Dutch guidelines on care for extremely premature infants:Navigating between personalisation and standardization

OBJECTIVE: There is no international consensus on what type of guideline is preferred for care at the limit of viability. We aimed to conceptualize what type of guideline is preferred by Dutch healthcare professionals: 1) none; 2) gestational-age-based; 3) gestational-age-based-plus; or 4) prognosis-based via a survey instrument. Additional questions were asked to explore the grey zone and attitudes towards treatment variation. FINDING: 769 surveys were received. Most of the respondents (72.8%) preferred a gestational-age-based-plus guideline. Around 50% preferred 24+0/7 weeks gestational age as the lower limit of the grey zone, whereas 26+0/7 weeks was the most preferred upper limit. Professionals considered treatment variation acceptable when it is based upon parental values, but unacceptable when it is based upon the hospital's policy or the physician's opinion. CONCLUSION: In contrast to the current Dutch guideline, our results suggest that there is a preference to take into account individual factors besides gestational age

Effectiveness of High Fidelity Video-Assisted Real-Time Simulation: A Comparison of Three Training Methods for Acute Pediatric Emergencies

Background. Video-assisted real-time simulation (VARS) offers the possibility of developing competence in acute medicine in a realistic and safe environment. We investigated the effectiveness of the VARS model and compared it with educational methods like Problem-Based Learning (PBL) and Pediatric Advanced Life Support (PALS). Methods. 45 fourth-year medical students were randomized for three educational methods. Level of knowledge and self-efficacy were measured before and after intervention. Clinical performance was measured by a blinded observer using a video checklist of prescripted scenarios on a high-fidelity simulator. Results. Knowledge test and self-efficacy scores improved significantly (P < 0.001) without differences between educational groups. The VARS group showed significantly (P < 0.05) higher scores on both postintervention scenarios concerning structure and time. Conclusion. VARS training is an effective educational method teaching pediatric acute care skills in the undergraduate curriculum. When compared to PBL and PALS training, VARS training appears to be superior in enhancing short-term clinical performance

Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants

Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.</p

Diagnosis of alpha-1-antitrypsin deficiency in bleeding disorder-related neonatal death

Alpha-1-antitrypsin (AAT) deficiency is a rare genetic disorder characterized by hepatitis in neonates, childhood and adulthood (protease inhibitor (PI)*ZZ) and emphysema with or without hepatitis (PI*ZZ)/(PI*SS,SZ or null) in adulthood. We report the case of a female neonate born at 40 weeks of gestation who presented with vitamin K deficiency-related intracranial bleeding and cholestasis of which she died at 28 days of age. At autopsy, the infant was found to have intracranial bleeding, hepatomegaly, and cholestasis with paucity of bile ducts in the liver. Small periodic acid-Schiff diastase positive intrahepatic granules and positive staining with antibodies against AAT protein suggested an AAT deficiency. AAT is a glycoprotein that has a protease inhibitor function. Its deficiency can be the result of various point mutations in Serpin 1 located on chromosome 14. The diagnosis AAT deficiency was confirmed by mutation analysis showing the PI*ZZ genotype in the neonate. In conclusion, AAT deficiency is a rare genetic disorder that can lead to a serious bleeding disorder in the neonatal period if not recognised on time. Pathological diagnosis together with verifying molecular analysis can be used to identify index patients

Resonant two-site tunnelling dynamics of bosons in a tilted optical superlattice

We study the non-equilibrium dynamics of a 1D Bose-Hubbard model in a gradient potential and a superlattice, beginning from a deep Mott insulator regime with an average filling of one particle per site. Studying a quench that is near resonance to tunnelling of the particles over two lattice sites, we show how a spin model emerges consisting of two coupled Ising chains that are coupled by interaction terms in a staggered geometry. We compare and contrast the behavior in this case with that in a previously studied case where the resonant tunnelling was over a single site. Using optimized tensor network techniques to calculate finite temperature behavior of the model, as well as finite size scaling for the ground state, we conclude that the universality class of the phase transition for the coupled chains is that of a tricritical Ising point. We also investigate the out-of-equilibrium dynamics after the quench in the vicinity of the resonance and compare dynamics with recent experiments realized without the superlattice geometry. This model is directly realizable in current experiments, and reflects a new general way to realize spin models with ultracold atoms in optical lattices.Comment: 12 pages, 6 figure

