The "3R Team" in action! Implementation of a program of learning from excellence in a neonatal and pediatric intensive care unit in France.

BACKGROUND: The pursuit of improving quality of care and of patient safety is a crucial objective in intensive care units (ICUs). Classically, safety is characterized by analyzing adverse events. Neonatal and pediatric ICUs (NICUs/PICU) are highly technological units, with evidence of risk for elevated levels of emotional exhaustion and thus a significant level of staff turnover. We hypothesized that appreciative inquiry (AI), currently used in many organizations, could be introduced in our ICU. In the PICU and NICU, this new concept is termed "learning from excellence" (LFE). OBJECTIVE: To assess the impact of the implementation of an LFE program on well-being and on an educational program in the NICU/PICU of a tertiary care center in France. METHODS: We created a workgroup composed of caregivers called the "3R team" for "right resuscitations reviews," based on the concept of AI. Before and 1 year after implementation, we administered two validated surveys-the Maslach Burnout Inventory and the Siegrist survey-to the entire staff of the 22-bed unit. RESULTS: The questionnaire on satisfaction revealed a high percentage (93%) of satisfaction with the work of the 3R team and that scores of well-being and burnout were improved. The educational program was highly enhanced, especially simulation. Benevolence and happiness were increased. CONCLUSION: Implementation of an LFE program in a NICU and PICU is feasible, and tends to increase the well-being and self-confidence of all categories of caregivers. It promotes educational programs of dynamic learning, including simulation. The next important step will be to study the impact on staff turnover and on quality of care.

Proportion versus absolute counts of B cell populations in the assessment of immunological profiles of kidney transplant recipients.

Immunophenotyping lymphocytes in kidney transplant recipients often raises questions as to whether proportions or absolute counts should be considered, especially for longitudinal assessment. Several studies conclude the pathophysiology of rejection based on proportions of naive and memory B cells. We compared the two analytical methods for B cells sampled from 82 clinically stable, adult kidney transplant recipients. Time post-transplant was analyzed both as a continuous variable and as tertiles (<1.5 years, 1.5-8 years, and > 8 years). B cells were stained for CD38 and IgD and were classified according to mature B cells (Bm) classification. The proportion of cells in the naive Bm2 compartment decreased by more than half in the late versus the early tertile, whereas the percentages of memory early Bm5 tripled and that of memory Bm5 cells doubled. In contrast, we observed a substantial reduction in naive B cell counts, but very stable memory B cell counts. Linear regressions showed that the absolute reduction in the Bm2 cell compartment was independent of age, sex, graft function, immunosuppression scheme, and rejection occurrence. In conclusion, the physiological reservoir of naive cells decreases over time post-transplant in kidney recipients, whereas that of memory B cells remains stable. Peripheral B subset percentages should be interpreted cautiously when analyzing pathophysiological processes.

Assessing the accuracy of measurements obtained by dual-energy X-ray absorptiometry on pig carcasses and primal cuts.

Accuracy, trueness, and precision of dual-energy X-ray absorptiometry (DXA) assessment of pig carcasses and primal cuts dissected tissues were evaluated using available region of interests (ROI) and Total Body and Small Animal software modes. Fat mass, lean mass, and bone mineral content (BMC) DXA values were compared to dissected tissue weights (fat, muscle, and bones). Used ROI influenced (P < 0.05) DXA measurements of BMC, fat mass, and lean mass. Configuration modes influenced (P < 0.05) DXA fat mass in shoulders and bellies, whereas BMC estimates differed (P < 0.05) among configuration modes. Equations predicting dissected composition on the basis of DXA measurements showed high coefficients of determination, particularly for fat and lean masses. DXA is able to accurately evaluate the composition of pig carcasses and primal cuts. From a methodological viewpoint, and considering the variations observed in this study, the method for image acquisition and analysis should be chosen on the basis of the item to be evaluated.

Repeatability and reproducibility of measurements obtained by dual-energy X-ray absorptiometry on pig carcasses.

