Search

To evaluate the impact of human milk and different neonatal variables on tidal breathing flow-volume loop (TBFVL) parameters within three months' corrected age (CA) in infants born ≤32 wks or weighing1500 g.We retrospectively studied 121 infants with gestational age (GA) ≤ 32 weeks or birth weight (BW) 1500 gr who had lung function assessment within three months' CA by TBFVL analysis between June 2009 and April 2018. We investigated the impact of GA, gender, being Small for GA (SGA), sepsis, days of mechanical ventilation (MV) and human milk feeding (HMF) on later respiratory function, both in the entire group and according to BW ( ≤1000 g and1000 g).The mean(SD) z-score for tidal volume (Vt) and time to peak expiratory flow to expiratory time (tPTEF/tE) were respectively -4.3 (2.5) and -0.8 (2.0) for the overall population with no significant differences between infants1000 g or ≥1000 g. The mean(SD) Vt standardized for body weight was 6.2(2.0) ml/kg. Being female was associated with better Vt/Kg, whereas longer MV or being born SGA were associated with worst tPTEF/tE. For infants with BW 1000 gr, tPTEF/tE was positively associated with HMF.An early TBFVL assessment within three months' CA already reveals lung function alteration in preterm infants. Being female is associated with better Vt/Kg, while longer duration of MV or being born SGA negatively affect tPTEF/tE. The positive association between HMF and better tPTEF/tE in infants with BW1000 g has emerged, which deserves further investigation.

Objective To evaluate COVID-19 pandemic preparedness, available resources, and guidelines for neonatal care delivery among neonatal health care providers in low- and middle-income countries (LMICs) across all continents. Study design Cross-sectional, web-based survey administered between May and June, 2020. Results Of 189 invited participants in 69 LMICs, we received 145 (77%) responses from 58 (84%) countries. The pandemic provides significant challenges to neonatal care, particularly in low-income countries. Respondents noted exacerbations of preexisting shortages in staffing, equipment, and isolation capabilities. In Sub-Saharan Africa, 9/35 (26%) respondents noted increased mortality in non-COVID-19-infected infants. Clinical practices on cord clamping, isolation, and breastfeeding varied widely, often not in line with World Health Organization guidelines. Most respondents noted family access restrictions, and limited shared decision-making. Conclusions Many LMICs face an exacerbation of preexisting resource challenges for neonatal care during the pandemic. Variable approaches to care delivery and deviations from guidelines provide opportunities for international collaborative improvement.

Background: Current criteria for surfactant administration assume that hypoxia is a direct marker of lung-volume de-recruitment. Objectives: To evaluate whether lung reactance (Xrs) assessment by FOT within 2h of birth identifies infants who would need surfactant within 24h; to eventually determine Xrs performance and a cut-off value for early detection of infants requiring surfactant. Methods: We conducted a prospective, observational, non-randomized study in our tertiary NICU in Milan. Eligible infants were born between 27+0 and 34+6 weeks' gestation presenting respiratory distress after birth. Exclusion criteria: endotracheal intubation at birth, major malformations. We assessed Xrs during nasal CPAP at 5cmH2O at 10Hz within 2h of life, recording flow and pressure tracing through a Fabian Ventilator for off-line analysis. Clinicians were blinded to FOT results. Results: We enrolled 61 infants, with a median[IQR] gestational age of 31.9[30.3; 32.9]weeks and birth weight 1490[1230; 1816]g. 14/59 infants received surfactant within 24h. Xrs predicted surfactant need with a cut-off -33.4 cmH2O*s/L and AUC-ROC=0.86 (0.76-0.96), with sensitivity 0.85 and specificity 0.83. An Xrs cut-off value of -23.3 cmH2O*s/L identified infants needing surfactant or respiratory support >28 days with AUC-ROC=0.89 (0.81-0.97), sensitivity 0.86 and specificity 0.77. Interestingly, 12 infants with Xrs

