A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units

(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.

Ultrasound Guidance Superiority in Pediatric Sialorrhea Treatment With Intraglandular Botulinum Toxin Application: A Four-Year Retrospective Study

Introduction The management of sialorrhea in children with multiple disabilities is extremely important not only for aesthetic/psychosocial reasons but also for functional and clinical ones. There are several recommended management methods with strong evidence of the effectiveness of intraglandular application of botulinum toxin A. Materials and methods In this four-year retrospective report, we compare two populations who received intraglandular type A botulinum toxin injections in the pediatric unit of the Physical Medicine and Rehabilitation (PM&R) Department at a central hospital. The injections were administered using either ultrasound guidance (US) or anatomical landmarks. Results Out of a total of 29 patients with neurological conditions, 16 met the eligibility criteria for this study. The study group comprised seven females (44%) and nine males (56%), with a median age of 9 years. The average pre-procedure sialorrhea staging was four. A total of 23 procedures were performed, with 16 conducted under ultrasound guidance (US) and seven via anatomical landmarks (non-US). In the US group, a statistically significant difference in sialorrhea staging was observed at one and three months post-procedure (p<0.05), but not at six months post-procedure. Conversely, no statistically significant difference in sialorrhea staging was found at any time point in the non-US group. The comparison between the two groups supports the use of ultrasound guidance, showing superior outcomes at one and three months post-procedure (p<0.05). Conclusion The results of this study align with global trends seen in medical publications and guidelines advocating for the use of ultrasound in this procedure. Future prospective and larger-scale studies are essential to validate these findings.

Variation in delivery room management of preterm infants across Europe: a survey of the Union of European Neonatal and Perinatal Societies

The aim of the present study, endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Italian Society of Neonatology (SIN), was to analyze the current delivery room (DR) stabilization practices in a large sample of European birth centers that care for preterm infants with gestational age (GA) < 33 weeks. Cross-sectional electronic survey was used in this study. A questionnaire focusing on the current DR practices for infants < 33 weeks' GA, divided in 6 neonatal resuscitation domains, was individually sent to the directors of European neonatal facilities, made available as a web-based link. A comparison was made between hospitals grouped into 5 geographical areas (Eastern Europe (EE), Italy (ITA), Mediterranean countries (MC), Turkey (TUR), and Western Europe (WE)) and between high- and low-volume units across Europe. Two hundred and sixty-two centers from 33 European countries responded to the survey. At the time of the survey, approximately 20,000 very low birth weight (VLBW, < 1500 g) infants were admitted to the participating hospitals, with a median (IQR) of 48 (27-89) infants per center per year. Significant differences between the 5 geographical areas concerned: the volume of neonatal care, ranging from 86 (53-206) admitted VLBW infants per center per year in TUR to 35 (IQR 25-53) in MC; the umbilical cord (UC) management, being the delayed cord clamping performed in < 50% of centers in EE, ITA, and MC, and the cord milking the preferred strategy in TUR; the spotty use of some body temperature control strategies, including thermal mattress mainly employed in WE, and heated humidified gases for ventilation seldom available in MC; and some of the ventilation practices, mainly in regard to the initial FiO2 for < 28 weeks' GA infants, pressures selected for ventilation, and the preferred interface to start ventilation. Specifically, 62.5% of TUR centers indicated the short binasal prongs as the preferred interface, as opposed to the face mask which is widely adopted as first choice in > 80% of the rest of the responding units; the DR surfactant administration, which ranges from 44.4% of the birth centers in MC to 87.5% in WE; and, finally, the ethical issues around the minimal GA limit to provide full resuscitation, ranging from 22 to 25 weeks across Europe. A comparison between high- and low-volume units showed significant differences in the domains of UC management and ventilation practices.    Conclusion: Current DR practice and ethical choices show similarities and divergences across Europe. Some areas of assistance, like UC management and DR ventilation strategies, would benefit of standardization. Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs. What is Known: • Delivery room (DR) support of preterm infants has a direct influence on both immediate survival and long-term morbidity. • Resuscitation practices for preterm infants often deviate from the internationally defined algorithms. What is New: • Current DR practice and ethical choices show similarities and divergences across Europe. Some areas of assistance, like UC management and DR ventilation strategies, would benefit of standardization. • Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs.

Raccoon eyes in a newborn

Introduction:Periorbital ecchymoses or "raccoon eyes" in the neonate/infant may be due to basal skull fractures or neuroblastoma.Case Report:A term male baby born by vacuum-assisted delivery developed a medium size subgaleal hematoma on the first day of life (DOL). On the third DOL, bilateral periorbital ecchymosis (raccoon eyes) developed. The cerebral ultrasound, hematologic and coagulation studies were normal. The raccoon eyes were interpreted as an extension of the subgaleal hematoma to the orbital ridges. At DOL 38, he was thriving and the raccoon eyes were resolved.Discussion:"Raccoon eyes" may result from a subgaleal hematoma without fracture caused by birth trauma.

294 Implementation of Colorectal Robotic Assisted Surgical Programme During a Global Pandemic: Collaboration Between Territorial and National Waiting Times Centre

Introduction

Golden Jubilee National Hospital (GJNH) established a thoracic Robotic Assisted Surgical (RAS) programme in 2018. In March 2021, GJNH invested in a new elective colorectal service and in response to the Scottish Government robotic investment established a collaboration with a territorial health board to host their robot and start a RAS colorectal programme. We provide an overview of barriers and facilitators leading to establishing this new collaboration.

Method

An observational review of RAS training timeline. Demographics, surgical operations, and hospital length of stay were documented. Surgeons, perioperative team, management, and industry (Intuitive) were interviewed to provide insights into implementation and training.

Results

Boards approved RAS business case in April 2021, robot on-site with GJNH governance approval in May. First cohort of colorectal surgeons completed proctored training July 2021. To date, 17 RAS resections performed (mean age 64, 9 males: 8 female). Mean length of stay 4.65 days. No anastomotic leaks and no mortality reported. Interviews revealed key facilitators: advantage of having an established RAS perioperative team and building on pre-existing industry links; developing and strengthening collaborative working between different health boards and surgeons. Barriers included: education of all team members to ensure patient safety for new specialty; multisite collaborative working.

