Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

[CME MMC: Evaluation of a continuous medical education tool by e-learning from the morbi-mortality conferences of the Burgundy]

OBJECTIVES

The objective of this study was to validate a continuing medical education e-learning tool.

METHODS

The CME MMC was for all health professionals maternity Burgundy and concerned regional morbidity and mortality conferences. It was divided into steps: a pre-test for an assessment of initial knowledge, an access to the recommendations of each RMM and a post-test to assess the progress of participants. A satisfaction questionnaire was proposed after the test. The primary endpoint was the comparison of the post-test scores than the pre-test.

RESULTS

CME MMC was opened 3 months and recorded 156 participants among 598 health professionals in Burgundy, a rate 2.4 times higher than the average participation rate at MMC the past two years. A statistically significant increase was demonstrated individually by comparing the post-test scores than the pre-test (P<0.00001). The increase was significantly higher for midwives and professionals absents at the RMM. Finally, 96.2% of participants have been satisfied by this formation.

CONCLUSION

This prospective multicenter study validates our tool. CME MMC is accessible, without geographic or time restrictions, not expensive, and efficient because it proves that it can update our knowledge in obstetrics and perinatology.

Vitamin A deficiency and nocturnal vision in teenagers with cystic fibrosis

The aim of this study was to document plasma retinol status and nocturnal vision in ten eutrophic adolescents with cystic fibrosis (CF) receiving daily retinol supplementation. Plasma retinol, alpha and beta carotenes and retinol binding protein were measured in ten clinically stable CF patients (mean age: 14.3 years; Shwachman score: 80-100). Nocturnal vision evaluation was performed with a Beyne optometer. Plasma retinol (mean 0.42 +/- 0.16 mg/l), alpha carotene and beta carotene levels were below the lower limit of normal in all but one patient. Five out of ten patients with normal standard opthalmological examination presented a poor (n = 3 patients) or a pathological (n = 2) dark adaptation test. These two patients showed a dramatic increase in nocturnal vision after 1 year of adapted retinol supplementation.

CONCLUSION

Low vitamin A levels occur frequently in clinically stable, eutrophic and retinol supplemented CF adolescents. Since vitamin A deficiency is associated with poor nocturnal vision and since this pattern can be reversed by adapted retinol supplementation, we recommend monitoring plasma vitamin A levels in CF patients and evaluation of dark adaptation in retinol deficient patients.

[Survey on the practice of extrarenal hemofiltration in pediatrics]

BACKGROUND

Several methods of dialysis are currently available. The choice of whether to use one of them is determined by multiple factors that are analyzed in this study.

PATIENTS AND METHODS

One hundred and twenty-six children (mean age: 48 +/- 6 months) were treated in 29 French intensive care units and/or departments of nephrology during 1991. The underlying diseases were: hemolytic-uremic syndrome (HUS) in 28% of patients, other renal diseases in 6%, metabolic diseases in 8%, septic shock in 8%, cardiogenic shock in 9%, hypovolemic shock in 10%, multiple organ failure in 7%, acute liver disease in 9% and other diseases in 15%.

RESULTS

Peritoneal dialysis (PD) was the favorite method in patients less than 10 years: intermittent hemodialysis (IHD), continuous hemofiltration and hemodiafiltration, (HF, HDF) were preferentially used above this age. PD was used in 85% of HUS, 58% of shocks and 50% of metabolic diseases. Sixty percent of acute renal diseases other than HUS were treated by IHD. HF and HDF were used in 66% of acute liver diseases and 42% of shocks. Overall mortality was 40% but no death could be directly ascribed to the different methods of dialysis.

CONCLUSION

The choice of method depends on the type of underlying disease, age of the patient but also the equipment of centers. Progress in evaluating indications and results of the different methods of dialysis are necessary.

Removal of branched-chain amino acids and alpha-ketoisocaproate by haemofiltration and haemodiafiltration

Venovenous haemofiltration (VVHF) and haemodiafiltration (VVHDF) were performed with a neonatal haemo(dia)filter (Miniflow 10, Hospal) on 8 anaesthetized rabbits infused with branched-chain amino acids (leucine, isoleucine and valine) and alpha-ketoisocaproate. The branched-chain amino acids (BCAA) and alpha-ketoisocaproate blood levels were close to those previously observed in neonates with maple syrup urine disease when extracorporeal blood purification was required. VVHF and VVHDF performances were assessed with two different blood flows (Qb = 8.3 and 16.6 ml/min). VVHDF was performed with four dialysate flow rates (Qd = 0.5, 1.0, 2.0 and 3.0 L/h). Within each period, clearances of the three BCAA were strictly similar. BCAA clearances obtained by VVHF were similar to ultrafiltration rates (respectively, 0.78 +/- 0.14 and 1.79 +/- 0.28 ml/min at high and low Qb; p < 0.05). The alpha-ketoisocaproate clearances obtained by VVHF were 0.39 +/- 0.17 and 0.92 +/- 0.43 ml/min at low and high Qb (not significantly different). Whatever the Qd value, the VVHDF procedures always allowed higher BCAA and alpha-ketoisocaproate clearances as compared with the corresponding VVHF period with similar Qb. BCAA clearances obtained by VVHDF with a 0.5 L/h dialysate flow were 4.1 +/- 0.5 and 5.4 +/- 0.5 mL/min at low and high Qb, respectively. The concurrent alpha-ketoisocaproate clearances were 2.5 +/- 0.8 and 2.9 +/- 1.0 ml/min.

