Invasive explorations in children younger than 3years

PurposeIn children with drug-resistant focal epilepsy who are candidates for surgery, invasive exploration is sometimes required. However, this is being controversially discussed for children younger than 3 years. The question of its necessity, feasibility and its risks is often raised, since it concerns primarily lesional epilepsy and a lesionectomy might be proposed right away. However, this attitude does not take into account the specificities of epilepsy at this age, including poor specificity of electroclinical semiology and the ongoing myelination challenging the interpretation of magnetic resonance imaging (MRI).MethodsWe retrospectively studied the records of children with drug-resistant epilepsy who were younger than 3 years of age at the time of their invasive exploration at our institution from 2000 to 2009. We reviewed the clinical, imaging and electrophysiological data, and included post-operative outcome for those who underwent surgery.Key findings26 Children met the inclusion criteria. All had drug-resistant epilepsy that started at an average of 5.2 months (range 0–20 months) with multiple daily seizures in all and developmental delay in 16. The average age at the time of exploration was 21.8 months (range 5–35). In 20 children, subdural electrodes in combination with two or three depth electrodes were implanted, and in six children aged over 2 years a stereo-electro-encephalography (SEEG) was performed. SEEG was considered technically difficult to achieve before the age of 2 years. The tolerance of invasive exploration was good with a 3% morbidity consisting of one subdural hematoma during exploration by subdural electrodes, evacuated without any particular sequelae. In 25 patients, the exploration permitted to propose a focal resection. The surgical intervention was in the frontal lobe in 12 cases, the parietal lobe in six, the occipital lobe in two patients, and the temporal lobe in one child who underwent an additional resection. Four children had a resection of two or three lobes. Five underwent a second surgery, following a second invasive exploration. Histologically, the resected tissue revealed focal cortical dysplasia in 21 cases (including three patients with tuberous sclerosis), two post-ischemic lesions, one dysembryoplastic neuroepithelial tumor, and one gangliglioma associated with dysplasia. The mean postoperative follow-up period was 51 months (range 4–110). For the children operated on twice, follow-up was counted from the second surgery on. Seventeen children (68%) had an outcome of Engel class 1. In five (20%), seizure frequency was significantly improved (Engel class 3). In two of three patients without improvement in seizure frequency (Engel class 4), a new SEEG is planned and the third is presently a candidate for hemispherotomy.SignificanceInvasive exploration is feasible, well tolerated and carries a low morbidity in children under 3 years of age. At this age, it is indicated for drug-resistant lesional epilepsy associated with developmental delay. It permits delineating the lesion, which is not possible with MRI. The choice of the technique is in part age-dependent. The discussion of its indication arises in the same way as in the older child.     

Intraoperative blood loss during decompressive craniectomy for intractable intracranial hypertension after severe traumatic brain injury in children

Purpose

There are no data available on the risk of intraoperative bleeding during decompressive craniectomy (DC) after traumatic brain injury (TBI) in children. The objectives of this study were to assess the risk of intraoperative bleeding during DC for intractable intracranial hypertension after TBI, to identify potential factors associated with the risk of bleeding during DC, and to assess the impact of DC on systemic and cerebral hemodynamics and on coagulation.

Methods

Twelve children were identified as having undergone DC after TBI from April 2009 to June 2013 in our center. Subjects were allocated into two groups according to the percentage of blood loss (IBL) during the intraoperative period (<or ≥50 % of the estimated blood volume (EBV)).

Results

The median IBL during DC was 49 [17–349] % of the EBV. Children with an IBL?≥?50 % of EBV had higher preoperative intracranial pressure (ICP) (p?=?0.03) and international normalized ratio (INR) (p?=?0.02) than those with an IBL?<?50 % of EBV. DC induced significant decreases in ICP (p?=?0.0005), mean arterial pressure (p?=?0.01), and a significant increase in norepinephrine flow rate (p?=?0.04) between the immediate pre- and postoperative periods.

