Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital.

BACKGROUND: Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes. PURPOSE: To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital. METHODS: The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization. FINDINGS: NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention. IMPLICATIONS FOR PRACTICE: Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals. IMPLICATIONS FOR RESEARCH: Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

Cognitive development in preterm infants: multifaceted deficits reflect vulnerability of rigorous neurodevelopmental pathways.

Prematurity remains the major cause of neonatal morbidity and mortality, with 15 million preterm births occurring worldwide in 2010. Infants born less than 37 weeks gestation are at high risk of abnormal neurodevelopmental outcomes, given that the central nervous system is extremely sensitive to an abnormal intra- and extra-uterine environment. Children born preterm have multiple neurodevelopmental sequelae involving dynamic and complex cognitive deficits. Former preterm infants have difficulty with each domain of cognition, including executive function, language, learning and memory, complex attention, perceptual-motor function and social cognition when compared to children born at term. Although deficits are not always severe, even mild delays can be impactful, resulting in a spectrum of outcomes from difficulties in school to an inability to lead an independent adult life. Here, we review current literature on the cognitive outcomes of infants born preterm with a focus on how specific disruption in crucial neurodevelopmental pathways render these children vulnerable to dynamic deficits in cognition as they mature. Further, we highlight promising therapies and intervention strategies aimed at mitigating these deficits, including the use of erythropoietin. With an increasing number of preterm infants surviving, understanding developmental deficits will allow therapies to be developed and optimized, in order to ensure the best outcome for this vulnerable patient population.

PERFORMANCE OF A1C VERSUS OGTT FOR THE DIAGNOSIS OF PREDIABETES IN A COMMUNITY-BASED SCREENING.

OBJECTIVE: Reliable identification of individuals at risk for developing diabetes is critical to instituting preventative strategies. Studies suggest that the accuracy of using hemoglobin A1c as a sole diagnostic criterion for diabetes may be variable across different ethnic groups. We postulate that there will be lack of concordance between A1c and the oral glucose tolerance test (OGTT) for diagnosing prediabetes across Hispanic and non-Hispanic white (NHW) populations. METHODS: A total of 218 asymptomatic adults at risk for type 2 diabetes (T2D) were assessed with A1c and OGTT for the diagnosis of prediabetes. Glucose homeostasis status was assigned as no diabetes (A1c <5.7% [39 mmol/mol]), prediabetes (A1c 5.7 to 6.4% [46 mmol/mol]), and T2D (A1c >6.4% [46 mmol/mol]). Inclusion criteria were age >18 years and at least one of the following: a family history of diabetes, a history of gestational diabetes, Hispanic ethnicity, non-Caucasian race, or obesity. Subjects received a fasting 75-g OGTT and A1c on the same day. Bowker's test of symmetry was employed to determine agreement between the tests. RESULTS: Data from 99 Hispanic patients and 79 NHW patients were analyzed. There was no concordance between A1c and OGTT for Hispanic (P = .002) or NHW individuals (P = .003) with prediabetes. CONCLUSION: A1c is discordant with OGTT among Hispanic and NHW subjects for the diagnosis of prediabetes. Sole use of A1c to designate glycemic status will result in a greater prevalence of prediabetes among Hispanic and NHW New Mexicans. ABBREVIATIONS: A1c = hemoglobin A1c BMI = body mass index CDC = Centers for Disease Control CI = confidence interval FPG = fasting plasma glucose NHW = non-Hispanic white OGTT = oral glucose tolerance test T2D = type 2 diabetes WHO = World Health Organization.

Postnatal diagnosis of de novo complex der(8) in a boy with prenatal diagnosis of recombinant chromosome 8 syndrome.

Recombinant chromosome 8 syndrome is caused by duplication of 8q and deletion of 8p. A fetus with anomalies was misdiagnosed with this syndrome based on an amniocyte karyotype. Postnatal chromosomal microarray and other studies identified a de novo derivative chromosome 8. For fetal anomalies, detailed genetic studies may be required.

Association of passive and active smoking with pre-diabetes risk in a predominantly Hispanic population.

Smoking is the leading cause of avoidable death and is associated with type 2 diabetes (T2D) risk. Previous studies on the impact of passive smoking have not been applied to a Hispanic-majority population. We investigated the association between active smoking, exposure to environmental tobacco smoke (ETS), and pre-diabetes risk in a New Mexico population. We hypothesized that pre-diabetes risk increases with increasing smoking status after adjustment for important covariates. We screened 219 adults from an ongoing study who were categorized according to their smoking status (never smoker, current smoker, previous smoker) and their exposure to ETS (exposed or unexposed). Glucose homeostasis status was assigned using A1c: no diabetes (A1c <5.7%), pre-diabetes (A1c 5.7-6.4%), and T2D (A1c >6.4%). Among 160 patients with complete data, 51.6% had no diabetes and 48.4% had pre-diabetes. The mean age was 44.8±13.5 years. The study population was predominantly female (64.4%), and the ethnic composition was 44.4% Hispanic, 39.4% non-Hispanic White (NHW), 10.6% American Indian, 2.5% African-American, and 3.1% other. Using a logistic model with 2-way interactions, all predicted probabilities for being at risk for pre-diabetes were significant at the 0.001 level for smoking status and ETS exposure after adjusting for age, sex, ethnicity, family history of diabetes, alcohol consumption, BMI, and blood pressure. Active or passive smoking is independently associated with pre-diabetes risk.

