UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS)

BACKGROUND AND AIMS

International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK.

METHODS

Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved.

RESULTS

39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers.

CONCLUSIONS

An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.

Effects of hunger on neuronal histone modifications slow aging in Drosophila

Hunger is an ancient drive, yet the molecular nature of pressures of this sort and how they modulate physiology are unknown. We find that hunger modulates aging in Drosophila. Limitation of branched-chain amino acids (BCAAs) or activation of hunger-promoting neurons induced a hunger state that extended life span despite increased feeding. Alteration of the neuronal histone acetylome was associated with BCAA limitation, and preventing these alterations abrogated the effect of BCAA limitation to increase feeding and extend life span. Hunger acutely increased feeding through usage of the histone variant H3.3, whereas prolonged hunger seemed to decrease a hunger set point, resulting in beneficial consequences for aging. Demonstration of the sufficiency of hunger to extend life span reveals that motivational states alone can be deterministic drivers of aging.

Genetic background determines behavioral responses during fear conditioning

Freezing behavior is used as a measure of a rodent's ability to learn during fear conditioning. However, it is possible that the expression of other behaviors may compete with freezing, particularly in rodent populations that have not been thoroughly studied in this context. Rearing and grooming are complex behaviors that are frequently exhibited by mice during fear conditioning. Both behaviors have been shown to be stress-sensitive, and the expression of these behaviors is dependent upon strain background. To better understand how genetic background impacts behavioral responses during fear conditioning, we examined freezing, rearing, and grooming frequencies prior to fear conditioning training and across different stages of fear conditioning testing in male mice from eight inbred mouse strains (C57BL/6J, DBA/2J, FVB/NJ, SWR/J, BTBR T + ltpr3Tf/J, SM/J, LP/J, 129S1/SvlmJ) that exhibited diverse freezing responses. We found that genetic background determined rearing and grooming expression throughout fear conditioning, and their patterns of expression across stages of fear conditioning were strain dependent. Using publicly available SNP data, we found that polymorphisms in Dab1, a gene that is implicated in both grooming and learning phenotypes, separated the strains with high contextual grooming from the others using a hierarchical clustering analysis. This suggested a potential genetic mechanism for the observed behavioral differences. These findings demonstrate that genetic background determines behavioral responses during fear conditioning and suggest that shared genetic substrates underlie fear conditioning behaviors.

A utilisation profile of publicly financed oral examinations in the Republic of Ireland

AIM

To develop a utilisation profile for oral examinations performed under the remit of publicly financed dental services in the Republic of Ireland as a proxy for the overall level of service use.

BASIC RESEARCH DESIGN

Collation of data from multiple administrative datasets for 2018, and generation of an age-specific oral examination utilisation profile.

MAIN OUTCOME MEASURE

Age-specific oral examination rates per 1,000 population.

RESULTS

A total of 1,163,399 publicly financed oral examinations were performed. Comparably low population-adjusted oral examination rates were observed in the 0-15, 16-24 and 75+ age cohorts.

CONCLUSIONS

The National Oral Health Policy in Ireland aims to improve access to oral healthcare services across the life-course. Young children and older adults are highlighted as population subgroups with low levels of service eligibility and engagement, respectively. These results reinforce the need to focus on these age cohorts.

Une expérience clinique du pramipexole chez 64 patients déprimés uni ou bipolaires suivis en ambulatoire

Du fait de l’analogie entre apathie et dépression [1,2], nous avons utilisé le pramipexole [3] chez 64 patients déprimés (39 patients présentant une dépression uni ou bipolaire, 25 patients présentant des troubles dysthymiques). Tous les patients, depuis trois mois au moins, prenaient un traitement par inhibiteur sélectif de la recapture de la sérotonine (ISRS) maintenu sans modification. Il s’agit d’une étude rétrospective portant sur quatre années d’utilisation du pramipexole La sévérité de la dépression a été cotée par le patient sur l’échelle de Hamilton 21 items et par l’investigateur sur l’échelle Montgomery and Asberg Depression Rating Scale (MADRS). Tous les patients ont été revus un à deux mois après l’introduction du pramipexole. La posologie du pramipexole a été de 1,4 mg par jour atteinte en 16 jours. Les critères d’amélioration ont été définis comme l’obtention d’un score inférieur à 10 sur l’échelle de Hamilton et un score inférieur à 10 sur l’échelle MADRS. Parmi les 25 patients présentant un trouble dysthymique, 3 patients ont été améliorés Parmi les 39 patients présentant une dépression uni- ou bipolaire, 35 ont été améliorés. L’amélioration chez ces 38 patients est survenue 10 à 15 jours après le début du traitement. Tous les patients améliorés présentaient une variation franche de l’humeur au cours de la journée avec moindre intensité de la souffrance en fin de journée. La médiane de suivi a été de 23 mois. Les nausées (5 patients) et la somnolence (6 patients) n’ont pas nécessité de modification dans la progression de la posologie. Deux patients ont présenté un épisode maniaque résolutif en 5 à 10 jours après l’arrêt du pramipexole, 1 patient a présenté des hallucinations visuelles résolutives 15 jours après l’arrêt du pramipexole et 1 patient a présenté un priapisme résolutif dès l’arrêt du pramipexole. Aucun cas d’addiction au pramipexole n’a été observé. Au total, le pramipexole semble être un traitement bien toléré et efficace chez les patients présentant une dépression dans le cadre d’un trouble uni ou bipolaire. Il ne semble pas avoir d’indication lors de troubles dysthymiques.

Penile Paget's Disease: A Case Report and Review of the Literature

Extramammary Paget's Disease (EMPD) is a rare cutaneous, slow growing, intraepithelial adenocarcinoma that can be either primary (intraepithelial arising within the epidermis) or secondary (intraepithelial spread of a visceral carcinoma). Here we present the case of a 63-year-old male with EMPD of the glans penis stemming from underlying urothelial carcinoma. Our treatment decision elected for management with chemotherapy and local treatment with radiation therapy. Subsequent, review of the literature demonstrated a rare disease with a variety of underlying malignancies causing this secondary pathology. Caregivers should be aware of the association of Paget's disease and urothelial cancer and should have a high index of suspicion that erythematous penile lesions may represent Paget's disease and that penile biopsies should be performed early in this setting.

