Immune reconstitution after transplantation of autologous peripheral stem cells in children: a comparison between CD34+ selected and nonmanipulated grafts.

BACKGROUND AND AIMS: High-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT) improves the prognosis in pediatric patients with several solid tumors and lymphomas. Little is known about the reconstitution of the immune system after ASCT and the influence of CD34+ cell selection on the reconstitution in pediatric patients. METHODS: Between 1990 and 2001, 94 pediatric patients with solid tumors and lymphomas received autologous CD34+ selected or unmanipulated peripheral stem cells after HDC. CD34+ selection was carried out with magnetic microbeads. The absolute numbers of T cells, B cells and natural killer (NK) cells were measured and compared in both groups at various time points post-transplant. RESULTS: Recovery of T cells was significantly faster in the unmanipulated group at day 30, with no significant difference later on. Reconstitution of B and NK cells was similar in both groups without significant differences at any time. The CD34+-selected group was divided into patients receiving less or more than 5.385 × 106/kg CD34+ cells. Patients in the CD34+ high-dose group displayed significantly faster reconstitutions of neutrophiles and lymphocyte subsets than the CD34+ low-dose group. CONCLUSIONS: Engraftment and reconstitution of leukocytes, B cells and NK cells after transplantation of CD34+ selected stem cells were comparable to that in patients receiving unmanipulated grafts. T-cell recovery was faster in the unmanipulated group only within the first month. However, this delay could be compensated by transplantation of >5.385 × 106 CD34+ cells/kg. Especially for patients receiving immunotherapy after HDC large numbers of immune effector cells such as NK and T cells are necessary to mediate antibody-dependent cellular cytotoxicity. Therefore, in patients receiving autologous CD34+-selected grafts, our data emphasize the need to administer high stem cell counts.

Simulation of Aerosol and Droplet Spread during Upper Airway and Gastrointestinal Endoscopy.

BACKGROUND AND AIMS: Aerosols and droplets are the main vectors in transmission of highly contagious SARS-CoV-2. Invasive diagnostic procedures like upper airway and gastrointestinal endoscopy have been declared as aerosol-generating procedures. Protection of healthcare workers is crucial in times of the COVID-19 pandemic. METHODS: We simulated aerosol and droplet spread during upper airway and gastrointestinal endoscopy with and without physico-mechanical barriers using a simulation model. RESULTS: A clear plastic drape as used for central venous access markedly reduced visualized aerosol and droplet spread during endoscopy. CONCLUSION: A simple and cheap drape has the potential to reduce aerosol and droplet spread during endoscopy. In terms of healthcare worker protection, this may be important particularly in low- or moderate-income countries.

Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Healthcare Providers: The Role of Simulation for Pandemics and Other Disasters.

OBJECTIVES: Early preparation for the training and education of healthcare providers, as well as the continuation or modification of routine medical education programs, is of great importance in times of the coronavirus disease 2019 pandemic or other public health emergencies. The goal of this study was to characterize these self-reported efforts by the pediatric simulation community. DESIGN: This was a global, multicenter survey developed via a Delphi process. SETTING: International survey study. SUBJECTS: The survey was sent to 555 individual members of the three largest international pediatric simulation societies (The International Pediatric Simulation Society, International Network for Simulation-based Pediatric Innovation, Research & Education, and Netzwerk Kindersimulation e.V.) between April 27, 2020, and May 18, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Description of coronavirus disease 2019 pandemic simulation-based preparation activities of pediatric acute and critical care healthcare providers. The Delphi process included 20 content experts and required three rounds to reach consensus. The survey was completed by 234 participants (42.2%) from 19 countries. Preparation differed significantly between the geographic regions, with 79.3% of Anglo-American/Anglo-Saxon, 82.6% of Indian, and 47.1% of European participants initiating specifically coronavirus disease 2019-related simulation activities. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued noncoronavirus disease 2019-related simulation training. CONCLUSIONS: The swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. The approach used, however, depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements.

Leg-heel chest compression as an alternative for medical professionals in times of COVID-19.

