Switching to a fixed-ratio combination of insulin degludec/liraglutide (IDegLira) is associated with improved glycaemic control in a real-world population with type 2 diabetes mellitus in the United Arab Emirates: Results from the multicentre, prospective INTENSIFY study

AIM

Investigate the effectiveness of IDegLira, a fixed-ratio combination of insulin degludec/liraglutide, in a real-world setting in patients with type 2 diabetes mellitus in the United Arab Emirates.

METHODS

This non-interventional study enrolled adults switching to IDegLira from basal insulin (BI) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with/without concomitant oral antidiabetic drugs (OADs). Primary endpoint was change in HbA1c from baseline, assessed using a mixed model for repeated measurements.

RESULTS

Among 263 patients (BI ± OADs, n = 206; GLP-1 RA ± OADs, n = 57), mean baseline HbA1c was 9.29 % (78 mmol/mol). After 26 weeks, HbA1c was significantly reduced (BI ± OADs, -0.83 % [-9.0 mmol/mol] and GLP-1 RA ± OADs, -1.24 % [-13.5 mmol/mol]; both p < 0.0001). Fasting plasma glucose (FPG) was significantly reduced (-39.48 mg/dL [BI ± OADs] and -82.49 mg/dL [GLP-1 RA ± OADs]; both p < 0.0001). Before treatment initiation, 3/263 patients experienced ≥ 1 severe hypoglycaemic episode and 7/263 patients experienced ≥ 1 non-severe hypoglycaemic episode compared with 1/263 patients who had ≥ 1 severe and 1/263 who had ≥ 1 non-severe episode at end of study. Body weight decreased significantly among patients switching from BI ± OADs (-1.05 kg [p < 0.0001]). Treatment was well tolerated.

CONCLUSIONS

IDegLira significantly reduced HbA1c and FPG in this real-world setting, along with less frequent episodes of hypoglycaemia. Switching to IDegLira offers effective treatment intensification for type 2 diabetes patients with inadequate glycaemic control.

Sterile water moisturizer of the skin of extremely low birth weight infants

OBJECTIVE

To assess the feasibility of sterile water application to the skin of the extremely low birth weight (ELBW) newborns in the first week of life and examine its effects on their skin integrity and outcomes.

DESIGN

Pilot randomized controlled trial.

SETTING

Open-bay, 18 bed Level III NICU in the Eastern United States.

PARTICIPANTS

Twenty-eight ELBW neonates. Two newborns expired, sixteen newborns remained in the intervention group and twelve newborns in the control group.

METHODS

ELBW neonates were either assigned to receive frequent sterile water wash to skin or not during care for the first week of life. Using the Neonatal Skin Condition Scale (NSCS), assessments were performed twice a day during the first week. Fluid intake, serum electrolytes, culture proven sepsis and other morbidities, and length of stay (LOS) were compared while controlling for confounding variables using multiple regression analysis.

RESULTS

There was no difference in the demographic or clinical characteristics between both groups. Sterile water wash application to skin was not associated with differences in skin health indices or fluid intake. However, it was associated with higher median sodium level and with early regression of bilirubin level when compared to controls.

CONCLUSION

Frequent skin washes with sterile water are feasible and safe. However, they may not be associated with improved skin integrity or fluid intake.

Is it feasible to avoid suction before spontaneous breathing is established?

BACKGROUND

Suctioning of the posterior pharynx immediately after birth during neonatal resuscitation can produce a vagal response resulting in bradycardia or apnea. The feasibility of delaying any airway suctioning and avoiding deep suctioning has not been studied.

OBJECTIVES

To test the hypothesis that newborn resuscitation is feasible with the following two guidelines: 1) avoiding any suctioning until the infant establishes spontaneous respiration, and 2) avoiding the use of deep suction with catheters.

STUDY DESIGN

A quality improvement project was implemented using these two guidelines. Infants' mouth was cleaned with a dry cloth. No suction was started until infants establish spontaneous breathing. Then, bulb suction was used to clear secretions from the sides of the mouth and the nose without reaching the back of the pharynx. Deep suction using catheters was not used. Neonatal staff and physicians received biweekly training to support these changes. Resuscitation data before and after the practice change were compared.

RESULTS

A total of 999 sequential cases were compared; of them 501 and 498 infants were resuscitated before and after the implementation of the new practice, respectively. Suction before spontaneous breathing occurred in 12.4% in the first cohort. There were no differences between groups except for less use of oxygen with the new guidelines (12.4% vs 4.4%, P < 0.001).

CONCLUSION

Avoidance of any suction prior to spontaneous breathing and not applying deep suction with catheters are feasible during newborn resuscitation. These practices are associated with decreased exposure to oxygen in the delivery room.

1432 Simplifying Processes to Improve Rate of Surgical Site Infections

Aim

Surgical site infection (SSI) is a common healthcare associated infection, complicating 10-15% of operations. These have the potential to cause significant harm to patients, prolong hospital stays and are costly to the NHS. Although the cause is multifactorial, appropriate antibiotic prophylaxis plays a role in reducing SSIs. Due to a higher-than-average rate of SSIs at ASPH, an audit was performed to review the use of antibiotics prior to surgery.

Method

Local antibiotic policies for surgical prophylaxis were used as the audit standard. Data was collected prospectively over a two-week period. Recovery nurses filled out a proforma identifying type of surgery, patients’ weight, antibiotics received and dose.

Results

120 datasets were collected. Due to incomplete data, 113 were analysed; 81 patients required prophylactic antibiotics. The audit identified that current practice was not aligned with local policy. Where antibiotic use was indicated, all bar one patient received appropriate antibiotics. The primary issue identified was incorrect gentamicin dosing when a 5mg/kg dose based on creatine clearance was required. Gentamicin was dosed appropriately in 15 out of 49 cases, with 160mg administered in most cases regardless of policy.

Conclusions

Reasons underlying this are likely to be multifactorial, including ototoxicity risk, dose calculation and administration time; at present, the scheduling of theatre cases does not allow for a 30-minute gap from induction of anaesthesia to start of surgery. Working in partnership with the microbiologists we plan to create a gentamicin dose reference chart for display in all anaesthetic rooms to simplify dosing and improve compliance.