Effects of theophylline on renal insufficiency in neonates with respiratory distress syndrome

We report here 6 cases of critically ill newborn infants with both RDS and acute renal insufficiency, unresponsive to conventional treatment (furosemide, dopamine). Theophylline, an adenosine antagonist, has been shown to prevent hypoxemia-induced renal insufficiency in rabbits and our patients thus received compassionately a low-dose of theophylline (1 mg . kg-1 i.v.). Urinary water excretion and creatinine clearances increased significantly in 5 out of 6 neonates, thus suggesting a beneficial role of theophylline in neonatal prerenal failure.

Protection from hypoxemic renal dysfunction by verapamil and manganese in the rabbit

The ability of calcium channel blockers to prevent and/or to reverse the hypoxemia-induced renal dysfunction was studied in anesthetized and mechanically-ventilated rabbits. Renal blood flow (RBF) and glomerular filtration rate (GFR) were determined by para-aminohippuric acid and inulin clearance, respectively. Each animal was considered as its own control. In 9 rabbits (group 1), verapamil infusion, 1 microgram.kg-1.min-1, did not change basal renal hemodynamics. In a second group (n = 9), hypoxemia induced marked significant decreases in GFR, RBF and urine flow rate (-22 +/- 5%, -18 +/- 6% and -34 +/- 7% respectively). The administration of verapamil partially reversed the hypoxemia-induced renal dysfunction. Likewise, hypoxemia did not induce any change in renal function in verapamil pretreated rabbits (n = 8). This study shows that verapamil is able to prevent and to partially reverse the adverse effects of hypoxemia on renal hemodynamics. The intrarenal infusion of manganese chloride, another calcium channel blocker, was also effective in blunting the hypoxemia-induced changes in the left infused kidney, but not in the contralateral kidney. The overall results demonstrate that a significant protection from hypoxemic renal dysfunction can be achieved by inhibitors of calcium ion transport.

[Simultaneous recording of pH in the distal and proximal esophagus]

A 24 hour esophageal pH recording was performed in 46 infants (age: 10 +/- 12 months). Two probes were placed in the proximal and distal esophageal sites respectively. A significant correlation was shown between the upper and lower part of the esophagus for the numbers of acid (pH fall below 4 for at least 15 s) and weakly acid (fall in pH of more than one unit, irrespective of whether or not the pH fell below 4) gastroesophageal reflux (GER), the reflux index and the number of acid GER longer than 5 min. The number of acid GER and the time spent at pH less than 4 at the proximal esophagus were significantly greated in group 1 (reflux index greater than 5% in the distal esophagus, n = 10), than in group 2 (reflux index less than 5% in the distal esophagus, n = 36). The proportion of distal acid and weakly acid reflux reaching the upper esophagus presented with marked variation coefficients. These findings indicate that data obtained in the distal esophagus are poorly predictive of the results in the proximal esophagus, even if infants present high reflux index at the lower esophagus. Weakly acid GER reached the upper esophagus more frequently than acid GER.

Hemiballismus revealing multiple sclerosis in an infant

The authors report a case of a 15-month-old infant who presented a left hemiballismus associated with left Marcus-Gunn pupil, and retrobulbar optic neuritis, which disappeared spontaneously in 7 days. Six weeks later, the infant experienced a mild paraparesis with a palsy of the left sixth cranial nerve, which disappeared following steroid therapy. Evoked visual potentials elicited abnormal latencies; cerebrospinal fluid (CSF) showed a rise in white cells and oligoclonal bands. According to the usual classification, this case corresponds to definite multiple sclerosis. The fact that hemiballismus was the initial clinical feature in an infant makes this observation very interesting. In the literature, eight cases of hemiballismus in patients with multiple sclerosis are reported; however, only two cases of multiple sclerosis in infancy have been published, making our case report of particular interest.

[Nosocomial Staphylococcus epidermidis and Staphylococcus aureus septicemias in neonates]

Sixteen neonates developed staphylococcal septicemia (S. epidermidis in 10 cases and S. aureus in six). Two infections were due to maternofetal contamination and four to contaminated foreign material. Clinical symptoms included non-specific evidence of neonatal bacterial infection and, in S. aureus infections, suggestive skin or bone localizations. Fifteen patients recovered without sequelae and one died as a result of S. aureus septicopyemia. In view of the patterns of resistance to antimicrobial agents exhibited by S. aureus and S. epidermidis, the vancomycin-amikacin combination seems the most appropriate treatment in neonatal staphylococcal septicemias. However, the fosfomycin-cefotaxim combination can be proposed for the treatment of staphylococcal infections with osteoarticular or meningeal involvement.