Among Tidal Breathing Flow Volume (TBFV) parameters, tPTEF/tE is a reproducible marker of airway obstruction associated with infants’ wheezing. Few studies evaluated tPTEF/tE in preterm infants in association with respiratory outcomes post-discharge. Objectives: 1) characterise tPTEF/tE over the first 2yrs of life; 2) evaluate tPTEF/tE predictive value for hospitalisation for respiratory infections (HRI) in preterm infants ± Bronchopulmonary Dysplasia (BPD). We retrospectively analysed TBFV measurements performed at 0-6, 6-12 and 12-24months corrected age in 97 infants ≤32wks’ gestation. We assessed the association between tPTEF/tE z-score and subsequent HRI using uni- and multi-variable logistic regressions and compared nested models by likelyhood ratio test (LRT). tPTEF/tE was lower than normal at all time-points (Fig1), was significantly associated with HRI, particularly in infants without BPD (Fig2), and significantly added to BPD classifications alone in predicting HRI (LRT p < 0.001). Preterm infants present a persistent airway obstruction over the first 2yrs. tPTEF/tE predicts HRI and may be of particular interest for identifying infants at risk without BPD.

To investigate, in infants born preterm with or without bronchopulmonary dysplasia (BPD), the trajectory of tidal breathing flow-volume (TBFV) parameters in the first 2 years of life; the association between TBFV parameters and perinatal risk factors; and the predictive value of TBFV parameters for rehospitalizations due to respiratory infections and wheeze.We retrospectively analyzed TBFV measurements performed at 0-6, 6-12, and 12-24 months of corrected age in 97 infants32 weeks of gestation and1500 g. We assessed the association between TBFV parameters and perinatal risk-factors using linear regressions and the predictive capacity for subsequent respiratory morbidity using logistic regressions. We used the area under the curve and likelihood ratio test (LRT) to compare nested models.Time to peak tidal expiratory flow/expiratory time ratio (tPTEF/tE) was lower than normal for the first 2 years of corrected age. Longer duration of oxygen supplementation, intubation, and respiratory support were associated with reduced tPTEF/tE at all time points. For each z-score increase in tPTEF/tE, the OR for rehospitalizations decreased by 0.70. tPTEF/tE added significantly to BPD classifications alone in predicting rehospitalizations (area under the receiver operating characteristic curve = 0.81 vs 0.76, P value for LRT = .0012), and wheeze (area under the receiver operating characteristic curve = 0.76 vs 0.71, P value for LRT.001).Infants born preterm, with and without BPD, display persistent airway obstruction during the first 2 years of life. tPTEF/tE may identify infants at greater risk of severe respiratory morbidity.

OBJECTIVE: To provide a non-invasive approach to monitoring lung function in spontaneously breathing lambs, from birth to five months of life, by the forced oscillation technique (FOT). This report describes the experimental set-up, data processing, and identification of normal predicted values of resistance (Rrs) and reactance (Xrs) of the respiratory system, along with normal bronchodilator response for bronchial reversibility testing. APPROACH: Rrs and Xrs at 5, 11, and 19 Hz were measured monthly for five months in 20 normal term lambs that breathed spontaneously. In seven lambs, repeated measurements also were made within the first month of life (at 3, 7, 14, and 21 d of life). We determined the repeatability and reproducibility of the measurements and characterized the relationship between lung mechanics and age, sex, and body dimensions, using regression analysis, and measured changes in lung mechanics in response to inhaled bronchodilator. MAIN RESULTS: The measurements provided repeatable and reproducible data. Rrs decreased, whereas Xrs increased, with growth from birth through the first two months of life, after which no statistically significant differences were detected. We identified normal value equations for Rrs and Xrs and for each of the measured anthropometric variables. Respiratory system mechanics were not affected by the bronchodilator. SIGNIFICANCE: The FOT provides reliable non-invasive measurement of respiratory system mechanics in spontaneously breathing term lambs from birth to five months of age. The methods and normal reference values defined in this study will facilitate testing of the pathophysiological consequences of preterm birth and prolonged respiratory support on respiratory system mechanics.

To describe the interrelationship between antenatal steroids, exogenous surfactant, and two approaches to lung recruitment at birth on oxygenation and respiratory system compliance (Cdyn) in preterm lambs.Lambs (n = 63; gestational age 127 ± 1 d) received either surfactant at 10-min life (Surfactant), antenatal corticosteroids (Steroid), or neither (Control). Within each epoch lambs were randomly assigned to a 30-s 40 cmH2O sustained inflation (SI) or an initial stepwise positive end-expiratory pressure (PEEP) open lung ventilation (OLV) maneuver at birth. All lambs then received the same management for 60-min with alveolar-arterial oxygen difference (AaDO2) and Cdyn measured at regular time points.Overall, the OLV strategy improved Cdyn and AaDO2 (all epochs except Surfactant) compared to SI (all P0.05; two-way ANOVA). Irrespective of strategy, Cdyn was better in the Steroid group in the first 10 min (all P0.05). Thereafter, Cdyn was similar to Steroid epoch in the OLV + Surfactant, but not SI + Surfactant group. OLV influenced the effect of steroid and surfactant (P = 0.005) on AaDO2 more than SI (P = 0.235).The antenatal state of the lung influences the type and impact of a recruitment maneuver at birth. The effectiveness of surfactant maybe enhanced using PEEP-based time-dependent recruitment strategies rather than approaches solely aimed at initial lung liquid clearance.

