Racial and Ethnic Disparities in Cesarean Morbidity.

OBJECTIVE: Maternal race and ethnicity have been identified as significant independent predictors of obstetric morbidity and mortality in the United States. An appreciation of the clinical contexts in which maternal racial and ethnic disparities are most pronounced can better target efforts to alleviate these disparities and improve outcomes. It remains unknown whether cesarean delivery precipitates these divergent outcomes. This study assessed the association between maternal race and ethnicity and cesarean complications. STUDY DESIGN: We conducted a retrospective cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Nulliparous women with non-anomalous singleton gestations who underwent primary cesarean section were included. Race/ethnicity was categorized as non-Hispanic White, non-Hispanic Black, Hispanic, Asian, Native American, or unknown. The primary outcome was a composite of maternal cesarean complications including hysterectomy, uterine atony, blood transfusion, surgical injury, arterial ligation, infection, wound complication, and ileus. A composite of neonatal morbidity was evaluated as a secondary outcome. We created a multivariable logistic regression model adjusting for selected demographic and obstetric variables that may influence the likelihood of the primary outcome. RESULTS: A total of 14,570 women in the parent trial met inclusion criteria with an 18.8% incidence of the primary outcome (2,742 women). After adjusting for potential confounding variables, maternal surgical morbidity was found to be significantly higher for non-Hispanic Black (adjusted odds ratios [aORs] 1.96, 95% confidence intervals [CIs] 1.63-2.35) and Hispanic (aOR 1.66, 95% CI 1.37-2.01) women as compared with non-Hispanic white women. Neonatal morbidity was similarly found to be significantly associated with the Black race and Hispanic ethnicity. CONCLUSION: In this cohort, the odds of cesarean-related maternal and neonatal morbidity were significantly higher for non-Hispanic Black and Hispanic women. These findings suggest race as a distinct risk factor for cesarean complications, and efforts to alleviate disparities should highlight cesarean section as an opportunity for improvement in outcomes. KEY POINTS: · Non-Hispanic Black and Hispanic women experienced more cesarean complications than non-Hispanic White women.. · These findings suggest that disparities in maternal and neonatal outcomes exist specifically following cesarean section.. · Efforts to alleviate disparities in obstetrics should highlight cesarean section as an opportunity for improvement..

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units.

OBJECTIVE: To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). STUDY DESIGN: We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. RESULTS: Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. CONCLUSIONS: From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Functional characterization of activating mutations in the sulfonylurea receptor 1 (ABCC8) causing neonatal diabetes mellitus in Asian Indian children.

BACKGROUND: Gain-of-function of ATP-sensitive K+ (KATP ) channels because of mutations in the genes encoding SUR1 (ABCC8) or Kir6.2 (KCNJ11) is a major cause of neonatal diabetes mellitus (NDM). Our aim is to determine molecular defects in KATP channels caused by ABCC8 mutations in Asian Indian children with NDM by in vitro functional studies. METHODS: Wild-type (WT; NM_000352.4) or mutant sulfonylurea receptor 1 (SUR1) and Kir6.2 were co-expressed in COSm6 cells. Biogenesis efficiency and surface expression of mutant channels were assessed by immunoblotting and immunostaining. The response of mutant channels to cytoplasmic ATP and ADP was assessed by inside-out patch-clamp recordings. The response of mutant channels to known KATP inhibitors in intact cells were determined by 86 Rb efflux assays. RESULTS: Five SUR1 missense mutations, D212Y, P254S, R653Q, R992C, and Q1224H, were studied and showed increased activity in MgATP/MgADP. Two of the mutants, D212Y and P254S, also showed reduced response to ATP4- inhibition, as well as markedly reduced surface expression. Moreover, all five mutants were inhibited by the KATP channel inhibitors glibenclamide and carbamazepine. CONCLUSIONS: The study shows the mechanisms by which five SUR1 mutations identified in Asian Indian NDM patients affect KATP channel function to cause the disease. The reduced ATP4- sensitivity caused by the D212Y and P254S mutations in the L0 of SUR1 provides novel insight into the role of L0 in channel inhibition by ATP. The results also explain why sulfonylurea therapy is effective in two patients and inform how it should be effective for the other three patients.

