Apnoea of prematurity - discontinuation of methylxanthines in a resource-limited setting

Background: Methylxanthines such as caffeine have been proven to reduce apnoea of prematurity and are often discontinued at 35 weeks’ corrected gestational age (GA). Objective. To ascertain whether a caffeine protocol based on international guidelines is applicable in our setting, where GA is often uncertain. Methods: A prospective folder review was undertaken of all premature infants discharged home over a 2-month period. Results: Fifty-five babies were included. All babies born at less than 35 weeks’ GA were correctly started on caffeine as per protocol. GA was assigned in 85.5% of cases by Ballard scoring and in 14.5% from antenatal ultrasound findings. Caffeine was discontinued before 35 weeks in 54.5%. Discussion: The main reason for discontinuing caffeine early was the baby’s ability to feed satisfactorily, a demonstration of physiological maturity. As feeding behaviours mature significantly between 33 and 36 weeks, the ability to feed may be a good indication that caffeine therapy can be stopped

Short-term outcomes of inborn v. outborn very-low-birth-weight neonates (

Background. The Groote Schuur Hospital (GSH) neonatal nursery provides level 3 care for the Metro West Health District in the Western Cape Province of South Africa. Worldwide, very-low-birth-weight (VLBW) neonates delivered in level 3 neonatal units have better outcomes than those transported from other facilities.Objectives. To identify the characteristics and outcomes of VLBW neonates at GSH, with emphasis on differences between inborns and outborns.Methods. This was a retrospective cohort study. VLBW neonates admitted to the GSH neonatal nursery between 1 January 2012 and 31 December 2013 were enrolled on the Vermont Oxford Network database and reviewed.Results. Of 1 032 VLBW neonates enrolled, 906 (87.8%) were delivered at GSH and 126 (12.2%) were outborn. Access to antenatal care, antenatal steroids and inborn status were statistically significant predictors of mortality and survival without morbidity. The mothers of inborn patients were more likely than those of outborn patients to have received antenatal care (89.1% v. 57.9%; p<0.0001) and antenatal steroids (64.2% v. 15.2%; p<0.0001). Inborns required less ventilatory support (16.2% v. 57.9%; p<0.0001) and surfactant administration than outborns (25.3% v. 65.1%; p<0.0001), and developed less late infection (8.8% v. 23.4%; p<0.0001), severe intraventricular haemorrhage (3.7% v. 13.9%; p<0.0001) and chronic lung disease (5.3% v. 13.4%; p=0.003). The incidence of necrotising enterocolitis was similar in the two groups (5.9% v. 8.7%; p=0.227). The mortality rate was 18.4% for inborns and 33.3% for outborns (p<0.0001). Mortality declined as birth weight increased. Of the survivors, 85.0% of inborns and 70.2% of outborns did not develop serious morbidity (p=0.003).Conclusions. VLBW neonates delivered at GSH had better outcomes than their outborn counterparts. Perinatal regionalisation is beneficial to our patients, with antenatal care, timeous transfer in utero and antenatal steroids contributing to excellent outcomes

Short-term outcomes of inborn v. outborn very-low-birth-weight neonates (<1 500 g) in the neonatal nursery at Groote Schuur Hospital, Cape Town, South Africa

Background. The Groote Schuur Hospital (GSH) neonatal nursery provides level 3 care for the Metro West Health District in the Western Cape Province of South Africa. Worldwide, very-low-birth-weight (VLBW) neonates delivered in level 3 neonatal units have better outcomes than those transported from other facilities. Objectives. To identify the characteristics and outcomes of VLBW neonates at GSH, with emphasis on differences between inborns and outborns. Methods. This was a retrospective cohort study. VLBW neonates admitted to the GSH neonatal nursery between 1 January 2012 and 31 December 2013 were enrolled on the Vermont Oxford Network database and reviewed. Results. Of 1 032 VLBW neonates enrolled, 906 (87.8%) were delivered at GSH and 126 (12.2%) were outborn. Access to antenatal care, antenatal steroids and inborn status were statistically significant predictors of mortality and survival without morbidity. The mothers of inborn patients were more likely than those of outborn patients to have received antenatal care (89.1% v. 57.9%; p<0.0001) and antenatal steroids (64.2% v. 15.2%; p<0.0001). Inborns required less ventilatory support (16.2% v. 57.9%; p<0.0001) and surfactant administration than outborns (25.3% v. 65.1%; p<0.0001), and developed less late infection (8.8% v. 23.4%; p<0.0001), severe intraventricular haemorrhage (3.7% v. 13.9%; p<0.0001) and chronic lung disease (5.3% v. 13.4%; p=0.003). The incidence of necrotising enterocolitis was similar in the two groups (5.9% v. 8.7%; p=0.227). The mortality rate was 18.4% for inborns and 33.3% for outborns (p<0.0001). Mortality declined as birth weight increased. Of the survivors, 85.0% of inborns and 70.2% of outborns did not develop serious morbidity (p=0.003). Conclusions. VLBW neonates delivered at GSH had better outcomes than their outborn counterparts. Perinatal regionalisation is beneficial to our patients, with antenatal care, timeous transfer in utero and antenatal steroids contributing to excellent outcomes

