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Conte L, Amodeo I, De Nunzio G, Raffaeli G, Borzani I, Persico N, Griggio A, Como G, Cascio D, Colnaghi M, Mosca F, Cavallaro G. Congenital diaphragmatic hernia: automatic lung and liver MRI segmentation with nnU-Net, reproducibility of pyradiomics features, and a machine learning application for the classification of liver herniation. Eur J Pediatr 2024; 183:2285-2300. [PMID: 38416256 PMCID: PMC11035462 DOI: 10.1007/s00431-024-05476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
Prenatal assessment of lung size and liver position is essential to stratify congenital diaphragmatic hernia (CDH) fetuses in risk categories, guiding counseling, and patient management. Manual segmentation on fetal MRI provides a quantitative estimation of total lung volume and liver herniation. However, it is time-consuming and operator-dependent. In this study, we utilized a publicly available deep learning (DL) segmentation system (nnU-Net) to automatically contour CDH-affected fetal lungs and liver on MRI sections. Concordance between automatic and manual segmentation was assessed by calculating the Jaccard coefficient. Pyradiomics standard features were then extracted from both manually and automatically segmented regions. The reproducibility of features between the two groups was evaluated through the Wilcoxon rank-sum test and intraclass correlation coefficients (ICCs). We finally tested the reliability of the automatic-segmentation approach by building a ML classifier system for the prediction of liver herniation based on support vector machines (SVM) and trained on shape features computed both in the manual and nnU-Net-segmented organs. We compared the area under the classifier receiver operating characteristic curve (AUC) in the two cases. Pyradiomics features calculated in the manual ROIs were partly reproducible by the same features calculated in nnU-Net segmented ROIs and, when used in the ML procedure, to predict liver herniation (both AUC around 0.85). Conclusion: Our results suggest that automatic MRI segmentation is feasible, with good reproducibility of pyradiomics features, and that a ML system for liver herniation prediction offers good reliability. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04609163?term=NCT04609163&draw=2&rank=1 ; Clinical Trial Identification no. NCT04609163. What is Known: • Magnetic resonance imaging (MRI) is crucial for prenatal congenital diaphragmatic hernia (CDH) assessment. It enables the quantification of the total lung volume and the extent of liver herniation, which are essential for stratifying the severity of CDH, guiding counseling, and patient management. • The manual segmentation of MRI scans is a time-consuming process that is heavily reliant upon the skill set of the operator. What is New: • MRI lung and liver automatic segmentation using the deep learning nnU-Net system is feasible, with good Jaccard coefficient values and satisfactory reproducibility of pyradiomics features compared to manual results. • A feasible ML system for predicting liver herniation could improve prenatal assessments and CDH patient management.
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Affiliation(s)
- Luana Conte
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio De Nunzio
- Department of Mathematics and Physics "E. De Giorgi", Laboratory of Biomedical Physics and Environment, Università del Salento, Lecce, Italy.
- Advanced Data Analysis in Medicine (ADAM), Laboratory of Interdisciplinary Research Applied to Medicine (DReAM), Local Health Authority (ASL) Lecce and Università del Salento, Lecce, Italy.