Prenatal natural history of congenital pulmonary malformations: MALFPULM population-based cohort study

OBJECTIVES

To assess prenatal changes in the volume of congenital pulmonary malformations (CPM) and examine whether these changes differ in lesions that appear cystic on ultrasound compared with hyperechoic lesions, and to study the relationship between CPM volume and risk of fetal compression.

METHODS

We conducted a nationally representative, multicenter, prospective cohort study, which included 579 ultrasound examinations in 176 pregnant women with a diagnosis of fetal CPM, between March 2015 and November 2016. Several ultrasound examinations were performed between diagnosis and delivery, including measurement of CPM volume. We modeled changes in CPM volume ratio (CVR) as a function of gestational age, overall and for cystic/mixed vs hyperechoic malformations, and examined the association between CVR and signs of compression during pregnancy.

RESULTS

When modeling CVR changes over time, there was a statistically significant decrease in CVR with increasing gestational age (P < 0.001), but the pattern of change differed according to CPM phenotype at first ultrasound examination: cystic/mixed CPM were characterized by a monotonic decrease in CVR with increasing gestational age (P = 0.002), whereas hyperechoic CPM showed an initial increase in CVR up to 27 weeks of gestation, followed by a decrease thereafter (P < 0.001). Peak CVR values were predicted as early as 21-22 weeks for cystic/mixed CPMs compared with 25-26 weeks for hyperechoic malformations. Regardless of CPM phenotype, fetuses that showed no sign of compression at any point had substantially lower CVR at first CVR measurement, and the CVR remained relatively constant thereafter. Among the subpopulation of fetuses with no sign of compression at first CVR measurement, the odds of a subsequent compression was 7-fold higher (adjusted odds ratio, 7.0; 95% CI, 1.6-29.9) if initial CVR was > 0.4 vs CVR ≤ 0.4 cm² .

CONCLUSIONS

Predicted changes in CVR during pregnancy differ between cystic and hyperechoic malformations. This may be the result of different pathophysiological mechanisms or differences in the timing of occurrence of these different types of CPM. CVR measured at the initial diagnostic ultrasound examination was strongly associated with the odds of subsequent compression. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Convergent synthesis and properties of photoactivable NADPH mimics targeting nitric oxide synthases

A new series of photoactivable NADPH mimics bearing one or two O-carboxymethyl groups on the adenosine moiety have been readily synthesized using click chemistry. These compounds display interesting one- or two-photon absorption properties. Their fluorescence emission wavelength and quantum yields (Φ) are dependent on the solvent polarity, with a red-shift in a more polar environment (λ_max,em = 460-467 nm, Φ > 0.53 in DMSO, and λ_max,em = 475-491 nm, Φ < 0.17 in Tris). These compounds show good binding affinity towards the constitutive nNOS and eNOS, confirming for the first time that the carboxymethyl group can be used as a surrogate of phosphate. Two-photon fluorescence imaging of nanotriggers in living cells showed that the presence of one carboxymethyl group (especially on the 3' position of the ribose) strongly favors the addressing of nanotriggers to eNOS in the cell context.

The immature platelet fraction: creating neonatal reference intervals and using these to categorize neonatal thrombocytopenias

OBJECTIVE

The immature platelet fraction (IPF) is a laboratory measurement analogous to the reticulocyte count, but reflecting the thrombopoietic state. Similar to a reticulocyte count, it can be expressed as a percent (IPF%=percent of platelets that are immature) or as an absolute number per μl blood; the immature platelet count (IPC=IPF% × platelets per μl of blood).

STUDY DESIGN

Using a retrospective analysis of de-identified data from non-thrombocytopenic neonates, we created reference intervals for IPF% and IPC. We then tested the value of these measurements for categorizing thrombocytopenic neonates.

RESULTS

New charts display reference intervals for IPF% and IPC on the day of birth according to gestational age, and during the first 90 days after birth. Neonates with hyporegenerative varieties of thrombocytopenias (syndromes, small for gestational age, birth asphyxia) had lower IPF% and IPC than did neonates with consumptive thrombocytopenias (immune-mediated, infection, disseminated intravascular coagulation, necrotizing enterocolitis; both P<0.0001).

CONCLUSION

The new reference interval charts can be used to recognize abnormal IPFs. The IPF parameters can help clarify the kinetic mechanism responsible for thrombocytopenias in neonates.

Reference intervals for reticulocyte parameters of infants during their first 90 days after birth

OBJECTIVE

The automated reticulocyte parameters (absolute reticulocyte count, immature reticulocyte fraction (IRF) and reticulocyte hemoglobin content (RET-He)) are of value in managing adults and older children with a variety of hematological disorders. However, the lack of reference intervals for these parameters in neonates and young infants has limited their application to that population.

STUDY DESIGN

During a span of 12 months (29 May 2014 to 5 May 2015), a convenience sample of reticulocyte parameters were run from clinically ordered complete blood counts (CBCs) of infants within the first 90 days after birth. Measuring the reticulocyte parameters as a research-only adjunct to the CBC did not require any additional blood or generate a patient charge, and the reticulocyte results were not reported to the provided and did not appear in the clinical records. Values from neonates who had a transfusion or a diagnosis of anemia were subsequently excluded from the reference data set.

RESULTS

Nine Intermountain Healthcare clinical laboratories contributed 8438 CBCs to the initial reticulocyte parameter database. From these, 1806 were excluded because of a transfusion or a diagnosis of anemia, leaving 6632 in the reference interval database. The parameters charted over the first 90 days after birth were: (1) blood hemoglobin concentration (g dl(-1)), (2) mean corpuscular volume (fL), (3) reticulocyte count (x10(3) per μl), (4) IRF (%) and (5) RET-He (pg).

