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Background: Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆P ES ) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆P ES in children. We sought to identify risk factors for P0.1 over or underestimating ∆P ES in ventilated children., Methods: Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆P ES (∆P ES-REAL ), P0.1 and predicted ∆P ES (∆P ES-PRED  = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆P ES-REAL and ∆P ES-PRED were aligned (low, normal, and high effort and drive), two where ∆P ES-REAL and ∆P ES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes., Results: We analyzed 953 patient days (222 patients). ∆P ES-REAL and ∆P ES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017)., Conclusions: In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome., Trial Registration: NCT03266016; August 23, 2017., (© 2024. The Author(s).)

Purpose: Patients with syndromic hemifacial microsomia (SHFM) are at risk of obstructive sleep apnea (OSA). The aim of the study was to describe the prevalence of OSA and its management, especially in patients with Goldenhar syndrome (GS)., Methods: The respiratory polygraphies and clinical management of 15 patients, aged 2 to 23 years, evaluated at a national reference center, were analyzed., Results: Four (27%) patients had no OSA, 4 (27%) had mild OSA, and 7 (46%), of whom 5 were ≤ 2 years old, had severe OSA. None of the patients had central apneas. Only one patient had alveolar hypoventilation, and another one had nocturnal hypoxemia. Two patients had severe OSA despite prior adenoidectomy or mandibular distraction osteogenesis. Median duration of follow-up was 3.5 years (range 0.5-9 years). None of the patients without OSA or with mild OSA at baseline respiratory polygraphy developed OSA during the follow up. Among the 7 patients with severe OSA, 3 required continuous positive airway pressure or noninvasive ventilation, and one patient required a tracheostomy., Conclusion: In conclusion, patients with SHFM are at high risk of severe OSA at any age, underlining the importance of systematic sleep studies to diagnose and evaluate the severity of OSA. Individualized treatment should be privileged, based on a careful examination of the entire upper airway, taking in account potential associated risk factors. All patients with SHFM should be managed by a pediatric expert multidisciplinary medical/surgical team until the end of post pubertal growth., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Right ventricle impairment (RVI) is common during acute respiratory distress syndrome (ARDS) in adults and children, possibly mediated by the level of transpulmonary pressure (P L ). We sought to investigate the impact of the level of P L on ARDS-associated right ventricle impairment (RVI)., Methods: Adults and children (> 72 h of life) were included in this two centers prospective study if they were ventilated for a new-onset ARDS or pediatric ARDS, without spontaneous breathing and contra-indication to esophageal catheter. Serial measures of static lung, chest wall, and respiratory mechanics were coupled to critical care echocardiography (CCE) for 3 days. Mixed-effect logistic regression models tested the impact of lung stress (ΔP L ) along with age, lung injury severity, and carbon dioxide partial pressure, on RVI using two definitions: acute cor pulmonale (ACP), and RV dysfunction (RVD). ACP was defined as a dilated RV with septal dyskinesia; RVD was defined as a composite criterion using tricuspid annular plane systolic excursion, S wave velocity, and fractional area change., Results: 46 patients were included (16 children, 30 adults) with 106 CCE (median of 2 CCE/patient). At day one, 19% of adults and 4/7 children > 1 year exhibited ACP, while 59% of adults and 44% of children exhibited RVD. In the entire population, ACP was present on 17/75 (23%) CCE. ACP was associated with an increased lung stress (mean ΔP L of 16.2 ± 6.6 cmH 2 O in ACP vs 11.3 ± 3.6 cmH 2 O, adjusted OR of 1.33, CI95% [1.11-1.59], p = 0.002) and being a child. RVD was present in 59/102 (58%) CCE and associated with lung stress. In children > 1 year, PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] cmH 2 O in ACP vs 15.0 [11.9; 16.3] cmH 2 O, p = 0.03)., Conclusion: Lung stress was associated with RVI in adults and children with ARDS, children being particularly susceptible to RVI. Trial registration Clinical trials identifier: NCT0418467., (© 2024. The Author(s).)