The precision of a dual-energy X-ray absorptiometry (DXA) device in terms of repeatability and reproducibility was evaluated on nine left half-carcasses from pigs with large variability in body weight and fat content. Repeatability was assessed by scanning each carcass 10 times sequentially in the same position. Reproducibility was assessed by scanning each carcass in 10 different positions. Images were analyzed with DXA software using a custom region of interest (ROI) and the standard head, trunk, arm, and leg ROI. Predicted values from the DEXA for bone mineral content (BMC), bone area, bone mineral density (BMD), total weight, soft-tissue weight, fat-tissue weight, and lean-tissue weight were considered. Repeatability was associated with the variance between measurements on the same carcass in the same position (repeatability conditions). An average variance value was obtained with all the carcasses combined, and the SD was calculated as the square root of this combined variance. The CV was the ratio between the SD of the measurements and its average value. Reproducibility was calculated for each carcass as the difference between the variance obtained under the reproducibility conditions and that obtained under the repeatability conditions. The effects of the ROI and conditions were evaluated by ANOVA and Tukey's test. Means of BMC, bone area, BMD, fat tissue, and lean tissue differed among the ROI (P < 0.05) in both the repeatability and reproducibility conditions. The CV of DXA measurements under repeatability condition obtained in the head, arm, and leg ROI was lesser than 1%. Only the repeatability errors of fat tissue differed (P < 0.05) among the ROI, with the lowest precision found for the trunk ROI. The reproducibility errors of BMC, bone area, fat tissue, and lean tissue differed (P < 0.05) among the ROI. The custom ROI had reproducibility errors greater than 2% for fat tissue and greater than 3.5% for BMC and bone area. In addition, the trunk ROI had the highest reproducibility errors for fat tissue (20.7%) and lean tissue (6.2%) when compared to the other ROI. In conclusion, repeatability and reproducibility results obtained for most of the studied ROI indicate that DXA is a valuable tool for carcass evaluation. From a methodological viewpoint and considering the variations observed in this study, the ROI should be chosen based on the item to be evaluated or on the conditions in which the DXA measurements are to be taken.

How to assess hemodynamic status in very preterm newborns in the first week of life?

BACKGROUND: Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery. OBJECTIVES: This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment. CONCLUSIONS: This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.

[Prenatal diagnosis of a right thoracic congenital ectopic kidney with a diaphragmatic hernia: a combination with a good prognosis]. / Diagnostic anténatal d'un rein droit thoracique et d'une hernie de coupole diaphragmatique droite: une association de bon pronostic.

Ectopic intrathoracic kidney is a rare congenital anomaly, usually asymptomatic. This anomaly is sometimes associated with a diaphragmatic hernia. Few cases of this combination have been described, often in the absence of a prenatal diagnosis. We report on the case of a female newborn infant who was diagnosed with an ectopic intrathoracic right kidney and a diaphragmatic hernia upon 33 weeks of gestation. The patient underwent surgery on the first day of life and the respiratory and renal outcomes were simple. We review the literature and discuss the seemingly good prognosis of this combination.

Review and prospect of emerging contaminants in waste--key issues and challenges linked to their presence in waste treatment schemes: general aspects and focus on nanoparticles.

The presence in waste of emerging pollutants (EPs), whose behaviours and effects are not well understood, may present unexpected health and environmental risks and risks for the treatment processes themselves. EP may include substances that are newly detected in the environment, substances already identified as risky and whose use in items is prohibited (but which may be present in old or imported product waste) or substances already known but whose recent use in products can cause problems during their future treatment as waste. Several scientific studies have been conducted to assess the presence of EP in waste, but they are mostly dedicated to a single category of substance or one particular waste treatment. In the absence of a comprehensive review focused on the impact of the presence of EP on waste treatment schemes, the authors present a review of the key issues associated with the treatment of waste containing emerging pollutants. This review presents the typologies of emerging pollutants that are potentially present in waste along with the major challenges for each treatment scheme (recycling, composting, digestion, incineration, landfilling and wastewater treatment). All conventional treatment processes are affected by these new pollutants, and they were almost never originally designed to consider these substances. In addition to these general aspects, a comprehensive review of available data, projects and future R&D needs related to the impact of nanoparticles on waste treatment is presented as a case study.

