Prakesh S. Shah

Outcomes of preterm infants <29 weeks gestation over 10-year period in Canada: a cause for concern?

Objective:To compare risk-adjusted changes in outcomes of preterm infants <29 weeks gestation born in 1996 to 1997 with those born in 2006 to 2007.Study Design:Observational retrospective comparison of data from 15 units that participated in the Canadian Neonatal Network during 1996 to 1997 and 2006 to 2007 was performed. Rates of mortality and common neonatal morbidities were compared after adjustment for confounders.Result:Data on 1897 infants in 1996 to 1997 and 1866 infants in 2006 to 2007 were analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had lower acuity of illness on admission. Unadjusted analyses revealed reduction in mortality (unadjusted odds ratio (UAOR): 0.83, 95% confidence interval (CI): 0.63, 0.98), severe retinopathy (UAOR: 0.68, 95% CI: 0.50 to 0.92), but increase in bronchopulmonary dysplasia (UAOR: 1.61, 95% CI: 1.39 to 1.86) and patent ductus arteriosus (UAOR: 1.22, 95% CI: 1.07 to 1.39). Adjusted analyses revealed increases in the later cohort for bronchopulmonary dysplasia (adjusted odds ratio (AOR): 1.88, 95% CI: 1.60 to 2.20) and severe neurological injury (AOR: 1.49, 95% CI: 1.22 to 1.80). However, the ascertainment methods for neurological findings and ductus arteriosus differed between the two time periods.Conclusion:Improvements in prenatal care has resulted in improvement in the quality of care, as reflected by reduced severity of illness and mortality. However, after adjustment of prenatal factors, no improvement in any of the outcomes was observed and on the contrary bronchopulmonary dysplasia increased. There is need for identification and application of postnatal strategies to improve outcomes of extreme preterm infants.

Is Adjuvant Laser Therapy Effective for Preventing Pain, Swelling, and Trismus After Surgical Removal of Impacted Mandibular Third Molars? A Systematic Review and Meta-Analysis

PURPOSE To assess the efficacy and safety of low-level laser energy irradiation (LLEI) for decreasing pain, swelling, and trismus after surgical removal of impacted mandibular third molars (IMTMs). MATERIALS AND METHODS MEDLINE, EMBASE, and the Central Register of Controlled Trials of the Cochrane Library were searched from their inception, and conference proceedings, cross-references, and gray literature were searched for the last 5 years for randomized and quasi-randomized controlled trials that evaluated the effects of any type of LLEI, compared with active or inactive treatments, in patients undergoing surgical removal of IMTMs. Risk of bias in included studies was assessed by 2 independent evaluators using the Cochrane Risk of Bias tool. A random-effects model meta-analysis was used to estimate the mean difference of trismus between the groups. Heterogeneity was assessed using Cochran χ(2) and I(2). RESULTS Ten eligible trials were included in this systematic review. The included studies overall had a moderate risk of bias. Because of heterogeneity in the intervention and outcomes assessments, pain and swelling outcomes were only qualitatively summarized and indicated no beneficial effects of LLEI over placebo. Patients receiving LLEI had an average of 4.2 mm (95% confidence interval, 1.2 to 7.2) and 5.2 mm (95% confidence interval, 1.8 to 8.2) less trismus than patients receiving no active treatment on the second and seventh day after the surgery, respectively. CONCLUSIONS There was no benefit of LLEI on pain or swelling and a moderate benefit on trismus after removal of IMTMs. It is necessary to standardize the intervention and outcomes assessment and to conduct adequately powered, well-designed trials to evaluate the efficacy of LLEI.

