Combined Outcome Of Death Research Articles

Low serum testosterone is associated with adverse outcome in men with cirrhosis independent of the model for end-stage liver disease score.

Low serum testosterone has been retrospectively associated with mortality in men on the liver transplant waiting list. The impact of testosterone deficiency on other outcomes has not previously been assessed. We conducted a single center prospective observational study of all men with cirrhosis seen between 2013 and 2014. Baseline data included sex hormone profile, Model for End-Stage Liver Disease (MELD) score, and standard biochemistry. Outcomes were recorded over 12 months including major infection, liver transplantation, and death. Of 268 cirrhotic men, the median MELD score was 10 (interquartile range [IQR], 8-15) and median serum testosterone was 17.4 nmol/L (IQR, 8.9-25.0 nmol/L). During the study period, 32 (12%) men died, 18 (7%) received a liver transplant, and 51 (19%) suffered a major infection. Mortality markedly increased when total testosterone fell below a threshold value of 8.3 nmol/L, and this cutoff was used for further analysis. Testosterone below 8.3 nmol/L was associated with the combined outcome of death or transplantation independently of the MELD score (hazard ratio [HR], 2.36; IQR, 1.16-4.81; P = 0.02) for testosterone (and HR, 1.22; IQR, 1.18-1.27; P < 0.001 for MELD). Low total testosterone was also an independent risk factor for major infection (HR, 3.61; IQR, 1.61-8.06; P < 0.001) and nearly significant for mortality alone (HR, 2.39; IQR, 0.97-5.88; P = 0.057). Low free testosterone (<139 pmol/L) was similarly independently associated with death or transplantation (HR, 2.43; IQR, 1.12-5.29; P = 0.03) and infection (HR, 3.3; IQR, 1.46-7.46; P = 0.004). In conclusion, low testosterone is a novel prognostic marker in men with cirrhosis that is numerically associated with increased mortality or need for transplantation, as well as risk for major infection. Interventional studies of testosterone therapy are required to investigate whether correcting low testosterone can reduce mortality and improve other clinical outcomes. Liver Transplantation 22 1482-1490 2016 AASLD.

Refractory anastomotic bile leaks after orthotopic liver transplantation are associated with hepatic artery disease

Anastomotic bile leaks are common after orthotopic liver transplant (OLT), and standard treatment consists of placement of a biliary endoprosthesis. The objectives of this study were to identify risk factors for refractory anastomotic bile leaks and to determine the morbidity associated with refractory bile leaks after OLT. Consecutive adult patients who underwent ERCP for treatment of post-OLT biliary adverse events between 2009 and 2014 at a high-volume transplant center were retrospectively identified. A refractory leak was defined as a bile leak that persisted after placement of a plastic biliary endoprosthesis and required repeat endoscopic or surgical intervention. Forty-three subjects met study inclusion criteria. Median age was 57 years, and 36 (84%) subjects were men. Refractory bile leaks were diagnosed in 40% of subjects (17/43). Time-to-event analysis revealed an association between refractory bile leaks and the combined outcome of death, repeat transplant, or surgical biliary revision (hazard ratio, 3.78; 95% confidence interval, 1.25-11.45; P= .01). Hepatic artery disease was more common with refractory compared with treatment-responsive bile leaks (53% vs 8%, P= .001). Refractory anastomotic bile leaks after liver transplantation are associated with decreased event-free survival. Hepatic artery disease is associated with refractory leaks. Large-scale prospective studies should be performed to define the optimal management of patients at risk for refractory bile leaks.

Outcomes of infants born at 22–27 weeks' gestation in Victoria according to outborn/inborn birth status

ObjectivesTo compare mortality and serious morbidity rates between outborn and inborn livebirths at 22–27 weeks' gestation.DesignPopulation-based cohort study.SettingVictoria, Australia.PatientsLivebirths at 22–27 weeks' gestation free of major malformations in 2010–2011.InterventionsOutcome data...

Late Surfactant Administration in Very Preterm Neonates With Prolonged Respiratory Distress and Pulmonary Outcome at 1 Year of Age: A Randomized Clinical Trial.

