Prospective case series study on the use of a novel analgosedation protocol for ultrasound-guided catheterization in Neonatal Intensive Care Unit.

Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheters (CICCs) inserted by ultrasound-guided puncture of the internal jugular or brachio-cephalic vein. Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation. The aim of this study is to evaluate the feasibility of a novel protocol of sedation. Data from 46 patients were prospectively collected. The feasibility was assessed throughout the monitoring of adverse events and the incidence of spontaneous movements. The procedure was completed in 100% of cases. There were no cases of escalation of the baseline ventilatory support despite the procedure and no case of hypotension, and all spontaneous movements were controlled with additional boluses when required. CONCLUSION: Our study represents the very first step towards the design of a validated protocol for analgosedation during ultrasound-guided CICC insertion in NICU. WHAT IS KNOWN: • Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheter. • Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation. WHAT IS NEW: • The use of this new protocol for analgosedation is able to achieve a good level of sedation and pain control without significant adverse event. • Ultrasound-guided CICC insertion can be performed even in non-ventilated newborns.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs). STUDY DESIGN: This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis. RESULTS: In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%). CONCLUSIONS: In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments. TRIAL REGISTRATION: UMIN-CTR Clinical Trial; Registration number: R000045844.

The neonatal DAV-expert algorithm: a GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access in newborns.

In most NICUs, the choice of the venous access device currently relies upon the operator's experience and preferences. However, considering the high failure rate of vascular devices in the neonatal population, such clinical choice has a critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems in line with the current scientific evidence. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in the neonatal population. After a systematic review of the available evidence, the panel of the consensus (which included Italian neonatologists specifically experts in this area) has provided structured recommendations answering four sets of questions regarding (1) umbilical venous catheters, (2) peripheral cannulas, (3) epicutaneo-cava catheters, and (4) ultrasound-guided centrally and femorally inserted central catheters. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.  Conclusion: The goal of the present consensus is to offer a systematic set of recommendations on the choice of the most appropriate vascular access device in Neonatal Intensive Care Unit.

Normal values for superior vena cava flow in preterm neonates using a new echocardiographic approach.

OBJECTIVE: Recently, a novel approach to imaging Superior Vena Cava (SVC) flow has been presented, showing better repeatability and better agreement with MRI-derived SVC flow measures. The objective was to establish normal values of SVC flow with the novel approach in the first 48 h of life. STUDY DESIGN: This was a prospective, observational study. All infants with gestational age (GA) less than 31 weeks were eligible. Echocardiographic evaluation was performed at 5, 12, 24, 48 h of postnatal life. A subgroup of uncomplicated infants was studied to define a normal range for SVC flow. RESULTS: Forty-five infants were enrolled. We estimated normative values in a subgroup of 31 uncomplicated infants. The median SVC flow significantly increases from 83 ml/kg/min at 5 h of life to 153 ml/kg/min at 48 h (p < .001). CONCLUSION: Using the novel approach we derived normal values of SVC flow in a cohort of uncomplicated preterm population at high risk for developing IVH.

Real-Time Ultrasound Tip Location Reduces Malposition and Radiation Exposure during Epicutaneo-Caval Catheter Placement in Neonates.

OBJECTIVE: Epicutaneo-caval catheters (ECCs) are essential for the care of sick infants who require long-term medical and nutritional management. The aim of this study was to investigate the use of real-time ultrasound as an alternative to X-rays to reduce the incidence of primary malpositions during catheter insertion. STUDY DESIGN: Data on ECCs were retrospectively collected in a tertiary neonatal intensive care unit. Catheter were analyzed considering the tip location technique (standard chest-abdominal radiograph vs real-time ultrasound) RESULTS: A total of 248 ECCs were analyzed. Of these, 118 catheters had primary malposition (47.6%). The tip of 165 catheters was assessed using standard chest-abdominal X-rays and 107 (64.8%) were found to be in an inappropriate location. In the group of 83 catheters that were placed using real-time ultrasound for tip location, only 11 catheters (13.2%) had primary malposition. The rate of malposition among the two groups showed a statistically significant difference (p < 0.001). Hypothetically, 300 chest X-rays could have been saved if real-time ultrasound had been used to locate the tip, reducing radiation exposure to infants. CONCLUSION: The use of a real-time ultrasound may be beneficial in reducing primary catheter malpositions compared with conventional radiography. In addition, secondary malpositions and catheter-related complications can be monitored over time. KEY POINTS: · Conventional radiology cannot be considered the "gold standard" for ECC tip location.. · Ultrasound is more accurate and reduces insertion time reducing the rate of primary malposition.. · Ultrasound can be performed in real time and it is the best technique for ECC tip location in infants..

