Longitudinal analysis of the skin microbiome in association with hand eczema, hand hygiene practices and moisturizer use

BACKGROUND

The skin microbiota maintains a physical and immunological barrier to the environment. Little is known about how the microbiome changes over time or the effect of hand hygiene practices and moisturizer use.

OBJECTIVES

To assess sex-specific changes in skin bacteria over time, and how the microbiome is related to self-reported hand eczema, hand hygiene practices and use of moisturizers.

METHODS

Swab samples from the dorsal hand were collected at baseline and 6.5 years later during the COVID-19 pandemic, in 168 participants from the RHINESSA study in Bergen, Norway. The skin samples were analysed by 16S rRNA amplicon sequencing.

RESULTS

The alpha diversity of the hand microbiome increased from baseline to follow-up, and beta diversity differed by sex at both time points. The relative abundance increased for several bacteria from baseline to follow-up, with sex-specific differences. Current hand eczema and aggravating hand eczema during the COVID-19 pandemic were associated with an increase in Staphylococcus. High hand washing frequency at home was associated with lower alpha diversity and with higher abundance of Staphylococcus, Corynebacterium, Finegoldia, and Pseudomonas and lower abundance of Propionibacterium and Pelomonas. The alpha diversity increased with increasing time passing between hand washing and sampling, whereas more frequent moisturizer use was associated with significantly lower alpha diversity, and a change in abundance for some bacteria, such as more Pseudomonas.

CONCLUSIONS

This longitudinal study revealed an overall increase in skin microbial diversity over a 6-year period, which was unexpected since follow-up was performed during the COVID-19 pandemic when vigorous hand hygienic practices were introduced. Sex-specific differences were identified at both time points. Individuals with hand eczema seem to develop a more dysbiotic skin bacterial community over time. Hand washing and use of moisturizers, with typically gender-specific habitual patterns, may lead to change in bacterial composition.

Advanced neonatal procedural skills: a simulation-based workshop: impact and skill decay

BACKGROUND

Trainees aiming to specialize in Neonatal Perinatal Medicine (NPM), must be competent in a wide range of procedural skills as per the Royal College of Canada. While common neonatal procedures are frequent in daily clinical practice with opportunity to acquire competence, there are substantial gaps in the acquisition of advanced neonatal procedural skills. With the advent of competency by design into NPM training, simulation offers a unique opportunity to acquire, practice and teach potentially life-saving procedural skills. Little is known on the effect of simulation training on different areas of competence, and on skill decay.

METHODS

We designed a unique simulation-based 4-h workshop covering 6 advanced procedures chosen because of their rarity yet life-saving effect: chest tube insertion, defibrillation, exchange transfusion, intra-osseus (IO) access, ultrasound-guided paracentesis and pericardiocentesis. Direct observation of procedural skills (DOPS), self-perceived competence, comfort level and cognitive knowledge were measured before (1), directly after (2), for the same participants after 9-12 months (skill decay, 3), and directly after a second workshop (4) in a group of NPM and senior general pediatric volunteers.

RESULTS

The DOPS for all six procedures combined for 23 participants increased from 3.83 to 4.59. Steepest DOPS increase pre versus post first workshop were seen for Defibrillation and chest tube insertion. Skill decay was evident for all procedures with largest decrease for Exchange Transfusion, followed by Pericardiocentesis, Defibrillation and Chest Tube. Self-perceived competence, comfort and cognitive knowledge increased for all six procedures over the four time points. Exchange Transfusion stood out without DOPS increase, largest skill decay and minimal impact on self-assessed competence and comfort. All skills were judged as better by the preceptor, compared to self-assessments.

CONCLUSIONS

The simulation-based intervention advanced procedural skills day increased preceptor-assessed directly observed procedural skills for all skills examined, except exchange transfusion. Skill decay affected these skills after 9-12 months. Chest tube insertions and Defibrillations may benefit from reminder sessions, Pericardiocentesis may suffice by teaching once. Trainees' observed skills were better than their own assessment. The effect of a booster session was less than the first intervention, but the final scores were higher than pre-intervention.

TRIAL REGISTRATION

Not applicable, not a health care intervention.

Can artificial intelligence fill in the gaps in heart failure guidelines by providing precision medicine in medication advice?

Background

The treatment of heart failure (HF) consists of many different types of medication. It is not yet known which patients benefit most from which medication type. Artificial intelligence (AI) may be helpful to predict the best individual combination of drugs and dosages, but such a model is lacking.

Purpose

We present an AI model that can predict optimal medication regimen per patient based on mortality and hospitalisation risk.

Methods

A total of 620 patients of the Randomized controlled multicenter Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) study were divided into a training and a test population across different sections of patients. They were evaluated by a fixed multi-layer combination of different AI/machine learning models. The steps of the model include; (1) making segmentation by medication treatment: optimal or not optimal; (2) evaluation by general prognostic model and model optimised for patients with non-optimal medication (3); finding optimal medication recommendation for all outcomes of step 2. After optimising the model with the training population, the model was validated retrospectively on the test population. Prognosis was based on mortality and hospitalisation during up to 5 years follow-up.

Results

Of the 620 patients, 59% were male, age 76.9±7.6 years, and median follow-up was 2.2 years. The optimised model identified variables that are important to generate an accurate medication recommendation. These included biomarkers, symptoms, and patient characteristics. In the first step of clustering, data showed that at T0, 68% of the patients were not in optimal medical therapy range, and their outcome prediction was poor (Figure 1). During the follow-up period, this group decreased to 36%, and was almost equal in size to the group with good prognosis despite not optimal medication range (38%). Furthermore, the group with a good medical therapy range and good prognosis increased during the study.

Finally, validation of the medication prediction model showed that model-based therapy adjustments could significantly reduce hospitalisation rate and death. For patients who had therapy according to the AI model recommendation, the death rate and hospitalisation rate were three times lower (Table 1).