Background: Tidal volume (Vt) delivery during mechanical ventilation is influenced by gas compression, humidity, and temperature., Objectives: This bench study aimed at assessing the accuracy of Vt delivery by paediatric intensive care ventilators according to the humidification system. Secondary objectives were to assess the following: (i) the accuracy of Vt delivery in ventilators with an integrated Y-piece pneumotachograph and (ii) the ability of ventilators to deliver and maintain a preset positive end-expiratory pressure., Methods: Six latest-generation intensive care ventilators equipped with a paediatric mode were tested on the ASL5000 test lung in four simulated paediatric bench models (full-term neonate, infant, preschool-age chile, and school-age child), under volume-controlled mode with a heated humidifier (HH) or a heat moisture exchanger, with various loading conditions. Three ventilators equipped with a Y-piece pneumotachograph were tested with or without the pneumotachograph in the neonatal and infant models. "Accurate Vt" delivery was defined as a volume error (percentage of the preset Vt under body temperature and pressure and saturated water vapour conditions) being ≤10 % of the absolute preset value., Results: Vt accuracy varied significantly across ventilators but was acceptable in almost all the ventilators and all the models, except the neonatal model. The humidification system had an impact on Vt delivery in the majority of the tested conditions (p < 0.05). The use of an HH was associated with a better Vt accuracy in four ventilators (V500, V800, R860, and ServoU) and allowed to achieve an acceptable level of volume error in the neonatal model as compared to the use of heat moisture exchanger. The use of an integrated pneumotachograph was associated with lower volume error in only one ventilator (p < 0.01). All the tested ventilators were able to maintain adequate positive end-expiratory pressure levels., Conclusion: The humidification system affects Vt accuracy of paediatric intensive care ventilators, especially in the youngest patients for whom the HH should be preferred., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Because of the difficult challenges of nanopharmaceutics, the development of a variety of nanovectors is still highly desired. Photodynamic therapy, which uses a photosensitizer to locally produce reactive oxygen species to kill the undesired cells, is a typical example for which encapsulation has been shown to be beneficial. The present work describes the use of coumarin-functionalized polymeric nanovectors based on the self-assembly of amphiphilic poly(2-oxazoline)s. Encapsulation of pheophorbide a, a known PDT photosensitizer, is shown to lead to an increased efficiency compared to the un-encapsulated version. Interestingly, the presence of coumarin both enhances the desired photocytotoxicity and enables the crosslinking of the vectors. Various nanovectors are examined, differing by their size, shape and hydrophilicity. Their behaviour in PDT protocols on HCT-116 cells monolayers is described, the influence of their crosslinking commented. Furthermore, the formation of a protein corona is assessed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Rationale: Use of life support with extracorporeal membrane oxygenation (ECMO) is associated with brain injury. However, the consequences of these injuries on subsequent neurologic development and health-related quality of life (HRQoL) are poorly described in children., Objectives: The aim of this preliminary study was to describe short- and long-term neurologic outcomes in survivors of ECMO, as well as their HRQoL., Design: Retrospective identified cohort with contemporary evaluations., Setting: Necker Children's Hospital academic PICU., Patients: Forty survivors who underwent ECMO (October 2014 to January 2020) were included in follow-up assessments in May 2021., Interventions: None., Measurement and Main Results: We first reviewed the outcomes of ECMO at the time of PICU discharge, which included a summary of neurology, radiology, and Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores. Then, in May 2021, we interviewed parents and patients to assess HRQoL (Pediatric Quality of Life Inventory [PedsQL]) and POPC/PCPC for children 3 years old or older, and Denver II test (DTII) for younger children. An evaluation of DTII in the youngest patients 1 year after ECMO decannulation was also added. Median age at ECMO was 1.4 years (interquartile range [IQR], 0.4-6 yr). Thirty-five children (88%) underwent a venoarterial ECMO. At PICU discharge, 15 of 40 patients (38%) had neurologic impairment. Assessment of HRQoL was carried out at median of 1.6 years (IQR, 0.7-3.3 yr) after PICU discharge. PedsQL scores were over 70 of 100 for all patients (healthy peers mean results: 80/100), and scores were like those published in patients suffering with chronic diseases. In May 2021, seven of 15 patients had a normal DTII, and 36 of 40 patients had a POPC/PCPC score less than or equal to 3., Conclusions: None of our patients presented severe disability at long term, and HRQoL evaluation was reassuring. Considering the risk of neurologic impairment after ECMO support, a systematic follow-up of these high-risk survivor patients would be advisable., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Positive end-expiratory pressure (PEEP) consists of the delivery of a constant positive pressure in the airways by means of a noninvasive interface aiming to maintain airway patency throughout the entire respiratory cycle. PEEP is increasingly used in the chronic care of children with anatomical or functional abnormalities of the upper airways to correct severe persistent obstructive sleep apnea despite optimal management which commonly includes adenotonsillectomy in young children. PEEP may be used at any age, due to improvements in equipment and interfaces. Criteria for CPAP/NIV initiation, optimal setting, follow-up and monitoring, as well as weaning criteria have been established by international experts, but validated criteria are lacking. As chronic PEEP is a highly specialised treatment, patients should be managed by an expert pediatric multidisciplinary team., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: Improving or maintaining the quality of life of the family of children treated with long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) is a major concern; but studies are scarce. The aim of the study was to evaluate the impact of long term CPAP or NIV in children on anxiety, depression, quality of sleep, and quality of life of their parents., Methods: Validated questionnaires evaluating anxiety and depression (hospital anxiety and depression scale), sleep quality (Pittsburgh sleep quality index), daytime sleepiness (Epworth sleepiness scale), and parents' quality of life (PedsQL family impact module) were completed by parents of children who were started on CPAP/NIV before (M0) and after 6-9 months (M6) of treatment., Results: The questionnaires of 36 parents (30 mothers, 6 fathers) of 31 children were analyzed. For the entire group, no significant change was observed in anxiety, depression, sleep quality, daytime sleepiness, and quality of life between M0 and M6. When analyzing questionnaire class changes between M0 and M6: anxiety was relieved in 23% of parents and worsened in 29%, depression was relieved in 14% and worsened in 20%, sleep quality improved in 43% and worsened in 27%, sleepiness improved in 26% and worsened in 17%, with no change in the other parents., Conclusion: Long term CPAP/NIV in children had no significant effect on parents' anxiety, depression, sleep quality, and quality of life., (© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Background: Home CPAP and noninvasive ventilation (NIV) are increasingly used in children. An appropriate choice of the CPAP/NIV device, according to the manufacturer recommendations, should guarantee accurate data collection software. However, not all devices display accurate patient data. We hypothesized that the detection of patient breathing may be expressed as a minimal tidal volume (V T min ) rather than a minimal weight. The aim of the study was to estimate the V T min detected by home ventilators when set on CPAP., Methods: Twelve level I-III devices were analyzed using a bench test. Pediatric profiles were simulated with increasing V T values to determine the V T min that the ventilator may detect. The duration of CPAP use and the presence/absence of waveform tracings on the built-in software were also gathered., Results: V T min varied according to the device, ranging from 16-84 mL, independent of level category. The duration of CPAP use was underestimated in all level I devices, which were either not able to display any waveform or only intermittently, until V T min was reached. The duration of CPAP use was overestimated for the level II and III devices, with the display of different waveforms according to the device as soon as the device was switched on., Conclusions: Based on the V T min detected, some level I and II devices may be suitable for infants. A careful testing of the device should be done at CPAP initiation, with a review of data generated from ventilator software., Competing Interests: Dr Lebret is a part-time employee of Air Liquide Medical Systems. The remaining authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Objectives: To assess if noninvasive positive pressure ventilation (NIPPV) is associated with a greater reduction in respiratory effort as compared to continuous positive airway pressure (CPAP) during severe acute bronchiolitis, with both supports set either clinically or physiologically., Methods: Twenty infants (median [IQR] age 1.2 [0.9; 3.2] months) treated <24 h with noninvasive respiratory support (CPAP Clin, set at 7 cmH 2 O, or NIPPV Clin) for bronchiolitis were included in a prospective single-center crossover study. Esogastric pressures were measured first with the baseline support, then with the other support. For each support, recordings were performed with the clinical setting and a physiological setting (CPAP Phys and NIPPV Phys), aiming at normalising respiratory effort. Patients were then treated with the optimal support. The primary outcome was the greatest reduction in esophageal pressure-time product (PTP ES /min). Other outcomes included improvement of the other components of the respiratory effort., Results: NIPPV Clin and Phys were associated with a lower PTP ES /min (164 [105; 202] and 106 [78; 161] cmH 2 O s/min, respectively) than CPAP Clin (178 [145; 236] cmH 2 O s/min; p = 0.01 and 2 × 10 -4 , respectively). NIPPV Clin and Phys were also associated with a significant reduction of all other markers of respiratory effort as compared to CPAP Clin. PTP ES /min with NIPPV (Clin or Phys) was not different from PTP ES /min with CPAP Phys. There was no significant difference between physiological and clinical settings., Conclusion: NIPPV is associated with a significant reduction in respiratory effort as compared to CPAP set at +7 cmH 2 O in infants with severe acute bronchiolitis. CPAP Phys performs as well as NIPPV Clin., (© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