Nasal high-flow therapy (nHFT) is commonly used for noninvasive respiratory support in the neonatal intensive care unit. Our objective was to determine which aspects of neonatal nHFT have achieved adequate evidence base to support consensus among experienced clinical investigators, and to document areas lacking consensus to promote future investigations. Prospective, modified Delphi collation of tabular queries related to specific aspects of neonatal nHFT. Seven international nHFT clinical researchers were queried regarding approaches to initiation, escalation, weaning and discontinuing nHFT. Completed tables were reviewed independently by each investigator, results clarified and discussed and areas of consensus determined. Consensus agreement was reached for many aspects of nHFT including: need for adequate heating and humidification, need to prevent nares occlusion, maximum flow rate of 8 l min−1, assessment of fraction of inspired oxygen (FiO2) and work of breathing for either flow escalation or weaning, equivalence of nHFT to nasal continuous positive airway pressure (nCPAP) for noninvasive support of infants of ⩾28 weeks with resolving respiratory distress and use of nHFT for noninvasive support of stable infants on nCPAP. There was general agreement for initial gas flow rates in the range of 4 to 6 l min−1 and for nHFT as primary therapy for mild respiratory distress. There was no consensus on the approach to discontinuing nHFT. Among an experienced group of nHFT clinical researchers, there was general consensus in the approach to neonatal nHFT. Additional randomized studies are indicated to provide better evidence related to several aspects of nHFT, as well as to identify other clinical conditions where nHFT may provide safe, effective noninvasive support.

Importance Heated, humidified high-flow nasal cannula (HHHFNC) has gained increasing popularity as respiratory support for newborn infants thanks to ease of use and improved patient comfort. However, its role as primary therapy for respiratory distress syndrome (RDS) of prematurity needs to be further elucidated by large, randomized clinical trials. Objective To determine whether HHHFNC provides respiratory support noninferior to nasal continuous positive airway pressure (nCPAP) or bilevel nCPAP (BiPAP) as a primary approach to RDS in infants older than 28 weeks’ gestational age (GA). Design, Setting, and Participants An unblinded, monocentric, randomized clinical noninferiority trial at a tertiary neonatal intensive care unit. Inborn infants at 29 weeks 0 days to 36 weeks 6 days of GA were eligible if presenting with mild to moderate RDS requiring noninvasive respiratory support. Criteria for starting noninvasive respiratory support were a Silverman score of 5 or higher or a fraction of inspired oxygen higher than 0.3 for a target saturation of peripheral oxygen of 88% to 93%. Infants were ineligible if they had major congenital anomalies or severe RDS requiring early intubation. Infants were enrolled between January 5, 2012, and June 28, 2014. Interventions Randomization to either HHHFNC at 4 to 6 L/min or nCPAP/BiPAP at 4 to 6 cm H 2 O. Main Outcomes and Measures Need for mechanical ventilation within 72 hours from the beginning of respiratory support. The absolute risk difference in the primary outcome and its 95% confidence interval were calculated to determine noninferiority (noninferiority margin, 10%). An intention-to-treat analysis was performed. Results A total of 316 infants were enrolled in the study: 158 in the HHHFNC group (mean [SD] GA, 33.1 [1.9] weeks; 52.5% female) and 158 in the nCPAP/BiPAP group (mean [SD] GA, 33.0 [2.1] weeks; 47.5% female). The use of HHHFNC was noninferior to nCPAP with regard to the primary outcome: failure occurred in 10.8% vs 9.5% of infants, respectively (95% CI of risk difference, −6.0% to 8.6% [within the noninferiority margin]; P = .71). Significant between-group differences in secondary outcomes were not found between the HHHFNC and nCPAP/BiPAP groups, including duration of respiratory support (median [interquartile range], 4.0 [2.0 to 6.0] vs 4.0 [2.0 to 7.0] days; 95% CI of difference in medians, −1.0 to 0.5; P = .45), need for surfactant (44.3% vs 46.2%; 95% CI of risk difference, −9.8 to 13.5; P = .73), air leaks (1.9% vs 2.5%; 95% CI of risk difference, −3.3 to 4.5; P = .70), and bronchopulmonary dysplasia (4.4% vs 5.1%; 95% CI of risk difference, −3.9 to 7.2; P = .79). Conclusions and Relevance In this study, HHHFNC showed efficacy and safety similar to those of nCPAP/BiPAP when applied as a primary approach to mild to moderate RDS in preterm infants older than 28 weeks’ GA. Trial Registration clinicaltrials.gov Identifier:NCT02570217