POS0537 TRENDS AND PREDICTORS OF INPATIENT MORTALITY IN PATIENTS WITH CLOSTRIDIODES DIFFICILE INFECTION AMONG THOSE WITH AND WITHOUT RHEUMATOID ARTHRITIS: A NATIONWIDE ANALYSIS

Background:

People with rheumatoid arthritis (RA) have a higher risk of serious infections. The most common nosocomial infection in the United States (US) is Clostridioides difficile infection (CDI) and yet, little is known regarding the impact of comorbid RA on outcomes in persons hospitalized with CDI.

Objectives:

To evaluate the trends over time and predictors of inpatient mortality in hospitalized patients with CDI comparing those with and without RA.

Methods:

We used the National Inpatient Sample (NIS) database, the largest available all-payer database of inpatient hospitalizations in the US. Patients aged ≥18 years admitted with CDI from 2006-2018 were included. Patients with RA were identified using the International Classification of Diseases (ICD) 9 and 10 codes. Categorical variables between CDI patients with and without RA were compared using Chi-squared test. Temporal trends of hospitalization charges, length of stay (LOS) and inpatient mortality were assessed using the Cochrane Armitage test. Predictors of inpatient mortality were assessed using multivariable logistic regression adjusting for: age ≥65, sex, race, presence of RA, and Elixhauser comorbidity index.

Results:

There were 4,396,945 hospitalizations with a discharge diagnosis of CDI in the study period, of which 111,336 (2.5%) had a coexisting diagnosis of RA. Over the study period, the proportion of CDI patients with a diagnosis of RA increased from 1.7% in 2006 to 3.3% in 2018 with a statistically significant trend of rise (p trend<0.001). There were significantly more females in the RA group (78.2%) than without RA (57.5%), p <0.001. RA group was significantly younger (68.0 vs 70.7, P<0.001). Races were similar between the groups.

The inflation-adjusted average charge for hospitalization for CDI without RA was significantly higher than for CDI with RA ($95,863 vs $73,025, p<0.001). There was an increasing trend in inflation-adjusted average charge for hospitalization for both CDI without RA ($76,966 in 2006 to $104,552 in 2018, p<0.001) and CDI with RA ($55,689 in 2006 to $77,295 in 2018, p<0.001). Patients with or without RA had the same median length of stay (LOS) of 7 days. But when trended over time, for patients without RA, the median LOS decreased from 8 days in 2006-08 to 6 days in 2016-18 whereas for patients with RA, the median LOS fluctuated between 6 and 7 days over the course of study period.

CDI patients without RA had a significantly higher mortality over the study period than those with RA (7.8% vs 6.1%, p<0.001). Among non-RA CDI patients, mortality decreased from 9.3% in 2006 to 6.3% in 2018 (p trend <0.001). Hospitalizations of people with CDI and comorbid RA showed an overall decreasing trend (p trend <0.001).

The multivariable analyses found age≥65 was associated with increased inpatient mortality (adjusted odds ratio [aOR], 1.77, 95% confidence interval [CI], 1.73-1.80), whereas a diagnosis of RA was associated with a decreased mortality (aOR 0.86, 95% CI, 0.81-0.91) (Table 1).

Table 1.

Predictors of inpatient mortality

aOR95% C.I. for aORP-valueLowerUpperAge ≥ 651.7651.7301.801<0.001Hospitalization years -Years 2006-2011Ref -Years 2011-20140.7070.6930.721<0.001 -Years 2015-20180.5820.5690.594<0.001Elixhauser Comorbidity Index1.0561.0551.056<0.001Rheumatoid Arthritis0.8590.8100.911<0.001Female0.8700.8550.885<0.001Race -WhiteRef -African American1.0711.0441.099<0.001 -Hispanic1.1441.1081.180<0.001 -Asian/Pacific Islander1.2671.2001.337<0.001 -Native American1.0220.9101.1470.716 -Other races1.2631.2011.329<0.001

aOR = Adjusted Odds Ratio; C.I.= confidence interval

Conclusion:

In this nationwide study, among hospitalized patients with CDI, those with comorbid RA had significantly decreased odds of inpatient mortality than those without RA. Further studies are needed to understand this association.

Figure 1.

Disclosure of Interests:

None declared

Understanding the Gaps in Obesity Management in the UAE: Perceptions, Barriers, and Attitudes

<b><i>Introduction:</i></b> Obesity is a chronic relapsing disease of which, globally, the prevalence has reached epidemic proportions. The ACTION-IO study (NCT03584191) investigated the perceptions, attitudes, and behaviors of people with obesity (PwO) and healthcare professionals (HCPs), which can help in devising strategies for its optimal management. Here, we present the results from the United Arab Emirates (UAE). <b><i>Methods:</i></b> The ACTION-IO study was a cross-sectional study conducted in 11 countries, including the UAE, that collected data via a survey. Eligible UAE PwO were ≥18 years with a BMI of ≥30 kg/m² (self-reported height and weight). Eligible HCPs were in direct patient care. Data were collected in the UAE between July 11, 2018, and September 5, 2018. <b><i>Results:</i></b> A total of 750 PwO and 200 HCPs completed the survey in the UAE. Both PwO (82%) and HCPs (78%) acknowledged obesity as a chronic disease and agreed that it has a large impact on overall health (PwO 88% and HCPs 80%). More HCPs felt that diabetes and stroke (both 91%) had a larger impact on overall health than did obesity. Many PwO (76%) assumed full responsibility for their weight loss; 84% of HCPs acknowledged responsibility for actively contributing to patient weight loss efforts. The top motivator for weight loss among PwO was wanting to be more fit/in better shape (45%), while HCPs believed the main motivator was general health concerns (83%). The top barrier against initiating weight management discussions provided by HCPs was that they felt PwO were not interested in losing weight (69%), whereas only 10% of PwO selected this response. The mean delay between struggling with excess weight and having a weight management discussion with an HCP was 4 years. <b><i>Discussion/Conclusion:</i></b> These UAE results highlight differences in the perceptions and attitudes toward obesity from PwO and HCPs and reflect a need to understand weight management concerns to initiate earlier and more effective PwO–HCP conversations. The findings will inform educational needs on the biological basis of obesity and its clinical management and will help to address regional barriers for effective obesity care.

