Effects of practice change on outcomes of extremely preterm infants with patent ductus arteriosus.

AIM: To determine whether a decrease in patent ductus arteriosus (PDA) treatment or ligation in extremely preterm (EP) infants was associated with changes in rates of mortality and/or morbidities. METHODS: Observational study on EP infants admitted from 2008 to 2015. The small baby guidelines do not mandate ligation, however, in late 2010 the guidelines were amended based on new literature suggested that ligation may increase rates of morbidities. RESULTS: There were 717 EP infants admitted during the study period. There were no significant changes in gestational age, birthweight or annual admissions during the study period. The annual rate of PDA medical treatment declined significantly (R = 0.83, p = 0.01), while the annual rate of PDA ligation declined substantially (R = 0.88, p = 0.004). The annual mortality rate also declined significantly (R = 0.81, p = 0.014). The annual rates of bronchopulmonary dysplasia (BPD), necrotising enterocolitis and intraventricular haemorrhage did not change significantly. CONCLUSION: In this cohort of EP patients, the rate of PDA ligation decreased substantially since 2010, with no apparent adverse effects on mortality or rates of BPD. These data are consistent with the concept that ligation does not improve outcomes in EP infants.

The effect of ovine peripheral blood mononuclear cells on Haemonchus contortus larval morbidity in vitro.

The objective of this study was to determine the effects of peripheral blood mononuclear cells (PBMC), derived from parasite-resistant St. Croix (STC) hair sheep and parasite-susceptible Suffolk (SUF) sheep, on Haemonchus contortus L3 stage larval death in vitro, with or without autologous serum. Larval morbidity was quantified by measuring larval ATP concentration following incubation with PBMC. Larvae exposed to either STC- or SUF-derived PBMC had lower ATP than live larvae (0.12 µmol/L ATP and 0.16 µmol/L ATP vs 0.27 µmol/L ATP, respectively) (P<.001) and greater ATP of dead larvae (0.03 µmol/L ATP) (P<.001). Breed differences were observed with addition of autologous serum. Larvae exposed to SUF-derived PBMC with autologous serum were not significantly different from live larval ATP. STC-derived serum did not significantly reduce larval ATP compared to PBMC alone (0.11 µmol/L ATP), but was significantly reduced compared to live larvae (0.22 µmol/L ATP) and SUF-derived PBMC with autologous serum (0.23 µmol/L ATP) (P<.001). These data indicate that a cellular response alone is capable of significantly reducing larval ATP in a breed-independent manner. However, addition of serum to SUF-PBMC failed to reduce larval ATP, indicating breed-dependent humoral response to H. contortus.

Effects of peripheral blood mononuclear cells on Haemonchus contortus larval motility in vitro.

The objective of this experiment was to determine effects of peripheral blood mononuclear cells (PBMC), derived from parasite-resistant St. Croix (STC) and parasite-susceptible Suffolk (SF) sheep, on motility of Haemonchus contortus L3 stage larvae in vitro. Peripheral blood mononuclear cells were collected from 10 lambs of each breed, 5 naïve and 5 which had received a priming infection with H. contortus. Larval motility was quantified using a MIF Nikon Sweptfield microscope and NIS Elements AR software, and measurements included path length (PL) (µm), velocity (VEL) (µm/s) and acceleration (ACC) (µm/s2 ). After 18 h of incubation, PL and VEL were greatest in larvae cultured with SF-derived PMBC and were significantly different from all other groups (P < 0·01). No difference was observed in PL or VEL between larvae exposed to naïve or primed STC-derived PBMC and primed-SF PBMC. Differences in ACC were detected between larvae cultured with primed STC-derived PBMC (10·91 µm/s2 ) and naïve SF-derived PBMC (45·7 µm/s2 ) (P = 0·035). These data indicate an innate ability of STC-derived PBMC to severely inhibit larval motility.

Empowerment programme for parents of extremely premature infants significantly reduced length of stay and readmission rates.

