Effect of recombinant erythropoietin on "late" transfusions in the neonatal intensive care unit: a meta-analysis.

OBJECTIVES: Using the approach of a meta-analysis, we sought to determine whether the administration of recombinant erythropoietin (rEpo) to very low birth weight (VLBW) infants, after the first week of life, results in fewer "late" transfusions. STUDY DESIGN AND METHODS: The guidelines set forth by the Cochrane Neonatal Review Group were used to identify all relevant studies. Medline was searched from January 1990 to November of 2000. Studies that used a randomized, placebo-controlled, and double-masked design were deemed acceptable. RESULTS: Eight studies meet the inclusion criteria. These involved 357 VLBW neonates: 183 rEpo and 174 placebo recipients. The neonates in the rEpo group received fewer erythrocyte transfusions during the study period than did those in the placebo group; the common odds ratio (OR)=0.33; 95% confidence interval (CI) 0.21-0.51. Furthermore, the rEpo effect size was a function of the dose of rEpo administered (p=0.0001). CONCLUSION: A meta-analysis of the most scientifically rigorous studies on this topic indicates that administration of rEpo to VLBW infants reduces "late" erythrocyte transfusions in a dose-dependent manner.     

Effect of administering recombinant erythropoietin to women with postpartum anemia: a meta-analysis.

OBJECTIVES: Recombinant erythropoietin (rEpo) has been administered to women with postpartum anemia in an attempt to accelerate their increase in hemoglobin concentration and reduce postpartum transfusions. However, it is not clear whether such an approach can be supported by evidence and should be generally recommended. STUDY DESIGN AND METHODS: Medical and scientific literature from January 1990 to December 2002 was searched and studies that reported the administration of rEpo to women with postpartum anemia were evaluated. RESULTS: Eight evaluated studies reported an aggregate of 480 women; 300 rEpo recipients and 180 controls. Significant diversity in design was observed in rEpo dose, route of rEpo administration, iron supplementation, and baseline hemoglobin. No significant safety concerns were reported. In all five studies where it was reported, 4 to 7 days after beginning treatment, greater increases in hemoglobin concentration were observed among the rEpo recipients than among the controls. However, heterogeneity of results (Q-test statistic, p<0.01) indicated that it was not appropriate to apply summary statistics. The effect of rEpo on postpartum transfusion rate was not measurable by summary statistics because of the limited number of transfusions given (no transfusions among the 300 rEpo recipients vs two transfusions among the 180 controls). CONCLUSION: Administration of rEpo to women with postpartum anemia appears to be safe, and is associated with a trend toward a faster increase in hemoglobin concentration. However, its efficacy in terms of diminishing postpartum transfusions is unproven.     

Unique risks of red blood cell transfusions in very-low-birth-weight neonates: associations between early transfusion and intraventricular hemorrhage and between late transfusion and necrotizing enterocolitis

Abstract

Red blood cell transfusions can be life-saving for neonates with severe anemia or active hemorrhage. However, risks of transfusions exist and should always be weighed against potential benefits. At least two transfusion risks are unique to very low birth weight neonates. The first is an association between transfusions given in the first days after birth and the subsequent occurrence of a grade 3 or 4 intraventricular hemorrhage. The second is an association between “late” RBC transfusions and the subsequent occurrence of necrotizing enterocolitis. Much remains to be discovered about the pathogenesis of these two outcomes. Moreover, work is needed to clearly establish whether transfusions are causatively-associated with these outcomes or are co-variables. This review will provide basic data establishing these associations and propose mechanistic explanations.     

Performance of a dosage individualization table for extended interval gentamicin in neonates beyond the first week of life

Objective: To assess the performance of a gentamicin dosing table for the individualization of extended-interval dosing (EID) in a neonatal population >7 days old.

Methods: A prospective observational study was carried out on gentamicin concentrations achieved using a dosing table in neonates >7 days old. Neonates were given 5?mg/kg IV gentamicin; then a table using 22?h post-first dose gentamicin concentrations was used to individualize dosing intervals. Pre- and post-serum gentamicin concentrations were measured and used to calculate the true peak and trough concentrations achieved.

