Although there are similarities in the pathophysiology of acute respiratory distress syndrome in adults and children, pediatric-specific practice patterns, comorbidities, and differences in outcome ...necessitate a pediatric-specific definition. We sought to create such a definition.
A subgroup of pediatric acute respiratory distress syndrome investigators who drafted a pediatric-specific definition of acute respiratory distress syndrome based on consensus opinion and supported by detailed literature review tested elements of the definition with patient data from previously published investigations.
International PICUs.
Children enrolled in published investigations of pediatric acute respiratory distress syndrome.
None.
Several aspects of the proposed pediatric acute respiratory distress syndrome definition align with the Berlin Definition of acute respiratory distress syndrome in adults: timing of acute respiratory distress syndrome after a known risk factor, the potential for acute respiratory distress syndrome to coexist with left ventricular dysfunction, and the importance of identifying a group of patients at risk to develop acute respiratory distress syndrome. There are insufficient data to support any specific age for "adult" acute respiratory distress syndrome compared with "pediatric" acute respiratory distress syndrome. However, children with perinatal-related respiratory failure should be excluded from the definition of pediatric acute respiratory distress syndrome. Larger departures from the Berlin Definition surround 1) simplification of chest imaging criteria to eliminate bilateral infiltrates; 2) use of pulse oximetry-based criteria when PaO2 is unavailable; 3) inclusion of oxygenation index and oxygen saturation index instead of PaO2/FIO2 ratio with a minimum positive end-expiratory pressure level for invasively ventilated patients; 4) and specific inclusion of children with preexisting chronic lung disease or cyanotic congenital heart disease.
This pediatric-specific definition for acute respiratory distress syndrome builds on the adult-based Berlin Definition, but has been modified to account for differences between adults and children with acute respiratory distress syndrome. We propose using this definition for future investigations and clinical care of children with pediatric acute respiratory distress syndrome and encourage external validation with the hope for continued iterative refinement of the definition.
IMPORTANCE: Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. OBJECTIVE: To compare clinical characteristics and outcomes ...of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). SETTING, DESIGN, AND PARTICIPANTS: Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase–polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. EXPOSURE: SARS-CoV-2. MAIN OUTCOMES AND MEASURES: Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. RESULTS: Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference RD, 21.4% 95% CI, 16.1%-26.7%; aRR, 1.51 95% CI, 1.33-1.72 vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% 95% CI, 5.6%-16.0%; aRR, 1.43 95% CI, 1.17-1.76 vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% 95% CI, 42.4%-52.0%; aRR, 2.99 95% CI, 2.55-3.50 vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% 95% CI, 4.7%-10.6%; aRR, 2.49 95% CI, 2.05-3.02 vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% 95% CI, 2.3%-7.3%; aRR, 2.29 95% CI, 1.84-2.85 vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P < .001), higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; P < .001), and lower platelet count (<150 ×103 cells/μL 212/523 {41%} vs 84/486 {17%}, P < .001). A total of 398 patients (73.8%) with MIS-C and 253 (43.8%) with COVID-19 were admitted to the intensive care unit, and 10 (1.9%) with MIS-C and 8 (1.4%) with COVID-19 died during hospitalization. Among patients with MIS-C with reduced left ventricular systolic function (172/503, 34.2%) and coronary artery aneurysm (57/424, 13.4%), an estimated 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days. CONCLUSIONS AND RELEVANCE: This case series of patients with MIS-C and with COVID-19 identified patterns of clinical presentation and organ system involvement. These patterns may help differentiate between MIS-C and COVID-19.
An analysis of surveillance data on inpatients younger than 21 years of age who had multisystem inflammatory syndrome in children and were hospitalized between March 15 and October 31, 2020, showed ...that initial treatment with IVIG plus glucocorticoids was associated with a lower risk of cardiovascular dysfunction and a lower incidence of adjunctive therapy use than IVIG alone.
