Abdominal circumference discordance for prediction of small for gestational age at birth in twin pregnancies.

OBJECTIVE: To evaluate whether single sonographic abdominal circumference (AC) discordancy estimation can predict small for gestational age (SGA) at birth in twin gestations. METHODS: A retrospective analysis of prospectively collected data. Cohort included all twin gestations delivered at one university-affiliated medical center between 2010 and 2018, with available sonographic evaluation from 22 gestational weeks to term. Pregnancies complicated by fetal chromosomal abnormalities, major anomalies or twin to twin transfusion syndrome were excluded. One sonographic evaluation per pregnancy was selected randomly. AC discordance was calculated as (large twin AC - small twin AC)/large twin AC*100. Prediction of SGA at birth for at least one newborn (<10% percentile for gestational age by gender-specific local curves for multiples) was evaluated using ROC statistics with calculation of Youden index to establish best AC discordance cutoff. AC discordance prediction performance was compared to estimated fetal weight discordance performance. Results were adjusted for confounders using logistic regression analysis. RESULTS: After exclusion, 236 twin gestations entered analysis. Of them, 200/236 (84.7%) were dichorionic-diamniotic twins. Mean gestational age at ultrasound evaluation and at delivery were 30.9 ± 4.4 and 35.9 ± 2.4 weeks, respectively. In 28/236 (11.8%) pregnancies, at least one neonate was born SGA. AC discordance predicted SGA at birth as good as sonographic estimated fetal weight (sEFW) discordance: ROC-AUC 0.76, 95% CI 0.67-0.85 vs. 0.77 95% CI 0.66-0.87, p < .001 for all. Best AC discordance cutoff for prediction of SGA at birth was 7.1% (57% sensitivity, 87% specificity), ROC-AUC 0.72 (95% CI 0.61-0.84, p < .001). Results remained significant after adjustment for maternal age, nulliparity, chorionicity and ultrasound to delivery interval (aOR 1.21 95% CI 1.1-1.32, p < .001). CONCLUSION: According to our results, AC discordance at single sonographic evaluation can predict SGA at birth in twin gestations as good as sEFW discordance. Best cutoff for SGA prediction was 7.1%.

The Accuracy of Sonographic Fetal Head Circumference in Twin Pregnancies.

OBJECTIVE: To assess the accuracy of sonographic estimation of fetal head circumference in twin gestations. METHODS: A retrospective analysis of sonographic evaluations of twin gestations >34 weeks, performed within 7 days of delivery, in a single university-affiliated medical centre. Sonographic head circumference was compared with neonatal head circumference. Measures of accuracy included systematic error, random error, proportion of estimates within 5% of neonatal head circumference, and reliability analysis. Accuracy of sonographic head circumference was compared between the first and second twin. RESULTS: Overall, 103 twin gestations were evaluated at a median of 4 days before delivery. The majority of twins were dichorionic-diamniotic (83%). Median gestational age at delivery was 37 weeks, with a median birth weight of 2645 grams for the first twin and 2625 grams for the second twin. For all fetuses, median sonographic head circumference was lower than the neonatal head circumference (first twin: 317.5 vs. 330 mm; second twin: 318.4 vs. 330 mm, P > 0.05 for both). Measures of accuracy showed no significant difference between first and second twin. There was no difference in the number of sonographic head circumference evaluations that were within 5% of the neonatal head circumference between fetuses (64% for both twins). Cronbach α value was higher for the second twin (0.746 vs. 0.613), suggesting higher accuracy for head circumference measurement for the second twin. CONCLUSION: In our cohort, sonographic head circumference underestimated postnatal head circumference. Accuracy measurements were not significantly different between the first and second twin.

The role of orotic acid measurement in routine newborn screening for urea cycle disorders.

