A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol.

INTRODUCTION: Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes. METHODS AND ANALYSIS: The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27-34+6 weeks' gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25-0.35 in the first 2-24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05. ETHICS AND DISSEMINATION: Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004). TRIAL REGISTRATION: PACTR202307490670785.

Cryptosporidium infection and associated risk factors among children from rural areas in Peru: a nested case-control study.

This study aimed to detect the frequency of Cryptosporidium infection and associated risk factors among children from rural areas in Peru. A case-control study was conducted, nested in a cohort in two rural communities that included children between 6 and 13 months who were followed for 6 months. Cases were children whose fecal samples tested positive for Cryptosporidium infection using an immunochromatography test. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to analyze risk factors associated with Cryptosporidium infection. Among 72 children, 13 (18%) were cases. Cryptosporidium infection was associated with below secondary education of the mother (OR 7.62, 95% CI 1.50-36.72) and with having more siblings living at home (OR 1.71, 95% CI 1.04-2.82). An important frequency of Cryptosporidium infection among children from rural areas in Peru was reported, more research is needed to understand its true burden and risk factors among children in Peru.

Extra-genital Neisseria gonorrhoeae infections with genetic mutations conferring ciprofloxacin resistance among men who have sex with men and transgender women in Lima, Peru.

BACKGROUND: The increasing prevalence of drug-resistant Neisseria gonorrhoeae (NG) infections has caused great concern. Ciprofloxacin remains the empiric antimicrobial recommended to treat NG infections in Peru disregarding the susceptibility profile of circulating NG strains. We report the prevalence of individuals infected with NG strains presenting mutations in the gyrA gene that confers ciprofloxacin resistance. METHODS: We conducted a descriptive study assessing extragenital swab samples collected from a cohort of men who have sex with men and transgender women in Lima, Peru. Anal and pharyngeal NG positive swabs for Aptima Combo 2 assay (Hologic Inc., USA) were used for DNA extraction. We performed TaqMan real time PCR assays to detect a point mutation at codon Ser91 of the gyrase A (gyrA) gene. RESULTS: From 156 individuals who had at least one positive sample for NG reported by the Aptima assay, 80 individuals had at least one amplified DNA for the gyrA gene. We found that 67 of them (84.0%) were infected with a gyrA-mutated NG strain at the Ser91 codon. CONCLUSIONS: We report a high prevalence of gyrA mutation conferring ciprofloxacin resistance among individuals with extragenital NG infection. Empirical treatment of NG needs to be urgently updated in Peru in concordance with international guidelines.

Class 1 and 2 Integrons in Escherichia coli Strains Isolated from Diarrhea and Bacteremia in Children Less Than 2 Years of Age from Peru.

Class 1 and Class 2 integrons are mobilizable elements able to carry a variety of antibiotic resistance determinants. In the present study, Class 1 and 2 integrons present in 355 pathogenic Escherichia coli (285 diarrheagenic, of these 129 were enteropathogenic, 90 enteroaggregative, 66 enterotoxigenic, and 70 bacteremic) isolated from healthy and ill children under age 5 from periurban areas of Lima, Peru, were characterized. The presence of integrase 1 and 2 was established by polymerase chain reaction (PCR), and variable regions were grouped by PCR-restriction fragment length polymorphism and subsequent sequencing. Antimicrobial resistance was established by disk diffusion. Ninety-seven isolates (27.3%) presented integrase 1, and 16 (4.5%) presented integrase 2 (P < 0.0001); in addition, seven (2.0%) isolates, six diarrheagenic and one bacteremic, presented both integrase genes. The presence of integrase 1 was more frequent among bacteremic isolates (P = 0.0004). Variable regions were amplified in 76/120 (63.3%) isolates with up to 14 gene arrangements. The most prevalent gene cassettes were those encoding dihydrofolate reductases as well as aminoglycoside modifying enzymes. Of note, Class 1 integrons tended to be associated with the presence of extended-spectrum ß-lactamases (ESBLs). A variety of Class 1 and 2 integrons were detected in diarrheagenic and bacteremic E. coli, demonstrating the heterogeneity of variable regions circulating in the area. The association of integrons with ESBLs is worrisome and has an impact on the development of multidrug resistance.

The changing landscape in epilepsy imaging: Unmasking subtle and unique entities.

