Perioperative nutritional assessment and support in visceral surgery.

Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.

Application and potential of artificial intelligence in neonatal medicine.

Neonatal care is becoming increasingly complex with large amounts of rich, routinely recorded physiological, diagnostic and outcome data. Artificial intelligence (AI) has the potential to harness this vast quantity and range of information and become a powerful tool to support clinical decision making, personalised care, precise prognostics, and enhance patient safety. Current AI approaches in neonatal medicine include tools for disease prediction and risk stratification, neurological diagnostic support and novel image recognition technologies. Key to the integration of AI in neonatal medicine is the understanding of its limitations and a standardised critical appraisal of AI tools. Barriers and challenges to this include the quality of datasets used, performance assessment, and appropriate external validation and clinical impact studies. Improving digital literacy amongst healthcare professionals and cross-disciplinary collaborations are needed to harness the full potential of AI to help take the next significant steps in improving neonatal outcomes for high-risk infants.

The newborn delivery room of tomorrow: emerging and future technologies.

Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.

Feasibility of a Novel ECG Electrode Placement Method in Newborn Infants.

BACKGROUND: International newborn resuscitation guidelines recommend electrocardiogram (ECG) heart rate (HR) monitoring at birth. We evaluated the application time of pre-set ECG electrodes fixed to a polyethene patch allowing adhesive-free attachment to the wet skin of the newborn chest. OBJECTIVES: Using a three-electrode pre-set ECG patch configuration, application success was calculated using video analysis and measured at three time points, the time to (1) apply electrodes; (2) detect recognizable QRS complexes after application; and (3) display a HR after application. METHOD: A prospective observational study in two UK tertiary maternity units was undertaken with 71 newborns including 23 who required resuscitation. RESULTS: The median (IQR) time for ECG patch application was 8 (6-10) seconds, detection of recognizable QRS complexes 8 (2-12) seconds, and time to output HR was 23 (15-37) seconds. CONCLUSION: Pre-set ECG chest electrodes allow rapid HR information at birth without electrode detachment or compromising skin integrity.

Accurate neonatal heart rate monitoring using a new wireless, cap mounted device.

AIM: A device for newborn heart rate (HR) monitoring at birth that is compatible with delayed cord clamping and minimises hypothermia risk could have advantages over current approaches. We evaluated a wireless, cap mounted device (fhPPG) for monitoring neonatal HR. METHODS: A total of 52 infants on the neonatal intensive care unit (NICU) and immediately following birth by elective caesarean section (ECS) were recruited. HR was monitored by electrocardiogram (ECG), pulse oximetry (PO) and the fhPPG device. Success rate, accuracy and time to output HR were compared with ECG as the gold standard. Standardised simulated data assessed the fhPPG algorithm accuracy. RESULTS: Compared to ECG HR, the median bias (and 95% limits of agreement) for the NICU was fhPPG -0.6 (-5.6, 4.9) vs PO -0.3 (-6.3, 6.2) bpm, and ECS phase fhPPG -0.5 (-8.7, 7.7) vs PO -0.1 (-7.6, 7.1) bpm. In both settings, fhPPG and PO correlated with paired ECG HRs (both R2  = 0.89). The fhPPG HR algorithm during simulations demonstrated a near-linear correlation (n = 1266, R2  = 0.99). CONCLUSION: Monitoring infants in the NICU and following ECS using a wireless, cap mounted device provides accurate HR measurements. This alternative approach could confer advantages compared with current methods of HR assessment and warrants further evaluation at birth.

Improving newborn heart rate assessment using a simple visual timer.

OBJECTIVE: Newborn resuscitation relies on accurate heart rate (HR) assessment, which, during auscultation, is prone to error. We investigated if a 6 s visual timer (VT) could improve HR assessment accuracy during newborn simulation. DESIGN: Prospective observational study of newborn healthcare professionals. SETTING: Three-phase developmental approach: phase I: HR auscultation during newborn simulation using a standard clock timer (CT) or the VT; phase II: repeat phase I after using a bespoke training app (NeoRate); phase III: following the Newborn Life Support course, participants assessed random HRs using the CT or VT. MAIN OUTCOME MEASURES: HR accuracy (within ±10 beats/min, correct HR category, i.e. <60, 60-100 and >100 beats/min), assessment time and error-free rates were compared. RESULTS: Overall, 1974 HR assessments were performed with participants more accurate using the VT for ±10 beats/min (70% CT vs 86% VT, p<0.001) and correct HR category (78% CT vs 84% VT, p<0.01). The VT improved accuracy across all three phases. Additionally, following app training in phase II, the HR accuracy of both the CT and VT improved. The VT resulted in faster HR assessment times of 11 s (IQR 9-13) compared with the CT at 15 s (IQR 9-23, p<0.001). Error-free scenarios increased from 24% using the CT to 57% using the VT (p<0.001), with a shorter assessment time (CT 116 s (IQR 65-156) vs VT 53 s (IQR 50-64), p<0.001). CONCLUSION: Using a VT to assess simulated newborn HR combined with a training app significantly improves accuracy and reduces assessment time compared with standard methods. Evaluation in the clinical setting is required to determine potential benefits.

