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Although there are several reports in the literature of SARS‐CoV‐2 infection in cats, few SARS‐CoV‐2 sequences from infected cats have been published. In this study, SARS‐CoV‐2 infection was evaluated in two cats by clinical observation, molecular biology (qPCR and NGS), and serology (microsphere immunoassay and seroneutralization). Following the observation of symptomatic SARS‐CoV‐2 infection in two cats, infection status was confirmed by RT‐qPCR and, in one cat, serological analysis for antibodies against N‐protein and S‐protein, as well as neutralizing antibodies. Comparative analysis of five SARS‐CoV‐2 sequence fragments obtained from one of the cats showed that this infection was not with one of the three recently emerged variants of SARS‐CoV‐2. This study provides additional information on the clinical, molecular, and serological aspects of SARS‐CoV‐2 infection in cats., This study provides additional information on the clinical, molecular, and serological aspects of SARS‐CoV‐2 infection in cats.

Objectives: 1) To investigate the current practice in point-of-care ultrasound use in PICUs across Europe; 2) to understand the barriers for point-of-care ultrasound implementation in the clinical practice; 3) to identify existing point-of-care ultrasound training programs; and 4) to assess training needs.Design: Cross-sectional electronic survey.Subjects: Medical directors of European PICUs.Measurements and Main Results: The response rate was 42.3%; 142 of the 336 invited PICU medical directors from 26 European countries completed the survey. The clinicians in almost all the PICUs across Europe were reported to use point-of-care ultrasound in some form. A significant variation in the clinical practice according to the patient characteristics and presence of a fellowship training program was observed. PICUs with cardiosurgical patients reported using point-of-care ultrasound significantly more often than others. Ultrasound-guided vascular access was the most common point-of-care ultrasound indication, except in PICUs providing joint care for neonates and children. Units with a fellowship training program reported an increased use of point-of-care ultrasound for hemodynamic evaluation, during resuscitation and a positive impact on collaboration with imaging specialties. Although no barrier was deemed substantial to impede point-of-care ultrasound implementation, a number of potential hindrances to its implementation were reported-such as lack of formal training curriculum, collaborative learning opportunities, and quality assurance processes. Bedside informal teaching in point-of-care ultrasound was reported the most common method to acquire point-of-care ultrasound skills.Conclusions: Point-of-care ultrasound is being used extensively across heterogeneously organized PICU settings in Europe. However, there remains a significant variation in the clinical practice across the units. Clear needs for improved point-of-care ultrasound training programs and clinical governance structure were identified. Evidence-based point-of-care ultrasound guidelines, structured training programs dedicated to neonatal and pediatric intensive care settings, and educational research in point-of-care ultrasound use may help in strengthening clinical governance, making clinical practice uniform and enhancing quality assurance.

Summary The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post‐1984 literature there are no published reports of aspiration‐associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus‐derived algorithm in which each patient is first risk‐stratified during their pre‐sedation assessment, using evidence‐based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Background Domestic pets can contract severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection; however, it is unknown whether the UK B.1.1.7 variant can more easily infect certain animal species or increase the possibility of human‐to‐animal transmission. Methods This is a descriptive case series reporting SARS‐CoV‐2 B.1.1.7 variant infections in a group of dogs and cats with suspected myocarditis. Results The study describes the infection of domestic cats and dogs by the B.1.1.7 variant. Two cats and one dog were positive to SARS‐CoV‐2 PCR on rectal swab, and two cats and one dog were found to have SARS‐CoV‐2 antibodies 2–6 weeks after they developed signs of cardiac disease. Many owners of these pets had developed respiratory symptoms 3–6 weeks before their pets became ill and had also tested positive for COVID‐19. Interestingly, all these pets were referred for acute onset of cardiac disease, including severe myocardial disorders of suspected inflammatory origin but without primary respiratory signs. Conclusions These findings demonstrate, for the first time, the ability for pets to be infected by the B.1.1.7 variant and question its possible pathogenicity in these animals.

Although Zika virus (ZIKV) circulates in sub-Saharan Africa, no case of ZIKV-associated microcephaly has thus far been reported. Here, we report evidence of a possible association between a 2007 outbreak of febrile illness and an increase in microcephaly and possibly ZIKV infection in Gabon.

The official national COVID-19 dashboard of Belgium was first put online on 31 Dec 2020. 1 year later, it was composed of 12 pages, 35 indicators, 73 charts and 15 tables. Lots of decisions were taken to arrive there: the definition of the indicators, the charts, the pages, the hierarchical order of the information, the colors, the footnotes & annotations... How were all of these decided? Who influenced the decisions and what was the dynamic with the decision makers and the general public? And how did it change over time? What are the particularities of the Belgian dashboard? What makes it different from the dashboard of Kosovo? What are the lessons learned and how would it be different if started from scratch?

INTRODUCTION: Toxicity related to calcium-channel blockers remains a significant cause of morbidity and mortality. Amlodipine-induced shock is unique in that its mechanism of action is thought to occur in part via the release of nitric oxide (NO) in the peripheral vasculature. Specific therapeutic interventions, including methylene blue (an NO scavenger), have been suggested, but efficacy studies are severely limited. To facilitate a larger porcine study into the effect of various interventions on amlodipine toxicity, we undertook this model development and feasibility study. METHODS: Intravenous amlodipine was prepared by dissolving commercially obtained amlodipine tablets in dimethylsulfoxide. The concentration of the drug was verified using ultraviolet spectroscopy. We administered this solution to three animals in order to determine a toxic dose, capable of facilitating a two-arm study of amlodipine toxicity. RESULTS: The first pig died rapidly after the bolus infusion. The second pig developed mild toxicity, but the dissolution of the plastic tubing by the solvent and subsequent leakage limited the interpretability of the result. The third animal developed expected toxicity with an infusion rate between 2.0 and 5.5 mg/kg/h. CONCLUSION: This study demonstrates a potentially repeatable model of amlodipine-induced toxic shock using intravenous administration of amlodipine and several methodological considerations for researchers undertaking similar work.

