Safety and efficacy of delayed umbilical cord clamping in multiple and singleton premature infants - A quality improvement study

OBJECTIVES

To evaluate the safety and efficacy of a quality improvement (QI) program of delayed umbilical cord clamping (DCC) in multiple and singleton preterm infants born at our center.

METHODS

After DCC protocol implementation, compliance and success rate were assessed. Clinical outcomes of selected 150 preterm infants <34 weeks gestation born in 2014 after protocol implementation (Epoch II) were compared to those of preterm infants born in 2013 before protocol implementation (Epoch I).

RESULTS

Overall protocol compliance rate was 92% (246/267). DCC was successfully performed in 77% (205/267) after protocol implementation. There were higher multiple births in Epoch II compared to Epoch I (27.3 vs. 15.3% , p <  0.01). At birth, infants in Epoch II had significantly decreased need for intubation in delivery room (23.3 vs. 39.3% , p <  0.01), had higher hematocrit (46.4±7.3 vs. 44.0±7.1% , p <  0.01) and less metabolic acidosis (base excess -4.1±2.7 vs. -5.3±4.2 mmol/L, p <  0.01) compared to those born in Epoch I. During hospital stay, fewer infants in Epoch II received rescue surfactant therapy (45.3 vs. 56.7% , p = 0.05), medical treatment for PDA (6.7 vs. 16.6% , p = 0.04%) and red blood cell transfusions (20.7 VS. 32.0% , p <  0.01) compared to Epoch I.

CONCLUSIONS

Protocol-guided practice of DCC for 30 seconds can be safely performed in multiple and singleton preterm infants. In addition to higher initial hematocrit, infants in our QI project had lower need for delivery room resuscitation and less metabolic acidosis at birth. We also observed decreased need for rescue surfactant therapy, medical treatment for PDA and red blood cell transfusions after DCC protocol implementation.

Neonatal-perinatal risk factors for the development of persistent pulmonary hypertension of the newborn in preterm newborns

There is a long-held belief that preterm newborns lack sufficient arteriolar musculature to maintain a prolonged elevated pulmonary vascular resistance (PVR) after birth. Net ductal flow is thought to be minimal, with the developing pulmonary circulation incapable of significant vasoconstriction. We identified retrospectively 15 premature newborns over a 10-year period weighing < or = 1500 g and with a gestational age of < or = 30 weeks with documented persistent pulmonary hypertension of the newborn (PPHN) in the first 24 hours after birth. We matched 36 newborns of similar weight and gestation with no clinical evidence of shunting. The control group weaned to an FiO2 < or = 0.50 by 12 hours after birth. Despite similar gestational ages, the PPHN group (n = 15) had significantly higher birth weights than the control group (n = 36). The duration of ruptured membranes, maternal tobacco use, and use of antenatal steroids were significantly higher in the PPHN group. We speculate that these three factors might act in a synergistic relationship with which to accelerate pulmonary vascular smooth muscle development in premature newborns.

Cytokine, Chemokine, and Metalloprotease Activation in the Serum of Patients with Nephropathia Epidemica from the Republic of Tatarstan and the Republic of Mordovia, Russia

Nephropathia Epidemica (NE), endemic to several Volga regions of Russia, including the Republic of Tatarstan (RT) and the Republic of Mordovia (RM), is a mild form of hemorrhagic fever with renal syndrome caused by infection with rodent-borne orthohantaviruses. Although NE cases have been reported for decades, little is known about the hantavirus strains associated with human infection in these regions. There is also limited understanding of the pathogenesis of NE in the RT and the RM. To address these knowledge gaps, we conducted comparative analyses of patients with NE in the RT and the RM. Clinical symptoms were more severe in patients with NE from the RM with longer observed duration of fever symptoms and hospitalization. Analysis of patient sera showed changes in the levels of numerous cytokines, chemokines, and matrix metalloproteases (MMPs) in patients with NE from both the RT and the RM, suggesting leukocyte activation, extracellular matrix degradation, and leukocyte chemotaxis. Interestingly, levels of several cytokines were distinctly different between patients NE from the RT when compared with those from the RM. These differences were not related to the genetic variation of orthohantaviruses circulating in those regions, as sequence analysis showed that Puumala virus (PUUV) was the causative agent of NE in these regions. Additionally, only the “Russia” (RUS) genetic lineage of PUUV was detected in the serum samples of patients with NE from both the RT and the RM. We therefore conclude that differences in serum cytokine, chemokine, and MMP levels between the RT and the RM are related to environmental factors and lifestyle differences that influence individual immune responses to orthohantavirus infection.

Safety of immediate skin-to-skin contact after vaginal birth in vigorous late preterm neonates - A pilot study

BACKGROUND

To evaluate the safety of immediate skin-to-skin contact (SSC) in vigorous late preterm neonates, where observation under radiant warmer is standard of care, in a prospective, randomized, controlled, and equivalence pilot study.

METHODS

Singletons born vaginally at 35-36 6/7 weeks gestation were randomized to initiate immediate SSC or standard of care with continuous pulse oximeter monitoring for the first hour of life.

RESULTS

Forty-seven dyads were randomized to SSC (n = 21) or radiant warmer (n = 26). Vitals were recorded at designated time intervals to assess tolerance of postnatal transitioning. We found no significant difference in the number of SSC interruptions, pulse oximeter readings, initial glucose level, and rates of hypoglycemia, hypothermia, or NICU admission between the two groups.

CONCLUSIONS

Vigorous late preterm neonates transitioned to immediate SSC without additional risks compared to control counterparts. Large, multicenter, and randomized-control studies need to be conducted to establish standardized guidelines for this practice.