Hypoglycaemia Among Insulin-Treated Patients with Diabetes: Evaluation of the United Arab Emirates cohort of the International Operations-Hypoglycaemia Assessment Tool study

Objectives

This study aimed to evaluate the incidence of hypoglycaemia among insulin-treated patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) from the United Arab Emirates (UAE) cohort of the non-interventional International Operations-Hypoglycaemia Assessment Tool study.

Methods

This cross-sectional observational study took place at 25 patient care centres in the UAE from October 2014 to May 2015. All adult patients with T1DM or T2DM who had been treated with insulin for >12 months were included. Self-assessment questionnaires and patient diaries were used to determine the incidence of documented hypoglycaemia both prospectively (four weeks after baseline) and retrospectively (six months and four weeks before baseline for severe and non-severe hypoglycaemic events, respectively).

Results

A total of 325 patients were enrolled in the study, of which 82 (25.2%) had T1DM and 243 (74.8%) had T2DM. Among patients with T1DM, 71.4% reported hypoglycaemic events retrospectively, with an incidence rate (IR) of 102.8 events per patient-year (PY), while 95% reported hypoglycaemic events prospectively, with an IR of 63.1 events per PY. Additionally, 56.3% of patients with T2DM reported hypoglycaemic events retrospectively, with an IR of 42.2 events per PY, while 91.9% reported hypoglycaemic events prospectively, with an IR of 33.3 events per PY.

Conclusion

The prevalence and incidence of hypoglycaemia were high among insulin-treated patients with T1DM and T2DM in the UAE. Individualised glycaemic goals, patient education and blood glucose monitoring may help to reduce the incidence of hypoglycaemia in this population.

Patent ductus arteriosus in premature infants: to treat or not to treat?

OBJECTIVE

Closing patent ductus arteriosus (PDA) is a widely accepted approach in the management of very low birth weight (VLBW) infants. Our objective is to test the hypothesis that conservative management (no treatment) of PDA will not affect survival without chronic lung diseases (CLD).

STUDY DESIGN

This retrospective study utilizes a prospectively collected database to compare two cohorts of VLBW infants. Infants in the first group (2001 to 2009) had their PDA treated with pharmacological and if necessary with surgical ligation. PDA in the second group (2010 to 2014) was not treated with medical or surgical intervention. The primary outcome was survival without oxygen requirement at 36 weeks. Pulmonary and non-pulmonary morbidities were also compared. Logistic regression analyses were performed to control for confounders.

RESULTS

This study included 643 VLBW infants, of them 415 infants in the Treat group and 228 in the No-Treat group. The rate of survival without CLD did not differ between Treat and No-Treat groups (78.4% vs 83.9%, respectively; adjusted odds ratio (aOR)=1.72, confidence interval (CI): 0.92 to 3.23, P=0.09). Mortality declined in No-Treat group (15.2% vs 10.5%, aOR=0.51, CI: 0.25 to 0.99, P=0.049), but the two groups did not differ in the incidence of CLD among survivors (5.8% vs 5.0%,=P0.47). Pulmonary complications and non-pulmonary morbidities did not differ between groups.

CONCLUSIONS

Conservative management (no treatment) of PDA may not compromise survival without CLD and is not associated with increased morbidities in VLBW infants. Prospective physiological studies are needed to determine the sector of VLBW infants, if any, who could benefit from PDA treatment.

Lipid peroxides in the serum of asphyxiated neonates

OBJECTIVE

Lipid peroxides (LPOs) are released when free radicals react with unsaturated fatty acids in cell membranes during hypoxic ischemic insult in neonates. We aimed to assess LPO concentrations in the serum of asphyxiated and non-asphyxiated neonates and examine their correlation with the severity of asphyxia.

STUDY DESIGN

This prospective cross-sectional study was conducted on a group of asphyxiated neonates and controls. Serum LPO concentrations was measured by enzyme-linked immunosorbent assay at 4-6 h of life in all subjects. Encephalopathy was classified according to Sarnat's stages into mild, moderate and severe at 12-24 h of life. LPO was compared between groups and was correlated with severity of encephalopathy and mortality.

RESULTS

A total of 90 infants were enrolled; of them 45 had asphyxia. Serum LPO (nmol ml(-1)) was significantly greater in the asphyxia group (6.9±3.01 vs 1.78±1.09, P<0.001). It correlated positively with severity of encephalopathy (P<0.001) and negatively with Apgar score at 5 min (r=-0.532, P<0.001) and with initial blood gases pH (r=-0.664, P<0.001). LPO measured greater concentrations in infants who died compared with asphyxiated survivors (11.64±1.31 vs 6.18±2.48, P=0.0004).

CONCLUSION

LPO was increased and correlated with severity of asphyxia as well as with mortality. Further studies are warranted to examine whether it is only a marker for outcome or a contributor in the pathogenesis of hypoxic-ischemic brain injury.

Maternal juvenile rheumatoid arthritis may be associated with preterm birth but not poor fetal growth

OBJECTIVE

Adverse pregnancy outcomes in mothers with juvenile rheumatoid arthritis (JRA) are not known. The objective of this study was to examine the risk of preterm birth and restricted fetal growth in pregnant mothers diagnosed with JRA, and to examine the impact of race/ethnicity and maternal age on this association.

STUDY DESIGN

Hospital discharge records for mothers who gave birth in 2011 and 2012 were examined in the National Inpatient Sample (NIS) database. JRA, preterm birth (<37 weeks of gestation), birth weight that is small for gestational age (SGA) and other demographic and clinical variables were identified using ICD-9 (International Classification of Disease--9th revision) diagnostic codes. The associations of JRA with preterm birth and restricted fetal growth were examined controlling for confounding variables.