Results: Use of the table resulted in dosing intervals that provided appropriate peak (mean 9.8?±?1.8?mg/L) and trough (mean 0.6?±?0.3?mg/L) concentrations in all neonates (n?=?38). All trough concentrations were <2?mg/L, 83% were <1?mg/L. The majority of peak concentrations were in the usual target range (87%, 5–12?mg/L), with a few being in a higher, although likely safe range (13%, 12.1–15.7?mg/L).

Conclusions: Use of this dosing table to individualize extended-interval gentamicin dosages in neonates >7 days old resulted in appropriate peak and trough concentrations in all neonates studied. This allows appropriate extended-interval aminoglycoside dosages in neonates early in treatment.     

重组人类基因促红细胞生成素对早产儿视网膜病变影响的分析

目的　探讨重组人类基因促红细胞生成素（rhu-EPO）的应用对早产儿视网膜病变（ROP）的影响。方法 　对2005年3月至2008年6月期间收住福建医科大学附属漳州市医院新生儿科的早产儿（体重 ≤ 1500 g）病例资料进行分析,应用rhu-EPO治疗的94例为治疗组,未应用rhu-EPO的65例为对照组,生后6周或纠正胎龄35周时行眼底检查,根据ROP国际分期标准进行ROP诊断和分期,同时对多种相关因素进行统计分析。结果　治疗组严重ROP的患病率高于对照组（P < 0.05）;单因素分析显示rhu-EPO治疗 ≥ 10剂,发生严重ROP的风险高于rhu-EPO治疗剂数<10剂（r = 6.429,P < 0.001）,开始治疗时间 ≥ 14 d发生严重ROP风险明显高于 < 14 d（ r =46.000,P < 0.001）;多因素Logistic分析显示rhu-EPO治疗剂数 ≥ 10剂发生严重ROP风险高（r = 9.348,P < 0.001）。结论　应用rhu-EPO是早产儿ROP的一个独立危险因素。     

Effect of recombinant granulocyte colony-stimulating factor on blood neutrophil concentrations among patients with "idiopathic neonatal neutropenia": a randomized, placebo-controlled trial.

OBJECTIVES: We previously described a severe, prolonged, idiopathic, but self-resolving, variety of neutropenia among preterm neonates. In the present study, we sought to assess the marrow neutrophil reserves of these patients by serially measuring blood neutrophils following the administration of recombinant granulocyte colony-stimulating factor (rG-CSF) or placebo. STUDY DESIGN: Prospective, randomized trial of rG-CSF vs placebo for infants with "idiopathic neonatal neutropenia". RESULTS: During 36 consecutive months, 2407 neonates were admitted to the neonatal intensive care unit; 429 weighed less than 1500 g at birth, 14 of these were later diagnosed with "idiopathic neonatal neutropenia"; 10 were enrolled in this trial. The five rG-CSF recipients had an immediate, marked increase in blood neutrophil concentration, indicating adequate rG-CSF-mobilizable marrow neutrophil reserves. This effect persisted to day 5, but counts were not different from those of the five placebo recipients on days 12 and 15. CONCLUSIONS: Patients with "idiopathic neonatal neutropenia" have a substantial rG-CSF-mobilizable marrow neutrophil reserve. On that basis, we speculate that this variety of neonatal neutropenia does not constitute a significant deficiency in antibacterial defense.     

Sudden unexpected neonatal death in the first week of life: Autopsy findings from a specialist centre

Objective. Sudden unexpected early neonatal death (SUEND) in the first week of life shares features with sudden unexpected death in infancy (SUDI) but is not included as SUDI, which is limited to post-perinatal deaths. The aim of this study was to review SUEND autopsies performed in a single specialist centre over a 10-year period, (1996–2005).

Methods. Retrospective analysis of >1500 consecutively performed paediatric autopsies performed by paediatric pathologists at one centre conducted according to a standard protocol including ancillary investigations. SUENDs were identified and autopsy findings reviewed.

