Severe Episodes Research Articles

Changes of water-soluble inorganic sulfate and nitrate during severe dust storm episodes in a coastal city of North China

Dust storms are one of the largest sources of non-exhaust emissions in China, which can adversely affect air quality and human health during long-distance transportation. To study the influence of dust storms on aerosol particle composition, samples of fine aerosol (PM2.5) were collected before, during, and after the severe dust storm episodes in a coastal city of North China. Then the water-soluble inorganic ions in the filters were analyzed. The results showed that the chemical composition varied significantly in different sampling periods. Before the dust storm periods (Phase 1), the weather was characterized by high relative humidity. NO3− was the main water-soluble inorganic ion, accounting for about 1/3 of the total mass of PM2.5, which is very different from the situation a few years ago when sulfate was the dominant. The results indicated that the chemical composition of the atmosphere in China has changed significantly after the implementation of strict air pollution control measures. During the severe dust storm periods (within a few hours after the dust invasion, Phase 2), the proportion of Ca2+ in PM2.5 was high; the sulfate formation was limited due to adiabatic air mass affected by the cold front, and the sulfate content might be mainly from desert soil. However, a small amount of nitrate can be formed during their long-distance transportation. After the dust storm periods (Phase 3), dust plums and local polluted air mass mixed well. The proportion of secondary inorganic ions increased, and nitrate formation was still the main. The changes in the chemical composition from a few years ago during Phase 1 and the sharp changes in different water-soluble inorganic ions during different Phases should be carefully considered to evaluate their implications for air quality and human health.

Electroconvulsive Therapy in Heart Transplant Patients: To Avoid or Embrace?

Patients with heart disease are at an increased risk of depression. Electroconvulsive therapy (ECT) is a highly effective treatment for severe depressive episodes. However, ECT may increase the risk for adverse outcomes in certain patients because of changes in blood pressure and heart rate secondary to an initial parasympathetic surge followed by a sympathetic surge and peripheral catecholamine release. In post-cardiac transplant patients, these acute hemodynamic changes on a denervated heart may bring clinical challenges. The available data on ECT in heart transplant patients are limited. The authors of this article present a summary of the available literature relating to ECT in heart transplant patients.The authors performed a literature search of 6 online databases yielding 6 English-language case reports of ECT in cardiac transplant patients. All patients experienced changes in hemodynamic variables during and immediately after ECT, ranging from moderate decrease in blood pressure to extreme hypertension. The cases did not report any serious cardiac complications during the course of ECT. In the 5 patients whose psychiatric responses to treatment were detailed, all had improvement in their depressive symptoms. Electroconvulsive therapy may be considered for severe cases of depression in patients with a history of cardiac transplant, but the potential benefit of ECT needs to be weighed against risks. In the limited number of cases reported in the literature, ECT seems to have been relatively safe and effective.

Comparison of recent anaphylaxis diagnostic criteria in real life: Can more patients be diagnosed as having anaphylaxis?