Marine debris, directly and indirectly, threatens marine habitat and biota. Fishing activity is generally recognised as a contributor to marine debris, but the relative input from recreational ...fishing remains unassessed. Here we provide the first comprehensive literature review of recreational fishing marine debris (RFMD) on a global scale. A systematic literature review identified 70 studies related to RFMD, and plastic and metal respectively were the dominant debris materials found. Nearshore coastal areas and reefs, acted as both sources and sinks of RFMD and a diverse suite of potential impacts such as ghost fishing and entanglement were identified at local scales. Overall, research of RFMD is lacking globally, however, its role in marine debris input is likely underestimated. We recommend more research on the volumes and risks, using a standardised classification approach. Where intervention is required, we suggest cooperative approaches between the sector and authorities.
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•Research on recreational fishing marine debris is lacking globally.•Plastic was the dominant material found.•Nearshore coastal areas are sources and sinks of recreational fishing debris.•The role of recreational fishing in marine debris input is likely underestimated.•It has diverse impacts on biota and habitat such as entanglement and ghost fishing.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Purpose
Requiring PaO
2
/FiO
2
ratio (PF) to define ARDS may bias towards children with cardiovascular dysfunction and hypoxemia. We sought to evaluate (1) the Berlin definition of ARDS in children ...using PF; (2) the effect of substituting SpO
2
/FiO
2
(SF) ratio; (3) differences between patients with and without arterial blood gases; and (4) the ability of SpO
2
and PaO
2
indices to discriminate ICU mortality.
Methods
Single center retrospective review (3/2009–4/2013) of mechanically ventilated (MV) children. Initial values for PF, SF, oxygenation index (OI), and oxygen saturation index (OSI) after intubation and average values on day 1 of MV were analyzed against ICU mortality, subgrouped by Berlin severity categories.
Results
Of the 1,833 children included, 129 met Berlin PF ARDS criteria (33 % mortality); 312 met Berlin SF ARDS criteria (22 % mortality). Children with a PaO
2
on day 1 of MV had higher mortality and severity of illness, were older, and had more vasoactive-inotropic infusions (
p
< 0.001). SF could be calculated for 1,201 children (AUC for ICU mortality 0.821), OSI for 1,034 (0.793), PF for 695 (0.706), and OI for 673 (0.739). Average SF on day 1 discriminated mortality better than PF (
p
= 0.003).
Conclusions
Berlin PF criteria for ARDS identified less than half of the children with ARDS, favoring those with cardiovascular dysfunction. SF or OSI discriminate ICU mortality as well as PF and OI, double the number of children available for risk stratification, and should be considered for severity of illness scores and included in a pediatric-specific definition of ARDS. Multicenter validation is required.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Shark-human interactions are some of the most pervasive human-wildlife conflicts, and their frequencies are increasing globally. New South Wales (Australia) was the first to implement a broad-scale ...program of shark-bite mitigation in 1937 using shark nets, which expanded in the late 2010s to include non-lethal measures. Using 196 unprovoked shark-human interactions recorded in New South Wales since 1900, we show that bites shifted from being predominantly on swimmers to 79 % on surfers by the 1980s and increased 2-4-fold. We could not detect differences in the interaction rate at netted versus non-netted beaches since the 2000s, partly because of low incidence and high variance. Although shark-human interactions continued to occur at beaches with tagged-shark listening stations, there were no interactions while SMART drumlines and/or drones were deployed. Our effect-size analyses show that a small increase in the difference between mitigated and non-mitigated beaches could indicate reductions in shark-human interactions. Area-based protection alone is insufficient to reduce shark-human interactions, so we propose a new, globally transferable approach to minimise risk of shark bite more effectively.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Classical biological control is an important method for controlling invasive alien weeds. Univoltine insects can be highly effective biological control agents of annual weeds because they are well ...synchronized with their host plant. However, having only one generation per year makes it difficult and slow to multiply them in the laboratory for initial field releases. If it were possible to terminate reproductive diapause early, then we could rear multiple generations per year, which would greatly increase annual production. We used a recently approved biocontrol agent,