Context: Although cerebral perfusion (CP) is preserved across a wide range of mean arterial pressures (MAP) through cerebral-vascular autoregulation, the relationship between MAP and CP in refracto...

Although there are several reports in the literature of SARS-CoV-2 infection in cats, few SARS-CoV-2 sequences from infected cats have been published. In this report, SARS-CoV-2 infection was evaluated in two cats by clinical observation, molecular biology (qPCR and NGS), and serology (Microsphere immunoassay and seroneutralization). Following the observation of symptomatic SARS-CoV-2-infection in two cats, infection status was confirmed by RT-qPCR and, in one cat, serological analysis for antibodies against N-protein and S-protein, as well as neutralizing antibodies. Comparative analysis of five SARS-CoV-2 sequence-fragments obtained from one of the cats showed that this infection was not with one of the three recently emerged variants of SARS-CoV-2. This study provides additional information on the clinical, molecular, and serological aspects of SARS-CoV-2 infection in cats.

Domestic pets can contract SARS-CoV-2 infection but, based on the limited information available to date, it is unknown whether the new British B.1.1.7 variant can more easily infect certain animal species or increase the possibility of human-to-animal transmission. In this study, we report the first cases of infection of domestic cats and dogs by the British B.1.1.7 variant of SARS-CoV-2 diagnosed at a specialist veterinary hospital in the South-East of England. Furthermore, we discovered that many owners and handlers of these pets had developed Covid-19 respiratory symptoms 3-6 weeks before their pets became ill and had also tested PCR positive for Covid-19. Interestingly, all these B.1.1.7 infected pets developed atypical clinical manifestations, including severe cardiac abnormalities secondary to myocarditis and a profound impairment of the general health status of the patient but without any primary respiratory signs. Together, our findings demonstrate for the first time the ability for companion animals to be infected by the B.1.1.7 variant of SARS-CoV-2 and raise questions regarding its pathogenicity in these animals. Moreover, given the enhanced infectivity and transmissibility of B.1.1.7 variant for humans, these findings also highlights more than ever the risk that companion animals may potentially play a significant role in SARS-CoV-2 outbreak dynamics than previously appreciated.

In a survey of household cats and dogs of laboratory-confirmed COVID-19 patients, we found a high seroprevalence of SARS-CoV-2 antibodies, ranging from 21% to 53%, depending on the positivity criteria chosen. Seropositivity was significantly greater among pets from COVID-19+ households compared to those with owners of unknown status. Our results highlight the potential role of pets in the spread of the epidemic.

This article corrects the Guidelines by Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP on behalf of the International Committee for the Advancement of Procedural Sedation, ‘An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children’ [1]. The authors thank a careful reader who identified that a study from this table by Rajasekaran et al should have been excluded, as it included fewer than 5000 patients. The corrected table without this study is shown below, and this change does not alter our other findings and conclusions. An author and corresponding affiliation were omitted and is now revised as follows: 1 Table Literature estimates of aspiration risk during procedural sedation* (Table presented.) * To include just the largest studies we display those with 5,000 or more patients. We also exclude studies which report duplicate sub-sets of patients.

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways.What is Known:•There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years.What is New:•Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery.•The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner.•This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Despite the probable zoonotic origin of SARS-CoV-2, only limited research efforts have been made to understand the role of companion animals in SARS-CoV-2 epidemiology. According to recent serological prevalence studies, human-to-companion animal transmission is quite frequent, which led us to consider that the risk of SARS-CoV-2 transmission from animal to human, albeit negligible in the present context, may have been underestimated. In this study, we provide the results of a prospective survey that was conducted to evaluate the SARS-CoV-2 isolation rate by qRT-PCR in dogs and cats with different exposure risks and clinical statuses. From April 2020 to April 2021, we analyzed 367 samples and investigated the presence of SARS-CoV-2 RNA using qRT-PCR. Only four animals tested positive, all of them being cats. Three cats were asymptomatic and one presented a coryza-like syndrome. We describe in detail the infection in two cats and the associated clinical characteristics. Importantly, we obtained SARS-CoV-2 genomes from one infected animal and characterized them as Alpha variants. This represents the first identification of the SARS-CoV-2 Alpha variant in an infected animal in France.