Background The surge in uptake of nasal continuous positive airway pressure (CPAP) for respiratory support in preterm infants has occurred in the absence of an authentic animal model. Such a model would allow investigation of research questions of physiological and therapeutic importance. We therefore aimed to develop a preterm lamb model of the non-intubated very preterm infant on CPAP. Methods After staged exteriorisation and instrumentation, preterm lambs were delivered from anaesthetised ewes at 131 to 133 days gestation. Via a single nasal prong (4-mm internal diameter, 6- to 7-cm depth), positive pressure was delivered from the outset, with nasal intermittent positive pressure ventilation (NIPPV) used until transition to nasal CPAP was attempted, and periodically thereafter for hypoventilation. Caffeine and doxapram were used as respiratory stimulants. Gastric distension was prevented with an oesophageal balloon. Cardiorespiratory parameters and results of arterial blood gas analyses were monitored throughout the study period, which continued for 150 min after first transition to CPAP. Results Ten preterm lambs were studied, at gestation 132 ± 1 days (mean ± SD) and birth weight 3.6 ± 0.45 kg. After stabilisation on NIPPV, transition to nasal CPAP was first attempted at 28 ± 11 min. There was transient respiratory acidosis, with gradual resolution as spontaneous respiratory activity increased. In the final hour, 79% ± 33% of time was spent on CPAP alone, with typical respiratory rates around 60 breaths per minute. PaCO2 at end-experiment was 58 ± 36 mmHg. Conclusions Non-intubated preterm lambs can be effectively transitioned to nasal CPAP soon after birth. This animal model will be valuable for further research.

Despite of improved survival of premature infants, the incidence of long term pulmonary complications, mostly associated with ventilation-induced lung injury, remains high. Non invasive ventilation (NIV) is able to reduce the adverse effects of mechanical ventilation. Although nasal continuous positive airway pressure (NCPAP) is an effective mode of NIV, traumatic nasal complications and intolerance of the nasal interface are common. Recently high flow nasal cannula (HFNC) is emerging as a better tolerated form of NIV, allowing better access to the baby's face, which may improve nursing, feeding and bonding. HFNC may be effective in the treatment of some neonatal respiratory conditions while being more user-friendly for care-givers than conventional NCPAP. Limited evidence is available to support the specific role, efficacy and safety of HFNC in newborns and to demonstrate efficacy compared with NCPAP; some studies suggest a potential role for HFNC in respiratory care of the neonate as a distinct non invasive ventilatory support. We present the preliminary data of a randomized clinical trial; the aim of this study was to assess efficacy and safety of HFNC compared to NCPAP in preterm newborns with mild to moderate respiratory distress syndrome (RDS).

