Under a watchful eye...: New Medication and Monitoring of Sedation and Analgesia in Pediatric Intensive Care

Ernstig zieke kinderen op een kinder-intensive care (IC) afdeling, krijgen regelmatig kalmerende middelen (sedativa) en pijnstillers (analgetica) toegediend om discomfort, onrust en pijn te voorkomen. Om bijwerkingen van deze middelen te voorkomen en om er voor te zorgen dat ze goed hun werk doen, is gedegen onderzoek nodig. Helaas zijn kinderen vaak de laatsten waarvoor medicijnen getest worden. Om deze reden hebben wij twee veel gebruikte sedativa, te weten midazolam en propofol, alsmede een nieuwe toedieningsvorm (intraveneus) van de pijnstiller paracetamol onderzocht op hun veiligheid en werkzaamheid. Daarnaast hebben wij onderzocht hoe de diepte van sedatie bij kinderen op de IC het best kan worden bepaald. Van midazolam wordt d.m.v. farmacokinetiek en farmacodynamiek beschreven dat een oplaaddosis midazolam van 0,1 mg/kg met daarop volgend een continu infuus van 0,05 mg/kg/u leidt tot lichte sedatie. Propofol bij kinderen op de IC is begin jaren '90 ter discussie komen te staan toen enkele 'case reports' een fatale afloop meldden. Uit ons onderzoek blijkt dat er geen bijwerking werd geconstateerd bij gebruik van propofol tot een dosering van 4 mg/kg/u. Paracetamol wordt normaliter in de vorm van een zetpil toegediend, maar is al 25 jaar ook intraveneus toepasbaar. In een dubbel blind gerandomiseerde trial werd i.v. propacetamol met rectale paracetamol vergeleken. Bij kinderen < 2 jaar leidt i.v. toediening veel sneller tot voldoende hoge concentraties van paracetamol. Bovendien zijn de concentraties veel beter voorspelbaar dan na toediening van een zetpil. De diepte van sedatie bij kinderen op de IC kan het best worden bepaald d.m.v. gedragsobservatieschalen. De bruikbaarheid van de Ramsay sedatie schaal werd onderzocht door deze te vergelijken met de COMFORT-gedragschaal. We vonden een goede correlatie tussen de RS en de COMFORT-gedragschaal. Echter, aangezien de RS een schaal is die slechts één aspect meet met zes antwoordmogelijkheden, kon in een aantal gevallen de diepte van sedatie niet bepaald worden. Verder is de RS een schaal die eerder het bewustzijn meet dan de diepte van sedatie. Een andere methode om de diepte van sedatie te meten zou de Bispectraal Index monitor kunnen zijn. Deze hersenfunctie monitor is uit de anesthesie afkomstig en werd tijdens verschillende omstandigheden op de kinder-IC onderzocht. Zo werd gekeken naar de waarde van de BIS monitor tijdens spierverslapping, barbituraten coma, sedatie en normale slaap bij kinderen. De hartslag en bloeddruk bleken geen adequate indicatoren van stress of pijn te zijn tijdens spierverslapping; dit in tegenstelling tot de BIS monitor. Verder bleek de BIS monitor de mate van barbituraten coma adequaat te kunnen monitoren. Bij kinderen onder 1 jaar bleek de BIS monitor niet altijd betrouwbaar. In het algemeen heeft de BIS monitor vele mogelijkheden op de kinder-IC, maar pleiten we wel voor een nieuw BIS algoritme voor kinderen onder de 1 jaar. Een tweede hersenfunctiemonitor, de Auditory Evoked Potential monitor (AEP monitor/2), maakt gebruik van de eerste respons van de hersenschors van de patiënt op een geluidsprikkel om de diepte van sedatie te meten. De AEP monitor/2 produceerde in 80% van de metingen geluidsprikkels van 75 dB. Dit geluidsniveau, met daarbij opgeteld het omgevingsgeluid, is veel te hoog voor een kinder-IC. Daarnaast bleek de correlatie tussen de AAI en de COMFORT-gedragschaal matig te zijn. Na 8 patiënten werd de studie gestopt. We adviseren dan ook om de AEP monitor/2 niet op de kinder-IC te gebruiken