Conclusion

The AI model was successful in predicting the optimal medication regimen in the validation population. Where HF guidelines are ambiguous about optimal treatment, the model may fill these knowledge gaps. Furthermore, the model emphasises the hypothesis that a standard approach to HF treatment is not beneficial for all patients. There is a group outside the optimal medication range that has a poor outcome, but there is also a group that has a good outcome despite a non-optimal medication range. Therefore, the latter group would possibly be better off with less medication. These findings need to be validated prospectively in further research.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE

Quality of Life, Risk and Recovery in a National Forensic Mental Health Service: A D-FOREST study from DUNDRUM Hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life.

Objectives

This aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning.

Methods

This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).

Results

Lower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life.

Conclusions

The quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function.

Disclosure

No significant relationships.

AB0623 A review of the evidence behind the recommendation of rituximab for ANCA associated vasculitis

Background

Cyclophosphamide (CYC) is currently used to induce remission in patients with ANCA-associated vasculitis (AAV). Once remission induction is successful Azathioprine (AZA) is given as maintenance (1). Concerns surround the use of cyclophosphamide which has an undesirable safety profile, limiting its use in patients. AZA has shown to be effective at maintenance, however rates of relapse on AZA are high.

Rituximab (RTX) is a biologic with a high specificity to B cells. Its mechanism of action (B cell apoptosis) may mean that it can be used for both the induction and maintenance of remission, with a superior long-term safety profile.

Objectives

To conduct a systematic review of literature to determine the efficacy of rituximab as a remission inducing and maintaining agent.

Methods

A systematic review of literature was conducted by searching PubMed and Cochrane library with the search phrase “rituximab AND ANCA-associated vasculitis”. The following criteria was then applied: randomised controlled trial (RCT) in the English language. Only original papers were accepted if it pertained to RTX for either induction or maintenance of remission.

Results

1008 papers were initially identified and after the search strategy was applied 9 RCTs were analysed.

The RAVE trial compared RTX to CYC in 197 patients with AAV in a double-blind double-dummy trial. The result of the RAVE trial indicated that RTX was as effective as CYC at maintaining remission. The RITUXVAS trial, which was partially blinded and had a sample of 44 patients also came to the same conclusion. Both the RAVE and RITUXVAS trials also showed that an initial dose of RTX was as effective as continuous immunosuppression over the trial length.

Further RCTs were published from the RAVE and RITUXVAS studies including a follow up of patients from the RITUXVAS trial at 24 months which showed no increased rates of relapse or adverse events between the groups. The RAVE study also showed that RTX was effective to be used on multiple occasions to induce remission irrespective of the initial remission inducing agent.

The MAINRITSAN1 study was a non-blinded randomised trial which compared RTX with azathioprine for maintenance in 115 patients with AAV. The results of this trial showed that RTX was superior than AZA at maintenance with only 5% on RTX compared with 29% on AZA relapsing. The long-term follow up of patients in the trial, showed that at 60 months, patients who received RTX were less likely to have relapsed.

The MAINRITSAN2 trial indicated that there was no difference between a fixed vs tailored RTX dose, meaning that a lower tailored dose was as effective as a higher fixed dose. The MAINRITSAN 3 paper was a double-blind trial that indicated that biannual RTX for maintenance was superior than placebo at maintaining remission.

Conclusion

RTX is as effective as CYC at inducing remission, with both the RAVE and RITUXVAS trials sharing similar conclusions.

Currently the research indicates that an initial dose of RTX can maintain remission at similar rates as continuous AZA, however its superiority is yet to be determined. The MAINRITSAN 1 trial was unblinded in its protocol with the data indicating it drastically overestimated the efficacy of both RTX and AZA. Therefore, more research is needed to validate the claim that RTX is superior than AZA at maintenance.

References

[1]Yates, M, et al. 2016. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Annals of the Rheumatic Diseases 75, 1583–1594. doi:10.1136/annrheumdis-2016-209133

Acknowledgements

I would like to thank Dr Marwan Bukhari for his continued support and feedback during this project.

Disclosure of Interests

None declared

Supplementation with a probiotic mixture accelerates gut microbiome maturation and reduces intestinal inflammation in extremely preterm infants

Probiotics are increasingly administered to premature infants to prevent necrotizing enterocolitis and neonatal sepsis. However, their effects on gut microbiome assembly and immunity are poorly understood. Using a randomized intervention trial in extremely premature infants, we tested the effects of a probiotic product containing four strains of Bifidobacterium species autochthonous to the infant gut and one Lacticaseibacillus strain on the compositional and functional trajectory of microbiome. Daily administration of the mixture accelerated the transition into a mature, term-like microbiome with higher stability and species interconnectivity. Besides infant age, Bifidobacterium strains and stool metabolites were the best predictors of microbiome maturation, and structural equation modeling confirmed probiotics as a major determinant for the trajectory of microbiome assembly. Bifidobacterium-driven microbiome maturation was also linked to an anti-inflammatory intestinal immune milieu. This demonstrates that Bifidobacterium strains are ecosystem engineers that lead to an acceleration of microbiome maturation and immunological consequences in extremely premature infants.

To sim or not to sim—choosing wisely for procedural skills training in paediatrics

Objectives

Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula.

Method

We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice.

Results

Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement.

