Ventilatory Support, Extubation, and Cerebral Perfusion Changes in Pre-Term Neonates: A Near Infrared Spectroscopy Study.

Early extubation is considered to be beneficial for pre-term neonates. On the other hand, premature extubation can cause lung derecruitment, compromised gas exchange, and need for reintubation, which may be associated with severe brain injury caused by sudden cerebral blood flow changes. We used near infrared spectroscopy (NIRS) to investigate changes in cerebral oxygenation (rScO2) and fractional tissue oxygen extraction (+) after extubation in pre-term infants. This is a single-center retrospective study of NIRS data at extubation time of all consecutive pre-term neonates born at our institution over a 1-year period. Comparison between subgroups was performed. Nineteen patients were included; average gestational age (GA) was 29.4 weeks. No significant change was noted in rScO2 and cFTOE after extubation in the whole population. GA and germinal matrix hemorrhage (GMH)-intraventricular hemorrhage (IVH) showed a significant change in rScO2 and cFTOE after extubation. A significant increase in cFTOE was noted in patients with previous GMH-IVH (+0.040; p = 0.05). To conclude, extubation per se was not associated with significant change in cerebral oxygenation and perfusion. Patients with a diagnosed GMH-IVH showed an increase in cFTOE, suggesting perturbation in cerebral perfusion suggesting further understanding during this challenging phenomenon. Larger studies are required to corroborate our findings.

Severe cellulitis from methicillin-resistant Staphylococcus aureus (MRSA) in a couple of preterm twins: a case report.

BACKGROUND: Preterms are at risk of systemic infections as the barrier function of their immature skin is insufficient. The long period of hospitalization and the huge number of invasive procedures represent a risk factor for complications. Among the nosocomial infections of the skin, methicillin-resistant Staphylococcus aureus (MRSA) is associated with significant morbidity and mortality. We report a clinical case of cellulitis and abscess in two preterm twins caused by MRSA in a tertiary level Neonatal Intensive Care Unit (NICU). CASE PRESENTATION: Two preterm female babies developed cellulitis from MRSA within the first month of extrauterine life. The first one (BW 990 g) showed signs of clinical instability 4 days before the detection of a hyperaemic and painful mass on the thorax. The second one (BW 1240 g) showed signs of clinical instability contextually to the detection of an erythematous, oedematous and painful area in the right submandibular space. In both cases the diagnosis of cellulitis was confirmed by ultrasound. A broad spectrum, multidrug antimicrobial therapy was administered till complete resolution. CONCLUSIONS: Due to the characteristic antibiotic resistance of MRSA and the potential complications of those infections in such delicate patients, basic prevention measures still represent the key to avoid the spreading of neonatal MRSA infections in NICUs, which include hand hygiene and strict precautions, as well as screening of patients for MRSA on admission and during hospital stay, routine prophylactic topical antibiotic of patients, enhanced environmental cleaning, cohorting and isolation of positive patients, barrier precautions, avoidance of ward crowding, and, in some units, surveillance, education and decolonization of healthcare workers and visiting parents.

Disruption of Cerebellar Granular Layer as a Consequence of Germinal Matrix Intraventricular Hemorrhage in Extreme Prematurity: An Acute Direct Mechanism Too?

Cerebellum is an important brain structure for the future development of motor, cognitive, and behavioral abilities in children. This structure undergoes its most significant growth during the third trimester of pregnancy. Prematurity gathers several risk factors for cerebellar impairment and underdevelopment, and among them is ventricular dilatation following germinal matrix intraventricular hemorrhage (GMH-IVH). In this report, we illustrate how this prevalent complication associated with prematurity may induce secondary cerebellar cortical damage. A premature male born by an emergency Caesarean section displayed massive GMH-IVH at brain ultrasound performed after three hours of extrauterine life and died after 18 hours of life, despite maximized vital support. We report a postmortem histopathological specimen of the cerebellar cortex showing the disruption of the external granular layer (EGL) by hemorrhagic content flowing from the supratentorial ventricles into the fourth ventricle and cisterna magna. The expansion of the ventricular system and the presence of blood in the lateral ventricles can cause inflammation and damage to the cerebellar gyri. Experimental models have shown a thinning of the EGL, suggesting that blood surrounding the cerebellum has a harmful action. Additionally, a sudden influx of cerebrospinal fluid from the lateral ventricles may directly contribute to cerebellar damage, indicating that this may be another way in which the cerebellar gyri are impaired during acute severe GMH-IVH. This is the first histopathologically confirmed case of acute disruption in the cerebellar cortex during a GMH-IVH in a premature baby.