Although immature neonate survival has improved, there is an increased risk of developing bronchopulmonary dysplasia, leading to significant respiratory morbidity. Measures to reduce bronchopulmonary dysplasia are not always effective or have important adverse effects. To evaluate the effect of late surfactant administration in infants with prolonged respiratory distress on ventilation duration, respiratory outcome at 36 weeks' postmenstrual age, and at 1 year postnatal age. Double-blind randomized clinical trial at 13 level III French perinatal centers. Participants included 118 neonates at less than 33 weeks' gestation who still required mechanical ventilation on day 14 (SD, 2) with fraction of inspired oxygen of more than 0.30. All survivors were eligible for follow-up. We performed an intent-to-treat analysis. Infants received 200 mg/kg of poractant alfa (surfactant) or air after randomization. At 1 year, after parents' interview, infants underwent physical examination by pediatricians not aware of the randomization. The duration of ventilation was the primary outcome. The combined outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age and respiratory morbidity at 1 year of age were the main secondary outcome measures. Of the 118 infants who participated in the study, 65 (55%) were male. Fraction of inspired oxygen requirements dropped after surfactant, but not air, for up to 24 hours after instillation (0.36 [0.11] vs 0.43 [0.18]; P < .005). Severe bronchopulmonary dysplasia/death rates at 36 weeks' postmenstrual age were similar (27.1% vs 35.6%; P = .32). Less surfactant-treated infants needed rehospitalization for respiratory problems after discharge (28.3% vs 51.1%; P = .03); 39.5% vs 50% needed respiratory physical therapy (P = .35). No difference was observed for weight (7.8 [1.2] kg vs 7.6 [1.1] kg), height (69 [5] cm vs 69 [3] cm), and head circumference (44.4 [1.7] cm vs 44.2 [1.7] cm) measured at follow-up, nor for neurodevelopment outcome. Late surfactant administration did not alter the early course of bronchopulmonary dysplasia. However, surfactant-treated infants had reduced respiratory morbidity prior to 1 year of age. clinicaltrials.gov Identifier: NCT01039285.

The potential utility of urinary biomarkers for risk prediction in combat casualties: a prospective observational cohort study.

IntroductionTraditional risk scoring prediction models for trauma use either anatomically based estimations of injury or presenting vital signs. Markers of organ dysfunction may provide additional prognostic capability to these models. The objective of this study was to evaluate if urinary biomarkers are associated with poor outcomes, including death and the need for renal replacement therapy.MethodsWe conducted a prospective, observational study in United States Military personnel with traumatic injury admitted to the intensive care unit at a combat support hospital in Afghanistan.ResultsEighty nine patients with urine samples drawn at admission to the intensive care unit were studied. Twelve patients subsequently died or needed renal replacement therapy. Median admission levels of urinary cystatin C (CyC), interleukin 18 (IL-18), L-type fatty acid binding protein (LFABP) and neutrophil gelatinase-associated lipocalin (NGAL) were significantly higher in patients that developed the combined outcome of death or need for renal replacement therapy. Median admission levels of kidney injury molecule-1 were not associated with the combined outcome. The area under the receiver operating characteristic curves for the combined outcome were 0.815, 0.682, 0.842 and 0.820 for CyC, IL-18, LFABP and NGAL, respectively. Multivariable regression adjusted for injury severity score, revealed CyC (OR 1.97, 95 % confidence interval 1.26-3.10, p = 0.003), LFABP (OR 1.92, 95 % confidence interval 1.24-2.99, p = 0.004) and NGAL (OR 1.80, 95 % confidence interval 1.21-2.66, p = 0.004) to be significantly associated with the composite outcome.ConclusionsUrinary biomarker levels at the time of admission are associated with death or need for renal replacement therapy. Larger multicenter studies will be required to determine how urinary biomarkers can best be used in future prediction models.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0965-y) contains supplementary material, which is available to authorized users.

Elevated plasma and cerebrospinal fluid interleukin-1 beta and tumor necrosis factor-alpha concentration and combined outcome of death or abnormal neuroimaging in preterm neonates with early-onset clinical sepsis.

