Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - "IN-REC-SUR-E" - in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial.

BACKGROUND: Although beneficial in clinical practice, the INtubate-SURfactant-Extubate (IN-SUR-E) method is not successful in all preterm neonates with respiratory distress syndrome, with a reported failure rate ranging from 19 to 69 %. One of the possible mechanisms responsible for the unsuccessful IN-SUR-E method, requiring subsequent re-intubation and mechanical ventilation, is the inability of the preterm lung to achieve and maintain an "optimal" functional residual capacity. The importance of lung recruitment before surfactant administration has been demonstrated in animal studies showing that recruitment leads to a more homogeneous surfactant distribution within the lungs. Therefore, the aim of this study is to compare the application of a recruitment maneuver using the high-frequency oscillatory ventilation (HFOV) modality just before the surfactant administration followed by rapid extubation (INtubate-RECruit-SURfactant-Extubate: IN-REC-SUR-E) with IN-SUR-E alone in spontaneously breathing preterm infants requiring nasal continuous positive airway pressure (nCPAP) as initial respiratory support and reaching pre-defined CPAP failure criteria. METHODS/DESIGN: In this study, 206 spontaneously breathing infants born at 24(+0)-27(+6) weeks' gestation and failing nCPAP during the first 24 h of life, will be randomized to receive an HFOV recruitment maneuver (IN-REC-SUR-E) or no recruitment maneuver (IN-SUR-E) just prior to surfactant administration followed by prompt extubation. The primary outcome is the need for mechanical ventilation within the first 3 days of life. Infants in both groups will be considered to have reached the primary outcome when they are not extubated within 30 min after surfactant administration or when they meet the nCPAP failure criteria after extubation. DISCUSSION: From all available data no definitive evidence exists about a positive effect of recruitment before surfactant instillation, but a rationale exists for testing the following hypothesis: a lung recruitment maneuver performed with a step-by-step Continuous Distending Pressure increase during High-Frequency Oscillatory Ventilation (and not with a sustained inflation) could have a positive effects in terms of improved surfactant distribution and consequent its major efficacy in preterm newborns with respiratory distress syndrome. This represents our challenge. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02482766 . Registered on 1 June 2015.

First molecular identification of the zoonotic parasite Anisakis pegreffii (Nematoda: Anisakidae) in a paraffin-embedded granuloma taken from a case of human intestinal anisakiasis in Italy.

BACKGROUND: Anisakiasis is an important fish-borne zoonosis provoked by larval stages of nematodes belonging to the genus Anisakis. The detection and identification of human infections is difficult. This is due to: a) the low specificity of the clinical features and symptomatology related to human infections; b) the paucity of diagnostic features of larvae found in granulomatous lesions characteristic of "invasive anisakiasis"; and c) the lack morphological characters diagnostic at the specific level when larvae of Anisakis are detected. Thus, molecular-based diagnostic approaches are warranted. METHOD: We have developed a PCR method that amplifies the DNA of Anisakis spp. in fixed paraffin-embedded tissues. This method was applied to a granuloma removed from a human case of intestinal anisakiasis in Italy. Specific primers of the mtDNA cox2 gene were used and sequence analysis was performed according to the procedures already established for species of Anisakis. RESULTS: The sequence obtained (629 bp) was compared with those of the other species of Anisakis which have so far been genetically characterized and with sequences obtained from larval stages of Anisakis collected from the Mediterranean fish Engraulis encrasicolus. This enabled the genetic identification of the larva in the human tissue as A. pegreffii. This is the first instance of human intestinal anisakiasis diagnosed using PCR of DNA purified from a fixed eosinophilic granuloma embedded in paraffin. CONCLUSION: The case of human anisakiasis presented reinforces the pathological significance of the species A. pegreffii to humans. The molecular/genetic methodological approach based on mtDNA cox2 sequence analysis, described here, can allow easy and rapid identification of Anisakis spp. in formalin-fixed and paraffin embedded tissues removed from cases of either gastric or intestinal human anisakiasis.

Adenomyomatosis of the gallbladder in childhood: report of a case and review of the literature.