CONCLUSIONS

The new reference interval charts can help clinicians identify abnormalities in the reticulocyte parameters. This information could be of value in identifying and following neonates with various hematological problems including hemolytic disorders, occult hemorrhage, or iron deficiency or other limitations of erythrocyte production.

Evaluation of the Effect of Hypercapnia on Vascular Function in Normal Tension Glaucoma

INTRODUCTION

Altered ocular perfusion and vascular dysregulation have been reported in glaucoma. The aim of this paper was to evaluate the vascular response to a hypercapnic stimulus.

METHODS

Twenty normal tension glaucoma (NTG) patients and eighteen age- and gender-matched controls had pulsatile ocular blood flow (POBF) measurements, systemic cardiovascular assessment, and laser Doppler digital blood flow (DBF) assessed. Measurements were taken at baseline, after 10-minutes rest, in the stable sitting and supine positions and following induction and stabilization of hypercapnia, which induced a 15% increase in end-tidal pCO2. The POBF response to hypercapnia was divided into high (>20%) and low responders (<20%).

RESULTS

65% of NTG patients had a greater than 41% increase in POBF following CO2 rebreathing (high responders). These high responders had a lower baseline POBF, lower baseline DBF, and a greater DBF response to thermal stimulus.

CONCLUSION

NTG patients that have a greater than 20% increase in POBF after a hypercapnic stimulus have lower baseline POBF and DBF values. This suggests that there is impaired regulation of blood flow in a significant subgroup of NTG patients. This observation may reflect a generalised dysfunction of the vascular endothelium.

Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates?

OBJECTIVE

To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines.

STUDY DESIGN

This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes.

RESULT

Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually.

CONCLUSION

Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.

An experimental study of the electronic absorption and fluorescence spectral properties of new p-substituted-N-phenylpyrroles and their electrosynthesized polymers

Electronic absorption and fluorescence spectral properties of new p-substituted-N-phenylpyrroles (N-PhPys), including HOPhPy, MeOPhPy, ThPhPy, PhDPy, DPhDPy, PyPhThThPhPy, and their available, electrosynthesized polymers were investigated. Electronic absorption spectra, fluorescence excitation and emission spectra, fluorescence quantum yields (ΦF) and lifetimes (τF), and other photophysical parameters of these N-PhPy derivatives and their polymers were measured in DMF, DMSO diluted solutions and/or solid state at room temperature. The electronic absorption spectra of N-PhPy derivatives and their polymers included one to several bands, located in the 270-395 nm region, according to the p-phenyl substituent electron-donating effect and conjugated heteroaromatic system length. The fluorescence excitation spectra were characterized by one broad main peak, with, in most cases, one (or more) poorly resolved shoulder (s), appearing in the 270-405 nm region, and their emission spectra were generally constituted of several bands located in the 330-480 nm region. No significant shift of the absorption, fluorescence excitation and emission spectra wavelengths was found upon going from the monomers to the corresponding polymers. ΦF values were high, varying between 0.11 and 0.63, according to the nature of substituents(s) and to the conjugated system extension. Fluorescence decays were mono-exponential for the monomers and poly-exponential for PyPhThThPhPy and for polymers. τF values were relatively short (0.35-5.17 ns), and markedly decreased with the electron-donor character of the phenyl group p-substituent and the conjugated system extension.

Differential behaviour of cationic triphenylamine derivatives in fixed and living cells: triggering and imaging cell death

Nuclear staining by cationic triphenylamines is spontaneous in fixed cells while a cytoplasm–nucleus translocation is strictly dependent on light illumination in living cells and concomitant to a fast cell death process.

Randomised proof-of-concept phase II trial comparing targeted therapy based on tumour molecular profiling vs conventional therapy in patients with refractory cancer: results of the feasibility part of the SHIVA trial

Background:

The SHIVA trial is a multicentric randomised proof-of-concept phase II trial comparing molecularly targeted therapy based on tumour molecular profiling vs conventional therapy in patients with any type of refractory cancer. Results of the feasibility study on the first 100 enrolled patients are presented.

Methods:

Adult patients with any type of metastatic cancer who failed standard therapy were eligible for the study. The molecular profile was performed on a mandatory biopsy, and included mutations and gene copy number alteration analyses using high-throughput technologies, as well as the determination of oestrogen, progesterone, and androgen receptors by immunohistochemistry (IHC).

Results:

Biopsy was safely performed in 95 of the first 100 included patients. Median time between the biopsy and the therapeutic decision taken during a weekly molecular biology board was 26 days. Mutations, gene copy number alterations, and IHC analyses were successful in 63 (66%), 65 (68%), and 87 (92%) patients, respectively. A druggable molecular abnormality was present in 38 patients (40%).

Conclusions:

The establishment of a comprehensive tumour molecular profile was safe, feasible, and compatible with clinical practice in refractory cancer patients.

A risk stratification model to predict adverse neonatal outcome in labor

OBJECTIVE

The development and evaluation of a labor risk model consisting of a combination of antepartum risk factors and intrapartum fetal heart rate (FHR) characteristics that can reliably identify those infants at risk for adverse neonatal outcome in labor.

STUDY DESIGN

A nested case-control study of term singleton deliveries at the nine hospitals between March 2007 and December 2009. Eligibility criteria included: gestational age ≥ 37.0 weeks; singleton pregnancy; documented continuous FHR monitoring for ≥ 2 h before delivery; assessment of FHR tracing at least every 20 min; and, available maternal and neonatal outcomes. Adverse neonatal outcome was defined as nonanomalous infants admitted to the newborn intensive care unit with either a 5 minute Apgar score <7 or an umbilical artery pH<7.1. Initial risk score was determined using data available at 1 h after admission. Patients with an initial risk score between 7 and 15 were considered high risk. Intrapartum risk scores were then created for these patients using FHR tracing data and labor characteristics.

RESULT

A total of 51 244 patients were identified meeting study criteria. Of the antepartum variables evaluated (n=31), 10 were associated with an adverse outcome. The high-risk group made up 28% of the population and accounted for 59.8% of the adverse outcomes. Intrapartum characteristics were then evaluated in this high-risk group. Intrapartum evaluation identified the highest risk group with a C/S rate of 40% and adverse outcome rate of 11.3%.

