Gunnar Sjörs

Incidence of and risk factors for neonatal morbidity after active perinatal care : extremely preterm infants study in Sweden (EXPRESS)

Aims:  The aim of this study was to determine the incidence of neonatal morbidity in extremely preterm infants and to identify associated risk factors.

Transepidermal water loss in infants born at 24 and 25 weeks of gestation

The rate of evaporation of water from the skin of 13 infants born at 24 (n= 3) and 25 (n= 10) weeks of gestation was measured on the first day after birth and at postnatal ages of 1,3,7 and 28 d, using the gradient method. Transepidermal water loss was estimated from this rate and corrected to an ambient relative humidity (RH) of 50%. Transepidermal water loss, corrected to 50% RH, was high on the first day after birth (58.4 ± 14.8gm 2 h?1) and remained at the same level during the second day (59.3 ± 17.6gm?2h?1). It then decreased significantly to 43.8 ± 9.5 at a postnatal age of 3 d, 36.1 ± 12.6 at 7 d and 24.2 ± 7.7gm?2h?1 at 28 d (p < 0.001). Within the group investigated, there was no significant correlation between transepidermal water loss and body or skin temperature, birth weight, gender, mode of delivery or gestational age. Transepidermal water loss on the first day after birth was somewhat lower than the highest losses previously found in infants born at 25 weeks of gestation, and of the same magnitude as previously reported for infants born at 25‐27 weeks. Transepidermal water loss at postnatal ages of 1,3,7 and 28 d in the present study was higher than that previously found in the group of infants born at 25‐27 weeks. In conclusion, in infants born at 24‐25 completed weeks of gestation transepidermal water loss was high immediately after birth and decreased with increasing postnatal age, but at a slower rate than previously reported for slightly more mature infants.

Water loss from the skin of term and preterm infants nursed under a radiant heater

The rate of evaporation from the skin (g/m2/h) was measured in 12 full-term and 16 preterm infants (gestational age 25–34 wk) both during incubator care and when nursed under a radiant heater. The method for evaporation rate measurement is noninvasive and based on determination of the water vapor pressure gradient close to the skin surface. Measurements were first made with the infant nursed in an incubator with a controlled environment with respect to humidity, temperature, and air velocity. The measurements in the term infants were performed at an ambient relative humidity (RH) of 50%, and in the preterm infants first at 50% and subsequently at 30–40%. Evaporation rate was then measured with the infant nursed under a radiant heater. In term infants, mean evaporation rate was 3.3 g/m2/h during incubator care (RH 50%) and 4.4 g/m2/h during care under the radiant heater. In preterm infants, the corresponding values were 15.5 g/m2/h in the incubator at RH 50%, 16.7 g/m2/h at RH 30–40%, and 17.9 g/m2/h under the radiant heater. It is concluded that the evaporative water loss from the skin depends on the ambient water vapor pressure, irrespective of whether the infant is nursed in an incubator or under a radiant heater. The higher rate of evaporation during care under a radiant heater is due to the lower ambient water vapor pressure and not to any direct effect of the nonionizing radiation on the skin.

EXPRESS study shows significant regional differences in 1-year outcome of extremely preterm infants in Sweden

The aim of this study was to investigate differences in mortality up to 1 year of age in extremely preterm infants (before 27 weeks) born in seven Swedish healthcare regions.

The International Network for Evaluating Outcomes of very low birth weight, very preterm neonates (iNeo): a protocol for collaborative comparisons of international health services for quality improvement in neonatal care

BackgroundThe International Network for Evaluating Outcomes in Neonates (iNeo) is a collaboration of population-based national neonatal networks including Australia and New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the UK. The aim of iNeo is to provide a platform for comparative evaluation of outcomes of very preterm and very low birth weight neonates at the national, site, and individual level to generate evidence for improvement of outcomes in these infants.Methods/designIndividual-level data from each iNeo network will be used for comparative analysis of neonatal outcomes between networks. Variations in outcomes will be identified and disseminated to generate hypotheses regarding factors impacting outcome variation. Detailed information on physical and environmental factors, human and resource factors, and processes of care will be collected from network sites, and tested for association with neonatal outcomes. Subsequently, changes in identified practices that may influence the variations in outcomes will be implemented and evaluated using quality improvement methods.DiscussionThe evidence obtained using the iNeo platform will enable clinical teams from member networks to identify, implement, and evaluate practice and service provision changes aimed at improving the care and outcomes of very low birth weight and very preterm infants within their respective countries. The knowledge generated will be available worldwide with a likely global impact.

Intensity of Perinatal Care for Extremely Preterm Infants: Outcomes at 2.5 Years

OBJECTIVE: To examine the association between intensity of perinatal care and outcome at 2.5 years’ corrected age (CA) in extremely preterm (EPT) infants (<27 weeks) born in Sweden during 2004–2007. METHODS: A national prospective study in 844 fetuses who were alive at the mother’s admission for delivery: 707 were live born, 137 were stillborn. Infants were assigned a perinatal activity score on the basis of the intensity of care (rates of key perinatal interventions) in the infant’s region of birth. Scores were calculated separately for each gestational week (gestational age [GA]–specific scores) and for the aggregated cohort (aggregated activity scores). Primary outcomes were 1-year mortality and death or neurodevelopmental disability (NDI) at 2.5 years’ CA in fetuses who were alive at the mother’s admission. RESULTS: Each 5-point increment in GA-specific activity score reduced the stillbirth risk (adjusted odds ratio [aOR]: 0.90; 95% confidence interval [CI]: 0.83–0.97) and the 1-year mortality risk (aOR: 0.84; 95% CI: 0.78–0.91) in the primary population and the 1-year mortality risk in live-born infants (aOR: 0.86; 95% CI: 0.79–0.93). In health care regions with higher aggregated activity scores, the risk of death or NDI at 2.5 years’ CA was reduced in the primary population (aOR: 0.69; 95% CI: 0.50–0.96) and in live-born infants (aOR: 0.68; 95% CI: 0.48–0.95). Risk reductions were confined to the 22- to 24-week group. There was no difference in NDI risk between survivors at 2.5 years’ CA. CONCLUSIONS: Proactive perinatal care decreased mortality without increasing the risk of NDI at 2.5 years’ CA in EPT infants. A proactive approach based on optimistic expectations of a favorable outcome is justified.

