Vein of Galen Aneurysmal Malformation: A Case Report

Vein of Galen aneurysmal malformation is a relatively rare disease in which failure of the median prosencephalic vein of Markowski to involute early in gestation leads to a grossly dilated deep cerebral vein with multiple arterial feeders, causing a large arteriovenous shunt which leads to high-output cardiac failure. We describe a case of a term neonate who presented to a tertiary neonatal centre on day one of life with history, symptoms, and signs consistent with perinatal asphyxia; however, in the context of worsening multi-organ dysfunction and cardiomegaly, the infant was found to have a severe vein of Galen aneurysmal dilatation leading to high-output cardiac failure. The patient was transferred to a tertiary paediatric hospital and underwent a total of four coiling procedures to embolise the multiple feeder arteries supplying the aneurysmal malformation. This case highlights the difficulties in diagnosing this relatively uncommon condition, particularly in the context of a possible perinatal insult.

Improved survival at the cost of more chronic lung disease? Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory: 2010-2020

BACKGROUND

Since 2010, most tertiary care hospitals in Australia have changed how they care for extremely premature infants. However, in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs, especially respiratory outcomes. This study examined the trend in outcomes since these changes were introduced, particularly the prevalence of chronic neonatal lung disease (CLD).

METHODS

This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units' (NICUS) database of all perinatal intensive care units in New South Wales and the Australian Capital Territory, including infants born at ≥ 24 and ≤ 28 weeks of gestational age in tertiary perinatal units between January 1, 2010, and December 31, 2020. Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models.

RESULTS

This study included 3258 infants. We saw significant changes in antenatal magnesium sulfate (75% increase), delayed cord clamping (66% increase), delivery room intubations (30% decrease), any time (20% decrease), duration on mechanical ventilation (100-hour decrease), and hours on noninvasive ventilation (200-hour increase). Mortality decreased from 17% to 6%. The incidence of CLD increased significantly even when adjusted for confounders (15% increase). Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD. This study could not find a significant association of any of the protective antenatal treatments on CLD.

CONCLUSIONS

The last decade saw a significant improvement in survival and survival to discharge without major morbidity. There was increased use of magnesium sulfate, delayed cord clamping, and less invasive respiratory management of extremely preterm infants. The avoidance of mechanical ventilation may impact the incidence of CLD.

Neurodevelopmental outcomes of extremely preterm infants with bronchopulmonary dysplasia (BPD) - A retrospective cohort study

OBJECTIVE

To investigate the neurodevelopmental outcomes for preterm infants born < 29 weeks gestation with/without bronchopulmonary dysplasia (BPD).

STUDY DESIGN

Preterm infants < 29 weeks' gestation born 2007-2018 in New South Wales and the Australian Capital Territory, Australia, were included. Infants who died < 36 weeks' postmenstrual age and those with major congenital anomalies were excluded. Subjects were assessed at 18-42 months corrected age using the Bayley Scales of Infant Development, 3rd edition.

RESULTS

1436 infants without BPD (non-BPD) and 1189 infants with BPD were followed. The BPD group, 69 % infants were discharged without respiratory support (BPD1), 29 % on oxygen (BPD2) and 2 % on pressure support/tracheostomy (BPD3). Moderate neurodevelopmental impairment (NDI) was evident in 5.7 % of non-BPD infants, 11 % BPD1, 15 % BPD2, 15 % BPD3 infants. Severe NDI was seen in 1.7 % non-BPD infants, 3.4 % BPD1, 7.3 % BPD2, 35 % BPD3 infants. After adjusting for confounders, infants with BPD2 (OR 2.24, 99.9 % CI 1.25 to 5.77) or BPD3 (OR 5.99, 99.9 % CI 1.27 to 46.77) were more likely to have moderate-severe NDI compared to non-BPD infants.

CONCLUSION

The majority of infants with BPD were discharged home without respiratory support and had better neurocognitive outcomes in early childhood compared to those that required home-based oxygen or respiratory support.

Strengthening Reporting of Neonatal Trials

BACKGROUND AND OBJECTIVES

There is variability in the selection and reporting of outcomes in neonatal trials with key information frequently omitted. This can impact applicability of trial findings to clinicians, families, and caregivers, and impair evidence synthesis. The Neonatal Core Outcomes Set describes outcomes agreed as clinically important that should be assessed in all neonatal trials, and Consolidated Standards of Reporting Trials (CONSORT)-Outcomes 2022 is a new, harmonized, evidence-based reporting guideline for trial outcomes. We reviewed published trials using CONSORT-Outcomes 2022 guidance to identify exemplars of neonatal core outcome reporting to strengthen description of outcomes in future trial publications.