IntroductionIn 2020, World Allergy Organization (WAO) updated their diagnostic criteria for anaphylaxis, which differed as a result from the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria which were still used in the 2021 update of the European Academy of Allergy and Clinical Immunology (EAACI) anaphylaxis guideline. Our aim was to evaluate and to compare both diagnostic criteria and attempt to identify factors affecting severity of anaphylaxis. MethodsThe medical records of the patients who were evaluated with suspected anaphylaxis at 3 medical centers in Türkiye between 2014 and 2021, and underwent a detailed diagnostic work-up, were analyzed retrospectively. Diagnosis of anaphylaxis was evaluated based on the WAO 2020 and EAACI 2021 and NIAID/FAAN diagnostic criteria. The severity of anaphylaxis was determined according to the WAO systemic allergic reaction grading system. Grade 5 anaphylaxis was defined as having respiratory failure, collapse/hypotension, loss of consciousness. Patients’ demographic and clinical characteristics were further analyzed depending on the severity of the reaction. ResultsOne thousand and six patients were evaluated and 232 patients without a convincing diagnosis of anaphylaxis were excluded from the study. The remaining 774 patients (70.6% female, median [Inter quartile range (IQR) 25–75] age: 42 [33–52]) were included for further examination. Anaphylaxis was diagnosed in 729 (94.2%) patients meeting both criteria whereas 35 patients (4.5%) with isolated laryngeal involvement and 10 (1.3%) patients with isolated respiratory involvement were only diagnosed according to the WAO 2020 criteria. Twenty-three patients (3.0%) had a diagnosis of indolent systemic mastocytosis. Mastocytosis was related to grade 5 anaphylaxis [p = 0.022, OR (CI) = 2.9 (1.1–7.6)]. Venom allergy was a risk factor for grade 5 anaphylaxis among those for whom an eliciting allergen could be determined [p = 0.03, OR (CI) = 2.7 (1.1–6.8)]. For drug induced anaphylaxis, parenteral route of drug administration and proton pump inhibitor (PPI) allergy were considered as risk factors for grade 5 anaphylaxis [p < 0.001, OR (CI) = 6.5 (2.5–17.0); p = 0.011, OR (CI) = 10.3 (1.6–63.3)]. ConclusionThis multicenter study demonstrated that both criteria identified the majority of patients with anaphylaxis, but the WAO 2020 diagnostic criteria identified an additional 6%. Hymenoptera stings, PPI allergy, parenteral drug administration, and underlying mastocytosis were associated with more severe episodes.

A comparative study using insulin pump therapy and continuous glucose monitoring in newly diagnosed very young children with type 1 diabetes: it is possible to bend the curve of HbA1c.

The target of metabolic control (HbA1c < 7% or 53mmol/mol) recommended by the ADA and ISPAD is attained by 30% of children with Type 1 Diabetes (T1D). Advances in technologies for T1D aim to improve metabolic outcomes and reduce complications. This observational study assesses the long-term outcomes of advanced technologies for treatment of T1D compared to conventional approach started at onset in a group of very young children with T1D. 54 patients with less 4years old at onset of T1D were enrolled and followed for up to 9years after diagnosis. 24 subjects started continuous subcutaneous insulin (CSII) treatment and 30 subjects received MDI therapy from onset. Auxological data, HbA1c and total daily insulin dose (TDD/kg) have been collected at admission and every 4months. HbA1cAUC>6%, rates of acute complications, glycemic variability indices and glucometrics were also recorded. Patients with CSII therapy had significantly lower mean HbA1c values compared to subjects receiving MDI treatment. CSII approach also recorded lower mean HbA1cAUC>6% and TDD/kg than MDI therapy. At the last download data, the time in range (TIR) was higher in patients with CSII and hyperglycemia events were lower. Better glycemic variability indices have been described during CSII therapy, including mean glycemia, standard deviation, coefficient of variation (CV), glycemia risk index (GRI) and high blood glucose index (HBGI). There was no statistically significant difference between frequency of severe hypoglycemia and ketoacidosis episodes between groups. Early initiation of diabetes technologies is safe and able to determine a better long term glycemic control in young children with T1D. It also allows to flatten the trajectory of HbA1c, probably reducing microvascular, macrovascular and neurological complications of diabetes in this very peculiar age group.

Evaluating Ease of Use and Patient Safety of Dasiglucagon Hypo Pal Autoinjector for the Management of Hypoglycemia.

Severe hypoglycemia is a medical emergency that must be treated promptly in order to prevent complications or death in a patient. Patients who have been diagnosed with Type 1 diabetes and treated with insulin have the potential to experience a severe hypoglycemia episode, or low blood sugar. When a patient is experiencing severe hypoglycemia, it is imperative for this patient to receive glucose quickly. However, patients who are experiencing low blood sugar may not be able to manage for themselves, take food or liquid orally or may be unconscious. Glucagon is a medication that reverses low blood sugar. Up until 2018, glucagon had to be reconstituted immediately before injection because of the medication's lack of stability after reconstitution. A medication recently approved for patients 6 years through adult is Dasiglucagon. This form of glucagon comes in a ready-to-administer, pre-filled syringe, making it easier for caretakers and bystanders to administer in an emergency situation due to the readiness of the medication. The purpose of the paper is to evaluate literature that pertains to the ease of use and patient safety of dasiglucagon HypoPal autoinjector for the management of severe hypoglycemia.

