International recommendations on neonatal management with congenital diaphragmatic hernia: literature review

Congenital diaphragmatic hernia (CDH) is a defect of diaphragm development which is characterized by herniation of the abdominal content into the chest resulting in pulmonary hypoplasia and pulmonary hypertension of various degrees. Mortality and sickness rates among survived children with this pathology remain high all over the world. Prenatal diagnostics of high quality will help to find neonates with severe CDH and promote mobilization of human and material resources for optimal management at the tertiary level of giving medical aid. Attention of specialists in prenatal ultrasound diagnostics should be drawn to the necessity of measuring observed/expected lung(to(head ratio and location of the liver in fetus. Optimal treatment of neonates during preoperative period is focused on mild ventilation, avoidance of oxygen toxicity, baro/volutrauma of a hypoplastic lung and cardiac support. Administration of pulmonary vasodilator therapy including inhaled nitric oxide and extracorporal membrane oxygenation is pathogenetically substantiated for patients with pulmonary hypertension, and surgical correction should be delayed till stabilization of patient's condition. Echocardiography is a critically important diagnostic method. It enables to determine severity of pulmonary hypertension and myocardial functional disorders, to find targeted systemic methods of treatment that improve hemodynamic function or decrease pulmonary vascular resistance. Considering an insufficient level of evidence of the existing international recommendations, large(scale multi(center randomized studies on investigation of the best methods to prevent, diagnose and treat neonates with CDH are essential. No conflict of interest was declared by the authors. Key words: congenital diaphragmatic hernia; neonate; lung-to-head ratio; pulmonary hypertension; extracorporal membrane oxygenation.

Circulating Nucleosomes as Potential Markers to Monitor COVID-19 Disease Progression

The severity of coronavirus disease 2019 (COVID-19) varies significantly with cases spanning from asymptomatic to lethal with a subset of individuals developing Severe Acute Respiratory Syndrome (SARS) and death from respiratory failure. To determine whether global nucleosome and citrullinated nucleosome levels were elevated in COVID-19 patients, we tested two independent cohorts of COVID-19 positive patients with quantitative nucleosome immunoassays and found that nucleosomes were highly elevated in plasma of COVID-19 patients with a severe course of the disease relative to healthy controls and that both histone 3.1 variant and citrullinated nucleosomes increase with disease severity. Elevated citrullination of circulating nucleosomes is indicative of neutrophil extracellular trap formation, neutrophil activation and NETosis in severely affected individuals. Importantly, using hospital setting (outpatient, inpatient or ICU) as a proxy for disease severity, nucleosome levels increased with disease severity and may serve as a guiding biomarker for treatment. Owing to the limited availability of mechanical ventilators and extracorporal membrane oxygenation (ECMO) equipment, there is an urgent need for effective tools to rapidly assess disease severity and guide treatment selection. Based on our studies of two independent cohorts of COVID-19 patients from Belgium and Germany, we suggest further investigation of circulating nucleosomes and citrullination as biomarkers for clinical triage, treatment allocation and clinical drug discovery.

The first experience of extracorporal membrane oxygenation application in severe primary graft failure following heart transplantation

Introduction. The number of surgically treated cases of heart failure by means of orthotopic heart transplantation is increasing every year. At the same time, there is a shortage of optimal donors for heart transplantation, being a factor that leads to a primary graft dysfunction in the intra- and immediate postoperative period. In order to reduce the risk of complications and increase patient survival rates in primary heart graft dysfunction, a number of transplant centers resort to the choice of the treatment by means of mechanical circulatory support, such as extracorporeal membrane oxygenation. Clinical case. In the early postoperative period after heart transplantation, the patient was diagnosed with developing primary graft dysfunction. The clinical response to medication support of hemodynamics was unsatisfactory. Venoarterial extracorporeal membrane oxygenation was performed. On the 4th day, the regional contractility of the left ventricle restored, the ejection fraction of both ventricles increased, their systolic function improved. The patient was discharged on the 21st day in a satisfactory condition. Conclusion. Mechanical circulatory support modalities, such as venoarterial extracorporeal membrane oxygenation, can compensate for the emerging primary myocardial dysfunction in recipients. The efficiency of the extracorporeal membrane oxygenation is achieved not only by knowledge of current clinical recommendations, but also depends on the implementation of other clinics' experience as well as technical readiness of the center and medical personnel' qualification.