AIM: Extremely premature infants experience long hospitalisation and high readmission rates within 30 days of discharge. This quality control investigation retrospectively explored the impact of the Creating Opportunities for Parent Empowerment (COPE©) programme on these rates in an all referral, Level-IV small baby intensive care unit setting. METHODS: The parents of 303 extremely premature infants participated in the study. Of those, 135 were admitted before the implementation of COPE© and served as baseline historical controls, and the remaining 168 neonates received the intervention. Length of stay and readmission rates were analysed using parametric and nonparametric tests. Additional analyses were used to compare the two groups in terms of gestational age, birthweight and other acuity measures. RESULTS: Neonates who received COPE© required significantly reduced lengths of stay than the control neonates (COPE© 127.1 ± 55.8 days vs. control 139.6 ± 61.9 days, p < 0.05) and significantly lower readmission rates (COPE© 23.9% vs. control 13.2%, p = 0.05). CONCLUSION: The COPE© programme promoted active parental engagement in the unit and significantly reduced hospital stays and readmission rates. Future interventions should identify the specific components of the programme that support the parents of extremely premature infants during the various phases of hospitalisation.

Incidence of central line related/associated bloodstream infections in an acute hospital.

Bloodstream infection related to a central venous catheter in the intensive care unit is a substantial clinical and economic problem. The aim of the study was to examine the incidence of central line related bloodstream infections and central line associated bloodstream infections in Our Lady of Lourdes Hospital, Drogheda, during a six month period, using an active patient based prospective surveillance method. CLRBSI rate in ICU/HDU was 0.93/1000 central line days. There was no CLABSI identified in the studied time period. However, further interventions are needed, particularly with CVC care bundle. Also, the implementation of 2% chlorhexidin in 70% isopropylalcohol use for skin asepsis, which is recommended by the Irish national guidelines, would be beneficial.

The effects of parenteral fish oil on neurodevelopment in preterm infants: A narrative review.

OBJECTIVE: This narrative review aimed to summarize studies assessing the effects of parenteral fish oil on neurodevelopment in preterm infants. METHODS: PubMed was searched (July 1985 to October 2023). We reviewed randomized controlled trials, and observational studies assessing intravenous lipid emulsion with fish oil in preterm infants (born less than 37 weeks' gestation), that reported long-term neurodevelopmental outcomes. RESULTS: We identified four publications relating to three randomized controlled trials in addition to four cohort studies. Study designs and outcomes were heterogenous and precluded meta-analyses. Results of trials were null for a selection of neurodevelopmental outcomes, however possible benefits of parenteral fish oil supplementation for neurodevelopment was reported in three cohort studies. Certainty of the evidence is hindered by methodological limitations of available trials and observational studies. CONCLUSIONS: Further research is required to firmly establish the effects of parenteral fish oil on preterm neurodevelopment.

Risk of Proliferative Vitreoretinopathy in the Second Eye in Adult Patients with Bilateral Retinal Detachment.

PURPOSE: To examine the incidence and risk factors of proliferative vitreoretinopathy (PVR) in the patients who develop rhegmatogenous retinal detachment (RRD) in their fellow eye after having a prior RRD complicated by PVR. DESIGN: Multicenter, retrospective observational study. SUBJECTS: Eyes with retinal detachment and PVR between 2015 and 2023 were identified through the Vestrum Health Database. METHODS: Risk factors for PVR development, specifically documented PVR in the fellow eye, gender, age, lens status, and presenting and final visual acuity (VA), were evaluated. MAIN OUTCOME MEASURES: Odds ratio (OR) for PVR development during 6 months postoperative period. RESULTS: Of 57 264 patients, 11% had PVR in ≥1 eye. Of the 50 989 patients who did not develop PVR after the initial RRD, 4834 developed RRD in the fellow eye. One hundred sixty-six of these patients developed PVR in their second eye for a PVR rate of 3% in the fellow eye. Of the 6275 patients who developed PVR after primary RRD repair, 406 of these patients went on to develop RRD in their fellow eye. Forty-two of these patients developed PVR in their second eye for a PVR rate of 10%. A regression model that also included age, gender, and VA led to an OR of 3.42 (P < 0.001). The OR of PVR development generally decreased with age. Pseudophakic patients had a higher OR for PVR development, 1.48 (P = 0.017). Initial patients with VA 20/40 to 20/80 had an OR of 2.15 (P = 0.003). Patients with VA worse than 20/200 had an OR of 2.89 for PVR development (P < 0.001). CONCLUSIONS: Patients with a history RRD with PVR in 1 eye have approximately 3.5 times higher rate of PVR in their second eye after RRD compared with patients without a history of PVR. This finding potential impacts surgical decisions and use of prophylactic anti-PVR therapy if the patient's second eye has RRD. The final VA in the second eye of patients with a history of PVR is better than for the second eye of patients with no history of PVR, which may indicate surgeons are already taking steps to prevent PVR in the patient's second eye. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Validity and reliability of the behavioral signs of respiratory instability (BSRI) © scale during activity for infants with bronchopulmonary dysplasia.