CONCLUSION

Incorporation of maternal and antepartum risk factors with FHR analysis can improve the ability to identify the fetus at risk in labor.

Neonatal outcomes following a tight nuchal cord

OBJECTIVE

The best practices for the care of a neonate born after a tight nuchal cord have not been defined. As a step toward this, we compared the outcomes of neonates born after a tight nuchal cord vs those born after a loose nuchal cord vs those born after no nuchal cord.

STUDY DESIGN

This was a retrospective comparison using electronic data of all deliveries during a 6-year period (2005 to 2010) in a multihospital healthcare system in the western United States. At the time of delivery, each birth was recorded as having a tight nuchal cord, a loose nuchal cord or no nuchal cord. Nuchal cord was defined as a loop of umbilical cord ≥360° around the fetal neck. 'Tight' was defined as the inability to manually reduce the loop over the fetal head, and 'loose' as the ability to manually reduce the loop over the head.

RESULT

Of 219,337 live births in this period, 6.6% had a tight nuchal cord and 21.6% had a loose nuchal cord. Owing to the very large number of subjects, several intergroup differences were statistically significant but all were judged as too small for clinical significance. For instance, those with a tight nuchal cord had a very slightly older gestational age, a very slightly lower birth weight, a preponderance of male fetuses, primagravid women, singleton pregnancies and shoulder dystocia (all P<0.001). Term neonates with a tight nuchal cord were slightly more likely to be admitted to a Neonatal Intensive Care Unit (6.6% vs 5.9% admission rate, P=0.000). Those with a tight nuchal cord were not more likely to have dopamine administered or blood hemoglobin measured on the first day, nor were they more likely to receive a transfusion or to die. The subset of very low birth weight neonates with a tight nuchal cord, compared with those with no nuchal cord, were of the same gestational age and birth weight, with the same Apgar scores, and were not more likely to have severe intraventrucular hemorrhage, retinopathy of prematurity or periventricular leukomalacia, or to die.

CONCLUSION

The presence of a tight nuchal cord is not uncommon, occurring in 6.6% of over 200,000 consecutive live births in a multihospital health system. No differences in demographics or outcomes, judged as clinically significant, were associated with a tight nuchal cord. Thus, we speculate that the best practices for neonatal care after a tight nuchal cord do not involve an obligation to conduct extra laboratory studies or extra monitoring solely on the basis of the report of a tight nuchal cord.

Neonates presenting with bloody stools and eosinophilia can progress to two different types of necrotizing enterocolitis

OBJECTIVE

We hypothesized that neonates with bloody stools and concomitant eosinophilia are likely to have atopic enteropathy rather than necrotizing enterocolitis (NEC).

STUDY DESIGN

This was a retrospective cross-sectional study using electronic medical records and paper charts. Records of neonates admitted to any Intermountain Healthcare NICU between 1 January 2005 and 30 June 2010 were eligible if 'bloody stools' were listed in any archive. Qualifying records were divided into two groups depending on whether or not within 72 h of passing bloody stool eosinophil counts were above the 95th percentile reference range limit for age.

RESULT

Bloody stools were identified in 275 predominantly Caucasian neonates. Fifty-four of these had eosinophilia and 221 had normal eosinophil counts. Those with eosinophilia were born at a slightly younger gestational age (31.3 ± 4.6 vs 32.6 ± 4.0 weeks, mean ± s.d., P=0.032). Contrary to our hypothesis, those with eosinophilia did not have a lower rate of pneumatosis or bowel resection, or death ascribed to NEC. Eosinophilia was more common among those who had a red blood cell (RBC) transfusion within 48 h before passing bloody stools (P<0.001). Those with a recent RBC transfusion were the only neonates to have NEC surgery or to die from NEC. Preceding the bloody stools, those with no antecedent transfusion had been fed a larger volume (P=0.014), and had trends toward receiving calorically enriched feedings (P=0.055) and recent addition of human milk fortifier (P=0.060). Eosinophil counts following RBC transfusion tended to increase for 3-6 days, but when bloody stools were not preceded by transfusion the eosinophil counts were more static over that period.

CONCLUSION

In this predominantly Caucasian group of neonates with bloody stools, the presence of eosinophilia did not identify a benign condition distinct from NEC. A total of 44% of these neonates had transfusion-associated NEC. Eosinophils could have a previously unrecognized role in the pathogenesis of this NEC subtype.

Effect of ampicillin on bleeding time in very low birth-weight neonates during the first week after birth

OBJECTIVE

On the day of birth, the bleeding time of very low birth-weight (VLBW, <1500 g) neonates is generally prolonged, compared with term neonates. However, their bleeding time generally improves (shortens) over the next 7 to 10 days. Ampicillin can prolong the bleeding times of term and late preterm neonates, but its effect on VLBW neonates, who already have a somewhat prolonged bleeding time initially, is not known.

STUDY DESIGN

This was a prospective, single-centered, paired, before vs after test of the effect of ampicillin on template bleeding time and PFA-100 time (platelet function analyzer). Ampicillin was dosed at every 12 h intravenously, but decisions about discontinuation were made by the responsible clinician, independent of this study.

RESULT

A total of 20 VLBW neonates were studied. They ranged from 23- to 30-weeks gestation at birth and weighed 500 t 1410 g. Initial bleeding times averaged 166 s (95% CI, 138 to 194) and initial PFA-100 times averaged 119 s (95% CI, 90 to 148). In all, 10 had ampicillin dosing stopped after a shorter course (4 to 7 doses) and 10 had it continued for a longer course (10 to 15 doses). Blood cultures were sterile in all 20, and no differences in laboratory or clinical features were found between those treated with a shorter vs longer course. After stopping the ampicillin following a short course the bleeding times and PFA-100 times were similar to the initial values. However, after a longer course the bleeding times were prolonged by an average of 2 min, to 284 s (95% CI, 242 to 326; P=0.001 vs initial). The PFA-100 times also trended longer by an average of 44 s (P=0.07). The number of doses of ampicillin received in the first week correlated with the degree of prolongation in bleeding time (r=0.68).

