Heti Pisarev

Ante- and Perinatal Factors for Cerebral Palsy: Case-Control Study in Estonia

Establishing consistency between cerebral palsy registries in reporting of new cases enables more effective collaboration in terms of researching predisposing factors. To identify antenatal and intrapartum risk factors for cerebral palsy in the Estonian population, we undertook a matched case-control study of 153 children with cerebral palsy, ascertained from a population-based survey. One hundred two maternal, antenatal, and intrapartum variables were initially retrieved from medical records. Main outcome measures were the odds ratio estimates of relative risk of cerebral palsy. As a result of the study, and considering the whole spectrum of severity, the relevant risk factors during pregnancy were bleeding after 20 weeks, anemia in the second half of pregnancy, pregnancy-induced hypertension in the second half of pregnancy, and preeclampsia. The most important intrapartum factors were premature birth, placental abruption, an acute hypoxic event during delivery, and any fetal presentation other than vertex. Predisposing factors related to neonatal condition were an Apgar score ≤ 7 at the first and fifth minutes of life, hypoxic-ischemic encephalopathy, and assisted ventilation. Our findings suggest that intrapartum factors, including those hypothetically realized through hypoxic-ischemic pathways, are not of low importance in the etiology of cerebral palsy. (J Child Neurol 2005;20:654—661).

Risk factors associated with gut and nasopharyngeal colonization by common Gram-negative species and yeasts in neonatal intensive care units patients.

AIM To characterize dynamics of mucosal colonization of neonates by common aerobic Gram negative species and Candida spp. and to identify independent perinatal, neonatal, and environmental factors influencing the colonization process. STUDY DESIGN The nasopharyngeal (n=1145) and rectal (n=1242) swabs were collected on admission and thereafter twice a week in neonates with risk factors of early onset sepsis (n=276) admitted within the first 72 h of life. The association between colonization by different microbes and a total of 22 predefined risk factors was assessed using univariate and multiple logistic regression analyses. RESULTS Throughout the study about half of the patients had rectal (55.8%) or nasopharyngeal colonization (42.8%) with common Gram-negative microorganisms. Colonization dynamics and risk factors were in general similar for a given bacterial species in both mucosal sites; nonfermentative microbes more often found in nasopharyngeal swabs and Enterobacteriaceae in rectal swabs. All organisms except Escherichia coli were influenced by the duration of intensive care unit stay but other risk factors were species specific, perhaps reflecting their mode of acquisition. While colonization by E. coli and Candida albicans was associated with perinatal factors like term birth, vaginal delivery, and breast milk feeding; colonization by Klebsiella pneumoniae, Enteribacter cloacae, Acinetobacter spp. and non-albicans Candida spp. were mostly determined by hospital environment (treatment unit and period, artificial interventions and their duration) and gestation age ≤ 28 weeks. CONCLUSIONS The knowledge of risk factor profiles may permit the development of strategies to prevent heavy colonization and subsequent invasive disease in high risk infants.

Off label use of prescription medicines in children in outpatient setting in Estonia is common.

We aimed to analyse the availability of paediatric information in Summaries of Product Characteristics (SPC) of ambulatory prescription medicines used in children and to compare the SPC information with other information sources.

Factors influencing quality of life of people living with HIV in Estonia: a cross-sectional survey.

BackgroundIdentification of factors that determine quality of life is important in order to better tailor health and social care services, and thereby improve the functioning and well being of people living with HIV. The estimated number of people living with HIV in eastern Europe and central Asia is 1.6 million. Little is known about the quality of life of people living with HIV in this region. The main purpose of the present study was to identify the factors influencing quality of life in a sample of HIV-infected persons in Estonia.MethodsA convenient sample of 451 patients attending three infectious diseases clinics for routine HIV clinical care visits was recruited for a cross-sectional survey. The World Health Organizations Quality of Life HIV instrument was used to measure quality of life of the participants and medical data was abstracted from clinical records.ResultsGood overall quality of life was reported by 42.6% (95% CI: 38.0–47.2%) of the study participants (53% men, 60% self-identify as injecting drug users, 82% <30 years of age, 30% with CD4+ T cell count <300 cells/mm3, and 22% on antiretroviral treatment). We identified the following variables as independent predictors of good overall quality of life: being currently employed or studying (AOR: 2.27, 95% CI: 1.18–4.38); and the absence of HIV-related symptoms (AOR: 2.31, 95% CI: 1.24–4.29).ConclusionA comprehensive and competent care system, including health care providers and social workers, is required for an effective response. In addition, social interventions should seek to enhance the economic and employment opportunities for people living with HIV in the region.

