超出生体重児に対する早期デキサメサゾン投与の有用性 : National Institute of Child Health and Human Development Neonatal research Network報告 (海外誌掲載論文の和文概要とそれに対するコメント)

Cisplatin is a widely used and highly effective cancer chemotherapeutic agent. One of the limiting side effects of cisplatin use is nephrotoxicity. Research over the past 10 years has uncovered many of the cellular mechanisms which underlie cisplatin-induced renal cell death. It has also become apparent that inflammation provoked by injury to renal epithelial cells serves to amplify kidney injury and dysfunction in vivo. This review summarizes recent advances in our understanding of cisplatin nephrotoxicity and discusses how these advances might lead to more effective prevention.

Mechanisms of Cisplatin nephrotoxicity.

Objective: T o de v elop a North American Society for Pediatric Ga str oen te rol og y , He pat olo gy , and Nut ri tio n (N ASP GH AN) and Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n (ES PGH AN ) int er nat io nal con se ns us on th e di agn os is an d ma nag em ent of gas tr oes op hag eal refl ux and gas tr oes op hag eal re flu x di sea se in th e ped ia tr ic po pu la tio n. Methods: An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which de v eloped these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-av ailable e vidence from PubMed, Cumulati ve Index to Nursing and Allied Health Literature, and bibliographies. The committee con v ened in face-to-face meetings 3 times. Consensus was achie v ed for all recommendations through nominal group technique, a structured, quantitati v e method. Articles were e v aluated using the Oxford Centre for Evidence-based Medicine Le vels of Evidence. Using the Oxford Grades of Recommendation, the quality of e vidence of each of the recommendations made by the committee was determined and is summarized in appendices. Results: More than 600 articles were re vie wed for this work. The document provides e vidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. Conclusions: Th is do cum ent is int end ed to be us ed in dai ly pra cti ce fo r th e de v el op me nt of fut ure cli ni cal pra ct ic e gu ide lin es and as a bas is for cli ni cal tr ia ls . JP GN 49 :49 8 – 54 7, 20 09 . Ke y Wo rd s: Cli nic al pra ct ic e gu id el ine s — Di agn os tic te sts — Ga str oes op hag ea l refl ux (GE R) — Ga str oes op hag ea l refl ux di sea se (GE RD ) — The rap eut ic mod al iti es. # 20 09 by Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n and No rt h Am er ica n So ci ety for Pe dia tri c Ga str oen te rol og y , Hep at ol og y , an d Nu tr iti on

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Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

Obesity is the accumulation of abnormal or excessive fat that may interfere with the maintenance of an optimal state of health. The excess of macronutrients in the adipose tissues stimulates them to release inflammatory mediators such as tumor necrosis factor α and interleukin 6, and reduces production of adiponectin, predisposing to a pro-inflammatory state and oxidative stress. The increased level of interleukin 6 stimulates the liver to synthesize and secrete C-reactive protein. As a risk factor, inflammation is an imbedded mechanism of developed cardiovascular diseases including coagulation, atherosclerosis, metabolic syndrome, insulin resistance, and diabetes mellitus. It is also associated with development of non-cardiovascular diseases such as psoriasis, depression, cancer, and renal diseases. On the other hand, a reduced level of adiponectin, a significant predictor of cardiovascular mortality, is associated with impaired fasting glucose, leading to type-2 diabetes development, metabolic abnormalities, coronary artery calcification, and stroke. Finally, managing obesity can help reduce the risks of cardiovascular diseases and poor outcome via inhibiting inflammatory mechanisms.

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Obesity and inflammation: the linking mechanism and the complications.

Context Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS. Objectives To determine the national incidence of NAS and antepartum maternal opiate use and to characterize trends in national health care expenditures associated with NAS between 2000 and 2009. Design, Setting, and Patients A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The Nationwide Inpatient Sample (NIS) was used to identify mothers using diagnosis related groups for vaginal and cesarean deliveries. Clinical conditions were identified using ICD-9-CM diagnosis codes. NAS and maternal opiate use were described as an annual frequency per 1000 hospital births. Missing hospital charges ( Main Outcome Measures Incidence of NAS and maternal opiate use, and related hospital charges. Results The separate years (2000, 2003, 2006, and 2009) of national discharge data included 2920 to 9674 unweighted discharges with NAS and 987 to 4563 unweighted discharges for mothers diagnosed with antepartum opiate use, within data sets including 784 191 to 1.1 million discharges for children (KID) and 816 554 to 879 910 discharges for all ages of delivering mothers (NIS). Between 2000 and 2009, the incidence of NAS among newborns increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1000 hospital births per year (P for trend  Conclusion Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.

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Neonatal Abstinence Syndrome and Associated Health Care Expenditures

Sudden infant death syndrome (SIDS) is the most common type of post-neonatal death in infants aged under 1 year, and is defined as the sudden death of a baby that is unexpected from the baby's history and unexplained by a thorough post-mortem examination ( [Hunt, 1992][1]). Current aetiological

/pdf/sudden-infant-death-syndrome-and-psychiatric-disorders-4vivid6o8d.pdf

Sudden infant death syndrome and psychiatric disorders.

Objectives Infants of smoking (S) and substance misusing (SM) mothers have an increased risk of sudden infant death syndrome. The aim of this study was to test the hypothesis that infants of SM or S mothers compared with infants of non-SM, non-smoking mothers (controls) would have a poorer ventilatory response to hypoxia, which was particularly marked in the SM infants. Design Physiological study. Setting Tertiary perinatal centre. Patients 21 SM; 21 S and 19 control infants. Infants were assessed before maternity/neonatal unit discharge. Interventions Maternal and infant urine samples were tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine and benzodiazepines. Main outcome measures During quiet sleep, the infants were switched from breathing room air to 15% oxygen and changes in minute volume were assessed. Results The SM infants had a greater mean increase (p=0.028, p=0.034, respectively) and a greater magnitude of decline (p Conclusions Antenatal substance misuse and smoking affect the infant9s ventilatory response to a hypoxic challenge.

