Objective To compare end-of-life decisions for neonatal and pediatric patients. Study design This study involved a chart review of all pediatric deaths occurring over a 2-year period at a large ...maternal-child university hospital. Modes of death were compared. Results Of the 220 deaths analyzed, 145 occurred in intensive care units (ICUs), including 77 in the neonatal ICU (NICU) and 68 in the pediatric ICU (PICU). Only 6% of deaths were preceded by cardiopulmonary resuscitation. Dying while on the respirator was the most common mode of death in the PICU (51%) and the least common in the NICU (5%; P < .05). Unstable physiology at time of death was much more common in the PICU (82% vs 47%; P < .05). Withdrawal of life-sustaining interventions (LSI) in stable patients for quality of life reasons was the most common cause of death in the NICU (53% vs 16%; P < .05). Seventy-five children died outside of an ICU because LSI were withheld; neonates died mainly of extreme prematurity, and older children died mainly from terminal illness. Conclusion The majority of pediatric deaths occur in ICUs. Modes of death in the NICU and the PICU are strikingly different. A greater proportion of deaths in the NICU occur in infants with stable physiology who might not have died had LSI not been withdrawn. Most deaths outside of ICUs are attributable to withholding of LSI. A significant proportion of neonates in whom LSI are withheld have a possibility of intact survival, unlike older patients.
Up to 7% of term and late-preterm neonates in high-income countries receive antibiotics during the first 3 days of life because of suspected early-onset sepsis. The prevalence of culture-proven ...early-onset sepsis is 0·1% or less in high-income countries, suggesting substantial overtreatment. We assess whether procalcitonin-guided decision making for suspected early-onset sepsis can safely reduce the duration of antibiotic treatment.
We did this randomised controlled intervention trial in Dutch (n=11), Swiss (n=4), Canadian (n=2), and Czech (n=1) hospitals. Neonates of gestational age 34 weeks or older, with suspected early-onset sepsis requiring antibiotic treatment were stratified into four risk categories by their treating physicians and randomly assigned 1:1 using a computer-generated list stratified per centre to procalcitonin-guided decision making or standard care-based antibiotic treatment. Neonates who underwent surgery within the first week of life or had major congenital malformations that would have required hospital admission were excluded. Only principal investigators were masked for group assignment. Co-primary outcomes were non-inferiority for re-infection or death in the first month of life (margin 2·0%) and superiority for duration of antibiotic therapy. Intention-to-treat and per-protocol analyses were done. This trial was registered with ClinicalTrials.gov, number NCT00854932.
Between May 21, 2009, and Feb 14, 2015, we screened 2440 neonates with suspected early-onset sepsis. 622 infants were excluded due to lack of parental consent, 93 were ineligible for reasons unknown (68), congenital malformation (22), or surgery in the first week of life (3). 14 neonates were excluded as 100% data monitoring or retrieval was not feasible, and one neonate was excluded because their procalcitonin measurements could not be taken. 1710 neonates were enrolled and randomly assigned to either procalcitonin-guided therapy (n=866) or standard therapy (n=844). 1408 neonates underwent per-protocol analysis (745 in the procalcitonin group and 663 standard group). For the procalcitonin group, the duration of antibiotic therapy was reduced (intention to treat: 55·1 vs 65·0 h, p<0·0001; per protocol: 51·8 vs 64·0 h; p<0·0001). No sepsis-related deaths occurred, and 9 (<1%) of 1710 neonates had possible re-infection. The risk difference for non-inferiority was 0·1% (95% CI −4·6 to 4·8) in the intention-to-treat analysis (5 0·6% of 866 neonates in the procalcitonin group vs 4 0·5% of 844 neonates in the standard group) and 0·1% (−5·2 to 5·3) in the per-protocol analysis (5 0·7% of 745 neonates in the procalcitonin group vs 4 0·6% of 663 neonates in the standard group).