Dramatic changes have occurred recently in the field of epilepsy, including a fundamental shift in the etiology of epileptogenic substrates found at surgery. Hippocampal sclerosis is no longer the most common etiology found at epilepsy surgery and this decrease has been associated with an increase in the incidence of focal cortical dysplasia and encephaloceles. Significant advances have been made in molecular biology and genetics underlying the basis of malformations of cortical development, and our ability to detect epileptogenic abnormalities with MR imaging has markedly improved. This article begins with a discussion of these trends and reviews imaging techniques essential for detecting of subtle epilepsy findings. Representative examples of subtle imaging findings are presented, which are often overlooked but should not be missed. These include temporal lobe encephaloceles, malformations of cortical development (and especially focal cortical dysplasia), hippocampal sclerosis, hippocampal malformation (also known as HIMAL), ulegyria, autoimmune encephalitis, and Rasmussen's encephalitis. Recent findings on the pathophysiology and genetic underpinnings of several causes of localization-related epilepsy are incorporated. For instance, it has been recently found that focal cortical dysplasia IIb, tuberous sclerosis, hemimegalencephaly, and gangliogliomas are all the result of mutations of the mTOR pathway for cell growth.

Trial of aerosolised surfactant for preterm infants with respiratory distress syndrome.

OBJECTIVE: To evaluate the safety of an aerosolised surfactant, SF-RI 1, administered via nasal continuous positive airway pressure (nCPAP) and a prototype breath synchronisation device (AeroFact), to preterm infants with respiratory distress syndrome (RDS). DESIGN: Multicentre, open-label, dose-escalation study with historical controls. SETTING: Newborn intensive care units at Mater Mothers' Hospital, Brisbane, and Royal Hospital for Women, Sydney, Australia. PATIENTS: Infants 26 weeks through 30 weeks gestation who required nCPAP 6-8 cmH2O and fraction of inspired oxygen (FiO2) <0.30 at <2 hours of age. INTERVENTIONS: In part 1, infants received a single dose of 216 mg/kg of aerosolised surfactant. In part 2, infants could receive up to four doses of aerosolised surfactant. Three historical control infants were matched for each enrolled infant. MAIN OUTCOME MEASURES: Treatment failure was defined as Respiratory Severity Score (FiO2×cmH2O nCPAP) >2.4, nCPAP >8 cmH2O, arterial carbon dioxide >65 mm Hg, pH <7.20 or three severe apnoeas within 6 hours during the first 72 hours of life. Other outcomes included tolerance of the AeroFact treatment and complications of prematurity. RESULTS: 10 infants were enrolled in part 1 and 21 in part 2 and were compared with 93 historical controls. No safety issues were identified. In part 2, 6 of 21 (29%) AeroFact-treated infants compared with 30 of 63 (48%) control infants met failure criteria. Kaplan-Meier analysis of patients in part 2 showed a trend towards decreased rate of study failure in the AeroFact-treated infants compared with historical controls (p=0.10). CONCLUSION: The AeroFact system can safely deliver aerosolised surfactant to preterm infants with RDS who are on nCPAP. TRIAL REGISTRATION NUMBER: ACTRN12617001458325.

Secretory immunoglobulin A (sIgA) in saliva versus virulence proteins of enteropathogenic Escherichia coli (EPEC) in ill and colonized children / Inmunoglobulina A secretoria en saliva frente a proteínas de virulencia de Escherichia coli enteropatogénica en niños enfermos y colonizados

INTRODUCTION: We evaluated the presence of sIgA in saliva, versus Escherichia coli secreted proteins (Esp) related to the type III secretion system (T3SS), and its semi-quantitative concentration in children under 2 years-old (no longer breastfed) who were previously colonized or infected with enteropathogenic E. coli (EPEC). METHODS: We analyzed the presence of sIgA in 40 children, who previously had positive cultures for EPEC associated (n = 17) or not associated (n = 23) with diarrhea, using the Western Blot technique versus E. coli secreted proteins: EspABCD. A semi-quantitative measurement of the reaction for each protein was made by its density peaks (OD). RESULTS: We found sIgA versus all or some EspABCD proteins in both groups. However, the ill patients had higher concentrations of these antibodies than colonized patients. DISCUSSION: The presence of sIgA in saliva could reflect an intestinal immune response and their levels could be related to a greater exposure and/or bacterial load