Comparing the Hadlock fetal growth standard to the Eunice Kennedy Shriver National Institute of Child Health and Human Development racial/ethnic standard for the prediction of neonatal morbidity and small for gestational age.

BACKGROUND: The fetal growth standard in widest use was published by Hadlock >25 years ago and was derived from a small, homogeneous cohort. In 2015, The Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Study published updated standards that are specific to race/ethnicity. These do not allow for precise estimated fetal weight percentile calculation, however, and their effectiveness to predict neonatal morbidity and small for gestational age has not yet been compared to the long-standing Hadlock standard. OBJECTIVE: We compared the ability of the Hadlock standard to predict neonatal morbidity and small for gestational age at birth with that of The Eunice Kennedy Shriver National Institute of Child Health and Human Development race-/ethnicity-specific standard. Our secondary objective was to compare their performance among our Native American population, which is not accounted for in the Eunice Kennedy Shriver National Institute of Child Health and Human Development standard. STUDY DESIGN: For this retrospective study of diagnostic accuracy, we reviewed deliveries at the University of New Mexico Hospital from Jan. 1, 2013, through March 31, 2017. We included mothers with singleton, well-dated pregnancies and nonanomalous fetuses with an estimated fetal weight within 30 days of delivery. Cubic spline interpolation was performed on the Eunice Kennedy Shriver National Institute of Child Health and Human Development estimated fetal weight-percentile tables to calculate percentiles specific to the gestational day. Estimated fetal weight percentiles were then calculated using both the Hadlock and Eunice Kennedy Shriver National Institute of Child Health and Human Development race-/ethnicity-specific standards according to maternal self-identified race/ethnicity. We calculated the receiver operator area under the curve of each method to predict composite and severe composite neonatal morbidity and small for gestational age at birth (birthweight <10th percentile). As an additional measure of method accuracy, we calculated the mean ultrasound-birthweight percentile discrepancy. For Native Americans, percentiles were calculated using the Hadlock and Eunice Kennedy Shriver National Institute of Child Health and Human Development race/ethnicity standards (white, black, Hispanic, Asian), and test characteristics were calculated for each to predict neonatal morbidity and small for gestational age. RESULTS: We included 1514 women, with a mean ultrasonography-to-delivery interval of 14.4 days (±8.8) and a small for gestational age rate of 13.6% (n = 206). For the prediction of both composite and severe composite neonatal morbidity, the Hadlock method had superior performance, with higher areas under the curve than the Eunice Kennedy Shriver National Institute of Child Health and Human Development method (P < .001 for both), though neither had good discriminatory value (all areas under the curve <0.8). For the prediction of small for gestational age at birth, the Hadlock standard had higher sensitivity (61.1%) than the Eunice Kennedy Shriver National Institute of Child Health and Human Development standard, both when using the interpolated Eunice Kennedy Shriver National Institute of Child Health and Human Development method (36.2%, P < .01) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development whole-week 10th percentile cutoff (46.7%, P < .01). The Hadlock method also had a higher area under the curve than the Eunice Kennedy Shriver National Institute of Child Health and Human Development interpolated method to predict small for gestational age (0.89 vs 0.88, P < .01). The Hadlock method had a lower ultrasound-birthweight percentile discrepancy than the Eunice Kennedy Shriver National Institute of Child Health and Human Development method (6.1 vs 16.5 percentile points, P < .01). Fetuses classified as growth restricted by Hadlock but not Eunice Kennedy Shriver National Institute of Child Health and Human Development had significantly higher composite morbidity than normally grown fetuses. Among Native American women, the Hadlock method had the highest area under the curve to predict composite and severe composite morbidity, while the Hadlock and all Eunice Kennedy Shriver National Institute of Child Health and Human Development race-/ethnicity-specific methods performed comparably to predict small for gestational age. CONCLUSION: Despite its publication >25 years ago, the Hadlock standard is superior to the Eunice Kennedy Shriver National Institute of Child Health and Human Development race-/ethnicity-specific standard for the prediction of both neonatal morbidity and small for gestational age.