Nadolol is a β-adrenergic antagonist that has been shown to be efficacious in the treatment of infantile hemangioma. It has been suggested that this drug may have fewer side effects compared with the gold standard therapy, propranolol, because it does not exhibit membrane-stabilizing effects and has little ability to cross the blood-brain barrier. However, the pharmacokinetics and safety of nadolol in infants are not well understood, potentially making this therapy dangerous. β-adrenergic antagonist toxicity causes bradycardia, hypotension, hypoglycemia, and even death. We report a case of a 10-week-old girl who was started on nadolol for infantile hemangioma, died 7 weeks later, and was found to have an elevated postmortem cardiac blood nadolol level of 0.94 mg/L. The infant had no bowel movements for 10 days before her death, which we hypothesize contributed to nadolol toxicity. Pharmacokinetics studies show a large fraction of oral nadolol either remains in the feces unchanged or is excreted into feces via the biliary system, allowing continued absorption over time in infants who stool infrequently. Propranolol may be a safer therapy overall. Not only does it have a shorter half-life, but propranolol is hepatically metabolized and renally eliminated, allowing for less drug accumulation in healthy infants with variable stooling patterns. We suggest that if nadolol is selected for therapy, pediatricians should instruct parents to monitor their infants’ bowel movements closely and encourage early intervention in the event of decreased stooling. This intervention may greatly improve the safety of nadolol in this vulnerable patient population.

INTRODUCTION: Calcium channel blocker (CCB) overdoses cause significant morbidity and mortality. Dihydropyridine CCBs cause peripheral vascular dilation and at high doses cardiac dysfunction. Amlodipine, a dihydropyridine, causes peripheral vasodilation from release of nitric oxide (NO) in addition to calcium channel blockade; NO scavenging is a potential treatment. Methylene blue (MB) inhibits NO directly and inhibits NO production. We compared the effects of MB versus norepinephrine (NE), with time to death as the primary outcome, in a porcine amlodipine toxicity model. METHODS: Animals were anesthetized and instrumented, and an amlodipine infusion was administered to mimic oral overdose. After 70 minutes, each group was resuscitated with normal saline. Animals in each group were then randomized to receive either MB or NE. Hemodynamic parameters, including mean arterial pressure and cardiac output, were recorded every 10 minutes. The primary outcome was survival time (Kaplan-Meier analysis and log-rank test). RESULTS: Interim analysis after 15 animals (7 MB, 8 NE) revealed that MB was clearly not superior to NE. Overall, 1 of 7 animals in the MB group survived to 300 minutes compared with 2 of 8 animals in the NE group. The median survival time was 100 minutes for the MB group and 177 minutes for the NE group. Survival time did not differ by group (log-rank test p = 0.29). CONCLUSION: In this porcine model of amlodipine toxicity, methylene blue did not improve survival time compared with norepinephrine. Whether methylene blue is beneficial in combatting distributive shock in amlodipine toxicity remains unclear and requires further study.

Background: Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress. Methods: Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents. Results: The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures. Conclusion: In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families. (C) 2020 The Authors. Published by Elsevier Ltd.

Although pain is one of the most prevalent and bothersome symptoms children with cancer experience, evidence-based guidance regarding assessment and management is lacking. With 44 international, multidisciplinary healthcare professionals and nine patient representatives, we aimed to develop a clinical practice guideline (following GRADE methodology), addressing assessment and pharmacological, psychological, and physical management of tumor-, treatment-, and procedure-related pain in children with cancer. In this paper, we present our thorough methodology for this development, including the challenges we faced and how we approached these. This lays the foundation for our clinical practice guideline, for which there is a high clinical demand.

INTRODUCTION: Dextromethorphan hydrobromide is widely available as an over-the-counter cough suppressant. A semi-synthetic opioid displaying N-methyl-d-aspartate receptor antagonism, it is commonly abused for recreational purposes. Spuriously elevated serum chloride concentrations are a well-described phenomenon in the setting of dextromethorphan hydrobromide toxicity, but evidence to suggest the development of tolerance is limited to case reports. CASE: A 32-year-old male known to chronically ingest dextromethorphan hydrobromide for recreational purposes presented to regional hospitals on 179 occasions over 110 months and was treated for dextromethorphan toxicity on 163/174 (93.7%) of these visits. He reported a subjective need to increase his dosing over time to achieve the same degree of intoxication. Measured serum chloride over this period (n = 217) ranged from 98 to 138 mEq/L (median 115 mEq/L, IQR 110–123 mEq/L). Measured concentrations over the 110-month period progressively rose, with a fitted plot of 111.15 + 0.00232x describing the rise in measured chloride. Though not formally assessed, anion gaps tended to become progressively more negative over the observed period. DISCUSSION: We report a patient with persistent dextromethorphan hydrobromide abuse at escalating doses whose mean serum chloride concentration increased, on average, by 0.00232 mEq/L every day over a 110-month period. This case demonstrates progressive spurious hyperchloremia secondary to bromide interference in hospital-based chloride assays, supporting the patient’s reported need to dose escalate to the same desired effect. Although this artefactual laboratory finding is a well-documented result of bromide ingestion, it may be useful in identifying patterns of dextromethorphan hydrobromide use that suggest tolerance.

We present a patient who presented 37 times after large acute acetaminophen ingestions without residual signs of liver dysfunction. The presentations were all very similar: witnessed ingestions of ...

Objective Human bocavirus (HBoV) is a viral pathogen which causes respiratory tract diseases and acute gastroenteritis worldwide. This virus mainly affected children under 5 years old. There is little information on HBoV in Gabon. Two first studies was conducted to determine the prevalence of respiratory and enteric viruses in children under 5 years old who visited health centers for influenza-like illness (ILI) or diarrhea in Gabon from March 2010 to June 2011. However, HBoV was not included in the screening. The aim of this retrospective study was to evaluate the prevalence and the HBoV genotype in children under 5 years old with ILI or diarrhea in Gabon. Results A total of 810 nasal swabs and 317 feces samples collected during the two first study were analyzed among which 32 (4.4%) and 7 (2.2%) were positive for HBoV respectively. While there were no significant differences in prevalence between age groups in children with ILI, all children with diarrhea were under 12 months of age. Moreover, 84.4 and 42.8% were diagnosed in co-infections with at least one other respiratory virus, or enteric viruses respectively. Finally, HBoV subtype 1 has been detected in both respiratory and gastrointestinal tracts with very low variability.

