Integrated Neonatal Support with Placental Transfusion and Resuscitation (Inspire): A Feasibility Study

BACKGROUND: Compromised neonates do not receive placental transfusion (PT), but receive immediate cord clamping to facilitate resuscitation. Animal studies suggest possible benefit of resuscitation during PT.

OBJECTIVES: To study the feasibility of initiating resuscitative care during PT for 90s in preterm infants.

DESIGN/METHODS: We designed a mobile, battery powered resuscitation platform (iNSPiRe) that contains a scale, warm gel mattress, oxygen and air tanks, blender, T piece resuscitator, pulse oximeter (PO), and suction device (Fig. 1). Resuscitative care included initial steps, and respiratory support at 30s following Neonatal Resuscitation Program guidelines. Thermoregulation was maintained using a hat, warmed blankets, and gel mattress. Heart rate was auscultated at 30, 60 and 90s. PO was placed on the right wrist/hand. The cord was clamped at 90s. The baby and platform were mobilized from mother’s bedside to a radiant warmer by one provider, while another provider maintained respiratory support. Once on the warmer, axillary temperature (AT) was measured. Resuscitation interventions and management during first 24 hours were recorded.

RESULTS: Seven infants born vaginally, median (range) gestational age (GA) was 30 weeks (28 to 36) and birth weight 1500g (1270 to 2650), were managed using iNSPiRe. Table 1 shows time (T) to initiate interventions, cord pH and Apgar scores. Five infants received continuous positive airway pressure (CPAP) and one received positive pressure ventilation; none had hypotension, pneumothorax, or received surfactant. No incidence of intraventricular hemorrhage.

CONCLUSION: It is feasible to commence resuscitative care during PT in infants ≥30 weeks' GA for 90s. Further research is needed to assess the feasibility in smaller and sicker preterm infants.

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Neurodevelopmental Outcomes Following Extensive Cardiopulmonary Resuscitation in the Delivery Room for Infants Born <29 Weeks’ Gestational Age

BACKGROUND: Neurodevelopmental outcomes of preterm infants who receive extensive CPR (ECPR), defined as chest compression with or without epinephrine in the delivery room, remain unclear.

OBJECTIVES: To compare the neurodevelopmental outcomes of preterm infants admitted to Canadian NICUs requiring ECPR versus those who did not require ECPR in the delivery room.

DESIGN/METHODS: Preterm infants born at <29 weeks GA between January 1, 2010 and September 30, 2011 and evaluated at CNFUN centers were retrospectively evaluated. The primary outcome was a composite of death or neurodevelopmental impairment (NDI) at 18-21 months CA defined as presence of any one or more of the following: definitive cerebral palsy or Bayley- III cognitive, language, motor scores <85 on any one of the components or hearing impairment or visual impairment. Demographic factors, neurodevelopmental status including Bayley III cognitive, language and motor scores and sensory impairments were compared between the ECPR and the no ECPR group using univariate and multivariate analyses. RESULTS: Of 2488 eligible infants, 197 (7.9%) received ECPR. 83% of surviving infants had follow-up data. Demographic and outcomes data are summarized below in Table 1 and 2 respectively.

Successful Implementation of a Change in Practice to Optimize Timing of Umbilical Cord Clamping in Preterm Neonates: A Quality Improvement Initiative

BACKGROUND: Natural, also known as delayed, umbilical cord clamping (NCC) is recommended for at least 60 seconds (s) in preterm infants. However, changing the institutional guidelines only may not result in satisfactory adoption and change in practice.

OBJECTIVES: To determine if a structured multidisciplinary educational approach during the implementation of the new guideline of NCC in pre-term infants will result in over 50% compliance rate.

DESIGN/METHODS: The evidence supporting NCC was presented in a grand round to all health care providers involved in maternal-newborn care. A multidisciplinary team comprised of neonatologists, obstetricians, neonatal nurse practitioners, respiratory therapists and nurses developed NCC clinical practice guideline. Local champions at each of the 4 city hospitals were identified to create change in culture and establish lines of open communication between disciplines. Following completion of education of all staff involved in delivery room care, formal implementation of NCC began October 2013 for gestational age (GA) 33-35 weeks, January 2014 for GA ≥28 weeks, and April 2014 for GA ≥26 weeks. Data were collected from October 2013 until April 2015.