Objective To compare the effect of heated, humidified, high-flow nasal cannula (HHHFNC) and nasal continuous positive airways pressure (NCPAP) on lung function and mechanics in preterm infants with respiratory distress syndrome (RDS) at the same level of retropharyngeal pressure (P rp ). Design Randomised crossover trial. Setting Neonatal intensive care unit, Ospedale Maggiore Policlinico, Milan, Italy. Patients 20 preterm infants (gestational age: 31±1 wks) with mild-moderate RDS requiring non-invasive respiratory support within 96 h after birth. Interventions Infants were exposed to a randomised sequence of NCPAP and HHHFNC at different settings (2, 4 and 6 cmH 2 O for NCPAP and 2, 4, 6 L/min for HHHFNC) to enable comparison at the same level of P rp . Main outcome measures Tidal volume by respiratory inductance plethysmography, pleural pressure estimated by oesophageal pressure, and gas exchange were evaluated at each setting and used to compute breathing pattern parameters, lung mechanics and work of breathing (WOB). Results A poor linear regression between flow and P rp was found during HHHFNC (P rp =0.3+0.7*flow; r 2 =0.37). Only in 15 out of 20 infants it was possible to compare HHHFNC and NCPAP at a P rp of 2 and 4 cmH 2 O. No statistically significant differences were found in breathing pattern, gas exchange, lung mechanics and total WOB. Resistive WOB in the upper airways was slightly but significantly higher during HHHFNC (0.65 (0.49;1.09) vs 1.57 (0.85;2.09) cmH 2 O median (IQR)). Conclusions Despite differing mechanisms for generating positive airway pressure, when compared at the same P rp , NCPAP and HHHFNC provide similar effects on all the outcomes explored.

Outbreaks of nosocomial pathogens are one of the most relevant problems in Neonatal Intensive Care Unit (NICU). Many factors contribute to the onset of an epidemic, including virulence of the pathogen and vulnerability of the infants hospitalized in NICU. Outbreaks are often caused by multidrug-resistant organisms (MDROs). MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. MDROs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and certain gram-negative bacilli (GNB), have important infection control implications. Once MDROs are introduced into a healthcare setting, transmission and persistence of the resistant strain is determined by the availability of vulnerable patients, selective pressure exerted by antimicrobial use, increased potential for transmission from larger numbers of infected or colonized patients (“colonization pressure”), and the impact of adherence to prevention efforts. Often, routine infection control measures are not enough to contain outbreaks, and additional control measures are needed, including implementation of hand hygiene, cohorting of infected/colonized infants, neonatal surveillance cultures, screening of healthcare workers and decolonization of neonates and/or healthcare workers in selected cases. In this review, we report the practices we developed in our NICU to contain an epidemic. These recommendations reflect the experience of the group, as well as the findings of the current literature.

Despite of improved survival of premature infants, the incidence of long term pulmonary complications, mostly associated with ventilation-induced lung injury, remains high. Non invasive ventilation (NIV) is able to reduce the adverse effects of mechanical ventilation. Although nasal continuous positive airway pressure (NCPAP) is an effective mode of NIV, traumatic nasal complications and intolerance of the nasal interface are common. Recently high flow nasal cannula (HFNC) is emerging as an efficient, better tolerated form of NIV, allowing better access to the baby’s face, which may improve nursing, feeding and bonding. The aim of this review is to discuss the available evidence of effectiveness and safety of HFNC in preterm newborns with respiratory distress syndrome (RDS). It is known that distending pressure generated by HFNC increases with increasing flow rate and decreasing infant size and varies according to the amount of leaks by nose and mouth. The effects of HFNC on lung mechanics, its clinical efficacy and safety are still insufficiently investigated. In conclusion, there is a growing evidence of the feasibility of HFNC as an alternative mode of NIV. However, further larger randomized trials are required, before being able to recommend HFNC in the treatment of moderate respiratory distress of preterm infants.

The purpose of this investigation was to collect information regarding rhinovirus (RV) circulation in children with lower respiratory tract infections (LRTIs) in Burundi, Central Africa. We enrolled all of the children aged between 1 month and 14 years who were admitted to the hospital of Kiremba, North Burundi, with fever and signs and symptoms of LRTI (i.e., cough, tachypnea, dyspnea or respiratory distress, and breathing with grunting or wheezing sounds with rales) between 1 November 2010 and 31 October 2011, and obtained nasopharyngeal swabs for RV detection by means of polymerase chain reaction (PCR). The VP4/VP2 region of the positive samples was sequenced to determine the species of RV (A, B, or C). Four hundred and sixty-two children were enrolled: 160 (34.6 %) with bronchitis, 35 (7.6 %) with infectious wheezing, and 267 (57.8 %) with community-acquired pneumonia (CAP). RV infection was demonstrated in 186 patients [40.3 %; mean age ± standard deviation (SD) 1.77 ± 2.14 years]. RV infection was detected in 78 patients aged12 months (40.0 %), 102 aged 12-48 months (44.3 %), and six aged48 months (16.7 %; p 0.01 vs. the other age groups). The most frequently identified RV was RV-A (81 cases, 43.5 %), followed by RV-C (47, 25.3 %) and RV-B (18, 9.7 %); subtyping was not possible in 40 cases (21.5 %). RV-A was significantly associated with bronchitis and CAP (p 0.01) and RV-C with wheezing (p 0.05). In Burundi, RVs are frequently detected in children with LRTIs. RV-A seems to be the most important species and is identified mainly in patients with bronchitis and CAP.

