NICU patients receiving more than twenty-five platelet transfusions

OBJECTIVE

A few patients in neonatal intensive care units (NICU) receive numerous platelet transfusions. These patients can become refractory, defined as transfusions of ≥10 mL/kg failing to increase the platelet count by at least 5000/µL. Causes of, and best treatments for, platelet transfusion refractoriness in neonates have not been defined.

STUDY DESIGN

Multi-NICU multi-year retrospective analysis of neonates receiving >25 platelet transfusions.

RESULTS

Eight neonates received 29 - 52 platelet transfusions. All eight were blood group O. Five had sepsis, four were very small for gestational age, four had bowel resections, two Noonan syndrome, two had cytomegalovirus infection. All eight had some (19 - 73%) refractory transfusions. Many (2 - 69%) of the transfusions were ordered when the platelet count was >50,000/µL. Higher post-transfusion counts occurred after ABO-identical transfusions (p=0.026). Three of the eight had late NICU deaths related to respiratory failure; all five survivors had severe bronchopulmonary dysplasia requiring tracheostomy for prolonged ventilator management.

CONCLUSION

Neonates who are high users of platelet transfusions appear to be at high risk for poor outcomes, especially respiratory failure. Future studies will examine whether group O neonates are more likely to develop refractoriness and whether certain neonates would have a higher magnitude of post-transfusion rise if they received ABO identical donor platelets.

Final survival analysis of NSGO-AVANOVA2/ENGOT-OV24: Combination of niraparib and bevacizumab versus niraparib alone as treatment of recurrent platinum-sensitive ovarian cancer—A randomized controlled chemotherapy-free study

6012

Background: We previously reported significantly improved progression-free survival (PFS) with the chemotherapy-free regimen of niraparib and bevacizumab compared to niraparib alone, in women with platinum-sensitive relapsed ovarian cancer (PSROC), regardless of homologous recombination deficiency (HRD) status (MyChoice HRD), duration of chemotherapy-free interval (CFI) and number of previous lines of therapy (Mirza MR et al, Lancet Oncol 2019). We now present the updated PFS, overall survival (OS) and other efficacy and safety endpoints. Methods: In this randomized, open-label, phase 2 study, women with measurable/evaluable, high-grade serous or endometrioid PSROC were randomized to niraparib 300mg once daily or the combination of niraparib 300mg once daily and bevacizumab 15mg/kg IV every 3 weeks until disease progression (1:1 randomization). The primary endpoint was PFS. Stratification was according to HRD status and CFI (6-12months (mo) vs. > 12mo). First-line maintenance bevacizumab was permitted. Results: Of 97 enrolled patients, 48 were randomized to niraparib monotherapy and 49 to the chemotherapy-free combination. The combined treatment significantly improved PFS compared to niraparib alone: updated median PFS 12.5 mo vs. 5.5 mo; hazard ratio (HR) adjusted for stratification factors 0.34; 95% confidence interval (CI) [0.21 to 0.55]; P < 0.0001. Preplanned exploratory subgroup analyses: patients with HRD-positive tumors (n = 54) HR 0.41 (CI, 0.23-0.76); HRD-negative disease (n = 43) HR, 0.40 (CI, 0.20-0.79); Time to First Subsequent Therapy (TFST) (n=97) HR, 0.4 (CI, 0.25-0.64); PFS2 (n=97) HR 0.55 (CI, 0.35-0.88); Time to Second Subsequent Therapy (TSST) (n=97) HR, 0.56 (CI, 0.35-0.90); OS (49 events only) HR, 0.77 (CI, 0.42-1.41). There was no difference in treatment-emergent grade 3-4 adverse events except for the rate of hypertension (22.9% vs. 0%) and neutropenia (8.3% vs. 2.0%). Patient-reported outcomes measured using EORTC QLQ-C30 and OV28 were similar for both treatment arms. Conclusions: Updated PFS consistently demonstrates that the niraparib-bevacizumab combination had clinically and statistically meaningful activity in PSROC. This phase 2 study was not powered to detect differences in OS or any other efficacy endpoints however TFST, PFS2 & TSST are significantly improved while there is a trend towards OS improvement with niraparib-bevacizumab combination. Clinical trial information: NCT02354131.

Niraparib plus bevacizumab versus niraparib alone for platinum-sensitive recurrent ovarian cancer (NSGO-AVANOVA2/ENGOT-ov24): a randomised, phase 2, superiority trial

BACKGROUND

Platinum-based chemotherapy is the foundation of treatment for platinum-sensitive recurrent ovarian cancer, but has substantial toxicity. Bevacizumab and maintenance poly(ADP-ribose) polymerase (PARP) inhibitors both significantly improve efficacy versus standard therapy, primarily in terms of progression-free survival, and offer the potential for chemotherapy-free treatment. AVANOVA2 compared niraparib and bevacizumab versus niraparib alone as definitive treatment for platinum-sensitive recurrent ovarian cancer.

METHODS

This open-label, randomised, phase 2, superiority trial in 15 university hospitals in Denmark, Sweden, Finland, Norway, and the USA enrolled women aged 18 years or older with measurable or evaluable high-grade serous or endometrioid platinum-sensitive recurrent ovarian cancer. Patients had to have an Eastern Cooperative Oncology Group performance status of 0-2, and had to have previously received platinum-containing therapy for primary disease but ≤1 prior non-platinum-containing regimen for recurrent disease. Previous treatment with bevacizumab or first-line maintenance PARP inhibitors was permitted. Eligible patients were randomly assigned 1:1 (by random permuted blocks with block sizes of two and four, no masking), stratified by homologous recombination deficiency status and chemotherapy-free interval, to receive once-daily oral niraparib 300 mg alone or with intravenous bevacizumab 15 mg/kg once every 3 weeks until disease progression. The primary endpoint was progression-free survival, assessed by the investigators in the intention-to-treat population after events in at least 62 patients. Safety was analysed in all patients who received at least one dose of study drug. This ongoing trial is registered with ClinicalTrials.gov, number NCT02354131.

FINDINGS

Between May 23, 2016, and March 6, 2017, 97 patients were enrolled and randomly assigned: 48 to niraparib plus bevacizumab and 49 to single-agent niraparib. Median follow-up was 16·9 months (IQR 15·4-20·9). Niraparib plus bevacizumab significantly improved progression-free survival compared with niraparib alone (median progression-free survival 11·9 months [95% CI 8·5-16·7] vs 5·5 months [3·8-6·3], respectively; adjusted hazard ratio [HR] 0·35 [95% CI 0·21-0·57], p<0·0001). Grade 3 or worse adverse events occurred in 31 (65%) of 48 patients who received niraparib plus bevacizumab and 22 (45%) of 49 who received single-agent niraparib. The most common grade 3 or worse adverse events in both groups were anaemia (7 [15%] of 48 vs 9 [18%] of 49) and thrombocytopenia (5 [10%] vs 6 [12%]), and hypertension in the combination group (10 [21%] vs 0). Niraparib plus bevacizumab was associated with increased incidences of any-grade proteinuria (10 [21%] of 48 patients vs 0) and hypertension (27 [56%] of 48 vs 11 [22%] of 49) compared with niraparib alone. No treatment-related deaths occurred.

INTERPRETATION

The efficacy observed with this chemotherapy-free combination of approved agents in women with platinum-sensitive recurrent ovarian cancer warrants further evaluation. A randomised phase 3 trial investigating niraparib plus bevacizumab versus chemotherapy plus bevacizumab in platinum-sensitive recurrent ovarian cancer is planned.

FUNDING

Nordic Society of Gynaecological Oncology and Tesaro.

ENGOT-Ov41/GEICO-69-O/ANITA trial: A phase III randomized, double-blinded trial of platinum-based chemotherapy (CT) with or without atezolizumab (ATZ) followed by niraparib maintenance with or without ATZ in patients with recurrent ovarian, tubal or peritoneal cancer (OC) and platinum treatment-free interval (TFIp) >6 months

TPS5599

Background: Platinum-based CT is the treatment of choice for OC patients (pts) with TFIp > 6 months suitable for platinum. Niraparib is an oral PARP inhibitor that significantly prolongs the progression-free survival (PFS) of OC pts when given as maintenance therapy after a response to platinum-rechallenge (both in gBRCA and non-gBRCA mutated pts). Atz is a humanized monoclonal antibody targeting PD-L1 that showed activity in heavily pretreated OC pts. Combination of anti-PD-L1 and CT may improve the activity of the anti-PD-L1 antibody by increasing the amount of antigens released after immunogenic cell death induced by CT. Combination of PARPi and anti-PD-L1/PD-1 has shown synergy in preclinical models and promising clinical activity in certain indications. Methods: ANITA (NCT03598270) is a phase III, randomized (1:1), double-blinded, multi-center study to assess the efficacy of the addition of Atz to platinum-based doublet CT followed by maintenance niraparib in patients with recurrent high grade serous or endometrioid OC with a TFIp > 6 months. Approximately 414 patients with ECOG 0-1, known BRCA status, at least one measurable lesion and ≤ 2 prior lines will be randomized to placebo of Atz (Arm A) or Atz (Arm B) in combination with one of three possible standard platinum-based CT regimens (investigator’s choice) followed by maintenance niraparib in combination with placebo or Atz, according to randomization, if experiencing response or stable disease by RECIST after CT. Stratification factors: 1) Platinum-based regimen (paclitaxel-carboplatin vs gemcitabine-carboplatin vs PLD-carboplatin); 2) Platinum-free interval (6-12 vs > 12 months); and 3) BRCA status (mutated vs non-mutated). Dose of Atz is 1200 mg q3 weeks or 840 mg q2 weeks depending on the platinum-based regimen selected. Niraparib initial dose (300 vs 200 mg) is decided based on body weight and platelet counts after CT according to RADAR analysis. Primary endpoint is PFS based on investigator assessment by RECIST v1.1. Clinical trial information: NCT03598270.

