Pediatric admissions that include intensive care: a population-based study

Background Pediatric admissions to intensive care outside children’s hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population. Methods We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010-2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU). Results Of 498,466 pediatric hospitalizations, 7,525 (1.5%) included time in an intensive care unit – 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die. Conclusions A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.NHMRC, NSW Mo

Able Flight at Purdue: Opportunities in Technology

Developing aircraft piloting skills takes years of training with experts to meet flight certification requirements. Not everyone can reach those standards, and the challenge is even greater for those with physical disabilities. There are opportunities to modify aircraft and train physically impaired students to be pilots; however, due to the high cost, few are able to do so. Able Flight seeks to change that by providing scholarship opportunities for people with disabilities to learn to fly and opening up new educational and career opportunities. Over 30 individuals with various disabilities have received scholarships since Able Flights inception, and all have successfully completed the requirements for a sport pilots’ license

Nitrogen substrate–dependent nitrous oxide cycling in salt marsh sediments

Nitrous oxide (N2O) is important to Earth\u27s climate because it is a strong absorber of radiation and an important ozone depletion agent. Increasing anthropogenic nitrogen input into the marine environment, especially to coastal waters, has led to increasing N2O emissions. Identifying the nitrogen compounds that serve as substrates for N2O production in coastal waters reveals important pathways and helps us understand their control by environmental factors. In this study, sediments were collected from a long-term fertilization site in Great Sippewissett Marsh, Falmouth, Massachusetts. The 15N tracer incubation time course experiments were conducted and analyzed for potential N2O production and consumption rates. The two nitrogen substrates of N2O production, ammonium and nitrate, correspond to the two production pathways, nitrification and denitrification, respectively. When measurable nitrate was present, despite ambient high ammonium concentrations, denitrification was the major N2O production pathway. When nitrate was absent, ammonium became the dominant substrate for N2O production, via nitrification and coupled nitrification-denitrification. Net N2O consumption was enhanced under low oxygen and nitrate conditions. N2O production and consumption rates increased with increasing levels of nitrogen fertilization in long-term experimental plots. These results indicate that increasing anthropogenic nitrogen input to salt marshes can stimulate sedimentary N2O production via both nitrification and denitrification, whereas episodic oxygen depletion results in net N2O consumption

Trends in use of neonatal CPAP: a population-based study

<p>Abstract</p> <p>Background</p> <p>Continuous positive airway pressure (CPAP) is used widely to provide respiratory support for neonates, and is often the first treatment choice in tertiary centres. Recent trials have demonstrated that CPAP reduces need for intubation and ventilation for infants born at 25-28 weeks gestation, and at > 32weeks, in non-tertiary hospitals, CPAP reduces need for transfer to NICU. The aim of this study was to examine recent population trends in the use of neonatal continuous positive airway pressure.</p> <p>Methods</p> <p>We undertook a population-based cohort study of all 696,816 liveborn neonates ≥24 weeks gestation in New South Wales (NSW) Australia, 2001-2008. Data were obtained from linked birth and hospitalizations records, including neonatal transfers. The primary outcome was CPAP without mechanical ventilation (via endotracheal intubation) between birth and discharge from the hospital system. Analyses were stratified by age ≤32 and > 32 weeks gestation.</p> <p>Results</p> <p>Neonates receiving any ventilatory support increased from 1,480 (17.9/1000) in 2001 to 2,486 (26.9/1000) in 2008, including 461 (5.6/1000) to 1,465 (15.8/1000) neonates who received CPAP alone. There was a concurrent decrease in mechanical ventilation use from 12.3 to 11.0/1000. The increase in CPAP use was greater among neonates > 32 weeks (from 3.2 to 11.8/1000) compared with neonates ≤32 weeks (from 18.1 to 32.7/1000). The proportion of CPAP > 32 weeks initiated in non-tertiary hospitals increased from 6% to 30%.</p> <p>Conclusions</p> <p>The use of neonatal CPAP is increasing, especially > 32 weeks gestation and among non-tertiary hospitals. Recommendations are required regarding which infants should be considered for CPAP, resources necessary for a unit to offer CPAP and monitoring of longer term outcomes.</p

