6-dichlorophenol in bidistilled and water from the river Danube were treated in plasma reactor. In this reactor, based on coaxial dielectric barrier discharge at atmospheric pressure, plasma is formed over a thin layer of treated water. After one pass through the reactor, starting chlorophenols concentration of 20 mg/l was diminished up to 95%. Kinetics of the chlorophenols degradation was monitored by High Pressure Liquid Chromatography method (HPLC).24TH SUMMER SCHOOL AND INTERNATIONAL SYMPOSIUM ON THE PHYSICS OF IONIZED GASES, CONTRIBUTED PAPER