INTRODUCCIÓN: Evaluamos la presencia de inmunoglobulina secretoria A (sIgA) frente a proteínas secretadas por E. coli (Esp) relacionadas con el sistema de secreción tipo III (T3SS) en saliva, y su concentración semicuantitativa en niños menores de 2 años (no lactantes) colonizados o infectados previamente con E. coli enteropatógena (EPEC). MÉTODOS: Analizamos la presencia de sIgA en 40 niños con cultivos positivos previos para EPEC asociados (n=17) o no (n=23) con diarrea, mediante la técnica de Western-blot frente a las proteínas secretadas por E. coli (EspABCD), realizando mediciones semicuantitativas de la reacción de cada proteína mediante sus picos de densidad (OD). RESULTADOS: Ambos grupos presentaron sIgA frente a las proteínas EspABCD, aunque los pacientes enfermos presentaron mayores concentraciones de estos anticuerpos que los colonizados. DISCUSIÓN: La presencia de sIgA en la saliva podría reflejar una respuesta inmune intestinal y sus niveles podrían estar relacionados con una mayor exposición y/o carga bacteriana

Baby's first bath: Changes in skin barrier function after bathing full-term newborns with water vs liquid baby cleanser.

BACKGROUND: The impact of the newborn's first bath, whether given with water alone or water with skin cleansing products, on skin barrier function is unknown. METHODS: We evaluated skin barrier function, measured by skin surface pH (primary outcome), transepidermal water loss (TEWL), and hydration of the stratum corneum (SCH) in 100 newborns before and after their first bath, randomizing this cohort to bathing with water alone or with water and a liquid baby cleanser. Two consecutive measurements of each parameter were obtained at two anatomic locations, the volar forearm, and below the sternum. Randomization was by mode of delivery, with 50 vaginal and 50 cesarean section (C/S) delivered newborns. RESULTS: Skin pH decreased significantly following the first bath at both anatomic sites regardless of whether the bath was performed with water or with cleanser, and there was no significant effect on the change in pH in these two groups. Baseline TEWL and SCH measurements were significantly lower in the sternum area compared to the volar forearm. TEWL decreased significantly after the first bath except when the bath was given with water alone on the sternum site. SCH also decreased significantly after the first bath except in the forearm when the bath was given with water alone. CONCLUSIONS: We conclude that skin surface pH, TEWL, and SCH all decrease significantly following the first bath, an indication of the development of skin barrier function in the newly born infant. In addition, bathing with water alone or water and a liquid baby cleanser does not impact the developing skin barrier.

Secretory immunoglobulin A (sIgA) in saliva versus virulence proteins of enteropathogenic Escherichia coli (EPEC) in ill and colonized children.

INTRODUCTION: We evaluated the presence of sIgA in saliva, versus Escherichia coli secreted proteins (Esp) related to the type III secretion system (T3SS), and its semi-quantitative concentration in children under 2 years-old (no longer breastfed) who were previously colonized or infected with enteropathogenic E. coli (EPEC). METHODS: We analyzed the presence of sIgA in 40 children, who previously had positive cultures for EPEC associated (n=17) or not associated (n=23) with diarrhea, using the Western Blot technique versus E. coli secreted proteins: EspABCD. A semi-quantitative measurement of the reaction for each protein was made by its density peaks (OD). RESULTS: We found sIgA versus all or some EspABCD proteins in both groups. However, the ill patients had higher concentrations of these antibodies than colonized patients. DISCUSSION: The presence of sIgA in saliva could reflect an intestinal immune response and their levels could be related to a greater exposure and/or bacterial load.

Stunting Is Preceded by Intestinal Mucosal Damage and Microbiome Changes and Is Associated with Systemic Inflammation in a Cohort of Peruvian Infants.

Stunting, defined as height-for-age Z score equal to or lower than -2, is associated with increased childhood mortality, cognitive impairment, and chronic diseases. The aim of the study was to investigate the relationship between linear growth, intestinal damage, and systemic inflammation in infants at risk of stunting. We followed up 78 infants aged 5-12 months living in rural areas of Peru for 6 months. Blood samples for biomarkers of intestinal damage (intestinal fatty-acid-binding protein [I-FABP] and zonulin) and systemic inflammation (interleukin-1ß, interleukin-6, tumor necrosis factor α [TNF-α], soluble CD14, and lipopolysaccharide-binding protein [LBP]) and fecal samples for microbiome analysis were collected at baseline and closure of the study. The children's growth and health status were monitored through biweekly home visits by trained staff. Twenty-one percent of the children became stunted: compared with non-stunted children, they had worse nutritional parameters and higher levels of serum I-FABP at baseline. The likelihood of becoming stunted was strongly associated with an increase in sCD14 over time; LBP and TNF-α showed a trend toward increase in stunted children but not in controls. The fecal microbiota composition of stunted children had an increased beta diversity compared with that of healthy controls throughout the study. The relative abundance of Ruminococcus 1 and 2, Clostridium sensu stricto, and Collinsella increased in children becoming stunted but not in controls, whereas Providencia abundance decreased. In conclusion, stunting in our population was preceded by an increase in markers of enterocyte turnover and differences in the fecal microbiota and was associated with increasing levels of systemic inflammation markers.

