Therapeutic Hypothermia for Postnatal Refractory Hypoxemia

Therapeutic Hypothermia for Postnatal Refractory Hypoxemia THERAPEUTIC HYPOTHERMIA FOR POSTNATAL REFRACTORY HYPOXEMIA « A CASE REPORT IN A TERM NEONATE K. Sarafidis1, E. Diamanti1, V. Soubasi1, K. Mitsakis2, V. Orossou-Agakidou1, Bianca Popovici3, M. Moga3 Summary We describe a term neonate treated with whole-body hypothermia several days after birth to counteract refractory hypoxemia due to persistent pulmonary hypertension unresponsive to optimal treatment. This approach was selected to improve oxygenation and protect the brain from the consequences of hypoxemia. In our experience, hypothermia did not worsen pulmonary hypertension, although no beneficial effect on oxygenation was noted. Never ­theless, the favorable neurological outcome of die neonate provides some evidence for neuroprotection against refractory hypoxemia using hypothermia. Key words: persistent pulmonary hypertension of the neonate, neuroprotection, mechanical ventilation Rà ©sumà © Lhypothermie thà ©rapeutique pour lhypoxà ©mie rà ©fractaire post-natale: prà ©sentation dun cas dun nouveau-nà © à   terme Nous dà ©crivons un nouveau-nà © à   terme traità © par hypothermie du corps entier quelques jours aprà ¨s la naissance afin de neutraliser lhypoxà ©mie rà ©fractaire due à   lhypertension pulmonaire persistante qui ne rà ©pond pas à   un traitement optimal. Cette approche a à ©tà © choisie pour amà ©liorer loxygà ©nation et protà ©ger le cerveau contre les consà ©quences de lhypoxà ©mie. Dans notre expà ©rience, lhypo ­thermie na pas aggravà © lhypertension artà ©rielle pulmonaire, mais il na à ©tà © notà © aucun effet bà ©nà ©fique sur loxygà ©nation. Nà ©anmoins, là ©volution neurologique favorable du nouveau-nà © a fourni des preuves de neuroprotection contre lhypoxà ©mie rà ©fractaire à   laide de lhypothermie. Mots clefs: hypertension pulmonaire persistante, neuroprotection Introduction anagement of late preterm and term neonates with moderate-severe hypoxic- ischemic encephalopathy (HIE) following perinatal asphyxia is, hitherto, the only evidence-based application of hypothermia in neonatology as it reduces mortality without increasing major disability in survivors [1, 2]. Other situations such as perinatal arterial ischemic stroke, neonates with HIE beyond the therapeutic window of the first 6 hours after birth or less than 36 weeks gestation and those with unexpected postnatal collapse could potentially benefit from this neuroprotective treatment, but, at present, only few or no data is available [2, 3]. This case describes a term neonate treated with whole-body hypothermia several days after birth to counteract refractory hypoxemia and protect the brain from its consequences. Case report A female, 3.470 g newborn was transferred to our hospital at 10 hours of life for respiratory distress. The baby was bom at 39+4 weeks gestation after caesarian section due to mild fetal distress. Bag and mask ventilation were given at birth, and the 1 and 5 minute Apgar scores were 6 and 9, respectively. Conventional mechanical venti ­lation was started upon admission to our department while the lung X-ray was suggestive of transient tachypnea. Temporal improvement in oxygenation was noted following exogenous surfactant administration (Beractant, 100 mg/Kg/dose). Thereafter, oxygen requirements increased significantly, despite optimal ventilation (including high-frequency oscillatory ventilation) and supportive management (sedation-analgesia, inotropes). Following X-rays consis ­tently showed the absence of parenchymal lung disease. Car ­diac ultrasound confirmed the clinical diagnosis of persistent pulmonary hypertension of the neonate (PPHN), but inhaled nitric oxide (iNO) at 20 ppm and other adjunctive therapies (oral sildenafil, bosentan) had no clinical effect. Repeat sepsis work-up was negative. Continuing, severe impairment in oxygenation prompted us to apply whole-body hypo ­thermia (Tecotherm Neo ®, target rectal temperature 33.5 ±0.5  °C)for 72 hours starting from day of life (DOL) 6, which was well tolerated. During hypothermia, the respira ­tory failure slightly improved, in the short term, as indicated by the reduction of alveolar-arterial difference of oxygen (fig. 1). Despite refractory hypoxemia, no clinical seizures were obsewed whereas there were no pathologic findings on head ultrasound scans and amplitude-integrated-EEG. Interestingly, the sleep-wake cycle was lost during cooling but normalized after the end of this treatment. From DOL 14 onwards, oxygenation started to improve (although still with variable) finally allowing weaning from the ventilator (DOL 20) (fig. 1). Brain imaging (ultrasound scan, magnetic resonance imaging) were normal at hospital discharge (DOL 