RESULT

The sample included 8,273,987 birthing mothers, of these 1236 (0.01%) had JRA. The prevalence of preterm birth and SGA was 6.08% and 2.34%, respectively. Preterm birth in mothers with JRA was 12.9% compared with 6.1% in mothers without JRA with an adjusted odds ratio (OR) of 2.1 (confidence interval (CI): 1.74 to 2.42, P<0.001). The incidence of SGA in infants born to mothers with JRA was 3.34% compared with 2.34% in non-JRA mothers, which was not statistically significant. Adjusted OR for preterm birth in association with JRA among White mothers was 1.78 (CI: 1.41 to 2.24, P<0.001). However, Hispanic mothers with JRA (12%) were the ethnicity to suffer the most from preterm birth with an adjusted OR of 4.43 (CI: 2.97 to 6.62, P<0.001). Preterm birth among advanced maternal age (AMA) mothers with JRA was 25% compared with 7% in those without JRA with an adjusted OR of 5.42 (CI: 3.51 to 8.35, P<0.001).

CONCLUSION

JRA is associated with preterm birth but not with SGA. This association is significantly influenced by race/ethnicity and maternal age. More studies are needed to examine these findings in relation to medications used, severity of the disease and exacerbation during pregnancy to understand the genetic/socioeconomic factors behind these racial/ethnic differences.

Jaundice, phototherapy and DNA damage in full-term neonates

OBJECTIVE

Phototherapy is the standard therapeutic approach for neonatal hyperbilirubinemia. Oxidative effects of phototherapy may have potential harms, including DNA damage. Unconjugated bilirubin (UCB) might also possess antigenotoxic potential. Intensive phototherapy is more efficacious than conventional phototherapy in treating hyperbilirubinemia. This study aimed to assess the impact of hyperbilirubinemia and the two different types of phototherapy on DNA damage in peripheral blood mononuclear cells of neonates.

STUDY DESIGN

The study was conducted on term neonates with non-hemolytic hyperbilirubinemia and control healthy neonates. Genotoxicity was assessed using single-cell gel electrophoresis (Comet assay) in peripheral mononuclear cells. Blood samples were obtained at enrollment in all infants and after intensive or conventional phototherapy in jaundiced infants.

RESULT

DNA damage did not significantly differ between jaundiced and non-jaundiced neonates (11.4±8.7 and 10.9±8.3 arbitrary units (AU), respectively, P=0.58). It increased significantly after exposure to phototherapy compared with prephototherapy values (45.6±14.7 vs 11.4±8.7 AU, respectively, P<0.001). The duration of phototherapy correlated positively with markers of DNA damage (r=0.86, P<0.001); however, the intensity of used light did not significantly impact genotoxicity.

CONCLUSION

Hyperbilirubinemia does not influence DNA damage, whereas both conventional and intensive phototherapy are associated with DNA damage in term infants with hyperbilirubinemia.

Impact of Duplex arterial mapping on decision making in non-acute ischemic limb patients

AIM

The aim of this study was to demonstrate the impact of Duplex arterial mapping on decision making in non-acute ischemic limb patient group reporting pain onset between 15 days and 3 months.

METHODS

We prospectively evaluated patients presented with critical limb ischemia who reported pain onset of duration between 15 days and 3 months in one-year period. Our series included thirty cases (mean age=61.3 years old), as Duplex arterial mapping was the sole preoperative imaging tool performed in all of them. All patients, in whom duplex indicated thrombosis in long occluded segments, were candidates for fluoroscopically guided thrombectomy. When Duplex defined chronic arterial occlusions, patients underwent endovascular or bypass revascularisation procedures. Impact of Duplex wall interrogation on decision-making between the two groups (subacute and chronic) was measured.

RESULTS

Duplex arterial mapping categorized correctly all 30 patients into either subacute ischemia with removable clot (N.=14) or chronic ischemia (N.=16). Fluoroscopic guided thrombectomy was performed in 14 cases when Duplex advised long occluded arterial segments as indicted by intact intima with echogenic thrombus inside. Bypass surgery was performed in 8 patients. Percutaneous transluminal angioplasty (PTA) was done in 7 cases and thrombendartrectomy of common femoral artery in a single case. One-year patency rate in our series was 86.6%. It was 71.4% in thrombosis group. Limb salvage rate was 93.3%.

CONCLUSION

Duplex arterial mapping could be used to differentiate the subacute ischemia with removable thrombus and chronic arterial occlusions guiding for the best revascularization procedure accordingly.

A prospective study on hyperglycemia and retinopathy of prematurity

OBJECTIVE

Retinopathy of prematurity (ROP) constitutes a significant morbidity in premature infants that can lead to blindness. Multiple retrospective studies have identified neonatal hyperglycemia as a risk for developing ROP. However, in the absence of any reported prospective study, it is not clear whether hyperglycemia is associated with ROP independent of the commonly associated comorbidities. The objective of this study was to investigate whether hyperglycemia in premature infants is independently associated with ROP.

STUDY DESIGN

Premature infants (<1500 g or⩽32 weeks gestational age) were enrolled in a prospective longitudinal cohort study. All demographic, clinical and laboratory data were collected. Bedside whole-blood glucose concentration was measured every 8 h daily for 7 days. For any glucose reading<50 or>150 mg dl(-1), serum sample was sent to the laboratory for confirmation. Hyperglycemia was defined as any blood glucose level⩾150 mg dl(-1). ROP patients were compared with non-ROP patients in a bivariate analysis. Variables significantly associated with ROP were studied in a logistic regression model.

RESULT

A total of 65 patients were enrolled with gestational age 31.1±1.2 weeks and birth weight 1385±226 g. Thirty-one patients (48%) were identified with hyperglycemia. On eye examination, 19 cases (29.2%) had ROP (13 with stage 1, 4 with stage 2 and 2 with stage 3). There were more cases of ROP in the hyperglycemia group compared with the euglycemia group (45% vs 15%, P=0.007). Patients who developed ROP had significantly higher maximum and average glucose concentrations when compared with non-ROP patients. Multiple factors have been associated with ROP on bivariate analysis, including gestational age, exposure to oxygen, respiratory support and poor weight gain. However, in a logistic regression model including all significant variables, average blood glucose in the first week of life was the factor independently associated with ROP with an odds ratio of: 1.77 (95% confidence interval: 1.08 to 2.86), P=0.024.