Postnatal gestational age estimation of newborns using Small Sample Deep Learning.

A baby's gestational age determines whether or not they are premature, which helps clinicians decide on suitable post-natal treatment. The most accurate dating methods use Ultrasound Scan (USS) machines, but these are expensive, require trained personnel and cannot always be deployed to remote areas. In the absence of USS, the Ballard Score, a postnatal clinical examination, can be used. However, this method is highly subjective and results vary widely depending on the experience of the examiner. Our main contribution is a novel system for automatic postnatal gestational age estimation using small sets of images of a newborn's face, foot and ear. Our two-stage architecture makes the most out of Convolutional Neural Networks trained on small sets of images to predict broad classes of gestational age, and then fuses the outputs of these discrete classes with a baby's weight to make fine-grained predictions of gestational age using Support Vector Regression. On a purpose-collected dataset of 130 babies, experiments show that our approach surpasses current automatic state-of-the-art postnatal methods and attains an expected error of 6 days. It is three times more accurate than the Ballard method. Making use of images improves predictions by 33% compared to using weight only. This indicates that even with a very small set of data, our method is a viable candidate for postnatal gestational age estimation in areas were USS is not available.

Development of a Clinical Interface for a Novel Newborn Resuscitation Device: Human Factors Approach to Understanding Cognitive User Requirements.

BACKGROUND: A novel medical device has been developed to address an unmet need of standardizing and facilitating heart rate recording during neonatal resuscitation. In a time-critical emergency resuscitation, where failure can mean death of an infant, it is vital that clinicians are provided with information in a timely, precise, and clear manner to capacitate appropriate decision making. This new technology provides a hands-free, wireless heart rate monitoring solution that easily fits the clinical pathway and procedure for neonatal resuscitation. OBJECTIVE: This study aimed to understand the requirements of the interface design for a new device by using a human factors approach. This approach combined a traditional user-centered design approach with an applied cognitive task analysis to understand the tasks involved, the cognitive requirements, and the potential for error during a neonatal resuscitation scenario. METHODS: Fourteen clinical staff were involved in producing the final design requirements. Two pediatric doctors supported the development of a visual representation of the activities associated with neonatal resuscitation. This design was used to develop a scenario-based workshop. Two workshops were carried out in parallel and involved three pediatric doctors, three neonatal nurses, two advance neonatal practitioners, and four midwives. Both groups came together at the end to reflect on the findings from the separate sessions. RESULTS: The outputs of this study have provided a comprehensive description of information requirements during neonatal resuscitation and enabled product developers to understand the preferred requirements of the user interface design for the device. The study raised three key areas for the designers to consider, which had not previously been highlighted: (1) interface layout and information priority, as heart rate should be central and occupy two-thirds of the screen; (2) size and portability, to enable positioning of the product local to the baby's head and allow visibility from all angles; and (3) auditory feedback, to support visual information on heart rate rhythm and reliability of the trace with an early alert for intervention while avoiding parental distress. CONCLUSIONS: This study demonstrates the application of human factors and the applied cognitive task analysis method, which identified previously unidentified user requirements. This methodology provides a useful approach to aid development of the clinical interface for medical devices.

Eukaryotic Life Inhabits Rhodolith-forming Coralline Algae (Hapalidiales, Rhodophyta), Remarkable Marine Benthic Microhabitats.

Rhodoliths are benthic calcium carbonate nodules accreted by crustose coralline red algae which recently have been identified as useful indicators of biomineral changes resulting from global climate change and ocean acidification. This study highlights the discovery that the interior of rhodoliths are marine biodiversity hotspots that function as seedbanks and temporary reservoirs of previously unknown stages in the life history of ecologically important dinoflagellate and haptophyte microalgae. Whereas the studied rhodoliths originated from offshore deep bank pinnacles in the northwestern Gulf of Mexico, the present study opens the door to assess the universality of endolithic stages among bloom-forming microalgae spanning different phyla, some of public health concerns (Prorocentrum) in marine ecosystems worldwide.

Neonatal head and torso vibration exposure during inter-hospital transfer.