Conclusions

DC allows a significant decrease in ICP after severe pediatric TBI but is a surgical procedure at a high risk of bleeding. High ICP and INR during the immediate preoperative period are the main factors associated with increased IBL during DC. Further studies are needed to confirm our results and to assess the impact of the amount of IBL on the postoperative survival and functional outcome.     

Resolution of thromboemboli in patients with acute pulmonary embolism: a systematic review

STUDY OBJECTIVES: Much attention has been paid in recent years to optimizing the diagnosis of acute pulmonary embolism (PE). However, little is known about the changes in clot burden that occur at the level of the pulmonary arteries after documented PE. It is often problematic to distinguish between a new or residual defect on lung scintigraphy or helical CT. This may lead to falsely labeling patients with residual PE as having recurrent PE and consequent unnecessary treatment changes. DESIGN: We performed a systematic analysis of studies of imaging tests (radionuclide and CT) evaluating resolution rate of PE with independent assessment of predefined methodologic criteria by two investigators. RESULTS: We identified 29 clinical studies. Of these, 25 studies were excluded and 4 studies were included in our review. Because studies differed largely in patient selection, duration of anticoagulation, and timing of follow-up, the studies were not pooled but briefly described. The percentage of patients with residual pulmonary thrombi was 87% at 8 days after diagnosis, 68% after 6 weeks, 65% after 3 months, 57% after 6 months, and 52% after 11 months. DISCUSSION: This review shows that complete resolution of PE is not routinely achieved between 8 days and 11 months after diagnosis. More than 50% of patients with PE still have defects 6 months after diagnosis, after which resolution of thrombi appears to reach a plateau phase. Physicians should be aware of the high percentage of incomplete resolution of pulmonary emboli. Routine re-imaging after cessation of anticoagulant therapy in patients with PE to obtain a new baseline could be considered.     

Fetal gastrointestinal MRI: all that glitters in T1 is not necessarily colon

Background

It has been described that both the colon and distal ileum present with a physiological hypersignal on T1-weighted sequences during the second and third trimesters of pregnancy because of their protein-rich meconium content, it was unclear whether the normal characteristics that have been described on fetal MRI can be applied to gastrointestinal (GI) obstructions.

Objective

To analyse the localisation value of T1 hypersignal within dilated bowel loops in fetuses with gastrointestinal tract obstruction.

Materials and methods

A retrospective 4-year multicentre study analysing cases of fetal GI obstruction in which MRI demonstrated T1 hypersignal content in the dilated loops. Data collected included gestational age (GA) at diagnosis, bowel appearance on US, CFTR gene mutations and amniotic levels of gastrointestinal enzymes. The suggested prenatal diagnosis was eventually compared to postnatal imaging and surgery.

Results

Eleven patients were included. The median GA at US diagnosis was 23 weeks (range 13–32). In eight cases there was a single dilated loop, while several segments were affected in three. The median GA at MRI was 29 weeks (range 23–35). One case presented with cystic fibrosis mutations. Final prenatally suspected diagnoses were distal ileal atresia or colon in nine cases and proximal atresia in two. Postnatal findings were proximal jejunal atresia in nine cases and meconium ileus in two. In five cases the surgical findings demonstrated short bowel syndrome.

Conclusion

In cases of fetal occlusion, T1 hypersignal should not be considered as a sign of distal ileal or colonic occlusion. The obstruction may be proximal, implying a risk of small bowel syndrome, which requires adequate parental counselling.     

Frequencies and demographic determinants of breastfeeding and DHA supplementation in a nationwide sample of mothers in Germany

Purpose

German guidelines recommend breast milk as ideal for infant’s nutrition, supporting exclusive breastfeeding for at least 4 months. Moreover, in mothers with insufficient fish intake, DHA status may be improved by supplementation during pregnancy and lactation. However, little is known on current rates of breastfeeding and DHA supplementation in Germany. The objective of this study was to analyse frequencies and demographic determinants of breastfeeding and DHA supplementation in Germany.