Conclusions

This work provides a template model for future RAS collaborations between different sites and health boards. Collaborative working in a green-hospital setting may improve equity of access for patients whilst future-proofing surgery against further waves of the pandemic.

Neonatal Resuscitation Practices in Europe: A Survey of the Union of European Neonatal and Perinatal Societies

BACKGROUND

We aimed to evaluate the policies and practices about neonatal resuscitation in a large sample of European hospitals.

METHODS

This was a cross-sectional electronic survey. A 91-item questionnaire focusing on the current delivery room practices in neonatal resuscitation domains was individually sent to the directors of 730 European neonatal facilities or (in 5 countries) made available as a Web-based link. A comparison was made between hospitals with ≤2,000 and those with >2,000 births/year and between hospitals in 5 European areas (Eastern Europe, Italy, Mediterranean countries, Turkey, and Western Europe).

RESULTS

The response rate was 57% and included participants from 33 European countries. In 2018, approximately 1.27 million births occurred at the participating hospitals, with a median of 1,900 births/center (interquartile range: 1,400-3,000). Routine antenatal counseling (p < 0.05), the presence of a resuscitation team at all deliveries (p < 0.01), umbilical cord management (p < 0.01), practices for thermal management (p < 0.05), and heart rate monitoring (p < 0.01) were significantly different between hospitals with ≤2,000 births/year and those with >2,000 births/year. Ethical and educational aspects were similar between hospitals with low and high birth volumes. Significant variance in practice, ethical decision-making, and training programs were found between hospitals in 5 different European areas.

CONCLUSIONS

Several recommendations about available equipment and clinical practices recommended by the international guidelines are already implemented by centers in Europe, but a large variance still persists. Clinicians and stakeholders should consider this information when allocating resources and planning European perinatal programs.

Does nosocomial COVID-19 result in increased 30-day mortality? A multi-centre observational study to identify risk factors for worse outcomes in patients with COVID-19

This study aimed to determine whether nosocomial coronavirus disease 2019 (COVID-19) has a worse outcome compared with community-acquired COVID-19. This was a prospective cohort study of all hospitalized patients with confirmed COVID-19 in three acute hospitals on 9th April 2020. Patients were followed-up for at least 30 days. Nosocomial infection was defined as a positive swab after 7 days of admission. In total, one hundred and seventy-three patients were identified, and 19 (11.0%) had nosocomial infection. Thirty-two (18.5%) patients died within 30 days (all cause) of a positive swab test; there were no significant differences in 30-day all-cause mortality rates between the three groups (i.e. patients admitted with suspected COVID-19, patients with incidental COVID-19 and patients with nosocomial COVID-19): 21.1% vs 17.6% vs 21.6% (P=0.755). Nosocomial COVID-19 is not associated with increased mortality compared with community-acquired COVID-19.

[Very Low Birth Weight Infants in a Portuguese Intensive Care Unit and the Vermont Oxford Network: 15 Years of Registry Data]

INTRODUCTION

Our neonatal service is part of a differentiated perinatal hospital and has contributed to the Vermont Oxford Network for more than 15 years. This data base includes data on the morbidity and mortality of newborns born in the member hospitals with birth weight between 401 and 1500 g and/ or from 22 to 29 weeks and six days of gestation, or those admitted to these hospitals with up to 28 days of age. It thus allows the analysis of clinical practice and its comparison with similar units. The goal of the present paper is to disclose some of our data from the past 15 years and to compare it with the Vermont Oxford Network data trying to identify areas of possible improvement and permitting other neonatal units to compare their data with our in a benchmarking process.

MATERIAL AND METHODS

Observational, retrospective study. It included newborns with birth weight ≤ 1500 g (very low birth weight newborns) born and treated at our hospital from 2001 to 2015. Descriptive data analysis, chi-square test and ANOVA, significance when p < 0.05.

RESULTS

A total of 869 very low birth weight newborns were studied, median weight 1100 g and gestational age 29 weeks. Twinning was found in 37.6%. In the delivery room, 23% did not require any resuscitation, 52.2% of the newborns required invasive intubation, 78.3% had surfactant, and, since 2011, 29.7% have started noninvasive ventilation. Of the total very low birth weight newborns, 12.9% had oxygen therapy at 36 weeks of corrected age, 23% patent ductus arteriosus and late sepsis in 17.1%. There was higher neurological morbidity compared to the Vermont Oxford Network except in the case of retinopathy of prematurity. Overall mortality was 14% (122 newborns). The time of hospitalization was on average 52.7 ± 34.4 days. The 629 newborns that were discharged home had equivalent length of stay and head circumference measure but a lower weight than those in the Vermont Oxford Network, and 14.3% went home with exclusive breastfeeding.

DISCUSSION

This work allowed us to study our very low birth weight newborns data and compare it with one of the largest neonatal world networks. Our population is similar from the point of view of gestational age, somatometric data, pregnancy surveillance rates and cesarean section with the most noticeable difference being the percentage of low birthweight for gestational age babies, twin pregnancies and antenatal corticosteroid treatment, superior in our center. Cardio-pulmonary and gastrointestinal disorders were overlapping. It is urgent to improve our rate of sepsis, neurologic sequelae, post-partum hypothermia control and neuroprotection with magnesium sulphate. The mortality rate and the length of stay at discharge was similar.

CONCLUSION

This study allowed us to compare our population of very low birth weight newborns with those registered in the network. We have verified that we have been accompanying the evolution of Neonatology over the past years and we have identified areas for improvement.

[Being a Mother After 35 Years: Will it be Different?]

INTRODUCTION

Advanced maternal age is defined as maternity after 35 years old and is associated with more complications during pregnancy and neonatal period as well as decreased fertility. This study aims to examine the relationship between advanced maternal age and their maternal and fetal consequences, as well as maternal perception of the risk of pregnancy after 35 years old.