There are no validated criteria to initiate noninvasive ventilation (NIV) in children and young adults with neuromuscular disease (NMD). In order to analyze NIV initiation criteria, we reviewed the polysomnography (PSG) criteria that led to the initiation of NIV in 61 consecutive patients with NMD, median age 4.1 (0.8-21) years, who had a PSG during their routine care. NIV was initiated on abnormal PSG data (apnea-hypopnea index (AHI) > 10 events/h and/or a transcutaneous carbon dioxide pressure > 50 mmHg and/or a pulse oximetry 〈 90%, both during at least 2% sleep time or 〉 5 consecutive minutes) in 11 (18%) patients. Six of these 11 patients had an AHI ≤ 10 events/h and would not have been ventilated if only AHI was retained. However, one of these 6 patients had isolated nocturnal hypoxemia, 3 isolated nocturnal hypercapnia and 2 abnormal respiratory events. Six (10%) patients with a normal PSG were started on NIV on clinical criteria. Our results show the limitation of the AHI when taken as the unique PSG criterion for NIV initiation in young patients with NMD and underline the need to include also abnormalities of overnight gas exchange into the NIV decision-making process., Competing Interests: Declaration of Competing Interest All the authors declare that they have no conflict of interest with the data of this manuscript. Pr Brigitte Fauroux, on behalf of all the co-authors, (Copyright © 2023 Elsevier B.V. All rights reserved.)

