Trends in neonatal mortality and morbidity in very-low-birth-weight (VLBW) infants over a decade: Singapore national cohort study.

BACKGROUND: Very preterm infants are at risk for neurodevelopmental impairment because of postnatal morbidities. This study aims to (1) compare the outcomes of very-low-birth-weight (VLBW) infants in Singapore during two time periods over a decade; 2) compare performances among Singaporean neonatal intensive care units (NICUs); and 3) compare a Singapore national cohort with one from the Australian and New Zealand Neonatal Network (ANZNN). METHODS: Singapore national data on VLBW infants born during two periods, 2007-2008 (SG2007, n = 286) and 2015-2017 (SG2017, n = 905) were extracted from patient medical records. The care practices and clinical outcomes among three Singapore NICUs were compared using SG2017 data. Third, using data from the ANZNN2017 annual report, infants with gestational age (GA) ≤29 weeks in SG2017 were compared with their Oceania counterparts. RESULTS: SG2017 had 9.9% higher usage of antenatal steroids (p < 0.001), 8% better survival for infants ≤26 weeks (p = 0.174), and used 12.7% lesser nonsteroidal anti-inflammatory drugs for patent ductus arteriosus closure (p < 0.001) than those of SG2007 cohort. Rate of late-onset sepsis (LOS) was almost halved (7.4% vs. 14.0%, p < 0.001), and exclusive human milk feeding after discharge increased threefold (p < 0.001). SG2017, in contrast, had a higher rate of chronic lung disease (CLD) (20.0% vs. 15.1%, p = 0.098). Within SG2017, the rates of LOS, CLD, and human milk feeding varied significantly between the three NICUs. When compared with ANZNN2017, SG2017 had significantly lower rates of LOS for infants ≤25 weeks (p = 0.001), less necrotizing enterocolitis for infants ≤27 weeks (p = 0.002), and less CLD across all GA groups. CONCLUSION: Postnatal morbidities and survival rates for VLBW infants in Singapore have improved over a decade. Outcomes for VLBW infants varied among three Singapore NICUs, which provide a rationale for collaboration to improve clinical quality. The outcomes of Singaporean VLBW infants were comparable to those of their ANZNN counterparts.

Restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants: a systematic review and meta-analysis.

AIM: A systematic review was conducted to examine the effects of restrictive versus liberal red blood cell (RBC) transfusion thresholds on clinically important outcomes in very low birth weight (VLBW) infants. METHODS: Randomised controlled trials (RCTs) of varying RBC transfusion thresholds in VLBW infants were identified by searching MEDLINE, EMBASE, CINAHL, all of the Cochrane Library and other supplementary sources. Selected studies included one of the following outcomes: total number of red blood cell transfusions, donor exposure rate, cranial ultrasonographically diagnosed brain injury, retinopathy of prematurity, bronchopulmonary dysplasia, necrotising enterocolitis or death. Studies to be included were selected by two reviewers who also assessed the risk of bias of each trial. Data extraction and analyses were independently performed by two reviewers. All data were analysed using RevMan 5. RESULTS: Six RCTs were identified. One trial did not meet the inclusion criteria, while two had inadequate methodological quality. Pooled analysis of two trials showed that the restrictive transfusion group received a significantly lower mean number of transfusions per infant (mean difference (MD) -1.35, 95% confidence interval (CI) [-2.61, -0.09]) and donor exposure rate (MD -0.54, 95% CI [-0.93, -0.15]). No other statistically significant differences were observed. CONCLUSION: Restrictive RBC transfusion thresholds in VLBW infants may be utilised without incurring clinically important increases in the risk of death or major short-term neonatal morbidities.

Short- and long-term outcomes at 2, 5 and 8 years old for neonates at borderline viability--an 11-year experience.

