Isoniazid urine spectrophotometry for prediction of serum pharmacokinetics in adults with TB

BACKGROUND

Isoniazid (INH) is an important drug in many TB regimens, and unfavorable treatment outcomes can be caused by suboptimal pharmacokinetics. Dose adjustment can be personalized by measuring peak serum concentrations; however, the process involves cold-chain preservation and laboratory techniques such as liquid chromatography (LC)/mass spectrometry (MS), which are unavailable in many high-burden settings. Urine spectrophotometry could provide a low-cost alternative with simple sampling and quantification methods.

METHODS

We enrolled 56 adult patients on treatment for active TB. Serum was collected at 0, 1, 2, 4, 6, and 8 h for measurement of INH concentrations using validated LC-MS/MS methods. Urine was collected at 0-4, 4-8, and 8-24 h intervals, with INH concentrations measured using colorimetric methods.

RESULTS

The median peak serum concentration and total serum exposure over 24 h were 4.8 mg/L and 16.4 mg*hour/L, respectively. Area under the receiver operator characteristic curves for urine values predicting a subtherapeutic serum concentration (peak <3.0 mg/L) were as follows: 0-4 h interval (AUC 0.85, 95% CI 0.7-0.96), 0-8 h interval (AUC 0.85, 95% CI 0.71-0.96), and 0-24 h urine collection interval (AUC 0.84, 95% CI 0.68-0.96).

CONCLUSION

Urine spectrophotometry may improve feasibility of personalized dosing in high TB burden regions but requires further study of target attainment following dose adjustment based on a urine threshold.

Development and Validation of a UPLC-MS/MS Method for Therapeutic Drug Monitoring, Pharmacokinetic and Stability Studies of First-Line Antituberculosis Drugs in Urine

Tuberculosis (TB) remains one of the leading global causes of mortality. Several methods have been established to detect anti-TB agents in human plasma and serum. However, there is a notable absence of studies analyzing TB drugs in urine. Thus, our objective was to validate a method for quantifying first-line anti-TB agents: isoniazid (INH), pyrazinamide (PZA), ethambutol (ETH), and rifampicin (RIF), along with its metabolite 25-desacetylrifampicin, and degradation products: rifampicin quinone and 3-formyl-rifampicin in 10 µL of urine. Chromatographic separation was achieved using a Kinetex Polar C18 analytical column with gradient elution (5 mM ammonium acetate and acetonitrile with 0.1% formic acid). Mass spectrometry detection was carried out using a triple-quadrupole tandem mass spectrometer operating in positive ion mode. The lower limit of quantification (LLOQ) was 0.5 µg/mL for INH, PZA, ETH, and RIF, and 0.1 µg/mL for RIF's metabolites and degradation products. The method was validated following FDA guidance criteria and successfully applied to the analysis of the studied compounds in urine of TB patients. Additionally, we conducted a stability study of the anti-TB agents under various pH and temperature conditions to mimic the urine collection process in different settings (peripheral clinics or central laboratories).

Simplified urine-based method to detect rifampin underexposure in adults with tuberculosis: a prospective diagnostic accuracy study

Variable pharmacokinetics of rifampin in tuberculosis (TB) treatment can lead to poor outcomes. Urine spectrophotometry is simpler and more accessible than recommended serum-based drug monitoring, but its optimal efficacy in predicting serum rifampin underexposure in adults with TB remains uncertain. Adult TB patients in New Jersey and Virginia receiving rifampin-containing regimens were enrolled. Serum and urine samples were collected over 24 h. Rifampin serum concentrations were measured using validated liquid chromatography-tandem mass spectrometry, and total exposure (area under the concentration-time curve) over 24 h (AUC0-24) was determined through noncompartmental analysis. The Sunahara method was used to extract total rifamycins, and rifampin urine excretion was measured by spectrophotometry. An analysis of 58 eligible participants, including 15 (26%) with type 2 diabetes mellitus, demonstrated that urine spectrophotometry accurately identified subtarget rifampin AUC0-24 at 0-4, 0-8, and 0-24 h. The area under the receiver operator characteristic curve (AUC ROC) values were 0.80 (95% CI 0.67-0.90), 0.84 (95% CI 0.72-0.94), and 0.83 (95% CI 0.72-0.93), respectively. These values were comparable to the AUC ROC of 2 h serum concentrations commonly used for therapeutic monitoring (0.82 [95% CI 0.71-0.92], P = 0.6). Diabetes status did not significantly affect the AUC ROCs for urine in predicting subtarget rifampin serum exposure (P = 0.67-0.92). Spectrophotometric measurement of urine rifampin excretion within the first 4 or 8 h after dosing is a simple and cost-effective test that accurately predicts rifampin underexposure. This test provides critical information for optimizing tuberculosis treatment outcomes by facilitating appropriate dose adjustments.

New approach to rifampicin stability and first-line anti-tubercular drug pharmacokinetics by UPLC-MS/MS

Successful tuberculosis (TB) therapy requires achieving sufficient exposure to multiple drugs. Limited stability of several first-line anti-TB drugs might compromise reliable therapeutic drug monitoring (TDM). We developed and validated a sensitive and selective UPLC-MS/MS method for simultaneous quantification of isoniazid (INH), pyrazinamide (PZA), rifampicin (RIF), its metabolite 25-desacetylrifampicin and degradation products: rifampicin quinone and 3-formyl-rifampicin. Analysis was completed from a very small plasma volume (20 µL) using only protein precipitation with methanol. Chromatographic separation was achieved on a Kinetex Polar C18 column (2.6 µm; 150 × 3 mm) with a mobile phase consisting of 5 mM ammonium acetate and acetonitrile, both containing 0.1 % formic acid, in gradient elution. The analytes were detected using a positive ionization mode by multiple reaction monitoring. The LLOQ for RIF and its degradation products was 0.1 µg/mL, 0.05 µg/mL for INH, and 0.2 µg/mL for PZA. The method was validated based on the FDA guidance. The application of the method was confirmed in the analysis of RIF, INH, and PZA, as well as RIF metabolism/degradation products in plasma samples of patients with TB. Based on the detailed stability study of the analyzed compounds at various storage conditions, we proposed recommendations for handling the plasma and serum samples in TDM and other pharmacokinetic studies.

