Outcomes up to age 36 months after congenital Zika virus infection-U.S. states

BACKGROUND

To characterize neurodevelopmental abnormalities in children up to 36 months of age with congenital Zika virus exposure.

METHODS

From the U.S. Zika Pregnancy and Infant Registry, a national surveillance system to monitor pregnancies with laboratory evidence of Zika virus infection, pregnancy outcomes and presence of Zika associated birth defects (ZBD) were reported among infants with available information. Neurologic sequelae and developmental delay were reported among children with ≥1 follow-up exam after 14 days of age or with ≥1 visit with development reported, respectively.

RESULTS

Among 2248 infants, 10.1% were born preterm, and 10.5% were small-for-gestational age. Overall, 122 (5.4%) had any ZBD; 91.8% of infants had brain abnormalities or microcephaly, 23.0% had eye abnormalities, and 14.8% had both. Of 1881 children ≥1 follow-up exam reported, neurologic sequelae were more common among children with ZBD (44.6%) vs. without ZBD (1.5%). Of children with ≥1 visit with development reported, 46.8% (51/109) of children with ZBD and 7.4% (129/1739) of children without ZBD had confirmed or possible developmental delay.

CONCLUSION

Understanding the prevalence of developmental delays and healthcare needs of children with congenital Zika virus exposure can inform health systems and planning to ensure services are available for affected families.

IMPACT

We characterize pregnancy and infant outcomes and describe neurodevelopmental abnormalities up to 36 months of age by presence of Zika associated birth defects (ZBD). Neurologic sequelae and developmental delays were common among children with ZBD. Children with ZBD had increased frequency of neurologic sequelae and developmental delay compared to children without ZBD. Longitudinal follow-up of infants with Zika virus exposure in utero is important to characterize neurodevelopmental delay not apparent in early infancy, but logistically challenging in surveillance models.

Association of Provider Recommendation and Receipt of Influenza Vaccine Among Pregnant Women by Race and Ethnicity

Background: All pregnant women and those who may become pregnant are recommended by the Advisory Committee on Immunization Practices to receive the flu vaccine to prevent severe illness in the woman and infant. Despite the increased risk for complications in this population, flu vaccine uptake in pregnant women was 68.1% in the 2020-2021 flu season, with disparities by race and ethnicity. We sought to describe associations between provider recommendation with flu vaccine uptake by race and ethnicity in Tennessee women with a recent live birth. Materials and Methods: Weighted analysis used data from the 2016 to 2020 Tennessee Pregnancy Risk Assessment Monitoring System complex survey analysis procedures. Uptake was measured as receipt of flu vaccine in the 12 months before the most recent live birth, and positive recall of receiving provider advice to get the shot was the independent variable; for both we estimated 5-year averages stratified by race/ethnicity. Differences were assessed using chi-square tests. We modeled receipt of flu vaccine and estimated marginal predicted prevalence ratios (PRs); stratified models by race/ethnicity were constructed to estimate unadjusted and adjusted PRs. Results: The 5-year average for vaccine uptake before or during pregnancy was 56.7% but varied by race and ethnicity. Stratified bivariate analyses yielded different magnitudes of association by race/ethnicity between provider recommendation and flu vaccine receipt. After adjustment for payment source at delivery, marital status, age group, urbanicity, and maternal education, receiving a provider recommendation was strongly associated with flu vaccine uptake for all stratified models of pregnant women included in the study. The effect size was of a larger magnitude among non-Hispanic Black women, a population with a lower vaccine uptake. Conclusions: Given the association between provider recommendation and vaccine uptake in all groups, attention should be focused on increasing rates of provider recommendation.

Association of Preterm Birth Rate With COVID-19 Statewide Stay-at-Home Orders in Tennessee

This cohort study analyzes preterm birth rates during statewide stay-at-home orders in Tennessee during the coronavirus disease 2019 (COVID-19) pandemic.

Improving Safe Sleep Modeling in the Hospital through Policy Implementation

Introduction Sleep-related infant deaths are major contributors to Tennessee's high infant mortality rate. The purpose of this initiative was to evaluate the impact of policy-based efforts to improve modeling of safe sleep practices by health care providers in hospital settings across Tennessee. Methods Safe sleep policies were developed and implemented at 71 hospitals in Tennessee. Policies, at minimum, were required to address staff training on the American Academy of Pediatrics' safe sleep recommendations, correct modeling of infant safe sleep practices, and parent education. Hospital data on process measures related to training and results of crib audits were compiled for analysis. Results The overall observance of infants who were found with any risk factors for unsafe sleep decreased 45.6% (p ≤ 0.001) from the first crib audit to the last crib audit. Significant decreases were noted for specific risk factors, including infants found asleep not on their back, with a toy or object in the crib, and not sleeping in a crib. Significant improvements were observed at hospitals where printed materials or video were utilized for training staff compared to face-to-face training. Discussion Statewide implementation of the hospital policy intervention resulted in significant reductions in infants found in unsafe sleep situations. The most common risk factors for sleep-related infant deaths can be modeled in hospitals. This effort has the potential to reduce sleep-related infant deaths and ultimately infant mortality.

