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Sinusitis, a common disease of the maxillary sinus, is initially managed with saline solution and medication, resulting in the resolution of symptoms within a few days in most cases. However, Functional Endoscopic Sinus Surgeries are recommended if pharmacological treatments prove ineffective. This research aims to investigate the effects of maxillary sinus surgery on the airflow field, pressure distribution within the nasal cavity, and overall ventilation. This study utilized a three-dimensional realistic nasal cavity model constructed from CT images of a healthy adult. Virtual surgery including uncinectomy with Middle Meatal Antrostomy, two standard procedures performed during such surgeries, was performed on the model under the supervision of a clinical specialist. Two replicas representing pre- and post-operative cases were created using 3D printing for experimental purposes. Various breathing rates ranging from 3.8 to 42.6 L/min were examined through experimental and numerical simulations. To ensure the accuracy of the numerical simulations, the results were compared to measured pressure data, showing a reasonable agreement between the two. The findings demonstrate that uncinectomy and Middle Meatal Antrostomy significantly enhance the ventilation of the maxillary sinuses. Furthermore, increasing inspiratory rates leads to further improvements in ventilation. The static pressure distribution within the maxillary sinuses remains relatively uniform, except in regions close to the sinus ostium, even after surgical intervention.

Objectives: Chronic musculoskeletal pain is associated with decreased parasympathetic and increased sympathetic activity in the autonomic nervous system. The objective of this study was to determine the associations between objective measures of heart rate variability (a measure of autonomic nervous system function), actigraphy (a measure of activity and sleep quality), respiration rates, and subjective patient-reported outcome measures (PROMs) of central sensitization, kinesiophobia, disability, the effect of pain on sleep, and life quality. Methods: Thirty-eight study subjects were divided into two subgroups, including low symptoms of central sensitization (n = 18) and high symptoms of central sensitization (n = 20), based on patient-reported scores on the Central Sensitization Inventory (CSI). Heart rate variability (HRV) and actigraphy measurements were carried out simultaneously in 24 h measurement during wakefulness and sleep. Results: A decrease in HRV during the first 2 h of sleep was stronger in the low CSI subgroup compared to the high CSI subgroup. Otherwise, all other HRV and actigraphy parameters and subjective measures of central sensitization, disability, kinesiophobia, the effect of pain on sleep, and quality of life showed only little associations. Discussion: The high CSI subgroup reported significantly more severe symptoms of disability, kinesiophobia, sleep, and quality of life compared to the low CSI subgroup. However, there were only small and nonsignificant trend in increased sympathetic nervous system activity and poorer sleep quality on the high central sensitization subgroup. Moreover, very little differences in respiratory rates were found between the groups.

Personality traits, the consistent individual behavioral differences, are currently gaining much attention in studies of natural bird populations. However, associations between personality traits and parasite infections are not often investigated. Even less attention has been given to studies of birds in the high-elevation region such as the Tibetan plateau. This research aims to examine the relationship between avian malaria parasites and two personality traits in a population of the Chestnut Thrush (Turdus rubrocanus) breed in the Tibetan plateau. Our results revealed no evidence of sex bias in malaria parasite prevalence. Furthermore, we found no effect of infection status on two personality scores: activity and boldness. Additionally, no effects on the activity level or boldness were observed for different parasite lineages of Haemoproteus, Leucocytozoon, the sex of the birds, or their interactions. Similarly, we did not find any relationship between activity level and boldness with nestling numbers, sex, or their interactions. Notably, individuals with a larger number of offspring tended to display greater boldness. Our findings indicate that blood parasite infections are common in this population but do not significantly impact the personality of the birds.

Personality traits, the consistent individual behavioral differences, are currently gaining much attention in studies of natural bird populations. However, associations between personality traits and parasite infections are not often investigated. Even less attention has been given to studies of birds in the high-elevation region such as the Tibetan plateau. This research aims to examine the relationship between avian malaria parasites and two personality traits in a population of the Chestnut Thrush (Turdus rubrocanus) breed in the Tibetan plateau. Our results revealed no evidence of sex bias in malaria parasite prevalence. Furthermore, we found no effect of infection status on two personality scores: activity and boldness. Additionally, no effects on the activity level or boldness were observed for different parasite lineages of Haemoproteus, Leucocytozoon, the sex of the birds, or their interactions. Similarly, we did not find any relationship between activity level and boldness with nestling numbers, sex, or their interactions. Notably, individuals with a larger number of offspring tended to display greater boldness. Our findings indicate that blood parasite infections are common in this population but do not significantly impact the personality of the birds.

Personality traits, the consistent individual behavioral differences, are currently gaining much attention in studies of natural bird populations. However, associations between personality traits and parasite infections are not often investigated. Even less attention has been given to studies of birds in the high-elevation region such as the Tibetan plateau. This research aims to examine the relationship between avian malaria parasites and two personality traits in a population of the Chestnut Thrush (Turdus rubrocanus) breed in the Tibetan plateau. Our results revealed no evidence of sex bias in malaria parasite prevalence. Furthermore, we found no effect of infection status on two personality scores: activity and boldness. Additionally, no effects on the activity level or boldness were observed for different parasite lineages of Haemoproteus, Leucocytozoon, the sex of the birds, or their interactions. Similarly, we did not find any relationship between activity level and boldness with nestling numbers, sex, or their interactions. Notably, individuals with a larger number of offspring tended to display greater boldness. Our findings indicate that blood parasite infections are common in this population but do not significantly impact the personality of the birds.

