Intrauterine Extremity Gangrene and Cerebral Infarction at Term: A Case Report

Intrauterine extremity gangrene in combination with cerebral infarction is a serious and rare event. We present a case with a healthy mother who gave birth to a child with this condition. At term, the mother presented at the antenatal clinic with decreased fetal movements. Cardiotocography (CTG) showed signs of fetal distress and a caesarean section was performed. The left arm of the newborn was found gangrenous. Amputation of the arm was necessary and the child was subsequently treated with anticoagulant therapy due to thrombosis and cerebral infarction in the left hemisphere found by magnetic resonance imaging (MRI). At one year of age the boy was doing well and had prosthesis as a left arm. He had no signs of further complications. Despite thorough examination of the parents and the child, the reason for the thrombosis is still unknown

Mediators of lifestyle behaviour changes in obese pregnant women. Secondary analyses from the DALI lifestyle randomised controlled trial

Altres ajuts: The project described has received funding from the European Community's 7th Framework Programme (FP7/2007-2013) under grant agreement no. 242187. In the Netherlands, additional funding was provided by the Netherlands Organization for Health Research and Development (ZonMw) (grant no. 200310013). In Poland, additional funding was obtained from Polish Ministry of Science (grant no. 2203/7. PR/2011/2). In Denmark, additional funding was provided by the Odense University Free Research Fund. In the United Kingdom, the DALI team acknowledge the support received from the NIHR Clinical Research Network: Eastern, especially the local diabetes clinical and research teams based in Cambridge. In Spain, additional funding was provided by CAIBER 1527-B-226. The funders had no role in any aspect of the study beyond funding.A better understanding of what drives behaviour change in obese pregnant overweight women is needed to improve the effectiveness of lifestyle interventions in this group at risk for gestational diabetes (GDM). Therefore, we assessed which factors mediated behaviour change in the Vitamin D and Lifestyle Intervention for GDM Prevention (DALI) Lifestyle Study. A total of 436 women, with pre-pregnancy body mass index ≥29 kg/m , ≤19 + 6 weeks of gestation and without GDM, were randomised for counselling based on motivational interviewing (MI) on healthy eating and physical activity, healthy eating alone, physical activity alone, or to a usual care group. Lifestyle was measured at baseline, and at 24-28 and 35-37 weeks of gestation. Outcome expectancy, risk perception, task self-efficacy and social support were measured at those same time points and considered as possible mediators of intervention effects on lifestyle. All three interventions resulted in increased positive outcome expectancy for GDM reduction, perceived risk to the baby and increased task self-efficacy. The latter mediated intervention effects on physical activity and reduced sugared drink consumption. In conclusion, our MI intervention was successful in increasing task self-efficacy, which was related to improved health behaviours

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS\u3csup\u3e®\u3c/sup\u3e) Society Recommendations

Background: Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery. Methods: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process. Results: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline. Discussion: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties

The importance of maternal insulin resistance throughout pregnancy on neonatal adiposity

Background: Although previous studies evaluated the association of maternal health parameters with neonatal adiposity, little is known regarding the complexity of the relationships among different maternal health parameters throughout pregnancy and its impact on neonatal adiposity. Objectives: To evaluate the direct and indirect associations between maternal insulin resistance during pregnancy, in women with obesity, and neonatal adiposity. In addition, associations between maternal fasting glucose, triglycerides (TG), non-esterified fatty acids (NEFA), and neonatal adiposity were also assessed. Methods: This is a longitudinal, secondary analysis of the DALI study, an international project conducted in nine European countries with pregnant women with obesity. Maternal insulin resistance (HOMA-IR), fasting glucose, TG, and NEFA were measured three times during pregnancy (<20, 24-28, and 35-37 weeks of gestation). Offspring neonatal adiposity was estimated by the sum of four skinfolds. Structural equation modelling was conducted to evaluate the direct and indirect relationships among the variables of interest. Results: Data on 657 mother-infant pairs (50.7% boys) were analysed. Neonatal boys exhibited lower mean sum of skinfolds compared to girls (20.3 mm, 95% CI 19.7, 21.0 vs 21.5 mm, 95% CI 20.8, 22.2). In boys, maternal HOMA-IR at <20 weeks was directly associated with neonatal adiposity (β = 0.35 mm, 95% CI 0.01, 0.70). In girls, maternal HOMA-IR at 24-28 weeks was only indirectly associated with neonatal adiposity, which implies that this association was mediated via maternal HOMA-IR, glucose, triglycerides, and NEFA during pregnancy (β = 0.26 mm, 95% CI 0.08, 0.44). Conclusions: The timing of the role of maternal insulin resistance on neonatal adiposity depends on fetal sex. Although the association was time-dependent, maternal insulin resistance was associated with neonatal adiposity in both sexes

