Determinants of depressive and alcohol use disorders among female sex workers in Ethiopia: evidence from a national bio-behavioral survey, 2020

BACKGROUND

Female sex workers (FSWs) face an elevated risk of developing mental health disorders and alcohol use disorders (AUD), which in turn increase their vulnerability to HIV and other sexually transmitted infections (STIs) and other negative outcomes. To effectively address both of these health issues, it is crucial to understand the shared key determinants underlying these illnesses, which is a substantial knowledge gap in Ethiopia and elsewhere in the world. Therefore, this study aimed to identify the common key determinants of depression and AUD among FSWs in Ethiopia using a bivariate multivariable ordinal logistic model.

METHODS

We analyzed cross-sectional biobehavioral data collected in 2020 from 16 cities and major towns in Ethiopia using the respondent-driven sampling (RDS) technique, which involved a total of 6,085 FSWs. FSWs who had lived at the study sites for at least a month before the study period were deemed eligible for recruitment. Major depressive disorder (DD) and AUD were screened using the Patient Health Questionnaire (PHQ9) and alcohol use disorder identification test (AUDIT), respectively. We used descriptive statistics to summarize study population characteristics and bivariate multivariable ordinal logistic regression (BMOLR) to identify common determinants of DD and AUD combined and their nonnormal correlation.

RESULTS

Among 6085 FSWs screened for DD and AUD, 13.5% and 4.0% have met the criteria for moderate and severe depressive disorder, respectively, and 20.3% and 34.7% have met the AUDIT criteria for harmful or hazardous behavior and alcohol dependence, respectively. FSW with experience of inconsistent condom use, condom failure, violence, mobility, use of any drugs, non-paying partners, abortion, and selling sex for more than five years were associated with an increase in the severity of both disorders. A high average income from selling sex and the number of paying partners reduced the severity of depression and increased the level of alcohol dependence. Being HIV positive and ever having anal sex were associated only with an increase in depression.

CONCLUSION

Major DD and AUD are prevalent among FSWs in Ethiopia. The findings revealed that common key determinants, which exacerbated the severity of both disorders, were also risk factors for HIV and other STIs. Consequently, integrated STI strategies are essential in the screening, referral, and treatment of depression and AUD. Intervention packages should encompass determinants of depression and AUD, including condom utilization, drug use, mobility between towns, abortion, violence, and counseling services. Additionally, strategies to ensure economic security should be incorporated.

Comparison of porcine versus bovine surfactant in preterm respiratory distress syndrome: Evidence from real-world data. A multicentre collaboration from Karnataka

BACKGROUND & OBJECTIVES

Porcine surfactant (200 mg/kg initial dose) seems to be superior to bovine surfactants (100 mg/kg) in respiratory distress syndrome (RDS). There is limited data on the choice of surfactant from the developing world. Logically, using higher doses of porcine surfactant comes with an additional cost burden. We decided to evaluate the clinical effects of different types of surfactants.

METHODS

A retrospective analysis was conducted from August 2019 to December 2022 in six tertiary centers. Neonates 24-34 weeks of gestation with RDS requiring either porcine (200 mg/kg) or bovine surfactant (100 mg/kg) were enrolled. The proportion of BPD, redosing, and other morbidities in either group were analyzed. The outcomes in preterm ≥28 and <28 weeks subgroups were analyzed.

RESULTS

Of 1149 eligible babies, 302 (26%) received surfactant after stabilization with CPAP. One hundred fifty-eight received porcine, and 144 received bovine surfactant. There was a higher BPD in porcine compared to the bovine group on univariate analysis [24 (15%) vs. 6 (4%); OR: 4; 95% CI: 1.6-10; p = 0.002]. On logistic regression, the gestational age and PDA requiring treatment were independent predictors of BPD, and the type of surfactant and centres did not influence BPD. Redosing [27 (17%) vs. 18 (12%), OR: 1.4; 95% CI: 0.7-2.7; p = 0.2] was not different between both surfactant types. Other morbidities like mortality, air leaks, invasive ventilation, and CPAP duration were also not different between the groups.

CONCLUSION

We could not find a difference in the outcomes of BPD and redosing using porcine surfactant at 200 mg/kg compared to bovine surfactant. Considering the cost burden in the developing world, efficacy needs to be evaluated in randomized clinical trials.

Gastric Fluid Metabolomics Predicting the Need for Surfactant Replacement Therapy in Very Preterm Infants Results of a Case-Control Study

Respiratory distress syndrome (RDS) is a major morbidity of prematurity. In this case-control study, we prospectively evaluated whether untargeted metabolomic analysis (gas chromatography-mass spectrometry) of the gastric fluid could predict the need for surfactant in very preterm neonates. 43 infants with RDS necessitating surfactant (cases) were compared with 30 infants who were not treated with surfactant (controls). Perinatal-neonatal characteristics were recorded. Significant differences in gastric fluid metabolites (L-proline, L-glycine, L-threonine, acetyl-L-serine) were observed between groups, but none could solely predict surfactant administration with high accuracy. Univariate analysis revealed significant predictors of surfactant administration involving gastric fluid metabolites (L-glycine, acetyl-L-serine) and clinical parameters (gestational age, Apgar scores, intubation in the delivery room). Multivariable models were constructed for significant clinical variables as well as for the combination of clinical variables and gastric fluid metabolites. The AUC value of the first model was 0.69 (95% CI 0.57-0.81) and of the second, 0.76 (95% CI 0.64-0.86), in which acetyl-L-serine and intubation in the delivery room were found to be significant predictors of surfactant therapy. This investigation adds to the current knowledge of biomarkers in preterm neonates with RDS, but further research is required to assess the predictive value of gastric fluid metabolomics in this field.

HIV and hepatitis B, C co-infection and correlates of HIV infection among men who have sex with men in Rwanda, 2021: a respondent-driven sampling, cross-sectional study

BACKGROUND

Men who have sex with men (MSM) are a key population group disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. In Rwanda, the HIV epidemic remains a significant public health concern, and understanding the burden of HIV and hepatitis B and C coinfections among MSM is crucial for designing effective prevention and control strategies. This study aims to determine the prevalence of HIV, hepatitis B, and hepatitis C infections among MSM in Rwanda and identify correlates associated with HIV infection within this population.

METHODS

We used respondent-driven sampling (RDS) to recruit participants between November and December 2021. A face-to-face, structured questionnaire was administered. Testing for HIV infection followed the national algorithm using two rapid tests: Alere Combo and STAT PAK as the first and second screening tests, respectively. Hepatitis B surface antigen (HBsAg) and anti-HCV tests were performed. All statistics were adjusted for RDS design, and a multivariable logistic regression model was constructed to identify factors associated with HIV infection.

RESULTS

The prevalence of HIV among MSM was 6·9% (95% CI: 5·5-8·6), and among HIV-positive MSM, 12·9% (95% CI: 5·5-27·3) were recently infected. The prevalence of hepatitis B and C was 4·2% (95% CI: 3·0-5·7) and 0·7% (95% CI: 0·4-1·2), respectively. HIV and hepatitis B virus coinfection was 0·5% (95% CI: 0·2-1·1), whereas HIV and hepatitis C coinfection was 0·1% (95% CI: 0·0-0·5), and no coinfection for all three viruses was observed. MSM groups with an increased risk of HIV infection included those who ever suffered violence or abuse because of having sex with other men (AOR: 3·42; 95% CI: 1·87-6·25), those who refused to answer the question asking about 'ever been paid money, goods, or services for sex' (AOR: 10·4; 95% CI: 3·30-32·84), and those not consistently using condoms (AOR: 3·15; 95% CI: 1·31-7·60).

CONCLUSION

The findings suggest more targeted prevention and treatment approaches and underscore the importance of addressing structural and behavioral factors contributing to HIV vulnerability, setting interventions to reduce violence and abuse against MSM, promoting safe and consensual sexual practices, and expanding access to HIV prevention tools such as condoms and preexposure prophylaxis (PrEP).

Association between in-country migration and HIV infection among transgender women from northeastern Brazil: a respondent-driven sampling survey

BACKGROUND

Migration is common among transgender women (TGW), often driven by the desire to escape stigma, find acceptance, establish new connections, access body modifications, or enter new avenues of sex work. Given the heightened mobility of TGW, they are mostly vulnerable to human immunodeficiency virus (HIV) due to migration. This study aimed to evaluate the association between in-country migration and HIV infection among TGW in Northeast Brazil.

METHODS

The DIVAS was a cross-sectional, multicity study investigating risk behaviors and sexually transmitted infections (STI) among TGW in 2016-2017. A total of 864 TGW were recruited through respondent-driven sampling from three capital cities in Northeast Brazil. Logistic regression estimating odds ratios (OR) and 95% confidence intervals (CI) was used to assess the relationship between in-country migration and HIV infection.

RESULTS

The prevalence of HIV among TGW was 24.5%, 21.4% among those aged 18-34 and 36.1% among those ≥ 35 years old. In-country migration increased the odds of HIV infection among TGW aged 18-34 years (OR = 1.84; 95%CI:1.04-3.27) and even higher among those aged ≥ 35y old (OR = 3.08; 95%CI:1.18-8.04).

CONCLUSIONS

These data reinforce the pressing need for public health policies that provide comprehensive access and strategies for demand creation for HIV/AIDS prevention and care for TGW who are already highly vulnerable to infection.

A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units

(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.