Personality traits, the consistent individual behavioral differences, are currently gaining much attention in studies of natural bird populations. However, associations between personality traits and parasite infections are not often investigated. Even less attention has been given to studies of birds in the high-elevation region such as the Tibetan plateau. This research aims to examine the relationship between avian malaria parasites and two personality traits in a population of the Chestnut Thrush (Turdus rubrocanus) breed in the Tibetan plateau. Our results revealed no evidence of sex bias in malaria parasite prevalence. Furthermore, we found no effect of infection status on two personality scores: activity and boldness. Additionally, no effects on the activity level or boldness were observed for different parasite lineages of Haemoproteus, Leucocytozoon, the sex of the birds, or their interactions. Similarly, we did not find any relationship between activity level and boldness with nestling numbers, sex, or their interactions. Notably, individuals with a larger number of offspring tended to display greater boldness. Our findings indicate that blood parasite infections are common in this population but do not significantly impact the personality of the birds.

Personality traits, the consistent individual behavioral differences, are currently gaining much attention in studies of natural bird populations. However, associations between personality traits and parasite infections are not often investigated. Even less attention has been given to studies of birds in the high-elevation region such as the Tibetan plateau. This research aims to examine the relationship between avian malaria parasites and two personality traits in a population of the Chestnut Thrush (Turdus rubrocanus) breed in the Tibetan plateau. Our results revealed no evidence of sex bias in malaria parasite prevalence. Furthermore, we found no effect of infection status on two personality scores: activity and boldness. Additionally, no effects on the activity level or boldness were observed for different parasite lineages of Haemoproteus, Leucocytozoon, the sex of the birds, or their interactions. Similarly, we did not find any relationship between activity level and boldness with nestling numbers, sex, or their interactions. Notably, individuals with a larger number of offspring tended to display greater boldness. Our findings indicate that blood parasite infections are common in this population but do not significantly impact the personality of the birds.

Weight loss is one of the first line treatments for people with obstructive sleep apnea (OSA); however, people with OSA may have difficulties losing weight. Few studies have investigated the factors underlying these challenges in people with OSA. The aim of this study was to compare dietary intake, eating behavior and physical activity data in people with OSA and without OSA. Seventy-four patients referred to a sleep disorders clinic for suspected OSA underwent a standard clinical overnight polysomnography and completed questionnaires assessing dietary intake, physical activity and eating behavior prior to treatment. On the Three Factor Eating Questionnaire-R18 patients with OSA (n = 49, AHI 19.5 [13.0-55.4] events/h) had higher levels of uncontrolled eating (adjusted means, 19.7 (0.7) vs 16.1 (1.0): F (1, 69) = 7.103, p = 0.010 partial eta2 = 0.093), than those who did not have OSA (n = 25, AHI 3.3 [0.8-4.4] events/h) after adjusting for age, fat mass % and depression. There were no differences between groups in dietary intake measures or physical activity. These results suggest that people with OSA may need specific attention to eating behavior when undergoing weight loss interventions.Copyright © 2020, Japanese Society of Sleep Research.

Study Objectives: Preterm infants undergoing intensive care are often placed prone to improve respiratory function. Current clinical guidelines recommend preterm infants are slept supine from 32 weeks' postmenstrual age, regardless of gestational age at birth. However, respiratory function is also related to gestational and chronological ages and is affected by sleep state. We aimed to identify the optimal timing for adopting the supine sleeping position in preterm infants, using a longitudinal design assessing the effects of sleep position and state on cardiorespiratory stability. Method(s): Twenty-three extremely (24-28 weeks' gestation) and 33 very preterm (29-34 weeks' gestation) infants were studied weekly from birth until discharge, in both prone and supine positions, in quiet and active sleep determined by behavioral scoring. Bradycardia (heart rate <=100 bpm), desaturation (oxygen saturation <=80%), and apnea (pause in respiratory rate >=10 s) episodes were analyzed. Result(s): Prone positioning in extremely preterm infants reduced the frequency of bradycardias and desaturations and duration of desaturations. In very preterm infants, prone positioning only reduced the frequency of desaturations. The position-related effects were not related to postmenstrual age. Quiet sleep in both preterm groups was associated with fewer bradycardias and desaturations, and also reduced durations of bradycardia and desaturations in the very preterm group. Conclusion(s): Cardiorespiratory stability is improved by the prone sleep position, predominantly in extremely preterm infants, and the improvements are not dependent on postmenstrual age. In very preterm infants, quiet sleep has a more marked effect than the prone position. This evidence should be considered in individualizing management of preterm infant positioning.Copyright © Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved.

With advances in digital stethoscopes, internet of things, signal processing and machine learning, chest sounds can be easily collected and transmitted to the cloud for remote monitoring and diagnosis. However, low quality of recordings complicates remote monitoring and diagnosis, particularly for neonatal care. This paper proposes a new method to objectively and automatically assess the signal quality to improve the accuracy and reliability of heart rate (HR) and breathing rate (BR) estimation from noisy neonatal chest sounds. A total of 88 10-second long chest sounds were taken from 76 preterm and full-term babies. Six annotators independently assessed the signal quality, number of detectable beats, and breathing periods from these recordings. For quality classification, 187 and 182 features were extracted from heart and lung sounds, respectively. After feature selection, class balancing, and hyperparameter optimization, a dynamic binary classification model was trained. Then HR and BR were automatically estimated from the chest sound and several approaches were compared. The results of subject-wise leave-one-out cross-validation, showed that the model distinguished high and low quality recordings in the test set with 96% specificity, 81% sensitivity and 93% accuracy for heart sounds, and 86% specificity, 69% sensitivity and 82% accuracy for lung sounds. The HR and BR estimated from high quality sounds resulted in significantly less median absolute error (4bpm and 12bpm difference, respectively) compared to those from low quality sounds. The methods presented in this work, facilitates automated neonatal chest sound auscultation for future telehealth applications.Copyright IEEE

