Organ donation by Maastricht-III pediatric patients: Recommendations of the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP) and Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF) Part I: Ethical considerations and family care.

The French Transplant Health Authority (Agence de la Biomédecine) has broadened its organ- and tissue-donation criteria to include pediatric patients whose death is defined by circulatory criteria and after the planned withdrawal of life-sustaining therapies (WLST) (Maastricht category III). A panel of pediatric experts convened to translate data in the international literature into recommendations for organ and tissue donation in this patient subgroup. The panel estimated that, among children aged 5 years or over with severe irreversible neurological injury (due to primary neurological injury or post-anoxic brain injury) and no progression to brain death, the number of potential donors, although small, deserves attention. The experts emphasized the importance of adhering strictly to the collegial procedure for deciding to withdraw life support. Once this decision is made, the available data should be used to evaluate whether the patient might be a potential donor, before suggesting organ donation to the parents. This suggestion should be reserved for parents who have unequivocally manifested their acceptance of WLST. The discussion with the parents should include both the pediatric intensive care unit (PICU) team under the responsibility of a senior physician and the hospital organ- and tissue-procurement team. All recommendations about family care during the end of life of a child in the PICU must be followed. The course and potential challenges of organ donation in Maastricht-III pediatric patients must be anticipated. The panel of experts recommended strict compliance with French recommendations (by the Groupe Francophone de Réanimation et Urgences Pédiatriques) about WLST and providing deep and continuous sedation until circulatory arrest. The experts identified the PICU as the best place to implement life-support discontinuation and emphasized the importance of returning the body to the PICU after organ donation. French law prohibits the transfer of these patients from one hospital to another. A description of the expert-panel recommendations regarding the organization and techniques appropriate for children who die after controlled circulatory arrest (Maastricht III) is published simultaneously in the current issue of this journal..

Organ donation by Maastricht-III pediatric patients: Recommendations of the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP) and Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF). Part II: Specific organizational and technical considerations.

A panel of pediatric experts met to develop recommendations on the technical requirements specific to pediatric controlled donation after planned withdrawal of life-sustaining therapies (Maastricht category III). The panel recommends following the withdrawal of life-sustaining therapies protocol usually applied in each unit, which may or may not include immediate extubation. The organ retrieval process should be halted if death does not occur within 3 h of life-support discontinuation. Circulatory arrest is defined as loss of pulsatile arterial pressure and should be followed by a 5-min no-touch observation period. Death is declared based on a list of clinical criteria assessed by two senior physicians. The no-flow time should be no longer than 30, 45, and 90 min for the liver, kidneys, and lungs, respectively. At present, the panel does not recommend pediatric heart donation after death by circulatory arrest. The mean arterial pressure cutoff that defines the start of the functional warm ischemia (FWI) phase is 45 mmHg in patients older than 5 years and/or weighing more than 20 kg. The panel recommends normothermic regional perfusion in these patients. The FWI phase should not exceed 30 and 45 min for retrieving the pancreas and liver, respectively. There is no time limit to the FWI phase for the lungs and kidneys. The panel recommends routine sharing of experience with Maastricht-III donation among all healthcare institutions involved in order to ensure optimal outcome assessment and continuous discussion on the potential difficulties, notably those related to the management of normothermic regional perfusion in small children.

The crucial choice of reference genes: identification of miR-191-5p for normalization of miRNAs expression in bone marrow mesenchymal stromal cell and HS27a/HS5 cell lines.

Bone marrow mesenchymal stromal cells (BM-MSCs) have a critical role in tissue regeneration and in the hematopoietic niche due to their differentiation and self-renewal capacities. These mechanisms are finely tuned partly by small non-coding microRNA implicated in post-transcriptional regulation. The easiest way to quantify them is RT-qPCR followed by normalization on validated reference genes (RGs). This study identified appropriate RG for normalization of miRNA expression in BM-MSCs and HS27a and HS5 cell lines in various conditions including normoxia, hypoxia, co-culture, as model for the hematopoietic niche and after induced differentiation as model for regenerative medicine. Six candidates, namely miR-16-5p, miR-34b-3p, miR-103a-3p, miR-191-5p, let-7a-5p and RNU6A were selected and their expression verified by RT-qPCR. Next, a ranking on stability of the RG candidates were performed with two algorithms geNorm and RefFinder and the optimal number of RGs needed to normalize was determined. Our results indicate miR-191-5p as the most stable miRNA in all conditions but also that RNU6a, usually used as RG is the less stable gene. This study demonstrates the interest of rigorously evaluating candidate miRNAs as reference genes and the importance of the normalization process to study the expression of miRNAs in BM-MSCs or derived cell lines.