Synthetic surfactant with a combined SP-B and SP-C analogue is efficient in rabbit models of adult and neonatal respiratory distress syndrome

Respiratory distress syndrome (RDS) in premature infants is caused by insufficient amounts of endogenous lung surfactant and is efficiently treated with replacement therapy using animal-derived surfactant preparations. On the other hand, adult/acute RDS (ARDS) occurs secondary to for example, sepsis, aspiration of gastric contents, and multitrauma and is caused by alveolar endothelial damage, leakage of plasma components into the airspaces and inhibition of surfactant activity. Instillation of surfactant preparations in ARDS has so far resulted in very limited treatment effects, partly due to inactivation of the delivered surfactants in the airspace. Here, we develop a combined surfactant protein B (SP-B) and SP-C peptide analogue (Combo) that can be efficiently expressed and purified from Escherichia coli without any solubility or purification tag. NMR spectroscopy shows that Combo peptide forms α-helices both in organic solvents and in lipid micelles, which coincide with the helical regions described for the isolated SP-B and SP-C parts. Artificial Combo surfactant composed of synthetic dipalmitoylphosphatidylcholine:palmitoyloleoylphosphatidylglycerol, 1:1, mixed with 3 weights % relative to total phospholipids of Combo peptide efficiently improves tidal volumes and lung gas volumes at end-expiration in a premature rabbit fetus model of RDS. Combo surfactant also improves oxygenation and respiratory parameters and lowers cytokine release in an acid instillation-induced ARDS adult rabbit model. Combo surfactant is markedly more resistant to inhibition by albumin and fibrinogen than a natural-derived surfactant in clinical use for the treatment of RDS. These features of Combo surfactant make it attractive for the development of novel therapies against human ARDS.

Antenatal magnesium sulfate and the need for mechanical ventilation in the first three days of life

BACKGROUND

Antenatal administration of magnesium sulfate (MgSO4) to women in preterm labor has gained widespread use. This study examined the relationship between MgSO4 exposure with neonatal respiratory outcomes.

METHODS

Very low birth weight (VLBW) infants exposed to antenatal MgSO4 were included. Infants who were intubated anytime during the first three days of life were compared to those who were not intubated regarding their demographic and clinical characteristics, MgSO4 therapy, immediate respiratory outcomes, and occurrence of intraventricular hemorrhage (IVH) using student t-test, chi square testing and logistic regression analysis to control for confounding variables. Correlation coefficient of MgSO4 cumulative dose given and duration of infusion with delivery room resuscitation and need for mechanical ventilation in the first 3 days of life were also calculated. Multilinear regression analysis was used to control for confounding factors.

RESULTS

Intubated group included 96 infants while non-intubated group included 171 infants. Although, intubated group has younger gestational age (26 vs. 29 weeks, p < 0.01) and lower birth weight (786 vs. 1115 g (g), p < 0.01), there were no significant differences between groups in regard to MgSO4 cumulative dose (24 vs. 27 g, p = 0.29), infusion time (14.6 vs. 18 h, p = 0.19) or infants' serum magnesium level (2.6 vs. 2.8 milliequivalents (mEq)/L p = 0.86). There was no correlation between cumulative MgSO4 dose with endotracheal intubation or cardiac resuscitation in the delivery room (cc: -0.03, p = 0.66; and 0.02, p = 0.79, respectively) or the need for mechanical ventilation in the first 3 days of life (cc: -0.04 to -0.07, p = 0.21-0.51). In addition, there was no relationship between MgSO4 dose, duration of infusion, or infant's serum magnesium level and occurrence of IVH.

CONCLUSION

Regardless of dose or duration of infusion, antenatal MgSO4 exposure is not associated with increased intubation or mechanical ventilation early in life.

Hepatitis C virus prevalence among men who have sex with men: a cross-sectional study in 12 Brazilian cities

BACKGROUND

Despite the preventive policies adopted, reduction in sexually transmitted infections (STIs) among men who have sex with men (MSM) has been limited. The risk of hepatitis C virus (HCV) infection has increased among the most vulnerable population groups, including MSM. The aim of this study was to estimate the prevalence of HCV infection and to assess risky practices among MSM from 12 Brazilian cities.

METHODS

This study was carried out from June to December 2016 using respondent driven sampling (RDS). Participants completed a self-administered questionnaire to collect behavioral, socioeconomic, and demographic variables. In addition, the rapid diagnostic test (RDT) for HCV was offered. Positive results were sent to Instituto Adolfo Lutz for confirmation.

RESULTS

A total of 4,176 participants were recruited and 23 samples were sent for confirmation. Of these, 16 were confirmed, resulting in a prevalence of 0.7% (95% CI: 0.3%-1.7%). The Southeast region showed a prevalence of 0.9% (95% CI: 0.3-2.6), followed by the South region, with 0.6% (95% CI: 0.2-2.1). The Northeast region had a prevalence of 0.3% (95% CI: 0.1-1.0) and the Midwest 0.1% (95% CI: 0.0-0.7). No positive cases were found in the North. Single men aged 40 years or older were the majority of participants exposed to HCV. High levels of alcohol consumption, illicit drug use, irregular condom use, in addition to infection with other STIs, were associated with exposure to HCV.

CONCLUSIONS

STIs continue to be important health problems in Brazil and globally. Many STIs are inapparent for many years until they bring more serious consequences. Extra investment in HCV is also warranted, given that it can be eliminated. Relying solely on clinical data to provide information about inapparent infection, especially in stigmatized populations, will make that goal more difficult to achieve. Surveillance studies, such as the one reported here need to be repeated over time to demonstrate trends and to provide information for evaluation, program and policies. Investments in the most vulnerable populations are critical to achieve the World Health Organization global health goals including the elimination of viral hepatitis by 2030.

Effect of preterm chorioamnionitis on lung ultrasound score used to guide surfactant replacement

OBJECTIVE

Lung ultrasound score (LUS) accurately guides surfactant replacement in preterm neonates with respiratory distress syndrome due to surfactant deficiency. However, surfactant deficiency is not the unique pathobiological feature, as there may be relevant lung inflammation, such as in certain cases of clinical chorioamnionitis (CC). We aim to investigate if CC influences LUS and ultrasound-guided surfactant treatment.

DESIGN

Retrospective (2017-2022), large, cohort study targeted to recruit a homogeneous population treated with unchanged respiratory care policy and lung ultrasound protocol. Patients with (CC+: 207) and without (CC-: 205) chorioamnionitis were analyzed with propensity score matching and subsequent additional multivariate adjustments.

RESULTS

LUS was identical at unmatched and matched comparisons. Consistently, at least one surfactant dose was given in 98 (47.3%) and 83 (40.5%) neonates in the CC+ and CC- matched cohorts, respectively (p = .210). Multiple doses were needed in 28 (13.5%) and 21 (10.2%) neonates in the CC+ and CC- cohorts, respectively (p = .373). Postnatal age at surfactant dosing was also similar. LUS was higher in patients who were diagnosed with neonatal acute respiratory distress syndrome (NARDS) (CC+ cohort: 10.3 (2.9), CC- cohort: 11.4 (2.6)), than in those without NARDS (CC+ cohort: 6.1 (3.7), CC- cohort: 6.2 (3.9); p < .001, for both). Surfactant use was more frequent in neonates with, than in those without NARDS (p < .001). Multivariate adjustments confirmed NARDS as the variable with greater effect size on LUS.

CONCLUSIONS

CC does not influence LUS in preterm neonates, unless inflammation is enough severe to trigger NARDS. The occurrence of NARDS is key factor influencing the LUS.

A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol

INTRODUCTION

Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes.

METHODS AND ANALYSIS

The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27-34+6 weeks' gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25-0.35 in the first 2-24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004).

TRIAL REGISTRATION

PACTR202307490670785.

Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis

Background

The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS.

Methods

The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life.

Findings

58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low.

Interpretation

Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound.

Funding

None.

Machine learning algorithms and computational validation of single-nucleotide polymorphisms of antioxidant enzymes and oxidative stress markers in neonates

Aim: To evaluate machine learning algorithms (MLAs) for predicting factors (oxidative stress biomarkers [OSBs] and single-nucleotide polymorphism of the antioxidant enzymes) for respiratory distress syndrome (RDS) and significant alterations in the liver functions (SALVs). Materials & methods: MLAs were applied for predicting the RDS and SALV (with OSB and single-nucleotide polymorphisms in the antioxidant enzymes) with area under the curve (AUC) as the accuracy measure. Results: The C5.0 algorithm best predicted SALV (AUC: 0.63) with catalase as the most important predictor. Bayesian network best predicted RDS (AUC: 0.6) and ENOS1 was the most important predictor. Conclusion: MLAs carry great potential in identifying the potential genetic and OSBs in neonatal RDS and SALV. Validation in prospective studies is needed urgently.

Assessment of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis prevalence using a molecular Point of Care: Findings from a respondent driven sampling study among MSM

Objectives

Due to the limited data available within the Moroccan context, the aim of the study was therefore to estimate the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) infection and co-infection among men who have sex with men (MSM) as well as to update the behavioral indicators for this population.

Methods

During the period of November 2020 to January 2021, 275 and 303 MSM in Agadir and Fes respectively, were recruited by using respondent-driven sampling protocol (RDS). Eligibility criteria for participants included men identified as having anal sex with another man in the last 6 months, aged 18 years or older and residing in either Agadir or Fes, regardless of their nationality, for the past 6 months.Anal swabs were collected from 445 respondents for molecular investigation of CT, NG, and TV. GeneXpert (Cepheid, USA) was used to test all samples. A survey on the socio-demographic, and risk behavior was then administered to participants.

