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Abstract Background Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. Methods In this study, 382 infants born at 24+0–27+6 weeks’ gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks’ postmenstrual age. The secondary outcomes are BPD at 36 weeks’ postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24+0 to 25+6 weeks or 26+0 to 27+6 weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). Discussion This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24+0–27+6 weeks’ gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks’ postmenstrual age of life. Trial registration ClinicalTrials.gov NCT05711966. Registered on February 3, 2023.

Introduction Evidence on the use of health apps to support healthcare and promote the health of individuals aged 55 and older is limited. Older adults face challenges with literacy, usability and accessibility of digital tools. This scoping review aims to explore how digital health apps promote healthy living and self-empowerment while identifying successful applications for older adultsMethods and analysis This study will adopt the JBI methodology for scoping reviews, guided by the (Population, Concept, Context) framework. The results will be comprehensively reported in the final scoping review and illustrated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The inclusion criteria include studies from 2016 to 2024 that investigate the use of health applications within healthcare services for older adults.Ethics and dissemination Ethical approval is not required for this scoping review. The findings will highlight potential directions for future research and improve knowledge among professionals, researchers and the public. The results will be published in a peer-reviewed journal and disseminated through professional networks. Data will be available from the Open Science Framework.

Abstract Introduction We describe three different fetal or neonatal outcomes in the offspring of a mother who had persistent circulating thyrotropin receptor antibodies despite having undergone a total thyroidectomy several years before. Case presentation The three different outcomes were an intrauterine death, a mild and transient fetal and neonatal hyperthyroidism and a severe fetal and neonatal hyperthyroidism that required specific therapy. Conclusions The three cases are interesting because of the different outcomes, the absence of a direct correlation between thyrotropin receptor antibody levels and clinical signs, and the persistence of thyrotropin receptor antibodies several years after a total thyroidectomy.

Could Turkey dam the Tigris and Euphrates and deprive its downstream neighbors of vital water resources? Could Brazil over-pump the Guarani Aquifer System to the detriment of the other aquifer states? Could Egypt put pressure on upstream Nile states and prevent them from developing river related infrastructure that might limit downstream flow? International law in the field of transboundary water cooperation has evolved and would appear to condemn unilateral practices such as the ones suggested above. However, hydro politics and the lack of reception of international water law instruments by many countries sometimes make it difficult to see international law properly reflected in the management of major rivers, lakes and aquifers around the world. In this essay, I first highlight what international law dictates when it comes to the tension between national sovereignty and transboundary water cooperation. I then explore how this tension plays out in the three examples noted above. Due to limited acceptance of the existing international, bilateral, or regional legal instruments, the resolution of the tension between national sovereignty and transboundary water cooperation will often be left to customary international law.

Islandness is often considered to be a disadvantage. However, it has helped the residents of islands to delay, deter, and, in some cases, totally insulate themselves from COVID-19. While islanders have been quick to lock themselves down, this has had a tremendous impact on their connectivity and on tourism, which in many cases is their major economic sector. Yet, the association of islands with being safe, “COVID-19 free” zones has helped these spaces to be among the first destinations to restart the tourism economy once travel restrictions were lifted. After several weeks of lockdown, and with the COVID-19 threat still looming, social distancing remained the norm. Travellers were thus eager to immerse themselves in island environments while avoiding crowds and seeking small accommodation facilities in less densely populated rural areas to limit the risks of infection — a package offered by several islands in the central Mediterranean. With many travellers opting to travel close to home, islands benefited from domestic tourism — a key market segment for islands in this region. Islands have thus performed relatively well in fighting the COVID-19 pandemic and in restarting their economies; but the pandemic has also exposed challenges including a dangerous overreliance on tourism.

A case of vertical transmission in a 35-year-old pregnant woman, gravida 4, para 2 with an unknown medical history of carrying primary syphilis is described. A routine 3rd trimester scan was performed at 30 + 5 weeks of pregnancy, which revealed fetal growth restriction (FGR) associated with absent fetal movement, a pathologic neuroscan characterized by cortical calcifications and ominous Doppler waveform analysis of the umbilical artery and ductus venosus. Computerized electronic fetal monitoring (EFM) showed a Class III tracing, according to the American College of Obstetricians and Gynecologists (ACOG) guidelines. An emergency C-section was performed and a female newborn weighing 1470 g was delivered. The Apgar scores were 5 and 8 at the first and fifth min, respectively. Besides the prompted obstetrical and neonatal interventions, the neonate died after 7 days. A histologic examination of the placenta revealed a chorioamnionitis at stage 1/2 and grade 2/3. The parenchyma showed diffuse delayed villous maturation, focal infarcts, and intraparenchymal hemorrhages. The decidua presented with chronic deciduitis with plasma cells. The parents declined the autopsy. Congenital syphilis is an emerging worldwide phenomenon and the multidisciplinary management of the mother and the fetus should be mandatory.