Abalakov: Posterior mandibular anchorage technique for orthodontic treatment.

INTRODUCTION: Abalakov is a mountaineering technique consisting in drilling two holes that intersect to form a V in order to thread a rope through to make an anchorage point. This technique can be applied to orthodontic treatment and constitutes a posterior mandibular orthodontic anchorage. TECHNICAL NOTE: The technique can be performed on its own during local anaesthesia or during surgery for the extraction of wisdom teeth. The posterior anchorage point is located in the ramus of the mandible. It consists in drilling two holes that intersect to form a V and then threading a steel wire through to make an anchorage point. DISCUSSION: This technique is simple, inexpensive, fast and non-invasive, providing an anchorage system with immediate loading and which is not dependent on the quality of the bone.

Contribution of single-photon emission computed tomography in the diagnosis and follow-up of CNS toxicity of a cytarabine-containing regimen in pediatric leukemia.

PURPOSE: Cytarabine (ara-C) is one of the most effective chemotherapeutic agents in patients with acute leukemia (AL), with a clear dose effect. Use of high-dose ara-C is hampered, however, by a noticeable toxicity, particularly to the CNS. We investigated the usefulness of CNS perfusion imaging with technetium-99m ((99m)Tc)-hexamethyl-propylene-amine oxime (HMPAO) single-photon emission computed tomography (SPECT) concurrent to magnetic resonance imaging (MRI) to specifically assess the effects of standard- and high-dose ara-C in children with AL. PATIENTS AND METHODS: Twenty-six perfusion studies using (99m)Tc-HMPAO SPECT were performed in 12 children (age range, 4 to 15 years) with AL after induction therapy, which consisted of a standard-dose ara-C, immediately after consolidation with high-dose ara-C, and later during follow-up (range, 6 to 44 months). The chemotherapy-related adverse events were monitored and correlated to SPECT and MRI. RESULTS: After the induction phase, all children were neurologically normal on MRI. On SPECT imaging, four children displayed a slightly heterogeneous perfusion. After high-dose ara-C (4 to 36 g/m(2)), five children had regressive neurologic signs of potential toxic origin. Of these five children, only one had an abnormal MRI scan, whereas all patients showed evidence of diffuse cerebral and/or cerebellar heterogeneous perfusion on SPECT. The seven other patients without any neurologic symptoms had normal MRI scans; SPECT was normal for three patients and abnormal for four patients. On follow-up, for four children who had presented with clinical neurologic toxicity, SPECT improved in three patients and remained unchanged in one patients. In two of these four children, delayed abnormalities (T2 white matter hypersignal and cerebellar atrophy) appeared on MRI scans. CONCLUSION: In our series, diffuse heterogeneous brain hypoperfusion is often the sole early objective imaging feature identified by SPECT of high-dose ara-C neurotoxicity, where MRI still demonstrates normal pictures.

A new 123I-MIBG whole body scan scoring method--application to the prediction of the response of metastases to induction chemotherapy in stage IV neuroblastoma.

A new semi-quantitative scoring system is proposed, especially designed for the comparative interpretation of sequential whole-body meta-iodo-benzyl-guanidine (MIBG) scans in stage IV neuroblastoma children. This method was applied to assess whether MIBG scan at mid-course of induction chemotherapy could predict the final response. 27 newly diagnosed children were investigated by three sequential 123I-MIBG scans performed at the beginning, at mid-course (6 weeks) and at the end of neoadjuvant chemotherapy (12 weeks). Whole body scans were divided into nine regions in which the extension of bone metastases was separately quoted (score range: 0-3). The overall absolute scores were obtained by adding the scores of the nine regions. Relative scores were calculated by dividing the absolute score at each time by the corresponding pretreatment score. The score at mid-induction correctly predicted the overall response of metastases at the end of induction (P < 0.0001) in most cases. This method is easy to use, reproducible, subject to little inter-investigator variation, and thus well adapted to multicentric trials.

Refining interpretation of MIBG scans in children.