36) as was later neurodevelopment (6 months). Discussion To the best of our knowledge, this is the first case to report the use of whole-body hypothermia in neonates with refractory hypoxemia secondary to PPHN as adjunct to mechanical ventilation and as neuroprotection. PPHN is an important cause of neonatal respiratory failure associated with increased mortality and neurological impairments in survivors [4]. Hypothermia reduces oxygen consumption as well as C02 production [5]. Moreover, experimental animal data show that hypothermia may protect [6] or attenuate the ventilator-induce lung injury mitigating the pro-inflammatory response [7]. Improved gas exchange has also been reported in the latter investigations [7]. Similarly, there is evidence although limited from studies in critically ill adults suggesting an improvement in oxygenation [81 and ventila ­tion [91 with hypothermia. Therefore, this therapeutic technique could potentially be beneficial in our patient breaking the vicious circle of hypoxemia, PPHN and ventila ­tor-induced lung injury. On the other hand, aggravation of Figure 1 Supportive care and serial changes of alveolar-arterial difference of oxygen (AaD02, best and worse) during the first 3 weeks of life (B and C). Initial lung X-rays (A) and snapshot of the a-EEG recording before and during hypothermia (D) are also shown. hfov CMV: Conventional mechanical ventilation, DOL: Day of life, HFOV: High-frequency oscillatory ventilation, iNO: Inhaled nitric oxide PPHN was a possible clinical scenario, given the metabolic response to cold stress (increased catecholamines and pulmonary vascular resistance) [5]. In large randomized controlled trials of hypothermia in perinatal asphyxia, PPHN at randomization was considered as an exclusion criterion [21. It is our clinical observation that a slight and temporal improvement in alveolar-arterial difference of oxygen was indeed observed during hypothermia. However, this could be an oxygen extraction issue. At lower temperatures, oxyhemo globin dissociation curve is shifted to the left resulting in decreased oxygen release to the tissues which in turn have decreased oxygen demands [5]. Nevertheless, the fact that improved oxygenation was not sustained and, also, that coin ­cided with the application of high frequency ventilation does not allow us to support any significant effect of whole-body hypothermia per se on oxygenation. Yet, this trend towards improvement in oxygenation is in line with the most recent relevant meta-analysis, in which hypothermia was found not to increase the risk of PPHN, at least as indicated by the need for Ino [1]. Extracorporeal membrane oxygenation (ECMO) could be an alternative treatment to PPHN [4], but no ECMO center was available. Conversely, this invasive intervention encompasses severe risks for the brain. Actually, for this very reason mild hypothermia was preventively attempted for 12 hours in a small cohort of neonates receiving ECMO. Unfortunately, neurodevelopment outcome was not assessed [10]. We applied therapeutic hypothermia as this is a promising means of neuroprotection in neonates. None the less, two facts merit comment in the present case: the lack of any clinical or other evidence of brain injury (normal head ultrasound scan, a-EEG) when cooling was decided and the application of hypothermia several days after birth. So far, hypothermia is only indicated as early as possible in neonates with evidence of HIE following an acute perinatal event, so as to limit the already activated molecular mecha ­nisms of neuronal damage and death [11]. It is impossible to know whether prolonged hypoxemia triggered such a cascade of events in our neonate. However, therapeutic hypothermia has also been tested in neonatal conditions, independent of neuroprotection. Advanced necrotizing enterocolitis in preterm infants is such an example, where mild hypothermia was applied as an alternative therapy to reduce intestinal injury and distal organ damage [12]. Specific biochemical biomark ers or more sophisticated techniques (e.g., magnetic resonance spectroscopy) could possibly have provided some indications as to the presence of cerebral injury secondary to refractory hypoxemia and the impact of hypothermia. Such techniques, however, are available for use at the bedside only in a few centers [13]. Additionally, our baby-girl was not part of a relevant study and, therefore, no investigations beyond those indicated in everyday clinical practice were performed. Nonetheless, its favorable neurological outcome is encouraging. Since we are not, however, able to know whether and to what extent hypothermia had any neuroprotective effect against hypoxemia related to respiratory failure, this approach needs to be evaluated in large trials.