Duration of prodromal phase and severity of hemolytic uremic syndrome.

Some data have recognized an association between shorter prodromal phase and severe episode of Shiga toxin-producing Escherichia coli-related hemolytic uremic syndrome (STEC-HUS). Our aims were to confirm such association and analyze characteristics of STEC-HUS patients according to duration of the prodromal phase. Patients treated from 2000 to 2022 were compared according to the presence of severe (> 10days of dialysis and/or extra-renal complications) or non-severe disease. Association between prodromal phase duration and disease severity was assessed by ROC curve and by classifying the cohort in 3 groups according to time to diagnosis. Non-severe (n = 145) and severe (n = 71) cases were compared. The latter had shorter prodromal phase, higher leukocyte count, hemoglobin, lactic dehydrogenase, liver enzymes, C-reactive protein, urea and creatinine, and lower albumin and sodium; only prodromal phase duration (p = 0.02) and leukocyte count (p = 0.02) remained significant in multivariate analysis. By ROC curve analysis, time to diagnosis resulted in a poor predictor of outcomes (AUC = 0.27). Since prodromal phase duration was 5days (IQR 3-7), we divided the cohort into Groups A (1-2days), B (3-7days), and C (≥ 8days). Rates of severe disease were 75.8%, 29.6%, and 11.4%, respectively. Taking Group B as reference, Group A patients had higher risk of complications (p = 0.00001; OR 7.4, 95% CI: 2.98-18.7) while Group C ones had significantly less risk (p = 0.02; OR 0.3, 95% CI: 0.1-0.91). This study found that duration of prodromal phase is an independent predictor of complicated STEC-HUS and confirms that shorter prodromal phase is associated with worse prognosis. A higher resolution version of the Graphical abstract is available as Supplementary information.

The small molecule fibroblast growth factor receptor inhibitor infigratinib exerts anti-inflammatory effects and remyelination in a model of multiple sclerosis.

Fibroblast growth factors and receptors (FGFR) have been shown to modulate inflammation and neurodegeneration in multiple sclerosis (MS). The selective FGFR inhibitor infigratinib has been shown to be effective in cancer models. Here, we investigate the effects of infigratinib on prevention and suppression of first clinical episodes of myelin oligodendrocyte glycoprotein (MOG)35-55 -induced experimental autoimmune encephalomyelitis (EAE) in mice. The FGFR inhibitor infigratinib was given over 10days from the time of experimental autoimmune encephalomyelitis induction or the onset of symptoms. The effects of infigratinib on proliferation, cytotoxicity and FGFR signalling proteins were studied in lymphocyte cell lines and microglial cells. Administration of infigratinib prevented by 40% and inhibited by 65% first clinical episodes of the induced experimental autoimmune encephalomyelitis. In the spinal cord, infiltration of lymphocytes and macrophages/microglia, destruction of myelin and axons were reduced by infigratinib. Infigratinib enhanced the maturation of oligodendrocytes and increased remyelination. In addition, infigratinib resulted in an increase of myelin proteins and a decrease in remyelination inhibitors. Further, lipids associated with neurodegeneration such as lysophosphatidylcholine and ceramide were decreased as were proliferation of T cells and microglial cells. This proof of concept study demonstrates the therapeutic potential of targeting FGFRs in a disease model of multiple sclerosis. Application of oral infigratinib resulted in anti-inflammatory and remyelinating effects. Thus, infigratinib may have the potential to slow disease progression or even to improve the disabling symptoms of multiple sclerosis.