CONCLUSION

Over the first week of life, a period when the bleeding time of VLBW neonates normally shortens, the opposite occurred (the bleeding time lengthened) if ≥ 10 doses of ampicillin were administered.

Measurement of flow velocity profiles in tank structures using the prototype device OCM Pro LR

Generally, studies investigating the treatment efficiency of tank structures for storm water or waste water treatment observe pollutant flows in connection with conditions of hydraulic loading. Further investigations evaluate internal processes in tank structures using computational fluid dynamic (CFD) modelling or lab scale tests. As flow paths inside of tank structures have a considerable influence on the treatment efficiency, flow velocity profile (FVP) measurements can provide a possibility to calibrate CFD models and contribute to a better understanding of pollutant transport processes in these structures. This study focuses on tests carried out with the prototype FVP measurement device OCM Pro LR by NIVUS in a sedimentation tank with combined sewer overflow (CSO) situated in Petange, Luxembourg. The OCM Pro LR measurement system analyses the echo of ultrasonic signals of different flow depths to get a detailed FVP. A comparison of flow velocity measured by OCM Pro LR with a vane measurement showed good conformity. The FVPs measured by OCM Pro LR point out shortcut flows within the tank structure during CSO events, which could cause a reduction of the cleaning efficiency of the structure. The results prove the applicability of FVP measurements in large-scale structures.

Effect of ampicillin on the bleeding time of neonatal intensive care unit patients

OBJECTIVE

Studies in adults indicate that ampicillin, in a dose-dependent manner, impairs platelet function and moderately prolongs the bleeding time (generally by 60 to 90 s). Unlike aspirin, the inhibition induced by ampicillin involves both reversible and irreversible mechanisms and is not observed immediately after initial dosing (generally requiring approximately 24 h). Ampicillin is administered commonly to neonatal intensive care unit (NICU) patients, but its effect on bleeding time in this population has not been reported earlier.

STUDY DESIGN

We performed neonatal template bleeding times and platelet function analyzer (PFA)-100 tests on 15 NICU patients before and at various intervals after intravenous ampicillin dosing.

RESULT

Neonates were only studied if no beta-lactam antibiotics were administered to their mother during labor, and if they had ampicillin ordered by the clinician at a dose of 50 to 100 mg kg(-1) every 12 h. Subjects ranged from 33 to 41 weeks gestation and weighed 1760 to 3835 g. Bleeding times before the first ampicillin dose (n=15) averaged 134 s (95% confidence interval (CI), 120 to 148 s) and PFA-100 times averaged 123 s (95% CI, 96 to 149 s). After the first dose of ampicillin (n=5), bleeding times and PFA-100 times did not increase, but after the third (n=5) and fourth doses (n=4) bleeding times lengthened by an average of 60 s (95% CI, 37 to 83 s, P<0.001) and PFA-100 times lengthened by an average of 20 s (95% CI, -20 to 60 s, P=0.15).

CONCLUSION

Ampicillin administered intravenously to NICU patients prolongs the bleeding time, with a magnitude-of-effect and time-to-effect similar to that shown earlier in adults.

Reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period defined from over 63 000 records in a multihospital health-care system

OBJECTIVE

Blood concentrations of eosinophils and monocytes are part of the complete blood count. Reference ranges for these concentrations during the neonatal period, established by very large sample sizes and modern methods, are needed for identifying abnormally low or high values.

STUDY DESIGN

We constructed reference ranges for eosinophils per microl and monocytes per microl among neonates of 22 to 42 weeks of gestation, on the day of birth, and also during 28 days after birth. Data were obtained from archived electronic records over an eight and one-half-year period in a multihospital health-care system. In keeping with the reference range concept, values were excluded from neonates with a diagnosis of infection or necrotizing enterocolitis (NEC).

RESULT

Eosinophils and monocytes per microl of blood were electronically retrieved from 96 162 records, of which 63 371 that lacked a diagnosis of infection or NEC were included in this reference range report. The mean value for eosinophils per microl on the day of birth increased linearly between 22 and 42 weeks of gestation, as did the 5 and 95% values. The reference range at 40 weeks was 140 to 1300 microl(-1) (mean 550 microl(-1)). Similarly, the mean value for monocytes increased linearly over this interval, with a reference range at 40 weeks of 300 to 3300 microl(-1) (mean 1400 microl(-1)). Over the first 4 weeks after birth, no appreciable change was observed in 5% limit and mean eosinophil count, with a slight increase in the 95% limit in week 4. A slight increase in monocyte count was observed during the first 2 weeks after birth.

CONCLUSION

The results of this analysis describe reference ranges for blood concentrations of eosinophils and monocytes during the neonatal period. Additional study is needed for determining the relevance of values falling outside the reference range.

Proton radiography of a shock-compressed target

In this paper we report on the radiography of a shock-compressed target using laser produced proton beams. A low-density carbon foam target was shock compressed by long pulse high-energy laser beams. The shock front was transversally probed with a proton beam produced in the interaction of a high intensity laser beam with a gold foil. We show that from radiography data, the density profile in the shocked target can be deduced using Monte Carlo simulations. By changing the delay between long and short pulse beams, we could probe different plasma conditions and structures, demonstrating that the details of the steep density gradient can be resolved. This technique is validated as a diagnostic for the investigation of warm dense plasmas, allowing an in situ characterization of high-density contrasted plasmas.

Thrombocytosis in neonates and young infants: a report of 25 patients with platelet counts of > or = 1000000 microl(-1)

OBJECTIVE

Thrombocytosis has been reported in neonates and young infants, but little is known of its prevalence, timing of onset, associated conditions, sequelae and outcomes. To better understand this condition, we used the data repositories of a multi-hospital health-care system to identify all individuals <or=140 days old (20 weeks) who, during the past 6 years, had a platelet count of >or=1000000 microl(-1).

