French neonatal society position paper stresses the importance of an early family-centred approach to discharging preterm infants from hospital

AIM

The families of hospitalised preterm infants risk depression and post-traumatic stress and the preterm infants risk re-hospitalisation. The French neonatal society's aim was to review the literature on how the transition from hospital to home could limit these risks and to produce a position paper.

METHODS

A systematic literature review was performed covering 1 January 2000 to 1 January 2018, and multidisciplinary experts examined the scientific evidence.

RESULTS

We identified 939 English and French papers and 169 are quoted in the position paper. Most studies stressed the importance of early, personalised and progressive involvement of the family. Healthcare staff and families should assess discharge preparations jointly. This evaluation should assess the capacities of the newborn infant, with regard to its physiological maturity. It should also assess the family's ability to supply the medical, psychological and social assistance required before and after discharge. There should be a structured follow-up process that includes effective communication, various tools, interventions, networks, health and social professionals.

CONCLUSION

Discharge preparations may improve the transition from hospital to home and the outcomes for the parents and newborn preterm infant. This early family-centred approach should be structured, coordinated and based on individual needs and circumstances.

Detection of fetal cardiac anomalies: cost-effectiveness of increased number of cardiac views

OBJECTIVE

To compare the recommended three-view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost-effective strategy in unselected (low-risk) pregnancies.

METHODS

A decision-analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four-chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three-vessel (3V) view and three-vessels-and-trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare-system perspective, with a cost-effectiveness willingness-to-pay threshold set at $100 000 per quality-adjusted life year (QALY). Baseline analysis, one-way sensitivity analysis and Monte-Carlo simulation were performed.

RESULTS

In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness-to-pay threshold. The five-view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte-Carlo and one-way sensitivity analysis.

CONCLUSION

Although current guidelines recommend a minimum of three views for detecting CHD during the mid-trimester anatomy scan, screening with five axial views is a cost-effective strategy that may lead to improved outcome compared with three-view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal dynamics of herd-level Mycobacterium bovis MLVA type surveillance in cattle in Northern Ireland 2003-2016

Investigating genetically-structured diversity in pathogen populations over time is important to better understand disease maintenance and spread. Herd-level surveillance of Mycobacterium bovis genotypes (multi-locus VNTR analysis types, MLVA types) from all culture-confirmed bovine tuberculosis (TB) herd cases was undertaken in Northern Ireland (NI), generating an unparalleled, longitudinal, population-level 14-year survey for this pathogen. Across this population, 295 genetically-distinct M. bovis MLVA types were identified in the 19,717 M. bovis isolates surveyed. Of these, the most frequent was MLVA type 002 (23.0%); 151 MLVA types were represented more than once, in groups ranging from 2 to 4438 isolates. Only 23 MLVA types were isolated in all 14 years. Investigating inter-annual frequency of M. bovis MLVA types, examples of statistically-significant expansions (MLVA types 002, 004, 006, 009 and 027), contractions (MLVA types 001, 007 and 011) and maintenance (MLVA types 003 and 005) were disclosed, during a period of fluctuating bovine TB herd-level incidence at the NI scale. The fixed period frequency distribution of MLVA types remained highly right-skewed. Novel VNTR copy number variant MLVA types (N = 242; an average of 17 per annum) were identified throughout the survey. The MLVA type distribution in the landscape was not random; MLVA types showed statistically-significant geographical localization and strong spatial associations with Divisional Veterinary Office (DVO) regions. There was also evidence of differential risk of particular MLVA types across breeds (Holstein/Friesian vs. other), age-class, and sex and some evidence of an association between the number of animals testing positive for bovine TB during the disclosing test and particular MLVA types, although there was substantial variation.

Recommendation for hygiene and topical in neonatology from the French Neonatal Society

We sought to establish guidelines for hygiene care in newborns based on a systematic review of the literature and grading of evidence using the Groupe de Réflexion et d'Evaluation de l'Environement des Nouveau-nés (GREEN) methodology. We examined 45 articles and 4 reports from safety agencies. These studies recommend a tub bath (rather than a sponge bath) for full-term infants and a swaddle bath for preterm newborns. They also recommend against daily cleansing of preterm infants. The literature emphasized that hygiene care must consider the clinical state of the newborn, including the level of awareness and behavioral responses. Hospitalized newborns treated with topical agents may also experience high exposure to potentially harmful excipients of interest. Caregivers should therefore be aware of the excipients present in the different products they use. In high-resource countries, the available data do not support the use of protective topical agents for preterm infants.Conclusions: We recommend individualization of hygiene care for newborns. There is increasing concern regarding the safety of excipients in topical agents that are used in neonatology. A multidisciplinary approach should be used to identify an approach that requires lower levels of excipients and alternative excipients. What is known: • Hygiene care is one of the most basic and widespread types of care received by healthy and sick newborns worldwide. • There is no current guideline on hygiene for preterm or hospitalized term newborn. What is new: • The French Group of Reflection and Evaluation of the environment of Newborns (GREEN) provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' behavioral responses to hygiene care, exposition to excipients of interest, and the potential risk of protective topical agents in a preterm infant. provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' possible behavioral responses to hygiene care, exposition to excipients of interest and the potential risk of protective topical agents in a preterm infant.