Meteorological Drought Characterization in the Calabria Region (Southern Italy)

Due to the important role of water resources in the growth of the world’s economy, drought causes global concern for its severe worldwide implications on different sectors, such as biodiversity, farming, public water supply, energy, tourism, human health, and ecosystem services. In particular, drought events can have strong environmental and socioeconomic impacts in countries depending on rain-fed agriculture such as the ones in the Mediterranean region, which, due to a detected increase in warming and precipitation decrease, is considered a climate change hotspot. In this context, in this paper, meteorological drought in the Calabria region (southern Italy) has been characterized considering the Standardized Precipitation Index (SPI) evaluated at different timescales. First, the temporal distribution of the most severe dry episodes has been evaluated. Then, a trend analysis has been conducted considering the different seasons, the wet (autumn and winter) and dry (spring and summer) periods, and the annual scale. Finally, the relationship between drought and some teleconnection patterns (the North Atlantic Oscillation—NAO, the El Niño–Southern Oscillation—ENSO, and the Mediterranean Oscillation—MO) has been investigated. Results show that the majority of the severe/extreme drought events have been observed between 1985 and 2008. Moreover, a decrease in SPI values has been observed in winter and spring, in both the wet and dry periods, and upon the annual scale considering the 12-month SPI and the 24-month SPI. Finally, a link between the drought episodes in the Calabria region and the NAO phases and the MO has been identified. Since drought episodes can severely impact water resources and their uses, the findings presented in this work can be useful to plan and manage the water supply for household, farming, and industrial uses.

Prediction of the occurrence of leprosy reactions based on Bayesian networks.

Leprosy reactions (LR) are severe episodes of intense activation of the host inflammatory response of uncertain etiology, today the leading cause of permanent nerve damage in leprosy patients. Several genetic and non-genetic risk factors for LR have been described; however, there are limited attempts to combine this information to estimate the risk of a leprosy patient developing LR. Here we present an artificial intelligence (AI)-based system that can assess LR risk using clinical, demographic, and genetic data. The study includes four datasets from different regions of Brazil, totalizing 1,450 leprosy patients followed prospectively for at least 2 years to assess the occurrence of LR. Data mining using WEKA software was performed following a two-step protocol to select the variables included in the AI system, based on Bayesian Networks, and developed using the NETICA software. Analysis of the complete database resulted in a system able to estimate LR risk with 82.7% accuracy, 79.3% sensitivity, and 86.2% specificity. When using only databases for which host genetic information associated with LR was included, the performance increased to 87.7% accuracy, 85.7% sensitivity, and 89.4% specificity. We produced an easy-to-use, online, free-access system that identifies leprosy patients at risk of developing LR. Risk assessment of LR for individual patients may detect candidates for close monitoring, with a potentially positive impact on the prevention of permanent disabilities, the quality of life of the patients, and upon leprosy control programs.

Exome sequencing reveals IFT172 variants in patients with non-syndromic cholestatic liver disease.

Gene defects contribute to the aetiology of intrahepatic cholestasis. We aimed to explore the outcome of whole-exome sequencing (WES) in a cohort of 51 patients with this diagnosis. Both paediatric (n = 33) and adult (n = 18) patients with cholestatic liver disease of unknown aetiology were eligible. WES was used for reassessment of 34 patients (23 children) without diagnostic genotypes in ABCB11, ATP8B1, ABCB4 or JAG1 demonstrable by previous Sanger sequencing, and for primary assessment of additional 17 patients (10 children). Nasopharyngeal swab mRNA was analysed to address variant pathogenicity in two families. WES revealed biallelic variation in 3 ciliopathy genes (PKHD1, TMEM67 and IFT172) in 4 clinically unrelated index subjects (3 children and 1 adult), heterozygosity for a known variant in PPOX in one adult index subject, and homozygosity for an unreported splice-site variation in F11R in one child. Whereas phenotypes of the index patients with mutated PKHD1, TMEM67, and PPOX corresponded with those elsewhere reported, how F11R variation underlies liver disease remains unclear. Two unrelated patients harboured different novel biallelic variants in IFT172, a gene implicated in short-rib thoracic dysplasia 10 and Bardet-Biedl syndrome 20. One patient, a homozygote for IFT172 rs780205001 c.167A>C p.(Lys56Thr) born to first cousins, had liver disease, interpreted on biopsy aged 4y as glycogen storage disease, followed by adult-onset nephronophthisis at 25y. The other, a compound heterozygote for novel frameshift variant IFT172 NM_015662.3 c.2070del p.(Met690Ilefs*11) and 2 syntenic missense variants IFT172 rs776310391 c.157T>A p.(Phe53Ile) and rs746462745 c.164C>G p.(Thr55Ser), had a severe 8mo cholestatic episode in early infancy, with persisting hyperbilirubinemia and fibrosis on imaging studies at 17y. No patient had skeletal malformations. Our findings suggest association of IFT172 variants with non-syndromic cholestatic liver disease.

