Search

The distribution of ventilation during high-frequency ventilation (HFV) is asynchronous, nonhomogeneous, and frequency dependent. We hypothesized that differences in the regional distribution of ventilation at different oscillatory frequencies may affect gas exchange efficiency. We studied 15 newborn infants with a median gestational age of 28.9 (26.4–30.3) wk and body weight of 1.0 (0.8–1.4) kg. Five ventilation frequencies (5, 8, 10, 12, and 15 Hz) were tested, keeping carbon dioxide diffusion coefficient constant. The displacements of 24 passive markers placed on the infant’s chest wall were measured by optoelectronic plethysmography. We evaluated the amplitude and phase shift of displacements of single markers placed along the midline and the regional displacements of the chest wall surface. Blood gases were unaffected by frequency. Chest wall volume changes decreased from 1.6 (0.4) ml/kg at 5 Hz to 0.7 ml/kg at 15 Hz. At all frequencies, the abdomen (AB) oscillated more markedly than the ribcage (RC). The mean (SD) AB/RC ratio was 1. 95 (0.7) at 5 Hz, increased to 2.1 (1.3) at 10 Hz, and then decreased to 1.1 (0.5) at 15 Hz ( P < 0.05 vs. 10 Hz). Volume changes in the AB lagged the RC and this phase shift increased with frequency. The AB oscillated more than the RC at all frequencies. Regional oscillations were highly inhomogeneous up to 10 Hz, and they became progressively more asynchronous with increasing frequency. When the carbon dioxide diffusion coefficient is held constant, such differences in regional chest wall expansion do not affect gas exchange. NEW & NOTEWORTHY We characterized the regional distribution of chest wall displacements in infants receiving high-frequency oscillatory ventilation at different frequencies. When carbon dioxide diffusion coefficient is held constant, there is no combination of frequency and tidal volume that optimizes gas exchange. The relative displacement between different chest wall compartments is not affected by frequency. However, at high frequencies, chest wall displacements are lower, with the potential to reduce total and regional overdistension without affecting gas exchange.

Summary Background The importance of lung recruitment before surfactant administration has been shown in animal studies. Well designed trials in preterm infants are absent. We aimed to examine whether the application of a recruitment manoeuvre just before surfactant administration, followed by rapid extubation (intubate-recruit-surfactant-extubate [IN-REC-SUR-E]), decreased the need for mechanical ventilation during the first 72 h of life compared with no recruitment manoeuvre (ie, intubate-surfactant-extubate [IN-SUR-E]). Methods We did a randomised, unblinded, controlled trial in 35 tertiary neonatal intensive care units in Italy. Spontaneously breathing extremely preterm neonates (24 + 0 to 27 + 6 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 h of life were randomly assigned (1:1) with a minimisation algorithm to IN-REC-SUR-E or IN-SUR-E using an interactive web-based electronic system, stratified by clinical site and gestational age. The primary outcome was the need for mechanical ventilation in the first 72 h of life. Analyses were done in intention-to-treat and per-protocol populations, with a log-binomial regression model correcting for stratification factors to estimate adjusted relative risk (RR). This study is registered with ClinicalTrials.gov , NCT02482766 . Findings Of 556 infants assessed for eligibility, 218 infants were recruited from Nov 12, 2015, to Sept 23, 2018, and included in the intention-to-treat analysis. The requirement for mechanical ventilation during the first 72 h of life was reduced in the IN-REC-SUR-E group (43 [40%] of 107) compared with the IN-SUR-E group (60 [54%] of 111; adjusted RR 0·75, 95% CI 0·57–0·98; p=0·037), with a number needed to treat of 7·2 (95% CI 3·7–135·0). The addition of the recruitment manoeuvre did not adversely affect the safety outcomes of in-hospital mortality (19 [19%] of 101 in the IN-REC-SUR-E group vs 37 [33%] of 111 in the IN-SUR-E group), pneumothorax (four [4%] of 101 vs seven [6%] of 111), or grade 3 or worse intraventricular haemorrhage (12 [12%] of 101 vs 17 [15%] of 111). Interpretation A lung recruitment manoeuvre just before surfactant administration improved the efficacy of surfactant treatment in extremely preterm neonates compared with the standard IN-SUR-E technique, without increasing the risk of adverse neonatal outcomes. The reduced need for mechanical ventilation during the first 72 h of life might facilitate implementation of a non-invasive respiratory support strategy. Funding None.

Purpose Delayed cord clamping for at least 60 s is recommended to improve neonatal outcomes. The aim of this study is to evaluate whether there are differences in cord BGA between samples collected after double clamping the cord or without clamping the cord, when blood collection occurs within 60 s from birth in both groups. Methods A cross-sectional study was carried out, collecting data from 6884 high-risk women who were divided into two groups based on the method of cord sampling (clamped vs unclamped). Results There were significant decrease in pH and BE values into unclamped group compared with the clamped group. This difference remained significant when considering pathological blood gas analysis parameters, with a higher percentage of pathological pH or BE values in the unclamped group. Conclusion Samples from the unclamped cord alter the acid–base parameters compared to collection from the clamped cord; however, this difference does not appear to be of clinical relevance. Findings could be due to the large sample size, which allowed to achieve a high power and to investigate very small numerical changes between groups, leading to a statistically significant difference in pH and BE between samples even when we could not appreciate any clinical relevant difference of pH or BE between groups. When blood gas analysis is indicated, the priority should be given to the timing of blood collection to allow reliable results, to assess newborns status at birth and intervene when needed.