Optimizing haemoglobin measurements in VLBW newborns: Insights from a comparative retrospective study.

INTRODUCTION: Haemoglobin levels assessment is a crucial part of neonatal intensive care practice, the painful experience of repeated heel pricks and venepunctures blood sampling may negatively affect neonatal clinical course. To date the reliability of haemoglobin levels obtained by point-of-care testing (POCT) analysis if compared to standard blood cell count remains controversial. MATERIALS AND METHODS: Retrospective study conducted on all inborn premature infants (gestational age < 32 weeks) admitted to NICU of the IRCCS Giannina Gaslini Institute during the period May 2021-April 2023. We considered blood samplings occurred within the first 28 days of life recording the laboratory haemoglobin levels (Hblab) (reference method), the point-of-care haemoglobin levels (HbPOCT) (alternative method) and the type of puncture (arterial, venous and capillary). A Bland-Altman analysis was performed to evaluate the Hb agreement, it determines the bias (mean difference between the reference and alternative methods) and limits of agreement (LOA; lower, l-LOA; upper, u-LOA) of measures. An acceptable limit of agreement was 1 g/dl according to the existing literature. RESULTS: We considered 845 blood samplings from 189 enrolled patients. The comparison between the reference and the alternative method showed a good agreement for the capillary sampling technique with l-LOA of -0.717 (-0.776; -0.659) and u-LOA of 0.549 (0.490; 0.607), these results were not achievable with the other techniques, with LOAs over ±1 g/dl threshold (venous

Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children.

Point-of-care brain ultrasound and transcranial doppler or color-coded doppler is being increasingly used as an essential diagnostic and monitoring tool at the bedside of critically ill neonates and children. Brain ultrasound has already established as a cornerstone of daily practice in the management of the critically ill newborn for diagnosis and follow-up of the most common brain diseases, considering the easiness to insonate the brain through transfontanellar window. In critically ill children, doppler based techniques are used to assess cerebral hemodynamics in acute brain injury and recommended for screening patients suffering from sickle cell disease at risk for stroke. However, more evidence is needed regarding the accuracy of doppler based techniques for non-invasive estimation of cerebral perfusion pressure and intracranial pressure, as well as regarding the accuracy of brain ultrasound for diagnosis and monitoring of acute brain parenchyma alterations in children. This review is aimed at providing a comprehensive overview for clinicians of the technical, anatomical, and physiological basics for brain ultrasonography and transcranial doppler or color-coded doppler, and of the current status and future perspectives of their clinical applications in critically ill neonates and children. CONCLUSION: In critically ill neonates, brain ultrasound for diagnosis and follow-up of the most common cerebral pathologies of the neonatal period may be considered the standard of care. Data are needed about the possible role of doppler techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles. In pediatric critical care, doppler based techniques should be routinely adopted to assess and monitor cerebral hemodynamics. New technologies and more evidence are needed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. WHAT IS KNOWN: • In critically ill neonates, brain ultrasound for early diagnosis and follow-up of the most common cerebral and neurovascular pathologies of the neonatal period is a cornerstone of daily practice. In critically ill children, doppler-based techniques are more routinely used to assess cerebral hemodynamics and autoregulation after acute brain injury and to screen patients at risk for vasospasm or stroke (e.g., sickle cell diseases, right-to-left shunts). WHAT IS NEW: • In critically ill neonates, research is currently focusing on the use of novel high frequency probes, even higher than 10 MHz, especially for extremely preterm babies. Furthermore, data are needed about the role of doppler based techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles, also integrated with a non-invasive assessment of brain oxygenation. In pediatric critical care, new technologies should be developed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. Furthermore, large multicenter studies are needed to clarify role and accuracy of doppler-based techniques to assess cerebral perfusion pressure and its changes after treatment interventions.

RiNeo MR: A mixed reality simulator for newborn life support training.