Results

Most MSM subjects were identified as being young, and homosexual. CT prevalence was 11.3% (95%CI, 7.2 to 15.4) and 12.5% (95%CI, 7.5 to 17.5) in Agadir and Fes respectively; NG was 13.3% (95%CI, 8.5 to 18.1) in Agadir and 5.5% (95%CI, 1.9 to 9.2) in Fes. Meanwhile, TV prevalence was 0.4% (95%CI, 0 to 1.1) in Agadir and 0.2% (95%CI, -0.2 to 0.6) in Fes. A CT/NG co-infection was found in 4.5% (95%CI, 3.5 to 5.9) of cases in Agadir and 2.7% (95%CI, 1.9 to 3.9), in Fes.

Conclusion

It follows that a regular risk assessment and Sexually Transmitted Infectious (STIs) screening should be administered in these two cities as part of a global strategy to enhance the sexual health of the key populations in question.

Comparison of Beractant Administration by thin Catheter vs Intubation-Surfactant-Extubation (INSURE) in Preterm Infants Less than 34 Weeks Gestational Age with Respiratory Distress Syndrome - A Single Centre Experience

BACKGROUND

Poractant administration with thin catheter is gradually gaining popularity compared to the INSURE technique. However, there is little evidence to use thin catheters for administration of beractant. With this background, we compared the effect of beractant administration with INSURE vs thin catheter in preterm infants less than 34 weeks with RDS on death/chronic lung disease (CLD).

METHODS

This prospective cohort study was conducted in a tertiary NICU where inborn preterm infants≤34 weeks with RDS receiving beractant by INSURE or thin catheter were studied over two epochs- Epoch1- INSURE (Jan 2020-Oct 2020) & Epoch 2- Surfactant through thin catheter (Nov 2020-July 2021).The primary outcome was occurrence of death/CLD. Procedure related complications like transient bradycardia/desaturation, pneumothorax, failure of procedure, rates of other outcomes like failure of CPAP within 72hr, duration of invasive mechanical ventilation/ CPAP support, oxygen supplementation, other major neonatal morbidities & mortality were evaluated as secondary outcomes.

RESULTS

The combined outcome of death/CLD was significantly lower in the thin catheter epoch (RR 0.56 95% CI 0.34-0.90, p = 0.012). When analyzed independently for death/CLD, we found significantly lower number of deaths in the thin catheter epoch (RR 0.44 95% CI 0.23-0.83, p = 0.008). Number of infants who failed CPAP within 72 hrs of life was lower in thin catheter epoch (RR 0.59 95% CI 0.41-0.85, p = 0.003). Transient bradycardia/desaturation was higher during thin catheter technique (RR 4.17 95% CI 2.22-7.69, p <  0.001). Incidence of severe IVH was lower with thin catheter technique (RR 0.13 95% CI 0.02-0.98, p = 0.034).

CONCLUSION

Beractant administration by thin catheter reduces combined outcome of death/CLD.

Rapid Hepatomegaly From Ruxolitinib Discontinuation Syndrome

Introduction

Ruxolitinib (RUX) is a Food and Drug Administration-approved Janus Kinase (JAK) inhibitor shown to be effective in improving hypercatabolic symptoms and splenomegaly in patients with myelofibrosis (MF). RUX therapy provides symptomatic benefits for MF patients but is often discontinued for various reasons including worsening cytopenias. Ruxolitinib Discontinuation Syndrome (RDS) involves an acute cytokine-storm rebound phenomenon that can manifest as an acute relapse of symptoms, worsening splenomegaly, respiratory distress, systemic inflammatory response syndrome, or disseminated intravascular coagulopathy.

Case Presentation

We present the case of a patient with JAK2-positive post-polycythemia vera MF, whose RUX therapy was discontinued due to an active gastrointestinal (GI) bleed and worsening cytopenias. The patient had recently started azacitidine and was on the drug combination prior to hospitalization. The patient developed what appears to be the first case of acute onset accelerated massive hepatomegaly, a previously undescribed clinical manifestation of RDS.

Conclusion

Although rare, medical professionals should maintain a high suspicion of RDS in hospitalized patients following the discontinuation of RUX.

Limited awareness of HIV Status hinders uptake of treatment among female sex workers and sexually exploited adolescents in Wau and Yambio, South Sudan

BACKGROUND

Several factors determine uptake of HIV testing services (HTS) by female sex workers (FSW), including their knowledge of HIV and their awareness of services supporting people who are HIV-positive. HTS provided entry into the UNAIDS 90-90-90 cascade of care. We conducted a cross-sectional biobehavioural survey (BBS) to determine HIV prevalence and progress towards UNAIDS 90-90-90 cascade targets among this population in South Sudan.

METHODS

Respondent-driven sampling (RDS) was used to recruit women and sexually exploited girls aged 13-18 years who exchanged sex for goods or money in the past 6 months and resided in the town for at least 1 month. Consenting participants were interviewed and tested for HIV and, if positive, they were also tested for their viral load (VL). Data were weighted in RDS Analyst and analyzed with Stata 13.

RESULTS

A total of 1,284 participants were recruited. The overall HIV cascade coverages were 64.8% aware of their HIV-positive status; 91.0% of those aware of their positive status were on ART; and VL suppression among those on ART was 93.0%.

CONCLUSION

Being unaware of their HIV-positive status limits, the uptake of HIV treatment among FSW in South Sudan. This underscores the importance of optimized case-finding approaches to increase HTS among FSW and sexually exploited minors.

Population Size Estimation of Men Who Have Sex With Men in Rwanda: Three-Source Capture-Recapture Method

BACKGROUND

Globally, men who have sex with men (MSM) continue to bear a disproportionately high burden of HIV infection. Rwanda experiences a mixed HIV epidemic, which is generalized in the adult population, with aspects of a concentrated epidemic among certain key populations at higher risk of HIV infection, including MSM. Limited data exist to estimate the population size of MSM at a national scale; hence, an important piece is missing in determining the denominators to use in estimates for policy makers, program managers, and planners to effectively monitor HIV epidemic control.

OBJECTIVE

The aims of this study were to provide the first national population size estimate (PSE) and geographic distribution of MSM in Rwanda.

METHODS

Between October and December 2021, a three-source capture-recapture method was used to estimate the MSM population size in Rwanda. Unique objects were distributed to MSM through their networks (first capture), who were then tagged according to MSM-friendly service provision (second capture), and a respondent-driven sampling survey was used as the third capture. Capture histories were aggregated in a 2k-1 contingency table, where k indicates the number of capture occasions and "1" and "0" indicate captured and not captured, respectively. Statistical analysis was performed in R (version 4.0.5) and the Bayesian nonparametric latent-class capture-recapture package was used to produce the final PSE with 95% credibility sets (CS).

RESULTS

We sampled 2465, 1314, and 2211 MSM in capture one, two, and three, respectively. There were 721 recaptures between captures one and two, 415 recaptures between captures two and three, and 422 recaptures between captures one and three. There were 210 MSM captured in all three captures. The total estimated population size of MSM above 18 years old in Rwanda was 18,100 (95% CS 11,300-29,700), corresponding to 0.70% (95% CI 0.4%-1.1%) of total adult males. Most MSM reside in the city of Kigali (7842, 95% CS 4587-13,153), followed by the Western province (2469, 95% CS 1994-3518), Northern province (2375, 95% CS 842-4239), Eastern province (2287, 95% CS 1927-3014), and Southern province (2109, 95% CS 1681-3418).

CONCLUSIONS

Our study provides, for the first time, a PSE of MSM aged 18 years or older in Rwanda. MSM are concentrated in the city of Kigali and are almost evenly distributed across the other 4 provinces. The national proportion estimate bounds of MSM out of the total adult males includes the World Health Organization's minimum recommended proportion (at least 1.0%) based on 2012 census population projections for 2021. These results will inform denominators to be used for estimating service coverage and fill existing information gaps to enable policy makers and planners to monitor the HIV epidemic among MSM nationally. There is an opportunity for conducting small-area MSM PSEs for subnational-level HIV treatment and prevention interventions.

Prime Editing Strategy to Install the PRPH2 c.828+1G>A Mutation

Mutations in peripherin 2 (PRPH2) are associated with a spectrum of inherited retinal diseases (IRDs) including retinitis pigmentosa (RP) and macular degeneration. As PRPH2 is localized to cone and rod outer segments, mutations in PRPH2 lead the disorganization or absence of photoreceptor outer segments. Here, we report on a patient with PRPH2-linked RP who exhibited widespread RPE atrophy with a central area of macular atrophy sparing the fovea. In future studies, we plan to model the pathobiology of PRPH2-based RP using induced pluripotent stem cell (iPSC)-derived retinal organoids. To effectively model rare mutations using iPSC-derived retinal organoids, we first require a strategy that can install the desired mutation in healthy wild-type iPSC, which can efficiently generate well-laminated retinal organoids. In this study, we developed an efficient prime editing strategy for the installation of the pathogenic PRPH2 c.828+1 G>A splice-site mutation underlying our patient's disease.

