Juan Manuel Lozano

Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive airway pressure: A randomized, controlled trial

BACKGROUND. Chronic lung disease is one of the most frequent and serious complications of premature birth. Because mechanical ventilation is a major risk factor for chronic lung disease, the early application of nasal continuous positive airway pressure has been used as a strategy for avoiding mechanical ventilation in premature infants. Surfactant therapy improves the short-term respiratory status of premature infants, but its use is traditionally limited to infants being mechanically ventilated. Administration of very early surfactant during a brief period of intubation to infants treated with nasal continuous positive airway pressure may improve their outcome and further decrease the need for mechanical ventilation. OBJECTIVE. Our goal was to determine if very early surfactant therapy without mandatory ventilation improves outcome and decreases the need for mechanical ventilation when used in very premature infants treated with nasal continuous positive airway pressure soon after birth. DESIGN/METHODS. Eight centers in Colombia participated in this randomized, controlled trial. Infants born between 27 and 31 weeks’ gestation with evidence of respiratory distress and treated with supplemental oxygen in the delivery room were randomly assigned within the first hour of life to intubation, very early surfactant, extubation, and nasal continuous positive airway pressure (treatment group) or nasal continuous airway pressure alone (control group). The primary outcome was the need for subsequent mechanical ventilation using predefined criteria. RESULTS. From January 1, 2004, to December 31, 2006, 279 infants were randomly assigned, 141 to the treatment group and 138 to the control group. The need for mechanical ventilation was lower in the treatment group (26%) compared with the control group (39%). Air-leak syndrome occurred less frequently in the treatment group (2%) compared with the control group (9%). The percentage of patients receiving surfactant after the first hour of life was also significantly less in the treatment group (12%) compared with the control group (26%). The incidence of chronic lung disease (oxygen treatment at 36 weeks’ postmenstrual age) was 49% in the treatment group compared with 59% in the control group. All other outcomes, including mortality, intraventricular hemorrhage, and periventricular leukomalacia were similar between the groups. CONCLUSIONS. In premature infants treated with nasal continuous positive airway pressure early after birth, the addition of very early surfactant therapy without mandatory ventilation decreased the need for subsequent mechanical ventilation, decreased the incidence of air-leak syndrome, and seemed to be safe. Reduction in the need for mechanical ventilation is an important outcome when medical resources are limited and may result in less chronic lung disease in both developed and developing countries.

Pulse oximetry reference values at high altitude.

Pulse oximetry is becoming popular for measuring oxygen saturation of haemoglobin in paediatric patients. There are no reference values for children living at high altitudes, and the aim of this study was to determine the values of oxygen saturation of haemoglobin in healthy children in Bogota (2640 m above sea level). The saturation was determined in 189 children aged 5 days to 24 months with a Nellcor N10 oximeter. Mean values and 95% confidence intervals (CI) were calculated. Analysis of variance was used for assessing the differences in saturation with age and physiological status. The values were normally distributed with a mean (SD) of 93.3 (2.05)% and 95% CI of 93.0% to 93.6%. There were no clinically important differences in the oxygen saturation of haemoglobin in the range of ages included. The mean saturation in sleeping children was significantly lower than that during other physiological states (91.1% v 93.3%) but the difference was not clinically important. As expected, the values for the oxygen saturation of haemoglobin in the children studied were lower than those reported from children living at sea level. These estimates can be used for interpreting results of the oxygen saturation in haemoglobin in children from Bogota and other cities located at a similar altitude.

Brief Hospitalization and Pulse Oximetry for Predicting Amoxicillin Treatment Failure in Children with Severe Pneumonia

OBJECTIVE. In settings with limited assessment tools, we sought to determine whether early clinical signs and symptoms and blood oxygen saturation would predict amoxicillin treatment failure in children with severe pneumonia (as defined by the World Health Organization). METHODS. Data were from a previously reported, multinational trial of orally administered amoxicillin versus injectable penicillin for the treatment of World Health Organization–defined severe pneumonia in children 3 to 59 months of age. We assessed all 857 participants assigned randomly to the experimental amoxicillin arm. Six multivariate logistic regression models were created and evaluated for their ability to predict failure after 48 hours of therapy. Regression models included vital signs, symptoms, and laboratory data collected at baseline and after 12 or 24 hours of observation. Oxygen saturation data were included in 3 models. RESULTS. Clinical treatment failure occurred for 18% of children. Younger age, increased initial respiratory rate, and baseline hypoxia predicted treatment failure in all models. Data available after 24 hours improved the ability to predict failure compared with data available at baseline or 12 hours. The inclusion of oximetry data improved the predictive ability at baseline, 12 hours, and 24 hours. The ability to predict failure after 12 hours of observation with oximetry data was similar to the predictive ability after 24 hours without pulse oximetry data. CONCLUSIONS. Assessment of clinical parameters at presentation and after 24 hours improved the ability to predict clinical failure of oral amoxicillin therapy, compared with assessment at presentation alone or at presentation and after only 12 hours, for children with World Health Organization–defined severe pneumonia.