Patients' willingness to allow residents to learn to practice medical procedures

PURPOSE

Consent for teaching procedures has been the focus of ethical discussion recently. Patients may consent to a procedure but be unaware that the procedure is to be performed by a resident, perhaps for the first time. In such cases, patients have not specifically consented to the practice of teaching medical procedures. The authors studied patients' awareness of resident training and willingness to allow residents to perform procedures on them.

METHOD

A survey was administered to a convenience sample of 202 Vanderbilt University Medical Center emergency department patients from February to April 2000. Three procedures (intubation, lumbar puncture, and sutures) were demonstrated. Patients were asked about their awareness of residents' training and willingness to allow a resident to perform the procedures for the first time versus the tenth time.

RESULTS

In all, 60% of patients did not realize they could be the first person a resident performs a procedure on. Only 49% of the patients were completely comfortable being the first patient for sutures, 29% for intubation, and 15% for a lumbar puncture. Most patients felt they should be informed if it was the resident's first time performing procedures (66% for sutures, 69% for intubation, and 82% for lumbar puncture).

CONCLUSION

Not only do the majority of patients not know that they might be the first patient on whom a resident performs a procedure, more than two thirds believed they should be told if they are the first patient. Particularly for intubation and lumbar puncture, patients indicated that they would be uncomfortable being the first patient on whom these procedures were performed. These data raise ethical questions regarding physicians' obligations to inform patients about resident-performed procedures.

Living anonymous kidney donation: what does the public think?

BACKGROUND

Health professionals are increasingly turning to living organ donation to augment cadaveric donation. Although living donation is currently performed with donors who are either genetically or emotionally related to the recipient, a 1997 British Columbia Transplant Society survey indicated that 32% of BC residents would be willing to donate a kidney, while alive, to a stranger (unpublished data). The goal of this study is to tap the public pulse about the living anonymous donor (LAD) by replicating and expanding the 1997 findings.

METHODS

Five hundred BC residents completed a telephone survey including demographic information, questions about their organ donation behaviors and attitudes, and their willingness to donate a kidney, while alive, to particular individuals (child, spouse, parent, relative, friend, and stranger). To improve the methodological rigor of the 1997 study, an informed condition was added in the current study where participants learned about living donation before being asked about their willingness to donate.

RESULTS

There were no differences among the 1997 results and the two conditions in the 2000 survey. Twenty-eight percent of participants in the uninformed condition and 29% of participants in the informed condition indicated that they would be willing to be LADs. LADs were more likely than self-reported non-donors to have registered as cadaveric donors and to endorse attitudes that were congruent with wanting to donate to a stranger.

CONCLUSIONS

This study replicates the 1997 findings and increases confidence that a significant minority of British Columbians support living anonymous donation and that some would consider becoming LADs themselves.

Predictors of bile leaks after T-tube removal in orthotopic liver transplant recipients

Bile leaks after T-tube removal are a frequent cause of morbidity in orthotopic liver transplant recipients. The aim of this study was to determine factors that predict the development of these leaks in liver transplant recipients. Records of all patients who had undergone liver transplantation at the University of Washington Medical Center between January 1990 and September 1993 were reviewed. The following were excluded: patients with a Roux-en-Y anastomosis or inadvertent early T-tube removal and patients who died or underwent retransplantation before T-tube removal. All T-tube cholangiograms were reviewed blindly by two authors. Using logistic regression, several variables were assessed for possible association with bile leaks after T-tube removal; these included patient demographics, intraoperative variables, and clinical and cholangiographic variables related to T-tube removal. Of the 166 liver transplants performed in 150 patients, 99 transplants in 97 patients were evaluable for bile leak after T-tube removal. Thirty-three patients developed symptomatic bile leaks, and 21 underwent endoscopic or operative intervention for persistent symptoms. Only duct mural irregularities on the final cholangiogram were strongly associated with the development of a bile leak after T-tube removal (P = 0.001). In conclusion, bile leaks after T-tube removal occurred in one-third of patients undergoing orthotopic liver transplantation; the majority of these patients required some intervention. Duct mural irregularities were associated with bile leaks.