Results. Of 1516 post-mortem examinations, 180 were first-week neonatal deaths, 55 (31%) presenting as SUEND. Thirty-two (58%) were explained following autopsy, whilst the remainder were unexplained; most deaths during sleep were associated with adult co-sleeping. Around 40% of explained deaths were associated with undiagnosed congenital abnormalities, mainly congenital heart disease. In addition, there were nine infection-related deaths and three deaths from unsuspected metabolic disease (fatty acid oxidation defects).

Conclusion. There are distinct differences between SUEND and SUDI, with significantly more explained deaths in the former and a much greater proportion due to congenital abnormalities and metabolic disease.     

The effect of blood transfusion on the hemoglobin oxygen dissociation curve of very early preterm infants during the first week of life

A study was conducted during the first week of life to determine the changes in P50 (PO2 required to achieve a saturation of 50% at pH 7.4 and 37 degrees C) and the proportions of fetal hemoglobin (HbF) and adult hemoglobin (HbA) prior to and after transfusion in very early preterm infants. Eleven infants with a gestational age < or = 27 weeks have been included in study. The hemoglobin dissociation curve and the P50 was determined by Hemox-analyser. Liquid chromatography was also performed to determine the proportions of HbF and HbA. The mean gestational age of the 11 infants was 25.1 weeks (+/- 1 weeks) and their mean birth weight was 736 g (+/- 125 g). They received 26.9 mL/kg of packed red cells. The mean P50 prior and after transfusion was 18.5 +/- 0.8 and 21.0 +/- 1 mm Hg (P = .0003) while the mean percentage of HbF was 92.9 +/- 1.1 and 42.6 +/- 5.7%, respectively. The data of this study show a decrease of hemoglobin oxygen affinity as a result of blood transfusion in very early preterm infants prone to O2 toxicity. The shift in HbO2 curve after transfusion should be taken into consideration when oxygen therapy is being regulated for these infants.     

Serum alpha-fetoprotein in adults, in women during pregnancy, in children at birth, and during the first week of life: a sex difference.

In order to investigate whether a sex difference exists in alpha-fetoprotein serum concentration, blood samples were collected from 133 adult men, 52 adult women, 239 pregnant women at different ages of gestation, 16 girls and 18 boys at birth, and seven girls and seven boys during the first week of life. In the case of 15 boys and 10 girls, blood samples were also collected from their mothers at the time of delivery. Serum AFP was measured by a radioimmunoassay method. In all neonates the mean value was 625 times higher than in all mothers at the time of delivery and 13,000 times higher than in adults. No difference was found between mothers of girls and those of boys both during pregnancy and at the time of delivery. However, at birth, the fetal AFP serum concentration was 1.8 (p less than 0.001) times higher in boys than in girls. This sex difference was maintained during the first week of life. The half-life of serum AFP was 5 to 6 days in the neonate. The origin and the possible physiologic significance of such sex difference in AFP deserve further investigations.     

Effect of heparin on the outcome of IVF treatment: a systematic review and meta-analysis

The effect of heparin on IVF outcome has been widely debated in the literature. A systematic review and meta-analysis of the published literature was conducted to evaluate the effect of heparin treatment on IVF outcome. Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science and identified 10 relevant studies (five observational and five randomized) comprising 1217 and 732 IVF cycles, respectively. The randomized studies included small numbers of women and exhibited high methodological heterogeneity. Meta-analysis of the randomized studies showed no difference in the clinical pregnancy rate (RR 1.23, 95% CI 0.97–1.57), live birth rate (RR 1.27, 95% CI 0.89–1.81) implantation rate (RR 1.39, 95% CI 0.96–2.01) and miscarriage rate (RR 0.77, 95% CI 0.24–2.42) in women receiving heparin compared with placebo during IVF treatment. However, meta-analysis of the observational studies showed a significant increase in the clinical pregnancy rate (RR 1.83, 95% CI 1.04–3.23, P = 0.04) and live birth rate (RR 2.64, 95% CI 1.84–3.80, P < 0.0001). The role of heparin as an adjuvant therapy during IVF treatment requires further evaluation in adequately powered high-quality randomized studies.The effect of heparin on IVF outcome is widely debated. Despite the results of published studies being conflicting, it has been suggested that the use of heparin results in increased pregnancy rates following IVF treatment. We conducted a systematic and comprehensive of the published literature to evaluate the effect of heparin treatment on IVF outcome. Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science. We identified 10 studies from the literature and extracted the relevant data from the studies. Analyses of the data from randomized trials showed no improvement in the clinical pregnancy rate or the live birth rate in the group that received heparin. However, the studies included had small numbers of women and high methodological heterogeneity. The role of heparin in this context requires further evaluation in adequately powered randomized studies.     