Combination of niraparib and bevacizumab versus niraparib alone as treatment of recurrent platinum-sensitive ovarian cancer: A randomized controlled chemotherapy-free study—NSGO-AVANOVA2/ENGOT-OV24

5505

Background: Standard treatment of platinum-sensitive recurrent ovarian cancer (PSROC) is platinum based combination chemotherapy ± bevacizumab. However, this treatment modality is hardly curative, and is associated with significant toxicity. Both bevacizumab (BEV) and PARP inhibitors (PARPi) have demonstrated efficacy in PSROC. There is preclinical evidence of enhanced activity of the combination. This is the proof-of-concept randomized trial of PARPi-BEV combination against PARPi monotherapy as treatment in PSROC, regardless of number of previous lines of therapies. Methods: In this randomized, open-label, phase 2 study, women with measurable/evaluable, high-grade serous or endometrioid PSROC were randomized to niraparib 300mg once daily or the combination of niraparib 300mg once daily and BEV 15mg/kg IV every 3 weeks until disease progression (1:1 randomization). The primary endpoint was progression-free survival (PFS). Stratification was according to homologous recombination-deficiency(HRD) status (MyChoice HRD) and chemotherapy-free-interval (CFI)(6-12months (mo) vs. >12mo). First-line maintenance bevacizumab was permitted. Results: Of 97 enrolled patients, 48 were randomized to niraparib monotherapy and 49 to the chemotherapy-free combination. The combined treatment significantly improved PFS compared to niraparib alone: median 11.9 vs. 5.5 mo; hazard ratio (HR) adjusted for stratification factors 0.35; 95% confidence interval (CI),[0.21 to 0.57]; P<0.001. Pre-planned exploratory subgroup analyses: patients with HRD-positive tumors (n=54) HR 0.36 (CI, 0.18-0.69); HRD-negative disease (n=43) HR, 0.47 (CI, 0.24-0.95); g BRCAmut patients (n=34) HR 0.53 (CI, 0.23-1.21); non-g BRCAmut patients (n=63) HR 0.33; CI, 0.18-0.61); CFI of 6 to 12 mo (n=38) HR, 0.29 (CI, 0.14 to 0.62); CFI of ≥12 mo (n=59) HR, 0.42; (CI, 0.22 to 0.80). There was no difference in treatment-emergent grade 3-4 adverse events except for the rate of hypertension (26.5% vs. 0%) and neutropenia (12.2% vs. 2.1%). Patient-reported outcomes measured using EORTC QLQ-C30 and OV28 were similar for both treatment arms. Conclusions: Both niraparib alone and the combination had meaningful activity in PSROC. Compared to niraparib alone, the chemotherapy-free regimen of niraparib and BEV significantly improved PFS in women with PSROC,regardless of HRD status and duration of CFI. Clinical trial information: NCT02354131.

Patient-initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early-stage endometrial cancer

OBJECTIVE

To test the hypothesis that patient-initiated follow up reduces the fear of cancer recurrence (FCR) and healthcare use when compared with traditional hospital-based follow up.

DESIGN

Pragmatic, multicentre randomised trial.

SETTING

Four Danish departments of gynaecology between May 2013 and May 2016.

POPULATION

One hundred and fifty-six women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I low-intermediate risk endometrial carcinoma.

METHODS

Women allocated to the control group attended hospital-based follow up consisting of regular outpatient visits for 3 years after primary treatment. Women in the intervention group were instructed in patient-initiated follow up, which included careful instruction in alarm symptoms and options for self-referral rather than a schedule of examinations.

MAIN OUTCOME MEASURES

The primary end point was FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) after 10 months of follow up. Secondary end points included cancer-related use of primary and secondary health care during the first 10 months after treatment.

RESULTS

In the primary analysis, FCR decreased significantly more in the control group from baseline to 10 months of follow up (difference -5.9, 95% CI -10.9 to -0.9). The majority of this improvement happened after only 3 months of follow up. Women receiving the intervention had fewer examinations at the department compared with the control group (0 versus 2 median visits, P < 0.01) and 58% of these examinations were scheduled because of vaginal bleeding.

CONCLUSIONS

Hospital-based follow up alleviates FCR significantly more than patient-initiated follow up, though the estimated difference was small. Patient-initiated follow up is a feasible, potentially cost-reducing follow-up approach in a population of endometrial cancer survivors with low risk of recurrence. The decision to use patient-initiated follow up should balance these benefits and harms.

TWEETABLE ABSTRACT

Patient-initiated follow up reduces healthcare use but maintains fear of recurrence in endometrial cancer.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Follow up of women with endometrial cancer is resource consuming and previous research suggests that it is not effective. Even though the women benefit from reassurance at follow up, routine examinations may also remind the women of the disease and induce fear of cancer recurrence. Furthermore, routine follow up may delay recurrence diagnosis, because the women do not report their symptoms until the next scheduled visit. In the research explained in this article, patient-initiated follow up was evaluated as an alternative to traditional follow up. The women were randomly assigned to one of two follow-up programmes: regular gynaecological examinations at the department of gynaecology or self-referral with careful instruction in alarm symptoms, that is, patient-initiated follow up. The level of fear of cancer recurrence in the two groups was obtained by questionnaires. Information on healthcare use was obtained by questionnaires and a chart review. What were the main findings? Regular examinations at the department of gynaecology reduced the fear of cancer recurrence significantly more than patient-initiated follow up, though the difference was small. Women who were instructed in alarm symptoms, under self-referral, were able to monitor their symptoms, and this approach significantly reduced the number of examinations at the department of gynaecology. What are the limitations of the work? Participants in the self-referral group knew that they were examined less than other women, and this may have induced fear of cancer recurrence. Similarly, the regular completion of questionnaires regarding fear of cancer recurrence may have reminded the women of the disease and diminished the difference between the two groups. What are the implications for patients Patient-initiated follow up reduced healthcare use but maintained fear of cancer recurrence in women who had survived early-stage endometrial cancer. Future analyses on quality of life and cost-effectiveness are needed to balance the benefits and harms of patient-initiated follow up.

Effectiveness of a comprehensive interactive eHealth intervention on patient-reported and clinical outcomes in patients with an implantable cardioverter defibrillator [ACQUIRE-ICD trial]: study protocol of a national Danish randomised controlled trial

BACKGROUND

In Denmark and other countries, there has been a shift in the management of patients with an implantable cardioverter defibrillator (ICD) with remote device monitoring largely replacing in-hospital visits. Less patient-nurse and patient-physician interaction may lead to gaps in patients' quality of care and impede patients' adaptation to living successfully with the ICD. A comprehensive eHealth intervention that include goal-setting, monitoring of symptoms of depression, anxiety, and quality of life, psychological treatment, information provision, supportive tools, online dialogues with nursing staff and access to an online community network, may help fill these gaps and be particularly beneficial to patients who suffer from anxiety and depression. This study will evaluate the effectiveness of the ACQUIRE-ICD care innovation, a comprehensive and interactive eHealth intervention, on patient-reported and clinical outcomes.

METHODS

The ACQUIRE-ICD study is a multicenter, prospective, two-arm, unblinded randomised controlled superiority trial that will enroll 478 patients implanted with a first-time ICD or ICD with cardiac synchronisation therapy (CRT-D) from the six implanting centers in Denmark. The trial will evaluate the clinical effectiveness and cost-effectiveness of the ACQUIRE-ICD care innovation, as add-on to usual care compared with usual care alone. The primary endpoint, device acceptance, assessed with the Florida Patient Acceptance Survey, is evaluated at 12 months' post implant. Secondary endpoints, evaluated at 12 and 24 months' post implant, include patient-reported outcomes, return to work, time to first ICD therapy and first hospitalisation, mortality and cost-effectiveness.

DISCUSSION

The effectiveness of a comprehensive and interactive eHealth intervention that relies on patient-centred and personalised tools offered via a web-based platform targeted to patients with an ICD has not been assessed so far. The ACQUIRE-ICD care innovation promotes and facilitates that patients become active participants in the management of their disease, and as such addresses the need for a more patient-centered disease-management approach. If the care innovation proves to be beneficial to patients, it may not only increase patient empowerment and quality of life but also free up time for clinicians to care for more patients.

TRIAL REGISTRATION

The trial has been registered on https://clinicaltrials.gov/ct2/show/NCT02976961 on November 30, 2016 with registration number [ NCT02976961 ].

The immature platelet fraction: creating neonatal reference intervals and using these to categorize neonatal thrombocytopenias

OBJECTIVE

The immature platelet fraction (IPF) is a laboratory measurement analogous to the reticulocyte count, but reflecting the thrombopoietic state. Similar to a reticulocyte count, it can be expressed as a percent (IPF%=percent of platelets that are immature) or as an absolute number per μl blood; the immature platelet count (IPC=IPF% × platelets per μl of blood).

STUDY DESIGN

Using a retrospective analysis of de-identified data from non-thrombocytopenic neonates, we created reference intervals for IPF% and IPC. We then tested the value of these measurements for categorizing thrombocytopenic neonates.

RESULTS

New charts display reference intervals for IPF% and IPC on the day of birth according to gestational age, and during the first 90 days after birth. Neonates with hyporegenerative varieties of thrombocytopenias (syndromes, small for gestational age, birth asphyxia) had lower IPF% and IPC than did neonates with consumptive thrombocytopenias (immune-mediated, infection, disseminated intravascular coagulation, necrotizing enterocolitis; both P<0.0001).

CONCLUSION

The new reference interval charts can be used to recognize abnormal IPFs. The IPF parameters can help clarify the kinetic mechanism responsible for thrombocytopenias in neonates.