Rationale: Swallow may be compromised in COPD leading to aspiration and adverse respiratory consequences. However, prevalence and consequences of detectable aspiration in stable COPD are not known. Objective(s): We tested the hypothesis that a significant number of patients with stable COPD will have detectable aspiration during swallow (prandial aspiration) and that they would experience more frequent severe acute exacerbations of COPD (AECOPD) over the subsequent 12 months. Method(s): Patients (n=151) with verified and stable COPD of all severities were recruited at a tertiary care hospital. Videofluoroscopy was conducted to evaluate aspiration using Rosenbek's scale for penetration-aspiration during 100-mL cup drinking. AECOPD was documented as moderate (antibiotics and/or corticosteroid treatment) or severe (emergency department admission or hospitalisation) over the ensuing 12 months. Measurements and Main Results: Aspiration was observed in 30 out of 151 patients (19.9%, 18 males, 12 females; mean age 72.4 years). Patients with aspiration had more overall AECOPD events (3.03 versus 2 per patient; p=0.022) and severe AECOPD episodes (0.87 versus 0.39; p=0.032). Severe AECOPD occurred in more patients with aspiration (50% of patients versus 18.2%; OR 4.5, CI 1.9-10.5; p=0.001) and with silent aspiration (36.7% versus 18.2%; OR 2.6, CI 1.1-6.2; p=0.045). Aspiration was related to a shorter exacerbation-free period during the 12-month follow-up period (p=0.038). Conclusion(s): Prandial aspiration is detectable in a subset of patients with COPD and was predictive of subsequent severe AECOPD. Studies to examine if the association is causal are essential to direct strategies aimed at prevention of aspiration and AECOPD.Copyright © ERS 2021.

Weight loss is one of the first line treatments for people with obstructive sleep apnea (OSA); however, people with OSA may have difficulties losing weight. Few studies have investigated the factors underlying these challenges in people with OSA. The aim of this study was to compare dietary intake, eating behavior and physical activity data in people with OSA and without OSA. Seventy-four patients referred to a sleep disorders clinic for suspected OSA underwent a standard clinical overnight polysomnography and completed questionnaires assessing dietary intake, physical activity and eating behavior prior to treatment. On the Three Factor Eating Questionnaire-R18 patients with OSA (n = 49, AHI 19.5 [13.0-55.4] events/h) had higher levels of uncontrolled eating (adjusted means, 19.7 (0.7) vs 16.1 (1.0): F (1, 69) = 7.103, p = 0.010 partial eta2 = 0.093), than those who did not have OSA (n = 25, AHI 3.3 [0.8-4.4] events/h) after adjusting for age, fat mass % and depression. There were no differences between groups in dietary intake measures or physical activity. These results suggest that people with OSA may need specific attention to eating behavior when undergoing weight loss interventions.Copyright © 2020, Japanese Society of Sleep Research.

Study Objectives: Preterm infants undergoing intensive care are often placed prone to improve respiratory function. Current clinical guidelines recommend preterm infants are slept supine from 32 weeks' postmenstrual age, regardless of gestational age at birth. However, respiratory function is also related to gestational and chronological ages and is affected by sleep state. We aimed to identify the optimal timing for adopting the supine sleeping position in preterm infants, using a longitudinal design assessing the effects of sleep position and state on cardiorespiratory stability. Method(s): Twenty-three extremely (24-28 weeks' gestation) and 33 very preterm (29-34 weeks' gestation) infants were studied weekly from birth until discharge, in both prone and supine positions, in quiet and active sleep determined by behavioral scoring. Bradycardia (heart rate <=100 bpm), desaturation (oxygen saturation <=80%), and apnea (pause in respiratory rate >=10 s) episodes were analyzed. Result(s): Prone positioning in extremely preterm infants reduced the frequency of bradycardias and desaturations and duration of desaturations. In very preterm infants, prone positioning only reduced the frequency of desaturations. The position-related effects were not related to postmenstrual age. Quiet sleep in both preterm groups was associated with fewer bradycardias and desaturations, and also reduced durations of bradycardia and desaturations in the very preterm group. Conclusion(s): Cardiorespiratory stability is improved by the prone sleep position, predominantly in extremely preterm infants, and the improvements are not dependent on postmenstrual age. In very preterm infants, quiet sleep has a more marked effect than the prone position. This evidence should be considered in individualizing management of preterm infant positioning.Copyright © Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved.

With advances in digital stethoscopes, internet of things, signal processing and machine learning, chest sounds can be easily collected and transmitted to the cloud for remote monitoring and diagnosis. However, low quality of recordings complicates remote monitoring and diagnosis, particularly for neonatal care. This paper proposes a new method to objectively and automatically assess the signal quality to improve the accuracy and reliability of heart rate (HR) and breathing rate (BR) estimation from noisy neonatal chest sounds. A total of 88 10-second long chest sounds were taken from 76 preterm and full-term babies. Six annotators independently assessed the signal quality, number of detectable beats, and breathing periods from these recordings. For quality classification, 187 and 182 features were extracted from heart and lung sounds, respectively. After feature selection, class balancing, and hyperparameter optimization, a dynamic binary classification model was trained. Then HR and BR were automatically estimated from the chest sound and several approaches were compared. The results of subject-wise leave-one-out cross-validation, showed that the model distinguished high and low quality recordings in the test set with 96% specificity, 81% sensitivity and 93% accuracy for heart sounds, and 86% specificity, 69% sensitivity and 82% accuracy for lung sounds. The HR and BR estimated from high quality sounds resulted in significantly less median absolute error (4bpm and 12bpm difference, respectively) compared to those from low quality sounds. The methods presented in this work, facilitates automated neonatal chest sound auscultation for future telehealth applications.Copyright IEEE