Training van werkgeheugen en inhibitie bij kinderen en adolescenten met obesitas

Obesitas bij kinderen is de afgelopen decennia sterk toegenomen. Er is een aantal redenen om te interveniëren bij obesitas op de kinderleeftijd. Cardiovasculaire risicofactoren komen bij ernstige obese kinderen veel vaker voor dan bij kinderen zonder gewichtsproblemen en obesitas op de kinderleeftijd vergroot het risico op cardiovasculaire morbiditeit en mortaliteit op volwassen leeftijd1. Bovendien zijn de psychosociale gevolgen van obesitas vaak aanzienlijk en hinderen ze het kind in zijn ontwikkeling2. Preventie en behandeling zijn vereist, maar de resultaten zijn wisselend en eerder zwak met een grote kans op terugval

Propofol for endotracheal intubation in neonates: A dose-finding trial

Objective: To find propofol doses providing effective sedation without side effects in neonates of different gestational ages (GA) and postnatal ages (PNA). Design and setting: Prospective multicentere dose-finding study in 3 neonatal intensive care units. Patients: Neonates with a PNA <28 days requiring non-emergency endotracheal intubation. Interventions: Neonates were stratified into 8 groups based on GA and PNA. The first 5 neonates in every group received a dose of 1.0 mg/kg propofol. Based on sedative effect and side effects, the dose was increased or decreased in the next 5 patients until the optimal dose was found. Main outcome measures: The primary outcome was the optimal single propofol starting dose that provides effective sedation without side effects in each age group. Results: After inclusion of 91 patients, the study was prematurely terminated because the primary outcome was only reached in 13% of patients. Dose-finding was completed in 2 groups, but no optimal propofol dose was found. Effective sedation without side effects was achieved more often after a starting dose of 2.0 mg/kg (28%) than after 1.0 mg/kg (3%) and 1.5 mg/kg (9%). Propofol-induced hypotens

IL-4 and IL-13 exposure during mucociliary differentiation of bronchial epithelial cells increases antimicrobial activity and expression of antimicrobial peptides

The airway epithelium forms a barrier against infection but also produces antimicrobial peptides (AMPs) and other inflammatory mediators to activate the immune system. It has been shown that in allergic disorders, Th2 cytokines may hamper the antimicrobial activity of the epithelium. However, the presence of Th2 cytokines also affects the composition of the epithelial layer which may alter its function. Therefore, we investigated whether exposure of human primary bronchial epithelial cells (PBEC) to Th2 cytokines during mucociliary differentiation affects expression of the human cathelicidin antimicrobial protein (hCAP18)/LL-37 and human beta defensins (hBD), and antimicrobial activity

White matter alterations in glaucoma and monocular blindness differ outside the visual system

The degree to which glaucoma has effects in the brain beyond the eye and the visual pathways is unclear. To clarify this, we investigated white matter microstructure (WMM) in 37 tracts of patients with glaucoma, monocular blindness, and controls. We used brainlife.io for reproducibility. White matter tracts were subdivided into seven categories ranging from those primarily involved in vision (the visual white matter) to those primarily involved in cognition and motor control. In the vision tracts, WMM was decreased as measured by fractional anisotropy in both glaucoma and monocular blind subjects compared to controls, suggesting neurodegeneration due to reduced sensory inputs. A test-retest approach was used to validate these results. The pattern of results was different in monocular blind subjects, where WMM properties increased outside the visual white matter as compared to controls. This pattern of results suggests that whereas in the monocular blind loss of visual input might promote white matter reorganization outside of the early visual system, such reorganization might be reduced or absent in glaucoma. The results provide indirect evidence that in glaucoma unknown factors might limit the reorganization as seen in other patient groups following visual loss

New Species in the Old World: Europe as a Frontier in Biodiversity Exploration, a Test Bed for 21st Century Taxonomy

The number of described species on the planet is about 1.9 million, with ca. 17,000 new species described annually, mostly from the tropics. However, taxonomy is usually described as a science in crisis, lacking manpower and funding, a politically acknowledged problem known as the Taxonomic Impediment. Using data from the Fauna Europaea database and the Zoological Record, we show that contrary to general belief, developed and heavily-studied parts of the world are important reservoirs of unknown species. In Europe, new species of multicellular terrestrial and freshwater animals are being discovered and named at an unprecedented rate: since the 1950s, more than 770 new species are on average described each year from Europe, which add to the 125,000 terrestrial and freshwater multicellular species already known in this region. There is no sign of having reached a plateau that would allow for the assessment of the magnitude of European biodiversity. More remarkably, over 60% of these new species are described by non-professional taxonomists. Amateurs are recognized as an essential part of the workforce in ecology and astronomy, but the magnitude of non-professional taxonomist contributions to alpha-taxonomy has not been fully realized until now. Our results stress the importance of developing a system that better supports and guides this formidable workforce, as we seek to overcome the Taxonomic Impediment and speed up the process of describing the planetary biodiversity before it is too late

Novel 1,4-benzoxazine and 1,4-benzodioxine inhibitors of angiogenesis.