[Presence of multidrug resistant Enterobacteriaceae and Escherichia coli in meat purchased in traditional markets of Lima]. / Presencia de Enterobacteriaceae y Escherichia coli multirresistente a antimicrobianos en carne adquirida en mercados tradicionales en Lima.

OBJECTIVE.: The objective of this study was to describe the presence of Enterobacteriaceae in meat samples collected in traditional markets of Lima and to establish the levels of antimicrobial resistance and the presence of extended spectrum beta-lactamases (BLEE) and AmpC in Escherichia coli. MATERIALS AND METHODS.: A total of 138 meat samples, 64 (46.4%) chicken, 44 (31.9%) beef and 30 (21.7%) pork were collected. The isolated bacteria belonged to 17 different genera and, specifically, 14 were classified as Enterobacteriaceae. Sensitivity to ten antimicrobial agents was analyzed using the Kirby-Bauer disc diffusion method, BLEE and AmpC were determined by double disc and imipenem-ceftazidime induction tests, respectively. RESULTS.: Antimicrobial resistance levels were high against trimethoprim-sulfamethoxazole, ampicillin, tetracycline, nalidixic acid, ciprofloxacin and chloramphenicol. There are significant differences in antibiotic resistance levels depending on the type of meat (chicken, beef and pork) (p <0.05). Multiple drug resistance (MDR) levels were particularly high in chicken and pork (98.2% and 86.4%, respectively). In addition, the presence of BLEE in Escherichia coli isolated from chicken meat was 59.4%. CONCLUSIONS.: Multiple drug resistance levels were high compared to antibiotics frequently used in humans; chicken and beef are highlighted as potential reservoirs of BLEE and pAmpC-producing Escherichia coli, respectively.

OBJETIVOS.: El objetivo del presente estudio fue describir la presencia de Enterobacteriaceae en muestras de carne recolectadas en mercados tradicionales de Lima y establecer los niveles de resistencia a antimicrobianos y la presencia de betalactamasas de espectro extendido (BLEE) y AmpC en Escherichia coli. MATERIALES Y MÉTODOS.: Se recolectaron un total de 138 muestras de carne, 64 (46,4 %) de pollo, 44 (31,9 %) de carne de res y 30 (21,7%) de carne de cerdo. Las bacterias aisladas pertenecieron a 17 géneros diferentes, y específicamente 14 fueron clasificados como Enterobacteriaceae. Se analizó la sensibilidad frente a diez agentes antimicrobianos mediante el método de difusión de disco Kirby-Bauer, se determinó la presencia de BLEE y AmpC mediante las pruebas de doble disco y de inducción de imipenem-ceftazidima, respectivamente. RESULTADOS.: Los niveles de resistencia a los antimicrobianos fueron altos frente a trimetoprima-sulfametoxazol, ampicilina, tetraciclina, ácido nalidíxico, ciprofloxacino y cloranfenicol. Existen diferencias significativas en los niveles de resistencia a los antibióticos según el tipo de carne (pollo, carne de res y cerdo) (p <0,05). Los niveles de resistencia a múltiples antimicrobianos (MDR) fueron particularmente altos en pollo y cerdo (98,2 % y 86,4 %, respectivamente). Además, la presencia de BLEE en Escherichia coli aisladas de carne de pollo fue del 59,4 %. CONCLUSIONES.: Los niveles de resistencia a los antimicrobianos fueron altos frente a los antibióticos usados frecuentemente en humanos, se destaca el pollo y la res como potenciales reservorios de Escherichia coli productoras de BLEE y pAmpC, respectivamente.