Rationale: Swallow may be compromised in COPD leading to aspiration and adverse respiratory consequences. However, prevalence and consequences of detectable aspiration in stable COPD are not known. Objective(s): We tested the hypothesis that a significant number of patients with stable COPD will have detectable aspiration during swallow (prandial aspiration) and that they would experience more frequent severe acute exacerbations of COPD (AECOPD) over the subsequent 12 months. Method(s): Patients (n=151) with verified and stable COPD of all severities were recruited at a tertiary care hospital. Videofluoroscopy was conducted to evaluate aspiration using Rosenbek's scale for penetration-aspiration during 100-mL cup drinking. AECOPD was documented as moderate (antibiotics and/or corticosteroid treatment) or severe (emergency department admission or hospitalisation) over the ensuing 12 months. Measurements and Main Results: Aspiration was observed in 30 out of 151 patients (19.9%, 18 males, 12 females; mean age 72.4 years). Patients with aspiration had more overall AECOPD events (3.03 versus 2 per patient; p=0.022) and severe AECOPD episodes (0.87 versus 0.39; p=0.032). Severe AECOPD occurred in more patients with aspiration (50% of patients versus 18.2%; OR 4.5, CI 1.9-10.5; p=0.001) and with silent aspiration (36.7% versus 18.2%; OR 2.6, CI 1.1-6.2; p=0.045). Aspiration was related to a shorter exacerbation-free period during the 12-month follow-up period (p=0.038). Conclusion(s): Prandial aspiration is detectable in a subset of patients with COPD and was predictive of subsequent severe AECOPD. Studies to examine if the association is causal are essential to direct strategies aimed at prevention of aspiration and AECOPD.Copyright © ERS 2021.

Study objectives: Unobtrusive monitoring of sleep and sleep disorders in children presents challenges. We investigated the possibility of using Ultra-Wide band (UWB) radar to measure sleep in children. Methods: Thirty-two children scheduled to undergo a clinical polysomnography participated; their ages ranged from 2 months to 14 years. During the polysomnography, the children's body movements and breathing rate were measured by an UWB-radar. A total of 38 features were calculated from the motion signals and breathing rate obtained from the raw radar signals. Adaptive boosting was used as machine learning classifier to estimate sleep stages, with polysomnography as gold standard method for comparison. Results: Data of all participants combined, this study achieved a Cohen's Kappa coefficient of 0.67 and an overall accuracy of 89.8% for wake and sleep classification, a Kappa of 0.47 and an accuracy of 72.9% for wake, rapid-eye-movement (REM) sleep, and non-REM sleep classification, and a Kappa of 0.43 and an accuracy of 58.0% for wake, REM sleep, light sleep and deep sleep classification. Conclusion: Although the current performance is not sufficient for clinical use yet, UWB radar is a promising method for non-contact sleep analysis in children., Mechanical, Maritime and Materials Engineering, Bio-Electronics

Global Proprioceptive Resonance (GPR) is a recently developed approach conceived to solicit the various cutaneous mechanoreceptors, through application of mechanical multifocal vibration at low amplitude and at definite body sites, limiting the stimulation of the profound structures. This interventional study evaluated the effects of GPR on cardiorespiratory function during the post-exertional recovery period. A group of volunteers involved in Triathlon (a multisport discipline consisting of sequential swim, cycle, and run disciplines higly demanding in terms of metabolic engagment), underwent two maximal incremental exercise tests until exhaustion followed alternatively to (a) a 13 minutes section of GPR or (b) a standard low intensity exercise acute trend of the same duration. These effects of these two approaches were compared in terms of recovery of: heart rate (HR), respiratory rate (RR), peripheral oxygen saturation (SpO2) and venous lactate concentration (Lac). The physiological parameters (HR, RR, SpO2 and Lac) recorded in the pre-exertion session showed similar values between the 40 volunteers while several differences were recorded in the post-exertion phase. After 6 min of GPR recovery it was recorded a drop in RR below baseline (19.4±4.15 min-1 vs. 12.2± 0.4 min-1; p<0.001) coupled with an increase in peripheral oxygen saturation above the baseline (GPR: 99.0%±0.16% vs. 96.6%±0.77%, p<0.001). Moreover, the most striking result was the drop in lactate concentration measured after 13 min of GPR recovery: 84.5±3.5% in GPR vs 2.9±7.6% reduction in standard recovery (p<0.001). Notably no differences were recorded recovery of heart rate. GPR has promising effects on post-exercise recovery on RR, SpO2 and lactate level on young athletes. © 2020 PAGEPress Publications. All rights reserved.

Study objectives: Unobtrusive monitoring of sleep and sleep disorders in children presents challenges. We investigated the possibility of using Ultra-Wide band (UWB) radar to measure sleep in children. Methods: Thirty-two children scheduled to undergo a clinical polysomnography participated; their ages ranged from 2 months to 14 years. During the polysomnography, the children's body movements and breathing rate were measured by an UWB-radar. A total of 38 features were calculated from the motion signals and breathing rate obtained from the raw radar signals. Adaptive boosting was used as machine learning classifier to estimate sleep stages, with polysomnography as gold standard method for comparison. Results: Data of all participants combined, this study achieved a Cohen's Kappa coefficient of 0.67 and an overall accuracy of 89.8% for wake and sleep classification, a Kappa of 0.47 and an accuracy of 72.9% for wake, rapid-eye-movement (REM) sleep, and non-REM sleep classification, and a Kappa of 0.43 and an accuracy of 58.0% for wake, REM sleep, light sleep and deep sleep classification. Conclusion: Although the current performance is not sufficient for clinical use yet, UWB radar is a promising method for non-contact sleep analysis in children., Mechanical, Maritime and Materials Engineering, Bio-Electronics

This work presents a seat-occupancy detection system based on a PCR (Pulsed Coherent Radar) at the unlicensed 60 GHz ISM band. The radar can measure distances with sub-millimeter resolution. Therefore, the system can detect the presence of people occupying the seats by measuring small movements of the body, such as those produced by breathing. In consequence, the system not only measures seat-occupancy but also breathing rate, which is estimated from the amplitude peaks after filtering the amplitude measured by the radar to remove the noise. The effect of the car vibrations and random body movement is experimentally studied. Measurements performed with adults, as well as with a baby emulator sitting in a child seat, are presented. Comparison of the system with another that measures the breath based on airflow shows good agreement and permits its validation.