[Neonatal cellulitis caused by group B Streptococcus]. / Cellulite néonatale à streptocoque du groupe B.

Dermohypodermitis (cellulitis) in newborn infants and in infants aged up to 3 months is uncommon and often not typical. Because group B Streptococcus is known to induce rapid life-threatening complications, early diagnosis leading to emergency treatment is of utmost importance. We report on the case of a 14-day-old girl, initially admitted for viral bronchiolitis with suspected bacterial pulmonary infection, in the absence of any cutaneous injury. The disease actually was cellulitis of the face, caused by group B Streptococcus. The baby presented with a severe septic clinical condition. Early treatment with antibiotics (intravenous amoxicillin for 10 days) allowed a favorable course, with rapid control of the sepsis and regression of the submandibular tumefaction.

Discrete salt crystallization at the surface of a porous medium.

Efflorescence refers to crystallized salt structures that form at the surface of a porous medium. The challenge is to understand why these structures do not form everywhere at the surface of the porous medium but at some specific locations and why there exists an exclusion distance around an efflorescence where no new efflorescence forms. These are explained from a visualization experiment, pore-network simulations and a simple efflorescence growth model.

[Severe hydrogen sulfide intoxication: a pediatric case of survival]. / Intoxication accidentelle grave à l'hydrogène sulfuré: un cas pédiatrique de survie.

We report a paediatric case of survival following severe hydrogen sulfide (H2S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H2S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H2S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.

Bronchoalveolar lavage fluid cytology and cytokine messenger ribonucleic Acid expression of racehorses with exercise intolerance and lower airway inflammation.

BACKGROUND: There is limited information relating bronchoalveolar lavage (BAL) cytology and cytokine messenger ribonucleic acid (mRNA) expression in racehorses with inflammatory airway disease (IAD). HYPOTHESIS AND OBJECTIVE: We hypothesize that cytokine expression in BAL cells would correlate with cytology. Thus, we evaluated the mRNA expression of selected cytokines in BAL cells in racehorses with exercise intolerance and lower airway inflammation. ANIMALS: Thirty-one client-owned Standardbred racehorses with exercise intolerance. METHODS: Prospective, observational study. Cells were obtained by BAL, and mRNA expression of interleukin (IL)-1ß, IL-4, IL-8, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ was determined by reverse transcription quantitative polymerase chain reaction (RT-qPCR). RESULTS: Nine horses had normal BAL cell differential cytology (Controls), while 22 horses had evidence of IAD based on BAL fluid cytology. Relative expressions of TNF-α/glyceraldehyde 3-phosphate dehydrogenase (GAPDH; 0.0092 ± 0.010 versus 0.0045 ± 0.005, P= .034), IL-4/GAPDH (0.001 ± 0.002 versus 0.0003 ± 0.0003, P= .029), and IFN-γ/GAPDH (0.0027 ± 0.003 versus 0.0009 ± 0.001, P= .028) were greater in horses with IAD compared with controls. Furthermore, IL-4/GAPDH (0.001 ± 0.002 versus 0.0002 ± 0.0003, P < .0001) and IFN-γ/GAPDH (0.003 ± 0.003 versus 0.001 ± 0.001, P= .002) mRNA expression was increased in horses with increased metachromatic cell counts compared with horses with normal metachromatic cell counts. Only the mRNA expression of IL-1ß/GAPDH (1.1 ± 0.7 versus 0.3 ± 0.3, P= .045) was increased with airway neutrophilia. CONCLUSIONS AND CLINICAL IMPORTANCE: Differences in gene expression were associated with the presence of IAD and with specific cell types present in airway secretions of Standardbred racehorses with poor performance. These findings suggest that different pathophysiological pathways are implicated in IAD.

[Circular shunting of blood: a complication of neonatal Ebstein anomaly]. / Le shunt circulaire: complication de la maladie d'Ebstein de forme néonatale.