Prolonged outbreak of Serratia marcescens in Tartu University Hospital: a case–control study

BackgroundThe aim of our study was to investigate and control an outbreak and identify risk factors for colonization and infection with Serratia marcescens in two departments in Tartu University Hospital.MethodsThe retrospective case–control study was conducted from July 2005 to December 2006. Molecular typing by pulsed field gel electrophoresis was used to confirm the relatedness of Serratia marcescens strains. Samples from the environment and from the hands of personnel were cultured.ResultsThe outbreak involved 210 patients, 61 (29%) developed an infection, among them 16 were invasive infections. Multivariate analysis identified gestational age, arterial catheter use and antibiotic treatment as independent risk factors for colonization and infection with Serratia marcescens. Molecular typing was performed on 83 Serratia marcescens strains, 81 of them were identical and 2 strains were different.ConclusionsGiven the occasionally severe consequences of Serratia marcescens in infants, early implementation of aggressive infection control measures involving patients and mothers as well as the personnel is of utmost importance.

Impact of empiric antibiotic regimen on bowel colonization in neonates with suspected early onset sepsis

The purpose of this study was to compare the impact of ampicillin and penicillin used for empiric treatment of early onset sepsis (EOS) on initial gut colonization by aerobic and facultative anaerobic microorganisms. A cluster-randomized, two-center, switch-over study was conducted in two paediatric intensive care units in Estonia and included 276 neonates. Rectal swabs were collected twice a week until discharge or day 60. Colonizing microbes were identified on species level and tested for ampicillin resistance (AR). The number of patients colonized with Gram negative microorganisms and Candida spp was similar in both treatment arms but ampicillin resulted in longer colonization duration (CD) of K. pneumonia (p = 0.012), AR Serratia spp (p = 0.012) and Candida spp (p = 0.02) and penicillin in that of AR Acinetobacter spp (p = 0.001). As for Gram positive microorganisms penicillin treatment was associated with a greater number of colonized patients and higher CD of Enterococcus spp and S. aureus but lower ones of S. haemolyticus and S. hominis. Influence of ampicillin and penicillin on initial gut colonization is somewhat different but these differences are of low clinical relevance and should not be a limiting step when choosing between these two antibiotics for the empiric treatment of EOS.

Clinical parameters predicting failure of empirical antibacterial therapy in early onset neonatal sepsis, identified by classification and regression tree analysis

BackgroundAbout 10-20% of neonates with suspected or proven early onset sepsis (EOS) fail on the empiric antibiotic regimen of ampicillin or penicillin and gentamicin. We aimed to identify clinical and laboratory markers associated with empiric antibiotic treatment failure in neonates with suspected EOS.MethodsMaternal and early neonatal characteristics predicting failure of empiric antibiotic treatment were identified by univariate logistic regression analysis from a prospective database of 283 neonates admitted to neonatal intensive care unit within 72 hours of life and requiring antibiotic therapy with penicillin or ampicillin and gentamicin. Variables, identified as significant by univariate analysis, were entered into stepwise multiple logistic regression (MLR) analysis and classification and regression tree (CRT) analysis to develop a decision algorithm for clinical application. In order to ensure the earliest possible timing separate analysis for 24 and 72 hours of age was performed.ResultsAt 24 hours of age neonates with hypoglycaemia ≤ 2.55 mmol/L together with CRP values > 1.35 mg/L or those with BW ≤ 678 g had more than 30% likelihood of treatment failure. In normoglycaemic neonates with higher BW the best predictors of treatment failure at 24 hours were GA ≤ 27 weeks and among those, with higher GA, WBC ≤ 8.25 × 109 L-1 together with platelet count ≤ 143 × 109 L-1. The algorithm allowed capture of 75% of treatment failure cases with a specificity of 89%. By 72 hours of age minimum platelet count ≤ 94.5 × 109 L-1 with need for vasoactive treatment or leukopaenia ≤ 3.5 × 109 L-1 or leukocytosis > 39.8 × 109 L-1 or blood glucose ≤ 1.65 mmol/L allowed capture of 81% of treatment failure cases with the specificity of 88%. The performance of MLR and CRT models was similar, except for higher specificity of the CRT at 72 h, compared to MLR analysis.ConclusionThere is an identifiable group of neonates with high risk of EOS, likely to fail on conventional antibiotic therapy.