MATERIAL AND METHODS

Observational, retrospective and comparative study, between two groups: advanced maternal age group (aged ≥ 35 years) and non-advanced maternal age group (age < 35 years), conducted between March and June 2015. Chi-square test and Fisher's exact test were used and considered significant if p < 0.05.

RESULTS

Of the 736 women admitted to the hospital (32.2% with advanced maternal age), 306 were included in the study (153 in each group). In the non-advanced maternal age group there was a greater number of primiparous women (p < 0.01). In the advanced maternal age group, more previous miscarriages were observed (p < 0.001), as well as a higher use of assisted reproductive techniques (p < 0.01), preformed of amniocentesis (p < 0.001) and dystocia, including caesarean sections (p < 0.001). No association was found regarding the presence of maternal complications in pregnancy, birth defects, need for neonatal resuscitation or prematurity. As for the perception of risk in pregnancy, the non-advanced maternal age group considered it to be superior (p < 0.05).

DISCUSSION

Most women of advanced maternal age have term deliveries without complications. Neonatal outcomes seem not to have been influenced by the advanced maternal age.

CONCLUSION

The consequences of an advanced maternal age pregnancy in this sample did not have the same clinical expression as described in the literature. In the future, advanced maternal age will possibly be considered after age 40.

Frequencies of red blood cell major blood group antigens and phenotypes in the Chinese Han population from Mainland China

Alloantibodies directed to red blood cell (RBC) antigens play an important role in alloimmune-mediated haemolytic transfusion reactions and haemolytic disease of the foetus and newborn. The frequencies and phenotypes of RBC antigens are different in populations from different geographic areas and races. However, the data on major blood group antigens in the Chinese Han population from Mainland China are still very limited; thus, we aimed to investigate them in this study. A total of 1412 unrelated voluntary Chinese Han blood donors were randomly recruited. All donors were typed for blood group antigens: D, C, c, E, e, C(w) , Jk(a) , Jk(b) ,M, N, S, s, Le(a) , Le(b) , K, k. Kp(a) , Kp(b) , Fy(a) , Fy(b) , Lu(a) , Lu(b) , P1 and Di(a) using serological technology. Calculations of antigen and phenotype frequencies were expressed as percentages and for allele frequencies under the standard assumption of Hardy-Weinberg equilibrium. Amongst the Rh antigens, D was the most common (98.94%) followed by e (92.28%), C (88.81%), c (58.43%), E (50.78%) and C(w) (0.07%) with DCe/DCe (R1 R1 , 40.72%) being the most common phenotype. In the Kell blood group system, k was present in 100% of the donors and a rare phenotype, Kp (a+b+), was found in 0.28% of the donors. For the Kidd and Duffy blood group systems, Jk (a+b+) and Fy (a+b-) were the most common phenotypes (44.05% and 84.35%, respectively). In the MNS blood group system, M+N+S-s+ (45.54%) was the most common, whereas M+N-S-s- and M-N+S-s- were not found. The rare Lu (a-b-) and Lu (a+b+) phenotypes were identified in 0.43% and 1.13% of the donors, respectively. Le(a) and Le(b) were seen in 17.92% and 63.03% of donors, respectively. The frequency of Di(a) was 4.75%, which was higher than in the Chinese population in Taiwan region or the Caucasian and Black populations (P < 0.0001). This study systematically describes the frequencies of 24 blood group antigens in the Chinese Han population from Mainland China. The data can be helpful in creating a donor database for preparation of indigenous cell panels and providing antigen-negative blood to patients with multiple alloantibodies.

[Encephalomeningocele: Inside the Picture]

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Genetic characterization and genotyping of hepatitis B virus (HBV) isolates from donors with an occult HBV infection

BACKGROUND AND OBJECTIVES

Screening of Thai blood donors has resulted in the detection of donors with an occult HBV infection (OBI), where HBsAg is undetectable, but hepatitis B virus (HBV) DNA is present in serum in low concentrations. This study was designed to determine whether the occurrence of OBI in donors was linked to the HBV genotype and possibly to mutations in the surface (S) and core (C) gene regions.

MATERIALS AND METHODS

Mutations in the S and C gene regions in 48 Thai donors with OBI were mapped by sequencing. Genotyping was determined with the INNO-LiPA test and by phylogenetic analysis of sequences from the S and C genes.

RESULTS

The majority of OBI samples were genotype C (81·3%) with 6·3% of samples being genotype B. In addition, two genotype I isolates were identified. Mutations in the S region (100%) were found especially in loop 1 of the major hydrophilic loop (MHL) at positions I110L, T114S, T126I and S113T, whereas mutations in the C region (65%) were within the basal core promoter region (position A1762T/G1764A) and precore region (position G1896A).

CONCLUSION

The majority of OBI samples were HBV genotype C, although genotype I, which is newly emerging in Thailand, was also detected. The study demonstrated that OBI was probably not associated with a particular HBV genotype or with certain mutations in the S and C gene regions. However, mutations in the C gene region which could potentially impair viral replication and HBsAg production and potentially lead to OBI were identified.

Detection and identification of occult HBV in blood donors in Taiwan using a commercial, multiplex, multi-dye nucleic acid amplification technology screening test

BACKGROUND

The ability of a new generation commercial, multiplex, multi-dye test from Roche, the cobas TaqScreen MPX test, version 2.0, to detect and identify occult HBV infections was evaluated using routine donor samples from Kaohsiung Blood Bank, Taiwan.

STUDY DESIGN AND METHODS

A total of 5973 samples were tested by nucleic acid amplification technology (NAT); 5898 in pools of six, 66 in pools of less than six and nine samples individually. NAT-reactive samples were retested with alternative NAT tests, and follow-up samples from the donors were tested individually by NAT and for all the HBV serological markers.

RESULTS

Eight NAT-only-reactive donors were identified, and follow-up samples were obtained from six of the donors. The results indicated that all eight donors had an occult HBV infection with viral loads <12 IU/ml.

CONCLUSION

The cobas(®) TaqScreen MPX test, version 2.0, has an advantage over the current Roche blood screening test, the cobas TaqScreen MPX test, for screening donations in countries with a high prevalence of occult HBV infections since the uncertainty associated with identifying samples with very low viremia is removed by the ability of the test to identify the viral target in samples that are reactive with the cobas TaqScreen MPX test, version 2.0.