Paracetamol versus ibuprofen for the treatment of patent ductus arteriosus in preterm neonates: a meta-analysis of randomized controlled trials

Background: Paracetamol has been suggested as an effective treatment for patent ductus arteriosus (PDA). However, the comparative efficacy and safety between paracetamol and ibuprofen were not determined.

Methods: A meta-analysis of randomized controlled trials (RCTs) was performed. Relevant studies were identified via database searching. A fixed or random effect model was applied depending on the extent of heterogeneity.

Results: Five RCTs with 677 neonates were included. The efficacies for the primary (risk ratio [RR]: 1.03, p?=?.56) and overall PDA closure were comparable between the two medications (RR: 1.02, p?=?.62). Neonates of the two groups were comparable for the incidence of PDA complications, including necrotizing enterocolitis (RR: 0.86, p?=?.70), intraventricular hemorrhage (RR: 0.84, p?=?.55), bronchopulmonary dysplasia (RR: 0.69, p?=?.16), and retinopathy of prematurity (RR: 0.58, p?=?.15), and the risks of sepsis (RR?=?0.88, p?=?.48) and death (RR: 1.45, p?=?.45) within hospitalization. However, treatment with paracetamol was associated with a trend of reduced risk of renal failure (RR: 0.20, p?=?.07), and a significantly reduced risk of gastrointestinal bleeding (RR: 0.28, p?=?.009).

Conclusions: Paracetamol may confer comparable treatment efficacy for the closure of PDA as ibuprofen, although paracetamol is associated with lower risk of adverse events.     

Effect comparison of metformin with insulin treatment for gestational diabetes: a meta-analysis based on RCTs

Purpose

To compare the effects of metformin with insulin on maternal and neonatal outcomes in gestational diabetes mellitus (GDM).

Methods

A literature search in PUBMED, EMBASE, Science Direct, Springer link, and Cochrane library was conducted using the following search terms: “Gestational Diabetes” or “GDM”, and “insulin” and “metformin”. Quality assessment of included studies was determined with Quality Assessment of Diagnostic Accuracy Studies. Review Manger 5.2 was used to analyze mean difference (MD)/risk ratio (RR) and 95 % confidence interval (CI) in random-effects model or fixed-effects model depending on the level of heterogeneity.

Results

A total of 11 studies were identified. There was no significant difference of the effect on maternal outcomes between the two treatments in glycohemoglobin A1c levels (P = 0.37), fasting blood glucose (P = 0.66), and the incidence of preeclampsia (P = 0.26); whereas, significantly reduced results were found in the metformin group in pregnancy-induced hypertension (PIH) rate (RR = 0.53, 95 % CI 0.31–0.90, P = 0.02), average weight gains after enrollment (MD = ?1.28, 95 % CI ?1.54 to ?1.01, P < 0.0001), and average gestational ages at delivery (MD = 0.94, 95 % CI ?0.21 to ?0.01, P = 0.03). Regarding neonatal outcomes, when compared with insulin group, metformin presented significantly lower average birth weights (MD = ?44.35, 95 % CI ?85.79 to ?2.90, P = 0.04), incidence of hypoglycemia (RR = 0.69, 95 % CI 0.55–0.87, P = 0.001) and neonatal intensive care unit (NICU) (RR = 0.82, 95 % CI 0.67–0.99, P = 0.04).