An analysis of the effects of intrapartum factors, neonatal characteristics, and skin-to-skin contact on early breastfeeding initiation.

This study aims to determine relationships between intrapartum factors, neonatal characteristics, skin-to-skin contact (SSC), and early breastfeeding initiation after spontaneous vaginal and Caesarean section or operative vaginal birth. A total of 915 mother-newborn dyads were considered in a hypothetical model based on integrated concepts of breastfeeding initiation model, infant learning framework, and attachment theory. Multiple-group path analysis was used to determine whether differences exist between effects of immediate SSC (≤30 min) on early breastfeeding initiation in different modes of birth. SSC, mode of birth, labour duration, and neonatal intensive care unit admission were significantly associated with early breastfeeding initiation, as indicated by the path analysis model, which included all samples. Women with immediate SSC were more likely to initiate early breastfeeding in different modes of birth. In the spontaneous vaginal birth group, women showed a lower likelihood of initiating early breastfeeding when their neonates were admitted to the neonatal intensive care unit and presented an Apgar score of <7 at 1 min. Multiple-group analysis showed no significant difference between effects of immediate SSC on early breastfeeding initiation in different modes of birth (critical ratio = -0.309). Results showed that models satisfactorily fitted the data (minimum discrepancy divided by degrees of freedom = 1.466-1.943, goodness of fit index = 0.981-0.986, comparative fit index = 0.947-0.955, and root mean square error of approximation = 0.023-0.032). Our findings emphasize the crucial importance of prioritizing promotion of immediate SSC under different modes of birth.

Umbilical cord-care practices in low- and middle-income countries: a systematic review.

BACKGROUND: Neonatal sepsis is the third leading cause of deaths for infants in their first month of life. The newly cut umbilical cord can be a pathway for bacteria that can cause newborn sepsis and death. Optimal umbilical cord care practices for newborns and during the first week of life, especially in settings with poor hygiene, has the potential to avoid these preventable neonatal deaths. The purpose of this review of cord care practices is to assist in the development of behavior-change strategies to support introduction of novel cord-care regimens, particularly 7.1% chlorhexidine digluconate for umbilical cord care. METHODS: We searched domestic and international databases for articles that were published in English between January 1, 2000, and August 24, 2016. We found 321 articles and reviewed 65 full-text articles using standardized inclusion criteria. The primary criteria for inclusion was a description of substances applied to the umbilical cord stump in the days following birth. RESULTS: We included 46 articles in this review of umbilical cord-care practices. Articles included data from 15 low- and middle-income countries in sub-Saharan Africa (8 countries), Asia (5 countries), North Africa (1 country), and Latin America and the Caribbean (1 country). Findings from this review suggest that documentation of cord-care practices is not consistent throughout low- and middle-income countries, yet existing literature depicts a firm tradition of umbilical cord care in every culture. Cord-care practices vary by country and by regions or cultural groups within a country and employ a wide range of substances. The desire to promote healing and hasten cord separation are the underlying beliefs related to application of substances to the umbilical cord. The frequency of application of the substance (either the number of days or the number of times per day the substance was applied), and source and cost of products used is not well-characterized. CONCLUSIONS: This desire to actively care for the umbilical cord of a newborn-as noted in the variety of cord care practices and beliefs identified in this review-points toward the need to contextualize any behavior change approach to align with the local culture.

Women with an HbA1c of 41-49 mmol/mol (5.9-6.6%): a higher risk subgroup that may benefit from early pregnancy intervention.