Methods

Data derived from a nationwide consumer survey of 986 mothers with children between 5 and 36 months of age in Germany.

Results

78.3 % reported that they ever breastfed their children, and 55.6 % of the mothers exclusively breastfed for at least 4 months. Mothers who did not breastfeed were less likely to be informed by their paediatrician or midwife and were more often not informed at all; 27.8 % of mothers used DHA supplements during pregnancy, 16.8 % postnatal. DHA supplementation was more common in women with a high versus a low fish intake. The social status was the major determinant of breastfeeding initiation and exclusivity and also DHA supplementation.

Conclusion

Breastfeeding initiation and duration of exclusive breastfeeding in Germany need to be improved. Professional counselling and support, with a focus on mothers from lower social classes, appears necessary to increase current rates of breastfeeding initiation, duration, and exclusiveness, but also to ensure a sufficient supply with DHA in pregnant and lactating women, particularly in women with low fish consumption.     

Prospective associations between serum biomarkers of lipid metabolism and overall,breast and prostate cancer risk

Experimental studies provided evidence about mechanisms by which cholesterol, especially high density lipoprotein cholesterol (HDL-C), could influence carcinogenesis, notably through antioxidant and anti-inflammatory properties. However, prospective studies that investigated the associations between specific lipid metabolism biomarkers and cancer risk provided inconsistent results. The objective was to investigate the prospective associations between total cholesterol (T-C), HDL-C, low density lipoprotein cholesterol, apolipoproteins A1 (apoA1) and B, and triglycerides and overall, breast and prostate cancer risk. Analyses were performed on 7,557 subjects of the Supplémentation en Vitamines et Minéraux Antioxydants Study, a nationwide French cohort study. Biomarkers of lipid metabolism were measured at baseline and analyzed regarding the risk of first primary incident cancer (N = 514 cases diagnosed during follow-up, 1994–2007), using Cox proportional hazards models. T-C was inversely associated with overall (HR_{1mmol/L increment} = 0.91, 95 % CI 0.82–1.00; P = 0.04) and breast (HR_{1mmol/L increment} = 0.83, 95 % CI 0.69–0.99; P = 0.04) cancer risk. HDL-C was also inversely associated with overall (HR_{1mmol/L increment} = 0.61, 95 % CI 0.46–0.82; P = 0.0008) and breast (HR_{1mmol/L increment} = 0.48, 95 % CI 0.28–0.83; P = 0.009) cancer risk. Consistently, apoA1 was inversely associated with overall (HR_{1g/L increment} = 0.56, 95 % CI 0.39–0.82; P = 0.003) and breast (HR_{1g/L increment} = 0.36, 95 % CI 0.18–0.73; P = 0.004) cancer risk. This prospective study suggests that pre-diagnostic serum levels of T-C, HDL-C and ApoA1 are associated with decreased overall and breast cancer risk. The confirmation of a role of cholesterol components in cancer development, by further large prospective and experimental studies, may have important implications in terms of public health, since cholesterol is already crucial in cardiovascular prevention.     

Total Fat and Fatty Acid Intake among 1–7-Year-Old Children from 33 Countries: Comparison with International Recommendations

This work reviews available data on dietary intakes of total fat, saturated fatty acids (SFA) and individual polyunsaturated fatty acids (PUFA) in children in different countries worldwide and for the first time, compares them with recent international recommendations. Studies published before June 2021 reporting total fat, total SFA and individual PUFA intakes in children aged 1–7 y were included. Observed intakes were evaluated against FAO/WHO and EFSA recommendations. 65 studies from 33 countries were included. Fat intake was too low in 88% of studies in young children (1–3 y). SFA intake was >10%E in 69–73% of children, especially in Europe. Linoleic acid intake was <3%E in 24% of studies in 1–2 y olds and within FAO/WHO recommendations among all other ages. Alpha-linolenic acid intake was <0.5%E in almost half of studies. Docosahexaenoic acid (DHA) or eicosapentaenoic acid + DHA intakes were below recommendations in most studies. In summary, while total fat intake was too low among younger children, SFA intake was above, especially in Europe and n-3 PUFA intake, especially DHA, were below recommendations for all ages. Intake of n-3 PUFA, especially DHA, is generally suboptimal. More data, particularly from developing countries, are required to refine these findings and guide implementation of adapted nutrition policies.     