Conclusion

Metformin can significantly reduce several adverse maternal and neonatal outcomes including PIH rate, incidence of hypoglycemia and NICU, thus it may be an effective and safe alternative or additional treatment to insulin for GDM women.

     

延迟钳夹脐带对剖宫产新生儿早期血液灌输的影响研究

目的　探讨延迟钳夹脐带对剖宫产新生儿早期血液灌输的影响。方法　2007年7月至2009年9月东莞石龙博爱医院产科经剖宫产分娩的137例新生儿随机分成两组,即常规钳夹脐带组（71例）和延迟钳夹脐带组（66例）。比较分析两组剖宫产新生儿的钳夹脐带时间、生后48 h血常规及生后3d内静脉血胆红素值和贫血的发生率。结果　两组剖宫产新生儿钳夹脐带时间、生后48 h内血常规指标及贫血发生率的比较差异有统计学意义（P < 0.05）,延迟钳夹脐带组贫血发生率减少。结论　延迟钳夹脐带对剖宫产新生儿早期血红蛋白（Hb）、红细胞压积（HCT）有显著影响,可减少剖宫产新生儿早期贫血的发生率。     

New Hampshire House Bill 1719-FN. "An act defining human life as beginning at the moment of fertilization for the purposes of prenatal, pregnancy, and maternity services and programs"

Recently, the author was asked by the New Hampshire State Medical Society to testify before the State of New Hampshire's House Judiciary Committee, to address a bill that would establish the definition of when human life begins. Other states, such as South Dakota, recently passed a ban on abortion. Such legislation will severely limit a woman's ability to exercise her right to terminate her pregnancy. With the present composition of the US Supreme Court, it seems possible that in the not-too-distant future there will be a successful challenge to Roe v Wade. It is important that as health care providers we take the time to educate our public officials and general citizenry about the complexity of such issues. The subsequent editorial will paraphrase the statement that was delivered. Fortunately, the bill was defeated.     

Effect of a single dose of sodium bicarbonate given during neonatal resuscitation at birth on the acid-base status on first day of life.

OBJECTIVE: To study the effect of a single dose of sodium bicarbonate given during neonatal resuscitation at birth on the acid-base status on the first day of life. SETTING: Tertiary care Level III NICU. STUDY DESIGN: A total of 55 consecutively born asphyxiated neonates continuing to receive positive pressure ventilation at 5 minutes of life were randomized to receive either 4 ml/kg (1.8 meq/kg) of sodium bicarbonate or 5% dextrose. RESULTS: The mean pH, base deficit and PaCO(2) were similar between the Base group and the Control group for the first 24 hours of life. The number of babies with persistent metabolic acidosis at 1, 6, 12 and 24 hours were comparable between the two groups. CONCLUSION: Sodium bicarbonate given during neonatal resuscitation did not change the acid-base status in the first 24 hours of life.     

Effect of psychosocial interventions on the severity of premenstrual syndrome: a meta-analysis

Introduction: Premenstrual syndrome (PMS) is common in women with reproductive age and it affects the normal life. Psychosocial interventions are recommended for some women who experience less severe PMS. So far, no meta-analyses have investigated the effect of overall psychosocial interventions on the severity of PMS as an outcome. This review aims to explore the effectiveness of psychosocial intervention for PMS.

Methods: We performed a systematic literature search in PubMED, CINAHL, EMbase and PsycINFO in December 2016, following methodological guidelines outlined in the literature (www.york.ac.uk/crd/ guidance). The primary outcome was the severity of PMS. Data were pooled using a random-effects meta-analysis model.

Results: Pooled effects of 11 psychosocial interventions (n?=?324) showed statistically significant beneficial effects on the severity of PMS (SMD –0.29, 95% CI –0.45 to –0.13, I²?=?27%). Participants who received coping skills training had significantly low severity of PMS than the control group (SMD –0.53, 95% CI –0.77 to –0.28, p?<?.001, I²?=?3%). There were no effects found for education program nor social support intervention.

