The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.

The effects of a sleeve knee brace during stair negotiation in patients with symptomatic patellofemoral osteoarthritis.

BACKGROUND: The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients. METHODS: 30 patellofemoral joint osteoarthritis patients (40-70 years) ascended and descended an instrumented staircase with force plates under two conditions - wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded. FINDINGS: During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.70, P = 0.002), maximal adduction angle (2.00, P = 0.044), total sagittal range of motion (2.00, P = 0.008), total frontal range of motion (1.70, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.80, P = 0.039) and total sagittal range of motion (1.50, P = 0.045) compared to control. INTERPRETATION: The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.

The effect of high-flow nasal oxygen flow rate on gas exchange in apnoeic patients: a randomised controlled trial.

High-flow nasal oxygen can be administered at induction of anaesthesia for the purposes of pre-oxygenation and apnoeic oxygenation. This intervention is claimed to enhance carbon dioxide elimination during apnoea, but the extent to which this occurs remains poorly quantified. The optimal nasal oxygen flow rate for gas exchange is also unknown. In this study, 114 patients received pre-oxygenation with high-flow nasal oxygen at 50 l.min-1. At the onset of apnoea, patients were allocated randomly to receive one of three nasal oxygen flow rates: 0 l.min-1; 70 l.min-1; or 120 l.min-1. After 4 minutes of apnoea, all oxygen delivery was ceased, tracheal intubation was performed, and oxygen delivery was recommenced when SpO2 was 92%. Mean (SD) PaCO2 rise during the first minute of apnoea was 1.39 (0.39) kPa, 1.41 (0.29) kPa, and 1.26 (0.38) kPa in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.16. During the second, third and fourth minutes of apnoea, mean (SD) rates of rise in PaCO2 were 0.34 (0.08) kPa.min-1, 0.36 (0.06) kPa.min-1 and 0.37 (0.07) kPa.min-1 in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.17. After 4 minutes of apnoea, median (IQR [range]) arterial oxygen partial pressures in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups were 24.5 (18.6-31.4 [12.3-48.3]) kPa; 36.6 (28.1-43.8 [9.8-56.9]) kPa; and 37.6 (26.5-45.4 [11.0-56.6]) kPa, respectively; p < 0.001. Median (IQR [range]) times to desaturate to 92% after the onset of apnoea in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, were 412 (347-509 [190-796]) s; 533 (467-641 [192-958]) s; and 531 (462-681 [326-1007]) s, respectively; p < 0.001. In conclusion, the rate of carbon dioxide accumulation in arterial blood did not differ significantly between apnoeic patients who received high-flow nasal oxygen and those who did not.

Exercise Compared to Mindfulness for Physical and Mental Wellbeing in Medical Students.

Aim Physical Activity (PA) and Mindfulness-Based Stress Reduction (MBSR) both have positive effects on medical student well-being. The 'MED-WELL' programme is a curricular intervention that combines PA and education on exercise as medicine. This trial evaluates whether there is a mean difference in outcomes of participants of an exercise intervention, the 'MED-WELL' programme, versus a control group which engages in a MBSR programme. Methods All second-year medical students were voluntarily allocated into the intervention or control group. Data on overall health and well-being, sleep quality, loneliness, current level of PA, and confidence in prescribing exercise as medicine was analysed from both groups at baseline and after eight weeks. Results Within groups the intervention and control groups showed statistically significant improvements in overall well-being (p=0.010, p=0.005 respectively) and in sleep quality (p<0.001, p=0.007 respectively). The intervention group had statistically significant improvements in levels of PA (p=0.003) and confidence in prescribing exercise (p<0.001). However, there were no statistically significant differences in changes in outcome measures between groups. Conclusion This study has shown that participants in an exercise intervention, the 'MED-WELL' programme, had similar improvements in overall wellbeing and sleep quality to those in a control group who participated in a MBSR programme of the same duration.

Pre-oxygenation with facemask oxygen vs high-flow nasal oxygen vs high-flow nasal oxygen plus mouthpiece: a randomised controlled trial.