Designing negative feedback loops in enzymatic coacervate droplets

Membraneless organelles within the living cell use phase separation of biomolecules coupled with enzymatic reactions to regulate cellular processes. The diverse functions of these biomolecular condensates motivate the pursuit of simpler in vitro models that exhibit primitive forms of self-regulation based on internal feedback mechanisms. Here, we investigate one such model based on complex coacervation of the enzyme catalase with an oppositely charge polyelectrolyte DEAE-dextran to form pH-responsive catalytic droplets. Upon addition of hydrogen peroxide "fuel", enzyme activity localized within the droplets causes a rapid increase in the pH. Under appropriate conditions, this reaction-induced pH change triggers coacervate dissolution owing to its pH-responsive phase behavior. Notably, this destabilizing effect of the enzymatic reaction on phase separation depends on droplet size owing to the diffusive delivery and removal of reaction components. Reaction-diffusion models informed by the experimental data show that larger drops support larger changes in the local pH thereby enhancing their dissolution relative to smaller droplets. Together, these results provide a basis for achieving droplet size control based on negative feedback between pH-dependent phase separation and pH-changing enzymatic reactions.

Alternative Methods for Therapeutic Drug Monitoring and Dose Adjustment of Tuberculosis Treatment in Clinical Settings: A Systematic Review

BACKGROUND AND OBJECTIVE

Quantifying exposure to drugs for personalized dose adjustment is of critical importance in patients with tuberculosis who may be at risk of treatment failure or toxicity due to individual variability in pharmacokinetics. Traditionally, serum or plasma samples have been used for drug monitoring, which only poses collection and logistical challenges in high-tuberculosis burden/low-resourced areas. Less invasive and lower cost tests using alternative biomatrices other than serum or plasma may improve the feasibility of therapeutic drug monitoring.

METHODS

A systematic review was conducted to include studies reporting anti-tuberculosis drug concentration measurements in dried blood spots, urine, saliva, and hair. Reports were screened to include study design, population, analytical methods, relevant pharmacokinetic parameters, and risk of bias.

RESULTS

A total of 75 reports encompassing all four biomatrices were included. Dried blood spots reduced the sample volume requirement and cut shipping costs whereas simpler laboratory methods to test the presence of drug in urine can allow point-of-care testing in high-burden settings. Minimal pre-processing requirements with saliva samples may further increase acceptability for laboratory staff. Multi-analyte panels have been tested in hair with the capacity to test a wide range of drugs and some of their metabolites.

CONCLUSIONS

Reported data were mostly from small-scale studies and alternative biomatrices need to be qualified in large and diverse populations for the demonstration of feasibility in operational settings. High-quality interventional studies will improve the uptake of alternative biomatrices in guidelines and accelerate implementation in programmatic tuberculosis treatment.

Real-world effectiveness and rheumatologist satisfaction with secukinumab in the treatment of patients with axial spondyloarthritis

OBJECTIVES

To assess the effectiveness of secukinumab in patients with axSpA treated in routine clinical settings in 5 European countries.

METHODS

Retrospective analysis of a cross-sectional survey to assess real-world effectiveness of secukinumab in the management of axSpA and rheumatologist satisfaction with treatment in France, Germany, Italy, Spain and the UK from March to December 2018. Outcomes collected included patient demographics, clinical characteristics and rheumatologist- and patient-reported satisfaction with secukinumab treatment.

RESULTS

Five hundred thirty-five patients receiving secukinumab for more than 4 months were assessed, 359 of whom were diagnosed with AS and 178 with nr-axSpA. Rheumatologist assessment of disease status at treatment initiation indicated that 39 (7.3%) had stable/improving disease. Secukinumab treatment for 4 months or longer resulted in 515 (95.9%) patients judged as stable/improving. Treatment was associated with benefits from initiation to assessment in terms of BASDAI (6.2 vs 2.8), 44-joint count score (9.7 vs 6.6), rheumatologist global VAS score (56.9 vs 23.0) and patient global VAS scores (64.4 vs 25.5). These benefits for key clinical outcomes were sustained for periods of 12 months or longer. Patient-reported outcomes on health status using EQ-5D, global functioning using the ASAS health index and overall work impairment via WPAI were sustained over the treatment period, while patient and rheumatologist satisfaction with secukinumab treatment remained very high at 80.2 and 91.2%, respectively.

CONCLUSION

Consistent benefits across multiple clinical and patient-reported outcomes were seen with secukinumab treatment in patients with AS and nr-axSpA treated in routine clinical settings across five European countries. Key Points • In routine clinical settings across five European countries, secukinumab treatment resulted in improvements in a wide range of clinical outcomes including physician-reported disease severity, disease status, pain, BASDAI, 44-joint count score and global VAS scores. • Key clinical and patient reported outcomes were sustained for a 12-month period or longer with secukinumab treatment. • Rheumatologist- and patient-reported treatment satisfaction was high with secukinumab.

An unusual case of paediatric plasmablastic lymphoma presenting with malignant effusion and the challenges in its diagnosis

Plasmablastic lymphoma (PBL) is an aggressive non-Hodgkin lymphoma occurring commonly in the oral mucosa and jaw of human immunodeficiency virus (HIV) positive adult males. PBL is not a common occurrence in children and a presentation with malignant effusion is rarely reported. Herein, we share our experience in the challenges confronted in the diagnosis of PBL in a 6-year-old, HIV positive boy presenting with malignant pleural and peritoneal effusions along with gum hypertrophy, lymphadenopathy and paranasal sinus mass. Amenability of pleural effusion to exfoliative cytology led to an initial cytological examination demonstrating large atypical lymphoid cells with plasmacytoid morphology and a plasmablastic variant of Burkitt lymphoma was initially considered. However immunophenotyping by flowcytometry (FCM) and a cell block immunohistochemical evaluation of the serous effusion suggested a plasma cell immunophenotype and a diagnosis of PBL was favored. A subsequent biopsy from the paranasal sinus mass confirmed the diagnosis of PBL but showed tumour cell angiocentricity on morphology and CD45 expression on immunohistochemistry (IHC), both unusual features in PBL. A CD20 negative/MUM-1 positive immunoprofile and presence of a solid tumour mass in a typical location in addition to malignant effusion substantiated the diagnosis of PBL. The patient was offered HAART (highly active antiretroviral therapy) and chemotherapy and is on follow-up. Paediatric PBL with malignant effusion is rarely reported and this case stresses the importance of use of a multimodality diagnostic approach for an accurate diagnosis.