Transfusion-associated necrotising enterocolitis in neonates

Objective To evaluate the association between blood transfusion in previous 2 days and necrotising enterocolitis (NEC) in infants admitted to neonatal intensive care units in Canada. Patients and Methods Using the Canadian Neonatal Network database of admissions to neonatal intensive care units from 2003 to 2008, cases with NEC were matched with controls by gestational age (GA) at birth. Exposure to transfusion within 2 days of NEC (for cases) or 2 days before the median age of NEC diagnosis among cases of the same GA (for controls) was determined. After controlling for confounders, the differences in characteristics and neonatal outcomes of transfusion-associated NEC (TANEC) and NEC not associated with transfusion (non-TANEC) were compared. Results NEC cases (n=927) were matched with 2781 controls. Transfusion in previous 2 days was significantly higher in NEC cases than in controls (15.5 vs 7.7%; adjusted OR (AOR) 2. 44; 95% CI 1.87 to 3.18). TANEC cases versus non-TANEC cases had a lower mean GA (25.8 vs 29.3 weeks), a lower mean birthweight (885 vs 1373 grams), and a higher proportion of infants with SNAPII score >20 (52.1 vs 22.9%). After adjustment for confounders, no significant differences in mortality (AOR 1.28, 95% CI 0.82 to 2.01), severe retinopathy (AOR 1.15, 95% CI 0.71 to 1.87), or severe neurological injury (AOR 0.83, 95% CI 0.43 to 1.60) were identified. Conclusions Exposure to transfusion in previous 2 days was an independent risk factor for NEC. After controlling for confounders, no significant differences in mortality and morbidities were observed between infants who had transfusion-associated NEC and those with NEC not associated with transfusion.

Neonatal group B streptococcal disease: Incidence, presentation, and mortality

Objectives. To ascertain the incidence, and compare the clinical characteristics, laboratory parameters, and immediate mortality of neonates with early-onset (symptomatic and asymptomatic) and late-onset group B streptococcal (GBS) disease. Methods. A chart review of 81 neonates with GBS disease (either blood and/or cerebrospinal fluid culture-proven) born between 1995 and 2002 admitted to two tertiary care perinatal centers in Toronto was conducted. Clinical characteristics were compared for (1) asymptomatic early-onset, symptomatic early-onset, and late-onset GBS disease and (2) survivors and non-survivors. Results. The incidence of GBS disease was 1.13/1000 live births. One or more antepartum or intrapartum predisposing factors were recognized in 62% of cases. Early-onset was noted in 65 (80%) neonates (23 asymptomatic and 42 symptomatic). All full-term infants survived. The mortality was 6% and was confined to preterm neonates with early symptomatic disease who presented with shock and had thrombocytopenia. Conclusion. Antepartum or intrapartum known predisposing risk factors of GBS disease were lacking in one third of patients. Patients who died were preterm infants in the early symptomatic group.

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.

Withdrawal of artificial nutrition and hydration in the Neonatal Intensive Care Unit: parental perspectives

Objective To review the experience of the practice of withdrawal of artificial nutrition and hydration (WANH) and to describe parental perspectives on the process. Design A retrospective chart review and parental survey. Setting Tertiary level Neonatal Intensive Care Unit (NICU). Participants Infants who had WANH after withdrawal of other life-sustaining treatment, and their parents. Main outcome measure Parental perspectives on the care and process were obtained through a survey administered 1 to 4 years after the death of their infant. Results Fifteen cases (5.5% of all mortality and 0.5% of all admissions) of WANH were identified, and 10 parents participated in the survey. The median (range) gestational age was 40 weeks (31–42) and birth weight was 3409 g (2000–4640). The reason for WANH was predicted poor outcome due to severe neurological injury/disease. The median (range) time between WANH and death was 16 days (2–37). All parents reported favourable perceptions of preparation, support, communication and care. Seven parents reported concerns regarding pain experienced by their infant. Parents reported the ability to spend quality time, creating tangible memories and the virtues and professional qualities of the caregivers to be helpful, but identified that consistency and continuity of care could be improved. Conclusion Within the spectrum of palliative care in neonates, WANH can be a tenable, justifiable and humane practice in the NICU.

Effect of gestational age at birth on neonatal outcomes in gastroschisis

Introduction Induced birth of fetuses with gastroschisis from 34 weeks gestational age (GA) has been proposed to reduce bowel damage. We aimed to determine the effect of birth timing on time to full enteral feeds (ENT), length of hospital stay (LOS), and sepsis. Methods A retrospective analysis (2000–2014) of gastroschisis born at ≥ 34 weeks GA was performed. Associations between birth timing and outcomes were analyzed by Mann–Whitney test, Cox regression, and Fishers exact test. Results 217 patients were analyzed. Although there was no difference in ENT between those born at 34–36 + 6 weeks GA (median 28 range [6–639] days) compared with ≥ 37 weeks GA (27 [8–349] days) when analyzed by Mann–Whitney test (p = 0.5), Cox regression analysis revealed that lower birth GA significantly prolonged ENT (p = 0.001). LOS was significantly longer in those born at 34–36 + 6 weeks GA (42 [8–346] days) compared with ≥ 37 weeks GA 34 [11–349] days by both Mann–Whitney (p = 0.02) and Cox regression analysis (p < 0.0005). Incidence of sepsis was higher in infants born at 34–36 + 6 weeks (32%) vs. infants born at ≥ 37 weeks (17%; p = 0.02). Conclusions Early birth of fetuses with gastroschisis was associated with delay in reaching full enteral feeds, prolonged hospitalization, and a higher incidence of sepsis.