Postoperative chemotherapy or no further treatment for patients with node-negative stage I-II intermediate or high risk endometrial cancer: The ENGOT-EN2/DGCG trial

TPS5613

Background: Patients with medium and high-risk stage I and II endometrial cancers (EC) have, despite radical surgery, a high risk for progression. Adjuvant brachytherapy or EBRT is the traditional therapy for many decades although without impacting on survival. Several studies have failed to demonstrate superiority of adjuvant chemotherapy in unselected population with a high number of low-risk patients. It is of utmost importance to demonstrate efficacy of adjuvant combination chemotherapy in a randomized trial comparing to no further treatment in the medium and high-risk node negative stage I and stage II patients. Methods: The primary objective of this trial is to evaluate the effect on overall survival of carboplatin-paclitaxel combination chemotherapy against no further systemic treatment. Key eligibility criteria include: histologically confirmed EC, stage I grade 3 endometrioid adenocarcinoma or stage II endometrioid adenocarcinoma or stage I and II type 2 histology (clear cell, serous, squamous cell carcinoma, carcinosarcoma or undifferentiated carcinoma); prior surgery with pelvic lymphadenectomy or sentinel lymph node biopsy. Patients may receive vaginal brachytherapy in both arms. 240 patients are randomized to receive six courses of adjuvant carboplatin (AUC5) and paclitaxel (175mg/m2) combination on day one every 21 days or no further treatment (1:1 randomization). Primary endpoint is overall survival of endometrioid subgroup. Secondary endpoints include overall survival of whole study population, disease specific survival, progression-free survival, toxicity, compliance, Quality of Life (assessed via EORTC QLQ-C30 and EORTC QLQ-EN24), rate of isolated pelvic or distant relapses, as well as mixed relapses. Trial is enrolling patients. The following cooperative groups are participating: DGCG (DK), NSGO (DK, FIN, SWE), BGOG (BEL), MaNGO (ITA), MITO (ITA), GEICO (SPA), NOGGO (GER), CEEGOG (Czech), ISGO (ISR) & MDACC (USA). Clinical trial information: NCT01244789.

Long-term benefit of niraparib treatment of recurrent ovarian cancer (OC)

5534

Background: Current therapies for recurrent OC include chemotherapy (C) or bevacizumab (B) in combination with C followed by continuous B, which showed improved progression-free survival (PFS) compared with C followed by placebo (P) over 3.4 months (GOG-0213) or 4.0 months (OCEANS). Potential impact of B on effectiveness of subsequent therapies has not been described. Niraparib (N) is a highly selective PARP 1/2 inhibitor (PARPi). In preclinical studies, N concentrates in the tumor; N showed significantly longer PFS vs P in patients (pts) with recurrent OC following complete/partial response (CR/PR) to platinum based chemotherapy (Plat) in the randomized, controlled, double-blind phase 3 ENGOT-OV16/NOVA trial. We report the long term effect of treatment with N and its impact on subsequent therapy. Methods: Eligibility for NOVA included recurrent OC, fallopian tube or peritoneal cancer, no prior PARPi use, and completion of ≥2 prior courses of Plat, with a CR or PR following the most recent Plat. Pts were enrolled into g BRCAmut or non-g BRCAmut cohorts based on BRCA mutation test results and randomized 2:1 to receive N 300 mg qd or P until progression of disease or death (PD). Tumors were tested for homologous recombination deficiency (HRD). Estimated probability of PD in each cohort at 12, 18 and 24 months post randomization, representing ~18, 24 and 30 months post chemotherapy initiation, was determined; the difference between PFS2 and PFS (PFS2-PFS) was evaluated in all randomized pts. Results: 203 pts were randomized in the g BRCAmut cohort. Of 350 pts randomized in the non-g BRCAmut cohort, 162 had HRD+ and 134 HRD− tumors. Estimated probability (product-limit method) of PFS at 12, 18 and 24 months was greater in the niraparib arm than in the placebo arm in each cohort and subgroup at each time interval. Probabilities (95% CI) at 24 months for niraparib vs control were 0.42 (0.30, 0.55) vs 0.16 (0.07, 0.28) (gBRCAmut) and 0.27 (0.19, 0.35) vs 0.12 (0.06, 0.21) (non-gBRCAmut). PFS2-PFS was similar in the 2 treatment arms in the combined cohorts (HR 1.02, 95% CI 0.765, 1.349). Conclusions: Niraparib provided long term benefit in pts with recurrent OC irrespective of g BRCAmut or HRD status, and no decrement in the benefit of subsequent therapy was observed. Clinical trial information: NCT01847274.

Palbociclib versus placebo in combination with letrozole for patients with advanced or recurrent endometrial cancer: The NSGO ENGOT-EN3/PALEO trial

TPS5612

Background: Endometrial cancer (EC) patients with advanced or recurrent disease and endometrioid histology have a short progression-free survival (PFS). These malignancies are hormone dependent and endocrine therapy with aromatase inhibitors is well established. Palbociclib is an oral and selective inhibitor of cyclin-dependent kinases CDK4 and CDK6. Studies in breast cancer have demonstrated superiority of letrozole treatment in combination with palbociclib vs. letrozole monotherapy in oestrogen receptor positive (ER+) HER2- advanced disease. The combination is generally well tolerated with an acceptable toxicity profile. This multicenter, prospective, double-blind, placebo-controlled, randomized, phase II trial is evaluating the efficacy of letrozole when combined with palbociclib against letrozole-placebo combination therapy in women with ER+ advanced or recurrent EC. Methods: The primary objective of this trial is to demonstrate superiority of palbociclib against placebo in combination with letrozole, as defined by investigator-assessed progression-free survival (PFS). Key eligibility criteria include: histologically confirmed ER+ EC of endometrioid type; stage 4 or recurrent disease; prior surgery, adjuvant chemotherapy, radiation therapy, hormonal therapy (e.g. megestrol acetate) is permitted; measurable/evaluable disease according to RECIST 1.1. 78 patients will be randomized 1:1 to receive palbociclib 125mg daily or placebo on days 1-21 and letrozole 2.5mg daily on days 1-28 in a 28 days cycle until disease progression, unacceptable toxicity, or withdrawal. Secondary endpoints include PFS in sub-populations, overall response rate, disease control rate, PFS2, time to first subsequent therapy, time to second subsequent therapy, overall survival, safety & tolerability, patient reported outcomes (assessed via EORTC QLQ-C30 and EORTC QLQ-EN24) and PFS in patients with or without retinoblastoma protein-expressing tumors. The following cooperative groups are participating: NSGO (DK, FIN, NOR), MITO (ITA), GEICO (SPA) & NOGGO (GER). Clinical trial information: NCT02730429.

The iron status at birth of neonates with risk factors for developing iron deficiency: a pilot study

OBJECTIVE

Small-for-gestational-age (SGA) neonates, infants of diabetic mothers (IDM) and very-low-birth weight premature neonates (VLBW) are reported to have increased risk for developing iron deficiency and possibly associated neurocognitive delays.

STUDY DESIGN

We conducted a pilot study to assess iron status at birth in at-risk neonates by measuring iron parameters in umbilical cord blood from SGA, IDM, VLBW and comparison neonates.

RESULTS

Six of the 50 infants studied had biochemical evidence of iron deficiency at birth. Laboratory findings consistent with iron deficiency were found in one SGA, one IDM, three VLBW, and one comparison infant. None of the infants had evidence of iron deficiency anemia.

CONCLUSIONS

Evidence of biochemical iron deficiency at birth was found in 17% of screened neonates. Studies are needed to determine whether these infants are at risk for developing iron-limited erythropoiesis, iron deficiency anemia or iron-deficient neurocognitive delay.

Recombinant tissue plasminogen activator to restore catheter patency: efficacy and safety analysis from a multihospital NICU system

OBJECTIVE

In 2001, the US Food and Drug Administration approved recombinant tissue plasminogen activator (alteplase, Cathflo Activase) to reestablish patency of central catheters occluded, presumably, by a fibrin clot. We conducted a multicenter quality improvement study to determine the value of this procedure in our Neonatal Intensive Care Unit (NICUs), including analyses of efficacy, safety and costs.

STUDY DESIGN

We conducted a retrospective quality analysis of neonates in level III NICUs, who received alteplase for the purpose of reestablishing patency of occluded central catheters.

RESULTS

Alteplase was administered to 169 neonates, each given one to four doses, totaling 205 episodes of administration. The most common type of catheter where alteplase was used was percutaneously inserted central catheter (PICC) lines (78% of uses), 8% were umbilical venous catheters (UVCs), 6% arterial lines, 5% chest tubes and 3% other catheters. Postnatal age at first dose ranged from 0 to 132 days (median, 12); dosed patients were 22 to 41 weeks gestation at birth (median, 31). Fifty-eight percentage of administrations restored catheter function. Success was more likely at younger postnatal age (10±2 days old in successful vs 14±1 days in unsuccessful treatments; P=0.023). Seventy-two percentage of the re-canalized catheters remained functional until they were no longer needed (2 to 30 days later). Nine percentage of episodes were treated with a second dose 1 to 17 days later for re-occlusion and 50% of those were successful. Bleeding consequences were identified in only one case, where three separate lines were treated (chest tube, PICC and UVC) within a 6-h period. Costs to the health system of doses, minus savings to the system by not needing to replace lines, averaged a net of $34 per dose.

CONCLUSIONS

The apparent safety and favorable value analysis prompted us to develop a consistent approach to alteplase usage in the Intermountain Healthcare NICUs, using the data in this report to standardize the guidelines across our health system.

Chemotherapy vs tamoxifen in platinum-resistant ovarian cancer: a phase III, randomised, multicentre trial (Ovaresist)

Background:

Chemotherapy in platinum-resistant ovarian cancer (PROC) aims for palliation and prolonging of progression-free survival (PFS). This study compares Health-related Quality of Life (HRQoL) and efficacy between single-agent chemotherapy and tamoxifen in PROC.

Methods:

Patients with PROC were randomised (2 : 1) to chemotherapy (weekly paclitaxel 80 mg m⁻² or four weekly pegylated liposomal doxorubicin 40 mg m⁻²) or tamoxifen 40 mg daily. The primary end point was HRQoL. Secondary end points were PFS by RECIST and overall survival (OS).