CONCLUSION

In a cohort of premature infants, elevated average blood glucose concentrations in the first week of life is independently associated with the development of ROP.

Impact of race on male predisposition to birth asphyxia

OBJECTIVE

To examine the associations of: (a) neonatal sex with mild-to-moderate and severe birth asphyxia, (b) fetal sex with mortality due to birth asphyxia and (c) neonatal race with severe birth asphyxia.

STUDY DESIGN

We used the Nationwide Inpatient Sample (NIS) Database including the years 1993 to 2008 or its pediatric sub portion Kid's Inpatient Database (KID) for the years 1997, 2000, 2003 and 2006. NIS database is collected annually from more than 1000 hospitals across the United States for millions of inpatient discharge summaries. We included newborns older than 36 weeks gestational age or more than 2500 g at birth. We excluded newborns with congenital heart disease, major congenital anomalies and chromosomal disorders. We compared birth asphyxia in males to females, and in each race compared with whites, and examined effect of sex in association with birth asphyxia within each race/ethnicity.

RESULT

There were 9 708 251 term infants (51.8% males) included in the study. There were 15 569 newborns diagnosed with severe birth asphyxia (1.6 in 1000); of them 56.1% were males. Odds ratio (OR)to have severe birth asphyxia in male newborns was 1.16 (confidence interval (CI): 1.12 to 1.20, P<0.001). Compared with Whites, African-American newborns had more birth asphyxia, OR 1.23 (CI: 1.16 to 1.31, P<0001), whereas Hispanics and Asians had less birth asphyxia. Native American newborns did not differ from their white counterparts. On comparing males to females within each race, male sex was associated with increased birth asphyxia in all races but Native American.

CONCLUSION

Male sex and African-American race were associated with increased prevalence of birth asphyxia.

Birth region, race and sex may affect the prevalence of congenital diaphragmatic hernia, abdominal wall and neural tube defects among US newborns

OBJECTIVE

Birth defects are number one cause of death among infants below 1 year of age. The objective is to examine the interaction of sex, race/ethnicity and place of birth on the prevalence of major congenital birth anomalies.

STUDY DESIGN

We analyzed the data sets produced by the Healthcare Cost and Utilization Project (HCUP) for the years 1997-2004. We identified the malformations: congenital diaphragmatic hernia (CDH), abdominal wall defects (AWD) and neural tube defects (NTD) using their respective International Classification of Disease 9 diagnostic codes. Newborns were classified according to their birth region into four groups; Northeast, South, Midwest and West. We calculated prevalence of each disease for the overall sample then for every sex, race and birth region. Using stratified analysis and χ(2) test, we calculated the odds ratio (OR) risk for each disease comparing females with males, different races/ethnicity to Caucasians and different US regions to Northeast.

RESULT

There were 1291 newborns with CDH representing 0.031% of the sample. (AWD: 2184 (0.052%) and NTD: 979 (0.024%)). West region had the highest prevalence of CDH (OR=1.62 (confidence intervals (CI): 1.4-1.9, P<0.001)). Female-to-male risk disparities were most observed among Caucasians in the South (OR=1.44 (CI: 1.1-1.8, P=0.003)). African Americans had the least prevalence of CDH but only in the South (OR=0.67 (CI: 0.5-0.8, P=0.001)). Native Americans had higher risk for AWD in the Midwest and West regions compared with Caucasians.

CONCLUSION

This study links the birth region as a detrimental factor like sex and race in the prevalence of CDH, AWD and NTD. These findings implicate a possible role for environmental factors in the pathogenesis of these diseases.

Viability and neural differentiation of mesenchymal stem cells derived from the umbilical cord following perinatal asphyxia

OBJECTIVE

Hypoxia-ischemia is the leading cause of neurological handicaps in newborns worldwide. Mesenchymal stem cells (MSCs) collected from fresh cord blood of asphyxiated newborns have the potential to regenerate damaged neural tissues. The aim of this study was to examine the capacity for MSCs to differentiate into neural tissue that could subsequently be used for autologous transplantation.

STUDY DESIGN

We collected cord blood samples from full-term newborns with perinatal hypoxemia (n=27), healthy newborns (n=14) and non-hypoxic premature neonates (n=14). Mononuclear cells were separated, counted, and then analyzed by flow cytometry to assess various stem cell populations. MSCs were isolated by plastic adherence and characterized by morphology. Cells underwent immunophenotyping and trilineage differentiation potential. They were then cultured in conditions favoring neural differentiation. Neural lineage commitment was detected using immunohistochemical staining for glial fibrillary acidic protein, tubulin III and oligodendrocyte marker O4 antibodies.

RESULT

Mononuclear cell count and viability did not differ among the three groups of infants. Neural differentiation was best demonstrated in the cells derived from hypoxia-ischemia term neonates, of which 69% had complete and 31% had partial neural differentiation. Cells derived from preterm neonates had the least amount of neural differentiation, whereas partial differentiation was observed in only 12%.

CONCLUSION

These findings support the potential utilization of umbilical cord stem cells as a source for autologous transplant in asphyxiated neonates.

Mortality in infants with congenital diaphragmatic hernia: a study of the United States National Database

OBJECTIVE

To examine the effect of regionalization of care on outcomes of neonates with congenital diaphragmatic hernia (CDH).

STUDY DESIGN

We analyzed the National Inpatient Sample and the 'Kids' database for the years 1997 to 2004. Infants with CDH were grouped based on whether they underwent surgical repair at the hospital of birth, or at another facility. Groups were compared using chi-square, t-test and logistic regression.