The Role of Peripherin-2/ROM1 Complexes in Photoreceptor Outer Segment Disc Morphogenesis

The light-sensitive outer segment organelle of photoreceptor cells contains a stack of hundreds of flat, disc-shaped membranes called discs. The rims of these discs contain a photoreceptor-specific tetraspanin protein peripherin-2 (also known as rds or PRPH2). Mutations in the PRPH2 gene lead to a wide variety of inherited retinal degenerations in humans. The vast majority of these mutations occur within a large, intradiscal loop of peripherin-2, known as the D2 loop. The D2 loop mediates well-established intermolecular interactions of peripherin-2 molecules among themselves and a homologous protein ROM1. These interactions lead to the formation of large, highly ordered oligomers. In this chapter, we discuss the supramolecular organization of peripherin-2/ROM1 complexes and their contribution to the process of outer segment disc morphogenesis and enclosure.

Newborn Cry-Based Diagnostic System to Distinguish between Sepsis and Respiratory Distress Syndrome Using Combined Acoustic Features

Crying is the only means of communication for a newborn baby with its surrounding environment, but it also provides significant information about the newborn's health, emotions, and needs. The cries of newborn babies have long been known as a biomarker for the diagnosis of pathologies. However, to the best of our knowledge, exploring the discrimination of two pathology groups by means of cry signals is unprecedented. Therefore, this study aimed to identify septic newborns with Neonatal Respiratory Distress Syndrome (RDS) by employing the Machine Learning (ML) methods of Multilayer Perceptron (MLP) and Support Vector Machine (SVM). Furthermore, the cry signal was analyzed from the following two different perspectives: 1) the musical perspective by studying the spectral feature set of Harmonic Ratio (HR), and 2) the speech processing perspective using the short-term feature set of Gammatone Frequency Cepstral Coefficients (GFCCs). In order to assess the role of employing features from both short-term and spectral modalities in distinguishing the two pathology groups, they were fused in one feature set named the combined features. The hyperparameters (HPs) of the implemented ML approaches were fine-tuned to fit each experiment. Finally, by normalizing and fusing the features originating from the two modalities, the overall performance of the proposed design was improved across all evaluation measures, achieving accuracies of 92.49% and 95.3% by the MLP and SVM classifiers, respectively. The MLP classifier was outperformed in terms of all evaluation measures presented in this study, except for the Area Under Curve of Receiver Operator Characteristics (AUC-ROC), which signifies the ability of the proposed design in class separation. The achieved results highlighted the role of combining features from different levels and modalities for a more powerful analysis of the cry signals, as well as including a neural network (NN)-based classifier. Consequently, attaining a 95.3% accuracy for the separation of two entangled pathology groups of RDS and sepsis elucidated the promising potential for further studies with larger datasets and more pathology groups.

A potential syndemic effect associated with symptoms of depression among men who have sex with men

INTRODUCTION

Globally, depression rates are high among men who have sex with men (MSM). Multiple factors may interact synergistically to increase this risk. This analysis assessed the prevalence of symptoms of depression among MSM in Brazil and synergistic effects of several factors.

METHODS

Cross-sectional study conducted in 12 cities using respondent-driven sampling. Sociodemographic and behavioral characteristics were collected. The PHQ-9 was used to screen for depression. Having moderate-severe depressive symptoms was compared to none-mild using logistic regression. The syndemic factor was a composite of hazardous alcohol use, sexual violence, and discrimination due to sexual orientation. Those with one to three of these factors were compared to those with none.

RESULTS

The weighted prevalence of moderate-severe depressive symptoms was 24.9% (95%CI = 21.8-28.8) and 16.2%, 22.9%, 46.0% and 51.0% when none, one, two, or three syndemic factors were present, respectively, indicating a dose-response effect. Perception of HIV risk, high level of HIV knowledge, known HIV infection, and health self-rated as poor or very poor were also associated with depressive symptoms.

CONCLUSION

The prevalence of moderate-severe depressive symptoms among MSM in Brazil is high, and selected factors act synergistically in increasing their prevalence. Public health policies should consider holistic depression prevention and treatment interventions for this population.

Post-INSURE Administration of Heated Humidified High-Flow Therapy Versus Nasal Continuous Positive Airway Pressure in Preterm Infants More Than 28 Weeks Gestation with Respiratory Distress Syndrome: A Randomized Non-Inferiority Trial

In preterm infants with respiratory distress syndrome (RDS), non-invasive ventilation (NIV) is usually provided using nasal continuous positive airway pressure (NCPAP) or non-invasive mechanical ventilation after surfactant administration by INtubation-SURfactant-Extubation (INSURE) method. Heated humidified high-flow nasal cannula (HHHFNC) is a mode of NIV with advantages of ease of application, less grades of nasal injury and easy handling. This study was done to compare the effectiveness of HHHFNC therapy administration as post-INSURE respiratory support in preterm infants as compared to NCPAP. The primary outcome was to compare the rate of treatment failure within 7 days of randomization to HHHFNC or NCPAP as a post-INSURE ventilatory modality. It was a pilot trial wherein all preterm infants more than 1 kg and more than 28 weeks gestational age with RDS who required surfactant were randomized to receive NCPAP or HHHFNC. Infants with an urgent need for intubation and mechanical ventilation were considered to have treatment failure. Thirty babies were enrolled-15 in each group. Baseline demographic characteristics were comparable. There was no significant difference in the primary outcome of early failure rate, i.e. mechanical ventilation rate within 7 days of starting treatment. There were no significant differences in other outcomes except nasal injury which was significantly lesser in the HHHFNC group. In conclusion, HHHFNC appears to be non-inferior to NCPAP when used in preterm infants more than 28 weeks gestation with RDS as a post-INSURE ventilatory modality.

Effects of psyllium fiber on in vitro digestion and structure of different types of starches

BACKGROUND

Starch digestibility in foods strongly depends on the structure, other ingredients and processing conditions used. This study aimed to investigate the effect of psyllium fiber on gelatinization, crystallinity and in vitro digestibility of starches having different crystalline structures (A, B and C). Wheat, potato and tapioca starches with and without added psyllium fiber were heated at 90 °C for 10 min at three different solid:water (w:v) ratios (1:1, 1:2 and 1:5). The added fiber content was 50% (dry base) in the solid fraction for the fiber-added samples.

RESULTS

Wheat, potato and tapioca starches showed different structural, morphological and starch digestibility properties. The effect of cooking and fiber addition on starch digestion differed for the starch types, mainly wheat starch. Psyllium addition during cooking decreased the rapidly digestible starch (RDS) fractions while increasing the slowly digestible starch (SDS) and remaining/resistant starch (RS) fractions. The effect of psyllium fiber addition was not limited to restricting the swelling and gelatinization of starch granules during heating. Psyllium fiber effectively restricted the mobility of digestive enzymes during digestion.

CONCLUSION

Understanding the relationship between psyllium and starch digestibility for different types of starch could assist in designing food formulations with lower starch digestibility. These in vitro data, however, should be confirmed by in vivo studies. © 2021 Society of Chemical Industry.

Mobile phone access, willingness, and usage for HIV-related services among young adults living in informal urban settlements in Kenya: A cross-sectional analysis

BACKGROUND

Mobile phone-based health (mHealth) interventions have the potential to improve HIV outcomes for high-risk young adults living in informal urban settlements in Kenya. However, less is known regarding young adults' differential access to mobile phones and their willingness and use of mobile phone technologies to access HIV prevention, care, and treatment services. This is important as young adults make up the largest demographic segment of impoverished, informal urban settlements and are disproportionately impacted by HIV.

METHODS

This study used observational survey data from 350 young adults, aged 18-22, who were living informal urban settlements in Nairobi, Kenya. Respondent driven sampling methods were used to recruit and enroll eligible youth. Using descriptive statistics and logistical regressions, we examined the prevalence of mobile phone access, willingness, and use for HIV services. We also assessed associated demographic characteristics in the odds of access, willingness, and use.

RESULTS

The mean age of participants was 19 years (±1.3). 56% were male. Mobile phone coverage, including text messaging and mobile internet, was high (>80%), but only 15% of young adults had ever used mobile phones to access HIV services. Willingness was high (65%), especially among those who had individual phone access (77%) compared to lower willingness (18%) among those who shared a phone. More educated (OR = 1.84, 95 %CI:1.14-2.97) and employed (OR = 1.70, 95 %CI:1.02 = 2.83) young adults were also more willing to use phones for HIV services. In contrast, participants living in large households (OR = 0.47, 95 %CI:0.24-0.921), were religious minorities (OR = 0.56, 95 %CI:0.32-0.99), partnered/married (OR = 0.30, 95 %CI:0.10-0.91), or female (OR = 0.29, 95 %CI:0.16-0.55) were significantly less likely to have mobile phone access or usage, limiting their potential participation in HIV-related mHealth interventions. Given the low usage of mobile phones currently for HIV services, no differences in demographic characteristics were observed.

CONCLUSION

Mobile health technologies may be under-utilized in HIV services for at-risk youth. Our findings highlight the importance of preliminary, formative research regarding population differences in access, willingness, and use of mobile phones for HIV services. More efforts are needed to ensure that mHealth interventions account for potential differences in preferences for mobile phone-based HIV interventions by gender, age, religion, education, and/or employment status.

Influence of prenatal steroid therapy on the incidence of respiratory disorders in late premature infants

OBJECTIVES

This study was conducted because of conflicting data on the role of corticosteroids administered before delivery in the late premature period. The aim of the study was to assess the frequency of respiratory disorders in 'late premature infants' and the impact of using prenatal steroid therapy.