Prematurity and sepsis are the major contributors of neonatal mortality and neurodevelopmental sequelae. The present study was conducted to measure the plasma and cerebrospinal fluid (CSF) concentration of interleukin (IL)-1β and tumor necrotic factor (TNF)-α in preterm neonates with early-onset clinical sepsis (EOCS), and to find out their association with combined outcome of death or abnormal neuroimaging. Thirty-two preterm (⩽34 weeks) neonates with EOCS and 32 gestational age-matched, healthy neonates served as cases and controls, respectively. Samples were collected soon after birth. Neonates were followed up clinically and by serial cranial ultrasonography (CUS) until discharge and subsequently by magnetic resonance imaging (MRI) of brain until 1 year. Developmental screening was done by Denver Developmental Screening test-II. In EOCS group, no neonate had any clinical/microbiological evidence of meningitis. Blood culture was positive in 17 (53%). CUS was abnormal in 12 (37%) (intracranial hemorrhage-11, periventricular leukomalacia-1). Ten (31%) neonates expired. Significant elevation of plasma and CSF IL-1β and TNF-α was observed in the EOCS group. On follow-up, seven (22%) neonates showed evidence of white matter damage in MRI, two of them had developmental delay and microcephaly. Plasma and CSF IL-1β and TNF-α concentration were significantly elevated in deceased neonates and those with abnormal neuroimaging. Both biomarkers demonstrated high predictive accuracy for poor outcome in receiver-operating curve analysis. Elevation of plasma and CSF IL-1β and TNF-α is associated with an increase in the combined outcome of death or abnormal neuroimaging in preterm neonates with EOCS in the absence of clinical/microbiological evidence of meningitis with high predictive accuracy.

Association Between Transjugular Intrahepatic Portosystemic Shunt and Survival in Patients With Cirrhosis

A transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment of refractory ascites and variceal bleeding. However, it is unclear whether a TIPS affects long-term survival. We investigated whether a TIPS is associated with survival in patients with cirrhosis awaiting liver transplantation. By using the United Network for Organ Sharing registries from 2002 to 2013, we followed up a cohort of transplant-naive adults with cirrhosis (N= 97,063) from the time of transplant listing until the time of death or transplantation. We used Cox proportional hazards and competing-risks analyses to compare these primary outcomes between patients with a TIPS (n= 7475; 7.7%) and without a TIPS (n= 89,588; 92.3%) at the time of listing, adjusting for baseline characteristics. During an average follow-up period of 1.61 years, 23,305 (24%) patients died before undergoing transplantation, 47,563 (49%) underwent transplantation, and the remaining 26,195 (27%) still were alive without having received a liver transplant. Compared with patients without a TIPS, patients with a TIPS had a lower risk of death (adjusted subhazard ratio, 0.95; 95% confidence interval, 0.9-0.99), transplantation (adjusted subhazard ratio, 0.92, 95% confidence interval, 0.88-0.95), or the combined outcome of death or transplantation (adjusted hazard ratio, 0.85; 95% confidence interval, 0.83-0.88). Among patients with cirrhosis awaiting liver transplantation, patients with a TIPS had a lower mortality rate than patients without a TIPS.

Comparison of Liver Transplant–Related Survival Benefit in Patients With Versus Without Hepatocellular Carcinoma in the United States

Patients with T2 hepatocellular carcinoma (HCC) can obtain an exception that allows them to undergo liver transplantation with much lower actual Model for End-Stage Liver Disease (MELD) scores than patients without HCC. We compared patients who received liver transplants, with and without HCC, with regard to transplantation-related survival benefit. We modeled the post-transplantation survival of adult, first-time liver transplant recipients with HCC (n = 9135) or without (n = 25,890) from 2002 through 2013 using Cox proportional hazards regression. We modeled waitlist survival of patients listed for transplantation with HCC (n = 15,605) or without (n = 85,229) using competing risks analysis and combined outcomes of death or liver failure (defined as MELD score ≥30). We used these survival models to calculate monthly transition probabilities and 5-year life expectancies. Survival benefit was calculated as the difference between post-transplantation and waitlist life expectancy. The 5-year survival benefit increased with actual MELD score for patients with and without HCC, ranging from just a few months in patients with low MELD scores (ie, 6-8) to 4 years in patients with the highest MELD scores (ie, 36-40). The survival benefit of patients with HCC was similar to that of patients without HCC who had the same actual MELD score, irrespective of tumor burden or serum level of α-fetoprotein. However, because patients with HCC received liver transplants when they had a lower mean MELD score (13.3 ± 6.2) than patients without HCC (21.8 ± 8.0), a much lower mean 5-year survival benefit was achieved by providing liver transplants to patients with HCC (0.12 years/patient) than patients without HCC (1.47 years/patient). The HCC MELD exception policy has unintentionally resulted in a large reduction in transplantation-related survival benefit.