HTLV-1 infection is considered as highly endemic in central Africa. Thirty years ago, a first epidemiological study was performed in Gabon, central Africa, and revealed that the prevalence varied from 5.0 to 10.5%. To evaluate current distribution of HTLVs in Gabon, 4.381 samples were collected from rural population living in 220 villages distributed within the 9 provinces of country. HTLVs prevalence was determined using two ELISA tests and positive results were confirmed by Western Blot. The overall HTLV-1 seroprevalence was of 7.3% among the rural Gabonese population; with 5.4% for men and 9.0% for women. Prevalence of HTLV-1 differed by province, ranging from 2.3% to 12.5% into the rain forest. Being a woman older than 51 years represented a high risk for HTLV-1 acquisition. Hospitalization, operation/surgery, transfusion and medical abortion or fever, arthritis and abdominal pain are also significant risk factors. In addition, 0.1% of samples were found as HTLV-2 positive, while 12.0% had an indeterminate HTLV serological pattern. HTLV-3 and HTLV-4 were not found. Phylogenetic analysis was performed on 87 samples and demonstrated that HTLV-1 present in Gabon belongs mostly to subtype B, however the rare subtype D was also found. Altogether, our results demonstrate that almost thirty years after the first epidemiological study prevention of HTLVs infection is still an issue in Gabon., Author summary HTLV-1 is endemic in Africa where it infects millions of individuals and causes Adult T Leukemia. Thirty years ago, an epidemiological study was performed in Gabon, where HTLV-1 is endemic. This revealed a high prevalence of this retroviral infection. Thirty years later, we performed a larger study in the general Gabonese population. This reveals that this oncogenic retrovirus is still highly frequent in this country and that prevalence remains unchanged. It would be extremely important to inform the general population about this infection in order to be able to decrease this retrovirus transmission.

International audience; For more than 95% of acute febrile jaundice cases identified through surveillance for yellow fever, a reemerging arthropod-borne viral disease, no etiological exploration is ever done. The aim of this study was to test for other arthropod-borne viruses that can induce the same symptoms in patients enrolled in the yellow fever surveillance in the Democratic Republic of the Congo (DRC). Of 652 patients included in the surveillance of yellow fever in DRC from January 2003 to January 2012, 453 patients that tested negative for yellow fever virus (YFV) immunoglobulin M (IgM) antibodies were selected for the study. Real-time polymerase chain reaction was performed for the detection of dengue, West Nile, Chikungunya, O'nyong-nyong, Rift Valley fever, Zika, and YFV. The average age of patients was 22.1 years. We reported 16 cases (3.5%; confidence interval [CI]: 0.8-5.2) of dengue (serotypes 1 and 2) and 2 cases (0.4%; CI: 0.0-1.0) of Chikungunya. Three patients were co-infected with the two serotypes of dengue virus. Three cases of dengue were found in early July 2010 from the city of Titule (Oriental province) during a laboratory-confirmed outbreak of yellow fever, suggesting simultaneous circulation of dengue and yellow fever viruses. This study showed that dengue and Chikungunya viruses are potential causes of acute febrile jaundice in the DRC and highlights the need to consider dengue and Chikungunya diagnosis in the integrated disease surveillance and response program in the DRC. A prospective study is necessary to establish the epidemiology of these diseases.

Chronic renal failure leads to many metabolic disorders affecting reproductive function. For men, hypergonadotropic hypogonadism, hyperprolactinemia, spermatic alterations, decreased libido and erectile dysfunction are described. Kidney transplantation improves sperm parameters and hormonal function within 2 years. But sperm alterations may persist with the use of immunosuppressive drugs. In women, hypothalamic-pituitary-ovarian axis dysfunction due to chronic renal failure results in menstrual irregularities, anovulation and infertility. After kidney transplantation, regular menstruations usually start 1 to 12 months after transplantation. Fertility can be restored but luteal insufficiency can persist. Moreover, 4 to 20% of women with renal transplantation suffer from premature ovarian failure syndrome. In some cases, assisted reproductive technologies can be required and imply risks of ovarian hyperstimulation syndrome and must be performed with caution. Pregnancy risks for mother, fetus and transplant are added to assisted reproductive technologies ones. Only 7 authors have described assisted reproductive technologies for patients with kidney transplantation. No cases of haemodialysis patients have been described yet. So, assisted reproductive technologies management requires a multidisciplinary approach with obstetrics, nephrology and reproductive medicine teams' agreement.

Active surveillance in health care centers in Gabon during 2009–2011 detected 72 clinical cases of pandemic (H1N1) 2009 (pH1N1). We found that pH1N1 virus was introduced in mid-2009 but spread throughout the country in 2010. Thus, Gabon was also affected by pH1N1.

Providing effective sedation and analgesia in infants and children admitted on a Pediatric Intensive Care Unit (PICU) is a cornerstone of daily patient care and probably one of the most challenging tasks facing PICU professionals. The wide range in age, weight and body composition, underlying medical and neurological diseases, the usually high sensory stimulatory environment, the repetitive physical stimuli related to medical therapy (e.g., physical examination, invasive procedures, and interventions) and—most importantly—the scarcity of high quality evidence applicable for daily practice may all contribute to this difficulty. A holistic comfort directed policy, including both pharmacological interventions as well as non-pharmacological strategies is promoted. For assessing comfort and/or pain several instruments are available. Particular attention should be paid to certain challenging clinical problems related to sedation, i.e. the management of refractory agitation, drug withdrawal and delirium.