This review aims to: (1) describe the rationale of pleural (P PL ) and transpulmonary (P L ) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on P L in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (P ES ) and P L measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. P L corresponds to the difference between airway pressure and P PL Oesophageal manometry allows measurement of P ES , a good surrogate of P PL , to estimate P L directly at the bedside. Lung stress is the P L , while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with P L and P PL being key components. P L -targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory P L (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory P L value close to zero; (2) Protective ventilation based on end-inspiratory P L (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20-25 cmH 2 O; (3) P PL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) P PL or P L measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, P PL and P L measurements may help to characterise how changes in PEEP affect P PL and potentially haemodynamics. In the PICU, P PL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of P PL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, P ES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate P PL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. P PL and P L monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of P L and multimodal respiratory monitoring may be worth to be evaluated in the future., Competing Interests: Competing interests: AD reports personal fees from Medtronic, grants, personal fees and non-financial support from Philips, personal fees from Baxter, personal fees from Hamilton, personal fees and non-financial support from Fisher & Paykel, grants from French Ministry of Health, personal fees from Getinge, grants and personal fees from Respinor, grants and non-financial support from Lungpacer, outside the submitted work. MV-C reports non-financial support from Sentec, outside the submitted work. RK reports personal fees from OrangeMed Nihon Kohden, and grants from Masimo outside the submitted work., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cerebral hypoperfusion and impaired oxygen delivery during pediatric critical illness may result in acute neurologic injury with subsequent long-term effects on neurodevelopmental outcome. Yet, the impact of norepinephrine on cerebral hemodynamics is unknown in children with shock. We aimed to describe the norepinephrine effects on cerebral perfusion and oxygenation during pediatric shock., Patients and Methods: We conducted an observational multicentre prospective study in 3 French pediatric intensive care units. Children <18 years of age excluding traumatic brain injury were included in the study if they need norepinephrine for shock. Systemic and cerebral hemodynamics were compared between the time of initiation of norepinephrine (T 0 ), and the steady-state (T ss ). Cardiac output (CO) was measured using ultrasound. Cerebral perfusion was assessed on middle cerebral arteries (MCA) using transcranial doppler ultrasound. Cerebral tissue oxygen saturation (rScO 2 ) was recorded using near infrared spectroscopy, and we calculated cerebral fractional tissue oxygen extraction (cFTOE = SpO 2 -rScO 2 /SpO 2 )., Main Results: Fourteen children (median [IQR] age of 3.5[1; 13.5] years) were included. Norepinephrine at 0.2[0.1; 0.32] μg/kg/min significantly increased mean arterial blood pressure (61[56; 73] mmHg at T ss vs. 49[42;54] mmHg at T 0 , p=10 -3 ) without change of CO. MCA velocities, pulsatility index, rScO 2 , and cFTOE did not significantly change between T 0 and T ss . Some individuals observed variations in estimated CBF, which slightly improved in 7 patients, remained unchanged in 5, and was impaired in 2. No patient experienced significant variations of rScO 2 ., Conclusions: Low-dosing norepinephrine, despite a homogeneous and significant increase in arterial blood pressure, had little effects on cerebral perfusion and oxygenation during pediatric shock. This reinforces the need for personalized tailored therapies in this population., Trial Registration: Clinicaltrials.gov, NCT03731104. Registered 6 November, 2018. https://clinicaltrials.gov/ct2/show/NCT03731104., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Vedrenne-Cloquet, Chareyre, Léger, Genuini, Renolleau and Oualha.)

COVID-19 has infected more than 275 million worldwide (at the beginning of 2022). Children appear less susceptible to COVID-19 and present with milder symptoms. Cases of children with COVID-19 developing clinical features of Kawasaki-disease have been described. Here we utilise Mass Spectrometry proteomics to determine the plasma proteins expressed in healthy children pre-pandemic, children with multisystem inflammatory syndrome (MIS-C) and children with COVID-19 induced ARDS. Pathway analyses were performed to determine the affected pathways. 76 proteins are differentially expressed across the groups, with 85 and 52 proteins specific to MIS-C and COVID-19 ARDS, respectively. Complement and coagulation activation are implicated in these clinical phenotypes, however there was significant contribution of FcGR and BCR activation in MIS-C and scavenging of haem and retinoid metabolism in COVID-19 ARDS. We show global proteomic differences in MIS-C and COVID-ARDS, although both show complement and coagulation dysregulation. The results contribute to our understanding of MIS-C and COVID-19 ARDS in children., (© 2022. The Author(s).)