Major Adverse Events One Year After Acute Kidney Injury After Contrast-Enhanced Computed Tomography

Recent studies have demonstrated that a single episode of acute kidney injury from a number of causes can increase the risk of severe long-term outcomes, including major cardiovascular events and death. We tested the hypothesis that patients who develop acute kidney injury consistent with contrast-induced nephropathy after contrast-enhanced computed tomography (CT) imaging are at increased risk of major adverse events at 1 year. We followed a prospective, heterogeneous cohort of consecutive emergency department patients undergoing contrast-enhanced CT for the outcomes of acute kidney injury consistent with contrast-induced nephropathy and major adverse events, defined as the combined outcome of death (all cause), renal failure, myocardial infarction, and stroke or other arterial vascular events, in any anatomic territory, requiring invention within 1 year. The primary outcome, major adverse events, was determined by the consensus of 2 of 3 blinded adjudicators. We followed 633 patients undergoing contrast-enhanced CT, of whom 11% developed acute kidney injury consistent with contrast-induced nephropathy and 15% (95/633; 95% confidence interval [CI] 12% to 18%) experienced at least 1 major adverse event within 1 year, including 7% (46/633; 95% CI 5% to 9%) who died. The development of acute kidney injury after contrast-enhanced CT was associated with an increased risk of 1-year major adverse event: the incident risk ratio was 4.01 (95% CI 2.61 to 6.05) and was 2.36 (95% CI 1.49 to 3.75) after adjusting for age, existing coronary artery disease, active malignancy, and 1 or more additional exposures to intravascular iodinated contrast media. The development of acute kidney injury after contrast-enhanced CT was associated with a 2-fold increase in 1-year major adverse events. Further research is needed to validate this observation.

Serial Plasma Metabolites Following Hypoxic-Ischemic Encephalopathy in a Nonhuman Primate Model

Biomarkers that indicate the severity of hypoxic-ischemic brain injury and response to treatment and that predict neurodevelopmental outcomes are urgently needed to improve the care of affected neonates. We hypothesize that sequentially obtained plasma metabolomes will provide indicators of brain injury and repair, allowing for the prediction of neurodevelopmental outcomes. A total of 33 Macaca nemestrina underwent 0, 15 or 18 min of in utero umbilical cord occlusion (UCO) to induce hypoxic-ischemic encephalopathy and were then delivered by hysterotomy, resuscitated and stabilized. Serial blood samples were obtained at baseline (cord blood) and at 0.1, 24, 48, and 72 h of age. Treatment groups included nonasphyxiated controls (n = 7), untreated UCO (n = 11), UCO + hypothermia (HT; n = 6), and UCO + HT + erythropoietin (n = 9). Metabolites were extracted and analyzed using comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry and quantified by PARAFAC (parallel factor analysis). Using nontargeted discovery-based methods, we identified 63 metabolites as potential biomarkers. The changes in metabolite concentrations were characterized and compared between treatment groups. Further comparison determined that 8 metabolites (arachidonic acid, butanoic acid, citric acid, fumaric acid, lactate, malate, propanoic acid, and succinic acid) correlated with early and/or long-term neurodevelopmental outcomes. The combined outcomes of death or cerebral palsy correlated with citric acid, fumaric acid, lactate, and propanoic acid. This change in circulating metabolome after UCO may reflect cellular metabolism and biochemical changes in response to the severity of brain injury and have potential to predict neurodevelopmental outcomes.

Anaerobic antimicrobial therapy after necrotizing enterocolitis in VLBW infants.