AIMS: To examine whether women with an HbA1c of 41-49 mmol/mol (5.9-6.6%) at diagnosis of gestational diabetes are higher risk than women with an HbA1c of < 41 mmol/mol (5.9%) and whether pregnancy outcomes are improved if treated at < 24 weeks' gestation. METHODS: This was an observational study of women with gestational diabetes diagnosed by early HbA1c screening or subsequent oral glucose tolerance test at < 34 weeks' gestation who delivered at National Women's Health, Auckland, from July 2012 to June 2014. Data were extracted from the hospital database. Women with HbA1c 41-49 mmol/mol (5.9-6.6%) were divided into those seen < 24 weeks (Early, n = 134) and those seen ≥ 24 weeks (Later, n = 151). Those with HbA1c < 41 mmol/mol (5.9%) were labelled Other GDM (n = 661). RESULTS: The Early and Later groups, compared with Other GDM, had more Polynesian and fewer (non-Indian) Asian women, higher BMI and more required medication (P < 0.001). More were smokers (P = 0.007, 0.02) and more had chronic hypertension (P < 0.001, 0.02). There were higher rates of adverse outcomes in the Later group than the Other GDM group (pre-eclampsia 8.0% vs. 2.4%, P = 0.001, preterm birth 16.6% vs. 8.2%, P = 0.002, neonatal admission 15.5% vs. 9.2%, P = 0.02). Outcomes were similar between the Early group and Other GDM group (pre-eclampsia 1.5% vs. 2.4%, P = 0.5, preterm birth 10.5% vs. 8.2% P = 0.4, neonatal admission 13.6% vs. 9.2%, P = 0.12). Comparing the Early and Later groups, the Early group had less pre-eclampsia, 1.5% vs. 8.0%, adjusted P = 0.03. Other outcomes were not statistically different. CONCLUSIONS: An HbA1c of 41-49 mmol/mol (5.9-6.7%) identifies a higher-risk group of women with gestational diabetes. Overall, our data support early treatment of women with an HbA1c ≥ 41 mmol/mol (5.9%).

PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana.

BACKGROUND: While Ghana is a leader in some health indicators among West African nations, it still struggles with high maternal and neonatal morbidity and mortality rates, especially in the northern areas. The clinical causes of mortality and morbidity are relatively well understood in Ghana, but little is known about the impact of social and cultural factors on maternal and neonatal outcomes. Less still is understood about how such factors may vary by geographic location, and how such variability may inform locally-tailored solutions. METHODS/DESIGN: Preventing Maternal And Neonatal Deaths (PREMAND) is a three-year, three-phase project that takes place in four districts in the Upper East, Upper West, and Northern Regions of Ghana. PREMAND will prospectively identify all maternal and neonatal deaths and 'near-misses', or those mothers and babies who survive a life threatening complication, in the project districts. Each event will be followed by either a social autopsy (in the case of deaths) or a sociocultural audit (in the case of near-misses). Geospatial technology will be used to visualize the variability in outcomes as well as the social, cultural, and clinical predictors of those outcomes. Data from PREMAND will be used to generate maps for local leaders, community members and Government of Ghana to identify priority areas for intervention. PREMAND is an effort of the Navrongo Health Research Centre and the University of Michigan Medical School. DISCUSSION: PREMAND uses an innovative, multifaceted approach to better understand and address neonatal and maternal morbidity and mortality in northern Ghana. It will provide unprecedented access to information on the social and cultural factors that contribute to deaths and near-misses in the project regions, and will allow such causal factors to be situated geographically. PREMAND will create the opportunity for local, regional, and national stakeholders to see how these events cluster, and place them relative to traditional healer compounds, health facilities, and other important geographic markers. Finally, PREMAND will enable local communities to generate their own solutions to maternal and neonatal morbidity and mortality, an effort that has great potential for long-term impact.

The impact of ethnic population dynamics on neonatal ECMO outcomes: a single urban institutional study.