Multisystem inflammatory syndrome in children related to COVID-19: A systematic review

Importance. In April 2020, multiple reports of an association between a hyperinflammatory, Kawasaki-like condition and SARS-CoV-2 were published and termed as pediatric inflammatory multisystem syndrome (PIMS) or multisystem inflammatory syndrome (MIS). A thorough characterization of this syndrome (demographics, presentation, diagnosis, and outcome) is currently lacking. Objective. We aimed to perform a systematic review of published cases of this novel multisystem inflammatory syndrome in children associated with COVID-19. Evidence review. A literature search of Pubmed, Embase, BioRxiv, MedRxiv and COVID-19 specific research repositories (Cochrane COVID‐19 Study Register and the World Health Organization (WHO) COVID‐19 Global Research Database) was conducted from December 30th, 2019 to June 30th, 2020. Publications describing inflammatory syndromes associated with COVID-19 were included. Of 333 unique publications, 229 records were excluded based on title and abstract. After screening the full text, 40 observational studies and case reports were included, comprising 687 cases (published between May 9th, 2020 and June 30th, 2020). Findings. In contrast to classic Kawasaki disease, epidemiological enrichment for adolescents (median age 9 [6.0-12.3]) and ethnic minorities (35.8% black and 24.5% Hispanic/Latino) was observed. There was a male predominance (59.1%). Apart from obesity (24.4%), pre-existing conditions were infrequent. The majority suffered from gastrointestinal (87.2%) and cardiocirculatory (79.2%) manifestations. Respiratory symptoms (51.2%) were less frequent. Over half of patients (56.3%) presented with hemodynamic shock, and critical care interventions were often necessary (inotropics (56.5%), mechanical ventilation (22.9%), non-invasive ventilation (30.6%), extracorporal membrane oxygenation (ECMO;4.5%)). Anti-SARS-CoV-2 IgG and RT-PCR were positive in respectively 69.4% and 36.7%. Eleven deaths were reported (1.6%). The RCPCH case definition proved to be most comprehensive comprising all single cases. In contrast, WHO and CDC MIS definitions are more stringent, with the CDC case definition often missing severe cases requiring intensive care (n = 33 out of 95 cases). Conclusions and Relevance. This novel pediatric multisystem hyperinflammatory condition, associated with COVID-19, is characterized by a severe and heterogeneous disease spectrum. Despite frequent intensive care interventions, mortality rate was low and short-term outcome favorable. Long-term follow-up of possible chronic complications and additional clinical research, to elucidate the underlying immunological pathogenesis and possible genetic predisposition is crucial.

COVID-19 Assessment with Bedside Lung Ultrasound in a Population of Intensive Care Patients Treated with Mechanical Ventilation and ECMO

The COVID-19 pandemic has increased the need for an accessible, point-of-care and accurate imaging modality for pulmonary assessment. COVID-19 pneumonia is mainly monitored with chest X-ray, however, lung ultrasound (LUS) is an emerging tool for pulmonary evaluation. In this study, patients with verified COVID-19 disease hospitalized at the intensive care unit and treated with ventilator and extracorporal membrane oxygenation (ECMO) were evaluated with LUS for pulmonary changes. LUS findings were compared to C-reactive protein (CRP) and ventilator settings. Ten patients were included and scanned the day after initiation of ECMO and thereafter every second day until, if possible, weaned from ECMO. In total 38 scans adding up to 228 cineloops were recorded and analyzed off-line with the use of a constructed LUS score. The study indicated that patients with a trend of lower LUS scores over time were capable of being weaned from ECMO. LUS score was associated to CRP (R = 0.34; p < 0.03) and compliance (R = 0.60; p < 0.0001), with the strongest correlation to compliance. LUS may be used as a primary imaging modality for pulmonary assessment reducing the use of chest X-ray in COVID-19 patients treated with ventilator and ECMO.

Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes

The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients. Methods: A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité. Results: During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients. Conclusions: Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.

PROSPECTS OF EXTRACORPORAL MEMBRANE OXYGENATION IN PRACTICE OF CARDIOPULMONARY RESUSCITATION

The article presents a review of modern approach to the application of extracorporeal membrane oxygenation to aid cardiopulmonary resuscitation in patients with cardiac arrest, discuss main include and exclude criteria for the patients.