Evaluación ecocardiográfica de la función ventricular derecha para la detección temprana de la cardiotoxicidad inducida por antraciclinas / Avaliação ecocardiográfica da função ventricular direita para a detecção precoce de cardiotoxicidade induzida por antraciclinas / Echocardiographic evaluation of right ventricular function for the early detection of anthracycline-induced cardiotoxicity

Las enfermedades cardiovasculares y el cáncer son las principales causas de muerte. Actualmente, existe un importante progreso en la oncología en cuanto a su diagnóstico precoz y su correspondiente tratamiento, como a la mejora de la sobrevida y de la calidad de vida debido al uso de tratamientos antineoplásicos combinados. Al mismo tiempo, se han incrementado los efectos adversos cardiológicos de dichos tratamientos, dando origen a una nueva cohorte de pacientes, quienes alcanzarán una supervivencia suficiente como para padecer complicaciones cardíacas derivadas del tratamiento oncológico. Este trasfondo clínico hace que la cardiotoxicidad derivada del tratamiento oncológico (quimioterapia y radioterapia) se transforme en una de sus principales complicaciones, por lo cual una respuesta multidisciplinaria que asocie el conocimiento de los oncólogos e internistas al de los cardiólogos será cada vez más necesaria para el mejor manejo de una población crónica en crecimiento constante. La ecografía ha sido validada como el método diagnóstico que proporciona mayor precisión en el cálculo de la fracción de eyección, siendo el método de elección para la evaluación inicial y el seguimiento de los pacientes tratados oncológicamente. La detección temprana de alteraciones cardiovasculares en pacientes tratados con quimioterapia presenta el beneficio de obtener terapias alternativas, disminuyendo así la incidencia de cardiotoxicidad y su morbilidad y mortalidad asociadas.

Cardiovascular diseases and cancer are the leading causes of death. Currently, there is an important progress in oncology regarding early diagnosis and its corresponding treatment, as well as the improvement of survival and quality of life due to the use of combined antineoplastic treatments. At the same time, the cardiological adverse effects of these treatments have been increased, creating a new cohort of patients who will experience sufficient survival to develop the cardiac complications derived from oncological treatment. This clinical background makes the cardiotoxicity derived from oncologic treatment (chemotherapy and radiotherapy) become one of its main complications, so a multidisciplinary response that associates the knowledge of oncologists and internists with that of cardiologists will be increasingly necessary for the best management of a chronic population in constant growth. Ultrasonography has been validated as the diagnostic method that provides greater accuracy in the calculation of ejection fraction, being the method of choice for the initial evaluation and follow-up of patients treated oncologically. The early detection of cardiovascular alterations in patients treated with chemotherapy has the benefit of obtaining alternate therapies, thereby decreasing the incidence of cardiotoxicity and its associated morbidity and mortality.

As doenças cardiovasculares e o câncer são as principais causas de morte. Atualmente, há um importante progresso em oncologia em relação ao diagnóstico precoce e seu correspondente tratamento, bem como a melhoria da sobrevida e qualidade de vida devido à utilização de tratamentos antineoplásicos combinados. Ao mesmo tempo, os efeitos adversos cardiológicos destes tratamentos foram aumentados, criando uma nova coorte de pacientes que alcançaram uma sobrevivência suficiente para desenvolver as complicações cardíacas derivadas do tratamento oncológico. Este contexto clínico faz que a cardiotoxicidade derivada do tratamento oncológico (quimioterapia e radioterapia) se torne uma de suas principais complicações, portanto, uma resposta multidisciplinar que associe o conhecimento de oncologistas e internistas com os cardiologistas será cada vez mais necessária para o melhor manejo de uma população crônica em constante crescimento. A ultrassonografia foi validada como o método de diagnóstico que fornece maior precisão no cálculo da fração de ejeção, sendo o método de escolha para avaliação inicial e seguimento de pacientes tratados oncologicamente. A detecção precoce de alterações cardiovasculares em pacientes tratados com quimioterapia tem o benefício de obter terapias alternativas, diminuindo assim a incidência de cardiotoxicidade e sua morbidade e mortalidade associadas.