INTRODUCTION: Neonatal extracorporeal membrane oxygenation ECMO has been clinically used for the last 25 y. It has been an effective tool for both cardiac and non cardiac conditions. The impact of ethno-demographic changes on ECMO outcomes however remains unknown. We evaluated a single institution's experience with non cardiac neonatal ECMO over a 28-y period. METHODS: A retrospective review of all neonates undergoing noncardiac ECMO between the y 1984 and 2011 was conducted and stratified into year groups I, II, III (≤1990, 1991-2000, and ≥2001). Demographic, clinical, and outcome data were collected. The patient specifics, ECMO type, ECMO length, blood use, complications, and outcomes were analyzed. Univariate, bivariate, and multivariate analyses were then performed. RESULTS: Data was available for 827 patients. The number of African-American and Hispanic patients increased over the last 27 y (27.5% versus 45.0% and 3.3% versus 21.5%, year group I versus year group III, respectively). The proportion of congenital diaphragmatic hernia (CDH) patients by ethnicity also increased for African-Americans and Hispanics between the two year groups (22.0% to 33.0% and 4.9% to 33.0%, respectively). Similar pattern was noted for non-CDH diagnoses. Low birth weight, low APGAR scores, CDH, primary pulmonary hypertension, central nervous system hemorrhage, and ECMO were independent predictors of mortality. Ethnicity, in itself however, was not associated with mortality on adjusted analysis. CONCLUSION: More African-Americans and Hispanics have required ECMO over the years with a concurrent decrease in the number of Caucasians. While ethnicity was not an independent predictor of mortality, it appears to be a surrogate for fatal but sometime preventable diagnoses among minorities. Further investigations are needed to better delineate the reason behind this disparity.

Infant mortality and subsequent risk of stillbirth: a retrospective cohort study.

OBJECTIVE: To examine the association between infant mortality in a first pregnancy and risk for stillbirth in a second pregnancy. DESIGN: Population-based, retrospective cohort study. SETTING: Maternally linked cohort data files for the state of Missouri. POPULATION: Women who had two singleton pregnancies in Missouri during the period 1989-2005 (n = 320 350). METHODS: Women whose first pregnancy resulted in infant death were compared with those whose infant from the first pregnancy survived the first year of life. The Kaplan-Meier product limit estimator was employed to compare probabilities for stillbirth in the second pregnancy between both groups of women. Adjusted hazard ratios (AHRs) and 95% confidence intervals (95% CIs) were generated to assess the association between infant mortality in the first pregnancy and stillbirth in the second pregnancy. MAIN OUTCOME MEASURES: Exposure was defined as infant mortality in the first pregnancy, and the outcome was defined as stillbirth in the second pregnancy. RESULTS: Women with prior infant deaths were about three times as likely to experience stillbirth in their subsequent pregnancy (AHR 2.91; 95% CI 2.02-4.18). White women with a previous infant death were nearly twice as likely to experience a subsequent stillbirth, compared with white women with a surviving infant (AHR 1.96; 95% CI 1.13-3.39). Black women with a previous infant death were more than four times as likely to experience subsequent stillbirth, compared with black women with a surviving infant (AHR 4.28; 95% CI 2.61-6.99). CONCLUSIONS: Previous infant mortality results in an elevated risk for subsequent stillbirth, with the most profound increase observed among black women. Interconception care should consider prior childbearing experiences to avert subsequent fetal loss.

Pregnancy outcome in immigrant women with gestational diabetes mellitus.

Recent studies show adverse outcomes of pregnancy among immigrant women from countries with high diabetes rates. We compared maternal and fetal outcomes in immigrant and Italian women with gestational diabetes mellitus (GDM) followed up at our center. Maternal characteristics considered were age, pre-pregnancy body mass index (BMI), HbA1c, frequency of insulin treatment, timing and mode of delivery, and hypertensive disorders; and, for fetal outcome, infants large or small for gestational age, and fetal complications. Pre-pregnancy BMI and HbA1c were higher in immigrant GDM women than in Italians, and more of them were on insulin. No differences in maternal outcome emerged between the two groups. More large for gestational age (LGA) babies were born to immigrant women than to Italians, but no other differences emerged. Apart from newborn LGA, maternal and fetal outcomes were comparable in our immigrant and Italian GDM women. Immigrant GDM women have favourable outcomes if given access to health care and language and cultural barriers are removed.