Presencia de Enterobacteriaceae y Escherichia coli multirresistente a antimicrobianos en carne adquirida en mercados tradicionales en Lima / Presence of multidrug resistant Enterobacteriaceae and Escherichia coli in meat purchased in traditional markets of Lima

RESUMEN Objetivos. El objetivo del presente estudio fue describir la presencia de Enterobacteriaceae en muestras de carne recolectadas en mercados tradicionales de Lima y establecer los niveles de resistencia a antimicrobianos y la presencia de betalactamasas de espectro extendido (BLEE) y AmpC en Escherichia coli. Materiales y métodos. Se recolectaron un total de 138 muestras de carne, 64 (46,4 %) de pollo, 44 (31,9 %) de carne de res y 30 (21,7%) de carne de cerdo. Las bacterias aisladas pertenecieron a 17 géneros diferentes, y específicamente 14 fueron clasificados como Enterobacteriaceae. Se analizó la sensibilidad frente a diez agentes antimicrobianos mediante el método de difusión de disco Kirby-Bauer, se determinó la presencia de BLEE y AmpC mediante las pruebas de doble disco y de inducción de imipenem-ceftazidima, respectivamente. Resultados. Los niveles de resistencia a los antimicrobianos fueron altos frente a trimetoprima-sulfametoxazol, ampicilina, tetraciclina, ácido nalidíxico, ciprofloxacino y cloranfenicol. Existen diferencias significativas en los niveles de resistencia a los antibióticos según el tipo de carne (pollo, carne de res y cerdo) (p <0,05). Los niveles de resistencia a múltiples antimicrobianos (MDR) fueron particularmente altos en pollo y cerdo (98,2 % y 86,4 %, respectivamente). Además, la presencia de BLEE en Escherichia coli aisladas de carne de pollo fue del 59,4 %. Conclusiones. Los niveles de resistencia a los antimicrobianos fueron altos frente a los antibióticos usados frecuentemente en humanos, se destaca el pollo y la res como potenciales reservorios de Escherichia coli productoras de BLEE y pAmpC, respectivamente.

ABSTRACT Objective. The objective of this study was to describe the presence of Enterobacteriaceae in meat samples collected in traditional markets of Lima and to establish the levels of antimicrobial resistance and the presence of extended spectrum beta-lactamases (BLEE) and AmpC in Escherichia coli. Materials and Methods. A total of 138 meat samples, 64 (46.4%) chicken, 44 (31.9%) beef and 30 (21.7%) pork were collected. The isolated bacteria belonged to 17 different genera and, specifically, 14 were classified as Enterobacteriaceae. Sensitivity to ten antimicrobial agents was analyzed using the Kirby-Bauer disc diffusion method, BLEE and AmpC were determined by double disc and imipenem-ceftazidime induction tests, respectively. Results. Antimicrobial resistance levels were high against trimethoprim-sulfamethoxazole, ampicillin, tetracycline, nalidixic acid, ciprofloxacin and chloramphenicol. There are significant differences in antibiotic resistance levels depending on the type of meat (chicken, beef and pork) (p <0.05). Multiple drug resistance (MDR) levels were particularly high in chicken and pork (98.2% and 86.4%, respectively). In addition, the presence of BLEE in Escherichia coli isolated from chicken meat was 59.4%. Conclusions. Multiple drug resistance levels were high compared to antibiotics frequently used in humans; chicken and beef are highlighted as potential reservoirs of BLEE and pAmpC-producing Escherichia coli, respectively.

Progressive T1 Shortening of the Dentate Nucleus in Patients With Multiple Sclerosis: Result of Multiple Administrations of Linear Gadolinium Contrast Agents Versus Intrinsic Disease.

