Pandemics, professionalism and the duty of care: Concerns from the coalface.

It is likely that the SARS-CoV-2 pandemic will affect a large part of the world's population and will last for several years. Many critical ethical issues have arisen in the healthcare context. While response from healthcare professionals to participating in the care of patients in the era of COVID-19 has generally been positive, there have also been disturbing experiences on the ground. The practice of medicine is a social contract with humanity. Challenges have arisen because the patient is both a victim and a vector of the coronavirus. All humans should have a natural instinct to care for those in need. Ethically and legally, healthcare professionals cannot be expected to assume a significant and unreasonable risk of harm. While fear is understandable, altruism and interest in serving the sick exemplify the value of solidarity. Social harms like stigmatisation and discrimination can occur. Concerns have been raised regarding protection of privacy and respect for rights of infected individuals. In the era of COVID-19, fear, misinformation and a detachment from one's calling put professionalism strongly to the test.

Pandemics, professionalism and the duty of care: Concerns from the coalface

It is likely that the SARS-CoV-2 pandemic will affect a large part of the world's population and will last for several years. Many critical ethical issues have arisen in the healthcare context. While response from healthcare professionals to participating in the care of patients in the era of COVID-19 has generally been positive, there have also been disturbing experiences on the ground. The practice of medicine is a social contract with humanity. Challenges have arisen because the patient is both a victim and a vector of the coronavirus. All humans should have a natural instinct to care for those in need. Ethically and legally, healthcare professionals cannot be expected to assume a significant and unreasonable risk of harm. While fear is understandable, altruism and interest in serving the sick exemplify the value of solidarity. Social harms like stigmatisation and discrimination can occur. Concerns have been raised regarding protection of privacy and respect for rights of infected individuals. In the era of COVID-19, fear, misinformation and a detachment from one's calling put professionalism strongly to the test

Effect of Prophylactic Phenobarbital on Seizures; Encephalopathy and Mortality in Neonates with Perinatal Asphyxia

Background. Seizures after an asphyxial insult may result in brain damage in neonates. Prophylactic phenobarbital may reduce seizures.Objective. To determine the effect of prophylactic phenobarbital on seizures; death and neurological outcome at hospital discharge.Methods. Neonates with base deficit 16 mmol/l and Apgar score at 5 minutes 7 or requiring resuscitation for 5 minutes at the time of birth were randomised to prophylactic phenobarbital 40 mg/kg (n=50) or placebo (controls) (n=44) within the first 6 hours of life. They were monitored for clinical seizures; hypoxic ischaemic encephalopathy (HIE) and mortality.Results. Seizures developed in 30.0 of the phenobarbital group as opposed to 47.7 of the control group (relative risk 0.63; 95 confidence interval -0.37 - 1.06; p=0.083). The proportions of patients who had died and/or had HIE II or III at time of discharge from hospital were similar in the two groups (42.0 v. 45.5). There were no differences in mortality between the two groups (14.0 v. 15.9). Conclusion. In infants with asphyxia; prophylactic phenobarbital does not reduce the incidence of seizures; HIE and mortality

Growth of Infants Born To HIV-Positive Mothers Fed a Whey-Adapted Acidified Starter Formula with Prebiotics and Nucleotides

Objectives: The objectives of this study were to evaluate whether infants born to known HIV-positive mothers; but who were not themselves infected with HIV and who were fed a chemically acidified starter formula with prebiotics with or without nucleotides during their first six months; displayed growth rates equal to uninfected infants fed a chemically acidified starter formula without prebiotics or nucleotides. Design: The design was a multi-centre; double-blinded randomised controlled trial. Setting: The study was carried out in four academic hospitals; three in Johannesburg and one in Cape Town; South Africa. Subjects and intervention: The subjects were newborn infants born to consenting HIV-positive women who had previously decided not to breast feed. The infants were randomised to receive one of three milk formulas. The intervention comprised chemically acidified formula without prebiotics or nucleotides; with prebiotics only; or with prebiotics and nucleotides. Outcome measures: The outcome measures were the growth parameters through the first six months of life. Results: Of the 150 randomised infants; 50 did not complete the study and 16 (12.8of those tested) were infected with HIV; leaving 84 infants available for analysis. All three formulas were tolerated well; with no differences in growth parameters seen with the addition of prebiotics and nucleotides. The growth rates of the study infants up to the age of six months were very good; showing an increase in Z-scores from negative values at the time of enrolment in the first week after birth to around zero for length and 0.5 for weight.Conclusions: The three chemically acidified formulas were tolerated well and resulted in good growth over the first six months of life. No benefits were seen with the addition of prebiotics or nucleotides. The growth rates were similar to those found in previous studies of ours on biologically acidified formulas. The chemical acidification of infant formulas appears to be a realistic alternative to biological acidification should an acidified formula be required

Growth of Infants Born To HIV-Positive Mothers Fed a Whey-Adapted Acidified Starter Formula with Prebiotics and Nucleotides