Complementing Texts: Homer’s The Odyssey and Dante’s Inferno Essay

Ever since human beings started telling stories for entertainment or for edification, heroes have made incredible journeys against what seem like impossible odds. In the beginning, heroes often these journeys to reach a goal, often in defiance of the gods who, for whatever reason, had imposed limits upon the main character of the story. In Homer’s story, The Odyssey, this limitation is that the gods will block his way home until he speaks to the sage Tiresias. By contrast, Dante Alighieri’s character of Dante primarily seeks to find answers to his questions; that is, knowledge, as a means to find salvation. While both heroes interact with the underworld to accomplish their aims, the stories complement each other, rather than mirror each other. In many ways, Dante’s text â€Å"corrects† the story found in Homer’s work, making it suitable for Christian audiences. Careful examination of texts reveals how some of these areas differ significantly between them. Some of these differences include the nature of the underworld itself and the hero’s interaction with it, the knowledge that Odysseus’ mother has of the living world, and the shared rule of the underworld. The Nature of the Underworld and the Heroes’ Interaction with It Like Dante’s Hell, Homer’s underworld is not a pleasant place to spend eternity. It is dark and gloomy; the inhabitants have dulled senses. The underworld into which Odysseus looks is Hades, not the Elysian Fields, where heroes were blessed with eternal happiness. Rather, the â€Å"unhappy dead† live there, cursed to bleak and boring existences for the rest of eternity. The dead who exist in Hades are those who have died unburied, like Odysseus’ friend, Elpenor, who died falling from a ladder leading from Circe’s roof, as well as Tiresias and Odysseus’ unhappy mother. And yet, misery of the inhabitants is one of several similarities between the two underworlds. One interesting difference between the Homer’s Hades and Dante’s Hell is that the stories’ heroes find their entrances in extremely different locations. Odysseus finds the entrance to Hades in a harbor at the â€Å"western edge of the world,† while Dante finds the entrance to Hell in the midst of a dark wood. While these differences might seem insignificant, they are, in truth, indicative of the different purposes behind the journeys that the heroes undertake. The harbor at the end of the world represents physical distance traveled; Odysseus is on a quest to return home to Ithaca, a goal that the gods have prevented him from attaining. It is an earthly goal, however, with measurable distances that must be traversed. While the ocean that Odysseus travels provides room for a communal journey through which he attempts to bring his crew home, Dante’s dark wood provides a far narrower field. It is restrictive and personal, perhaps driven by the solitary nature of Dante’s quest for knowledge and redemption. The distance that Dante must travel, therefore, is not one of finite measurement; rather, it exists within himself. It is a spiritual journey with no physical boundaries. Ultimately, this difference is magnified by the many levels of Hell, with its myriad levels, terraces, and malboges. In addition to the differing nature of the underworld as portrayed by each poet, the nature of the interaction that each hero has with the underworld and its inhabitants also varies. In order to interact at all with the inhabitants of the underworld, both heroes must make a rite of passage. Odysseus enters the realm of Hades by making a blood sacrifice of a ram, collecting its blood in a pit. Through this offering and by offering the appropriate supplications to the gods, Odysseus is able to call forth the souls of the dead. Being surrounded by the dead causes him to become afraid; however, he regains sufficient courage to control them and to question them. The character of Dante, however, must actually pass through the gates of Hell, ‘abandoning hope’ in order to learn what he desires. Although Odysseus is in the world of the dead, he is sure enough of himself to regain control, as opposed to Dante, who relinquishes all of his control to Virgil as then enter the underworld realm. While less â€Å"heroic† than Odysseus’ actions, this submissive behavior is actually of great importance, which again is based in the heroes’ purpose in entering the underworld. It is clear, that although both heroes must enter the realm of the underworld, each for his own purpose, Odysseus does not actually travel through Hades as Dante does through Hell. Rather, the dead approach Odysseus, coming