MATERIAL AND METHODS

The study included 513 newborns born between the 34-36 week of pregnancy. They were divided into two groups. In the first group, there were 439 newborns (85.58%) who did not receive prenatal steroid therapy, and in the second group, there were 74 newborns (14.42%) born after the prenatal steroid course. The frequency of occurrence of respiratory disorders requiring the use of non-invasive respiratory support methods as well as intubation and mechanical ventilation was compared in both groups.

RESULTS

In the group of premature infants after steroid therapy 43/74 (58.12%) did not require respiratory support compared to the group of infants without prenatal steroid therapy where in 368/439 (83.8%) cases no respiratory disorders were found.

CONCLUSIONS

If there is a risk of preterm labor in the 34-36 week of pregnancy, the use of steroid therapy should be considered. Steroidotherapy at this moment of gestation may not be such beneficial, like in the more premature delivery, before 34 weeks of pregnancy.

Hypothesizing in the Face of the Opioid Crisis Coupling Genetic Addiction Risk Severity (GARS) Testing with Electrotherapeutic Nonopioid Modalities Such as H-Wave Could Attenuate Both Pain and Hedonic Addictive Behaviors

In the United States, amid the opioid overdose epidemic, nonaddicting/nonpharmacological proven strategies are available to treat pain and manage chronic pain effectively without opioids. Evidence supporting the long-term use of opioids for pain is lacking, as is the will to alter the drug-embracing culture in American chronic pain management. Some pain clinicians seem to prefer classical analgesic agents that promote unwanted tolerance to analgesics and subsequent biological induction of the "addictive brain". Reward genes play a vital part in modulation of nociception and adaptations in the dopaminergic circuitry. They may affect various sensory and affective components of the chronic pain syndromes. The Genetic Addiction Risk Severity (GARS) test coupled with the H-Wave at entry in pain clinics could attenuate pain and help prevent addiction. The GARS test results identify high-risk for both drug and alcohol, and H-Wave can be initiated to treat pain instead of opioids. The utilization of H-Wave to aid in pain reduction and mitigation of hedonic addictive behaviors is recommended, notwithstanding required randomized control studies. This frontline approach would reduce the possibility of long-term neurobiological deficits and fatalities associated with potent opioid analgesics.

Surfactant Administration Through Laryngeal or Supraglottic Airways (SALSA): A Viable Method for Low-Income and Middle-Income Countries

Administration of liquid surfactant through an endotracheal tube for the treatment of respiratory distress syndrome has been the standard of care for decades. A skilled health care provider is needed to perform this procedure. In lower-income and middle-income countries (LMICs), healthcare resources are often limited, leading to increased mortality of premature infants, many of whom would benefit from surfactant administration. Therefore, having a simplified procedure for delivery of surfactant without the need for advanced skills could be life-saving, potentially diminish gaps in care, and help ensure more equitable global neonatal survival rates. Modifications to the standard approach of surfactant administration have been put into practice and these include: INtubation-SURfactant-Extubation (INSURE), thin catheter surfactant administration (TCA), aerosolized surfactant, and surfactant administration through laryngeal or supraglottic airways (SALSA). Although there is a need for larger studies to evaluate the comparative effectiveness of these newer methods, these methods are being embraced by the global community and being implemented in various settings throughout the world. Because the SALSA technique does not require laryngoscopy, a provider skilled in laryngoscopy is not required for the procedure. Therefore, because of the ease of use and safety profile, the SALSA technique should be strongly considered as a viable method of delivering surfactant in LMICs.

Enhanced INSURE (ENSURE): an updated and standardised reference for surfactant administration

There is no firm consensus about the optimal technique for the administration of exogenous surfactant in preterm neonates, and different techniques may be equally effective. The intubation-surfactant-extubation (INSURE) procedure has not been fully described, and important details, such as duration and mode of ventilation, remain unclear, leading to significant clinical practice variations and influencing its suitability and feasibility. Since the first INSURE description, our knowledge in respiratory care has largely progressed, but the technique has not been updated according to current evidence-based practice. Thus, our aim is to formally describe a modern way to perform INSURE, based on the current knowledge and technology, to increase its feasibility and patients' safety. We offer ENSURE (Enhanced INSURE) as an updated and standardised technique for surfactant administration, clarifying crucial issues of the original method by applying current state-of-the-art concepts of respiratory care. We performed a cross-sectional observational study enrolling 57 preterm neonates describing ENSURE feasibility and safety.   Conclusion: ENSURE can be used as a reference technique in clinical practice, teaching and research. What is Known: • There is no consensus about the optimal method for surfactant administration. INSURE technique has been originally described many years ago without considering modern principles of neonatal respiratory care and the available state-of-the-art technology. What is New: • We here describe a modern way to perform INSURE, based on the current knowledge and technology. We called it ENSURE (Enhanced INSURE) and clarified crucial points of the original technique, in light of the current knowledge. We verified feasibility and safety of ENSURE in a cross-sectional observational study enrolling 57 preterm neonates.

Synchronized Nasal Intermittent Positive Pressure Ventilation

Avoiding MV is a critical goal in neonatal respiratory care. Different modes of noninvasive respiratory support beyond nasal CPAP, such as nasal intermittent positive pressure ventilation (NIPPV) and synchronized NIPPV (SNIPPV), may further reduce intubation rates. SNIPPV offers consistent benefits over nonsynchronized techniques such as a more efficient positive pressure transmission to the lung, an effective increase in transpulmonary pressure during ventilation, and a better stabilization of the chest wall during inspiration. This review discusses mechanisms of action, benefits and limitations of synchronized noninvasive ventilation, describes the different modes of synchronization, and analyzes properties and clinical results.

Traffic-related polycyclic aromatic hydrocarbons (PAHs) occurrence in a tropical environment

Traffic-related PAH emissions over the urban area of Natal, Brazil, have shown a significant increase because of automobile usage and have become a major concern due to their potential effects on human health and the environment. Therefore, this research measured PAH contamination on major roads and river compartments in a tropical catchment (Pitimbu River) over an expanding urban area. Road PAH concentrations spanned from 692 to 2098 ng g^-1 and suggest the predominance of heavy (diesel-powered) and light-duty (gasoline plus alcohol-powered) vehicle emission sources. High concentrations of naphthalene (515 ng g^-1) and acenaphthylene (145 ng g^-1) were found in river sediments, indicating oil-related spillage and low-temperature combustion sources. Diagnostic ratios indicated the prevalence of biomass, coal and petroleum combustion processes and refined oil products. The ecological risk assessment indicated an ecological contamination risk ranging between low and moderate because of naphthalene and acenaphthylene concentrations higher than ERL threshold values. Toxicity risks caused by PAHs were assessed by using the BaP-equivalent carcinogenic power (BaPE). Results indicated that both RDS and riverbed sediment samples are at low toxicity risk.

Physiologic Effects of Instilled and Aerosolized Surfactant Using a Breath-Synchronized Nebulizer on Surfactant-Deficient Rabbits

Surfactant administration incorporates liquid bolus instillation via endotracheal tube catheter and use of a mechanical ventilator. Aerosolized surfactant has generated interest and conflicting data related to dose requirements and efficacy. We hypothesized that aerosolized surfactant with a novel breath-actuated vibrating mesh nebulizer would have similar efficacy and safety as instilled surfactant. Juvenile rabbits (1.50 ± 0.20 kg, n = 17) were sedated, anesthetized, intubated, and surfactant was depleted via lung lavage on mechanical ventilation. Subjects were randomized to receive standard dose liquid instillation via catheter (n = 5); low dose surfactant (n = 5) and standard dose surfactant (n = 5) via aerosol; and descriptive controls (no treatment, n = 2). Peridosing events, disease severity and gas exchange, were recorded every 30 min for 3 h following surfactant administration. Direct-Instillation group had higher incidence for peridosing events than aerosol. Standard dose liquid and aerosol groups had greater PaO₂ from pre-treatment baseline following surfactant (p < 0.05) with greater ventilation efficiency with aerosol (p < 0.05). Our study showed similar improvement in oxygenation response with greater ventilation efficiency with aerosol than liquid bolus administration at the same dose with fewer peridosing events. Breath-synchronized aerosol via nebulizer has potential as a safe, effective, and economical alternative to bolus liquid surfactant instillation.

Biomarkers in premature calves with and without respiratory distress syndrome

BACKGROUND

Approaches to the evaluation of pulmonary arterial hypertension (PAH) in premature calves by using lung-specific epithelial and endothelial biomarkers are needed.

OBJECTIVE

To investigate the evaluation of PAH in premature calves with and without respiratory distress syndrome (RDS) by using lung-specific epithelial and endothelial biomarkers and determine the prognostic value of these markers in premature calves.

ANIMALS

Fifty premature calves with RDS, 20 non-RDS premature calves, and 10 healthy term calves.

METHODS

Hypoxia, hypercapnia, and tachypnea were considered criteria for RDS. Arterial blood gases (PaO2 , PaCO2 , oxygen saturation [SO2 ], base excess [BE], and serum lactate concentration) were measured to assess hypoxia. Serum concentrations of lung-specific growth differentiation factor-15 (GDF-15), asymmetric dimethylarginine (ADMA), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF), and surfactant protein D (SP-D) were measured to assess PAH.