AB0755 REAL WORLD EFFECTIVENESS OF SECUKINUMAB IN PSORIATIC ARTHRITIS: FINDINGS FROM A RECENT CROSS SECTIONAL SURVEY OF RHEUMATOLOGISTS AND PATIENTS IN EUROPE

Background:

Secukinumab has demonstrated significant and sustained reduction of disease activity and improvement in physical functioning and quality of life in PsA pts in RCTs.1

Objectives:

This study assessed effectiveness of secukinumab in PsA in a real-world setting.

Methods:

This was a cross-sectional survey of rheumatologists, dermatologists and pts in France, Germany, Italy, Spain, and UK. Data were collected online from June-Dec 2018 via physician-completed patient record forms. Pts receiving any treatment for PsA were included in survey (n=1675). Pts receiving secukinumab >4 months were included in this analysis. Pts reported quality of life, work, and disability measures at their current consultation. Physicians reported patient demographic and disease characteristics, concomitant and previous treatments, and time since diagnosis. Physicians also reported overall, skin and joint disease severity, pain (1-10 scale), BSA psoriasis involvement, global VAS score, PASI score, SJC, and TJC for 2 time points: initiation of treatment and at the time of data collection (current consultation). Data were analysed descriptively. The data analysed here is representative of pts that are currently receiving secukinumab and does not assess pts that have discontinued treatment.

Results:

572 PsA pts were receiving secukinumab >4 months at their current consultation. Patient mean age was 47.9 yrs, with 43% female, 59% working full time, and a mean BMI of 26.6. On average, pts were diagnosed with PsA 5.6 years before the current consultation, had received secukinumab for 11.0 months, and for 59% of pts secukinumab was their 1st advanced therapy (bDMARDs or tsDMARDs), 24% their 2nd and 16% their 3rd or more. 25% of pts were also receiving a csDMARD concurrently. Pts reported a mean EQ5D utility score of 0.83, mean WPAI overall work impairment of 24.3%, mean HAQ-DI score as 0.6, and mean PsAID12 score as 2.6 at current consultation. Proportion of pts with moderate and severe overall disease severity, and skin and joint severity decreased at current consultation vs at the initiation treatment (Table 1). Between initiation of treatment and current consultation, pts achieved a significant reduction in disease activity scores, pain score, global VAS scores, BSA, PASI score as well as a greater proportion of pts achieving a BSA < 3%, a PASI score < 3 (Table 2).

Conclusion:

This multinational study demonstrated secukinumab effectiveness in routine care in PsA pts, with significant improvements across all outcomes.

References:

[1]Mease et al. RMD Open. 2018; 4(2): e000723

Table 1.

Disease severity at initiation of secukinumab and at current consultation

At initiation of secukinumab (n=572)At current consultation (n=572)Overall disease severity, n (%)Mild32 (5.6)432 (75.5)Moderate316 (55.2)131 (22.9)Severe218 (38.1)9 (1.6)Don’t know6 (1.0)-Skin severity, n (%)Mild93 (16.3)478 (83.6)Moderate287 (51.2)82 (14.3)Severe154 (26.9)12 (2.1)Don’t know38 (6.6-Joint severity, n (%)Mild50 (8.7)444 (77.6)Moderate329 (57.5)118 (20.6)Severe181 (31.6)10 (1.7)Don’t know12 (2.1)-Table 2.

Physician reported outcomes at initiation of secukinumab and at current consultation, mean (SD)

At initiation of secukinumab (n=572)At current consultation (n=572)BSAa19.2 (15.3)4.6 (8.7)BSA < 3%, n (%)28 (8.2)213 (62.5)PASI score (0-72)a17.2 (11.5)4.2 (8)PASI score < 3, n (%)11 (7.1)99 (64.3)DAS28 scorea5.2 (1.5)*2.8 (1.3)TJC (0-68)a12.1 (9.9)2.5 (3.6)SJC (0-66)a10.0 (9.5)2.9 (7.5)Pain score (1-10)6.3 (2.0)2.6 (1.6)Physician global VAS score (1-100)a59.4 (24.2)23.3 (22.2)Patient global VAS score (1-100)a56.7 (30.4)23.4 (18.3)

1.aCalculated on available data.

Disclosure of Interests:

Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Elizabeth Holdsworth Employee of: Adelphi Real World, Haijun Tian Shareholder of: Novartis Pharmaceutical Corporation, Employee of: Novartis Pharmaceutical Corporation, Nicola Booth Consultant of: Janssen, Papa Anthony: None declared, Niraj Modi Employee of: Novartis Healthcare Pvt Ltd, Dorothy Keininger Shareholder of: Novartis Pharma AG, Employee of: Novartis Pharma AG, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Use of pasteurised human donor milk across neonatal networks in England

OBJECTIVES

To describe the use of pasteurised human donor milk (pHDM) in England and the influence of a human milk bank in the network.

DESIGN

Prospective observational study SETTING: All 163 neonatal units (23 networks) in England 2012-2013.

PATIENTS

Preterm infants born at <32 weeks gestational age (GA).

MAIN OUTCOME MEASURES

Proportion of infants and care-days fed pHDM during the first 30 postnatal days by network METHODS: We extracted daily patient-level data from the National Neonatal Research Database (NNRD). We fitted a logistic regression of pHDM exposure on the presence of a pHDM bank within the network, with GA, BW z score and network as covariates. Significance was assessed by the likelihood ratio (chi-squared) test.

RESULTS

Data for 13,463 infants were included in the study. Across the networks, the proportion (95%CI) of infants ranged from 2.0% (1.0, 3.0) to 61.0% (57.4%, 64.6%), and the proportion of care-days in which pHDM was fed from 0.08% (0.04%, 0.10%) to 21.9% (19.9%, 24.0%). In three networks <5%, and in seven networks >30% of infants received any pHDM. Variation in the use of pHDM across networks remained significant after adjustment for presence of a human milk bank within the network and all covariates (p < 0.001).

CONCLUSIONS

Wide variation of pHDM use in England is not fully explained by presence of a pHDM bank or patient characteristics. This suggests clinical uncertainty about the use of pHDM.

Extended C-band tunable multi-channel InP-based coherent receiver PICs

Fully integrated monolithic, multi-channel InP-based coherent receiver PICs and transceiver modules with extended C-band tunability are described. These PICs operate at 33 and 44 Gbaud per channel under dual polarization (DP) 16-QAM modulation. Fourteen-channel monolithic InP receiver PICs show integration and data rate scaling capability to operate at 44 Gbaud under DP 16-QAM modulation for combined 4.9 Tb/s total capacity. Six channel simultaneous operation of a commercial transceiver module at 33 Gbaud is demonstrated for a variety of modulation formats including DP 16-QAM for >1.2Tbit/s aggregate data capacity.

