Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Orthostatic tremor: report of a case and review of the literature

Orthostatic tremor is a rare movement disorder characterized by tremulousness of the lower limbs on standing that disappears on walking, sitting or on lying down and a distinctive electromyographic burst of 14 to 16 Hz. On inspection, fine ripples can sometimes be seen over the quadriceps on standing. The tremor has a tendency to reappear even in the supine posture if the lower limb muscles are put to an isometric contraction state, indicating thereby that in spite of the fact that the tremor occurs on standing, it is essentially 'orthostasis independent' and the central factor is the contraction of the muscles. As a matter of fact, the tremor is abolished if the subject is suspended by harness, thus relieving him of muscle contraction. Doubts are being cast whether it is a variant of essential tremor since a number of families are being reported to be suffering from this disease as well. Positron emission tomography reveals hyperactivity of cerebellum in orthostatic tremor as it shows in essential tremor, therefore lending credence to such a hypothesis. However, lack of response to alcohol, propranolol and primidone in orthostatic tremor stands out as a serious challenge to such a view. Lack of positive family history, synchrony of contracting group of muscles and negative 'resetting' of the tremor by increasing peripheral load-phenomena consistently observed in orthostatic tremor and not in essential tremor, are other features that often help to distinguish between the two conditions. We report a case of orthostatic tremor that presented with the classical clinical and electromyographic features. Relevant literature in this regard is also being reviewed.

The prognostic significance of marrow micrometastases in women with early breast cancer

Twenty-five patients with early breast cancer (T0-T2, N0-N1, M0) have been studied prospectively to determine the relationship between marrow micrometastases, disease-free interval and survival. Marrow specimens were aspirated from three sites immediately prior to breast surgery. An immunocytochemical technique using monoclonal antibody LICR.LON.M8.4 was employed to detect micrometastases. The minimum follow-up was 38 months. Twelve of the 25 patients (48%) had micrometastatic lesions in their marrow at presentation. Four of these patients developed distal recurrence during follow-up, causing death in two of them. Five of the 13 patients with no evidence of micrometastases developed distant recurrence and four of them have died. There was no correlation between the state of the marrow and the development of metastatic disease, although axillary lymph node status, disease stage and tumour volume correlated significantly with outcome (all P less than 0.025). Micrometastatic lesions appear to be common in the marrow of patients with early breast cancer. We have been unable to demonstrate that they have prognostic significance.

Wound sepsis in 10,000 surgical patients

A twelve year prospective wound audit was undertaken in an academic surgical unit. Data from 10,000 operations were analysed. Overall, wound infection rates decreased during this time. Infection rates in contaminated wounds in particular fell from 19.2% to 4.7%. This decrease in wound infection may be related in part to a change in the antibiotic prophylactic regimen and in part to the institution of the wound sepsis audit which provided regular information on the unit infection rates. This audit permitted early detection of adverse trends, and may have had a direct influence on surgical techniques.

High colloidal uptake in axillary nodes with metastatic disease

Axillary lymphoscintigraphy using 99Tcm antimony sulphide colloid has been carried out in 29 patients with suspected breast cancer and was correlated with histology. Of the 23 with proved tumour, axillary node metastases were found in 19 and, although 10 did have diminished uptake on the side of the lesion, 5 had an equal uptake in both sides and 4 had an increased uptake on the side of the lesion. Further, some of the nodes in which the high uptake had occurred were those heavily infiltrated by tumour. It is concluded that: a, lymphoscintigraphy with antimony sulphide colloid is not a reliable technique for the detection of metastatic disease in the regional nodes; b, any lymphoscintigraphy with this or any other agent requires more meticulous histological correlation than hitherto before it can be assumed to have any proved clinical value.

Idiopathic intestinal pseudo-obstruction: a familial visceral neuropathy

Four individuals with idiopathic intestinal pseudo-obstruction (IIP), a familial visceral neuropathy with autosomal dominant inheritance, are presented. The disorder is characterised by abdominal colic, abdominal distension and diarrhoea, and is of a progressive nature with relapses and remissions. The main feature is a disturbance of motility in the affected intestine, with histological evidence of a neuronal disorder, characterised by hyperplasia and eventual atrophy. Management of the condition is difficult; initially, treatment should be conservative by nasogastric suction with intravenous nutrition. When laparotomy is undertaken to exclude mechanical obstruction, resection of the intestine is inadvisable, and ileo-colic anastomosis may be beneficial.

Surgical care in the village

The care of people suffering from surgical disease or injury is unique in requiring, even at its simplest level, a certain degree of psychomotor skill and technological support. This cannot be achieved and maintained in isolation with any consistency. Villages must therefore be interdependent and related to supervision from the district hospital. The responsibility for village care rests with the district physician. He must be adequately trained for this purpose and provided with the simple facilities that are required. He extends his reach into the villages through the auxiliary health workers, who must be taught the skills necessary for simple surgical procedures and be trained to stabilize those patients that they cannot treat for transport to the district hospital. Although the skills and facilities required must be determined locally, there is a need to define the broad principles of training and to develop simple and adequate technology at village and district levels.