[Conditions for neonatal resuscitation in Portuguese delivery rooms: a national survey (2009)]

INTRODUCTION

In Portugal, since 1989, the rates of maternal, perinatal and neonatal mortality present a significant decrease, after the implemented perinatal network. The continuous assessment of the existing conditions at the different levels of perinatal care is essential to identify deviations from normality and may allow the optimization of quality of care.

OBJECTIVES

To obtain information on and to evaluate the conditions and practices of neonatal resuscitation at the Portuguese delivery rooms, in order to propose measures for improvement of neonatal care.

MATERIAL AND METHODS

An electronic questionnaire was sent to 35 hospitals with maternity. The survey included questions regarding to human and material resources, characteristics of delivery room practices used in stabilization / resuscitation of the newborn, number of deliveries and number of newborns transferred after birth per year, as well as issues related with the collaboration of obstetric teams.

RESULTS

Thirty centres (86%) answered the questionnaire, 16 of the respondents were level III maternities/hospitals. In eight (27%) centres a paediatrician is present at all deliveries, whereas in the remaining centres a paediatrician is available only for risk situations. The material unavailable in some centres include cardio-respiratory monitoring equipment, support device with pressure controlled ventilation, oxygen blender, ventilator, CPAP (continuous positive airway pressure), neonatal transport incubators and equipments for thoracocentesis and paracentesis. The criteria used for prophylactic surfactant and oxygen use are very different among the various centres. All centres reported transferring newborns after birth, either because of lack of differentiation of care or vacant beds. The centres with perinatal support reported less cooperation of the obstetric teams.

CONCLUSIONS

The care of the newborn in the national delivery rooms can and should be improved. It is necessary to adapt the equipment and human resources to the needs of each centre. Protocols and practices such as oxygen and "prophylactic" surfactant must be updated, transport after birth must be reduced and the communication with the obstetric teams should be improved.

Early nasal continuous positive airway pressure versus INSURE in VLBW neonates

BACKGROUND

Evidence suggests the INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is superior to mechanical ventilation (MV) with rescue surfactant for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates. There is limited data, however, to assess whether INSURE is superior to nCPAP alone. We aimed to compare these two strategies regarding early and late outcomes.

METHODS

Retrospective cohort study from Jan/2002 to Aug/2008. We included VLBW neonates with gestational age (GA) ≤ 30 weeks registered in the Vermont Oxford Network that used either nCPAP alone (nCPAP group, N=40), or with INSURE (INSURE group, N=56). We assessed early (RDS, need for rescue surfactant, and CPAP failure with MV) and late outcomes (chronic lung disease of prematurity (CLD), mortality, and composite outcome of mortality and/or CLD).

RESULTS

Neonates in the INSURE group had lower mean GA, while other baseline variables were comparable. The proportion of RDS was significantly superior in the nCPAP group (53% vs. 30%; adjusted OR [95% CI] - 0.2 [0.1-0.6]). Therapeutic surfactant was administered to all cases with RDS in the nCPAP group, but to none from the INSURE group. MV was more frequently required in the nCPAP group (11/ 40, 28% vs. 9/ 56, 12%; p=0.04). No statistically significant differences were found in either of the late outcomes.

CONCLUSION

The use of nCPAP alone in VLBW neonates with GA ≤ 30 weeks may be associated with slightly poorer early outcomes than the INSURE strategy, but there were no significant differences in CLD or mortality.

Endoscopists' estimation of size should not determine surveillance of colonic polyps

OBJECTIVE

Current British Society of Gastroenterology guidelines use adenomatous polyp size as one of the key factors in determining polyp follow-up. This study aimed to compare polyp size assessment by colonoscopists and pathologists before and after fixation to determine the optimal method for measurement.

METHOD

Thirty-five colorectal polyps were found during pre-arranged colonoscopies in one centre. Polyp size was measured to the nearest 1 mm by three different methods: 1. by the endoscopist at colonoscopy; 2. by the pathologist fresh, following removal; 3. by the pathologist fixed, following fixation. The endoscopist and the pathologist were blinded to each other's measurements.

RESULTS

Seventeen men, eighteen women with mean age of 66.2 years (SD: 9.4, range: 38.7-85.5) underwent polypectomy/s with all polyps removed intact. Polypectomies were performed by consultants (43%), nurse specialists (34%) and specialist registrars (23%). The median size (mm) of polyps measured were endoscopically, 6.5 (2-25 mm); fresh specimen 7.0 (4-28 mm) and fixed 7.0 (4-28 mm). Endoscopic measurements were significantly lower than that of fresh and fixed sizes (P < 0.001 and P = 0.003 respectively), with poor correlation [correlation of variance (CV): 21.0% and intraclass correlation coefficient (ICCC): 0.841 for endoscopic and fresh measurements; CV: 21.1% and ICCC: 0.838 for endoscopic and fixed measurements]. There was no statistical difference between fresh and fixed specimen measurements (P > 0.05; CV: 4.2%, ICCC: 0.974). In three patients, the endoscopic measurement was < 1 cm in polyps that were found to be >or= 1 cm on pathological measurement.

CONCLUSIONS

Endoscopists consistently underestimated polyp size. Fixation had no effect on polyp size. Pathologists' measurement of polyp size on fixed specimens should determine the need for further colonoscopic follow-up.

Respiratory support strategies for the preterm newborn - National survey 2008

BACKGROUND

Respiratory support strategies for the preterm newborn have been the subject of intense research.

AIM

To survey neonatal respiratory support practices in Portugal and to determine whether they reflect evidence from randomised trials.

METHODS

Questionnaires were given out to 31 Portuguese neonatal units to determine the types of ventilators, modes of ventilation, lung function monitoring, use of exogenous surfactant, oxygen saturation levels used and the prevalence of chronic lung disease in the preterm newborn.