Results:

Between March 2002 and December 2007, 156 and 82 patients were randomised to chemotherapy and tamoxifen, respectively. In the chemotherapy arm, a significantly larger proportion of patients experienced a worsening in their social functioning. There was no difference in the proportion of patients experiencing improvement of gastrointestinal symptoms. Median PFS on tamoxifen was 8.3 weeks (95% CI, 8.0–10.4) compared with 12.7 weeks (95% CI, 9.0–16.3) on chemotherapy (HR, 1.54; 95% CI, 1.16–2.05; log-rank P=0.003). There was no difference in OS between the treatment arms.

Conclusions:

Patients on chemotherapy had longer PFS but experienced more toxicity and poorer HRQoL compared with tamoxifen. Control over gastrointestinal symptoms was not better on chemotherapy. These data are important for patient counselling and highlight the need to incorporate HRQoL end points in studies of PROC.

Medical and non-medical predictors of initiating long-term use of proton pump inhibitors: a nationwide cohort study of first-time users during a 10-year period

BACKGROUND

Studies of the increasing use of proton pump inhibitors (PPIs) have mainly focused on prevalent long-term use and associations with gastrointestinal morbidity and comedication. Little is known about non-medical characteristics of first-time users of PPI, and predictors of initiating long-term use of PPIs.

AIMS

To describe medical and non-medical characteristics of first-time PPI users during a 10-year period and to analyse predictors of initiation of long-term use (>60 defined daily doses (DDDs) within 6 months) of PPIs.

METHODS

A nationwide cohort study of first-time users of PPI. Data were collected from Danish national registers. Individuals redeeming their first prescription for a PPI (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) in 2001 and 2011 were identified. Redemption of more than 60 DDDs of PPI within 6 months defined long-term use. Logistic regression models were used to determine the associations between previous diagnoses, comedication and socio-economic characteristics and initiation of long-term use of PPIs in 2011.

RESULTS

From 2001 to 2011 incidence of first-time users increased with an incidence rate ratio of 1.53 and mean quantity of PPI redeemed at first prescription increased by 44.6%. In 2011 a total of 37.6% redeemed >60 DDDs within 6 months, and 96% of the long-term users did not have a diagnosis registered which indicated treatment. New onset long-term use was significantly associated with low income and low educational level when adjusting for other predisposing variables.

CONCLUSIONS

Proton pump inhibitor treatment is increasingly initiated with larger quantities prescribed for indications that are unidentifiable from the registers. Morbidity and comedication seem to be the strongest predictors of new onset long-term use of PPIs. However, there is also an independent social gradient.

General practice variation when initiating long-term prescribing of proton pump inhibitors: a nationwide cohort study

Background

Suggestions of overprescribing of proton pump inhibitors (PPIs) for long-term treatment in primary care have been raised. This study aims to analyse associations between general practice characteristics and initiating long-term treatment with PPIs.

Methods

A nationwide register-based cohort study of patients over 18 years redeeming first-time prescription for PPI issued by a general practitioner in Denmark in 2011. Patients redeeming more than 60 defined daily doses (DDDs) of PPI within six months were defined first-time long-term users. Detailed information on diagnoses, concomitant drug use and sociodemography of the cohort was extracted. Practice characteristics such as age and gender of the general practitioner (GP), number of GPs, number of patients per GP, geographical location and training practice status were linked to each PPI user. Logistic regression analysis was used to determine associations between practice characteristics and initiating long-term prescribing of PPIs.

Results

We identified 90 556 first-time users of PPI. A total of 30 963 (34.2 %) met criteria for long-term use at six months follow-up. GPs over 65 years had significantly higher odds of long-term prescribing (OR 1.32, CI 1.16-1.50), when compared to younger GPs (<45 years). Furthermore, female GPs were significantly less likely to prescribe long-term treatment with PPIs (OR 0.87, CI 0.81-0.93) compared to male GPs.

Conclusions

Practice characteristics such as GP age and gender could explain some of the observed variation in prescribing patterns for PPIs. This variation may indicate a potential for enhancing rational prescribing of PPIs.

Reference intervals for reticulocyte parameters of infants during their first 90 days after birth

OBJECTIVE

The automated reticulocyte parameters (absolute reticulocyte count, immature reticulocyte fraction (IRF) and reticulocyte hemoglobin content (RET-He)) are of value in managing adults and older children with a variety of hematological disorders. However, the lack of reference intervals for these parameters in neonates and young infants has limited their application to that population.

STUDY DESIGN

During a span of 12 months (29 May 2014 to 5 May 2015), a convenience sample of reticulocyte parameters were run from clinically ordered complete blood counts (CBCs) of infants within the first 90 days after birth. Measuring the reticulocyte parameters as a research-only adjunct to the CBC did not require any additional blood or generate a patient charge, and the reticulocyte results were not reported to the provided and did not appear in the clinical records. Values from neonates who had a transfusion or a diagnosis of anemia were subsequently excluded from the reference data set.

RESULTS

Nine Intermountain Healthcare clinical laboratories contributed 8438 CBCs to the initial reticulocyte parameter database. From these, 1806 were excluded because of a transfusion or a diagnosis of anemia, leaving 6632 in the reference interval database. The parameters charted over the first 90 days after birth were: (1) blood hemoglobin concentration (g dl(-1)), (2) mean corpuscular volume (fL), (3) reticulocyte count (x10(3) per μl), (4) IRF (%) and (5) RET-He (pg).

CONCLUSIONS

The new reference interval charts can help clinicians identify abnormalities in the reticulocyte parameters. This information could be of value in identifying and following neonates with various hematological problems including hemolytic disorders, occult hemorrhage, or iron deficiency or other limitations of erythrocyte production.

Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates?

OBJECTIVE

To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines.

STUDY DESIGN

This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes.

RESULT

Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually.

CONCLUSION

Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.

Redefining high-risk patients with stage II colon cancer by risk index and microRNA-21: results from a population-based cohort

Background:

The aim of the present study was to analyse the prognostic value of microRNA-21 (miRNA-21) in patients with stage II colon cancer aiming at a risk index for this group of patients.

Methods:

A population-based cohort of 554 patients was included. MicroRNA-21 was analysed by qPCR based on tumour tissue. An index was created using the coefficients obtained from a collective multiple Cox regression. The entire procedure was cross-validated (10-fold). The performance of the index was quantified by time-dependent receiver operating characteristics curves.

Results:

High miRNA-21 expression was associated with an unfavourable recurrence-free cancer-specific survival (RF-CSS), hazard ratio 1.35 (95% confidence interval, 1.03–1.76) (P=0.028). The generated RF-CSS index divided the traditional high-risk patients into subgroups with 5-year RF-CSS rates of 87% and 73%, respectively (P<0.001). The overall survival (OS) index identified three different subgroups (P<0.001). Cross-validated 5-year OS rates were 88%, 68%, and 50%, respectively.

Conclusions:

This population-based study supports miRNA-21 as an additional prognostic biomarker in patients with stage II colon cancer. Furthermore, the introduction of a risk index may guide the use of postoperative adjuvant treatment in a more appropriate way compared with current practice.

Primary non-adherence in general practice: a Danish register study

PURPOSE

The aim of this study was to describe primary non-adherence (PNA) in a Danish general practitioner (GP) setting, i.e. the extent to which patients fail to fill the first prescription for a new drug. We also assessed the length of time between the issuing of a prescription by the GP and the dispensing of the drug by the pharmacist. Lastly, we sought to identify associations between PNA and the characteristics of the patient, the drug and the GP.

METHODS

By linking data on issued prescriptions compiled in the Danish General Practice Database with data on redeemed prescriptions contained in the Danish National Prescription Registry, we calculated the rate of PNA among Danish patients from January 2011 through to August 2012. Characteristics associated with PNA were analysed using a mixed effects logistic regression model.

RESULTS

A total of 146,959 unique patients were started on 307,678 new treatments during the study period. The overall rate of PNA was 9.3 %, but it varied according to the major groups of the Anatomical Therapeutic Chemical (ATC) Classification System, ranging from 16.9 % for "Blood and bloodforming organs" (ATC group B) to 4.7 % for "Cardiovascular system" (ATC group C). Most of the patients redeemed their prescriptions within the first week. Older age, high income and a diagnosis of chronic obstructive pulmonary disease were found to be significantly associated with lower rates of PNA, while polypharmacy and a diagnosis of ischaemic heart disease were associated with higher rates of PNA.

CONCLUSIONS

The overall rate of PNA among Danish residents in a GP setting was 9.3 %. Certain drug classes and patient characteristics were associated with PNA.

Influence of comorbidity on cancer patients' rehabilitation needs, participation in rehabilitation activities and unmet needs: a population-based cohort study

PURPOSE

This study aims to investigate possible associations between cancer survivors' comorbidity status and their (1) need for rehabilitation, (2) participation in rehabilitation activities and (3) unmet needs for rehabilitation in a 14-month period following date of diagnosis.

METHODS

We performed a population-based cohort study including incident cancer patients diagnosed from 1 October 2007 to 30 September 2008 in two regions in Denmark. Fourteen months after diagnosis, participants completed a questionnaire measuring different aspects and dimensions of rehabilitation. Individual information on comorbidity was based on hospital contacts from 1994 and until diagnosis, subsequently classified according to the Charlson comorbidity index. Logistic regression analyses were used to explore the association between comorbidity and outcomes for rehabilitation. Analyses were conducted overall and stratified for gender, age and cancer type.

RESULTS

A total of 3,439 patients responded (70%). Comorbidity at all levels was statistically significant associated with a physical rehabilitation need, and moderate to severe comorbidity was statistically significant associated with a need in the emotional, family-oriented and financial areas as well as participation in physical-related rehabilitation activities. Stratified analyses showed that significant results in most cases were related to being older than 65 years or having colorectal or prostate cancer.

CONCLUSIONS

Comorbidity at all levels was significantly associated with needs for physical rehabilitation. Moderate to severe comorbidity was further associated with other areas of need and participation in physical area activities. This should be taken into account when planning rehabilitation interventions for cancer survivors. Differences among subgroups could help target interventions and should be explored further.