Conclusion

Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

Range of factors in the reduction of hyperhydricity associated with in vitro shoots of Salvia santolinifolia Bioss

Hyperhydricity is a serious physiological disorder and affects In vitro propagation of many plants and as well of Salvia santolinifolia. The donor material to initiate the in vitro culture was the callus taken from the in vitro shoots produced on Murashig and Skoogs (MS) medium at 4.0 mg/l BA. This callus formed numerous hyperhydric shoots on culturing upon the medium of the same composition. The aim was to systematically evaluate the effect of cytokinins (Benzyladnine (BA) and N6-(-2-isopentenyl) adenine (2iP), culture vessels magnitude, medium solidification, source of nitrogen and calcium chloride for the alleviation of hyperhydricity. In the tissue cultures of S. santolinifolia BA and 2iP induced severe hyperhydricity, when other factors i.e. culture vessels magnitude and a suitable concentration of agar, ammonium nitrate (NH4NO3), potassium nitrate (KNO3) & calcium chloride (CaCl2.2H2O) were not optimized. After 30 days' culture, we observed 83.82% hyperhydric shoots at increased level (1.5 mg/l 2iP) and 81.59% at decreased levels (1.0 mg/l 2iP). On the other hand, hyperhydricity percentage at decreased (0.4%) and at increased (0.8%) levels of agar were 72.37% and 39.08%, respectively. MS medium modification with NH4NO3 (412 mg/l), KNO3 (475 mg/l) and CaCl2.2H2O (880 mg/l) was found the best medium to reduced hyperhydricity (23.6%).

Effectiveness of Alberta Family Integrated Care on infant length of stay in level II neonatal intensive care units: a cluster randomized controlled trial

Background

Parents of infants in neonatal intensive care units (NICUs) are often unintentionally marginalized in pursuit of optimal clinical care. Family Integrated Care (FICare) was developed to support families as part of their infants’ care team in level III NICUs. We adapted the model for level II NICUs in Alberta, Canada, and evaluated whether the new Alberta FICare™ model decreased hospital length of stay (LOS) in preterm infants without concomitant increases in readmissions and emergency department visits.

Methods

In this pragmatic cluster randomized controlled trial conducted between December 15, 2015 and July 28, 2018, 10 level II NICUs were randomized to provide Alberta FICare™ (n = 5) or standard care (n = 5). Alberta FICare™ is a psychoeducational intervention with 3 components: Relational Communication, Parent Education, and Parent Support. We enrolled mothers and their singleton or twin infants born between 32 ^0/7 and 34 ^6/7 weeks gestation. The primary outcome was infant hospital LOS. We used a linear regression model to conduct weighted site-level analysis comparing adjusted mean LOS between groups, accounting for site geographic area (urban/regional) and infant risk factors. Secondary outcomes included proportions of infants with readmissions and emergency department visits to 2 months corrected age, type of feeding at discharge, and maternal psychosocial distress and parenting self-efficacy at discharge.

Results

We enrolled 654 mothers and 765 infants (543 singletons/111 twin cases). Intention to treat analysis included 353 infants/308 mothers in the Alberta FICare™ group and 365 infants/306 mothers in the standard care group. The unadjusted difference between groups in infant hospital LOS (1.96 days) was not statistically significant. Accounting for site geographic area and infant risk factors, infant hospital LOS was 2.55 days shorter (95% CI, − 4.44 to − 0.66) in the Alberta FICare™ group than standard care group, P = .02. Secondary outcomes were not significantly different between groups.

Conclusions

Alberta FICare™ is effective in reducing preterm infant LOS in level II NICUs, without concomitant increases in readmissions or emergency department visits. A small number of sites in a single jurisdiction and select group infants limit generalizability of findings.

Trial registration

ClinicalTrials.gov Identifier NCT02879799, retrospectively registered August 26, 2016.

Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry

Introduction

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in patients. DM is highly prevalent in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple step-by-step strategy with an integrated, holistic approach to AF management: A, Avoid stroke (Anticoagulation); B, Better symptom management; C, Cardiovascular and comorbidity risk management.

Aim

Evaluation of the AF treatment compliance to ABC pathway regimen in patients with DM based on a large real-world registry from the Middle East region. We assessed the impact of ABC-pathway compliance on all-cause mortality and the composite outcome of stroke or systemic embolism, all-cause death and cardiovascular hospitalizations.

Methods

From 2043 patients in the Gulf SAFE registry, 603 patients with DM were included in an analysis of compliance with components of the ABC pathway: A, oral anticoagulation (OAC) use in patients with CHA2DS2-VASc score ≥1 (≥2 in females); B, AF symptoms according to the European Heart Rhythm Association (EHRA) score; C, Optimized management of cardiovascular comorbidities e.g. blood pressure control, statins for vascular disease, etc.

Results

From 606 patients, 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC-adherent group vs non-ABC compliant (5.8% vs 15.9%, p=0.0014, respectively) (Figure). On multivariate analysis, ABC-adherent management was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI, 0.42–0.75 and OR 0.54; 95% Cl, 0.30–1.00, respectively) and at 1 year (OR 0.30; 95% Cl,0.11–0.76 and OR 0.57; 95% Cl, 0.33–0.97, respectively) vs the non-ABC group (Table).

Conclusions

Integrated AF care, according to ABC pathway, was independently associated with a lower risk of all-cause death and the composite outcome, in DM patients with AF. This highlights the importance of a comprehensive and holistic approach to AF management.

Events rates and outcomes odds ratio

Funding Acknowledgement

Type of funding source: None

Pharmacological inhibition of C-C chemokine receptor 4 aggravates atherosclerosis through prevention of regulatory T cell recruitment to the lesions

Background

Regulatory T cells (Tregs) are demonstrated to play a protective role in the development of atherosclerosis. However, their sites of action in atherosclerosis remain unclear. Although C-C chemokine receptor 4 (CCR4) has been shown to contribute to the accumulation of Tregs in inflamed tissues and prevention of experimental autoimmune diseases, the role of CCR4 in Treg migration to atherosclerotic lesions and suppression of plaque formation remains unknown.