Study region: Latin America. Parana Basin. Argentina, Brazil, Paraguay, Uruguay. Study focus: This article traces the trajectory of transboundary cooperation over the past fifteen years for the Guarani Aquifer System. A new insight for the region: The Guarani Aquifer System is a transboundary aquifer shared by Argentina, Brazil, Paraguay, and Uruguay. It stands as one of the largest reservoirs of freshwater worldwide and is one of the few transboundary aquifers whose management is regulated by an international treaty, the Guarani Aquifer Agreement (GAA). The latter is also the first to refer in its preamble to the UN International Law Commission Draft Articles on the Law of Transboundary Aquifers. A first period (2002–2010) of positive collaboration in which the four countries actively moved forward towards a better understanding of the aquifer, culminated with the adoption of the GAA in August 2010. A second period (2010–2017) has been marked by a slowdown in transboundary cooperation, limited in this period to sporadic cross-border projects and initiatives linked to past and existing international projects. In this period, Argentina and Uruguay, and more recently Brazil have ratified the GAA. A third phase seems to be emerging in 2017 due to the possibility that finally Paraguay ratifies the GAA allowing it to enter into force. This article argues that in the future implementation of the agreement countries should build on the good practices, both substantive and institutional, stemming from the first period of transboundary cooperation. Keywords: Guarani Aquifer System, Transboundary aquifer cooperation, Water resource governance, Guarani Aquifer Agreement, Water management

Este trabajo aborda el valor jurídico y práctico que puede llegar a tener el proyecto de artículos sobre el derecho de los acuíferos transfronterizos de la CDI, sobre el cual no parece previsible que se vaya a adoptar una convención a corto plazo. Para ello, se toma como referencia el estudio del valor jurídico y práctico que han tenido otros trabajos de la CDI que no han llegado a convertirse en una convención internacional en vigor. Este análisis nos permite apreciar que su aplicación práctica depende no tanto de su forma, sino más bien del valor jurídico de su contenido, es decir, de su naturaleza consuetudinaria o de desarrollo progresivo; y, en este último caso, de su capacidad para generar nuevas costumbres internacionales a través de su aceptación por los Estados.

In the past few years, the Chinese government opted to restrict the export of selected minerals on environmental and health grounds, subsequently leading to an uproar in countries and regions that rely heavily on imports from China to develop their renewable industry sector. This paper places the focus on the law and policy of the Chinese export restrictions of critical minerals, and its implications for the global renewables energy industry. The paper critically assesses how such export restrictions have been dealt with under the dispute settlement system of the World Trade Organisation (WTO). Drawing on this WTO jurisprudence, we posit that litigation on export restrictions of the kind imposed by China poses a threat to the legitimacy of the WTO. We therefore conclude by exploring whether there are any alternatives to litigation as a means to deal with countries choosing to impose mineral export restrictions.

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Objective: The primary aim is to evaluate the surgical and oncological outcome of robotic radical hysterectomy (RRH) plus pelvic lymphadenectomy in locally advanced cervical cancer (LACC) after neoadjuvant chemotherapy (NACT). The secondary aim is to compare the surgical and oncological results of RRH after NACTwith a historical cohort of patients undergoing laparoscopic radical hysterectomy or abdominal radical hysterectomy plus pelvic lymphadenectomy for LACC after NACT. Methods: We enrolled a total of 41 patients in this study with LACC undergoing RRH, who achieved a clinical partial or complete response to NACT. The surgical and oncological outcomes of 2 historical groups were compared: the laparoscopic group (41 patients) with the laparotomic group (43 patients). Results: The median estimated blood loss, operative time, and length of hospital stay were statistically significant and in favor of the robotic group. No conversion to laparotomy in the robotic group was necessary. There were no significant differences between the 3-year overall survival and disease-free survival rates in the minimally invasive groups; nevertheless, the robotic group showed the same recurrence rate of laparoscopic in a short-interval follow-up. Conclusions: The robotic approach could be considered a feasible and safe alternative to other surgical options. Multicenter randomized clinical trials with longer follow-ups are necessary to evaluate the overall oncologic outcomes of this procedure. [ABSTRACT FROM AUTHOR]

Poor production of breast milk is the most frequent cause of breast lactation failure. Often, physician prescribe medications or other substances to solve this problem. The use of galactogogues should be limited to those situations in which reduced milk production from treatable causes has been excluded. One of the most frequent indication for the use of galactogogues is the diminution of milk production in mothers using indirect lactation, particularly in the case of preterm birth. The objective of this review is to analyze to the literature relating to the principal drugs used as galactogogues (metoclopramide, domperidone, chlorpromazine, sulpiride, oxytocin, growth hormone, thyrotrophin releasing hormone, medroxyprogesterone). Have been also analyzed galactogogues based on herbs and other natural substances (fenugreek, galega and milk thistle). We have evaluated their mechanism of action, transfer to maternal milk, effectiveness and potential side effects for mother and infant, suggested doses for galactogogic effect, and recommendation for breastfeeding.