Urea cycle disorders (UCDs), including OTC deficiency (OTCD), are life-threatening diseases with a broad clinical spectrum. Early diagnosis and initiation of treatment based on a newborn screening (NBS) test for OTCD with high specificity and sensitivity may contribute to reduction of the significant complications and high mortality. The efficacy of incorporating orotic acid determination into routine NBS was evaluated. Combined measurement of orotic acid and citrulline in archived dried blood spots from newborns with urea cycle disorders and normal controls was used to develop an algorithm for routine NBS for OTCD in Israel. Clinical information and genetic confirmation results were obtained from the follow-up care providers. About 1147986 newborns underwent routine NBS including orotic acid determination, 25 of whom were ultimately diagnosed with a UCD. Of 11 newborns with OTCD, orotate was elevated in seven but normal in two males with early-onset and two males with late-onset disease. Orotate was also elevated in archived dried blood spots of all seven retrospectively tested historical OTCD patients, only three of whom had originally been identified by NBS with low citrulline and elevated glutamine. Among the other UCDs emerge, three CPS1D cases and additional three retrospective CPS1D cases otherwise reported as a very rare condition. Combined levels of orotic acid and citrulline in routine NBS can enhance the detection of UCD, especially increasing the screening sensitivity for OTCD and differentiate it from CPS1D. Our data and the negligible extra cost for orotic acid determination might contribute to the discussion on screening for proximal UCDs in routine NBS.

[INFECTIOUS DISEASE ASSESSMENT OF TERM INFANTS WITH RISK FACTORS - EVALUATION OF NECESSITY AND METHODS OF PREVENTION].

AIMS: To characterize the demography of infants for whom blood tests were indicated due to perinatal risk factors for infection and to elaborate on ways to minimize these invasive tests. METHODS: A retrospective study based on an analysis of the medical records of term and late-preterm infants born between January 1st, 2013 and December 31st, 2015, for whom blood cultures were indicated due to maternal risk factors. RESULTS: The study included 583 infants. Each infant had between 1 to 4 cultures taken (an average 1.9) - reaching a total of 1041 cultures, 11 of which were positive (1.05%). We discovered no statistically significant relationship between positive blood cultures and the duration of membrane rupture. Moreover, no significant relationship was detected between positive blood cultures and membrane rupture lasting more than 18 hours (despite shorter durations of antibiotic treatment - less than 4 hours). Among those with positive blood cultures, we found a statistically significant relationship between carriers of Group B streptococcus (GBS) born at 35-36 gestation and membrane ruptures lasting 14 hours or less. On the other hand, maternal fever was related to membrane rupture lasting 14-18 hours, but not to membrane rupture lasting 18 hours or more. When evaluating the rate of positive cultures in our study, no statistically significant difference was found between Arab and Jewish populations. CONCLUSIONS: Our findings support the presumption that the benefit of blood tests taken in healthy neonates with maternal risk factors is questionable; Out of 583 infants, only 11 had positive blood cultures. The policy of initiating antibiotic treatment 14 hours after membrane rupture has little or no value in preventing the need for assessing those born 18 hours or more after membrane rupture. This study joins other studies around the world that support the conclusion that there is a very small benefit in blood tests taken from a healthy newborn with maternal risk factors. Other ways of assessing the presence of congenital infection in a healthy newborn with maternal risk factors should be found.

[PREFERENCES OF PARENTS FOR PEDIATRIC INPATIENT WARD PHYSICIAN'S ATTIRE].

BACKGROUND: The preferred attire for physicians has not been defined to date. In Israel, where casual attire is acceptable in most circumstances, patients' preferences have not yet been systematically evaluated. METHODS: This is a cross-sectional study that was designed to evaluate parents' preferences for physicians' attire in a pediatric inpatient ward. A volunteer was dressed in four types of clothes sets: elegant attire, sportive attire, careless attire and scrubs - all of which were displayed, with or without a white coat. Parents were asked whether or not they felt the physician was an important component of the medical encounter; they were also asked to choose the picture of the doctor they preferred to care for their child. RESULTS: A total of 250 parents participated in the study; 68% of the parents believe that the physician's attire is an important component of the medical encounter; 41% of the parents preferred the doctor to wear scrubs with a white coat, 22% preferred scrubs without a white coat. Careless attire was the least preferred attire. CONCLUSIONS: The physicians' attire was important for most of the participants. We recommend that doctors in inpatient wards wear scrubs.

Antimicrobial Resistance Among Uropathogens That Cause Childhood Community-acquired Urinary Tract Infections in Central Israel.