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Irene Borzani
- Pediatric Radiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Persico
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Griggio
- ASST Fatebenefratelli Sacco, Ospedale Macedonio Melloni, Milan, Italy
| | - Giuseppe Como
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Donato Cascio
- Department of Physics and Chemistry, Università Degli Studi Di Palermo, Palermo, Italy
| | - Mariarosa Colnaghi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Kumar RS, Otero NA, Abubakar MO, Elliott MR, Wiggins JY, Sharif MM, Sullivan BA, Fairchild KD. Framework for Considering Abnormal Heart Rate Characteristics and Other Signs of Sepsis in Very Low Birth Weight Infants. Am J Perinatol 2024; 41:706-712. [PMID: 34875699 DOI: 10.1055/a-1715-3727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE A heart rate characteristics index (HeRO score), incorporating low variability and superimposed decelerations, was developed as a sepsis risk indicator for preterm infants in the neonatal intensive care unit (NICU). A rise in the risk score should prompt consideration of other clinical changes that may be signs of sepsis to decide whether a workup and antibiotics are needed. We aimed to develop a framework to systematically consider signs potentially indicating sepsis in very low birth weight (VLBW) infants. STUDY DESIGN We developed easy-recall acronyms for 10 signs of sepsis in VLBW infants. Over 12 months in a level IV NICU, neonatology fellows completed a brief survey after each shift to document changes prompting sepsis workups. We analyzed associations between survey data, hourly heart rate characteristic data, and the diagnosis of the workup, grouped as culture-positive sepsis (CXSEP, positive blood or urine culture), clinical sepsis (CLINSEP, negative cultures treated with antibiotics ≥5 days), or sepsis ruled out (SRO, negative cultures and <3 days antibiotics). RESULTS We analyzed 93 sepsis workups in 48 VLBW infants (35 CXSEP, 20 CLINSEP, and 38 SRO). The most frequently cited changes prompting the workups were heart rate patterns and respiratory deterioration, which were common in all three categories. Low blood pressure and poor perfusion were uncommonly cited but were more likely to be associated with CXSEP than the other signs. A rise in the HeRO score ≥1 from 0 to 12 hours before compared with 12to 72 hours prior the blood culture occurred in 31% of workups diagnosed as CXSEP, 16% CLINSEP, and 31% SRO. CONCLUSION The HeRO score can alert clinicians to VLBW infants at high or increasing risk of a sepsis-like illness, but heart rate characteristic patterns are highly variable in individual babies. The easy-recall NeoSEP-10 framework can assist clinicians in considering other clinical changes when making decisions about sepsis workups and the duration of antibiotics. KEY POINTS · Abnormal heart rate characteristics can indicate sepsis or other pathologies in preterm infants.. · We developed a simple bedside tool to consider clinical signs potentially associated with sepsis.. · Considering vital sign trends together with clinical changes is a key to right-timing antibiotics..
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Affiliation(s)
- Rupin S Kumar
- Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | | | - Maryam O Abubakar
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Megan R Elliott
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jaclyn Y Wiggins
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Misky M Sharif
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Brynne A Sullivan
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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Feng W, Zhang H, Yan H, Yang ZB, Zhao JL, Zhang LB. Gastrointestinal perforation in extremely low birth weight infants: A single center retrospective study in China. Pediatr Neonatol 2024; 65:111-116. [PMID: 38114414 DOI: 10.1016/j.pedneo.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/06/2023] [Accepted: 11/02/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Gastrointestinal perforation in extremely low birth weight infants, characterized by its rapid onset, multiple complications, and critical condition, poses a significant risk of infant mortality. The aim of this study was to investigate the clinical characteristics of pneumoperitoneum in extremely low birth weight infants (ELBWI) and explore the risk factors associated with gastrointestinal perforation in very low birth weight preterm infants. Additionally, we shared our surgical experiences in managing gastrointestinal perforation among extremely low birth weight infants. METHODS The Department of Neonatology at Chengdu Women and Children's Central Hospital conducted a retrospective study on gastrointestinal perforation in extremely low birth weight infants (birth weight <1000 g) who were admitted between 2014 and 2021. After baseline analysis and comparing it with the control group, we identified the risk factors associated with gastrointestinal perforation in ELBWI by multiple logistic regression analysis. The Kaplan-Meier analysis was performed to assess the adverse effect of gastrointestinal perforation for survival in ELBW infants. Cox multivariate regression analysis was used to evaluate hazard level of different variables for ELBW infants survival. RESULTS Hemodynamically significant patent ductus arteriosus (hsPDA)(p = 0.043, OR = 2.779) and sepsis (p = 0.014, OR = 2.265) were significant risk factors for gastrointestinal perforation in extremely low birth weight infants. The Cox proportional hazard model revealed that intraventricular hemorrhage (HR = 2.854, p<0.001) Sepsis (HR = 1.645, p = 0.015) and gastrointestinal perforation (HR = 1.876, p = 0.008) had detrimental effects on the survival of extremely low birth weight infants; conversely, ibuprofen (HR = 0.304, p<0.001) and blood transfusion (HR = 0.372, p<0.001) are beneficial factors for their survival. The preoperative indicators of infection in infants with spontaneous intestinal perforation (SIP) were significantly better than those in the necrotizing enterocolitis (NEC) group (p < 0.05). CONCLUSIONS Gastrointestinal perforation poses a significant threat the survival of extremely low birth weight (ELBW) infants, with hsPDA and sepsis serving as predisposing factors for gastrointestinal perforation. The gastrointestinal perforation caused by various diseases exhibits distinct clinical characteristics, necessitating tailored surgical approaches based on operative conditions.