Importance: A multicenter randomized clinical trial (RCT) showed a lung recruitment maneuver using high-frequency oscillatory ventilation just before surfactant administration (ie, intubate-recruit-surfactant-extubate [IN-REC-SUR-E]) improved the efficacy of treatment compared with the standard intubate-surfactant-extubate (IN-SUR-E) technique without increasing the risk of adverse neonatal outcomes., Objective: To examine follow-up outcomes at corrected postnatal age (cPNA) 2 years of preterm infants previously enrolled in an RCT and treated with IN-REC-SUR-E or IN-SUR-E in 35 tertiary neonatal intensive care units., Design, Setting, and Participants: This was a follow-up study of infants recruited into the primary RCT from 2015 to 2018 at 35 tertiary neonatal intensive care units (NICUs) in Italy. Follow-up examinations included neurodevelopmental, growth, and respiratory outcomes of these children at cPNA 2 years. Participants included spontaneously breathing extremely preterm neonates (24 0/7 to 27 6/7 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 hours of life. Data were analyzed from April 2023 to January 2024., Intervention: Infants were randomly assigned (1:1) to IN-REC-SUR-E or IN-SUR-E and then followed up., Main Outcomes and Measures: The primary outcome was the occurrence of death after discharge or major disability at cPNA 2 years. Secondary outcomes were neurodevelopmental outcomes (major disability, cerebral palsy, cognitive impairment, visual deficit, or auditory deficit), anthropometric measurements (weight, length, and head circumference), and recurrent respiratory infections and hospitalizations because of respiratory causes at 2y cPNA., Results: A total of 137 extremely preterm infants (median [IQR] gestational age, 26.5 [25.3-27.5] weeks and 75 [54.7%] female), initially enrolled in the original RCT, were followed up at cPNA 2 years, including 64 infants in the IN-SUR-E group and 73 infants in the IN-REC-SUR-E group. There were no significant differences in the occurrence of death after discharge or major disability at cPNA 2 years (IN-SUR-E: 13 children [20.3%] vs IN-REC-SUR-E: 10 children [13.7%]; P = .36). There were no significant differences in incidence of disability, cerebral palsy, or cognitive impairment in the IN-REC-SUR-E group compared with the IN-SUR-E group. There were no significant differences in anthropometric measurements (weight, length, and head circumference) between groups. There were no significant differences in the incidence of recurrent respiratory infections or in hospitalizations because of respiratory causes between groups., Conclusions and Relevance: In this RCT of lung recruitment before surfactant vs standard care there were no significant differences between the 2 groups in death, neurodevelopmental outcomes, anthropometric measurements, or recurrent respiratory infections at the 2-year follow-up. These findings can aid clinicians in decision-making for the best strategy to administer surfactant, considering long-term outcomes.

Chylous ascites has been reported only rarely as a possible consequence of congenital diaphragmatic hernia (CDH) surgical treatment. The present report regards a case of chylous ascites that developed after surgical treatment of CDH and was interestingly anticipated by increased scrotal volume. The aim was to alert neonatologists and pediatric surgeons about the potential usefulness of this clinical sign as a precocious "alarm bell" for chylous ascites development.

We report a case of hypertrabeculated left ventricular myocardium associated with congenital hypothyroidism in a preterm infant. The myocardical anomalies and long QT interval, absent at birth, appeared simultaneously to abnormal thyroid hormones and progressively improved until complete recovery during Levo-Thyroxine treatment. We speculate that thyroid dysfunction could be the potential cause of transient hypertrabecular aspect of the left ventricle.

Introduction: We describe three different fetal or neonatal outcomes in the offspring of a mother who had persistent circulating thyrotropin receptor antibodies despite having undergone a total thyroidectomy several years before., Case Presentation: The three different outcomes were an intrauterine death, a mild and transient fetal and neonatal hyperthyroidism and a severe fetal and neonatal hyperthyroidism that required specific therapy., Conclusions: The three cases are interesting because of the different outcomes, the absence of a direct correlation between thyrotropin receptor antibody levels and clinical signs, and the persistence of thyrotropin receptor antibodies several years after a total thyroidectomy.