RESULTS

There was a 94% response rate. Draeger babylog was the most frequently used ventilator in neonates. Twelve (41%) units prefer to use early nasal continuous positive airway pressure (NCPAP) whenever possible. Triggered ventilation is the choice of invasive ventilation in 24 (83%) units (SIMV, SIPPV, PSV); four (14%) units have high frequency oscillation ventilation. SIMV is the most frequent (n=13, 45%) weaning mode. Exogenous surfactant is used as prophylactic in 12 (41%) units. All units use lung function measurements to aid choice of ventilator settings and five (17%) units monitor PaCO2 (transcutaneous = 3; capnometry = 2). Seventeen (59%) units allow oxygen saturation levels from 90% to 95% in infants with respiratory distress syndrome and 15 (52%) levels from 85% to 90% in infants with chronic lung disease. Prevalence of chronic lung disease of prematurity ranged from 0% to 75% (median: 10).

CONCLUSIONS

Many respiratory strategies for extremely low birth weight infants reflect the result of large randomised trials. More effective methods may be required to encourage the use of early NCPAP preferably with binasal prongs, the use of SIPPV as the main weaning mode, the use of volume targeted ventilation and a more judicious use of exogenous surfactant in order to ensure evidence-based practice.

Blood donor screening with cobas s 201/cobas TaqScreen MPX under routine conditions at German Red Cross institutes

BACKGROUND

In 1997 the German Red Cross (GRC) blood donor services introduced mini-pool nucleic acid testing (NAT) for human immunodeficiency virus (HIV)-1, hepatitis C virus (HCV) and hepatitis B virus (HBV) to increase blood safety. With the new cobas s 201/cobas TaqScreen MPX, a fully automated extraction method and a multiplex amplification system specifically adapted to the needs of blood donation services is available.

METHODS

The cobas s 201 system was evaluated at the GRC BTS locations Hagen, Springe and Frankfurt. In phase A, the analytical sensitivity for the detection of HBV, HCV and HIV-1 was investigated and in phase B, at least 60,000 samples at each test site were screened in parallel with the MPX test on s 201 system and the existing routine mini-pool NAT system to compare the diagnostic specificity and the diagnostic sensitivity.

RESULTS

Comparable analytical sensitivities in a range of 1.6-3.6 IU/ml, 4.9-10.9 IU/ml and 14.7-26.6 IU/ml for HBV, HCV HIV, respectively, for the MPX test on s 201 system (95% probability based on probit analysis) were determined at all test sites. The diagnostic sensitivity was 99.8% and the diagnostic specificity was 99.85%.

CONCLUSIONS

The MPX test on s 201 system is a fully automated NAT system suitable for routine blood donor screening. The analytical sensitivity as well as the diagnostic sensitivity fulfilled all requirements of the Paul Ehrlich Institute for blood donor screening in mini-pools up to 96 donations per pool. A major benefit of the automated NAT system is the reduced personnel time and the extensive complete barcode-controlled process documentation.

Changes in pneumococcal serotypes and antibiotypes carried by vaccinated and unvaccinated day-care centre attendees in Portugal, a country with widespread use of the seven-valent pneumococcal conjugate vaccine

The seven-valent pneumococcal conjugate vaccine (PCV7) has been available in Portugal since June 2001, but is not included in the National Vaccination Plan. Its impact on colonization is unknown. A point-prevalence study to evaluate PCV7 usage was carried out in 2006 among day-care centre attendees from the Lisbon area. Pneumococcal carriage rates, serotypes, and antibiotypes were determined and compared with results from a similar study conducted in 2001 before vaccine approval. In 2001 and 2006, 717 and 571 children, respectively, were enrolled. In 2006, 45.9% of the participants were appropriately vaccinated and 11.5% were incompletely vaccinated. Carriage of pneumococci remained stable (64.9% in 2001; 68.7% in 2006). Vaccine types (VT) decreased from 53.1% of all pneumococci to 11.2% (p <0.001). Serotype replacement was observed among vaccinated and unvaccinated children. Non-vaccine types (NVT) 1, 6C, 7F, 15A, 16F, 21, 23A, 29, and non-typeable (NT) strains increased significantly; serotype 19A increased, but not significantly. Rates of resistance to penicillin, erythromycin, clindamycin and tetracycline remained stable (p >0.05) due to significant increases in intermediate resistance to penicillin (from 5.5% to 17.8%), erythromycin (from 9.2% to 21.8%), clindamycin (from 6.4% to 19.3%) and tetracycline (from 8.3% to 15.8%) among NVT. Whereas in 2001 resistance among NVT was mostly associated with serotype 19A and NT strains, in 2006 resistance was also found among serotypes 6C, 15A, 24F and 33F. In conclusion, dramatic shifts in serotypes of colonizing pneumococci were observed among vaccinated and unvaccinated children. Rates of antibiotic resistance remained unchanged due to a balance between reduction in VT and an increase in antimicrobial-resistant NVT.

Humanized anti-CEACAM6 PEGylated scFv: A promising novel therapy for pancreatic cancer

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Background: Novel Therapies for pancreatic cancer (PC) based on biological insight are urgently needed. CEACAM6, a member of the carcinoembryonic antigen (CEA) family, is a cell surface oncogene on PC cells. It is a glycoprotein composed of 3 Ig-like domains (Mr ∼35.2kD) and is linked to the plasma membrane via a glycophospholipid linked anchor. It is over-expressed on ≥95% PC patients’ found irrespective of stage of disease and represents a target for antibody therapy. Methods: Murine anti-CEACAM6 monoclonal antibody (Mab) 13–1 was humanized by a structure-based approach and single chain variable fragments (scFv) designed consisting of a Gly/Ser-linker which includes a cysteine residue for PEGylation. Murine scFv and 4 humanized scFv fragments (Version.1, 2, 7, 8) were bacterially expressed, purified, PEGylated and evaluated for activity alone or in combination with gemcitabine in human PC cell lines and mouse xenograft tumors. Cell viability, apoptosis and in-cell Westerns were done for efficacy and binding. Mouse xenograft tumors were treated with scFv or PEGylated scFv or combination with gemcitabine. Tumors (treated Vs untreated) were analyzed by immunohistochemistry for Ki-67, CD31, CEACAM6 and Caspase 3 Results: Mab 13–1, murine and 4 humanized scFvs’ were cytotoxic to CEACAM6 expressing PC cells (BxPC-3, HPAF-2) and not to PC cells that lack CEACAM6 (CaPan-2) with increased PARP-cleavage that was dose dependent (IC50=10μg/mL). Western blotting of culture media and serum from xenograft mice showed that CEACAM6 is not shed. In-cell Western confirmed humanized V.7 to be the best binder (KD=1–10μg/mL) confirming protein-protein interaction studies performed in silico with homology models of murine and humanized scFvs’ and CEACAM6. The murine scFv alone or the humanized scFV (V.8) in combination with gemcitabine delayed tumor growth by >50%. This tumor reduction correlated well with the immunohistochemical markers of response. Conclusions: We have demonstrated that CEACAM6 is a clinically relevant target in PC and that a PEGylated humanized scFv is a novel effective therapy alone and/or in combination with gemcitabine. Humanized scFv V.7 is undergoing mouse xenograft evaluation and expect will be the most effective agent to take forward into clinical development.