OBJECTIVE: The purpose of this article is to study the effect of the administration of multiple IV doses of gadolinium-based contrast agent on the intrinsic T1 hyperintensity in the dentate nucleus and globus pallidus in patients with multiple sclerosis (MS). MATERIALS AND METHODS: A retrospective review of imaging in patients with relapsing-remitting MS was performed. Images of 20 patients who received four or more doses of gadolinium-based contrast agent were reviewed. Patients received the linear agent gadopentetate dimeglumine before 2011 and the macrocyclic agent gadobutrol from 2011 onward. Dentate nucleus-to-pons and globus pallidus-to-thalamus signal intensity (SI) ratios were evaluated. SI ratios were compared over time with multiple injections of gadolinium. Similar SI ratios were evaluated for six patients who received gadopentetate dimeglumine and then underwent multiple subsequent MRI studies without contrast agent administration. RESULTS: The increase in the dentate nucleus-to-pons SI ratio after multiple administrations of the linear agent gadopentetate dimeglumine (mean = 1.44; SD = 2.50) was significantly higher than that with the macrocyclic agent gadobutrol (mean = -0.11; SD = 2.33) (p < 0.001). The globus pallidus-to-thalamus and dentate nucleus-to-CSF ratios also increased with multiple contrast injections over time, but the changes were not found to be statistically significant. The increase in SI in the dentate nucleus was not observed in patients who stopped receiving contrast injections, after showing a previous increase over time with gadolinium. CONCLUSION: In patients with MS, SI within the dentate nucleus and globus pallidus increased on unenhanced T1-weighted images and was significantly greater with the administration of a linear agent than with a macrocyclic agent. This increase in SI over time is likely a reflection of gadolinium deposition and not due to intrinsic disease, as previously postulated.

Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT.

PURPOSE: To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. METHODS: A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome. RESULTS: A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. CONCLUSIONS: MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination. KEY POINTS: • MRI has limited utility after negative cervical CT in blunt trauma. • MRI is frequently positive for non-specific soft-tissue injury. • Unstable injury missed on CT is infrequent.

Molecular and Phenotypic Characterization of Diarrheagenic Escherichia coli Strains Isolated from Bacteremic Children.

Escherichia coli is an important cause of Gram-negative bacteremia. The aim of this study was to characterize at the molecular and phenotypic levels E. coli strains belonging to different diarrheagenic pathotypes [diarrheagenic E. coli (DEC)] isolated from bacteremia in children younger than 5 years of age. Seventy bacteremia E. coli strains were collected in a prospective study in 12 hospitals in Lima, Peru. The presence of virulence genes associated with DEC [enterotoxigenic (lt and st), enteropathogenic (eaeA), shiga toxin-producing (stx1and stx2), enteroinvasive (ipaH), enteroaggregative (aggR), and diffusely adherent (daaD)] was determined by multiplex real-time polymerase chain reaction (PCR). Those positive E. coli strains were further analyzed for 18 additional virulence factors encoding genes and others phenotypic features. Virulence genes associated with DEC were identified in seven bacteremic children (10%), including: one aggR-positive [enteroaggregative E. coli (EAEC)], one eaeA-positive [enteropathogenic E. coli (EPEC)], one st-positive [enterotoxigenic E. coli (ETEC)], one daaD-positive [diffusely adherent E. coli (DAEC)], and three strain positive for aggR and daaD (EAEC/DAEC) at the same time. All strains, except EPEC, had the Ag43 adhesin, and all, except ETEC had the siderophore gene fyuA. The phylogenetic profile of these strains was variable, two (B2), two (D), two (A), and one (B1) strain. These isolates were susceptible to all tested antibacterial agents except to ampicillin and gentamicin. The three EAEC/DAEC strains showed biofilm formation and aggregative adhesion and had the same repetitive extragenic palindromic-PCR patterns. These findings suggest that some DEC strains, especially agg-R and daa-D positive, might cause bacteremia in children.

Patterns of Change in Facial Skeletal Aging.