High-flow nasal oxygen used before and during apnoea prolongs time to desaturation at induction of anaesthesia. It is unclear how much oxygenation before apnoea prolongs this time. We randomly allocated 84 participants to 3 minutes of pre-oxygenation by one of three methods: 15 l.min-1 by facemask; 50 l.min-1 by high-flow nasal cannulae only; or 50 l.min-1 by high-flow nasal cannulae plus 15 l.min-1 by mouthpiece. We then anaesthetised and intubated the trachea of 79 participants and waited for oxygen saturation to fall to 92%. Median (IQR [range]) times to desaturate to 92% after pre-oxygenation with facemask oxygen, high-flow nasal oxygen only and high-flow nasal oxygen with mouthpiece, were: 309 (208-417 [107-544]) s; 344 (250-393 [194-585]) s; and 386 (328-498 [182-852]) s, respectively, p = 0.014. Time to desaturation after facemask pre-oxygenation was shorter than after combined nasal and mouthpiece pre-oxygenation, p = 0.006. We could not statistically distinguish high-flow nasal oxygen without mouthpiece from the other two groups for this outcome. Median (IQR [range]) arterial oxygen partial pressure after 3 minutes of pre-oxygenation by facemask, nasal cannulae and nasal cannulae plus mouthpiece, was: 49 (36-61 [24-66]) kPa; 57 (48-62 [30-69]) kPa; and 61 (55-64 [36-72]) kPa, respectively, p = 0.003. Oxygen partial pressure after 3 minutes of pre-oxygenation with nasal and mouthpiece combination was greater than after facemask pre-oxygenation, p = 0.002, and after high-flow nasal oxygen alone, p = 0.016. We did not reject the null hypothesis for the pairwise comparison of facemask pre-oxygenation and high-flow nasal pre-oxygenation, p = 0.14.

Apnoeic oxygenation in paediatric anaesthesia: a narrative review.

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.

Probiotic Bacillus amyloliquefaciens H57 ameliorates subclinical necrotic enteritis in broiler chicks by maintaining intestinal mucosal integrity and improving feed efficiency.

Subclinical necrotic enteritis (NE) was induced in broiler chicks using a high dose of Eimeria spp. vaccine in the drinking water on day 9, and Clostridium perfringens (Cp) culture mixed in the feed on days 14 and 15. The aim was to evaluate the effects of probiotic Bacillus amyloliquefaciens strain H57 (H57) in preventing NE in chicks. Day-old Ross 308, male broilers were weighed and randomly assigned to 6 treatment groups (6 replicate cages/treatment and 8 birds/cage). Birds in group 1 (control) were fed the basal wheat-soybean diet without H57 or NE infection; in group 2 (Eimeria) were treated with Eimeria alone; in group 3 (Cp) were treated with Cp alone; in group 4 (NE) received both Eimeria and Cp; in group 5 (NE-H57) received NE infection and H57; and group 6 (H57) received H57. The basal diet of chicks in groups 5 and 6 was supplemented with H57 at a density of 2 × 108 spores/g feed from 1 D of age. On day 21, there were no significant treatment effects on BW and feed intake between control and H57 birds. However, on day 21, the feed conversion ratio of NE-H57 birds was significantly improved when compared with NE birds (1.28 vs. 1.36; P < 0.001). Birds challenged with NE had a higher occurrence of pasty vent than birds infected with either Eimeria, Cp, or NE-H57 (41 vs. 27 vs. 29 vs. 19%, respectively; P < 0.001). Intestinal lesion scores of NE birds were also higher than those of Eimeria, Cp, and NE-H57 birds (5.67 vs. 2.56 vs. 2.78 vs. 2.10, respectively; P < 0.001) and correlated with pasty vent (Pearson's r = 0.56; P < 0.001). Microscopic evaluation showed mucosal damage and necrosis in NE birds. In contrast, villi from NE-H57 birds were normal, with no damage or infiltration with Eimeria or Cp. H57 appears to be effective in challenged birds, as it maintained epithelial barrier integrity and improved feed efficiency.

Supplementation of rangeland primiparous Bos indicus x Bos taurus beef heifers during lactation. 1. Effects on dam milk production and liveweight, bull calf growth, live carcass characteristics and metabolic hormone concentrations.