RESULTS

Arterial blood pH, PaO2 , SO2 , and BE of premature calves with RDS were significantly lower and PaCO2 and lactate concentrations higher compared to non-RDS premature and healthy calves. The ADMA and SP-D concentrations of premature calves with RDS were lower and serum ET-1 concentrations higher than those of non-RDS premature and healthy calves. No statistical differences for GDF-15 and VEGF were found among groups.

CONCLUSIONS AND CLINICAL IMPORTANCE

Significant increases in serum ET-1 concentrations and decreases in ADMA and SP-D concentrations highlight the utility of these markers in the diagnosis of PAH in premature calves with RDS. Also, we found that ET-1 was a reliable diagnostic and prognostic biomarker for PAH and predicting mortality in premature calves.

Neonatal Lung Ultrasound and Surfactant Administration: A Pragmatic, Multicenter Study

BACKGROUND

Previous research shows that a lung ultrasound score (LUS) can anticipate CPAP failure in neonatal respiratory distress syndrome.

RESEARCH QUESTION

Can LUS also predict the need for surfactant replacement?

STUDY DESIGN AND METHODS

Multicenter, pragmatic study of preterm neonates who underwent lung ultrasound at birth and those given surfactant by masked physicians, who also were scanned within 24 h from administration. Clinical data and respiratory support variables were recorded. Accuracy of LUS, oxygen saturation to Fio₂ ratio, Fio₂, and Silverman score for surfactant administration were evaluated using receiver operating characteristic curves. The simultaneous prognostic values of LUS and oxygen saturation to Fio₂ ratio for surfactant administration, adjusting for gestational age (GA), were analyzed through a logistic regression model.

RESULTS

Two hundred forty infants were enrolled. One hundred eight received at least one dose of surfactant. LUS predicted the first surfactant administration with an area under the receiver operating characteristic curve (AUC) of 0.86 (95% CI, 0.81-0.91), cut off of 9, sensitivity of 0.79 (95% CI, 0.70-0.86), specificity of 0.83 (95% CI, 0.76-0.89), positive predictive value of 0.79 (95% CI, 0.71-0.87), negative predictive value of 0.82 (95% CI, 0.75-0.89), positive likelihood ratio of 4.65 (95% CI, 3.14-6.89), and negative likelihood ratio of 0.26 (95% CI, 0.18-0.37). No significant difference was shown among different GA groups: 25 to 27 weeks' GA (AUC, 0.91; 95% CI, 0.84-0.99), 28 to 30 weeks' GA (AUC, 0.81; 95% CI, 0.72-0.91), and 31 to 33 weeks' GA (AUC, 0.88; 95% CI, 0.79-0.95), respectively. LUS declined significantly within 24 h in infants receiving one surfactant dose. When comparing Fio₂, oxygen saturation to Fio₂ ratio, LUS, and Silverman scores as criteria for surfactant administration, only the latter showed a significantly poorer performance. The combination of oxygen saturation to Fio₂ ratio and LUS showed the highest predictive power, with an AUC of 0.93 (95% CI, 0.89-0.97), regardless of the GA interval.

INTERPRETATION

LUS is a reliable criterion to administer the first surfactant dose regardless of GA. Its association with oxygen saturation to Fio₂ ratio significantly improves the prediction power for surfactant need.

Prediction of extubation readiness using lung ultrasound in preterm infants

We aimed to test the hypothesis that a lung ultrasound severity score (LUS) and assessment of left ventricular eccentricity index of the interventricular septum (LVEI) by focused heart ultrasound can predict extubation success in mechanically ventilated infants. We conducted a prospective study on premature infants less than 34 weeks' of gestation. LUS was performed on postnatal Days 3 and 7 by an investigator who was masked to infants' ventilator parameters. LVEI and pulmonary artery pressure (PAP) were measured at postnatal Day 3. A receiver operator curve was constructed to assess the ability to predict extubation success. Spearman correlation was performed between LVEI and PAP. A total of 104 studies were performed to 66 infants; of them 39 had mild and 65 had moderate-severe lung disease. LUS predicted extubation success with a sensitivity and a specificity of 91% and 69%, respectively. Area under the curve was 0.83 (CI: 0.75-0.91). LVEI did not differ between infants that succeeded and failed extubation. It correlated with PAP during systole (r = .66). We conclude that LUS predicts extubation success in mechanically ventilated preterm infants whereas LVEI correlates with high PAP.

Short-term effects of synchronized vs. non-synchronized NIPPV in preterm infants: study protocol for an unmasked randomized crossover trial

BACKGROUND

Non-invasive ventilation (NIV) has been recommended as the best respiratory support for preterm infants with respiratory distress syndrome (RDS). However, the best NIV technique to be used as first intention in RDS management has not yet been established. Nasal intermittent positive pressure ventilation (NIPPV) may be synchronized (SNIPPV) or non-synchronized to the infant's breathing efforts. The aim of the study is to evaluate the short-term effects of SNIPPV vs. NIPPV on the cardiorespiratory events, trying to identify the best ventilation modality for preterm infants at their first approach to NIV ventilation support.

METHODS

An unmasked randomized crossover study with three treatment phases was designed. All newborn infants < 32 weeks of gestational age with RDS needing NIV ventilation as first intention or after extubation will be consecutively enrolled in the study and randomized to the NIPPV or SNIPPV arm. After stabilization, enrolled patients will be alternatively ventilated with two different techniques for two time frames of 4 h each. NIPPV and SNIPPV will be administered with the same ventilator and the same interface, maintaining continuous assisted ventilation without patient discomfort. During the whole duration of the study, the patient's cardiorespiratory data and data from the ventilator will be simultaneously recorded using a polygraph connected to a computer. The primary outcome is the frequency of episodes of oxygen desaturation. Secondary outcomes are the number of the cardiorespiratory events, FiO₂ necessity, newborn pain score evaluation, synchronization index, and thoracoabdominal asynchrony. The calculated sample size was of 30 patients.

DISCUSSION

It is known that NIPPV produces a percentage of ineffective acts due to asynchronies between the ventilator and the infant's breaths. On the other hand, an ineffective synchronization could increase work of breathing. Our hypothesis is that an efficient synchronization could reduce the respiratory work and increase the volume per minute exchanged without interfering with the natural respiratory rhythm of the patient with RDS. The results of this study will allow us to evaluate the effectiveness of the synchronization, demonstrating whether SNIPPV is the most effective non-invasive ventilation mode in preterm infants with RDS at their first approach to NIV ventilation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03289936 . Registered on September 21, 2017.

Antenatal Corticosteroids: Extending the Practice for Late-Preterm and Scheduled Early-Term Deliveries?

Respiratory distress in late-preterm and early term infants generally may warrant admission to a special care nursery or an intensive care unit. In particular, respiratory distress syndrome and transient tachypnea of the newborn are the two most common respiratory morbidities. Antenatal corticosteroids (ACS) facilitate surfactant production and lung fluid resorption. The use of ACS has been proven to be beneficial for preterm infants delivered at less than 34 weeks' gestation. Literature suggests that the benefits of giving antenatal corticosteroids may extend to late-preterm and early term infants as well. This review discusses the short-term benefits of ACS administration in reducing respiratory morbidities, in addition to potential long term adverse effects. An update on the current practices of ACS use in pregnancies greater than 34 weeks' gestation and considerations of possibly extending versus restricting this practice to certain settings will also be provided.

Effect of ventilator modes on neonatal cerebral and peripheral oxygenation using near-infrared spectroscopy

AIM

The effect of ventilator modes on regional tissue oxygenation in premature neonates with respiratory distress syndrome (RDS) has yet to be delineated. Previous studies have looked at global oxygen delivery and have not assessed the effects on regional tissue oxygenation. Our aim in this study was to assess such tissue oxygenation in premature babies with RDS in relation to differing modes of ventilation using near-infrared spectroscopy (NIRS).

METHODS

In 24 stable preterm infants with RDS, undergoing elective wean in ventilator mode, cerebral and muscle tissue oxygenation were assessed using NIRS. Infants were weaned from high-frequency oscillator or jet ventilator to conventional invasive ventilation (CV) or extubated from CV to non-invasive mechanical ventilation. Data at 30 minutes prior and at one hour after change in ventilator mode were compared (paired t test).

RESULTS

In babies changed from high-frequency oscillation to CV, jet to CV and CV to non-invasive ventilation, the differences in cerebral NIRS (mean ± SD) were 1.7 ± 9.9%, 2.3 ± 5.7% and 2.1 ± 8.4%, respectively. The concomitant changes in muscle NIRS were -2.9 ± 8.5%, 8.1 ± 9.7% and 3.6 ± 22.4%, respectively. No changes were statistically significant.

CONCLUSION

Our data suggest that there is no alteration in regional tissue oxygenation related to ventilator mode in stable preterm infants with improving RDS.

Analysis of Pathology in Premature Infants in Obstetrics and Gynecology Clinic at St George University Hospital, Plovdiv between 2013 and 2015

INTRODUCTION

Premature birth is now one of the most profound prenatal problems worldwide because of the high morbidity and mor-tality it is associated with at the beginning of life. Advances in prenatal medicine over the past decades have led to a significant improve-ment of neonatal survival in risk groups of newborns. Infants of gestational age of 22-25 weeks represent the greatest medical, social, and ethical dilemma in neonatology. Most of these newborns need intensive care to survive, and most infants born between 28 and 32 weeks of gestation require special care. Those born 34 to 36 weeks' gestation also have higher rates of short-term morbid premature birth-related conditions such as respiratory distress syndrome (RDS) and intraventricular hemorrhage (IVH) than their peers born at term.