Research ethics committee decision-making in relation to an efficient neonatal trial

OBJECTIVE

Randomised controlled trials, a gold-standard approach to reduce uncertainties in clinical practice, are growing in cost and are often slow to recruit. We determined whether methodological approaches to facilitate large, efficient clinical trials were acceptable to UK research ethics committees (RECs).

DESIGN

We developed a protocol in collaboration with parents, for a comparative-effectiveness, randomised controlled trial comparing two widely used blood transfusion practices in preterm infants. We incorporated four approaches to improve recruitment and efficiency: (i) point-of-care design using electronic patient records for patient identification, randomisation and data acquisition, (ii) short two-page information sheet; (iii) explicit mention of possible inclusion benefit; (iv) opt-out consent with enrolment as the default. With the support of the UK Health Research Authority, we submitted an identical protocol to 12 UK REC.

SETTING

RECs in the UK.

MAIN OUTCOME

Number of REC granting favourable opinions.

RESULTS

The use of electronic patient records was acceptable to all RECs; one REC raised concerns about the short parent information sheet, 10 about inclusion benefit and 9 about opt-out consent. Following responses to queries, nine RECs granted a favourable final opinion and three rejected the application because they considered the opt-out consent process invalid.

CONCLUSIONS

A majority of RECs in this study consider the use of electronic patient record data, short information sheets, opt-out consent and mention of possible inclusion benefit to be acceptable in neonatal comparative-effectiveness research. We identified a need for guidance for RECs in relation to opt-out consent processes. These methods provide opportunity to facilitate large randomised controlled trials.

Perinatal health services organization for preterm births: a multinational comparison

OBJECTIVE

To explore population characteristics, organization of health services and comparability of available information for very low birth weight or very preterm neonates born before 32 weeks' gestation in 11 high-income countries contributing data to the International Network for Evaluating Outcomes of Neonates (iNeo).

STUDY DESIGN

We obtained population characteristics from public domain sources, conducted a survey of organization of maternal and neonatal health services and evaluated the comparability of data contributed to the iNeo collaboration from Australia, Canada, Finland, Israel, Italy, Japan, New Zealand, Spain, Sweden, Switzerland and UK.

RESULTS

All countries have nationally funded maternal/neonatal health care with >90% of women receiving prenatal care. Preterm birth rate, maternal age, and neonatal and infant mortality rates were relatively similar across countries. Most (50 to >95%) between-hospital transports of neonates born at non-tertiary units were conducted by designated transport teams; 72% (8/11 countries) had designated transfer and 63% (7/11 countries) mandate the presence of a physician. The capacity of 'step-down' units varied between countries, with capacity for respiratory care available in <10% to >75% of units. Heterogeneity in data collection processes for benchmarking and quality improvement activities were identified.

CONCLUSIONS

Comparability of healthcare outcomes for very preterm low birth weight neonates between countries requires an evaluation of differences in population coverage, healthcare services and meta-data.

Hypertensive disorders of pregnancy and outcomes of preterm infants of 24 to 28 weeks' gestation

OBJECTIVE

To examine the relationship between hypertensive disorders of pregnancy (HDPs) and mortality and major morbidities in preterm neonates born at 24 to 28 weeks of gestation.

STUDY DESIGN

Using an international cohort, we retrospectively studied 27 846 preterm neonates born at 24⁰ to 28⁶ weeks of gestation during 2007 to 2010 from 6 national neonatal databases. The incidence of HDP was compared across countries, and multivariable logistic regression analyses were conducted to examine the association of HDP and neonatal outcomes including mortality to discharge, bronchopulmonary dysplasia, severe brain injury, necrotizing enterocolitis and treated retinopathy of prematurity.

RESULTS

The incidence of HDP in the entire cohort was 13% (range 11 to 16% across countries). HDP was associated with reduced odds of mortality (adjusted odds ratio (aOR) 0.77; 95% confidence interval (CI) 0.67 to 0.88), severe brain injury (aOR 0.74; 95% CI 0.62 to 0.89) and treated retinopathy (aOR 0.82; 95% CI 0.70 to 0.96), but increased odds of bronchopulmonary dysplasia (aOR 1.16; 95% CI 1.05 to 1.27).

CONCLUSIONS

In comparison with neonates born to mothers without HDP, neonates of HDP mothers had lower odds of mortality, severe brain injury and treated retinopathy, but higher odds of bronchopulmonary dysplasia. The impact of maternal HDP on newborn outcomes was inconsistent across outcomes and among countries; therefore, further international collaboration to standardize terminology, case definition and data capture is warranted.

The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

OBJECTIVE

To estimate the effect of the provision of a one-to-one nurse-to-patient ratio on mortality rates in neonatal intensive care units.

DESIGN

A population-based analysis of operational clinical data using an instrumental variable method.

SETTING

National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing, and Clinical Outcomes Project.

PARTICIPANTS

43 tertiary-level neonatal units observed monthly over the period January 2008 to December 2012.

INTERVENTION

Proportion of neonatal intensive care days or proportion of intensive care admissions for which one-to-one nursing was provided.

OUTCOMES

Monthly in-hospital intensive care mortality rate.

RESULTS

Over the study period, the provision of one-to-one nursing in tertiary neonatal units declined from a median of 9.1% of intensive care days in 2008 to 5.9% in 2012. A 10 percentage point decrease in the proportion of intensive care days on which one-to-one nursing was provided was associated with an increase in the in-hospital mortality rate of 0.6 (95% CI 1.2 to 0.0) deaths per 100 infants receiving neonatal intensive care per month compared with a median monthly mortality rate of 4.5 deaths per 100 infants per month. The results remained robust to sensitivity analyses that varied the estimation sample of units, the choice of instrumental variables, unit classification and the selection of control variables.

CONCLUSIONS

Our study suggests that decreases in the provision of one-to-one nursing in tertiary-level neonatal intensive care units increase the in-hospital mortality rate.

A randomised controlled trial of flow driver and bubble continuous positive airway pressure in preterm infants in a resource-limited setting

OBJECTIVES

The variable-flow flow driver (FD; EME) and continuous-flow bubble (Fisher-Paykel) continuous positive airway pressure (CPAP) systems are widely used. As these differ in cost and technical requirements, determining comparative efficacy is important particularly where resources are limited.

DESIGN

We performed a randomised, controlled, equivalence trial of CPAP systems. We specified the margin of equivalence as 2 days. We analysed binary variables by logistical regression adjusted for gestation, and log transformed continuous variables by multiple linear regression adjusted for gestation, sex and antenatal steroids.