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Affiliation(s)
- Wei Feng
- The Department of Pediatric Surgery, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Hong Zhang
- Department of Pediatric Endocrinology, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Huan Yan
- The Department of Pediatric Surgery, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Zheng-Bing Yang
- The Department of Pediatric Surgery, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jin-Liang Zhao
- The Department of Pediatric Surgery, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Li-Bing Zhang
- The Department of Pediatric Surgery, Chengdu Women's and Children' Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China.
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Beam K, Sharma P, Levy P, Beam AL. Artificial intelligence in the neonatal intensive care unit: the time is now. J Perinatol 2024; 44:131-135. [PMID: 37443271 DOI: 10.1038/s41372-023-01719-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/24/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
Artificial intelligence (AI) has the potential to revolutionize the neonatal intensive care unit (NICU) care by leveraging the large-scale, high-dimensional data that are generated by NICU patients. There is an emerging recognition that the confluence of technological progress, commercialization pathways, and rich data sets provides a unique opportunity for AI to make a lasting impact on the NICU. In this perspective article, we discuss four broad categories of AI applications in the NICU: imaging interpretation, prediction modeling of electronic health record data, integration of real-time monitoring data, and documentation and billing. By enhancing decision-making, streamlining processes, and improving patient outcomes, AI holds the potential to transform the quality of care for vulnerable newborns, making the excitement surrounding AI advancements well-founded and the potential for significant positive change stronger than ever before.
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Affiliation(s)
- Kristyn Beam
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Puneet Sharma
- Division of Newborn Medicine, Department of Pediatrics Boston Children's Hospital, Boston, MA, USA
| | - Phil Levy
- Division of Newborn Medicine, Department of Pediatrics Boston Children's Hospital, Boston, MA, USA
| | - Andrew L Beam
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
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Kurul Ş, Beckers FLM, Vermeulen MJ, Suurland J, Hasbek JE, Ramakers CRB, Simons SHP, Reiss IKM, Taal HR. Inflammation, sepsis severity and neurodevelopmental outcomes of late-onset sepsis in preterm neonates. Pediatr Res 2023; 94:2026-2032. [PMID: 37468719 DOI: 10.1038/s41390-023-02742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/15/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The aim of this study was to investigate the association between inflammatory biomarkers (C-reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6)) and sepsis severity (neonatal-Sequential-Organ-Failure-Assessment (nSOFA)) and neurodevelopmental outcomes at 2 years, among very preterm neonates. METHODS Data on preterm neonates (gestational age <30 weeks) from 2016 until 2020 were reviewed. Outcomes of interest were NDI (no, mild, severe) and the motor and cognitive score on the Dutch-Bayley-Scales-of-Infant-and-Toddler-Development (Bayley-III-NL) assessed at the corrected age of 2 years. Logistic and linear regression analysis were used for categorical and continuous outcomes, respectively. All analyses were adjusted for gestational age, sex and birthweight-for-gestational-age SD-score. RESULTS In total 410 patients were eligible for analysis. Maximum CRP concentrations were associated with lower motor and cognitive scores (effect estimate -0.03 points,(95% CI -0.07; -0.00) and -0.03 points,(95% CI -0.06; -0.004), respectively) and increased risk of severe NDI (odds ratio (OR) 1.01, (95% CI 1.00; 1.01)). High nSOFA scores (≥4) during sepsis episodes were associated with an increased risk of mild NDI (OR 2.01, (95% CI 1.34; 3.03)). There were no consistent associations between IL-6, PCT and the outcomes of interest. CONCLUSION High CRP concentrations and sepsis severity in preterm neonates seem to be associated with neurodevelopmental outcomes in survivors at the age of 2 years. IMPACT STATEMENT The level of inflammation and sepsis severity are associated with neurodevelopmental outcome in preterm neonates at 2 years of corrected age. Sepsis is a major health issue in preterm neonates and can lead to brain damage and impaired neurodevelopment. Biomarkers can be determined to assess the level of inflammation. However, the relation of inflammatory biomarkers with neurodevelopmental outcome is not known. The level of inflammation and sepsis severity are related to neurodevelopmental outcome in preterm neonates. Maximum CRP concentration and high nSOFA scores are associated with an increased risk of neurodevelopmental impairment in survivors at the corrected age of 2 years.