IMPORTANCE: Research in facial aging has focused on soft-tissue changes rather than bony changes despite evidence of the importance of underlying bony structural changes. Research has also been limited by comparing different patients in separate age groups rather than the same patients over time. OBJECTIVE: To longitudinally document patterns of change in the facial skeleton and determine a consistent methodology for measuring these changes. DESIGN, SETTING, AND PARTICIPANTS: Case series study of university hospital system records using facial computed tomographic (CT) images timed at least 8 years apart in adults initially aged 40 to 55 years with no history of facial surgery who required repeated facial imaging that included the entire midface and cranium. MAIN OUTCOMES AND MEASURES: Face CTs were analyzed for 3-dimensional constructions and 2-dimensional measurements to document changes in glabellar, piriform, and maxillary angles and piriform height and width. RESULTS: Fourteen patients (5 men, 9 women; mean [SD] age, 51.1 [5.8] years) with mean (SD) follow-up of 9.7 (1.4) years were eligible for 2-dimensional analysis, which revealed statistically significant decreases in mean (SD) glabellar angles (from 68.8° [7.6°] to 66.5° [8.6°]) and maxillary angles on both the right (from 82.5° [6.3°] to 81.0° [7.1°]) and left (from 83.0° [5.8°] to 81.0° [7.0°]), as well as increases in mean (SD) piriform width (from 24.5 [1.6] mm to 25.5 [1.3] mm). Nine patients (3 men, 6 women; mean [SD] age, 51.4 [6.3] years) with mean (SD) follow-up imaging at 9.6 (1.5) years were eligible for 3-dimensional analysis, which revealed statistically significant decreases in mean (SD) maxillary angles (from 56.5° [6.6°] to 51.6° [7.6°]) and piriform angles (from 50.8° [3.4°] to 49.1° [3.4°]). Statistically significant differences between the sexes were also noted: Initial mean (SD) glabellar angle for men was 61.7° (5.7°) vs 72.7° (5.4°) for women, with final values of 57.9° (4.9°) vs 71.2° (6.0°). Mean (SD) maxillary angle initial values were 87.8° (6.1°) (right) and 87.1° (4.9°) (left) for men, with 79.6° (4.3°) and 80.6° (5.0°) for women, respectively. Final values were 87.0° (4.4°) and 86.9° (4.1°) for men and 77.7° (6.1°) and 77.7° (6.2°) for women, respectively. Mean (SD) piriform height for men was 35.0 (2.0) mm initially and 35.5 (2.1) mm finally, vs 31.3 (2.8) and 31.6 (3.0) mm for women, respectively. CONCLUSIONS AND RELEVANCE: Our pilot study of repeated CT images of patients over several years supports previous studies of bony facial aging and further characterizes these changes. This study is the first, to our knowledge, to document bony changes of the face in the same group of patients at different time points to better characterize facial aging. We also detail an improved methodology to study bony aging to contribute to additional research in the field. LEVEL OF EVIDENCE: NA.

MRI findings of optic pathway involvement in Miller Fisher syndrome in 3 pediatric patients and a review of the literature.

BACKGROUND: Miller Fisher syndrome (MFS) is a rare demyelinating condition which may have involvement of cranial nerves. There are a few case reports of optic pathway involvement in children. We describe 3 patients with optic pathway enhancement in pediatric patients with MFS. CASE SERIES: We retrospectively reviewed brain imaging findings in 17 pediatric patients with of Guillain-Barré syndrome (GBS) meeting Brighton criteria who had brain MRIs performed during their acute illness. Cranial nerve enhancement was seen in 6/17 patients and optic nerve/chiasm enhancement was seen in 3 patients. CONCLUSION: Cranial nerve enhancement and optic pathway in particular, can be seen in patients with MFS. Imaging findings do not always correlate with clinical manifestations of cranial nerve involvement.

The Randomized, Controlled Trial of Late Surfactant: Effects on Respiratory Outcomes at 1-Year Corrected Age.

OBJECTIVE: To determine the effects of late surfactant on respiratory outcomes determined at 1-year corrected age in the Trial of Late Surfactant (TOLSURF), which randomized newborns of extremely low gestational age (≤28 weeks' gestational age) ventilated at 7-14 days to late surfactant and inhaled nitric oxide vs inhaled nitric oxide-alone (control). STUDY DESIGN: Caregivers were surveyed in a double-blinded manner at 3, 6, 9, and 12 months' corrected age to collect information on respiratory resource use (infant medication use, home support, and hospitalization). Infants were classified for composite outcomes of pulmonary morbidity (no PM, determined in infants with no reported respiratory resource use) and persistent PM (determined in infants with any resource use in ≥3 surveys). RESULTS: Infants (n = 450, late surfactant n = 217, control n = 233) were 25.3 ± 1.2 weeks' gestation and 713 ± 164 g at birth. In the late surfactant group, fewer infants received home respiratory support than in the control group (35.8% vs 52.9%, relative benefit [RB] 1.28 [95% CI 1.07-1.55]). There was no benefit of late surfactant for No PM vs PM (RB 1.27; 95% CI 0.89-1.81) or no persistent PM vs persistent PM (RB 1.01; 95% CI 0.87-1.17). After adjustment for imbalances in baseline characteristics, relative benefit of late surfactant treatment increased: RB 1.40 (95% CI 0.89-1.80) for no PM and RB 1.24 (95% CI 1.08-1.42) for no persistent PM. CONCLUSION: Treatment of newborns of extremely low gestational age with late surfactant in combination with inhaled nitric oxide decreased use of home respiratory support and may decrease persistent pulmonary morbidity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01022580.