â€Å"up in a crowd from Erebos: young men and brides, old men who had suffered much, and tender maidens to whom sorrow was a new thing; others killed in battle, warriors clad in bloodstained armor† (124) all surround his sacrificial pit in response to the ram’s blood that he has offered. This difference is also a significant one and related to the point made above it. Although Odysseus immediately appears to be the supplicant, by making the blood offering that attracts the dead, he is also in control of it. The dead must do his bidding in order to feed and give him the information that he requires. By contrast, the character of Dante physically travels into the midst of the souls of the damned. While he is under his own volition, Dante is a pilgrim, who must make an effort to gain his knowledge. He follows Virgil as Virgil leads, interacting with the souls on their own level in their own environment. This difference would also make Dante’s tale more appealing to Christian audiences. Although Odysseus’ cunning and strength were admired by the audience that lived at his time, the lesson of humility that the character of Dante both learns and teaches would be considered more acceptable to Alighieri’s audience. Although he is taking the initiative to learn on his own, like a proper pilgrim he is taking instruction from a master and listening to the moral lessons set before him. For those in the audience who recognize that he might have been contemplating suicide, Dante is also in the process of repenting. Knowledge of the Living World Odysseus seeks not merely wisdom from Tiresias, but he also seeks knowledge of his future in the living world. In truth, both Tiresias and Odysseus’ mother have clear knowledge of the living world, which they freely share with him in their turn. What is more, it is accurate knowledge, which allows him to prepare for his future, should he ever arrive at his destination. In a sense, both Tiresias and Odysseus’ mother are as living beings that have merely been transported to a new existence on an alternate plane, in that they can take initiative to see what lies ahead and then share it with him. Given that in other myths inhabitants of Hades are able to travel freely between the worlds with the gods’ permission, it seems apparent that the ancient Greeks saw the underworld as a place from which people could escape to return to the living if they had enough virtue or if they had a hero to aid them. This kind of belief is opposed to both Dante’s belief and to the belief of the Christians who formed his audience. Dante’s souls, perpetually trapped in their state of torment, must continuously atone for their actions on earth. They are surrounded by the reminders of their sins, perhaps tormented by the very things that they desired in life. At times, their appearance is dramatically altered to match their crimes. The only hope for the souls in Hell is Judgment Day, at which time they may be redeemed–or they may find themselves condemned to suffer throughout eternity. Even then, redeemed souls would not interact with the living; instead, they would pass into Heaven. Once again, the difference between the two realms and their inhabitants may be explained by virtue of the perception of the audiences for which the poets were writing. To the Greeks, life in the underworld was not necessarily a punishment. Certainly, the inhabitants of the underworld could experience punishment, even that of a perpetual nature. One good example of this kind of punishment would be Sisyphus, condemned to roll a boulder to the top of a hill for eternity, only to have it escape him and roll to the bottom again before it reaches the peak. However, the underworld is a plane of existence to which all humans will eventually travel. The underworld itself is divided into sections that provide reward or punishment or which simply continues the miserable existence that people had when on earth. This difference is, once again, quite different from the perspective of the Christian audience served by Dante, which viewed the underworld for punishment only. It is this understanding of the underworld being for punishment that would also limit the dead’s interaction with the living. Dante’s dead are unable to access the living world and, when encountering the character of Dante, are unable to learn from what he tells them. They have no minds and no insight, unlike the dead that Odysseus encounters, who know that they are suffering and why and yet are unable to interact with the world of the living in order to minimize their experiences. The Shared Rule of the Underworld In The Odyssey, both Hades and his