UNLABELLED: In pediatrics, the distribution of radioiodinated metaiodobenzylguanidine (MIBG) has been studied primarily in neuroblastoma. However, normal patterns in children show a number of particularities and pitfalls related to the context of pediatric oncology which must be identified. METHODS: We report on 28 equivocal scans in 24 children. In all cases, two experienced observers judged the scans to be equivocal and the definite interpretations were confirmed by follow-up. RESULTS: Difficulties in interpreting the scans were observed at the level of the thorax (15 patients), the abdomen (5 patients), the head (4 patients) or elsewhere (4 patients). The final interpretation of the scans was attributed to an unusual physiological pattern linked to age (9 patients), tumoral context (17 patients) or artifacts (2 patients). CONCLUSIONS: A number of important physiological areas of uptake in soft tissues can lead to false-positive interpretations of normal scans, such as the physiological upper thoracic uptake which has never been previously described. Numerous technical and physiological possibilities exist and those pitfalls must be ruled out. A precise knowledge of these technical difficulties and physiological variants can reduce the number of equivocal MIBG scans.

Satellite DNA transcription in Diadromus pulchellus (Hymenoptera).

Previous studies have shown that the satellite DNAs in Hymenoptera account for 1-25% of the genome. They mainly correspond to a single family, or to several subfamilies having the same evolutionary origin. We have now showed that the satellite DNAs in the genomes of the hymenopterans Diadromus pulchellus, Diadromus collaris, Eupelmus vuilletti and Eupelmus orientalis are transcribed in both males and females. Satellite DNA transcripts could only be extracted with NP40/Urea, indicating that they are strongly associated with proteins. The satellite DNA in D. pulchellus was transcribed on the two DNA strands. The satellite DNA transcripts were single-stranded and not polyadenylated in vivo. The transcripts were found in embryos, larvae and imagos stages. The transcripts detected included one major transcript (1.9 kb) and several discrete smaller transcripts. The in vivo synthesis of these satellite DNA transcripts was explored by identifying their putative initiation sites.

Cortisol levels in saliva and mood changes in early puerperium.

Cortisol levels in saliva were measured in 22 women, daily from the 2nd to 7th day after they had given birth and in 7 control women for 6 consecutive days. During the same period the mothers filled out a mood self-rating scale. The cortisol levels of the mothers were higher than those of the controls and progressively decreased after birth except for the 4th day post-partum when there was an increase. Five mothers had post-partum blues, but their cortisol levels were not different from those of other mothers. However, there was a significant correlation between cortisol level and the mood of mothers who bottle fed their babies.

Quantitative autoradiography using a radioimager based on a multiwire proportional chamber.

Determination of the biodistribution of radiopharmaceuticals is an important issue for the evaluation of their performance in diagnosis and therapy. In this study, we evaluated a digital radioimager (RI) based on a multiwire proportional chamber for quantitative autoradiography (AR). The RI allows direct detection of electronic emissions of gamma emitters. Its qualitative and quantitative performances were tested on 99mTc and (111)In labelled sections and compared with conventional film AR. Linearity of count rate versus activity was verified over a 104 range of activity. As compared with film AR, a substantial improvement of the detection limit was obtained even for acquisition periods up to 20 times less than film exposure times. We provided the basis for quantitative analysis with tissue equivalent paste standards: the 99mTc and (111)In RI counting efficiencies were respectively 1.19% and 2.35%. We illustrated the respective values of RI and film AR in two rat studies: 99mTc-DMSA in kidney and dual-isotope 99mTc-MIBI and (111)In-antimyosin in heart. Calculated activity concentrations on sections of rat organs confirmed good correlation to gamma counting (deviation less than 12%). We suggest RI as a convenient technique for fast localization of single or dual-isotope tracers and determination of activity distribution.

Evolution of maternal mood state and of the auditory and olfactory perception of their newborn: preliminary data.

The auditory and olfactory discrimination ability of mothers, in relation to stimuli from their newborn infants, was concomitantly measured in a sample of 12 mother-newborn dyads during the 1st week after the child's birth. Both types of discrimination ability had a parallel evolution from one day to the next. The performances continued to increase from day to day, except on the 4th and 7th days. These 2 days corresponded to times when the mothers were more depressed. Half of the mothers were more skilled in one sensorial skill than the other.

[Screening of depressive disorders during the postpartum period with the Zerssen self-evaluation scale]. / Détection des états dépressifs du post-partum avec l'échelle d'auto-évaluation de Zerssen.