Estimating the nucleated red blood cell 'emergence time' in neonates

OBJECTIVE

The time between onset of fetal hypoxia and first appearance of nucleated red blood cells (NRBCs) in the blood can conceptually be divided into two periods; (1) the 'erythropoietin (EPO) generation time', which previous fetal studies suggest is 4 to 5 h, and (2) the 'NRBC emergence time'. In this study, we estimated the latter as the time required for NRBC to appear in the blood after administering a dose of recombinant EPO.

STUDY DESIGN

This was a retrospective analysis of data from a multihospital healthcare system (Intermountain Healthcare). Data were included only for neonates born ≥34 weeks gestation between the dates 1 January 2005 and 31 October 2012 and only if they received a dose of darbepoetin during their neonatal intensive care unit stay and had one or more complete blood cell counts (CBCs) obtained during the 3-day period before the dose was given and one or more CBCs in the 7-day period after the dose.

RESULT

The study involved 31 neonates who received 34 doses of darbepoetin. Seven doses were 4 μg kg(-1) and twenty-seven doses were 10 μg kg(-1). Twenty-six CBCs were obtained during the 24-h period following the darbepoetin dose and none had NRBC identified. NRBC first appeared in the blood between 24 and 36 h after the dose. Recipients of the higher dose generally had a higher peak NRBC count but the NRBC 'emergence time' did not appear to depend on dose.

CONCLUSION

Following fetal hypoxia, transcription and translation of the EPO gene result in an elevation in plasma EPO concentration. Previous fetal studies suggest this process requires 4 to 5 h. The present studies suggest that, following the increase in plasma EPO, NRBC emerge into the circulation in ≥24 h. If this model serves as a reasonable estimate, it suggests that neonates with an elevated NRBC count at birth had the onset of hypoxia at least 28 to 29 h before birth.

A neonate with Coombs-negative hemolytic jaundice with spherocytes but normal erythrocyte indices: a rare case of autosomal-recessive hereditary spherocytosis due to alpha-spectrin deficiency

The diagnosis of hereditary spherocytosis (HS) in a newborn infant is generally made on the basis of a positive family history, spherocytes on blood film and Coombs-negative hemolytic jaundice of variable severity with an elevated mean corpuscular hemoglobin concentration (MCHC) and a low mean corpuscular volume (MCV). In general, sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) quantification of erythrocyte membrane proteins is not needed to make the clinical diagnosis of HS. However, we observed that a neonate with no family history of HS, but with abundant spherocytosis on repeated blood films, Coombs-negative hemolytic jaundice and normal MCHC and MCV measurements, where SDS-PAGE revealed alpha-spectrin deficiency, a rare autosomal-recessive variety of HS that generally has a severe clinical phenotype.

Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions

OBJECTIVE

We previously described a method for reducing early phlebotomy losses from very low birth weight (VLBW) neonates by obtaining the initial blood tests from otherwise discarded fetal blood from the placenta. In the present study we sought to; (1) measure the feasibility of performing this method in actual practice, (2) test the hypothesis that this method would result in higher hemoglobin concentrations and lower erythrocyte transfusion rates in the first week after birth.

METHODS

We conducted two studies in three Intermountain Healthcare NICUs. The first was a feasibility analysis involving 96 VLBW neonates, measuring the success of obtaining the NICU admission laboratory blood tests this way. The second study used case-control methodology to test the hypothesis that this method would result in a higher blood hemoglobin 12 to 24 h after birth, and a lower proportion receiving an erythrocyte transfusion in the first week.

RESULT

In 91 of 96 VLBW neonates (95%) the initial blood tests were successfully obtained with this method. The success rate was not diminished by delayed cord clamping or cord milking, as it was successful in 35 of 36 (97%) such instances. Cases and controls were well matched on demographic and level of illness comparisons. Among cases the hemoglobin generally increased between birth and 12 to 24 h later, but among controls the hemoglobin generally decreased (P<0.05). In the week following birth fewer cases received vasopressors (P<0.01) and erythrocyte transfusions (P<0.001).

CONCLUSION

We judge that it is feasible to collect the initial blood tests of VLBW neonates using otherwise discarded umbilical cord/placental blood, in that this can be accomplished in about 95% of VLBW deliveries. This method, which can be used in addition to either delayed clamping of the umbilical cord or cord milking, results in higher hemoglobin concentrations, less vasopressor use and fewer transfusions in the first week.

Neonatal outcomes following a tight nuchal cord

OBJECTIVE

The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord.

STUDY DESIGN

This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head.

RESULT

Of 219,337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die.

CONCLUSION

The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200,000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord.

Process-related factors associated with disciplinary board decisions

BACKGROUND

In most health care systems disciplinary boards have been organised in order to process patients' complaints about health professionals. Although, the safe-guarding of the legal rights of the involved parties is a crucial concern, there is limited knowledge about what role the complaint process plays with regard to board decision outcomes. Using complaint cases towards general practitioners, the aim of this study was to identify what process factors are statistically associated with disciplinary actions as seen from the party of the complainant and the defendant general practitioner, respectively.

METHODS

Danish Patient Complaints Board decisions concerning general practitioners completed in 2007 were examined. Information on process factors was extracted from the case files and included complaint delay, complainant's lawyer involvement, the number of general practitioners involved, event duration, expert witness involvement, case management duration and decision outcome (discipline or no discipline). Multiple logistic regression analyses were performed on compound case decisions eventually involving more general practitioners (as seen from the complainant's side) and on separated decisions (as seen from the defendant general practitioner's side).

RESULTS

From the general practitioner's side, when the number of general practitioners involved in a complaint case increased, odds of being disciplined significantly decreased (OR=0.661 per additional general practitioner involved, p<0.001). Contrarily, from the complainant's side, no association could be detected between complaining against a plurality of general practitioners and the odds of at least one general practitioner being disciplined. From both sides, longer case management duration was associated with higher odds of discipline (OR=1.038 per additional month, p=0.010). No association could be demonstrated with regard to complaint delay, lawyer involvement, event duration, or expert witness involvement. There was lawyer involvement in 5% of cases and expert witness involvement in 92% of cases. The mean complaint delay was 3 months and 18 days and the mean case management duration was 14 months and 7 days.

CONCLUSIONS

Certain complaint process factors might be statistically associated with decision outcomes. However, the impact diverges as seen from the different parties. Future studies are merited in order to uncover the judicial mechanisms lying behind.

Neonates presenting with bloody stools and eosinophilia can progress to two different types of necrotizing enterocolitis

OBJECTIVE

We hypothesized that neonates with bloody stools and concomitant eosinophilia are likely to have atopic enteropathy rather than necrotizing enterocolitis (NEC).

STUDY DESIGN

This was a retrospective cross-sectional study using electronic medical records and paper charts. Records of neonates admitted to any Intermountain Healthcare NICU between 1 January 2005 and 30 June 2010 were eligible if 'bloody stools' were listed in any archive. Qualifying records were divided into two groups depending on whether or not within 72 h of passing bloody stool eosinophil counts were above the 95th percentile reference range limit for age.

RESULT

Bloody stools were identified in 275 predominantly Caucasian neonates. Fifty-four of these had eosinophilia and 221 had normal eosinophil counts. Those with eosinophilia were born at a slightly younger gestational age (31.3 ± 4.6 vs 32.6 ± 4.0 weeks, mean ± s.d., P=0.032). Contrary to our hypothesis, those with eosinophilia did not have a lower rate of pneumatosis or bowel resection, or death ascribed to NEC. Eosinophilia was more common among those who had a red blood cell (RBC) transfusion within 48 h before passing bloody stools (P<0.001). Those with a recent RBC transfusion were the only neonates to have NEC surgery or to die from NEC. Preceding the bloody stools, those with no antecedent transfusion had been fed a larger volume (P=0.014), and had trends toward receiving calorically enriched feedings (P=0.055) and recent addition of human milk fortifier (P=0.060). Eosinophil counts following RBC transfusion tended to increase for 3-6 days, but when bloody stools were not preceded by transfusion the eosinophil counts were more static over that period.

CONCLUSION

In this predominantly Caucasian group of neonates with bloody stools, the presence of eosinophilia did not identify a benign condition distinct from NEC. A total of 44% of these neonates had transfusion-associated NEC. Eosinophils could have a previously unrecognized role in the pathogenesis of this NEC subtype.

The relationship between microRNA-126 and maintenance therapy with bevacizumab after bevacizumab plus chemotherapy as first-line treatment for patients with metastatic colorectal cancer: Results of the phase III Nordic ACT trial NCT00598156 translational study

3573

Background: Maintenance therapy during chemotherapy free intervals is a debatable topic in metastatic colorectal cancer (mCRC). In the Nordic ACT trial patients benefitting from induction chemotherapy plus bevacizumab were randomized to bevacizumab with or without erlotinib. MicroRNA-126 (miRNA-126) is believed to influence angiogenesis in several ways, and we investigated the relationship between miRNA-126 and progression free survival (PFS) under maintenance therapy. Methods: The miRNA-126 was analysed by polymerase chain reaction on both genomic DNA (by the pri-miRNA-126 (A24G) single nucleotide polymorphism (SNP)) and paraffin embedded primary tumors, (which were classified as low or high miRNA-126 expressing tumours using the median value as cut-off). Diagnostic biopsies were not processed due to limited tumour tissue. Of the 159 randomized patients blood samples were available from 151 and primary tumours from 91. The PFS (from time of randomization) was compared using the Kaplan-Meier method and the log rank test. The Cox Regression analyses were used to test for independent contributions. Results: The A24G SNP was not related to PFS, but a significant association was seen between genotypes and miRNA-126 expression levels.Furthermore, the PFS was increased in patients with high tumor miRNA-126 expression compared to patients with low expression, hazard ratio (HR) 0.58 (95% confidence interval (CI) 0.38-0.90), p = 0.015. The median PFS was 6.2 months (95% CI 4.3-6.6 months) and 4.0 months (95% CI 2.6-4.5 months), respectively. Results did not differ between treatment arms, but the Cox Regression analysis confirmed an independent prognostic value of the tumor miRNA-126 expression, HR 0.61 (95% CI 0.39-0.95), p = 0.030. Conclusions: The miRNA-126 may be a potential marker for bevacizumab containing maintenance therapy. A similar relationship with PFS has recently been demonstrated in patients with mCRC treated with chemotherapy only. The results call for validation.