Esters of 1,4-benzoxazine and 1,4-benzodioxine compounds 1 and 10, which combine thrombin inhibitory and GPIIb/IIIa antagonistic activity in one molecule are shown to inhibit endothelial cell migration and tube formation in vitro and angiogenesis in the chicken chorioallantoic membrane (CAM) assay. The corresponding carboxylic acids 1 (R2 = H) and 11 were devoid of antiangiogenic activity, most probably due to their insufficient entry into the cell. Although thrombin inhibition remains the most probable explanation for their inhibition of angiogenesis, VEGFR2 kinase assay suggest that other targets such as VEGFR2 might be involved

Physiological-based cord clamping in very preterm infants:the Aeration, Breathing, Clamping 3 (ABC3) trial—statistical analysis plan for a multicenter randomized controlled trial

Background: Mortality, cerebral injury, and necrotizing enterocolitis (NEC) are common complications of very preterm birth. An important risk factor for these complications is hemodynamic instability. Pre-clinical studies suggest that the timing of umbilical cord clamping affects hemodynamic stability during transition. Standard care is time-based cord clamping (TBCC), with clamping irrespective of lung aeration. It is unknown whether delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) is more beneficial. This document describes the statistical analyses for the ABC3 trial, which aims to assess the efficacy and safety of PBCC, compared to TBCC. Methods: The ABC3 trial is a multicenter, randomized trial investigating PBCC (intervention) versus TBCC (control) in very preterm infants. The trial is ethically approved. Preterm infants born before 30 weeks of gestation are randomized after parental informed consent. The primary outcome is intact survival, defined as the composite of survival without major cerebral injury and/or NEC. Secondary short-term outcomes are co-morbidities and adverse events assessed during NICU admission, parental reported outcomes, and long-term neurodevelopmental outcomes assessed at a corrected age of 2 years. To test the hypothesis that PBCC increases intact survival, a logistic regression model will be estimated using generalized estimating equations (accounting for correlation between siblings and observations in the same center) with treatment and gestational age as predictors. This plan is written and submitted without knowledge of the data. Discussion: The findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management at birth. Trial registration: ClinicalTrials.gov NCT03808051. Registered on 17 January 2019.</p

No Evidence for XMRV in German CFS and MS Patients with Fatigue Despite the Ability of the Virus to Infect Human Blood Cells In Vitro

BACKGROUND: Xenotropic murine leukemia virus-related virus (XMRV), a novel human retrovirus originally identified in prostate cancer tissues, has recently been associated with chronic fatigue syndrome (CFS), a disabling disease of unknown etiology affecting millions of people worldwide. However, several subsequent studies failed to detect the virus in patients suffering from these illnesses or in healthy subjects. Here we report the results of efforts to detect antibody responses and viral sequences in samples from a cohort of German CFS and relapsing remitting multiple sclerosis (MS) patients with fatigue symptoms. METHODOLOGY: Blood samples were taken from a cohort of 39 patients fulfilling the Fukuda/CDC criteria (CFS), from 112 patients with an established MS diagnosis and from 40 healthy donors. Fatigue severity in MS patients was assessed using the Fatigue Severity Scale (FSS). Validated Gag- and Env-ELISA assays were used to screen sera for XMRV antibodies. PHA-activated PBMC were cultured for seven days in the presence of IL-2 and DNA isolated from these cultures as well as from co-cultures of PBMC and highly permissive LNCaP cells was analyzed by nested PCR for the presence of the XMRV gag gene. In addition, PBMC cultures were exposed to 22Rv1-derived XMRV to assess infectivity and virus production. CONCLUSION: None of the screened sera from CFS and MS patients or healthy blood donors tested positive for XMRV specific antibodies and all PBMC (and PBMC plus LNCaP) cultures remained negative for XMRV sequences by nested PCR. These results argue against an association between XMRV infection and CFS and MS in Germany. However, we could confirm that PBMC cultures from healthy donors and from CFS patients can be experimentally infected by XMRV, resulting in the release of low levels of transmittable virus

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London