Variation in Mycobacterium bovis genetic richness suggests that inwards cattle movements are a more important source of infection in beef herds than in dairy herds

Background

We used genetic Multi-Locus VNTR Analysis (MLVA) data gathered from surveillance efforts to better understand the ongoing bovine tuberculosis (bTB) epidemic in Northern Irish cattle herds. We modelled the factors associated with Mycobacterium bovis MLVA genotype richness at three analytical scales; breakdown level, herd level, and patch level, and compared the results between dairy and non-dairy production types.

Results

In 83% of breakdowns and in 63% of herds, a single MLVA genotype was isolated. Five or more MLVA genotypes were found in less than 3 % of herds. Herd size and the total number of reactors were important explanatory variables, suggesting that increasing MLVA genotype richness was positively related to increases in the number of host animals. Despite their smaller relative size, however, the highest MLVA genotype richness values were observed in non-dairy herds. Increasing inwards cattle movements were important positive predictors of MLVA genotype richness, but mainly in non-dairy settings.

Conclusions

The principal finding is that low MLVA genotype richness indicates that small-scale epidemics, e.g. wildlife, contiguous farms, and within-herd recrudescence, are important routes of M. bovis infection in cattle herds. We hypothesise that these mechanisms will maintain, but may not explicitly increase, MLVA genotype richness. The presence of elevated MLVA richness is relatively rare and likely indicates beef fattening enterprises, which purchase cattle from over long distances. Cattle movements were furthermore an important predictor of MLVA genotype richness in non-dairy herds, but not in dairy herds; this may represent reduced cattle purchasing levels in dairy enterprises, compared to beef. These observations allude to the relative contribution of different routes of bTB infection between production types; we posit that infection associated with local factors may be more evident in dairy herds than beef herds, however in beef herds, inwards movements offer additional opportunities for introducing M. bovis into the herd.

Electronic supplementary material

The online version of this article (10.1186/s12866-019-1530-7) contains supplementary material, which is available to authorized users.

Long-term outcomes of saline boluses in very preterm infants

BACKGROUND

Normal saline bolus is commonly used in clinical practice for treating hypotension in very preterm infants during resuscitation at an early age despite the paucity of high quality evidence supporting this practice.

OBJECTIVES

To determine the effects of early (<7 days after birth) saline boluses given to very preterm infant (VPI) from 23 to 31 weeks GA.

METHOD

This is a population-based cohort analysis of the use of normal saline boluses given to VPI. The outcomes were extracted from the Perinatal Follow-Up Program Database which included all VPI from Halifax County admitted to the NICU at the IWK Health Centre, Halifax, Nova Scotia, Canada between January 2006 to December 2010. We excluded infants with major congenital anomalies and those not offered resuscitation in the delivery room. Our primary outcome was the composite of death or disability by 18-36 months while secondary outcomes were neonatal death, BPD, CP, IVH, PVL, ROP, BSITD III (Bayley Scales of Infant and Toddler Development®, Third Edition) Cognitive, Motor and Language score.

RESULTS

Death or disability in those who received saline bolus occurred in 15 (53.6%) compared with 9 (32.1%) in non saline group. Significantly higher rates of CP (p = 0.04), lower scores on the BSITDIII for motor (p = 0.04) and language scales (p = 0.03) were noted for infants who received saline boluses. Cognitive scores approached significance (p = 0.05) with lower scores in the saline bolus group.

CONCLUSION

Significant differences were found between the two groups in terms of long term neurodevelopmental outcome and one of the short-term outcome (i.e. BPD). Given the limitations of this retrospective study and the small sample size, a larger cohort from Canadian Neonatal Network database is warranted to evaluate the effects of using normal saline boluses during early life on neurodevelopmental.

Spatiotemporal analysis of prolonged and recurrent bovine tuberculosis breakdowns in Northern Irish cattle herds reveals a new infection hotspot

Despite a state-led eradication programme, bovine tuberculosis (bTB) remains endemic in Northern Ireland (NI). Of particular concern are "chronic" prolonged and recurrent bTB breakdowns, which represent significant financial and administrative burdens. However, little is known regarding the spatiotemporal distribution of chronic breakdowns in NI. We therefore analysed both the spatial and spatiotemporal distributions of chronic bTB breakdowns between 2004 and 2014. Significantly positive values for Moran's Index of spatial autocorrelation were found, and Local Moran's I clustering was employed to assess for spatial associations in the number and prevalence of chronic bTB breakdowns across NI. Additional spatio-temporal analysis using SaTScan showed that the burden of chronic bTB infection tends to be found where bTB levels are already high. However, a novel hotspot was revealed wherein the prevalence of chronic breakdowns was higher than expected; this should be the subject of follow-up surveillance.

