Retrospective Analysis of Factors Associated With a Revised Fall Prevention Bundle in Hospitalized Patients.

OBJECTIVE: The study aims to describe factors associated and injuries sustained with inpatients who fell while hospitalized and identify the impact of a revised fall-prevention bundle. BACKGROUND: Approximately 1 million falls occur in hospitals annually, accounting for approximately 70% of inpatient accidents. Inpatient falls can result in physical injury, increased patient mortality and morbidity, decreased quality of life, and increased length of stay and cost. METHODS: We used a retrospective review of patient fall data for adult inpatients who fell while hospitalized. RESULTS: After reeducation and implementation of all elements of a revised fall-prevention bundle, there were fewer falls per patient day. We identified additional characteristics indicating when patients were more likely to be injured in a fall. CONCLUSIONS: A fall-prevention bundle is effective in decreasing inpatient falls and falls with injury. Raising awareness of additional factors may decrease risk of injuries during an inpatient fall.

Ramelteon is Not Associated With Improved Outcomes Among Critically Ill Delirious Patients: A Single-Center Retrospective Cohort Study.

BACKGROUND: Delirium commonly affects critically ill patients and is associated with high morbidity and mortality. Some studies have suggested that ramelteon may prevent delirium, but ramelteon's impact on treating delirium is unknown. OBJECTIVE: To compare outcomes of critically ill delirious patients treated with ramelteon versus those who were not. METHODS: Retrospective cohort study of 322 intensive care unit patients stratified based on ramelteon exposure after a nonnegative Confusion Assessment Method-ICU score. MAIN OUTCOMES: Primary outcomes were hours alive without delirium or coma and likelihood of delirium-coma resolution. Secondary outcomes were ventilator-free hours, likelihood of extubation, and mortality. RESULTS: Hazard ratios for delirium-coma resolution, extubation, and 10-day mortality were 1.05 (95% confidence interval 0.54-2.01), 1.20 (95% confidence interval 0.47-3.03), and 0.31 (95% confidence interval 0.07-1.32), respectively. Median delirium-coma free hours did not differ between ramelteon exposed and unexposed patients. Median ventilator-free hours were higher in the ramelteon group, however, ramelteon was administered postextubation in 92% of cases. CONCLUSIONS: Ramelteon was not associated with increased likelihood of delirium-coma resolution, extubation, or changes in mortality.

Early Adolescent Substance Use and Mental Health Problems and Service Utilisation in a School-based Sample.

OBJECTIVE: This paper reports on substance use, mental health problems, and mental health service utilisation in an early adolescent school-based sample. METHOD: Participants were 1,360 grade 7 and 8 students from 4 regions of Ontario, Canada. Students completed an in-class survey on mental health and substance use. The sampling strategy and survey items on demographics, substance use, service utilisation, and distress were adapted from the Ontario Student Drug Use and Health Survey. Internalising and externalising mental health problems were assessed using the Global Assessment of Individual Needs - Short Screener. Distress was defined as fair or poor self-rated mental health. RESULTS: Rates of internalising and/or externalising problems above the threshold exceeded 30%; yet, fewer than half had received mental health services in the past 12 mo. Substance use was associated with increased odds of internalising and externalising problems above the threshold and distress. Youth using cannabis had 10-times the odds of exceeding the threshold for internalising or externalising problems. The use of substances other than alcohol or cannabis was associated with increased odds of fair or poor self-rated mental health among grade 8 students. Of the youth who confirmed at least a substance use problem, most also reported mental health problems; this association was stronger among girls than boys. CONCLUSIONS: Early adolescent substance use was associated with concurrent self-reported mental health problems in a non-clinical sample. The low levels of service utilisation reported highlight the need for improved access to early identification and intervention to prevent the development of concurrent disorders.

Childhood Corporal Punishment and Future Perpetration of Physical Dating Violence.