The COVID-19 pandemic has highlighted a large amount of challenges to address. To combat the spread of the virus, several safety measures, such as wearing face masks, have been taken. Temperature controls at the entrance of public places to prevent the entry of virus carriers have been shown to be inefficient and inaccurate. This paper presents a smart mask that allows to monitor body temperature and breathing rate. Body temperature is measured by a non-invasive dual-heat-flux system, consisting of four sensors separated from each other with an insulating material. Breathing rate is obtained from the temperature changes within the mask, measured with a thermistor located near the nose. The system communicates by means of long-range (LoRa) backscattering, leading to a reduction in average power consumption. It is designed to establish the relative location of the smart mask from the signal received at two LoRa receivers installed inside and outside an access door. Low-cost LoRa transceivers with WiFi capabilities are used in the prototype to collect information and upload it to a server. Accuracy in body temperature measurements is consistent with measurements made with a thermistor located in the armpit. The system allows checking the correct placement of the mask based on the recorded temperatures and the breathing rate measurements. Besides, episodes of cough can be detected by sudden changes in thermistor temperature.

Clinical surveillance provides essential data on changes in a patient's condition. The common method for performing this surveillance is the assessment of vital signs. Despite the importance of these signs, research has found that vital signs are not rigorously assessed in clinical practice. Respiratory rate, arguably the most important vital sign, is the most neglected. Poor understanding might contribute to nurses incorrectly valuing oxygen saturation more than respiratory rate. Nurses need to understand the importance of respiratory rate assessment as a vital sign and the benefits and limitations of pulse oximetry as a clinical tool. By better understanding pulse oximetry and respiratory rate assessment, nurses might be more inclined to conduct rigorous vital signs' assessment. Research is needed to understand why many nurses do not appreciate the importance of vital signs' monitoring.

Study Objectives: Preterm infants undergoing intensive care are often placed prone to improve respiratory function. Current clinical guidelines recommend preterm infants are slept supine from 32 weeks' postmenstrual age, regardless of gestational age at birth. However, respiratory function is also related to gestational and chronological ages and is affected by sleep state. We aimed to identify the optimal timing for adopting the supine sleeping position in preterm infants, using a longitudinal design assessing the effects of sleep position and state on cardiorespiratory stability. Method(s): Twenty-three extremely (24-28 weeks' gestation) and 33 very preterm (29-34 weeks' gestation) infants were studied weekly from birth until discharge, in both prone and supine positions, in quiet and active sleep determined by behavioral scoring. Bradycardia (heart rate <=100 bpm), desaturation (oxygen saturation <=80%), and apnea (pause in respiratory rate >=10 s) episodes were analyzed. Result(s): Prone positioning in extremely preterm infants reduced the frequency of bradycardias and desaturations and duration of desaturations. In very preterm infants, prone positioning only reduced the frequency of desaturations. The position-related effects were not related to postmenstrual age. Quiet sleep in both preterm groups was associated with fewer bradycardias and desaturations, and also reduced durations of bradycardia and desaturations in the very preterm group. Conclusion(s): Cardiorespiratory stability is improved by the prone sleep position, predominantly in extremely preterm infants, and the improvements are not dependent on postmenstrual age. In very preterm infants, quiet sleep has a more marked effect than the prone position. This evidence should be considered in individualizing management of preterm infant positioning.Copyright © Sleep Research Society 2020. Published by Oxford University Press on behalf of the Sleep Research Society.

Objective The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations. Patients and methods An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED. Results A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients. Conclusion Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion.Copyright © 2019 Lippincott Williams and Wilkins. All rights reserved.

Dissection of a cervical artery is a well-known cause of stroke, especially in younger patients. We describe the case of a 39-year-old male, who presented to our emergency department after a one-day history of headache and vomiting, with associated sudden onset posterior neck pain and cerebellar signs following a massage. Computed tomography angiogram and brain demonstrated bilateral vertebral artery dissection and cerebellar stroke. He was admitted to hospital for monitoring and conservative management with antiplatelet therapy, resulting in a good outcome. This is the first reported case of bilateral vertebral artery dissection and stroke to be associated with massage. This case also suggests, unlike many reports in the literature, that significant vascular pathology can result from massage even without cervical spine manipulation.Copyright © NZMA

Clinical surveillance provides essential data on changes in a patient's condition. The common method for performing this surveillance is the assessment of vital signs. Despite the importance of these signs, research has found that vital signs are not rigorously assessed in clinical practice. Respiratory rate, arguably the most important vital sign, is the most neglected. Poor understanding might contribute to nurses incorrectly valuing oxygen saturation more than respiratory rate. Nurses need to understand the importance of respiratory rate assessment as a vital sign and the benefits and limitations of pulse oximetry as a clinical tool. By better understanding pulse oximetry and respiratory rate assessment, nurses might be more inclined to conduct rigorous vital signs' assessment. Research is needed to understand why many nurses do not appreciate the importance of vital signs' monitoring.