Objectives: To determine the short-term tolerance, efficacy, and lung deposition of supraglottic atomized surfactant in spontaneously breathing lambs receiving continuous positive airway pressure. Design: Prospective, randomized animal study. Setting: Animal research laboratory. Subjects: Twenty-two preterm lambs on continuous positive airway pressure (132 +/- 1 d gestational age). Interventions: Animals receiving continuous positive airway pressure via binasal prongs at 8 cm H 2 O were randomized to receive atomized surfactant at approximately 60-minute of life (atom; n = 15) or not (control; n = 7). The atom group received 200 mg/kg of poractant alfa (Curosurf; Chiesi Farmaceutici SpA, Parma, Italy) over 45 minutes via a novel atomizer located in the upper pharynx that synchronized surfactant delivery with the inspiratory phase. Measurements and Main Results: Arterial blood gas, regional distribution of tidal ventilation (electrical impedance tomography), and carotid blood flow were recorded every 15 minutes until 90 minutes after stabilizing on continuous positive airway pressure. Gas exchange, respiratory rate, and hemodynamic variables, including carotid blood flow, remained stable during surfactant treatment. There was a significant improvement in arterial alveolar ratio after surfactant delivery in the atom group (p < 0.05; Sidak posttests), while there was no difference in Paco 2. Electrical impedance tomography data showed a more uniform pattern of ventilation in the atom group. In the atom group, the median (interquartile range) deposition of surfactant in the lung was 32% (22-43%) of the delivered dose, with an even distribution between the right and the left lungs. Conclusions: In our model of spontaneously breathing lambs receiving CPAP, supraglottic atomization of Curosurf via a novel device was safe, improved oxygenation and ventilation homogeneity compared with CPAP only, and provided a relatively large lung deposition suggesting clinical utility.

We hypothesized that ventilating at the resonant frequency of the respiratory system optimizes gas exchange while limiting the mechanical stress to the lung in newborns receiving high-frequency oscillatory ventilation (HFOV). We characterized the frequency dependence of oscillatory mechanics, gas exchange, and pressure transmission during HFOV. We studied 13 newborn infants with a median (interquartile range) gestational age of 29.3 (26.4–30.4) weeks and body weight of 1.00 (0.84–1.43) kg. Different frequencies (5, 8, 10, 12, and 15 Hz) were tested, keeping carbon dioxide diffusion coefficient (DCO2) constant. Oscillatory mechanics and transcutaneous blood gas were measured at each frequency. The attenuation of pressure swings (ΔP) from the airways opening to the distal end of the tracheal tube (TT) and to the alveolar compartment was mathematically estimated. Blood gases were unaffected by frequency. The mean (SD) resonant frequency was 16.6 (3.5) Hz. Damping of ΔP increased with frequency and with lung compliance. ΔP at the distal end of the TT was insensitive to frequency, whereas ΔP at the peripheral level decreased with frequency. There is no optimal frequency for gas exchange when DCO2 is held constant. Greater attenuation of oscillatory pressure at higher frequencies offers more protection from barotrauma, especially in patients with poor compliance.

Nutrition and pulmonary function in very-low-birth-weight infants (VLBWIs) are strictly related. Preterm infants on noninvasive ventilation may have respiratory instability that can interfere with feeding tolerance. Moreover, feeding may impair pulmonary function. These infants have nutritional requirements different from nonventilated infants. The main challenge of the nutritional support in such patients is to guarantee adequate caloric intake while avoiding episodes of feeding intolerance. The aim of this study was to review the issues and strategies of enteral feeding of preterm infants on noninvasive ventilation.

To evaluate surfactant effectiveness for the treatment of respiratory distress syndrome (RDS) in late preterm infants.We performed a retrospective cohort study of infants born between 34We studied 562 infants with RDS, 252 (45%) were treated with surfactant and 310 (55%) were not. FiOSurfactant therapy was followed by a quick and persisting significant improvement of respiratory function in late preterm infants with RDS. Surfactant did not improve short-term outcomes in our population probably because other factors such as the gestational age, occurrence of complications and poor feeding play a relevant role.

Objective Despite technical specifications of neonatal mechanical ventilators (MVs) guarantee clinically irrelevant discrepancies between the set and the delivered values of ventilation parameters, previous studies reported large deviations. Most studies characterized performances of a given model/brand by studying a single device, disregarding possible intramodel differences, and leaving the accuracy of the ventilation parameters effectively delivered in clinical settings unknown. The aim of this study was to evaluate the real-life accuracy of pressure and volume parameters delivered by neonatal ventilators ready to be used on patients in neonatal intensive care units (NICUs). Study design In vitro study. Subjects selection Neonatal ventilators (n = 33 of 8 different models) available in four European NICUs. Methodology The MVs were connected to a test lung (resistance = 50 cmH2 O*s/L, compliance = 0.35 mL/cmH2 O) provided with pressure and flow sensors. MVs were tested over two different ventilation modes randomly: (a) pressure controlled (PC) with a peak inspiratory pressure (PIP) of 22 cmH2 O, and (b) PC with volume targeted ventilation (VTV) with a tidal volume (VT ) of 6 mL. In all tests, positive end-expiratory pressure (PEEP) was set to 6 cmH2 O, respiratory rate to 45 breaths/min, inspiratory time to 0.33 seconds, and oxygen fraction to 0.3. Results During PC the median (min-max) values delivered were: PEEP = 5.84(4.95-6.48) cmH2 O, PIP = 21.63(20.04-22.62) cmH2 O. During VTV, VT was 5.94(4.63-8.01) mL. VT was considerably variable, ranging from -22% to +33% of the set and displayed values. Differences in accuracy among devices of the same model were comparable to those found among different models. Conclusions Our findings suggest that loss of accuracy in ventilation variables is likely related to daily use of the devices rather than weakness in the design or manufacturing process, urging the improvement of maintenance and quality control procedures to preserve the performances of neonatal MVs during their entire lifespan.