AIM

To carry out an analysis of morbidity during the neonatal period in premature babies.

MATERIALS AND METHODS

A retrospective triennial study was conducted on 598 premature newborns.

RESULTS

The results of the study show that morbidity rate in premature born infants is high. The most frequent reasons for admission to the neonatal intensive care unit are the other forms of respiratory distress syndrome (45%). Respiratory distress syndrome (RDS) was observed in 23.41% of the prematurity, 10.7% of them were suspected of having other pathology, and 20.9% of premature neonates  manifested no complications in the neonatal period. There was a significant difference in the diagnosis of newborns after birth (p=0.0001, r=0.58), with the newborns with RDS demonstrating the most complications in the neonatal period.

CONCLUSIONS

The conclusions to be drawn from the analysis of the data are as follows: there is wide comorbidity in the prematurity of RDS. Lower gestational age strongly correlates with the development of RDS. If no corticosteroid therapy is administered the risk of developing hyaline membrane disease increases. There is extremely high probability of neonatal mortality in children with hyaline membrane disease. There is significant difference between the primary diagnosis and the condition of the child at discharge from the medical establishment. Adequate and specialized prenatal care is essential when trying to reduce the incidence of preterm birth.

Relation of asymmetric dimethylarginine with pulmonary morbidities in neonatal respiratory distress syndrome

BACKGROUND

Asymmetric Dimethyl Arginine (ADMA) is an endogenous inhibitor of nitric oxide synthase (NOS) is important in different diseases characterized by decreased nitric oxide (NO) availability. We aimed to assess the serum ADMA level in preterm infants suffering from respiratory distress syndrome (RDS) and its relationship with pulmonary outcomes.

METHODS

This prospective study included 50 preterm neonates suffering from RDS aging≤32 weeks and weighing≤1500  gm. Serum ADMA levels were estimated in the 1st and 28th day of life by ELISA, and its correlation with surfactant requirement, duration of ventilation, and development of BPD was assessed.

RESULTS

Fifty preterm infants with RDS were included, 30 infants were treated with surfactant within 12 hours after birth, the 1stday ADMA level was higher significantly in infants who required surfactant treatment than infants without surfactant treatment, At 36 weeks postmenstrual age, 16 infants were diagnosed with BPD, the 28th day ADMA level was significantly higher in infants with BPD than others without BPD. 1st-day ADMA level was significantly correlated with days on mechanical ventilation but there were no significant correlations between 1st day ADMA and days on CPAP and days on supplemental O2.

CONCLUSION

Elevated serum ADMA level in preterm neonates with RDS estimated in the 1st and 28th day of life is a good predictor for pulmonary morbidities such as surfactant requirement, duration of mechanical ventilation, and development of BPD.

Flow-synchronized NIPPV with double-inspiratory loop cannula: An in vitro study

BACKGROUND

Although short binasal prongs (SBP) are the most common interface for noninvasive ventilation, the "double-inspiratory loop cannulas" (DILC) have recently been introduced into many neonatal intensive care units. DILC show advantages over SBP, including reduced nasal trauma and increased comfort. However, their higher intrinsic resistance may compromise ventilation. Our aim was to test a new, low resistance DILC interface.

METHODS

A test lung was programmed to simulate preterm neonates (500-2000 g BW) with moderate-to-severe respiratory distress syndrome. The artificial nose was designed to keep prongs-to-nares leaks to around 30%. Giulia® ventilator (GINEVRI srl) was used to provide nasal continuous positive airway pressure (NCPAP) and flow synchronized nasal intermittent positive pressure ventilation (NIPPV). NCPAP was set at 4-10 cmH₂ O and synchronized-NIPPV (SNIPPV) at peak inspiratory pressure, 15-20-25 cmH₂ O; inspiratory time, 0.3-0.5 s; and positive end-expiratory pressure, 5-8 cmH₂ O. Four sizes of Sync-flow Cannula® (GINEVRI srl) were tested. The Sync-flow Cannula® was compared with Neotech RAM® cannula and Ginevri SBP®. The outcome measures were the flow/pressure relationship through the four Sync-flow Cannula® sizes, the difference in resistance, the drop in ventilator-alveoli pressure measured by the test lung and the system response time during flow-SNIPPV.

RESULTS

The smaller DILC sizes had the lowest flow-pressure ratio. The resistance of the RAM® cannula was significantly higher compared to the other interfaces (p < .001). With 30% leaks, there was a 4-38% ventilator-alveoli drop in pressure, depending on interface size. The system response time was excellent (~65-70 ms).

CONCLUSIONS

With about 30% leaks, the Sync-flow Cannula® interfaces result in good pressure transmission and give optimal performance for flow-SNIPPV. Clinical studies are needed to confirm the clinical relevance of these data.

Role of lung ultrasound in the assessment of recruitment maneuvers in ventilated preterm neonates with respiratory distress syndrome and its correlation with tracheal IL-6 levels: A randomized controlled trial

BACKGROUND

This study's aim is to evaluate lung ultrasound (LUS) efficacy in detecting opening and closing lung pressures and its correlation with the tracheal interleukin 6 (IL-6) level.

METHOD

This single-blinded randomized controlled study was done at Ain Shams University Children's Hospital neonatal intensive care units, Egypt. It consists of 44 mechanically ventilated preterm neonates with Respiratory Distress Syndrome (RDS). Initial LUS assessment was done followed by randomization to one of 2 groups; group I: 22 patients underwent LUS guided RM and group II: 22 patients underwent non-ultrasound guided RM. Tracheal IL-6 level was measured before and after RM in both groups.

RESULTS

The LUS scores showed a sensitivity of 86.7%, specificity of 62.10% and accuracy of 70.45% at the cut-off point >B1 grade. After RM, there was a higher percentage of changes in mean airway pressure (p = 0.03), FiO2 (p = 0.01), PaO2/FiO2 ratio (p = 0.01), and IL-6 (p < 0.01) in group I. The duration of oxygen requirement (6 vs.13.5 days, p = 0.01), invasive ventilation (3 vs.5.5 days, p = 0.03), non-invasive ventilation (2.5 vs. 5 days, p = 0.02) and NICU stay (21.5 vs. 42.5 days, p = 0.03) were less in group I. A positive correlation is found between reaeration score and the duration of O2 requirement (p = 0.002), duration of invasive ventilation (p = 0.001), NICU length of stay (p = 0.002) and negative correlation with PaO2/FiO2 ratio before RM (p = 0.012). The best cut-off point for the reaeration score is >21 with a sensitivity of 75%, specificity of 71.43% and area under the curve of 78.1%.

CONCLUSION

LUS-guided RM achieved earlier lowest FiO2, shorter O2 dependency, lesser NICU stay and marked decrease in lung inflammation by decreasing atelectotrauma and shortening the duration of invasive ventilation.

Efficacy of noninvasive respiratory support modes for primary respiratory support in preterm neonates with respiratory distress syndrome: Systematic review and network meta-analysis

OBJECTIVES

To compare the efficacy of different noninvasive respiratory support (NRS) modes for primary respiratory support of preterm infants with respiratory distress syndrome (RDS).

DESIGN

Systematic review and network meta-analysis using the Bayesian random-effects approach. MEDLINE, EMBASE, and CENTRAL were searched.

INTERVENTIONS

High flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bilevel CPAP (BiPAP), noninvasive positive pressure ventilation (NIPPV).

MAIN OUTCOME MEASURES

Requirement of invasive mechanical ventilation (MV), any treatment failure.

RESULTS

A total of 35 studies including 4078 neonates were included. NIPPV was more effective in decreasing the requirement of MV than CPAP (risk ratios [95% credible interval]: 0.60 [0.44, 0.77]) and HFNC [0.66 (0.43, 0.97)]. Surface under the cumulative ranking curve (SUCRA) for NIPPV, BiPAP, HFNC, and CPAP were 0.95, 0.59, 0.32, and 0.13. For the outcome of treatment failure, both NIPPV and BiPAP were more efficacious compared to CPAP and HFNC (0.56 [0.44, 0.71] {NIPPV vs CPAP}, 0.69 [0.51, 0.93] {BiPAP vs CPAP}, 0.42 [0.30, 0.63] {NIPPV vs HFNC}, 0.53 [0.35, 0.81] {BiPAP vs HFNC}). The SUCRA for NIPPV, BiPAP, CPAP, and HFNC were 0.96, 0.70, 0.32, and 0.01. NIPPV was associated with a reduced risk of air leak compared to BiPAP and CPAP (0.36 [0.16, 0.73]; 0.54 [0.30, 0.87], respectively). NIPPV resulted in lesser incidence of bronchopulmonary dysplasia or mortality when compared to CPAP (0.74 [0.52, 0.98]). Nasal injury was lesser with HFNC compared to CPAP (0.15 [0.01, 0.60]).

CONCLUSIONS

Most effective primary mode of NRS in preterm neonates with RDS was NIPPV.

Predictors of CPAP Failure - 10 years' Data of Multiple Trials from a Single Center: A Retrospective Observational Study

OBJECTIVES

To identify risk factors and outcomes associated with early failure of nasal continuous positive airway pressure (CPAP) in premature infants with respiratory distress (RD).

