Mechanical ventilation of the premature neonate

Although the trend in the neonatal intensive care unit is to use noninvasive ventilation whenever possible, invasive ventilation is still often necessary for supporting pre-term neonates with lung disease. Many different ventilation modes and ventilation strategies are available to assist with the optimization of mechanical ventilation and prevention of ventilator-induced lung injury. Patient-triggered ventilation is favored over machine-triggered forms of invasive ventilation for improving gas exchange and patient-ventilator interaction. However, no studies have shown that patient-triggered ventilation improves mortality or morbidity in premature neonates. A promising new form of patient-triggered ventilation, neurally adjusted ventilatory assist (NAVA), was recently FDA approved for invasive and noninvasive ventilation. Clinical trials are underway to evaluate outcomes in neonates who receive NAVA. New evidence suggests that volume-targeted ventilation modes (ie, volume control or pressure control with adaptive targeting) may provide better lung protection than traditional pressure control modes. Several volume-targeted modes that provide accurate tidal volume delivery in the face of a large endotracheal tube leak were recently introduced to the clinical setting. There is ongoing debate about whether neonates should be managed invasively with high-frequency ventilation or conventional ventilation at birth. The majority of clinical trials performed to date have compared high-frequency ventilation to pressure control modes. Future trials with premature neonates should compare high-frequency ventilation to conventional ventilation with volume-targeted modes. Over the last decade many new promising approaches to lung-protective ventilation have evolved. The key to protecting the neonatal lung during mechanical ventilation is optimizing lung volume and limiting excessive lung expansion, by applying appropriate PEEP and using shorter inspiratory time, smaller tidal volume (4-6 mL/kg), and permissive hypercapnia. This paper reviews new and established neonatal ventilation modes and strategies and evaluates their impact on neonatal outcomes.     

High-intensity focused ultrasound ablation:An effective bridging therapy for hepatocellular carcinoma patients

AIM:To analyze whether high-intensity focused ultrasound(HIFU) ablation is an effective bridging therapy for patients with hepatocellular carcinoma(HCC).METHODS:From January 2007 to December 2010,49 consecutive HCC patients were listed for liver transplantation(UCSF criteria).The median waiting time for transplantation was 9.5 mo.Twenty-nine patients received transarterial chemoembolization(TACE) as a bringing therapy and 16 patients received no treatment before transplantation.Five patients received HIFU ablation as a bridging therapy.Another five patients with the same tumor staging(within the UCSF criteria) who received HIFU ablation but not on the transplant list were included for comparison.Patients were comparable in terms of Child-Pugh and model for end-stage liver disease scores,tumor size and number,and cause of cirrhosis.RESULTS:The HIFU group and TACE group showed no difference in terms of tumor size and tumor number.One patient in the HIFU group and no patient in the TACE group had gross ascites.The median hospital stay was 1 d(range,1-21 d) in the TACE group and two days(range,1-9 d) in the HIFU group(P < 0.000).No HIFU-related complication occurred.In the HIFU group,nine patients(90%) had complete response and one patient(10%) had partial response to the treatment.In the TACE group,only one patient(3%) had response to the treatment while 14 patients(48%) had stable disease and 14 patients(48%) had progressive disease(P = 0.00).Seven patients in the TACE group and no patient in the HIFU group dropped out from the transplant waiting list(P = 0.559).CONCLUSION:HIFU ablation is safe and effective in the treatment of HCC for patients with advanced cirrhosis.It may reduce the drop-out rate of liver transplant candidate.     

Nationwide shifts in the double burden of overweight and underweight in Vietnamese adults in 2000 and 2005: two national nutrition surveys

Background  

In developing countries, overweight prevalence is increasing while underweight prevalence is still high. This situation is known as the double nutrition burden. Both underweight and overweight are related to increased risk of chronic non-communicable diseases, reduced well-being and quality of life. This study aims to compare the prevalence of overweight and underweight among Vietnamese adults in 2000 and 2005.     

Determining resectability for hepatocellular carcinoma: the role of laparoscopy and laparoscopic ultrasonography

We reviewed our experience with preoperative determination of resectability in patients with hepatocel‐lular carcinoma (HCC) over the last 10 years, and evaluated the role of laparoscopy with laparoscopic ultrasonography (USG) since we instituted this technique in June 1994. From January 1989 to December 1998, 500 of 1741 patients with HCC (28.7%) were considered suitable for hepatic resection after preoperative assessment. Significantly more contrast‐enhanced computed tomography (CT) scans and fewer percutaneous USGs or hepatic arteriograms were performed in the 299 patients managed since June 1994 (group 2) than in the 201 patients managed before then (group 1). One hundred and ninety‐eight patients in group 2 (66%) underwent laparoscopy with laparoscopic USG. Unresectable disease was found in 41 patients in group 1 (20.4%) (all at laparotomy), and in 68 patients in group 2 (22.7%) (16 at laparotomy without laparoscopic examination, 31 at laparoscopic examination alone, and 21 at laparotomy after an inconclusive laparoscopic examination) (P = 0.5). The most common features of unresectable disease were the presence of bilobar intrahepatic metastases and an inadequate liver remnant with cirrhosis. The adoption of the laparoscopic examination after June 1994 improved the overall resection rate at laparotomy in group 2 from 77.3% to 86.2%, which was better than that in group 1 (79.6%,P = 0.057). For patients with unresectable disease, the operation time and hospital stay were significantly shorter in group 2. The postoperative morbidity and mortality rates were 9.8% and 4.9%, respectively, in group 1, and 5.9% and 2.9% in group 2. There was no operative morbidity in the 31 patients who had unresectable disease detected by the laparoscopic examination alone. Laparoscopy with laparoscopic USG avoids unnecessary laparotomy, and has a definite role in determining resectability in patients with HCC.     