The frequency of post-partum depressive states is well know. Post-partum blues is considered in the literature, to be a frequent transitory and benign syndrome, as it affects between 20 and 80% of women after childbirth. This blues only lasts a few days, and generally occurs around the 4th days post-partum. Research dealing with the relations between the mother and her newborn needs to include an evaluation of mothers' mood which could modify these interactions. The study of transitory post-partum blues requires a standardized mood measuring instrument which can be adapted to an experimental situation (as for instance, the study of the first relations between the mother and the newborn). The scale must be easy and fast to use so as not to over-burden the mothers with tests. The test must also be able to be used day after day to show the rapid variations in mood. The Zerssen self-rating scale, which requires ten minutes to complete was used. 61 women filled out the rating scale each morning from the 2nd to 7th day after the birth of her child. The score obtained with this scale became a quantitative evaluation of the mothers' depressive mood. Each score can be put into one of the following five categories: [table: see text] The results show that 23% of the mothers suffered from transitory post-partum depression, 23% of the mothers are anxious and 54% are relaxed. The days when the mothers were depressed were day 3 and to a lesser extend, day 4 post-partum.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prospective study of neonatal genital mycoplasma colonization and infection]. / Etude prospective de la colonisation et de l'infection néonatales à mycoplasmes génitaux.

Genital mycoplasmas have been implicated in different neonatal diseases as pneumonia, sepsis and meningitis. This prospective study was conducted to specify their role in these diseases. POPULATION AND METHODS--A pharyngeal or tracheal swab specimen for mycoplasmas culture was obtained from 100 infants admitted consecutively to the Neonatal Care Unit (NCU) during the first 24 hours of life. Mycoplasma culture of blood and cerebrospinal fluid was also performed. Pharyngeal and/or tracheal specimens were collected again on days 5, 15 and 28 if the child was still in the NCU. Mycoplasma hominis (Mh) and Ureaplasma urealyticum (Uu) were identified by culture in a modified Hayflick's medium. RESULTS--Three-hundred and ten pharyngeal or tracheal swabs were obtained (100 on day 0, 89 on day 5, 72 on day 15 and 49 on day 28). Twenty-one infants had one or more positive swabs in the first five days of life (20 on day 0 and one on day 5); those forming the "Myco+" group and the others forming the "Myco-" group. Uu was isolated alone from 20 infants, associated with Mh from one. Both groups were similar for gestational age, birth weight, maternal fever during labor, prolonged rupture of the fetal membranes or chorioamnionitis and for the incidence of acute respiratory distress. There was a statistically significant difference for the route of delivery (chi 2 < 0.02). One blood culture (from 92 performed) was positive for Uu and another positive for Uu and Mh. Both children were cured without any specific mycoplasmacidal therapy. Three children had probable Uu infection and were also cured without specific therapy. CONCLUSIONS--A pharyngeal colonization with genital mycoplasmas is common in the first days of life (21%) but our data do not allow us to conclude that they are accountable for newborn infections.

[Daily and seasonal variations in olfactory sensitivity of mothers after parturition and their capacity to discriminate the body odor of their newborn. Preliminary findings]. / Variations quotidiennes et saisonnières de la sensibilité olfactive des mères après l'accouchement et de leur capacité à discriminer l'odeur corporelle de leur nouveau-né. Données préliminaires.

The present study describes daily and seasonal variations in the discrimination capacities of mothers in relation to their newborn's odour and olfactory detection thresholds of a non specific molecule (thiophene) by mothers. The tests are carried out during the 2nd, 4th and 6th days after the parturition. The results show that the abilities of the mothers to discriminate the odours of their newborn increase gradually from the morning to evening, with the exception of the second part of the 4th day when the mother's performances decrease between 05:30 P.M. and 08:00 P.M. This daily variation is not observed in olfactory thresholds of mothers in relation to thiophene as they decrease between 08:00 A.M. and 01:30 P.M. and increase between 01:30 P.M. and 08:00 P.M. for the three days of test. Nevertheless, seasons, seem to have the same effect about the two types of mothers' performances. The results suggest that the variations in the abilities of the mothers to discriminate the corporal odour of their newborn and the variations of their olfactory thresholds for a non specific odour are based on different biological and psychobiological mechanisms.

[Nuclear medicine in children]. / Médecine nucléaire chez l'enfant.