Resource implications of adopting a restrictive neonatal blood transfusion policy

Background. Blood transfusions (BTFs) are not without risk and pose a significant financial burden on resource-limited services. In line with current international evidence, the nursery at Groote Schuur Hospital (GSH), Cape Town, South Africa, introduced a restrictive BTF protocol to minimise transfusions and manage costs.Objective. To determine whether adopting a restrictive BTF policy results in fewer transfusions. Methods. Data were retrospectively collected on all infants who received BTFs in the GSH nursery over a 6-month period following adoption of a restrictive BTF policy in 2010. BTF figures for a similar time period before the restrictive policy, during 2008, were obtained for comparison.Results. After introduction of the restrictive BTF policy, 42 of 1 097 infants admitted (3.8%) received a total of 64 BTFs. In comparison, 102 of a total of 940 infants (10.9%) admitted during a period of the same length before introduction of the restrictive BTF policy received a total of 121 transfusions. Comparison between the number of BTFs administered before and after the restrictive policy showed a highly statistically significant difference (p&lt;0.001). The total cost of the blood products used in the two 6-month periods was R91 870 v. R48 640, based on current prices. Conclusions. By adopting a restrictive policy, we were able to halve the number of BTFs, reduce risks associated with transfusions, and achieve significant cost benefits. Following evidence-based guidelines results in high standards of care, while also making the most effective use of resources.

Undetectable mannose binding lectin and corticosteroids increase serious infection risk in Rheumatoid Arthritis

Background: Infection is the leading cause of death in rheumatoid arthritis (RA). Corticosteroid (CS) use is a known and important risk factor for serious infections (SIs). Mannose binding lectin (MBL) is a genetically determined component of the innate immune system implicated in neonatal infections. Objective: Our aim was to determine whether MBL deficiency is a risk factor for SIs in RA and to compare it with CS use and also synthetic and biologic disease-modifying antirheumatic drug (DMARD) therapy. Methods: Data on 228 patients with RA were collected for up to 7 years (median = 5.9 years). Serum MBL concentrations were determined in all patients receiving synthetic (n = 96) or biologic (n = 132) DMARD therapy. Results: High rates of SIs were observed in RA irrespective of treatment (17%). Similar rates of SIs were observed in synthetic and biologic DMARD users. The rates of single and multiple Sis were similar, irrespective of the use of a biologic agent. Undetectable MBL (\u3c56 ng/mL) concentrations and maintenance prednisolone at 10 mg per day or higher were associated with an increased risk for an SI, with incident risk ratio of 4.67 (P = .001) and 4.70 (P \u3c .001), respectively. Conclusions: Undetectable MBL and prednisolone confer a high risk for an SI. The use of biologic DMARDs did not confer substantial SI risk in this observational study. MBL deficiency is hitherto an unrecognized risk factor for an SI in RA

Alterations in Retinal Microvascular Geometry in Young Type 1 Diabetes

OBJECTIVE - To describe retinal microvascular geometric parameters in young patients with type 1 diabetes. RESEARCH DESIGN AND METHODS - Patients with type 1 diabetes (aged 12-20 years) had clinical assessments and retinal photography following standardized protocol at a tertiary-care hospital in Sydney. Retinal microvascular geometry, including arteriolar and venular tortuosity, branching angles, optimality deviation, and length-to-diameter ratio (LDR), were measured from digitized photographs. Associations of these geometric characteristics with diabetes duration, A1C level, systolic blood pressure (SBP), and other risk factors were assessed. RESULTS - Of 1,159 patients enrolled, 944 (81.4%) had gradable photographs and 170 (14.7%) had retinopathy. Older age was associated with decreased arteriolar (P = 0.024) and venular (P = 0.002) tortuosity, and female subjects had larger arteriolar branching angle than male subjects (P = 0.03). After adjusting for age and sex, longer diabetes duration was associated with larger arteriolar branching angle (P ≤ 0.001) and increased arteriolar optimality deviation (P = 0.018), higher A1C was associated with increased arteriolar tortuosity (>8.5 vs. ≤8.5%, P = 0.008), higher SBP was associated with decreased arteriolar LDR (P = 0.002), and higher total cholesterol levels were associated with increased arteriolar LDR (P = 0.044) and decreased venular optimality deviation (P = 0.044). These associations remained after controlling for A1C, retinal vessel caliber, and retinopathy status and were seen in subjects without retinopathy. CONCLUSIONS - Key diabetes-related factors affect retinal microvascular geometry in young type 1 diabetes, even in those without evidence of retinopathy. These early retinal alterations may be markers of diabetes microvascular complications. © 2010 by the American Diabetes Association.link_to_OA_fulltex