Methods and results

We intraperitoneally injected 8-week-old apolipoprotein E–deficient mice fed a normal diet with vehicle (n=9) or a 4-μg dose of a CCR4 antagonist (n=10) 3 times weekly for 8 weeks and evaluated atherosclerotic lesions at 16 weeks old. Administration of the CCR4 antagonist significantly aggravated atherosclerotic plaque formation (aortic sinus plaque area: 2.91±0.87×104 μm2 versus 5.41±0.98×104 μm2 in control vehicle-treated and CCR4 antagonist-treated mice, respectively; P<0.05), associated with increased accumulation of macrophages and CD4+T cells in the plaques. Flow cytometric analysis revealed a decrease in Foxp3+ Tregs in the para-aortic lymph nodes and thoracoabdominal aortas of CCR4 antagonist-treated mice, along with a tendency toward increase in CD44highCD62Lloweffector T cells in para-aortic lymph nodes, indicating CCR4-dependent migration of Tregs to atherosclerotic lesions and their possible atheroprotective role. We observed no changes in splenic Foxp3+ Tregs and effector T cells following CCR4 antagonist treatment. We also investigated the effect of CCR4 blockade on advanced atherosclerosis using LDL receptor–deficient mice fed a high-cholesterol diet. Although 8-week treatment with the CCR4 antagonist led to a decrease in Foxp3+ Tregs in the atherosclerotic lesions, atherosclerotic lesion formation was not significantly affected, suggesting that CCR4-dependent Treg accumulation in atherosclerotic lesions is not critical for prevention of advanced atherosclerosis.

Conclusions

Our findings indicate an important role for CCR4 in promotion of Treg recruitment into atherosclerotic lesions and subsequent prevention of early atherosclerosis and suggest CCR4 as a novel therapeutic target for atherosclerosis.

Funding Acknowledgement

Type of funding source: None

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

1436Overexpression of Cytotoxic T-Lymphocyte Associated Antigen-4 suppresses aortic immunoinflammatory responses and prevents angiotensin II-induced abdominal aortic aneurysm formation in mice

Aims

Vascular inflammation via T-cell-mediated immune responses has been shown to be critically involved in the pathogenesis of abdominal aortic aneurysm (AAA). T-cell coinhibitory molecule cytotoxic T-lymphocyte–associated antigen-4 (CTLA-4) is known to act as a potent negative regulator of immune responses. However, the role of this molecule in the development of AAA remains completely unknown. In the present study, we determined the effects of CTLA-4 overexpression on experimental AAA.

Methods and results

We continuously infused 12-week-old CTLA-4 transgenic (CTLA-4-Tg)/apolipoprotein E–deficient (Apoe−/−) mice (n=35) or control Apoe−/− mice (n=40) fed a high-cholesterol diet with angiotensin II by implanting osmotic mini-pumps and evaluated the development of AAA. Ninety percent of angiotensin II-infused mice developed AAA, with 50% mortality because of aneurysm rupture. Overexpression of CTLA-4 significantly reduced the incidence (66%), mortality (26%), and diameter (18%) of AAA (incidence: P=0.0104; mortality: P=0.031; diameter: P=0.011). These protective effects were associated with a decreased number of effector CD4+ T cells and the downregulated expression of costimulatory molecules CD80 and CD86, ligands for CTLA-4, on CD11c+ dendritic cells in lymphoid tissues. In addition, by performing in situ zymography of the abdominal aortic aneurysm lesions, we observed a trend toward a decrease in MMP activity in the aneurysmal lesion following overexpression of CTLA-4. Finally, CTLA-4-Tg/Apoe−/− mice had reduced macrophage and CD4+ T cell accumulation and MMP activity in the aneurysmal lesion, leading to attenuated aortic inflammation, preserved vessel integrity, and decreased susceptibility to AAA and aortic rupture.

Conclusion

Our findings suggest that CTLA-4 protects against AAA by suppressing immunoinflammatory responses and could be an attractive therapeutic target for AAA.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

USE OF SIMULATION-BASED SKILL ACQUISITION INSTRUCTION (SSAI) FOR MANUAL MASK VENTILATION (MMV) IMPROVES THE ABILITY OF NEONATAL RESUSCITATION PROGRAM (NRP) PROVIDERS TO DELIVER AND RETAIN EFFECTIVE MMV SKILLS

BACKGROUND

Ten percent of infants require resuscitation at birth. Effective manual mask ventilation (MMV) establishes functional residual capacity and delivers tidal volumes that promote gas exchange. A standard 4 to 6-hour NRP workshop does not ensure MMV competence. In fact, studies show that MMV is ineffective in 30 to 70% of simulated resuscitations. Effective MMV requires continual evaluation, and appropriate use of corrective steps when necessary. We hypothesize that simulation-based learning with video feedback improves MMV performance compared to traditional teaching.

OBJECTIVES

1. To assess MMV skills in NRP providers before and after simulation-based skill acquisition instruction (SSAI) using video-feedback.

2. To compare MMV performance between SSAI intervention and control groups.

3. To determine retention of MMV skills at 3 to 4 months post-intervention.

DESIGN/METHODS

In this randomized controlled study, perinatal care providers who had completed a standard NRP workshop were randomly assigned to an intervention (SSAI) or control group. All participants were assessed and videorecorded performing a standard MMV skill station using a NeoNatalie™ manikin. The intervention group reviewed their videorecordings and received instructor feedback on MMV performance. The control group reviewed the MMV chapter in the NRP textbook and received instructor feedback using a standard performance checklist without reviewing their videorecording. Feedback included observation of chest rise. Participants were assessed at 3 periods: (a) after first MMV station, (b) after immediate feedback, and (c) 3 to 4 months later.

Video recordings were scored by two investigators blinded to the randomization groups using a 13-item MMV skill scale. (0=not done; 1= done partly; 2 = done correctly) giving a maximum score of 26. We compared scores between the two groups.

RESULTS

Of the 91 participants, 46 were assigned to intervention and 45 to control group. The mean scores for the control group were: 20.1 (pre); 22.6 (post); and 21.6 (at 3–4 months post) compared to 22.1 (pre); 25.1 (post) and 24.7 (at 3–4 months post) for the intervention group.

Repeated measures analysis showed that there is an effect of group and time, with the intervention group performing and retaining skills better at follow up, Wilks’ lambda = 0.66, F(3,67) = 11.31, p < .001.