STUDY DESIGN

We identified all infants with extreme thrombocytosis (using the Sutor definition of a platelet count of >or=1000000 microl(-1)) during the period of January 2003 through December 2008 in any Intermountain Healthcare facility. We obtained the information provided in this report from electronic and paper records.

RESULT

Among 40 471 infants who had one or more platelet counts performed in this period, 25 had extreme thrombocytosis. No cases were identified in the first week after birth, 40% were recognized between the second and fourth weeks and 40% between the fifth and eighth week. The prevalence of thrombocytosis had no relationship with birth weight or gestational age but a slight predominance of female patients (15/25) was noted. In all, 26 episodes were found among the 25 infants: 12 episodes involved an antecedent infectious disease, 8 had an antecedent surgical procedure, 4 had the anemia of prematurity and 1 each had congenital adrenal hyperplasia and opiate withdrawal syndrome. No pathological thromboses or hemorrhages or other sequelae were detected and all episodes resolved with no deaths.

CONCLUSION

The thrombocytosis cases that we report were all consistent with reactive thrombocytosis (also known as secondary thrombocytosis); none seemed to be essential (primary) thrombocytosis. We speculate that the pathogenesis involves increased platelet production due to megakaryopoietic stimulators induced by an infectious or inflammatory condition. From this series and previous reports, young infants with platelet counts up to 1300000 microl(-1) do not seem to have a significant risk of thrombotic or hemorrhagic problems, and do not generally require anti-platelet or cytoreductive treatment.

Antecedents of Bell stage III necrotizing enterocolitis

OBJECTIVE

New biopharmaceuticals hold promise for preventing or treating necrotizing enterocolitis. However, it is unclear whether any such biopharmaceutical that requires enteral administration could be administered using an 'early-treatment' paradigm. This study was undertaken to assess this issue based on data from every case of Bell stage III NEC cared for during the past 7 years at Intermountain Healthcare.

STUDY DESIGN

Patients with Bell stage III NEC were identified from electronic medical record repositories and the diagnosis was validated using operative reports. Electronic and paper records of each patient were then used to identify potential clinical and laboratory antecedents occurring within the 48 h period preceding the diagnosis of NEC.

RESULT

One hundred eighteen patients had Stage III NEC. The earliest recognized antecedents were nonspecific for NEC (apnea/bradycardia, skin mottling and irritability). These were recorded at 2.8+/-2.1, 4.5+/-3.1 and 5.4+/-3.7 (mean+/-s.d.) hours, respectively, before NEC was diagnosed. The most commonly identified gastrointestinal antecedents were blood in the stools, increased abdominal girth and elevated pre-feeding gastric residuals or emesis. These were identified 2.0+/-1.9, 2.8+/-3.1 and 4.9+/-4.0 h before NEC was recognized. Thirty-eight percent had a blood transfusion (18+/-12 h) preceding the NEC. Tachycardia, tachypnea, hypotension and diarrhea were rarely identified as antecedents and no consistent laboratory antecedents were discovered.

CONCLUSION

We judge that an 'early treatment of NEC' paradigm testing any pharmacological agent that must be administered enterally is not feasible. The first recognized antecedents of Bell stage III NEC are nonspecific for gastrointestinal pathology and insufficient time exists for dosing between the first gastrointestinal signs and placement of the gastric decompression tube.

Multiple Breast Cancer Risk Factors Do Not Improve Patient Acceptance of Chemoprevention

Background: Patients may be at increased risk of developing breast cancer due to hereditary or familial risk or a pathological diagnosis of breast atypia or lobular carcinoma in situ (LCIS). Although tamoxifen and raloxifene are effective and approved chemopreventive agents to reduce risk of developing breast cancer in high risk individuals, acceptance of chemoprevention as a risk reduction strategy is low. Our objective was to assess whether chemoprevention is more readily accepted by those at genetic or familial risk versus pathologic risk, and if the presence of multiple breast cancer risk factors improves chemoprevention acceptance.Methods: All patients seen at the Loyola University Cancer Risk Assessment and Prevention clinic completed information including demographics, health, family and social history. Patients with a family history of either a first or second degree family member with breast cancer (FH) were compared to those who presented due to atypia or LCIS on breast biopsy as well as those with an elevated Gail score. Acceptance of risk reducing strategies between these groups was compared.Results: The initial 115 patients presenting to the clinic were analyzed. Thirty-six (31%) women had FH only, 26 (23%) had a biopsy with atypia or LCIS only, 10 (9%) had an elevated Gail score, 17 (15%) had a biopsy indicating atypia or LCIS plus FH, and 26 (23%) had an elevated Gail plus FH. Seventy-three patients were candidates for chemoprevention; 16 (22%) accepted chemoprevention. Patients with a FH plus atypia/LCIS did not accept chemoprevention more than patients with FH alone (p=1.00). Patients with a FH plus atypia/LCIS did not accept chemoprevention more than than patients with atypia/LCIS alone (p=0.451). Pts with elevated Gail plus FH did not accept chemoprevention more than patients with elevated Gail alone (p=0.144). Four women in the FH group were known BRCA mutation carriers; all elected to proceed with risk reducing surgery, none accepted chemoprevention.Conclusions: Acceptance of chemoprevention is low in women at genetic or familial risk, those at risk due to atypia/LCIS, and those with an elevated Gail score. Having both familial and pathologic risk factors for breast cancer development did not increase acceptance of chemoprevention. Better understanding of women's comprehension of breast cancer risk, and barriers to patient acceptance of chemoprevention are needed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1039.

Isolated elevated blood neutrophil concentration at altitude does not require NICU admission if appropriate reference ranges are used

OBJECTIVE

The Intermountain Healthcare hospitals use a clinical pathway algorithm for early-onset infection, which is based on the 2002 Centers for Disease Control and Prevention (CDC) guidelines for perinatal group B streptococcal disease. As part of this pathway, neonates in the well baby nursery, who seem to be well but have risk factors for infection, receive a 'limited laboratory evaluation including a CBC', and if the complete blood cell count (CBC) is abnormal, antibiotic treatment and neonatal intensive care unit (NICU) monitoring are initiated. We recently found that reference ranges for absolute neutrophil counts (ANCs) are much wider at our altitude (4800 to 5000 ft) than at sea level. On this basis, we speculated that some well babies with risk factors for infection are mistakenly judged as having an abnormal CBC, and are unnecessarily admitted to the NICU.