Traumapotilaan golden hour Kainuun ensihoidossa : Tutkimus traumapotilaan golden hour:n toteutumisesta sekä siihen vaikuttavista tekijöistä Kainuun ensihoidossa

Tutkimuksen tarkoituksena oli kuvailla Kainuun ensihoidon laatua traumapotilaiden hoidossa. Opinnäytetyömme on tehty yhteistyössä Kainuun sosiaali- ja terveydenhuollon kuntayhtymän ensihoidon kanssa. Tutkimuksen tavoitteena oli hyödyntää tutkimusta Kainuun ensihoidossa traumapotilaiden hoidon kehittämisessä. Tutkimuksemme on toteutettu kvantitatiivisena ja retrospektiivisena tutkimuksena. Aineiston keräämiseen käytimme valmista tiedonkeruupohjaa, johon keräsimme 391 ensihoitotehtävän tiedot. Analysoimme tutkimuksen tulokset Excel- ja SPSS-ohjelmilla. Tutkimuksen perusteella 50 % (N= 196) traumapotilaista pääsi kultaisen tunnin aikana lopulliseen hoitopaikkaan. Keskimäärin ensihoitajilla kului kohteessa 21 minuuttia, joka on yli suositellun 10 minuutin. Tutkimuksen mukaan 15 %:lla (N= 58) ensihoitotehtävistä kuljetus päästiin aloittamaan 10 minuutin sisällä. Tutkimuksessa kävi ilmi, että mitä enemmän kohteessa tehtiin hoitotoimenpiteitä, sitä pidempi kohteessa oloaika oli. Tutkimuksessa kävi ilmi, että ensihoitotehtävien kokonaisajasta suurin osa kului matkalla potilaan luokse ja potilaan kuljettamiseen hoitolaitokseen. Tämä selittyy Kainuun alueen pitkillä välimatkoilla. Ensihoitotehtävien kokonaisaika kasvoi huomattavasti, mikäli potilas jatkokuljetettiin Kainuun keskussairaalasta yliopistolliseen sairaalaan Ouluun. Ensihoitotehtävillä, joissa potilas jatkokuljetettiin, aikaa kului merkittävästi keskussairaalassa potilaan tilan stabilointiin ennen jat-kokuljetuksen aloittamista. Tutkimme myös vaikuttaako ensihoitotehtävien kokonaisaikaan eri viranomaisjohtajuudet. Tutkimuksen perusteella voidaan todeta, että poliisijohtoisilla ensihoitotehtävillä kohteessa oloaika oli keskimäärin kaikista lyhyin. Opinnäytetyötämme voidaan hyödyntää ensihoidon laadun kehittämiseksi Kainuun ensihoidossa sekä henkilöstön ammattitaidon ylläpitämiseksi. Tutkimustuloksia voidaan käyttää simulaatiokoulutuksen suunnittelun tukena, jolloin tunnistetaan mahdolliset kehittämishaasteet ensihoitajien toiminnassa. Traumapotilaiden lopullinen hoito tapahtuu aina sairaalassa, jossa on mahdollista saada mm. leikkaushoitoa. Jotta traumapotilas saa parasta mahdollista hoitoa, tulee ensihoidossa pyrkiä mahdollisimman nopeaan kuljetukseen, jolla pyritään turvaamaan traumapotilaan nopea sairaalahoitoon pääsy.Purpose of this study was to describe the quality of emergency care in Kainuu in trauma patients care. Our thesis is made in co-operation with emergency care centre of Kainuu. Objective of the study was to exploit research in developing of care for trauma patients in emergency care of Kainuu. Our study is implemented as a quantitative and retrospective research. For collecting the material, we used ready data collection sheet which we gathered the information of 391 alarms. We analyzed the result of the research by using Excel- and SPSS-programs. Based on the study 50% (N= 196) of trauma patients were transported in the final sequel care facility during the golden hour. Paramedics spent approximately 21 minutes on scene which is over than the recommended 10 minutes. According to the study in 15% (N= 58) of the alarms transportation was achieved to start within 10 minutes. The study showed that the on-scene time was the longer the more procedures were accomplished in the destination. The study also showed that most of the time on the alarms were spent by travelling to the patient and transporting the patient to care facility. This is explained by the long distances of the area of Kainuu. The total time of alarms was highly increased if the patient was sequel transported from central Hospital of Kainuu to University Hospital in Oulu. In alarms which the patient was sequel transported, significant amount of time was spent in central Hospital stabilizing the patient before continuing the transport. We also investigated if authority leaderships affect to the total time spent on alarms. The study lightened out that in those alarms which was lead by police, the on-scene time was averagely shortest. Our thesis can be utilized in developing the quality of emergency care in Kainuu and maintaining the professionality of personnel. Results of the study can be used as a support of simulation education which allows to identify the possible developing challenges in the action of paramedics. The final care of trauma patients always occurs at hospital where multiple procedures are availa-ble. To guarantee that the patient receives best care, must emergency care always strive to quick transportation which secures that patients gets quickly the care they need