We report a severe neonatal presentation of Ebstein anomaly with homodynamic aggravation at birth attributed to patent ductus arteriosus and circular shunt. Prenatal diagnosis of Ebstein anomaly of the tricuspid valve with functional pulmonary atresia was made at 37 weeks gestation by fetal two- and three-dimensional echocardiography. A cesarean section was performed in view of poor fetal tolerance. The newborn was born with hydrops and multivisceral failure. A post-natal echocardiography demonstrated a left-to-right shunt across the patent ductus arteriosus and functional pulmonary atresia with severe pulmonary insufficiency with absent forward flow. This created a circular shunt, where blood flowed through the ductus to the pulmonary arteries, retrograde through the pulmonary artery and Ebstein valve, across the patent foramen ovale and out the aorta. Prostaglandin E1 infusion was stopped, resulting in clinical and echocardiographic improvement. The management of the phenomenon of a circular shunt across a patent ductus arteriosus with Ebstein malformation involves promoting early ductal closure by stopping prostaglandin therapy.

Winery wastewater treatment using the land filter technique.

This study outlines a new approach to the treatment of winery wastewater by application to a land FILTER (Filtration and Irrigated cropping for Land Treatment and Effluent Reuse) system. The land FILTER system was tested at a medium size rural winery crushing approximately 20,000 tonnes of grapes. The approach consisted of a preliminary treatment through a coarse screening and settling in treatment ponds, followed by application to the land FILTER planted to pasture. The land FILTER system efficiently dealt with variable volumes and nutrient loads in the wastewater. It was operated to minimize pollutant loads in the treated water (subsurface drainage) and provide adequate leaching to manage salt in the soil profile. The land FILTER system was effective in neutralizing the pH of the wastewater and removing nutrient pollutants to meet EPA discharge limits. However, suspended solids (SS) and biological oxygen demand (BOD) levels in the subsurface drainage waters slightly exceeded EPA limits for discharge. The high organic content in the wastewater initially caused some soil blockage and impeded drainage in the land FILTER site. This was addressed by reducing the hydraulic loading rate to allow increased soil drying between wastewater irrigations. The analysis of soil characteristics after the application of wastewater found that there was some potassium accumulation in the profile but sodium and nutrients decreased after wastewater application. Thus, the wastewater application and provision of subsurface drainage ensured adequate leaching, and so was adequate to avoid the risk of soil salinisation.

[Evidence versus experience in neonatal practice: the example of extremely premature infants]. / Niveaux de preuves versus pratiques cliniques: l'exemple de l'extrême prématurité

We focused on current nutritional and ventilation strategies of extremely preterm infants and reviewed the evidence and the practical experience in four French neonatal intensive care units. The recommendations from reviews and the local clinical guidelines were compared and were overall in agreement. We wanted then to evaluate if different ventilatory and nutritional styles existed between four French intensive neonatal units, and if these approaches had an effect on short term outcomes. 399 infants delivered at a gestational age <28 weeks between January 2005 and December 2006 were retrospectively studied (unit I = 141, unit II = 97, unit III = 85, unit IV = 76). Data were collected from birth to discharge. The study groups were similar with regard to gestational age, birth weight, gender, prenatal steroids, rate of inborn. There were significant differences in ventilatory and nutritional strategies between the units. Incidence of NEC, IVH grade 3-4 and PVL were similar between the units. Mortality rate during the hospitalization stay was 14.9 %, 35.0 %, 29.4 % and 29 % (p<0.05). A national database would be useful to analyse differences in strategies and long term outcomes.

Comparison of radiography and ultrasonography to detect osteochondrosis lesions in the tarsocrural joint: a prospective study.