STUDY DESIGN

This was a retrospective observational cohort study of neonates of >37 weeks gestation admitted to either of two Intermountain Healthcare NICUs for intravenous antibiotic treatment during a recent 36-month period.

RESULTS

During the study period 3217 patients were admitted to the two NICUs, 1049 (32.6%) of which were born at>37 weeks gestation. Of these, 14 (1.3%) were found to have been admitted to the NICU on the basis of an abnormal CBC (elevated ANC), when in retrospect, using the appropriate ANC chart, their CBCs were completely normal. None of the 14 neonates had a leukocyte left shift (immature to total neutrophil ratio >0.3) or thrombocytopenia. None were treated with supplemental oxygen or mechanical ventilation in the NICU. All 14 had sterile blood cultures. All had antibiotics stopped in 48 to 72 h, and all were discharged home as well babies.

CONCLUSION

We identified 14 neonates who, while in the well baby nursery, were found to have risk factors for early-onset infection, but did not seem to be infected, and were subsequently admitted to a NICU for intravenous antibiotic treatment and monitoring under the mistaken impression that they had an abnormal CBC. We maintain that use of an appropriate neutrophil reference range chart can reduce NICU admissions and can limit unnecessary antibiotic exposure.

Factors associated with unprotected anal intercourse among men who have sex with men in Douala, Cameroon

OBJECTIVES

Research on men who have sex with men (MSM) in sub-Saharan Africa was neglected for a long time. The objective of this study was to understand factors associated with unprotected anal intercourse (UAI) with male partners among a group of MSM living in the city of Douala, Cameroon.

METHODS

In 2008, a survey on the sexual activity and practices of MSM was set up in Douala in collaboration with a local community-based organisation. Data were collected among a convenience sample of 168 MSM during face-to-face interviews with trained interviewers.

RESULTS

A total of 142 individuals reported sexual activity during the previous 6 months, among whom 80 (57%) reported UAI with male partners. In a multivariate logistic regression model adjusted for the frequency of sexual intercourse, not having had access to prevention interventions and not knowing any HIV-infected person were both independently associated with a higher risk of UAI. Other factors associated with this higher risk included having had a stable male partnership at some point in one's life and not having been out of Douala for more than 4 weeks during the previous year.

CONCLUSIONS

This community-based research is the first study of MSM in Cameroon and the HIV transmission risks they face. Results show the importance of HIV prevention interventions from peers, and underline the need to maintain efforts to develop specific interventions targeting MSM more efficiently in the African context.

Ibuprofen lysine administration to neonates with a patent ductus arteriosus: effect on platelet plug formation assessed by in vivo and in vitro measurements

OBJECTIVE

Ibuprofen might have advantages over indomethacin, when used to effectuate closure of a neonate's patent ductus arteriosus (PDA). Several previous studies indicate that platelet plug formation is impaired after administration of indomethacin, but it is not clear whether a similar impairment occurs following ibuprofen dosing.

STUDY DESIGN

We performed template bleeding times and PFA-100 tests (platelet function analyzer) on 20 neonates who had a PDA, before and again at various preset intervals following ibuprofen dosing.

RESULT

Patients ranged from 23 to 40 weeks gestation and weighed 511 to 2566 g. Their first dose of ibuprofen was administered at 72 h (18 to 363 h) after birth (median, range). None of the subjects had clinical bleeding problems noted during the days they received ibuprofen dosing. The template bleeding times before dosing ranged from 135 to 450 s. Repeat tests were performed in groups of four, at 2 h, 4 to 6 h, 12 to 18 h, 24 h after the first dose, and at 2 h after the third dose of ibuprofen. No changes in bleeding times were detected. (P=0.299) A PFA-100 time was performed on all 20 patients before and again after the ibuprofen administration. However, 3 of the 40 tests were unsuccessful, because of microclots in the blood sample (n=1) or failure of the analyzer for an unspecified reason (n=2). Before the dosing the PFA-100 time ranged from 52 to 300 s. A paired t-test showed a slight but statistically significant lengthening in PFA-100 time after the ibuprofen administration (P=0.019). The correlation between the bleeding time and the PFA-100 was poor (R(2)=0.212, P=0.576).

CONCLUSION

On the basis of our present studies, we speculate that ibuprofen lysine administration to neonates with a PDA, when used according to the manufacturer's recommendations, has little adverse effect on platelet plug formation. This information might be a factor to consider when deciding whether to select indomethacin or ibuprofen for PDA closure.

Necrotizing enterocolitis during the first week of life: a multicentered case-control and cohort comparison study

OBJECTIVE

Necrotizing enterocolitis (NEC) is rare during the first week of life; most cases occur after 2 to 4 weeks. We hypothesized that when NEC develops in the first week, certain predisposing factors and feeding practices are identifiable. To test this, we sought to identify every case of NEC diagnosed during the first week within the Intermountain Healthcare system during the most recent 6-year period.

STUDY DESIGN

Data were collected from neonates admitted to any Intermountain Healthcare neonatal intensive care unit (NICU) with a date of birth from 1 January 2001 through 31 December 2006. Electronic and paper records were obtained for all with a diagnosis of NEC (Bell stage >or=II) within the first 168 h. X-rays, physician notes, nursing records, laboratory reports and operative reports were subjected to critical review to reexamine the diagnosis of NEC. Among those with confirmed NEC, we recorded underlying conditions and every feeding given prior to the diagnosis of NEC. Comparisons were made with patients that did not develop NEC, yet were cared for in the same NICUs, during the same period of time, and of the same gestational ages.