OBJECTIVE: To test whether experiencing childhood corporal punishment is linked to later perpetration of dating violence. STUDY DESIGN: Young adults (n = 758; 61% female; mean age of 20 years), originally recruited for a longitudinal study as 9th- and 10th-grade Texas high school students, were asked about their childhood experiences with corporal punishment and physical abuse, as well as current experiences with dating violence. A path model was used to determine whether childhood corporal punishment was related to recent perpetration of physical dating violence, while controlling for childhood physical abuse, age, sex, ethnicity, and socioeconomic status. RESULTS: In all, 19% of participants (n = 134) reported physical dating violence perpetration and 68% reported experiencing corporal punishment as children (n = 498). Analysis showed a significant positive association between corporal punishment and physical perpetration of dating violence (OR 1.30, 95% CI 1.07-1.59). Even after controlling for sex, ethnicity, age, parental education, and child physical abuse, childhood corporal punishment was associated significantly with physical dating violence perpetration (aOR 1.29, 95% CI 1.02-1.62). CONCLUSIONS: The finding that childhood corporal punishment was associated with perpetration of young adult physical dating violence, even after controlling for several demographic variables and childhood physical abuse, adds to the growing literature demonstrating deleterious outcomes associated with corporal punishment.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence.

BACKGROUND: Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities. METHODS: Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents. RESULTS: Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25). CONCLUSIONS: The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.

Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection.

Widespread antibiotic use in clinical medicine and the livestock industry has contributed to the global spread of multidrug-resistant (MDR) bacterial pathogens, including Acinetobacter baumannii We report on a method used to produce a personalized bacteriophage-based therapeutic treatment for a 68-year-old diabetic patient with necrotizing pancreatitis complicated by an MDR A. baumannii infection. Despite multiple antibiotic courses and efforts at percutaneous drainage of a pancreatic pseudocyst, the patient deteriorated over a 4-month period. In the absence of effective antibiotics, two laboratories identified nine different bacteriophages with lytic activity for an A. baumannii isolate from the patient. Administration of these bacteriophages intravenously and percutaneously into the abscess cavities was associated with reversal of the patient's downward clinical trajectory, clearance of the A. baumannii infection, and a return to health. The outcome of this case suggests that the methods described here for the production of bacteriophage therapeutics could be applied to similar cases and that more concerted efforts to investigate the use of therapeutic bacteriophages for MDR bacterial infections are warranted.

Predictors and outcomes of unplanned early rehospitalization in the first year following lung transplantation.

Unplanned early rehospitalization (UER), defined as an unscheduled admission within 30 days of a hospital discharge, is associated with graft loss and recipient mortality in some solid organ transplants but has not been investigated in lung transplant. In this retrospective study, we collected socio-demographic and clinical factors to determine predictors and outcomes of UER in the first year following lung transplantation. There were 193 patients who underwent lung transplantation and survived to discharge during the 7.9-year study period. There were 116 (60.1%) patients with at least one UER. Infections (32.8%) and post-surgical complications (11.8%) were the most common reasons for UER. On multivariate analysis, the strongest predictor of having an UER was discharge to a long-term acute care facility (odds ratio: 3.01, 95% confidence interval [CI] 1.46-6.20; P=.003). Patients with any UER in the first year following transplantation had worse adjusted survival (hazard ratio: 1.89, 95% CI 1.02-3.50; P=.04). It is unclear, however, to what extent UERs reflect preventable outcomes. Further large-scale, prospective research is needed to identify the extent to which certain types of UER are modifiable and to define patients at high-risk for preventable UER.

The Effect of Pretransplant Depression and Anxiety on Survival Following Lung Transplant: A Meta-analysis.

BACKGROUND: Current lung transplant allocation guidelines recommend considering psychological function when assessing candidacy despite limited data on whether patients with conditions, such as anxiety and depression, have reduced benefit from transplant because of decreased survival after transplant. OBJECTIVE: The aim of this article was to determine whether pretransplant depression and anxiety are associated with worse posttransplant survival. METHODS: We searched Medline, Journal Storage, and Embase for original articles that assessed the effect of pretransplant depression and anxiety on survival following lung transplant published up to November 2015. We calculated a summary estimate of hazard ratios for death using a random effects model. RESULTS: In total, 6 prospective longitudinal cohort studies were included in the meta-analysis, 4 of which used continuous scores on validated instruments to measure anxiety and depression. There were 711 patients of whom 345 (48.5%) died during the available follow-up time (mean = 7.8 years). Pretransplant anxiety and depression were not associated with posttransplant survival (hazard ratio = 1.009; 95% CI: 0.998-1.019). Heterogeneity was not detected (I(2) = 0.00%, Q = 5.87, p = 0.66) and the results did not differ whether anxiety or depression was treated as the exposure of interest. CONCLUSIONS: There is sufficient evidence to conclude that scores on indices of depression and anxiety pretransplant are not associated with worse survival following lung transplant.