Procalcitonin-guided decision making was superior to standard care in reducing antibiotic therapy in neonates with suspected early-onset sepsis. Non-inferiority for re-infection or death could not be shown due to the low occurrence of re-infections and absence of study-related death.
The Thrasher Foundation, the NutsOhra Foundation, the Sophia Foundation for Scientific research.
The large, international, randomized controlled NeoPInS trial showed that procalcitonin (PCT)-guided decision making was superior to standard care in reducing the duration of antibiotic therapy and ...hospitalization in neonates suspected of early-onset sepsis (EOS), without increased adverse events. This study aimed to perform a cost-minimization study of the NeoPInS trial, comparing health care costs of standard care and PCT-guided decision making based on the NeoPInS algorithm, and to analyze subgroups based on country, risk category and gestational age.
Data from the NeoPInS trial in neonates born after 34 weeks of gestational age with suspected EOS in the first 72 h of life requiring antibiotic therapy were used. We performed a cost-minimization study of health care costs, comparing standard care to PCT-guided decision making.
In total, 1489 neonates were included in the study, of which 754 were treated according to PCT-guided decision making and 735 received standard care. Mean health care costs of PCT-guided decision making were not significantly different from costs of standard care (€3649 vs. €3616). Considering subgroups, we found a significant reduction in health care costs of PCT-guided decision making for risk category 'infection unlikely' and for gestational age ≥ 37 weeks in the Netherlands, Switzerland and the Czech Republic, and for gestational age < 37 weeks in the Czech Republic.
Health care costs of PCT-guided decision making of term and late-preterm neonates with suspected EOS are not significantly different from costs of standard care. Significant cost reduction was found for risk category 'infection unlikely,' and is affected by both the price of PCT-testing and (prolonged) hospitalization due to SAEs.
A review of 917 relative sea-level (RSL) data-points has resulted in the first quality-controlled database constraining the Holocene sea-level histories of the western Mediterranean Sea (Spain, ...France, Italy, Slovenia, Croatia, Malta and Tunisia). We reviewed and standardized the geological RSL data-points using a new multi-proxy methodology based on: (1) modern taxa assemblages in Mediterranean lagoons and marshes; (2) beachrock characteristics (cement fabric and chemistry, sedimentary structures); and (3) the modern distribution of Mediterranean fixed biological indicators. These RSL data-points were coupled with the large number of archaeological RSL indicators available for the western Mediterranean. We assessed the spatial variability of RSL histories for 22 regions and compared these with the ICE-5G (VM2) GIA model. In the western Mediterranean, RSL rose continuously for the whole Holocene with a sudden slowdown at ~7.5kaBP and a further deceleration during the last ~4.0kaBP, after which time observed RSL changes are mainly related to variability in isostatic adjustment. The sole exception is southern Tunisia, where data show evidence of a mid-Holocene high-stand compatible with the isostatic impacts of the melting history of the remote Antarctic ice sheet.
Our results indicate that late-Holocene sea-level rise was significantly slower than the current one. First estimates of GIA contribution indicate that, at least in the northwestern sector, it accounts at least for the 25–30% of the ongoing sea-level rise recorded by Mediterranean tidal gauges. Such contribution is less constrained at lower latitudes due to the lower quality of the late Holocene index points. Future applications of spatio-temporal statistical techniques are required to better quantify the gradient of the isostatic contribution and to provide improved context for the assessment of 20th century acceleration of Mediterranean sea-level rise.
Purpose
To describe the vacuum-assisted mini-percutaneous nephrolithotomy (vmPCNL) technique performed via the 16Ch ClearPetra sheath, to evaluate its outcomes and to analyze intrarenal pressure ...(IRP) fluctuations during surgery.
Methods
Data from all consecutive vmPCNL procedures from September 2017 to October 2019 were prospectively collected. Data included patients’ and stones characteristics, intra and peri-operative items, post-operative complications and stone clearance. Patients undergoing vmPCNL from March to October 2019 were submitted to IRP measurement during surgery.