To evaluate the effect of anaerobic antimicrobial therapy for necrotizing enterocolitis (NEC) on clinical outcomes in very low birth weight (≤1500 g) infants. We identified very low birth weight infants with NEC from 348 US NICUs from 1997 to 2012. Anaerobic antimicrobial therapy was defined by antibiotic exposure on the first day of NEC. We matched (1:1) infants exposed to anaerobic antimicrobial therapy with infants who were not exposed by using a propensity score stratified by NEC severity (medical and surgical). The primary composite outcome was in-hospital death or intestinal stricture. We assessed the relationship between anaerobic antimicrobial therapy and outcome by using a conditional logistic regression on the matched cohort. A total of 1390 infants exposed to anaerobic antimicrobial therapy were matched with 1390 infants not exposed. Mean gestational age and birth weight were 27 weeks and 946 g, respectively, and were similar in both groups. We found no significant difference in the combined outcome of death or strictures, but strictures as a single outcome were more common in the anaerobic antimicrobial therapy group (odds ratio 1.73; 95% confidence interval, 1.11-2.72). Among infants with surgical NEC, mortality was less common with anaerobic antimicrobial therapy (odds ratio 0.71; 95% confidence interval, 0.52-0.95). Anaerobic antimicrobial therapy was not associated with the composite outcome of death or strictures but was associated with an increase in intestinal strictures. This higher incidence of intestinal strictures may be explained by the fact that death is a competing outcome for intestinal strictures, and mortality was slightly lower in the anaerobic cohort. Infants with surgical NEC who received anaerobic antimicrobial therapy had lower mortality.

Sustained inflation versus positive pressure ventilation at birth: a systematic review and meta-analysis

ContextSustained inflation (SI) has been advocated as an alternative to intermittent positive pressure ventilation (IPPV) during the resuscitation of neonates at birth, to facilitate the early development of an effective...

Population-based trends in mortality and neonatal morbidities among singleton, very preterm, very low birth weight infants over 16 years

BackgroundImproved survival of singleton very preterm, very low birth weight (VPTVLBW) infants has been associated with increasing rates of severe neonatal morbidities. AimTo assess changes in mortality and neonatal morbidities among singleton VPT-VLBW infants. Study designPopulation-based observational study of data collected by the Israel Neonatal Network. Subjects10,705 singleton VPT-VLBW infants born at 24–32 gestational weeks in 1995–2010. Outcome measuresMortality and major neonatal morbidities over 3 time periods: 1995–2000, 2001–2005, and 2006–2010. Major neurological morbidities comprised intraventricular hemorrhage grades 3–4, periventricular leukomalacia and retinopathy of prematurity grades 3–4. ResultsThe mortality rate decreased over time from 20.2% to 13.8% for all birth weight and gestational age groups. Compared to the 1995–2000 period, the adjusted odds ratios (aORs) (95% confidence intervals,) for mortality in 2001–2005 and 2006–2010 were 0.78 (0.67–0.90) and 0.72 (0.62–0.84), respectively. The combined outcomes of death or major neurological morbidities, aOR 0.74 (0.65–0.84) and death or major neurological morbidities and/or bronchopulmonary dysplasia aOR 0.85 (0.75–0.96) decreased significantly between the first and last periods. A significant improvement in mortality rates and survival without one or more major neonatal morbidity was observed for all birth weight and gestational age groups.Among 8,886 surviving infants the rates of major neurological morbidities decreased from 16.4% to 12.8%, aOR 0.80 (0.68–0.95). ConclusionThe improving survival of singleton VTP-VLBW infants was not associated with a concomitant increase in the risk for major neonatal neurological morbidities among surviving infants. Bronchopulmonary dysplasia, however, remained a significant burden. This analysis emphasizes the need to direct efforts towards the prevention and treatment of adverse respiratory sequelae.