Psychiatrists' Attitudes Toward Non-Pharmacologic Factors Within the Context of Antidepressant Pharmacotherapy.

OBJECTIVE: Recent meta-analyses of antidepressant clinical trials have suggested that up to 82 % of response can be attributed to non-medication-related factors. The present study examines psychiatrists' attitudes regarding non-pharmacologic factors within the context of antidepressant pharmacotherapy. METHODS: A web-based, 20-question cross-sectional survey was distributed to 101 staff psychiatrists and 48 post-graduate trainees in psychiatry at an academic hospital in Boston, MA. Demographics, practice characteristics, beliefs about non-pharmacologic factors affecting prescribing practices, perceived response and remission rates, and opinions about the need for further investigations in the psychopharmacology process were assessed. RESULTS: Overall completion rate was 53 %. The final sample included 79 responses. The medians for clinician-perceived response rates (54 %) and remission rates (33 %) were in agreement with published rates. The reported median of the what portion of clinical outcomes is believed to be due to placebo effects (26 %) was numerically lower than suggested by literature. The contribution of the active ingredients of medications was perceived to be significantly higher than the contribution of patient characteristics and clinician characteristics. A longer time since graduation from medical school was significantly associated with higher belief in the effect of the active ingredients of antidepressant medications and with less perceived importance of placebo effects. CONCLUSION: These findings suggest a discrepancy between empirical evidence and psychiatrists' beliefs on the impact of placebo effects on clinical outcomes. Educating antidepressant prescribers about the evidence based on psychosocial mediators of placebo effects' contribution to outcome may represent a promising strategy for improving clinical outcomes.

Community Markets for Conservation (COMACO) links biodiversity conservation with sustainable improvements in livelihoods and food production.

In the Luangwa Valley, Zambia, persistent poverty and hunger present linked challenges to rural development and biodiversity conservation. Both household coping strategies and larger-scale economic development efforts have caused severe natural resource degradation that limits future economic opportunities and endangers ecosystem services. A model based on a business infrastructure has been developed to promote and maintain sustainable agricultural and natural resource management practices, leading to direct and indirect conservation outcomes. The Community Markets for Conservation (COMACO) model operates primarily with communities surrounding national parks, strengthening conservation benefits produced by these protected areas. COMACO first identifies the least food-secure households and trains them in sustainable agricultural practices that minimize threats to natural resources while meeting household needs. In addition, COMACO identifies people responsible for severe natural resource depletion and trains them to generate alternative income sources. In an effort to maintain compliance with these practices, COMACO provides extension support and access to high-value markets that would otherwise be inaccessible to participants. Because the model is continually evolving via adaptive management, success or failure of the model as a whole is difficult to quantify at this early stage. We therefore test specific hypotheses and present data documenting the stabilization of previously declining wildlife populations; the meeting of thresholds of productivity that give COMACO access to stable, high-value markets and progress toward economic self-sufficiency; and the adoption of sustainable agricultural practices by participants and other community members. Together, these findings describe a unique, business-oriented model for poverty alleviation, food production, and biodiversity conservation.

Sector connectors, specialists and scrappers: How cities use civic capital to compete in high-technology markets.

This article uses three cities in the same Canadian province (Ontario): Toronto, Ottawa and Waterloo, to examine how regions compete in high-technology markets. We find that regions use civic capital to leverage new, technological windows of opportunity, but they do so in very different ways. Tracing Toronto's evolution from a marketing hub for foreign multinationals into a centre for entrepreneurship, we illustrate how weak ties and cross-sectoral buzz created a 'super connector', scaling high-technology firms in a wide variety of areas. In Ottawa, task-specific cooperation in R&D, education and specialised infrastructure enabled the region to overcome the disadvantages of its small size as a 'specialist' in a single, capital-intensive niche, telecommunications equipment. Finally, entrepreneurs in Waterloo eschewed task-specific cooperation for peer-to-peer mentoring. By diffusing generic knowledge about how to circumvent the liabilities of smallness, mentoring networks enabled this 'scrapper' city to support smaller start-ups in a broad range of niches.