Flumazenil, the first specific benzodiazepine (BZD) antagonist, is one of the most innovative drugs to become available within the last few years. Flumazenil is indicated for the reversal of the centrally depressant effects of BZDs, in BZD-induced anaesthesia, in BZD sedation in intensive care and in patients comatose after drug overdoses including BZDs. A conference of experts experienced in the treatment of mixed drug overdoses by various means, including flumazenil, was held in order to try to reach a consensus regarding the safe use of flumazenil in this indication. From the knowledge and experience gained to date, it was concluded that flumazenil may be useful and safe in the treatment of suspected BZD and mixed drug overdoses, provided that the appropriate precautions are observed.

In order to investigate whether sleep deprivation activates the photoconvulsive response 35 patients were investigated electroencephalographically after 24–36 h of waking. In 34 cases with sleep depri

This paper reports on 294 patients with presumptive symptoms of epilepsy but no noteworthy, or only suspicious, EEG findings. With recording during sleep after 24–27 h of sleep deprivation, 138 person

The specificity of localized periodic complexes (PC) in the EEG is discussed by means of a case. This patient presented rapidly evolving focal symptoms of the CNS together with fever. The EEG showed localized PCs and in the CT scan there was a hyperdense lesion in a region corresponding to the EEG finding. Postmortem examination revealed a subcortical bleeding in the temporal region. Possible mechanisms for the origin of these PCs and their diagnostic value are discussed.

Computerized transaxial tomography was carried out on 112 patients with partial seizures with complex symptomatology. Structural abnormalities were defined in 33% of their studies: tumors in 8 patients, diffuse cerebral atrophy in 2, focal cortical atrophy in 27 and vascular abnormality in 1 case.

The authors themselves studied 26 patients. The EEGs were classified in terms of increasing severity in 5 categories. Incorporating over 400 cases from the literature, the authors correlated the initial EEG findings with the clinical outcome following cardiac arrest. Grade I EEG findings (normal alpha with theta-delta activity) imply a very good prognosis. A complete remission can be expected in most cases. Grade II (dominant theta-delta activity with detectable normal alpha) and grade III (dominant theta-delta activity without detectable normal alpha) findings have no definite prognosis. Grade IV [low-voltage delta, possibly with short isoelectric intervals; dominant, monomorphic, non-reactive alpha-activity (alpha coma); periodic generalized phenomena (spikes, sharp waves, slow waves with very low background activity)] and grade V (very flat to isoelectric EEG) findings have a very serious prognosis.

A 24-year-old female with gastrointestinal disturbances, nausea and vomiting, had a convulsion with loss of urine and bitten lips on the 5th day of hospitalization. A significant decrease of sodium and potassium levels and lowered osmolality of the serum as well as urinary hyperosmolality permitted the diagnosis of the so-called syndrome of inappropriate antidiuretic hormone release (SIADH) of unknown aetiology, described by Schwartz-Bartter. Twice short tests for porphyria were negative; then the elevated porphyrin precursors collected in 24 h urine indicated the existence of an acute intermittent porphyria. A clinical follow-up and improvement were demonstrated by the EEG findings. Since animal experiments and pathohistological findings indicate that porphyrin metabolites such as delta-amino laevulinic acid and porphobilinogen may influence inhibitory and neurosecretory structures in central nervous tissue and interfere with GABA, cerebral hyperexcitability as well as disturbance of electrolytes may be explained. Finally, the question of whether the EEG changes are due to the significant electrolyte disturbances or are typical signs of acute intermittent porphyria is discussed.