Etiology and Mechanism of Intermittent Hypoxemia Episodes in Spontaneously Breathing Extremely Premature Infants

To evaluate the mechanisms leading to intermittent hypoxemia (IH) episodes in spontaneously breathing extremely premature infants at 32 weeks and 36weeks postmenstrual age (PMA). We studied spontaneously breathing premature infants born at 23-28weeks of gestational age who presented with IH episodes while on noninvasive respiratory support at 32 or 36weeks PMA. Daytime recordings of arterial oxygen saturation (SpO2), esophageal pressure, respiratory inductive plethysmography of the abdomen, chest wall, and their sum were obtained during 4hours at 32 weeks and 36 weeks PMA. IH episodes (SpO2<90% for ≥5seconds) and severe IH episodes (SpO2<80% for ≥5seconds) were classified as resulting from apnea, active exhalation and breath holding, reduced tidal volume (VT), or reduced respiratory rate (RR) during the preceding 60seconds. Fifty-one infants with a mean gestational age of 25.9 ±1.5weeks and a mean birth weight of 846± 185g were included. Of these, 31 and 41 were included in the analysis at 32 weeks and 36weeks PMA, respectively. At both 32 weeks and 36weeks PMA, greater proportions of all IH episodes and severe IH episodes were associated with active exhalation and breath holding than with apnea, reduced RR, or reduced VT. The severity and duration of the IH episodes did not differ between mechanisms. In this group of premature infants, the predominant mechanism associated with daytime IH was active exhalation and breath holding. This etiology is more closely associated with behavioral factors than abnormal respiratory control and can have implications for prevention.

Factors associated with salbutamol overuse in bronchiolitis.

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs. Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Role of glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 in hypertriglyceridemia and diabetes.

In diabetes, the impairment of insulin secretion and insulin resistance contribute to hypertriglyceridemia, as the enzymatic activity of lipoprotein lipase (LPL) depends on insulin action. The transport of LPL to endothelial cells and its enzymatic activity are maintained by the formation of lipolytic complex depending on the multiple positive (glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 [GPIHBP1], apolipoprotein C-II [APOC2], APOA5, heparan sulfate proteoglycan [HSPG], lipase maturation factor 1 [LFM1] and sel-1 suppressor of lin-12-like [SEL1L]) and negative regulators (APOC1, APOC3, angiopoietin-like proteins [ANGPTL]3, ANGPTL4 and ANGPTL8). Among the regulators, GPIHBP1 is a crucial molecule for the translocation of LPL from parenchymal cells to the luminal surface of capillary endothelial cells, and maintenance of lipolytic activity; that is, hydrolyzation of triglyceride into free fatty acids and monoglyceride, and conversion from chylomicron to chylomicron remnant in the exogenous pathway and from very low-density lipoprotein to low-density lipoprotein in the endogenous pathway. The null mutation of GPIHBP1 causes severe hypertriglyceridemia and pancreatitis, and GPIGBP1 autoantibody syndrome also causes severe hypertriglyceridemia and recurrent episodes of acute pancreatitis. In patients with type 2 diabetes, the elevated serum triglyceride levels negatively correlate with circulating LPL levels, and positively with circulating APOC1, APOC3, ANGPTL3, ANGPTL4 and ANGPTL8 levels. In contrast, circulating GPIHBP1 levels are not altered in type 2 diabetes patients with higher serum triglyceride levels, whereas they are elevated in type 2 diabetes patients with diabetic retinopathy and nephropathy. The circulating regulators of lipolytic complex might be new biomarkers for lipid and glucose metabolism, and diabetic vascular complications.

Video polysomnographic analysis of elevated EMG activity and rapid eye movements before abnormal behaviors in REM sleep behavior disorder.