Neonatal resuscitation is an uncommon, albeit critical task that is more likely to succeed if performed properly and promptly. In this context, simulation is an appropriate way for training and assessing the abilities of all medical staff involved in delivery room care. Recent studies have shown that learning is enhanced if the simulation experience is realistic and engaging. Hence, Virtual Reality can be beneficial for newborn resuscitation training. However, the difficulty of providing realistic haptic interaction limits its use. To overcome this constraint, we have designed RiNeo MR, a simulator for newborn life support training, combining a sensorized manikin to monitor in real time resuscitation skills, with a Virtual Reality application. The system includes a Virtual Reality headset, Leap Motion to track the user's hands, sensorized bag valve mask, and manikin to monitor head and mask positioning, ventilation, and chest compression. RiNeo MR can be used in two modalities: 2D to let the trainee practice resuscitation manoeuvres on the physical manikin, while receiving real time feedback; 3D that allows the user to be immersed in a virtual environment and practice in an hospital-like setting. In the 3D mode, virtual and real manikins are overlapped and communicate in real time. Tests on 16 subjects (11 controls without medical expertise and 5 paediatric residents) demonstrated that the simulator is well tolerated in terms of discomfort. Moreover, the simulator is high rated for user experience and system usability, suggesting that RiNeo MR can be a promising tool to improve newborn life support training. RiNeo MR is a proof of concept of a mixed-reality newborn life support simulator that can be a promising tool to spread newborn resuscitation high-quality training among healthcare providers involved in perinatal medicine.

Precocious Puberty Diagnoses Spike, COVID-19 Pandemic, and Body Mass Index: Findings From a 4-year Study.

Context: Since the COVID-19 outbreak, the number of girls with suspected precocious puberty has increased. Objective: To compare the incidence of idiopathic central precocious puberty (ICPP) during COVID-19 with that of the previous 4 years. Methods: Anthropometric, biochemical, and radiological parameters were collected between January 2016 and June 2021 from 133 girls who met the Rapidly Progressive ICPP criteria (RP-ICPP). Results: We found a higher incidence of RP-ICPP between March 2020 and June 2021 (group 2) compared with January 2016 through March 2020 (group 1) (53.5% vs 41.1%); 2021 showed the highest annual incidence (P < .05). Group 1 and group 2 differed in age at diagnosis (7.96 ± 0.71 vs 7.61 ± 0.94; P < .05), mean Tanner stage (2.86 ± 0.51 vs 2.64 ± 0; P < .05), and in the time between the appearance of thelarche and diagnosis (0.93 ± 0.75 vs 0.71 ± 0.62 years, P < .05). There was an increase in the number of girls aged <8 years in group 2 and a significantly higher number of girls aged >8 years was found in group 1 (42 in group 1 vs 20 in group 2, P < 0.05). Overall body mass index SD score showed higher values ​​in group 2 (1.01 ± 1.23 vs 0.69 ± 1.15; P = .18), which spent an average of 1.94 ± 1.81 hours per day using electronic devices; 88.5% of this group stopped any physical activity. Conclusions: A spike in new diagnoses of idiopathic (1.79-fold higher) and RP-CPP coincided with the COVID-19 pandemic. The incidence of RP-ICPP was 1.3-fold higher during COVID-19 with a trend toward an increase in body mass index SD score. The expanding use of digital devices and the reduction of daily physical activity represent possible risk factors.

Clinical, Endocrine and Neuroimaging Findings in Girls With Central Precocious Puberty.

CONTEXT: The etiology of central precocious puberty (CPP) includes a spectrum of conditions. Girls younger than age 6 years with CPP should undergo cranial magnetic resonance imaging (MRI), but it remains controversial whether all girls who develop CPP between the ages of 6 and 8 years require neuroimaging examination. OBJECTIVE: To investigate the frequency of brain MRI abnormalities in girls diagnosed with CPP and the relationship between maternal factors, their age at presentation, clinical signs and symptoms, hormonal profiles, and neuroimaging findings. METHODS: Data were collected between January 2005 and September 2019 from 112 girls who showed clinical pubertal progression before 8 years of age who underwent brain MRI. RESULTS: MRI was normal in 47 (42%) idiopathic (I) scans, 54 (48%) patients had hypothalamic-pituitary anomalies (HPA) and/or extra-HP anomalies (EHPA), and 11 (10%) had brain tumors or tumor-like conditions (BT/TL), including 3 with neurological signs. Associated preexisting disorders were documented in 16. Girls with BT/TL had a higher LH peak after GnRH test (P = 0.01) than I, and those older than age 6 years had a higher craniocaudal diameter of the pituitary gland (P = 0.01); their baseline FSH and LH (P = 0.004) and peak FSH (P = 0.01) and LH (P = 0.05) values were higher than I. Logistic regression showed maternal age at menarche (P = 0.02) and peak FSH (P = 0.02) as BT/TL risk factors. CONCLUSIONS: MRI provides valuable information in girls with CPP by demonstrating that fewer than half have a normal brain MRI and that few can have significant intracranial lesions after the age of 6, despite the absence of suggestive neurological signs.