Objective of the work is the development of prognostic machine learning models that predict qualitative and quantitative measures of postnatal growth in very low birth weight preterm infants. Observational retrospective data about 964 infants at risk are retrieved from “Fondazione Monza e Brianza per il bambino e la mamma“’s electronic medical record. Both prenatal (gestational, socioeconomic, etc.) and perinatal (nutritional, respiratory assistance, drug prescription and daily growth) data up to a week after birth are the features included. Model’s performances are compared to previous literature and human performance, showing a substantial improvement (in e.g., best regression MAE=0.49, best classification AUC=0.94).

Neonatal myocardial infarction (MI) is a very rare but potentially life-threatening condition with an approximated mortality rate of 80%. Congenital heart disease, anomalous coronary artery anatomy, thromboembolism, coagulopathy, birth asphyxia or myocarditis have been suggested as possible causes of MI. Here we report the case of a premature infant who died at about 40 h of life from a massive MI. Autopsy revealed an occlusive thrombus in the right coronary artery. An isolated prothrombotic status, characterized by a double copy variant of the MTHFR A1298C mutation, was identified at the postmortem genetic studies as a possible explanation for the coronary artery thrombosis. No other risk factors were detected.

Background: Oral propranolol reduces retinopathy of prematurity (ROP) progression, although not safely. Propranolol 0.1% eye micro-drops administered to newborns with stage 2 ROP are well-tolerated, but not sufficiently effective. Methods: A multi-center open-label trial was conducted to assess the safety and efficacy of propranolol 0.2% eye micro-drops in newborns with stage 1 ROP. The progression of the disease was evaluated with serial ophthalmologic examinations. Hemodynamic, respiratory, biochemical parameters, and propranolol plasma levels were monitored. Demographic and perinatal characteristics, co-morbidities and co-intervention incidences, together with ROP progression, were compared with a historical control group in the same centers participating in the trial. Results: Ninety-eight newborns were enrolled and compared with the historical control group. Populations were not perfectly homogeneous (as demonstrated by the differences in the Apgar score and the different incidence rate in surfactant administration and oxygen exposure). The progression to ROP stage 2 or 3 plus was significantly lower than the incidence expected on the basis of historical data (Risk Ratio 0.521, 95% CI 0.297– 0.916). No adverse effects related to propranolol were observed and the mean propranolol plasma level was significantly lower than the safety cut-off of 20 ng/mL. Unexpectedly, three newborns treated with oral propranolol before the appearance of ROP, showed a ROP that was unresponsive to propranolol eye micro-drops and required laser photocoagulation treatment. Conclusion: Propranolol 0.2% eye micro-drops were well-tolerated and appeared to reduce the ROP progression expected on the basis of a comparison with a historical control group. Propranolol administered too early appears to favor a more aggressive ROP, suggesting that a β-adrenoreceptor blockade is only useful during the proliferative phase. Further randomized placebo-controlled trials are required to confirm the current results. Clinical Trial Registration The trial was registered at ClinicalTrials.gov with Identifier NCT02504944 and with EudraCT Number 2014-005472-29.

Objectives In preterm infants, the application of nasal Continuous Positive Airway Pressure (nCPAP) improves lung function through several mechanisms and may interact with the control of breathing. Our aim was to evaluate the effect of increasing/decreasing nCPAP on gas exchange, breathing pattern, and its variability in preterm infants. Methods Fifeteen infants with mild to moderate respiratory distress syndrome (RDS) were studied on the first day of life. Infants had a mean (SD) gestational age of 30 + 4 (3 + 4) weeks + day and body weight of 1405 (606) g. nCPAP was increased every 10 min stepwise (0-4-8-10 cmH2 O) and then decreased every 20 min (8-6-4-2 cmH2 O). At each step, vital parameters, oxygenation, and chest wall volume changes (optoelectronic plethysmography) were evaluated. Tidal volume (VT ), inter-breath interval (IBI), end-expiratory lung volume (EELV) changes, and other breathing pattern parameters were computed breath-by-breath. The correlation properties of VT , IBI, and EELV were quantified by detrended fluctuation analysis, computing the scaling exponent α. Results During nCPAP, oxygenation improved and VT decreased significantly compared with no nCPAP. No significant changes in breathing pattern were observed between nCPAP levels. α of EELV was significantly higher off nCPAP than during nCPAP, suggesting that nCPAP helps stabilize EELV control mechanisms. Conclusions In our population of preterm infants with mild to moderate RDS, in the first day of life, nCPAP improved gas exchange, VT , and EELV stability independent of nCPAP level.

Fetal growth restriction (intra-uterine growth restriction [IUGR]) has a considerable impact on perinatal morbidity. Preterm IUGR infants are prone to impaired intestine function. Near-infrared spectroscopy (NIRS) has been used to monitor oxygenation status of the brain and of the intestine.We conducted a prospective case-control study at our NICU in 20 preterm infants of whom 10 infants complicated by compared with 10 non-IUGR preterm infants. Splanchnic and cerebral regional oximetry values were measured with NIRS. Three hours of consecutive recordings were performed in the first 24 h of life, T0, and during the transitional period, T1. The cerebral/splanchnic oxygenation ratio, CSOR, (cerebral regional saturations [rScO2]/splanchnic regional saturations [rSsO2]) was also calculated.Both in the IUGR and the non-IUGR infants, at T0 and T1 monitoring time-points, the rSO2 values were higher in the cerebral district when compared to those of the splanchnic area. Comparison of the NIRS parameters between the IUGR and non-IUGR infants at T0 showed no difference in rScO2, while rSsO2 was significantly lower in the IUGR group. At T1, rScO2 was significantly lower and rSsO2 higher in the IUGR group.Cerebral/splanchnic vascular adaptation of IUGR infants to the extra-uterine environment is characterized by a postnatal persistence of the brain sparing effect with reperfusion in the transitional period.