The pathogenesis of rapid eye movement (REM) sleep behavior disorder (RBD) is unclear. According to the cortical hypothesis, severe RBD episode (RBDE) occurs when spinal motoneurons are less inhibited and cortical and limbic systems are more active. We made this study to prove the hypothesis for the development of RBDE using video-polysomnography (VPSG). VPSG records of 35 patients with RBD were analyzed. According to severity, RBDEs were classified into three motor events (MEs): ME 1; small movements or jerks, ME 2; proximal movements including violent behavior, and ME 3; axial movements including bed falls. For each ME, we measured the number of MEs preceded or not preceded by both REM sleep without atonia (RWA) and REMs during the 10-s-period immediately before ME onset. In severe RBDE (ME 3), the number of MEs preceded by both RWA and REMs was significantly higher than that of MEs not preceded by both (0.8 vs. 0.2, P = 0.033). This was not the case for mild RBDE (ME 1) and moderate RBDE (ME 2). Our results suggest that both RWA and REMs are associated with the development of severe RBDE.

Beneficial effect of digoxin-specific Fab fragments in bipolar disorder- a preliminary study

A vast amount of experimental data supports the notion that Na+, K+-ATPase and endogenous cardiac steroids (ECS) such as digoxin and ouabain are involved in bipolar disorders. The aim of the study was to examine the possible beneficial effect of Digoxin-specific antibody Fab fragments Digibind, in bipolar disorder (BD) patients. In a pilot, open-label study without a control group, BD inpatient subjects received a single dose of Digibind, injected intravenously. During the 72 hrs following the intervention. the response to Digibind was measured using the Montgomery-Asberg Depression Rating Scale (MADRS). A total 6 patients with a moderate to severe bipolar depressive episode (MADRS 30.3, 24–38) participated in the study. We found a significant clinical improvement at all time points after Digibind administration, manifested by a maximal decrease in the MADRS score of 8.3 points at 24 hrs, followed by a gradual rebound to baseline scores. No control group was included, treatment was open-label, and only 6 patients were studied. This preliminary study showed that a one-time injection of Digibind resulted in a transient significant beneficial effect on depression symptoms in BD patients.

Psilocybin therapy: A novel approach to treating depression

Psilocybin therapy: A novel approach to treating depression

Fluctuations in Oxygen Saturation during Synchronized Nasal Intermittent Positive Pressure Ventilation and Nasal High-Frequency Oscillatory Ventilation in Very Low Birth Weight Infants: A Randomized Crossover Trial

Background: Very low birth weight (VLBW) infants on noninvasive ventilation (NIV) experience frequent fluctuations in oxygen saturation (SpO₂) that are associated with an increased risk for mortality and severe morbidities. Methods: In this randomized crossover trial, VLBW infants (n = 22) born 22+3 to 28+0 weeks on NIV with supplemental oxygen were allocated on two consecutive days in random order to synchronized nasal intermittent positive pressure ventilation (sNIPPV) and nasal high-frequency oscillatory ventilation (nHFOV) for 8 h. nHFOV and sNIPPV were set to equivalent mean airway pressure and transcutaneous pCO₂. Primary outcome was the time spent within the SpO₂ target (88–95%). Results: During sNIPPV, VLBW infants spent significantly more time within the SpO₂ target (59.9%) than during nHFOV (54.6%). The proportion of time spent in hypoxemia (22.3% vs. 27.1%) and the mean fraction of supplemental oxygen (FiO₂) (29.4% vs. 32.8%) were significantly reduced during sNIPPV, while the respiratory rate (50.1 vs. 42.6) was significantly higher. Mean SpO₂, SpO₂ above the target, number of prolonged (>1 min) and severe (SpO₂ <80%) hypoxemic episodes, parameters of cerebral tissue oxygenation using NIRS, number of FiO₂ adjustments, heart rate, number of bradycardias, abdominal distension and transcutaneous pCO₂ did not differ between both interventions. Conclusions: In VLBW infants with frequent fluctuations in SpO₂, sNIPPV is more efficient than nHFOV to retain the SpO₂ target and to reduce FiO₂ exposure. These results demand more detailed investigations into cumulative oxygen toxicities during different modes of NIV over the weaning period, particularly with regard to consequences for long-term outcomes.