Cohort Study of Probiotics in a North American Neonatal Intensive Care Unit

Studies have confirmed a major reduction in necrotizing enterocolitis (NEC) and death with routine use of probiotics in high-risk preterm infants. Although no major differences were reported in the preparations containing lactobacilli, just bifidobacteria, and a mixture, mixtures of different organisms may be more effective than a single species. This prospective cohort study was performed to determine the clinical outcomes after starting probiotics use in a neonatal intensive care unit (NICU). After the first 17 months of using probiotics, incidences of NEC and death were compared with those during the prior 17 months before introducing probiotics. All infants at less than 32 weeks’ gestation at birth were eligible to receive probiotics unless they had a gastrointestinal malformation. They received FloraBABY probiotic mixture, containing Bifidobacterium breve, Bifidobacterium bifidum, Bifidobacterium infantis, Bifidobacterium longum, and Lactobacillus rhamnosus GG (2 × 109 colony-forming units/0.5 g) mixed with 1 mL water just before milk feeding once daily. Probiotics were started at the time of the first feed and continued until the infant reached 34 weeks’ postmenstrual age. Mortality was defined as death before discharge home. Health care–associated infection (HCAI) was defined by a positive culture of a normally sterile body fluid, occurring after 3 days of age. As a proxy for feeding tolerance, the day that intravenous (IV) nutrition was first stopped and the final day of receiving IV nutrition were recorded. The preprobiotic and probiotic cohorts included 317 and 294 infants, respectively. Compared with the preprobiotic cohort, the probiotic cohort had a significant reduction in the incidence of NEC (10% vs 5%; P < 0.05), a nonsignificant reduction in death (10% vs 7%), and a significant reduction in the proportion of infants who died or developed NEC (17% vs 11%; P < 0.05). No significant effect on HCAI (18% vs 17%) was noted. The average duration of therapy was 24 ± 16 days, and the average time of starting probiotics was day 4.3 ± 5.1. When only the infants with a birth weight of less than 1001 g were analyzed, similar percentage reductions in NEC and the combined outcome of death and NEC were found. The 2 cohorts did not differ significantly in average gestational age or in proportions who were small for gestational age, female, or less than 26 weeks’ gestation. The odds ratios for NEC, death, NEC or death, and HCAI were 0.51 (95% confidence interval [CI], 0.26–0.0.98), 0.71 (95% CI, 0.38–1.34), 0.56 (95% CI, 0.33–0.93), and 0.98 (95% CI, 0.81–1.98), respectively, with receipt of probiotics. The mean difference in the time to first stopping IV nutrition was 4.6 days (95% CI, 1.8–7.3 days), and the mean difference in time to finally stopping IV nutrition was 5.3 days (95% CI, 0.8–9.9 days). Administration of probiotic organisms to prevent NEC is feasible, supported by clinical evidence, and has a beneficial balance. Studies comparing strains and examining additional NICU populations and length of therapy are needed.

Myocardial viability and impact of surgical ventricular reconstruction on outcomes of patients with severe left ventricular dysfunction undergoing coronary artery bypass surgery: Results of the Surgical Treatment for Ischemic Heart Failure trial

In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone. Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria. At 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality. In patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.

51 Plasma MMP-3: A Novel Indicator of Left Ventricle Remodelling and Adverse Outcomes in Patients with Acute Heart Failure

PurposeChanges in the intercellular matrix have previously been found to be important in left ventricle (LV) remodelling in chronic heart failure (HF). We investigated whether plasma matrix metalloproteinase (MMP) 3...

Apgar scores after hypoxic-ischaemic encephalopathy

Journal of Paediatrics and Child HealthVolume 50, Issue 3 p. 242-242 Heads UpFree Access Apgar scores after hypoxic-ischaemic encephalopathy First published: 27 March 2014 https://doi.org/10.1111/jpc.12527 edited by Craig Mellis ([email protected]) AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Children enrolled in a US randomised controlled trial of whole body cooling for neonatal hypoxic-ischaemic encephalopathy were evaluated at 6–7 years of age by Wechsler Preschool and Primary Scale of Intelligence or Wechsler Intelligence Scale for Children IV, depending on age.1 A secondary analysis examined the relationship between 10-min Apgar scores and a combined outcome of death or severe disability by logistic regression after adjusting for birth weight, gestation, gender, place of birth (inborn or outborn), and hypothermia treatment and centre. Of the 85 children evaluated who had a 10-min Apgar score of 0–3, 64 (75%) had death or severe disability compared with 40 (45%) of 89 with Apgar score of 4 or greater. Each point increase in 10-min Apgar score was associated with a decreased risk of death and/or disability, including cerebral palsy or IQ < 70. An Apgar score of 0 at 10 min did not always indicate a poor prognosis: five (20.8%) of 24 such children survived without demonstrable disability. This study shows an important correlation between 10-min Apgar score and performance at primary school age but also suggests that resuscitation should be continued beyond 10 min even for infants with an Apgar score of 0. Reference 1 Natarajan G et al. Arch. Dis. Child. Fetal Neonatal Ed. 2013; 98: F473– 479. Reviewer: David Isaacs, [email protected] Volume50, Issue3March 2014Pages 242-242 ReferencesRelatedInformation