Aim: To assess the diagnostic performance of a simplified lung point-of-care ultrasound (POCUS) to confirm the correct positioning of an endotracheal tube (ETT) in a pediatric intensive care unit (PICU) used to chest radiography (CXR), and to compare the time to obtain the ETT position between POCUS and CXR., Methods: We conducted a single-center prospective study in critically ill children requiring urgent endotracheal intubation. Esophageal tube malposition was first avoided using auscultation and end-tidal CO2. The ETT position was assessed with CXR and lung POCUS using the lung sliding sign on a pleural window. All of the investigators had to read guidelines and received 1-h training on the technical aspects of lung sliding. The primary objective was the accuracy of POCUS in confirming correct nonselective endotracheal intubation as compared with CXR., Results: A total of 71 patients were included from December 2016 to November 2018. CXR identified proper nonselective ETT placement in 43 of 71 (61%) patients, while the rate for selective intubation was 39%. The sensitivity and specificity of POCUS as compared with CXR were 77% and 68%, respectively. Median time to POCUS was significantly shorter than CXR (2 min to perform POCUS, 10 min to obtain radiographs, p<10-4)., Conclusion: Pleural ultrasound, although faster than CXR, appears to be inadequate for identifying selective ETT after urgent intubation in a PICU less accustomed to this kind of ultrasound. In this heterogeneous and fragile population, timely POCUS may remain useful at the bedside as compared with auscultation, aiming at guiding optimal ETT placement and reducing respiratory complications, provided by trained physicians., Competing Interests: Declaration of competing interest None., (Copyright © 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

In our continuing search of saponins from the plant of Sapindaceae family, phytochemical investigation of the stem barks of Pancovia turbinata Radlk., led to the isolation and structural characterization of two new triterpenoid saponins, named turbinatosides A-B (1-2), one new farnesyl glycoside, named turbinoside A (3), one new coumarin glucoside, named panturboside A (4), together with a known saponin (5). The structures of the new compounds were established, using extensive analysis of NMR techniques, mainly 1D NMR ( 1 H, 13 C, and DEPT) and 2D NMR (COSY, NOESY, HSQC, HSQC-TOCSY and HMBC) experiments, HRESIMS and by comparison with the literature data, as 3-O-β-d-xylopyranosyl-(1 → 3)-α-l-arabinopyranosyl-(1 → 4)-β-d-glucopyranosyl-(1 → 3)-α-l-rhamnopyranosyl-(1 → 2)-α-l-arabinopyranosylhederagenin 28-O-β-d-glucopyranosyl ester (1), 3-O-α-l-arabinopyranosyl-(1 → 4)-β-d-glucopyranosyl-(1 → 3)-α-l-rhamnopyranosyl-(1 → 2)-α-l-arabinopyranosylhederagenin 28-O-β-d-xylopyranosyl-(1 → 4)-β-d-glucopyranosyl ester (2), 1-O-{β-d-glucopyranosyl-(1 → 3)-α-l-rhamnopyranosyl-(1 → 2)-[α-l-rhamnopyranosyl-(1 → 6)]-β-d-glucopyranosyl}-(2E,6E)-farnes-1,12-diol (3), and 5-O-β-d-glucopyranosyl-5,6,7-trihydroxy-8-methoxycoumarin (4), respectively. Our findings highlight the presence of - 3 Rha- 2 Ara- 3 hederagenin oligosaccharidic sequence usually described in saponins from Sapindoideae subfamily of Sapindaceae family, as well as farnesol glycosides, and represent therefore a valuable contribution to the chemotaxonomy of the Sapindoideae subfamily., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Acute brain injury (ABI) is a frequent complication of pediatric extracorporeal membrane oxygenation (ECMO) that could be detected by continuous neuromonitoring. Cerebral near-infrared spectroscopy (NIRS) allows monitoring of cerebral oxygenation., Objective: To assess whether an impaired cerebral oxygenation was associated with short-term outcome during pediatric ECMO., Methods: We conducted a single-center retrospective study in a pediatric intensive care unit. Children under 18 years old were included if receiving veno-venous or veno-arterial ECMO with concurrent NIRS monitoring. Cerebral saturation impairment was defined as rScO2 under 50% or 20% from the baseline for desaturation, and above 80%. Cerebral imaging (magnetic resonance imaging or CT scan) was performed in case of neurological concern. A radiologist blinded for patient history identified ABI as any hemorragic or ischemic lesion, then classified as major or minor. Primary endpoint was the outcome at hospital discharge. Poor outcome was defined as death or survival with a pediatric cerebral performance category scale (PCPC) score ≥ 3 and/or a major ABI. Good outcome was defined as survival with a PCPC score ≤ 2 and/or a minor or no ABI. Secondary endpoint was mortality before PICU discharge., Results: Sixty-three patients met inclusion criteria; 48 (76%) had veno-arterial ECMO. Mortality rate was 51%. Forty-eight of sixty-three patients (76%) evolved with a poor outcome, including 20 major ABI. Mean rScO2 in the right/left hemisphere was 73 ± 9%/75 ± 9%. Cerebral desaturation and decline of rScO 2 below 20% from the baseline, regardless of side, were each associated with poor outcome (multivariable-adjusted odds ratio (OR), 4 [95%CI 1.2; 15.1], p = 0.03, and 3.9 [95%CI 1.1; 14.9], p = 0.04, respectively), as well as a mean right rScO 2  < 70% during the ECMO course (adjusted OR, 5.6 [95%CI 1.3; 34], p = 0.04). Left rSCO 2  ≥ 80% was inversely correlated with hospital mortality (adjusted OR of 0.14 [95%CI 0.02; 0.8], p = 0.04)., Conclusions: Cerebral desaturation attested by NIRS was associated with a poor short-term outcome in children of all ages undergoing ECMO, and rScO2 > 80% seemed to be protective. NIRS monitoring might be included within multimodal neuromonitoring to assess the risk of the brain injury related to pediatric ECMO., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

