National cohort of infants born before 24 gestational weeks showed increased survival rates but no improvement in neonatal morbidity.

AIM: To describe survival and neonatal morbidities in infants born before 24 weeks of gestation during a 12-year period. METHODS: Data were retrieved from national registries and validated in medical files of infants born before 24 weeks of gestation 2007-2018 in Sweden. Temporal changes were evaluated. RESULTS: In 2007-2018, 282 live births were recorded at 22 weeks and 460 at 23 weeks of gestation. Survival to discharge from hospital of infants born alive at 22 and 23 weeks increased from 20% to 38% (p = 0.006) and from 45% to 67% (p < 0.001) respectively. Caesarean section increased from 12% to 22% (p = 0.038) for infants born at 22 weeks. Neonatal morbidity rates in infants alive at 40 weeks of postmenstrual age (n = 399) were unchanged except for an increase in necrotising enterocolitis from 0 to 33% (p = 0.017) in infants born at 22 weeks of gestation. Bronchopulmonary dysplasia was more common in boys than girls, 90% versus 82% (p = 0.044). The number of infants surviving to 40 weeks doubled over time. CONCLUSION: Increased survival of infants born before 24 weeks of gestation resulted in increasing numbers of very immature infants with severe neonatal morbidities likely to have a negative impact on long-term outcome.

Vessel health and preservation: An integrative review.

AIMS AND OBJECTIVES: To describe and synthesise current knowledge on the maintenance and preservation of vessels in patients who need the placement of a vascular access device. INTRODUCTION: To administer drugs, blood or intravenous fluids, nurses or doctors insert a peripheral vascular access device on the arm using the traditional approach. This approach implies that devices are blindly inserted until flow is satisfactory and all possible sites have been exhausted. A proactive approach would ensure at the outset that the best device is used for each patient, eliminating repeated attempts at cannulation. DESIGN: An integrative review was conducted using data recorded until July 2017. Searches were conducted in PubMed, Cochrane Library, CINAHL and Scopus. REVIEW METHOD: A modified version of Cooper's five-stage method and the PRISMA guidelines were used to perform the integrative review. RESULTS: Nine papers were included in this review. The patients were active participants in a proactive approach to vessel health and preservation. The involvement of each healthcare professional in vessel health and preservation improves outcomes and expands the use of a proactive approach to vascular device management. Because nurses are directly involved in the use of such devices and support patients during the decision-making process, they should take the lead in the use of the proactive approach. CONCLUSION: Despite the many documented advantages of the proactive approach to preserving vessels in many settings and healthcare systems, it has not been widely tested. Future research is needed to guarantee high-quality vessel health and preservation care, thus contributing to the development and dissemination of the proactive approach. RELEVANCE TO CLINICAL PRACTICE: The proactive approach preserves vessels for future needs, improves the delivery of the treatment plan and reduces length of stay, costs, risk of infection, complications and pain perceived by patients. This approach also ensures better use of nurses' time and vascular access device material.

Proactive approach at the limits of viability improves the short-term outcome of neonates born after 23 weeks' gestation.

OBJECTIVE: The aim of this single-center study was to identify factors that affect the short-term outcome of newborns delivered around the limits of viability. METHODS: A group of 137 pregnant women who gave birth between 22+0/7 and 25+6/7 weeks of gestation was retrospectively studied. The center supports a proactive approach to infants around the limits of viability. Perinatal and neonatal characteristics were obtained and statistically evaluated. RESULTS: A total of 166 live-born infants were enrolled during a 6-year period; 162 (97.6%) of them were admitted to the neonatal intensive care unit (ICU) and 119 (73.5%) survived until discharge. The decrease in neonatal mortality was associated with an advanced gestational age (P<0.001) and a completed course of corticosteroids (P=0.002). Neonatal morbidities were common among infants of all gestational ages. The incidence of severe intraventricular hemorrhage significantly depended on gestational age (P<0.001) and a completed course of corticosteroids (P=0.002). Survival without severe neonatal morbidities was 39.5% and occurred mostly after 24+0/7 weeks of gestation. CONCLUSION: The short-term outcome of newborns delivered around the limits of viability is mostly affected by gestational age and antenatal corticosteroid treatment. A consistently proactive approach improves the survival of infants at the limits of viability. This is most pronounced in cases where the delivery is delayed beyond 24 completed gestational weeks.

Strategies to prevent peritoneal carcinomatosis arising from colorectal cancer.