CONCLUSION

Use of SSAI with video-feedback in the teaching of MMV skills improves the ability of NRP providers to deliver and retain effective MMV in a manikin. NRP providers should be trained using SSAI. Video-feedback should be considered during NRP training. Video-feedback following real-life resuscitations should be studied for its potential benefit.

Is Less Noise, Light and Parental/Caregiver Stress in the Neonatal Intensive Care Unit Better for Neonates?

In utero sensory stimuli and interaction with the environment strongly influence early phases of fetal and infant development. Extremely premature infants are subjected to noxious procedures and routine monitoring, in addition to exposure to excessive light and noise, which disturb the natural sleep cycle and induce stress. Non-invasive ventilation, measures to prevent sepsis, and human milk feeding improve short-term and long-term neurodevelopmental outcomes in premature infants. To preserve brain function, and to improve quality of life and long-term neurodevelopmental outcomes, the focus now is on the neonatal intensive care unit (NICU) environment and its impact on the infant during hospital stay. The objectives of this write-up are to understand the effects of environmental factors, including lighting and noise in the NICU, on sensory development of the infant, the need to decrease parental and caregiver stress, and to review existing literature, local policies and recommendations.

Is Less Noise, Light and Parental/Caregiver Stress in the Neonatal Intensive Care Unit Better for Neonates?

In utero sensory stimuli and interaction with the environment strongly influence early phases of fetal and infant development. Extremely premature infants are subjected to noxious procedures and routine monitoring, in addition to exposure to excessive light and noise, which disturb the natural sleep cycle and induce stress. Non-invasive ventilation, measures to prevent sepsis, and human milk feeding improve short-term and long-term neurodevelopmental outcomes in premature infants. To preserve brain function, and to improve quality of life and long-term neurodevelopmental outcomes, the focus now is on the neonatal intensive care unit (NICU) environment and its impact on the infant during hospital stay. The objectives of this write-up are to understand the effects of environmental factors, including lighting and noise in the NICU, on sensory development of the infant, the need to decrease parental and caregiver stress, and to review existing literature, local policies and recommendations.

Is the Correlation between Salivary Cortisol and Serum Cortisol Reliable Enough to Enable Use of Salivary Cortisol Levels in Preterm Infants?

Background Newborn premature infants are susceptible to development of relative adrenal insufficiency following transition from fetal to extrauterine life. However, the best diagnostic test for adrenal insufficiency in neonates has yet to be developed.

Objectives and Methods The aim of this study was (1) to assess the feasibility of obtaining sufficient saliva sample to allow measurement of cortisol by liquid chromatography coupled to tandem mass spectrometry and (2) to assess the correlation, if any, between salivary and serum cortisol in preterm infants of ≤32 weeks' gestational age at birth.

Results Samples for 230 paired serum and saliva cortisol levels from 90 preterm infants were analyzed. 87.5% of samples collected had sufficient salivary volumes for measurement. Despite being statistically significant (p < 0.0001), the correlation (Spearman r = 0.674) between serum and salivary cortisol was not strong.

Conclusion Salivary free cortisol measurement is feasible but cannot be used to accurately reflect serum total cortisol. Further studies comparing salivary free cortisol to serum free cortisol and establishing normative data are needed before salivary cortisol can be used for diagnostic purposes.

Reprogramming of Molecular Switching Events in UPR Driven ER Stress: Scope for Development of Anticancer Therapeutics

The incitement of unfolded protein response (UPR) during endoplasmic reticulum (ER) stress by diverse intracellular (hypoxia, nutrient deprivation, etc.) or extracellular (environmental or drug induced) stimuli is considered a major threat for perturbing cellular homeostasis leading to the aggregation of unfolded proteins inside the cell. The catastrophic UPR events emerge as a prime cellular adaptation by remodeling cancer cell signaling and restoring ER homeostasis in favor of tumor growth. The transient ER stress protects cancer cells from undergoing apoptosis, whereas the prolonged stress response further activates many cell death pathways. The present review summarizes the UPR mediated triggering of transcriptional and translational reprogramming, which will provide novel therapeutic strategies towards pro-death mechanisms rather than a cellular adaptation in tumorigenesis. Nonetheless, the current topic also points out the reprogramming of emerging molecular switching events by complex UPR-mediated signaling to trigger apoptosis. The novel agents from various natural, semi-synthetic and synthetic sources that target ER stress signaling pathway to modulate selectively the UPR phenomena with preclinical efficacy are outlined. Since major emphasis on ER stress-induced transcriptional and translational reprogramming remains to be explored, we believe that the current subject will instigate more attention from the biomedical researchers in this certain research direction.

Long-Term Neurodevelopmental and Growth Outcomes of Premature Infants Born at <29 week Gestational Age with Post-Hemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt

OBJECTIVE

To compare long-term neurodevelopmental and growth (NDG) outcomes at 3 y corrected gestational age (GA) in premature infants with grade ≥ III intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus who were treated with ventriculo-peritoneal shunt with those who were not treated with shunt.

METHODS

In a retrospective cohort study, NDG outcomes were compared between preterm infants of <29 wk GA with IVH treated with shunt (IVHS) and IVH with no shunt (IVHNS). This was a single centre study. The primary outcome was moderate to severe cerebral palsy (CP).

RESULTS

Of 1762 preterm infants who survived to discharge, 90 had grade ≥ III IVH. Infants in IVHS group had more grade IV IVH than IVHNS (p < 0.05). Seventy percent of the patients in IVHNS groups had no hydrocephalus. IVHS group had increased CP (76% vs. 30%; p 0.003), and higher odds of CP after controlling for GA and IVH grade [odds ratio (OR); 4.23 (1.38 to 13.00)]. Growth delay was not different between groups.

CONCLUSIONS

Infants with IVHS are at increased risk of CP but not growth delay.

De novo transcriptome analysis shows differential expression of genes in salivary glands of edible bird's nest producing swiftlets

BACKGROUND

Edible bird's nest (EBN), produced from solidified saliva secretions of specific swiftlet species during the breeding season, is one of the most valuable animal by-products in the world. The composition and medicinal benefits of EBN have been extensively studied, however, genomic and transcriptomic studies of the salivary glands of these birds have not been conducted.