The chemical investigation of the flowers and twigs of Calliandra calothyrsus (Fabaceae) led to the isolation of three new oleanane-type triterpenoid saponins, named calothyrsusosides AC (13). Their structures were established by direct interpretation of their spectral data, mainly HRESIMS, 1D NMR and 2D NMR ( 1 H, 1 H NMR DOSY, 13 C NMR, COSY, HSQC, HMBC, HSQC-TOCSY and NOESY) and by comparison with literature data. Compounds 1 and 2 were tested for their antiproliferative activity against two digestive carcinoma human cell lines: Hep3B (hepatocellular carcinoma) and Caco-2 (epithelial colorectal adenocarcinoma). Both compounds exhibited an antiproliferative activity against the Hep3B cell line, with IC 50 values of 6.0 and 6.5 μM, respectively, while no effect was detected against the epithelial colorectal adenocarcinoma Caco-2 (CC 50  > 25 μM)., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflicting interest., (Copyright © 2020. Published by Elsevier B.V.)

Chemical investigation of the methanol extract of the roots of Lecaniodiscus cupanioides led to the isolation and characterisation of three new sesquiterpene glycosides, named cupanioidesosides A (1), B (2) and C (3), together with one new triterpenoid saponin named lecanioside A (4), Their structures were established by extensive analysis of spectroscopic methods including 1D and 2D NMR techniques (COSY, NOESY, TOCSY, HSQC, and HMBC) and HRESIMS. The four new compounds were evaluated for their antiproliferative activity against the Caco-2 cell line (human epithelial cell line). None of the isolated compounds showed positive activity in our assay. Our findings represent a valuable contribution to the chemotaxonomy Lecaniodiscus genus of the subfamily of Sapindoideae of Sapindaceae family, known to be a rich source of farnesol glycosides., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes., Methods: This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included., Results: We analyzed the data of 27 children. Comorbidities (n=19, 70%) were mainly neurological (n=7), respiratory, (n=4), or sickle cell disease (n=4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n=9), catecholamine (n=4), erythropheresis (n=4), renal replacement therapy (n=1), and extracorporeal membrane oxygenation (n=1). Five children died, of whom three were without past medical history., Conclusion: This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children., (Copyright © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Mareya micrantha, an Ivoirian medicinal plant, was investigated for its chemical constituents and antioxidant properties. This study carried out on the hydroethanolic extract of the leaves led to three new nor-cucurbitacins named: 29-nor-1,2,3,4,5,10-dehydro-3,15α,20β-trihydroxy-16α-acetyl-11,22-dioxo-cucurbita-23-ene 2-O-β-D-glucopyranoside (1), 29-nor-2β,20β,25-trihydroxy-16α-acetyl-3,11,22-trioxo-cucurbita-4,23-diene (2) and 29-nor-2β,15α,20β-trihydroxy-16α-acetyl-3,11,22-trioxo-cucurbita-4,23-diene 2-O-β-D-glucopyranoside (3). The structures were established on the basis of spectral data (NMR, UV, MS and IR). The antioxidant properties evaluated by DPPH and CUPRAC methods gave the best activity with compound 1. The chemotaxonomic significance of the isolation of these compounds in Mareya micrantha, a species belonging to the Euphorbiaceae family, is discussed., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: This study aimed to describe cerebral Near InfraRed Spectroscopy (NIRS) profiles during neonatal intubation using two different premedication regimens. Methods: Neonates requiring non-emergency intubation were enrolled in an ancillary study, conducted in two French Neonatal Intensive Care Units participating in a larger on-going multicenter, double blind, randomized, controlled trial. Patients were randomly assigned to the "atropine-propofol" (Prop) group or the "atropine-atracurium-sufentanil" (SufTrac) group. Regional cerebral oxygen saturation (rScO 2 ), pulse oxymetry (SpO 2 ), mean arterial blood pressure (MABP), and transcutaneous partial pressure of carbon dioxide (TcPCO 2 ) were collected at 9 predefined time points from 1 min before to 60 min after the first drug injection. The two primary outcomes were a decrease in rScO 2 value >20% from baseline and a decrease in fractional cerebral tissue oxygen extraction (FTOE) value >10% from baseline, at any time point. Secondary outcomes included physiological parameters changes over time and correlations between mean arterial blood pressure, and FTOE at different time points. Descriptive results were obtained and exploratory statistical analyses were performed for 24 included patients. Results: rScO 2 decreased in 5/11 (46%) infants from the Prop group and 10/13 (77%) from the SufTrac group ( p = 0.11); FTOE decreased in 10/11 (91%) infants from the Prop group, and 12/13 (92%) from the SufTrac group ( p = 0.90). rScO 2 values decreased over time in both groups, whereas FTOE's pattern appeared more stable. SpO 2 and transcutaneous TcPCO 2 seemed more preserved in the Prop group while MABP seemed more preserved in the SufTrac group. No important correlation was observed between MABP and FTOE (r = 0.08 to 0.12 across the time points). Conclusion: Our results suggest a frequent decrease in cerebral oxygenation without obvious impairment in cerebral autoregulation during neonatal intubation with premedication. This study confirms the feasibility and the informative value of cerebral NIRS monitoring in this setting. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02700893.