In the last decades, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy became a curative option for peritoneal metastases in selected patients, otherwise considered for palliative therapy alone. Better knowledge of physiopathology of peritoneal spread and identification of predictive factors for peritoneal relapse prompted specialized centers to investigate the role of a 'proactive approach' in order to early detect peritoneal metastasis. These encouraging data could justify an active attitude in selected patients at high risk of peritoneal recurrence after curative resection of primary tumor. Selection criteria and the timing of complementary hyperthermic intraperitoneal chemotherapy remain important points of discussion. In this article, we will discuss treatment principles and future perspectives to early treat and, if possible, to prevent peritoneal dissemination after curative treatment of colorectal cancer.

Comparing minimally invasive and proactive initial management of extremely preterm infants.

AIM: In 2005, we changed our minimally invasive departmental policy for infants born before 26 weeks of gestation to a proactive approach. This included structured guidelines as well as intubation and surfactant in the delivery room, if the parents agreed. The aim of this study was to evaluate the effect of this change of policy. METHOD: We compared the Ages and Stages Questionnaire (ASQ) scores, mortality rates and use of mechanical ventilation before (1999-2003) and after (2005-2011) the introduction of the new policy. RESULTS: Twenty-two per cent of 61 infants in the before group had an ASQ z-score of <-2 standard deviation at 18 months' corrected age, compared with 26% of 55 infants in the after group. Mortality decreased from 46% to 36% (p = 0.06) and the use of mechanical ventilation at any time during admission increased from 64% to 87% (p < 0.0001). CONCLUSION: We demonstrated that changing our policy to a proactive approach to the initial care of infants born before 26 weeks did not result in a major increase in psychomotor deficit. However, the use of mechanical ventilation increased significantly and survival tended to improve.

Conflict-Based safety evaluations at unsignalized intersections using surrogate safety measures.

Conflict-based road safety assessments may provide a deeper insight into the processes leading to crashes compared to assessments solely based on field crash data. The evaluation of road safety is conducted on specific road segments using different surrogate measure of safety indicators, such as temporal, spatial, and kinematic proximity measures, depending on the relevant context and applicability of these measures. Therefore, this study endeavored to develop a methodology by adopting safety measures such as post encroachment time (PET) and conflicting speeds of through vehicles for crossing maneuvers and time to collision (TTC) for rear-end collisions at five unsignalized intersections in urban mixed traffic conditions. Critical conflicts are calculated by calculating a speed variable known as the critical speed, which is based on the braking distance. A study found that the motorized two wheeler (MTW) categories involve the highest proportion of critical conflict with right-turning vehicles, followed by cars, autos, and light commercial vehicle (LCVs). Furthermore, crossing conflicts were modeled as a function using the generalized linear regression approach. The findings revealed that the most significant factors were traffic volume and vehicular composition in a conflicting stream. The unsupervised classification technique k-mean clustering was used to determine the defined severity level threshold for rear-end maneuvers. The result observed was that a TTC threshold of less than 1.15 s was identified as high-risk vehicular interaction. Additional investigation indicated that presence of certain moving vehicle categories, including MTWs and cars, led to a higher proportion of critical crossing conflicts. The conceptualized safety framework can be applied to evaluate safety at unsignalized intersections in the mixed traffic scenarios.

Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life.

INTRODUCTION: The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach. MATERIAL AND METHODS: This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation. RESULTS: Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases. DISCUSSION: Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status. CONCLUSIONS: Over time, some patients suffered loss of bladder wall compliance. Hence, even if a proactive approach is followed since birth, it is essential to continue with the ongoing monitoring of the renal status and thus avoid greater renal deterioration.

[PET with C-methionine and hyperparathyroidism].

Scintigraphy 99mTc-sestamibi, in association ultrasound of the neck, is currently the technique of choice for the location of parathyroid adenomas in patients with hyperparathyroidism then undergo parathyroidectomy. After surgery, from 2% to 7% of patients continues to have a persistence of the disease. In this case, the sensitivity of scintigraphy with MIBI in locating ectopic parathyroid glands is limited and varies from 30% to 80%. Thanks to the introduction of a new method radiological, PET with 11C-methionine, it is now possible to detect the possible presence of parathyroid adenomas in patients with MIBI scintigraphy been examined and is also useful for false positives. PET with 11C-methionine is a diagnostic accurate in locating the parathyroid adenomas of the neck with a sensitivity of 91%, allowing you to run parathyroidectomy focused with a reduced invasiveness of surgery, with reduction of postoperative pain and better results aesthetic. In addition, a method is clinically useful in patients with secondary hyperparathyroidism and tertiary. The limits of this promising method are the poor availability of the tracer, the fact that it is executed in only four centers in Italy and the high cost. We present the cases of two patients who are diagnosed with hyperparathyroidism. They are submitted in the first instance to MIBI parathyroid scintigraphy parathyroidectomy and after removal of pathological glands. Persisting high values of PTH, patients are executed before a new scintigraphy with MIBI which is however negative and then a PET with 11C-methionine which shows accumulation of tracer in a different place not detected by scintigraphy.