Objectives: The objectives of this study were to evaluate whether infants born to known HIV-positive mothers; but who were not themselves infected with HIV and who were fed a chemically acidified starter formula with prebiotics with or without nucleotides during their first six months; displayed growth rates equal to uninfected infants fed a chemically acidified starter formula without prebiotics or nucleotides. Design: The design was a multi-centre; double-blinded randomised controlled trial. Setting: The study was carried out in four academic hospitals; three in Johannesburg and one in Cape Town; South Africa. Subjects and intervention: The subjects were newborn infants born to consenting HIV-positive women who had previously decided not to breast feed. The infants were randomised to receive one of three milk formulas. The intervention comprised chemically acidified formula without prebiotics or nucleotides; with prebiotics only; or with prebiotics and nucleotides. Outcome measures: The outcome measures were the growth parameters through the first six months of life. Results: Of the 150 randomised infants; 50 did not complete the study and 16 (12.8of those tested) were infected with HIV; leaving 84 infants available for analysis. All three formulas were tolerated well; with no differences in growth parameters seen with the addition of prebiotics and nucleotides. The growth rates of the study infants up to the age of six months were very good; showing an increase in Z-scores from negative values at the time of enrolment in the first week after birth to around zero for length and 0.5 for weight.Conclusions: The three chemically acidified formulas were tolerated well and resulted in good growth over the first six months of life. No benefits were seen with the addition of prebiotics or nucleotides. The growth rates were similar to those found in previous studies of ours on biologically acidified formulas. The chemical acidification of infant formulas appears to be a realistic alternative to biological acidification should an acidified formula be required

Growth of Infants Born To HIV-Infected Women; When Fed a Biologically Acidified Starter Formula With and Without Probiotics

"Objectives: To compare the growth of HIV-exposed uninfected infants fed a biologically acidified milk formula with or without probiotics (Bifidobacterium lactis) during the first six months of life; with control infants fed a standard starter formula.Design: Multi-centre; double-blinded randomised controlled trial.Setting: Infants born to HIV-infected women delivering at one of three academic hospitals in Johannesburg; South Africa.Subjects: Consenting HIV-positive women; who had previously decided not to breast-feed; were randomised to receive one of three milk formulas for their newborn infants.Outcome measures: Comparisons of growth parameters through the first four months of life were made between infants fed the acidified formula without probiotics and those fed the control formula (""acidification effect""); and between infants fed the acidified formulas with and without added probiotics (""probiotic effect"").Results: Of 131 randomised infants; 33 (25) did not complete the study and 13 (10) were HIV infected; leaving 85 infants available for analysis. Infants receiving the acidified formula with probiotics had more rapid head growth (p=0.04) and showed a trend towards more rapid weight gain (p=0.06) over the first four months of life than the infants receiving the acidified formula without probiotics.No other significant differences between the feeding groups were demonstrated.Conclusions: Infants in all study groups grew well; with increased head growth and a trend towards increased weight gain for those receiving probiotics.There were no differences in morbidity between the three study groups and no evidence of adverse effects of the study formulas."

Survival of very-low-birth-weight infants according to birth weight and gestational age in a public hospital.

OBJECTIVES: To determine the survival rates for infants weighing 500 - 1 499 g according to birth weight (BW) and gestational age (GA). DESIGN: This was a retrospective cohort study. Pregnancy and delivery data were collected soon after birth and neonatal data at discharge or at death. SETTING: Chris Hani Baragwanath Hospital (CHBH), a public-sector referral hospital, affiliated to the University of the Witwatersrand. SUBJECTS: Live births weighing between 500 g and 1 499 g delivered at or admitted to CHBH from January 2000 to December 2002. OUTCOME MEASURES: BW and GA-specific survival rates for all live infants born at CHBH and for those admitted for neonatal care. RESULTS: Seventy-two per cent of infants survived until discharge. The survival to discharge rate was 32% for infants weighing < 1 000 g, and 84% for those weighing 1 000 - 1 499 g. Survival rates at 26, 27 and 28 weeks' gestation were 38%, 50% and 65% respectively. Survival rates for infants admitted to the neonatal unit were better than rates for all live births, especially among those weighing < 1 000 g or with a GA < 28 weeks. There was a marked increase in survival between the 900 - 999 g and 1 000 - 1 099 g weight groups. Provision of antenatal care, caesarean section, female gender and an Apgar score more than 5 at 1 or 5 minutes were associated with better survival to hospital discharge. CONCLUSION: Survival among infants weighing less than 1 000 g is poor. In addition to severe prematurity, the poor survival among these infants (< 1 000 g) is most likely related to the fact that they were not offered mechanical ventilation. Mechanical ventilation should be offered to infants weighing < 1 000 g as it may improve their survival even in institutions with limited resources.

Survival of low-birth-weight infants at Baragwanath Hospital--1950-1996.

OBJECTIVES: To examine changes in survival rates among low-birth-weight (LBW) infants between the years 1950 and 1996. METHODS: Survival figures were analysed for LBW infants managed at Baragwanath Hospital, a tertiary care centre in Soweto, Johannesburg, over four periods spanning five decades. RESULTS: The overall mortality rates of LBW infants decreased markedly between the early 1950s and the period 1995/96. By the mid-1990's approximately four times the number of infants with birth weight less than 1,500 g were surviving compared with the early 1950s. The reduction in mortality rates occurred in all LBW groups during the first three decades. However, since 1981 infants who weighed less than 1,500 g at birth were the major contributors to the overall reduction in mortality. Between the years 1981/82 and 1995/96, survival increased significantly from 64% to 79% for infants with birth weight 1,000-1,499 g, and from 14% to 32% for those with birth weight less than 1,000 g. Since infants in the latter group were seldom offered mechanical ventilation or artificial surfactant, a large part of these increases in survival can be attributed to improvement in the general level of care. CONCLUSION: There have been dramatic improvements in the survival of LBW infants over this time period at Baragwanath Hospital. Although newer interventions such as mechanical ventilation and artificial surfactant have played a significant role, improvement in care at primary and secondary levels has been of major importance.