Pediatric nuclear medicine (PNM) is now well established as a major imaging modality in children. Recent technical advances in gamma cameras and associated data processing, together with the development of new tracers has modified routine practice in PNM. In order to better ascertain how PNM is routinely used in France, all nuclear medicine departments in Paris and its suburbs answered a detailed questionnaire. The results show three main indications for PNM: exploration of the skeleton (33.3%), the urinary tract (23.5%) and the lung (22.5%).

[For a better use of the venous system]. / Pour une meilleure utilisation du capital veineux.

Iatrogenic lesions of the venous system may jeopardize not only the patient's comfort, but also future possibilities of treatment. The fact that the medical staff has little knowledge of the equipment and drugs used for intravenous therapy has been demonstrated by a recent survey. As a result of this survey, several measures aimed at preventing iatrogenic venous lesions are described.

[Renal scintigraphy: a major test for urologic diseases in children]. / Scintigraphie rénale: un examen majeur pour les uropathies de l'enfant.

The number of asymptomatic uropathies detected by ultrasound has increased dramatically with antenatal diagnosis. Some of them only threaten the renal parenchyma and require surgery. Therefore, screening for patients at risk is a major challenge. During the initial evaluation and follow up of a dilated system, MAG3 scans evaluate and quantify the physiologic significance of a radiologically detected anatomic abnormality by measuring the relative renal function and wash out of the radiopharmaceutical. Moreover, DMSA scans show renal functional abnormalities due to pyelonephritis or dysplasia associated with vesicoureteral reflux or obstructive uropathy. With a low radiation burden, renal scintigraphy is now a major imaging modality for uropathies in pediatrics.

[Urology and nuclear medicine in children. Experience from a series of 1200 renal scintigraphies]. / Médecine nucléaire en urologie pédiatrique. A propos d'une série de 1,200 scintigraphies rénales.

During the last 4 years, we have performed 1200 renal scintigraphies in children under the age of 6 years: 57% of dynamic renal scintigraphies using MAG3 for antenatally diagnosed uropathies (mainly pelvic dilatations and megaureters), 36% of static renal scintigraphies using DMSA for renal sequelae of pyelonephritis with or without vesicoureteric reflux, and 6% of direct isotope cystography for follow-up of vesicoureteric reflux. Renal scintigraphy, which provides low radiation hazards (1 mSv), is now a major imaging modality for paediatric urinary tract disease.

[Ureteropyelostomy for obstructed duplicated ureter an easy and reliable operation in infants]. / La place de l'anastomose urétéro-pyélique dans le traitement des duplications urétérales pathogènes.

AIM: Ureteropyelostomy is one of the surgical options to treat obstructed duplicated ureter. We retrospectively analysed the results of this procedure in a group of young children with prenatal diagnosis. MATERIAL AND METHODS: Between 1992 and 1996, 11 children underwent ureteropyelostomy for obstructed functioning duplicated ureter using the following procedures. 7 cases were revealed by prenatal ultrasound and 4 by acute pyelonephritis; an ureterocele was identified in 7 cases. The mean age at surgery was 6 months for the whole group (3-46 weeks), while in the subgroup of prenatal diagnosis, it was 8 weeks (3-9 weeks). The follow-up ranged from 6 months to 4 years. RESULTS: There were no postoperative complications. None of the anastomoses needed revision, and the conserved segments maintained their functioning appearance, on follow-up. 3 children needed a subsequent ureterovesical reimplantation for urinary tract infections due to reflux in the lower segment ureter. DISCUSSION: Ureteropyelostomy is of great interest for the management of the obstructed dilated upper pole ureter revealed by prenatal diagnosis. This specific group of children needs early management to avoid septic complications and ureteropyelostomy is an easy and reliable method at this young age.

[First-line vesico-psoas hitch ureteroneocystostomy for primary obstructive megaureter]. / Méga-uretère primitif obstructif: réimplantation sur vessie psoïque de première intention.

Between 1989 and 1997, 23 children with primary obstructive megaureter underwent surgical repair, routinely using a vesico-psoas hitch ureteroneocystostomy. Ten of them had a antenatal diagnosis. Mean postoperative follow-up was 3 years. No postoperative obstruction and no vesicoureteric reflux occurred. Assessment of renal function on the operated side showed improvement in 7 cases and stabilization in all other cases. No bladder dysfunction was observed. Vesicopsoas hitch is an advantageous procedure in this indication. It is almost always unnecessary to perform ureteral tailoring and its specific complications can be avoided. Psoas hitch is easily performed in infants and young children and this technique is particularly appropriate in the subgroup of patients with antenatal diagnosis.