Urban HEART Detroit: a Tool To Better Understand and Address Health Equity Gaps in the City

The Urban Health Equity Assessment Response Tool (Urban HEART) combines statistical evidence and community knowledge to address urban health inequities. This paper describes the process of adopting and implementing this tool for Detroit, Michigan, the first city in the USA to use it. The six steps of Urban HEART were implemented by the Healthy Environments Partnership, a community-based participatory research partnership made up of community-based organizations, health service providers, and researchers based in academic institutions. Local indicators and benchmarks were identified and criteria established to prioritize a response plan. We examine how principles of CBPR influenced this process, including the development of a collaborative and equitable process that offered learning opportunities and capacity building among all partners. For the health equity matrix, 15 indicators were chosen within the Urban HEART five policy domains: physical environment and infrastructure, social and human development, economics, governance, and population health. Partners defined the criteria and ranked them for use in assessing and prioritizing health equity gaps. Subsequently, partners generated a series of potential actions for indicators prioritized in this process. Engagement of community partners contributed to benchmark selection and modification, and provided opportunities for dialog and co-learning throughout the process. Application of a CBPR approach provided a foundation for engagement of partners in the Urban HEART process of identifying health equity gaps. This approach offered multiple opportunities for discussion that shaped interpretation and development of strategies to address identified issues to achieve health equity.

Malignant Myositis Ossificans. A Case Report

A patient presented with an ossifying thigh mass suggestive of myositis ossificans. He had no antecedent trauma to the area. The mass was found to be an ossifying soft tissue metastasis from an occult gastric adenocarcinoma primary. Malignancy, and especially metastatic malignancy, is rarely considered in the differential diagnosis of a radiographic presentation of myositis ossificans.

Modelling the variation in skin-test tuberculin reactions, post-mortem lesion counts and case pathology in tuberculosis-exposed cattle: Effects of animal characteristics, histories and co-infection

Correctly identifying bovine tuberculosis (bTB) in cattle remains a significant problem in endemic countries. We hypothesized that animal characteristics (sex, age, breed), histories (herd effects, testing, movement) and potential exposure to other pathogens (co-infection; BVDV, liver fluke and Mycobacterium avium reactors) could significantly impact the immune responsiveness detected at skin testing and the variation in post-mortem pathology (confirmation) in bTB-exposed cattle. Three model suites were developed using a retrospective observational data set of 5,698 cattle culled during herd breakdowns in Northern Ireland. A linear regression model suggested that antemortem tuberculin reaction size (difference in purified protein derivative avium [PPDa] and bovine [PPDb] reactions) was significantly positively associated with post-mortem maximum lesion size and the number of lesions found. This indicated that reaction size could be considered a predictor of both the extent (number of lesions/tissues) and the pathological progression of infection (maximum lesion size). Tuberculin reaction size was related to age class, and younger animals (<2.85 years) displayed larger reaction sizes than older animals. Tuberculin reaction size was also associated with breed and animal movement and increased with the time between the penultimate and disclosing tests. A negative binomial random-effects model indicated a significant increase in lesion counts for animals with M. avium reactions (PPDb-PPDa < 0) relative to non-reactors (PPDb-PPDa = 0). Lesion counts were significantly increased in animals with previous positive severe interpretation skin-test results. Animals with increased movement histories, young animals and non-dairy breed animals also had significantly increased lesion counts. Animals from herds that had BVDV-positive cattle had significantly lower lesion counts than animals from herds without evidence of BVDV infection. Restricting the data set to only animals with a bTB visible lesion at slaughter (n = 2471), an ordinal regression model indicated that liver fluke-infected animals disclosed smaller lesions, relative to liver fluke-negative animals, and larger lesions were disclosed in animals with increased movement histories.

Who Speaks for Me? Addressing Variability in Informed Consent Practices for Minimal Risk Research Involving Foster Youth

BACKGROUND

Youth in protective custody (e.g.. foster care) are at higher risk for poorer physical and mental health outcomes compared with those who are not in custody. These differences may be due in part to the lack of research on the population to create evidence-based recommendations for health care delivery. A potential contributor to this lack of research is difficulties in obtaining informed consent for empirical studies in this population. The objective of this study was to describe the approaches to obtaining informed consent in minimal risk studies of foster youth and provide recommendations for future requirements.

METHODS

We conducted a systematic review of the literature to characterize the informed consent approaches in published minimal risk research involving youth in foster care. We searched PubMed, CINAHL, PsychINFO, Embase, ERIC, Scopus, and EBMR. Inclusion criteria were: studies conducted in the United States, included current foster youth, minimal risk, peer reviewed, and published in English. Full text was reviewed, and individuals required to consent and assent were extracted.

RESULTS

Forty-nine publications from 33 studies were identified. Studies required 0 to 3 individuals to consent. Individuals required to give consent included case workers (16, 48%), foster caregivers (12, 36%), biological parents (7, 21%), judges (5, 15%), and guardian ad litems (2, 6%). Twenty-nine (88%) studies required the youth's assent. The studies used 14 different combinations of individuals. One (3%) study utilized a waiver of consent.

CONCLUSIONS

There is no consistent approach for obtaining informed consent for foster youth to participate in minimal risk research. Consent should ideally involve individuals with legal authority and knowledge of the individual youth's interests and should not be burdensome. Consensus regarding consent requirements may facilitate research involving foster youth.