Less sedentary time is associated with a more favourable glucose-insulin axis in obese pregnant women-a secondary analysis of the DALI study

Altres ajuts: In Spain, additional funding was provided by CAIBER 1527-B-226.Obese pregnant women are at high risk of developing gestational diabetes mellitus (GDM), which might be reduced by sufficient physical activity (PA) and reduced sedentary time (ST). We assessed whether PA and ST are longitudinally associated with the glucose-insulin axis in obese pregnant women. In this secondary analysis of the DALI (vitamin D And Lifestyle Intervention for gestational diabetes mellitus prevention) study, pregnant women, <20 weeks gestation, with a pre-pregnancy body mass index (BMI) ≥ 29 kg/m 2, without GDM on entry were included. Time spent in moderate-to-vigorous PA (MVPA) and ST were measured objectively with accelerometers at < 20 weeks, 24-28 weeks and 35-37 weeks of gestation. Fasting glucose (mmol/l) and insulin (mU/l), insulin resistance (HOMA-IR) and first-phase and second-phase insulin release (Stumvoll first and second phase) were assessed at the same time. Linear mixed regression models were used to calculate between-participant differences and within-participant changes over time. Analyses were adjusted for gestational age, randomisation, pre-pregnancy BMI, education and age. MVPA, Insulin, HOMA-IR and Stumvoll first and second phase were log-transformed for analyses due to skewness. 232 women were included in the analysis. Concerning differences between participants, more ST was associated with higher fasting glucose (Estimate: 0.008; 95% CI: 0.002, 0.014), fasting insulin (0.011; 0.002, 0.019), HOMA-IR (0.012; 0.004, 0.021) and Stumvoll first and second phase (0.008; 0.001, 0.014 and 0.007; 0.001, 0.014). Participants with more MVPA had lower Stumvoll first and second phase (−0.137; −0.210, −0.064 and −0.133; −0.202, −0.063). Concerning changes over time, an increase in ST during gestation was associated with elevated Stumvoll first and second phase (0.006; 0.000, 0.011). As the glucose-insulin axis is more strongly associated with ST than MVPA in our obese population, pregnant women could be advised to reduce ST in addition to increasing MVPA. Moreover, our findings suggest that behaviour change interventions aiming at GDM risk reduction should start in early or pre-pregnancy

A reduction in sedentary behaviour in obese women during pregnancy reduces neonatal adiposity : the DALI randomised controlled trial

Altres ajuts: Funding The project described has received funding from the European Community's 7th Framework Programme (FP7/2007-2013) under grant agreement no. 242187. In the Netherlands, additional funding was provided by the Netherlands Organisation for Health Research and Development (ZonMw) (grant no. 200310013). In Poland, additional funding was obtained from the Polish Ministry of Science (grant no. 2203/7, PR/2011/2). In Denmark, additional funding was provided by Odense University Free Research Fund. In the UK, the DALI team acknowledges the support received from the National Institute for Health Research Clinical Research Network Eastern, especially the local diabetes clinical and research teams based in Cambridge. In Spain, additional funding was provided by CAIBER (Consorcio de Apoyo a la Investigación Biomédica en Red; 1527-B-226). The funders had no role in any aspect of the study beyond funding.Aims/hypothesis: Offspring of obese women are at increased risk of features of the metabolic syndrome, including obesity and diabetes. Lifestyle intervention in pregnancy might reduce adverse effects of maternal obesity on neonatal adiposity. Methods: In the Vitamin D And Lifestyle Intervention for Gestational Diabetes Mellitus (GDM) Prevention (DALI) lifestyle trial, 436 women with a BMI ≥29 kg/m were randomly assigned to counselling on healthy eating (HE), physical activity (PA) or HE&PA, or to usual care (UC). In secondary analyses of the lifestyle trial, intervention effects on neonatal outcomes (head, abdominal, arm and leg circumferences and skinfold thicknesses, estimated fat mass, fat percentage, fat-free mass and cord blood leptin) were assessed using multilevel regression analyses. Mediation of intervention effects by lifestyle and gestational weight gain was assessed. Results: Outcomes were available from 334 neonates. A reduction in sum of skinfolds (−1.8 mm; 95% CI −3.5, −0.2; p = 0.03), fat mass (−63 g; 95% CI −124, −2; p = 0.04), fat percentage (−1.2%; 95% CI −2.4%, −0.04%; p = 0.04) and leptin (−3.80 μg/l; 95% CI −7.15, −0.45; p = 0.03) was found in the HE&PA group, and reduced leptin in female neonates in the PA group (−5.79 μg/l; 95% CI −11.43, −0.14; p = 0.05) compared with UC. Reduced sedentary time, but not gestational weight gain, mediated intervention effects on leptin in both the HE&PA and PA groups. Conclusions/interpretation: The HE&PA intervention resulted in reduced adiposity in neonates. Reduced sedentary time seemed to drive the intervention effect on cord blood leptin. Implications for future adiposity and diabetes risk of the offspring need to be elucidated. Trial registration: ISRCTN70595832