wife, Persephone, rule the underworld. Although Hades has control over the underworld as a whole, Persephone is the Queen of the Women, with the ability to overrule even her husband in control of that group. In terms of importance, while this difference might seem trivial to some readers, it is perhaps of greatest significance of all of these points. Hades is not omnipotent, in that Persephone has equal control, if not greater control in some aspects of ruling the underworld. She strikes fear in Odysseus’ heart equal to that of her husband, in that Odysseus describes Hades as â€Å"mighty,† but Persephone as being â€Å"awful,† which would be synonymous with her being terrifying. This kind of rule would be unsurprising to the ancient Greeks, who lived in a world ruled by many gods. It also paralleled the arrangement of the gods on Mount Olympus, to a certain extent: Hades and Persephone, who ruled the world of the dead, mirrored Zeus and Hera, who ruled the world of the living. To the Christians that formed Dante’s audience, this arrangement would have been more than just a little shocking. Christians worship a single God who, while He might have different and while He may employ different helpers in the angels and the saints, has dominion over the living and the dead. As with the ancient Greek deities, God and Satan somewhat mirror each other. Despite Satan’s impressive appearance in The Inferno, however, he is as much a prisoner of Hell as its other residents. In addition, Satan does not mirror God’s power; rather, he is only capable of destruction, not creation. Conclusion In many ways, Dante’s Inferno complements and corrects Homer’s The Odyssey. Both are tales that bring a hero into contact with the underworld in order to achieve a particular goal. In the case of Odysseus, this goal is worldly and finite, while in the case of Dante, the goal is spiritual and may lead to eternal salvation. Several differences, among others, that indicate the complementary and corrective nature of Dante’s work are those of the nature of the respective underworlds and the heroes’ interaction with the inhabitants, the knowledge that the dead have of the living world, and the shared rule that Hades and Persephone have over the ancient Greek underworld. The story of heroic travels through the underworld is not a new one, neither was it new when Homer wrote The Odyssey. In the days of passing history and learning through oral means, such stories were necessary teaching tools. However, each culture imposed its morals and beliefs on this kind of tale. The different between these two stories provide an excellent example of how this cultural influence stamps this kind of heroic story with differences throughout history.

The Hidden Truth About Photography Argumentative Essay Topics

The Hidden Truth About Photography Argumentative Essay Topics You might have to figure out what you wish to write in your essay. Out of the many kinds of essays, photo essays are definitely the most illustrious. It is possible to buy argumentative essay from a specialist writer. You could be writing an argumentative essay to argue for a specific point of view or to may do a persuasive essay to spell out the steps necessary to finish a task. Therefore, either you would like to learn more about how to compose an essay, or you desire some essay writing services or even in the event you would like to go through some sample essays, then just refer to WritingBest and all of your requirements will be fulfilled once possible. If you are searching for top essay writing companies, try out the mentioned above. By obeying the above-given ideas you will readily attain an impactful argumentative essay. The most effective argumentative essay writing service on the world wide web is a business that gives good quality and reasonably priced help on argumentative essay and argumentative essay topics. The Bizarre Secret of Photography Argumentative Essay Topics So it makes sense that parents begin the lengthy journey of letting go! Students lead busy lives and frequently forget about an approaching deadline. Life After Photography Argumentative Essay Topics A great photograph can tell numerous things to the viewer. If you believe a photo essay is something that you may want to try, here are a couple of ideas to hopefully get you going. 