Lung recruitment before surfactant administration in extremely preterm neonates with respiratory distress syndrome (IN-REC-SUR-E): a randomised, unblinded, controlled trial.

BACKGROUND: The importance of lung recruitment before surfactant administration has been shown in animal studies. Well designed trials in preterm infants are absent. We aimed to examine whether the application of a recruitment manoeuvre just before surfactant administration, followed by rapid extubation (intubate-recruit-surfactant-extubate [IN-REC-SUR-E]), decreased the need for mechanical ventilation during the first 72 h of life compared with no recruitment manoeuvre (ie, intubate-surfactant-extubate [IN-SUR-E]). METHODS: We did a randomised, unblinded, controlled trial in 35 tertiary neonatal intensive care units in Italy. Spontaneously breathing extremely preterm neonates (24 + 0 to 27 + 6 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 h of life were randomly assigned (1:1) with a minimisation algorithm to IN-REC-SUR-E or IN-SUR-E using an interactive web-based electronic system, stratified by clinical site and gestational age. The primary outcome was the need for mechanical ventilation in the first 72 h of life. Analyses were done in intention-to-treat and per-protocol populations, with a log-binomial regression model correcting for stratification factors to estimate adjusted relative risk (RR). This study is registered with ClinicalTrials.gov, NCT02482766. FINDINGS: Of 556 infants assessed for eligibility, 218 infants were recruited from Nov 12, 2015, to Sept 23, 2018, and included in the intention-to-treat analysis. The requirement for mechanical ventilation during the first 72 h of life was reduced in the IN-REC-SUR-E group (43 [40%] of 107) compared with the IN-SUR-E group (60 [54%] of 111; adjusted RR 0·75, 95% CI 0·57-0·98; p=0·037), with a number needed to treat of 7·2 (95% CI 3·7-135·0). The addition of the recruitment manoeuvre did not adversely affect the safety outcomes of in-hospital mortality (19 [19%] of 101 in the IN-REC-SUR-E group vs 37 [33%] of 111 in the IN-SUR-E group), pneumothorax (four [4%] of 101 vs seven [6%] of 111), or grade 3 or worse intraventricular haemorrhage (12 [12%] of 101 vs 17 [15%] of 111). INTERPRETATION: A lung recruitment manoeuvre just before surfactant administration improved the efficacy of surfactant treatment in extremely preterm neonates compared with the standard IN-SUR-E technique, without increasing the risk of adverse neonatal outcomes. The reduced need for mechanical ventilation during the first 72 h of life might facilitate implementation of a non-invasive respiratory support strategy. FUNDING: None.

Treatment of poikiloderma of Civatte using intense pulsed light source: 7 years of experience.

BACKGROUND AND OBJECTIVE: The treatment of choice of poikiloderma of Civatte should address both pigmented and vascular lesions at the same time. A broad-spectrum, noncoherent intense pulsed light (IPL) source can be used to obtain this effect. In this study, we investigated the clinical efficacy and side effects of treating this condition with IPL. MATERIALS AND METHODS: A total of 175 patients with poikiloderma of Civatte of the neck and chest were treated with IPL at various settings. The mean age of patients of various skin types (Fitzpatrick I to III) was 49 years. They were subjected to a treatment protocol including three sessions every 3 weeks. At follow-up visit, performed 3 months after the last treatment, clinical improvement was evaluated for all patients by comparing pre- and posttreatment photographs. The patients also scored their overall satisfaction. RESULTS: Clearance of more than 80% of vascular and pigmented components of poikiloderma of Civatte was observed. Minimal and transient side effects occurred in 5% of the patients. No scarring or pigment disturbances were noted after the treatments. CONCLUSIONS: The IPL source can be considered a safe and effective therapeutic option for poikiloderma of Civatte, allowing a marked improvement of vascular and pigmented lesions with minimal side effects.

Q-switched alexandrite laser-assisted treatment of melasma: 2-year follow-up monitoring.

Melasma is a common disorder of hyperpigmentation involving sun exposed face and neck areas. Three clinical patterns of melasma are recognized: the centrofacial, the malar, and the mandibular ones. Several factors have been implicated in the pathogenesis of this disorder including pregnancy, oral contraceptive therapy, sun exposure, genetic factors, cosmetics, and race. This condition is most frequently observed in women and affects all racial groups; however, it is commonly found in darker-complexioned individuals (skin types IV through VI) and in Asian women who live and work under strong sunlight exposure for long periods. Melasma is very difficult to treat and often resistant to therapy. Treatment of melasma includes various hypopigmenting agents, chemical peeling, and laser surgery with unsatisfactory results. We report 3 cases of facial melasma successfully treated with a Q-switched Alexandrite laser.

Skin toxicity from glyphosate-surfactant formulation.

Glyphosate (N-[phosphonomethyl]glycine) is a nonselective herbicide used in agriculture as a foliage spray for the control and the destruction of herbaceous plants. Adverse skin reactions due to contact with this compound have been rarely described. We report a case of a 78-year-old woman presenting with extensive chemical burns on her trunk and legs caused by accidental contact with a glyphosate-surfactant formulation. The lesions healed in four weeks without scarring.