METHODS

Neonatal trials including >100 participants per arm published between 2015 to 2020 with a primary outcome included in the Neonatal Core Outcome Set were identified. Primary outcome reporting was reviewed using CONSORT 2010 and CONSORT-Outcomes 2022 guidelines by assessors recruited from Cochrane Neonatal. Examples of clear and complete outcome reporting were identified with verbatim text extracted from trial reports.

RESULTS

Thirty-six trials were reviewed by 39 assessors. Examples of good reporting for CONSORT 2010 and CONSORT-Outcomes 2022 criteria were identified and subdivided into 3 outcome categories: "survival," "short-term neonatal complications," and "long-term developmental outcomes" depending on the core outcomes to which they relate. These examples are presented to strengthen future research reporting.

CONCLUSIONS

We have identified examples of good trial outcome reporting. These illustrate how important neonatal outcomes should be reported to meet the CONSORT 2010 and CONSORT-Outcomes 2022 guidelines. Emulating these examples will improve the transmission of information relating to outcomes and reduce associated research waste.

Examining the impact of premature birth on parental mental health and family functioning in the years following hospital discharge: A review

BACKGROUND

This review provides an update of the current research related to the impact of extreme and very premature birth on parental mental health and family functioning following discharge from hospital.

METHODS

Full-text peer reviewed articles in English, describing parents' and families' health and wellbeing after the discharge from hospital of their baby using validated questionnaires, were evaluated. Results of included studies are presented in a summarized format. Embase, Medline and PsycINFO databases were accessed in January 2021.

RESULTS

38 studies were included. Nine manuscripts reported on parental mental health and 13 on stress, which are a concern after the birth of a premature infant, especially in the first year. Depression, anxiety, and stress are known to measure higher compared to parents of infants born at term. Over several years, these measures of mental health decrease significantly. Four reported on quality of life for parents of premature infants, which is reduced immediately after discharge, but then improves over time. The impact of premature birth on the family functioning was described in ten included studies and was described to have positive and negative consequences.

CONCLUSION

The negative impact of the premature birth and hospital journey on parental mental health lessens significantly with time.

Individualized vancomycin dosing in infants: prospective evaluation of an online dose calculator

BACKGROUND

Empiric vancomycin dosing regimens fail to achieve recommended target trough concentrations of 10-20 mg/L in the majority of infants. This study assessed the performance of a model-based dosing calculator (Vanc App) in achieving target vancomycin concentrations at first steady-state level.

METHODS

This was a multicenter prospective study in four tertiary pediatric hospitals over an 18-month period. Infants aged 0-90 days with suspected Gram-positive sepsis requiring empiric vancomycin treatment were included if they did not meet any of the exclusion criteria: post-menstrual age (PMA) <25 weeks, weight <500 g, glycopeptide allergy, receiving extracorporeal membrane oxygenation, vancomycin use within the previous 72 h, and renal impairment. The Vanc App used a published population pharmacokinetic model to generate a dose based on the infant's PMA, weight, creatinine, and target vancomycin concentration.

RESULTS

A total of 40 infants were included; 40% were female, median (range) weight was 2505 (700-4460) g and median (range) PMA was 37.4 (25.7-49.0) weeks. The median (range) vancomycin dose was 45 (24-79) mg/kg/day. All infants had trough vancomycin concentrations measured at steady-state (24-<48 hours) and 30 (75%) infants achieved target concentrations. Five infants had supratherapeutic (median 25, range 21-38 mg/L) and five had subtherapeutic (median 6, range <5-9 mg/L) concentrations. An area under the concentration-time curve (AUC_0-24) of 400-650 mg/L.h was achieved in 33 (83%) infants. There were no infusion-related reactions or nephrotoxicity.

CONCLUSION

Individualized intermittent vancomycin dosing using a model-based online calculator resulted in 75% and 83% of infants achieving target trough and AUC_0-24, respectively, at first steady-state level. There were no vancomycin-related nephrotoxicity or infusion-related reactions.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

Infants With Congenital Heart Disease at Risk of Early Atherosclerotic Disease

Background

Aortic intima‐media thickness (aIMT) measurement is an established indicator of preclinical atherosclerosis. We aimed to describe the aIMT in infants with congenital heart disease undergoing cardiac surgery over the first year of life and explore its association with cardiopulmonary bypass, growth velocity, and a diagnosis of left heart obstruction.