The practice of feeding replacement-breeding bulls on high energy diets after weaning to meet liveweight (LW) and carcass expectations between 18 and 24 months of age negatively affects reproductive potential. This experiment reports upon the effects of an alternative management strategy aimed at improving calfhood nutrition in rangeland-reared bulls to enhance LW and live carcass characteristics at 2 years. Following artificial insemination (AI cohort; n = 26), or natural mating, subsequent to the addition of bulls at 39 d post-AI (NM cohort; n = 36), primiparous Santa Gertrudis heifers grazing rangeland pastures with bull calf progeny were allocated at parturition to receive either nil supplement (control; CON) or provided with unrestricted access to a pelleted vegetable protein meal-based supplement containing 35% CP (SUPP) until weaning at 199 ± (SD) 26 d. The mean estimated pellet consumption by SUPP heifers during lactation was 2.6 ± (SEM) 0.5 kg DM daily. Grazing diet quality measurements indicated nutritional restriction of CON heifers until at least 115 d of lactation. This was confirmed by lower blood urea nitrogen concentrations at 88 d (P < 0.001) and greater mean NEFA (P < 0.001) concentrations. Rainfall during mid-lactation subsequently improved grazing diet quality; thus the CON heifers experienced moderate nutritional restriction across lactation, but sufficient to reduce milk yield by 1.6 kg/d (P < 0.001) and maternal LW at weaning by 18.4 kg (P < 0.001). Bulls reared by SUPP heifers were 17.5 kg heavier at weaning (P = 0.001) and had elevated IGF-I and leptin concentrations between 4 and 4.5 months of age (P < 0.05). Effects on metabolic hormones during calfhood were cohort specific, with greater concentrations of IGF-I confined to AISUPP bulls and NMSUPP bulls demonstrating greater concentrations of leptin. Bulls were amalgamated at weaning and grazed common pastures without supplementation until the experiment concluded at 675 d. Pre-weaning plane of nutrition did not affect the LW, carcass fat depth, IGF-I or leptin concentrations of bulls after weaning. Mean eye muscle area (EMA) was greater in SUPP compared to CON bulls (68.5 ± 0.9 cm2vs 65.2 ± 0.9 cm2; P < 0.05) and AISUPP bulls tended to have greater EMA (P = 0.06) than AICON bulls from 495 d of age. Thus when primiparous heifers experience moderate nutritional restriction during lactation, supplementation may have persistent effects upon increasing carcass muscle characteristics of bull progeny.

Supplementation of rangeland primiparous Bos indicus x Bos taurus beef heifers during lactation. 2. Effects upon the reproductive development of bull calf progeny.

This experiment evaluated the effect of pre-weaning plane of nutrition of dams upon reproductive development in Bos indicus x Bos taurus bull offspring reared under extensively managed conditions in the northern Australia rangelands. Following artificial insemination (AI cohort; n = 26), or natural mating (NM cohort; n = 36), grazing primiparous heifers received either nil supplement (Control; CON), thereby experiencing a moderate nutritional restriction, or were provided a protein supplement (SUPP) between parturition and weaning at mean age 199 ± (SD) 26 d. Bull progeny grazed rangeland pastures without supplementation from weaning until the experiment concluded at 675 d. At 120 ± 3 d and 140 d ± 10 d age, within the AI and NM cohort, respectively, bull calves were subjected to a GnRH challenge (1.5 µg/kg of body weight i.m.). Jugular blood samples collected immediately before and at 60 min after administration of GnRH were analysed for LH, FSH, testosterone and inhibin concentrations. Overall mean concentrations of testosterone in SUPP bulls were greater in both the AI cohort (P = 0.05) and the NM cohort (P = 0.06). At 60 d intervals during the post-weaning period, scrotal circumference (SC) was measured and semen collected to assess concentration, progressive motility and morphology of sperm. Bulls reared by SUPP heifers had greater (P = 0.05) SC at 375 d and tended to have greater (P = 0.09) mean percentage of morphologically normal sperm (PNS). Within the NM cohort, NMSUPP bulls had greater (P = 0.04) overall mean SC and tended (P = 0.07) to demonstrate both greater progressive motility and PNS. A greater incidence of sperm morphological abnormalities, associated with sexual immaturity, were observed in CON bulls. Consequently, NMCON bulls demonstrated delayed (P = 0.03) age of sexual maturity as compared to NMSUPP bulls. In summary, improving the plane of nutrition supplied to Bos indicus x Bos taurus bulls between parturition and weaning via moderate supplementation of grazing dams reduces age at sexual maturity with consequent economic advantages to the producer.

Where next for youth mental health services in Ireland?

To date, Ireland has been a leading light in the provision of youth mental health services. However, cognisant of the efforts of governmental and non-governmental agencies working in youth mental health, there is much to be done. Barriers into care as well as discontinuity of care across the spectrum of services remain key challenges. This editorial provides guidance for the next stage of development in youth mental care and support that will require significant national engagement and resource investment.

Genetic Landscape of Rett Syndrome Spectrum: Improvements and Challenges.