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Affiliation(s)
- Şerife Kurul
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Famke L M Beckers
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marijn J Vermeulen
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jill Suurland
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jasmin E Hasbek
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | | | - Sinno H P Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - H Rob Taal
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
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Ko H, Lakshmanan A, Maxwell JR. Hydrocortisone may spare head growth, but the debate for steroid use rages on. Pediatr Res 2023; 94:1867-1869. [PMID: 37845521 DOI: 10.1038/s41390-023-02845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Hellen Ko
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Jessie R Maxwell
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Department of Neurosciences, University of New Mexico Health Science Center, Albuquerque, NM, USA.
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Vardar G, Rzayev T, Tezel KG, Ozek E. Can We Estimate Late-Onset Sepsis by Serial Methemoglobin Levels? An Observational Study in Preterm Neonates. Fetal Pediatr Pathol 2023; 42:753-765. [PMID: 37318102 DOI: 10.1080/15513815.2023.2223308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
Objective: To assess serial methemoglobin (MetHb) levels in preterm infants as a possible diagnostic method for late-onset sepsis (LOS). Methods: Preterm infants were assigned into two groups: those with culture-proven LOS and controls. Serial MetHb levels were measured. Results: The MetHb values of the LOS group were found to be significantly increased (p < 0.001). The cutoff value for the detection of LOS was calculated as MetHb > 1.75%, optimized for a sensitivity of 81.9% and specificity of 90%. After antimicrobial therapy, MetHb values were found to decrease significantly (p < 0.001). MetHb had an AUC of 0.810 for mortality using the calculated cutoff of >2% (p < 0.005). Conclusions: MetHb levels increase at the onset of LOS and decrease following treatment. MetHb can be added to other sepsis biomarkers as a rapid infectious process indicator for preterm neonates. MetHb > 2% is associated with LOS mortality.