Results
A total of 122 vmPCNL procedures were performed. Median stone volume was 1.92 cm
3
. Median operative time was 90 min and median lithotripsy and lapaxy time was 28 min. Stone clearance rate was 71.3%. Thirty-one (25.2%) patients experienced post-operative complications, seven of which were Clavien 3. Postoperative fever occurred in nine (7.4%) patients and one (0.8%) needed a transfusion. No sepsis were observed. IRPs were measured in 22 procedures. Mean IRP was 15.3 cmH
2
O and median accumulative time with IRP > 40.78 cmH
2
O (pyelovenous backflow threshold) was 28.52 sec. Maximum IRP peaks were reached during the surgical steps when aspiration is closed (mainly pyelograms), whereas during lithotripsy and suction-mediated lapaxy, the threshold of 40.78 cmH
2
O was overcome in three procedures.
Conclusions
vmPCNL is a safe procedure with satisfactory stone clearance rates. Mean IRP was always lower than the threshold of pyelo-venous backflow and the accumulative time with IRP over this limit was short in most of the procedures. During lithotripsy and vacuum-mediated lapaxy, IRP rarely raised over the threshold.
Purpose
To report a retrospective series of patients implanted with a novel hydrophilic acrylic single-piece intraocular lens (IOL) designed for sutureless scleral fixation (FIL-SSF Carlevale lens, ...Soleko, Italy) injectable through a 2.2-mm incision.
Methods
Seventy-eight patients with minimum 6-month follow-up were divided into 6 groups: dropped nucleus, luxated IOL, trauma, aphakia, IOL exchange, and Marfan’s syndrome. Surgery included peritomy and scleral flap creation at 3 and 9 o’clock position. The IOL was then injected and grasped with 25G forceps through a hole created 2 mm posterior to the limbus underneath the sculped scleral flap.
Results
The study included 78 patients (mean age 71.9 ± 12.6 years) and average follow-up 10.2 ± 4.2 months. Average surgery duration was 69.4 ± 26.1 min and vision significantly improved from 0.86 ± 0.56 logMAR to 0.38 ± 0.42 logMAR at 6 months post-operative (
p
< 0.001). Intraoperative complications included corneal edema, retinal tears, and vitreous bleeding each in 2/78 patients (2.5%); 1/78 (1.3%) localized retinal detachment and 1/78 (1.3%) rupture of one T-shaped IOL harpoon. Post-operative complications included 4/78 (5.1%) cystoid macular edemas, 2/78 retinal tears, 2/78 retinal detachments, 2/78 developed ocular hypertension, and 1/78 corneal decompensation requiring DSAEK.
Conclusion
The Carlevale lens is designed for sutureless intrascleral fixation and can be successfully used in a variety of indications including difficult trauma cases with good rehabilitation. An implant requires experience and delicate manipulation.
Laser-induced graphene (LIG) emerged as one of the most promising materials for flexible functional devices. However, the attempts to obtain LIG onto elastomeric substrates never succeed, hindering ...its full exploitation for stretchable electronics. Herein, a novel polymeric composite is reported as a starting material for the fabrication of graphene-based electrodes by direct laser writing. A polyimide (PI) powder is dispersed into the poly(dimethylsiloxane) (PDMS) matrix to achieve an easily processable and functional elastomeric substrate, allowing the conversion of the polymeric surface into laser-induced graphene (LIG). The mechanical and electrical properties of the proposed material can be easily tuned by acting on the polyimide powder concentration. The reported procedure takes advantage from the simple casting process, typical of silicone elastomer, allowing to produce electrodes conformable to any kind of shape and surface as well as complex three-dimensional structures. Electrochemical capacitors and strain gauges are selected as flexible prototypes to demonstrate the multifunctional properties of the obtained LIG on the PDMS/PI composite substrate.
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