Scoping review shows wide variation in the definitions of bronchopulmonary dysplasia in preterm infants and calls for a consensus

The use of different definitions for bronchopulmonary dysplasia (BPD) has been an ongoing challenge. We searched papers published in English from 2010 and 2015 reporting BPD as an outcome, together with studies that compared BPD definitions between 1978 and 2015. We found that the incidence of BPD ranged from 6% to 57%, depending on the definition chosen, and that studies that investigated correlations with long‐term pulmonary and/or neurosensory outcomes reported moderate‐to‐low predictive values regardless of the BPD criteria.

Treatment of Metastatic Malignant Melanoma With Vemurafenib During Pregnancy

Introduction The prognosis of stage IV malignant melanoma (MM) has for decades remained poor with median survival of 6 to 9 months. Half of MM tumors carry an activating mutation of the proto-oncogene, B-RAF. The BRAF-inhibitor vemurafenib increases overall and progression-free survival compared with treatment with the chemotherapeutic agent dacarbazine in MM patients with advanced disease. Vemurafenib is since August 2011 approved by the US Food and Drug Administration and since January 2012 by the European Medical Agency. Treatment strategies in pregnant patients suffering from cancer require multidisciplinary approaches. To our knowledge, this is the first described case of therapy with the BRAF inhibitor vemurafenib during pregnancy. MM is a common disease, its incidence grows rapidly and vemurafenib is becoming an established treatment. In addition, MM occurs frequently in younger people and the B-RAF mutation is more common in younger patients. These factors mean that similar cases are highly likely to occur in the future making this report of particular value.

Earlier Apgar Score Increase in Severely Depressed Term Infants Cared for in Swedish Level III Units With 40% Oxygen Versus 100% Oxygen Resuscitation Strategies: A Population-Based Register Study

OBJECTIVES. The aim of this study was to evaluate whether a resuscitation strategy based on administration of 40% oxygen influences mortality rates and rates of improvement in 5-minute Apgar scores, compared with a strategy based on 100% oxygen administration. METHODS. A population-based study evaluated data from 4 Swedish perinatal level III centers during the period of 1998 to 2003. During this period, the centers used either of 2 resuscitation strategies (initial oxygen administration of 40% or 100%). Live-born, singleton, term infants with 1-minute Apgar scores of <4, with a birth weight appropriate for gestational age, and without major malformations were included in the study (n = 1223). RESULTS. Infants born in hospitals using a 40% oxygen strategy had a more rapid Apgar score increase than did infants born in hospitals using a 100% oxygen strategy; however, no difference remained at 10 minutes. The mean Apgar score increased from 2.01 at 1 minute to 6.74 at 5 minutes in the 2 hospitals initiating resuscitation with 40% oxygen, compared with 2.01 to 6.38 in the 2 hospitals using 100% oxygen, with a mean difference in Apgar score increases of 0.36. At 5 minutes, 44.3% of infants born in the hospitals using 100% oxygen had an Apgar score of <7, compared with 34.0% of infants at the hospitals using 40% oxygen. At 10 minutes, the mean Apgar scores were 8.16 at the hospitals using 40% oxygen and 8.07 at the hospitals using 100% oxygen. There were no significant differences in rates of neonatal death, hypoxic ischemic encephalopathy, or seizures in relation to the 2 oxygen strategies. CONCLUSION. Severely depressed term infants born in hospitals initiating resuscitation with 40% oxygen had earlier Apgar score recovery than did infants born in hospitals using a 100% oxygen strategy.

Hypertensive disorders of pregnancy and outcomes of preterm infants of 24 to 28 weeks' gestation.

Objective:To examine the relationship between hypertensive disorders of pregnancy (HDPs) and mortality and major morbidities in preterm neonates born at 24 to 28 weeks of gestation.Study Design:Using an international cohort, we retrospectively studied 27 846 preterm neonates born at 240 to 286 weeks of gestation during 2007 to 2010 from 6 national neonatal databases. The incidence of HDP was compared across countries, and multivariable logistic regression analyses were conducted to examine the association of HDP and neonatal outcomes including mortality to discharge, bronchopulmonary dysplasia, severe brain injury, necrotizing enterocolitis and treated retinopathy of prematurity.Results:The incidence of HDP in the entire cohort was 13% (range 11 to 16% across countries). HDP was associated with reduced odds of mortality (adjusted odds ratio (aOR) 0.77; 95% confidence interval (CI) 0.67 to 0.88), severe brain injury (aOR 0.74; 95% CI 0.62 to 0.89) and treated retinopathy (aOR 0.82; 95% CI 0.70 to 0.96), but increased odds of bronchopulmonary dysplasia (aOR 1.16; 95% CI 1.05 to 1.27).Conclusions:In comparison with neonates born to mothers without HDP, neonates of HDP mothers had lower odds of mortality, severe brain injury and treated retinopathy, but higher odds of bronchopulmonary dysplasia. The impact of maternal HDP on newborn outcomes was inconsistent across outcomes and among countries; therefore, further international collaboration to standardize terminology, case definition and data capture is warranted.