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Affiliation(s)
- Gonca Vardar
- Division of Neonatology, Department of Pediatrics, School of Medicine, Marmara University, Pendik/Istanbul, Turkey
| | - Turkay Rzayev
- Division of Neonatology, Department of Pediatrics, School of Medicine, Marmara University, Pendik/Istanbul, Turkey
| | - Kubra Gokce Tezel
- Division of Neonatology, Department of Pediatrics, School of Medicine, Marmara University, Pendik/Istanbul, Turkey
| | - Eren Ozek
- Division of Neonatology, Department of Pediatrics, School of Medicine, Marmara University, Pendik/Istanbul, Turkey
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Poggi C, Ciarcià M, Miselli F, Dani C. Prognostic accuracy of Neonatal SOFA score versus SIRS criteria in preterm infants with late-onset sepsis. Eur J Pediatr 2023; 182:4731-4739. [PMID: 37572145 PMCID: PMC10587306 DOI: 10.1007/s00431-023-05143-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/30/2023] [Indexed: 08/14/2023]
Abstract
Neonatal SOFA score was reported as an accurate predictor of mortality while the prognostic accuracy of SIRS criteria is unknown. The aim was to compare neonatal SOFA and SIRS criteria for the prediction of late onset sepsis-related mortality in preterm newborns. Newborns ≤ 32 weeks with late onset sepsis were retrospectively studied. Neonatal SOFA and SIRS criteria were calculated at onset of sepsis (T0), and after 6 ± 1 (T1), 12 ± 3 (T2) and 24 ± 3 h (T3). Outcome was death during antibiotic treatment for late onset sepsis. We studied 112 newborns with gestational age 26.9 ± 2.3 weeks; 11% met the study outcome. Neonatal SOFA was significantly higher in non-survivors vs. survivors at all time intervals; SIRS criteria were significantly higher in non-survivors vs. survivors at T1, T2 and T3. Neonatal SOFA increased over time in non-survivors (p = 0.003). At T0, the area under receiver operating characteristics curve was significantly higher for neonatal SOFA score than SIRS criteria (0.950 vs. 0.569; p = 0.0002), and the best calculated cut-off for T0 neonatal SOFA score was 4. In multivariate analysis T0 and T1 neonatal SOFA were predictors of late onset sepsis-related mortality (p = 0.048 and p < 0.001). Conclusion: Neonatal SOFA score showed greater discriminatory capacity for mortality than SIRS criteria and might be helpful to plan management for patients at higher risk of death. What is Known: • Neonatal SOFA score may be an accurate prognostic tool. • No prognostic score has been fully standardized for septic newborns in NICU. What is New: • Neonatal SOFA score outperformed SIRS criteria for the prediction of prognosis in preterm infants with late onset sepsis. • Neonatal SOFA score assessed at onset of sepsis and 6 hrs later is a predictor of mortality.
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Affiliation(s)
- Chiara Poggi
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, Florence, Italy.
| | - Martina Ciarcià
- Department of Neurosciences, Drug Research and Child Health, University of Florence, PsychologyFlorence, Italy
| | - Francesca Miselli
- Department of Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Dani
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, Florence, Italy
- Department of Neurosciences, Drug Research and Child Health, University of Florence, PsychologyFlorence, Italy
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Xu D, Dong Z, Yin X, Yang Y, Wang Y. Neonatal sequential organ failure assessment score within 72 h after delivery reliably predicts bronchopulmonary dysplasia in very preterm infants. Front Pediatr 2023; 11:1233189. [PMID: 37842024 PMCID: PMC10570456 DOI: 10.3389/fped.2023.1233189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Background The neonatal sequential organ failure assessment (nSOFA) score is an operational definition of organ dysfunction employed to predict sepsis-associated mortality. However, the relationship between the nSOFA score and bronchopulmonary dysplasia (BPD) has not been investigated clearly. This study evaluates whether the nSOFA score within 72 h after delivery could be used to predict the occurrence of BPD in very preterm infants. Methods In this retrospective, single-center cohort study, preterm infants born between 2019 and 2021 were investigated, the nSOFA score was calculated from medical records after admission to the neonatal intensive care unit (NICU) within 72 h after delivery, and the peak value was used for calculation. A logistic regression model was used to evaluate the relationship between the nSOFA score and BPD. Propensity score matching and subgroup analysis were performed to verify the reliability of the results. Results Of 238 infants meeting the inclusion criteria, 93 infants (39.1%) were diagnosed with BPD. The receiver operating characteristic curve of the nSOFA score in predicting BPD was 0.790 [95% confidence interval (CI): 0.731-0.849]. The logistic regression model showed that an increment of one in the nSOFA score was related to a 2.09-fold increase in the odds of BPD (95% CI: 1.57-2.76) and 6.36-fold increase when the nSOFA score was higher than 1.5 (95% CI: 2.73-14.79). Conclusions The nSOFA score within 72 h after delivery is independently related to BPD and can be used to identify high-risk infants and implement early interventions.
