RESUMO
Congenital mesoblastic nephroma is a rare pediatric renal tumor and has been reported in patients presenting with palpable abdominal mass, arterial hypertension, hematuria, polyuria, or hypercalcemia. Here we present the case of a 1-month-old neonate with suspected parathyroid hormone (PTH)-related peptide (PTH-rp)-mediated severe hypercalcemia revealing congenital mesoblastic nephroma. Preoperatively, hypercalcemia was corrected with hydration, furosemide, pamidronate, and low-calcium infant formula. Unilateral nephrectomy led to the resolution of hypercalcemia, transient hyperparathyroidism, and transient vitamin D and mineral supplementation. We conclude that congenital mesoblastic nephroma can secrete PTH-rp that can cause severe hypercalcemia.
Assuntos
Hipercalcemia/congênito , Neoplasias Renais/congênito , Nefroma Mesoblástico/congênito , Cálcio/sangue , Feminino , Alimentos Fortificados , Furosemida/uso terapêutico , Humanos , Hipercalcemia/etiologia , Hipercalcemia/terapia , Hipertensão , Fórmulas Infantis , Recém-Nascido , Neoplasias Renais/complicações , Neoplasias Renais/cirurgia , Nefrectomia , Nefroma Mesoblástico/complicações , Nefroma Mesoblástico/cirurgia , Pamidronato/uso terapêutico , Resultado do TratamentoRESUMO
It is of great importance to understand the molecular characteristics and substantial chemical transformations due to yeast-yeast interaction. Non-targeted metabolomics was used to unravel must in fermentation composition, inoculated with non-Saccharomyces (NS) yeasts and Saccharomyces cerevisiae (S) for sequential fermentation. ultrahigh-resolution mass spectrometry was able to distinguish thousands of metabolites and provides deep insights into grape must composition allowing better understanding of the yeast-yeast interactome. The dominance of S, characterized by a metabolic richness not found with NS, is dependent on inoculation time and on the yeast species present. Co-inoculation leads to the formation of new compounds, reflecting a reshuffling of yeast metabolism linked to interaction mechanisms. Among the modifications observed, metabolomic unravels deep changes in nitrogen metabolism due to yeast-yeast interactions and suggests that the redistribution pattern affects two different routes, the pentose phosphate and the amino acid synthesis pathways.
Assuntos
Vitis , Vinho , Fermento Seco , Fermentação , Saccharomyces cerevisiae , Vinho/análiseRESUMO
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..
Assuntos
Parada Cardíaca , Obtenção de Tecidos e Órgãos , Criança , Humanos , Unidades de Terapia Intensiva Pediátrica , Doadores de TecidosRESUMO
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.
Assuntos
Parada Cardíaca , Obtenção de Tecidos e Órgãos , Extubação , Criança , Morte , Humanos , Perfusão/métodosRESUMO
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
Assuntos
Cuidados Críticos/normas , Unidades de Terapia Intensiva Pediátrica/normas , Cuidados Paliativos/normas , Ordens quanto à Conduta (Ética Médica) , Suspensão de Tratamento , Serviços Médicos de Emergência , Humanos , Sociedades MédicasRESUMO
This retrospective study was performed to precise indications of emergency CT in a general hospital over a 30 months period. We tried to determine, with help of prior studies, the indications for CT of the brain in the management of acute meningitis, acute headache, and in the management of head injury. In acute meningitis, there is no evidence to recommend CT of the brain before lumbar puncture, except to identify patients at increased risk of cerebral herniation. The imaging study of choice in subarachnoid hemorrhage is non enhanced CT scan. This exam has to be performed in case of acute headache. The CT evaluation of patients with minor head injury remains controversial.
Assuntos
Hospitais Gerais/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Doença Aguda , Encéfalo/diagnóstico por imagem , Encefalopatias/diagnóstico por imagem , Transtornos Cerebrovasculares/diagnóstico por imagem , Traumatismos Craniocerebrais/diagnóstico por imagem , Emergências , Encefalocele/diagnóstico por imagem , França/epidemiologia , Cefaleia/diagnóstico por imagem , Humanos , Meningite/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Punção Espinal , Hemorragia Subaracnóidea/diagnóstico por imagemRESUMO
Long-term administration of pancuronium for ventilatory support of adults with ARDS may result in severe tetraparesis, with areflexia and atrophy of distal muscles. This adverse effect occurs rarely in paediatric intensive care units. We describe a case of tetraparesis after prolonged pancuronium infusion in a 9-month-old girl who experienced a severe bronchopneumonia caused by para-influenza virus, requiring endotracheal intubation and mechanical ventilation. To decrease chest wall rigidity, pancuronium was administered over 11 days, with a total dose of approximately 120 mg of pancuronium bromide. The day after discontinuation of the muscle relaxant she had a severe tetraplegia with areflexia, but normal head movements. Electromyography showed a normal neuromuscular transmission. She recovered from tetraplegia three months later. Other causes of peripheral neuropathy were eliminated. Electroencephalograms and head CT-scans were normal. The recovery pattern observed in our patient corresponded to the process of regeneration seen after axonal degeneration. It is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment, associated with corticosteroid and aminoglycoside administration.