Methods and Results

A prospective cohort study measuring mean and maximum aIMT preoperatively, at 3 months, and 1 year of age in neonates with congenital heart disease undergoing cardiac surgery. Twenty‐four infants with a median gestation of 39 weeks and a median birth weight of 3184 g were included. Sixteen (67%) infants had left outflow tract obstruction. Gestation correlated inversely with baseline mean aIMT (β=−0.027, P =0.018) and positively with the percentage of increase in mean and maximum aIMT between baseline and 3 months (β=17%, P =0.027 and β=15%, P =0.023). The presence of left outflow obstruction was significantly associated with increasing mean and maximum aIMT between baseline and 1 year (mean aIMT change: β=34%, P =0.017 and maximum aIMT change β=43%, P =0.001). Both subgroups of left heart obstruction and non‐left heart obstruction significantly changed over time ( P =0.001 and P <0.001) but trends were not statistically different between both subgroups ( P =0.21). Growth velocity and cardiopulmonary bypass were not associated with baseline or change in aIMT over the first year of life.

Conclusions

AIMT significantly increased over the first 3 months in our cohort of infants with repaired congenital heart disease. Increasing gestation was associated with decreasing aIMT at 3 months. Growth velocity and cardiopulmonary bypass were not associated with aIMT changes over the first year. Left heart obstruction was associated with a trend toward increased aIMT.

Implementation of the 'PicNic' handover huddle: A quality improvement project to improve the transition of infants between paediatric and neonatal intensive care units

AIMS

Thorough handover and effective communication are crucial to the transfer of clinical information between different intensive care units. Following a sentinel patient safety event, an improvement project was initiated to reduce patient safety risks associated with the transfer of complex patients between the neonatal and paediatric intensive care.

METHODS

A handover tool was implemented over a 4-month period, guiding handover through means of a handover huddle. The tool ensured a full ISBAR (Introduction, Situation, Background, Assessment, Response) handover, with a specified attendance register. It acknowledged specific safety points inclusive of outstanding investigations, procedural history and medication transcription. Post implementation, huddle checklist sheets were audited for compliance and a staff satisfaction survey was conducted.

RESULTS

Thirty-nine handovers took place during this trial period, of which 69% were captured in the huddle process. Senior medical and nursing staff attendance was greater than 95% throughout the process, and 100% of huddles attended to a full ISBAR handover. Sixty staff satisfaction survey responses were received, 90% of which identified the process to improve the safety of patient handover. Responses also identified safety issues such as discontinuity of medication transcription between the units, and inappropriate patient transfers occurring outside of working hours. Qualitative feedback highlighted how the tool improved interdepartmental educational and collaboration opportunities.

CONCLUSIONS

The 'PicNic' huddle effectively facilitated a standardised handover between paediatric and neonatal intensive care. It also recognised the importance of interdepartmental collaboration and education surrounding culturally different clinical practices. Further improvement cycles continue to progress the tool and initiate a digital format for ongoing use.

Neurodevelopmental outcomes in neonatal extracorporeal membrane oxygenation survivors: An institutional perspective

AIM

To describe the neurodevelopmental outcomes following extracorporeal membrane oxygenation (ECMO) in early infancy.

METHODS

Thirty-seven patients who had survived following ECMO support from 2008 to 2018 had their neurodevelopmental outcomes assessed and analysed using the Bayley Scales of Infant and Toddler Development. Developmental outcome was defined as impairment in any of the developmental domains of motor function, cognition and language with mild impairment being 1-2 standard deviations below the test mean, moderate being 2-3 standard deviations below and severe being greater than 3 standard deviations below.

RESULTS

Of these 37 patients, the median age at admission to Paediatric Intensive Care Unit was 0.4 months (interquartile range 2.8 months) with all of the study patients having an underlying diagnosis of congenital cardiac disease and 37/40 (92.5%) ECMO runs occurring in the immediate post-operative period. Of the 29 patients who had had follow-up at 12 months of age or older, 3 (10.3%) had severe impairment, 4 (13.8%) had moderate impairment, 12 (41.3%) had mild impairment and 10 (34.5%) had no impairment. Gross motor function was most significantly impacted in 18/29 (62.1%) patients, of which 7/18 (38.9%) had severe impairment. This was followed by impairment of receptive language in 8/29 (27.6%) patients and expressive language in 6/29 (20.1%) patients.

CONCLUSIONS

One in four infants undergoing ECMO treatment in early infancy has moderate to severe neurodevelopmental impairment. Gross motor and language are the most affected developmental domains.

Continuous local anaesthetic wound infusion of bupivacaine for postoperative analgesia in neonates: a randomised control trial (CANWIN Study)

OBJECTIVE

To determine the effect of continuous wound infusion of local anaesthetic drug (bupivacaine) on total amount of systemic opioid use in the first 72 hours in newborn infants undergoing laparotomy.