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Bethell GS, Hall NJ. Recent advances in our understanding of NEC diagnosis, prognosis and surgical approach. Front Pediatr 2023; 11:1229850. [PMID: 37583622 PMCID: PMC10424793 DOI: 10.3389/fped.2023.1229850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023] Open
Abstract
Necrotising enterocolitis (NEC) remains a devasting condition that has seen limited improvement in outcomes in recent years. The incidence of the disease is increasing as more extremely premature infants survive. NEC is responsible for 1 in 10 neonatal deaths and up to 61% of survivors have significant neurodevelopmental delay. The aim of this review is to highlight recent advances in diagnosis, prognosis and surgical approach in this condition. Many recent studies have reported novel methods of diagnosis of NEC with the aim of earlier and more accurate identification. These include imaging and machine learning techniques. Prognostication of NEC is particularly important to allow earlier escalation of therapy. Around 25% of infants with NEC will require surgery and recent data has shown that time from disease onset to surgery is greater in infants whose indication for surgery is failed medical management, rather than pneumoperitoneum. This indication was also associated with worse outcomes compared to pneumoperitoneum. Ongoing research has highlighted several new methods of disease prognostication which includes differentiating surgical from medical NEC. Finally, recent randomised controlled trials in surgical technique are discussed along with the implications of these for practice. Further, high quality research utilising multi-centre collaborations and high fidelity data from electronic patient records is needed to address the issues discussed and ultimately improve outcomes in NEC.
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Affiliation(s)
- George S Bethell
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nigel J Hall
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Koppens HJ, Onland W, Visser DH, Denswil NP, van Kaam AH, Lutterman CA. Heart Rate Characteristics Monitoring for Late-Onset Sepsis in Preterm Infants: A Systematic Review. Neonatology 2023; 120:548-557. [PMID: 37379804 PMCID: PMC10614451 DOI: 10.1159/000531118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/03/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Early diagnosis of late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) by monitoring heart rate characteristics (HRC) of preterm infants might reduce the risk of death and morbidities. We aimed to systematically assess the effects of HRC monitoring on death, LOS, and NEC. METHODS A systematic search was performed in MEDLINE, Embase, Cochrane Library, and Web of Science. RESULTS Fifteen papers were included in this review. Three of these papers reported results from the only identified randomized controlled trial (RCT). This RCT showed that HRC monitoring resulted in a small but significant reduction in mortality (absolute risk reduction 2.1% [95% confidence interval 0.01-4.14]) without any differences in neurodevelopmental impairment. The risk of bias was rated high due to performance and detection bias and failure to correct for multiple testing. Most diagnostic cohort studies showed high discriminating accuracy in predicting LOS but lacked sufficient quality and generalizability. No studies for the detection of NEC were identified. CONCLUSION Supported by multiple observational cohort studies, the RCT identified in this systematic review showed that HRC monitoring as an early warning system for LOS might reduce the risk of death in preterm infants. However, methodological weaknesses and limited generalizability do not justify implementation of HRC in clinical care. A large international RCT is warranted.
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Affiliation(s)
- Hugo J. Koppens
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Douwe H. Visser
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Nerissa P. Denswil
- Amsterdam UMC Location University of Amsterdam, Medical Library, Amsterdam, The Netherlands
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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Husain AN, Eiden E, Vesoulis ZA. Use of an electronic medical record to optimize a neonatal sepsis score for mortality prediction. J Perinatol 2023; 43:746-751. [PMID: 36450852 PMCID: PMC10580075 DOI: 10.1038/s41372-022-01573-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Late-onset sepsis (LOS) is a significant cause of mortality in preterm infants. The neonatal sequential organ failure assessment (nSOFA) provides an objective assessment of sepsis risk but requires manual calculation. We developed an EMR pipeline to automate nSOFA calculation for more granular analysis of score performance and to identify optimal alerting thresholds. METHODS Infants born <33 weeks of gestation with LOS were included. A SQL-based pipeline calculated hourly nSOFA scores 48 h before/after sepsis evaluation. Sensitivity analysis identified the optimal timing and threshold of nSOFA for LOS mortality. RESULTS Eighty episodes of LOS were identified (67 survivors, 13 non-survivor). Non-survivors had persistently elevated nSOFA scores, markedly increasing 12 h prior to culture. At sepsis evaluation, the AUC for nSOFA >2 was 0.744 (p = 0.0047); thresholds of >3 and >4 produced lower AUCs. CONCLUSIONS nSOFA is persistently elevated for infants with LOS mortality compared to survivors with an optimal alert threshold >2.