The prognostic importance of miRNA-21 in stage II colon cancer: A population-based study

3513

Background: Adjuvant chemotherapy for stage II colon cancer patients is still controversial and the debate on which patients should be considered as high risk patients is still ongoing. The decision is based on clinical and pathological markers of risk, which are inadequately informative in most of the patients, and better methods are highly needed. The aim of the present study was to investigate the possible prognostic importance of miRNA-21, quantified by in situ hybridization (ISH), in a unique, large population-based cohort of patients treated for stage II colon cancer patients. Methods: The study included all patients diagnosed with stage II colon cancer in Denmark in the year 2003 (711 patients), representing a full population of five million people. Patients receiving adjuvant chemotherapy were excluded (N=15). One paraffin-embedded tissue block was obtained from each patient. A 6μm-thick section was processed for formazan-based chromogenic miR-21 ISH analysis and counter stained with nuclear red. The blue miR-21 ISH signal was assessed by image analysis to obtain two quantitative expression estimates: the total blue area (TB) and the ratio of TB with the nuclear density (TBR). Results: The miRNA-21 signal was predominantly observed in fibroblast-like cells located in the stromal compartment of the tumors. Patients expressing high levels of miRNA-21 (high mean TBR) had significantly inferior cancer specific survival (CSS): HR = 1.26 (95% CI; 1.15-1.60), p <0.001. In the COX regression analysis (including; gender, T-category, malignancy grade, localization, tumor perforation, tumor fixation, number of lymph nodes and MSI status), mean TBR was found to be an independent predictive marker of poor CSS, HR = 1.41 (95%CI; 1.19-1.67, p< 0.001). The same applied to TB. Conclusions: The present study shows that increasing miRNA-21 expression level is significantly correlated to decreasing CSS. Analyses of miRNA-21 should be considered as a potential adjunct in the selection of high risk stage II patients.

First-line treatment of advanced ovarian cancer with paclitaxel/carboplatin with or without epirubicin (TEC versus TC)--a gynecologic cancer intergroup study of the NSGO, EORTC GCG and NCIC CTG

BACKGROUND

The addition of anthracyclines to platinum-based chemotherapy may provide benefit in survival in ovarian cancer patients. We evaluated the effect on survival of adding epirubicin to standard carboplatin and paclitaxel.

PATIENTS AND METHODS

We carried out a prospectively randomized phase III study comparing carboplatin plus paclitaxel (TC; area under the curve 5 and 175 mg/m(2)) with the same combination and epirubicin (TEC; 75 mg/m(2) i.v.). Between March 1999 and August 2001, 887 patients with epithelial ovarian, tubal or peritoneal cancer International Federation of Gynecology and Obstetrics stages IIB-IV were randomized to receive either TC (442 patients) or TEC (445 patients).

RESULTS

Median time to progression was 16.4 months in the TEC arm and 16.0 months in the TC arm (hazard ratio 0.99; 95% confidence interval [CI]: 0.9-1.2). Median overall survival time was 42.4 months for the TEC arm and 40.2 for the TC arm (hazard ratio 0.96; 95% CI: 0.8-1.1). Grade 3/4 hematologic toxic effects and most grade 3/4 non-hematologic toxic effects were more frequent in the TEC arm. Accordingly, a quality-of-life analysis showed inferiority of TEC versus TC.

CONCLUSION

The addition of epirubicin to standard carboplatin and paclitaxel treatment did not improve survival in patients with advanced ovarian, tubal or peritoneal cancer.

A neonate with the Pelger-Huët anomaly, cleft lip and palate, and agenesis of the corpus callosum, with a chromosomal microdeletion involving 1q41 to 1q42.12

We observed a neonate with cleft lip and palate, 13 sets of ribs, agenesis of the corpus callosum, slightly small penis, hypoglycemia, and what initially appeared to be a marked leukocyte 'left shift' on complete blood count, but which was actually a Pelger-Huët anomaly. A chromosomal microdeletion was identified at1q41-42.12.

Is a small platelet mass associated with intraventricular hemorrhage in very low-birth-weight infants?

OBJECTIVE

We sought to determine whether, among very low-birth-weight (VLBW) neonates, the platelet mass was associated with common perinatal factors, and whether a low platelet mass in the first days following birth was associated with a higher incidence and/or severity of intraventricular hemorrhage (IVH).

STUDY DESIGN

This was a cross-sectional, retrospective cohort analysis of VLBW infants admitted to a level 3 neonatal intensive care unit from June 2003 to July 2006, n=408. Platelet mass was calculated and recorded on the day of birth and for 2 consecutive days thereafter. All neonates had a screening cranial sonogram on day 4 of life. Statistical analysis included analysis of variance and Mann-Whitney U-test.

RESULT

Neonates born to mothers with pre-eclampsia had a smaller platelet mass (1921 fl/nl ± 603 vs 2297 fl/nl ± 747; P<0.01). The same was found among neonates with intrauterine growth restriction (IUGR). In contrast, neonates born after histological chorioamnionitis had a larger platelet mass (2400 fl/nl ± 749 vs 2036 fl/nl ± 674; P<0.01). No effect of platelet mass, measured on the day of birth, was observed related the outcomes of IVH, severe IVH or death. However, those with a platelet mass <10th percentile on the 2 subsequent days following birth were more likely to have severe IVH or death.

CONCLUSION

Among VLBW neonates, pre-eclampsia and IUGR are associated with a lower platelet mass, owing to their effect on platelet count. Histological chorioamnionits is associated with a larger platelet mass. A mass <10th percentile on the days following birth was associated with severe IVH and/or death, but it remains unclear whether this is a cause of, or an effect of, the IVH.

Effect of ampicillin on bleeding time in very low birth-weight neonates during the first week after birth

OBJECTIVE

On the day of birth, the bleeding time of very low birth-weight (VLBW, <1500 g) neonates is generally prolonged, compared with term neonates. However, their bleeding time generally improves (shortens) over the next 7 to 10 days. Ampicillin can prolong the bleeding times of term and late preterm neonates, but its effect on VLBW neonates, who already have a somewhat prolonged bleeding time initially, is not known.

STUDY DESIGN

This was a prospective, single-centered, paired, before vs after test of the effect of ampicillin on template bleeding time and PFA-100 time (platelet function analyzer). Ampicillin was dosed at every 12 h intravenously, but decisions about discontinuation were made by the responsible clinician, independent of this study.

RESULT

A total of 20 VLBW neonates were studied. They ranged from 23- to 30-weeks gestation at birth and weighed 500 t 1410 g. Initial bleeding times averaged 166 s (95% CI, 138 to 194) and initial PFA-100 times averaged 119 s (95% CI, 90 to 148). In all, 10 had ampicillin dosing stopped after a shorter course (4 to 7 doses) and 10 had it continued for a longer course (10 to 15 doses). Blood cultures were sterile in all 20, and no differences in laboratory or clinical features were found between those treated with a shorter vs longer course. After stopping the ampicillin following a short course the bleeding times and PFA-100 times were similar to the initial values. However, after a longer course the bleeding times were prolonged by an average of 2 min, to 284 s (95% CI, 242 to 326; P=0.001 vs initial). The PFA-100 times also trended longer by an average of 44 s (P=0.07). The number of doses of ampicillin received in the first week correlated with the degree of prolongation in bleeding time (r=0.68).

CONCLUSION

Over the first week of life, a period when the bleeding time of VLBW neonates normally shortens, the opposite occurred (the bleeding time lengthened) if ≥ 10 doses of ampicillin were administered.

Effect of ampicillin on the bleeding time of neonatal intensive care unit patients

OBJECTIVE

Studies in adults indicate that ampicillin, in a dose-dependent manner, impairs platelet function and moderately prolongs the bleeding time (generally by 60 to 90 s). Unlike aspirin, the inhibition induced by ampicillin involves both reversible and irreversible mechanisms and is not observed immediately after initial dosing (generally requiring approximately 24 h). Ampicillin is administered commonly to neonatal intensive care unit (NICU) patients, but its effect on bleeding time in this population has not been reported earlier.

STUDY DESIGN

We performed neonatal template bleeding times and platelet function analyzer (PFA)-100 tests on 15 NICU patients before and at various intervals after intravenous ampicillin dosing.

RESULT

Neonates were only studied if no beta-lactam antibiotics were administered to their mother during labor, and if they had ampicillin ordered by the clinician at a dose of 50 to 100 mg kg(-1) every 12 h. Subjects ranged from 33 to 41 weeks gestation and weighed 1760 to 3835 g. Bleeding times before the first ampicillin dose (n=15) averaged 134 s (95% confidence interval (CI), 120 to 148 s) and PFA-100 times averaged 123 s (95% CI, 96 to 149 s). After the first dose of ampicillin (n=5), bleeding times and PFA-100 times did not increase, but after the third (n=5) and fourth doses (n=4) bleeding times lengthened by an average of 60 s (95% CI, 37 to 83 s, P<0.001) and PFA-100 times lengthened by an average of 20 s (95% CI, -20 to 60 s, P=0.15).

CONCLUSION

Ampicillin administered intravenously to NICU patients prolongs the bleeding time, with a magnitude-of-effect and time-to-effect similar to that shown earlier in adults.

Reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period defined from over 63 000 records in a multihospital health-care system

OBJECTIVE

Blood concentrations of eosinophils and monocytes are part of the complete blood count. Reference ranges for these concentrations during the neonatal period, established by very large sample sizes and modern methods, are needed for identifying abnormally low or high values.