Even if the accuracy of mechanical ventilators (MV) stated by manufacturers are largely within clinically relevant ranges, Govoni et al. (2012) found large deviations from original specifications in adult MV during real life usage, especially on volume-related parameters. This loss of accuracy can be extremely critical in neonatal MV, where the recent spreading of the volume guarantee (VG) modality made flow measurements more critical. The aim of this study was to evaluate the real life performances of MV used in neonatal intensive care unit (NICU). A test lung (TL) equipped with pressure and flow sensors mimicking a mild RDS (R=50cmH2O*s/l, C=0.35ml/cmH2O) baby was connected to the MVs ready to be used on patients (n=20) available in 3 NICUs. MVs were tested in both pressure controlled (PC, peak inspiratory pressure PIP=22cmH2O) and PC with VG (tidal volume VT=6ml) modalities in random order. In all tests, positive end-expiratory pressure (PEEP) was 6cmH2O, respiratory rate 45breaths/min, inspiratory time 0.33s, oxygen fraction 30%. The values of PEEP, PIP (during PC) and VT (during VG) delivered by MVs are reported in Figure. In several MVs, the ventilation delivered was considerably different from the set one with actual VT ranging from 5.3 to 8.0ml, urging the need of improving quality control procedures for preserving the performances of MVs with usage.

Optimization of nutritional management of preterm infants is crucial for achievement of their long-term health. Enteral nutrition is preferred to total parenteral nutrition (TPN) because the former avoids complications related to vascular catheterization, sepsis, adverse effects of TPN, and fasting. Due to the lack of ability of preterm infants to coordinate suckling, swallowing, and breathing, tube feeding is necessary for most infants less than 1500 g to ensure sufficient feeding tolerance, to support optimal growth and to reduce the risk of aspiration. Therefore, feeding by orogastric or nasogastric tube using either continuous or intermittent bolus delivery of formula or human milk is common practice for these infants. Theoretical risks and benefits of both continuous nasogastric milk feeding and intermittent bolus milk feeding have been proposed. According to the literature, continuous nutrition could be preferred in smaller infants (as those with a birthweight below 1250 g) or hemodynamically impaired infants; in stable growing infants nutrition can be administered intermittently as in healthy term infants.

Intrauterine growth restriction (IUGR) infants are thought to have impaired gut function after birth secondary to intrauterine redistribution of the blood flow, due to placental insufficiency, with a consequent reduction of gut perfusion. For this reason, infants complicated by IUGR have been considered at higher risk of feeding intolerance. Postnatal evaluation of splanchnic perfusion, through Doppler of the superior mesenteric artery, and of splanchnic oxygenation, through near infrared spectroscopy measurements, may be useful in evaluating the persistence (or not) of the redistribution of blood flow occurred in utero.

Summary A study was undertaken to analyze the clinical presentation, pulmonary function, and pathological features in two female siblings with neonatal pulmonary surfactant metabolism dysfunction, type 3 (MIM 610921). The clinical records of the siblings were examined; the genes encoding surfactant protein B (SFTPB), surfactant protein C (SFTPC), and ATP-binding cassette transporter 3 protein (ABCA3) were analyzed with direct sequencing and Southern blotting. The infants were homozygous for a 5,983 bp deletion in ABCA3 including exons 2–5 as well as the start AUG codon and a putative Golgi exit signal motif. Dense abnormalities of lamellar bodies at electron microscopy and absence of ABCA3 at immunohistochemical staining were in agreement with the presence of two null alleles. In addition, an increased lipid synthesis suggested a compensatory mechanism. The clinical course in the two sisters was influenced by different environmental factors like the time needed for molecular confirmation, the ventilatory assistance adopted, the occurrence of infections. A less aggressive clinical approach did not improve the course of the disease; the prognosis was always poor. Development of a fast molecular test, able to detect also structural variants, is needed. Pediatr Pulmonol. 2014; 49:E116–E120. © 2014 Wiley Periodicals, Inc.

Although beneficial in clinical practice, the INtubate-SURfactant-Extubate (IN-SUR-E) method is not successful in all preterm neonates with respiratory distress syndrome, with a reported failure rate ranging from 19 to 69 %. One of the possible mechanisms responsible for the unsuccessful IN-SUR-E method, requiring subsequent re-intubation and mechanical ventilation, is the inability of the preterm lung to achieve and maintain an “optimal” functional residual capacity. The importance of lung recruitment before surfactant administration has been demonstrated in animal studies showing that recruitment leads to a more homogeneous surfactant distribution within the lungs. Therefore, the aim of this study is to compare the application of a recruitment maneuver using the high-frequency oscillatory ventilation (HFOV) modality just before the surfactant administration followed by rapid extubation (INtubate-RECruit-SURfactant-Extubate: IN-REC-SUR-E) with IN-SUR-E alone in spontaneously breathing preterm infants requiring nasal continuous positive airway pressure (nCPAP) as initial respiratory support and reaching pre-defined CPAP failure criteria. In this study, 206 spontaneously breathing infants born at 24+0–27+6 weeks’ gestation and failing nCPAP during the first 24 h of life, will be randomized to receive an HFOV recruitment maneuver (IN-REC-SUR-E) or no recruitment maneuver (IN-SUR-E) just prior to surfactant administration followed by prompt extubation. The primary outcome is the need for mechanical ventilation within the first 3 days of life. Infants in both groups will be considered to have reached the primary outcome when they are not extubated within 30 min after surfactant administration or when they meet the nCPAP failure criteria after extubation. From all available data no definitive evidence exists about a positive effect of recruitment before surfactant instillation, but a rationale exists for testing the following hypothesis: a lung recruitment maneuver performed with a step-by-step Continuous Distending Pressure increase during High-Frequency Oscillatory Ventilation (and not with a sustained inflation) could have a positive effects in terms of improved surfactant distribution and consequent its major efficacy in preterm newborns with respiratory distress syndrome. This represents our challenge. ClinicalTrials.gov identifier: NCT02482766 . Registered on 1 June 2015.