Viewpoint: Virtual and Augmented Reality in Basic and Advanced Life Support Training.

The use of augmented reality (AR) and virtual reality (VR) for life support training is increasing. These technologies provide an immersive experience that supports learning in a safe and controlled environment. This review focuses on the use of AR and VR for emergency care training for health care providers, medical students, and nonprofessionals. In particular, we analyzed (1) serious games, nonimmersive games, both single-player and multiplayer; (2) VR tools ranging from semi-immersive to immersive virtual and mixed reality; and (3) AR applications. All the toolkits have been investigated in terms of application goals (training, assessment, or both), simulated procedures, and skills. The main goal of this work is to summarize and organize the findings of studies coming from multiple research areas in order to make them accessible to all the professionals involved in medical simulation. The analysis of the state-of-the-art technologies reveals that tools and studies related to the multiplayer experience, haptic feedback, and evaluation of user's manual skills in the foregoing health care-related environments are still limited and require further investigation. Also, there is an additional need to conduct studies aimed at assessing whether AR/VR-based systems are superior or, at the minimum, comparable to traditional training methods.

RiNeo MR: A mixed-reality tool for newborn life support training.

The first minute of life, the Golden Minute, has been defined as a critical window in which fundamental physiological processes occur for establishing spontaneous ventilation in a newborn. Resuscitation is more likely to succeed if it is performed properly and at the right time. In this scenario, simulation is an appropriate tool for training and evaluating the abilities of all staff working in the delivery room, as well as students. As simulations require a high degree of immersivity in order to be effective, the use of technologies like Virtual (VR) and mixed reality (MR) have garnered more interest in training. Currently, some VR and MR applications have been developed for adult life support training, but neonatal tools are still missing. To overcome this limitation, we present RiNeo MR, a prototype of a MR simulator for neonatal resuscitation training. The simulator consists of (i) a sensorized physical model of the newborn that allows monitoring chest compressions; (ii) a VR head mounted display that allows visualizing a virtual 3D model of the manikin and scenarios of the delivery and operating rooms. This enables students, and healthcare providers to be immersed in realistic hospital settings while performing life support procedures on the newborn manikin. Clinical Relevance-The newborn life support training (NLS) in facilities reduces term intrapartum-related deaths by 30%.

Endocrine Outcomes In Central Diabetes Insipidus: the Predictive Value of Neuroimaging "Mismatch Pattern".

CONTEXT: The etiology of central diabetes insipidus (CDI) in children is often unknown. Clinical and radiological features at disease onset do not allow discrimination between idiopathic forms and other conditions or to predict anterior pituitary dysfunction. OBJECTIVE: To evaluate the evolution of pituitary stalk (PS) thickening and the pattern of contrast-enhancement in relation with etiological diagnosis and pituitary function. METHODS: We enrolled 39 children with CDI, 29 idiopathic and 10 with Langerhans cell histiocytosis (LCH). Brain magnetic resonance images taken at admission and during follow-up (332 studies) were examined, focusing on PS thickness, contrast-enhancement pattern, and pituitary gland size; T2-DRIVE and postcontrast T1-weighted images were analyzed. RESULTS: Seventeen of 29 patients (58.6%) with idiopathic CDI displayed "mismatch pattern," consisting in a discrepancy between PS thickness in T2-DRIVE and postcontrast T1-weighted images; neuroimaging findings became stable after its appearance, while "mismatch" appeared in LCH patients after chemotherapy. Patients with larger PS displayed mismatch more frequently (P = 0.003); in these patients, reduction of proximal and middle PS size was documented over time (P = 0.045 and P = 0.006). The pituitary gland was smaller in patients with mismatch (P < 0.0001). Patients with mismatch presented more frequently with at least one pituitary hormone defect, more often growth hormone deficiency (P = 0.033). CONCLUSIONS: The PS mismatch pattern characterizes patients with CDI, reduced pituitary gland size, and anterior pituitary dysfunction. The association of mismatch pattern with specific underlying conditions needs further investigation. As patients with mismatch show stabilization of PS size, we assume a prognostic role of this peculiar pattern, which could be used to lead follow-up.