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Affiliation(s)
- Ameena N Husain
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Elise Eiden
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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13
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Schuurman AR, Sloot PMA, Wiersinga WJ, van der Poll T. Embracing complexity in sepsis. Crit Care 2023; 27:102. [PMID: 36906606 PMCID: PMC10007743 DOI: 10.1186/s13054-023-04374-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/19/2023] [Indexed: 03/13/2023] Open
Abstract
Sepsis involves the dynamic interplay between a pathogen, the host response, the failure of organ systems, medical interventions and a myriad of other factors. This together results in a complex, dynamic and dysregulated state that has remained ungovernable thus far. While it is generally accepted that sepsis is very complex indeed, the concepts, approaches and methods that are necessary to understand this complexity remain underappreciated. In this perspective we view sepsis through the lens of complexity theory. We describe the concepts that support viewing sepsis as a state of a highly complex, non-linear and spatio-dynamic system. We argue that methods from the field of complex systems are pivotal for a fuller understanding of sepsis, and we highlight the progress that has been made over the last decades in this respect. Still, despite these considerable advancements, methods like computational modelling and network-based analyses continue to fly under the general scientific radar. We discuss what barriers contribute to this disconnect, and what we can do to embrace complexity with regards to measurements, research approaches and clinical applications. Specifically, we advocate a focus on longitudinal, more continuous biological data collection in sepsis. Understanding the complexity of sepsis will require a huge multidisciplinary effort, in which computational approaches derived from complex systems science must be supported by, and integrated with, biological data. Such integration could finetune computational models, guide validation experiments, and identify key pathways that could be targeted to modulate the system to the benefit of the host. We offer an example for immunological predictive modelling, which may inform agile trials that could be adjusted throughout the trajectory of disease. Overall, we argue that we should expand our current mental frameworks of sepsis, and embrace nonlinear, system-based thinking in order to move the field forward.
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Affiliation(s)
- Alex R Schuurman
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Peter M A Sloot
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.
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14
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Monitoring of heart rate characteristics to detect neonatal sepsis. Pediatr Res 2022; 92:1070-1074. [PMID: 34916625 DOI: 10.1038/s41390-021-01913-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Monitoring of heart rate characteristics (HRC) index may improve outcomes of late-onset neonatal sepsis (LOS) through early detection. We aimed at describing the association between LOS and elevated HRC index. METHODS This single-center retrospective case-control study included neonates who presented with blood culture-proven hospital-acquired LOS. Controls were matched to cases (ratio 1:2) based on gestational age, postnatal age, and birthweight. We compared the highest HRC indexes in the 48 h preceding blood culture sampling in LOS cases to the highest HRC indexes at the same postnatal days in controls. RESULTS In 59 LOS cases and 123 controls, an HRC index > 2 was associated with LOS (OR 7.1, 95% CI 2.6-19.0). Sensitivity and specificity of an HRC index > 2 to predict LOS were 53% (32/59) and 79% (98/123). Sensitivity increased from 25% in infants born > 32 weeks to 76% in infants born < 28 weeks. Specificity decreased from 97% in infants > 32 weeks to 63% in those born < 28 weeks. CONCLUSIONS An increase of HRC index > 2 has a significant association with the diagnosis of LOS, supporting the use of HRC monitoring to assist early detection of LOS. Clinicians using HRC monitoring should be aware of its diagnostic accuracy and limitations in different gestational age groups. IMPACT There is a paucity of data regarding the predictive value of heart rate characteristics (HRC) monitoring for early diagnosis of late-onset neonatal sepsis (LOS) in daily clinical practice. Monitoring of heart rate characteristics provides valuable information to assist the early diagnosis of LOS across all gestational age groups. However, the strong influence of gestational age on positive and negative predictive values adds complexity to the interpretation of HRC indexes.