Observations of adolescent peer resistance skills following a classroom-based healthy relationship program: a post-intervention comparison.

This study examines peer resistance skills following a 21-lesson classroom-based intervention to build healthy relationships and decrease abusive and health-risk behaviors among adolescents. The Fourth R instructs students in positive relationship skills, such as negotiation and delay, for navigating challenging peer and dating scenarios. Observational data from 196 grade 9 students participating in a larger cluster randomized controlled trial were used to evaluate post-intervention acquisition of peer resistance skills. Pairs of students engaged in a role play paradigm with older student actors, where they were subjected to increasing pressure to comply with peer requests related to drugs and alcohol, bullying, and sexual behavior. Specific and global measures of change in peer resistance responses were obtained from two independent sets of observers, blinded to condition. Specific peer resistance responses (negotiation, delay, yielding to pressure, refusal, and compliance) were coded by research assistants; global peer resistance responses were rated by teachers from other schools (thinking / inquiry, application, communication, and perceived efficacy). Students who received the intervention were more likely to demonstrate negotiation skills and less likely to yield to negative pressure relative to controls. Intervention students were also more likely to use delay than controls; control girls were more likely to use refusal responses; the number of times students complied with peer requests did not differ. Teacher ratings demonstrated significant main effects favoring intervention youth on all measures. Program and research implications are highlighted.

Longitudinal prediction and concurrent functioning of adolescent girls demonstrating various profiles of dating violence and victimization.

Adolescent girls are involved in physical dating violence as both perpetrators and victims, and there are negative consequences associated with each of these behaviors. This article used a prospective design with 519 girls dating in grade 9 to predict profiles of dating violence in grade 11 based on relationships with families of origin (child maltreatment experiences, harsh parenting), and peers (harassment, delinquency, relational aggression). In addition, dating violence profiles were compared on numerous indices of adjustment (school connectedness, grades, self-efficacy and community connectedness) and maladjustment (suicide attempts, distress, delinquency, sexual behavior) for descriptive purposes. The most common profile was no dating violence (n = 367) followed by mutual violence (n = 81). Smaller numbers of girls reported victimization or perpetration only (ns = 39 and 32, respectively). Predicting grade 11 dating violence profile membership from grade 9 relationships was limited, although delinquency, parental rejection, and sexual harassment perpetration predicted membership to the mutually violent group, and delinquency predicted the perpetrator-only group. Compared to the non-violent group, the mutually violent girls in grade 11 had lower grades, poorer self-efficacy, and lower school connectedness and community involvement. Furthermore, they had higher rates of peer aggression and delinquency, were less likely to use condoms and were much more likely to have considered suicide. There were fewer differences among the profiles for girls involved with dating violence. In addition, the victims-only group reported higher rates of sexual intercourse, comparable to the mutually violent group and those involved in nonviolent relationships. Implications for prevention and intervention are highlighted.

Identity development as a buffer of adolescent risk behaviors in the context of peer group pressure and control.

We examined identity development as a moderator of the relation between peer group pressure and control and adolescents' engagement in risk behaviors. Participants (n=1070; M(age)=15.45 years) completed a self-report measure of identity exploration, the degree to which they have explored a variety of self-relevant values, beliefs and goals, and identity commitment, the degree to which they have secured a personal identity. Participants further reported on their frequency of risk behaviors (substance use and general deviancy) and experienced peer group pressure and control. Results confirmed that identity commitment was a buffer of substance use and identity exploration was a buffer of general deviancy in more pressuring peer groups. In more controlling peer groups, teens with greater identity commitment engaged in less risk behavior than teens with low-identity commitment. Thus, identity development may be a suitable target to deter negative effects of peer pressure in high-risk adolescents.

Postpartum Thoughts of Infant-Related Harm and Obsessive-Compulsive Disorder: Relation to Maternal Physical Aggression Toward the Infant.