RESULT

A total of 2140 infants were included: 41% were females, 42% were Caucasians, 48% were transported, 20% reported the use of extracorporeal membrane oxygenation (ECMO)and 33% died. Only 79% underwent operative repair, in which 85% survived after surgery. Survival among operated patients who used ECMO was 40%. Transported infants used more ECMO than non-transported ones (25 vs 15%; adjusted odds ratio (OR) 1.46; confidence interval 1.1 to 1.9, P=0.007), and had higher mortality after surgery (16 vs 13%; adjusted OR 1.46; confidence interval 1.1 to 2, P=0.02).

CONCLUSION

The utilization of neonatal transport of CDH patients is associated with increased mortality and increased need for ECMO. This study supports the need for regionalization of care, and favors maternal transport before delivery of CDH newborns.

Ascorbic acid combined with ibuprofen in hypoxic ischemic encephalopathy: a randomized controlled trial

OBJECTIVE

Free oxygen radicals and proinflammatory cytokines are important causes for brain injury in neonates with hypoxic ischemic encephalopathy (HIE). Our objectives were to test the hypothesis that a combination of antioxidants (ascorbic acid) and anti-inflammatory agents (ibuprofen) can ameliorate the brain injury in HIE and improve neurodevelopmental outcomes when given to term infants immediately after birth.

STUDY DESIGN

In a prospective, randomized, double-blinded controlled trial, 60 asphyxiated term infants were assigned to one of two groups, intervention and control. The intervention group (n=30) received intravenous ascorbic acid and oral ibuprofen for 3 days; and the control group (n=30) received similar volumes of a placebo. We measured a panel of cytokines at enrollment and administered the treatment drugs within 2 h after birth. Neurological evaluations and developmental screenings were performed for all survivors at 6 months of age.

RESULT

The Intervention and Control groups did not differ in the severity of HIE at enrollment, the concentrations of IL-1 beta and IL-6, the incidence of mortality (37 vs 33%), the incidence of neurological abnormalities at hospital discharge (47 vs 55%) and the incidence of developmental delay at 6 months of age (32 vs 40%), respectively. None of the observed complications were related to intervention. Serum interleukin (IL)-1 beta and IL-6 concentrations correlated positively with the severity of HIE at birth (P<0.01), whereas only serum IL-6 correlated with neurodevelopmental outcome at 6 months (P<0.001).

CONCLUSION

Early administration of ascorbic acid and ibuprofen did not affect outcomes in infants with perinatal asphyxia. This study does not explain whether our intervention was not effective in blocking free radicals and inflammatory cytokines, if the dosing and route of administration were inadequate, or if other mediators existed that could have a more powerful role in brain injury during hypoxia-ischemia.

Massage with kinesthetic stimulation improves weight gain in preterm infants

OBJECTIVE

The aim of this study was to evaluate the effects of massage with or without kinesthetic stimulation on weight gain and length of hospital stay in the preterm infant.

STUDY DESIGN

A prospective randomized clinical trial was conducted evaluating the effects of massage with or without kinesthetic stimulation (KS) on weight gain and length of stay (LOS) in medically stable premature (<1500 g and/or <or=32 weeks gestational age) neonates. Infants were randomized either to receive no intervention (control), massage therapy alone (massage), or massage therapy with KS (M/KS). Linear regression analysis was performed to evaluate differences in the primary outcomes between the groups after controlling for covariates. Post hoc analysis with stratification by birthweight (BW> and <1000 g) was also performed.

RESULT

A total of 60 premature infants were recruited for this study; 20 infants in each group. Average daily weight gain and LOS were similar between the groups after controlling for covariates. For infants with BW>1000 g, average daily weight gain was increased in the intervention groups compared to control. This effect was mainly attributable to the M/KS group.

CONCLUSION

Massage with KS is a relatively simple and inexpensive intervention that can improve weight gain in selected preterm infants. Length of hospital stay is not impacted by massage with or without KS. Further studies are needed to evaluate the effect of massage in the extremely low BW(<1000 g) infant.

Erythromycin and feeding intolerance in premature infants: a randomized trial

OBJECTIVES

To evaluate the effectiveness of low-dose oral erythromycin to treat feeding intolerance in preterm infants.

DESIGN

This study was a prospective, double-blind, randomized, placebo-controlled trial on 60 premature infants suffering from feeding intolerance. Thirty infants were given oral erythromycin 1 mg/kg every 8 h and 30 infants were given placebo (normal saline). Randomization was stratified on enrollment according to gestational age whether >32 weeks or <or=32 weeks. The primary end point was the length of time taken to establish full enteral feeding since enrollment. Potential adverse effects associated with erythromycin were also monitored. Groups of each corresponding stratum were compared using two-tail t-test and Mann-Whitney for continuous variables, and chi (2) and Fisher's exact for categorical variables.

RESULTS

For infants with gestational age >32 weeks, the erythromycin group achieved full enteral feeding earlier than placebo group (10.5+/-4.1 vs 16.3+/-5.7 days, respectively; P=0.01) had fewer episodes of gastric residuals (P<0.05) and shorter duration of parenteral nutrition (PN) (P<0.05). On the other hand, in infants with gestational age <or=32 weeks, there were no significant differences between erythromycin and placebo groups regarding any of these variables.

CONCLUSION

Low-dose enteral erythromycin is associated with better tolerance of feeding and shorter duration of PN in infants >32 weeks gestation. A similar effect on younger preterm infants was not demonstrable.

Can delivery room management impact the length of hospital stay in premature infants?

OBJECTIVES

To evaluate the impact of initiating early nasal continuous positive airway pressure (ENCPAP) on the length of hospital stay (LOS) for the very low birth weight (VLBW) infants.

STUDY DESIGN

LOS at the George Washington University Hospital (GW) after the institution of ENCPAP policy was compared to benchmark values using two-tail t-tests. The incidence of neonatal morbidity was calculated using Bonferroni corrected 95% confidence interval as compared to benchmark rates (alpha=0.001). Comparisons were repeated after stratification of the population into four birth weight subcategories: group A (GrpA) (501 to 750 g), GrpB (751 to 1000 g), GrpC (1001 to 1250 g) and GrpD (1251 to 1500 g).