Assessment of special care newborn units in India.

The neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge. The units are located in some remotest districts where the burden of neonatal deaths is high, and access to special newborn care is poor. The study was conducted to assess the functioning of SCNUs in eight rural districts of India. The evaluation was based on an analysis of secondary data from the eight units that had been functioning for at least one year. A cross-sectional survey was also conducted to assess the availability of human resources, equipment, and quality care. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of 3-5 years considering the first year of operationalization as the base. Correlation coefficients were estimated to understand the possible association of case-fatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average duration of stay, and bed occupancy rate, and the asepsis score was determined. The rates of admission increased from a median of 16.7 per 100 deliveries in 2008 to 19.5 per 100 deliveries in 2009. The case-fatality rate reduced from 4% to 40% within one year of their functioning. Proportional mortality due to sepsis and low birthweight (LBW) declined significantly over two years (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio (1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median 103%), and the average duration of stay ranged from two days to 15 days (median 4.75 days). Repair and maintenance of equipment were a major concern. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries, although several challenges relating to human resources, maintenance of equipment, and maintenance of asepsis remain.

Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates.

OBJECTIVE: To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates. DESIGN: Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST. RESULTS: Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74). CONCLUSIONS: Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.

Maternal country of origin, breast milk characteristics and potential influences on immunity in offspring.

Breast milk contains pro- and anti-inflammatory cytokines and chemokines with potential to influence immunological maturation in the child. We have shown previously that country of birth is associated with the cytokine/chemokine profile of breast milk. In this study we have investigated how these differences in breast milk affect the cellular response of cord blood mononuclear cells (CBMCs) and intestinal epithelial cells (IECs, cell line HT-29) to microbial challenge. Ninety-five women were included: 30 from Mali in West Africa, 32 Swedish immigrants and 33 native Swedish women. CBMCs or IECs were stimulated in vitro with breast milk, alone or in combination with lipopolysaccharide (LPS) or peptidoglycan (PGN). Breast milk in general abrogated the LPS-induced down-regulation of surface CD14 and Toll-like receptor (TLR)-4 expression on CB monocytes, while inhibiting the PGN-induced TLR-2 up-regulation. However, breast milk from immigrant women together with LPS induced a lower CBMC release of interleukin (IL)-6 (P = 0·034) and CXCL-8/IL-8 (P = 0·037) compared with breast milk from Swedish women, while breast milk from Swedish women and Mali women tended to increase the response. The same pattern of CXCL-8/IL-8 release could be seen after stimulation of IECs (HT-29). The lower CBMC and IEC (HT-29) responses to microbial compounds by breast milk from immigrant women could be explained by the fact that breast milk from the immigrant group showed a divergent pro- and anti-inflammatory content for CXCL-8/IL-8, transforming growth factor-ß1 and soluble CD14, compared to the other two groups of women. This may have implications for maturation of their children's immune responses.

Biliary atresia: East versus west.

Biliary atresia (BA) is a common cause of surgical jaundice during the neonatal period. It is currently considered as a spectrum of diseases with a common final pathology characterized by obliteration of the extrahepatic biliary tract and the absence of normally branching intrahepatic ducts. Though it is a global disease that can be found in all ethnicities there are some clear differences between BA arising in the East and the West. This is likely to be related to different genetic, environmental and cultural factors. BA is more frequently found in Far Eastern infants (both Chinese and Japanese) though the syndromic associations are much less common. Many Eastern countries have national screening programmes not seen in the West possibly due to debate over its cost effectiveness in countries where incidence is low. Kasai portoenterostomy (KPE) is considered as the primary treatment of BA but its outcome still remains unsatisfactory across the region. Given the complexity of BA, it is unlikely that strategic advances could be made by the sole effort of individual countries and we believe that collaboration between the East and West is the way forward.