No significant financial relationships to disclose.

Characterization of a reference material for BCR-ABL (M-BCR) mRNA quantitation by real-time amplification assays: towards new standards for gene expression measurements

Monitoring of BCR-ABL transcripts has become established practice in the management of chronic myeloid leukemia. However, nucleic acid amplification techniques are prone to variations which limit the reliability of real-time quantitative PCR (RQ-PCR) for clinical decision making, highlighting the need for standardization of assays and reporting of minimal residual disease (MRD) data. We evaluated a lyophilized preparation of a leukemic cell line (K562) as a potential quality control reagent. This was found to be relatively stable, yielding comparable respective levels of ABL, GUS and BCR-ABL transcripts as determined by RQ-PCR before and after accelerated degradation experiments as well as following 5 years storage at -20 degrees C. Vials of freeze-dried cells were sent at ambient temperature to 22 laboratories on four continents, with RQ-PCR analyses detecting BCR-ABL transcripts at levels comparable to those observed in primary patient samples. Our results suggest that freeze-dried cells can be used as quality control reagents with a range of analytical instrumentations and could enable the development of urgently needed international standards simulating clinically relevant levels of MRD.

Natural history of drug-resistant clones of Streptococcus pneumoniae colonizing healthy children in Portugal

A total of 3,539 Streptococcus pneumoniae (Pn) were recovered from 4,969 nasopharyngeal samples of children attending 13 day-care centers (DCCs) located in Lisbon, Portugal, during a surveillance study from January, 2001, through March, 2003, integrated in the European intervention project (EURIS, European Resistance Intervention Study). All Pn isolates were tested for anti-biotyping and drug-resistant pneumococci (DRPn) were further tested by serotyping and pulsed-field gel electrophoresis (PFGE). Overall carriage of Pn was very high (71.2%) and 39.9% of the isolates were resistant to antimicrobials (22.5% with decreased susceptibility to penicillin and 17.4% susceptible to penicillin and resistant to other antimicrobials). Serotypes 6B, 14, 23 F, 19F, and 19 A were prevalent among the 1,287 DRPn and 5.8% of the isolates were non-typeable. Eighty PFGE patterns were identified among 1,285 DRPn, and 93.1% of the DRPn belonged to 26 major clonal types that comprised: Pneumococcal Molecular Epidemiology Network (PMEN) clones (76.3%), Portuguese (PT)-DCC clones, previously detected in 1996-1999 (14.3%), and EURIS PT-DCC new clones, identified for the first time in the EURIS study, during 2001-2003 (9.4%). Comparing with previous Portuguese surveillance studies carried out since 1996, we observed that carriage increased from 47% to 71%, but no major changes were detected on the prevalence of pneumococcal serotypes. Moreover, although PMEN clones were predominant in all DCCs, in the present study the majority of them were gradually decreasing in time whereas several PT-DCC and new clones seemed to be increasing.

A World Health Organization International Standard for hepatitis A virus RNA nucleic acid amplification technology assays

BACKGROUND AND OBJECTIVES

Sixteen laboratories from 10 different countries participated in an international collaborative study to evaluate candidate materials as the first World Health Organization (WHO) International Standard for hepatitis A virus (HAV) RNA nucleic acid amplification technology (NAT) assays.

MATERIALS AND METHODS

Five candidate materials were analysed in this study: materials AA and BB were lyophilized, while materials CC, DD and EE were liquid preparations. Samples were diluted in pooled plasma or in pooled cryo-poor plasma (sample EE). Serial dilutions of the candidate materials were tested by each laboratory in four independent assays and the results were analysed statistically.

RESULTS

The mean log(10)'equivalents' per ml were 5.29 for sample AA, 5.07 for sample BB, 4.99 for sample CC, 5.40 for sample DD and 4.08 for sample EE.

CONCLUSIONS

Based on the results of this study, sample AA was established as the first International Standard for HAV RNA NAT assays at the WHO Expert Committee on Biological Standardizaton (ECBS) meeting held in February 2003. The code number of this preparation is 00/560 and the potency, based on the study, is 100 000 International Units (IU)/ml.

World Health Organization collaborative study to establish a replacement WHO international standard for hepatitis C virus RNA nucleic acid amplification technology assays

BACKGROUND AND OBJECTIVES

A collaborative study was undertaken to establish a replacement for the current (1st) World Health Organization (WHO) hepatitis C virus (HCV) International Standard, 96/790.

MATERIALS AND METHODS

Both the 1(st) International Standard and the replacement standard were prepared from the same starting material by diluting a high titre genotype 1a HCV isolate in pooled, human plasma. The only difference was that each standard was lyophilized in two, separate lyophilisation runs but under the same conditions.

RESULTS

In the study to establish the 1st International Standard, no significant difference in potency was found between the material eventually designated as the 1st International Standard and that now selected as the 2nd International Standard. The present study also showed no significant differences between the materials stored at -20 degrees C and no evidence of degradation over 5 years.