SETTING

A neonatal unit with no blood gas analyser or surfactant availability and limited X-ray and laboratory facilities

PATIENTS

Neonates <37 weeks of gestation.

INTERVENTIONS

We provided CPAP at delivery followed by randomisation to FD or bubble (B).

OUTCOMES

Primary outcome included total days receiving CPAP; secondary outcomes included days receiving CPAP, supplemental oxygen, ventilation, death, pneumothorax and nasal excoriation.

RESULTS

We randomised 125 infants (B 66, FD 59). Differences in infant outcomes on B and FD were not statistically significant. The median (range) for CPAP days for survivors was B 0.8 (0.04 to 17.5), FD 0.5 (0.04 to 5.3). B:FD (95% CI) ratios were CPAP days 1.3 (0.9 to 2.1), CPAP plus supplementary oxygen days 1.2 (0.7 to 1.9). B:FD (95% CI) ORs were death 2.3 (0.2 to 28), ventilation 2.1 (0.5 to 9), nasal excoriation 1.2 (0.2 to 8) and pneumothorax 2.4 (0.2 to 26).

CONCLUSIONS

In a resource-limited setting we found B CPAP equivalent to FD CPAP in the total number of days receiving CPAP within a margin of 2 days.

TRIAL REGISTRATION NUMBER

ISRCTN22578364.

Practical preterm parenteral nutrition: systematic literature review and recommendations for practice

Current practice in relation to the prescribing, compounding and administration of parenteral nutrition for extremely preterm infants is inconsistent and based on largely historical evidence. Increasingly there are calls for more 'aggressive' nutritional interventions to prevent 'postnatal growth failure'. However the evidence base for these recommendations is weak, and there are no long-term studies examining the impact of such practices. Here we summarise the evidence for preterm parenteral nutrition interventions. We suggest principles to guide practice based on evidence from a systematic search and review of evidence to date, and recommend actions necessary to advance the understanding of this important aspect of preterm care.

Sir Harold Ridley: innovator of cataract surgery

Cataract surgery has evolved greatly over the years, from the ancient practice of 'couching' where the lens is dislodged, to the modern surgical techniques of today. Sir Harold Ridley's invention of the intraocular lens (IOL) has altered the approach towards cataract surgery, benefitting individuals worldwide. This has been his most notable contribution, it is therefore interesting to explore the build up to this event and gain an understanding of the issues faced by Sir Ridley. This paper explores the significant events and key developments that influenced one of the most valuable innovations in the context of cataract surgery--the intraocular lens.

The impact of a regional care bundle on maternal breast milk use in preterm infants: outcomes of the East of England quality improvement programme

OBJECTIVE

To evaluate a quality improvement (QI) programme to increase the use of maternal breast milk (MBM) in preterm infants.

DESIGN

Interrupted time series analysis.

SETTING

17 neonatal units in the East of England (EoE) Perinatal Network; 144 in the rest of the UK Neonatal Collaborative (UKNC).

PATIENTS

Infants born ≤32(+6) weeks gestation admitted to neonatal care between 2009 and 2012.

INTERVENTION

A 'care bundle' to promote MBM in the EoE.

OUTCOMES

Percentage of infants receiving exclusive or any MBM at discharge and care days where any MBM was received.

METHODS

Data were extracted from the National Neonatal Research Database; outcomes were compared preintervention and postintervention, and in relation to the rest of the UKNC.

RESULTS

Exclusive and any MBM use at discharge increased from 26% to 33% and 50% to 57% respectively in the EoE, though there was no evidence of a step or trend change following the introduction of the care bundle. Exclusive MBM use at discharge improved significantly faster in EoE than the rest of the UKNC; 0.22% (95% CI 0.11 to 0.34) increase per month versus 0.05% (95% CI 0.01 to 0.09, p=0.007 for difference). The percentage of infants receiving MBM at discharge and care days where any MBM was received was not significantly different between EoE and the rest of the UKNC.

CONCLUSIONS

This QI programme was associated with some improvement in MBM use in preterm infants that would not have been evident without the use of routinely recorded national comparator data.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

OBJECTIVE

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.

DESIGN

A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.

SETTING

165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.

PARTICIPANTS

20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011.

INTERVENTION

Tertiary designation or high-volume neonatal care at the hospital of birth.

OUTCOMES

Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.

RESULTS

Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.

CONCLUSIONS

High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

The diabetic pregnancy and offspring blood pressure in childhood: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Offspring of diabetic mothers have increased risk of the metabolic syndrome in adulthood. Studies examining BP in offspring of diabetic mothers have conflicting conclusions. We performed a systematic review and meta-analysis of studies reporting offspring BP in children born to diabetic mothers.

METHODS

Citations were identified in PubMed. Authors were contacted for additional data. Systolic and diastolic BP in offspring of diabetic mothers and controls were compared. Subgroup analysis of type of maternal diabetes and offspring sex were performed. Fixed-effects models were used, and random-effects models where significant heterogeneity was present. Meta-regression was used to test the relationship between offspring systolic BP and prepregnancy BMI.

RESULTS

Fifteen studies were included in the review and 13 in the meta-analysis. Systolic BP was higher in offspring of diabetic mothers (mean difference 1.88 mmHg [95% CI 0.47, 3.28]; p = 0.009). Offspring of mothers with gestational diabetes had similar diastolic BP to controls, but higher systolic BP (1.39 mmHg [95% CI 0.00, 2.77]; p = 0.05); results for type 1 diabetes were inconclusive and there were no separate data available on offspring of type 2 diabetic mothers. Male offspring of diabetic mothers had higher systolic BP (2.01 mmHg [95% CI 0.93, 3.10]; p = 0.0003) and diastolic BP (1.12 mmHg [95% CI 0.36, 1.88]; p = 0.004) than controls; in female offspring there was no difference (systolic: 0.54 mmHg [95% CI -1.83, 2.90], p = 0.66; diastolic: 0.51 mmHg [95% CI -1.07, 2.09], p = 0.52). The correlation between offspring systolic BP and maternal prepregnancy BMI was not significant (p = 0.37).

CONCLUSIONS/INTERPRETATION

Offspring of diabetic mothers have higher systolic BP than controls. Differences related to sex and type of maternal diabetes require further investigation.

Impact of managed clinical networks on NHS specialist neonatal services in England: population based study

OBJECTIVE

To assess the impact of reorganisation of neonatal specialist care services in England after a UK Department of Health report in 2003.