Racial and Ethnic Disparities in Maternal and Neonatal Adverse Outcomes in College-Educated Women.

OBJECTIVE: To compare composite maternal and neonatal adverse outcomes among women with at least a bachelor's degree by racial and ethnic groups. METHODS: This was a retrospective cohort study using the U.S. vital statistics data sets. We included women with at least a bachelor's degree who delivered a nonanomalous live singleton neonate at 24-40 weeks. The primary outcome, composite maternal adverse outcome, included admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure after delivery. The secondary outcome, composite neonatal adverse outcome, included 5-minute Apgar score less than 5, assisted ventilation for more than 6 hours, neonatal seizure, birth injury, or neonatal death. Multivariable regression models were used to estimate the association between maternal race and adverse outcomes. RESULTS: Of 11.8 million live births, 2.2 million (19%) met the inclusion criteria; 81.5% were to non-Hispanic white women, 8.5% to non-Hispanic black women, and 10% Hispanic women. The overall rate of composite maternal adverse outcome was 5.3 per 1,000 live births. Compared with non-Hispanic white women, the risk of the composite maternal adverse outcome was significantly higher among non-Hispanic black women (adjusted relative risk [aRR] 1.20; 95% CI 1.13-1.27), but lower among Hispanic women (aRR 0.69; 95% CI 0.64-0.74), a pattern which varied among different gestational age groups. The overall rate of composite neonatal adverse outcome was 11.6 per 1,000 live births. The risk of composite neonatal adverse outcome was significantly higher among neonates with non-Hispanic black mothers (aRR 1.25; 95% CI 1.20-1.30), but lower among neonates with Hispanic mothers (aRR 0.71; 95% CI 0.68-0.75), compared with neonates delivered by non-Hispanic white mothers and varied across gestational age. CONCLUSION: Among women with at least a bachelor's degree, small but measurable racial and ethnic disparities in composite maternal and neonatal adverse outcomes.

Factors related to quilombola attendance to child follow-up appointments.

OBJECTIVE: To understand factors interfering with the attendance of quilombola children to growth and development follow-up appointments. METHOD: It is a qualitative research based on Symbolic interactionism, during which 14 mothers of children bellow 1 year-old were interviewed, who attended to the Family Health Unit at Ilha de Maré, Bahia, Brazil. RESULTS: Appointment attendance is affected by factors intrinsic to mothers (meaning of child health follow-up; association between appointments and children falling ill; personal issues) and extrinsic factors, related to the service (availability, long waiting time for appointments and its quality). FINAL CONSIDERATIONS: An administration prioritizing the service's organization is required, which can prioritize attendances and the reduction of waiting time, specially given the personal issues that compromise going to the unit.

Molecular basis of neonatal diabetes in Japanese patients.

CONTEXT: Neonatal diabetes mellitus (NDM) is classified clinically into a transient form (TNDM), in which insulin secretion recovers within several months, and a permanent form (PNDM), requiring lifelong medication. However, these conditions are genetically heterogeneous. OBJECTIVE: Our objective was to evaluate the contribution of the responsible gene and delineate their clinical characteristics. PATIENTS AND METHODS: The chromosome 6q24 abnormality and KCNJ11 and ABCC8 mutations were analyzed in 31 Japanese patients (16 with TNDM and 15 with PNDM). Moreover, FOXP3 and IPF1 mutations were analyzed in a patient with immune dysregulation, polyendocrinopathy, enteropathy X-linked syndrome and with pancreatic agenesis, respectively. RESULTS: A molecular basis for NDM was found in 23 patients: 6q24 in eleven, KCNJ11 in nine, ABCC8 in two, and FOXP3 in one. All the patients with the 6q24 abnormality and two patients with the KCNJ11 mutation proved to be TNDM. Five mutations were novel: two (p.A174G and p.R50G) [corrected] in KCNJ11, two (p.A90V and p.N1122D) in ABCC8, and one (p.P367L) in FOXP3. Comparing the 6q24 abnormality and KCNJ11 mutation, there were some significant clinical differences: the earlier onset of diabetes, the lower frequency of diabetic ketoacidosis at onset, and the higher proportion of the patients with macroglossia at initial presentation in the patients with 6q24 abnormality. In contrast, two patients with the KCNJ11 mutations manifested epilepsy and developmental delay. CONCLUSIONS: Both the 6q24 abnormality and KCNJ11 mutation are major causes of NDM in Japanese patients. Clinical differences between them could provide important insight into the decision of which gene to analyze in affected patients first.