Less sedentary time is associated with a more favourable glucose-insulin axis in obese pregnant women : a secondary analysis of the DALI study

Background/objectives Obese pregnant women are at high risk of developing gestational diabetes mellitus (GDM), which might be reduced by sufficient physical activity (PA) and reduced sedentary time (ST). We assessed whether PA and ST are longitudinally associated with the glucose-insulin axis in obese pregnant women. Subjects/methods In this secondary analysis of the DALI (vitamin D And Lifestyle Intervention for gestational diabetes mellitus prevention) study, pregnant women, <20 weeks gestation, with a pre-pregnancy body mass index (BMI) ≥ 29 kg/m2, without GDM on entry were included. Time spent in moderate-to-vigorous PA (MVPA) and ST were measured objectively with accelerometers at <20 weeks, 24–28 weeks and 35–37 weeks of gestation. Fasting glucose (mmol/l) and insulin (mU/l), insulin resistance (HOMA-IR) and first-phase and second-phase insulin release (Stumvoll first and second phase) were assessed at the same time. Linear mixed regression models were used to calculate between-participant differences and within-participant changes over time. Analyses were adjusted for gestational age, randomisation, pre-pregnancy BMI, education and age. MVPA, Insulin, HOMA-IR and Stumvoll first and second phase were log-transformed for analyses due to skewness. Results 232 women were included in the analysis. Concerning differences between participants, more ST was associated with higher fasting glucose (Estimate: 0.008; 95% CI: 0.002, 0.014), fasting insulin (0.011; 0.002, 0.019), HOMA-IR (0.012; 0.004, 0.021) and Stumvoll first and second phase (0.008; 0.001, 0.014 and 0.007; 0.001, 0.014). Participants with more MVPA had lower Stumvoll first and second phase (−0.137; −0.210, −0.064 and −0.133; −0.202, −0.063). Concerning changes over time, an increase in ST during gestation was associated with elevated Stumvoll first and second phase (0.006; 0.000, 0.011). Conclusions As the glucose-insulin axis is more strongly associated with ST than MVPA in our obese population, pregnant women could be advised to reduce ST in addition to increasing MVPA. Moreover, our findings suggest that behaviour change interventions aiming at GDM risk reduction should start in early or pre-pregnancy

Temporal relationships between maternal metabolic parameters with neonatal adiposity in women with obesity differ by neonatal sex : Secondary analysis of the DALI study

To investigate the importance of time in pregnancy and neonatal sex on the association between maternal metabolic parameters and neonatal sum of skinfolds. This was a longitudinal, secondary analysis of the vitamin D and lifestyle intervention for gestational diabetes mellitus study, conducted in nine European countries during 2012 to 2015. Pregnant women with a pre-pregnancy body mass index (BMI) of ≥29 kg/m were invited to participate. We measured 14 maternal metabolic parameters at three times during pregnancy: <20 weeks, 24 to 28 weeks, and 35 to 37 weeks of gestation. The sum of four skinfolds assessed within 2 days after birth was the measure of neonatal adiposity. In total, 458 mother-infant pairs (50.2% female infants) were included. Insulin resistance (fasting insulin and HOMA-index of insulin resistance) in early pregnancy was an important predictor for boys' sum of skinfolds, in addition to fasting glucose and maternal adiposity (leptin, BMI and neck circumference) throughout pregnancy. In girls, maternal lipids (triglycerides and fatty acids) in the first half of pregnancy were important predictors of sum of skinfolds, as well as fasting glucose in the second half of pregnancy. Associations between maternal metabolic parameters and neonatal adiposity vary between different periods during pregnancy. This time-dependency is different between sexes, suggesting different growth strategies