W Poole

Changes in mortality and morbidities among infants born at less than 25 weeks during the post-surfactant era

Objectives: To compare mortality and death or major morbidity (DOMM) among infants <25 weeks estimated gestational age (EGA) born during two post-surfactant era time periods. Study design and patients: Comparative cohort study of very low birthweight (501–1500 g) infants <25 weeks EGA in the NICHD Neonatal Research Network born during two post-surfactant era time periods (group I, 1991–1994, n u200a=u200a 1408; group II, 1995–1998, n u200a=u200a 1348). Perinatal and neonatal factors were compared, and group related mortality and DOMM risk were evaluated. Results: Mortality was higher for group I (63.1% v 56.7%; p u200a=u200a 0.0006). Antenatal steroids (ANS) and antenatal antibiotics (AABX), surfactant (p<0.0001), and bronchopulmonary dysplasia (p u200a=u200a 0.0008) were more prevalent in group II. In a regression model that controlled for basic and delivery factors only, mortality risk was greater for group I than for group II (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2 to 1.7); the addition of AABX and surfactant, or ANS (OR 0.97, 95% CI 0.79 to 1.2) to the model appeared to account for this difference. There was no difference in DOMM (86.8% v 88.4%; p u200a=u200a 0.2), but risk was lower for group I in regression models that included ANS (OR 0.70, 95% CI 0.52 to 0.94). Conclusion: Survival to discharge was more likely during the more recent period because of group differences in ANS, AABX, and surfactant. However, this treatment shift may reflect an overall more aggressive management approach. More consistent application of treatment has led to improving survival of <25 week EGA infants during the post-surfactant era, but possibly at the cost of greater risk of major in-hospital morbidities.

Effects of delayed cord clamping in very-low-birth-weight infants.

Objective:Delayed cord clamping (DCC) may be beneficial in very-preterm and very-low-birth-weight infants.Study Design:This study was a randomized unmasked controlled trial. It was performed at three centers of the NICHD (National Institute of Child Health and Human Development) Neonatal Research Network. DCC in very-preterm and very-low-birth-weight infants will result in an increase in hematocrit levels at 4u2009h of age. Infants with a gestational age of 24 to 28 weeks were randomized to either early cord clamping (<10u2009s) or DCC (30 to 45u2009s). The primary outcome was venous hematocrit at 4u2009h of age. Secondary outcomes included delivery room management, selected neonatal morbidities and the need for blood transfusion during the infants’ hospital stay.Result:A total of 33 infants were randomized: 17 to the immediate cord clamping group (cord clamped at 7.9±5.2u2009s, mean±s.d.) and 16 to the DCC (cord clamped at 35.2±10.1u2009s) group. Hematocrit was higher in the DCC group (45±8% vs 40±5%, P<0.05). The frequency of events during delivery room resuscitation was almost identical between the two groups. There was no difference in the hourly mean arterial blood pressure during the first 12u2009h of life; there was a trend in the difference in the incidence of selected neonatal morbidities, hematocrit at 2, 4 and 6 weeks, as well as the need for transfusion, but none of the differences was statistically significant.Conclusion:A higher hematocrit is achieved by DCC in very-low-birth-weight infants, suggesting effective placental transfusion.

Predictors of Death or Bronchopulmonary Dysplasia in Preterm Infants with Respiratory Failure

Objectives:To identify the variables that predict death/physiologic bronchopulmonary dysplasia (BPD) in preterm infants with severe respiratory failure.Study Design:The study was a secondary analysis of data from the NICHD Neonatal Research Network trial of inhaled nitric oxide (iNO) in preterm infants. Stepwise logistic regression models and Classification and Regression Tree (CART) models were developed for the outcome of death or physiologic BPD (O2 at 36 weeks post-menstrual age).Result:Death and/or BPD was associated with lower birth weight, higher oxygen requirement, male gender, additional surfactant doses, higher oxygenation index and outborn status, but not the magnitude of response in PaO2 to iNO. The positive predictive value of the CART model was 82% at 95% sensitivity.Conclusions:The major factors associated with death/BPD were an increased severity of respiratory failure, lower birth weight, male gender and outborn status, but not the magnitude of initial response to iNO.

Inhaled nitric oxide in infants >1500 g and <34 weeks gestation with severe respiratory failure.

Objective:Inhaled nitric oxide (iNO) use in infants >1500u2009g, but <34 weeks gestation with severe respiratory failure will reduce the incidence of death and/or bronchopulmonary dysplasia (BPD).Study Design:Infants born at <34 weeks gestation with a birth weight >1500u2009g with respiratory failure were randomly assigned to receive placebo or iNO.Results:Twenty-nine infants were randomized. There were no differences in baseline characteristics, but the status at randomization showed a statistically significant difference in the use of high-frequency ventilation (P=0.03). After adjustment for oxygenation index entry strata, there was no difference in death and/or BPD (adjusted relative risk (RR) 0.80, 95% confidence interval (CI) 0.43 to 1.48; P=0.50), death (adjusted RR 1.26, 95% CI 0.47 to 3.41; P=0.65) or BPD (adjusted RR 0.40, 95% CI 0.47 to 3.41; P=0.21).Conclusions:Although sample size limits our ability to make definitive conclusions, this small pilot trial of iNO use in premature infants >1500u2009g and <34 weeks with severe respiratory failure suggests that iNO does not affect the rate of BPD and/or death.

A characterisation of patient drop outs in a cohort of HIV positive homosexual/bisexual men and intravenous drug users

NFU 0.031 0.018 0.021 0.043 0.024 0.029 0.019 0.011 0.013 FU-NE 0.176 0.140 0.114 0.014 0.069 0.056 0.027 0.021 0.017 FU-E 0.015 0.125 0.032 0.031 0.264 0.068 0.028 0.235 0.060 Total 0.222 0.283 0.167 0.088 0.357 0.153 0.074 0.267 0.090

Hypothermia for perinatal asphyxial encephalopathy.

n engl j med 362;11 nejm.org march 18, 201