Objective: Unwanted intrusive thoughts (UITs) of intentional infant-related harm are ubiquitous among new mothers and frequently raise concerns about infant safety. The purpose of this research was to assess the relation of new mothers' UITs of intentional, infant-related harm and obsessive-compulsive disorder (OCD) with maternal aggression toward the infant and to document the prevalence of maternal aggression toward the infant.Methods: From a prospective, province-wide, unselected sample of 763 English-speaking postpartum women, a total of 388 participants provided data for this portion of the research. Participants completed 2 questionnaires and interviews postpartum to assess UITs of infant-related harm, OCD (based on DSM-5 criteria), and maternal aggression toward the infant. Data for this research were collected from February 9, 2014, to February 14, 2017.Results: Overall, few participants (2.9%; 95% CI, 1.5% to 4.7%) reported behaving aggressively toward their infant. Participants who reported UITs of intentional, infant-related harm (44.4%; 95% CI, 39.2% to 49.7%) were not more likely to report aggression toward their newborn compared with women who did not report this ideation (2.6%; 95% CI, 0.9% to 5.8%; and 3.1%; 95% CI, 1.3% to 6.2%, respectively). The same was true for women with and without OCD (1.9%; 95% CI, 0.3% to 6.4%; and 3.5%; 95% CI, 1.8% to 6.0%), respectively.Conclusions: This study found no evidence that the occurrence of either UITs of intentional, infant-related harm or OCD is associated with an increased risk of infant harm. The prevalence of child abuse of infants in this sample (2.9%) is lower than reported in others (4%-9%). Findings provide critical and reassuring information regarding the relation between new mothers' UITs of intentional harm and risk of physical violence toward the infant.

Validation of a New High-Throughput BD COR System Using the BD CTGCTV2 Assay.

This study determined the precision and reproducibility of results for the BD CTGCTV2 (CTGCTV2) assay on the BD COR System (COR). The clinical performance of the CTGCTV2 assay conducted on COR was compared with its performance on the BD MAX System (MAX) for detecting Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The multiday precision and multisite reproducibility studies were conducted using contrived panels of positive and negative urine and PreservCyt specimens. A total of 433 panel members, generated from remnant clinical specimens, were tested in the clinical comparison study. Each panel member was tested three times on MAX and three times on COR. The results in the same testing group were compared for agreement by target. The cycle threshold scores from MAX and COR were analyzed by paired t-test and Deming regression. The CTGCTV2 assay on COR showed high reproducibility in the multiday and multisite precision analysis. The point estimates of positive percent agreement and negative percent agreement in the clinical comparison study for all three targets were greater than 95%, with all corresponding lower bounds of two-sided 95% CIs greater than 90%. Cycle threshold score comparison showed no systematic difference between the two systems. The results of this study show equivalent performance of the CTGCTV2 assay on the MAX and COR systems.

Genetic deletions and high diversity of Plasmodium falciparum histidine-rich proteins 2 and 3 genes in parasite populations in Ghana.

Rapid diagnostic tests (RDTs) are used to diagnose malaria in Ghana and other malaria endemic countries. Plasmodium falciparum histidine-rich protein 2 (PFHRP2) based RDTs are widely used, however the occurrence of deletions of the pfhrp2 gene in some parasites have resulted in false negative test results. Monoclonal antibodies of PFHRP2 cross reacts with PFHRP3 because they share structural similarities and this complements the detection of the parasites by RDT. These two genes were investigated in Ghanaian P. falciparum parasite population to detect deletions and the polymorphisms in exon 2 of the pfhrp2 and pfhrp3 genes. Parasite isolates (2,540) from children ≤ 12 years with uncomplicated malaria from 2015 to 2020 transmission seasons were used. Both genes were amplified using nested PCR and negative results indicated the presence of the deletion of genes. Amplified genes were sequenced for the detection of the amino acid repeats. Deletions were observed in 30.7% (780/2,540) and 17.2% (438/2,540) of the samples for pfhrp2 and pfhrp3 respectively with increasing trends over the three time periods (χ2 -10.305, p = 0.001). A total of 1,632 amplicons were sequenced for each gene, analysis was done on 1,124 and 1,307 good quality sequences for pfhrp2 and pfhrp3 respectively. Pfhrp2 repeat polymorphisms were dominantly of types 2 (AHHAHHAAD) and 7 (AHHAAD) with large numbers of variants. A novel variant of type 14 (AHHANHATD) was seen for pfhrp2. For the pfhrp3 repeat types, 16 (AHHAAN), 17 (AHHDG) and 18 (AHHDD) were the dominant types observed. Variants of type 16 (AHHAAH) and (AHHASH) were also dominant. Repeat types 1, 2, 3, 4, 5, 6, 7, 8, 11, 13, 15, 16, and 19 were observed be shared by both genes. The haplotype diversity of both genes ranged between 0.872 and 1 indicating high diversity of the polymorphisms in the isolates. The implication of the findings of the frequencies of the pfhrp2 and pfhrp3 deletions as well as the variants of the main epitopes of the monoclonal antibodies for the RDT (types 2 and 7) in our isolates is an indication of decreased sensitivity of the RDTs in diagnosing malaria infections in Ghana.