Objective To detect changes in splanchnic perfusion and oxygenation induced by 2 different feeding regimens in infants with intrauterine growth restriction (IUGR) and those without IUGR. Study design This was a randomized trial in 40 very low birth weight infants. When an enteral intake of 100 mL/kg/day was achieved, patients with IUGR and those without IUGR were randomized into 2 groups. Group A (n = 20) received a feed by bolus (in 10 minutes), then, after at least 3 hours, received the same amount of formula by continuous nutrition over 3 hours. Group B (n = 20) received a feed administered continuously over 3 hours, followed by a bolus administration (in 10 minutes) of the same amount of formula after at least 3 hours. On the day of randomization, intestinal and cerebral regional oximetry was measured via near-infrared spectroscopy and Doppler ultrasound (US) of the superior mesenteric artery was performed. Examinations were performed before the feed and at 30 minutes after the feed by bolus and before the feed, at 30 minutes after the start of the feed, and at 30 minutes after the end of the feed for the 3-hour continuous feed. Results Superior mesenteric artery Doppler US showed significantly higher perfusion values after the bolus feeds than after the continuous feeds. Near-infrared spectroscopy values remained stable before and after feeds. Infants with IUGR and those without IUGR showed the same perfusion and oxygenation patterns. Conclusion According to our Doppler US results, bolus feeding is more effective than continuous feeding in increasing splanchnic perfusion. Trial registration ClinicalTrials.gov: NCT01341236.

The organization of perinatal care has been a pivotal mean for improvement in neonatal survivals. Despite the excellent standard of assistance in Lombardy, Obstetrics and Neonatal Units of MBBM Foundation-Monza, Manzoni Hospital-Lecco and Niguarda Hospital-Milan put forward a pilot project proposing reorganization of perinatal care in the northern part of Lombardy. The main goals of the project are implementation of maternal transport system and use of neonatal back transport as a system to increase the availability of intensive care beds. The project's fundamental steps and critical points will be discussed.

This work reports an experimental comparison between two measurement techniques of crack openings: a traditional method based on a mechanical device and the OTTO system based on fiber optic sensors and developed by CELM. The main characteristics of both methods are presented, with their main advantages, drawbacks, and peculiarities. The testing campaign conducted on a historical church erected in the first half of the eighteenth century is then described in detail. Cracks evaluation has a key role in the safety assessment of a monumental building and it is the base for a proper restoration design and intervention plan. The measurements monthly collected using the two described methods are compared and the performances of the two monitoring systems are discussed from both technical and economical points of view. Of particular interest are the unique characteristics of fiber Bragg gratings (FBG) sensors including their noninvasiveness and their extremely high precision in both displacement and time resolutions. These features make FBG sensors the ideal candidates for long term or not invasive monitoring. On the other hand, mechanical measurements remain the best candidates for initial or sporadic measurements. Copyright © 2010 John Wiley & Sons, Ltd.

The study of respiratory mechanics in infants requires a noninvasive accurate measurement of the lung volume changes (DeltaVL). Optoelectronic plethysmography (OEP) allows the assessment of DeltaVL through the measurement of the chest wall surface motion and it has been proved to be accurate in adults. The aim of this study was to apply OEP to newborns and to validate it by comparison to pneumotachography. Twenty term and preterm newborns (GA = 34 +/- 5 wk) in stable condition were studied during 1 to 2 min periods of quiet breathing in supine position. Airway opening flow was measured by applying a facemask connected to a pneumotachograph (PNT) and integrated to provide the DeltaVL. Chest wall volume changes were simultaneously measured by OEP. The tidal volume values measured by pneumotachography and by OEP were compared for each breath. A total of 771 breaths from all patients were considered. Bland-Altmann analysis showed a mean difference of -0.08 mL and a limit of agreement ranging from -2.98 to 2.83 mL. Linear regression analysis demonstrated good correlation between the two techniques (r = 0.95, q = 1.00 mL, m = 0.96). OEP provides accurate measurements of DeltaVL in newborns and may be useful to study respiratory mechanics and breathing patterns during spontaneous breathing and mechanical ventilation.

Objective: To describe common etiologies and diagnostic evaluations performed on term and late preterm neonates with neonatal apnea and to compare these etiologies and evaluations with those infants with infantile acute life threat ening event (ALTE). Methods: Infants 35 weeks, with diagnosis of apnea or ALTE were identified at Bo ston Children's Hospital from June 2000 to June 2009. Medical rec ords were reviewed for diagnostic evaluations and discharge diagnoses. For analysis, neonates who presented with neonatal apnea within the first week of life and prior to discharge f rom the birth hospitalization were classified as the Inpatient Grou p and infants who presented with apnea post discharge were identified as the Outpatient Group. Infants with clear presenting etiologies were excluded from the study. Results: One hundred otherwise healthy subjects with diagnosis of apnea or ALTE in the study period were identified. Approxi- mately one third were classified as the Inpatient Group. Diag nostic evaluations were highly variable, but testing for ba cterial or viral sepsis was most commonly performed. In most cases, an etiology was not determined, and the diagnosis of "apnea of imma- turity" was assigned. Other defined etiologic diagnoses inc luded viral infection or pertussis, reflux/aspiration, lar yngomalacia, and seizures. Conclusions: Diagnostic evaluation for apnea, in otherwise well-appearing full-term and late preterm infants, remains highly variable. Testing for infection, seizure, laryngomalacia and reflux may determine the majority of treatable etiologie s. Guidelines for diagnostic evaluations and treatment strategies are cl early needed.