DESIGN

A two-arm parallel, open-label randomised controlled trial.

SETTING

A quaternary newborn intensive care unit.

PATIENTS

Infants>37 weeks of gestation undergoing laparotomy for congenital or acquired abdominal conditions.

INTERVENTIONS

Continuous wound infusion of local anaesthetic (bupivacaine) for the first 72 hours along with systemic opioid analgesia (catheter group) or only systemic opioid analgesia (opioid group).

MAIN OUTCOME

Total amount of systemic opioid used within the first 72 hours post laparotomy.

RESULTS

The study was underpowered as only 30 of the expected sample size of 70 infants were enrolled. 16 were randomised to catheter group and 14 to opioid group. The two groups were similar at baseline. There was no significant difference between the groups for the primary outcome of median total systemic opioid use in the first 72 hours post laparotomy (catheter 431.5 µg/kg vs opioid 771 µg/kg, difference -339.5 µg/kg, 90% CI_high 109, p value 0.28). There was no significant difference between the groups for any of the secondary outcomes including pain scores, duration of mechanical ventilation, time to reach full feeds and duration of hospital stay. There were no adverse events noted.

CONCLUSION

Continuous wound infusion of local anaesthetic along with systemic opioid analgesia is feasible. The lack of a difference in total systemic opioid use in the first 72 hours cannot be reliably interpreted as the study was underpowered.

TRIAL REGISTRATION NUMBER

ACTRN12610000633088.

Accuracy of bilirubin on the Siemens RAPIDPoint 500 blood gas analyser: A data mining study

AIM

Blood gas analysers which can measure bilirubin in whole blood are commonly available in neonatal intensive care units; however, the accuracy of these measurements is not well established. We sought to determine accuracy of whole blood bilirubin on the Siemens RAPIDPoint 500 blood gas analyser with reference to formal laboratory total serum bilirubin on the Ortho Vitros 5600.

METHODS

A method comparison of the bilirubin results from the blood gas analysers compared with the chemistry analysers was performed by data mining of results obtained as part of routine patient care. Results were included if patients underwent bilirubin testing by blood gas analyser and formal TSB, with both samples being collected within 20 min. Retrospective laboratory data was collected over a 28-month period, 1 January 2019 to 1 May 2021.

RESULTS

449 eligible sample pairs were included. A Bland-Altman plot was generated to identify systematic differences between the methods. A mean bias of -11 μmol/L was observed with 95% limits from -60 μmol/L to 38 μmol/L. Some blood gas bilirubin results were up to 70 μmol/L lower than formal TSB measurements around the clinically significant concentration range of 200 to 300 μmol/L.

CONCLUSION

Clinicians need to be aware of potential differences between the results from their blood gas analysers compared to formal TSB results. Sole reliance on blood gas bilirubin results which underestimate TSB may lead to under-recognition of neonatal jaundice that meets treatment thresholds. Formal measurement of TSB should be sought to inform decisions regarding treatment of neonatal jaundice.

Abdominal compartment syndrome monitoring in neonates with an acute abdomen - A pilot, retrospective, observational study

BACKGROUND

Abdominal compartment syndrome (ACS) is a pathological increase of the intra-abdominal pressure (IAP) with dysfunction of one or more organs. There is lack of clarity in neonates regarding what intravesical pressure (IVP) value, a surrogate marker for IAP, indicates the need for intervention for ACS.

METHODS

The medical records at a Children's Hospital NICU were reviewed to identify all neonates that had IVP/s monitored over a 10-year period (2008-2017). Demographic parameters, IVPs, and important clinical outcomes were obtained. Associations between IVP monitoring and clinical outcomes were explored.

RESULTS

Forty-six neonates had IVP monitoring, with 4 (8%) being diagnosed with ACS requiring further operative intervention. There was no significant correlation between IVP and need for surgery. There was a significant positive correlation between the maximum IVP and the need for total parenteral nutrition (rs = 0.350, p = 0.017), ventilator support (rs = 0.321, p = 0.034) and length of stay (rs = 0.362, p = 0.016) and between a diagnosis of ACS and neonatal mortality (rs = 0.299, p = 0.044).

CONCLUSIONS

IVP monitoring and raised IVP did not correlate with the need for surgical intervention. Raised IVP was associated with neonatal morbidity and maybe neonatal mortality. A large, prospective, observational study is required to evaluate the role of IVP monitoring in ACS and its associated outcomes.

LEVEL OF EVIDENCE

III.