Study Objectives: Preterm infants undergoing intensive care are often placed prone to improve respiratory function. Current clinical guidelines recommend preterm infants are slept supine from 32 weeks' postmenstrual age, regardless of gestational age at birth. However, respiratory function is also related to gestational and chronological ages and is affected by sleep state. We aimed to identify the optimal timing for adopting the supine sleeping position in preterm infants, using a longitudinal design assessing the effects of sleep position and state on cardiorespiratory stability. Method(s): Twenty-three extremely (24-28 weeks' gestation) and 33 very preterm (29-34 weeks' gestation) infants were studied weekly from birth until discharge, in both prone and supine positions, in quiet and active sleep determined by behavioral scoring. Bradycardia (heart rate <=100 bpm), desaturation (oxygen saturation <=80%), and apnea (pause in respiratory rate >=10 s) episodes were analyzed. Result(s): Prone positioning in extremely preterm infants reduced the frequency of bradycardias and desaturations and duration of desaturations. In very preterm infants, prone positioning only reduced the frequency of desaturations. The position-related effects were not related to postmenstrual age. Quiet sleep in both preterm groups was associated with fewer bradycardias and desaturations, and also reduced durations of bradycardia and desaturations in the very preterm group. Conclusion(s): Cardiorespiratory stability is improved by the prone sleep position, predominantly in extremely preterm infants, and the improvements are not dependent on postmenstrual age. In very preterm infants, quiet sleep has a more marked effect than the prone position. This evidence should be considered in individualizing management of preterm infant positioning.Copyright © Sleep Research Society 2020. Published by Oxford University Press on behalf of the Sleep Research Society.

Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.Copyright © 2020, Canadian Anesthesiologists' Society.

Objective: High-anion gap metabolic acidosis (HAGMA) most commonly results from excess urea, lactate, ketones and exposure to toxins such as salicylate and toxic alcohols. Accumulation of pyroglutamic acid (PGA) is a rare cause of HAGMA. The exact incidence of HAGMA caused by PGA accumulation is unknown. A recent prospective study reported that high urine PGA concentrations were associated with 10% of patients with HAGMA. PGA is processed by the glutamate-glutathione cycle. The commonest cause of PGA accumulation is glutathione depletion. This causes the loss of negative feedback on gamma-glutamylcysteine (PGA precursor) production. Other causes include malnutrition, alcoholism, liver failure and sepsis. Though rare, deficiency of either glutathione synthetase causing gamma-glutamylcysteine (PGA precursor) accumulation or 5-oxoprolinase resulting in reduced PGA metabolism, also cause PGA accumulation. We describe a case of confirmed PGA accumulation after repeated supratherapeutic paracetamol use. Case report: A 32-year-old female presented with ongoing pain from shingles despite having taken 96 x 665 mg modified-release paracetamol caplets over the preceding two days. Two years prior, she suffered a gastric ulcer perforation following excessive ibuprofen use for dysmenorrhea. She subsequently ceased using NSAIDs and substituted these with regular use of four modifiedrelease paracetamol tablets every 3-4 hours. On presentation vital signs were normal except a respiratory rate of 24/min. Venous blood gas showed pH 7.04, bicarbonate 5.0mmol/L, pCO2 19 mmHg, lactate 1.4mmol/L, sodium 150mmol/L, chloride 117 mmol/L and anion gap 28, indicating a partially compensated HAGMA. Serum ketones were 2.8mmol/L, salicylate undetected and normal osmolar gap. Serum paracetamol was 312 mumol/L, 2.5 hours after the last dose. Liver function, INR and creatinine were normal. PGA accumulation from chronic paracetamol misuse and glutathione depletion was suspected. Acetylcysteine was in

Dissection of a cervical artery is a well-known cause of stroke, especially in younger patients. We describe the case of a 39-year-old male, who presented to our emergency department after a one-day history of headache and vomiting, with associated sudden onset posterior neck pain and cerebellar signs following a massage. Computed tomography angiogram and brain demonstrated bilateral vertebral artery dissection and cerebellar stroke. He was admitted to hospital for monitoring and conservative management with antiplatelet therapy, resulting in a good outcome. This is the first reported case of bilateral vertebral artery dissection and stroke to be associated with massage. This case also suggests, unlike many reports in the literature, that significant vascular pathology can result from massage even without cervical spine manipulation.Copyright © NZMA

Objective The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations. Patients and methods An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED. Results A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients. Conclusion Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion.Copyright © 2019 Lippincott Williams and Wilkins. All rights reserved.

This work explores the use of a commodity ultra-wideband (UWB) radar based device to detect breathing rate for health monitoring applications. Health monitoring devices observe physiological signals to detect medical conditions. We focus on capturing the small mechanical movements caused by breathing. This is traditionally done via a strain gauge worn around the chest or stomach, but these systems limit user movement. Contactless systems provide a unique design that allows free user movement by eliminating all direct contact with the user. Additionally, these systems have the potential to support full health monitoring in a Smart Built Environment (SBE). In this work, a comparative evaluation is performed on a commodity UWB radar based device, the Walabot, to determine the accuracy and possible health monitoring applications. Based on results from a systematic review, six research challenges were identified: (1) high cost, functional limitations based on the user's (2) location, (3) orientation, and (4) movement, (5) dependency on system hardware placement, and (6) vulnerabilities in signal processing methods. A comparative evaluation was designed to test the Walabot against a medical grade wearable system in the context of these research challenges. The data was processed using two breathing rate derivation techniques: Fast Fourier Transformation (FFT) and Peak Detection. Results suggest great potential for the Walabot coupled with the FFT technique. However, the system requires further testing to address all of the research challenges. Overall, this work provides important steps toward using the Walabot in health monitoring applications.

Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial.Copyright © 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Raoultella planticola (R. planticola) is a Gram-negative, aerobic, rod bacteria found in water and soil that has been on rare occasions associated with clinical infections. However, in recent years, there has been both an increase in the frequency and severity of R. planticola infections. We present the first case of Meckel's diverticulum perforation and peritonitis in a child associated with R. planticola infection and a systematic review of the paediatric literature. At present, in the paediatric population, R. planticola presents good susceptibility to a variety of antibiotics with the exception of ampicillin.Copyright © 2019 The Authors

Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial.Copyright © 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Relapsing polychondritis is a rare autoimmune condition characterized by episodic and progressive cartilaginous inflammation. Its clinical presentation is vastly divergent and can affect various organs. We report the uncommon case of large airway involvement in a patient presenting with shortness of breath on the background of diagnosed relapsing polychondritis. Computed tomography (CT) chest demonstrated thickening of the cartilaginous portions of the trachea and bronchi with sparing of the posterior membranes, consistent with tracheobronchomalacia and repeated cartilaginous destruction. High doses of systemic glucocorticoids, accompanied by continuous positive airway pressure, were required for treatment. We highlight the importance of identifying the extent of airways affected and definitive positive airway pressure support for relapsing polychondritis affecting major airways in addition to conventional therapy of immunosuppression.Copyright © 2019 The Authors. Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology

Rationale: Oral appliance therapy is an increasingly prescribed non-PAP alternative for treating OSA, but its efficacy is challenging to predict in individual patients, limiting its application as a first-line therapy. In small physiological studies, we have shown that pathophysiological (endotype) traits causing OSA can predict patient response to oral appliance therapy. These traits include upper airway collapsibility, arousal threshold, and ventilatory control instability (loop gain, response to arousal). Estimating these traits require invasive measurement during sleep or complex model-fitting to full in-lab polysomnographic data. Here we apply a novel, simplified method for estimating the traits causing OSA in individual patients using the ventilation-profile of the average respiratory event. We aimed to determine if PSG-derived traits were associated with oral appliance efficacy (percent reduction in total AHI from baseline). Method(s): Forty-three subjects with total AHI >= 20 hr-1 were available for analysis. The ventilation-profile of the average respiratory event was determined using the following approach: First, all scored respiratory events (apneas, hypopneas) were identified. Second, the ventilation signal for each event was calculated (uncalibrated volume x respiratory rate, expressed as percentage of eupneic [mean] ventilation) and ensemble-averaged with event-termination set to time zero for all events (Figure 1a). Surrogate measures of the endotype traits were calculated from this average respiratory event ventilation-profile as follows: mean event depth was the reduction from eupnea of the mean ventilation during the events, and considered a surrogate of pharyngeal collapsibility; the ventilatory overshoot was the peak ventilation following events as a surrogate of the arousal threshold, and the disturbance was the area under the curve (below eupnea) during the events, which were both utilized used to calculate a surrogate of loop gain (overshoot

Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial.Copyright © 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

Raoultella planticola (R. planticola) is a Gram-negative, aerobic, rod bacteria found in water and soil that has been on rare occasions associated with clinical infections. However, in recent years, there has been both an increase in the frequency and severity of R. planticola infections. We present the first case of Meckel's diverticulum perforation and peritonitis in a child associated with R. planticola infection and a systematic review of the paediatric literature. At present, in the paediatric population, R. planticola presents good susceptibility to a variety of antibiotics with the exception of ampicillin.Copyright © 2019 The Authors

Background: Bronchiolitis is the most common reason for hospital admission in infants, with one third requiring oxygen therapy due to hypoxemia. It is unknown what proportion of hypoxemic infants with bronchiolitis can be managed with nasal high-flow in room air and their resulting outcomes. Objectives and Settings: To assess the effect of nasal high-flow in room air in a subgroup of infants with bronchiolitis allocated to high-flow therapy in a recent multicenter randomized controlled trial. Patients and Interventions: Infants allocated to the high-flow arm of the trial were initially treated with room air high-flow if saturations were >=85%. Subsequently, if oxygen saturations did not increase to >=92%, oxygen was added and FiO2 was titrated to increase the oxygen saturations. In this planned sub-study, infants treated during their entire hospital stay with high-flow room air only were compared to infants receiving either standard-oxygen or high-flow with oxygen. Baseline characteristics, hospital length of stay and length of oxygen therapy were compared. Finding(s): In the per protocol analysis 64 (10%) of 630 infants commenced on high-flow room air remained in room air only during the entire stay in hospital. These infants on high-flow room air were on average older and presented with moderate hypoxemia at presentation to hospital. Their length of respiratory support and length of stay was also significantly shorter. No pre-enrolment factors could be identified in a multivariable analysis. Conclusion(s): In a small sub-group of hypoxemic infants with bronchiolitis hypoxemia can be reversed with the application of high-flow in room air only. Trial registration: ACTRN12615001305516.© Copyright © 2019 Franklin, Babl, Gibbons, Pham, Hasan, Schlapbach, Oakley, Craig, Furyk, Neutze, Moloney, Gavranich, Shirkhedkar, Kapoor, Grew, Fraser, Dalziel, Schibler and PARIS and PREDICT.