OBJECTIVE: To evaluate leg-heel chest compression without previous training as an alternative for medical professionals and its effects on distance to potential aerosol spread during chest compression. METHODS: 20 medical professionals performed standard manual chest compression followed by leg-heel chest compression after a brief instruction on a manikin. We compared percentage of correct chest compression position, percentage of full chest recoil, percentage of correct compression depth, average compression depth, percentage of correct compression rate and average compression rate between both methods. In a second approach, potential aerosol spread during chest compression was visualized. RESULTS: Our data indicate no credible difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method. CONCLUSION: Under special circumstances like COVID-19-pandemic, leg-heel chest compression may be an effective alternative without previous training compared to manual chest compression while markedly increasing the distance to the patient.

Beliefs, preferences, and acceptance of personal protective equipment for a shock room team in a tertiary care center.

BACKGROUND: During coronavirus disease of 2019 pandemic a standard usage of personal protective equipment (PPE) in healthcare was mandatory, while actually the usage of PPE is currently decreasing. This raises the question about the further use of PPE in the clinical setting because healthcare workers (HCW) are at greater risk of being infected with SARS-CoV-2 than the general population. The primary objective of this study is to determine the proportion of shock room team members approving the further use of PPE including a FFP2 respirator in simulation training and reality. The secondary objectives are to describe the expertise and difficulties faced while using PPE in the shock room care. METHODS: Fifty-four HCW participated in a shock room simulation training at a large urban tertiary care hospital in Germany, utilizing a PPE comprising an FFP2 mask, gloves, goggles, and gown. Subsequently, participants completed an online questionnaire featuring 15 questions presented on a 5-point Likert scale or as multiple-choice questions with predefined answers. RESULTS: Sixty-eight point five percent of our participants voted for an established standard PPE in shock room care. The largest fraction of our participants (40.7%) favors a standard PPE consisting of FFP2 mask, gown, and gloves. Less HCW (31.5%) want to wear PPE in shock room simulation training. Except for goggles we could not detect relevant difficulties faced while using PPE in the shock room environment. Incorrect use of PPE was observed in 14.8%. CONCLUSION: A majority of our participants favored a standard PPE including a FFP2 respirator in shock room care. In addition, we recommend the use of PPE in shock room simulation training, while further awareness of and training in proper use of PPE seems to be necessary to reduce risk of infectious diseases for HCW.

Exploration of strategies to reduce aerosol-spread during chest compressions: A simulation and cadaver model.

OBJECTIVE: To evaluate the effect of strategies to reduce the spread of simulated aerosol during chest compressions on manikin and cadaver experimental models. METHODS: To evaluate aerosol-spread we nebulized ultraviolet sensitive detergents into the artificial airway of a resuscitation dummy and performed CPR. The spread of the visualized aerosol was documented by a camera. In a further approach we applied nebulized detergents into the airways of human cadavers and detected the simulated spread on the same way. Among others we did recordings with undergoing compression-only-CPR, with a surgical mask or an oxygen mask on the patients face and with an inserted supraglottic airway device with and without a connected airway filter. RESULTS: Most aerosol-spread at the direction of the provider was visualized during compression-only-CPR. The use of a surgical mask and of an oxygen mask on the patient's face deflected the spread. Inserting a supraglottic airway device connected to an airway filter lead to a remarkable reduction of aerosol-spread. CONCLUSION: The early insertion of a supraglottic airway device connected to an airway filter before starting chest compression may be beneficial for staff protection during CPR.

[Thoracic surgery in children--pain control after surgery]. / Thoraxchirurgie bei Kindern--Postoperative Schmerztherapie.

In the postoperative phase after thoracic surgery in children patients can suffer considerable pain. The repertoire of analgesic treatments consist of basic treatment with non-opioid analgesics such as paracetamol or ibuprofen, as well as need-determined treatments with opioids given under intensive care monitoring. In addition, local and regional anaesthetic methods are an important part of the big picture of effective pain control after thoracic surgery in children.