International audience; Technological innovations in the food sector have been driven by high-volume production lines over the past decades. Cost-efficiency of processing and price competitiveness of final products have been major factors. The economics of up-scaling have led to new technologies that are more efficient in terms of throughput and utilization of (homogenous) resources. The question now is whether there is a future for competitive, sustainable processing at small scale. To answer that question, we address two major issues. The first deals with process efficiency and the reliability and resilience of technologies for small-scale processing to be competitive. The second deals with localization of processing and the advantages and disadvantages of technologies for small-scale processing. Novel technologies, especially those based on electro-thermo-dynamic principles, may emerge with characteristics that appear more beneficial for applications at small-scale, and so may well contribute to the competitiveness of local producers of food and biobased products valorizing renewable resources in an integrated manner for a variety of business sectors. However, these novel technologies should go hand in hand with end-to-end innovation of the local food and biobased product system in order to be competitive with international-scale enterprises.

Examination and comparison of the current DSM-IV-TR and the proposed revisions for the forthcoming DSM-5, with regard to neuropsychiatric aspects of critical illness, identified five important issues. These remain to be addressed in order to improve the care of critically ill patients. These are 1) sickness behavior, as part of the organic reaction types of the brain; 2) delirium in children and the "Differential Diagnosis of Mental Disorders Due to a General Medical Condition" in children; 3) catatonia; 4) regressive disorders in childhood in relation to somatic disorders (e.g., anti-NMDAR encephalitis); 5) age-related diagnostic criteria in relation to neuro-psychiatric disorders.

International audience; Laboratory-acquired infections due to a variety of bacteria, viruses, parasites, and fungi have been described over the last century, and laboratory workers are at risk of exposure to these infectious agents. However, reporting laboratory-associated infections has been largely voluntary, and there is no way to determine the real number of people involved or to know the precise risks for workers. In this study, an international survey based on volunteering was conducted in biosafety level 3 and 4 laboratories to determine the number of laboratory-acquired infections and the possible underlying causes of these contaminations. The analysis of the survey reveals that laboratory-acquired infections have been infrequent and even rare in recent years, and human errors represent a very high percentage of the cases. Today, most risks from biological hazards can be reduced through the use of appropriate procedures and techniques, containment devices and facilities, and the training of personnel.

Background Extracorporeal photopheresis (ECP) is an established treatment for graft-versus-host disease (GVHD). Various haematocrit thresholds have been used to trigger red blood cells transfusion prior to ECP. Moderate-to-severe GVHD is frequently complicated by anaemia; the safety and collection efficiency with a lower haematocrit for ECP is unknown. Methods We prospectively enrolled 26 consecutive adult GVHD patients with haematocrits between 25% and 28·9% who received ECP on the CELLEX system. Preprocedural transfusion was withheld. We monitored the adverse events and transfusions avoided. A complete blood cell count with differential was performed on preprocedural peripheral blood and buffy coat collected. Lymphocyte fold enrichment (LFE) was compared between this cohort and two historical control groups with haematocrits of 29% or higher. Results Red Blood Cells transfusion was avoided in the lower-haematocrit cohort without adverse events. The median LFE was 4·5 (95%CI, 3·1–5·7) in the lower-haematocrit cohort and 5·2 (95%CI, 4·1–6·5) in the higher-haematocrit CELLEX-treated control group. The median difference was 0·7 (95%CI, −0·3 to 2·0, P = 0·14). It could not be established that the lower-haematocrit cohort was non-inferior to the higher-haematocrit control group with a prespecified non-inferiority margin of 1·3. However, LFE was significantly higher in the lower-haematocrit cohort than the higher-haematocrit UVAR XTS-treated control group (P < 0·01). Conclusion Buffy coat can be collected for ECP using CELLEX in GVHD patients with a haematocrit of 25% or higher, with a collection efficiency superior to that in patients with higher haematocrits but treated using UVAR XTS. No increase in adverse events was observed at these lower haematocrits.

Purpose of review Painful and/or stressful medical procedures mean a substantial burden for sick children. There is good evidence that procedural comfort can be optimized by a comprehensive comfort-directed policy containing the triad of non-pharmacological strategies (NPS) in all cases, timely or preventive procedural analgesia if pain is an issue, and procedural sedation. Recent findings Based both on well-established theoretical frameworks as well as an increasing body of scientific evidence NPS need to be regarded an inextricable part of procedural comfort care. Summary Procedural comfort care must always start with a child-friendly, nonthreatening environment in which well-being, confidence, and self-efficacy are optimized and maintained. This requires a reconsideration of the medical spaces where we provide care, reduction of sensory stimulation, normalized professional behavior, optimal logistics, and coordination and comfort-directed and age-Appropriate verbal and nonverbal expression by professionals. Next, age-Appropriate distraction techniques and/or hypnosis should be readily available. NPS are useful for all types of medical and dental procedures and should always precede and accompany procedural sedation. NPS should be embedded into a family-centered, care-directed policy as it has been shown that family-centered care can lead to safer, more personalized, and effective care, improved healthcare experiences and patient outcomes, and more responsive organizations.