Faecal bile acid concentration of patients with carcinoma or increased risk of carcinoma in the large bowel

Faecal 3-hydroxy bile acids were assayed enzymatically in patients with carcinoma, or at increased risk of developing carcinoma of the large bowel. No rise in bile acid concentration was demonstrated in patients with ulcerative colitis, previously resected adenoma, or resected carcinoma. Patients with carcinoma, before treatment, had faecal bile acid concentrations similar to control values, and surgery did not affect the mean level. These findings cast doubt on the importance of the 3-hydroxy bile acid concentration in the faeces in the pathogenesis of large bowel cancer.

The problems of massive small bowel resection and difficulties encountered in management

Massive small bowel resection is imperative in the management of several pathological conditions and is accompanied by high operative mortality. In those that survive, serious nutritional disturbances are inevitable. Intestinal adaptation is said to occur but cannot be relied upon. Long-term parenteral nutrition is problematical and often unsuccessful. Many surgical procedures have been adopted in an effort to improve prognosis and have been found wanting. Controlled experimental studies in the use of reversed segments and a limited number of reported clinical cases using the method after massive resection suggest that this technique may improve the function of the residual intestine to such an extent that other supportive measures are unnecessary.

Rhinophycomycosis entomophthorae occurring in a chimpanzee in the wild in East Africa: further report

The further progress of a wild chimpanzee with rhinophycomycosis entomophthorae is reported. The swellings remained unchanged for about a year but early in 1973 they increased greatly in size, making the animal virtually blind. They regressed following administration of two courses of iodide in massive doses, and the animal in now apparently pregnant.

Epithelial hamartoma of liver

The successful removal of an epithelial hamartoma from the liver of a 7-month-old African child is reported. This hamartoma weighed 1875 g. and is believed to be the largest tumour of this type described in such a young patient. This case indicates that a ‘hopeless abdomen’ is always worth exploring in anticipation of the occasional happy outcome.

Failure of trasylol to reduce intestinal content of trypsin and chymotrypsin in man

The daily output of trypsin and chymotrypsin was measured in the stools of four patients with an established ileostomy under controlled dietary and metabolic conditions for a control period of four days. Trasylol, given intravenously in a dose of 500,000 units over eight hours, failed to affect the output of enzymes over the next two days, or to alter the distribution of bound and soluble enzymes.

Effect of riboflavine deficiency on nucleic acid metabolism of liver in the rat

1. The effect of riboflavine deficiency on liver ribonuclease activity, RNA and DNA content, and32P incorporation into RNA and DNA has been studied in rats maintained on a 16% protein diet, a protein-free diet and on a protein-free diet subsequently replaced with a 40% protein diet.

2. Rats maintained on a riboflavine-deficient diet for 45 days showed decreased incorporation of32P into liver RNA but no effect on the RNA content of liver. The concentration of DNA in liver and33P incorporation into it remained unaffected. After a deficiency period of 70 days, both the RNA and DNA contents of liver were found to be decreased. When the riboflavine-deficient or control rats were given the protein diet for 30 days and then a proteinfree diet for 15 days, the RNA content of their livers decreased, while the liver DNA content was increased. Repletion with a 40% protein diet restored the RNA and DNA content in both control and riboflavine-deficient rats.

3. Liver ribonuclease activity was decreased after a deficiency period of 45 days, whereas it was increased after a deficiency period of 70 days.

4. A correlation between liver RNA level and liver ribonuclease activity in riboflavine deficiency is suggested.

Proteolytic enzymes of human intestinal mucosa in non-malignant diseases of the ileum and colon

Preparations of mucosal epithelium were made from 10 samples of normal colon, 10 of normal ileum, 20 from colon involved by ulcerative colitis, 10 from ileum affected by regional ileitis, 4 from colon resected for diverticulitis, 2 from megacolon, and 2 from colonic polyps. The activity of proteolytic enzymes using haemoglobin as substrate and tissue nitrogen as reference was measured at pH 3·75 and pH 6·50 in homogenates, supernatants and particulate preparations before and after treatment with detergent.

In normal colon and ileum, proteolytic activity at pH 3·75 was of similar magnitude and was mainly soluble; activity at pH 6·50 was greater in ileum, and in both tissues was mainly associated with particulate fractions.

Samples involved by ulcerative colitis gave lower activities in all fractions at both pH values, the extent of the reduction being related to the severity of the disease. No evidence for a lysosomal defect was obtained.

Samples affected by regional ileitis did not differ from normal ileum in proteolytic activity at pH 3·75, but values at pH 6·50 tended to be lower. At both pH values, a higher percentage of the total activity was soluble prior to treatment with detergent which solubilised little additional enzyme; this may indicate a lysosomal defect.

Diverticulitis samples had lower activity at pH 3·75, but did not differ from normal colon at pH 6·50. No striking abnormalities were noted in megacolon or colonic polyps.