Treatment of invasive candidiasis in neutropenic patients: systematic review of randomized controlled treatment trials

Abstract Candidemia and invasive candidiasis (CIC) is associated with considerable morbidity and mortality, with a paucity of controlled data in neutropenic patients. A systematic review was conducted of available data for the treatment of CIC during neutropenia. A structured OVID search of multiple databases was performed. Data from randomized controlled trials of CIC and of empirical antifungal therapy in febrile neutropenic patients was included. A total of 17 trials randomizing 342 neutropenic patients were included. Eight of the studies compared amphotericin B (AmB) to other non-polyene antifungal agents. Pooling of results favored use of comparator compounds (odds ratio [OR] 0.73; 95% confidence interval [CI] 0.42–1.29). To strengthen our analysis, a pre-planned sensitivity analysis was also conducted. Overall, there was a non-significant benefit in favor of non-polyene compounds. Across studies, echinocandins provided the benefit of favorable outcomes with fewest side effects and toxicity.

Percutaneously placed central venous catheter-related sepsis in Canadian neonatal intensive care units.

OBJECTIVES To estimate daily risk, variability between centers, and impact on outcomes of catheter-related sepsis (CRS) among preterm neonates. STUDY DESIGN Retrospective evaluation of data from centers in the Canadian Neonatal Network for neonates born at <29 weeks or <1000 g who had a percutaneously placed central venous catheter (PCVC) in place for ≥ 48 hours. RESULTS Of 2966 infants with a PCVC, 582 (19.6%) developed CRS (overall rate 11/1000 catheter days). The daily risk of CRS varied between 1% and 2% in the first 28 days, and rates of CRS varied between centers (0 to 37 infections/1000 catheter days). Birth weight and gestational age were lower, and Score for Neonatal Acute Physiology and day of life of insertion were higher among those with CRS. Average length of stay was 6.2 days longer for those with CRS. There was no difference in mortality or major morbidities between infants who had CRS and those without CRS. CONCLUSIONS No threshold length of catheter usage days within the first 28 days was identified at or after which the risk of CRS increased. Marked variability between centers was present. Patients with CRS had an increased length of stay, but no increased risk for mortality or major morbidities.

Inotrope use among extremely preterm infants in Canadian neonatal intensive care units: variation and outcomes.

OBJECTIVE To compare neonatal outcomes between infants who received inotropes and those who did not, and identify variation in inotrope use. STUDY DESIGN Retrospective review of data from neonates < 29 weeks gestation collected by the Canadian Neonatal Network during 2003 to 2010. After controlling for confounders and maternal/infant characteristics, rates of mortality and major morbidity were compared between those who received inotropes on days 1 and 3 of admission and those who did not. Rate of inotrope use was compared between sites. RESULTS Inotropes were administered to 772 (10%) of the 7,913 neonates. Infants who received inotropes had significantly higher illness severity, surfactant use, and need for mechanical ventilation. Inotrope use was also associated with significantly higher rates of mortality (adjusted odds ratio [AOR] = 2.05 [1.64, 2.57]), retinopathy of prematurity (AOR = 2.04 [1.54, 2.71]), intraventricular hemorrhage (AOR = 1.59 [1.29, 1.93]), bronchopulmonary dysplasia (AOR = 1.38 [1.11, 1.72]), and necrotizing enterocolitis (AOR = 2.06 [1.59, 2.67]). Rates of inotrope use varied significantly between participating sites (0-36%; AOR = 0 [0, 0.1]-7.7 [2.9, 21]). CONCLUSION Risk of mortality and major morbidities were significantly higher in neonates who received inotropes. Inotrope use varied significantly among Canadian neonatal intensive care units.