Adenomyomatosis of the gallbladder is considered an acquired pathologic condition that affects adults, with only 2 cases previously described in childhood. We report on a 5-year-old boy with incidental detection of this lesion by ultrasonography. Pathologic and clinical assessments are discussed in addition to treatment decision-making, including current insights into the relation between adenomyomatosis and malignancy of the gallbladder. The liberal use of ultrasonography in children with abdominal pain may result in detection of an increasing number of asymptomatic patients. Caregivers should be aware of this condition and its therapeutic implications in the pediatric population.

Soy protein formulas in children: no hormonal effects in long-term feeding.

Recently, the finding of high plasma concentration of phyto-oestrogens in soy protein formula (SPF) fed children has focused scientific attention on the phyto-oestrogens (isoflavones genistein, daidzein, and their glycosides) contained in SPFs. The aim of this study was to evaluate some hormonal and metabolic effects of long-term (more than 6 months) SPF feeding. We enrolled 48 children, mean age 37 months (range 7-96 months), 27 males and 21 females. All children underwent physical examination. Bone age, urinary markers of bone metabolism, serum levels of bone alkaline phosphatase, osteocalcin, 17beta-oestradiol, and intact parathyroid hormone were measured. Eighteen healthy children represented the control group. No abnormalities were observed in auxological parameters; none of the enrolled girls showed signs/symptoms of precocious puberty and none of the boys presented gynecomastia; bone age was within the normal range. The serum level of bone alkaline phosphatase, osteocalcin, 17beta-oestradiol, and intact parathyroid hormone, and the urinary levels of the markers of bone metabolism were all within normal values. We conclude that long-term feeding with SPFs in early life does not seem to produce oestrogen-like hormonal effects.

Posterior urethral valves and mirror image anomalies in monozygotic twins.

Monozygotic (MZ) twins with both posterior urethral valves (PUV) and additional mirror image malformations are described. This association suggests that an early embryonic event may lead to MZ twinning, PUV, and mirror image anomalies.

Glossopexy as an alternative to aortopexy in infants with repaired esophageal atresia and upper airway obstruction.

BACKGROUND/PURPOSE: Clinical manifestations of airway obstruction in infants with repaired esophageal atresia or tracheoesophageal fistula (EA/TEF) are attributed conventionally to tracheomalacia. In the current study, the authors tested the hypothesis that a retrodisplacement of the tongue (glossoptosis), by causing a functional upper airway obstruction (obstructive apnea/hypopnea), may play a role in the pathogenesis of the respiratory problems. METHODS: The records of 5 infants with repaired EA/TEF and respiratory symptoms treated by glossopexy, which serves to anchor the tongue forward, were reviewed. Prompt improvement after glossopexy in clinical manifestations, in blood gas exchange, and in weight velocity was used to establish a primary cause-effect relationship between glossoptosis and respiratory problems. RESULTS: Before glossopexy, all infants presented with severe respiratory distress. Three infants had life-threatening events requiring recurrent or chronic airway intubation. Four infants had severe tracheomalacia, diagnosed at bronchoscopy. All infants presented obstructive apnea/hypopnea with desaturation. Body weight was below the third percentile in all infants. After glossopexy, 3 presented a marked clinical improvement associated with significant increase in mean oxygen saturation (88% +/- 0.4 SE v 95% +/- 0.3 SE; P <.001). In another infant, glossopexy allowed permanent decannulation but did not relieve the problem during crying or excitement when obstructive hypopnea with desaturation required supplemental oxygen. After glossopexy and despite subsequent aortopexy, the last infant could not be extubated and died later of mycotic sepsis. Autopsy results showed a vascular ring. In the 4 surviving infants, glossopexy was followed promptly by significant catch-up growth and subsequent normal growth velocity (P =.03). CONCLUSIONS: Present findings support the concept that, in some infants with EA/TEF, respiratory problems are mainly caused by recurrent obstructive apnea/hypopnea, which may be treated successfully by lip-tongue adhesion procedures. Severe airway obstruction, not relieved by glossopexy, requires aortopexy to reduce the respiratory load imposed by tracheomalacia.