Pu(iii) and Cm(iii) in the presence of EDTA: aqueous speciation,redox behavior,and the impact of Ca(ii)

The impact of calcium on the solubility, redox behavior, and speciation of the An(iii)–EDTA (An = Pu or Cm) system under reducing, anoxic conditions was investigated through batch solubility experiments, X-ray absorption spectroscopy (XAS), density functional theory (DFT), and time-resolved laser fluorescence spectroscopy (TRLFS). Batch solubility experiments were conducted from undersaturation using Pu(OH)₃(am) as the solid phase in contact with 0.1 M NaCl–NaOH–HCl–EDTA–CaCl₂ solutions at [EDTA] = 1 mM, pH_m = 7.5–9.5, and [CaCl₂] ≤20 mM. Additional samples targeted brine systems represented by 3.5 M CaCl₂ and WIPP simulated brine. Solubility data in the absence of calcium were well-described by Pu(iii)–EDTA thermodynamic models, thus supporting the stabilization of Pu(iii)–EDTA complexes in solution. Cm(iii)–EDTA TRLFS data suggested the stepwise hydrolysis of An(iii)-EDTA complexes with increasing pH, and current Pu(iii)-EDTA solubility models were reassessed to evaluate the possibility of including Pu(iii)–OH–EDTA complexes and to calculate preliminary formation constants. Solubility data in the presence of calcium exhibited nearly constant log m(Pu)_tot, as limited by total ligand concentration, with increasing [CaCl₂]_tot, which supports the formation of calcium-stabilized Pu(iii)–EDTA complexes in solution. XAS spectra without calcium showed partial oxidation of Pu(iii) to Pu(iv) in the aqueous phase, while calcium-containing experiments exhibited only Pu(iii), suggesting that Ca–Pu(iii)–EDTA complexes may stabilize Pu(iii) over short timeframes (t ≤45 days). DFT calculations on the Ca–Pu(iii)–EDTA system and TRLFS studies on the analogous Ca–Cm(iii)–EDTA system show that calcium likely stabilizes An(iii)–EDTA complexes but can also potentially stabilize An(iii)–OH–EDTA species in solution. This hints towards the possible existence of four major complex types within Ca–An(iii)–EDTA systems: An(iii)–EDTA, An(iii)–OH–EDTA, Ca–An(iii)–EDTA, and Ca–An(iii)–OH–EDTA. While the exact stoichiometry and degree of ligand protonation within these complexes remain undefined, their formation must be accounted for to properly assess the fate and transport of plutonium under conditions relevant to nuclear waste disposal.

Combined advanced spectroscopy and solubility studies provide evidence for the formation of novel calcium-containing and hydrolyzed (Cm,Pu)(iii)–EDTA complex(es).     

Dysregulated expression of dickkopfs for potential detection of hepatocellular carcinoma

The prognosis for hepatocellular carcinoma (HCC) remains dismal due to the lack of diagnostic markers for early detection. This review will discuss the clinical potential of the dickkopf (DKK) family members as diagnostic and/or prognostic markers for HCC. In comparison to serum α-fetoprotein (AFP) level, which remains the gold standard for HCC diagnosis, high serum DKK1 levels have higher diagnostic value for HCC, especially for AFP-negative HCC, and can distinguish HCC from non-malignant chronic liver diseases. Additionally, the combination of serum DKK1 and AFP levels enhances diagnostic accuracy for HCC compared to serum DKK1 or AFP levels alone. Although DKK1 offers potential for its use in HCC diagnosis this review will discuss the challenges facing DKK1 and also shed some light on recent developments on the remaining DKK family members: DKK2, DKK3 and DKK4.     

The fabella sign: fabella displacement in synovial effusion and popliteal fossa masses. Normal and abnormal fabello-femoral and fabello- tibial distances

Posterior displacement of the fabella is a reliable sign of synovial effusion or mass which may be applied even when inflammation or post-traumatic edema obscures the extrasynovial fat lines of the knee joint. The fabella normally moves posteriorly as the knee is flexed, but correlation of fabella position with degree of flexion defined ranges of normal and abnormal fabella position which are useful in diagnosis. If all lateral views are obtained with the knee flexed over a standard angle bolster, fabella position is standardized and fabella displacement readily detected without need for measurement. With experience, fabella displacement is readily apparent in non-standard positions as well. Normal fabella position does not rule out small effusion or effusion which is confined to the suprapatellar pouch because the knee is extended.