Inter-hospital transport of premature infants is increasingly common, given the centralisation of neonatal intensive care. However, it is known to be associated with anomalously increased morbidity, most notably brain injury, and with increased mortality from multifactorial causes. Surprisingly, there have been relatively few previous studies investigating the levels of mechanical shock and vibration hazard present during this vehicular transport pathway. Using a custom inertial datalogger, and analysis software, we quantify vibration and linear head acceleration. Mounting multiple inertial sensing units on the forehead and torso of neonatal patients and a preterm manikin, and on the chassis of transport incubators over the duration of inter-site transfers, we find that the resonant frequency of the mattress and harness system currently used to secure neonates inside incubators is [Formula: see text]. This couples to vehicle chassis vibration, increasing vibration exposure to the neonate. The vibration exposure per journey (A(8) using the ISO 2631 standard) was at least 20% of the action point value of current European Union regulations over all 12 neonatal transports studied, reaching 70% in two cases. Direct injury risk from linear head acceleration (HIC15) was negligible. Although the overall hazard was similar, vibration isolation differed substantially between sponge and air mattresses, with a manikin. Using a Global Positioning System datalogger alongside inertial sensors, vibration increased with vehicle speed only above 60 km/h. These preliminary findings suggest there is scope to engineer better systems for transferring sick infants, thus potentially improving their outcomes.

[HIV infection and diabetes: experience and quality of life in patients with two chronic diseases]. / Infection par le virus de l'immunodéficience humaine et diabète: vécu et qualité de vie des patients confrontés à deux maladies chroniques.

OBJECTIVES: Diabetes mellitus is frequently associated with HIV infection but there's only limited evidence regarding the control and impact of this co-morbidity. This study aimed to estimate the prevalence of diabetes, compliance with treatment, perception and quality of life of HIV patients with diabetes. METHODS: We conducted a cross-sectional study among patients treated for diabetes and registered in the DMI2 databasis in a French university hospital in January 2010. Clinical assessment and follow-up data were collected using chart review and self-administered questionnaires. Quality of life (MOS SF-12) and compliance with treatment (simplified medication adherence questionnaire) were assessed using validated scales. RESULTS: The prevalence of treated diabetes mellitus was 3.9% (29/748, 95% confidence interval, 2.6% to 5.5%). Among these 29 HIV diabetic patients, 93% had a virologic control of HIV infection while only 22% had well-controlled diabetes. Ninety-six percent of patients were scared to die from HIV-which was rated as the main pathology-compared with 71% of patients for diabetes. The mean score for physical quality of life was 43.1 (13.2), which was lower than estimates for overall population. Non-compliance with treatment was reported for 35% of patients. DISCUSSION: Although anti-retroviral treatments turned HIV infection into a chronic disease, patient perception was not altered. This study shows a better control of HIV infection than diabetes. We have to find out ways (e.g. patient education programs, annual multidisciplinary consultation...) to give the patient a global feel for his health thereby improving prognosis and quality of life.

Genetic detection of sex-biased and age-biased dispersal in a population of wild carnivore, the red fox, Vulpes vulpes.

Field studies conducted on rural red fox (Vulpes vulpes) populations suggest that the majority of males tend to disperse while the majority of females tend to be philopatric, that males disperse farther than females, and that most of the foxes disperse during their first year of life. However, the quantification of dispersal parameters is poorly documented in the red fox, because this carnivore is notoriously difficult to follow from birth to maturity. The aim of this study was to test hypotheses from field data with the help of a molecular analysis using six random amplified polymorphic DNA (RAPD) markers. The study was conducted on samples collected from 85 foxes in a French rural population. Genetic and geographical distances between pairs of individuals were calculated for the 3570 potential pairs originating from this population to determine whether the foxes had dispersed. High genetic diversity and an absence of genetic clusters among studied individuals support the occurrence of intense and constant gene flow in the study population, probably induced by dispersion. At least 16.2% of the potential pairs we studied were subject to dispersal. Sex-biased dispersion was not observed, apart from a sex bias in favor of females towards long-distance dispersal. A predominance of males that ultimately dispersed a long distance could not thus be confirmed. Furthermore, it seems that dispersal did not occur primarily in the subadult age class in our rural study area, but that some pairs of juveniles may also have been involved in dispersal.

Cellular uptake and efflux of trans-piceid and its aglycone trans-resveratrol on the apical membrane of human intestinal Caco-2 cells.

Two stilbenes (trans-piceid and its aglycone trans-resveratrol) were investigated in the uptake across the apical membrane of the human intestinal cell line Caco-2 in order to determine their mechanisms of transport. The uptake was quantified using a reverse phase high-performance liquid chromatography method with fluorescence detection. The rate of cellular accumulation in the cells was found to be higher for trans-resveratrol than for trans-piceid. In addition, trans-resveratrol uses passive transport to cross the apical membrane of the cells, whereas the transport of trans-piceid is likely active. With regard to the mechanisms of transport, the involvement of the active transporter SGLT1 in the absorption of trans-piceid was deduced using various inhibitors directly or indirectly exploiting the activity of this transporter (glucose, phlorizin, and ouabain). Moreover, we investigated the involvement of the multidrug-related protein 2 (MRP2), an efflux pump present on the apical membrane, in stilbene efflux by Caco-2 cells. The effect of MK-571 (an MRP inhibitor) seems to implicate MRP2 as responsible for apical efflux of trans-piceid and trans-resveratrol.