Ophthalmic findings in neonates receiving sildenafil

AIM

To determine the risk of ocular complications of sildenafil therapy in neonates.

METHODS

Retrospective case review of neonates with persistent pulmonary hypertension of the newborn who received sildenafil therapy between 2010 and 2015 in a single, tertiary surgical neonatal intensive care unit in Australia. Ophthalmic examination findings in the neonatal intensive care unit and follow-up were examined.

RESULTS

Twenty-seven neonates with persistent pulmonary hypertension of the newborn received sildenafil. The median gestational age (GA) was 38 weeks (range 24-41 weeks), and median birthweight was 2690 g (range 454-4270 g). Ophthalmic review was undertaken in 23 neonates, and 16 neonates were term or near-term infants (GA 31-40 weeks). All of them had a normal initial ophthalmic examination; one child was later diagnosed with hypermetropia and another with infantile esotropia. Amongst the seven premature infants (GA 24-30 weeks), three had retinopathy of prematurity (ROP) diagnosed at the first ophthalmic review and the other four had normal initial examinations. Two patients later developed ROP, one of whom was also diagnosed with congenital motor nystagmus. All five patients diagnosed with ROP were extremely preterm (<28 weeks) with low birthweight (454-635 g).

CONCLUSIONS

There were no short-term complications attributable to sildenafil therapy identified in term or near-term neonates (GA ≥31 weeks). This cohort of neonates does not typically undergo ophthalmic review as part of the ROP screening protocol in our institution. Routine ophthalmic review of neonates on sildenafil therapy, who are not at risk of ROP, is therefore unlikely to be warranted. Further research is required to clarify the relationship between sildenafil and ROP.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy

PURPOSE OF REVIEW

Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.

RECENT FINDINGS

Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

A Dramatic Response to Sirolimus Therapy in a Premature Infant With Massive Cardiac Rhabdomyoma

Cardiac rhabdomyomas in neonates may cause significant cardiac risk. Recently, sirolimus has been used to treat these lesions. The dose, duration, and monitoring for therapy are unknown. A case of sirolimus use in a premature neonate is presented. No significant adverse effects were seen. Review of published cases is included. (Level of Difficulty: Advanced.)

Effect of Delayed Cord Clamping on Cerebral Oxygenation in Very Preterm Infants

BACKGROUND AND OBJECTIVE

The mechanism of reported benefits of delayed cord clamping (DCC) are unclear. We aimed to determine whether DCC compared to immediate cord clamping (ICC) in very preterm infants improves cerebral oxygenation in the first 24 h.

STUDY DESIGN

This is a prospective study of a subset of infants at < 30 weeks of gestation who were randomised to DCC (≥60 s) or ICC (< 10 s) and required an indwelling arterial catheter. Regional cerebral oxygenation (rScO2), blood pressure, PI, and peripheral saturation were measured and cerebral fractional tissue oxygen extraction (cFTOE) calculated for the following 3 time intervals: 3-6, 6-12, and 12-28 h of age. Functional ultrasound measures including superior vena cava flow, right ventricular output, ductus arteriosus size and shunt and anterior cerebral artery resistive index were determined.

RESULTS

The mean (±SD) gestation and birth weight of the 51 study infants were 27 ± 1 weeks and 1,046 ± 241 g respectively. Twenty infants received DCC and 31 received ICC. Baseline demographics were similar between the 2 groups. Comparing DCC and ICC infants, there was no difference in rScO2 or cFTOE at any time point. Three out of 20 infants did not receive DCC due to clinical concerns. A sensitivity analysis revealed that cord clamping ≥30 s was significantly associated with increased rScO2 and decreased cFTOE at all 3 time points after adjusting for gestation.

CONCLUSION

Although DCC was not associated with changes in cerebral oxygenation overall, sensitivity analysis suggested a possible effect of an increased rScO2 and a decreased cFTOE with ≥30 s of DCC.

Interobserver agreement and image quality of functional cardiac ultrasound measures used in a randomised trial of delayed cord clamping in preterm infants

OBJECTIVE

Functional cardiac ultrasound measures are used clinically and in trials for assessing the haemodynamic status of newborn infants. Superior vena cava (SVC) flow and right ventricular output (RVO) are established measures of systemic blood flow on the first postnatal day. The objective was to assess image quality and interobserver agreement of these measures in preterm infants enrolled in a randomised trial of immediate versus delayed cord clamping.

DESIGN AND SETTING

Image quality and interobserver agreement for SVC flow, RVO and ductus arteriosus (DA) size were assessed on measurements taken at 3-6, 6-12 and 20-28 hours for the first 10 infants enrolled at each of four sites (total 40). Bland-Altman plots were constructed; mean difference (bias) and limits of agreement (LOA) were calculated. Potential sources of variation were explored.