Rett syndrome (RTT) is an early-onset neurodevelopmental disorder that primarily affects females, resulting in severe cognitive and physical disabilities, and is one of the most prevalent causes of intellectual disability in females. More than fifty years after the first publication on Rett syndrome, and almost two decades since the first report linking RTT to the MECP2 gene, the research community's effort is focused on obtaining a better understanding of the genetics and the complex biology of RTT and Rett-like phenotypes without MECP2 mutations. Herein, we review the current molecular genetic studies, which investigate the genetic causes of RTT or Rett-like phenotypes which overlap with other genetic disorders and document the swift evolution of the techniques and methodologies employed. This review also underlines the clinical and genetic heterogeneity of the Rett syndrome spectrum and provides an overview of the RTT-related genes described to date, many of which are involved in epigenetic gene regulation, neurotransmitter action or RNA transcription/translation. Finally, it discusses the importance of including both phenotypic and genetic diagnosis to provide proper genetic counselling from a patient's perspective and the appropriate treatment.

Uses and mechanisms of apnoeic oxygenation: a narrative review.

Apnoeic oxygenation refers to oxygenation in the absence of spontaneous respiration or mechanical ventilation. It has been described in humans for over half a century and has seen a resurgence in interest given its potential to delay oxygen desaturation during airway management, especially with the advent of high-flow nasal cannulae. This narrative review summarises our current understanding of the mechanisms of gas exchange during apnoeic oxygenation and its diverse range of clinical applications, including its use at induction of anaesthesia and for the facilitation of 'tubeless anaesthesia'. Additional discussion covers use in critical care, obese, obstetric and paediatric sub-populations. The article also highlights current research efforts aiming to enhance the evidence base for the use of this technique.

Food environments in and around post-primary schools in Ireland: Associations with youth dietary habits.

BACKGROUND: The food environment within and surrounding schools may influence children's diets. This study explored if the internal and external school food environments were associated with intake of specific food groups among adolescents. METHODS: Participants were a subset of 5344 post-primary school students that took part in the Health Behaviour in School-aged Children (HBSC) survey. Four school-level variables were created: urban/rural, disadvantaged status, percentage fast food premises within one kilometer of the school and food sold in the school. Logistic regression models were used to examine school-level influences on daily food consumption controlling for individual and family food environmental factors. RESULTS: For students in disadvantaged schools, the odds of having soft drinks (OR 1.79, 95% CI 1.30-2.47) or chips (OR 1.82, 95% CI 1.17-2.83) daily were larger and the odds of consuming fruits (OR 0.79, 95% CI 0.62-0.99) or vegetables (OR 0.73, 95% CI 0.60-0.88) daily were smaller than for students at other schools. Girls and those from higher socioeconomic classes also had healthier eating habits. Attending a school where more than 10% of the food premises within one kilometer of the school were fast food outlets was associated with a 0.78 (95% CI 0.64 to 0.94) and a 0.79 (95% CI 0.66 to 0.93) decreased odds of daily fruit and vegetable intake, respectively. CONCLUSIONS: Fast food environments around post-primary schools are associated with less fruit and vegetable intake. Children in disadvantaged schools and from lower social classes are more likely to report poorer dietary habits than children in other schools or from higher social classes, respectively. Multiple contexts influence diet, and children at an economic or social disadvantage are at most risk of poor dietary habits.

A Cross-Sectional Study of Antibiotic Prescribing for Childhood Upper Respiratory Tract Infections in Irish General Practice

Introduction This study aimed to analyse antibiotic prescribing in cases of upper respiratory tract infection (URTI) in children under 6 years attending Irish daytime and out-of-hours General Practice (GP) services. There have been large scale changes in entitlements for free GP care for this group in recent years. Methods A cross-sectional study of children under 6 years with URTI presentations was performed, over a two-week period for three years from 2015 to 2017. Factors associated with antibiotic prescription and preferred antibiotic compliance were examined using multivariate logistic regression. Results 1,007 Under-6 patients presented with an URTI in our sample over the study period. Following introduction of free GP care, patients were 50% less likely to receive an antibiotic prescription. Overall antibiotic prescribing fell from 70% to 50% in daytime services and from 72% to 60% in the out-of-hours setting. Patients presenting to out-of-hours services were more likely to receive an antibiotic (OR: 1.42) and less likely to receive a deferred antibiotic (OR: 0.53). One quarter to one third of all prescriptions were for deferred antibiotics. Year-on-year trends showed a 13% decrease in prescriptions and 13% increase in preferred antibiotic use. Conclusion The introduction of free GP care led to significant reductions in antibiotic prescribing, which may be due to changes in health seeking behaviour by parents or other reasons. Antibiotic prescribing was more commonplace in the out-of-hours setting, and rates remains high by international standards. This study underlines the importance of ongoing work around GP antimicrobial stewardship, particularly in the out-of-hours setting.