RESULTS: Table 1 shows the compliance rates and the proportion of infants who received NCC ≥45s. In addition, we found that 18% of infants 26-32 weeks GA deemed eligible for NCC, received cord clamping at <45s to facilitate resuscitation.

CONCLUSION: Compliance with practice change can be successfully achieved through a structured team approach, establishing open lines of communication, and frequent feedback to the front line members. Further research may lead to more infants qualifying for and resuscitated during NCC.

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Efficacy and tolerability studies evaluating a sleep aid and analgesic combination of naproxen sodium and diphenhydramine in the dental impaction pain model in subjects with induced transient insomnia

STUDY OBJECTIVES

The aim of this study was to evaluate the efficacy and tolerability of novel combination naproxen sodium (NS) and diphenhydramine (DPH) in subjects with postoperative dental pain along with transient insomnia induced by 5 h sleep phase advance. The present studies aimed to demonstrate the added benefit and optimal dosages of the combination product over individual ingredients alone in improving sleep and pain.

METHODS

Each of the two studies was a two-centre, randomised, double-blind and double-dummy trial. In the first study, subjects were randomised into one of the following treatment arms: NS 440 mg/DPH 50 mg, NS 220 mg/DPH 50 mg, NS 440 mg or DPH 50 mg. In the second study, subjects received either NS 440 mg/DPH 25 mg, NS 440 mg or DPH 50 mg. The co-primary end-points in both studies were wake time after sleep onset (WASO) and sleep latency (SL) measured by actigraphy. Other secondary sleep and pain end-points were also assessed.

RESULTS

The intent-to-treat population included 712 and 267 subjects from studies one and two, respectively. In the first study, only the NS 440 mg/DPH 50 mg combination showed significant improvements in both WASO vs. NS alone (-70.3 min p = 0.0002) and SL vs. DPH alone (25.50 and 41.50 min respectively, p < 0.0001). In the second study, the NS 440 mg/DPH 25 mg combination failed to show any significant improvements vs. either component alone.

CONCLUSIONS

Only the NS 440 mg/DPH 50 mg combination demonstrated improvement in both sleep latency vs. DPH 50 mg and sleep maintenance (WASO) vs. NS 440 mg. There were no serious or unexpected adverse events reported in either study.

CLINICAL TRIAL REGISTRATION

NCT01280591 (study 1); NCT01495858 (study 2).

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

On the existence of high-frequency boundary resonances in layered elastic media

We analyse the asymptotic behaviour of high-frequency vibrations of a three-dimensional layered elastic medium occupying the domain Ω =(− a , a ) 3 , a >0. We show that in both cases of stress-free and zero-displacement boundary conditions on the boundary of Ω a version of the boundary spectrum, introduced in Allaire and Conca (1998 J. Math. Pures. Appl. 77, 153–208. ( doi:10.1016/S0021-7824(98)80068-8 )), is non-empty and part of it is located below the Bloch spectrum. For zero-displacement boundary conditions, this yields a new type of surface wave, which is absent in the case of a homogeneous medium.

Secukinumab administration by pre-filled syringe: efficacy, safety and usability results from a randomized controlled trial in psoriasis (FEATURE)

BACKGROUND

Secukinumab, a fully human anti-interleukin-17A monoclonal antibody, demonstrated efficacy and safety in moderate-to-severe plaque psoriasis when administered via subcutaneous injection. Self-administration by pre-filled syringe (PFS) can offer patients clinical benefits of a drug, with increased convenience.

OBJECTIVES

To assess efficacy, safety and usability of secukinumab administration via PFS in subjects with moderate-to-severe plaque psoriasis.