Poor production of breast milk is the most frequent cause of breast lactation failure. Often, physician prescribe medications or other substances to solve this problem. The use of galactogogues should be limited to those situations in which reduced milk production from treatable causes has been excluded. One of the most frequent indication for the use of galactogogues is the diminution of milk production in mothers using indirect lactation, particularly in the case of preterm birth. The objective of this review is to analyze to the literature relating to the principal drugs used as galactogogues (metoclopramide, domperidone, chlorpromazine, sulpiride, oxytocin, growth hormone, thyrotrophin releasing hormone, medroxyprogesterone). Have been also analyzed galactogogues based on herbs and other natural substances (fenugreek, galega and milk thistle). We have evaluated their mechanism of action, transfer to maternal milk, effectiveness and potential side effects for mother and infant, suggested doses for galactogogic effect, and recommendation for breastfeeding.

Background: An inadequate start of breastfeeding has been associated with reduced caloric intake, excessive weight loss and high serum bilirubin levels in the first days of life. The rooming-in has been proposed as an optimal model for the promotion of breastfeeding., Aim: The aim of this study was to compare two different feeding models (partial and full rooming-in) to evaluate differences as regard to weight loss, hyperbilirubinemia and prevalence of exclusive breastfeeding at discharge., Methods: A total of 903 healthy term newborns have been evaluated; all the newborns were adequate for gestational age, with birth weight > or = 2800 g and gestational age > or = 37 weeks., Results: The maximum weight loss (mean +/- SD), expressed as percent of birth weight, was not different in the two models (partial vs. full rooming-in 5.8% +/- 1.7%vs. 6% +/- 1.7%). A weight loss > or = 10% occurred in less than 1% in both groups. There were no statistical differences neither as mean of total serum bilirubin (partial vs. full rooming-in 10.5 +/- 3.3 vs. 10.1 +/- 2.9 mg/dl), nor as prevalence of hyperbilirubinemia (total serum bilirubin > or = 12 mg/dl). The prevalence of severe hyperbilirubinemia (total serum bilirubin > or = 18 mg/dl) and the use of phototherapy were not statistically different. Maximum weight loss was similar in the two models, even dividing by total serum bilirubin levels. At the discharge, exclusively breastfed newborns were 81% in full rooming-in and 42.9% in partial rooming-in., Conclusions: In conclusion, our results allow considering our assistance models similar as regards to severe hyperbilirubinemia and pathological weight loss in term healthy newborns even if full rooming-in is associated with higher prevalence of exclusive breastfeeding at the discharge.

Objectives: To know the mother's frequency with TRAb (TSH receptor antibodies) positivity during pregnancy in the population afferent to Agostino Gemelli Hospital in the five years 2002-2007 and the itself antibodies's role determining fetal and neonatal symptoms., Materials and Methods: We performed a prospective analysis with maternal and neonatal variables detection in 16 couples mother-newborn with TRAb positivity during the pregnancy. The method to dose neonatal TRAb is ELISA (enzyme linked immunosorbant assay)., Results: The prevalence of newborns of mothers with TRAb positivity during pregancy results 0.1 per thousand (16/16783). The prevalence of neonatal hyperthyroidism, clinical and biochemical, in the studied population results especially elevated equal to about 30% (5/16). The 5 newborns are born to mothers with Basedow disease with TRAb serum levels greater than TRAb levels of newborn without hyperthyroidism: 2 are showed the symptoms of clinical hyperthyroidism and 3 a transient biochemical hyperthirodism. 3 newborns with hyperthyroidism among 5 are born to mother undergo thyroidectomy with L-tiroxina teraphy during the pregnancy. Then the newborns of thyroidectomized mothers also many years before the pregnancy must be considered high risk of developing neonatal hyperthyroidism because of long-lasting persistence of mother's TRAb. The neonatal hyperthyroidism, clinical and biochemical, appears later in newborns of mothers using antithyroid drugs. The pharmacological treatment of neonatal hyperthyroidism was difficult to standardize and highly individualized., Conclusions: Although the neonatal hyperthyroidism is a very rare disease it is essential to apply specific protocol assistance, both during pregnancy and the neonatal period, in the presence of maternal TRAb positive for the risk of serious cardiovascular complications.

Many studies have recently analyzed the modulation of the intestinal microflora showing a benefic effects reducing the number of enteritis, improving the oligoelements absorption and stimulating the immunitary system. To do so three way are available: the use of prebiotics, the use of probiotics and the symbiotic way. Prebiotics are non-digestible oligosaccharides that can stimulate selectively the growth bifidogenus bacteria. Probiotics are dietary supplements made of live micro-organisms which improve the microbial environment of the gut. In this review literature is examined the possible efficacy of prebiotics and probiotics in the pediatric age; however, the studies available do not permit to obtain definitive conclusions.