Cohort Study of Probiotics in a North American Neonatal Intensive Care Unit

To determine whether routine probiotic administration to very preterm infants would reduce the incidence of necrotizing enterocolitis (NEC) without adverse consequences. Since the end of July 2011, we have administered a probiotic mixture to all admitted infants of <32 weeks' gestation. We give 0.5 g of a mixture of 4 bifidobacteria (Bifidobacterium breve, bifidum, infantis, and longum) and Lactobacillus rhamnosus HA-111 [corrected] (2 × 10(9) colony-forming units) per day, starting with the first feed, until the infant reaches 34 weeks. We compared complications among infants admitted during the first 17 months of routine use with those admitted during the previous 17 months. Two hundred ninety-four infants received probiotics, and 317 infants formed the comparison group. Introduction of probiotics was associated with a reduction in NEC (from 9.8% to 5.4%, P < .02), a nonsignificant decrease in death (9.8% to 6.8%), and a significant reduction in the combined outcome of death or NEC (from 17% to 10.5%, P < .05). After adjustment for gestational age, intrauterine growth restriction, and sex, the improvements remained significant (OR for NEC, 0.51; 95% CI, 0.26-0.98; OR for death or NEC, 0.56; 95% CI, 0.33-0.93). There was no effect of probiotics on health care-associated infection. A product that is readily available in North America, that has excellent quality control, and that contains strains similar to those that have been shown effective in randomized controlled trials substantially reduced the frequency of NEC in our neonatal intensive care unit.

Predictors of bronchopulmonary dysplasia or death in premature infants with a patent ductus arteriosus

BackgroundPreterm infants with a PDA are at risk for death or development of BPD. However, PDA treatment remains controversial. We investigated if PDA treatment and other clinical or echocardiographic (ECHO) factors were associated with the development of death or BPD.MethodsWe retrospectively studied clinical and ECHO characteristics of preterm infants with birth weight <1500 g and ECHO diagnosis of a PDA. Logistic regression and classification and regression tree (CART) analyses were performed to assess variables associated with the combined outcome of death or BPD.ResultsOf 187 preterm infants with a PDA, 75% were treated with indomethacin or surgery and 25% were managed conservatively. Death or BPD occurred in 80 (43%). Logistic regression found lower gestational age (OR 0.5), earlier year of birth during the study period (OR 0.9), and larger ductal diameter (OR 4.3) were associated with the decision to treat the PDA, while gestational age was the only variable associated with death or BPD (OR 0.6, 95% CI 0.5-0.8).ConclusionOnly lower gestational age and not PDA treatment or ECHO score was associated with the adverse outcome of death or BPD. Further investigation of PDA management strategies and effects on adverse outcomes of prematurity is needed.

Effects of Clopidogrel on Mortality, Cardiovascular and Bleeding Outcomes in Patients with Chronic Kidney Disease - Data from Taiwan Acute Coronary Syndrome Full Spectrum Registry

BackgroundThe efficacy of clopidogrel is inconclusive in the chronic kidney disease (CKD) population with acute coronary syndrome (ACS). Furthermore, CKD patients are prone to bleeding with antiplatelet therapy. We investigated the efficacy and safety of clopidogrel in patients with ACS and CKD.MethodsIn a Taiwan national-wide registry, 2819 ACS patients were enrolled. CKD is defined as an estimated glomerular filtration rate of less than 60 ml/min per 1.73 m2. The primary endpoints are the combined outcomes of death, non-fatal myocardial infarction and stroke at 12 months.ResultsOverall 949 (33.7%) patients had CKD and 2660 (94.36%) patients received clopidogrel treatment. CKD is associated with increased risk of the primary endpoint at 12 months (HR 2.39, 95% CI 1.82 to 3.15, p<0.01). Clopidogrel use is associated with reduced risk of the primary endpoint at 12 months (HR 0.42, 95% CI: 0.29–0.60, p<0.01). Cox regression analysis showed that clopidogrel reduced death and primary endpoints for CKD population (HR 0.35, 95% CI: 0.21–0.61 and HR 0.48, 95% CI: 0.30–0.77, respectively, both p<0.01). Patients with clopidogrel(−)/CKD(−), clopidogrel(+)/CKD(+) and clopidogrel(−)/CKD(+) have 2.4, 3.0 and 10.4 fold risk to have primary endpoints compared with those receiving clopidogrel treatment without CKD (all p<0.01). Clopidogrel treatment was not associated with increased in-hospital Thrombolysis In Myocardial Infarction (TIMI) bleeding in CKD population.ConclusionClopidogrel could decrease mortality and improve cardiovascular outcomes without increasing risk of bleeding in ACS patients with CKD.