Prelabor cesarean delivery for twin pregnancies close to term is associated with reduced mortality

Objectives: To examine short and longer term outcomes for twins born at or near term, comparing prelabor cesarean delivery (CD) to birth after trial of labor. Methods: A retrospective cohort of twin pregnancies delivered ≥ 36 weeks gestation from 2000 to 2009. Pregnancies with an antenatal death, lethal anomaly, birthweight discordance ≥25% or birthweight 4000 grams were excluded. Outcomes included severe hypoxia, stillbirth and neonatal death, and hospital admissions or death during the first 5 years of life. Results: 45.3% of 7099 twin pregnancies were delivered by prelabor CD. Compared to delivery after labor, prelabor CD was associated with significantly reduced risks of adverse infant outcomes including severe birth hypoxia (0.08% vs. 0.75%, RR 0.10, 95% CI 0.04-0.26), neonatal death (0.00% vs. 0.15%, RR 0.05, 95% CI 0.00-0.82), and death up to 5 years of age (0.16% vs. 0.40%, RR 0.41, 95% CI 0.20-0.85). Whereas total mortality for first twins was similar after labor (0.15%) compared to prelabor CD (0.16%), total mortality was four times more common in second twins born after labor (0.64%) compared to second twins born after prelabor CD (0.16%). Conclusions: Twin pregnancies at and beyond 36 weeks who are delivered after labor have increased risks for birth outcomes associated with hypoxia. These risks do not result in increased mortality in the first twin, but second twins have significantly increased mortality up to 5 years of age. However, the absolute mortality rate for relatively uncomplicated twin pregnancies born at or near term is low.The New South Wales (NSW) Ministry of Health provided access to the population health data and the NSW Centre for Health Record Linkage linked the data sets. This work was supported by an Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence Grant (1001066). CLR is supported by a NHMRC Senior Research Fellowship (#APP1021025)

Hospitalisations from one to six years of age: Effects of Gestational Age and Severe Neonatal Morbidity

Background: To investigate whether the adverse infant health outcomes associated with early birth and severe neonatal morbidity (SNM) persist beyond the first year of life and impact on paediatric hospitalisations for children up to six years of age. Methods: The study population included all singleton live births, >32 weeks gestation in New South Wales, Australia in 2001-2005, with follow-up to six years of age. Birth data were probabilistically linked to hospitalisation data (n=392,964). The odds of hospitalisation, mean hospital length of stay (LOS) and costs, and cumulative LOS were evaluated by gestational age and SNM using multivariable analyses. Results: A total of 74,341 (18.9%) and 41,404 (10.5%) infants were hospitalized once and more than once, respectively. SNM was associated with increased odds of hospitalisation once (adjusted odds ratio (aOR) 1.16 [95% CI 1.10, 1.22]), and more than once (aOR 1.51 [1.42, 1.60]). Decreasing gestational age was associated with increasing odds of hospitalisation more than once from aOR 1.19 at 37-38 weeks to 1.49 at 33-34 weeks. Average LOS and costs per hospital admission were increased with SNM but not with decreasing gestational age. Cumulative LOS was significantly increased with SNM and decreasing gestational age. Conclusions: Adverse effects of SNM and early birth persist between one and six years of age. Strategies to prevent early birth and reduce SNM, and to increase health monitoring of vulnerable infants throughout childhood may help reduce paediatric hospitalisations.NHMRC, NSW Health Population Health and Health Services Gran