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Lobo BBP, Marba STM, Machado HC, Caldas JPS. Neonatal Sequential Organ Failure Assessment as a late-onset sepsis mortality predictor in very low birth weight newborns: a Brazilian cohort study. Eur J Pediatr 2022; 181:3767-3774. [PMID: 35982172 DOI: 10.1007/s00431-022-04583-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 07/11/2022] [Accepted: 08/01/2022] [Indexed: 11/03/2022]
Abstract
Death is a frequent occurrence in late-onset neonatal sepsis (LOS). We aimed to evaluate if the Neonatal Sequential Organ Failure Assessment (nSOFA) is associated with mortality due to LOS in very low birth weight (VLBW) infants. This is a single-center Brazilian cohort study including VLBW infants admitted between 2006 and 2020 who were diagnosed with LOS caused by Staphylococcus aureus, Enterococcus sp or Gram-negative bacteria. The primary outcome was mortality associated with sepsis. Two groups of patients-survivors and non-survivors-were compared regarding descriptive maternal and neonatal variables and the nSOFA score, evaluated at nine moments, from 48 hours before the diagnosis of sepsis to 48 hours later (T-48, T-24, T-12, T-6, T0, T+6, T+12, T+24, T+48). Diagnostic accuracy was expressed as the area under the curve (AUC). Among the 1574 VLBW infants hospitalized in the period, 114 episodes of culture-confirmed LOS occurred. There were 21 sepsis-related deaths (18.4%), mostly from Gram-negative bacteria and Enterococcus sp. There were no statistically significant differences between the groups regarding maternal and neonatal variables. Median nSOFA was significantly higher in the non-survivor group at all time points (range 2 to 13 versus 1 to 3). In the logistic regression analysis, each increment of one point in the score significantly increases the risk of death in eight of the nine moments, but no difference was found in T-24. Time T-6 had the best accuracy (88.1%). Conclusion: The nSOFA score was significantly associated with the risk of death from LOS in VLBW infants. What is Known: • The neonatal sepsis may result in organ dysfunction and death, and it is important to find indicators that could identify this clinical progression. • The nSOFA score was proposed in 2020 to predict mortality from LOS, but since it is recent and still in the research phase, further studies are important to improve it before being widely used in clinical practice. What is New: • We showed a significative association between higher nSOFA scores and mortality. Our results corroborate the validity and the importance of the nSOFA score and highlight its high NPV.
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Affiliation(s)
- Bárbara B P Lobo
- Department of Pediatrics, State University of Campinas - Unicamp, School of Medical Sciences, Campinas, São Paulo, Brazil.
| | - Sergio T M Marba
- Department of Pediatrics, State University of Campinas - Unicamp, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Helymar C Machado
- State University of Campinas - Unicamp, Women's Hospital, São Paulo, Campinas, Brazil
| | - Jamil P S Caldas
- Department of Pediatrics, State University of Campinas - Unicamp, School of Medical Sciences, Campinas, São Paulo, Brazil
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Travers CP, Carlo WA, Ambalavanan N. The Future of Outcome Prediction for Preterm Infants in the Neonatal ICU. Am J Respir Crit Care Med 2022; 205:6-8. [PMID: 34710338 PMCID: PMC8865594 DOI: 10.1164/rccm.202109-2188ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Colm P Travers
- Division of Neonatology University of Alabama at Birmingham Birmingham, Alabama
| | - Waldemar A Carlo
- Division of Neonatology University of Alabama at Birmingham Birmingham, Alabama
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