Near Infrared Spectroscopy (NIRS) is an emerging technique for brain oxygenation monitoring in newborns complicated by acute and chronic hypoxia. However, data regarding cerebral oxygenation normal values are still lacking and matter of debate. Therefore, we investigate whether NIRS parameters in healthy preterm/term infants are gestational age and delivery modalities dependent and correlate with standard monitoring parameters. From January to December 2007, 100 healthy newborns with gestational age from 30 to 42 weeks' gestation were evaluated. Routine laboratory variables, daily clinical and neurological evaluation and ultrasound imaging were performed. The regional cerebral oxygen saturation (rSO2) and fractional cerebral tissue oxygen extraction (FTOE) were measured by NIRS in the first 6-hours after birth. Data were recorded by MetaVision ICU X-Edition software and analyzed by SPSS statistical package. rSO2 and FTOE correlated (R=-0.77; R=0.41; P

Objective To characterize changes in lung mechanics and right ventricular output (RVO) during incremental/decremental continuous distending pressure (CDP) maneuvers in newborn infants receiving high-frequency oscillatory ventilation, with the aim of evaluating when open lung maneuvers are needed and whether they are beneficial. Study design Thirteen infants on high-frequency oscillatory ventilation were studied with a median (IQR) gestational age of 26 1 (25 3 -29 1 ) weeks and median (IQR) body weight of 810 (600-1020) g. CDP was increased stepwise from 8 cmH 2 O to a maximum pressure and subsequently decreased until oxygenation deteriorated or a CDP of 8 cmH 2 O was reached. The lowest CDP that maintained good oxygenation was considered the clinically optimal CDP. At each CDP, the following variables were evaluated: oxygenation, respiratory system reactance (Xrs), and RVO by Doppler echocardiography. Results At maximal CDP reached during the trial, 19 [1] cmH 2 O (mean [SEM]), oxygenation markedly improved, and Xrs and RVO decreased. During deflation, oxygenation remained stable over a wide range of CDP settings, Xrs returned to the baseline values, and RVO increased but the baseline values were not readily restored in all patients. Conclusion These results suggest that Xrs and RVO are more sensitive than oxygenation to overdistension and they may be useful in clinical practice to guide open lung maneuvers.

Within the Project MO.NA.CO. the Environmental effectiveness of GAEC cross-compliance Standard 2.2 ‘Maintaining the level of soil organic matter through management of stubble and crop residues’ and economic evaluation of the competitiveness gap for farmers were evaluated. The monitoring was performed in eight experimental farms of the Council for agricultural research and economics (CREA), distributed throughout Italy and with different soil and climatic conditions. Yield parameters and several components of soil organic matter were evaluated in two contrasting treatments applied to one-year rotation of winter durum wheat and maize: i) incorporation into the soil of crop residues (Factual treatment) and ii) burning or removal of crop residues (Counterfactual treatment). The application of the standard ‘crop residue management’ has showed contrasting results with differences (for yield and soil) between the two treatments resulted almost always non significant. The analysis of economic competitiveness gap showed that the CR incorporation is more expensive than CR burning or removal, but the economic disadvantage can be considered rather small and thus easily compensated by Community aids. Therefore, the soil incorporation of crop residues can be considered a ‘good agricultural practice’ that does not penalize farmers in terms of production and cost and at the same time contributes to the maintenance of fertility and soil biodiversity. On the contrary, the removal and burning of residues result in a low or no-addition of organic matter into the soil. Moreover, burning can contribute to decrease the biodiversity and to increase the risk of air pollution, fires and road accidents.

Background: Excised lungs expand asynchronously and nonuniformly during high frequency ventilation (Lehr 1985). Moreover, in healthy adults, pressure oscillations above 4 Hz applied at the mouth propagate inhomogeneously in the chest wall (Dellaca et al 2003). Objective: In newborn infants receiving HFOV, characterizing the regional heterogeneities of chest wall displacements at different oscillatory frequencies. Methods: We studied 14 newborns (gestational age=29±4 wks; postnatal age=7±8 days; body weight=1.2±0.7 Kg). The following frequencies were tested: 5, 8, 10, 12 and 15 Hz. For each frequency, the displacements of 24 passive markers placed on the infant9s chest wall were measured by optoelectronic plethysmography. A subset of 6 points were used to evaluate chest wall movements in the cranio-caudal direction. For each marker we computed: the displacement normalized for the ventilation pressure amplitude, the phase shift vs. mrk 1. Results: Pressure oscillations propagation decreased with frequency and was higher in the abdominal than in the ribcage compartment (Figure 1 left). The asynchrony of displacements in the cranio-caudal direction increases with f (Figure 1 right). Conclusion: In infants receiving HFOV the chest wall oscillates asynchronously and non-uniformly. With increasing frequency the pressure oscillations propagation reduces with frequency, while asynchronies become more evident.

Background: Optimisation of oscillatory frequency (f) in HFOV is still an open issue. The f at which the pressure cost of achieving flow is minimal is the resonant frequency (f0) (Venegas & Fredberg 1994). However, to date no tools are available for the assessment of f0 at bedside. Objectives: We hypothesized that f0 would optimize gas exchange while minimizing the mechanical stress to the lung. In infants receiving HFOV, characterizing lung mechanics and gas exchange at different f. Methods: We studied 14 infants (gestational age=29±4 wks; postnatal age=5±8 days; body weight=1.35±0.8 Kg). f = 5, 8, 10, 12 and 15 Hz were tested in random order. Tidal volume (Vt) was adjusted to keep DCO 2 (=Vt 2 f) constant. For each frequency respiratory system reactance (Xrs) was measured by the forced oscillation technique without suspending ventilation (Dellaca et al 2013) and used to compute f0 as the point of zero crossing of the Xrs vs. f curve. Transcutaneous partial pressure of oxygen (PtrO 2 ) and carbon dioxide (PtrCO 2 ) ware continuously monitored. Results: Xrs increased from -53.6±29.6 to 10.86±1.9 cmH 2 O*s/L and always crossed the zero in the studied range of frequency. On average f0 was 10.9±1.9 Hz. At f0 PtrCO 2 was 43±7 mmHg and PtrO 2 /FiO 2 was 172±69 mmHg. Neither PtrCO 2 nor PtrO 2 /FiO 2 changed with oscillatory frequency: PCO 2 ranges from 41±7 at 5Hz to 42±7 mmHg at 15 Hz, while PtrO 2 /FiO 2 ranges from 177±61 at 5 Hz to 172±88 mmHg at 15 Hz. Conclusions: f0 was evaluated for the first time in infants receiving HFOV. Setting f at f0 did not result in better gas exchange than other f but has the potential to minimize the mechanical stress applied to the lung to achieve it.