RESULTS

Quality was judged satisfactory for >97% of images. The mean difference and LOA between the observers were 5.4 mL/kg/min and -49.0 to 59.8 mL/kg/min for SVC flow, -26.6 mL/kg/min and -131.4 to 78.2 mL/kg/min for RVO, and 0 mm and -0.8 to 0.8 mm for DA diameter, respectively. The principal source of measurement error for SVC flow was diameter, and for RVO, diameter and velocity time integral. The difference between observers for both SVC and RVO was significantly associated with site.

CONCLUSION

Interobserver variability for SVC flow is consistent with that previously reported, but higher for RVO. The findings should be incorporated into clinical practice, training, accreditation and trial design.

Management of orthodontic emergencies in primary care - self-reported confidence of general dental practitioners

Objective To determine general dental practitioners' (GDPs) confidence in managing orthodontic emergencies.Design Cross-sectional study.Setting Primary dental care.Subjects and methods An online survey was distributed to dentists practicing in Wales. The survey collected basic demographic information and included descriptions of ten common orthodontic emergency scenarios.Main outcome measure Respondents' self-reported confidence in managing the orthodontic emergency scenarios on a 5-point Likert scale. Differences between the Likert responses and the demographic variables were investigated using chi-squared tests.Results The median number of orthodontic emergencies encountered by respondents over the previous six months was 1. Overall, the self-reported confidence of respondents was high with 7 of the 10 scenarios presented scoring a median of 4 indicating that GDPs were 'confident' in their management. Statistical analysis revealed that GDPs who saw more orthodontic emergencies in the previous six months were more confident when managing the presented scenarios. Other variables such as age, gender, geographic location of practice and number of years practising dentistry were not associated with self-reported confidence.Conclusions Despite GDPs encountering very few orthodontic emergencies in primary care, they appear to be confident in dealing with commonly arising orthodontic emergency situations.

Delayed versus Immediate Cord Clamping in Preterm Infants

BACKGROUND

The preferred timing of umbilical-cord clamping in preterm infants is unclear.

METHODS

We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births.

RESULTS

Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P=0.96). The mortality was 6.4% in the delayed-clamping group and 9.0% in the immediate-clamping group (P=0.03 in unadjusted analyses; P=0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities.

CONCLUSIONS

Among preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping. (Funded by the Australian National Health and Medical Research Council [NHMRC] and the NHMRC Clinical Trials Centre; APTS Australian and New Zealand Clinical Trials Registry number, ACTRN12610000633088 .).

Unilateral vocal cord paralysis after surgical closure of a patent ductus arteriosus in extremely preterm infants

AIM

Left vocal cord paralysis (LVCP) is variably reported post ligation of patent ductus arteriosus (PDA). Our objective was to determine the incidence of LVCP and identify predictive factors and associated morbidities in preterm infants post PDA ligation.

METHODS

This is a retrospective cohort study of infants less than 29 weeks gestational age from 2006 to 2014 who underwent PDA ligation. Infants with laryngeal symptoms underwent flexible fibreoptic nasopharyngolaryngoscopy to evaluate vocal cord function. We compared short- and long-term morbidities among infants with and without symptomatic LVCP.

RESULTS

A total of 35 infants underwent PDA ligation in the study period, of which 11 infants (31%) developed symptomatic LVCP. Dysphonia was the presenting symptom in all neonates with LVCP and stridor was present in 46% (5/11) of them. The median (interquartile range) gestation (25 weeks (24-27) vs. 25 weeks (23-28)), birthweight (810 g (550-1180) vs. 825 g (550-1220)) and age at surgery (19 days (9-27) vs. 20 (5-69)) were similar in infants with and without LVCP, respectively. Infants with LVCP took significantly longer to reach suck feeds (128 vs. 90 days, P = <0.001), stayed longer in hospital (119 vs. 95 days, P = 0.01) and were more likely to go home on oxygen (73 vs. 27%; P = 0.024). Neurodevelopmental outcomes were similar in the two groups.

CONCLUSIONS

LVCP was noted in 31% of infants post PDA ligation and was associated with prolonged hospital stay, a longer time to reach suck feeds and a need for home oxygen. No predictive factors for development of LVCP were identified.