Health research programs targeting the population of Gabon and Equatorial Africa at the International Center for Medical Research in Franceville (CIRMF), Gabon, have evolved during the years since its inception in 1979 in accordance with emerging diseases. Since the reemergence of Ebola virus in Central Africa, the CIRMF "Emerging Viral Disease Unit" developed diagnostic tools and epidemiologic strategies and transfers of such technology to support the response of the National Public Health System and the World Health Organization to epidemics of Ebola virus disease. The Unit carries out a unique investigation program on the natural history of the filoviruses, emergence of epidemics, and Ebola virus pathogenesis. In addition, academic training is provided at all levels to regional and international students covering emerging conditions (host factors, molecular biology, genetics) that favor the spread of viral diseases.

Ebolavirus and Marburgvirus, two filoviruses belonging to the Filoviridae family, are among the most virulent pathogens for humans and non-human primates, causing outbreaks of fulminant hemorrhagic fever (HF) in Central African countries with case fatality rates of up to 90%. Fruit bats are the likely reservoir, and human infection occurs through contact with bats or infected large-animal carcasses or by person-to-person contact (through body fluids, medical care, and burial practices). Schematically, clinical manifestations occur in three successive phases and include general, gastrointestinal, and mucocutaneous disorders. Death usually results from hemorrhagic complications. Cutaneous manifestations rarely make a major contribution to disease severity but can assist with the diagnosis. Rash, the main cutaneous disorder, is nonspecific and cannot guide the differential diagnosis. Immunohistochemical examination of skin biopsy or necropsy specimens can confirm the diagnosis.

Objective The aim of the study was to assess, by a review of published evidence, the safest and most effective way to provide procedural sedation (PS) in children undergoing gastrointestinal endoscopy (GIE). Methods The databases MEDLINE, Cochrane Library, and Embase were used. Search terms "endoscopy, gastrointestinal" or "endoscopy, digestive system" were combined with "sedation," "conscious sedation," "moderate sedation," "deep sedation," and "hypnotics and sedatives." The final review was restricted to studies reporting specifically on safety (incidences of adverse events) and/or effectiveness (time characteristics, need for supplemental sedation, need for restraint, procedural success, provider satisfaction, and patient comfort) of PS for GIE in children younger than 18 years. Results The search yielded 182 references and the final selection included 11 randomized controlled trials (RCTs) and 15 non-RCTs. Six sedation categories were identified: propofol, opioid/benzodiazepine, premedication, ketamine-, sevoflurane-, and midazolam-based. Only a few RCTs have compared different categories. Opioid/benzodiazepine- and propofol-based PS have a similar safety profile and a low incidence of major adverse events. Propofol-based sedation turned out to be the most effective regimen, with effectiveness comparable to general anesthesia. The addition of midazolam, fentanyl, remifentanil, and/or ketamine to propofol may increase the effectiveness without creating more adverse events. Data on midazolam-, ketamine- and sevoflurane-based sedation were generally too limited to draw conclusions. Conclusions Despite a lack of RCTs containing all aspects of effectiveness and safety, the present evidence indicates propofol-based PS to be the best practice for PS in children undergoing GIE. Propofol can be safely administered by specifically trained nonanesthesiologists.

It is proposed to complement the numerous geometrical constructions of fault-related folds relevant to fold-and-thrust belts by the introduction of mechanical equilibrium and of the rock limited strength to discriminate between various deformation scenarios. The theory used to support this statement is the maximum strength theorem that is related to the kinematic approach of limit analysis known in soil mechanics. The classical geometrical construction of the fault-propagation fold (FPF) is proposed for illustration of our claim. The FPF is composed of a kink fold with migrating axial surfaces ahead of the region where the ramp propagates. These surfaces are assigned frictional properties and their friction angle is found to be small compared with the usual bulk friction angle to ensure the full development of the FPF, a first scenario. For larger values of the axial surface friction angle, this development during overall shortening is arrested by the onset of fault breaking through the front limb, a second scenario. The amount of shortening at the transition from folding to break-through faulting is established.

Introduction: Weight loss amongst women with polycystic ovary syndrome (PCOS) is crucial to reduce the risk of endocrine, reproductive and metabolic complications including hirsutism, menstrual disturbances and cardiovascular disease. With approximately 50% of women with PCOS being overweight or obese, effective dietary management of weight in PCOS is essential. However, there is inconsistent evidence as to whether specifically modified diets (e.g. reduced carbohydrate diets) are more effective at achieving weight loss amongst women with PCOS than are conventional healthy hypocaloric diets. Material and Methods: A systematic review and meta-analysis of randomized controlled trials that had compared weight and BMI between women with PCOS who had undergone either a specifically modified diet or a conventional healthy hypocaloric diet were performed. Six electronic databases were searched, a manual search of the reference lists of the included studies was carried out and authors were contacted for additional information. Nine studies with a total of 395 participants (all with a body mass index [BMI] ≥30) were included in the meta-analysis. The effect size used was the mean difference in post-intervention weight and BMI between participants who had undergone a specifically modified diet and participants who had undergone a conventional healthy hypocaloric diet. Results: There were no differences between groups in post-intervention weight (mean difference 1.26, 95% confidence interval (CI) -0.92 to 3.43, p = .26; heterogeneity I2 = 50%, p = .04) or BMI (mean difference 0.15, 95% CI -0.93 to 1.23, p = 0.79; heterogeneity I2 = 44%, p = 0.10). Subgroup analyses according to the presence of a dietary run-in period (a period at the start of the study during which all participants are placed on an identical diet in order to equalize them on variables influenced by diet), intervention duration and type of diet and a sensitivity analysis according to study quality were not significant. Conclusions: Whilst the results should be interpreted in light of the moderate heterogeneity observed, they suggest that specifically modified diets offer no added benefit for weight loss in women with PCOS over conventional healthy hypocaloric diets. The findings of this meta-analysis may promote the unification of guidelines for the dietary management of PCOS and allow clinicians to be confident in prescribing conventional healthy hypocaloric diets for weight loss amongst their PCOS patients.