Aerosolization of exogenous surfactant remains a challenge. This study is aimed to evaluate the efficacy of atomized poractant alfa (Curosurf) administered with a novel atomizer in preterm lambs with respiratory distress syndrome.Twenty anaesthetized lambs, 127 ± 1 d gestational age, (mean ± SD) were instrumented before birth and randomized to receive either (i) positive pressure ventilation without surfactant (Control group), (ii) 200 mg/kg of bolus instilled surfactant (Bolus group) at 10 min of life or (iii) 200 mg/kg of atomized surfactant (Atomizer group) over 60 min from 10 min of life. All lambs were ventilated for 180 min with a standardized protocol. Lung mechanics, regional lung compliance (electrical impedance tomography), and carotid blood flow (CBF) were measured with arterial blood gas analysis.Dynamic compliance and oxygenation responses were similar in the Bolus and Atomizer groups, and both better than Control by 180 min (all P0.05; two-way ANOVA). Both surfactant groups demonstrated more homogeneous regional lung compliance throughout the study period. There were no differences in CBFConclusion:In a preterm lamb model, atomized surfactant resulted in similar gas exchange and mechanics as bolus administration. This study suggests evaluation of supraglottic atomization with this system when noninvasive support is warranted.

Objectives To correlate confined placental mosaicism (CPM) for trisomy 15 with severe intrauterine growth restriction (IUGR) and early death after birth (age of 6 months). Methods Chromosome analysis was performed on amniotic fluid at 21st week of gestation, on peripheral blood at birth and on fibroblasts at death using conventional techniques. FISH was performed with Chromoprobe I-Multiprobe System kit and commercial probes according to manufacturer's protocol. DNA was extracted from parental and child peripheral blood, placenta tissue and skin fibroblasts, and UPD tests were done with microsatellites selected from Genome Data Base. Results The child presented severe hypospadias, micropenis, bilateral cryptorchidism and bifid scrotum, inguinal hernia, dolichomegacolon, severe thymic lymphatic depletion and heart hypertrophy, mainly involving right ventricle. Mosaic trisomy 15 (84%) was discovered by FISH on placental biopsy at term. Uniparental disomy (UPD) for chromosome 15 was excluded. Prenatal (amniotic fluid), postnatal (peripheral blood) karyotypes and analysis on skin fibroblast metaphases were normal. Since the autopsy showed some features suggesting genetic syndromes, such as CATCH22, Williams–Beuren syndrome, matUPD2, we excluded the presence of all these diseases. Conclusions The only explanation for this clinical case seems to be the presence of tris15CPM that is reported as one of IUGR causes. Copyright © 2005 John Wiley & Sons, Ltd.

Intra-uterine growth restriction (IUGR) is a severe and quite common problem in obstetrics. A condition of placental dysfunction can lead to a cardiovascular adaptation in the fetus characterized by a redistribution of cardiac output to maintain oxygen supply to the heart, adrenal glands and brain - the so-called brain sparing effect - at the expense of visceral organs (such as the gastrointestinal system). This condition may predispose IUGR infants to impaired gut function after birth. A higher incidence of necrotizing enterocolitis (NEC) is documented in IUGR preterm infants. Therefore, a common practice in neonatal intensive care units is to delay feeds to reduce the risk of feeding intolerance. Recent trials, however, have shown that early enteral feeding in IUGR infants is safe and it would appear, on the basis of the few available data, that breast milk could offer protection against NEC. This mini-review offers an update on feeding in IUGR infants. Future perspectives on the usefulness of Doppler and regional splanchnic and cerebral saturation monitoring for deciding when to start feeding are also provided.

The inadvertent connection between an enteral feeding system and a nonenteral system such as a vascular line may occur. Intravenous administration of an enteral admixture may lead to severe, sometimes lethal, complications. We report our experience with a new set of enteral devices that may prevent any risk of misconnection.

During the last few years, advances in the care of low-birth-weight and preterm neonates has stimulated research on the best dietetic program to improve survival and to reduce handicap incidence. At present, fortification of human milk with artificial formulas is the most usual dietetic solution. As yet, however, little is known about the composition of milk from mothers giving birth prematurely. The aim of this study was the quantification of different proteins in human milk during the lactation period. By use of an electrophoretic method, lactoferrin (LF), alpha-lactalbumin, beta-casein, and lysozyme concentrations were measured in milk from mothers delivering normally (TM) or prematurely (PM). LF concentration in milk from TM presented higher values in the very first days and a fast decrease to d 10. After d 10, the concentration reached a plateau. In milk from PM, the LF concentration in the first days was lower than for TM. Similar profiles of alpha-lactalbumin, beta-casein, and lysozyme concentrations were found in milk from TM and PM. A general higher variability in PM samples was observed both between different mothers and for the same woman during the lactation period. Lactation profiles for four human milk proteins are described here. No significant difference was observed (apart from LF in the very first days) between preterm and term milk samples, confirming the unsuitability of unfortified breast milk for preterm neonates.