Energy, economic, and environmental impacts of enhanced ventilation strategies on railway coaches to reduce Covid-19 contagion risks.

In the last years, the Covid-19 outbreak raised great awareness about ventilation system performance in confined spaces. Specifically, the heating, ventilation, and air conditioning system design and operating parameters, such as air change per hour, air recirculation ratio, filtration device performance, and vents location, play a crucial role in reducing the spread of viruses, moulds, bacteria, and general pollutants. Concerning the transport sector, due to the impracticability of social distancing, and the relatively loose requirements of ventilation standards, the SARS-COV-19 outbreak brought a reduction of payload (up to 50%) for different carriers. Specifically, this has been particularly severe for the railway sector, where train coaches are typically characterized by relatively elevated occupancy and high recirculation ratios. In this framework, to improve the Indoor Air Quality and reduce the Covid-19 contagion risk in railway carriages, the present paper investigates the energy, economic and environmental feasibility of diverse ventilation strategies. To do so, a novel dynamic simulation tool for the complete dynamic performance investigation of trains was developed in an OpenStudio environment. To assess the Covid-19 contagion risk connected to the investigated scenarios, the Wells-Riley model has been adopted. To prove the proposed approach's capabilities and show the Covid-19 infection risk reduction potentially achievable by varying the adopted ventilation strategies, a suitable case study related to an existing medium-distance train operating in South/Central Italy is presented. The conducted numerical simulations return interesting results providing also useful design criteria.

Formulation, pilot-scale preparation, physicochemical characterization and digestibility of a lentil protein-based model infant formula powder.

BACKGROUND: Infant formula is a human milk substitute for consumption during the first months of life. The protein component of such products is generally of dairy origin. Alternative sources of protein, such as those of plant origin, are of interest due to dairy allergies, intolerances, and ethical and environmental considerations. Lentils have high levels of protein (20-30%) with a good amino acid profile and functional properties. In this study, a model lentil protein-based formula (LF), in powder format, was produced and compared to two commercial plant-based infant formulae (i.e., soy; SF and rice; RF) in terms of physicochemical properties and digestibility. RESULTS: The macronutrient composition was similar between all the samples; however, RF and SF had larger volume-weighted mean particle diameters (D[4,3] of 121-134 µm) than LF (31.9 µm), which was confirmed using scanning electron and confocal laser microscopy. The larger particle sizes of the commercial powders were attributed to their agglomeration during the drying process. Regarding functional properties, the LF showed higher D[4,3] values (17.8 µm) after 18 h reconstitution in water, compared with the SF and RF (5.82 and 4.55 µm, respectively), which could be partially attributed to hydrophobic protein-protein interactions. Regarding viscosity at 95 °C and physical stability, LF was more stable than RF. The digestibility analysis showed LF to have similar values (P < 0.05) to the standard SF. CONCLUSION: These results demonstrated that, from the nutritional and physicochemical perspectives, lentil proteins represent a good alternative to other sources of plant proteins (e.g., soy and rice) in infant nutritional products. © 2021 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Interactions between whey proteins and calcium salts and implications for the formulation of dairy protein-based nutritional beverage products: A review.

Whey-based nutritional beverages are often fortified with calcium (Ca) in order to deliver the recommended intake of Ca. However, technical and product quality challenges are often experienced with Ca fortification of whey protein-based nutritional solutions, such as poor heat stability, high viscosity, colloidal instability, and impaired heat transfer. Understanding of the relationships and interactions between whey proteins and Ca relative to liquid process (e.g., ready to feed products, feed material prior to drying) is essential to designing and formulating nutritional whey-based products with desired physicochemical and colloidal stability properties. This article reviews the interactions between whey proteins and Ca salts used in the formulation of nutritional whey-based products as well as major processing implications associated with Ca fortification of whey-based solutions.