RESULT

A total of 28 neonates were identified electronically as having NEC during the first week. Critical review confirmed this in 21, but 5 were determined at laparotomy to have had spontaneous intestinal perforation, and 2 others were found on surgical reports to have had a congenital infarction of the colon. Total 20 of the 21 confirmed cases developed NEC while in a NICU being treated for another condition. The exception was a small-for-gestational-age neonate in a well baby nursery. Compared to 6100 controls, the 21 with early NEC were more likely to have had a meconium-positive test for illicit drug exposure (P<0.005), early onset sepsis (P<0.034) and respiratory distress (P<0.039). They were less likely than case-controls to have been fed human milk (P=0.003) and were more likely to have been fed formula exclusively (P=0.019). None who were fed human milk exclusively developed early NEC. Twelve of the twenty-one were fed (by gavage or bottle) amounts exceeding the upper limit of volumes taken by breastfed neonates.

CONCLUSION

We speculate that the prevalence of NEC during the first week could be reduced by identifying at-risk patients, feeding them human milk exclusively for the first week and using feeding volumes that do not exceed that taken by healthy breastfed neonates.

The road to zero preventable birth injuries

BACKGROUND

The Seton Family of Hospitals' experience in developing and implementing transformational practices in labor and delivery (L&D) units aimed at reducing the rate of birth trauma at our facilities was previously reported.

METHODS

Seton began its individual perinatal safety effort in earnest in October 2003. The endeavor brought together the four hospitals that offer obstetrical services, resulting in the establishment of an interdisciplinary team. The team meets monthly to develop and monitor best practices that are then shared, executed, and validated by each respective site's perinatal councils.

RESULTS

A 36% reduction in the use of vacuum and forceps (from a frequency of 7.4% to 4.7%) was previously reported; the current rate (fiscal year [FY] 2007-FY 2008 year-to-date; July 1, 2006-December 31, 2007) was 4.1%. The incidence of associated birth trauma decreased to 0% for the last 15 months (ending December 31, 2007). During the first three project years (FY 2004-FY 2006), the average length of stay for infants admitted to the neonatal intensive care unit for birth injury declined by 80% (as compared with the previous three years), from 15.8 to 3.1 days.

DISCUSSION

The perinatal safety team developed processes that have resulted in large and sustained reductions in the rate of serious birth trauma at all obstetric facilities.

Adherence to NICU transfusion guidelines: data from a multihospital healthcare system

OBJECTIVE

We critically reviewed every NICU blood component transfusion (packed erythrocytes, platelets, frozen plasma (FP) and cryoprecipitate) administered during a one-year period. This was done to determine the proportion of transfusions given out of compliance with the Intermountain Healthcare transfusion guidelines, and to look for patterns of non-compliance that could be addressed by quality improvement measures.

STUDY DESIGN

A detailed review was made of every transfusion administered to patients with a date of birth of 1 January 2006 through 31 December 2006, in any of three level III, perinatal-center-associated NICUs within Intermountain Healthcare.

RESULT

During 2006 the three NICUs cared for 1759 neonates. Seventeen percent of these received one or more (median 3) erythrocyte transfusions, 4% received one or more (median 3) platelet transfusions, 6% received one or more (median 1) FP infusions and 2% received cryoprecipitate (median 1 dose). Seventy percent of the erythrocyte transfusions were given in compliance with the guidelines, as were 69% of the platelet transfusions, 65% of the FP transfusions and 94% of the cryoprecipitate administrations. Patients who received large numbers of transfusions were more likely to receive transfusion that violated the guidelines. Forty-five percent of patients who received 1 to 3 transfusions received all transfusions within guidelines. However, only 18% of patients who received 4 to 10 transfusions received all within guidelines. No patient who received >10 transfusions received all within the guidelines. Erythrocyte transfusions given early in the hospital course were likely to be within guidelines; 72% (588/818) in the first 29 days were compliant with guidelines, but compliance fell to 61% (144/237) for transfusions administered after 29 days (P=0.002). About half of the platelet transfusions given early in the hospital course were in violation of guidelines, but after day 9, 83% of platelet transfusions were compliant with guidelines (P=0.000).

CONCLUSION

Opportunities exist in our healthcare system to improve compliance with our transfusion guidelines. Such opportunities are greatest among neonates receiving multiple transfusions, among those receiving erythrocyte transfusions late in their NICU course and among those receiving platelet transfusions early in their NICU course.

Do platelet transfusions in the NICU adversely affect survival? Analysis of 1600 thrombocytopenic neonates in a multihospital healthcare system

OBJECTIVE

Several studies have indicated a correlation between the number of platelet transfusions received by newborn intensive care unit (NICU) patients and the mortality rate. The number of platelet transfusions might be a marker for level of illness, and thus predictive of mortality. However, an alternative hypothesis is that multiple platelet transfusions themselves are harmful in this population.

STUDY DESIGN

We evaluated data from all thrombocytopenic neonates cared for in the Intermountain Healthcare NICUs in the past 4 years, seeking associations between the lowest platelet count recorded, number of platelet transfusions received and mortality rate. We also conducted a sensitivity analysis to examine the hypothesis that platelet transfusions were responsible for some fraction of the mortality rate.

RESULT

Transfusion and outcome data were examined from 1600 thrombocytopenic NICU patients. At any level of platelet count, some patients received platelet transfusions but others did not. However, at all levels of platelet count, those that received platelet transfusions had a higher mortality rate. Neonates not given any platelet transfusions had a mortality rate of 2%, those with 1 or 2 transfusions had a mortality rate of 11% (P<0.001); those with >10 had a mortality rate of 35% (P<0.001); and those with > or = 20 had a mortality rate of 50% (P<0.001). A sensitivity analysis suggested that the platelet transfusions themselves were very likely responsible for some fraction of the increasing mortality rate.

CONCLUSION

The number of platelet transfusions administered in the NICU predicts the mortality rate. Some of this correlation is ascribable to unknown and unmeasured factors such as level of illness. However, the present data and the sensitivity analysis both suggest that some of this correlation is due to harmful effects of multiple platelet transfusions in this group of patients.