1 photo essay idea I have always wished to try is to photograph one landmark from a number of different vantage points. Shot planning Before selecting from the a variety of photo essay topics one has to plan the shots that are required to be taken for the essay. Photo essays techniques are quite important. Have a look at the Eiffel Tower, and what number of photographs are taken of it. They can be a great source of entertainment and a form of art, but when it comes to portraying reality, it may not succeed all the time. Sometimes they can also create a hyper-reality which exaggerates the reality and thus cannot be the truth. Definitions of Photography Argumentative Essay Topics There have been a number of incidences before where photographs are faked or misinterpreted creating havoc situation. For example it's helpful to preserve our culture, ancients medieval and contemporary architecture of the Earth, history might also be understood through the photographs in a better means. No matter in which you live, there'll be countless neighborhood events throughout the year. There's no exception for art. Top Photography Argumentative Essay Topics Secrets To defend your subject, you can recall the effect of overloaded schedule on college g rades. 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General overview would incorporate information that's covering the topic for language essay for a whole while specific overview is only going to speak about particular problems. Critics always debates on the subject of whether photography is truly an art or only a mechanical procedure. Get acquainted with the next creative argumentative essay topics and select the one that fits your needs the very best. As always, our list is only here in order to light a spark of imagination and motivate you to develop an original topic by yourself. If you're assigned a specific topic, consider the techniques to develop it. Quite frequently, the ideal topic is one which you truly care about, but you also will need to get ready to research it. Occasionally, selecting a perfect argumentative essay topics will be quite tough. If you successfully determine the objective of language essay than you ought to make sure that the subject of language essay should fit in the objective. Argumentative writings is a particular kind of a paper. By way of example, in college, you might be requested to compose a paper from the opposing viewpoint. In the end, towards the conclusion of your conclusion, you might reflect on the way the essay compares to something else such as modern occasions or the future. For an argumentative essay it's a good idea to set up three claims which provides a strong reason behind your stance on the topic issue. Obviously, you need to carefully choose every shot.

Mt. Cameroon, East Of Nigeria - 999 Words

Mount Cameroon is located within the Republic of Cameroon, east of Nigeria. It is considered to be one of Africa s most active and largest volcanoes, having recently erupted in 2000 followed by a smaller eruption in 2012. Mt. Cameroon belongs to a seamount chain of volcanoes that extends northeast from the Gulf of Guinea. Cameroon does not lie on a plate boundary, making it an intraplate volcano. Despite being one of the most active volcanoes in Africa, the risks it poses does not necessarily include the massive, fiery, plinian eruptions one would associate with a volcano considered very large and most active over an entire continent. However, Mt. Cameroon does have other risks and hazards due to its nature, and requires preventative†¦show more content†¦While Cameroon has shown moderate eruptions in the past, the volcano also showcases a more effusive type of eruption. The low viscosity lava flow Cameroon exhibits is not much of a surprise because the volcano is part of a chain of volcanoes, indicating that it is currently sitting over a hot spot. The significance behind a chain of volcanoes is that hot spots, mantle plumes, â€Å"... tend to be largely unaffected by plate motions† (howvolcanoeswork). This allows the mantle plume to create a volcano, have the crust shift due to plate tectonics, create another volcano, and so on. The fact that Mt. Cameroon is intraplate also reinforces a hot spot mechanism because there is no subduction present to cause flux melting. The last major eruption of Mt. Cameroon took place in 2000. It was reported that during the initial explosion, â€Å"... [Cameroon] produced only tephra and ballistic blocks† (Smithsonian). An a a lava flow was also noted, which flowed about 850 meters. Due to the volcanoes remote location, information about the a a lava flow was collected using the MODIS Thermal Alert System, or MODVOLC. The way this works is that NASA has a satellite equipped with Moderate Resolution Im aging Spectroradiometer sensors that orbits the Earth in a 48 hours period. While it performs it s global scan, a specific algorithm is used to search each pixel in every image it takes for heat anomalies. These