Calcium: A comprehensive review on quantification, interaction with milk proteins and implications for processing of dairy products.

Calcium (Ca) is a key micronutrient of high relevance for human nutrition that also influences the texture and taste of dairy products and their processability. In bovine milk, Ca is presented in several speciation forms, such as complexed with other milk components or free as ionic calcium while being distributed between colloidal and serum phases of milk. Partitioning of Ca between these phases is highly dynamic and influenced by factors, such as temperature, ionic strength, pH, and milk composition. Processing steps used during the manufacture of dairy products, such as preconditioning, concentration, acidification, salting, cooling, and heating, all contribute to modify Ca speciation and partition, thereby influencing product functionality, product yield, and fouling of equipment. This review aims to provide a comprehensive understanding of the influence of Ca partition on dairy products properties to support the development of kinetics models to reduce product losses and develop added-value products with improved functionality. To achieve this objective, approaches to separate milk phases, analytical approaches to determine Ca partition and speciation, the role of Ca on protein-protein interactions, and their influence on processing of dairy products are discussed.

An exploration of task based fMRI in neonates using echo-shifting to allow acquisition at longer TE without loss of temporal efficiency.

Optimal contrast to noise ratio of the BOLD signal in neonatal and foetal fMRI has been hard to achieve because of the much longer T2(⁎) values in developing brain tissue in comparison to those in the mature adult brain. The conventional approach of optimizing fMRI sequences would suggest matching the echo time (TE) and the T2(⁎) of the neonatal and foetal brain. However, the use of a long echo time would typically increase the minimum repetition time (TR) resulting in inefficient sampling. Here we apply the concept of echo shifting to task based neonatal fMRI in order to achieve an improved contrast to noise ratio and efficient data sampling at the same time. Echo shifted EPI (es-EPI) is a modification of a standard 2D-EPI sequence which enables echo times longer than the time between consecutive excitations (TE>TS=TRNS, where NS is the number of acquired slices and TS the inter-slice repetition time). The proposed method was tested on neonatal subjects using a passive sensori-motor task paradigm. Dual echo EPI datasets with an identical readout structure to es-EPI were also acquired and used as control data to assess BOLD activation. From the results of the latter analysis, an average increase of 78±41% in contrast to noise ratio was observable when comparing late to short echoes. Furthermore, es-EPI allowed the acquisition of data with an identical contrast to the late echo, but more efficiently since a higher number of slices could be acquired in the same amount of time.

Proactive enteral nutrition in moderately preterm small for gestational age infants: a randomized clinical trial.

OBJECTIVE: To investigate the efficacy of a proactive feeding regimen (PFR) in reducing hospital length of stay in a population of moderately preterm small for gestational age (SGA) infants. STUDY DESIGN: SGA infants (z-score <-1.28) of gestational age (GA) 32-36 weeks and birth weight (BW) >1499 g were allocated at random to receive either a PFR, starting with 100 mL/kg/day and gradually increasing to 200 mL/kg/day by day 4, or a standard feeding regimen, starting with 60 mL/kg/day and gradually increasing to 170 mL/kg/day by day 9. All infants received human milk. RESULTS: A total of 72 infants were randomized to the 2 groups, 36 to the PFR group (mean GA, 35.1 ± 0.7 weeks; mean BW, 1761 ± 177 g) and 36 to the standard feeding regimen group (mean GA, 35.5 ± 1.2 weeks; mean BW, 1754 ± 212 g). Infants in the PFR group were discharged significantly earlier (mean, 9.8 ± 3.1 days vs 11.9 ± 4.7 days; P = .029). The need for intravenous fluids (2.8% vs 33.3%; P = .0013) and the incidence of hypoglycemia (0 vs 33.3%; P = .00016) were significantly lower in the PFR group. Feeding intolerance and fecal calprotectin levels did not differ between the 2 groups. CONCLUSION: A PFR in moderately preterm SGA infants is well tolerated and significantly reduces both the length of stay and the risk of neonatal hypoglycemia.