Assuntos
Doenças Neuromusculares/induzido quimicamente , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Pancurônio/efeitos adversos , Quadriplegia/induzido quimicamente , Broncopneumonia/terapia , Feminino , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Pancurônio/administração & dosagem , Respiração Artificial , Síndrome do Desconforto Respiratório do Recém-Nascido/terapiaRESUMO
IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.
Assuntos
Anestesia por Inalação/efeitos adversos , Atresia Esofágica/cirurgia , Dilatação Gástrica/etiologia , Gastrostomia , Fístula Traqueoesofágica/cirurgia , Bradicardia/etiologia , Diafragma/fisiopatologia , Dilatação Gástrica/cirurgia , Refluxo Gastroesofágico/etiologia , Parada Cardíaca/etiologia , Humanos , Hipóxia/etiologia , Recém-Nascido , Ventilação com Pressão Positiva Intermitente/efeitos adversos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Pneumopatias/etiologia , Masculino , Pneumonia Aspirativa/etiologia , Fatores de Risco , Choque/etiologia , Volume de Ventilação Pulmonar/fisiologiaRESUMO
OBJECTIVES: Leonetti Law of 2005 concerns procedures for questioning about the appropriateness of initiating or maintaining life-sustaining treatments. Decision of withdrawing and withholding treatment has long been practiced by neonatologists, adult and pediatricians intensivists. In this regard, the recommendations of societies encourage medical teams to assess their practices to improve them. Our evaluation is based on the document of the Ethics Committee of SRLF edited in 2010. TYPE OF STUDY: We achieved a retrospective evaluation of professional practices of the transcription of our decisions of withdrawing and withholding treatment. PATIENTS AND METHODS: This study included all children (95 patients) who have had a questioning about life-sustaining treatment of ICU between March 2008 and August 2011 in the pediatric intensive care unit of Children's Hospital of Lyon. Our evaluation is based on the document of the Ethics Committee of French Society of intensive care (SRLF) edited in 2010. We collected epidemiological data on children concerned by questioning about the appropriateness of initiating or maintaining LST and an evaluation of the transcription of our procedures for LST in our folders. Evaluation included 40 cases: 20 folders randomly selected prior an information meeting (January 2011) which were compared with 20 cases occurred consecutively after this information. This meeting was intended to remind recommendations of good practice and principal points of the law. The main assessment measure was the improvement of the practices respecting criteria of the document of the Ethics Committee of SRLF modified for pediatric care. MAIN RESULTS: Epidemiological data on procedures are comparable to literature data. Concerning the evaluation of our practices before/after a briefing and highlighted a tendency to the improvement without statistically significance. The transcription of reflection and the arguments of decision of withdrawing and withholding treatment and evaluation of pain was the points who need improvement. Finally, despite the positive developments in the therapeutic use of analgesics and sedatives, pain continues to be undervalued. CONCLUSION: The evaluation of professional practices is recommended to improve the procedures of questioning about life-sustaining treatments have become an area of expertise in intensive care.
Assuntos
Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Analgésicos/uso terapêutico , Criança , Pré-Escolar , Cuidados Críticos/estatística & dados numéricos , Uso de Medicamentos , Comitês de Ética Clínica , Feminino , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/uso terapêutico , Lactente , Unidades de Terapia Intensiva Pediátrica/ética , Unidades de Terapia Intensiva Pediátrica/legislação & jurisprudência , Tempo de Internação , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Medição da Dor , Pais , Ordens quanto à Conduta (Ética Médica) , Estudos Retrospectivos , Suspensão de Tratamento/ética , Suspensão de Tratamento/legislação & jurisprudênciaAssuntos
Diafragma/patologia , Hérnia Diafragmática/cirurgia , Complicações Pós-Operatórias/etiologia , Rabdomiólise/etiologia , Humanos , Infecções por Klebsiella/complicações , Klebsiella pneumoniae , Masculino , Pessoa de Meia-Idade , Necrose , Reoperação , Choque Séptico/etiologia , Choque Cirúrgico/etiologiaRESUMO
The authors report six new cases of necrosis of the fingers occurring during the course of a malignant condition. None of the patient was suffering from any other disease which could explain the digital necrosis. They discuss the mechanism of the relationship between the two conditions : blood hyperviscosity, thrombocytosis, polycythaemia, cryoglobulin and the production of immune complexes. The particular role of bleomycin is mentioned. The possibility of a true paraneoplastic syndrome is suggested.