INTRODUCTION: Neurodevelopmental outcome of borderline viability neonates have lagged behind improvement in survival figures. Accurate figures based on local outcome allow us to better counsel parents and to prognosticate with greater accuracy on both short- and longterm outcomes. MATERIALS AND METHODS: A retrospective cohort study of 101 consecutively born neonates, born from 21 to 26 weeks gestation over an 11-year period from 1 January 1994 to 31 December 2005 was conducted. Long-term outcomes were assessed at 2, 5 and 8 years of age in terms of mental developmental index (MDI) or intelligence quotient (IQ) scores, hearing and visual impairments, handicaps and impairments, school placement and interventions required. RESULTS: Survival rates were 20.0%, 60.9%, 70.4% and 73.2% for neonates born at 21 to 23, 24, 25 and 26 weeks gestation respectively. Factors that predicted increased mortality included higher alveolar-arterial oxygen difference (AaDO2) with odds ratio (OR) 1.005 and lower birth weight OR 0.993. Rates of severe retinopathy of prematurity (ROP) (stage 3 or worse) were 100%, 57.1%, 42.1% and 26.7% for 21 to 23, 24, 25 and 26 weeks gestation respectively. Rates of bronchopulmonary dysplasia (BPD) were 100.0%, 57.1%, 63.2% and 60.0% respectively. Rates of severe intraventricular haemorrhage (IVH) were 0%, 7.1%, 5.3% and 10.0% respectively. Moderate to severe disability rates at 2 years old were 100%, 44.4%, 33.3% and 30.4% respectively. At 5 years old, moderate to severe disability rates were 16.7%, 22.2% and 14.3% respectively for those born at 24, 25 and 26 weeks gestation. Interpretation at 8 years was limited by small numbers. CONCLUSION: Our results indicated that local figures for mortality and morbidity remained high at the limits of viability, although they were comparable to outcomes for large scale studies in advanced countries.

Smooth muscle cells cultured from human saphenous vein exhibit increased proliferation, invasion, and mitogen-activated protein kinase activation in vitro compared with paired internal mammary artery cells.

OBJECTIVE: Smooth muscle cell (SMC) proliferation, invasion, and matrix metalloproteinase (MMP) secretion are key events in the development of intimal hyperplasia, the lesion that causes coronary artery bypass graft (CABG) failure. Saphenous vein (SV) grafts are the most commonly used bypass conduits but are markedly more susceptible to intimal hyperplasia than internal mammary artery (IMA) grafts. We hypothesized that this may be due to inherent functional differences between SV-SMCs and IMA-SMCs. In this study we used paired cultures of SV-SMCs and IMA-SMCs from the same patients and compared their rates of proliferation, invasion, migration, and MMP-2 and MMP-9 secretion. METHODS: SMCs were cultured from explants of paired SV and IMA from 22 patients undergoing CABG. SMC populations of equivalent passage were used to determine proliferation in response to 10% fetal calf serum (FCS), 10 ng/mL platelet-derived growth factor (PDGF), and 10 ng/mL basic fibroblast growth factor (bFGF) by counting cells during a 7-day period. Immunoblotting was used to quantify phosphorylation of p44/42-mitogen-activated protein kinase (MAPK). Invasion and migration rates of paired SMCs were quantified using a modified Boyden chamber technique in the presence or absence of a Matrigel basement membrane barrier (BD Biosciences, Oxford, UK). Conditioned media from invasion assays were analyzed for secretion of MMP-2 and MMP-9 by gelatin zymography. RESULTS: Analysis of areas under curves for 7-day proliferation assays revealed that the number of SV-SMCs in response to FCS, PDGF, and bFGF was 2.1, 2.0, and 2.3 times higher, respectively, than that of paired IMA-SMCs. Basal MAPK activation in SV-SMCs was approximately double that of paired IMA-SMCs. SV-SMCs exhibited a 2.1-fold increase in invasion rate (Matrigel barrier) compared with IMA-SMCs, but migration rates (no Matrigel barrier) and MMP-2 and MMP-9 secretion were similar for the two cell types. CONCLUSIONS: Human SV-SMCs are inherently more proliferative and invasive than paired IMA-SMCs, likely due to a relative increase in p44/42-MAPK activation. These inherent functional differences between SMC of different origins may contribute to the increased prevalence of intimal hyperplasia in SV grafts compared with IMA grafts.

Streptococcus bovis meningitis in a neonate with Ivemark syndrome.

Although Streptococcus bovis infections in adults are associated with endocarditis and bowel neoplasms, S. bovis-associated meningitis is rare in neonates. We describe the case of a neonate with Ivemark syndrome, which possibly predisposed her to infection with this bacterium.