Utility of intranasal Ketamine and Midazolam to perform gastric aspirates in children: a double-blind, placebo controlled, randomized study.

BACKGROUND: We performed a prospective, randomized, placebo-controlled study aimed to evaluate the efficacy and safety of a sedation protocol based on intranasal Ketamine and Midazolam (INKM) administered by a mucosal atomizer device in uncooperative children undergoing gastric aspirates for suspected tuberculosis. PRIMARY OUTCOME: evaluation of Modified Objective Pain Score (MOPS) reduction in children undergoing INKM compared to the placebo group. SECONDARY OUTCOMES: evaluation of safety of INKM protocol, start time sedation effect, duration of sedation and evaluation of parents and doctors' satisfaction about the procedure. METHODS: In the sedation group, 19 children, mean age 41.5 months, received intranasal Midazolam (0.5 mg/kg) and Ketamine (2 mg/kg). In the placebo group, 17 children received normal saline solution twice in each nostril. The child's degree of sedation was scored using the MOPS. A questionnaire was designed to evaluate the parents' and doctors' opinions on the procedures of both groups. RESULTS: Fifty-seven gastric washings were performed in the sedation-group, while in the placebo-group we performed 51 gastric aspirates. The degree of sedation achieved by INMK enabled all procedures to be completed without additional drugs. The mean duration of sedation was 71.5 min. Mean MOPS was 3.5 (range 1-8) in the sedation-group, 7.2 (range 4-9) in the placebo-group (p <0.0001). The questionnaire revealed high levels of satisfaction by both doctors and parents in the sedation-group compared to the placebo-group. The only side effect registered was post-sedation agitation in 6 procedures in the sedation group (10.5%). CONCLUSIONS: Our experience suggests that atomized INKM makes gastric aspirates more acceptable and easy to perform in children. TRIAL REGISTRATION: Unique trial Number: UMIN000010623; Receipt Number: R000012422.

Retained medullary cord confirmed by intraoperative neurophysiological mapping.

INTRODUCTION: A retained medullary cord (RMC) is a rare dysraphic malformation, recently described as a late arrest of secondary neurulation. RMC is also a severely tethering lesion. The critical role of intraoperative neurophysiology to safely manage a RMC has been only anecdotally reported. CASE REPORT: We describe the case of a RMC in a 1.5-year-old child with Currarino syndrome. At surgery, an apparently normal-looking spinal cord, stretched and tethered by a lipoma to the level of S2-S3, was observed. The border between the functional conus and the non functional RMC was defined through neurophysiological mapping. The cord was sharply interrupted at this level and untethered. A specimen was sent for pathology, which confirmed the presence of glial and neural elements. The post-operative neurological exam was normal. CONCLUSION: Neurosurgical procedure for RMC should only be rendered with intraoperative neurophysiological mapping, as the anatomical judgment would not suffice to allow a safe cutting of these "normal-looking" neural structures.

A novel neonatal protocol for Safe Insertion of Umbilical Venous Catheters (SIUVeC): Minimizing complications in placement and management.

Insertion of umbilical venous catheters is a common procedure in neonatal intensive care. Though sometimes lifesaving, this maneuver is potentially associated with early and late complications, some of which may be severe and even life threatening (catheter malposition, hepatic lesions, venous thrombosis, pericardial effusion, etc.). The recent literature suggests several operative strategies that, if adopted systematically, may significantly reduce the incidence of both early and late catheter related complications. This paper describes a standardized protocol (Safe Insertion Umbilical Venous Catheter = SIUVeC) which incorporates such novel strategies, with the goal of minimizing the complications related to this procedure.

Exploiting Natural Niches with Neuroprotective Properties: A Comprehensive Review.