CONCLUSIONS

Material 96/798 was established as the 2nd HCV International Standard and assigned the same unitage as the 1st International Standard, i.e. 10(5) IU/ml (50,000 IU/vial).

Analytical and clinical sensitivity of West Nile virus RNA screening and supplemental assays available in 2003

BACKGROUND

Transfusion-transmitted West Nile virus (WNV) infections were first reported in 2002, which led to rapid development of investigational nucleic acid amplification tests (NAT). A study was conducted to evaluate sensitivities of WNV screening and supplemental NAT assays first employed in 2003.

STUDY DESIGN AND METHODS

Twenty-five member-coded panels were distributed to NAT assay manufacturers. Panels included five pedigreed WNV standards (1, 3, 10, 30, and 100 copies/mL), 15 or 16 donor units with very-low-level viremia identified through 2003 screening, and four or five negative control samples. Samples were tested neat in 10 replicates by all assays; for NAT screening assays, 10 replicates were also performed on dilutions consistent with minipool (MP)-NAT. The viral load distribution for 142 MP-NAT yield donations was characterized, relative to the analytical sensitivity of MP-NAT systems.

RESULTS

Analytical sensitivities (50% limits of detection [LoD] based on Poisson model of detection of WNV standards) for screening NAT assays ranged from 3.4 to 29 copies per mL; when diluted consistent with MP pool sizes, the 50 percent LoD of screening NAT assays was reduced to 43 to 309 copies per mL. Analytical sensitivity of supplemental assays ranged from 1.5 to 7.7 copies per mL (50% LoD). Detection of RNA in donor units varied consistent with analytical LoD of assays. Detection of low-level viremia after MP dilutions was particularly compromised for seropositive units, probably reflecting lower viral loads in the postseroconversion phase. Based on the viral load distribution of MP-NAT yield donations (median, 3519 copies/mL; range, < 50-690,000), 13 to 24 percent of units had viral loads below the 50 percent LoD of screening NAT assays run in MP-NAT format.

CONCLUSION

WNV screening and supplemental assays had generally excellent analytical sensitivity, comparable to human immunodeficiency virus-1 and hepatitis C virus NAT assays. The presence of low-level viremic units during epidemic periods and the impact of MP dilutions on sensitivity, however, suggest the need for further improvements in sensitivity as well as a role for targeted individual-donation NAT in epidemic regions.

Trends in drug resistance, serotypes, and molecular types of Streptococcus pneumoniae colonizing preschool-age children attending day care centers in Lisbon, Portugal: a summary of 4 years of annual surveillance

Of the nasopharyngeal cultures recovered from 942 day care center (DCC) attendees in Lisbon, Portugal, 591 (62%) yielded Streptococcus pneumoniae during a surveillance performed in February and March of 1999. Forty percent of the isolates were resistant to one or more antimicrobial agents. In particular, 2% were penicillin resistant and 20% had intermediate penicillin resistance. Multidrug resistance to macrolides, lincosamides, and tetracycline was the most frequent antibiotype (17% of all isolates). Serotyping and molecular typing by pulsed-field gel electrophoresis were performed for 202 out of 237 drug-resistant pneumococci (DRPn). The most frequent serotypes were 6B (26%), 14 (22%), 19F (16%), 23F (10%), and nontypeable (12%). The majority (67%) of the DRPn strains were representatives of nine international clones included in the Pneumococcal Molecular Epidemiology Network; eight of them had been detected in previous studies. Fourteen novel clones were identified, corresponding to 26% of the DRPn strains. The remaining 7% of the strains were local clones detected in our previous studies. Comparison with studies conducted since 1996 in Portuguese DCCs identified several trends: (i) the rate of DRPn frequency has fluctuated between 40 and 50%; (ii) the serotypes most frequently recovered have remained the same; (iii) nontypeable strains appear to be increasing in frequency; and (iv) a clone of serotype 33F emerged in 1999. Together, our observations highlight that the nasopharynxes of children in DCCs are a melting pot of successful DRPn clones that are important to study and monitor if we aim to gain a better understanding on the epidemiology of this pathogen.

Effect of the seven-valent conjugate pneumococcal vaccine on carriage and drug resistance of Streptococcus pneumoniae in healthy children attending day-care centers in Lisbon

AIMS

Prospective study to evaluate the impact of the 7-valent pneumococcal conjugate vaccine (Prevenar) on the nasopharyngeal (NP) carriage of drug-resistant Streptococcus pneumoniae (DRPn), by healthy children attending day-care centers (ages 6 months-6 years).

METHODS

Vaccinees (238 children) who received vaccine and controls (457 children) were followed for carriage of total S. pneumoniae and DRPn and for the serotypes and genetic backgrounds of DRPn during 6 consecutive sampling periods between May 2001 and February 2003.

RESULTS

We detected no significant differences between vaccinees and the control group in the total carriage rate of Pn (average, 68%) or in the frequency of carriage of DRPn (average, 38%), including the frequency of penicillin-nonsusceptible strains (average, 24%). In contrast, there was a decline in the carriage of DRPn with vaccine serotypes which was compensated by the appearance and gradual increase in the frequency of DRPn expressing unusual serotypes (6A, 10A, 15A and 15C, 19A, 23A, 33F) which were not present in the vaccine as well as an increase in nontypable strains. The majority of the DRPn with unusual serotypes showed different pulsed field gel electrophoresis patterns indicating replacement of the original resistant flora by other clonal types of drug-resistant bacteria. Antibiotic consumption and the frequency of respiratory tract infections were similar among the vaccinees and controls.

CONCLUSIONS

Pneumococcal vaccination did not change the frequency of carriage of drug-resistant strains being the initially dominant vaccine serotypes replaced by others expressing nonvaccine serotypes. Reduction in the carriage of DRPn may require a combination of the conjugate vaccine and a decrease in antibiotic pressure.

External quality assessment for the detection of blood-borne viruses in plasma by nucleic acid amplification technology: the first human immunodeficiency virus and hepatitis B virus studies (HIV EQA/1 and HBV EQA/1) and the fifth hepatitis C virus study (HCV EQA/5)

BACKGROUND AND OBJECTIVES

This External Quality Assessment (EQA) study was aimed at assessing the proficiency of blood centres and blood product manufacturers in detecting, by nucleic acid amplification technology (NAT), the possible contamination of plasma with hepatitis C virus (HCV), human immunodeficiency virus (HIV) and hepatitis B virus (HBV).