RESULTS

We studied 228 consecutive VLBW infants (birth weight: 995+/-294 g and gestational age: 27.7+/-2.7 weeks). Compared to benchmark values, the GW experience was associated with a significant reduction of 5.1 days in LOS (55.9+/-25.2 vs 61+/-32 days; P=0.04). The decrease in LOS was consistent in all subgroups, but was most noticeable in infants of the smallest weight subcategory (LOS in GrpA=86+/-21 vs 104+/-32, P=0.004; in GrpB=69.9+/-16.7 vs 79+/-27, P=0.018; in GrpC=48.2+/-13 vs 56+/-22, P<0.001 and in GrpD=31.7+/-12.5 vs 40+/-19, P=0.003). In the overall population, a lower incidence of chronic lung disease (CLD) (17.8 vs 29%, P<0.001) was also noted. There were no differences in mortality rates (9 vs 14%), or the incidence of necrotizing enterocolitis (NEC) (8 vs 6%) or intraventricular hemorrhage (6.2 vs 9%) between GW and the established benchmark rates.

CONCLUSION

ENCPAP may reduce LOS in VLBW infants in our study population. This relatively shorter LOS was associated with a lower incidence of CLD, which may be a contributing factor.

Early presentation of a congenital coronary artery fistula in a neonate

A neonate developed severe congestive heart failure secondary to a congenital coronary artery fistula requiring emergent surgery. Intraoperative transesophageal echocardiography helped guide successful emergent closure of the fistula without complications.

Changes in pulmonary vascular resistance in response to partial liquid ventilation

BACKGROUND/PURPOSE

Partial liquid ventilation (PLV) with perfluorocarbons decreases pulmonary vascular resistance (PVR) in injured piglet lungs without supplemental oxygen. These PVR changes may result either from direct mechanical effects or improved arterial oxygenation. In an uninjured hypoxic model of elevated PVR the authors asked the following questions: (1) Does prophylactic or therapeutic PLV ameliorate the PVR response to hypoxia? (2) Do prophylactic and therapeutic PLV have different PVR effects? (3) Does supplemental oxygen modify PVR response to PLV?

METHODS

Piglet (3 to 4 kg) lungs were isolated in situ without ischemia, hypoxia, or reperfusion injury. Pulmonary artery (PA) and left atrial (LA) cannulae were attached to a blood-primed extracorporeal membrane oxygenation (ECMO) perfusion circuit with a flow (QPA) of 80 mL/kg/min. Pressure-limited, volume-cycled ventilation (PIP < 25 mm Hg, Tv = 15 mL/kg) was initiated. PLV with perfluorodecalin (15 mL/kg) was administered endotracheally. Continuously monitored blood gas parameters allowed airway and extracorporeal adjustment of FiO2 to produce a PO2 appropriate to the experimental phase. PVR was calculated as (PPA - PLA/QPA). After a stable 30-minute normoxic baseline, animals were assigned randomly to three groups. In group I, control (n = 7), PVR was measured for 150 minutes in hypoxic lungs (FiO2 = 0.07, PPAO2 = 40 mm Hg, SPAO2 = 70%). In group II, prophylactic (n = 8), PLV was administered, followed by 90 minutes of hypoxia, and 60 minutes of oxygen recovery (FiO2 = 0.21-0.30, PPAO2 > 100 mm Hg, SPAO2 = 100%). In group III, therapeutic (n = 8), after 30 hypoxic minutes, PLV was administered and maintained for 90 minutes, followed by a 60-minute oxygen recovery phase. Results were expressed as mean +/- SEM. Statistical analysis of groups was performed by repeated measures of analysis of variance (ANOVA) and Tukey correction.

RESULTS

In group I normoxic gas-ventilated PVR was 174+/-12 mm Hg/L/kg/min. After 90 hypoxic minutes PVR was 318+/-37 (P < .01 vbaseline). In group II baseline PVR was 183+/-14. PVR after 30 normoxic minutes of PLV was 199+/-14 (P = ns v baseline). After 90 hypoxic minutes, PVR was 350+/-31 (P < .01 v baseline, and PLV alone) followed by a decrease to 192+/-19 after 60 minutes of oxygen recovery (P = ns v baseline or PLV alone). In group III baseline PVR was 160+/-17 and 325+/-29 after 30 hypoxic minutes. After 90 hypoxic minutes of PLV, PVR was 366+/-22 (P = ns v hypoxia control, P < .01 v normoxic baseline). PVR recovered to 189+/-19 after 60 minutes of oxygen recovery (P = ns v baseline).

CONCLUSIONS

Prophylactic/therapeutic PLV had no effect on hypoxia-induced increases in PVR and did not differ from each other. Although PLV alone decreases PVR in the injured lung without supplemental oxygen, elevated PVR associated with hypoxia was ameliorated only by supplemental oxygen in the liquid ventilated lung.

Weaning strategy with inhaled nitric oxide treatment in persistent pulmonary hypertension of the newborn

AIM

To determine if infants who had become dependent on inhaled nitric oxide treatment could be successfully weaned off it if FIO2 was increased briefly during withdrawal.

METHODS

Sixteen infants admitted for conditions associated with increased pulmonary vascular resistance responded well to inhaled nitric oxide treatment with a significant increase in PaO2 (maximum inhaled nitric oxide given 25 ppm). Weaning from inhaled nitric oxide in 5 ppm decrements was initiated once the FIO2 requirement was less than 0.5. When patients were stable on 5 ppm of inhaled nitric oxide, the gas was then discontinued. If a patient showed inhaled nitric oxide dependence-that is, oxygen saturation fell by more than 10% or below 85%-inhaled nitric oxide was reinstated at 5 ppm and the patient allowed to stabilise for 30 minutes. At this time, FIO2 was increased by 0.40 and weaning from inhaled nitric oxide was attempted again.

RESULTS

Nine infants were successfully weaned on the first attempt. The seven infants who failed the initial trial were all successfully weaned following the increase in FIO2. After successful weaning, FIO2 was returned to the pre-weaning level in mean 148(SD 51) minutes and inhaled nitric oxide was never reinstated.