Epidemiology of Nosocomial Infections in Selected Neonatal Intensive Care Units in Colombia, South America

OBJECTIVE:The epidemiology of nosocomial infections (NI) in neonatal intensive care units in developing countries has been poorly studied. We conducted a prospective study in selected neonatal units in Colombia, SA, to describe the incidence rate, causative organisms, and interinstitutional differences.STUDY DESIGN:Data were collected prospectively from February 20 to August 30, 2001 from eight neonatal units. NI was defined as culture-proven infection diagnosed after 72 h of hospitalization, resulting in treatment with antibiotics for >3 days. Linear regression models were used to describe associations between institutional variables and NI rates.RESULTS:A total of 1504 infants were hospitalized for more than 72 h, and therefore, at risk for NI. Of all, 127 infections were reported among 80 patients (5.3%). The incidence density rate was 6.2 per 1000 patient-days. Bloodstream infections accounted for 78% of NIs. Gram-negative organisms predominated over gram-positive organisms (55 vs 38%) and were prevalent in infants ≤2000 g (54%). The most common pathogens were Staphylococcus epidermidis (26%) and Klebsiella pneumonia (12%).CONCLUSION:Gram-negative organisms predominate in Colombia among infants <2000 g. The emergence of gram-negative organisms and their associated risk factors requires further study.

Risk Factors for Nosocomial Infections in Selected Neonatal Intensive Care Units in Colombia, South America

OBJECTIVE:This study was designed to identify risk factors for nosocomial infections among infants admitted into eight neonatal intensive care units in Colombia. Knowledge of modifiable risk factors could be used to guide the design of interventions to prevent the problem.STUDY DESIGN:Data were collected prospectively from eight neonatal units. Nosocomial infection was defined as culture-proven infection diagnosed after 72 hours of hospitalization, resulting in treatment with antibiotics for >3 days. Associations were expressed as odds ratios. Logistic regression was used to adjust for potential confounders.RESULTS:From a total of 1504 eligible infants, 80 were treated for 127 episodes of nosocomial infection. Logistic regression analysis identified the combined exposure to postnatal steroids and H2-blockers, and use of oral gastric tubes for enteral nutrition as risk factors significantly associated with nosocomial infection.CONCLUSION:Nosocomial infections in Colombian neonatal intensive care units were associated with modifiable risk factors including use of postnatal steroids and H2-blockers.

Randomized, Multicenter Trial of Conventional Ventilation Versus High-Frequency Oscillatory Ventilation for the Early Management of Respiratory Failure in Term or Near-Term Infants in Colombia

OBJECTIVE:To determine the efficacy and safety of high-frequency oscillatory ventilation (HFOV) compared to conventional ventilation (CV) for the treatment of respiratory failure in term and near-term infants in Colombia.STUDY DESIGN:Eligible infants with moderate to severe respiratory failure were randomized to early treatment with CV or HFOV. Ventilator management and general patient care were standardized. The main outcome was neonatal death or pulmonary air leak.RESULTS:A total of 119 infants were enrolled (55 in the HFOV group; 64 in the CV group) during the study period. Six infants in the HFOV group (11%) and two infants in the CV group (3%) developed the primary outcome (RR: 3.6, 95% CI: 0.8–16.9). Five infants in the HFOV group (9%) and one infant in the CV (2%) died before 28 days of life (RR: 5.9 CI: 0.7–48.2). Secondary outcomes were similar between groups.CONCLUSION:HFOV may not be superior to CV as an early treatment for respiratory failure in this age group. Standardization of ventilator management and general patient care may have a greater impact on the outcome in Colombia than mode of ventilation.