REASONS FOR PERFORMING STUDY: Lesions located on the medial malleolus of the tarsocrural joint can be difficult to image radiographically. Ultrasonography allows evaluation of articular cartilage and subchondral bone. OBJECTIVES: To compare dorso30 degrees lateral-plantaromedial-oblique (DL-PIMO) and dorso45 degrees views to detect lesions on the medial malleolus, to validate the use of ultrasonography to show lesions in the tarsocrural joint and to compare its sensitivity to radiography. METHODS: Tarsocrural joints (n=111) with osteochondrosis were evaluated ultrasonographically and radiographically prior to arthroscopic lesion debridement. A complete radiographic examination was made and the best view to detect each lesion recorded. Longitudinal and transverse ultrasonography of the dorsal aspect of the joint was performed and the best scan plane to image each lesion recorded. RESULTS: There were 94 joints with lesions on the distal intermediate ridge of tibia, 24 with lesions on the medial malleolus, and 4 with lesions on the lateral trochlear ridge. The sensitivity of radiography to detect lesions on the medial malleolus and distal intermediate ridge of tibia was 71 and 96%, respectively. Eighty-two percent of lesions on the medial malleolus were better imaged on dorso30 degrees view. The sensitivity of ultrasonography to detect lesions on the medial malleolus and distal intermediate ridge of tibia was 83 and 98%, respectively. Ultrasonography was significantly more sensitive than radiography to detect lesions on the medial malleolus and distal intermediate ridge of tibia. CONCLUSION: Dorso30 degrees lateral-plantaromedial-oblique view was the best to image lesions on the medial malleolus. Ultrasonography was a valuable diagnostic tool to diagnose lesions in the tarsocrural joint and was more sensitive than radiography for lesions located on the medial malleolus and distal intermediate ridge of tibia. CLINICAL RELEVANCE: Radiographic examination should include a dorso30 degrees view for detection of lesions on the medial malleolus and ultrasonography should be considered to diagnose osteochondrosis in the tarsocrural joints.

Effects of growth rate, sex and slaughter weight on fat characteristics of pork bellies.

A total of 119 Duroc×(Landrace×Yorkshire) commercial pigs were used to investigate the effect of growth rate (fast vs slow), sex (barrows vs gilts) and slaughter liveweight (107, 115 and 125kg) on the fat characteristics of bellies. Backfat thickness increased with weight (P<0.01). Fat firmness score was only affected by sex (P<0.05), with gilts showing softer bellies than barrows. Fat from gilts and slow growing pigs showed a lower proportion of saturated fatty acids (SFA; P<0.001 and P<0.01, respectively), a higher proportion of linoleic fatty acid (C18:2 n-6; P<0.01), a higher proportion of total polyunsaturated fatty acids (PUFA; P<0.001 and P<0.01, respectively), and an increased iodine value (P<0.001). Consequently, the fat from these bellies had higher PUFA:SFA ratios (P<0.001) and n-6:n-3 ratios (P<0.01 and P<0.001, respectively) than that from the bellies of barrows and fast growing pigs. The belly fat from barrows and fast growing pigs had higher stearic fatty acid (C18:0; P<0.01) and SFA proportions (P<0.001 and P<0.01, respectively) than that from gilts and slow growing pigs. The belly fat from gilts and slow growing pigs would better meet the health requirements of consumers, but it is more prone to rancidity during storage leading to a potentially reduced bacon shelf-life.

[Alveolar capillary dysplasia and persistent pulmonary hypertension of the newborn]. / La dysplasie alvéolo-capillaire: une cause exceptionnelle d'hypertension artérielle pulmonaire persistante du nouveau né. A propos d'un cas.

Alveolar capillary dysplasia is a rare cause of persistent pulmonary hypertension of the newborn. The diagnosis of this condition is made by histological study of a pulmonary biopsy. Familial forms and associated genitor-urinary and gastrointestinal malformations have been reported. Despite optimal management, the prognosis remains poor. The authors report the case of a neonate who developed cyanosis and cardiogenic shock on the 10th day of life. There was no associated neonatal pathology. Echocardiography showed supra-systemic pulmonary hypertension with normal cardiac structure. Pulmonary vasodilator therapies (inhaled NO, prostacyclin, sildenafil, bosentan) were ineffective and the child died on the 25th day of life. Autopsy revealed alveolar capillary dysplasia.