Fish Hydrolysate Supplementation Containing n-3 Long Chain Polyunsaturated Fatty Acids and Peptides Prevents LPS-Induced Neuroinflammation

Neuroinflammation constitutes a normal part of the brain immune response orchestrated by microglial cells. However, a sustained and uncontrolled production of proinflammatory factors together with microglial activation contribute to the onset of a chronic low-grade inflammation, leading to neuronal damage and cognitive as well as behavioral impairments. Hence, limiting brain inflammatory response and improving the resolution of inflammation could be particularly of interest to prevent these alterations. Dietary n-3 long chain polyunsaturated fatty acids (LC-PUFAs) and low molecular weight peptides are good candidates because of their immunomodulatory and proresolutive properties. These compounds are present in a fish hydrolysate derived from marine-derived byproducts. In this study, we compared the effect of an 18-day supplementation with this fish hydrolysate to a supplementation with docosahexaenoic acid (DHA) on lipopolysaccharide (LPS)-induced inflammation in mice. In response to peripherally injected LPS, the fish hydrolysate supplementation decreased the hippocampal mRNA expression of the proinflammatory cytokines IL-6 (p < 0.001), IL-1β (p = 0.0008) and TNF-α (p < 0.0001), whereas the DHA supplementation reduced only the expression of IL-6 (p = 0.004). This decline in proinflammatory cytokine expressions was associated with an increase in the protein expression of IκB (p = 0.014 and p = 0.0054 as compared to the DHA supplementation and control groups, respectively) and to a modulation of microglial activation markers in the hippocampus. The beneficial effects of the fish hydrolysate could be due in part to the switch of the hippocampal oxylipin profile towards a more anti-inflammatory profile as compared to the DHA supplementation. Thus, the valorization of fish byproducts seems very attractive to prevent and counteract neuroinflammation.     

Interactions between hippocampal activity and striatal dopamine in people at clinical high risk for psychosis: relationship to adverse outcomes

Preclinical models propose that increased hippocampal activity drives subcortical dopaminergic dysfunction and leads to psychosis-like symptoms and behaviors. Here, we used multimodal neuroimaging to examine the relationship between hippocampal regional cerebral blood flow (rCBF) and striatal dopamine synthesis capacity in people at clinical high risk (CHR) for psychosis and investigated its association with subsequent clinical and functional outcomes. Ninety-five participants (67 CHR and 28 healthy controls) underwent arterial spin labeling MRI and ¹⁸F-DOPA PET imaging at baseline. CHR participants were followed up for a median of 15 months to determine functional outcomes with the global assessment of function (GAF) scale and clinical outcomes using the comprehensive assessment of at-risk mental states (CAARMS). CHR participants with poor functional outcomes (follow-up GAF < 65, n = 25) showed higher rCBF in the right hippocampus compared to CHRs with good functional outcomes (GAF ≥ 65, n = 25) (p_fwe = 0.026). The relationship between rCBF in this right hippocampal region and striatal dopamine synthesis capacity was also significantly different between groups (p_fwe = 0.035); the association was negative in CHR with poor outcomes (p_fwe = 0.012), but non-significant in CHR with good outcomes. Furthermore, the correlation between right hippocampal rCBF and striatal dopamine function predicted a longitudinal increase in the severity of positive psychotic symptoms within the total CHR group (p = 0.041). There were no differences in rCBF, dopamine, or their associations in the total CHR group relative to controls. These findings indicate that altered interactions between the hippocampus and the subcortical dopamine system are implicated in the pathophysiology of adverse outcomes in the CHR state.Subject terms: Predictive markers, Psychosis