A Life Course Study on Traumatic Brain Injury and Physical and Emotional Trauma in Foster Children.

Foster children are exposed to high levels of abuse, violence, and other adverse events throughout their childhood and adolescent years. Forms of brain injury, notably traumatic brain injury (TBI), are understudied in the foster child population. This study aimed to explore different forms of brain injury and their cognitive, behavioral, and psychological/emotional effects on current and former foster children using a life course perspective. A thematic analysis with a life course perspective was used to examine semi-structured, open-ended interviews conducted with current and previous foster children between the ages of 16 and 29 years. The study included 47 participants: 25 males (53%) and 22 females (47%) with an average age of 21 years and an average of 11.2 years of education. Of 47 current and previous foster children between the ages of 16 and 29, two-thirds had sustained one or more TBIs. Through a thematic analysis, four overarching and inter-related themes emerged from the data: frequent TBI, normalization (of abuse, violence, injury, and neglect), emotional trauma, and dangerous coping methods such as alcohol use in 94% and recreational drug use in 81%. Normalization of adverse events, emotional trauma, and the use of dangerous coping methods occurred in 66%, 81%, and 49% of participants, respectively, and are the cumulative toxic long-term effects of early negative life experiences and repeated forms of brain injury. Early and continued exposure to TBI, abuse, violence, and/or neglect with continued maladaptive behaviors suggests that the participants may have experienced changes in brain structure and function over their lives that provided the milieu for continued vulnerability to personal and future injury to future generations. These behavioral and perceptual changes point to a toxic combination of injuries that result in continued vulnerability to repeated injury through contextual exposure to risks and maladaptive normalization, emotional trauma, and risky coping styles.

Cumulative impact of multiple evidence based strategies on postnatal growth of extremely-low-birth-weight infants.

BACKGROUND: Postnatal growth failure is common in very preterm infants and is associated with worse neurodevelopmental outcome. OBJECTIVE: To evaluate the cumulative impact of multiple evidence based strategies on the postnatal growth of extremely-low-birth-weight (ELBW) infants. METHODS: We conducted a prospective observational study. Based on current literature, changes were implemented to provide optimal parenteral and enteral nutrition. Daily intakes of calories, protein, lipids and carbohydrates were calculated. The average growth velocity (GV) was calculated using 2-point exponential model and is reported as grams/kg/day. The length and head circumference gains are reported as centimeters/week. RESULTS: The mean gestational age and birth weight for 38 ELBW survivors were 27.0 ± 2.1 weeks and 752 ± 147 g respectively. The GV was 13.2 ± 2.2 g/kg/day (range 8.8-17.4) and gains in length and head circumference were 0.88 ± 0.9 (range 0.15-1.42) and 0.71 ± 0.5 (range 0.22-0.96) centimeters/week respectively. Twenty nine (76.3%) infants were small-for-gestational-age (SGA) at discharge and 23 of these (60.5% of all infants) had weight below 3rd percentile. All 11 infants who were SGA at birth were SGA at discharge as well. Of 25 appropriate-for-gestational-age (AGA) infants at birth, 16 (64%) were SGA at discharge. The number of infants with length and head circumference below 10th percentile at birth and discharge were 11 (28.9%) and 29 (76.3%) for length and 20 (52.6%) and 27 (71.1%) for head circumference. Infants with multiple morbidities and more hospital days with no enteral feeds had lower GV. CONCLUSION: All infants born SGA at birth and majority of ELBW survivors born AGA at birth had weight, length and head circumference below 10th percentile at discharge despite aggressive nutrition supplementation.