A survey of undergraduate orthodontic teaching and factors affecting pursuit of postgraduate training

Background Undergraduate orthodontic teaching has been focused on developing an understanding of occlusal development in an effort to equip practitioners to make appropriate referrals for specialist-delivered care. However, there is a growing interest among general dentists in delivering more specialised treatments, including short-term orthodontic alignment. This study aimed to assess the levels of knowledge of occlusal problems among final year undergraduate dental students, as well as their interest in various orthodontics techniques and training.Methods A 36-item electronic questionnaire was sent to all final year undergraduate students in four dental institutes in the UK (Barts and the London, Kings College London, Cardiff and Dundee). The questionnaire explored satisfaction with undergraduate orthodontic teaching; students' perception of knowledge, based on General Dental Council learning outcomes; perceptions of the need for specialist involvement in the management of dental problems; interest in further training in orthodontics; and potential barriers to undertaking specialist training.Results The overall response rate was 66% (239/362). The majority of students (84.1%) were aware of GDC guidance in terms of undergraduate teaching. Students reported a preference for case-based and practical teaching sessions in orthodontics, with less interest in lectures or problem-based learning approaches. A high percentage were interested in further teaching in interceptive orthodontics (60.3%) and fixed appliance therapy (55.7%). Further training including specialist orthodontic training (36.4%), Invisalign (59%) and Six Month Smiles (41%) courses appealed to undergraduates. Levels of student debt, course fees and geographical issues were seen as potential barriers to formal, specialist training pathways.Conclusions Satisfaction with undergraduate orthodontic teaching is high and interest in further training, including specialist training pathways, continues to be high. While short-term orthodontics is not taught at undergraduate level, there appears to be an appetite to undertake alternatives to conventional orthodontics among dental students.

Dental students' experiences of treating orthodontic emergencies - a qualitative assessment of student reflections

INTRODUCTION

Professional regulatory bodies in the UK and Europe state that dental graduates should be able to manage orthodontic emergency patients. Therefore, the aim of this study was to explore dental student experiences of treating orthodontic emergencies within a teaching institution.

MATERIALS AND METHOD

This study was designed as a single-centre evaluation of teaching based in a UK university orthodontic department. The participants were fourth-year dental students who treated orthodontic emergency patients under clinical supervision as part of the undergraduate curriculum. Student logbook entries for one academic year detailing the types of emergencies treated and structured, reflective commentaries for each procedure were analysed using thematic analysis methods. The total numbers and types of orthodontic emergencies treated by students were presented. Overall, self-reported student confidence in managing orthodontic emergencies was calculated. Themes, which represented student reflections, were identified.

RESULTS

Seventy-two students participated in the study. Overall, 69% of students stated they were confident in managing orthodontic emergencies. Students treated a range of emergencies, of which the most frequent was debonded brackets (38%). Reflections from student commentaries were housed under a primary theme of building procedural confidence. Three subthemes were identified: (i) theory-practice integration; (ii) expanding clinical experience; and (iii) importance of a supportive clinical learning environment.

CONCLUSION

The majority of dental students were confident in managing orthodontic emergencies. Theoretical knowledge supplemented by exposure to a range of clinical problems within a supported learning environment made students feel more confident.

Multilevel principal component analysis (mPCA) in shape analysis: A feasibility study in medical and dental imaging

BACKGROUND AND OBJECTIVE

Methods used in image processing should reflect any multilevel structures inherent in the image dataset or they run the risk of functioning inadequately. We wish to test the feasibility of multilevel principal components analysis (PCA) to build active shape models (ASMs) for cases relevant to medical and dental imaging.

METHODS

Multilevel PCA was used to carry out model fitting to sets of landmark points and it was compared to the results of "standard" (single-level) PCA. Proof of principle was tested by applying mPCA to model basic peri-oral expressions (happy, neutral, sad) approximated to the junction between the mouth/lips. Monte Carlo simulations were used to create this data which allowed exploration of practical implementation issues such as the number of landmark points, number of images, and number of groups (i.e., "expressions" for this example). To further test the robustness of the method, mPCA was subsequently applied to a dental imaging dataset utilising landmark points (placed by different clinicians) along the boundary of mandibular cortical bone in panoramic radiographs of the face.

RESULTS

Changes of expression that varied between groups were modelled correctly at one level of the model and changes in lip width that varied within groups at another for the Monte Carlo dataset. Extreme cases in the test dataset were modelled adequately by mPCA but not by standard PCA. Similarly, variations in the shape of the cortical bone were modelled by one level of mPCA and variations between the experts at another for the panoramic radiographs dataset. Results for mPCA were found to be comparable to those of standard PCA for point-to-point errors via miss-one-out testing for this dataset. These errors reduce with increasing number of eigenvectors/values retained, as expected.