Assuntos
Dedos/irrigação sanguínea , Necrose/etiologia , Neoplasias/complicações , Adulto , Idoso , Complexo Antígeno-Anticorpo , Bleomicina/efeitos adversos , Viscosidade Sanguínea , Crioglobulinas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/fisiopatologia , Policitemia/complicações , Trombocitose/complicaçõesRESUMO
Estimation of the dietary exposure of French consumers to 10 pesticides (omethoate, oxydemeton, phosalon, phosphamidon, triazophos, dicofol (op' + pp'), parathion ethyl, dichlorvos, procymidon and vinchlozolin), three heavy metals (lead, cadmium and arsenic) and three radionuclides (134caesium, 137caesium and 131iodine) from collected duplicate portion in mass catering establishments in 1998/1999 are reported, and compared with those from previous French studies as well as those from other countries. Dietary exposure estimates appear to be reassuring, in that Estimated Daily Intake (EDI) estimates are generally low, representing at maximum only 4% of the Acceptable Daily Intake (ADI) for pesticide residues and 28% of the Provisional Tolerable Weekly Intake (PTWI) for heavy metals. Moreover, none of the three radionuclides has been found in duplicate meals. When comparisons are possible, estimated dietary exposures for heavy metals are lower than those from previous French studies and similar or above those from other countries.
Assuntos
Arsênio/análise , Cádmio/análise , Análise de Alimentos , Chumbo/análise , Resíduos de Praguicidas/análise , Radioisótopos/análise , Adolescente , Adulto , Idoso , Criança , Cromatografia Gasosa , França , Humanos , Espectrometria de Massas , Concentração Máxima Permitida , Pessoa de Meia-Idade , Espectrofotometria AtômicaRESUMO
Iodised oil is traditionally based on the fatty acids (FAs) of the poppyseed, an expensive commodity. An equipotent but cheaper vehicle would be welcome. Iodination of rapeseed oil yields a product (Brassiodol) with a total iodine content of 376 mg/mL. Brassiodol has been compared with the poppyseed-based Lipiodol in two villages in Chad in the west African goitre belt. A 2 mL dose of Brassiodol is followed by urinary spillover of half the ingested iodine. The other half undergoes tissue sequestration and slow release, allowing protection against iodine deficiency for 9 months and regression of stage I/II goitre for longer than was achieved with Lipiodol. The prolonged protection offered by Brassiodol can be attributed to its unique lipid profile. The urinary output argues that 1 mL should not be exceeded, and at that dose the cost would be only 20 US cents per person per year.
Assuntos
Bócio Endêmico/prevenção & controle , Óleo Iodado/uso terapêutico , Óleos de Plantas/uso terapêutico , Adulto , Brassica , Chade , Ácidos Graxos/metabolismo , Ácidos Graxos Monoinsaturados , Feminino , Bócio Endêmico/etiologia , Humanos , Iodo/deficiência , Iodo/urina , Masculino , Óleos de Plantas/metabolismo , Óleo de Brassica napus , Hormônios Tireóideos/sangueRESUMO
We investigated the usefulness and reliability of the Gram stain value versus quantitative cultures in the early diagnosis of ventilator-associated pneumonia (VAP) using the protected bronchoalveolar lavage (PBAL). One hundred four mechanically ventilated patients (age = 52 +/- 19; SAPS II = 38 +/- 15) with a strong suspicion of VAP were consecutively included. One hundred sixteen PBAL were performed and mini-bronchoalveolar lavage were analyzed using the Gram stain standard method and the conventional quantitative culture technique. VAP diagnosis was based on a positive quantitative culture of mini-bronchoalveolar lavage fluid (cutoff > or = 10(3) CFU/mL). A final diagnosis of VAP was established in 67 patients and there was no infection in 49 cases. Regarding detection of bacteria using the Gram stain, we found a sensitivity of 76.2%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 75.4%. There was a good agreement with the final diagnosis (kappa statistic 0.73; concordance 86.2%). The degree of qualitative agreement between Gram stain and quantitative cultures was analyzed in the VAP group: the correlation was complete in 39% (26 of 67 VAP), partial in 28% (19 of 67 VAP) and there was no correlation in 33% (22 of 67 VAP). We conclude that despite its overall "good agreement," the Gram stain is of limited use for the rapid diagnosis of VAP and unreliable for the early adaptation of empirical antimicrobial therapy when using the noninvasive PBAL procedure.