Risk adapted transmission prophylaxis to prevent vertical HIV-1 transmission: effectiveness and safety of an abbreviated regimen of postnatal oral zidovudine.

BACKGROUND: Antiretroviral drugs including zidovudine (ZDV) are effective in reducing HIV mother to child transmission (MTCT), however safety concern remains. The optimal duration of postnatal ZDV has not been established in clinical studies and there is a lack of consensus regarding optimal management. The objective of this study was to investigate the effectiveness and safety of a risk adapted two week course of oral postnatal ZDV as part of a combined intervention to reduce MTCT. METHODS: 118 mother infant pairs were treated according to the German-Austrian recommendations for HIV therapy in pregnancy and in HIV exposed newborns between 2000-2010. In the absence of factors associated with an increased HIV-1 transmission risk, children were assigned to the low risk group and treated with an abbreviated postnatal regimen with oral ZDV for 2 weeks. In the presence of risk factors, postnatal ZDV was escalated accordingly. RESULTS: Of 118 mother-infant pairs 79 were stratified to the low risk group, 27 to the high risk group and 11 to the very high risk group for HIV-1 MTCT. 4 children were lost to follow up. Overall Transmission risk in the group regardless of risk factors and completion of prophylaxis was 1.8% (95% confidence interval (CI) 0.09-6.6). If transmission prophylaxis was complete, transmission risk was 0.9% (95% CI 0.01-5.7). In the low risk group receiving two week oral ZDV transmission risk was 1.4% (95% CI 0.01-8.4) CONCLUSION: These data demonstrate the effectiveness of a short neonatal ZDV regimen in infants of women on stable ART and effective HIV-1 suppression. Further evaluation is needed in larger studies.

Effect of the introduction of diagnosis related group systems on the distribution of admission weights in very low birthweight infants.

BACKGROUND: Admission weight to neonatal intensive care units is used in several diagnosis related group (DRG) systems to assess reimbursement by health insurance programs for premature infants. Modifications of admission weights could significantly affect reimbursement in either direction. OBJECTIVE: Whether the introduction of the German DRG system in 2004 influenced the distribution of admission weights of premature infants was investigated. DESIGN/METHODS: All very low birthweight infants in the most heavily populated German federal state, North Rhine-Westphalia, born in 1999-2001 and 2004-2006, were investigated. Data were retrieved from the medical association of North Rhine-Westphalia on 13 180 very low birthweight infants (VLBW; birth weight <1500 g). These data included admission weight and gestational age. RESULTS: In 2004-2006 compared to 1999-2001, there were significantly more infants with admission weights below 1000 g (2004-2006; 949-999 g: 460 infants, p=0.007) and 1500 g (2004-2006; 1449-1499 g: 815 infants, p=0.0019), and fewer infants with documented weights above these cut-off values (1999-2001; 1000-1049 g: 346 infants and 2004-2006; 1500-1549 g: 658 infants). CONCLUSIONS: The introduction of the DRG system in Germany has affected the distribution of admission weights of premature infants. Potential reasons for this effect including upcoding are discussed.

Perinatal hemorrhagic shock after fetal scalp blood sampling.

BACKGROUND: Fetal scalp blood sampling is commonly used for fetal monitoring during labor to identify intrapartum fetal hypoxia. CASE: A male term neonate was monitored by fetal scalp blood sampling because of abnormal cardiotocographic recordings. After emergency cesarean delivery, the newborn presented with severe hemorrhagic shock as a result of fetal anemia from the scalp blood sampling. Two scalp incisions were identified as the bleeding source. The underlying reason for the development of hemorrhagic shock was factor IX-deficiency resulting from spontaneous mutation. The neonate was subsequently discharged a week later without further complications. CONCLUSION: Complications during fetal scalp blood sampling are very rare, but obstetricians and neonatologists should be aware of the potential presence of coagulopathies, especially with the persistence of scalp bleeding after delivery.

Severe hypernatremia in an extremely low birth weight infant with subsequent normal neurological development.

Severe preterm hypernatremia is a life-threatening electrolyte disorder which mainly causes neurological complications such as brain edema, intracranial hemorrhages, hemorrhagic infarctions and thromboses. We report the case of an extremely low birth weight infant (520 g, 24+6 weeks of gestation) with severe hypernatremia of 199 mmol/l due to a failure in the preparation of an infusion on the 7th day of life. The infant subsequently showed no signs of central nervous system complications and no neurological symptoms due to this mishap so far. MRI scan performed after 4 months showed no evidence of cerebral complications including white matter injury. Even severe hypernatremia might not inevitably lead to central nervous system dysfunction and seizures in extremely low birth weight infants.

Correlation between severity of disease and reimbursement of costs in neonatal and paediatric intensive care patients.

AIM: The aim of the present study was to investigate the correlation between neonatal, paediatric and adult disease severity scores and reimbursement by health insurances. METHODS: The setting was a university hospital's neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU). We performed a prospective study of all patients admitted over the 3-month study period. Data collected included five scoring systems to predict mortality or to quantify disease severity (Paediatric Index of Mortality [PIM], Paediatric Risk of Mortality [PRISM], Simplified Acute Physiological Score [SAPS], Score for Neonatal Acute Physiology [SNAP], Therapeutic Intervention Scoring System [TISS]) on a daily basis, the total reimbursement as calculated by the grouper according to the German diagnosis-related groups (DRG) system, age of the patient, length of stay (LOS), International Classification of Diseases (ICD)-10 and DRG diagnosis. Our intention was to determine the correlation between different neonatal, paediatric and adult scores (PIM, PRISM III, SAPS-II, SNAP, Core-10-TISS), and reimbursement by the health insurance on the basis of the German DRG system in its 2005 and 2007 version. RESULTS: No positive correlation between any score applied and reimbursement by the health insurance could be identified. Reimbursement was positively correlated to the length of hospital stay. Positive correlations could also be shown for some of the scores among each other. CONCLUSION: We conclude that other scoring systems or measures of disease severity urgently need to be established to terminate the chronic underfunding of paediatric intensive care medicine in the developed countries.