DESIGN

A population-wide observational comparison of outcomes over two epochs, before and after the establishment of managed clinical neonatal networks.

SETTING

Epoch one: 294 maternity and neonatal units in England, Wales, and Northern Ireland, 1 September 1998 to 31 August 2000, as reported by the Confidential Enquiry into Stillbirths and Sudden Deaths in Infancy Project 27/28. Epoch two: 146 neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit, 1 January 2009 to 31 December 2010.

PARTICIPANTS

Babies born at a gestational age of 27(+0)-28(+6) (weeks+days): 3522 live births in epoch one; 2919 babies admitted to a neonatal unit within 28 days of birth in epoch two.

INTERVENTION

The national reorganisation of neonatal services into managed clinical networks.

MAIN OUTCOME MEASURES

The proportion of babies born at hospitals providing the highest volume of neonatal specialist care (≥ 2000 neonatal intensive care days annually), having an acute transfer (within the first 24 hours after birth) and/or a late transfer (between 24 hours and 28 days after birth) to another hospital, assessed by change in distribution of transfer category ("none," "acute," "late"), and babies from multiple births separated by transfer. For acute transfers in epoch two, the level of specialist neonatal care provided at the destination hospital (British Association of Perinatal Medicine criteria).

RESULTS

After reorganisation, there were increases in the proportions of babies born at 27-28 weeks' gestation in hospitals providing the highest volume of neonatal specialist care (18% (631/3495) v 49% (1325/2724); odds ratio 4.30, 95% confidence interval 3.83 to 4.82; P<0.001) and in acute and late postnatal transfers (7% (235) v 12% (360) and 18% (579) v 22% (640), respectively; P<0.001). There was no significant change in the proportion of babies from multiple births separated by transfer (33% (39) v 29% (38); 0.86, 0.50 to 1.46; P=0.57). In epoch two, 32% of acute transfers were to a neonatal unit providing either an equivalent (n=87) or lower (n=26) level of specialist care.

CONCLUSIONS

There is evidence of some improvement in the delivery of neonatal specialist care after reorganisation. The increase in acute transfers in epoch two, in conjunction with the high proportion transferred to a neonatal unit providing an equivalent or lower level of specialist care, and the continued separation of babies from multiple births, are indicative of poor coordination between maternity and neonatal services to facilitate in utero transfer before delivery, and continuing inadequacies in capacity of intensive care cots. Historical data representing epoch one are available only in aggregate form, preventing examination of temporal trends or confounding factors. This limits the extent to which differences between epochs can be attributed to reorganisation and highlights the importance of routine, prospective data collection for evaluation of future health service reorganisations.

Differential binding and internalization of Clostridium difficile toxin A by human peripheral blood monocytes, neutrophils and lymphocytes

Colitis due to Clostridium difficile infection is mediated by secreted toxins A and B and is characterized by infiltration by cells from the systemic circulation. The aim of our study was to investigate interactions between fluorescently labelled toxin A and peripheral blood monocytes, neutrophils and lymphocytes. Purified toxin A was labelled with Alexa Fluor® 488 (toxin A(488)) and incubated with isolated human peripheral blood mononuclear cells or washed whole blood cells for varying time intervals at either 37 or 4 °C/ice. The ability of trypan blue to quench cell surface-associated (but not cytoplasmic) fluorescence was also investigated. At 37 °C, toxin A(488) -associated fluorescence in monocytes peaked at 1 h (majority internalized), with subsequent loss associated with cell death. In contrast to monocytes, binding of toxin A(488) in neutrophils was greater on ice than at 37 °C. Studies using trypan blue suggested that over 3 h at 37 °C, most of the toxin A(488)-associated fluorescence in neutrophils remained at the cell surface. Over 48 h (37 °C and ice/4 °C), there was minimal toxin A(488)-associated fluorescence in lymphocytes. These studies suggest major differences in interactions between toxin A and circulating cells that infiltrate the mucosa during colonic inflammation in C. difficile infection.

The diabetic pregnancy and offspring BMI in childhood: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Offspring of mothers with diabetes are at increased risk of metabolic disorders in later life. Increased offspring BMI is a plausible mediator. We performed a systematic review and meta-analysis of studies examining offspring BMI z score in childhood in relation to maternal diabetes.

METHODS

Papers reporting BMI z scores for offspring of diabetic (all types, and pre- and during-pregnancy onset) and non-diabetic mothers were included. Citations were identified in PubMed; bibliographies of relevant articles were hand-searched and authors contacted for additional data where necessary. We compared offspring BMI z score with and without adjustment for maternal pre-pregnancy BMI. We performed fixed effect meta-analysis except where significant heterogeneity called for use of a random effects analysis.

RESULTS

Data were available from nine studies. In the diabetic group unadjusted mean offspring BMI z score was 0.28 higher (all diabetic mothers vs controls (95% CI 0.09, 0.47; p = 0.004; nine studies; offspring of diabetic mothers n = 927, controls n = 26,384) and with adjustment for maternal pre-pregnancy BMI, 0.07 higher (95% CI -0.15, 0.28; p = 0.54; three studies; offspring of diabetic mothers n = 244, controls n = 11,206). There was no evidence of a difference in offspring BMI z score in relation to type of diabetes (gestational vs type 1, p = 0.95).

CONCLUSIONS/INTERPRETATION

Maternal diabetes is associated with increased offspring BMI z score, although this is no longer apparent after adjustment for maternal pre-pregnancy BMI in the limited number of studies in which this is reported. Causal mediators of the effect of maternal diabetes on offspring outcomes remain to be established; we recommend that future research includes adjustment for maternal pre-pregnancy BMI.

Regulation of mixed lineage kinase 3 is required for Neurofibromatosis-2-mediated growth suppression in human cancer

The Neurofibromatosis-2 (NF2) tumor suppressor merlin negatively regulates cell proliferation in numerous cell types. We have previously shown that the NF2 protein (merlin/schwannomin) associates with mixed lineage kinase 3 (MLK3), a mitogen-activated protein kinase (MAPK) kinase kinase that is required for the proliferation of normal and neoplastic cells. In this study, we show that merlin inhibits MLK3 activity, as well as the activation of its downstream effectors, B-Raf, extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK). The ability of merlin to regulate MLK3 activity requires a direct association between MLK3 and residues in the C-terminal region of merlin. Merlin integrates Rho GTPase family signaling with MAPK activity by inhibiting the binding between MLK3 and its upstream activator, Cdc42. Furthermore, we demonstrate that MLK3 is required for merlin-mediated suppression of cell proliferation and invasion. Collectively, these results establish merlin as a potent inhibitor of MLK3, ERK and JNK activation in cancer, and provide a mechanistic link between deregulated MAPK and Rho GTPase signaling in NF2 growth control.