Red cell and platelet transfusions in neonates: a population based study

Objectives: Reports of neonatal transfusion practices have focused predominantly on premature neonates admitted to neonatal intensive care units (NICU), however little is known about transfusion among other neonates. This study aimed to describe the use of blood products among all neonates. Design: Linked population-based birth and hospital discharge data from New South Wales (NSW), Australia was used to determine rates of blood product transfusion in the first 28 days of life. The study included all livebirths ≥23 weeks’ gestation in NSW between 2001 and 2011. Results: Between 2001-2011, 5326 of 989,491 live born neonates received a blood product transfusion (5.4 per 1000 births). Transfusion rates were 4.8 per 1000 for red cells, 1.3 per 1000 for platelets and 0.3 per 1000 for exchange transfusion. High transfusion rates were seen in neonates with prior in-utero transfusion (631/1000), congenital anomaly requiring surgery (440/1000) or haemolytic disorder (106/1000). Among transfused infants, 7% received transfusions in a hospital without a NICU. Of those transfused, 64% were born ≤32 weeks gestation (n=3384, 255/1000 births), with 96% of these receiving red cells. 36% were born >32 weeks gestation (n= 1942, 1.98/1000 births), with 76% receiving red cells and 38% receiving platelets. Conclusions: In this population based study, high transfusion rates were seen in neonates with haemolytic disorders or requiring surgery, as well as in those born preterm. Thirty-six percent of neonates who received blood products were born >32 weeks gestation and 7% were transfused in hospitals without a NICU.NHMRC, AR

Nutrient enrichment induces dormancy and decreases diversity of active bacteria in salt marsh sediments

© The Author(s), 2016. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Nature Communications 7 (2016): 12881, doi:10.1038/ncomms12881.Microorganisms control key biogeochemical pathways, thus changes in microbial diversity, community structure and activity can affect ecosystem response to environmental drivers. Understanding factors that control the proportion of active microbes in the environment and how they vary when perturbed is critical to anticipating ecosystem response to global change. Increasing supplies of anthropogenic nitrogen to ecosystems globally makes it imperative that we understand how nutrient supply alters active microbial communities. Here we show that nitrogen additions to salt marshes cause a shift in the active microbial community despite no change in the total community. The active community shift causes the proportion of dormant microbial taxa to double, from 45 to 90%, and induces diversity loss in the active portion of the community. Our results suggest that perturbations to salt marshes can drastically alter active microbial communities, however these communities may remain resilient by protecting total diversity through increased dormancy

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial

Background Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. Methods The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. Findings Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5–1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9–1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1–2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0–1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0–10·0] vs 2·0 days [0·0–7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4–0·9), intrapartum fever (0·4, 0·2–0·9), and use of postpartum antibiotics (0·8, 0·7–1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2–1·7). Interpretation In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term

Can programme theory be used as a 'translational tool’ to optimise health service delivery in a national early years’ initiative in Scotland: a case study

Background Theory-based evaluation (TBE) approaches are heralded as supporting formative evaluation by facilitating increased use of evaluative findings to guide programme improvement. It is essential that learning from programme implementation is better used to improve delivery and to inform other initiatives, if interventions are to be as effective as they have the potential to be. Nonetheless, few studies describe formative feedback methods, or report direct instrumental use of findings resulting from TBE. This paper uses the case of Scotland’s, National Health Service, early years’, oral health improvement initiative (Childsmile) to describe the use of TBE as a framework for providing feedback on delivery to programme staff and to assess its impact on programmatic action.&lt;p&gt;&lt;/p&gt; Methods In-depth, semi-structured interviews and focus groups with key stakeholders explored perceived deviations between the Childsmile programme 'as delivered’ and its Programme Theory (PT). The data was thematically analysed using constant comparative methods. Findings were shared with key programme stakeholders and discussions around likely impact and necessary actions were facilitated by the authors. Documentary review and ongoing observations of programme meetings were undertaken to assess the extent to which learning was acted upon.&lt;p&gt;&lt;/p&gt; Results On the whole, the activities documented in Childsmile’s PT were implemented as intended. This paper purposefully focuses on those activities where variation in delivery was evident. Differences resulted from the stage of roll-out reached and the flexibility given to individual NHS boards to tailor local implementation. Some adaptations were thought to have diverged from the central features of Childsmile’s PT, to the extent that there was a risk to achieving outcomes. The methods employed prompted national service improvement action, and proposals for local action by individual NHS boards to address this.&lt;p&gt;&lt;/p&gt; Conclusions The TBE approach provided a platform, to direct attention to areas of risk within a national health initiative, and to agree which intervention components were 'core’ to its hypothesised success. The study demonstrates that PT can be used as a 'translational tool’ to facilitate instrumental use of evaluative findings to optimise implementation within a complex health improvement programme.&lt;p&gt;&lt;/p&gt