Objective: To evaluate short-term respiratory outcomes in late preterm infants (LPI) compared with those of term infants (TI). Methods: A retrospective study conducted in a single third level Italian centre (2005–2009) to analyse the incidence and risk factors of composite respiratory morbidity (CRM), the need for adjunctive therapies (surfactant therapy, inhaled nitric oxide, pleural drainage), the highest level of respiratory support (mechanical ventilation – MV, nasal continuous positive airway pressure – N-CPAP, nasal oxygen) and the duration of pressure support (hours in N-CPAP and/or MV). Results: During the study period 14,515 infants were delivered. There were 856 (5.9%) LPI and 12,948 (89.2%) TI. CRM affected 105 LPI (12.4%), and 121 TI (0.9%), with an overall rate of 1.6%. Eighty-four LPI (9.8%) and 73 TI (0.56%) received respiratory support, of which 13 LPI (1.5%) and 16 TI (0.12%) were ventilated. The adjusted OR for developing CRM significantly increased from 3.3 (95% CI 2.0-5.5) at 37 weeks to 40.8 (95% CI 19.7-84.9%) at 34 weeks. The adjusted OR for the need of MV significantly increased from 3.4 (95% CI 1.2-10) at 37 weeks to 34.4 (95% CI 6.7-180.6%) at 34 weeks. Median duration of pressure support was significantly higher at 37 weeks (66.6 h vs 40.5 h). Twin pregnancies were related to a higher risk of CRM (OR 4.3, 95% CI 2.6-7.3), but not independent of gestational age (GA). Cesarean section (CS) was associated with higher risk of CRM independently of GA, but the OR was lower in CS with labour (2.2, 95% CI 1.4-3.4 vs 3.0, 95% CI 2.1-4.2). Conclusions: In this single third level care study late preterm births, pulmonary diseases and supportive respiratory interventions were lower than previously documented. LPI are at a higher risk of developing pulmonary disease than TI. Infants born from elective cesarean sections, late preterm twins in particular and 37 weekers too might benefit from preventive intervention.

The aims of the present study were (i) to characterize the relationship between mean airway pressure (PAW) and reactance measured at 5 Hz (reactance of the respiratory system (X RS), forced oscillation technique) and (ii) to compare optimal PAW (P opt) defined by X RS, oxygenation, lung volume (VL), and tidal volume (VT) in preterm lambs receiving high-frequency oscillatory ventilation (HFOV).Nine 132-d gestation lambs were commenced on HFOV at PAW of 14 cmH2O (P start). PAW was increased stepwise to a maximum pressure (P max) and subsequently sequentially decreased to the closing pressure (Pcl, oxygenation deteriorated) or a minimum of 6 cmH2O, using an oxygenation-based recruitment maneuver. X RS, regional V L (electrical impedance tomography), and V T were measured immediately after (t 0 min) and 2 min after (t 2 min) each PAW decrement. P opt defined by oxygenation, X RS, V L, and V T were determined.The PAW-X RS and PAW-VT relationships were dome shaped with a maximum at Pcl+6 cmH2O, the same point as P opt defined by VL. Below Pcl+6 cmH2O, X RS became unstable between t 0 min and t 2 min and was associated with derecruitment in the dependent lung. P opt, as defined by oxygenation, was lower than the P opt defined by X RS, V L, or V T.X RS has the potential as a bedside tool for optimizing PAW during HFOV.

Background: The objective of this study was to assess the ability of prenatal ultrasound to predict an unfavorable outcome and the need for postnatal surgery in cases of fetal hydronephrosis (HY). Methods: Antenatal HY was classified according to the renal pelvis anteroposterior (AP) diameter in the third trimester. Postnatal outcome was considered favorable in the presence of spontaneous resolution or postnatal diagnosis of HY 20 mm HY or urinary tract pathologies. Results: Prenatal diagnosis of HY was made in 120 fetuses (for a total of 161 abnormal renal units). The rates of postnatal urinary tract pathology were 14, 27 and 53% for antenatal HY of ≤7, 8–15 and >15 mm, respectively. An AP diameter ≥7 mm in the third trimester had a sensitivity of 100% and a specificity of 23% to predict unfavorable outcome. A formula inclusive of AP diameter and presence or absence of urinary tract anomalies can predict the need for postnatal surgery. Conclusions: The majority of infants with congenital HY have a favorable postnatal outcome. Risk of unfavorable outcome increases with the degree of dilatation of the renal pelvis and the presence of urinary tract anomalies. An AP diameter ≥7 mm in the third trimester warrants postnatal follow-up.

Aim To detect predictors of feeding tolerance in intrauterine growth restriction (IUGR) infants with or without brain-sparing effect (BS). Methods We conducted a case–control study in 70 IUGR infants (35 IUGR with BS, matched for gestational age with 35 IUGR infants with no BS). BS was classified as pulsatility index (PI) ratio [umbilical artery (UAPI) to middle cerebral artery (MCAPI) (U/C ratio)] > 1. Clinical parameters of feeding tolerance – days to achieve full enteral feeding (FEF) – were compared between the IUGR with BS and IUGR without BS infants. Age at the start of minimal enteral feeding (MEF) was analysed. Results Achievement of FEF was significantly shorter in IUGR infants without BS than in IUGR with BS. IUGR with BS started MEF later than IUGR without BS infants. Significant correlation of MEF and FEF with UA PI, U/C ratio and CRIB score was found. Multiple linear regression analysis showed significant correlations with CRIB score and caffeine administration (MEF only), and sepsis (FEF only) and U/C ratio (for both). Conclusion Impaired gut function can be early detected by monitoring Doppler patterns and clinical parameters.

The author presents a new technique for aspiration of local adipose deposits using a new appliance which allows the perfusion of physiological solution and local anaesthesia and the subsequent suction of the adipositary membrane, previously liquefied. The extreme simplicity of the method, which is noninvasive, the absence of the dimpling residual after the operation, and the lack of collateral effects are advantages over the traditional liposuction technique. We treated about 30 patients with local pathologies affecting the lower limbs and the flanks. The pathologies improved cutaneously and the average volume of aspirated fat was 300 cc. Moreover, we could underline an energetic retraction on part of the subcutaneous tissue, which, by adhering to the underlying structures, prevents possible depressions. The operating technique is explained.