Antenatal risk factors associated with unfavorable neurologic status in newborns and at 2 years of age

The aim of this prospective cohort study was to evaluate the influence of different antenatal factors on neurologic signs in the first days of life and neurodevelopmental outcome at 2 years of age. The study group consisted of 390 children drawn from a cohort of 828 consecutive live births. The data about potential antenatal risk factors, birth complications, and neonatal course were abstracted from pregnancy and delivery records and the hospital register. Odds ratio estimates with 95% confidence intervals were used to measure the associations between antenatal factors and neurologic status in newborns and at 2 years of age. Significance level was set at P < .05. At the mean age of 2 years, 49 of 390 children exhibited adverse neurodevelopmental outcome (cerebral palsy and other developmental disorders). The development of 341 children was normal. Comparative analysis of risk factors was conducted. The strongest correlation with development of hypoxic-ischemic encephalopathy during the first days of life was found in trichomoniasis during pregnancy (odds ratio 4.34; 95% confidence interval 1.32—14.23) and acute respiratory disease (temperatures 38°C) in the second half of pregnancy (odds ratio 2.86; 95% confidence interval 1.08—7.58). Of various antenatal factors, bacterial vaginosis combined with impending abortion in the first half of pregnancy (odds ratio 4.96; 95% confidence interval 1.35—18.26) had a significant association with adverse outcome at 2 years of age. The presence of at least one complication at delivery placed the child at risk of adverse neurologic outcome (odds ratio 2.44; 95% confidence interval 1.32—4.54). The study provides supportive evidence that antenatal factors associated with maternal infections can influence the development of hypoxic-ischemic encephalopathy and later neurodevelopmental outcome. These children should be assigned to risk groups for early intervention. (J Child Neurol 2004;19:116—122).

Long-term outcome of bystander-witnessed out-of-hospital cardiac arrest in Estonia from 1999 to 2002

OBJECTIVE To assess the long-term outcome of bystander-witnessed out-of-hospital cardiac arrest victims in Estonia by using the survival rate and quality of life assay. METHODS All resuscitation attempts made from 01.01.1999 to 31.12.2002 in Estonia were retrospectively screened for bystander-witnessed adult out-of-hospital cardiac arrests of cardiac origin. The patients who survived hospital discharge were included in the study. Their long-term survival data were retrieved from Estonian Population Registry on March 15, 2004. Quality of life was assessed by RAND-36 questionnaire. Comparisons were made with population norms, and patients suffering from myocardial infarction or angina pectoris. RESULTS 854 bystander-witnessed resuscitation attempts were made in four years. 91 patients (10.7%) survived to hospital discharge. Their one-year survival rate was 77.0% and five-year survival rate 64.3%. 44 patients responded to quality of life questionnaire, sent 16-62 months after out-of-hospital cardiac arrest (response rate 77.2%). Respondents rated their quality of life significantly worse than general population in five out of eight categories. The out-of-hospital cardiac arrest survivors with known cardiovascular disease in history (n=30) had quality of life similar to patients suffering from myocardial infarction or angina pectoris who had not required resuscitation. CONCLUSION In Estonia majority of bystander-witnessed out-of-hospital cardiac arrest victims who survive hospital discharge are alive one and also more than three years after resuscitation. Their quality of life is worse than that of general population.

Blood Loss Related to Participation in Pharmacokinetic Study in Preterm Neonates

Background: The amount of blood that can be safely drawn from a preterm neonate for scientific purposes is poorly established. Objectives: To provide scientific evidence on the amount of blood that can be drawn from very low birth weight (VLBW) neonates for study purposes. Methods: We performed a post-hoc analysis of a pharmacokinetic (PK) study of penicillin-G, enrolling 18 neonates with a birth weight of <1,200 g, gestational age of <28 weeks and postnatal age of <5 days, with a risk of early onset sepsis. A median of 2.3 ml/kg of blood was collected from each neonate for the PK analysis. Hemoglobin (Hgb), hematocrit (Ht), basic hemodynamic parameters, total fluid intake, number of blood component transfusions and number of blood analysis for clinical indications were recorded. The control group consisted of 35 gestational age-, postnatal age- and birth weight-matched neonates who had not participated in a PK study. Results: We did not observe significant differences in any studied safety parameter, including Hgb and Ht values, between the two groups. Median number of blood component transfusions (n = 2 in both groups), median volume of transfused red blood cells (22 vs. 24 ml/kg in study vs. control group) and total daily fluid requirement were similar. The median calculated blood loss on clinical indications was 1.9 ml/24 h in the control group and 1.66 ml/24 h in the study group. Conclusions: In VLBW neonates, up to 2.3 ml/kg of blood (corresponding to 2.4% of calculated circulating blood volume) can be drawn for scientific purposes without compromising basic hemodynamic parameters, Hgb and Ht values, blood component transfusions or fluid requirements.