Discussion: Psychosocial interventions, especially coping skills training for women with PMS, were effective in reducing the severity of PMS. However, needed caution due to the small number of studies.     

Impact of midwives’ training on postnatal depression screening in the first week post delivery: a quality improvement report

Backgroundpostnatal depression (PND) is a major public health problem. The objective of this study was to improve early PND screening by midwives in a maternity unit. Professional screening techniques were evaluated and compared with reference screening techniques [Edinburgh Postnatal Depression Scale (EPDS), Mini International Neuropsychiatric Interview (MINI-DSM-IV)].Methodsthe evaluation took place before and after the midwife training in order to determine the effectiveness of specific clinical recommendations for two successive 10-week inclusion periods (from November 2004 to September 2005). A short training course and posters were used to convey the recommendations, agreed by obstetricians, paediatricians and psychiatrists.Resultsa total of 463 postpartum women were included in the two phases of the study. Quantitative and qualitative PND screening by midwives improved significantly following training (Z=2.07, p=0.04; Z=2.62, p=0.008, respectively). Early detection of major depressive episodes increased by 37.7% (95% confidence interval 25.7–49.7) following training. A combination of midwives’ perception of poor emotional well-being and the EPDS led to a significant improvement in early detection of PND (Q=8.00, p=0.04).Discussiontargeted recommendations given to the midwives led to an improvement in the early detection of PND. Suitable programmes need to be offered to reduce the number of cases of PND. Perinatal psychiatrists should be seen to be meticulous and available for such prevention action.     

Identifying patients, on the first day of life, at high-risk of developing parenteral nutrition-associated liver disease.

BACKGROUND: Prolonged use of parenteral nutrition (PN) in neonates can lead to parenteral nutrition-associated liver disease (PNALD), manifested by elevated direct bilirubin concentrations, and in some cases progressing to hepatic failure. When new potential means of preventing PNALD in the neonatal intensive care unit (NICU), such as Omegaven usage, are tested in clinical trials, the studies should enroll neonates at a very high risk of developing PNALD. However, it is not always clear, in the first days of life, which neonates are most likely to develop PNALD. Therefore, preparatory to devising studies of prophylaxis against PNALD, we conducted an evaluation of all NICU patients who received PN for >or=14 day, assessing their likelihood of developing PNALD. METHODS: We performed an historic cohort analysis of all neonates in the Intermountain Healthcare system, receiving PN for 14 days or more during their stay, with dates of birth between 1 January, 2002 and 30 June, 2006. RESULTS: During the 4(1/2)-year period, 9861 neonates were cared for in the Intermountain Healthcare NICUs. Of these, 9547 (96.8%) survived for at least 28 days, and of these 6543 (68.5%) received PN. Twenty-one percent (1366 patients) of those receiving PN, received it for >or=14 days. PNALD was ascertained in this group by a direct bilirubin >or=2.0 mg/dl. Neonates receiving PN for 14-28 days had a 14% incidence of PNALD, those receiving PN for 29-56 days had a 43% incidence, those receiving PN for 57-100 days had a 72% incidence and those receiving PN for >100 days had a 85% incidence. Groups of patients identifiable on the first day of life as having the highest risk of developing PNALD were birth weight <500 g (odds ratio (OR), 30.7), birth weight 500-749 g (OR, 13.1), gastrochisis (OR, 20.3) and jejunal atresia (OR, 24.0). Among 357 patients who developed PNALD, the highest direct bilirubin concentrations correlated with the highest serum alkaline phosphatase and transaminase concentrations. Deaths after 28 days were much more common in those with the highest direct bilirubin and transaminase concentrations (P<0.0001). CONCLUSIONS: In the first days of life, certain NICU patients can be identified as being at very high risk for developing PNALD. These are patients <750 g birth weight, those with gastrochisis and those with jejunal atresia. We speculate that these groups would be reasonable subjects for including in a PNALD prophylaxis trial, testing new preventative strategies such as Omegaven usage.