OBJECTIVE: There is no reliable evidence on how best to evaluate the overall status of infants with severe forms of bronchopulmonary dysplasia (BPD). The Behavioral Signs of Respiratory Instability (BSRI) scale was developed as an objective measure of developmental capacity during occupational and physical therapy sessions. The purpose of this study was to determine the psychometric properties of the BSRI Scale. STUDY DESIGN: The BSRI and Respiratory Severity Score (RSS) were compared for 25 infants with BPD and 15 infants without BPD. A cross-sectional design was used to test inter-rater reliability among 10 NICU occupational and physical therapists. A prospective cohort design was used to evaluate validity. RESULTS: The BSRI demonstrated good to excellent inter-rater reliability (ρ = 0.47-0.91) and was strongly correlated with RSS (ρ = -0.77, p < 0.001; concurrent validity). CONCLUSION: The BSRI Scale has preliminary psychometric support. Standardized measures like the BSRI may provide accurate, objective data that can improve care planning within interdisciplinary teams that supports brain growth and potentially improves neurodevelopment.

Multiple Evanescent White-Dot Syndrome in a 9-Year-Old Girl.

Purpose: This work describes a case of multiple evanescent white-dot syndrome (MEWDS) in a 9-year-old girl. Methods: A case report is presented. Results: A case of MEWDS in a 9-year-old girl is described. Conclusions: To our knowledge this is the youngest presentation of MEWDS discussed in the literature. MEWDS should be considered in the differential diagnosis of ocular inflammation in the first decade of life.

Footpad dermatitis in poultry.

Footpad dermatitis (FPD) is a condition that causes necrotic lesions on the plantar surface of the footpads in growing broilers and turkeys. This condition not only causes downgrades and condemnations of saleable chicken paws, the portion of the leg below the spur, but is also an animal welfare concern in both the United States and in Europe.. Revenue from chicken paws in 2008 alone was worth $280 million. Harvesting large, unblemished paws has become a priority to poultry companies all over the world. Research on this subject has been ongoing since the 1940s and has looked into many different areas including nutrition, environment, and genetics. Early research looked at nutritional deficiencies such as riboflavin and biotin mainly in turkey poults. This early research was most likely looking at a separate form of dermatitis than what is being investigated now. Recent findings have suggested that there is a myriad of interacting factors that lead to FPD. Litter moisture appears to be the most likely culprit in the onset of this condition. Research has also shown a possible genetic link in the susceptibility to development of FPD lesions. Current chicken paw prices have skyrocketed due to a large export market in Asia. To produce unblemished paws for both increased profit and comply with current animal welfare recommendations, further research is needed to understand how the condition develops and what strategies can be used to prevent it.

Outcomes following indomethacin prophylaxis in extremely preterm infants in an all-referral NICU.