(a univoltine weevil), for yellow starthistle (
) as a model system to study the use of two insect hormones, 20-hydroxyecdysone (20E) and methoprene, to terminate reproductive diapause. Methoprene (1 μg applied topically) terminated reproductive diapause of female weevils, whereas doses of 0.0, 0.01 and 0.1 μg did not. The combination of methoprene and 20E had a stronger effect and induced an increase in eggs (1.51 ± 0.16 eggs/day, mean ± SE) compared with a methoprene only group (1.00 ± 0.13 eggs/day), and a control group (0.21 ± 0.04 eggs/day). Thus, topical application of these hormones should enable us to rear the weevil out of its normal season and produce more than one generation per year, which will increase productivity of mass-rearing it for field release. Once released in the field, the insect would continue as a univoltine agent that is well-synchronized with its host plant.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Bacteria in biofilms have higher antibiotic tolerance than their planktonic counterparts. A major outstanding question is the degree to which the biofilm-specific cellular state and its constituent ...genetic determinants contribute to this hyper-tolerant phenotype. Here, we used genome-wide functional profiling of a complex, heterogeneous mutant population of Pseudomonas aeruginosa MPAO1 in biofilm and planktonic growth conditions with and without tobramycin to systematically quantify the contribution of each locus to antibiotic tolerance under these two states. We identified large sets of mutations that contribute to antibiotic tolerance predominantly in the biofilm or planktonic setting only, offering global insights into the differences and similarities between biofilm and planktonic antibiotic tolerance. Our mixed population-based experimental design recapitulated the complexity of natural biofilms and, unlike previous studies, revealed clinically observed behaviors including the emergence of quorum sensing-deficient mutants. Our study revealed a substantial contribution of the cellular state to the antibiotic tolerance of biofilms, providing a rational foundation for the development of novel therapeutics against P. aeruginosa biofilm-associated infections.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Heated and humidified high-flow nasal cannula (HFNC) is a widely used form of respiratory support; however, data regarding optimal flows for a given patient size or disease state are lacking. A ...comprehensive study of the physiologic effects of HFNC is needed to better understand the mechanisms of action. The objective of the current study was to quantify the effect of HFNC settings in age-specific, anatomically correct nasal airways and spontaneously breathing lung models. We hypothesized that there is an effect of flow on pressure and ventilation.
Three-dimensionally printed upper airway models of a preterm neonate, term neonate, toddler, small child, and adult were affixed to the ASL 5000 test lung to simulate spontaneous breathing with age-appropriate normal ventilation parameters. CO
was introduced to simulate profound hypercapneic respiratory failure with an end-tidal partial pressure of carbon dioxide (P
) of 90 ± 1 mm Hg. Two commercially available HFNC systems were applied to the airway models, and PEEP, inspired CO
, and exhaled CO
(P
) were recorded for 6 min across a range of flow.
Increasing HFNC flow provided a non-linear increase in PEEP in closed-mouth models, with maximum tested flows generating 6 cm H
O in the preterm neonate to 20 cm H
O in the small child. Importantly, PEEP decreased by approximately 50% in open-mouth models. Increasing HFNC flow improved expiratory CO
elimination to a certain point, above which continued increases in flow had minimal additional effect. This change point ranged from 4 L/min in the preterm neonate to 10 L/min in the small child.
These findings may help clinicians understand the effects of HFNC at different settings and may inform management guidelines for patients with respiratory failure.
The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of ...hypoxemia. However, the relationship between age and mortality is unclear.
We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.
We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (
= 1,236), multiple adult ARDS trials (
= 5,547), and an adult observational ARDS cohort (
= 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, Pa
/Fi
, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.
There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.
There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
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