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Antenatal substance misuse and smoking and newborn hypoxic challenge response

Sir: Trisomy 9p may be the fourth most common autosomal condition after trisomies 21, 18 and 13. We report a child with trisomy 9p who had a partial Dandy-Walker malformation and maldevelopment of the limbic system. We suggest that these abnormalities may be part of the syndrome but have not been described previously due to the infrequent investigation of cases with MRI. The patient was the ®rst male child of nonconsanguinous Vietnamese parents. At 3 weeks of age the infant was referred to us by a community midwife and dysmorphic features were noted. The clinical features present were typical of trisomy 9p syndrome and included midfacial hypoplasia, hypertelorism, low-set ears, micrognathia, epicanthic folds, ``cup-like'' simple ears and downturned corners of the mouth. The infant also had bilateral simian palmar creases and bilateral clinodactyly but nail dysplasia, present in the majority of cases with trisomy 9p, was not found. His karyotype was 46,XY, dup(9)(p12p24). The karyotypes of both parents were normal. At follow up, because of a large anterior fontanelle and developmental delay, brain MRI was performed. This demonstrated the presence of a partial Dandy-Walker malformation with a possible cyst in the cisterna magna (Fig. 1) and abnormal development of the limbic system (Fig. 2). This case demonstrated some of the classical features of trisomy 9p [1]. The ®ndings on the MRI scan of a partial Dandy-Walker malformation and maldevelopment of the limbic system have not been previously reported although a similar picture has been described in trisomy 9 mosaicism [2]. It is likely that previous cases with trisomy 9p would not have had the bene®t of an MRI scan. We would recommend that a brain MRI should become part of the routine investigation of all children with trisomy 9p if they are to be appropriately evaluated.

An unusual presentation of trisomy 9p syndrome with a partial Dandy-Walker malformation.

Objective During proportional assist ventilation (PAV) the timing and frequency of inflations are controlled by the patient and the patient9s work of breathing may be relieved by elastic and/or resistive unloading. It is important and the authors9 objective to determine whether ventilators delivering PAV function well in situations mimicking neonatal respiratory conditions. Design In vitro laboratory study. Setting Tertiary neonatal ICU. Interventions Dynamic lung models were developed which mimicked respiratory distress syndrome, bronchopulmonary dysplasia and meconium aspiration syndrome to assess the performance of the Stephanie® neonatal ventilator. Main outcome measures The effects of elastic and resistive unloading on inflation pressures and airway pressure wave forms and whether increasing unloading was matched by an ‘inspiratory’ load reduction. Results During unloading, delivered pressures were between 1 and 4 cm H 2 O above those expected. Oscillations appeared in the airway pressure wave form when the elastic unloading was greater than 0.5 cm H 2 O/ml with a low resistance model and 1.5 cm H 2 O/ml with a high resistance model and when the resistive unloading was greater than 100 cm H 2 O/l/s. There was a time lag in the delivery of airway pressure of at least 60 ms, but increasing unloading was matched by an inspiratory load reduction. Conclusions During PAV, unloading does reduce inspiratory load, but there are wave form abnormalities and a time lag in delivery of the inflation pressure. The impact of these problems needs careful evaluation in the clinical setting.

https://fn.bmj.com/content/fetalneonatal/early/2010/06/04/adc.2009.170787.full.pdf

In vitro assessment of proportional assist ventilation

Chronic lung disease is a common adverse outcome of prematurely born infants and is associated with an early inflammatory response, which persists over weeks. As a consequence, it is possible that exhaled nitric oxide levels might be raised in affected infants. The majority of such infants will be ventilated in the first weeks of birth and thus it is important to determine the influence of mechanical ventilation on nitric oxide levels. As a consequence, our aim was to determine whether, during mechanical ventilation, simulated exhaled nitric oxide levels were influenced by changes in ventilator settings or the sampling catheter position. A lung model was created consisting of a rubber bag inside a 1 l jar. An endotracheal tube (ETT) was fixed securely within the neck of the bag. Nitric oxide was delivered into the bag at a constant rate to simulate production and sampled from within the ETT and the bag. The sampled nitric oxide was analysed using a Sievers chemiluminescence analyser. The ETT was attached to a neonatal ventilator and a nitric oxide scavenger placed in the ventilator's inspiratory limb to ensure nitric oxide free gas was delivered. Comparison of different sampling positions revealed that the highest peak nitric oxide level within the ETT was at the tip. Increasing peak inflating pressure and ventilator rate resulted in a decrease in the peak nitric oxide levels. Increasing the inspired oxygen concentration also was associated with a reduction in the peak nitric oxide levels, the effect being more pronounced when larger volume lung models were examined. The results emphasized that the conditions of measurement must be standardized in infants receiving respiratory support, if exhaled nitric oxide results are to be appropriately interpreted.

Simon Hannam

Papers

Sudden infant death syndrome and psychiatric disorders.

Antenatal substance misuse and smoking and newborn hypoxic challenge response

An unusual presentation of trisomy 9p syndrome with a partial Dandy-Walker malformation.

In vitro assessment of proportional assist ventilation

Influence of ventilatory settings and sampling position on measurements of simulated exhaled nitric oxide levels.