OBJECTIVE: We examined data from a contemporary cohort of extreme prematurity (EP) infants admitted to an all-referral Children's Hospital neonatal intensive care unit (NICU) to determine whether prophylactic indomethacin (PI) may continue to benefit these patients. STUDY DESIGN: An observational study utilizing the small baby ICU data registry that was queried for all EP infants admitted between 2005 and 2014 with documentation of PI use (671 total EP infants; 141 (21%) did not receive PI (control); 530 (79%) received PI (PI). This cohort of EP infants was born at outside hospitals and transferred to our level IV NICU with a mean age on admission of 13 days, well after the PI would have been administered. RESULTS: No difference existed between the control and PI groups in gestational age, birth weight, severity of illness, other in-hospital outcomes or developmental delay. PI infants had a significantly lower mortality rate (P=0.0004), lower relative risk (RR) for mortality 0.52 (95% confidence interval (CI) 0.37 to 0.73, P=0.0001) and lower RR of developing the combined outcome of death or bronchopulmonary dysplasia (RR 0.91, 95% CI 0.85 to 0.98, P=0.012) when compared with the control group. Notably, there was no significant effect of PI on incidence of severe intraventricular hemorrhage or patent ductus arteriosus ligation. CONCLUSION: PI administration was associated with improved survival in EP infants referred to a level IV Children's Hospital NICU.

Challenges, successes and opportunities for reducing readmissions in a referral-based children's hospital NICU.

AIM: To evaluate readmission data in a level IV neonatal intensive care unit (NICU) to identify patient characteristics and process failures which serve as drivers for readmission. METHODS: Our center is a primary referral center in Central and Southeast Ohio, providing us a unique opportunity to evaluate readmissions. We studied our current discharge process, caregiver perception of discharge readiness, parental comfort and the pre-discharge and post-discharge characteristics of infants. RESULTS: Our readmission rate during the 4 year period has remained stable at 9.8%. 74% of the caregivers rated that their perception of their baby's medical readiness for discharge was good to excellent. Duration of hospitalization and public insurance coverage (Medicaid) were significant risk factors for readmission (p = 0.00). In our setting, the majority of the patients are readmitted through the emergency department and nearly half of all readmissions were for 3 or fewer days. Patients discharged from our Comprehensive Center for BPD had similar readmission rate despite characteristics which should increase their readmission rate. CONCLUSIONS: Readmission rate is a poor indicator of the quality of care provided in the NICU. In addition to patient factors such as longer length of stay and Medicaid, our data suggests that preventing readmission depends on having systems in place to help families cope with transition of care after discharge.

The effect of rapamycin on the healing of the ureteric anastomosis and wound healing.

Rapamycin is a potent immunosuppressive agent that also inhibits fibroblastic activity and therefore may affect the healing of various tissues. The aim of this study was to investigate the effect of rapamycin on wound healing and the healing of the ureteric anastomosis. Large White/Landrace pigs were subjected to a laparotomy and division and immediate anastomosis of the ureter. The animals were randomly allocated to receive either rapamycin or placebo. The animals were sacrificed on postoperative day 5, and strips of the skin and fascia closure and the ureteric anastomosis excised and used to determine the tensile strength, hydroxyproline levels, and histological changes. The tensile strength and the hydroxyproline levels in the ureter and fascia were lower in the rapamycin-treated animals. There was no difference in the tensile strength in the skin, although the hydroxyproline levels were lower. This study shows that healing of the ureteric anastomosis and fascia and skin closure may be impaired by rapamycin.

Effect of rapamycin on the healing of the bile duct.

Besides its potent immunosuppressive properties, rapamycin also has antitumor and antifungal effects. Rapamycin also inhibits the proliferation of fibroblasts and therefore may impair the healing of various tissues. We investigated the effect of rapamycin on the healing of the bile duct anastomosis. The study was undertaken in pigs that were subjected to a laparotomy under general anesthesia. The bile duct was mobilized and divided and immediately reanastomosed. The animals were randomly allocated to receive either rapamycin or placebo. The animals were sacrificed on the postoperative day 5, then the biliary anastomosis was excised and used to determine the tensile strength, hydroxyproline levels, and the histological changes. The tensile strength and the hydroxyproline levels in the biliary anastomosis were lower in the animals treated with rapamycin. The liver function tests were normal. These studies show that rapamycin may impair the healing of the biliary anastomosis.