RESULTS

The study described the transcriptomes of salivary glands from three swiftlet species (28 samples) generated by RNASeq. A total of 14,835 annotated genes and 428 unmapped genes were cataloged. The current study investigated the genes and pathways that are associated with the development of salivary gland and EBN composition. Differential expression and pathway enrichment analysis indicated that the expression of CREB3L2 and several signaling pathways involved in salivary gland development, namely, the EGFR, BMP, and MAPK signaling pathways, were up-regulated in swiftlets producing white EBN (Aerodramus fuciphagus) and black EBN (Aerodramus maximus) compared with non-EBN-producing swiftlets (Apus affinis). Furthermore, MGAT, an essential gene for the biosynthesis of N-acetylneuraminic acid (sialic acid), was highly expressed in both white- and black-nest swiftlets compared to non-EBN-producing swiftlets. Interspecies comparison between Aerodramus fuciphagus and Aerodramus maximus indicated that the genes involved in N-acetylneuraminic and fatty acid synthesis were up-regulated in Aerodramus fuciphagus, while alanine and aspartate synthesis pathways were up-regulated in Aerodramus maximus. Furthermore, gender-based analysis revealed that N-glycan trimming pathway was significantly up-regulated in male Aerodramus fuciphagus from its natural habitat (cave) compared to their female counterpart.

CONCLUSIONS

Transcriptomic analysis of salivary glands of different swiftlet species reveal differential expressions of candidate genes that are involved in salivary gland development and in the biosynthesis of various bioactive compounds found in EBN.

Parenteral Fish-Oil Lipid Emulsions in the Prevention of Severe Retinopathy of Prematurity: A Systematic Review and Meta-Analysis

Objective Omega-3 fatty acids are vital for brain and retinal maturation. It is not clear if early use of ω-3 fatty acids in the form of fish-oil lipid emulsions (FLEs) prevents retinopathy of prematurity (ROP) in preterm infants. The aim of this meta-analysis is to evaluate whether early administration of parenteral FLEs reduces ROP requiring laser therapy or severe ROP ≥stage 3 in preterm infants. Methods A literature search was performed to identify studies comparing parenteral FLEs with soybean-based lipid emulsions (SLEs) in preventing ROP. The main outcome was incidence of severe ROP or ROP requiring laser therapy. Results Studies met the inclusion criteria (four RCTs and two observational studies). The pooled relative risk of ROP requiring laser therapy or severe ROP ≥ stage 3 in FLEs group was 0.47 [95% CI: 0.24-0.90] and 0.40 [95% CI: 0.22-0.76] in RCTs and observational studies, respectively. FLEs also reduced cholestasis; however, other secondary outcomes of bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, intraventricular hemorrhage (IVH), and mortality were similar. Conclusion The use of FLEs may reduce the incidence of severe ROP or need for laser therapy in preterm infants. A large multicenter RCT is required to confirm this.

Twenty-four-hour in-house neonatologist coverage and long-term neurodevelopmental outcomes of preterm infants

Objectives

To compare short- and long-term neurodevelopmental outcomes at 3 years of corrected age of preterm infants cared for by 24-hour in-house staff neonatologists and those cared for by staff neonatologists during daytime only.

Methods

Retrospective analysis of prospectively collected follow-up data on all nonanomalous preterm infants from 1998 to 2004 excluding year 2001 as a washout period. Infants were divided into two groups based on care provided by staff neonatologists: 24-hour in-house coverage (24-hour coverage 1998-2000) and daytime coverage (day coverage 2002-2004). Short- and long-term outcomes were compared.

Results

A total of 387 (78%) of the screened infants were included. Twenty-four-hour coverage (n=179) and day coverage (n=208) groups had a median birth weight (BW) of 875 g (range 470-1250) and 922 g (480-1530; P=0.028), respectively, and both had a median gestational age of 27 weeks. In the day coverage group, a smaller proportion of mothers had chorioamnionitis (20% vs. 30%; P=0.025), received less antibiotics (62% vs. 73%; P=0.023), and infants had fewer cases of confirmed sepsis (14% vs. 23%; P=0.022). In the day coverage group, a larger number of infants had respiratory distress syndrome (87% vs. 77%; P=0.011) and required prolonged mechanical ventilation (median 31 vs. 21 days; P=0.002). The incidence of major neurodevelopmental impairment was not significantly different between the two groups (odds ratio 0.76; 95% confidence interval 0.34-1.65).

Conclusions

Duration of mechanical ventilation was reduced with 24-hour in-house coverage by staff neonatologists. However, 24-hour coverage was not associated with any difference in neurodevelopmental (ND) outcomes at 3-year corrected age.

Renal consequences of preterm birth

Background

The developmental origin of health and disease concept identifies the brain, cardiovascular, liver, and kidney systems as targets of fetal adverse programming with adult consequences. As the limits of viability in premature infants have been pushed to lower gestational ages, the long-term impact of prematurity on kidneys still remains a significant burden during hospital stay and beyond.

Objectives

The purpose of this study is to summarize available evidence, mechanisms, and short- and long-term renal consequences of prematurity and identify nephroprotective strategies and areas of uncertainty.

Results

Kidney size and nephron number are known to be reduced in surviving premature infants due to disruption of organogenesis at a crucial developmental time point. Inflammation, hyperoxia, and antiangiogenic factors play a role in epigenetic conditioning with potential life-long consequences. Additional kidney injury from hypoperfusion and nephrotoxicity results in structural and functional changes over time which are often unnoticed. Nephropathy of prematurity and acute kidney injury confound glomerular and tubular maturation of preterm kidneys. Kidney protective strategies may ameliorate growth failure and suboptimal neurodevelopmental outcomes in the short term. In later life, subclinical chronic renal disease may progress, even in asymptomatic survivors.