Effect of polyclonal anti-TNFalpha antibody on endotoxic shock in suckling rats

The aim of this study was to evaluate the effect of anti-tumor necrosis factor alpha (TNFalpha) antibodies on the TNFalpha gene expression in a neonatal septic shock model. Ten-day-old Sprague-Dawley rats were divided into four groups and given intraperitoneal (ip) injection as follows: group 1: 0.1 ml saline; group 2: 0.1 mg/kg Salmonella enteritidis lipopolysaccharide (LPS); group 3: 1 mg/kg of anti-TNFalpha antibodies (Ab); group 4: 0.1 mg/kg of LPS and 1 mg/kg of Ab. We found that in group 2, LPS induced shock, demonstrating hypoglycemia and lactacidemia (p < 0. 05) and death (81.8%). Ab decreased the mortality significantly (35%) and attenuated the hypoglycemia (35 +/- 8 mg/dl in group 2 vs. 53 +/- 3 mg/dl in group 4) and lactacidemia (5.40 +/- 0.63 vs. 2.35 +/- 0.45 mmol) at 8 h in group 4 when compared to group 2. Northern blot demonstrated a significant decrease in TNFalpha mRNA expression in group 4 as compared to group 2, at 2 h after LPS injection. We conclude that the beneficial effects of anti-TNFalpha antibodies on LPS-induced shock may be due to decreased TNFalpha gene expression.

Atypical histological presentation of bone regeneration after insertion of cryoprotected allogeneic bone graft

BACKGROUND

To evaluate bone regenerative capacity of cryoprotected corticocancellous allogeneic bone graft performed in type II and III post-extraction sockets for ridge preservation after twelve weeks in-vivo.

MATERIAL AND METHODS

Twenty-seven type II or III bony-walled extraction sockets (mandible and maxilla) were selected for this study. Following atraumatic tooth-extraction a cryoprotected corticocancellous allogeneic bone graft material and a resorbable porcine-derived collagen membrane were used for ridge preservation. During re-entry surgery at approximately 12 weeks, bone core biopsies were obtained using a 3.2 mm trephine drill and samples were histologically processed and subjected to qualitative and quantitative histomorphometric analysis. Quantitative data was analyzed using a general linear mixed model with results presented as mean values with the corresponding 95% confidence interval values.

RESULTS

Healing without incident and ridge preservation allowed for the placement of dental implants after 12 weeks in 25 out of the 27 treated socket sites. Analyses yielded an average of ~21.0±7% of old/native bone, ~17±5.5% of newly regenerated bone (total of ~38±12.8% for all bone), 0.23±0.14% of new bone presenting with nucleating sites within the matrix, ~52±5.12% of soft tissue, and 3.6±2.09% of damaged bone. The average regenerated bone was statistically analogous to that of old/native bone (p=0.355). Furthermore, an atypical histological pattern of bone regeneration was observed, with newly formed bone exhibiting "infiltration-like" behavior and with new bone nucleating sites observed within the demineralized bone matrix.

CONCLUSIONS

Cryoprotected corticocancellous allogeneic bone-graft demonstrated osteoconductive, osteoinductive, and osteogenic properties, yielding unique healing patterns which does warrant further investigation.

RNA interacts with topoisomerase I to adjust DNA topology

Topoisomerase I (TOP1) is an essential enzyme that relaxes DNA to prevent and dissipate torsional stress during transcription. However, the mechanisms underlying the regulation of TOP1 activity remain elusive. Using enhanced cross-linking and immunoprecipitation (eCLIP) and ultraviolet-cross-linked RNA immunoprecipitation followed by total RNA sequencing (UV-RIP-seq) in human colon cancer cells along with RNA electrophoretic mobility shift assays (EMSAs), biolayer interferometry (BLI), and in vitro RNA-binding assays, we identify TOP1 as an RNA-binding protein (RBP). We show that TOP1 directly binds RNA in vitro and in cells and that most RNAs bound by TOP1 are mRNAs. Using a TOP1 RNA-binding mutant and topoisomerase cleavage complex sequencing (TOP1cc-seq) to map TOP1 catalytic activity, we reveal that RNA opposes TOP1 activity as RNA polymerase II (RNAPII) commences transcription of active genes. We further demonstrate the inhibitory role of RNA in regulating TOP1 activity by employing DNA supercoiling assays and magnetic tweezers. These findings provide insight into the coordinated actions of RNA and TOP1 in regulating DNA topological stress intrinsic to RNAPII-dependent transcription.

How much does a minimum weight at discharge delay discharge from the neonatal intensive care unit?

BACKGROUND

Current American Academy of Pediatrics guidelines recommend discharge at physiologic maturity regardless of weight; however, our institution's neonatal ICU policy requires a minimum weight of 1800 g for discharge even when infant is physiologically mature. So, we wanted to determine if discharge at physiologic maturity (PM), based on national guidelines, would decrease hospital days (HD).

METHODS

We reviewed 129 infants with birthweight 1300g- 1800 g. Data were analyzed by paired t-test/ Wilcoxon-rank-sum test.

RESULTS

Age at discharge vs. age at PM was 0.55d per infant higher (P-value 0.033) resulting in 71 total HD. For SGA babies, this difference was 1.47d vs 0.19d in non-SGA babies (P- value 0.0243) and this difference was an average of 2.63d (P-value < 0.001) for those who reached PM < 1800 g, contributing to 50 of 71 HD potentially saved.

CONCLUSION

There was a 0.55-2.6-day difference between age at discharge and age at PM, greater in SGA infants and infants who reached PM prior to 1800 g. There might be an opportunity to send infants home earlier to their families if there is no minimum weight required.