CONCLUSION

Infants showing inhaled nitric oxide dependency can be successfully weaned by increasing FIO2 transiently.

Partial liquid ventilation (PLV) and lung injury: is PLV able to modify pulmonary vascular resistance?

INTRODUCTION

Partial liquid ventilation (PLV) with perfluorocarbons can be advantageous in treating lung injury. We studied this phenomenon in isolated piglet lungs devoid of systemic detractors by studying the changes in pulmonary vascular resistance (PVR) after lung injury with and without PLV. The following questions were asked. (1) Does PLV alone affect PVR in the uninjured lung? (2) Does PLV prevent the increase in PVR associated with oleic acid-induced lung injury? (3) Does PLV modify the increase in PVR associated with oleic acid lung injury? (4) Are the prophylactic and therapeutic effects of PLV on the increased PVR associated with oleic acid-induced lung injury different?

METHODS

Neonatal piglet (3 to 4 kg) lungs were prepared without pulmonary ischemia, hypoxia, or reperfusion injury for in situ study. Before pulmonary vascular isolation (eg, aortic and ductus arteriosus ligation) the pulmonary artery (PA) and left atrium (LA) were cannulated and attached to a blood-primed perfusion circuit (flow; 80 mL/kg/min). Pressure-limited volume-cycled ventilation (FiO2, 0.21; TV, 15 mL/kg; PIP, 25 cm H2O) was accomplished via occlusive tracheostomy. Blood gas parameters were monitored continuously and maintained within normal range (SpaO2, 75%; pH, 7.35 to 7.45; pCO2, 35 to 45 torr). Pulmonary artery pressure (Ppa), left atrial pressure (PLa) and pulmonary blood flow (Qpa) were recorded and PVR calculated (PVR = Ppa - Pla/Qpa). After achieving a stable baseline with gas ventilation only, the animal preparations were assigned to one of the following four groups. In group 1 (n = 7) PLV was given alone, using endotracheally administered perfluorodecalin (15 mL/kg). In group 2 (Prophylactic, n = 7) PLV was given prophylactically 60 minutes before lung injury induced by injecting oleic acid (OA) at 0.08 mL/kg into the pulmonary artery. In group 3 (Therapeutic, n = 8) PLV was given 60 minutes after OA-induced lung injury. PPA, PLA, and QPA were measured and PVR was calculated. In group 4 (n = 7) OA was given alone. Significance of differences between groups was obtained by repeated measures analysis of variance (ANOVA). Results were expressed as mean +/- SEM (mm Hg/L/Kg).

RESULTS

Group I showed baseline PVR of the normoxic gas ventilated animals was 127 +/- 19 mm Hg/L/kg. PVR 180 minutes after PLV administration was 160 +/- 15 mm Hg/L/kg (P = ns v baseline). In group 2 after OA infusion, PVR increased from 109 +/- 13 to 281 +/- 26 mm Hg/L/kg (P < .01 v baseline), and 60 minutes later, PVR decreased to 193 +/- 22 mm Hg/L/kg (P < .05 v OA). In group 3 PVR on gas ventilation, before lung injury, was 137 +/- 28 mm Hg/L/kg. Sixty minutes after OA infusion, PVR increased to 314 +/- 23 mm Hg/L/kg (P < .01 v baseline). After 60 additional minutes of PLV, PVR decreased to 201 +/- 31 mm Hg/L/kg, (P < .05 v maximum). In group 4 baseline PVR was 96 +/- 16 mm Hg/L/kg. After 120 minutes of OA injection, PVR increased to 414 +/- 20 mm Hg/L/kg (P < .01 v baseline). Endpoint analysis of PVR at the conclusion of the recording interval showed no difference between group 2 and group 3 (P = not significant [ns]).

CONCLUSIONS

(1) PLV does not significantly after PVR in the uninjured lung when given for 2 hours; (2) prophylactic administration of PLV prevents the sustained increase in PVR known to be induced by OA injury; (3) PLV abates OA-induced elevation in PVR when given therapeutically after injury; and (4) Prophylactic and therapeutic PLV have similar effects on PVR in the OA-injured lung.

The significance of children's age in estimating the effect of maternal time use on children's well-being

The women's initiative launched by the United Nations Decade for Women has sparked unresolved controversy over the consequences of mothers' increased participation in economically productive activities on children's well-being. Clearly, in many developing countries, poor mothers face stringent time constraints requiring trade-offs in time allocated to various activities, including child caregiving. However, the impact of these trade-offs on children's well-being remains unclear. The effect of maternal time use on children's nutrition and health status requires more rigorous examination. In particular, the role of children's age in this relationship is critical. Although children's requirement for maternal care varies with factors such as their age (a proxy for stage of psychobiological and sociocultural development), season of year and family size and structure, children's age has not been highlighted in the debate or in the relevant research. This paper documents children's age as a critical factor in the relationship between maternal patterns of time use and the well-being of children 18-30 months of age in peri-urban Egypt. It describes differences in maternal patterns of daily time use according to children's age and illustrates the differential associations between maternal daily activity patterns and children's well-being by children's age. Quantitative data collected on 161 mother-toddler pairs included information on maternal daily time allocation, children's dietary energy intake and diarrheal morbidity, maternal hemoglobin, and household and individual sociodemographics. Data were stratified by children's age at 24 months and were analyzed cross-sectionally using multiple linear and logistic regression. Results indicated that the age of two is critical in Kalama. At this age, toddlers begin to receive less time-intensive care freeing mothers for economic and self production. With respect to children's well-being prior to age two, frequency of feeding was positively related to their energy intake and more time spent in household sanitation activities reduced children's risk of diarrhea (during the diarrhea season). After two years of age, the maternal behaviors measured did not affect children's energy intake; however, children's diarrheal risk was reduced (during the diarrhea season) when mothers held them more and allocated more time to household sanitation year-round. We recommend that other investigators carefully examine the relationships between children's well-being according to developmentally-defined child age intervals and maternal patterns of time use. Results will help to resolve concern over the effect of maternal participation in economically productive activities on children's well-being.