METHODS

This is a retrospective observational study of all the preterm infants with RD primarily supported on nasal CPAP and included in CPAP trials conducted at the study site. Data was collected from the raw excel sheets of the previous trials but limited to eligible patients from study site. Early CPAP failure was defined as the need for mechanical ventilation in the first 72 h after birth. Predictor variables for CPAP failure included baseline maternal and infant characteristics, CPAP care practices, morbidities and adjuvant therapies. The morbidities and outcomes were compared among infants with CPAP failure and CPAP success.

RESULTS

Six hundred and fifty-two infants were enrolled in the study. Early CPAP failure was seen in 96 infants (14.7%, 95% CI: 12%-17.5%). On logistic regression, adjusting for gestation and year of study, time of starting CPAP in hours (OR 1.01, 95% CI: 1.003-1.013), time of surfactant administration in hours (OR 1.12, 95% CI: 1.05-1.19), InSurE (Intubate Surfactant Extubate) (OR 2.7, 95% CI: 1.43-5.06) and higher starting FiO₂ (OR 1.03, 95% CI: 1.01-1.05) predicted early CPAP failure. Neonatal morbidities and hospital duration were significantly higher in infants who failed CPAP.

CONCLUSIONS

Early starting of CPAP, InSurE, early surfactant administration, lower CPAP pressures and lower FiO₂ at starting of CPAP were the important determinants of success.

Erythrocyte Complement Receptor 1 Gene Polymorphisms and Neonatal Respiratory Distress Syndrome

To evaluate the role of erythrocyte complement receptor 1 ( ECR1 ) gene in the predisposition to respiratory distress syndrome (RDS), we studied 50 infants with RDS and 50 controls. Real-time polymerase chain reaction allelic discrimination analysis of A3650G (rs2274567) and genotyping of the alleles (HindIII) were performed. Allele L of HindIII restricted single nucleotide polymorphism (SNP) associated with the severity of RDS. Duration of oxygen and ventilation in genotypes AA and AG of A3650G SNP was longer than genotype GG (17.6 ± 19.4 and 8.6 ± 4.5 days, p  = 0.01) and (8.9 ± 11.9 and 3.9 ± 3.53 days, p  = 0.03), respectively. A3650G and HINDIII digested gene polymorphisms of ECR1 may be of little importance for RDS.

Application of two different nasal CPAP levels for the treatment of respiratory distress syndrome in preterm infants-"The OPTTIMMAL-Trial"-Optimizing PEEP To The IMMAture Lungs: study protocol of a randomized controlled trial

Background

Nasal continuous positive airway pressure (CPAP) applies positive end-expiratory pressure (PEEP) and has been shown to reduce the need for intubation and invasive mechanical ventilation in very low birth weight infants with respiratory distress syndrome. However, CPAP failure rates of 50% are reported in large randomized controlled trials. A possible explanation for these failure rates is the application of insufficient low levels of PEEP during nasal CPAP treatment to maintain adequate functional residual capacity shortly after birth. The optimum PEEP level to treat symptoms of respiratory distress in very low birth weight infants has not been assessed in clinical studies. The aim of the study is to compare two different PEEP levels during nasal CPAP treatment in preterm infants.

Methods

In this randomized multicenter trial, 216 preterm infants born at 26 + 0–29 + 6 gestational weeks will be allocated to receive a higher (6–8 cmH₂O) or a lower (3–5 cmH₂O) PEEP during neonatal resuscitation and the first 120 h of life. The PEEP level within each group will be titrated throughout the intervention based on the FiO₂ (fraction of inspired oxygen concentration) requirements to keep oxygenation within the target range. The primary outcome is defined as the need for intubation and mechanical ventilation for > 1 h or being not ventilated but reaching one of the two pre-defined CPAP failure criteria (FiO₂ > 0.5 for > 1 h or pCO₂ ≥ 70 mmHg in two consecutive blood gas analyses at least 2 h apart).

Discussion

Based on available data from the literature, the optimum level of PEEP that most effectively treats respiratory distress syndrome in preterm infants is unknown, since the majority of large clinical trials applied a wide range of PEEP levels (4–8 cmH₂O). The rationale for our study hypothesis is that the early application of a higher PEEP level will more effectively counteract the collapsing properties of the immature and surfactant-deficient lungs and that the level of inspired oxygen may serve as a surrogate marker to guide PEEP titration. Finding the optimum noninvasive continuous distending pressure during early nasal CPAP is required to improve CPAP efficacy and as a consequence to reduce the exposure to ventilator-induced lung injury and the incidence of chronic lung disease in this vulnerable population of very preterm infants.

Trial registration

drks.de DRKS00019940. Registered on March 13, 2020

Maternal adipose tissue, antenatal steroids, and Respiratory Distress syndrome: complex relations

Çelik HT, Korkmaz A, Özyüncü Ö, Yiğit Ş, Yurdakök M. Maternal adipose tissue, antenatal steroids, and Respiratory Distress syndrome: complex relations. Turk J Pediatr 2019; 61: 859-866. The incidences of maternal obesity and obesity-related maternal, fetal and neonatal complications have increased considerably. Obese people may have lower, normal or increased fat mass independent from their body mass index. We aimed to investigate the relationships between antenatal steroid therapy and maternal body fat ratio for the risk of Respiratory distress syndrome (RDS) in preterm infants. Pregnant women and their newborn infants between 24-34 weeks of gestation, who received a full course of antenatal steroid therapy were included in the study. Mother`s body weight, body mass ındex (BMI), and body compositions (muscle, fat, water) were calculated using the bioelectrical impedance method 5 days after giving birth. Neonatal characteristics and respiratory outcomes were noted. A total of 42 mothers and their single premature infants were included in the study. Nineteen (45.2%) infants developed RDS (Group 1) while 23 (54.8%) infants did not develop RDS (Group 2). The mean body fat mass (kg), fat ratio (%), truncal fat mass (kg), and truncal fat ratio (%) were statistically significantly higher in Group 1 than in Group 2. The incidence of RDS was significantly higher in the group of mothers with a body fat ratio > 30.0% (n=15/24, 62.5%) when compared with the group of mothers with a body fat ratio ≤ 30% (n=4/18, 22.2%) (p=0.013). Maternal adipose tissue plays an important role and should be taken into consideration especially in obese women, before giving antenatal steroids to achieve positive effects of the therapy in preterm infants.

Embedded WAIS-IV Detection Strategies and Feigned Cognitive Impairment: An Investigation of Malingered ADHD

Malingered attention-deficit hyperactivity disorder (ADHD) may be strongly motivated on college campuses by recreational use of ADHD medications and to obtain unwarranted academic accommodations. Rather than rely on face-valid (easily faked) ADHD checklists, the study focused on the more complex Wechsler Adult Intelligence Scale-Fourth edition (WAIS-IV; Wechsler, 2008). However, the current literature has not yet investigated well-defined detection strategies for feigned WAIS-IV presentations. Using aprioristic standards, four different detection strategies from the feigning literature were adapted to certain WAIS-IV subscales. For example, significantly below-chance performance was applied to visual puzzles. Using a between-subjects simulation design, 74 undergraduate simulators were compared with archival data on 73 outpatients diagnosed with ADHD at a university psychology clinic. Very large effect sizes (Cohen's ds from 1.66 to 1.90) differentiated between genuine and feigned ADHD. Two strategies (significantly below-chance performance and floor effect) showed strong promise if cross-validated for other feigning presentations. The study concluded with clinical considerations and future avenues for research.

Reducing post-extubation failure rates in very preterm infants: is BiPAP better than CPAP?

Background and Aim: Continuous positive airway pressure (CPAP) is currently used in neonates after mechanical ventilation though it may occasionally be associated with air leaks syndromes or it may fail to support the baby. The pressure difference offered by bilevel continuous positive distending pressure (BiPAP) respect to CPAP may be an advantage to the spontaneously breathing patient. In this study, we compared the efficacy of CPAP and BiPAP in the firstweek post-extubation in a series of very preterm infants.Methods: Inborn neonates less than 30 weeks of gestational age who were intubated shortly after birth from January 2011 to December 2017 were enrolled in a retrospective study. The attending clinician assessed the patients for non-invasive respiratory support readiness and allocated them to CPAP (PEEP 4-6 cmH₂O) or BiPAP (PEEP 4-5 cmH₂O, rate 10-40; Thigh 0.7-1.2; upper-pressure level 8-10 cmH₂O). Both techniques were compared for preventing extubation failure within 7 days from extubation as defined per local protocol (primary outcome). Secondary outcomes were: definitive failure of extubation, pneumothorax during non-invasive respiratory support, periventricular leukomalacia, bronchopulmonary dysplasia, sepsis, patent ductus arteriosus and retinopathy of prematurity at discharge.Results: We enrolled 134 neonates; the CPAP group included 89 babies while 45 received BiPAP. Patients did not differ for their general characteristics (EG, antenatal steroids, incidence of SGA, maternal hypertension, surfactant replacement therapy). Short term extubation failure was significantly higher in the former group (23/89 in CPAP vs 5/45 in BiPAP; p = .005). No infant developed air leak syndrome. Secondary outcomes were comparable between groups. Multivariate analysis showed that on the whole population the extubation failure was correlated to the insurgence of late-onset sepsis.Conclusion: BiPAP safely reduced early extubation failure compared to CPAP in our cohort of very preterm neonates within 7 days from extubation.