In this retrospective study 829 positive urine cultures were analyzed. Escherichia coli bacterium was the leading uropathogen (86%). Almost 60% were resistant to ampicillin and first generation cephalosporins, and about 30% of them resistant to amoxicillin-clavulanic acid and trimethoprim-sulfamethoxazole. Almost none of them were resistant to second and third generation cephalosporins, aminoglycosides, ciprofloxacin or nitrofurantoin.

The Duration of Breastfeeding and Its Association with Metabolic Syndrome among Obese Children.

OBJECTIVE: The objective of this study was to evaluate whether duration of breastfeeding is associated with a lower prevalence of metabolic syndrome in obese children. METHODS: A retrospective analysis of obese children aged 3 to 18 years followed at a pediatric outpatient clinic at a single center between the years 2008 and 2012. The children were divided according to their breastfeeding duration: no breastfeeding, a short period of breastfeeding, and a long term breastfeeding. Also, they were divided into metabolic and nonmetabolic syndrome groups, based on physical examination and laboratory tests. RESULTS: Out of 4642 children who visited the clinic, 123 were obese and were included in the study. About half of them matched the metabolic syndrome criteria. There was no correlation between the prevalence of metabolic syndrome and the duration of breastfeeding. Hypertension, abnormal low levels of HDL, high levels of HbA1c, and high fasting triglyceride levels were very common in our study population, yet no statistical significance was noted among the different breastfeeding groups. CONCLUSION: In this study, breastfeeding was not associated with a reduced risk for metabolic syndrome, compared with formula feeding, in children who are obese.

Neonatal Chest Wall Rhabdomyosarcoma.

An infant was born at term with a huge chest mass diagnosed as rhabdomyosarcoma. Treatment consisted of surgical resection and chemotherapy. We describe this very rare congenital mass and the problematic therapeutic management of such a tumor in a newborn.

Parents' attitudes toward oral rehydration therapy in children with mild-to-moderate dehydration.

OBJECTIVE: According to current guidelines, the first line of treatment for mild-to-moderate dehydration is oral rehydration; the second line is rehydration through a nasogastric tube. Both methods are widely underused. This study was conducted to evaluate parents' attitudes towards rehydration methods used in pediatric emergency departments. DESIGN: 100 questionnaires were distributed to parents of children who visited emergency room due to gastroenteritis and suspected dehydration. RESULTS: 75 of the parents expected their child to get IV fluids. 49 of them would refuse to consider oral rehydration. 75 of the parents would refuse to consider insertion of nasogastric tube. Parents whose children were previously treated intravenously tended to be less likely to agree to oral treatment. Parents were more prone to decline oral rehydration if the main measurement of dehydration was the child's clinical appearance, clinical appearance with vomiting, or child's refusal to drink and were more likely to agree if the main measurement was diarrhea, diarrhea with clinical appearance, or clinical personnel opinion. CONCLUSIONS: This is the first study to examine parents' expectations. We found that in the majority of cases, parents' expectations contradict current guidelines. Efforts should be taken to educate parents in order to allow full implementation of the guidelines.

Do newborn infants of Ethiopian origin spit up more than other newborn infants?

BACKGROUND: Ethnic differences in the incidence of spitting up have not been reported. The nursing team at our well-baby nursery observed that newborn infants of Ethiopian origin appeared to spit up more than the others. OBJECTIVE: To determine whether there are such ethnic differences and what, if anything, is their clinical relevance. METHODS: Of the 3663 enrolled infants born at the Hillel Yaffe Medical Center during the 12 month study period, 55 were of Ethiopian origin and their medical records were retrospectively surveyed. The retrieved data were compared with those of 167 randomly selected non-Ethiopian newborns (controls). Exclusion criteria were preterm delivery, admission to the neonatal intensive care unit, and congenital birth defects. RESULTS: Newborn infants of Ethiopian origin spit up 57% more than control infants. The difference in the number of spit ups was more obvious when only the infants who spit up were compared (2.3 +/- 1.7 Ethiopian newborns vs. 1.5 +/- 0.9 controls, P=0.002), although the percentage of infants who spit up was the same in the two groups. There was no difference in weight gain, days of hospitalization, bilirubin levels or nutrition type between the groups. CONCLUSIONS: Infants of Ethiopian origin spit up more than the control newborn infants of non-Ethiopian origin, while other clinical parameters were similar. In the absence of other pathological signs, spitting up is a non-relevant clinical condition.