Tijdens magnetisch resonantie-onderzoek (MRI) hebben jonge kinderen en kinderen met een vertraagde ontwikkeling een vorm van procedurele sedatie (PS) nodig om voldoende (lang) bewegingloos te kunnen blijven liggen. In Nederland hebben zich in het afgelopen decennium ernstige ongevallen voorgedaan tijdens PS voor MRI. Het is aangetoond dat essentiele veiligheidsrichtlijnen ten aanzien van PS onvoldoende geimplementeerd zijn in de Nederlandse algemene kindergeneeskundige praktijk. Tevens bestaan er zorgen over de matige effectiviteit van vaak toegepaste PS-protocollen. Door middel van een enqueˆte onderzochten we welke PS-technieken en -medicijnen algemeen kinderartsen meestal gebruiken voor MRI bij kinderen. De gemiddelde praktijk werd vergeleken met de resultaten van een systematische review (SR) van de recente literatuur. Door middel van de SR proberen we de klinische vraag te beantwoorden wat op de kinderleeftijd de veiligste en meest effectieve techniek is voor PS tijdens MRI. Nederlandse kinderartsen doen voor MRI zelden beroep op anesthesie. Meestal wordt gebruikgemaakt van een PS op basis van chloralhydraat, midazolam en/of lytische cocktails. Deze sedativa hebben een suboptimale effectiviteit. Het is onbekend hoeveel onderzoeken hierdoor geheel of gedeeltelijk mislukken. Deze medicijnen hebben wel een reeel risico op ernstige complicaties. Het gebruik moet daarom steeds gepaard gaan met verregaande voorzorgsmaatregelen en de aanwezigheid van competente professionals. Van alle sedativa heeft propofol de hoogste effectiviteit. Propofol kan veilig worden gebruikt door competente nietanesthesiologen. Indien deze professionals niet beschikbaar zijn, verdient het aanbeveling om kinderen die gesedeerd moeten worden voor MRI, door te verwijzen naar een anesthesioloog.

Objectives Following two fatal accidents during paediatric procedural sedation (PS), the authors investigated the level of adherence to established safety standards on PS in a nationwide cohort of fully trained general paediatricians, entrusted with PS. Study design and methods: Sample survey Safety guidelines on PS were split into four domains (“Presedation Assessment”, “Monitoring during PS”, “Recovery after PS” and “Facilities and Competences for Emergencies and Rescue”). Each domain was operationalised into sub-domains and items. Items were presented within a questionnaire list as procedural points of attention on which respondents could give their personal adherence score. Percentages of full adherence were calculated. Non-adherence was defined as gradual deviation from full adherence. After factor and reliability analysis, observed scores were summed up to scales, and results were transformed to a 0–10 report mark (RM). An RM of ≥9 is considered as a satisfactory level of adherence while an RM Results Full adherence was rare. For most (sub) domains, only a minority of respondents achieved a satisfactory level of adherence. Large numbers of respondents had scores below 6. Conclusions Potentially unsafe PS practices are common under Dutch general paediatricians, despite the availability of guidelines. The design of guidelines should include a goal-directed plan for implementation including training, initiatives for continuous quality assurance and improvement and repeated measurements of adherence to guidelines.

Les tumeurs intracrâniennes, tous types confondus, sont frequentes en neurologie. Leur incidence suit celle des accidents vasculaires cerebraux et des demences. Leur prise en charge implique un partenariat multidisciplinaire. Ainsi, a l’heure de la preservation de la qualite de vie en oncologie, la neuropsychologie prend une place croissante dans la preparation de la prise en charge des patients presentant ces tumeurs. En effet, tant dans son optique evaluative/diagnostique que du point de vue de la mise en place d’une reeducation cognitive ou d’une prise en charge comportementale, le neuropsychologue s’allie aux neuro-oncologue, neuroradiologue, anatomopathologiste, neurochirurgien, radiotherapeute… Cet article expose les grandes lignes de l’evaluation neuropsychologique, propose des pistes pour un « bilan type » base sur l’experience de l’auteur dans les tumeurs cerebrales primitives que sont les gliomes de bas grade et suggere une reduction de ce bilan au fur et a mesure de l’evolution et de l’aggravation de la pathologie pour preconiser en cas de metastases cerebrales un bilan minimaliste adapte.