A model was developed to simulate the sewage sludge gasification in an atmospheric fluidised bed gasifier using Aspen Plus. The model here presented was based on the Gibbs free energy minimisation and the restricted equilibrium method was used to calibrate it against previously published experimental data obtained in a lab-scale gasification plant. A sensitivity analysis of the model was carried out by modifying parameters such as the temperature, equivalence ratio (ER) and the steam-to-biomass ratio. The modeled results were in good agreement with the experimental data (especially when air was used as gasifying agent) and reproduced satisfactorily the experimental trends found for the gas composition, the carbon conversion (Xc) and the cold gas efficiency (CGE) under different gasification conditions. Operating at higher temperatures increased the production of H 2 and CO, as well as the Xc and the CGE. The increase in ER produced higher Xc, yet the CGE experienced slight changes due to a decrease in the lower heating value of the resulting syngas, as well as the oxidation of combustible gases. The use of air+steam as gasifying agent increased the H 2 content of the produced gases but decreased the accuracy of the model.

Guillain-Barré Syndrome (GBS) is rare in infancy, and the diagnosis of atypical forms is difficult in this age range. The main differential diagnoses include congenital neuropathy. Biological and electrophysiological investigations remain important to confirm diagnosis and start treatment quickly. We report the case of an 8-month-old boy who presented with acquired hypotonia due to progressive descending limb paralysis, predominant in the upper limbs, associated with unexplained severe neutropenia. GBS was diagnosed thanks to the association of albuminocytologic dissociation on cerebrospinal fluid and demyelinating sensomotor polyradiculoneuropathy on electroneuromyography. Only one cycle of treatment with intravenous immunoglobulins was sufficient to achieve complete recovery after 1 year. Physicians should know that atypical forms of GBS exist in infants, in order to recognize the syndrome, rule out differential diagnoses, and start treatment as soon as possible. Medical follow-up remains important before and after remission, especially in infants, to identify relapses, which might be the symptom of a genetic neuropathy or a chronic inflammatory disease., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

This paper analyses the effects of policy making for air pollution abatement in Spain between 2000 and 2020 under an integrated assessment approach with the AERIS model for number of pollutants (NOx/NO2, PM10/PM2.5, O3, SO2, NH3 and VOC). The analysis of the effects of air pollution focused on different aspects: compliance with the European limit values of Directive 2008/50/EC for NO2 and PM10 for the Spanish air quality management areas; the evaluation of impacts caused by the deposition of atmospheric sulphur and nitrogen on ecosystems; the exceedance of critical levels of NO2 and SO2 in forest areas; the analysis of O3-induced crop damage for grapes, maize, potato, rice, tobacco, tomato, watermelon and wheat; health impacts caused by human exposure to O3 and PM2.5; and costs on society due to crop losses (O3), disability-related absence of work staff and damage to buildings and public property due to soot-related soiling (PM2.5). In general, air quality policy making has delivered improvements in air quality levels throughout Spain and has mitigated the severity of the impacts on ecosystems, health and vegetation in 2020 as target year. The findings of this work constitute an appropriate diagnosis for identifying improvement potentials for further mitigation for policy makers and stakeholders in Spain., (Copyright © 2015 Elsevier B.V. All rights reserved.)

The disulfonimide (R)-1 enables enantio-differentiation of a large scope of chiral O-heterocycles, thanks to the formation of diastereomeric adducts. The underlying H-bond has been investigated by NMR. (R)-1 has been used as a chiral solvating agent (CSA) to determine the stereochemical purity of D/L lactide by (1)H NMR.