Unsuspected paraganglioma of the urinary bladder with intraoperative hypertensive peak: A case report

Background. Bladder paraganglioma (BPG) is a very rare tumor. Case report: We report the case of a 48-year-old woman with a history of isolated hematuria. Cystoscopy showed a solid mass on the bottom of the bladder. During the intervention the patient experienced a severe hypertensive episode. BPG was then suspected. Pathology findings confirmed the diagnosis.123I-metaiodobenzylguanidine scan showed a pathological tracer accumulation in the left bladder wall consistent with BPG. The patient underwent a transurethral resection of the bladder after drug preparation. The postoperative course was uneventful and our patient was normotensive. Conclusion. Diagnosis of BPG is often made on histological examination of the tumor.

Modeling PM2.5 During Severe Atmospheric Pollution Episode in Lagos, Nigeria: Spatiotemporal Variations, Source Apportionment, and Meteorological Influences

AbstractIn 2021, the World Health Organization ranked Nigeria among the most polluted nations in the world, an indication of a deteriorating air quality, especially in the major urban areas of the country, which might pose adverse human health impacts. In this study, the Integrated Source Apportionment Method (ISAM) tool in the Community Multiscale Air Quality (CMAQ) model (CMAQ‐ISAM) was employed to quantify the contributions of eight emissions sectors to fine particulate matter (PM2.5) and its major components in Lagos during a prolonged severe atmospheric pollution episode (APE) in January 2021. The influence of meteorological conditions on the formation and dispersion of PM2.5 during the APE was also elucidated. Spatially, elevated PM2.5 concentrations were found in the northwestern region of Lagos, an urban area with larger anthropogenic emissions. Residential and industry were the two major sources of PM2.5. Residential contributed the most to total PM2.5 (∼40 μg/m3), followed by industry (∼20 μg/m3). High concentrations of secondary inorganic aerosols (SIA) at the northwest and upper northern areas of Lagos were majorly attributed to residential and industry sectors. In addition, sulfate accounted for the largest fraction of PM2.5, with residential, industry, and energy being its major sources. Residential, industry, and on‐road sectors dominated the contributions to nitrate, while residential and industry were the major contributors to ammonium. Furthermore, the elevated PM2.5 concentrations during the APE were greatly enhanced by unfavorable meteorological conditions. This study provides insights for designing effective emissions control strategies to mitigate future severe PM2.5 pollution episode in Lagos.

Identifying sensitive windows of prenatal household air pollution on birth weight and infant pneumonia risk to inform future interventions

BackgroundPrenatal household air pollution impairs birth weight and increases pneumonia risk however time-varying associations have not been elucidated and may have implications for the timing of public health interventions. MethodsThe Ghana Randomized Air Pollution and Health Study (GRAPHS) enrolled 1,414 pregnant women from Kintampo, Ghana and measured personal carbon monoxide (CO) exposure four times over pregnancy. Birth weight was measured within 72-hours of birth. Fieldworkers performed weekly pneumonia surveillance and referred sick children to study physicians. The primary pneumonia outcome was one or more physician-diagnosed severe pneumonia episode in the first year of life. We employed reverse distributed lag models to examine time-varying associations between prenatal CO exposure and birth weight and infant pneumonia risk. ResultsAnalyses included n = 1,196 mother-infant pairs. In models adjusting for child sex; maternal age, body mass index (BMI), ethnicity and parity at enrollment; household wealth index; number of antenatal visits; and evidence of placental malaria, prenatal CO exposures from 15 to 20 weeks gestation were inversely associated with birth weight. Sex-stratified models identified a similar sensitive window in males and a window at 10-weeks gestation in females. In models adjusting for child sex, maternal age, BMI and ethnicity, household wealth index, gestational age at delivery and average postnatal child CO exposure, CO exposure during 34–39 weeks gestation were positively associated with severe pneumonia risk, especially in females. ConclusionsHousehold air pollution exposures in mid- and late- gestation are associated with lower birth weight and higher pneumonia risk, respectively. These findings support the urgent need for deployment of clean fuel stove interventions beginning in early pregnancy.