CONCLUSIONS

We have shown that mPCA can be used in shape models for dental and medical image processing. mPCA was found to provide more control and flexibility when compared to standard "single-level" PCA. Specifically, mPCA is preferable to "standard" PCA when multiple levels occur naturally in the dataset.

Determining normal and abnormal lip shapes at border positions for use as a longitudinal surgical outcome measure

Objective measures of facial movement are important for interventions where surgical repositioning of facial structures can influence soft tissue mobility and include the management of patients with cleft lip, facial nerve palsy and orthognathic surgery. As such, the aim of this study is to present a method for determining the outcome of surgical procedures on lip shape during speech. A control group (CG) of 115 average subjects and 30 patients with a Class 3 malocclusion requiring bimaxillary surgery performed four reproducible verbal utterances during image capture using a non-invasive, three-dimensional (3D) motion scanner (3dMDFace™ Dynamic System). Landmark coordinates around the lips of the 3D facial shells were extracted and subjected to discriminant analysis and principal component analysis to statistically differentiate lip shapes between the CG and the patient group (PG) pre- and post-surgery. Pre-surgically, the PG showed statistically significant differences in lip shape during speech in the lateral and vertical dimensions, preferring a wider, shorter lip shape when compared with the CG for all the utterances. The shape differences normalised towards the CG post-surgery. The method presented utilises pre-existing statistical shape analyses and can be reproduced in the clinical setting to provide a diagnostic and functional outcome tool. In this example, correction of the Class 3 skeletal disproportions appeared to normalise lip shape during speech.

Noninvasive assessment of the early transitional circulation in healthy term infants

BACKGROUND

The early neonatal circulatory transition usually occurs smoothly but occasionally it is incomplete or reverts to the fetal state of high pulmonary vascular resistance, resulting in significant neonatal morbidity.

OBJECTIVE

To define the normal values for echocardiographic parameters during the early transitional circulation in term infants.

METHODS

Two-dimensional, M-mode, pulsed and color flow Doppler echocardiography was used to assess healthy term infants in the first 4 h of life. Left and right ventricular outputs (LVO and RVO) and myocardial performance indices (MPI), left ventricular fractional shortening, end-systolic diameter and end-diastolic diameter, ductal size, shunt and peak velocities, tricuspid regurgitation and left pulmonary artery diastolic velocities were documented.

RESULTS

A total of 21 normal term infants were assessed with median gestation of 39 weeks, birth weight of 3,470 g and postnatal age of 3 h and 22 min. The median echocardiographic values were LVO 193 ml/kg/min, RVO 216 ml/kg/min, left MPI 0.41, right MPI 0.63, and fractional shortening 29%. The ductus was patent in all 21 infants with a median size of 2.3 mm; ductal flow was bidirectional in 86% with median peak left-to-right velocity of 1.07 m/s. The median left pulmonary artery diastolic velocity was 0.31 m/s and physiological tricuspid regurgitation was present in all infants.

CONCLUSION

This study defines normal values for echocardiographic measurements in healthy term infants during the first 4 h after birth. These normative data may be useful in early identification of infants with abnormal circulatory transition, allowing more rapid determination of cardiovascular dysfunction.

Improving cross-cultural awareness. A review of Australian indigenous health for UK dentists

OBJECTIVE

The aim of this paper is to give an insight into the unique health issues faced by the indigenous population of Australia and their direct relationship to oral health, to help overseas dentists wishing to work in Australia to treat these groups of patients successfully and effectively. This applies equally to indigenous Australians living in remote Australia as well as to those living in general suburbia.

DATA SOURCES

A Medline search was carried out for any articles in dental and medical journals pertaining to Australian indigenous health and Australian oral health.

DATA SELECTION

Wherever possible, articles cited were obtained in full and where this was not possible, abstracts were obtained. Where no abstract was available, the article was not considered for evaluation.

DATA EXTRACTION

Articles were reviewed by a single observer and were subject to meeting inclusion criteria indicated in the review.

DATA SYNTHESIS

Articles were divided into historical, diet, oral health and general health categories. Subjective descriptions were then made.

CONCLUSIONS

The adoption of a 'westernised' diet by the Australian indigenous community has placed them as a high risk population for dental caries and periodontal disease. They also show some of the highest rates in the world for Non-Insulin Dependent Diabetes Mellitus (NIDDM) and Rheumatic Fever. The UK dentist should be aware of these health issues and their relationship to indigenous oral health before embarking on work within Australia.

Blindness following retrobulbar haemorrhage--it can be prevented

Delay in diagnosis and treatment of an elderly woman with a malar fracture that caused retrobulbar haemorrhage resulted in complete loss of vision in the right eye.