The treatment of chronic portal-systemic encephalopathy (PSE) was approached in a new manner by feeding the nonabsorbable disaccharide lactulose (1-4-beta-galactosido-fructose) in doses sufficiently large to produce a mild artificial disaccharide malabsorption syndrome. Six patients with advanced cirrhosis of the liver complicated by PSE were studied during several periods. Control of PSE as judged by clinical grading, electroencephalographic grading and blood ammonia levels was satisfactory in every case. Control treatment with laxatives and neomycin eliminated the possibility of a nonspecific effect. Protein tolerance increased during lactulose administration. Diarrhea, the major side effect, was not a problem when the administered doses were adjusted to each individual patient. In the literature 114 lactulose-treated patients with PSE have been described. The over-all experience suggests a success rate of 85 per cent and substantiates the impression that this therapy is particularly useful for long-term control of PSE. The beneficial effects of lactulose in PSE cannot be explained by the rather inconsistent decrease in putrefactive colonic bacteria, which correlated poorly with the clinical condition of two patients studied in detail. The lowered blood ammonia levels under treatment are compatible with the idea that ammonia absorption from the colon is decreased under lactulose treatment.

SUMMARY Two unusual cases of sensory precipitation of epileptic attacks are presented and briefly discussed. One patient had suffered from tonic and clonic seizures in her right arm for 11 years. The seizures were induced by touching this arm or even by carrying a heavy object. She never had a generalized seizure. The other patient had petit mal-like attacks when taking food, sometimes provoked by the mere sight of it. In both cases the epileptic nature was confirmed by the EEG and by successful anticonvulsant treatment. RESUME Deux cas inhabituels de declanchement sensoriel d'attaques epileptiques sont presentes et brievement discutes. L'un concerne une patiente souffrant de crises tonico-cloniques de son bras droit, depuis 11 ans, a l'exclusion de toute generalisation. Les crises etaient induites par le simple contact decebras, ou lorsqu'elle soulevait un objet lourd. L'autre patient avait des crises de type petit mal lorsqu'il absorbait de la nourriture ou meme parfois a la simple vue de celle-ci. Dans les deux cas, la nature epileptique a ete confirmee par l'E.E.G. et par les bons resultats d'une therapeutique anticonvulsivante.

• The accuracy of computed tomography, electroencephalography, and clinical features in the differential diagnosis of senile dementia was studied prospectively. Out of 50 demented patients, autopsy revealed 32 cases with either senile dementia of the Alzheimer's type (SDAT), multi-infarct dementia (MID), or a combination of both. Eighteen patients had dementia caused by other diseases. Based on a combination of computed tomography, electroencephalography, and clinical features, senile dementia of the Alzheimer's type was differentiated from all 50 patients, with a specificity of 83% and a sensitivity of 80%. Focusing on senile dementia of the Alzheimer's type, multi-infarct dementia, or a combination of both, specificity decreased to 65% and sensitivity to 47%. Comparing the different methods, multi-infarct processes were diagnosed with a higher sensitivity by the clinical features (73%) than by computed tomography (18%) or electroencephalography (18%). None of the methods validly differentiated multi-infarct dementia from a combination of multi-infarct dementia and senile dementia of the Alzheimer's type.

A case of subacute sclerosing leucoencephalitis is presented. EEG and EMG tracings were obtained in the waking state and during sleep. While awake there were no normal rhythms. Some theta activity was recorded and generalized repetitive complexes were prominent. In general, sleep was characterized by absence of spontaneous and provoked transients, a more regular repetition of complexes with a peak interval at 2–3 sec (by computing the intervals over 12 min) and a periodic activation of epileptic activity during slow sleep. EMG confirmed the disappearance of involuntary movements. The presence of REM sleep was ascertained by characteristic changes of eye movements, respiration and ECG. Fewer sharp waves were found during the periods of REM sleep and myoclonus reappeared intermittently. In both the waking and sleeping states we found a statistically significant difference between the number of EEG complexes during inspiration-expiration and the interval between them.

Respiratory diseases are a major cause of morbidity in neonates, especially preterm infants; a long term complication of prematurity such as bronchopulmonary dysplasia (BPD) is particularly relevant today. The exact role of the Pulmonary Function Test (PFT) in this area is not yet well defined; the PFT in newborns and infants - in contrast to what happens in uncooperative children and adults - are routinely used only in a few centers. The assessment of pulmonary function in newborns and infants, however, is nowadays possible with the same reliability that in cooperative patients with the possibility to extend the assessment of polmonary function from bench to bed. The assessment of pulmonary function must be carried out with non invasive and safe methods, at the bedside, with the possibility of continuous monitoring and providing adequate calculation and management of data. The ability to assess lung function helps to define the mechanisms of respiratory failure, improving the treatment and its effects and is therefore a useful tool in the follow-up of newborn and infant with pulmonary disease.