STUDY DESIGN

We constructed reference ranges for eosinophils per microl and monocytes per microl among neonates of 22 to 42 weeks of gestation, on the day of birth, and also during 28 days after birth. Data were obtained from archived electronic records over an eight and one-half-year period in a multihospital health-care system. In keeping with the reference range concept, values were excluded from neonates with a diagnosis of infection or necrotizing enterocolitis (NEC).

RESULT

Eosinophils and monocytes per microl of blood were electronically retrieved from 96 162 records, of which 63 371 that lacked a diagnosis of infection or NEC were included in this reference range report. The mean value for eosinophils per microl on the day of birth increased linearly between 22 and 42 weeks of gestation, as did the 5 and 95% values. The reference range at 40 weeks was 140 to 1300 microl(-1) (mean 550 microl(-1)). Similarly, the mean value for monocytes increased linearly over this interval, with a reference range at 40 weeks of 300 to 3300 microl(-1) (mean 1400 microl(-1)). Over the first 4 weeks after birth, no appreciable change was observed in 5% limit and mean eosinophil count, with a slight increase in the 95% limit in week 4. A slight increase in monocyte count was observed during the first 2 weeks after birth.

CONCLUSION

The results of this analysis describe reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period. Additional study is needed for determining the relevance of values falling outside the reference range.

Pyruvate kinase deficiency as a cause of extreme hyperbilirubinemia in neonates from a polygamist community

Neonatal hemolytic jaundice is a risk factor for kernicterus. Pyruvate kinase (PK) deficiency is a rare cause of neonatal hemolytic jaundice, with a prevalence estimated at 1 case per 20,000 births in the United States, but with a higher prevalence among the Amish communities in Pennsylvania and Ohio. We discovered four neonates with PK deficiency born in a small community of polygamists. All four had early, severe, hemolytic jaundice. PK deficiency should be considered in neonates with early hemolytic, Coombs-negative, non-spherocytic jaundice, particularly in communities with considerable consanguinity. Such cases should be recognized early and managed aggressively to prevent kernicterus.

Thrombocytosis in neonates and young infants: a report of 25 patients with platelet counts of > or = 1000000 microl(-1)

OBJECTIVE

Thrombocytosis has been reported in neonates and young infants, but little is known of its prevalence, timing of onset, associated conditions, sequelae and outcomes. To better understand this condition, we used the data repositories of a multi-hospital health-care system to identify all individuals <or=140 days old (20 weeks) who, during the past 6 years, had a platelet count of >or=1000000 microl(-1).

STUDY DESIGN

We identified all infants with extreme thrombocytosis (using the Sutor definition of a platelet count of >or=1000000 microl(-1)) during the period of January 2003 through December 2008 in any Intermountain Healthcare facility. We obtained the information provided in this report from electronic and paper records.

RESULT

Among 40 471 infants who had one or more platelet counts performed in this period, 25 had extreme thrombocytosis. No cases were identified in the first week after birth, 40% were recognized between the second and fourth weeks and 40% between the fifth and eighth week. The prevalence of thrombocytosis had no relationship with birth weight or gestational age but a slight predominance of female patients (15/25) was noted. In all, 26 episodes were found among the 25 infants: 12 episodes involved an antecedent infectious disease, 8 had an antecedent surgical procedure, 4 had the anemia of prematurity and 1 each had congenital adrenal hyperplasia and opiate withdrawal syndrome. No pathological thromboses or hemorrhages or other sequelae were detected and all episodes resolved with no deaths.

CONCLUSION

The thrombocytosis cases that we report were all consistent with reactive thrombocytosis (also known as secondary thrombocytosis); none seemed to be essential (primary) thrombocytosis. We speculate that the pathogenesis involves increased platelet production due to megakaryopoietic stimulators induced by an infectious or inflammatory condition. From this series and previous reports, young infants with platelet counts up to 1300000 microl(-1) do not seem to have a significant risk of thrombotic or hemorrhagic problems, and do not generally require anti-platelet or cytoreductive treatment.

Antecedents of Bell stage III necrotizing enterocolitis

OBJECTIVE

New biopharmaceuticals hold promise for preventing or treating necrotizing enterocolitis. However, it is unclear whether any such biopharmaceutical that requires enteral administration could be administered using an 'early-treatment' paradigm. This study was undertaken to assess this issue based on data from every case of Bell stage III NEC cared for during the past 7 years at Intermountain Healthcare.

STUDY DESIGN

Patients with Bell stage III NEC were identified from electronic medical record repositories and the diagnosis was validated using operative reports. Electronic and paper records of each patient were then used to identify potential clinical and laboratory antecedents occurring within the 48 h period preceding the diagnosis of NEC.

RESULT

One hundred eighteen patients had Stage III NEC. The earliest recognized antecedents were nonspecific for NEC (apnea/bradycardia, skin mottling and irritability). These were recorded at 2.8+/-2.1, 4.5+/-3.1 and 5.4+/-3.7 (mean+/-s.d.) hours, respectively, before NEC was diagnosed. The most commonly identified gastrointestinal antecedents were blood in the stools, increased abdominal girth and elevated pre-feeding gastric residuals or emesis. These were identified 2.0+/-1.9, 2.8+/-3.1 and 4.9+/-4.0 h before NEC was recognized. Thirty-eight percent had a blood transfusion (18+/-12 h) preceding the NEC. Tachycardia, tachypnea, hypotension and diarrhea were rarely identified as antecedents and no consistent laboratory antecedents were discovered.

CONCLUSION

We judge that an 'early treatment of NEC' paradigm testing any pharmacological agent that must be administered enterally is not feasible. The first recognized antecedents of Bell stage III NEC are nonspecific for gastrointestinal pathology and insufficient time exists for dosing between the first gastrointestinal signs and placement of the gastric decompression tube.

Isolated elevated blood neutrophil concentration at altitude does not require NICU admission if appropriate reference ranges are used

OBJECTIVE

The Intermountain Healthcare hospitals use a clinical pathway algorithm for early-onset infection, which is based on the 2002 Centers for Disease Control and Prevention (CDC) guidelines for perinatal group B streptococcal disease. As part of this pathway, neonates in the well baby nursery, who seem to be well but have risk factors for infection, receive a 'limited laboratory evaluation including a CBC', and if the complete blood cell count (CBC) is abnormal, antibiotic treatment and neonatal intensive care unit (NICU) monitoring are initiated. We recently found that reference ranges for absolute neutrophil counts (ANCs) are much wider at our altitude (4800 to 5000 ft) than at sea level. On this basis, we speculated that some well babies with risk factors for infection are mistakenly judged as having an abnormal CBC, and are unnecessarily admitted to the NICU.

STUDY DESIGN

This was a retrospective observational cohort study of neonates of >37 weeks gestation admitted to either of two Intermountain Healthcare NICUs for intravenous antibiotic treatment during a recent 36-month period.

RESULTS

During the study period 3217 patients were admitted to the two NICUs, 1049 (32.6%) of which were born at>37 weeks gestation. Of these, 14 (1.3%) were found to have been admitted to the NICU on the basis of an abnormal CBC (elevated ANC), when in retrospect, using the appropriate ANC chart, their CBCs were completely normal. None of the 14 neonates had a leukocyte left shift (immature to total neutrophil ratio >0.3) or thrombocytopenia. None were treated with supplemental oxygen or mechanical ventilation in the NICU. All 14 had sterile blood cultures. All had antibiotics stopped in 48 to 72 h, and all were discharged home as well babies.

CONCLUSION

We identified 14 neonates who, while in the well baby nursery, were found to have risk factors for early-onset infection, but did not seem to be infected, and were subsequently admitted to a NICU for intravenous antibiotic treatment and monitoring under the mistaken impression that they had an abnormal CBC. We maintain that use of an appropriate neutrophil reference range chart can reduce NICU admissions and can limit unnecessary antibiotic exposure.

Ibuprofen lysine administration to neonates with a patent ductus arteriosus: effect on platelet plug formation assessed by in vivo and in vitro measurements

OBJECTIVE

Ibuprofen might have advantages over indomethacin, when used to effectuate closure of a neonate's patent ductus arteriosus (PDA). Several previous studies indicate that platelet plug formation is impaired after administration of indomethacin, but it is not clear whether a similar impairment occurs following ibuprofen dosing.

STUDY DESIGN

We performed template bleeding times and PFA-100 tests (platelet function analyzer) on 20 neonates who had a PDA, before and again at various preset intervals following ibuprofen dosing.

RESULT

Patients ranged from 23 to 40 weeks gestation and weighed 511 to 2566 g. Their first dose of ibuprofen was administered at 72 h (18 to 363 h) after birth (median, range). None of the subjects had clinical bleeding problems noted during the days they received ibuprofen dosing. The template bleeding times before dosing ranged from 135 to 450 s. Repeat tests were performed in groups of four, at 2 h, 4 to 6 h, 12 to 18 h, 24 h after the first dose, and at 2 h after the third dose of ibuprofen. No changes in bleeding times were detected. (P=0.299) A PFA-100 time was performed on all 20 patients before and again after the ibuprofen administration. However, 3 of the 40 tests were unsuccessful, because of microclots in the blood sample (n=1) or failure of the analyzer for an unspecified reason (n=2). Before the dosing the PFA-100 time ranged from 52 to 300 s. A paired t-test showed a slight but statistically significant lengthening in PFA-100 time after the ibuprofen administration (P=0.019). The correlation between the bleeding time and the PFA-100 was poor (R(2)=0.212, P=0.576).

CONCLUSION

On the basis of our present studies, we speculate that ibuprofen lysine administration to neonates with a PDA, when used according to the manufacturer's recommendations, has little adverse effect on platelet plug formation. This information might be a factor to consider when deciding whether to select indomethacin or ibuprofen for PDA closure.