Restoration of liver mass after partial hepatectomy--implications for living donor liver transplantation.

In living donor liver transplantation, the recipient liver undergoes more rapid regeneration than the remnant liver in the donor. In this study we investigated the factors which may be responsible for the difference in the regenerative response between the donor and the recipient. Long Evans rats were subjected to either partial hepatectomy (PH) or sham operation (SH) and were treated with liver cytosol (C) and cyclosporine (Cy). The rats were sacrificed at 24, 48, 72 and 96 hours and 1 and 2 weeks postoperatively. The livers were removed to determine the liver weight/body weight (LW/BW) ratio and the mitotic index. The mitotic index, serum aspartate transferase (AST) and serum alanine transferase (ALT), although unchanged in the SH groups, were increased in the rats treated with PH + C + Cy, and were greater than after PH only. However LW/BW ratios increased after PH but had returned to preoperative levels by 2 weeks. The changes in LW/BW ratio were not modified by the cytosol or cyclosporine.

Early extubation attempts reduce length of stay in extremely preterm infants even if re-intubation is necessary.

OBJECTIVE: Prolonged mechanical ventilation in the extremely premature infant is associated with the development of bronchopulmonary dysplasia (BPD). Clinically, the decision to extubate the extremely low birth weight (ELBW) infant can be difficult. There is continued debate regarding whether it is better for an ELBW infant to remain on the ventilator or to extubate to nasal constant positive airway pressure (nCPAP). It has also been argued that repeated intubations may be detrimental to ELBW infants. We tested the hypothesis that earlier extubation attempts would decrease length of hospital stay and BPD. STUDY DESIGN: A database maintained on infants born at <27 completed weeks gestation admitted to our all referral NICU for a 36 month period was queried (n = 224). RESULTS: Day of life (DOL) of the first extubation attempt was inversely correlated with birth weight (p <  0.001) and gestational age (p <  0.01). The DOL of the 1st extubation attempt correlated with the need for re-intubation (p <  0.001), but not with mortality (p = 0.27). In survivors, earlier DOL of 1st extubation attempt was associated with shorter LOS (p <  0.001). Earlier DOL of the 1st extubation attempt was associated with less need for supplemental oxygen (p <  0.001) at 36 weeks CGA, while re-intubation was not (p = 0.50). CONCLUSION: In our cohort of extremely premature infants, the earlier the first extubation attempt the sooner the patient was discharged home and the less likely to develop BPD. Our study suggests that extubation should not be delayed in extremely premature infants due to fears of need for re-intubation.

Big endothelin-3 constricts forearm resistance vessels but not hand veins in humans.

BACKGROUND: Endothelin-3 (ET-3) and its inactive precursor, big endothelin-3 (big ET-3), are both found in human plasma. We investigated whether big ET-3 is converted to ET-3 in the human forearm resistance vessels and dorsal hand veins in vivo. METHODS: In a 4-phase study, 6 subjects received 90 minute intrabrachial artery infusions of big ET-3 (50 and 100 pmol x min(-1)) and ET-3 (5 and 10 pmol x min(-1)) in random order. Forearm blood flow was measured by venous occlusion plethysmography. In a second 3-phase study, 6 subjects received 90-minute dorsal hand vein infusions of saline solution, big ET-3 (50 pmol x min(-1)) and ET-3 (5 pmol x min(-1)) in random order. In a third 2-phase study, 6 subjects received 90-minute dorsal hand vein infusions of big ET-3 (100 pmol x min(-1)) and ET-3 (10 pmol x min(-1)). In the dorsal hand vein studies, vessel diameter was measured by the Aellig technique. RESULTS: Intra-arterial ET-3 caused local forearm vasoconstriction of 20%+/-9% (P = .009) at 5 pmol x min(-1) and 20%+/-10% (P = .001) at 10 pmol x min(-1) after 90 minutes, with no difference between doses (P = .69). Intra-arterial big ET-3 also caused local forearm vasoconstriction of 22%+/-6% at 50 pmol x min(-1) (P = .004) and 18%+/-3% at 100 pmol x min(-1) (P<.0001) after 90 minutes, with no difference between doses (P = .44). There were no significant differences between the responses to intra-arterial big ET-3 and ET-3 at these doses. Local intravenous ET-3 caused a constriction of 9%+/-2% at 5 pmol x min(-1) (P = .04) and 22%+/-8% at 10 pmol x min(-1) (P = .002) after 90 minutes. Big ET-3 at 50 pmol x min(-1) and 100 pmol x min(-1) did not affect hand vein tone. All responses were slowly progressive. CONCLUSIONS: Based on vasoconstriction, measurable conversion of big ET-3 to ET-3 occurs in forearm resistance vessels but not in dorsal hand veins in vivo. An endothelin-converting enzyme, capable of converting exogenously administered big ET-3 to ET-3, appears to be present in upper limb resistance arteries but not in capacitance vessels in humans.