Modeling is an essential tool for the development of atmospheric emission abatement measures and air quality plans. Most often these plans are related to urban environments with high emission density and population exposure. However, air quality modeling in urban areas is a rather challenging task. As environmental standards become more stringent (e.g. European Directive 2008/50/EC), more reliable and sophisticated modeling tools are needed to simulate measures and plans that may effectively tackle air quality exceedances, common in large urban areas across Europe, particularly for NO₂. This also implies that emission inventories must satisfy a number of conditions such as consistency across the spatial scales involved in the analysis, consistency with the emission inventories used for regulatory purposes and versatility to match the requirements of different air quality and emission projection models. This study reports the modeling activities carried out in Madrid (Spain) highlighting the atmospheric emission inventory development and preparation as an illustrative example of the combination of models and data needed to develop a consistent air quality plan at urban level. These included a series of source apportionment studies to define contributions from the international, national, regional and local sources in order to understand to what extent local authorities can enforce meaningful abatement measures. Moreover, source apportionment studies were conducted in order to define contributions from different sectors and to understand the maximum feasible air quality improvement that can be achieved by reducing emissions from those sectors, thus targeting emission reduction policies to the most relevant activities. Finally, an emission scenario reflecting the effect of such policies was developed and the associated air quality was modeled., (© 2013.)

This study assessed the applicability of a ferrous oxalate mediated photo-Fenton pretreatment for indigo-dyed wastewaters as to produce a biodegradable enough effluent, likely of being derived to conventional biological processes. The photochemical treatment was performed with ferrous oxalate and hydrogen peroxide in a Compound Parabolic Concentrator (CPC) under batch operation conditions. The reaction was studied at natural pH conditions (5-6) with indigo concentrations in the range of 6.67-33.33 mg L(-1), using a fixed oxalate-to-iron mass ratio (C(2)O(4)(2-)/Fe(2+)=35) and assessing the system's biodegradability at low (257 mg L(-1)) and high (1280 mg L(-1)) H(2)O(2) concentrations. In order to seek the optimal conditions for the treatment of indigo dyed wastewaters, an experimental design consisting in a statistical surface response approach was carried out. This analysis revealed that the best removal efficiencies for Total Organic Carbon (TOC) were obtained for low peroxide doses. In general it was observed that after 20 kJ L(-1), almost every treated effluent increased its biodegradability from a BOD(5)/COD value of 0.4. This increase in the biodegradability was confirmed by the presence of short chain carboxylic acids as intermediate products and by the mineralization of organic nitrogen into nitrate. Finally, an overall decrease in the LC(50) for Artemia salina indicated a successful detoxification of the effluent., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The aim of the present work was to characterize and treat a mature landfill leachate using a coagulation/flocculation process followed by a photo-Fenton oxidation treatment. The leachate was obtained from a landfill in Tetlama, Morelos (Mexico) during the drought season and was characterized in terms of its major pollutants. Considerable levels of chemical oxygen demand (COD), total carbon (TC) and NH4+ were identified, as well as high concentrations of Hg, Pb, and As. Other heavy metals such as Ni, Co, Zn, Cd, and Mn were detected at trace levels. The lethal concentration (LC50) of the leachate, evaluated on Artemia salina, was 12,161±11 mg/L of COD, demonstrating an antagonistic interaction among the leachate's components. The treatment of this effluent consisted of a coagulation-flocculation process using an optimal dose of FeCl3 · 6H2O of 300 mg/L. The supernatant was treated using a photo-Fenton process mediated with FeCl2 · 4H2O and H2O2 in a compound parabolic concentrator (CPC) photo-reactor operating in batch mode using an R ratio (R=[H2O2]/[Fe2+]) of 114. The global removal efficiencies after treatment were 56% for the COD, 95% for TC, and 64% for NH4+. The removal efficiencies for As, Hg, and Pb were 46%, 9%, and 85%, respectively., (Copyright © 2011 Elsevier B.V. All rights reserved.)

We describe the synthesis and the physicochemical study of new ion-pair amphiphiles from a mixture of bicyclic, cyclic, linear or branched amines and fatty acids of three chain lengths. Surface-tension measurements of bicyclic, cyclic and branched structures of ammonium/alkanoate acid ion pairs show a phase transition, with two plateaux in the plot of surface tension versus log(c) (c=concentration). Such behaviour is related to the structure of the counterion, the alkyl chain length and the temperature. Pulsed gradient spin echo NMR spectroscopy experiments were performed to demonstrate the existence of micelles on the first plateau and to confirm the phase transition. The existence of vesicles on the second plateau of the surface tension was proved by CryoTEM observation and dynamic light scattering (DLS) measurements. Mainly, according to the structure of the counterion, there is either a strong association and a positioning along the chain leading to vesicles or a less strong association leading to external positioning and the formation of micelles at low concentrations or vesicles at higher concentrations.