Necrotizing enterocolitis during the first week of life: a multicentered case-control and cohort comparison study

OBJECTIVE

Necrotizing enterocolitis (NEC) is rare during the first week of life; most cases occur after 2 to 4 weeks. We hypothesized that when NEC develops in the first week, certain predisposing factors and feeding practices are identifiable. To test this, we sought to identify every case of NEC diagnosed during the first week within the Intermountain Healthcare system during the most recent 6-year period.

STUDY DESIGN

Data were collected from neonates admitted to any Intermountain Healthcare neonatal intensive care unit (NICU) with a date of birth from 1 January 2001 through 31 December 2006. Electronic and paper records were obtained for all with a diagnosis of NEC (Bell stage >or=II) within the first 168 h. X-rays, physician notes, nursing records, laboratory reports and operative reports were subjected to critical review to reexamine the diagnosis of NEC. Among those with confirmed NEC, we recorded underlying conditions and every feeding given prior to the diagnosis of NEC. Comparisons were made with patients that did not develop NEC, yet were cared for in the same NICUs, during the same period of time, and of the same gestational ages.

RESULT

A total of 28 neonates were identified electronically as having NEC during the first week. Critical review confirmed this in 21, but 5 were determined at laparotomy to have had spontaneous intestinal perforation, and 2 others were found on surgical reports to have had a congenital infarction of the colon. Total 20 of the 21 confirmed cases developed NEC while in a NICU being treated for another condition. The exception was a small-for-gestational-age neonate in a well baby nursery. Compared to 6100 controls, the 21 with early NEC were more likely to have had a meconium-positive test for illicit drug exposure (P<0.005), early onset sepsis (P<0.034) and respiratory distress (P<0.039). They were less likely than case-controls to have been fed human milk (P=0.003) and were more likely to have been fed formula exclusively (P=0.019). None who were fed human milk exclusively developed early NEC. Twelve of the twenty-one were fed (by gavage or bottle) amounts exceeding the upper limit of volumes taken by breastfed neonates.

CONCLUSION

We speculate that the prevalence of NEC during the first week could be reduced by identifying at-risk patients, feeding them human milk exclusively for the first week and using feeding volumes that do not exceed that taken by healthy breastfed neonates.

Adherence to NICU transfusion guidelines: data from a multihospital healthcare system

OBJECTIVE

We critically reviewed every NICU blood component transfusion (packed erythrocytes, platelets, frozen plasma (FP) and cryoprecipitate) administered during a one-year period. This was done to determine the proportion of transfusions given out of compliance with the Intermountain Healthcare transfusion guidelines, and to look for patterns of non-compliance that could be addressed by quality improvement measures.

STUDY DESIGN

A detailed review was made of every transfusion administered to patients with a date of birth of 1 January 2006 through 31 December 2006, in any of three level III, perinatal-center-associated NICUs within Intermountain Healthcare.

RESULT

During 2006 the three NICUs cared for 1759 neonates. Seventeen percent of these received one or more (median 3) erythrocyte transfusions, 4% received one or more (median 3) platelet transfusions, 6% received one or more (median 1) FP infusions and 2% received cryoprecipitate (median 1 dose). Seventy percent of the erythrocyte transfusions were given in compliance with the guidelines, as were 69% of the platelet transfusions, 65% of the FP transfusions and 94% of the cryoprecipitate administrations. Patients who received large numbers of transfusions were more likely to receive transfusion that violated the guidelines. Forty-five percent of patients who received 1 to 3 transfusions received all transfusions within guidelines. However, only 18% of patients who received 4 to 10 transfusions received all within guidelines. No patient who received >10 transfusions received all within the guidelines. Erythrocyte transfusions given early in the hospital course were likely to be within guidelines; 72% (588/818) in the first 29 days were compliant with guidelines, but compliance fell to 61% (144/237) for transfusions administered after 29 days (P=0.002). About half of the platelet transfusions given early in the hospital course were in violation of guidelines, but after day 9, 83% of platelet transfusions were compliant with guidelines (P=0.000).

CONCLUSION

Opportunities exist in our healthcare system to improve compliance with our transfusion guidelines. Such opportunities are greatest among neonates receiving multiple transfusions, among those receiving erythrocyte transfusions late in their NICU course and among those receiving platelet transfusions early in their NICU course.

Do platelet transfusions in the NICU adversely affect survival? Analysis of 1600 thrombocytopenic neonates in a multihospital healthcare system

OBJECTIVE

Several studies have indicated a correlation between the number of platelet transfusions received by newborn intensive care unit (NICU) patients and the mortality rate. The number of platelet transfusions might be a marker for level of illness, and thus predictive of mortality. However, an alternative hypothesis is that multiple platelet transfusions themselves are harmful in this population.

STUDY DESIGN

We evaluated data from all thrombocytopenic neonates cared for in the Intermountain Healthcare NICUs in the past 4 years, seeking associations between the lowest platelet count recorded, number of platelet transfusions received and mortality rate. We also conducted a sensitivity analysis to examine the hypothesis that platelet transfusions were responsible for some fraction of the mortality rate.

RESULT

Transfusion and outcome data were examined from 1600 thrombocytopenic NICU patients. At any level of platelet count, some patients received platelet transfusions but others did not. However, at all levels of platelet count, those that received platelet transfusions had a higher mortality rate. Neonates not given any platelet transfusions had a mortality rate of 2%, those with 1 or 2 transfusions had a mortality rate of 11% (P<0.001); those with >10 had a mortality rate of 35% (P<0.001); and those with > or = 20 had a mortality rate of 50% (P<0.001). A sensitivity analysis suggested that the platelet transfusions themselves were very likely responsible for some fraction of the increasing mortality rate.

CONCLUSION

The number of platelet transfusions administered in the NICU predicts the mortality rate. Some of this correlation is ascribable to unknown and unmeasured factors such as level of illness. However, the present data and the sensitivity analysis both suggest that some of this correlation is due to harmful effects of multiple platelet transfusions in this group of patients.

ETCare: a randomized, controlled, masked trial comparing two solutions for upper airway care in the NICU

BACKGROUND

Small quantities of normal saline are sometimes instilled into the endotracheal tube of intubated neonates, to assist with the removal of thick secretions and maintain patency of the endotracheal tube. However, saline is detrimental to the innate immune system of the upper airway mucosa, rapidly unfolding and inactivating antimicrobial peptides such as LL-37. We previously reported the preparation and feasibility testing of 'ETCare', a low-sodium, physiologically based solution for airway care, and we now report results of a randomized, masked, controlled, two-centered study testing ETCare vs sterile saline among 60 intubated NICU patients.

STUDY DESIGN

Sixty intubated NICU patients were randomized to having their airway care with ETCare vs saline. Three hypotheses were tested: (1) tolerance - patients will tolerate ETCare for airway care as well as they tolerate saline, (2) nosocomial infections - ETCare will result in fewer tracheal aspirates where organisms grow and fewer cases of nosocomial sepsis, and (3) chronic lung disuse - ETCare will result in fewer patients discharged home on supplemental O2.

RESULTS

Thirty NICU patients with an endotracheal tube in place were randomized to receive their airway care with ETCare, and 30 to receive their care with saline. Only the pharmacist was aware of the randomization; the two solutions were visually indistinguishable and were dispensed in identical syringes. Tolerance of the solutions was similar. The ETCare recipients had trends toward fewer positive blood cultures (odds ratios (OR), 0.48; 95% confidence interval (CI), 0.13 to 1.68), and fewer discharges home on supplemental O2 (OR, 0.43; 95% CI, 0.14 to 1.32; P=0.075).

CONCLUSIONS

On the basis of this study and our previous 10-patient feasibility trial, we maintain that, for airway care, intubated NICU patients tolerate ETCare as well as saline. Data from this study can be used in estimating the sample sizes needed for a phase III trial. We speculate that such a trial will demonstrate that, compared with saline, ETCare will result in fewer nosocomial infections and less chronic lung disease.

Necrotizing enterocolitis in term neonates: data from a multihospital health-care system

OBJECTIVE

In the past 5(1/2) years, 30 term or near-term neonates in the Intermountain Healthcare system developed necrotizing enterocolitis (NEC) Bell's stage > or =II. We sought to identify possible explanations for why these patients developed NEC, by comparing them with 5847 others that did not develop NEC, from the same hospitals and of the same gestational ages, cared for during the same 5 1/2-year period.

STUDY DESIGN

Data were collected from neonates admitted to any of the Intermountain Healthcare NICUs with a birth date from 1 January 2001 to 30 June 2006, and a gestational age >36 weeks. A variety of patient features and feeding practices were compared between those that did vs did not develop NEC.

RESULT

Forty-one neonates >36 weeks gestation were listed in the discharge records as having NEC of Bell's stage II or higher. However, on review of these 41 medical records, 11 were seen to have had NEC of Bell's stage I, whereas the remaining 30 had radiographs and clinical courses indicative of Bell's stage > or =II. Those 30 formed the basis of this study. Twenty-eight of the 30 developed NEC after having been admitted to an NICU for some other reason; the other two developed NEC at home, within 2 days of being discharged from an NICU. The 30 that developed NEC were more likely than the 5847 that did not develop NEC, to have congenital heart disease (P=0.000), polycythemia (P=0.002), early-onset bacterial sepsis (P=0.004) or hypotension (P=0.017). All 30 received enteral feedings before NEC developed; 29 were fed either artificial formula or a mixture of formula and breast milk. The one that was exclusively fed human milk was fed human milk with added fortifier (24 cal/oz). The 30 that developed NEC were more likely to be fed formula exclusively (P=0.000). Seven of the 30 had a laparotomy for NEC; two of the seven had total bowel necrosis and support was withdrawn. The other five had perforations and bowel resections. The mortality rate was 13% (4/30).

CONCLUSION

In our series, NEC among term or near-term neonates was exclusively a complication developing among patients already admitted to a NICU for some other reason. We speculate that the combination of reduced mesenteric perfusion and feeding with artificial formula were factors predisposing them to develop NEC.