International audience; The objective is to capture the 3D spatial variation in the failure mode occurring in accretionary wedges and their analog experiments in the laboratory from the sole knowledge of the material strength and the structure geometry. The proposed methodology relies on the maximum strength theorem which is in- herited from the kinematic approach of the classical limit analysis. It selects the optimum virtual velocity field which minimizes the tectonic force. These velocity fields are constructed by interpolation thanks to the spatial discretization conducted with ten-noded tetra- hedra in 3D and six-noded triangles in 2D. The re- sulting, discrete optimization problem is first presented emphasizing the dual formalism found most appropri- ate in the presence of nonlinear strength criteria, such as the Drucker-Prager criterion used in all reported examples. The numerical scheme is first applied to a perfectly triangular 2D wedge. It is known that fail- ure occurs to the back for topographic slope smaller than and to the front for slope larger than a critical slope, defining subcritical and supercritical slope stabil- ity conditions, respectively. The failure mode is char- acterized by the activation of a ramp, its conjugate back thrust, and the partial or complete activation of the décollement. It is shown that the critical slope is captured precisely by the proposed numerical scheme, the ramp, and the back thrust corresponding to regions of localized virtual strain. The influence of the back- wall friction on this critical slope is explored. It is found that the failure mechanism reduces to a thrust rooting at the base of the back wall and the absence of back thrust, for small enough values of the friction angle. This influence is well explained by the Mohr construction and further validated with experimental results with sand, considered as an analog material. 3D applications of the same methodology are presented in a companion paper.

Resume L’enclouage centromedullaire de l’humerus s’est impose comme un des traitements de reference des fractures cephalotuberositaires a deux, trois ou quatre fragments. Nous avons pu revoir 38 patients âges en moyenne de 64,2 ans, avec un recul moyen de 18 mois. Les scores fonctionnels utilises etaient le score de Constant et Murley ainsi que l’auto-questionnaire de qualite de vie DASH. Des criteres radiologiques ont ete analyses, a savoir l’angle cephalique note αF et la presence d’une eventuelle osteolyse trochiterienne. Les patients ont ete regroupes en fonction du type de fracture, selon la classification de Neer, avec neuf cas dans le groupe Neer 2, 19 dans le groupe Neer 3 et dix dans le groupe Neer 4. Le score de Constant brut etait en moyenne de 53,4 points, pondere a 71,6 %. Les mobilites articulaires retrouvaient une elevation anterieure moyenne a 108°, une abduction a 100° et une rotation externe a 27°. Ces scores etaient d’autant plus mauvais que la fracture etait comminutive. Il n’a pas ete retrouve de correlation radioclinique entre la valeur de l’angle αF et l’evolution clinique, mais la presence d’osteolyse du trochiter etait significativement liee a de mauvais resultats fonctionnels tardifs. Cinq cas d’osteonecrose ont ete denombres, repartis en 10,5 % dans le stade Neer 3 et 30 % dans le stade Neer 4. Le score de Constant brut moyen chez ces patients etait de 38,5 points et pondere a 57,7 %. L’enclouage centromedullaire permet ainsi d’osteosyntheser les fractures comminutives a trois ou quatre fragments mais le controle de la fixation et la solidite du montage n’est pas toujours de rigueur. Chez les sujets jeunes ou la consolidation des tuberosites est essentielle, les plaques vissees semblent en etre une alternative favorable. Par ailleurs, la prothese totale inversee semble avoir de plus en plus d’arguments, pour s’imposer comme le traitement de choix vis-a-vis des fractures a quatre fragments chez les personnes âgees de plus de 75 ans.

International audience; The objective of this study was to investigate, under circumstances of routine care, the impact of paediatric delirium (PD) on length of stay in the paediatric intensive care unit (PICU) as well as on direct financial costs. A five-year prospective observational study (2002–2007) was carried out in a tertiary eight-bed PICU in the Netherlands. Critically ill children aged 1 to 18 years who were acutely, non-electively and consecutively admitted to the PICU and detected as having PD in routine care were compared to critically ill children aged 1 to 18 years without signs of PD. PD, population characteristics and severity of illness at admission were used as predictors for length of PICU stay. Differences in length of stay yielded short-term, direct medical costs associated with PD. Forty-nine children with and 98 children without PD were included. PD prolonged length of PICU stay with 2.39 days, independent of severity of illness, age, gender, mechanical ventilation and medical indication for admission ( = 0.38

Our aim was to evaluate a type 3 portable simplified device as a screening tool for obstructive sleep apnoea (OSA) in coronary patients.In 50 patients selected independently from sleep complaints, we compared the number of respiratory events per hour of valid recording time counted automatically by the device and the number counted manually per hour of sleep on polysomnography performed at home during the same night.Five patients were excluded because of technical failures. Estimated OSA prevalences (95% confidence interval) for apnoea/hypopnoea index (AHI) cut-offsor = 5,or = 15, andor = 30 by polysomnography were 0.93 (0.81-0.98), 0.69 (0.53-0.81), and 0.27 (0.15-0.42), respectively. The device would have correctly diagnosed 75% of patients with severe OSA (AHIor = 30 by polysomnography) and would have classified the remaining 25% as having moderate OSA.This ambulatory device may prove valuable in reducing the costs of diagnosing and managing OSA in coronary patients.

Kinderen met chronische respiratoire insufficientie kunnen in aanmerking komen voor thuisbeademing. Bij voorkeur wordt een dergelijke behandeling in electieve, niet-acute omstandigheden opgestart, nadat zorgvuldig afgewogen is of de patient ervoor in aanmerking komt. Als eenmaal besloten is dat de patient in aanmerking komt voor thuisbeademing, moet door middel van systematische screening en follow-up bepaald worden wanneer het beste hiermee gestart kan worden. Dit artikel formuleert praktische aanbevelingen hiervoor bij patienten met (1) een neuromusculaire aandoening, (2) centrale hypoventilatie, (3) het obstructief slaapapneusyndroom of (4) cystische fibrose.