Late better than early elective term Cesarean section.

AIM: Caesarean section (CS) deliveries have increased, mostly because of patient/obstetrician preference. Although CS decreases the risk of delivery-related injuries, it increases the risk for respiratory and neurological complications. Complication rates are reportedly higher for elective CSs for term infants performed at 37-38 gestational weeks than later. We investigated this difference in an Israeli cohort. METHODS: Data on all births in our medical centre during 2007-2009 were reviewed. Those on elective CSs for term infants were retrieved and divided into 'early' (37-38 gestational weeks) or 'late' (week 39 or later) groups whose epidemiological and outcome characteristics were compared. RESULT: Of the 12,276 births, 596 were early and 454 were late elective CSs. There were no differences in gender, ethnicity, Apgar score or length of hospital stay. Twenty-six infants from the early group and 11 infants from the late group were transferred to the neonatal intensive care unit. Within them, compared with all elective CSs, the morbidity rate was higher for the former infants than for the latter. CONCLUSION: Morbidity was higher among infants who were delivered at 37-38 gestational weeks by elective CS. We recommend postponing elective CSs to ≥39 weeks.

ISO 9001 in a neonatal intensive care unit (NICU).

PURPOSE: The aim of this paper is to present the process for approving and certifying a neonatal intensive care unit to ISO 9001 standards. DESIGN/METHODOLOGY/APPROACH: The process started with the department head's decision to improve services quality before deciding to achieve ISO 9001 certification. Department processes were mapped and quality management mechanisms were developed. Process control and performance measurements were defined and implemented to monitor the daily work. A service satisfaction review was conducted to get feedback from families. FINDINGS: In total, 28 processes and related work instructions were defined. Process yields showed service improvements. Family satisfaction improved. RESEARCH LIMITATIONS/IMPLICATIONS: The paper is based on preparing only one neonatal intensive care unit to the ISO 9001 standard. PRACTICAL IMPLICATIONS: The case study should act as an incentive for hospital managers aiming to improve service quality based on the ISO 9001 standard. ORIGINALITY/VALUE: ISO 9001 is becoming a recommended tool to improve clinical service quality.

Heparanase induces tissue factor pathway inhibitor expression and extracellular accumulation in endothelial and tumor cells.

Heparanase activity is implicated in cell invasion, tumor metastasis and angiogenesis. Recently, we have reported that heparanase stimulates tissue factor (TF) expression in endothelial and cancer cells, resulting in elevation of coagulation activity. We hypothesized that heparanase regulates other coagulation modulators, and examined the expression and localization of tissue factor pathway inhibitor (TFPI) following heparanase over-expression or exogenous addition. Primary human umbilical vein endothelial cells (HUVEC) and human tumor-derived cell lines were incubated with heparanase, or were stably transfected with heparanase gene-constructs, and TFPI expression and secretion were examined. Heparanase over-expression or exogenous addition stimulated TFPI expression by 2-3 folds. TFPI accumulation in the cell culture medium exceeded in magnitude the observed induction of TFPI gene transcription reaching 5- to 6-fold increase. Extracellular accumulation of TFPI was evident already 60 min following heparanase addition, prior to TFPI protein induction, and correlated with increased coagulation activity. This effect was found to be independent of heparanase enzymatic activity and interaction with heparan-sulfate, and correlated with reduced TFPI levels on the cell surface. Data were verified in heparanase transgenic mice tissues and plasma. Interaction between heparanase and TFPI was evident by co-immunoprecipitation. Interaction of heparanase with TFPI resulted in its displacement from the surface of the vascular endothelium and in increased pro-coagulant activity. Thus, heparanase facilitates blood coagulation on the cell surface by two independent mechanisms: dissociation of TFPI from the vascular surface shortly after local elevation of heparanase levels, and subsequent induction of TF expression.