Conclusion

Awareness of renal implications of therapeutic interventions and renal conservation efforts may lead to a variety of short and long-term benefits. Adequate monitoring and supplementation of microelement losses, gathering improved data on renal handling, and exploration of new avenues such as reliable markers of injury and new therapeutic strategies in contemporary populations, as well as long-term follow-up of renal function, is warranted.

Impact of Digoxin on Mortality in Patients With Atrial Fibrillation Stratified by Heart Failure: Findings From Gulf Survey of Atrial Fibrillation Events in the Middle East

OBJECTIVE

The use of digoxin in patients having atrial fibrillation (AF) with or without heart failure (HF) is not without controversy. The aim of this study was to examine the impact of digoxin therapy on mortality stratified by HF.

METHODS

Gulf Survey of Atrial Fibrillation Events was a prospective, multinational, observational registry of consecutive patients with AF recruited from the emergency department of 23 hospitals in 6 countries in the Middle East. Patients were recruited between October 2009 and June 2010 and followed up for 1 year after enrollment. Analyses were performed using univariate and multivariate statistical techniques.

RESULTS

The study included a total of 1962 patients with AF, with an overall mean age of 56 ± 16 years, and 52% (n = 1026) were males. At hospital discharge, digoxin was prescribed in 36% (n = 709) of the patients, whereas HF was present in 27% (n = 528) of the cohort. A total of 225 (12.1%) patients died during the 12-month follow-up period after discharge (5.3% [n = 104] were lost to follow-up). Patients with HF were consistently associated with higher mortality at 1 month (5.1% vs 2.1%; P < .001), 6 months (17.2% vs 5.0%; P < 0.001), and 12 months (24.3% vs 7.6%; P < .001) when compared to those without HF. When stratified by HF, digoxin therapy was associated with significantly higher mortality in those without HF at 6 months (8.7% vs 3.7%; adjusted odds ratio (aOR), 5.07; P < .001) and 12 months (12.3% vs 6.0%; aOR, 4.22; P < .001) but not in those with HF (6 months: 18.6% vs 14.7%; aOR, 1.62; P = .177 and 12 months: 25.4% vs 22.4%; aOR, 1.37; P = .317).

CONCLUSIONS

In patients with AF and HF, digoxin did not offer any survival advantages. However, in those without HF, digoxin therapy was, in fact, associated with significantly higher long-term mortality.

Arginine supplementation in prevention of necrotizing enterocolitis in the premature infant: an updated systematic review

BACKGROUND

Hypoxic-ischemic injury is thought to play a significant role in necrotizing enterocolitis (NEC). Nitric Oxide (NO) is the principal inhibitory neurotransmitter in the gut and is involved in regulation of mucosal blood flow and maintenance of mucosal integrity. NO is synthesized from L-arginine by NO synthases. Our primary objective was to determine the effectiveness of supplemental L-arginine versus placebo in prevention of NEC in preterm infants ≤ 34 weeks gestational age by systematic review of published randomized controlled trials (RCTs).

METHODS

This review included RCTs in which L-arginine was administered as a supplement to neonates to prevent NEC. Searches were conducted in OVID MEDLINE, EMBASE, PubMed, and CINAHL from their dates of inception to July, 2014. Inclusion criteria were informed parental consent, neonates born at ≤ 34 weeks gestation, and birth weight ≤ 1500 g. Exclusion criteria included neonates with severe congenital anomalies and inborn errors of metabolism. Incidence of NEC was the primary outcome measure. Whole data were analyzed by RevMan 5.1 (Update Software, Oxford, UK). Outcome data were analyzed to determine risk ratios, number needed to treat, confidence intervals, and test for overall effect.

RESULTS

Two trials including 425 neonates were eligible for this review. Of these, 235 neonates were included in the study. L-arginine had a 59% reduction in the incidence of stage II and III NEC (RR 0.41, 95% CI 0.20 to 0.85, NNT = 9) compared with placebo (P = 0.02). A similar finding was identified for all stages of NEC (60% reduction, RR 0.40, 95% CI 0.23 to 0.69, NNT = 5) (P = 0.001). At age 3 yrs, there was no significant difference between the 2 groups in terms of any neurodevelopmental disability (RR 0.65; 95% CI 0.23-1.83, P = 0.41).

CONCLUSIONS

L-arginine supplementation appears to be protective in prevention of NEC in preterm infants and without any significant impact on neurodevelopmental outcomes at 36 months of corrected age. With the addition of the results of one more study to the literature, an intriguing role for L-arginine supplementation continues to gain support. However, large multi-centre RCTs are needed before this can become common practice.

Procedural skills in paediatric residency: Re-evaluating the competencies

BACKGROUND

The Royal College of Physicians and Surgeons of Canada (RCPSC) sets objectives for residency training, including many skills that may not be commonly performed in practice.

OBJECTIVE

To describe attitudes of residents enrolled in Canadian paediatric residency programs toward procedural skills training, including perception of importance and perceived proficiency of the RCPSC-required procedures.

METHODS

An anonymous electronic survey was distributed to all senior residents enrolled in Canadian paediatric residencies, using a five-point Likert scale to address procedural importance and corresponding proficiency. Data were analyzed using descriptive statistics, with Pearson correlation coefficients used to describe relationships among variables.

RESULTS

A total of 68 residents responded. Fifteen skills had a mean importance ≥4 (very or extremely important) and five skills had a mean rating <3 (somewhat or not important). Residents believed they were extremely or very proficient (mean rating ≥4) for three skills (bag-mask ventilation, lumbar puncture and chest x-ray interpretation). They reported 23 procedures for which they felt somewhat to not proficient (mean <3). The correlation between importance and proficiency was high (Pearson's correlation coefficient = 0.87). However, proficiency was significantly lower than importance (P<0.05) for the majority of procedures (88%). The largest gaps between importance and proficiency were observed for chest tube insertion, gathering evidence of child maltreatment, defibrillation and intraosseous insertion.