Relapsing polychondritis is a rare autoimmune condition characterized by episodic and progressive cartilaginous inflammation. Its clinical presentation is vastly divergent and can affect various organs. We report the uncommon case of large airway involvement in a patient presenting with shortness of breath on the background of diagnosed relapsing polychondritis. Computed tomography (CT) chest demonstrated thickening of the cartilaginous portions of the trachea and bronchi with sparing of the posterior membranes, consistent with tracheobronchomalacia and repeated cartilaginous destruction. High doses of systemic glucocorticoids, accompanied by continuous positive airway pressure, were required for treatment. We highlight the importance of identifying the extent of airways affected and definitive positive airway pressure support for relapsing polychondritis affecting major airways in addition to conventional therapy of immunosuppression.Copyright © 2019 The Authors. Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology

Rationale: Oral appliance therapy is an increasingly prescribed non-PAP alternative for treating OSA, but its efficacy is challenging to predict in individual patients, limiting its application as a first-line therapy. In small physiological studies, we have shown that pathophysiological (endotype) traits causing OSA can predict patient response to oral appliance therapy. These traits include upper airway collapsibility, arousal threshold, and ventilatory control instability (loop gain, response to arousal). Estimating these traits require invasive measurement during sleep or complex model-fitting to full in-lab polysomnographic data. Here we apply a novel, simplified method for estimating the traits causing OSA in individual patients using the ventilation-profile of the average respiratory event. We aimed to determine if PSG-derived traits were associated with oral appliance efficacy (percent reduction in total AHI from baseline). Method(s): Forty-three subjects with total AHI >= 20 hr-1 were available for analysis. The ventilation-profile of the average respiratory event was determined using the following approach: First, all scored respiratory events (apneas, hypopneas) were identified. Second, the ventilation signal for each event was calculated (uncalibrated volume x respiratory rate, expressed as percentage of eupneic [mean] ventilation) and ensemble-averaged with event-termination set to time zero for all events (Figure 1a). Surrogate measures of the endotype traits were calculated from this average respiratory event ventilation-profile as follows: mean event depth was the reduction from eupnea of the mean ventilation during the events, and considered a surrogate of pharyngeal collapsibility; the ventilatory overshoot was the peak ventilation following events as a surrogate of the arousal threshold, and the disturbance was the area under the curve (below eupnea) during the events, which were both utilized used to calculate a surrogate of loop gain (overshoot

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

Context: Massive paracetamol ingestion causing mitochondrial dysfunction is uncommon. Use of sustained low-efficiency dialysis (SLED) to improve acidaemia and enhance paracetamol elimination has not been previously described. Case details: A 44-year-old male presented to the emergency department 2.5 hours post overdose of 200 g (2.5 g/kg) of paracetamol. Examination revealed a BP 85/60 mmHg, pulse 112 bpm, temperature 33.9 degreeC and blood glucose of 13.9 mmol/l. Venous blood gas 5.5-hours post-ingestion showed a pH 6.9, pCO2 58 mmHg, HCO3 13 mmol/l and lactate 14 mmol/l. Fifty-grams of nasogastric activated charcoal and double-strength intravenous acetylcysteine were administered. Paracetamol concentration peaked at 4207 micromol/l six hours post-ingestion. SLED was commenced nine-hours post ingestion and acetylcysteine dose was doubled again during dialysis. Paracetamol extraction ratio was 47-52%. Plasma paracetamol clearance was steady throughout SLED (53-58 ml/min). Hepatotoxicity did not develop and the patient recovered. Discussion(s): Intermittent hemodialysis (IHD) is more efficient than SLED or continuous renal replacement therapy for enhancing paracetamol elimination and clearance. IHD plasma clearance is reported to range from 36 to 215 ml/min compared with endogenous clearance of 224 ml/70 kg/min. Conclusion(s): SLED improved acidaemia with only moderate overall increase in paracetamol plasma clearance. Lack of development of hepatotoxicity was likely the result of early administration of acetylcysteine rather than any effect of SLED on paracetamol elimination.Copyright © 2017 Informa UK Limited, trading as Taylor & Francis Group.

BACKGROUND High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear. METHODS In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting =3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events. RESULTS The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy. CONCLUSIONS Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therap

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

Context: Massive paracetamol ingestion causing mitochondrial dysfunction is uncommon. Use of sustained low-efficiency dialysis (SLED) to improve acidaemia and enhance paracetamol elimination has not been previously described. Case details: A 44-year-old male presented to the emergency department 2.5 hours post overdose of 200 g (2.5 g/kg) of paracetamol. Examination revealed a BP 85/60 mmHg, pulse 112 bpm, temperature 33.9 degreeC and blood glucose of 13.9 mmol/l. Venous blood gas 5.5-hours post-ingestion showed a pH 6.9, pCO2 58 mmHg, HCO3 13 mmol/l and lactate 14 mmol/l. Fifty-grams of nasogastric activated charcoal and double-strength intravenous acetylcysteine were administered. Paracetamol concentration peaked at 4207 micromol/l six hours post-ingestion. SLED was commenced nine-hours post ingestion and acetylcysteine dose was doubled again during dialysis. Paracetamol extraction ratio was 47-52%. Plasma paracetamol clearance was steady throughout SLED (53-58 ml/min). Hepatotoxicity did not develop and the patient recovered. Discussion(s): Intermittent hemodialysis (IHD) is more efficient than SLED or continuous renal replacement therapy for enhancing paracetamol elimination and clearance. IHD plasma clearance is reported to range from 36 to 215 ml/min compared with endogenous clearance of 224 ml/70 kg/min. Conclusion(s): SLED improved acidaemia with only moderate overall increase in paracetamol plasma clearance. Lack of development of hepatotoxicity was likely the result of early administration of acetylcysteine rather than any effect of SLED on paracetamol elimination.Copyright © 2017 Informa UK Limited, trading as Taylor & Francis Group.

Radiotelemetry is increasingly being recognized not just as the gold standard but a necessity for validation of gestational hypertension seen in preeclampsia. Here we describe radiotelemetry probe implantation into the descending aorta of Sprague-Dawley rats to allow real-time blood pressure recording over the entire gestational period. This is a valuable tool to be able to track changes in maternal blood pressure throughout gestation and the efficacy of novel therapeutic agents in controlling hypertension.Copyright © 2018, Springer Science+Business Media LLC.

BACKGROUND High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear. METHODS In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting =3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events. RESULTS The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy. CONCLUSIONS Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therap