A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit hyperactivity disorder.

OBJECTIVE: This study evaluated the efficacy and safety of guanfacine in treating children with tic disorders and attention deficit hyperactivity disorder (ADHD). METHOD: Subjects from a specialty tic disorders clinic were randomly assigned to receive 8 weeks of treatment with guanfacine or placebo under double-blind conditions. Follow-up visits occurred every 2 weeks for safety monitoring and dose adjustment. RESULTS: Thirty-four medication-free subjects (31 boys and three girls with a mean age of 10.4 years) with ADHD, combined type, and a tic disorder participated. After 8 weeks of treatment, guanfacine was associated with a mean improvement of 37% in the total score on the teacher-rated ADHD Rating Scale, compared to 8% improvement for placebo. Nine of 17 subjects who received guanfacine were blindly rated on the Clinical Global Improvement scale as either much improved or very much improved, compared with none of 17 subjects who received placebo. The mean score on the parent-rated hyperactivity index improved by 27% in the guanfacine group and 21% in the placebo group, not a significant difference. On the Continuous Performance Test, commission errors decreased by 22% and omission errors by 17% in the guanfacine group, compared with increases of 29% in commission errors and of 31% in omission errors in the placebo group. Tic severity decreased by 31% in the guanfacine group, compared to 0% in the placebo group. One guanfacine subject with sedation withdrew at week 4. Guanfacine was associated with insignificant decreases in blood pressure and pulse. CONCLUSIONS: Guanfacine appears to be a safe and effective treatment for children with tic disorders and ADHD.

Step activity monitor: increased accuracy in quantifying ambulatory activity.

This study compares the accuracy of a two-dimensional accelerometer worn on the ankle (a step activity monitor) with that of an electronic, digital pedometer worn on the belt line. Twenty-nine human subjects were evaluated while they briskly walked 400 M, slowly walked 10 M, and ascended and descended a flight of stairs. The step activity monitor had less error in all activities; its mean absolute error was 0.54%, whereas that of the pedometer was 2.82%. The difference was more pronounced in obese subjects (body mass index greater than 30), with an overall mean absolute error of 0.48% for the step activity monitor and 6.12% for the pedometer (nearly 13 times that of the step activity monitor). For subjects with a body mass index less than 30, the step activity monitor had an overall error of 0.56% and the pedometer had an overall error of 1.56% (less than 3 times that of the step activity monitor). The absolute error of the pedometer was positively correlated with body mass index (r = 0.792, p < 0.0001) and weight (r = 0.753, p < 0.0001), whereas the error of the step activity monitor was not significantly correlated with either. Neither device was significantly biased by age, gender, or the presence of a lower-extremity joint prosthesis. The accuracy and additional capabilities, including a real-time memory record of activity, of the step activity monitor make it well suited for objectively quantifying ambulatory activity, especially for obese subjects.