MATERIALS AND METHODS

Three independent panels, one for each virus, were prepared at the Istituto Superiore di Sanità (ISS) by diluting the respective reference preparations. NAT methods used by the EQA participants included polymerase chain reaction (PCR) assays by Roche, transcription-mediated amplification (TMA) assays by Chiron and in-house PCR assays.

RESULTS

Forty-three of the 45 participants (95.6%) in the HCV EQA/5 who used a validated method were consistently able to detect a nominal concentration of 100 IU/ml for all six major genotypes. In the case of the HIV EQA/1, all 35 participants detected the samples containing 1000 IU/ml HIV, while five (14.3%) did not identify the samples containing 100 IU/ml HIV. With respect to the HBV EQA/1, all 16 participants correctly identified the positive samples containing either 1000 IU/ml or 100 IU/ml HBV. No false-positive results were observed with any of the three panels.

CONCLUSIONS

The HCV EQA/5 showed an improved proficiency of laboratories as compared with the HCV EQA/4. In fact, HCV genotypes 1, 2, 3 and 5 were correctly identified in 100% of the assays and genotypes 4 and 6 in 97.8% of the assays. While most of the participants in the HIV EQA/1 showed a good level of proficiency, an excellent performance was shown by all participants in the HBV EQA/1.

High proficiency in detecting the six major hepatitis C virus genotypes of laboratories involved in testing plasma by nucleic acid amplification technology

Since the introduction of mandatory HCV RNA testing of plasma pools for fractionation by nucleic acid amplification technology, we have organised External Quality Assessment studies (EQAs) addressed to blood products manufacturers and blood centres. Here we report the results of a new EQA, the first one to include all six major HCV genotypes. The results, reported by laboratories worldwide, showed that genotypes 1, 2 and 3 were correctly identified in 100% of the tests, genotype 4 in 96.7% and genotypes 5 and 6 in 98.3% of the assays. As detection of all HCV genotypes is critical for laboratories involved in testing plasma for HCV, all six genotypes should continue to be included in the next EQA studies.

Use of a rapid, single-round, multiplex PCR to detect malarial parasites and identify the species present

A new, rapid assay, based on a single-round, multiplex PCR, can be used to detect Plasmodium falciparum, P. vivax, P. malariae or P. ovale in human blood. The PCR, which targets the conserved 18S small-subunit RNA genes of the parasites, not only permits a malarial infection to be detected but also allows each Plasmodium species present to be identified, even in cases of mixed infection.

Collaborative study to calibrate hepatitis C virus genotypes 2-6 against the HCV International Standard, 96/790 (genotype 1)

BACKGROUND AND OBJECTIVES

A major requirement of a hepatitis C virus (HCV) RNA nucleic acid amplification technology (NAT) assay validation is the ability of the assay to detect the six major genotypes of HCV with equivalent sensitivities. The aim of this study was to characterize and calibrate an HCV genotype panel for use in such studies.

MATERIALS AND METHODS

Panels consisting of the first International Standard (IS) for HCV RNA NAT assays (96/790; HCV genotype 1a) and isolates of genotypes 2-6 were sent to 17 laboratories worldwide which use a variety of NAT tests, both qualitative and quantitative. The HCV RNA content of each panel member was determined and the mean titre calculated in International Units/ml (IU/ml).

RESULTS

The calculated mean titres (calibrated against the HCV International Standard), in log10 IU/ml, of the genotype 2-6 samples were 3.99, 3.81, 4.14, 4.18 and 4.61, respectively.

CONCLUSIONS

An HCV genotype panel, calibrated in IU/ml, has been established and should be valuable for assay validation. All the genotypes were detected by all the assays used, but it was not possible to demonstrate that the genotypes were detected with equal efficiencies.

Establishment of the first World Health Organization International Standard for human parvovirus B19 DNA nucleic acid amplification techniques

BACKGROUND AND OBJECTIVES

A collaborative study, involving 26 laboratories from 14 countries, was carried out in order to establish a World Health Organization (WHO) International Standard for human parvovirus B19 (B19) DNA nucleic acid amplification techniques (NAT).

MATERIALS AND METHODS

Four samples: AA, BB (which were lyophilized), CC and DD (which were liquid preparations) were analysed using several different NAT assays. The mean B19 DNA content of each sample was determined for each laboratory using an end-point dilution method.

RESULTS

There was good agreement between the overall mean 'equivalents'/ml obtained by the different assays. The mean log(10) 'equivalents'/ml were 5.76 for sample AA, 5.73 for sample BB, 5.82 for sample CC and 7.70 for sample DD. The differences in titre among samples AA, BB and CC were not statistically significant, but the titre of DD was significantly higher.

CONCLUSIONS

Despite the range of NAT assays used in the study, it was possible to calculate the mean B19 DNA concentrations in the four preparations. Lyophilized preparation AA was established as the first International Standard for B19 DNA NAT assays and was assigned a concentration of 10(6) international units (IU)/ml.

Multiple allosteric sites on muscarinic receptors

Proteins and small molecules are capable of regulating the agonist binding and function of G-protein coupled receptors by multiple allosteric mechanisms. In the case of muscarinic receptors, there is the well-characterised allosteric site that binds, for example, gallamine and brucine. The protein kinase inhibitor, KT5720, has now been shown to bind to a second allosteric site and to regulate agonist and antagonist binding. The binding of brucine and gallamine does not affect KT5720 binding nor its effects on the dissociation of [3H]-N-methylscopolamine from M1 receptors. Therefore it is possible to have a muscarinic receptor with three small ligands bound simultaneously. A model of the M1 receptor, based on the recently determined structure of rhodopsin, has the residues that have been shown to be important for gallamine binding clustered within and to one side of a cleft in the extracellular face of the receptor. This cleft may represent the access route of acetylcholine to its binding site.