Bleeding from gastric antral vascular ectasia in marrow transplant patients

BACKGROUND

Gastric antral vascular ectasia (GAVE) leads to blood loss in the disorders of "watermelon stomach" and portal gastropathy, but is not a commonly recognized complication of marrow transplantation.

METHODS

GAVE was diagnosed when capillary ectasia, focal capillary thromboses, and fibromuscular hyperplasia were identified in antral mucosal biopsy specimens. Marrow transplant patients bleeding from GAVE were reviewed to ascertain common variables in their pretransplant, posttransplant, and bleeding course.

RESULTS

Six patients developed bleeding due to GAVE. The onset of bleeding was 18 to 94 days after transplant and required an average of 37 U of blood (range, 2 to 130 U). Two patients stopped bleeding after restoration of platelet counts. Two patients had surgical antral resections; both died of multiorgan failure after surgery. Two patients had successful endoscopic laser ablation of vascular lesions and survived. Factors possibly associated with GAVE included male gender, VOD of the liver, oral busulfan as part of the conditioning regimen, and growth factor use after transplant.

CONCLUSIONS

GAVE was a cause of gastric bleeding in six patients with marrow transplant patients. Restoration of platelet counts and endoscopic laser photocoagulation are the therapies of choice for ongoing bleeding in these patients.

A randomized, double-blind, placebo-controlled trial of ursodeoxycholic acid in primary biliary cirrhosis

One hundred fifty-one patients with primary biliary cirrhosis (PBC) grouped into four strata based on entry serum bilirubin ( < 2 mg/dL vs. 2 md/dL or greater) and liver histology (stages I, II vs. stages III, IV-Ludwig criteria) were randomized within each stratum to ursodiol or placebo given in a single dose of 10 to 12 mg/kg at bedtime for 2 years. Placebo- (n = 74) and ursodiol- treated (n = 77) patients were well matched at baseline for demographic and prognostic factors. Ursodiol induced major improvements in biochemical tests of the liver in strata 1 and 2 (entry bilirubin < 2), but had less effect on laboratory tests in patients with entry serum bilirubin of > or +2 (strata 3 and 4). Histology was favorably affected by ursodiol in patients in strata 1 and 2 but not in strata 3 and 4. Ursodiol enrichment in fasting bile obtained at the conclusion of the trail was approximately 40% and comparable in all strata. Thus, differences in ursodiol enrichment of the bile acid pool do not explain better responses of laboratory tests and histology found in patients with less advanced PBC. Patients treated will ursodiol tended to develop a treatment failure less frequently that those who received placebo, particularly in strata 1 and 2 (ursodiol 42%, placebo 60%, P = .078). Development of severe symptoms (fatigue/pruritus) and doubling of serum bilirubin were reduced significantly in ursodiol-treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of season and testosterone treatment on gonadotrophin secretion and pituitary responsiveness to gonadotrophin-releasing hormone in castrated Romney and Poll Dorset rams

In castrated rams (Romney and Poll Dorset, n = 8 for each breed), inhibition by testosterone treatment (administered via Silastic capsules) of luteinizing hormone (LH) pulse frequency, basal and mean LH concentrations, mean follicle-stimulating hormone (FSH) concentration, and the peak and total LH responses to exogenous gonadotrophin-releasing hormone (GnRH) were significantly (P less than 0.01) greater during the nonbreeding than during the breeding season. Poll Dorset rams were less sensitive to testosterone treatment than Romney rams. In rams not receiving testosterone treatment, LH pulse frequency was significantly (P less than 0.05) lower during the nonbreeding season than during the breeding season in the Romneys (15.8 +/- 0.9 versus 12.0 +/- 0.4 pulses in 8 h), but not in the Poll Dorsets (13.6 +/- 1.2 versus 12.8 +/- 0.8 pulses in 8 h). It is concluded that, in rams, season influences gonadotrophin secretion through a steroid-independent effect (directly on hypothalamic GnRH secretion) and a steroid-dependent effect (indirectly on the sensitivity of the hypothalamo-pituitary axis to the negative feedback of testosterone). The magnitude of these effects appears to be related to the seasonality of the breed.

Cytogenetical analysis of an ovine male pseudohermaphrodite and the possible role of the Y chromosome in cryptorchidism of sheep

A previously unreported type of male pseudohermaphrodite sheep is described. The animal had XY sex chromosomes in all tissues studied and was chromatin negative. It had female external genitalia and undescended testicular gonads, with an histology distinct from that of previously reported sheep intersexes. Its origin could not be explained on the same basis as the more commonly reported female (XX) intersexes seen in man and other domestic animals. Comparison, however, of this sheep with the ovine cryptorchid suggests that the germ-cell aplasia seen in the latter is genetically determined and due to a possible gene locus or loci deletion of the Y chromosome.