Tenecteplase in the treatment of acute pulmonary thrombo-embolism

This is a retrospective study documenting the use of tenecteplase in 41 cases of suspected or confirmed pulmonary embolism receiving in-hospital tenecteplase as per weight-adjusted dosing in addition to standard heparin and oral anticoagulant therapy. The presenting symptoms of dyspnoea, chest pain, hemoptysis and syncope were found in 40 (97.56%), 19 (46.34%), 6 (14.63%) and 9 (21.95%) patients, respectively. There was one case of mortality who was a 26 yrs old female of postpartum pulmonary thrombo-embolism with severe hypotension, cyanosis, bilateral crepitations in lungs and pulmonary hypertension. In the 40 survived patients, there was alleviation of dyspnoea and hemoptysis in all patients. Significant reduction in tachycardia (P < 0.0001) and increase in the oxygen saturation (SaO₂) (P < 0.0001) were seen at discharge as compared to at the time of presentation. Eighteen patients had hypotension which recovered in all patients till the time of discharge (P < 0.0001). There was a significant reduction in right ventricular systolic pressure in all 18 patients who underwent 2-D echocardiography both before and after the tenecteplase therapy. Resolution of pulmonary embolism on CT pulmonary angiography was documented in only two patients. No bleeding events or any other adverse events were reported during this study. The present study suggests favourable efficacy of tenecteplase in patients with suspected or confirmed acute pulmonary embolism. Although no major adverse events were noted, a large prospective study on the use of tenecteplase in pulmonary embolism is suggested.

A case definition for national and international neonatal bloodstream infection surveillance

OBJECTIVE

Neonatal bloodstream infection (BSI) is a major contributor to mortality, health service costs, and the population burden of lifelong neurodisability. BSI surveillance, an essential component of infection control, requires an unambiguous standardised case definition as variability would invalidate any comparative analyses. In neonates a high proportion of blood cultures yield a mixed growth or skin commensals, principally coagulase-negative staphylococci (CoNS). As this might represent either genuine BSI or contamination, clinical correlates are necessary, but this adds to the difficulty of agreeing an objective, standardised case definition.

DESIGN

Utilising data from 26 UK neonatal units, the population prevalence of 12 predefined clinical signs of infection captured daily for 28 days was evaluated. The sensitivity, specificity, odds ratio and positive predictive value of each sign and sequential numbers of grouped signs were determined to develop a predictive model for a positive blood culture. Sandwich estimates of the standard errors of the logistic regression coefficients were used to take account of the correlations between these repeated measures. The model was tested in an independent data set.

RESULTS

> or =3 clinical signs had the best predictive accuracy for a positive blood culture (76.2% specificity; 61.5%, 46.9% and 78.2% sensitivity for all positive cultures, cultures yielding CoNS, or a recognised pathogen, respectively).

CONCLUSION

This study suggests that a simple case definition for national and international neonatal BSI surveillance is provided by a blood culture yielding a recognised pathogen in pure culture, or a mixed growth or skin commensal plus > or =3 predefined clinical signs.

Neonatal intrahepatocellular lipid

There is increasing evidence that preterm birth is a risk factor for the development of adiposity associated disease, although the pathophysiological basis is unclear. We have previously shown that preterm infants have increased internal abdominal (visceral) adiposity by term. In adults increased internal adiposity is associated with elevated intrahepatocellular lipid (IHCL). We measured IHCL using (1)H NMR spectroscopy in 26 infants (eight healthy preterm-at-term and 18 term-born) and compared values with a reference group of 32 adults. There was no significant difference between adult and term-born IHCL content. In preterm-at-term infants IHCL was significantly elevated when compared with term-born infants and with adults (IHCL CH2/water median (interquartile range): preterm 1.69 (1.04-3.53), term 0.21 (0-0.54) and adult 0.55 (0.08-1.57).

Paediatric trauma epidemiology in an urban scenario in India

PURPOSES

To identify the epidemiology of paediatric trauma in an urban scenario of India and compare results with studies from developed countries, and to formulate preventive measures to decrease such traumas.

METHODS

Between January 2004 and 2005 inclusive, 500 paediatric, orthopaedic trauma patients presenting to our hospital were prospectively studied. Information was recorded in a prescribed proforma.

RESULTS

The children's ages ranged from 0 to 16 years; 274 were males. Most fractures occurred in children aged 7 to 12 years and decreased in older children. The ratio of fractures in left versus right upper extremity was 2:1. In children aged 0 to 6 years, the most common injured site was the elbow, whereas in children aged 7 to 16 years it was the distal radius. In descending order, most injuries were sustained at home (47%), in school (21%), due to sports (17%), and due to vehicular accidents (13%).

CONCLUSION

An effective accident prevention programme in developing countries requires changes in lifestyle and environment, and overcoming obstacles such as ignorance, illiteracy, and inadequate resources.

Nosocomial diarrhoea

Toroviruses have been reported as a new cause of nosocomial viral diarrhoea, and the role of astroviruses has been further elucidated. Polymerase chain reaction methods promise to improve the diagnosis and understanding of the aetiology and control of hospital-acquired viral gastroenteritis. A clearer picture of the impact and extent of Clostridium difficile diarrhoea has emerged, and several control measures have been described. An epidemic Clostridium difficile strain and toxin A-deficient strains have been reported. There is growing evidence that enterotoxin-producing Clostridium perfringens can also cause antibiotic-associated diarrhoea.

Utility of carotid intimal medial thickness as a screening tool for evaluation of coronary artery disease in pre-transplant end stage renal disease

BACKGROUND

Coronary artery disease (CAD) is associated with a higher incidence of allograft failure and mortality in patients with end-stage renal disease (ESRD) following renal transplant.

AIM

To evaluate the efficacy of using carotid intimal medial thickness (CIMT) to predict the presence of CAD in patients with ESRD, using coronary angiography (CAG) as the gold standard.