Natural products from mushrooms, plants, microalgae, and cyanobacteria have been intensively explored and studied for their preventive or therapeutic potential. Among age-related pathologies, neurodegenerative diseases (such as Alzheimer's and Parkinson's diseases) represent a worldwide health and social problem. Since several pathological mechanisms are associated with neurodegeneration, promising strategies against neurodegenerative diseases are aimed to target multiple processes. These approaches usually avoid premature cell death and the loss of function of damaged neurons. This review focuses attention on the preventive and therapeutic potential of several compounds derived from natural sources, which could be exploited for their neuroprotective effect. Curcumin, resveratrol, ergothioneine, and phycocyanin are presented as examples of successful approaches, with a special focus on possible strategies to improve their delivery to the brain.

The SIECC protocol: A novel insertion bundle to minimize the complications related to epicutaneo-cava catheters in neonates.

Epicutaneo-cava catheters are the most widely used central venous catheters in the neonate, but their insertion and management are potentially associated with several complications, both during placement (failure to proceed with the catheter, primary malposition, etc.) and during maintenance (infection, venous thrombosis, catheter dislocation, secondary malposition, etc.). Recent studies have identified methods and techniques that may be effective in minimizing the risk of most of these complications. This paper proposes a structured, sequential insertion bundle-nicknamed "the SIECC protocol" (SIECC = Safe Insertion of Epicutaneo-Cava Catheters)-which includes seven evidence-based strategies which have been proven to increase the safety, effectiveness, and cost-effectiveness of the procedure.

Implications of bacteria‒bacteria interactions within the plant microbiota for plant health and productivity. / 植物微生物群落中细菌-细菌互作对植物健康和生产力的影响.

Crop production currently relies on the widespread use of agrochemicals to ensure food security. This practice is considered unsustainable, yet has no viable alternative at present. The plant microbiota can fulfil various functions for its host, some of which could be the basis for developing sustainable protection and fertilization strategies for plants without relying on chemicals. To harness such functions, a detailed understanding of plant‒microbe and microbe‒microbe interactions is necessary. Among interactions within the plant microbiota, those between bacteria are the most common ones; they are not only of ecological importance but also essential for maintaining the health and productivity of the host plants. This review focuses on recent literature in this field and highlights various consequences of bacteria‒bacteria interactions under different agricultural settings. In addition, the molecular and genetic backgrounds of bacteria that facilitate such interactions are emphasized. Representative examples of commonly found bacterial metabolites with bioactive properties, as well as their modes of action, are given. Integrating our understanding of various binary interactions into complex models that encompass the entire microbiota will benefit future developments in agriculture and beyond, which could be further facilitated by artificial intelligence-based technologies.

Real-Time Ultrasound Tip Location Reduces Malposition and Radiation Exposure during Umbilical Venous Catheter Placement in Neonates: A Retrospective, Observational Study.

INTRODUCTION: The umbilical venous catheter is a vital access device in neonatal intensive care units for preterm and critically ill infants. Correct positioning is crucial, as malpositioning can lead to severe complications. According to international guidelines, the position of the umbilical venous catheter tip must be assessed in real time; traditionally, the catheter is visualized with a thoracoabdominal X-ray, but one of the most effective and safest methods is therefore real-time ultrasound. METHODS: This study compares real-time ultrasound and traditional X-ray methods for assessing umbilical venous catheter tip location in 461 cases. The rate of tip malposition was analyzed retrospectively. The secondary aim was to assess indwelling time of umbilical venous catheters and reasons of removal. RESULTS: Real-time ultrasound tip location, found to be more reliable and efficient, demonstrated a significantly lower incidence of primary malpositioning compared to X-ray assessments (9.6 vs. 75.9%). The study also highlighted the association of real-time ultrasound with reduced catheter manipulation, fewer radiographs, and higher indwelling times of umbilical venous catheter. The multiple logistic regression showed a high probability of the central safe position of the umbilical venous catheter tip using real-time ultrasound tip location (odds ratio 29.5, 95% confidence interval: 17.4-49.4). CONCLUSION: The findings support the adoption of real-time ultrasound in clinical settings to enhance umbilical venous catheter placement accuracy and minimize associated risks. A minimal training investment is needed to attain the proficiency to visualize the umbilical venous catheters, offering a substantial advantage in terms of both cost-effectiveness for the procedure and enhanced patient safety.