MATERIALS AND METHODS

Subjects in this phase 3 trial were randomized 1 : 1 : 1 to secukinumab 300 or 150 mg or matching placebo. Results to week 12 are presented here. Each treatment was delivered using a PFS once weekly to week 4, and again at week 8. Co-primary endpoints were secukinumab superiority over placebo for week 12 PASI 75 (≥ 75% reduction in Psoriasis Area and Severity Index) and IGA mod 2011 (2011 modified Investigator's Global Assessment) 0/1 response rates. Secondary endpoints included PFS usability, determined by observer rating of successful, hazard-free self-injection and subject rating of acceptability by the Self-Injection Assessment Questionnaire (SIAQ).

RESULTS

Co-primary endpoints were met, with demonstration of superiority for each secukinumab dose vs. placebo at week 12 (PASI 75: 75·9%, 69·5% and 0% for secukinumab 300 mg, 150 mg and placebo; IGA mod 2011 0/1: 69·0%, 52·5% and 0%, respectively; P < 0·0001 for all comparisons vs. placebo). PFS usability was high: 100% of subjects successfully self-administered treatment at week 1, and subjects reported high SIAQ-assessed acceptability of the PFS throughout the trial. No new/unexpected safety signals were observed.

CONCLUSIONS

Secukinumab administration by PFS was effective, with an acceptable safety profile and high usability. The PFS provides a reliable, convenient form of secukinumab administration in subjects with moderate-to-severe plaque psoriasis.

Economic evaluation of treatment for MRSA complicated skin and soft tissue infections in Glasgow hospitals

In the UK, methicillin-resistant Staphylococcus aureus (MRSA)-associated skin and soft tissue infections (SSTIs) are predominantly managed in the hospital using intravenous (IV) glycopeptides. We set out to explore the potential for and relative healthcare costs of earlier hospital discharge through switch to oral antibiotic therapy (linezolid or rifampicin and doxycycline) or continuation of IV therapy (teicoplanin) via an outpatient parenteral antimicrobial therapy (OPAT) service. Over 16 months, 173 patients were retrospectively identified with MRSA SSTI, of whom 82.8 % were treated with IV therapy. Thirty-seven patients were potentially suitable for earlier discharge with outpatient therapy. The model assumed 3 days of inpatient management and a maximum of 14 days of outpatient therapy. For the status quo, where patients received only inpatient care with IV therapy, hospital costs were calculated at £12,316 per patient, with 97 % of costs accounted for by direct bed day costs. The mean total cost savings achievable through OPAT or oral therapy was estimated to be £6,136 and £6,159 per patient treated, respectively. A significant proportion of patients with MRSA SSTI may be suitable for outpatient management with either oral therapy or via OPAT, with the potential for significant reduction in healthcare costs.

Primary cutaneous posttransplant lymphoproliferative disorders in solid organ transplant recipients: a multicenter European case series

Primary cutaneous posttransplant lymphoproliferative disorders (PTLD) are rare. This retrospective, multicenter study of 35 cases aimed to better describe this entity. Cases were (re)-classified according to the WHO-EORTC or the WHO 2008 classifications of lymphomas. Median interval between first transplantation and diagnosis was 85 months. Fifty-seven percent of patients had a kidney transplant. Twenty-four cases (68.6%) were classified as primary cutaneous T cell lymphoma (CTCL) and 11 (31.4%) as primary cutaneous B cell PTLD. Mycosis fungoides (MF) was the most common (50%) CTCL subtype. Ten (90.9%) cutaneous B cell PTLD cases were classified as EBV-associated B cell lymphoproliferations (including one plasmablastic lymphoma and one lymphomatoid granulomatosis) and one as diffuse large B cell lymphoma, other, that was EBV-negative. Sixteen (45.7%) patients died after a median follow-up of 19.5 months (11 [68.8%] with CTCL [6 of whom had CD30(+) lymphoproliferative disorders (LPD)] and 5 [31.2%] with cutaneous B cell PTLD. Median survival times for all patients, CTCL and cutaneous B cell PTLD subgroups were 93, 93, and 112 months, respectively. Survival rates for MF were higher than those for CD30(+) LPD. The spectrum of primary CTCL in organ transplant recipients (OTR) is similar to that in the general population. The prognosis of posttransplant primary cutaneous CD30(+) LPD is worse than posttransplant MF and than its counterpart in the immunocompetent population. EBV-associated cutaneous B cell LPD predominates in OTR.