The international Perinatal Outcomes in the Pandemic (iPOP) study: protocol

Preterm birth is the leading cause of infant death worldwide, but the causes of preterm birth are largely unknown. During the early COVID-19 lockdowns, dramatic reductions in preterm birth were reported; however, these trends may be offset by increases in stillbirth rates. It is important to study these trends globally as the pandemic continues, and to understand the underlying cause(s). Lockdowns have dramatically impacted maternal workload, access to healthcare, hygiene practices, and air pollution - all of which could impact perinatal outcomes and might affect pregnant women differently in different regions of the world. In the international Perinatal Outcomes in the Pandemic (iPOP) Study, we will seize the unique opportunity offered by the COVID-19 pandemic to answer urgent questions about perinatal health. In the first two study phases, we will use population-based aggregate data and standardized outcome definitions to: 1) Determine rates of preterm birth, low birth weight, and stillbirth and describe changes during lockdowns; and assess if these changes are consistent globally, or differ by region and income setting, 2) Determine if the magnitude of changes in adverse perinatal outcomes during lockdown are modified by regional differences in COVID-19 infection rates, lockdown stringency, adherence to lockdown measures, air quality, or other social and economic markers, obtained from publicly available datasets. We will undertake an interrupted time series analysis covering births from January 2015 through July 2020. The iPOP Study will involve at least 121 researchers in 37 countries, including obstetricians, neonatologists, epidemiologists, public health researchers, environmental scientists, and policymakers. We will leverage the most disruptive and widespread “natural experiment” of our lifetime to make rapid discoveries about preterm birth. Whether the COVID-19 pandemic is worsening or unexpectedly improving perinatal outcomes, our research will provide critical new information to shape prenatal care strategies throughout (and well beyond) the pandemic

Self-Supervised Clustering on Image-Subtracted Data with Deep-Embedded Self-Organizing Map

Developing an effective automatic classifier to separate genuine sources from artifacts is essential for transient follow-ups in wide-field optical surveys. The identification of transient detections from the subtraction artifacts after the image differencing process is a key step in such classifiers, known as real-bogus classification problem. We apply a self-supervised machine learning model, the deep-embedded self-organizing map (DESOM) to this "real-bogus" classification problem. DESOM combines an autoencoder and a self-organizing map to perform clustering in order to distinguish between real and bogus detections, based on their dimensionality-reduced representations. We use 32x32 normalized detection thumbnails as the input of DESOM. We demonstrate different model training approaches, and find that our best DESOM classifier shows a missed detection rate of 6.6% with a false positive rate of 1.5%. DESOM offers a more nuanced way to fine-tune the decision boundary identifying likely real detections when used in combination with other types of classifiers, for example built on neural networks or decision trees. We also discuss other potential usages of DESOM and its limitations

Searching for electromagnetic counterparts to gravitational-wave merger events with the prototype Gravitational-wave Optical Transient Observer (GOTO-4)

We report the results of optical follow-up observations of 29 gravitational-wave (GW) triggers during the first half of the LIGO–Virgo Collaboration (LVC) O3 run with the Gravitational-wave Optical Transient Observer (GOTO) in its prototype 4-telescope configuration (GOTO-4). While no viable electromagnetic (EM) counterpart candidate was identified, we estimate our 3D (volumetric) coverage using test light curves of on- and off-axis gamma-ray bursts and kilonovae. In cases where the source region was observable immediately, GOTO-4 was able to respond to a GW alert in less than a minute. The average time of first observation was 8.79 h after receiving an alert (9.90 h after trigger). A mean of 732.3 square degrees were tiled per event, representing on average 45.3 per cent of the LVC probability map, or 70.3 per cent of the observable probability. This coverage will further improve as the facility scales up alongside the localization performance of the evolving GW detector network. Even in its 4-telescope prototype configuration, GOTO is capable of detecting AT2017gfo-like kilonovae beyond 200 Mpc in favourable observing conditions. We cannot currently place meaningful EM limits on the population of distant (⁠D^L=1.3 Gpc) binary black hole mergers because our test models are too faint to recover at this distance. However, as GOTO is upgraded towards its full 32-telescope, 2 node (La Palma & Australia) configuration, it is expected to be sufficiently sensitive to cover the predicted O4 binary neutron star merger volume, and will be able to respond to both northern and southern triggers