CONCLUSION

Many, but not all, RCPSC-required procedures are believed to be important. Residents do not believe that they are adequately proficient in many of these procedures. Skills with the greatest gap between importance and proficiency may be targets for curricular interventions.

Need for supplemental oxygen at discharge in infants with bronchopulmonary dysplasia is not associated with worse neurodevelopmental outcomes at 3 years corrected age

OBJECTIVES

To determine if chronic oxygen dependency (discharge home on supplemental oxygen) in children with bronchopulmonary dysplasia (BPD; defined as requirement for supplemental O2 at 36 weeks postmenstrual age) predicts neurodevelopmental disability rates and growth outcomes at 36 months corrected age (CA).

STUDY DESIGN

Longitudinal cohort study.

SETTING

Southern Alberta regional center located at high altitude.

PARTICIPANTS

Preterm infants weighing ≤1250 grams with no BPD, BPD, and BPD with chronic oxygen dependency.

MAIN OUTCOME MEASURES

Neurodevelopmental and growth outcomes.

RESULTS

Of 1563 preterm infants admitted from 1995-2007, 1212 survived. Complete follow-up data were available for 1030 (85%) children. Children in BPD and BPD with chronic oxygen dependency groups had significantly lower birth weights, gestational ages, prolonged mechanical ventilation and oxygen supplementation and received more postnatal steroids, compared to those without BPD. Children with BPD and BPD with chronic oxygen dependency were more likely to be below the 5th centile in weight and height compared to those without BPD but there was little difference between the BPD and BPD with chronic oxygen dependency groups. After controlling for confounding variables, children who had BPD and BPD with chronic oxygen dependency had higher odds of neurodevelopmental disability compared to those without BPD [OR (odds ratio) 1.9 (95%CI 1.1 to 3.5) and OR 1.8 (1.1 to 2.9), respectively], with no significant difference between BPD and BPD with chronic oxygen dependency [OR 0.9 (95% CI 0.6 to 1.5)].

CONCLUSIONS

BPD and BPD with chronic oxygen dependency in children predicts abnormal neurodevelopmental outcomes at 36 months CA. However, the neurodevelopmental disability rates were not significantly higher in BPD with chronic oxygen dependency children compared to children with BPD only. Compared to those without BPD, growth is impaired in children with BPD and BPD with chronic oxygen dependency, but no difference between the latter two groups.

The mystery of persistent pulmonary hypertension: an idiopathic infantile arterial calcification

BACKGROUND

Idiopathic infantile arterial calcification (IIAC) is a rare autosomal recessive disorder, characterized by wide spread calcifications in arterial walls, leading to vaso-occlusive ischaemia of multiple organs. Mortality is high, and there is no definitive treatment.

CASE PRESENTATION

A male neonate, 36+5 weeks gestation, 2.81 kg, was admitted to NICU for respiratory distress. At one hour of age, he was noted to be pale, hypoperfused, with weak pulses, a hyperdynamic precordium and a grade IV/VI pansystolic murmur. The rest of his examination was normal. A chest X-ray showed massive cardiomegaly and pulmonary oedema. An echocardiogram (ECHO) indicated moderate persistent pulmonary hypertension (PPHN) of unclear etiology. A diagnosis of Idiopathic infantile arterial calcification was made and a trial of Editronate therapy was given without success.

CONCLUSION

IIAC is a rare disorder, it should be considered whenever a neonate presents with unexplainable cardiac failure, PPHN, echogenic vessels on X-ray/ultrasound and, or concentric hypertrophic ventricles on ECHO. Serial antenatal ultrasound findings of echogenic cardiac foci should raise the suspicion of IIAC. Further studies to determine the long term effects of Editronate on vascular calcifications, disease outcome, and other treatment options are needed.

Citrobacter freundii brain abscess in a preterm infant: a case report and literature review

Intracranial abscesses are serious conditions but uncommon in preterm neonates. Citrobacter species are an uncommon cause of bacterial meningitis in neonates, but are associated with brain abscesses in a majority of cases. We report a preterm infant who developed Citrobacter freundii meningitis with brain abscess, who was successfully treated with antibiotics and surgical drainage. The infant had normal neurological outcome at follow-up. We report this case to highlight the importance of serial neuroimaging in the diagnosis of cerebral abscess in infants with Citrobacter meningitis.

Practicing medicine without borders: tele-consultations and tele-mentoring for improving paediatric care in a conflict setting in Somalia?

OBJECTIVES

In a district hospital in conflict-torn Somalia, we assessed (i) the impact of introducing telemedicine on the quality of paediatric care, and (ii) the added value as perceived by local clinicians.

METHODS

A 'real-time' audio-visual exchange of information on paediatric cases (Audiosoft Technologies, Quebec, Canada) took place between clinicians in Somalia and a paediatrician in Nairobi. The study involved a retrospective analysis of programme data, and a perception study among the local clinicians.

RESULTS

Of 3920 paediatric admissions, 346 (9%) were referred for telemedicine. In 222 (64%) children, a significant change was made to initial case management, while in 88 (25%), a life-threatening condition was detected that had been initially missed. There was a progressive improvement in the capacity of clinicians to manage complicated cases as demonstrated by a significant linear decrease in changes to initial case management for meningitis and convulsions (92-29%, P = 0.001), lower respiratory tract infection (75-45%, P = 0.02) and complicated malnutrition (86-40%, P = 0.002). Adverse outcomes (deaths and lost to follow-up) fell from 7.6% in 2010 (without telemedicine) to 5.4% in 2011 with telemedicine (30% reduction, odds ratio 0.70, 95% CI: 0.57-0.88, P = -0.001). The number needed to be treated through telemedicine to prevent one adverse outcome was 45. All seven clinicians involved with telemedicine rated it to be of high added value.

CONCLUSION

The introduction of telemedicine significantly improved quality of paediatric care in a remote conflict setting and was of high added value to distant clinicians.