MATERIALS AND METHODS

This prospective study enrolled consecutive patients with ESRD who underwent CAG as a part of pretransplant evaluation to rule out the presence of atherosclerotic CAD. An operator who was blinded with respect to the results of the CAG, measured carotid IMT in all patients prior to CAG and recorded it on videotape. Two independent observers blinded to the results of CAG measured carotid IMT offline to validate its predictive accuracy as a noninvasive test in predicting the presence or absence of CAD. Measurement of carotid IMT was done on USG B mode 7.5 MHZ probe [HP 5500 andover, Massachusetts]. Student's t-test was used for inter-group comparisons. Pearson correlation coefficient test was used to assess the relation between CAD and various risk factors and carotid IMT. Linear regression analysis was applied to identify independent factors determining presence of CAD. A P value < 0.05 was considered statistically significant.

RESULTS

Mean CIMT was significantly higher in those with CAD as compared to those without [0.80+/- 0.06 vs.0.70+/-0.06 mm, P< 0.0001). Patients with CIMT> 0.75 mm were older and had more incidence of diabetes(78% vs. 47%; P=0.001). Only 4/53 (7%) of patients with CIMT< 0.75 mm had CAD, vs. 38/52 (73%) in those with CIMT >0.75 mm. The sensitivity and specificity of using CIMT > 0.75 as a predictor of CAD was 90.47%and 73% and its positive and negative predictive values were 0.73 and 0.92. On multivariate analysis, only CIMT was a significant predictor of CAD.

CONCLUSION

Carotid IMT can be used to predict CAD in patients with ESRD. In the absence of other risk factors,patients with IMT< 0.75 mm may not need a pretransplant CAG.

Intraosseous haemangioma of the proximal femur: imaging findings

Haemangiomas of bone are uncommon lesions, accounting for approximately 1% of all primary bone tumours. The most frequent sites of involvement are the calvaria and the vertebral column. When haemangiomas involve long tubular bones, they are usually found in the diaphysis or metadiaphysis. Juxta-articular or epiphyseal location for a long bone haemangioma is rare. We present the imaging findings in a case of a histopathologically proven juxta-articular intraosseous haemangioma of the proximal femur. We believe ours is the first report of a haemangioma involving the proximal end of the femur.

Accelerated postnatal head growth follows preterm birth

BACKGROUND

Poor growth after preterm birth, particularly poor head growth, is associated with impaired neurodevelopmental outcome.

OBJECTIVE

To evaluate weight gain and head growth between birth and term in a contemporary cohort of preterm infants, taking into account breast milk intake and illness severity.

METHODS

Subjects were inborn infants <or=32 weeks gestation who remained in the neonatal unit up to >or=37 weeks postmenstrual age. Weight and head circumference (HC) were expressed as standard deviation score (SDS), growth between birth and discharge as SDS gain (SDSG), and illness severity and breast milk exposure as the number of days of level 1 (full) intensive care (%L1IC) and the number of days on which breast milk was received (%BM) as a percentage of days from birth to discharge.

RESULTS

Infants showed poor postnatal weight gain but accelerated head growth. There was a highly significant fall in mean (SD) weight SDS between birth and discharge (-0.31 (0.96) and -1.32 (1.02) respectively, p<0.001) and a highly significant increase in HC SDS (-0.52 (0.95) and -0.03 (1.25) respectively, p = 0.003). %L1IC had a highly significant negative impact on weight SDSG (p = 0.006), and %BM had a significant positive impact on HC SDSG (p = 0.043).

CONCLUSIONS

Accelerated postnatal head growth suggests catch up after antenatal restraint. This raises the possibility that poor neurocognitive outcomes after extremely preterm birth may in part be consequent on poor intrauterine brain growth. As postnatal head growth may be facilitated by breast milk, there is an urgent need to evaluate the optimal use of breast milk in preterm neonates. Illness severity is a significant determinant of poor postnatal weight gain.

Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study

INTRODUCTION

The incidence of venous thromboembolism (VTE) in Western populations undergoing major orthopaedic surgery without any thromboprophylaxis has been reported to range from 32% to 88%. There is however limited information on incidence of VTE in Indian patients and most of the Indian patients undergoing these surgeries do not receive any form of prophylaxis regardless of their risk profile.

METHODS

A prospective study was performed on 147 patients undergoing major orthopaedic surgery for total knee replacement (TKR), total hip replacement (THR), and proximal femur fracture fixation (PFF) without any prophylaxis. These patients were profiled for presence of the known risk factors responsible for development of VTE. A duplex ultrasound on both lower limbs was done 6 to 10 days after surgery. Twenty three patients underwent THR, 22 patients underwent TKR, and 102 underwent surgery for PFF. The patients were assessed clinically for any signs of deep venous thrombosis (DVT) and pulmonary embolism (PE). A helical CT scan was done in case of suspicion of PE and a duplex ultrasound was done in case of clinical suspicion of DVT irrespective of the stage of study.

RESULTS

The overall incidence of VTE was 6.12% and that of PE was 0.6%. The risk factors that were found to be significantly responsible for development of VTE (p < 0.05) were: immobility greater than 72 hours, malignancy, obesity, surgery lasting more than two hours.

CONCLUSION

The study reconfirms the belief that DVT has a lower incidence in Indian patients as compared with other ethnic groups.

Stress responses at birth: determinants of cord arterial cortisol and links with cortisol response in infancy

OBJECTIVE

To investigate (A) the determinants of infant stress response at delivery and (B) test the hypothesis that stress at birth, as reflected by cord arterial cortisol, influences cortisol response to vaccination at two months.

DESIGN

Prospective observational study.

SETTING

Tertiary referral maternity hospital.

POPULATION

One hundred and seventy-two primiparous women with uncomplicated singleton pregnancies.

METHODS

Women were recruited antenatally. At birth, cord arterial blood and obstetric data were collected. Saliva was collected from infants immediately before and after vaccination at two months. Cortisol was analysed from cord blood and saliva by radio-immunoassay.

MAIN OUTCOME MEASURES

Stress response at birth, as demonstrated by cord arterial cortisol; association with saliva cortisol response to vaccination at two months.

RESULTS

Cord arterial cortisol varied with mode of delivery, combined spinal/epidural use and pH. Salivary cortisol response at two months correlated with cord arterial cortisol (r= 0.24, P < 0.05). Infants with the highest and lowest cord arterial cortisol had markedly different cortisol responses at two months (P= 0.017). These groups had different modes of delivery with caesarean rates of <8% in the high cortisol response group and 83% in the low cortisol response group (P < 0.0001).

CONCLUSION

Babies born vaginally mount greater cortisol responses at birth than those delivered by caesarean section. Stress at delivery may influence the infant HPA axis response for up to two months.