Ethnic differences in risk factors for neonatal mortality and morbidity in the neonatal intensive care unit.

OBJECTIVE: Although our knowledge about how to care for high-risk neonates who require intensive care is continually improving, disparities in health outcomes among various ethnic groups living in developed countries are becoming more evident. The purpose of this study was to identify the risk factors for neonatal intensive care unit (NICU) mortality among Canadian-born minority infants and, furthermore, to determine whether ethnicity was in itself an independent predictor of mortality or major morbidity in the NICU. STUDY DESIGN: Data were prospectively gathered on 6528 infants admitted to nine regionally located NICUs across Canada. Multiple logistic regressions were used to develop risk-adjusted models for NICU mortality and major morbidity. RESULT: Despite adjusting for differences in small for gestational age (SGA), outborn status and gestational age less than or equal to 28 weeks, South Asian infants still had significantly greater odds of mortality in the NICU. Neonatal sepsis was the strongest predictor of mortality among African infants, even greater than birth at 28 weeks or less. At significantly greater odds of survival with major morbidity were Aboriginal males and East Asian females. CONCLUSION: There are ethnic disparities in the risks of neonatal mortality and morbidity in the NICU. Understanding these differences is important to be able to determine specific areas to target in improving healthcare delivery and reducing disparities in health outcomes among Canada's diverse population.

Prevalence of gestational diabetes among Chinese and South Asians: A Canadian population-based analysis.

BACKGROUND: There is considerable geographic variation in gestational diabetes mellitus (GDM) rates. We used data from two Canadian provinces, British Columbia (BC) and Alberta (AB), to determine the impact of ethnicity on GDM prevalence and neonatal outcomes. RESEARCH DESIGN AND METHODS: All deliveries between 04/01/2004 and 03/31/2010 in AB (n=249,796) and BC (n=248,217) were analyzed. We calculated GDM prevalence among Chinese, South-Asian, and the general population (predominantly Caucasian) women. RESULTS: Overall GDM prevalence was 4.8% (n=12,036) in AB and 7.2% (n=17,912) in BC. In both provinces, the prevalence of GDM was significantly higher in Chinese (AB:11%; BC:13.5%) and South Asian women (AB:8.4%;BC:13.9%) compared to the general population (AB:4.2%; BC: 5.8%). Chinese women were significantly older (AB:32.7; BC:33.0years) compared to the general population (AB:29.1; BC:30.1years). The odds of GDM relative to the general-population were 2-fold higher for South Asians in both provinces and almost 3-fold higher for Chinese in BC. Among GDM cases, compared to the general population, Chinese and South Asian infants were less likely to be LGA, more likely to be SGA, and had similar neonatal mortality rates. CONCLUSIONS: Compared to the general population, GDM prevalence is higher in Chinese and South Asian Canadians. Increased maternal age is a major contributor to higher prevalence of GDM in Chinese women. GDM rates were higher in both ethnic and general population women in BC compared to AB, suggesting that in addition to differences in ethnic distribution, differences in diagnostic practices are likely contributing to observed geographic differences in GDM prevalence.