An interrupted time series analysis of parenteral antibiotic use in Colombia

A University-based hospital in Bogotá, Colombia, developed and implemented an educational intervention to complement a new structured antibiotic order form. This intervention was performed after assessing the appropriateness of the observed antibiotic prescribing practices using a quasi-experimental study. An application of interrupted time series intervention analysis was conducted in three antibiotic groups (aminoglycosides, cephradine/cephalothin, and ceftazidime/cefotaxime) and their hospital weekly rate of incorrect prescriptions before and after the intervention. A fourth time series was defined on prophylactic antibiotic use in elective surgery. Preintervention models were used in the postintervention series to test for pre-post series level differences. An abrupt constant change was significant in the first, third, and fourth time series indicating a 47, 7.3, and 20% reduction of incorrect prescriptions after the intervention. We conclude that a structured antibiotic order form, coupled with graphic and educational interventions can improve antibiotic use in a university hospital.

ERASING THE GLOBAL DIVIDE IN HEALTH RESEARCH

Developing and developed countries are often viewed separately with respect to their health problems, health systems, and health services research. So although more than 90% of the worlds “potential years of life lost” belong to the developing world, only 5% of global research funds are devoted to studying the developing worlds health problems.1 Chronic diseases such as cancer, heart disease, and mental illness are usually regarded as problems of the developed world, but, as people live longer, developing nations will need strategies to cope with the associated health burden. Morbidity and mortality from communicable diseases are largely problems of the developing world but there are notable exceptions, in particular HIV infection. And for many healthcare problems the solutions are the same, irrespective of …

Regional Variation on Rates of Bronchopulmonary Dysplasia and Associated Risk Factors

Background. An abnormally high incidence (44%) of bronchopulmonary dysplasia with variations in rates among cities was observed in Colombia among premature infants. Objective. To identify risk factors that could explain the observed high incidence and regional variations of bronchopulmonary dysplasia. Study Design. A case-control study was designed for testing the hypothesis that differences in the disease rates were not explained by differences in city-of-birth specific population characteristics or by differences in respiratory management practices in the first 7 days of life, among cities. Results. Multivariate analysis showed that premature rupture of membranes, exposure to mechanical ventilation after received nasal CPAP, no surfactant exposure, use of rescue surfactant (instead of early surfactant), PDA, sepsis and the median daily FIO2, were associated with a higher risk of dysplasia. Significant differences between cases and controls were found among cities. Models exploring for associations between city of birth and dysplasia showed that being born in the highest altitude city (Bogotá) was associated with a higher risk of dysplasia (OR 1.82 95% CI 1.31–2.53). Conclusions. Bronchopulmonary dysplasia was manly explained by traditional risk factors. Findings suggest that altitude may play an important role in the development of this disease. Prenatal steroids did not appear to be protective at high altitude.

Niveles de alcohol en sangre y somnolencia en conductores estudiados en simuladores: un metaanálisis

Resumen Introduccion Los accidentes de transito ocasionados por conductores que se encuentran bajo el efecto del alcohol constituyen una de las principales causas de accidentalidad y mortalidad vial. Ante este problema, surge la necesidad de definir limites en cuanto al nivel de alcoholemia a partir del cual se pone en riesgo el estado de vigilia necesaria para la conduccion. Objetivos Determinar las concentraciones minimas de alcohol en sangre con las que se altera el estado de vigilia o se genera algun grado de somnolencia que pone en riesgo la habilidad y la destreza al conducir. Metodos Metanalisis de la literatura sobre los articulos publicados entre 1999 y 2009 que evaluaron la conduccion en simuladores despues de la ingesta de diferentes grados de alcohol y en los que se midio la somnolencia que estos grados producen en los conductores. Resultados Se produce mayor somnolencia en los conductores que estan bajo efecto de alcohol. Las diferencias medias estandarizadas (SMD) fueron de 0,81 (IC 95%: 0,54–1,09) para personas con niveles de concentraciones de alcohol en sangre (BAC) menores a 0,05 y de SMD = 1,16 (IC 95 %: 0,93–1,4) para las personas con niveles de BAC mayores a 0,05. En todas las escalas utilizadas para medir somnolencia se corroboro el efecto del alcohol. Conclusiones En todos los desenlaces se evidencio que, independientemente de la cantidad de alcohol en la sangre (niveles mayores y menores de BAC = 0,05), la ingesta de alcohol esta asociada con mayor somnolencia.