Primum non nocere:earlier cessation of glucose monitoring is possible

\u3cp\u3eNewborns are at relatively high risk for developing hypoglycaemia in the first 24 h after birth. Well-known risk factors are prematurity, small for gestational age (SGA) or large for gestational age (LGA), and maternal pre-existent or gestational diabetes mellitus. Prolonged hypoglycaemia is associated with poor neurodevelopmental outcomes; hence, prevention through proper monitoring and treatment is important. Given the ongoing debate concerning frequency and duration of screening for neonatal hypoglycaemia, therefore, we investigated the frequency and duration of glucose monitoring safe to discover neonatal hypoglycaemia in different risk groups. Data of newborns at risk for hypoglycaemia were retrospectively collected and analysed. Blood glucose concentrations were measured 1, 3, 6, 12, and 24 h after birth. Moderate hypoglycaemia was defined as a blood glucose concentration of &lt; 2.2 mM and severe hypoglycaemia as a concentration of &lt; 1.5 mM. Of 1570 newborns, 762 (48.5%) had at least one episode of hypoglycaemia in the first 24 h after birth; 30.6% of them had severe hypoglycaemia (all in the first 9 h after birth). Only three SGA and two LGA newborns had a first moderate asymptomatic hypoglycaemic episode beyond 12 h after birth. The incidence of hypoglycaemia increased with accumulation of multiple risk factors.\u3c/p\u3e\u3cp\u3eCONCLUSION: Safety of limiting the monitoring to 12 h still has to be carefully evaluated in the presence of SGA or LGA newborns; however, our results suggest that 12 h is enough for late preterm newborns (&gt; 34 weeks) and maternal diabetes. What is Known: • Newborns are at relatively high risk for developing hypoglycaemia and such hypoglycaemia is associated with adverse neurodevelopmental outcomes. • Proper glucose monitoring and prompt treatment in case of neonatal hypoglycaemia are necessary. What is New: • Glucose monitoring 12 h after birth is proficient for most newborns at risk. • Maternal diabetes leads to the highest risk of early neonatal hypoglycaemia and newborns with more than one risk factor are at increased risk of hypoglycaemia.\u3c/p\u3

Prescriptive birthweight charts can improve the prediction of adverse outcomes in very preterm infants who are small for gestational age

Aim: We compared three anthropometric charts to determine which provided the best predictions for adverse outcomes in very preterm small for gestational age (SGA) infants to address a lack of consensus on this subject. Methods: This was a retrospective cohort study of infants born below 32 weeks, who were admitted to two-level three neonatal intensive care units in The Netherlands from 2008 to 2013. The birthweights of 1720 infants were classified as SGA using a conventional, gender-specific birthweight chart, based on births in The Netherlands between 2000 and 2007, a prescriptive, gender-specific birthweight chart, based on the same data but without risk factors for intrauterine growth restriction (IUGR), and a non-gender-specific foetal weight chart derived from American ultrasonographic measurements. Results: The conventional, prescriptive and foetal weight charts classified 126 (7.3%), 494 (28.7%) and 630 (36.6%) infants as SGA. The prescriptive chart, which excluded IUGR, identified 368 SGA infants with significantly increased risks of neonatal mortality and morbidity. The 136 SGA infants just classified by the American foetal weight chart were not at increased risk. Conclusion: The prescriptive birthweight chart, which excluded infants with IUGR, was the most effective chart when it came to identifying clinically important risk increases in SGA infants

Correction to:Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals

Correction Following publication of the original article [1], the corresponding authors wrote to say that there was a mistake in the transfer of her article to PubMed: her name is R Geurtzen, but the pdf-file names her as ms R Geurtzen and pubmed names her as MR Geurtzen

What hinders and helps in the end-of-life decision-making process for children: Parents’ and physicians’ views

Aim: To investigate the main factors which facilitate or hinder end-of-life decision-making (EoLDM) in neonates and children. Methods: A qualitative inductive, thematic analysis was performed of interviews with a total of 73 parents and 71 physicians. The end-of-life decisions mainly concern decisions to withhold or withdraw life-sustaining treatment. Results: The importance of taking sufficient time and exchanging clear, neutral and relevant information was main facilitators expressed by both parents and physicians. Lack of time, uncertain information and changing doctors were seen as important barriers by both parties. Most facilitators and barriers could be seen as two sides of the same coin, but not always. For example, some parents and physicians considered the fact that parents hold strong opinions as a barrier while others considered this a facilitator. Furthermore, parents and physicians showed differences. Parents especially underlined the importance of physician-related facilitators, such as a personalised approach, empathy and trust. On the contrary, physicians underlined the importance of the child's visible deterioration and parents’ awareness of the seriousness of their child's condition and prognosis as facilitators of EoLDM. Conclusions: This study gained insight into what parents and physicians experience as the main barriers and facilitators in EoLDM for neonates and children

Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity

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